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JournaHGantet

Represents the Medical Profession of

Minnesota, North Dakota, South Dakota and Montana

The Official Journal of the

North Dakota State Medical Association
South Dakota State Medical Association
Medical Association of Montana

A Monthly Medical Journal

Index to

VOLUME LVII

New Series

January 1937 - December 1937

Minnesota Academy of Medicine
Sioux Valley Medical Association

Minneapolis Clinical Club
American Students’ Health Association

Great Northern Railway Surgeons’ Association

Minneapolis, Minn.

Lancet Publishing Co., Publishers

1937

THE JOURNAL-LANCET

552

INDEX OF AUTHORS

Anderson, Edward Dyer •

Observations on Pneumonia in Childhood.

Anderson, James Kerr -

The General Symptomatology of Common Rectal
and Anal Diseases.

Anderson, Karl W. ......

The Trend of Mortality in Insured Children.

Arnson, J. O. -

A Review of 1936 Literature on General Medicine.
Errors in the Diagnosis of Pulmonary Tuberculosis. -

Balsam, Elmer G. ......

A Review of 1936 Literature on Surgery.

Barnett, Crawford F. -

Allergy in General Medicine.

Billingsley, P. R.

A Review of 1936 Literature on Obstetrics and
Gynecology.

Black, J. H.

The Control of Allergic Manifestations.

Booth, Marguerite ......

The Present Day Status of the Vitamins.

Brown, Grafton Tyler -

The Treatment of Bacterial Allergy.

Bryant, Frank L. ......

Aural and Nasal Problems in General Practice.

Chenoweth, Laurence B.

The Unit Method of Teaching Hygiene in College.
Cohen, Bernard A.

Pneumonia Typing and Specific Treatment.

Comroe, Bernard I.

Nutritional Problems in University Students.

Cole, Llewellyn R.

Sensitivity to Scarlet Fever Streptococcus Toxin
Immunizing Dose (Case Report)

The Results of Routine Examination of Candidates
for Teachers' Certificates at the University of
Wisconsin. .....

Collins, Arthur N. .....

The Name of the Doctor. (Address).

Coops, Helen L. .....

The Unit Method of Teaching Hygiene in College.

Darrow, Kent E. .....

Some of the Problems in the Diagnosis of
Intestinal Obstruction.

Davison, Hal M. .....

Allergy in General Medicine.

Dearholt, Hoyt E.

The Willard Bequest.

Dixon, Claude F. - - - - -

Acute Abdominal Disease.

Dodds, G. Alfred .....

The Present Status of the Tuberculin Reaction.

Eckley, P. W.

Acute Infectious Mononucleosis.

Emerson, Kendall .....

Man. Tuberculosis and Superstition.

Evans, Edward T.

Growing Feet.

Fansler, Walter A.

A Review of 1936 Literature on Proctology.

Feinberg, Samuel M. .....
Asthma and Allergic Rhinitis From Molds.

Fellows, M. F. .....

Eyeground Examination as an Aid to Prognosis in
General Medicine.

Fitch. Thomas S. P. -

Epidural and Subdural Hemorrhages.

Forsythe. Warren E. -

Medical Care of University Students.

Garberson, J. H.

Perforations of the Intestine from an Unusual
Foreign Body (Case Report).

184

441

202

130

102

101

530

261

306

421

451

112

306

518

102

138

483

129

209

294

357

256

277

Gerrish, W. A. - - - - - - - 345

Presidential Address.

Goehl, R. O. - - - - - - 435

A Discussion of Protamine Insulin.

Griffith, W. H. 239

The Schilling Hemogram in Acute Infections.

Hansel, French K. ------ 83

Respiratory Allergy, The Incidence of Other Asso-
ciated Manifestations.

Hansen, Arild E. ----- - 530

The Present Day Status of the Vitamins.

Hanson, E. C. - - - - - - - 527

Ectopic Pregnancy.

Hill, Lee Forest - - - - - - 179

Clinical Changes Produced by Diarrhea and Their
Restitution.

Hilleboe, H. E. - - - - - - - 150

Comparative Study of Tuberculosis Among Insane
Persons.

Hinckley, Robert G. - - - - - - 478

Vital Capacity Determination in Health Examination.

Hinshaw, H. Corwin ...... 363

Treatment of Pneumonia.

Hubin, E. G. - - - - - - - 289

Tularemic Pneumonia.

Huenekens, E. J. - - - - - - 207

The Prevention of Whooping Cough.

Husband, M. W. 5 29

Tuberculin Tests in State 4-H Club Health
Contestants.

Johnson. Evelyn - - - - - - 410

A Clinical Evaluation of a New Feeding for Pre-
mature Infants.

Joslin, Elliott P. ...... 26

An Address.

Kalar, S. B. ....... 143

Teen Age Tuberculosis.

Kegaries, Donald L. - - - - - - 522

A Clinic on Disease of the Biliary Tract.

Kinsella, Thomas J. ----- - 495

When Surgery is Indicated in Pulmonary Tubercu-
losis.

Kleinschmidt, H. E. - - - - - - 148

Sick, Broke and Footloose.

Kler, Joseph H. - - - - - - - 107

Surgery of the Tonsils from the Anatomic Point
of View.

Koepcke, G. M. ------- 460

Vitamins and Infections of the Eye, Nose, Throat
and Sinuses.

Koons, Melvin E. - - - - - - 18

Laboratory Assistance to Physicians.

Larson, W. P. - - - - - - - 154

The Present Status of B. C. G. Vaccination.

Lamson, Robert W. ...... 90

Asthma. A Syndrome, Not a Clinical Entity.

Laymon, Carl W. ......

Urticaria. ...... 29

A Few Common Dermatoses of Infancy and Child-
hood. 197

Leggett, Elizabeth A. ..... 453

Brucellosis.

Levine, M. N. ------ - 298

Artificial Pneumothorax: A Standard Method of

Treatment.

Brucellosis ....... 453

Long. W. H. - - - - - - - 481

The Management of Nephritis.

Lowance, Mason I. - - - - - - 102

Allergy in General Medicine.

Loy, David T. - - - - - - - 529

Tuberculin Tests in State 4-H Club Health
Contestants.

Lundy, John S. - - - - - - - 438

Anesthesia and the Relief of Pain by the General
Practitioner.

Lyght, Charles E. ...... 23

Student Health Practice.

Acute Suppurative Mediastinitis .... 489

THE JOURNAL-LANCET

553

McLeod, J. L. - - - - - - 295

Acute Abdominal Symptoms Complicating Diag-
nosis, With Case Reports.

Mark, Hilbert - - - - - -160

Newer Concepts in the Epidemiology of Tubercu-
losis.

Merc.l, W. F. 364

Missed Abortion.

Minty, Earl W. - - - - - - 522

A Clinic on Disease of the Biliary Tract.

Movius, Arthur J. - - - - - - 5

Subphrenic Abscess.

Myers, J. A.

State Medicine in Minnesota . . - . 212

Artificial Pneumothorax: A Standard Method of

Treatment . 298

Brucellosis ....... 453

Myers, Thomas - - - - - - - 110

Burbot Liver Oil as an Antirachitic.

Parsons, J. G. - - - - - - 224

The Cultural Side of a Doctor's Life.

Petter, Charles K. ----- -

Some Thoughts on Tuberculosis of Fascia and

Muscle ....... 156

Vitamin C and Tuberculosis . _ . . 221

Phelps, Kenneth A. ------ 63

A Review of 1936 Literature on Ear, Nose, Throat
and Bronchoscopy.

Pittenger, E. A. - - - - - - 397

Address of the President-Elect.

Raadquist, C. S. - - - - - - 4 1 4

Silicosis.

Richards, W. G. ...... 404

Methods and Motives in Medicine.

Robbins, Owen F. - - - - - - 418

A Method of Roentgen Pelvimetry.

Robertson, George E. - - - - - - 444

Feeding Problems in Infancy.

Rucker, Charles Wilbur ----- 66

A Review of 1936 Literature on Ophthalmology.

Rudolph, J. A. - - - - - - - 457

Some Allergic Problems Puzzling to the General
Physician.

Russell, Albert E. ----- - 265

Silicosis and Other Dust Diseases.

Ryan, William J. - - - - - - 136

The Youth Sector in fhe.Fight Against Tuberculosis.

Schumacher, Henry C. - - - - - 503

College Mental Flygiene.

Sherbon, Florence Brown - - - - - 161

The Problem of Developing a Student Health
Service.

Sherwood, J. Vincent - - - - - 475

The Sanatorium Care of Tuberculosis in South
Dakota.

Shrader, E. Lee - - - - - - 72

A Student Health Opportunity.

Skelsey, A. W. - - - - - - - 35 3

50th Anniversary of the North Dakota State
Medical Association

Smith, L. E. - - - - - - - 145

The Human Factor in the Control of Tuberculosis.

Snell, Albert M. - - - - - - 522

A Clinic on Disease of the Biliary Tract.

Stiehm, R. H. ....... 33

Tuberculous Infection and Progressive Tuberculous
Lesions.

Stewart, Chester A. ------ 68

Progress in Pediatrics.

Stewart, J. L. - - - - - - - 394

President’s Address.

Stoesser, Albert V. - - - - - -

The Management and Feeding of the Premature

Infant ....... 190

A Clinical Evaluation of a New Feeding for Pre-
mature Infants . . . . . -410

Swanson, Roy E. - - - - - - 186

Asphyxia Neonatorum.

Tovey, David W. - - - - - - 1 14

The Use of the Vaginal Douche in Clinical Gyne-
cology.

Tuft, Louis ....... 93

Serum Allergy.

Tuohy, Edward B. ----- - 438

Anesthesia and the Relief of Pain by the General
Practitioner.

Vinson, Porter P. - - - - - 135

Indications and Contraindications for Bronchoscopy.

Visscher, Maurice B. - - - - - - 309

Physiological Principles of Importance in Heart
Failure and Its Treatment.

Waldschmidt, R. H. - - - - - 486

Initial Care and Treatment of Accidental Injuries.
Wangensteen, Owen H. - - - - -

High Gastric Resection in Cancer of the Stomach

with Relation of Personal Experiences . . ]

Benefactions of Surgery to Man .... 243

Wallin, C. C. 166

A Case of Unresolved Streptococcic Pneumonia
(Case Report).

Woutat, Philip H. ...... 287

Fulminating Laryngotracheo-Bronchitis.

Wright, Franklin R. ----- - 409

History of Medical Education in Minnesota.

Wright, W. A. 449

The Treatment of Burns.

York, W. H. 15

Acute Infectious Mononucleosis.

Young, C. B. - - - - - - - 212

State Medicine in Minnesota.

Youngs, Nelson A. ----- - 287

Fulminating Laryngotracheo-Bronchitis.

Ziskin, Thomas ------- 292

Theobromine Calcium Carbonate in the Treatment
of Cardiovascular Disease.

INDEX OF EDITORIALS
A

A Step Forward - - - - - - 276

Allergy, The Increasing Scope of - - - ll7

An Impressive Teacher - - - - - 169

Annual Pediatric Issue ----- 228

Annual Review of Literature 76

Bronchoscopist Makes Another Contribution, The 463
C

Cancer Mortality Rate ----- 36

Citadel, The ------- 463

Cold Compress, The - - - - - - 169

Do What You Can - - - - - - 76

Druggists’ Counter-Sale of Dangerous Drugs - 510

Doctor and the Press, The ----- 545

Doctor’s Vacation, The ----- 368

Farmer’s Aid Corporation - - - - 36

Hail to the Chief - - - - - - 313

Health at Flandreau Indian School - - - 118

It Is Later Than You Think - 275

Journal-Lancet and 1936, The - - - - 35

Keeping Up - - - - - - - 510

Liver, The - - - - - - - 36

THE JOURNAL-I.ANCET

■>5-4

Medical Defense Plan of State Medical
Associations -

Medical Profession and Its Dissenters, The -
Minnesota Defense Plan, The
Montana Meeting

New Plan, A - - - -

North Dakota, A Significant Meeting in

Old Age Assistance — Its Medical Danger
P

Pulmonary Abscess, Decreasing Incidence of

Reading With Emphasis ....
Regional Ileitis -

Sixty-Six Years ....

Socialization of Medicine, The -
Soup Thermometers -

South Dakota Meeting ....
Specialists, Apportionment of
Supplementing Private Practice
T

The Journal-Lancet and the Early Diagnosis
Campaign ------

The Whole Picture .....

Tuberculosis, Early Diagnosis and the

Eradication of .....

97
154
243
522

Albert M. Snell, Donald L. Kegaries, and
Earl W. Minty

422 Book Reviews - - 34, 74, 1 16, 178, 238, 286, 311

434, 462, 509, 550

I'® Broke and Footloose, Sick - - - - 148

423 H. E. Kleinschmidt

Bronchitis, Fulminating Laryngotracheo - - 287

75 Nelson A. Youngs and Philip H. Woutat

228 Bronchoscopy, Indications and Contraindica-

423 tions for ....... 135

22T Porter P. Vinson

547 Bronchoscopy, Review of 1936 Literature on
5 1 1 Ear, Nose, Throat, and ----- 63

Kenneth A. Phelps

Brucellosis ....... 453

M. N. Levine. J. Arthur Myers, and Elizabeth A. Leggett

Burbot Liver Oil as an Anti-rachitic - - - 110

1 1 ' Thomas Myers

Burns, The Treatment of - - - - - 449

168 W. A. Wright

313

546

367

275

228

227

464

Asthma and Allergic Rhinitis from Molds -
Samuel M. Feinberg

Asthma: A Syndrome, Not a Clinical Entity
Robert W. Lamson

Bacterial Allergy, The Treatment of -
Grafton Tyler Brown

B. C. G. Vaccination, The Present Status of
W. P. Larson

Benefactions of Surgery to Man, The
Owen H. Wangensteen

Biliary Tract, A Clinic on Disease of the

INDEX OF ARTICLES
A

Abdominal Symptoms, Acute, Complicating

Diagnosis, With Case Reports - - - 295

J. L. McLeod

Abortion, Missed - 364

W. F. Mercil

Abscess, Subphrenic ------ 5

Arthur J. Movius

Accidental Injuries, The Initial Care and Treat-

ment of .....-- 486

R. H. Waldschmidt

Acute Abdominal Disease - - - - 483

Claude F. Dixon

Address, An ------- 26

Elliott P. Joslin

Allergic Manifestations, The Control of - - 101

J. H. Black

Allergic Problems Puzzling to the General Prac-
titioner, Some ...... 457

J. A. Rudolph

Allergic Rhinitis, and Asthma, From Molds . - 87

Samuel M. Feinberg

Allergy, Bacterial, The Treatment of - - - 97

Grafton Tyler Brown

Allergy in General Medicine - - - - 102

Hal M. Davison, Mason I. Lowance, and Crawford F. Barnett

Allergy, Respiratory, The Incidence of Other

Associated Manifestations - - - - 83

French K. Hansel

Allergy, Serum ------- 93

Louis Tuft

Anal and Rectal Diseases, The General Symp-
tomatology of Common - - - - - 441

James Kerr Anderson

Anesthesia and the Relief of Pain by the Gen-
eral Practitioner - - - - - - 43 8

John S. Lundy and Edward B. Touhy

Asphyxia Neonatorum - - - - - 186

Roy E. Swanson

Calcium Carbonate, Theobromine, in the Treat-
ment of Cardiovascular Disease - - - 292

Thomas Ziskin

Cancer of the Stomach, High Gastric Resection

in, With Relation of Personal Experiences - 1

Owen H. Wangensteen

Cardiovascular Disease, Theobromine Calcium

Carbonate in the Treatment of - - - 292

Thomas Ziskin

Case Report: Acute Abdominal Symptoms Com-
plicating Diagnosis ..... 295

J. M. McLeod

Case Report: A Case of Unresolved Streptococ-
cic Pneumonia - - - - - - 1 6b

C. C. Wallin

Case Report: Perforations of the Intestine from

an Unusual Foreign Body .... 277

J. H. Garberson

Case Report: Sensitivity to Scarlet Fever Strep-
tococcus Toxin Immunizing Dose - - - 421

Llewellyn R. Cole

Childhood, Observations on Pneumonia in - - 184

Edward Dyer Anderson

Clinic on Disease of the Biliary Tract, A - - 522

Albert M. Snell, Donald L. Kegaries, and
Earl W. Minty

College Mental Hygiene ..... 503

Henry C. Schumacher

College, The Unit Method of Teaching Hygiene

in 306

Helen L. Coops, Ph D., and Laurence B. Chenoweth
Comparative Study of Tuberculosis Among In-
sane Persons - - - - - - -150

H. E. Hilleboe

Concepts, Newer, in the Epidemiology of Tu-
berculosis - - - - - - -160

Hilbert Mark

Control of Allergic Manifestations, The - - 101

J. H. Black

Control of Tuberculosis, The Human Factor in - 145

L. E. Smith

THE JOURNAL-LANCET

-W-

Cough, Whooping, The Prevention of
E. J. Huenekens

Cultural Side of a Doctor’s Life, The -
J. G. Parsons

Dermatoses of Infancy and Childhood, A Few-
Common ......

Carl W. Laymon

Diagnosis, Acute Abdominal Symptoms Compli-
cating (case report) ....

J. L. McLeod

Diagnosis of Intestinal Obstruction, Some of the
Problems in the .....

Kent E. Darrow

Diagnosis of Pulmonary Tuberculosis, Errors in
J. O. Arnson

Diarrhea, Clinical Changes Produced by, and
Their Restitution .....

Lee Forest Hill

Discussion of Protamine Insulin, A
R. O. Goehl

Doctor, The Name of the (address)

Arthur N. Collins

Doctor’s Life, The Cultural Side of a -
J. G. Parsons

Douche, Vaginal, Use of the, in Clinical Gyne-
cology .......

David W. Tovey

Dust Diseases, Silicosis and Other
Albert E. Russell

Ear, Nose, Throat and Bronchoscopy, A Review
of 1936 Literature on -

Kenneth A. Phelps

Ectopic Pregnancy ......

E. C. Hanson

Education in Minnesota, A History of Medical
Franklin R. Wright

Epidemiology of Tuberculosis, Newer Concepts
in the ........

Hilbert Mark

Epidural and Subdural Hemorrhages -
Thomas S. P. Fitch

Eyeground Examination as an Aid to Prognosis
in General Medicine -

M. F. Fellows

Examination of Candidates for Teachers Certifi-
cates at the University of Wisconsin, The Re-
sults of Routine -

Llewellyn R. Cole

Eye, Nose, Throat and Sinuses, Vitamins and
Infections of ......

G. M. Koepcke

Fascia and Muscle, Some Thoughts on Tubercu-
losis of -

Charles K. Petter

Feeding for Premature Infants, A Clinical Eval-
uation of a New ......

Albert V. Stoesser and Evelyn Johnson

Feeding of the Premature Infant, The- Manage-
ment and .......

Albert V. Stoesser

Feeding Problems in Infancy -

George E. Robertson

Footloose, Sick and Broke - - - - -

H. E. Kleinschmidt

Fulminating Laryngotracheo-Bronchitis

Nelson A. Youngs and Philip H. Woutat

Gastric Resection, High, in Cancer of the Stom-
ach, With Relation of Personal' Experiences

Owen H. Wangensteen

207 General Medicine, A Review of 1936 Literature

on - - - - - - - - 43

224 J- O. Arnson

General Medicine, Eyeground Examination as

an Aid to Prognosis in - - - - - 294

M. F. Fellows

General Physician, Some Allergic Problems
197 Puzzling to the ...... 457

J. A. Rudolph

General Practice, Aural and Nasal Problems in - 261

295 Frank L. Bryant

Growing Feet ....... 209

Edward T. Evans

518 Gynecology, A Review of the 1936 Literature on

Obstetrics and ...... 48

130 P. R. Billingsley

Gynecology, Clinical, The Use of the Vaginal

Douche in - - - - - - -114

179 David W. Tovey

435

112

224

114

265

527

409

160

357

294

451

460

156

410

190

444

148

287

Health Contestants, State 4-H Club, Tuberculin

Tests in - - - - - - - - 529

M. W. Husband and David T. Loy

Health Examinations, Vital Capacity Determi-
nations in - - - - - - - 478

Robert G. Hinckley

Health Opportunity, A Student - - - 72

E. Lee Shrader

Health Practice, Student ----- 23

Charles E. Lyght

Health Service, Student, The Problems of De-
veloping a- - - - - - -161

Florence Brown Sherbon

Hemogram, The Schilling, in Acute Infections - 239

W. H. Griffith

High Gastric Resection in Cancer of the Stom-
ach, With Relation of Personal Experiences - 1

Owen H. Wangensteen

History of Medical Education in Minnesota, A - 409

Franklin R. Wright

Hygiene, College Mental ..... 503

Henry C. Schumacher

Hygiene in College, The Unit Method of

Teaching ....... 306

Helen L. Coops, Ph.D., and Laurence B. Chenoweth

Human Factor in the Control of Tuberculosis,

The 145

L. E. Smith

Immunizing, Sensitivity to Scarlet Fever Strep-
tococcus Toxin Dose - - - - - 421

Llewellyn R. Cole

Indications and Contraindications for Bron-
choscopy - - - - - - - 135

Porter P. Vinson

Infancy and Childhood, A Few Common Der-
matoses of - - - - - - - 197

Carl W. Laymon

Infancy, Feeding Problems in 444

George E. Robertson

Infant, The Management and Feeding of the

Premature - - - - - - - 190

Albert V. Stoesser

Infants, A Clinical Evaluation of a New Feed-
ing for Premature - - - - - - 410

Albert V. Stoesser and Evelyn Johnson

Infections, Acute, The Schilling Hemogram in - 239

W. H. Griffith

Infections of the Eye, Ear, Nose and Sinuses,

Vitamins and ...... 460

G. M. Koepcke

Injuries, Accidental, The Initial Care and

Treatment of - - - - - - - 486

R. H. Waldschmidt

556

THE JOURNAL-LANCET

Insane Persons, Comparative Study of Tubercu-
losis Among - - - - - - - 150

H. E. Hilleboe

Insulin, Protamine, A Discussion of - - -' 435

R O. Goehl

International Post-Graduate Medical Associa-
tion, Program of the International Medical
Assembly ....... 427

Intestinal Obstruction, Some of the Problems in

the Diagnosis of - - - - - - 518

Kent E. Darrow

Intestine, Perforations of the, from an Unusual

Source (case report) ..... 277

J. H. Garberson
L

Laboratory Assistance to Physicians - - - 18

Melvin E. Koons, M.S.

Laryngotracheo-Bronchitis, Fulminating - - 287

Nelson A. Youngs and Philip H. Woucat

Lesions, Tuberculous Infection and Progressive

Tubercular ....... 33

R. H. Stiehm

Liver Oil, Burbot, As an Antirachitic - - - 110

Thomas Myers

Management and Feeding of the Premature

Infant, The 190

Albert V. Stoesser

Management of Nephritis, The - - - 481

W. H. Long

Man, Tuberculosis and Superstition - - -129

Kendall Emerson

Mediastinitis, Acute Suppurative - - - 489

Charles E. Lyght

New Feeding for Premature Infants, Clinical

Evaluation of a - - - - - - 410

Albert V. Stoesser and Evelyn Johnson

Medical Education in Minnesota, History of - 409

Franklin R. Wright

Mental Hygiene, College ..... 503

Henry C. Schumacher

Methods and Motives in Medicine ... 404

W. G. Richards

Method of Roentgen Pelvimetry, A - - - 418

Owen F. Robbins

Minneapolis Clinical Club 121, 172, 229, 369, 425, 464
Minnesota Academy of Medicine 37, 77, 1 19, 176, 280

316, 378, 466

Minnesota, History of Medical Education in - 409

Franklin R. Wright

Minnesota Radiological Society .... 279

Minnesota State Board of Medical Examiners,

List of Physicians Licensed by on Nov. 7, 1936 42

List of Physicians Licensed by on Feb. 6, 1937 167

List of Physicians Licensed by on May 1, 1937 312

List of Physicians Licensed by on June 29, 1937 433

Minnesota State Medical Association, Tentative

Program of Annual Meeting - - - - 170

Minnesota State Medical Association - - - 278

Minnesota, State Medicine in - - - -212

C. B. Young and J. Arthur Myers

Mononucleosis, Acute Infectious - - - 15

W. H. York and P. W. Eckley, B.S.

Montana, Medical Association of, Tentative

Program of Annual Meeting - - - - 278

Montana, Medical Association of, 59th Annual

Meeting of - - - - - - - 5 1 5

Mortality in Insured Children, The Trend of - 202

Karl W. Anderson

Muscle, and Fascia, Some Thoughts on Tuber-
culosis of - - - - - - - 156

Charles K. Petter

Name of the Doctor, The (address)

Arthur N. Collins

Nasal Problems in General Practice, Aural and
Frank L. Bryant

National Conference on College Hygiene, Pro-
ceedings of the Second ....

Nephritis, The Management of -
W. H. Long

New Feeding for Premature Infants, Clinical
Evaluation of a

Albert V. Stoesser and Evelyn Johnson
Newer Concepts in the Epidemiology of Tuber-
culosis .......

Hilbert Mark

North Dakota State Medical Association: The
President-Elect .....
North Dakota State Medical Association: The
Presidential Address ....

W. A. Gerrish

North Dakota State Medical Association, An-
nual Meeting at Grand Forks
North Dakota State Medical Association, Ten-
tative Program of Annual Meeting
North Dakota State Medical Association, Pro-
gram of Annual Meeting
North Dakota State Medical Association, The
50th Anniversary of the

A. W. Skelsey

North Dakota State Medical Association, Dis-
trict Society and Alphabetical Roster
North Dakota State Medical Association, Trans-
actions of the 50th Annual Session
Northern Minnesota Medical Association, Ten-
tative Program of Annual Meeting -
Nose, Throat, and Bronchoscopy, Review of
1936 Literature on Ear and ...

Kenneth A. Phelps

Obstetrics and Gynecology, A Review of 1936
Literature on .....

P. R. Billingsley

Oil, Burbot Liver, as an Antirachitic -

Thomas Myers

Ophthalmology, A Review of 1936 Literature on

Charles Wilbur Rucker

Pain, Anesthesia and the Relief of, by the
General Practitioner ....

Edward B. Tuohy and John S. Lundy
Pediatrics, Progress in

Chester A. Stewart

Pelvimetry, Roentgen, A Method of
Owen F. Robbins

Perforations of the Intestine From an Unusual
Foreign Body (case report) ...

J. H. Garberson

Physicians, Laboratory Aid to

Melvin E. Koons, M.S.

Physiological Principles of Importance in Heart
Failure and Its Treatment ...

Maurice B. Visscher

Pneumonia in Childhood, Some Observations
on -

Edward Dyer Anderson

Pneumonia, Treatment of -

H. Corwin Hinshaw

Pneumonia, Tularemic ....

E. G. Hubin

Pneumonia Typing and Specific Treatment
Bernard A. Cohen

112

261

424

481

410

160

321

345

279

172

228

353

349

323

368

110

438

418

277

309

184

363

289

THE JOURNAL-LANCET

■557

Pneumonia, Unresolved Streptococcic, A Case
of (case report) ......

C. C. Wallin

Pneumothorax, Artificial, A Standard Method
of Treatment .......

J. Arthur Myers and Ida Levine

Pregnancy, Ectopic ......

E. C. Hanson

Premature Infant, The Management and Feed-
ing of the .......

Albert V. Stoesser

Premature Infants, A Clinical Evaluation of a
New Feeding for ......

Albert V. Stoesser and Evelyn Johnson

Present Day Status of the Vitamins, The

Marguerite Booth and Arild E. Hansen

Present Status of B.C.G. Vaccination, The -
W. P. Larson

Present Status of the Tuberculous Reaction, The -
G. Alfred Dodds

Prevention of Whooping Cough, The -
E. J. Huenekens

Problem of Developing a Student Health
Service, The .......

Florence Brown Sherbon

Problems, Feeding, in Infancy -

George E. Robertson

Problems, Some Allergic, Puzzling to the Gen-
eral Physician ......

J. A. Rudolph

Proctology, A Review of 1936 Literature on
Walter B. Fansler

Prognosis in General Medicine, Eyeground Ex-
aminations as an Aid to -

M. F. Fellows

Protamine Insulin, A Discussion of -
R O. Goehl

Pulmonary Tuberculosis, Errors in the Diag-
nosis of ------- -

J. O. Arnson

Reaction, Tuberculin, The Present Status of the -
G. Alfred Dodds

Rectal and Anal Diseases, The General Symp-
tomatology of Common -

James Kerr Anderson

Relief of Pain by the General Practitioner,
Anesthesia and the -

Edward B. Tuohy and John S. Lundy
Resection, High Gastric, in Cancer of the Stom-
ach, with Relation of Personal Experiences
Owen H. Wangensteen

Respiratory Allergy: The Incidence of Other
Manifestations ......

French K. Hansel

Results of Routine Examination of Candidates
for the Teachers Certificate at the University
of Wisconsin .......

Llewellyn R. Cole

Review of 1936 Literature on the Ear, Nose,
Throat, and Bronchoscopy ....
Kenneth A. Phelps

Review of 1936 Literature on General Medicine
J. O. Arnson

Review of 1936 Literature on Obstetrics and
Gynecology .......

P. R. Billingsley

Review of 1936 Literature on Ophthalmology
Charles Wilbur Rucker

Review of 1936 Literature on Proctology
Walter A. Fansler

Review of 1936 Literature on Surgery
Elmer G. Balsam

Rhinitis From Molds, Asthma and Allergic

Samuel M. Feinberg

Roentgen Pelvimetry, A Method of - - - 418

Owen F. Robbins

Scarlet Fever Streptococcus Toxin Immunizing

Dose, Sensitivity to - - - - - 421

Llewellyn R. Cole

Schilling Hemogram in Acute Infections, The - 239

W. H. Griffith

Second National Conference on College Hy-
giene, Proceedings of the - - - - 424

Serum Allergy - - - - - - - 93

Louis Tuft

Silicosis - - - - - - - - 414

C. S. Raadquist

Silicosis and Other Dust Diseases - - - 265

Albert E. Russell

Sioux Valley Medical Association, Annual Meet-
ing at Sioux City, Iowa 39

Some Allergic Problems Puzzling to the General

Physician ....... 457

J. A. Rudolph

Some of the Problems in the Diagnosis of In-
testinal Obstruction - - - - - 518

Kent E. Darrow

South Dakota Academy of Ophthalmology and
Otolaryngology, Tentative Program of An-
nual Meeting - - - - - - 171

South Dakota State Medical Association, Dis-
trict Society and Alphabetical Roster - - 400

South Dakota State Medical Association: The

President’s Address ------ 394

J. L. Stewart

South Dakota State Medical Association, Presi-
dent-Elect’s Address ..... 397

E. A. Pittenger

South Dakota State Medical Association, Report

of the Annual Meeting .... 279

South Dakota State Medical Association, Ten-
tative Program of Annual Meeting - - 170

South Dakota State Medical Association, Trans-
actions of the 56th Annual Session — 1937 - 383

South Dakota, The Sanatorium Care of Tuber-
culosis in ....... 475

J. Vincent Sherwood

State Medicine in Minnesota - - - - 212

C. B. Young and J. Arthur Myers

Stomach, Cancer of the, High Gastric Resection

in, with Relation of Personal Experiences - 1

Owen H. Wangensteen

Streptococcic Pneumonia, A Case of Unresolved

(case report) - - - - - - - 166

C. C. Wallin

Streptococcus Toxin Immunizing Dose, Sensi-
tivity to Scarlet Fever - - - - - 421

Llewellyn R. Cole

Student Health Opportunity, A 72

E. Lee Shrader

Student Health Practice ----- 23

Charles E. Lyght

Student Health Service, The Problem of De-
veloping a - - - - - - - 161

Florence Brown Sherbon

Students, University, The Medical Care of - 256

Warren E. Forsythe

Students, University, Nutritional Problems in - 9

Bernard I. Comroe

Subdural Hemorrhages, and Epidural - - 357

Thomas S. P. Fitch

Subphrenic Abscess ...... 5

Arthur J. Movius

Surgery, Benefactions of, to Man - - - 243

Owen H. Wangensteen

166

298

527

190

410

530

154

207

161

444

457

294

435

130

441

438

451

558

THE JOURNAL-LANCET

Surgery of the Tonsils from the Anatomic Point
of View --------

Joseph H. Kler

Surgery, A Review of 1936 Literature on

Elmer G. Balsam

Symptomatology, General, of Common Rectal
and Anal Diseases .....

James Kerr Anderson

Teaching Hygiene in College, The Unit Method
of ........

Helen L. Coops, Ph.D., and Laurence B. Chenoweth

Teen Age Tuberculosis .....

S. B. Kalar

Theobromine Calcium Carbonate in the Treat-
ment of Cardiovascular Disease

Thomas Ziskin

Throat, Ear, Nose and Bronchoscopy, A Review
of 1936 Literature on .....

Kenneth A. Phelps

Tonsils, Surgery of the, from the Anatomic
Point of View ......

Joseph H. Kler

Toxin Immunizing Dose, Sensitivity to Scarlet
Fever Streptococcus .....

Llewellyn R. Cole

Treatment of Accidental Injuries, and Initial
Care of -

R. H. Waldschmidt

Treatment, Artificial Pneumothorax, A Stand-
ard Method of ----- -

J. Arthur Myers and Ida Levine

Treatment of Bacterial Allergy, The
Grafton Tyler Brown

Treatment of Burns, The .....

W. A. Wright

Treatment of Cardiovascular Disease, Theobro-
mine Calcium Carbonate in the

Thomas Ziskin

Treatment, Heart Failure and Its Physiological
Principles in -

Maurice B. Visscher

Treatment, Specific, and Pneumonia Typing

Bernard A. Cohen

Trend of Mortality in Insured Children, The

Karl W. Anderson

Tuberculin Reaction, The Present Status of the -

G. Alfred Dodds

Tuberculin Tests in State 4-H Club Health

Contestants .......

M. W. Husband and David T. Loy

Tuberculosis of Fascia and Muscles, Some
Thoughts on -

Charles K. Petter

Tuberculosis, The Human Factor in the Control
of --------

L. E. Smith

Tuberculosis, Man and Superstition

Kendall Emerson

Tuberculosis, Newer Concepts in the Epidem-
iology of .......

Hilbert Mark

Tuberculosis, Pulmonary, Errors in the Diag-
nosis of -

J. O. Arnson

Tuberculosis, Teen Age .....

S. B. Kalar

Tuberculosis, The Sanatorium Care of, in South
Dakota ........

J. Vincent Sherwood

Tuberculosis, Vitamin C and ....

Charles K. Petter

Tuberculosis, The Youth Sector in the Fight
Against --------

William J. Ryan ,/ ;•

Tuberculous Lesions, Progressive, and Tubercu-
lous Infection - - - - - - 3 3

R. H. Stiehm

Tularemic Pneumonia ..... 289

E. G. Hubin

Typing, Pneumonia, and Specific Treatment - 32

Bernard A. Cohen

Unit Method of Teaching Hygiene in College,

The ........ 305

Helen L. Coops. Ph. D., and Laurence B. Chenoweth

University Students, The Medical Care of - - 256

Warren E. Forsythe

University Students, Nutritional Problems in - 9

Bernard I. Comroe

University of Wisconsin, The Results of Routine
Examination of Candidates for the Teachers
Certificate at the - - - - - - 45 1

Llewellyn R. Cole

Unusual Foreign Body, Perforations of the In-
testine From an (case report) .... 277

J. H. Garberson

Unresolved Streptococcic Pneumonia, A Case

of (case report) - - - - - - 166

C. C. Wallin

Urticaria ........ 29

Carl W. Laymon

Use of the Vaginal Douche in Clinical Gyne-
cology, The - - - - - - - 114

David W. Tovey

Vaccination, B.C.G., The Present Status of - - 154

W. P. Larson

Vaginal Douche in Clinical Gynecology, Use

of the - - - - - - - - 1 1 4

David W. Tovey

Vital Capacity Determination in Health Exam-

inations - - - - - - - 478

R. G. Hinckley

Vitamin C and Tuberculosis - - - - 221

Charles K. Petter

Vitamins in Infections of the Eye, Nose,

Throat and Sinuses ..... 460

G. M. Koepcke

Vitamins, Present Day Status of the - - - 530

Marguerite Booth and Arild E. Hansen

When Surgery is Indicated in Pulmonary Tu-

berculosis ....... 495

Thomas J . Kinsella

Willard Bequest, The - - - - - 138

Hoyt E. Dearholt

Youth Sector in the Fight Against Tuberculosis,

The 136

William J. Ryan

OBITUARIES

Balsam, Elmer G. - - - - - - 276

Engstad, John E. - - - - - - 169

Greene, Lee Bey - - - - - - 277

Locken, Oscar E. 76

Lyon, Elias P. - - - - - - ■ 276

Mulligan, Thomas - - . * 368

Portmann, William (^, j. - * 547

107

441

306

143

292

107

421

486

298

449

292

309

202

529

156

145

129

160

130

143

475

221

136

Minneapolis, Minnesota
January, 1937

High Gastric Resection in Cancer of the Stomach
With Relation of Personal Experiences*

Owen H. Wangensteen, M.D.**
Minneapolis, Minn.

MORE than fifty years ago, Billroth did the first
successful gastric resection for cancer of the
stomach (1881). In 1890, before the German
Surgical Society, he reported that 24 such resections had
been done in his clinic. He ventured the prediction that
with improvement in operative technique and earlier
recognition, results would be better. A few years later,
X-ray examination came into being. With the develop-
ment of the opaque meal by Rieder, and studies of
gastro-intestinal motility by Cannon, earlier recognition
of cancer of the stomach through the agency of X-rays,
became practical.

In 1914, Friedenwald, of Baltimore, reviewed the
records of 1,000 cases with cancer of the stomach. In the
group, only nine had been found resectable, and not one
had been saved by operation, Friedenwald said. In 1922,
Cheever reported 236 cases that had been observed at
the Peter Bent Brigham Hospital in the ten-year period
intervening since the opening of the hospital. Half of
the cases had demonstrable metastases when they were
first seen. Of the patients explored, half were found to
be non-resectable. Of the resected cases, 13 per cent
survived more than five years. Since these and other
rather discouraging reports relative to cancer of the
stomach have become more widely known, there have
been expressions here and there, particularly amongst
internists, that cancer of the stomach is beyond remedy,
and that patients so afflicted should be left to their own
fate — it being, of course, well-understood that the mor-
tality of cases so managed would be 100 per cent. Any-
one not convinced of the value of surgery in the treat-

•Presented before the Minneapolis Surgical Society at the
January 9, 1936 meeting.

••From the Department of Surgery, University of Minnesota.

ment of cancer of the stomach and desirous of having
his faith strengthened, may, I believe, be readily con-
verted to such an attitude by the perusal of the surgical
literature of the last decade.1, 6

The Diagnosis

Before discussing the surgical problem presented by
the patient with the high lesion, I wish briefly to men-
tion a few items which bear intimately upon the prob-
lem of cancer of the stomach. In its recognition, if we
as physicians will always demand a diagnosis of a
dyspepsia rather than immediate relief by therapy, the
instances in which the diagnosis is made too late will
be considerably fewer. A patient who has a complaint
referable to the gastrointestinal canal should receive an
investigation including a barium study, and not powders
for the symptomatic control of the disorder. Whereas
in the hands of the expert, barium studies of the stom-
ach may be 95 per cent correct as to the presence or
absence of a lesion, in the hands of the novice, the
method may be equally as inaccurate. In order to secure
most for our patients, such examinations should be con-
centrated in the hands of persons who have had special
training and experience in fluoroscopy of the stomach
and interpretation of films. The roentgenologist is essen-
tially a diagnostician who encompasses the entire field
of medicine, but who has become master of one diag-
nostic agent.

A recent experience has taught me that gastroscopy
may be an important agent in the early recognition of
gastric malignancy. Drs. George Fahr and Arthur Kerk-
hof recently referred a patient for operation in which
X-ray films and fluoroscopy failed to demonstrate any

THE JOURNAL-LANCET

defect in the gastric wall. Dr. Kerkhof on gastroscopy
had observed a lesion which he interpreted to be a
carcinoma at the greater curvature at the points of junc-
ture of the middle and upper thirds of the stomach.
Roentgen restudy at the University Hospital failed to
demonstrate a gastric defect. At operation an indurated
area was found, extending over a three-inch length, at
the site described by Dr. Kerkhof. It was my impression
that the lesion was either linitis plastica or a scirrhous
carcinoma. Resection was easily done and the patient
made a satisfactory convalescence. Microscopic study
demonstrated the lesion to be scirrhous carcinoma. To
be certain, the lesion was at an unusual location, where
recognition by the employment of the roentgen rays
was difficult; but how many months more would such a
lesion have to be present before it could be demonstrated
on an X-ray film? A small lesion may be observed
through a cystoscope which obviously cannot be seen in
a cystogram. This analogy, to be sure, cannot be carried
over to the stomach; yet, in this contrast is indicated
the superiority of direct vision in the determination of
the nature of early lesions.

Is the Lesion Ulcer or Cancer?

Not infrequently, with the opinion of the roentgen-
ologist in hand, the clinician is unable to decide defi-
nitely whether the lesion is ulcer or cancer. In many
such instances, the ultimate determination of the exact
nature of the lesion must be left to the operating sur-
geon or the microscopist. How long symptoms have
been present is not a significant determining factor. I
have come to feel that there is as assuredly acute and
chronic cancer as there is acute and chronic infection.
The pathologist would speak of this difference, in terms
of disparities of rate of growth. Some of the best end-
results that have come to my attention in cancer of the
stomach have been observed in those instances, where
despite a rather long story, the patient still presents a
resectable lesion. The patient with cancer of the stom-
ach who presents himself with a large palpable mass,
with a story of three months’ duration, has less promise
than the man who comes after two years of trouble,
but whose lesion is still within bounds. Not for a
moment do I want to lend the impression of condoning
delay in the recognition of cancer of the stomach, but I
do wish to emphasize that the earliness with which the
patient presents himself is not the sole influencing factor
in the prognosis. The initial grade of malignancy, that
is, is it a rapid or slow growing cancer, is equally as
important.

When the patient has had symptoms for several years,
if the X-ray findings are not decisive, and particularly
if the symptoms are relieved by medical management
(non-irritating foods and alkaline powders) , common
practice is to conclude that the patient has an ulcer and
that such apparently satisfactory treatment should be
continued. A limited trial with supervised medical man-
agement (three weeks), as L. G. Cole, of New York,
has advised in such instances, is certainly in order; but
if roentgen examination fails to indicate definite heal-

ing of the lesion, operation is to be advised. In the series
of cases herewith reported, there is one whose lesion
proved to be a sarcoma when excised. His dyspepsia had
been of several years’ duration and he was completely
relieved of his symptoms by medical management under
hospital supervision. Only the persistent protest of the
roentgenologist saved further delay in ascertaining the
nature of the lesion.

Now, a statement which we have long been accus-
tomed to hear, and a suggestion which seems quite credi-
ble, is that cancer of the stomach with long histories
develops from benign ulcers. Such an occurrence has
adequate precedence in the known development of can-
cers upon chronic ulcers in the skin. However, satisfac-
tory proof must be offered to indicate that a similar
sequence of events occurs frequently in the stomach. The
best evidence for occurrence appears to be: (1)

those instances in^^ch cancer can be demonstrated
histologically in a small segment of an ulcer, and (2)
those cancers in which the muscle of the gastric wall
over the extent of the cancerous ulcer is missing. Cancer
invades muscle and rarely destroys it, as does a benign
ulcer of the stomach. Judged in the light of such cri-
teria, ulcer, it appears, precedes cancer in about 3 to 5
per cent of instances.

Papillomas undoubtedly are frequent precursors of
cancer in the stomach, as well as in the colon. At the
University Hospital, this transition from papilloma into
cancer, in patients who have refused operation for the
removal of a gastric polyp, has been observed.

The Resection Group

At the University Hospital during the last 30
months (from July 1, 1933, to January 1, 1936), 109
cases of cancer of the stomach were seen. Forty-four
were inoperable on admission because of distant metas-
tases or a general condition which would not permit of
operation. Of these 44 cases, 12, or 27 per cent, were
terminal on admission, and died in the hospital. Re-
section was done in 31 instances, of which number, 13
were done by me. There was one death among the 13
cases, or a mortality of 7.6 per cent. One of the 13 was
carried on the records as a case of cancer for more than
a year, but recent restudy shows it to be a benign ulcer.

All but two of these cases presented extensive lesions,
necessitating subtotal resection. In three instances, in-
cluding the case which died, resection was done without
clamps, because of the small residual gastric pouch left.
In six of the group, adherence of the tumor to the
pancreas or mesentery was present. In no instance, how-
ever, was it necessary to resect the transverse colon as
well. In two instances, because of enormous weight loss
incident to high-grade obstruction, a two-stage opera-
tion was done — a high anterior anastomosis being made
to the fundus of the stomach at the first operation with
an enteroanastomosis between the afferent and efferent
loops. In lesions with some fixation, it is invariably easier
to make a high anterior anastomosis than a posterior
one. One of these patients gained 20 pounds in weight
in a month’s time before the second operation. One of

THE JOURNAL-LANCE?

the patients in the group with an unusually large polyp-
oid adenocarcinoma of the stomach had an initial hemo-
globin of 1 1 per cent. After several preliminary trans-
fusions, operation was withstood without event despite
adherence of the growth to the mesentery and transverse
mesocolon.

A number of these operations undoubtedly must be
looked upon as being incomplete in nature. Yet, the
palliation afforded is much worth-while. We have no
patients who have survived gastroenterostomy as long as
two years when the cancer was not removed. Occasion-
ally, a patient will survive gastroenterostomy for an
obstructing cancer of the pylorus for as long as a year.
The removal of the lesion stops hemorrhage and usually
improves the nutrition and general status of the patient.
The anxiety to extend such palliation to patients whose
general condition is poor or to patients whose lesion is
fixed over a wide extent can only be purchased at the
cost of a higher operative mortality. The surgeon must
strive to keep the mortality of the operation within
reasonable limits; at the same time he must not deny
patients, whose general status is reasonably satisfactory,
the opportunity for palliation which a successful opera-
tion affords. In the main, our policy at the University
Hospital has been to operate upon all patients with
cancer of the stomach where the following conditions are
met: (1) the general condition warrants operation, (2)
there are no distant metastases, (3) ascites is not pres-
ent, and (4) from the roentgen standpoint the lesion is
operable — this means that the lesion does not extend to
the cardiac aperture.

In instances which are doubtfully operable, judged
in the light of the proximal extent of the lesion as
observed in the roentgenogram, I have come to insist
on a film made in the erect posture. In this position,
one can gain the best impression as to whether normal
stomach intervenes between the lesion and the cardiac
orifice. As one reviews critically every case with the
above considerations in mind, the operations which will
be limited to exploration will be few in number. The
matter of advanced age always pyramids the risk. This
factor, I believe, should be correlated with the patient’s
general physical condition. The oldest patient for whom
I have done a successful resection was 81, and strangely
enough, it turned out to be a benign ulcer! The oldest
patient for whom I have done resection for cancer of
the stomach was 79. He lived long enough to need endo-
scopic prostatic resection and finally succumbed to an
intra-oral malignancy.

Technical Considerations

Apart from the generally poorer physical status of
patients with cancer of the stomach as operative risks,
as contrasted with that of patients with benign ulcer,
an equally important consideration is the microbic char-
acter of the stomach and upper reaches of the intestine
in gastric cancer. Owing to the absence of free hydro-
chloric acid, the presence of a rich bacterial flora in the
fasting stomach is usual; in the normal stomach, on
the contrary, as well as in the stomach, the seat of ulcer,

the presence of free hydrochloric acid keeps the fasting
stomach free from bacteria. This occurrence is of major
importance in the operation for removal of the cancer-
ous stomach — as it is, too, in operations upon the lower
reaches of the intestinal canal which have a bacterial
flora in the presence of a normal stomach. Over a period
of several years now, I have had one-tenth normal hydro-
chloric acid instilled frequently into the stomach,
through an inlying duodenal tube, for several hours be-
fore operation — a total of 90 to 120 cc. being put into
the stomach in this manner over a three or four hour
interval before operation. That this procedure reduces
the bacterial counts in the fasting empty cancerous
stomach my associate, Dr. Rea, and I have been able
to show.

Similarly, at operation, greater care in the avoidance
of soiling is necessary in making the anastomosis. I have
the impression that, on the whole, surgeons have not
availed themselves enough of the employment of local
antiseptic measures at the time of operation upon the
alimentary canal. Experience with the establishment of
enteroanastomoses in patients with cancer of the colon,
in the presence of some obstruction, where feces may
be found accumulated in the bowel, proximal to the
obstruction, despite elaborate efforts at preliminary pre-
operative cleansing of the colon, have taught me the
value of local antiseptic measures at operation. If the
colon is carefully opened, the content removed without
the slightest soiling and the mucosal surfaces of the
bowel are lightly sponged with soap solution (sodium
ricinoleate 1 per cent) until they glisten, the hazards of
anastomoses under such circumstances are reduced to a
minimum. In operations upon the cancerous stomach,
similar precautions are rewarded by a considerably re-
duced risk of peritoneal infection.

After a trial of various anesthetic agents, I have
come to feel that ethylene followed by whatever
amount of ether is necessary, is the safest anesthesia;
even in patients in advanced years. The best approach
is afforded through a high left rectus incision. The
patient is sent to the operating room with the duodenal
tube in place. During the course of the operation, suc-
tion is continually in force; the tube is pulled up into
the residual gastric pouch as the resection proceeds.
During the postoperative convalescence, suction is con-
tinued until intermittent clamping of the tube occasions
no distress. The patient is allowed water by mouth when
awake and the tube can usually be withdrawn after
about four days.

I have usually made the posterior Polya anastomosis.
When the stoma in a high resection cannot be brought
below the transverse mesocolon, an enteroanastomosis is
also made. The anterior anastomosis of Balfour has the
advantage that a recurrent lesion is more readily oper-
ated upon after the anterior operation. Only once, how-
ever, have I felt justified in reoperating for recurrence
after resection for cancer of the stomach. The patient
did not survive the second resection. Recently, Dr.
Manson of our clinic did make a successful re-resection
of a stomach for recurrent cancer.

THE JOURNAL-LANCET

Figure 1. A suggested technique for total
gastrectomy — the operation to be done in
two stages. At the first operation the ad-
jacent limbs of a jejunal loop are drawn
through the transverse mesocolon and behind
the stomach and are sutures to the dia-
phragm and the mobilized subdiaphragmatic
esophagus. An entero-anastomosis is made
between the two limbs of the jejunal limb
near the root of the mesentery. The con-
tinuity of the gastro-intestinal canal is not
disturbed.

At the second operation, the stomach is
removed and the esophago-jejunal anasto-
mosis is completed.

Total Gastrectomy

The impression has been lent above that only resecta-
ble cancers are operable. In the main, this statement still
holds true, for whereas there have been now a fairly
large number of successful total gastrectomies for cancer
reported, the mortality has been great.0,9 I was fortu-
nate enough to have the first patient survive upon whom
I attempted total gastrectomy. In consequence, I was
led to try the procedure on several additional patients,
all of whom died in the hospital. This unhappy experi-
ence has discouraged me considerably. I still believe,
however, that an adequate technique can and will be
worked out. The anastomosis can be satisfactorily made
in suitable cases without too great difficulty. The chief
difficulties are concerned with: (1) the microbic char-
acter of the esophagus and the cancerous stomach, (2)
the tendency for the esophagus to retract into the
mediastinum. I have just recently again, for the first
time in a long time, attempted another total gastrec-
tomy. It was done after the plan shown on the accom-
panying diagram. At the first stage, the esophagus was
mobilized and pulled down after the avascular ligament
of the left lobe of the liver had been cut, permitting of
retraction of the liver out of the way, well to the right.
A loop of small intestine was brought through the
transverse mesocolon and sutured to the esophagus and
the diaphragm. This procedure was facilitated by open-
ings in the gastro-hepatic and gastro-colic omenta. The
blood supply of the stomach was not interfered with.
The adjacent edges of the afferent and efferent limbs
of the jejunal loop were approximated by a running
stitch of fine catgut, and an enteroanastomosis was made
between the two limbs just beneath the transverse
mesocolon.

This operation was well-tolerated. After two weeks,
the second stage was attempted, but an abscess was en-
countered in the abdominal wall. A month after the
first operation, the peritoneal cavity was opened. Un-
usually extensive adhesions were found throughout the
upper abdomen, making re-entry extremely difficult.
Total excision was done, but the technical difficulties
were great and the patient succumbed from his opera-
tion. Nevertheless, I have the impression that an opera-
tive procedure after the plan here suggested, done in
one or two stages, which will obviate retraction of the

esophagus and avoid contamination, will prove feasible.

In the patient upon whom I did a successful gastric
resection, the extraordinary observation was made that
the patient’s hunger sensations after gastrectomy were
in every way like those before excision of the stomach.10
This observation would suggest that hunger, like thirst,
probably originates in the tissues themselves.

Conclusion

Gastric cancer will be earlier identified, when diag-
nosis rather than symptomatic relief is demanded in
patients with dyspepsia. A long history does not of it-
self exclude malignancy and some of the best results
are obtained after resection in this group. Chronic and
acute cancer are as definite entities as acute and chronic
infection. The matter of a benign ulcer being confused
with cancer is of far more importance than the question
of the number of benign ulcers which may become
malignant. A more frequent precursor of gastric cancer
than ulcer is a gastric papilloma.

Of patients coming for operation with gastric malig-
nancy, a large number are inoperable. In the operable
group, however, a large number of lives are to be sal-
vaged by resection, with a reasonable operative mor-
tality. The risk of total gastrectomy is still prohibitive,
but elaboration of an adequate and suitable technique
will justify its more frequent performance for the relief
of gastric malignancy.

Bibliography

1. Balfour, D. C. : The technique of partial gastrectomy for

cancer of the stomach. Surg. Gynec. 6c Obst. 44:659. 1927.

2. Cushing, H. &C Livingood, L. E.: Experimental and surgical

notes upon the bacteriology of the upper portion of the aliment-
ary canal, with observations on the establishment there of an
amicrobic state as a prelim-nary to operative procedures on the
stomach and small intestine. John Hopkins Hospital. Reports,
9:543. 1900.

3. Cheever, D.: The operative curability of carcinoma of the

stomach. Annals of Surg. 78:332. 1923.

4. Dible, J. H.: Gastric ulcer and gastric carcinoma; an inquiry

into their relationship. Brit. J. Surg. 12:666. 1925.

5. Finney, J. M. T. 8c RienhoflF, W. F.: Gastrectomy. Arch.
Surg. 18:140. Jan., 1929.

6. Finsterer, H.: Immediate and permanent results of re-
section of the stomach for cancer. Internat’l. J. of Med. &:

Surg. 42:11 1. 1929.

7. Friedenwald, J.: A clinical study of 1000 cases of carcinoma

of the stomach. Amer. J. Med. Sc. 148:660. 1914.

8. Rea, C. E. 6C Wangensteen, O. H.: Unpublished data.

9. Waiters, W.: Total gastrectomy for carcinoma of the stom-

ach in Eusterman 8C Balfour’s monograph on the stomach and
duodenum. Saunders, p. 628. 1935.

10. Wangensteen, O. H. 6C Carlson, H. A.: Hunger sensations

in a patient after total gastrectomy. Proc. Soc. Exper. Biol. Qc
Med. 28:545. 1931.

THE JOURNAL-LANCET

Subphrenic Abscess*

Arthur J. Movius, M.D., F.A.C.S.

Billings, Montana

THE TITLE of this paper should be subphrenic
abscess, with special emphasis upon the right
posterior superior subphrenic space, and the
extra-peritoneal operation.

The subject of subphrenic abscess has been one of
more than usual interest tq us for a number of years.
The importance of this condition is apparently not
appreciated by many medical men. Perhaps the most
serious complication that can follow a case that sur-
vives an attack of peritonitis from any cause is sub-
phrenic abscess. It stands in the minds of numbers
of medical men as an almost hopeless situation, inas-
much as the reports of many surgeons in the past
showed a mortality ranging from 33 to 50 per cent or
more in the operated series. When we consider that a
majority of subphrenic infections are the result of an
intra-abdominal contamination, caused usually by the
spread of micro-organisms from an inflamed or rup-
tured abdominal organ, and that this is happening
over-and-over every day, it is clear we should give
this complication greater study. Medical literature
these later years has been enriched by numerous
observers. As a result, infections of the subphrenic
spaces are now being considered a possible complica-
tion in all septic intra-peritoneal processes, and cases
of insidious onset and long-continued fever in which
diagnosis has been in doubt. It would seem, therefore,
that every physician who handles cases of appendi-
citis, and that means all of us, should become sub-
phrenic-minded. This paper is presented for that very
purpose; that earlier diagnoses may be made and
proper treatment instituted before the fighting powers
of the patient are too seriously lowered. The incidence
of subphrenic abscess is given by some observers in
one to six per cent of all appendicitis cases. If this
be true, how much higher it must be in those cases
that have gone on to rupture and general peritonitis!

Our study is based on a review of the current lit-
erature and an experience with 20 proved and sus-
pected cases of subphrenic inflammation. Fortunately,
not all subphrenic infections go on to suppuration.
Ochsner states that he believes only 30 per cent go on
to abscess formation.

The history of subphrenic abscess is interesting.
Barton described it in 1845. The first recorded opera-
tion for drainage of such an abscess was performed by
Volkman in 1870. Heyden in 1886 again described the
clinical picture. The symptoms depicted by those
pioneers is very commonly accepted as typical today;
that is, the liver dullness is surmounted by a tympanitic
area. Above this area is a dullness due to a pleural
exudate. A gas bubble on top of the abscess in the

•Read before the Montana State Medical Meeting, Billings,
Montana, July 10, 1936.

upright position accounts for the tympanitic zone. Such
findings often represent a late stage of the condition.
If these signs are waited for, many cases will be over-
looked or valuable time lost in the treatment of the
patient.

It has been estimated that 90 per cent of the sub-
phrenic abscesses follow infections within the abdo-
men. Appendicitis, gastroduodenal lesions, and infec-
tions of the liver and bile passages are by far the
most frequent causes. The appendix is said to be the
most common offender. Fifield and Love found this
to be true in 35 per cent of their cases, and Ochsner
and Graves in 31 per cent of their series. Perfora-
tions of the stomach and duodenum are next in fre-
quency; 28 per cent in the Fifield and Love series, and
29 per cent in the Ochsner and Graves series. Lesions
of the gallbladder and bile passages were causative
agents in ten per cent) of their cases. Other causes are
cancer of the stomach and intestines, operations on the
stomach and intestines, pelvic disorders, trauma, abs-
cesses of the liver and kidney, etc. The bacteria re-
sponsible for the infection vary according to the origi-
nal process. Most frequently obtained were B. coli,
streptococci, and staphylococci, the first two predomi-
nating.

The anatomy of the subphrenic space was worked
out by two Frenchmen, Martinet in 1845, and Piquard
in 1910. It is commonly agreed that the space be-
tween the diaphragm above and the colon and meso-
colon below is the subphrenic space, and any localized
abscess in any part of this region is a subphrenic
abscess. This space is divided into several spaces by
the presence of the liver and various ligaments. The
liver divides it into superior and inferior spaces. The
reflexion of the peritoneum from the diaphragm to
the liver, the suspensory ligament, divides the superior
space into right and left superior spaces. The right
superior space is further divided into anterior and
posterior spaces by the coronary ligament, the right
prolongation of the suspensory ligament. On the left
there is only one superior space as the left prolonga-
tion of the suspensory ligament runs along the
posterior edge of the liver. On the under surface of
the liver there are three spaces, one on the right and
two on the left. The one on the right is under the
right lobe of the liver, often called the renal pouch.
On the left are two spaces, anterior and posterior,
divided from each other by the gastro-hepatic omen-
tum, the anterior being in front of the stomach and
the left in the lesser peritoneal cavity. Then there are
the retro-peritoneal spaces, the posterior one being of
very marked clinical significance, located in the cellu-
lar tissues back of the liver on the right side,

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The right posterior superior space is the most im-
portant of the spaces. To repeat: it lies between the
diaphragm and that part of the right lobe of the liver
which is behind and below the right lateral ligament.
Its lower border opens into the space below the liver
and communicates with the external paracolic sulcus.
Along this groove intraperitoneal inflammatory exu-
date may spread from the cecum and appendix or
even from the pelvis. By its junction with the renal
pouch this posterior-superior space may become in-
fected also from the duodenal area, pylorus, or from
the gallbladder. It is the space most frequently in-
volved in abscess formation and consequently the most
important for our consideration. Fifield and Love
found this space involved in 38 per cent of their
cases while Ochsner in a more recent series found 60
per cent of all his subphrenic abscesses in this space.
Fifty to 80 per cent of those abscesses followed a rup-
tured appendix.

The space under the right lobe of the liver cor-
responds to the right renal pouch; below it is the
hepatic flexure of the colon. The sources of infection
of this right inferior space are numerous. Perforations
of the pylorus or duodenum, and infections of the
gallbladder or bile ducts may involve the space by
rupture or direct spread into it. Suppuration may
spread to it from the right iliac fossa or from the
right posterior superior space. Yet this space is not
commonly infected to such an extent as to go on to
suppuration. Ochsner and Graves, for instance, col-
lected evidence to show that this space was involved
less than one-third as frequently as the first men-
tioned, the right posterior superior space. They sug-
gested that perhaps adhesions form and obliterate the
space before an abscess can form.

The left superior space between the left lobe of the
liver and diaphragm is rarely the seat of abscess
formation. The left anterior inferior space beneath the
left lobe of the liver and in front of the gastrohepatic
omentum is a common site of subphrenic abscess. The
usual cause of infection is a perforated ulcer of the
front wall of the stomach.

The lesser peritoneal cavity lies posterior to the
gastrohepatic omentum. In the presence of infection
the foramen of Winslow is very soon obliterated by
adhesions; then the sac becomes isolated from the rest
of the peritoneal cavity. The most likely cause of an
abscess in this space would be a perforation on the
back wall of the stomach, and pancreatitis. It may
also be infected by leakage from a retrocolic gastro-
intestinal anastomosis or by perforation of a gastro-
jejunal ulcer.

Avenues of Infection

Infection may gain entrance to the subphrenic
space in a number of different ways; first, by direct
extension by way of the peritoneal cavity along the
paracolic groove to the right kidney pouch. This is
probably the most frequent cause. In the horizontal

position, the diaphragm and the pelvis are the lowest
points in the abdominal cavity. Secondly, through the
lymphatics, either the peritoneal or retroperitoneal.
Extension is sometimes very rapid by this portal of
entry. In experimental animals it has been found that
graphite placed in the ileocecal area can be recovered
four hours later in the lymphatics under the dia-
phragm. Thirdly, the infection may travel by the
portal system producing a pyelophlebitis with the for-
mation of a liver abscess which ruptures into one of
the subphrenic spaces.

The symptoms of subphrenic infection depend upon
the space invaded. Primarily there is a continued sep-
tic temperature day after day, elevated pulse, high
leukocyte count and prostration. If a patient who has
had an antecedent suppurative intraperitoneal process
fails to improve as he normally should, and in whom
no other focus can be demonstrated to account for the
septic manifestations, one must consider subphrenic
infection until proven otherwise. There may or may
not be localizing signs. Occasionally there will be a
sense of pressure in the upper abdomen or loin, and
difficulty in breathing, especially on deep inspiration.
There is often tenderness and rigidity over the invaded
space. In those individuals with an infection of the
right superior posterior space, the first one described,
the pain when present may be referred to the right
lumbar region or right shoulder. Often the symptoms
are those of a pleurisy. If the right superior anterior
and inferior spaces are invaded, there is tenderness
along the right costal margin. Limitation of respira-
tory movements on the affected side occurs early. The
diaphragm is often elevated and its excursion dimin-
ished. Of greatest diagnostic importance is persistent
localized tenderness over the infected space.

If the abscess is in the right posterior superior
space, the space most frequently infected, there is
definite localized tenderness over the tip of the twelfth
rib. This may be the only diagnostic sign present. The
tenderness is localized along the costal margin on their
respective sides in infections of the other spaces. If
tenderness persists together with constant systemic
symptoms of unabating infection, one is justified in
diagnosing a subphrenic infection of the particular
space involved. If one bears in mind the possibility of
an abscess forming in one of these spaces, he will
choose to give his patient the benefit of the doubt and
operate, inasmuch as the mortality without operation
is nearly 100 per cent. On the whole, the symptoms
are vague, suggesting pus and infection in the gall-
bladder area, if on the right side. If, added to this,
the patient continues to run a septic temperature, per-
haps chills, hiccough, pain referred to the shoulder,
unproductive cough, and a persistent subcostal or
lumbar tenderness, one may be fairly sure he is deal-
ing with a subphrenic abscess.

Diagnosis

If one bears in mind the history of the case, con-
tinued septic manifestations, and is subphrenic-con-

THE JOURNAL-LANCET

scious, many more diagnoses of subphrenic abscess will
be made and many more lives saved. On the other
hand, reports indicate that the diagnosis is often over-
looked.

Touroff, in a recent number of Surgery, Gyne-
cology and Obstetrics, writing on "Unrecognized Post-
operative Infection” makes the following contribution
to our study: "The author became interested in the
subject as the result of an experience in which a death
which appeared undoubtedly to be due to 'livershock’
was found at subsequent postmortem examination to
have been caused by unrecognized extensive subphrenic
suppuration. Not only was the latter not detected dur-
ing life, but its presence was not even suspected.” He
goes on to say: "In this connection the following quo-
tation from Stanton is significant:

" 'Subdiaphragmatic abscess is very rarely diagnosed
clinically. On the other hand, it appears to be found
rather frequently at autopsy. I believe it is a more fre-
quent complication of gallbladder operations than the
figures would indicate.’ ”

Dr. J. H. Bridenbaugh, radiologist and my associ-
ate for many years, gtates that the X-ray findings in
subphrenic abscess are very helpful at times, and often
clinch the diagnosis. Elevation and fixation of the
diaphragm usually occurs. This may be present in
pneumonia and pleurisy as well. Often the X-ray study
will show a cloudiness through the right lower lobe, sug-
gesting a pneumonia. Sometimes there will be an
associated pleuritis with effusion or an empyema.
Ochsner states that the first two cases of subphrenic
abscess he saw, he treated for several weeks for
pleurisy with effusion without results. Bridenbaugh
further states that X-ray plates of the chest should
be made laterally as well as antero-posteriorly. In about
25 per cent of the cases an air bubble will show above
the abscess, a straight line indicating the fluid level.
This is a pathognomonic finding. The lateral view will
determine whether the abscess is in the anterior or
posterior space or both. Sometimes a second abscess
will be located in the right anterior inferior space.
Radiograms should be taken in the upright position
and the antero-posterior and lateral views taken on full
inspiration and expiration. Limitation of movement of
one-half of the diaphragm will be the first abnormality
noted. This suggests an inflamed lesion, but not neces-
sarily an abscess. However, elevation of the affected
half of the diaphragm is quite indicative of abscess
formation, but not always so. Kokumis states this is
shown in 90 per cent of the cases. Obliteration of the
costophrenic angle is a common sign.

The infection of a subphrenic space may be of two
or three different types. The first type is composed of
cases which come with sudden abrupt onset with signs
simulating acute intra-abdominal suppuration. These
are usually cases in which the1 causative agent, such as
perforative peptic ulcer, perforating appendicitis, etc.,
bring about contamination of the peritoneal cavity.
Whether operation for the same is undertaken or' not,

manifestations often continue and the patient does not
improve as normally. The second type are cases with
an insidious onset following an obscure intra-abdominal
lesion. This type is frequently not suspected and not
diagnosed. I shall here report briefly a case of each
kind.

Our first case correctly-diagnosed as an abscess in
the right posterior superior space was a boy, seven
years old. Dr. Ochsner states that this is the youngest
case on record. He came in with a history of a two-
day illness — of nausea, vomiting and general abdomi-
nal pain. The leukocytosis was 18,000. The tempera-
ture was 104 degrees and the pulse 140. The abdomen
was rigid. A diagnosis of general peritonitis due to
appendicitis was made. Immediate operation disclosed
an abdomen full of purulent fluid. The appendix was
not located. Drainage of the abdomen was instituted.
The patient rallied under the free administration of
fluids and sedatives. After a week he began to develop
more temperature again. This continued to be of
the septic type for two weeks. A retrocecal abscess was
suspected on account of tenderness over that area. This
was drained, but the patient did not improve. Inasmuch
as the abdomen was in good condition, a subphrenic
abscess was suspected. The physical signs denoted
tympany above the liver. X-ray examination by Dr..
Bridenbaugh showed gas under the diaphragm permit-
ting a tentative diagnosis of a subphrenic abscess in the
right posterior superior space. The abscess was drained
retro-peritoneally, according to the method to be des-
cribed. This resulted in the patient’s speedy recovery.
He left the hospital in ten days.

The next case is typical of the second type with
insidious onset. Male, 56, had chronic stomach trouble
and was a tabetic. He developed an obscure abdomi-
nal pain for which no explanation seemed plausible.
The temperature was 99 degrees to 101.6 degrees for
a week, and the blood count 25,000. The abdomen was
soft everywhere. Deep pressure gave some tenderness
in the right upper quadrant. Some rales and dullness
developed in the right lower chest. A diagnosis of
pneumonia was considered; but the symptoms did not
clear up. Aspiration of chest revealed clear fluid.
There was decided improvement for two and one-half
weeks. The temperature then assumed a septic course
for two and one-half weeks. Then a diagnosis of sub-
phrenic infection was considered. X-ray study by Dr.
Bridenbaugh showed an elevated diaphragm and a gas
shadow under the right diaphragm. This confirmed our
diagnosis of subphrenic abscess of the right posterior
superior space. Retro-peritoneal drainage was instituted
by the method to be discussed. This resulted in the
patient’s recovery.

Prognosis

Many writers state that when abscess formation has
once taken place, the mortality is close to 100 per
cent without operation, whereas, in those in which

THE JOURNAL-LANCET

operation is performed, unless proper drainage is
instituted, the mortality rate is 50 per cent or more.
A careful analysis reveals the fact that the high mor-
tality rate is due to delayed diagnosis resulting in the
development of a marked toxemia which obviously
decreases the patient’s chance of recovery, and to con-
tamination of one of the large serous cavities by
draining the abscess through either the pleura or an
unprotected portion of the peritoneal cavity.

Lockwood in 81 cases operated on had 27 deaths, a
33 per cent mortality; in 32 cases not operated, there
were 31 deaths, a 97 per cent mortality. Judd reported
a mortality ranging from 33 to 50 per cent, depend-
ing on the type of operation. Ochsner’s series of 50
personal cases gave a mortality of 50 per cent in cases
drained transpleurally, 41.6 per cent in cases drained
transperitoneally, while those drained by extramem-
branous methods gave a mortality of 13.6 per cent;
and in 3 1 cases in the right posterior superior sub-
phrenic space, using his technic of the retroperitoneal
operation, there was a mortality of only 9.7 per cent.
In our series there was a general mortality of 14.3
per cent.

Operative Procedure

The last 20 years have witnessed a great improve-
ment in the surgical treatment of subphrenic abscess
and a drop in the mortality of operative cases to less
than 20 per cent, when modern approved methods are
employed. This improvement is an indication of the
great interest and work recently done on this subject
resulting in earlier diagnosis and treatment before the
recuperative powers of the patient are gone. Russell
in 1929 reported three cases in which a subphrenic
abscess was not found until seven months, one year,
and seven years following the primary causes. How-
ever, not many cases will live over a few weeks or
months at the most after an abscess has formed.

A condition as serious as subphrenic abscess often
requires rare judgment on the part of the surgeon in
order to carry out the proper treatment. When once
the diagnosis has been made, drainage must be insti-
tuted by the least dangerous route. The mortality
figures just given indicate that some extra-membranous
method of approach must be made in order to give the
patient the best chance for recovery. Attacking an
abscess through unprotected pleural or peritoneal mem-
branes certainly invites disaster to an already debili-
tated patient. Various ingenious methods have been
devised to drain these subphrenic abscesses enclosed in
the thoracic cage. To do a transpleural operation in-
vites a septic empyema. Yet the classical operation for
years was to remove a section of two of the lower ribs
and stitch the pleura to the diaphragm or pack the
intervening space with gauze until adhesions formed,
usually causing a week’s delay before the second stage
could be done. The operation carried a mortality of
50 per cent or more and is condemned by that fact,
inasmuch as newer methods have been worked out that

give a much lower mortality. Any operation for the
drainage of a subphrenic abscess through unprotected
peritoneum is open to the same criticism. The at-
tempted aspiration of pus from a subphrenic abscess
is mentioned only to be condemned. There is grave
danger of contaminating unmolested portions of the
pleural and peritoneal cavities. Barnard reported a case
in which, following the transpleural aspiration of a
subphrenic abscess, the patient collapsed and died
three hours later. At autopsy, one and one-half pints
of pus were found to have leaked into the pleural
cavity. This undoubtedly caused the patient’s death.

Inasmuch as the right posterior superior space is the
one most commonly involved — 60 per cent of Ochs-
ner’s series of 50 cases — I shall direct my remarks
chiefly to the treatment of abscess in this space.

In 1922, Nathar and Ochsner worked out a technic
by dissections on the cadaver whereby abscesses in tne
right superior posterior space could be reached with-
out traversing any serous membrane, pleural or peri-
toneal. Their contribution to this subject has meant
the saving of many lives.

The operation is as follows: with the patient lying
on the unaffected side as for a kidney operation, the
anesthetic is begun, using preferably gas or paraverte-
bral block. An incision is made over the course of the
twelfth rib. A careful sub-periosteal resection of the
entire rib is made. Inasmuch as the costophrenic angle
reaches to the twelfth rib, the next step in the opera-
tion is very important. At the level of the center of
the first lumbar vertebra an incision is carried trans-
versely forward for three or four inches through the
root of the diaphragm. This incision is deepened until
the glistening renal fascia is in sight. Beneath it may
be seen the renal fat, also the liver edge in front of
the posterior peritoneum. Having cut across the root
of the diaphragm, which may be very thin, two fingers
are insinuated between the posterior peritoneum and
severed edge of the diaphragm. A gentle dissection is
now carried up until the posterior superior subphrenic
space is reached. As the fingers advance, a hard area
will be encountered, which is the abscess wall. This is
perforated by the fingers, and the pus allowed to
escape. Two drainage tubes are inserted to carry away
the discharge, so that irrigations may be employed if
necessary. Following Ochsner’s suggestion, we have
made it a habit of exploring the space in the renal
pouch before emptying the upper abscess, inasmuch
as both spaces may be involved. Should the case be
complicated by empyema, as one of our cases was, it
may be drained through the costophrenic angle in the
same incision. Another advantage of this operation lies
in the fact that sometimes an abscess in the right
antero-superior space may be evacuated by this method.
This is due to the fact that there is often a free
connection around the edge of the liver with the other
spaces on the right side.

THE JOURNAL-LANCET

Conclusions

Subphrenic abscess is not an uncommon condition. It
should be considered as a possible complication in every
intra-peritoneal septic process. The most frequent site
is in the right posterior superior space. The ruptured
appendix is the commonest offender. The symptoms
are often vague in character suggesting an infection in
the gallbladder region. Early diagnosis is frequently
rendered possible by X-ray plates in the upright, lat-

eral and antero-posterior positions. The mortality
approaches 100 per cent in cases not treated by opera-
tion; surgery offers the only chance for cure. Trans-
membranous methods of drainage are condemned. The
extra-peritoneal operation recommended by Ochsner
carries the lowest mortality.*

*1 am greatly indebted to Dr. Alton Ochsner, Prof, of Surgery,
Tulane University Medical School, New Orleans, La., for the use
of his slides showing the steps of the extraperitoneal operation.

Nutritional Problems in University Students

Bernard I. Comroe, M. D.*

Philadelphia

THE most common nutritional problems met
with in college students are obesity, under-
nutrition (including vitamin and mineral
deficiency), special dietary regimes in skin dis-
eases, renal stones, pyelitis, epilepsy, gastrointes-
tinal disorders, and food allergy. The common-
est of these is obesity. In examining the records
of 1765 male freshmen entering the University
in the years 1931 and 1932, Gammon1 found 17
per cent of these to be 10 per cent or more over-
weight (11.7 per cent being from 10 to 19 per
cent overweight, and 6.6 per cent more than 20
per cent overweight) . In the absence of standard
tables, Diehl2 has suggested a method of calcu-
lating the standard weight based on the sex,
height, and age of the individual. He analyzed3
the heights and weights of 40,000 male and female
American college students and showed that as a
group the college students are taller and heavier
than males and females of corresponding ages in
the general population.

We do not consider a patient obese unless he
is 20 per cent or more above his standard calcu-
lated weight. In any obese individual, we record
a careful history, and perform a thorough physi-
cal examination and any necessary laboratory
tests. The history should inquire for a family
history of obesity or endocrine disorders, sex his-
tory, weight curve, menstrual and marital history,
habits of exercise, and sample diets. In the phy-
sical examination one should note the particular
type of fat distribution, the condition of the hair
and skin, areas of pigmentation, visual fields,
breasts, gonads, blood pressure, thyroid gland,
abdominal striae, and edema. A complete blood
count, urinalysis, basal metabolism, and blood
cholesterol should be routine on all overweight
patients. If indicated, pituitary x-ray and glucose
tolerance tests may be performed.

^Instructor in Medicine, Medical School of the University of
Pennsylvania; Physician to the Student Health Service.

There is no evidence that obese individuals ex-
hibit any specific inability to oxidize either fat or
carbohydrate. Ogilvie4 found that glucose toler-
ance diminishes as the duration of simple obesity
increases. Joslin considers that the obese individ-
uals are 19 times as likely as persons of normal
weight to develop diabetes arising he believes
from prolonged excessive demands on the in-
sular apparatus of the pancreas. Mendel5 has
emphasized the enormous increase in sugar con-
sumption in the past century. The consumption
of sugar in 1823 was estimated at 8.8 pounds per
year per person; in 1931, the per capita con-
sumption amounted to 108 pounds. Himsworth6
suggests that diets with decreased carbohydrate
and increased fat may be responsible for obesity
and that the more fundamental association of
diabetes is not with overweight, but with the diet
which incidentally promoted obesity. Fellows7
has noted that the parents of overweight subjects
showed an incidence of overweight 10 times great-
er than that of the general adult population.
Both parents were overweight in 24 per cent of
the cases.

Abnormalities which must be watched for in
the obese include the not infrequent development
of diabetes, gout, abdominal hernia, gall bladder
disease, arteriosclerosis, hypertension, orthopedic
difficulties, constipation, hemorrhoids, and dis-
turbances in genital function. Furthermore, fatty
tissues are notoriously susceptible to infection and
to slow surgical healing.

In the dietary treatment of simple obesity, sev-
eral courses are open. Some clinicians have
recommended that the patient eat only half the
quantity of food to which he was accustomed, and
partake of no desserts prepared with flour or
sugar. Harrop8 prescribed a total daily intake of
4 to 6 fully ripened bananas, plus a quart of
skimmed milk or buttermilk. It has been our ex-
perience that the banana and milk diet does not

THE JOURNAL-LANCET

satisfy the appetite of the ordinary college student.
Strang et al'J have utilized a low caloric diet sup-
plying only the body requirements of protein,
vitamins, and salts. This averaged 360 calories
per day which were derived from 58 grams of
protein, 8 of fat, and 14 of carbohydrate. On
this regime 13 patients showed an average weight
loss of 0.6 pound per day for 59 days. Clinically
the patients wrere greatly benefited and showed
no untoward reactions. Patients were maintained
on this rigid diet without complications for 6
months; all were hospitalized during the course
of the weight reduction.

In the University Health Service, given a case
of simple obesity, our regime is as follows: the
patient is given a diet list composed of 3 divisions,
namely (1) Eat none of the following, (2) Eat
all you desire of the following,” and (3) "Eat
moderate portions of the following. He is al-
lowed no: potatoes, corn, rice, baked or lima
beans, macaroni, spaghetti, noodles, gravy, cream,
candy, cake, pie, nuts, peanut butter, preserves,
cereal, cream soups, ham, pork, bacon, fatty fish,
breaded meats, bananas, prunes, apples, fresh
peas, liquor, or soft drinks. He may eat as freely
as desired of: plain jello, plain broth or tomato
soup, tomatoes, spinach, celery, radishes, lettuce,
cabbage, sauerkraut, Brussels sprouts, cauliflower,
asparagus, watermelon, strawberries, tea, coffee,
and water. He is to take only average servings
of: beets, carrots, turnips, pumpkin, squash, string
beans, canned peas, oranges, meats and fish (as
excepted above) cutting off the fatty portions, and
of cottage cheese. One slice of bread is permitted
daily with very little butter. If vegetables are
served with cream sauce, he is to discard as much
of the sauce as possible. The last few drops of but-
ter in the vegetable dish must not be drained. A
sample diet consists of: breakfast — half a grape-
fruit or orange, one slice of toast and a cup of
coffee or tea with a small amount of milk and
sugar; lunch — a cup of broth, lettuce and tomato
salad with salt, pepper and vinegar dressing (or a
platter of several 5 per cent vegetables), and
jello; dinner — broth or plain tomato soup or to-
mato juice, ordinary helping of meat, large help-
ings of several 5 per cent vegetables and one 10
per cent vegetable, salad if desired (without may-
onnaise) and either no dessert or jello or a low
carbohydrate fruit. One essential of the diet is
that the student eat plenty of the foods allowed
him so that the sensation of hunger will rarely be
present.

Under the above regime, the student with sim-
ple obesity responsive to diet will lose 5 or 6
pounds the first week, 3 or 4 the second, and about
2 pounds each week thereafter. The patient
weighs himself daily on the same scales and at the
same time of the day so that fluctuations in weight

due to bowel movements or meals will not be a
major factor. The sense of satisfaction at the
weight loss noted by the individual himself
usually further stimulates him to adhere to the
diet. During the period of weight reduction, the
student prevents undue exposure to inclement
weather and does not closely associate himself
with individuals with respiratory infections. He
performs his usual amount of exercise. In our
hands, over exercising has led to a large appetite
and seems undesirable. It is a fact little known
that the energy consumed in certain forms of
exercise is relatively small; a student weighing
70 Kg, in an hour’s walk covering 2Vz miles,
would require only 140 calories10. If the patient
is to be kept on this diet for a considerable time,
he is given in addition viosterol and calcium
phosphate. The student reports for a weekly
checkup for the first month, after which he re-
ports every 3 weeks. Weight reduction is attempt-
ed in easy stages. For example, if the ideal
weight of a 240 pound student is 180, we set as
our goal an initial loss of 30 pounds — 6 pounds
the first week, 4 the second, and 2/z pounds
weekly thereafter so that in a period of 10 weeks,
the individual has reached 210 pounds. He is
then placed on a maintenance diet for a month
so that his body might accustom itself to its new
surroundings and to insure against vitamin or
mineral deficiency. Following this, we attempt to
affect a loss of an additional 15 pounds over a
period of 8 weeks, to be again followed by a rest
period of 6 weeks. Further weight reduction
will then depend on the general appearance and
condition of the individual.

Obese individuals frequently tell the doctor
they do not overeat. Often they are telling the
truth as they see it. In these individuals, one
should always have the patient write down at the
end of each day thd quantities of all foods con-
sumed during and between meals; this list, gone
over at the end of a week, is of great value to the
physician in checking the diet.

Occasionally, even though a student adheres to
a low caloric diet, no weight loss may result dur-
ing the first week. Newburgh and Johnston11
have shown how unstable the organism is in re-
gard to water, and that even when the body is in
nutritional balance, it may increase or diminish
its percentage of water from day to day. In the
early phases of dieting, the individual may pro-
gressively retain water in his tissues. The water
retention may neutralize the weight loss until,
after a number of days, this extra fluid is given
off.

To acquaint further the patient with dietary
facts, he is given a list showing approximately 100
calorie portions of some of our common foods
such as: a slice of bread, 3 graham crackers, 2/3
cup of cooked oatmeal, 1 shredded wheat biscuit,

THE JOURNAL-LANCET

1 large apple, medium sized banana, small glass of
grape juice, 7 ripe olives, a very large orange, 3
peaches, a large pear, 2 servings of strawberries,
a small ball of butter, a small glass of whole milk,
a medium sized potato, a small lamb chop, a dozen
oysters, etc. Another popular fallacy that must
be explained is that all of our common breads
(rye, white, or whole wheat) are of approximate-
ly the same food value. I have frequently had
students tell me that they were eating absolutely
no bread — i. e. only 2 or 3 slices of rye or whole
wheat bread with each meal. It must also be em-
phasized that prunes are fattening, three prunes
equaling a potato in calorie value.

A wide field for swindlers is present in the
treatment of obesity. These individuals employ
mechanical belts, purgatives, reducing breads,
food powders, bath salts, and dangerous drugs.
Most of the external preparations sold as pastes
are merely a mixture of soaps. Chewing gums
devised for reducing usually contain phenol-
phthalein or thyroid substance. Among other
reducing fads are Germania tea (mainly senna),
Jad salts condensed (a mixture of laxative salts),
Kellogg’s safe fat reducer (thyroid substance and
pokeroot), Marmola (containing thyroid sub-
stance, and phenolphthalein) , etc. One of the
newcomers is "Hollywood Diet,” a reducing food.
This is essentially 2/i cents worth of soy bean
flour, faintly flavored with cocoa and salt, and
sold for 1 or 2 dollars. Its advertising states that
"within 30 days you will thrill to your loveliest
image; you will radiate a more slender charm.”
The directions recommend a teaspoonful instead
of breakfast and another in place of lunch. A
heaping teaspoonful is only 8 grams, a total break-
fast and lunch of 32 calories!

We do not employ desiccated thyroid unless the
basal metabolic rate is below minus 15 per cent
and there is definite clinical evidence of hypo-
thyroidism. If thyroid substance is used, the
patient is seen twice a week and careful check
made of the pulse, basal metabolic rate and gen-
eral well being. We have discontinued the use
of the dinitrophenols because of their dangerous
complications such as cataracts, otitis media, and
agranulocytic angina.12'21 Dinitrophenol now
forms the basis of many patent medicines; slim,
nitromet, dinitrolac, nitro-phen, dinitriso, formula
281, dinitrose, nox-ben-ol, re-du, aldinol, dinitro-
nal, Rx No. 17, tabolin, and redusols.

There exists no good evidence with animals or
in clinical observations that the addition of excess
of any of the vitamins to the diet will increase
the resistance to infection when the host has al-
ready been consuming a normal diet22. There is
little reason to believe that the administration of
vitamins after the onset of an acute infection will
exercise any benefit on resistance. The public is

now being bombarded with ads hailing the anti-
infective power of foods or drugs containing this
or that vitamin.

Leanness, or underweight, may be a constitu-
tional inheritance or may result from inadequate
foods, improper eating habits, or from functional
or organic disease processes in the body. A care-
ful search must be made for evidences of organic
diseases such as tuberculosis, diabetes, toxic
goiter, smoldering rheumatic fever, subacute
bacterial endocarditis, bronchiectasis, neoplasms,
Hodgkin’s disease and leukemia. Certain under-
weight individuals will not gain weight on a high
caloric diet even when no disease process is pres-
ent. In these there is often a family (one or both
parents) history of failure to attain a normal
weight. However, most healthy individuals can
gain weight by eating a sufficient supply of the
proper food. In college students, to combat under-
nutrition necessitates the eating of between 3500
and 4500 calories daily, together with appropriate
stimulation of the appetite if necessary by tonics,
fresh air, moderate exercise, extra feedings be-
tween meals, and occasionally insulin. A rest per-
iod of 10 or 15 minutes before and after meals is
advised. Feedings such as orange juice to
which 10 or 20 grams of lactose have been added,
or a chocolate milk shake are often well tolerated.
A new role for vitamin B, helping the body gain
weight by building up fat is suggested by the ex-
periments of Whipple and Church25. The ad-
dition of half an ounce of olive or cod liver oil 2
or 3 times daily, if tolerated, is often of distinct
value.

Special dietary regimes have been of benefit in
many medical disorders. The occasional remark-
able cures of acne vulgaris following a low carbo-
hydrate diet or of psoriasis on a low protein diet
are well known. A dietary aid often overlooked
by physicians is the attempt to prevent further
stone formation in individuals who may have had
nephrolithiasis. A discussion of this subject is
beyond the scope of this paper, but the reader is
referred to the excellent work done along this
line by Higgins24, 25, and by Joly.26

In chronic pyelitis and epilepsy, ketogenic diets
have proved quite a valuable adjunct to our ther-
apeutic armamentarium. Special dietary handling
of gastro-intestinal diseases (duodenal ulcer, ul-
cerative colitis, catarrhal jaundice, acute gastro-
enteritis) , anemia, and vitamin deficiencies is well
recognized. One other important nutritional
problem is food allergy. The most common
offenders are wheat, milk, and eggs. Others in-
clude tomatoes, cabbage, chocolate, potatoes,
oranges, shell fish, strawberries, and pork. Com-
mon symptoms of gastro-intestinal allergy are
pain, nausea, vomiting, distention, constipation,
or diarrhea. Urticaria is especially apt to follow
fish, tomato, or cheese. Erythema or eczema may

THE JOURNAL-LANCET

occur after cereal, pork, or milk sensitization,
while asthma not infrequently occurs as a reaction
to egg protein. Especially useful in detecting
these offenders are skin tests, elimination diets,
and the decrease in the white blood count found
after the ingestion of the causative agent. It is
important to remember that an individual’s sen-
sitiveness to a given food may appear to develop
suddenly and may be transiently or intermittently
manifested.

Bibliography

1. Gammon, G. D. : The problem of the nutritional status of
a college group. Research Quarterly, 5, Mar., ’34.

2. Diehl, H. S.: Healthful Living, Whittlesey House, N. V.,
1935.

3. Diehl, H. S.: Heights and weights of American college men
and women. Human Biology, 5: 445, 600, Sept, and Dec., ’33.

4. Ogilvie, R. F.: Sugar tolerance in obese subjects. Quart.

J. Med. 4: 345, Oct.. ’35.

5. Mendel, L. B.: The changing diet of the American people.
J. A. M. A. 99:117. July 9, *32.

6. Himsworth, H. P.: Diet and the incidence of diabetes

mellitus. Clin. Sci. 2: 117, Sept. 30, ’35.

7. Fellows, H. H.: Studies of relatively normal obese individ-
uals during and after dietary restrictions. Am. J. Med. Sci. 181:
301, Mar., *31.

8. Harrop, G. A.: A milk and banana diet for the treatment
of obesity. J. A. M. A., 102: 2003, June 16, ’34.

9. Strang, J. M., McClugage, H. B., and Evans, F. A.: Further
studies in the dietary correction of obesity. Am. J. Med. Sci. 179:
687, May, ’30.

10. Editorial. J. A. M. A. 106: 44, Jan. 4, ’36.

11. Newburgh, L. H. and Johnston, M. W.: Endogenous obes-
ity, a misconception. Ann. Int. Med. 3: 813, Feb., ’30.

12. Cutting, W. C., Mehrten, H. G., and Tainter, M. L. :
Actions and uses of dinitrophenoi ; promising metabolic applica-
tions. J. A. M. A. 101: 193, July 15, ’33.

13. Dintenfass, H.: An ear complication from dinitrophenoi

medication. J. A. M. A. 102: 838, Mar. 17, ’34.

14. Editorial, J. A. M. A. 101: 1080, Sept. 30, ’33.

15. Anderson. H. H., Reed, A. C., and Emerson, G A.:

Toxicity of alphadinitrophenol. J. A. M. A. 101: 1053, Sept.

30. ’33.

16. Masserman, J. H., and Goldsmith, H.: Dinitrophenoi,

J. A. M. A. 102: 523, Feb. 17, ’34.

17. Matzer, E.: Can sensitivity to dinitrophenoi be determined
by skin tests? J. A. M. A. 103: 253, July 28, ’34.

18. Cogan, D. G. and Cogan, F. C. : Dinitrophenoi cataract,
J. A. M. A. 105: 793, Sept. 27, ’35.

19. Allen, T. D. and Benson, V. M.: Late development of
cataract following use of dinitrophenoi about a year before, J. A.
M. A. 105: 795, Sept. 7, ’35.

20. Editorial, J. A. M. A. 105:804, Sept. 7, ’35.

21. Editorial, J. A. M. A. 102:1 156, Apr. 7, ’34.

2 2. Clausen, S. W.: Nutrition and infection, J. A. M. A. 104:
793, Mar. 9, ’35.

23. Science News Letter, Part of vitamin B in body’s fat pro-
duction, p. 221, Apr. 4, '36.

24. Higgins, C. C. : The dietary management of urinary
lithiasis. Jour. Am. Dietetic Assoc. 11: 518, Mar., ’36.

2 5. Higgins, C. C.: Prevention of recurrent renal calculi, Jour,
of Urology, 35: 494, May, ’36.

26. Joly, J. S.: Stone and calculus disease of the urinary
organs, W. Heinemann, London, 1929.

The Present Status of the Tuberculin Reaction

G. Alfred Dodds, M. D.*

San Haven, N. D.

OWING to the number of inquiries received from
the public and from physicians throughout
North Dakota regarding the tuberculin test,
it is apparent that the true value and limitations of the
test are not fully appreciated. The purpose of this
paper, therefore, is to clarify various points about the
test that it may be more intelligently interpreted and
clinically correlated.

The Positive Reaction

The reaction of the skin to the injection of tuberculin
is merely the reaction of a sensitized organism to tuber-
culoprotein and is an index of tuberculous infection past
or present. At no time does it alone indicate an active
disease process or the degree of tuberculous pathology
present. These facts can be determined only by exam-
ination and X-ray. Furthermore, the intensity of the
tuberculin reaction does not show any relationship to
the clinical course which the disease will pursue.
Stewart1 illustrates this in his study of 188 children
with a primary infection. This group failed to show
any relationship between skin sensitivity to tuberculo-
proteins and the extent of the intra thoracic lesions pres-
ent.

The skin reacts positively to the injection of tuber-
culin about six weeks after infection of the individual
with the tubercule bacillus2. This sensitivity persists
for varying lengths of time, but will be lost after one

•State Sanatorium for Tuberculosis.

and a half to two years in 4 per cent of the positive
reactors3. This is further illustrated in the study of
any large series of chest X-rays which show calcified
hilar glands as evidence of a previous primary tubercu-
lous infection. In such a group four to five per cent of
these patients will be found to be negative tuberculin
reactors.

One of the great values of the positive tuberculin re-
action lies in the easy segregation of patients who have
been infected with the tubercle bacillus. Such reactors
can then be X-rayed for the presence or absence of
actual pulmonary tuberculosis. Advantage should be
taken of this in the study of school children, industrial
groups, and institutional residents. In young children
the positive reaction is extremely significant. As in the
case of children over five years of age, such a reaction
points to an open case of tuberculosis either in the school
or in the home. In children under five years of age
the source of infection is in 99 per cent of the cases in
the child’s immediate family.

It is true that the primary tuberculous infection
(childhood tuberculosis) usually runs a benign course;
however, in infants and young children a positive re-
action is of grave significance. To prove this, I refer
to the figures of the California State Board of Health
for the years 1928 to 1932. These state that in child-
ren of one to four years tuberculosis was the most com-
mon cause of death and represented one-third of the
total deaths in this age group.4 Of the deaths occur-

THE JOURNAL-LANCET

ring under five years of age the meningeal form accounts
for 39 per cent.5 It is highly advisable, then, that in
younger children known to have been in recent contact
with an open case of pulmonary tuberculosis which on
tuberculin testing shows a negative skin reaction, to
repeat this test in two or four months. During this in-
terval a positive reaction may develop thus changing the
prognosis and saving the family physician from criticism
in the event that the case has a fatal termination. It is
further felt by some that in children the four plus
tuberculin reaction is of definite clinical significance as
it represents that group which has had recent or re-
peated infection.15 Special attention should be given to
this group by yearly examination and X-ray.

It is well, at this point, to insert a word of caution
about lightly dismissing the positive tuberculin reactor
who shows on the X-ray enlarged or calcified hilar
glands as previous evidence of a tuberculous infection.
Many such patients are informed that their tuberculosis
is "all healed” and that they are "to forget about it.”
Such statements are unreliable. A large percentage of
the lesions referred to harbor viable tubercle bacilli which
await the opportunity to multiply in a fertile field pro-
vided by lowered resistance and intercurrent infection.
Our safest statement to such individuals is that their
disease is 'apparently arrested.’ In view of the ever
present potentiality for tuberculosis to become active
again it can almost be said, "once infected, always in-
fected.”7, 8 This, however, does not apply to the nega-
tively reacting group which shows calcified hilar glands
as evidence of previous infection with the tubercle
bacillus for these are definitely and permanently arrest-
ed.

The Negative Reaction

Due to the prevalent conception that a negative tuber-
culin reaction may occur in active pulmonary tubercu-
losis little value has been placed upon the test in adults
by many physicians. It is true that a negative reaction
will occur in active pulmonary tuberculosis, but only as
a terminal event in a patient whose X-ray presents a far
advanced stage of the disease.9 For the general prac-
titioner this phase of the reaction can be forgotten.
However, it must be remembered that there is a marked
decrease in skin sensitivity to tuberculoproteins in scarlet
fever and measles. This usually lasts one to two weeks
after the rash appears. The effect produced is not
specific but due to the local effect of the exanthems on
the skin. Chickenpox, pertussis, and diphtheria do not
have a depressing effect on the tuberculin reaction.10
This fact is well worth bearing in mind. A negative
reaction has also been reported to occur in such con-
ditions as lymphogranulomatosis, diseases of myeloid
and lymphoid tissue, and in patients with malignant dis-
ease.11 Nevertheless, at this institution we have been
unable to confirm this in one patient having a moderate-
ly advanced pulmonary tuberculosis with chronic myelo-
genous leukemia, and in another patient presenting a
hopelessly far advanced stage of the disease with an ex-

tensive carcinoma of the cervix. Others have reported
the depressing effects of X-ray therapy on skin sensi-
tivity. In the absence of the foregoing, the negative
tuberculin reaction in a patient with suspicious clinical
symptoms and dubious X-ray findings definitely rules
out tuberculosis.

In the face of X-ray findings which simulate pul-
monary tuberculosis the physician’s attention is then
directed to other types of pulmonary disease. This is
likewise true in patients in whom an extrapulmonary
form of tuberculosis is considered. This fact is clearly
revealed in Table 1 in which the initial and final diag-
noses of 13 patients not having tuberculosis is compared.
All of these patients were admitted to the sanatorium
with a diagnosis of either pulmonary or extra pulmonary
tuberculosis. In each instance the negative tuberculin
reaction was of the utmost value in arriving at the cor-
rect diagnosis and institution of proper treatment. This
table does not attempt to include a large group of
patients with negative tuberculin reactions originally ad-
mitted as tuberculous who were found to have had
recent nonspecific respiratory tract infections, broncho-
sinusitis, chronic tonsillitis, or undulant fever. In con-
nection with the foregoing, it is of interest to note that
of the patients admitted to the state sanatorium and
found to be nontuberculous 90% had never been tuber-
culin tested previous to admission. This indicates a
definite neglect on the part of the referring physician.

While it is true that individuals dwelling in metro-
politan areas will show a higher incidence of positive
tuberculin reactions than those in rural communities, yet
the negative reaction does appear often enough to war-
rant tuberculin testing in patients not presenting definite
manifestations of tuberculosis. This is particularly true
in pulmonary conditions, for in this group of cases I
feel that the failure to find sputum containing tubercle
bacilli is a definite indication for tuberculin testing.
The value of the negative Mantoux test has been further
emphasized by Lichtenstein12 who states, "the negative
tuberculin test rules out tuberculosis as much as organ-
isms in the sputum rule it in.”

In view of the fact that the laity still attach a definite
stigma to tuberculosis, it is well then to be certain that
some other form of pulmonary pathology is not being
dealt with before the patient is referred to a sanatorium.
Even though such an individual is proven to be non-
tuberculous at the sanatorium his or her associates con-
tinue to feel tuberculosis is present and that such a
person is to be avoided in the future. The practitioner,
then, will benefit both the patient and himself by the
performance of a tuberculin test in patients under sus-
picion.

Technic and Interpretation of the Test

The intracutaneous tuberculin test (Mantoux) is the
most accurate and best controlled of all tests. It is the
only one recommended. Previously, old tuberculin was
used for testing, but in the past two years a new type
of tuberculin known as P. P. D. (purified protein de-

THE JOURNAL-LANCET

CHART No. 1 — Showing the value of the negative tuberculin reaction as an aid in differentiating conditions
which simulate pulmonary and extra pulmonary tuberculosis.

Case Tuberculin

Number

Age

Admission Diagnosis

Test

Sputum

Remarks

Final Diagnosis

3646

Pulm. Tube, far adv.

Negative

Negative
for T.B.

lipiodol

injection

Bronchiectasis
bilateral basilar

3689

Tuberculous empyema

Negative

Pneumococci
in aspirated
pus.

Empyema-post

pneumonic

3697

Tuberculous Pneumonia

Negative

Lobar Pneumonia de-
layed resolution

3736

Pulm. Tube, far adv.
Tuberculous empyema

Negative

Guinea pig
neg.

Chronic pyopneumo-
thorax. Non-tuberc.

3765

Pulm. Tube. mod. adv.

Negative

Rheumatic endocarditis.
Cardiac decompensation

3791

Tuberculous adenitis

Negative

Biopsy

Hodgkin’s disease

3794

Pulm. Tube, far adv.

Negative

Pneumococci
in aspirated
pus.

Empyema-postpneumonic

3838

Pulm. Tube, far adv.

Negative

Lipiodol

injection

Saccular bronchiectasis
advanced — left lung

3863

Tuberculous spondylitis

Negative

Thoracic scoliosis post-
poliomyelitic

3837

Pulm. Tube. mod. adv.

Negative

Lipiodol

injection

bronchoscopy

Bronchiectasis, bilateral,
basilar

3937

Pulm. Tube. mod. adv.

Negative

Sputum

culture

bronchoscopy

Pulmonary

streptothricosis

3938

Pulm. Tube, minimal

Negative

Bronchial Asthma

3942

Tubercu.ous arthritis

Negative

Infectious arthritis
secondary anemia

rivative) has appeared. It is prepared by precipitating
with trichloracetic acid the active protein in a tuber-
culin obtained from tubercle bacilli grown on synthetic
media. This precipitate is then washed with ether and
dehydrated. This represents a stable purified tuberculo-
protein of uniform potency.13 It is marketed in tablet
form with a sterile diluent to be added at the time of
its use. This tuberculin is obtainable in five or 100 test
sizes. The initial intracutaneous dose is .0002 mgm. in
.10 cc. and .05 in 10 cc. as the second dose. If the
test is negative in 48 hours the second dose is then ad-
ministered. This new material offers an easily prepared
fresh tuberculin for testing purposes. Owing to its
uniform potency a large number of extensive reactions
previously seen with old tuberculin are eliminated. The
test is easily interpreted and owing to the uniformity
of the dosage an accurate check is possible in each
patient at various intervals regarding the degree of
hypersensitivity remaining to tuberculoproteins. Con-
trolled dosage also permits accurate epidemiologic
studies.

The site of injection, which is usually the forearm, is
examined at the end of 48 hours. In interpreting the
reaction, mere redness at the site of injection is dis-
regarded. Edema is the most important diagnostic
sign and should be looked for. The reactions are graded
as one plus where there is slight edema measuring not
more than 10 mm. across although the area of redness
is usually larger; two plus represents a well defined
edema of 10-20 mm.; three plus is an extensive edema,

redness and an area of central necrosis. This reaction
may be accompanied by constitutional symptoms. When
both first and second strengths have failed to elicit a
reaction the test is considered negative.

The type of tubercle bacillus being dealt with in any
given case can not be determined from the tuberculin
reaction. This is due to the fact that tuberculin ob-
tained from the human tubercle bacillus produces skin
reactions of equal intensity in those patients having an
infection with the bovine type of tubercle bacillus and
vice versa. Some of the early workers on purified tuber-
culoproteins well illustrated this fact and concluded that
there was a protein substance common to all acid fast
bacilli14.

Summary

The correct evaluation of the positive and negative
tuberculin test is discussed with emphasis made on the
prognostic importance of the positive reaction and the
diagnostic value of the negative reaction. The latter is
illustrated by an analysis of 13 cases originally admitted
to the sanatorium as tuberculous and later shown to be
nontuberculous. The arrival at the correct diagnosis
was facilitated in each instance by the negative Man-
toux reaction.

More extensive application of the tuberculin test is
recommended particularly in adults in the hope that
conditions resembling pulmonary tuberculosis will be
more correctly diagnosed.

THE JOURNAL-LANCET

The advantages of the new tuberculin P. P. D.
(purified protein derivative) are discussed and the value
of controlled dosage with this tuberculin is emphasized

Bibliography

1. Stewart, C. A.: J. A. M. A.. 103:176-179 July 24. 1 934.

2. Devine, M.: Pulmonary Tuberculosis in Childhood. Medical
Clinics of North America, 19:791, 1 936.

3. Loyd, W. E., McPherson, M.: Brit. Med. J., 1:818, 1933.

4. California and West. Med.. 44:20, Feb., 193 6.

5. Norris &C Landis, D seres of the Chest, 5th Edition, p. 453.
6 Fenger, E., Matill, P. M., Phelan, C. : Tuberculous Infection

in School Children. Amer. Rev. Tuberc., 21:183. Feb., 1930.

7. Opie, E. L., Aronson, J. D.: Tubercle Bacilli in Latent
Tuberculous Lesions and in Lung Tissue without Tuberculous
Lesions, Arch. Path., 4:1-21, 1927.

8. Robertson, H. E.: Persistence of Tuberculous Infections,

Amer. Jour. Path., IX — Supplement 71 1-717, 193 3.

9. Krause, A. K.: Human Resistance to Tuberculosis at Various
Ages of Life, Amer. Rev. Tuber., 11:303, 1925.

10. Westwater, J. S.: Tuberculin Allergy in Acute Infectious

Diseases: Study of Intracutaneous Test, Quarterly Jour. Med.,

Oxford. 4:203-344. July, 1935.

11. Parker. F.. Jr., Jackson. H., Jr., Fitzbaugh, G. and Spies,
T. B., Jour. Immun., 22:277, 1932.

12. Lichtenstein, M. R.: The Value of the Negative Intra-

cutaneous Tuberculin (Mantoux) Test in Adults, Amer. Rev.
Tuberc., 29:190, Feb., 1934.

13. Aronson, J. D. : The Purified Protein Derivative. Amer.
Rev. Tuberc.. 30:727-732, Dec., 1934.

14. Fenger. E. P. K. and Mariette, E. S.: The Present Status
of the Skin Reaction in Tuberculous and Not Tuberculous Sub-
jects, Amer. Rev. Tuberc., 35, March. 1932.

Acute Infectious Mononucleosis

Value of the N on-filament Count in the Differential Diagnosis

W. H. York, A. B., M. D.*

P. W. Eckley, B. S.*

Ithaca, New York

DURING the ten-year period, (1926-1936),
the Student Health Service of Cornell
University has had under observation
fifty-five cases of infectious mononucleosis.
Twenty-four of these cases were observed and
studied during the present academic year, which
might be looked upon as a mild epidemic. The
majority of the cases were sporadic in type,
occurring throughout any one school year with
very little relationship to the season or any in-
fectious conditions prevalent at the time, such as
epidemics of influenza, measles, etc.

It is interesting to observe this year that there
has been a high incidence of hemolytic strepto-
coccus cultured from the throats of both well
and ill students. Over 50 per cent of students
passing routinely through the medical office,
showed a positive culture of hemolytic strepto-
coccus. Nine out of eleven nurses at the Infirmary
gave a positive culture, and many of the patients
confined to the Infirmary, regardless of their ill-
ness, showed positive cultures. Whether this has
any relationship to the disease in question, is
problematical.

The importance of infectious mononucleosis
does not lie in the severity of the infection, since
it is a relatively benign disease, but in the con-
fusion that attends a dififerential diagnosis from
other serious diseases, such as acute leukemia and
acute infectious conditions in general. The
authors in presenting a review of their findings
admit their inability to contribute any new knowl-
edge to the etiology, but hope to add to the gen-
eral picture of the symptom complex and stress
the importance of routine blood examination in
all suspicious cases, with particular reference to
non-filament counting as a differential and diag-
nostic procedure.

•Student Health Service, Cornell University.

From the time of Pfieffer’s description of
glandular fever in 18891 there has been an in-
creasing interest shown in this apparently benign,
but at times, confused symptom-complex. That
it has the earmarks of a disease entity, was
brought out by the excellent study of Longcope
in 192 22 when he reported on ten cases. More
recently Gilbert and Coleman ( 1925 ) 3 ; McAlpine
(1935) 7 and McKinley, Downey and Stasney
(1935) 8 9 have given a more complete clinical
and blood picture of this disease, and have not
only made a careful review of the literature, but
have clarified through their own studies certain
aspects of the clinical picture.

Our own study of 55 cases has checked well
with the findings of other observers : namely, the
sporadic nature, the prevalence among the adole-
scent group, symptoms of a mild acute infection ;
the clinical findings of enlarged and tender lymph
nodes, palpable spleen, body rash and a char-
acteristic blood picture showing an increased
white blood count varying from a relative to an
absolute increase of lymphocytes.

The symptoms characterizing the onset of ill-
ness in their order of frequency, were as follows:
sore throat, indigestion and headache, enlarged
lymph nodes, malaise, fever and chills, coryza,
and in one case fainting. The onset may be sud-
den with a relatively high fever, either of the
septic type, or one well sustained for a few days.
In such cases chills are frequent with many of
the symptoms observed in the severe acute in-
fections, such as headache, nausea, vomiting,
malaise, etc., but there are no localized signs of
infection. A second type of onset is with fever
and sore throat, the febrile reaction being less
pronounced than the first type, constitutional
symptoms are less marked and few lymph nodes

THE JOURNAL-LANCET

are enlarged. Still a third type of onset, is with
mild fever and many enlarged, tender lymph
nodes. Occasionally the onset has been ushered
in with abdominal symptoms and mild fever.
During the course of the disease sweating is a
common complaint and in some cases a diffuse
macular rash has appeared on the face and body.
Rarely is the rash seen below the iliac crest.
Eight cases of our series showed this rash.

The average length of time required for hos-
pitalization was 12.6 days. There was no rela-
tion between the acuteness of the onset and the
length of time required for convalescence. In a
few cases too early discharge from the Infirmary
resulted in re-admission of the patient. In a
considerable number of the patients who were dis-
charged with a normal temperature, complaints of
weakness and fatigue persisted for some time, in-
dicating that complete convalescence may be de-
layed for several weeks or even months.

The blood picture in the following representa-
tive cases is given to show the value of the high
non-filament count in making a diagnosis of acute
infectious mononucleosis. Attention is also called
to the fact that often several white blood counts
with a differential count must be made before the
typical picture of leucocytosis and lymphocytosis
appears. Frequently the first counts may show a
leucopenia and this was marked in Case 3 of
W. H.

Common Clinical Types

Case i. — J. S. — Male student. Age: 21.

Admitted to the Infirmary with the complaint
of headache and sore throat 2/11/35. Time in
the Infirmary, 18 days.

Date

I y.B.c.

Poh.

Lymp.

Eos.

Bas.

N.F.

T emp.

2-15-35

7,400

63.5

0.5

101

2-18-35

7.800

46.5

52.5

102.4

2-20-35

7,720

1.0

99.4

2-21-35

15,040

31.5

2.0

98.6

2-25-35

18,640

1.0

98.6

Case 2. — G. L. — Male student. Age : 20.

Admitted to the Infirmary with cold, coughing,
abdominal pain, headache and rash 1/8/34. Time
in Infirmary, 10 days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

1-11-34

5,560

0.5

102.6

1-12-34

5,800

101

1-15-34

11,280

1-18-34

13,240

Case j. — W. H. — Male student. Age : 24.

Admitted to the Infirmary 4/17/35 with symp-
toms of grippe. Had been ill for past several
days. Time in Infirmary, 18 days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

4-19-35

6,520

103

4-21-35

2,450

35.5

63.5

104.4

4-22-35

7,420

42.5

56.5

102.6

4-23-35

10,360

34.5

64.5

101.2

4-24-35

9.600

28.5

0.5

100.8

4-25-35

10,520

101.6

4-26-35

9,600

102

4-28-35

16,600

103.4

4-29-35

22,400

70.5

0.5

102.2

4-30-35

21,400

99.2

5- 1-35

16,400

98.6

5- 2-35

15,080

1.0

98.6

1- 7-36

10,200

44.5

2.5

Case 4. — Mrs. J. — Female student. Age : 23.

Admitted to the Infirmary 1/20/34 with faint-
ing, pain in abdomen, chills and general malaise.
Complained of stiff neck. Time in Infirmary, 14
days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

1-22-34

6.000

33.5

63.5

99.4

1-23-34

4,960

65.5

2.5

99.6

1-24-34

8,760

35.5

60.5

100.4

1-25-34

10,800

38.5

59.5

1.5

100.4

1-26-34

13,640

56.5

3.5

99.4

1-27-34

13,600

2.5

0.5

100

1-28-34

12,640

40.5

57.5

99.2

1-29-34

13,240

65.5

0.5

99.4

1-30-34

10,880

27.5

66.5

98.8

1-31-34

12,160

3.5

0.5

98.6

2- 1-34

13,600

98.6

2- 3-34

16,040

31.5

2.5

98.6

Case 5.-

— M. D

. — Made student.

Age:

22.

Admitted to the Infirmary 11/10/35

with cold,

fatigue

and sore throat.

Time

in Infirmary, 21

days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

11-15-35

8,800

75.5

3.5

100

11-16-35

9,400

73.5

1.5

100.4

1 1-18-35

11,800

11.5

0.5

100

11-22-35

11,720

89.5

0.5

101.2

11-23-35

18,240

10.5

89.5

101

11-25-35

12,600

103

11-26-35

16,400

102

11-27-35

11,960

83.5

0.5

99.4

11-29-35

7,400

10.5

89.5

1- 7-36

6,480

51.5

0.5

98.6

Widal and undulant fever agglutination

nega-

tive 11/14/35.

Positive agglutination

for i

infectious mono-

nucleosis 11/22/35.

Case 6.-

-R. S.-

—Male student. .

Age : 24.

Admitted to

the Infirmary 11/9/35 with

sore

throat and swollen glands. Time in

Infirmary,

five day

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

11-11-35

7,000

75.5

1.5

100.4

11-12-35

6,640

5.5

0.5

98.2

1-20-36

11,400

56.5

2.5

Case 7.-

— S. M.

Male student.

Age:

19.

Admitted to the Infirmary 11/29/33 with the
complaint of nausea and vomiting, general abdom-
inal discomfort and slight headache. Time in
Infirmary, 11 days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

Temp.

- 3-33

4,800

50.5

99.8

- 4-33

7,000

32.5

98.6

- 5-33

9,480

20.5

79.5

- 7-33

7,600

58.5

97.8

- 9-33

8,400

41.5

58.5

97.8

Clinical symptoms characterized by macular
rash on back and abdomen.

Case 8. — G. C. — Male student. Age : 19.

Admitted to the Infirmary 1/15/36 with rash
and sore throat. Time in Infirmary, nine days.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F. Temp.

1-16-36

4,080

1-17-36

4,680

60.5

37.5

1-18-36

5,960

45.5

53.5

0.5

1-20-36

9,200

33.5

0.5

1-21-36

6,480

44.5

0.5

1-22-36

6,960

66.5

0.5

Case p. — A. S. — Female student. Age : 20.

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i 1

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F.

2-25-36

12,000

1.5

0.5

2-26-36

15,320

25.5

71.5

2.5

0.5

2-28-36

8,840

25.5

0.5

Positive agglutination 3/1/36.

Temp.

per cent. The average for normal adults is eight
per cent.

Discussion and Conclusion

Case io. — E. W. — Male student. Age : 23.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F. Temp.

2-24-36

7,440

2-25-36

6,240

46.5

0.5

2-26-36

6,000

55.5

41.5

3.0

2-27-36

7.200

37.5

1.5

Positive agglutination 3/1/36.

Macular rash on

back and abdomen.

Case ii. — J. G. — Male student. Age: 24.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F. Temp.

2-21-36

4,920

2-22-36

4,520

3-24-36

7,840

36.5

4.5

Positive agglutination 2/23/36.

3-24-36 follow-up note: Tires easily — “Not up
to par.”

Case 12. — W. L. B. — Male student. Age: 20.

Date

W.B.C.

Poly.

Lymp.

Eos.

Bas.

N.F. T emp.

2-18-36

16,120

2-19-36

17,240

84.5

1.5

2-20-36

17,280

20.5

79.5

3-14-36

7,720

65.5

32.5

Positive agglutination 2/22/36.

Filament — Non-filament Count

This method of studying the significance of the
appearance of the nuclear structure of neutro-
phils, was proposed by Farley, St. Clair and Reis-
inger.5 They used the criterion of Krumbhaar10
and Cooke and Ponder.11 The former had made
a division of the neutrophils into three classes:
(1) metamyelocytes, (2) the non-segmented types
and, (3) the segmented forms; the latter had
pointed out that all divided nuclear masses were
connected by a thin filament of nuclear material,
but they used a five-type classification. Combin-
ing these two systems, Farley, St. Clair and
Reisinger divided the polymorphonuclear neutro-
phils into two classes : the non-filamented im-
mature forms, and the filamented mature forms.

The method consisted of making thin smears,
stained with Wright’s stain. We used the modi-
fication as suggested by Mullin and Large,6 and
have based our figures on a count of a hundred
polymorphonuclear neutrophils. The upper limit
of normal for young forms (non-filament) is 16

Non-filament counts of 50 per cent and over,
usually indicate unfavorable prognosis. The high
non-filament count in acute infectious mono-
nucleosis is one of the few exceptions where
“shift to the left” has a favorable omen. The
consistency with which the high count appears
in the blood picture of this relatively benign dis-
ease entity, is of considerable diagnostic import-
ance, particularly in the differentiation from acute
leukemia and other infectious diseases involving
adenopathy, fever, and an increase in mononuclear
elements in the blood.

Although the causative agent of infectious
mononucleosis is unknown, the fact that we are
able to get a positive agglutination in a consider-
able proportion of cases, would probably indicate
the presence of a specific antigen. Sheep cell
agglutination tests may be used as an additional
laboratory aid in a differential diagnosis.

BIBLIOGRAPHY

1. Pfeiffer, E. : Drusenfieber Jahrb. f. Kinderh., 24, 257.

2. Longcope, Warfield T. : Infectious Mononucleosis (Glandu-
lar Fever) with a report on ten cases. American Journal of
the Medical Sciences (Dec., 1922).

.1. Gilbert, Ruth, and Coleman, M. B.: Laboratory Findings
in an Epidemic of Glandular Fever. American Journal of
Hygiene (Jan., 1925, Vol. V, No. 1, p. 35).

4. Baldridge, et al: Glandular Fever (Infectious Mononu-
cleosis). Archives of Internal Medicine (Oct., 1926, Vol. 38,
No. 4, p. 413).

5. Farley, W. L. ; St. Clair, Huston, and Reisinger, J. A.:
Normal Filament and Non-filament Polymorphonuclear Neutro-
phil Count. Its practical value as diagnostic aid. American
Journal of Medical Science, (180: 336-344, September, 1930).

6. Mullin, W. V., and Large, G. C. : The Filament — Non-
tilament Count. Its Diagnostic and Prognostic Value. Journal
of the American Medical Association, Vol. 97, No. 19, p. 1133
(Oct. 17, 1931).

7. McAlpine, K. R. : Acute Infectious Mononucleosis. Thi
Journal-Lancet, Vol. 55, No. 10, p. 306 (May 15, 1935).

8. McKinley, C. A.: Infectious Mononucleosis — Part 1, Clinical
Aspects. Journal American Medical Association, Vol. 105, No.
10, p. 761 (Sept. 7, 1935).

9. Downey, H., and Stasney, J.: Infectious Mononucleosis.
Part II. Hematologic Studies. Journal American Medical
Association, Vol. 105, No. 10, p. 764 (Sept. 7, 1935).

10. Pons, C., and Krumbhaar, E. B.: Studies in Blood Cell
Morphology and Function; Extreme Neutrophilic Leukocytosis
with Note on Simplified Arneth Count. Journal of Laboratory
and Clinical Medicine, 10, 123-126 (Nov., 1924).

11. Cook, W. E., and Ponder, Eric: The Poly-nuclear Count;
The Nucleus of the Neutrophile Polymorpho-nuclear Leukocyte
in Health and Disease with some observations on the Macro-
polycyte. Philadelphia, J. B. Lippincott Co., 1927.

12. Arneth, J.: Die Neutrophilen Leukozyten bei Infection-
skrankheiten, Deutsche Med. Wchuschr., 30: 54, 92, 1904.

13. von Schilling, Victor: Uber die Notwendig-keit grund-
satzicher Beachtung der Neutrophilen Kernverschiebung in
Leukozytenbilde und uber Praktische Erfolge dieser Methode.
Ltschr. f. klin. Med., 89: 1, 1920.

THE JOURNAL-LANCET

Laboratory Assistance to Physicians*

Melvin E. Koons, M.S.**

Grand Forks, North Dakota

VICTOR C. VAUGHAN, in an editorial pub-
lished in the October, 1915, issue of The Jour-
nal of Laboratory and Clinical Medicine, said
that he who practiced medicine without the aid of a
laboratory belonged to a past generation of physicians.
Granting the truth of this statement then, we know that
it is doubly true now.

Thirty or 40 years ago, laboratory tests were looked
upon with only the mildest curiosity; today every hos-
pi al, clinic and physician finds it advisable and neces-
sary to conduct routine and special laboratory tests.

Before the germ theory had been advanced, physi-
cians were striving to learn the causes for epidemics of
communicable diseases. Miasmatic conditions, unsanitary
environment, poor housing, etc., were looked upon as
factors causing these epidemics.

Eventually, after a period of hard struggles to find
the cause of the destructive agencies, the laboratory and
microscope came into use, and it was found that diph-
theria was a germ disease with certain characteristics,
and that typhoid fever was a germ disease transmitted
through various agencies, mainly polluted water, unsani-
tary milk or contaminated food. Out of all this came a
constructive public health program.

We all recognize now that public health is of vital
concern to the state's welfare, and one of the many pro-
visions aimed at fortifying and improving health condi-
tions is the laboratory.

Even today a practical handicap which is experienced
by the physicians practicing in the rural communities
and remote areas, is the difficulty and often, impossi-
bility, of obtaining the kind of clinical laboratory serv-
ice to which their more fortunate brothers in larger cities
and medical centers are accustomed, and which is con-
sidered by them essential in the proper practice of medi-
cine. Doctors who are trained in the fundamentals of
laboratory medicine truly appreciate the value of good
laboratory work in routine clinical diagnosis.

The laboratory should be an important cog in the
daily running of a physician’s life, whether it be the
state laboratory or not. It is, or rather should be, just
as important to the physician as gasoline is to an auto-
mobile. In other words, an automobile cannot run with-
out the proper fuel — so it is with a doctor. The labora-
tory serves in a way as fuel by helping the physician
run and maintain his daily practice. The laboratory
serves a two-fold purpose, not only does it help the
physician in making positive diagnoses on borderline
cases, and as a check on his clinical findings, but it also
serves as a place where research can be conducted which
will in the future be some aid to the medical profession.

"'Presented before the North Dakota Health Officers’ Associa-
tion Co'nference, Jamestown, North Dakota. May, 1936.

** Assistant Director State Public Health Laboratory, Grand
Forks. N. Dak.

In the running of the state laboratories, several ques-
tions ccme to my mind. First, just what does the physi-
cian expect of the laboratory? Second, what does the
laboratory expect of the physician? Let us consider the
first question. Primarily, the physician expects prompt,
efficient and reliable results on all specimens submitted
to the laboratory for examination. Naturally, if the lab-
oratory were slow in reporting specimens and were un-
reliable, the physician could not be blamed for not mak-
ing use of the laboratory.

The laboratory also gives invaluable service in con-
nection with control of treatment detection of carriers
and the release from or the beginning of quarantine.

In the control of treatment of certain diseases, such
as gonorrhea and syphilis, the laboratory can be of serv-
ice to the physician by running examinations on speci-
mens submitted at intervals during the treatment period.
This will enable the physician to get a better picture of
his method of treatment. The detection of carriers, espe-
cially typhoid, is practically impossible without the aid
of a laboratory. We can only suspect a typhoid carrier
if no laboratory examination is made. However, if urine
and s.ool specimens are submitted to a laboratory, one
can tell with some degree of accuracy whether or not
the patient harbors and disseminates the specific micro-
organism. If typhoid bacilli are isolated we have definite
proof that that particular person is a carrier.

In the same way a laboratory is needed when it comes
to releasing a typhoid patient from quarantine restric-
tions. How can anyone positively say after waiting the
required quarantine period that a typhoid patient is not
still disseminating the germs? Let us take a specific
example: Patient Jones has typhoid and makes a nor-
mal recovery; the quarantine period is up, so he is re-
leased without further examination; this patient al-
though perfectly well has become a carrier, yet he is
released without having either his urine or feces, or
preferably both, examined. You can well appreciate the
potential danger that this patient will be in his com-
munity. Here is a case where if urine and stool speci-
mens were submitted to the laboratory, the chances are
that the organisms would be isolated, thus preventing
any uncalled-for inconvenience or even a serious epi-
demic.

Another example of the need of a laboratory is found
in certain cases of diphtheria.

Many doctors do their own microscopic work or have
a technician who examines for diphtheria bacilli, which
is perfectly all right. However, they are not equipped
to run a virulence test if such is necessary. A person
may harbor organisms in his throat which upon micro-
scopic examination conform morphologically to the
diptheria bacillus, and yet are non-virulent. If such be

THE JOURNAL-LANCET

the case, a patient might well be quarantined, causing a
great inconvenience and possible economic loss.

Cases such as these which I have just mentioned are
only an example of a few instances where a laboratory
can be of great aid to a physician.

North Dakota has two state laboratories; one located
in Grand Forks and the other in Bismarck. The labora-
tory service is without expense to the physician or
patient, as no charge is made for examinations or sup-
plies furnished. The department furnishes special
approved mailing containers. The regulations of the
postoffice department specifically require the use of con-
tainers which have been approved by the postal authori-
ties for the mailing of infectious disease specimens.
These may be procured by making application direct
to the laboratories. The physician must pay all trans-
portation charges for sending specimens to the labora-
tory.

With this in mind, it might be of interest to explain
briefly some of the work done in the state laboratories.
We are at the present time equipped to run a large
variety of examinations. In fact, we do about everything
that is done in other state laboratories. All specimens
when received are immediately given the proper atten-
tion, with each individual specimen being given a thor-
ough examination and a report that is reliable. In a
great majority of cases, reports on specimens are mailed
within 15 to 18 hours from the time of receipt; but ma-
terial which is to be cultured may require a period cover-
ing 24 to 36 hours before diagnosis can be rendered.
Reports are made to physicians directly, unless otherwise
instructed by them. The scope of laboratory work in-
cludes such things as bacteriological diagnosis in diph-
theria, tuberculosis, typhoid fever, paratyphoid fever,
dysentery and meningitis; serological diagnosis in
typhoid, paratyphoid, dysentery, undulant fever and
tularemia; bacteriological examination of water and milk
and venereal disease service which includes Kolmer and
Wassermann tests, Kahn precipitation, darkfield exam-
ination, colloidal gold test and bacteriological diagnosis
for gonorrhea infection, and the examination of feces
and urine specimens. The laboratory also does guinea
pig inoculations for tuberculosis, for which there is a
nominal fee.

The report blanks now in use in the laboratories have
an explanation or interpretation of the phraseology used
by the laboratory in reporting the findings on any given
submitted specimen. We feel that this is of some benefit
to the physician and will not cause him any inconven-
ience or delay in trying to interpret our reports.

In the submission of specimens there are certain things
which should be adhered to. Diphtheria cultures should
never be submitted on old Loeffler’s media, as a nega-
tive diagnosis is never given on specimens sent in any
other way than on fresh culture media. A report of
"diphtheria” means that B. diphtheriae were found in
the specimen submitted. "No diphtheria bacilli found”
does not necessarily mean that the patient does not have
diphtheria; but means simply that diphtheria bacilli

were not found in the specimen examined. This may
have been due to, first, improper technic in applying
the swabs to nose and throat, or to the surface of the
culture medium and secondly, overgrowth of certain
bacteria capable of retarding the development of B.
diptheriae in vitro. A report of "Reserved” means that
no diagnosis could be given, and other cultures are
necessary for bacteriological diagnosis or release from
quarantine. The "Reserved” diagnosis may have been
due to, first, suspicious bacilli, secondly, saprophytic
bacteria which liquefy the medium, or otherwise mask
B. diptheriae, or thirdly, scant or no growth, which
may occur when dry medium is used, or when antiseptics
have been applied to nose or throat a short time before
taking of the specimen, or when the medium has not
been satisfactorily inoculated. Convalescents should not
be released from quarantine until two negative cultures,
taken at intervals of 24 hours, are found.

Sputum specimens should be submitted in public
health containers, as they contain a small amount of
carbolic acid which not only preserves the specimen in
transit, but also serves as some protection to those han-
dling the specimen. All sputa are examined micro-
scopically and a report of "tubercle bacilli present” indi-
cates tuberculosis and that the discharges of the patient
are dangerous to the public. "Tubercle bacilli not found”
may be explained by one of the following reasons: first,
the disease is in an early stage before the tubercles
have begun to break down; secondly, the avenues
through which the bacilli pass from the lesions to the
sputum are temporarily blocked or the lesions have been
healed; thirdly, so few bacilli are present as not to be
found in careful examination of several smears, and
fourthly, the patient is not tuberculous. Physicians
should disregard negative reports as valueless unless con-
firmed by repeated physical examination, prolonged tem-
perature record, clinical history, etc., and should send
other specimens.

The laboratory furnishes a specially-prepared blood
culture outfit for B. typhosus. During the first week of
illness frequently typhoid organisms can be isolated from
the patient’s blood stream. Usually after the seventh
to tenth day of illness, agglutinins appear in the blood,
and then the Widal test may reveal the infection. The
Widal test will be made on either wet or dried blood,
although 3 to 5 cc. of blood are preferred for making
accurate dilutions of the serum. A laboratory report of
"present” may indicate the patient now has typhoid
fever, recently had typhoid fever, is a typhoid carrier
with infection of the gall bladder, or had some other
latent or obscure focus of infection with B. typhosus,
unless the reaction is due to the previous administration
of typhoid vaccine.

An "atypical” report frequently occurs as a fore-
runner to "present” during the first week of typhoid
fever. "Present” usually appears in 7 to 10 days after
onset, as the specific agglutinins recede following re-
covery from typhoid fever, or as an indication of the
carrier state. Too little blood, wet blood, or the presence

THE JOURNAL- LANCET

of foreign material, may give rise to an "atypical”
reaction.

An "absent” report may indicate the absence of
typhoid infection, or that it is too early in the disease
for the appearance of the reaction.

For the examination of specimens for undulant fever
and tularemia, 3 to 5 cc. of whole blood are required.
The agglutination test is the recognized laboratory pro-
cedure for confirmation of clinical diagnosis.

Brucella and tularense agglutinations should be in-
terpreted in general in a manner similar to that of
typhoid as just mentioned. "Present" 1:80 and above,
with Brucella and "present 1:40” and above, with
tularense are diagnostically significant in the presence of
clinical symptoms. A transient or persistent agglutina-
tion with Br. mehtensis (abortus) antigen in a titre of
less than 1:80 or with Bact. tularense in a titre of less
than 1:40 may be regarded as having little, if any
significance in relation to the present illness. Agglutina-
tions of low titre occur early and late in these diseases.
Even high titre reactions may persist for years after an
attack of tularemia. Brucella agglutinin is usually pres-
ent in two to four weeks after onset, may not appear
for several months and rarely is not demonstrable.
Tularense agglutinins are usually present in 10 to 20
days after onset. In either Brucella or tularense infec-
tion, cross-agglutination with the opposite organisms
may occur in a low titre, and rarely in typhoid and other
infections a Brucella cross-agglutination may take place.

For Vincent’s angina, the causative organisms are
easily detected in smears made directly from the mucous
membrane of the affected parts. Such an examination is
reported as organisms characteristic of Vincent’s angina
are present or not found.

For spinal fluids, unless definite examination is stated,
we run a routine examination which consists of a micro-
scopic examination, culture of specimen, sugar and
globulin determinations. If a guinea pig inoculation,
colloidal gold, or Wassermann is desired, the specimen
should be so marked. An attempt is made to isolate and
identify all organisms found in a spinal fluid. Reports
on such specimens are always by letter, giving a concise
report of the findings.

For gonorrhea, a microscopic test of suspected ma-
terial from both male and female is the recognized
method of diagnosing the disease. Smears should be
allowed to dry in the air before being submitted to the
laboratory. Such an examination is reported as follows:
"Organisms corresponding morphologically and in stain-
ing-reaction to the gonococcus are present,” which means
that while it is impossible to make an absolute identifi-
cation of these organisms on microscopic examination
alone, without further study of the biological character-
istics, they are considered to be diagnostic of gonococcus
infection. "Organisms corresponding morphologically
and in staining-reaction to the gonococcus not found”
means that while such organisms have not been found
in the smear submitted, the possibility of gonococcus
infection is not excluded. This may be due to, first,

organisms not being contained in the material on the
slide even though they might be present in other smears
taken at the same time; secondly, organisms being so
few in number that a thorough search fails to reveal
them. A suspicious report is given when gram negative
diplococci characteristic of the gonococcus are found
extra-cellularly along with the presence of pus cells.

"Examination unsatisfactory” may be due to: too little
material submitted, too thick a smear, smears not being
thoroughly air-dried before packing, or smears being
overheated.

For the examination for syphilis the laboratory runs
both a complement fixation and precipitation test.
Approximately 5 cc. of blood are necessary for the test.
The Kolmer test as used in the laboratory is a modified
Wassermann test, which is widely-used and consistently
gives a high degree of accuracy. The Kahn test, which
is a precipitation test, is considered a good companion
test to the Kolmer, as it occasionally picks up a primary-
case and a return positive reaction after cessation of
treatment earlier than the Kolmer.

The laboratory furnishes small sterile glass vials
which should be used in submitting blood specimens for
examination. Physicians should avoid the use of miscel-
laneous bottles in submitting blood specimens. Much in-
justice has been done serologists, particularly by isolated
practitioners, in criticizing reports based on thoroughly
unsatisfactory material submitted for examination.
Hemolyzed specimens are unsatisfactory for diagnosis.
Water, extremes of heat or cold, age of specimens, and
unclean utensils predispose to hemolysis.

A report of "anti-complementary” means that the test
has been attempted; but due to certain factors inherent
in the specimen, such as contamination by bacteria, or
the use of non-sterile instruments in the collection of
blood, etc., the result is of no value.

A "Kolmer doubtful” means that the test does not
show complete negative or definite positive. This reaction
may be due to some error in technic, to the condition of
specimens or to tfie effect of treatment. It is always best
to repeat tests on such a report except in cases under
treatment.

A single negative report of blood serological test by
any procedure, no matter what claims are made for it,
means just nothing. A negative serological test always
requires interpretation, clinical and also serological. All
negatives should be repeated at least once if clinical
suspicion warrants.

A positive test should not be accepted without one
repetition. A diagnosis of syphilis should not be made
on one positive if the history and clinical evidence are
negative; or vice versa, repeated specimens should be
submitted. In practical terms, it may be said that no
patient should be given his diagnosis or placed on treat-
ment on the strength of a single positive serological test
any more than on the strength of a single negative one.
False positives in good laboratories run between 0.5 and
2 per cent. John H. Stokes in his latest book on
Modern Clinical Syphilology lists a summary of limita-
tions and possibilities in serological test control (labora-

THE JOURNAL-LANCET

tory phase) which I quote here in part as follows: "The
physician’s desire for consistent 100 per cent specificity
and sensitivity, and absolutely clear-cut reports cannot
be njet by any serological test for syphilis in routine per-
formance today. Disagreements must be expected be-
tween antigens in the same Wassermann test; between
the results of two or more tests in the same laboratory
on a single serum; this is true sometimes even when the
tests are of markedly different type as in Kolmer,
Wassermann and Kahn precipitation tests, or when they
are similar (Hinton and Kline) ; when the same serum
is tested in two different laboratories, even by sup-
posedly identical methods; when the serum of late and
latent syphilis or syphilis in pregnancy is tested by any
group of different methods (serological discord) ; when
the serum of the same patient is repeatedly tested by
identical methods on successive days or at longer inter-
vals; when the treatment has intervened to alter the
routine expectancy. The frequency of disagreement and
the margin of inevitable error diminishes with the per-
fection of technical performance, but it has never com-
pletely disappeared. Essential elements in securing maxi-
mum reliability in performance by the laboratory are:
a good specimen, experienced technical service, clean
glass; fresh animals (Wassermann test), uniform expert
reading conditions, avoidance of the experimental in
routine reports; a nonpartisan serologist; intralaboratory
check by multiple tests (but not too multiple) ; inter-
laboratory exchanges of sera periodically for test pur-
poses; laboratory-clinic check, againsj: the opinion and
experience of a syphilis clinic.”

As the Wassermann work constitutes a large part of
the routine work carried out in the laboratories, it might
be well to describe what the North Dakota Department
of Health is doing to insure correct Wassermann re-
sults. As we all know, the Wassermann test, being per-
formed with biological extracts and fluids, can hardly be
expected to behave with the same exactness as a purely
chemical test. This, in our opinion, is the very reason
why no effort should be spared in rendering this test as
accurate and reliable as its inherent biological factors
will permit. With every step of the test carefully con-
trolled, a high degree of precision can be attained.

It is evident that the Wassermann tests in a public
health laboratory should be of the highest accuracy. For
a public health laboratory to report a positive Wasser-
mann on one free from syphilis is a very grave error
indeed. There again to report a false negative might
result in seriously endangering the health of the com-
munity. To overcome both of these possibilities this de
partment, as mentioned above, runs two distinct tests
on every specimen submitted for examination, namely:
the Kolmer Wassermann and the Kahn precipitation
tests.

What the state laboratory is doing to render the re-
sults of the individual Wassermann tests of the high-
est accuracy will now be considered. First, of course, is
the checking by running two different, distinct tests as
was mentioned. Secondly * the laboratory runs a daily

titration on both the complement and amboceptor. The
complement is secured from normal healthy guinea
pigs every time the test is run, thereby insuring fresh
material of high quality. Thirdly, the sheep cells are
obtained from our own sheep (previously tested),
which makes the resistance of the corpuscles to hemo-
lysis practically constant. Fourthly, the antigen is care-
fully prepared and checked. The Kahn antigen is
standardized in the Kahn laboratory as comparable to
their own. The Kolmer antigen is also checked as to
titre in at least one reliable outside laboratory before
put into use. Fifthly, a daily control system is carried
out which gives us a check on the "run.”

We feel that our laboratories are giving Wasser-
mann tests of the highest possible accuracy and are
constantly striving to perfect the technic by incorporat-
ing all new methods in the preparation of reagents,
etc. Just recently the laboratory received the follow-
ing correspondence from the Surgeon General of the
U. S. Public Health Service:

"The Committee on evaluation of serodiagnostic
tests for syphilis has been completed, a study in which
has been demonstrated the ability of laboratories to
perform serologic tests for syphilis. The findings indi-
cate that a number of laboratories are able to perform
such tests in a way which compares creditably to the
performance of the serologists who originated the
various procedures. In other laboratories the perform-
ance has not been so efficient and, in a few instances,
the percentage of false positive reports on known nor-
mal specimens has been so high as to result in a most
serious condition if the reports of such tests are re-
garded by physicians in private practice as being reli-
able. In other laboratories, while no false positive re-
actions were reported, the sensitivity of the serologic
tests is extremely deficient in detecting cases of syphilis
so that large numbers of cases of latent syphilis would
not be noted in routine practice.

"The Committee has recommended that an oppor-
tunity be extended to state laboratories to compare the
results of their performance of serologic tests for
syphilis with those of well-qualified serologists in other
laboratories performing the same tests on comparable
samples from known syphilitic and known nonsyphi-
litic individuals. The Committee also feels that such
a system of comparative examination of serologic tests
should be extended annually to all State Laboratories.
In turn, the State Laboratories should offer a similar
service to local laboratories within their jurisdiction.

"The Public Health Service proposes to provide such
a system for measuring the efficiency of serologic test-
ing in state laboratories each year. This service will
be instituted in the autumn of the present calendar
year.”

Our laboratories most surely will take advantage of
this service, and we expect to have our serological
work evaluated, as it will enable us to give the practic-
ing physicians of North Dakota a better, more accu-
rate, and reliable service in this field.

THE JOURNAL-LANCET

Another phase of the laboratory work which has an
important bearing on the health of the public is the
bacteriological examination of water. Misinterpretation
placed on samples of water submitted for bacterio-
logical examination is quite a problem. While the great
majority of samples of water submitted to the labora-
tories for examination are from private sources, the
State Department of Health desires the assistance of
county and city health officers in helping to clarify
this misunderstanding on the part of the public.

It is a generally-accepted fact that the health of a
community depends in a very large measure on the
provisions of an abundant and pure water supply. The
quality of a water supply affects the health not only
of the community which it serves, but all communi-
ties connected by travel communication. Water can and
does transmit to man illness of very varied character,
and the causal agents conveyed by water may be
chemical or metallic, bacterial, protozoan, or due to
other higher forms of life. The danger to health by
the consumption of water arises only in rare instances
from the presence of an excess of one or another of
the inorganic salts that it may contain, and is com-
paratively rarely due to metallic matter such as lead,
etc., but what vastly more important as far as dis-
ease is concerned, is fecal impurity, particularly that
of human origin. The danger of polluted water comes
not from dead organic matter, but from living organ-
isms. The presence of pathogenic bacteria constitutes
the greatest danger with regard to water supplies as
outbreaks can be so widespread and destructive.

In the bacteriological analysis of water there are
two divisions, the first is the quantitative analysis,
which strives to show the actual number of bacteria
in a definite quantity of water. More important than
this is the qualitative analysis, which is designed to
show the presence of a definite group of organisms,
which is used as an index of pollution and for that
reason is oi more consequence than one which merely
tells the number present but gives no indication of
the potability of the water. Since the organisms found
in the Coli-aerogenes group are always present in the
intestine, their presence in water is an indication that
the water is polluted. It would be impractical, if not
impossible, to look for the individual disease-producing
organism in water, and such information, if obtained,
would be available only after a community had been
exposed. Therefore, the matter of finding and con-
demning a supply that is potentially dangerous is far
safer and more economical than waiting until the dis-
ease can actually be shown to be due to polluted
water.

The qualitative examination is made by inoculating
fermentation tubes of lactose broth with definite
amounts of the water to be tested. These are incu-
bated and examined after a certain period of time. If
there is gas production in any of the tubes the organ-
isms present are confirmed on a differential media to
determine whether or not they belong to the Coli

group. If there is no gas production, we assume that
the water is free of B. coli and no further work is
done with the samples.

One might ask the question, what does the presence
of B. coli in a water indicate? Briefly, it means that
the water in question contains bacteria that are ordi-
narily present in the intestine and therefore indicate
that the water is contaminated with fecal pollution.
This may be a permanent condition or it may be a
temporary contamination. Such a water is potentially
dangerous and should not be used for human con-
sumption as there is the danger that pathogenic organ-
isms may be present. However, a water should never be
condemned on the basis of only one examination, as
the results may have been due to carelessness in col-
lecting the samples or some other outside factor. The
source of contamination should be located if possible,
especially where a well water is concerned, as it may
be due to faulty construction. It is obvious that a sound
judgment in regard to the sanitary quality of a par-
ticular water supply should be based on a considera-
tion of the facts brought out by a careful sanitary
inspection as well as by analytical data. A sanitary
inspection by a competent person is of paramount im-
portance in checking the report of a bacteriological
analysis in order to determine the source of contamina-
tion. Water reported bad can be rendered safe to use
by boiling or by proper chemical treatment.

One might now ask the question, what is the signifi-
cance of a report where no B. coli is found? Such a
report simply means that as far as can be determined
by a bacteriological analysis, no B. coli was found in
the sample submitted for examination. Such a report
does not necessarily mean that the supply may always
remain safe. Here again a sanitary survey is very
essential in order to determine whether or not the
supply has the proper protection and is insured against
some future contamination. The keynote of modern
medicine is not cure but prevention. This can well be
applied here. We can cure a contaminated water sup-
ply so that it will be safe to use, but unless we inspect
and locate the source of contamination we cannot pre-
vent future trouble. If a supply of water is safe today,
it does not necessarily have to be safe tomorrow unless
the construction features are such that it would be im-
possible for contamination to enter. This especially
applies to well water supplies. In other words, we can
sum up the whole situation by saying that a bacterio-
logical analysis should be interpreted in the light of a
sanitary survey. Proper location, construction and
operation is of much more importance for assuring
a good water supply than a laboratory examination.
If all private wells were properly constructed and
located, one could assume with much confidence that the
water would remain safe for human consumption.

In such a case, a bacteriological examination can be
used as a check on the water supply. On the other
hand, an improperly-located or constructed well will
always be subject to contamination, and a bacterio-

THE JOURNAL-LANCET

logical examination in such a case would not have
much significance. One sample might be good and
another bad, depending upon when it was collected.
Naturally, the situation we hope for would be
to have all wells properly-constructed, and until this
is done we can not expect to have any sense of security
as to the water supply.

In conclusion, I might say that the laboratories can

be of great assistance to the physicians in North
Dakota. The laboratory knows the desires of the
physician and consequently is constantly striving to
improve its methods, in order that it may give service
of the highest quality. We are ready to assist you and
our hope is that you, the physicians of North Dakota,
will make use of the Public Health Service as it is now
given in our laboratories.

Student Health Practice*

Charles E. Lyght, M. D.j'

Madison, Wis.

STUDENT Health service, that began so
humbly many years ago as a well inten-
tioned but probably to many a doubtful
adjunct of what was then a big-muscle and
bath-once-a-week program, has grown until it
occupies a prominent place in the educational
scheme of most important schools, large or small,
on this continent. Now we see the triad of student
health, informational hygiene, and physical edu-
cation working side by side in common effort to
protect, preserve and improve the physical and
mental welfare of our students.

Pressure from within and without the student
health organization is slowly but surely altering
its conformation, and it must retain its faculty of
flexible adaptability if it is to cope with modern
demands, just as its power of stretching itself
thin enough during the days of depression en-
abled it to cover needs no one believed would ever
become as broad as they have.

The changing order of things is at once a chal-
lenge and an opportunity to student health serv-
ices everywhere to make friends rather than to
lose them. It must never be forgotten that health
service work is a vital sector of a united medical
front line. Strictly within the ranks of a socially
adjustive medical profession is where it belongs,
and by a preservation of high standards, by an
insistence upon unimpeachable ethics, that is
where it will remain. Our brethren practising in
other fields of the profession are learning to trust
and recognize legitimately conducted student
health endeavors, because they identify our
efforts as established and moving upon a high
plane. Through constant co-operation with family
physicians and parents, health services everywhere
should be found stimulating confidence and allay-
ing what prejudices may have existed previously.
Student Health work, properly conducted, is not
in any way competitive with organized medicine.
It is one important division of organized medi-
cine, performing specialized services for limited

'President’s Address, North Central Section of the American
Student Health Association, Northfield, Minn., May 22, 1936.
tFrom the Students’ Health Service, University of Wisconsin.

groups with a degree of efficiency not possible
through unco-ordinated agencies.

The value to the public and the profession of
the information constantly being accumulated by
alert student health departments as they perform
their primary functions of careful examination
and periodic rechecking of the apparently normal
toward the discovery of the incipient defect, is
incalculable. We are learning that a careful his-
tory of functions, of attitudes, of tendencies, is
as essential as any number of minute examinations
of parts. We are demonstrating in our patients
a woeful lack of real, practical, applied health
knowledge, and in the course of our duties of
examining, and advising, and compiling — not
merely statistics, but painstaking records — we are
gaining a first-hand acquaintance with those pre-
clinical signs of early disease that antedate the
text book picture and far precede the symptom.
I can visualize “preceptorships,” if you will, set
up in our departments and designed for medical
students, enabling them to learn the technique of
pre-clinical diagnosis, just as now they visit the
lying-in hospital to be instructed in the art of
obstetrics.

We are convincing ourselves as well as our
patients of the benefits of properly selected cor-
rective measures, begun at stages that promise
results. We are the daily practitioners of all
that immunology has to offer. Our efforts in the
realm of the early diagnosis and consequently
earlier and more certain cure of pulmonary
tuberculosis are bearing fruit in the shape of
lives preserved, of contacts and infection pre-
vented, of dollars and years saved, of beds made
sooner available for other victims, than where
formerly, late recognition and uncertain prognosis
was the reward of him who discovered cases only
because of their symptoms or physical findings.

Time and the depression have served to em-
phasize the need for expert neuropsychiatric ad-
vice for students maladjusted to their environ-
ment, or failing before the overwhelming on-
slaught of abnormal circumstances. The trend is

THE JOURNAL-LANCET

toward providing specialists experienced in this
branch of medicine, even though the supply still
lags far behind the demand. Deans, students, and
college health directors are as one in calling for
availability of this type of care.

The teaching of college hygiene, if geared for
progress, must embrace more of the theoretical at
the same time that it takes in more that is practi-
cal. Science is marching on. I believe we are
finally dispelling the mists instead of deepening
the mysteries. We must teach a technique and
not merely a text! A speaker I heard recently
said that we are now giving peopb prescriptions
for health “with the formula printed on the label."
We have passed the “brush-your-teeth” stage and
into the “see-your-doctor-early” period. This will
be successful, however, only if every doctor is
both by training and by attitude ready to be seen
by those who are still well and want to stay that
way. It will be time wasted if the physician
slaps an earnest man on the back, indulges in a
tolerant chuckle over his patient’s foolishly pre-
mature visit, and counsels him to return when he
really feels sick. If we are planning on giving
people “hygiene that’s loaded,” we must be pre-
pared to take the consequences if some, disil-
lusioned, throw it back at us just before it ex-
plodes. We must not allow patients in whom we
have laboriously developed an up-to-date preven-
tive consciousness, to revert, as one man puts
it. to the negligent state where they are content
to drop in at the doctor’s office for a friendly
chat on the way to the cemetery. A hygiene
lecture course without supplementary laboratory
work and practical example by a live, coincident
college health program, is destined to produce
almost as paying results as an appeal for col-
lection during a broadcast church service. The
listener means to do something about it, but he
never quite gets round to doing anything about
it. We have failed as physicians and as educators
if we send out graduates unprepared for modern
concepts of the best in medical care, and for
co-operation with doctors thinking in like terms.

I can visualize the time not far distant when
students will no longer come to our hands as
largely unassayed raw material, but rather as the
recognizable product of an unbroken chain of
expert medical supervision. This chain will have
its first link in the prenatal clinic, and will be
added to through grade and secondary schools,
with the family doctor and the school physician
and nurse engaged in an increasingly successful
co-operative venture of seeing to it that boys and
girls “fit for college” matriculate into our class-
rooms and our student health services. The im-
petus for this working backward to first prin-
ciples must arise in the direction, to those re-
sponsible, of the properly expressed dissatisfac-
tion of the college health officer with the all-too-
frequent mental and physical wrecks now strewn

through the freshman years. As long as we ac-
cept without protest medical risks that would
draw roars of pain and indignation from edu-
cators in other departments were the physical
defeats duplicated by academic lapses in prepara-
tion, little will be done about it, and that little
will be done slowly. An advanced tuberculosis
or a burned-out neurotic at entrance to college
will some day be considered no more a credit to
home or high school than the “dumb-bell’’ who
fails to hurdle his first mid-semester examinations.

I hold to the view that faculty and employee
coverage by our departments should be primarily
for the protection of the health of the students,
unless facilities are so extensive that both groups
can be supervised without slighting either. Ex-
amination of food handlers within the college,
however, and the diagnosis of communicable dis-
ease in the staff are functions not to be side-
stepped by us ; and, for the protection of the
individual and the college, first aid for occupa-
tional injuries seems distinctly our duty.

I will not go so far as to say that it is better
for a college to have no student health service
than to have a poor one, but I do reiterate a
warning that no institution is entitled to pretend
to a health program it is not prepared to support
or equipped to conduct. Funds available will in-
evitably determine that degree of equipment,
physical or professional, with which the work
must be carried on, and this will automatically
set the boundaries of the student health program.
Therefore, the only occasion an apology need be
forthcoming is when the load so overtaxes the
service that the latter either is forced to operate
without the factor of safety work of such gravity
demands, or actually breaks down and functions
not at all. The student health director who has
the chance of choosing between quantity and
quality of practice will unhesitatingly and un-
erringly make the proper choice if assured of the
sympathetic support of his college administration.
He should surely see his requests for equipment
met with the same generosity accorded those of
the Chemistry professor. He should no more be
asked to examine or treat an impossibly large
number of patients, than would his confrere in
English be required to teach groups unwieldy
beyond his powers or their welfare. Re-adjust-
ment to accommodate temporary stresses is legi-
timate, and must be done gracefully, but working
indefinitely at serious disadvantage is a short-
sighted policy not supportable in the light of the
health at stake.

In these days when so much of early diagnosis
depends upon the clinical laboratory, its findings
intelligently evaluated, there is no excuse for at-
tempting to practice without the best laboratory
facilities our budgets will permit. Otherwise we
are deluding and handicapping ourselves and
working a hardship on those we must protect,

THE JOURNAL-LANCET 25

just as the man who, because he was brought up
on the stethoscope, still stubbornly exalts it above
the Mantoux test, the X-ray film, and the fluoro-
scope as the detectors of tuberculosis in its earliest
recognizable forms.

It seems definitely necessary for colleges to
provide infirmary facilities or arrange for equiv-
alent hospital care if early diagnosis is to be fol-
lowed by prompt treatment at reasonable expense,
and if the well are to be protected by immediate
segregation of those suffering from communic-
able disease.

Where, in small college communities, hospital
facilities are totally lacking or unfortunately
meager, the college may well decide to take the
initiative in compaigning for an adequate hospital.
With the support of town, gown and physicians,
a structure and a service may be achieved quite
impossible of attainment through divided effort.
In such a set-up, the modernly conscious local
physician and surgeon will be found working
shoulder to shoulder with the college health
officer, and instead of any possibility of jealousy
or misunderstanding separating them, co-opera-
tion and friendship will dovetail and cement their
mutual responsibilities, with profit to all con-
cerned.

No student, in my opinion, should be asked
to contribute funds toward the erection of perma-
nent student health clinic or infirmary facilities,
or their equipment with basic necessities, unless
that portion of his health fee is kept optional. He
should be expected to pay only that fairly pro-
portionate sum that will guarantee him reason-
able protection and intelligent health supervision
during his stay intramurallv, plus a small addi-
tional fraction to insure against unpredictable
epidemics. The college, in the light of accumu-
lated experience and present sociologic and eco-
nomic standards, owes those within its walls
establishment of fundamental student health serv-
ices with all the certainty that it is expected to
provide classrooms, laboratories, heat and light,
or a playing field and gymnasium.

Where colleges find their resources unequal to
financing what they have learned would be gen-
erally considered an adequate modern program of
preventive medical supervision of their students,
they should not flinch away from the problem
under the possible misapprehension that these
students will rebel against an assessment suffi-
cient to guarantee it. The solution would seem
to lie both in securing basic funds from budget

sources, and then in enlisting voluntary co-opera-
tion of the students, who, in my experience, are
eager to assure themselves of readily available,
high class medical coverage at a fee commen-
surate with the modest sums most must rely upon
for the needs of a school year. Parents, too,
will generally be found heartily endorsing any
plan that provides competent, uniform medical
advice, and supervision up to a reasonable point,
for young people temporarily denied the home
and the family physician’s personal care. Too
many schools are marking time on the student
health front because they hesitate to increase the
health fee to a workable level, even though the
per capita levy would not be significantly raised
compared with the extra protection assured each
individual. They fear to cause even a mild dis-
location of the total fees, lest next year’s paying
guests be frightened away, when, actually, new
students would be attracted to colleges known to
possess up-to-the-minute facilities for the preven-
tion or early recognition of disease, and for its
immediate care, if found. Crippling expanse de-
veloping out of accident or illness may not in-
frequently interrupt or demolish a college career,
where a dollar or two added to the health fee
would obviate such a disaster, and provide the
same or better services.

Finally, I must say that I believe every insti-
tution of higher learning, always depending on
local conditions for the outline its program must
assume, should arrange for at least part-time well
trained medical supervision of its students. A
nurse is not sufficient ! No nurse should be ex-
pected or required by any school to perform
functions a physician would forbid were he pres-
ent. Frankly, such undue delegation of respon-
sibility is not only dangerous, it is illegal. The
essance of prevention, we teach over and over,
is in early consultation of the physicians by the
patient. Availability of service is admittedly what
makes such a plan operate. Early consultation,
however, inevitably slackens off in the face of
restricted or haphazard or prohibitively expen-
sive contact with physicians trained to think in
the terms I have outlined. But before any stu-
dent health program is ready for its launching,
it should be recalled by college administrators
that it is still true in this field as in all others
that “the laborer is worthy of his hire.’’ Student
health personnel, performing vast services of
high importance, serving and protecting student,
parent, college, community and nation, should be
properly paid.

THE JOURNAL-LANCET

An Address*

Elliott P. Joslin, M. D.,

Boston, Mass.

CHAIRMAN Hopkins, Ladies and Gentlemen,
Members of the inter- Allied Groups: I am very
happy indeed to be here. I never have been in
this part of the country before, and was much interested
in it and still more in the people who live here. I
approve of this idea and believe strongly in it. I am to
finish in 15 minutes, less time than put down for me,
out of regard to those gentlemen I want to hear.

It is pleasing that the dentists are in this group, be-
cause they are very important factors in the treatment
of diabetes. Each patient I have who enters the George
F. Baker Clinic is examined by a dentist. I know an in-
fection makes the diabetic worse; therefore while- in the
hospital each patient must have his teeth examined so
the source of trouble can be removed. We do it whole-
sale. The patients do not have so much money. Each
patient is examined by a dental hygienist who looks the
patient over. If in doubt, the patient will have an
X-ray of the teeth. The patients get free examination.
At first I subsidized it from other people — $1500 to
M800 a year. Now the Dental Department takes care
of itself.

If it does not seem there is need for a dentist to look
over them, he does not do so. If the patients need to
have their teeth cleaned, it is done for nothing if they
are unable to pay for it; but two or three dollars —
whatever the regular amount — is charged those able to
pay. The only dental work we do in the hospital is
the cleaning and extracting of teeth. Poor people get
their teeth extracted for nothing, generally right in the
hospital. Between 600 and 700 teeth are extracted for
my diabetic patients each year. That is done wholesale
so that we can have it done well.

Dr. Minor, Dean of the Harvard Dental School, and
Dr. Kent are on the staff. If there is a question of anes-
thesia, the dental hygienist looks it up. A dentist sees
the patient and extracts the teeth, but never sees him
again, because the hygienist takes care of him after-
ward. By doing wholesale work and working with the
dentists we are able to get expert care for the poor, and
those in moderate circumstances, and those well-to-do.
The scheme works so well it is "off the boards.” It pays
for itself.

There is a group which is not in this assembly. I
refer to the chiropodists? They are a great help to us.
Perhaps foot trouble does not exist to a great extent in
South Dakota. You do not have as many old people
to get corns and callouses, so you do not need the chiro-
podists. Just wait. Everyone is growing older, and by
and by the South Dakota folks will get old enough to
need the chiropodist, too. These organizations provide
for diabetic feet, and keep them in good condition.

Read before the South Dakota State Medical Association meet-
ing he.d at Sioux Falls, S. D., May 4 — 6, 1936.

We do not take care of their faces. That’s up to them.
Mr. Shearer gave me the money to organize the foot
parlor, and it now takes care of itself. That is the
fundamental need in the United States today — to start
things strong enough to support themselves when started.

In addition to the dentists and chiropodists, we have
our nurses. They are indispensable in the treatment of
diabetics. In the hospital we use the nurses to teach the
patients. We have a nurse in the hospital who teaches
each individual patient either in her office or at the
patient’s bedside. Besides that, she teaches all the nur-
ses diabetic nursing. We depend on nurses especially,
rather than dietitians, although last year we had two
dietitians. They really were very useful. We de-
pend chiefly upon the nurses because we must have the
patients taught a proper diet. That is only a minor
thing. We teach them to avoid coma and avoid gangrene,
and adjust themselves to the various exigencies which
come up in their lives. Nurses belong with any diabetic
group.

We have a wandering diabetic nurse. That idea
appealed to one of my friends. He gave me a thousand
dollars toward her support. She is most useful. She
goes to the homes of our children. We have over one
thousand children — about 900 scattered about the coun-
try. She may take a circuit through Maine, New
Hampshire, and Vermont. Once this wandering dia-
betic nurse was given an assignment to see 21 families.
She lived two days with each family. We wrote in ad-
vance to the doctor of the patient she was going to see.
Under the sponsorship of the association, she helped
that family in the care of the diabetic child.

Of the 21 homes, one paid her something as a salary,
and one paid her fare from the previous city to the next
city. We think she was very helpful.

We have changed a bit on that. This wandering
diabetic nurse now goes to the older patients — 65 years
of age and upward. When they go home after opera-
tion or treatment for gangrene or infection, she goes
into their homes and visits them and sees they are getting
along alright with their artificial legs. She is a tre-
mendous asset.

I was caught once with a child in a well-to-do family,
and no one but the wandering nurse to go there. They
sent me a thousand dollars, and have paid for a wan-
dering diabetic nurse ever since. That’s what she will
do for the people.

As to the hospital administrators, you are here. I
have something to say about them. The ordinary patient
can pay his board the first week in a hospital. Some can
pay the second week, if a small amount. After that
they are in trouble, and the hospitals are able to collect
bills that doctors never would collect. The hospitals col-
lect bills better than the doctors because they are im-

THE JOURNAL-LANCET

personal institutions. What is the point about that?
It is this: Our children cost upwards of $30 a week.
We can take care or but a few in the hospital. Dr.
Priscilla White will have 170 diabetic children in camps
at $10 a week. That’s the way we have solved the
children’s hospitalization problem.

At the Prendergrast Preventarium, with the contacts
who do not have tuberculosis but might get it, they took
30 or 40 children last summer, and had 75 this sum-
mer. This winter we had a lot of poor diabetic children,
and we went to the State of Massachusetts, to the Board
of Health and Welfare Boards of the towns. We nicked
up our poor diabetics and took them to the Prendergrast
Preventarium. We had a dozen children — practically
a diabetic boarding school. When one of these children
developed pneumonia, we took it to the hospital.

One more word. The laboratories and technicians
are in the hospital. We believe in the intimate relation
of the laboratory with the patients and doctors. We
can get laboratory work for nothing, if necessary, to a
certain extent. The doctors can not do it in private
practice. The State Commission appointed to revise
our health laws — such men as Green, Minot, and Osgood
— and in association with such authorities we formulated
a plan for various chronic diseases. We felt there
should be in perhaps ten or twelve places in Massachu-
setts arrangements by which the hospital could be sub-
sidized, so that a doctor could get blood sugar tests at a
reasonable rate. In this hospital they should have a
wandering diabetic nurse who not only teaches diabetic
nursing in the hospital, but who can be called upon to
help the doctor in his office. We have 15,000 diabetics
in Massachusetts. I think ten nurses would handle the
wandering diabetic nurse situation pretty well. Thar
would mean 1500 diabetics to one nurse. Many of them
would not need training.

The advantage of having certain centers where a
doctor has a chance to get health work if he needs it,
where he can get a nurse to teach his diabetics when he
does not have time, and a hospital where this unit is
organized, so that if you have a case of diabetic coma
you can send the patient to the hospital and get up-to-
date attention and tests within an hour of admission, is
obvious.

In one hospital in New York City they locked the
laboratory Saturday and opened it Monday morning.
That time is past. In obstetrics you do not say "No
one shall have a baby from Saturday night until Mon-
day morning;” so you can not tell a diabetic, "You
can’t get into trouble for the same period.” The tech-
nicians have found out they are no better than the
doctors who must see a woman in labor. Any technician,
I am sure, if it is presented to her properly, will be glad
to work day or night and save the life of a diabetic
patient who goes into coma.

Now as to the doctors, I have 300 who are diabetics.
There are about 100 of them dead. My diabetic doctors
last year lived on the average 11 years. I talked in
Pennsylvania, and next week I had a doctor from
Pennsylvania, 75 years old. He said, "I heard you sav

your diabetic doctors lived 1 1 years, and I have come
for treatment.”

I will tell you something new and striking. The last
93 1 of my diabetics who died preceding a year ago, died
at the average age of 63 and doctors die at this same age.
We have recently looked at my diabetic doctors again.
The last 32 who have died were 68 years old. How many
had coma? We know children can be gotten out of
coma. One-half of them may get it. If they have
good cooperative treatment of nurses, technicians, hos-
pital administration officials, and doctors, they will get
out of coma. With old people that isn’t so easy. Up-
wards of 30 per cent may die. Of coma cases, 10 per
cent may die. Just one of my doctors died of diabetic
coma. If the doctors won’t die of coma, the patients
may take for granted death from diabetic coma is un-
necessary, and ask the doctors to do as well by them.

I spoke this morning at the session on the increase
in diabetics. Diabetes has gone up tremendously be-
cause, in the first place, the people are older. I told the
group this morning that in Boston in 1840 about 80
per cent died under 40 years of age. This last year 80
per cent in Massachusetts died over that age. We may
not have all kinds of subsidies for farmers, but we are
raising up a crop of old people so that when they get
their old-age pensions we can get the benefit of them.
In the first place, there are twice as many diabetics over
as under 40. In the second place, it is the duty of every
diabetic to examine the urine of all the members of his
family and see if they have sugar; if so, send them to a
doctor.

Once I had a diabetic come to my office and we taught
her to do the Benedict test. She had a boarding house.
She tested the urine of all her boarders and found a
diabetic boy. That patient eventually came to me. I
asked him how he found out he had diabetes, and he
told me. Eleven days after she went home she con-
tracted pneumonia and died, at the age of 79. If a
woman of that age, with one visit to a doctor, will do
the urine of everybody in the boarding house and find
the one who has diabetes, certainly anyone ought to be
willing to test the urine of his relatives. That’s the way
to detect it. The disease is hereditary. Of diabetic
patients between 50 and 60, practically 99 out of 100
are fat.

How can a doctor retain his diabetic patient? When
a patient comes to a doctor, the doctor must tell that
patient more than the patient has read in newspapers.
The doctor must read his medical journals. Diabetics
pick up a lot of information in the newspapers, and it is
good. No doctor can keep his patient unless he knows
more than is in the newspapers, and each time the patient
comes, the doctor can tell him something that is bene-
ficial. One can not treat diabetics by giving prescrip-
tions. It is plain hard work and time and patience.
It is a great thing for doctors to keep them alive. For-
merly the patients lived a short time; now they live a
long time. We can safely say any diabetic going to a
doctor in the early stage of his disease will certainly
have an expectancy of 20 years. A child coming down

THE JOURNAL-LANCET

with diabetes will have an expectancy of 30 years.
These figures have been worked out by the Metropolitan
Life Insurance Co.

This morning I talked to a group of 23 diabetics.
Up to 1914, my diabetics lived 4.8 years. In 1922, that
figure crept to six years. The group this morning had
been diabetic over six years. This group before 1922
would have been dead. Now they are alive. When a
diabetic comes to the office of a doctor, if the diabetic
is young, the chances are he will bury the doctor.
Doctors only practice on the average about 30 years.
Diabetes is such a good disease for the doctors because
the quacks do not get a show at it as they did years ago
— thanks to F. M. Allen. He emphasized the import-
ance of examining the urine for sugar. If the patient
who has diabetes takes a patent remedy and sees the red
test, he knows the medicine isn’t doing him any good.

Last year we made a survey of diabetes in Boston.
Dr. Lynch, just out of medical school, said he would do
it. We only had $500.00. I told him I felt each dia-
betic in Boston should be investigated. They could not
do that in New \ ork City. W'e had 301 diabetics in
Boston last year. There were twice as many females as
males. Women over 40 must not get fat. Of this
number, 80 per cent were married. The reason married
women have diabetes more than single is because they
weigh 20 pounds more* than single women. I think it
is not due to the men but to the pounds.

This is the only consoling thought from that record:
No diabetic in Boston died last year under 19 years of
age. We found 41 cases of coma. Of the total of
301, 165 died in hospitals. In eight hospitals, 141
died. We doctors got together and got a surgeon there.
Dr. Lynch picked out 36 he considered had the least
cause for dying. We passed their case histories around
and each doctor read four cases to the others. We
decided we hospital doctors had better treat all comas
more promptly, and look after our surgical patients.
Then we can go to the laity. In the hospitals there
were only 21 autopsies.

Some one asked me to say something about the
management of pregnancies. Any diabetic woman who
becomes pregnant needs careful watching— at least
twice the ordinary care. For the last month of the
pregnancy every case, but certainly primiparae, should
be in the hospital because these cases change in a mo-
ment. One of my nice diabetic girls in Brooklyn married
the son of a doctor. She walked into her father-in-law’s
office in an uremic convulsion, and lost the baby. This
year I have seen a diabetic woman pregnant who had
lost her first baby. She came to the doctor to save her
baby. Her blood pressure was 120 until it registered
160 one night at five o’clock. We had a caesarian sec-
tion at six o’clock.

We have an elaborate, up-to-date arrangement for
keeping them warm. We have oxygen and carbon
dioxide for stimulating respiration. We have an aspira-
tion apparatus. Why do they die? For various reasons,

such as delay in performing the caesarian, asphyxia, and
they may die with hypoglycemia. Several times Dr.
White has given glucose subcutaneously with good re-
sults. All babies when first born have low blood sugars.
That may not be the whole reason.

As to state medicine in diabetics, I think this disease
can not be put in with state medicine except as I have in-
dicated by educating the doctors. Diabetes is a personal
disease. It is peculiarly a disease for a good doctor.
He knows about the family and the hereditary influen-
ces and can detect the new cases and warn against
obesity and all that. The diabetic must have confidence
in his doctor who can follow through the diabetic’s life.
In this day of chronic disease, upon investigation, we
found the diabetics were the ones who had doctors.
Only a small proportion of the rheumatic patients had
doctors they cared for. Cancer and heart disease were
down in the list.

There are 500,000 diabetics in the country. We may
expect 3,000,000 will develop diabetes before they die.
We must get across to the diabetic patient that he
carries the welfare of the other 499,999 each day. If
he lives correctly, he helps another diabetic. If he is
careless, he injures all the diabetics. One of my boys
was arrested for drunken driving. He wasn’t drunk.
He had an insulin reaction. The police doctor wanted
to know if the "Old Doctor” — meaning me — was there.
I don’t like that term. He said, "I never saw an insulin
reaction like that.” If two other diabetics had a similar
accident while driving, it wouldn’t be long before the
police would say. "No diabetic should run an auto-
mobile.”

I am glad to say diabetics are bright. One of my
diabetics was among the first six in his class at Harvard.
Their children will not transmit the disease if they
marry non-diabetics in non-diabetic families.

I like to have my diabetics look well. My next to the
last coma case would come along, all painted up. Never
discourage a diabetic from looking well. We want them
to be independent and self-supporting.

Protamine insulin is wonderful. I have treated more
than 900 cases with it. The variety used most has been
the protamine zinc insulin, which I hope will go on the
market soon.

We have been under the spell of the old insulin. With
the old insulin, diabetic coma dropped almost to the
vanishing point. But protamine insulin shows new ex-
periments can be done with it. We think the diabetic
patient can be put back more nearly to a physiological
status. It is the fact we have a fresh outlook which is
of most value in the discovery of protamine insulin. We
ought to give the name of the era to the one who made
this new outlook possible — Dr. Hagedorn, of Copen-
hagen.

THE JOURNAL-LANCET 29

Urticaria*

Carl W. Laymon, M. D., Ph. D.

Minneapolis

URTICARIA, though easily diagnosed, often
presents a most perplexing problem in
finding the etiologic agent, and since
successful therapy usually depends largely upon
removal of the cause, its discovery should be the
chief goal in every case. The purpose of this dis-
cussion is to analyze and summarize the reports
of various workers who have studied large series
of cases, in order to form a systematic method
of investigating the condition. When a patient
with urticaria presents himself for advice it is
not sufficient to prescribe an antipruritic lotion,
adrenalin or calcium. If any degree of success
is to be attained, a painstaking history must be
taken with special attention to details which may
on the surface seem irrelevant.

According to Coca,1 the primary urticarial
lesion (wheal) may be either allergic or non-
allergic in nature. Allergic urticaria, in turn, may
be atopic (reaginic) or non-atopic (non-reaginic),
depending upon the demonstration of anti-bodies
in the serum of the affected patient and the co-
existence of other atopic manifestations such as
asthma or hay fever. Taub and White2 classified
urticarias in essentially the same way into two
distinct groups :

I. Urticarias associated with mucous mem-
brane lesions such as hay fever and asthma
(atopic). In this group, usually caused by foods,
passive transfers are positive and the lesions can
be reproduced by ingestion or rectal administra-
tion of the offending excitant.

II. Urticarias without coincident mucous mem-
brane affection, usually due to drugs, serum,
various intoxications and, according to Taub and
White, foods only rarely (this includes both the
non-allergiq and non-reaginic urticaria of Coca’s
classification). Localized urticaria is usually of
the contact type, the lesions being caused by the
direct effect of irritants which come in contact
or are injected into the skin, such as nettles,
caterpillars, insect bites or stings, certain plants,
wool, etc.

Causes of Generalized Urticaria

1. Foods: Hopkins and Kesten3 believed foods
to be the most common cause of acute urticaria
but only occasionally a factor in the chronic
form. As Taub and White brought out, urticaria
due to foods may be either atopic or non-atopic,
the acute types such as those caused by un-
common foods (strawberries, shell-fish, etc.) be-
ing non-atopic as a rule. In certain cases food
is an important but not the only factor. Eichen-
laub,4 in a series of 58 cases of urticaria, be-

• From the Division of Dermatology, University of Minnesota,
and the Dermatology Service, General Hospital.

lieved food to be the chief but not always the
sole cause in 20 cases. In the series of 100 cases
analyzed by Stokes, Kulchar and Pillsbury,5
food intolerances were usually found associated
with other causes. Fink and Gay6 studied 170
cases of urticaria, of which 20 per cent were
considered allergic (not necessarily atopic).
Seventy-five per cent of these patients were
cured by avoiding the specific allergens to which
they were sensitive (chiefly foods but also in-
halants). In discussing this paper, Vanderveer
expressed the opinion that milk, chocolate, and
shell-fish were common offenders. Rowe7 be-
lieved that food allergy should be considered in
all cases of angioneurotic edema and cited 14
examples which were controlled by elimination
diets, one or more foods being the causative
factor.

LTrticaria due to food usually appears within
an hour or two following ingestion. In some in-
stances the quantitative factor enters in and the
lesions may appear only after excessive amounts
have been eaten and several days have elapsed.
The quantitative element in such cases is com-
parable to that in urticaria following the injec-
tion of serum.

In non-atopic urticaria due to foods, skin tests
are of no value. Rowe,7 in studying a group of
20 patients with urticaria, found that skin tests
were entirely negative in 35 per cent. The skin
of certain patients is so dermographic that the
slightest trauma causes wheal formation, making
testing impossible. Elimination diets in urticaria
due to foods offer a much greater chance of
success than cutaneous tests.

2. Drugs: Within recent years medications
have been mentioned as one of the chief causes
of urticaria. In discussing the paper by Fink and
Gay;6 Vanderveer, Rackemann, Cohen, and Sulz-
berger all emphasized the etiologic importance of
drugs. Of 58 cases which he studied, however,
Eichenlaub4 found drugs to be the chief cause
in only two instances. Almost any compound
may give rise to urticaria, although quinine,
aspirin, allonal and luminal are among the most
important. Urticaria is one of the prominent
symptoms of serum disease.

3. Infections: The association of urticaria with
various bacterial and mycotic infections is occa-
sionally observed and there have been numerous
reports of cases due to infected teeth, tonsils,
sinuses and gall bladders. Fink and Gay8 be-
lieved that 30 per cent of their 170 cases were
traceable to foci of infection. Seventy-four per
cent were completely cured by appropriate
therapy. Menagh8 felt that biliary tract infection
was the chief cause in 48.8 per cent of 260 cases

THE JOURNAL-LANCET

of urticaria which he studied, and at least a con-
tributory factor in an added 11.2 per cent. With
this in view, 45.2 per cent of the patients were
completely relieved and 38.6 improved, leaving
16.3 per cent who obtained no benefit from treat-
ment. Eichenlaub4 thought that foci of infection
constituted the chief cause in 14 of 58 cases
which he observed. Among the infections were
colitis, pyelitis, and breast abscess. Cohen ex-
pressed the opinion that the intestines may harbor
a focus of infection and that relief from urti-
caria may be obtained by autogenous vaccines
prepared from the intestinal bacteria in these
cases, combined with changing the flora with
sodium ricinoleate and acidopholus therapy.

4. Constitutional (Metabolic) Factors : Among
the various constitutional causes which have
been associated with urticaria are constipation,
endocrine disorders, renal disease, and gout.
Eichenlaub4 stated that constipation was the
most common contributing cause for the con-
dition in 58 cases which he studied. Among other
causes which he found were pregnancy in two
cases, cirrhosis of the liver (one), nephritis
(one), and malaria (one). Hopkins and Kesten,3
however, attached little significance to constipa-
tion in urticaria, since it is a so common and im-
measurable complaint.

Criep and Wechsler9 and later Criep10 thor-
oughly studied 40 cases of urticaria as to the
relationship of gastro-intestinal changes, thyroid
function, the acid-base balance and blood chem-
istry. They concluded that changes in gastro-
intestinal and thyroid function were for the most
part co-existant with, contributary to, or as a
result of the urticarial state. The lack of spe-
cificity of such changes led to the belief that
there was no direct relationship. They mentioned
the division of opinion as to whether urticaria
was associated with acidosis or alkalosis but
could find no significant changes in the CCU
combining power of the blood in any instance.
The blood sugar, non-protein nitrogen and urea
values were consistently normal. No abnormal
deviations in blood calcium were discovered,
though they felt that calcium therapy was of
some value in allergic disorders due to its efifect
on the nervous system. Ramirez11 also studied
the value of calcium in 50 cases of hay fever and
was unable to find calcium deficiency in any case
or note any instance where calcium therapy was
of any permanent value. Temporary improve-
ment, however, was noted in some patients. He
cited the work of Criep and McElroy12 which
substantiated his findings and that of Sterling,13
Brown and Hunter14 and others which disagreed
with his opinion.

Fink and Gay6 classified only 5 per cent of
170 cases as endocrine in origin, including dis-
orders of menstruation, pregnancy, the meno-
pause, and hyperthyroidism.

5. Inhalants: Urticaria due to pollens or other
inhalants may or may not be associated with
atopic conditions such as hay fever or asthma.

For example, Taub and White2 observed a
patient who had urticaria on the legs every sum-
mer from June 15 until fall. Although there was
no associated hay fever, skin tests to grass
pollens were positive. The avoidance of tennis
courts, golf links, etc., relieved the condition.

Sternberg,15 on the other hand, reported a
case of urticaria associated with hay fever.
Cutaneous tests with ragweed extract were posi-
tive and both conditions were relieved by appro-
priate pre-seasonal treatment. At the time of the
report Sternberg was unable to find a similar
case in the literature.

6. Intestinal Parasites : Ascaris, hookworm,
echinococcus or other intestinal parasites are
more frequent etiologic factors in chronic than
acute urticaria. M. Walzer16 mentioned that
reagins could sometimes be found in the blood of
these patients (passive transfers positive). The
study of patients with chronic urticaria should al-
ways include examination of the stools.

7. Cutaneous Manifestations of Physical Al-
lergy: The term physical allergy (“altered re-
action to physical agents”) was applied by
Duke17’ 18< 19 to such allergic manifestations as
urticaria, asthma, coryza, and weakness which
are brought about by mechanical irritation, heat,
cold, or light. The resulting reactions may in
general be immediate or delayed and localized
or generalized. Patients, as a rule, react to only
one of the physical agents.

The exact causes of the specific reactions to
physical agents are as yet unknown. Bray20 felt
that each type probably has a specific chemical
basis and mentioned that the skin may be sensi-
tized to light by the intravenous injection of
hematoporphyrin and that the effect of cold
allergy can be produced by histamine.

The same general principles of therapy apply
in cases of physical allergy as in other allergic
disorders : avoidance of primary causes, treat-
ment of associated illnesses, symptomatic meas-
ures, and finally specific therapy with the causa-
tive agents, such as heat, cold, etc., as the case
may be. In all, however, exposure to the cause
with small initial but gradually increasing dosage
is the basic principle just as in other allergic
diseases. Alexander21 cited the work of McKenzie
and Baldwin, who showed that the ability of the
skin to produce an allergic reaction became
exhausted after repeated injections of the allergen
at the test site. Duke18 stated that therapeutic
measures were reasonably successful in a majority
of cases and brilliant in selected cases.

8. Psychogenous Factors : In a recent de-

tailed article, Stokes, Kulchar and Pillsbury5
reported the results of their studies in 100 cases
of urticaria with special reference to psychogen-

THE JOURNAL-LANCET

ous factors. They found abnormal psychoneuro-
genous elements in the background of 83 per
cent of their cases as compared to 24 per cent
in a control series of acne, psoriasis and impetigo.
However, these factors, principal of which were
the tension make-up, neuroticism, the worry habit,
shocks, family troubles and finance, appeared in
a great majority of the cases in combination with
other possible causes such as food intolerances,
foci of infection, etc. In only 12 per cent was the
psychoneurogenous factor the sole recognized
cause. The authors believed that urticaria was a
disease of complex rather than single causation.

Sulzberger, in discussion of the paper of Fink
and Gay,6 expressed the opinion that to classify a
case of urticaria as psychogenous was the “em-
blem of allergic defeat.”

Papular Urticaria and Prurigo Mitis

The relationship of papular urticaria and
prurigo mitis to allergy was recently studied by
A. Walzer and Grolnick.22

The term papular urticaria was first used in
1860 by Hebra, though Willan in 1798 had de-
scribed and named the same condition strophulus.
Bateman, a pupil of Willan, thoroughly described
the disease under the name lichen urticatus. Many
other appelations have since been used.

French dermatologists led by Bazin, considered
papular urticaria a mild type of prurigo and
classed the two entities together, whereas the
German school at the time of Hebra thought of
the condition as a variety of ordinary urticaria.
The English were divided in their opinions. The
Americans, until the past few years, supported
the German view. More recently there has been
a tendency to class papular urticaria and prurigo
together.

The original prurigo which Hebra separated
from a number of itching dermatoses in 1860 was
regarded as an extremely chronic, incurable,
pruriginous, papular dermatitis. Kaposi later de-
scribed a milder type (prurigo mitis) which was
considered curable. The latter type is that which
was included in the study of Walzer and Grolnick.

The differential diagnosis between papular
urticaria and prurigo mitis cannot be made until
the characteristic prurigo papule appears, as both
conditions begin the same.

The following table illustrates the differences
in the two conditions :

PAPULAR URTICARIA

PRURIGO MITIS

Onset :

First year of life.

Lesions:

Papules, wheals.

Uniform, pale, conical papules.

Secondary Changes:
Slight.

Many. Lichenification, infec-
tion, excoriations, scars.

Distribution:

Evenly on the extremities.

More intense on forearms and
thighs.

Constitutional Symptoms:
Negative.

May be anemia, nervousness,
malnutrition.

Duration :

Shorter than prurigo.

Persists usually till puberty.

Walzer and Grolnick believed that the histories
of their patients suggested an atopic basis for
both disorders even though it has not been deter-
mined beyond doubt that they are manifestations
of hypersensitiveness.

Specific therapy based on the tests was of no
avail. Likewise non specific measures, such as
removal of foci of infection, physiotherapy, and
elimination of skin irritation produced no im-
provement. The authors concluded that papular
urticaria and prurigo mitis were probably atopic
but not medicated by the same mechanism as
other manifestations such as asthma, hay fever
and atopic dermatitis. Skin testing was appar-
ently of no value either in diagnosis or treatment.
Every indication pointed to the fact that the
cutaneous reactions in each instance and especi-
ally in the asthmatics were linked to the other
atopic manifestations of the patient rather than to
the cutaneous condition.

Comment

From a survey of the reports of various men
who have studied the condition and from personal
experience at the University and Minneapolis
General Hospitals, the impression is gained that
urticaria is frequently refractory to all types of
therapy unless the etiology is immediately obvious
as in the case of acute urticarias due to foods.
In many instances, despite careful and pains-
taking history taking and skin testing when in-
dicated it is impossible to determine the etiologic
factors and is necessary to resort to symptomatic
therapy. Urticaria due to physical agents seems
to offer no better prognosis than cases due to
other causes. The multiplicity of etiologic agents
in many cases undoubtedly increases the diffi-
culty in obtaining uniformly good response to
treatment. In various accounts in which the
therapeutic results have been published there were
approximately 40-60 per cent of patients cured,
25-50 per cent improved, and 6 to 16 per cent
failures. (Eichenlaub, Menagh, Fink and Gay,
Stokes, et al, etc.). In short, though careful study
will prove successful or at least yield improvement
in most cases of urticaria, there are certain ones
which defy all analysis in which the results are
poor.

LITERATURE

1. Coca, Arthur F., in Tice: Practice of Medicine, 1: 156,
1923, W. F. Prior Co., Inc., Hagerstown, Md.

2. Taub, S. J., and White, C. J.: Urticaria Due to Grass
Pollen, J. Allergy, 2: 186, 1931.

3. Hopkins, J. G., and Kesten, B. M. : Urticaria: Etiologic
Observations, Arch. Dermat. & Syph., 29: 358, 1934.

4. Eichenlaub. F. J.: Etiology of Urticaria and Allied Derma-
toses, Ann. of Int. Med., 4: 170, 1925.

5. Stokes, John H.; Kulchar, Geo. V., and Pillsbury, Donald
M. : Effect on the Skin of Emotional and Nervous States.
Etiologic Background of Urticaria with Special Reference to

THE JOURNAL-LANCET

the Psychoneurogcnous Factor, Arch. Dermat. & Syph., 31: 470
(April), 1935.

6. Fink, Arthur, and Gay, Leslie N.: A Critical Review of
170 Cases of Urticaria and Angioneurotic Edema Followed for
a Period of from Two to Ten Years, J. Allergy, 5: 615, 1934.

7. Rowe, Albert H.: Food Allergy. Its Manifestations, Diag-
nosis and Treatment, J. A. M. A., 92: 1623, Nov. 24, 1928.

8. Menagli, Frank R.: The Etiology and Results of Treatment
in Angioneurotic Edema and Urticaria, J. A. M. A., 90: 668,
March 3, 1928.

9. Criep, Leo II., and Wechsler, Lawrence: Studies in
Urticaria: The Influence of Metabolic Factors, J. Allergy, 3:
219, 1932.

10. Criep, Leo II.: Metabolic Studies in Urticaria, I. Acid
Base Balance. II. Blood Chemistry, J. Allergy, 3: 219, 1932.

11. Ramirez, M. A.: The Value of Calcium in Asthma, Hay
F'ever and Urticaria, J. Allergy, 1: 283. 1930.

12. Criep, Leo H., and McElroy, William S. : Blood Cal-
cium and Gastric Analysis, Arch. Int. Med., 42: 865, 1928.

13. Sterling, Alexander: The Value of Phosphorus and Cal-
cium in Asthma, llay Fever and Allied Diseases, J. Lab. &
Clin. Med., 13: 997, 1928.

14. Brown, G. T., and Hunter, O. E.: Calcium Deficiency in
Asthma, Hay Fever and Allied Conditions, Ann. Clin. Med., 4:

299, 1925.

15. Sternberg, Louis: Clinical Urticaria and Hay Fever, An
Unusual Symptom Complex, J. Allergy, 4: 336, 1933.

16. Walzer, A., and Walzer, M.: Urticaria. II. The Experi-
mental Wheal Produced on Normal Skin Through Internal
Channels, Arch. Dermat. & Syph., 17: 659, 1928.

17. Duke, W. W.: Treatment of Physical Allergy, J. Allergy,
3: 408, 1932.

18. Duke, W. W.: Urticaria Caused by Light (Preliminary
Report), J. A. M. A., 80: 1835, 1923.

19. Duke, W. W. : Urticaria Caused Specifically by the Action
of Physical Agents, J. A. M. A., 83: 3, 1924.

20. Bray, George W. : A Case of Physical Allergy. A Local-
ized and Generalized Allergic Type of Reaction to Cold, J.
Allergy, 3: 367, 1932.

21. Alexander, H. D. : "Physical Allergy.” Report of a Case
with Successful Treatment, J. Allergy, 2: 164, 1931.

22. Walzer, Abraham, and Grolniek, Max: The Relation of
Papular Urticaria and Prurigo Mitis to Allergy, J. Allergy,
5: 240, 1934.

Pneumonia Typing and Specific Treatment*

Bernard A. Cohen, M. D.**

Minneapolis, Minnesota

WITH the advent of specific type antipneu-
moccic serum on the market for types I, II,
V, VII, and VIII, the specific type deter-
mination of patients with pneumonia is becoming daily
more important. While 32 types (Cooper) 1 & of pneu-
mococci have thus far been isolated, at present for prac-
tical purposes, it is felt that patients should at least be
typed to correspond to the therapeutic sera available.

At the Deaconess Hospital during the year 1935-
1936 we have endeavored to handle this problem purely
from a practical standpoint. Cases have been typed by
the capsular swelling method of Neufeld and the ag-
glutination method of Sabin (Bullowa).2 If a type
was obtained for which serum was available, specific
type treatment was instituted. Those cases for which
no serum was available were given the usual sympto-
matic treatment.

We should like to present our experience with a small
group of 48 cases. This series might well be represent-
ative of the typed cases seen during a year at the aver-
age private hospital. Of this group 42 were typed from
the sputum while 6 patients, unable to raise sputum,
were typed from material obtained by gastric aspiration.
(Wittes, Bullowa)3. On part of each specimen obtained
the rapid direct Neufeld method of typing was done
for types I, II, III, V, VII and VIII. The remainder
of the specimen was injected into the peritoneal cavity
of a white mouse, and the typing was checked by the
Sabin method. If no Neufeld reaction was obtained for
the above mentioned types, we relied solely on the
Sabin method for type determination. The Sabin
method was used for types I thru 32. The peritoneal
fluid from the mouse taken 3 — 10 hours after injection
of the specimen to be typed was in each case subjected
to the bile solubility test.

Our results of typing and comparison of methods of
treatment are shown by the charts. Chart No. 1 shows

•Read before the Hennepin County Medical Society, December
2, 1936.

••From the Department of Pathology, Deaconess Hospital.

the number of cases in the various types encountered.
Chart No. 2 shows the type distribution and mortality
rate in those cases treated without serum. Chart No. 3
shows the type distribution and mortality rate in the
serum treated group. The 6 cases of type V indicated
on chart No. 2 were admitted to the hospital before
type V therapeutic serum was released on the market.
This fact enabled us to compare specific and non-specific
treatment in one particular type. The difference in
mortality is indicated by the charts.

In those cases treated with serum our object has been
to give as much serum as possible, in the shortest period
of time, and as early in the disease as possible. In all
cases the first dose was 10,000 units. This was followed
in one hour by 20,000 units. This later dose was re-
peated every 2 — 3 hours. All serum was given intra-
venously following the ophthalmic and skin tests for
serum sensitivity. The amount given varied from
50,000 units to 230,000 units and depended solely on
the condition of the patient. In those cases where
treatment was instituted early in the disease the response
was more rapid, and the amount of serum used was
less than in those cases treated later in the course of the
illness. Our fatal case of type VII was a chronic alco-
holic who was first treated on the second day of his
disease, and who had been under the influence of liquor
for three days prior to admission. He received 110,000
units of serum.

Comment: — This presentation is not offered as a
statistical study; we feel rather that our experience in
handling this problem from a purely practical stand-
point is worth mentioning. Although our small series
might not permit us to draw definite conclusions, we
have been impressed with the importance of specific type
determination and treatment of this common and ex-
tremely serious disease. From our charts the mortality
rate in the serum treated group is 4.76%. (Bullowa)4
in a series of cases of the same types treated without
serum reports an average mortality rate of 23.6%. Of
his series of type V cases he says, "Throughout the seven

THE JOURNAL-LANCET

years of our work the mortality from our type V pneu-

monias has been 21%. Of cases treated during the last

four years the

mortality

was 5%.”

( Correspondence

with the author).

Type

Cases

Type

Cases

VIII

III

XXI

II & V

XXXI Si XXXII

XXX

VII

Strep

Agt in all groups

Total

Chart 1. Type Distribution of All Cases.

Type

Cases

Deaths Mortality Rate

III

50%

VIII

XXI

100%

XXX

100%

II &: V

XXXI SiXXXII

100%

Strep

100%

Agt in all groups 1

37%

Chart 2. Mortality in Non-Serum Treated Group.

Type

II
V

VII

VIII

Cases

4
6
1

Deaths

Rate

Mortality
0
0
0

16.6%

21 1 4.76.%

Chart 3. Mortality in Serum Treated Group.

References

1. Cooper, G., Edwards, M., and Rosenstein, C. : The Separation
of Types Among the Pneumococci Hitherto Called Group IV. and
the Development of Therapeutic Antiserums for These Types.
J. Exp. Med., 49, 461, 1929.

1'. Cooper, G., Rosenstein, C., Walter, A., and Peizer, L.:
Further Separation of Types Among the Pneumococci Hitherto
Included in Group IV and the Development of Therapeutic Anti-
serums for These Types, Ibid., 55, 531, 1932.

2. Bullowa, J. G. M.: The Reliability of Sputum Typing and
Its Relation to Serum Therapy, J. Am. Med. Assn., 105, 1512,
1935.

3. Wittes, S. A., Bullov'a, J. G. M.: Gastric Aspiration in Child-
ren with Pneumonia to Obtain Material for Pneumoccus Typing,
Am. J. Dis. Child., 50, 1404, 1935.

4. Bullowa, J. G. M., Wilcox, C.: Incidence of Bacteremia in
the Pneumonias and Its Relation to Mortality, Arch. Int. Med.,
55, 558, 1935.

Tuberculous Infection and Progressive
Tuberculous Lesions

Resulting From An Open Case of Tuberculosis

R. H. Stiehm, M. D.*

Madison, Wisconsin

THE opportunity to study tuberculosis in-
fection in a group of individuals before and
after contact with an open case of pulmonary
tuberculosis rarely presents itself.

This report concerns a girl in her senior year
of college, who lived in a sorority house with
eighteen other girls. During the course of three
months (December, 1934 through February,
1935) before consulting a physician, she had
noted a persistent cough. On examination she
was found to be suffering from far advanced pul-
monary tuberculosis and her sputum contained
many tubercle bacilli.

Since all newly enrolled students, beginning
with the fall class of 1933, have received the tuber-
culin test, the opportunity was presented to ob-
serve formerly-known negatives. At the first test
either 0.1 mg. of Old Tuberculin Saranac Lab-
oratory or 0.0002 mg. of the Purified Protein
Derivative of Seibert and Long is given. If at the
end of 48 hours no reaction has occurred, the pro-
cedure is repeated, using 1 mg. O. T. or 0.005 mg.
of the P. P. D.

•From the Department of Student Health, University of
Wisconsin.

On checking records, it was found that of the
15 girls who reported for the tuberculin test, 11
had formerly been negative. Eight had been
tested in the fall of 1933 and two in the fall of
1934. One received a test in high school in 1932,
which was reported negative. Of the 1 1 known to
have been negative, all or 100 per cent showed a
positive reaction in March, 1935. Of the four
having no previous test, three or 75 per cent
were positive. The one individual showing a neg-
ative test stated that she had lived in the house
for only two weeks, and this short contact prob-
ably explains her escape from infection. Of the
15 tested, 14 or 93.3 per cent showed a positive
reaction. This compares with a percentage of
approximately 25 per cent in the entire student
body.

That an open case of pulmonary tuberculosis is
highly infectious to other members of a house-
hold seems to be clearly demonstrated by this
study.

Apropos to the above, it is of interest to note
subsequent developments as concerns tuberculo-
sis in this group of girls.

THE JOURNAL-LANCET

As graphically portrayed on the chart, roent-
genograms taken in March, 1935 (this procedure
was repeated in June, 1935) failed to show any
abnormal shadows. The entire group with the
exception of two returned to school in the fall —
all apparently enjoying the best of health. Further
X-ray study revealed, however, that two had de-
veloped progressive parenchymal lesions. One
had no symptoms at any time; the other noted
slight fatigue and an intermittent cough. On

How Tuberculosis Causes Tuberculosis

Status of Fifteen Girls September 1934

ooo@®oooo@o®ooo

o JNEGAJMf MAMTOUA TEST
O MOT TESTED

Contact with Sorority Sister

OCTOBER 1934 To MARCH 1935
SPUTUM FOUND POSWYE MAR / 93S

Status of Fifteen Girls March 1935

©<D©QO@0©O®Q©©0©

• pos/me reactions to mantoua test 93 3%

ROENTGENOGRAMS SHOWED MO INFILTRATIONS MARCH AMO MAY f93S

Status of Fifteen Girls Fall 1935

0^O^O®#O©G©O«O©

• MOT ATTENDING SCHOOL ttfT tV Nn’mt tw

C INFECTED ZTZLZZ USTsnui

• PWRf&rE roMRouasif LESIONS ir~a «

O THIS MUM D IN HOUSE OMIT 3 N/CS '***”' ca*rr*n

Percent Developing Pulmonary Tuberculosis to Date Jan 1936 - 13 3

withdrawal from school both had lesions minimal
in extent. Examinations of the aspirated morning
fasting gastric contents of one of the girls showed
the presence of acid-fast bacilli. A guinea pig
inoculated with this material showed tuberculosis
on post mortem examination. A similar examin-
ation of the gastric contents of the other girl
proved negative. Interestingly, whereas infection
in the student body as a whole is 28 per cent, in
this group it was 93.3 per cent. Progressive tuber-

culosis among students at the University of Wis-
consin amounts to less than one per cent. In this
group it totals 13.3 per cent.

That repeated tuberculin testing of the non-
infected and roentgen-ray study by means of the
fluoroscope and roentgenograms at regular inter-
vals is practical is manifest by the fact that since
1933, when this program was instituted (the girl
who infected the sorority group, unfortunately,
entered before that time), 35 cases of progressive
tuberculosis have been found, and with the ex-
ception of three who noted slight fatigue, ALL
WERE WITHOUT SYMPTOMS.

Encouraging, too, is the fact that since 1933,
all students developing progressive tuberculosis
with one exception were advised to withdraw from
the university while their lesions were in the min-
imal stage. In the exception mentioned, there de-
veloped in a minimal subclavicular lesion, a small
cavity. This occurred in a period of forty days
between roentgen-ray examinations. Interestingly,
on bed-rest alone, this cavity closed in a period of
three months. This highly favorable record does
not of course include those students who were
found to have on their entrance examination mod-
erately-advanced and in one instance far-advanced
pulmonary tuberculosis.

As the program continues, it becomes increas-
ingly obvious that tuberculosis in its minimal stage
can be found only by regularly examining the in-
fected as shown by the Mantoux test. Unfortu-
nately, these procedures are at the present limited
to scattered and relatively small groups. Even-
tually, the entire population should be given the
benefits of a tuberculosis program now available
only to a very limited number.

BOOK NOTICES

GENERAL MEDICINE: 1936

The 1936 Year Book of General Medicine, edited by GEORGE
F. DICK. M. D.; LAWRASON BROWN, M. D.; GEORGE
R. MINOT. M. D.; WILLIAM B. CASTLE. M. D.; WILLIAM
D. STROUD, M. D.; and GEORGE B. EUSTERMAN, M. D.;
1st edition, brown cloth, gold-stamped, 822 pages plus subject
index and author’s index, illustrated; Chicago: The Year Book
Publishers, Inc.: 1936. Price, #3.00.

Once again, it is seen that the editors of the 1936 Year Book
of Medicine have drawn copiously on The Journal-Lancet
for abstract material. The following are Journal-Lancet
papers that appear in this volume: From Childhood Infection
to Adult Type of Pulmonary Tuberculosis, by Professor
Arvid Wallgren, M. D., of Gothenburg, Sweden, in the
May issue; The Significance of Tuberculosis in the College
Age Group, by J. B. Amberson, Jr., M. D., in the April
issue; The Redistribution of Costs in the Care of the Tubercu-
lous, by H. E. Hillboe, M. D., St. Paul, Minn., in the March
issue; The Importance of Thoracic Cautery in the Management
of Pulmonary T uberculosis, by Professor W. Unverricht,
M. D., of Berlin, Germany, in the April issue; and The
Mechanism of the Paroxysm in Bronchial Asthma, by
Matthew Walzer, M. D., of Brooklyn, N. Y., in the March
issue.

For the general practitioner who wishes to have at his finger
tips a resume of the year’s advances in general medicine, The
1936 Year Book of General Medicine is strongly recommended.

SYMPOSIUM OF THE KIDNEY

The Kidney in Health 6C Disease; edited by HILDING BERG*
LUND, M. D., and GRACE MEDES, Ph. D., in collaboration
with G. CARL HUBER, M. D., and WARFIELD T. LONG-
COPE, M. D.; heavy dark blue cloth, 774 pages, gold-stamped,
163 engravings; Philadelphia: The W. B. Saunders Company:
1935. Price, ?10.00.

This volume represents the contributions to an important
symposium on the structure and function of the kidney in
health and disease. The symposium was initiated by Hilding
Berglund, M. D., formerly chief of the department of medi-
cine in the University of Minnesota Medical School; and was
conducted under the auspices of the University of Minnesota.
To it were invited the outstanding authorities on various phases
of the subject. So important were their contributions to the
present knowledge of this still-obscure field that it was gen-
erally agreed that the papers should be preserved in book form.

The papers have been revised and amplified by each of the
contributors to cover the recent advances, and to conform to
the latest conceptions. Several important contributions not in-
cluded in the original symposium have been added.

The various contributors deal with their subjects in a most
comprehensive manner, so that each division is a complete
authoritative monograph. Unity and progression prevail
throughout. The book surpasses any of the earlier texts on
the same subject.

This volume will be welcomed by every specialist and gen-
eral practitioner as a valued addition to his library.

Hilbert Mark, M. D.,
Saint Paul, Minnesota

Represents the Medical Profession of

MINNESOTA, NORTH DAKOTA, T SOUTH DAKOTA and MONTANA

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

Great Northern Railway Surgeons’ Assn.
American Student Health Association
Minneapolis Clinical Club

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

BOARD OF EDITORS

Dr. J. A. Evert Dr. E. D. Hitchcock Dr. A. S. Rider Dr. J. L. Stewart

Dr. W. A. Fansler Dr. S. M. Hohf Dr. T. F. Riggs Dr. E. L. Tuohy

Dr. W. E. Forsythe Dr. R. J. Jackson Dr. E. J. Simons Dr. O. H. Wangensteen

Dr. H. E. French Dr. A. Karsted Dr. J. H. Simons Dr. S. Marx White

Dr. W. A. Gerrish Dr. Martin Nordland Dr. S. A. Slater Dr. H. M. N. Wynne

Dr. Jam«»s M. Hayes Dr. J. C. Ohlmacher Dr. D. F. Smiley Dr. Thomas Ziskin

Dr. A. E. Hedback Dr. K. A. Phelps Dr. C. A. Stewart Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M. D., 1859-1931 W. L. Klein, 1851-1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., January 1, 1937

THE JOURNAL-LANCET AND 1936

The Journal-Lancet embarks upon the New Year with a re-endorsement of the policies which have
made for its present status. The standards of the papers presented through this Journal have been of
high excellence as demonstrated by the numerous abstracts, reviews, and quotations which have appeared
in other first-class medical publications. In this fact the Editorial Board takes considerable pride, since
its members have exercised much care in the selection of articles, as well as the requests that have been
made for special articles. The demand on the part of authors for publication in The Journal-Lancet
has so increased that we now have more unpublished articles of medical import on hand than has been
recorded in the sixty-seven years of the Journal’s history.

The Journal-Lancet is not in competition with any other medical journal. In fact, its policy has
been to retain the field in which it has served so long and to fill any other niches which are not being filled
by other medical journals. A few years ago it broadened its scope so as to include the American Student
Health Association publications, recognizing that the physicians working in this field have opportunities
for clinical observation and research unsurpassed and often unequalled by any other group in the nation.
This material was thought to be of inestimable value to the men in the general practice of medicine, as
well as those who confined their practice to limited fields. The present editorial policy is to further
strengthen the Journal by publishing only the most valuable and outstanding papers so that the definite
contributions to medical knowledge made through its pages will continue to make of it an indispensable
journal for the physician.

Therefore, in the Year of 1937 The Journal-Lancet plans to provide its readers with valuable
and timely articles. It is the wish of the Editorial Board that the brightness of The Journal-Lancet’s
future may be reflected in the lives of its readers for the coming year.

J. A. Myers, M. D.,

Chairman, Board of Editors

THE JOURNAL-LANCET

FARMERS’ AID CORPORATION

The South Dakota State Medical Association has
finally endorsed the program for medical relief proposed
by the Resettlement Administration for certain drouth
states. The society, after considerable hesitation, and a
referendum, recommends to its members cooperation
with the Farmers’ Aid Corporation, that being the body
set up by the Resettlement Administration for medical
relief. The endorsement is for one year only. Drug-
gists, hospitals, dentists, nurses and doctors are to be
paid for strictly emergency services. The executive sec-
retary of our state society assumes administrative res-
ponsibility.

The delay and hesitation of the state society in en-
dorsing this program were due;

1. To the character of the original set-up of the
corporation.

2. To advice to approach the program with great
caution given by the legal department of the
American Medical Association.

3. To the fear of advancing the cause of state
medicine.

The Farmers’ Aid Corporation at first provided a
fifty-year tenure and had power to bring practically
every citizen of South Dakota within its reach.

There is reason to believe that the medical director
of the Resettlement Administration, Dr. Williams,
neither approved nor desired such broad powers or long
tenure. The original form was perhaps due to the
usual habit of lawyers in giving the greatest possible
freedom of action in articles of incorporation. The
present form defines and limits activities more in har-
mony with the views of the society.

The states of North Dakota and Oklahoma had
already accepted and endorsed similar programs. The
other groups in South Dakota allied in our common
front, namely, dentists, nurses, druggists and hospital
associations, had also approved the program. The de-
sire for unity in action and policy with these groups was
a strong argument for endorsement by the State Med-
ical Society.

The fear of state medicine in a rural state is, in my
judgment, unfounded. The farmer is a very individ-
ualistic person, as many who have tried to develop co-
operative farm groups have found to their disappoint-
ment. When we have rain and fair prices, our farmers
will again hire their own doctors, choose their own
hospitals, select their own nurses, and patronize their
own druggists.

The advice of the legal department of the American
Medical Association perhaps reflects fears brought about
by conditions in Chicago. On a recent trip to Chicago,
I was informed by a member of the staff of the Albert
Billings Memorial Hospital that Chicago has now, to
all practical purposes, state medicine. Cook County
Hospital is now open to any Cook County resident who
wants to enter. About the only restraining factor is
class-feeling. The Albert Billings Memorial Hospital
with over 700 beds, employs a full time staff (head of

eye department is the one exception) and the hospital,
not the doctors, determines and receives the fees.

If the great majority of our farmers and a consider-
able proportion of city dwellers are to remain on relief
basis, some sort of medical service must and will be made
available. If they can become self-sustaining and have an
adequate income, they will again prefer to provide their
own medical care. The solution of our general economic
problem will determine the nature of our system of
medical service. Doctors, as I see it, will be able to in-
fluence the program largely, as they can aid in solving
the common problem.

A. S. R.

THE LIVER

It is a glorious evidence of the advance in the healing
art to observe from what various angles researchers
determine the importance of the liver. The inherent
researcher usually resists any attempts at overextension
of his findings or conclusions; rarely does he venture to
correlate his work with other than those engaged, like
himself, in some intimate problem. Clinicians, wisely
or unwisely, cultivate no such restrictions; and while
they may wander too far afield in search of practical
therapeutic or surgical principles, where they observe
patients accurately they complement in no small way
the cloistered investigator. It is thus that real advances
are made.

A mere recital of the accepted functions of the liver,
numerous as they are at this time, does not really do
the organ justice. The recent development of protamine
insulin, with its prolonged and steadied action, is remi-
niscent of the deaminizing function of the liver, and it
appears that protamine insulin is something more akin
to the natural products of the pancreas than is any type
previously used.

Macrocytosis is no longer known as a specific sign
of pernicious anemia; in a wide variety of clinical states
it connotes perverted liver function. In nutritional
edema and non-tropical sprue, however diverse the
chemical endocrine or metabolic factors may be, it is
evident that the liver stands as a balancing defense,
assisting, if not controlling, the formation of the es-
sential body fluids, until such time follows when it can
no longer compensate.

The story of the liver is indeed an intriguing one and
may gradually lead us back to the attitude of the an-
cients, who dubbed the nerve that supplied the dia-
phragm, the phrenic because, forsooth, it was the nerve
of frenzy. They thought it connected the liver with the
brain.

E. L. T.

CANCER MORTALITY RATE

What the tuberculin test and roentgenology have done
to reduce the number of deaths due to tuberculosis,
biopsy and the X-ray could do in reducing the mortality
rate of cancer.

While contagion and isolation are factors in one and
not the other disease, early diagnosis is the crux of the

THE JOURNAL-LANCET

problem in the conquest of both. At the beginning of
the present century, tuberculosis was Captain of the
Legions of Death. Now, cancer is usurping the posi-
tion of priority, and with its ascendancy, demand is
increasing that the problem be solved.

In 1885, the X-ray was discovered. In 1908, Mantoux
perfected the tuberculin test. Since then, champions in
the anti-tuberculosis fight combined their use to such an
advantage that every practitioner now has a successful
approach to any case suggestive of tuberculosis. It has
been the simplicity and universality of their usage which
has helped reduce the mortality rate of the disease.

Biopsy is only slightly more complicated than the
Mantoux test. X-ray facilities are available to every
physician. When these two procedures occupy the mind
of every physician studying a case with symptoms sug-
gestive of cancer, the mortality rate of cancer will begin
to decline. Briefly then, "When in doubt, biopsy or
X-ray.”

J. E. S.

REPORTS OF SOCIETIES

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of October 7, 1936

The regular monthly meeting of the Minnesota
Academy of Medicine was held at the Town and
Country Club on Wednesday evening, October 7th,
1936. The meeting was called to order at 8 o’clock by
the President, Dr. Thomas S. Roberts.

There were 52 members and one guest present.

Minutes of the May meeting were read and approved.

The scientific program consisted of two papers.

CHORDOMA

Dr. Arnold Schwyzer, St. Paul

Dr. Schwyzer read a paper on the above subject, reported a
case, and showed lantern slides.

Discussion

Dr. J. F. Corbett (Minneapolis) : I greatly enjoyed listen-
ing to this very complete discussion. I personally have had but
one case of chordoma, and that was just the opposite of Dr.
Schwyzer’s case. At the time I saw it, there was a large tumor
involving the second and third and several other cranial nerves.
It was on the front of the sphenoid. The remarkable thing
about it was that it could not be removed because of its size.
A decompression gave relief for a long period of time. The
tumor was undoubtedly slow in growth, although it was cellu-
lar, which would indicate there was some malignancy.

Dr. Robert Earl (St. Paul) , in discussion of Dr. Schwyzer’s
paper, reported the following case of chordoma:

The patient, Miss L., age 46, unmarried, first consulted me
on April 6, 1936. Her family and personal history were nega-
tive.

All of her laboratory findings were negative, except for a
moderate secondary anemia. She had never been sick until
August 15, 1935, when she developed a severe bearing-down
pain in the rectum which was more or less constant for two
weeks. She consulted a physician who told her she had a hemor-
rhage in the rectum. The patient had never seen any blood in
the stool. Hot sitz baths relieved her discomfort temporarily.
The pains and discomfort improved some, so she taught school
until April 3, 1936. On February 2, 1936, she was examined

by another physician, who diagnosed tumor of the uterus and
advised operation. When I saw her on April 3, 1936, her appe-
tite and digestion were normal. With the aid of mineral oil,
she had one slender-formed stool a day. No blood or mucus
were seen in the stools. Her periods had been irregular the
past few months. Her general physical examination was nega-
tive.

Pelvic examination disclosed a tumor in front of the sacrum
and left side of the pelvis extending down to the sphincter ani.
The vagina and rectum were pushed to the right anterior part
of the pelvis. The cervix could not be reached. Some irregular
masses could be palpated on the lower abdomen just above the
pubis.

On April 9, 1936, I explored through a midline suprapubic
incision. I found the uterus, tubes and ovaries essentially nor-
mal, but pushed up into the abdomen and resting on top of a
tense mass which filled the entire pelvis. On opening into this
mass, I found a broken-down degenerated mass containing some
brown cystic fluid and masses of broken-down tissue filling the
entire pelvis. I removed as much as possible of the degenerated
mass, and swabbed the cavity with formalin solution. I packed
the cavity with gauze, one end of which was brought through
an opening made in the vault of the vagina, through which it
was removed two days later.

The tubes and ovaries were removed. The uterus was not
removed, but was retroverted and sutured over the peritoneal
line of incision to reinforce it, and protect the peritoneal cavity.

Although the patient was given four postoperative courses
of deep X-ray therapy, the growth is recurring.

The microscopic section shows one of the typical forms of
chordoma of the more malignant type. On the lantern slide,
one can see the similarity to parts of the section from Dr.
Schwyzer’s case.

Dr. R. G. Allison (Minneapolis) : Several months ago we
had a young man sent in to us for X-ray examination who had
sustained a rather trivial injury to his back. The injury was
more on the order of a strain. We found a clean-cut line of
cleavage, showing only in the lateral plate, bisecting the body
of one of the lumbar vertebra. Subsequent plates have shown
no change in this line of cleavage. The consultants who have
seen this have diagnosed it as a remnant of the notochord. This
is the first of such cases I have seen and I have seen none
mentioned in the literature. I wonder if Dr. Schwyzer could tell
us if he has seen any such findings shown by X-ray examination.

Dr. Arnold Schwyzer (in closing) : I am sorry I cannot
answer Dr. Allison’s questions because I have not any sufficient
experience in these cases as to the X-ray findings.

The two cases reported by Dr. Corbett and Dr. Earl show
how these cases vary in malignancy. The case reported by Dr.
Corbett is that of a slow insidious growth. In that case, de-
compression would do good for a while; whereas, in the very
malignant case Dr. Earl reported, I do not think there is much
to be done unless one could get such a case at a very early date.

As for the diagnosis — I made that diagnosis myself when I
began to think about the case; and, on examining the sections
carefully, it was plain that we had a chordoma. The location
of these tumors is of great importance for the diagnosis. Ewing
said the location was more important than the microscopic
appearance. The microscopic picture may vary very much. Thus
the combination of the topography together with the micro-
scopic findings is important for the diagnosis.

* * *

SEVERE CUTANEOUS REACTIONS TO THE
BARBITURATES
by

Drs. S. E. Sweitzer and Carl W. Laymon
Minneapolis
Summary

1. Attention is called to the possible dangers attendant with
the administration of the barbiturates.

2. Four cases (three of which were fatal) of severe cutaneous
reactions to these drugs were reported.

3. The theoretical consideration of drug eruptions with ref-
erence to the mechanism of sensitivity, the localization of the

THE JOURNAL-LANCET

shock (issue, and the types of eruptions were briefly presented.

4. The resemblance of drug allergy to serum disease and of
certain eczematous drug eruptions to dermatitis of external
origin, makes it probable that the differences between these
three types of allergy (drug allergy, serum disease and contact
dermatitis) are not great.

5. It is believed that the site and type of hypersensitive
tissue which an excitant (drug, serum or external agent) reaches
is the chief factor in the type of response to that excitant,
rather than the mechanism of sensitizacion, or the route by
which the excitant reaches the tissue.

Discussion

Dr. E. L. Gardner (Minneapolis) : I am particularly inter
ested in this paper because, in functional gastrointestinal dis-
turbances, phenobarbitol in lA grain (or less) doses is used
over long periods of time. Personally, I have never seen any
reaction when prescribed in these small doses. Skin reactions,
usually occurring early, may occur after taking 1 Vi to 5 grains
in 24 hours; but these chronic cases taking the small doses
even for many month* do not show skin reactions or depres-
sion of the leukocyte count. Possibly the repeated small doses
desensitize the patients to the drug. I wonder if Dr. Sweitzer
has ever seen any reactions when the dose has been not over
% grain in any 24 hours? The cases Dr. Sweitzer reported were
very ill from other diseases, and this general debility may have
been the most important factor.

I think this is a very important contribution. Many of the
supposedly "harmless’’ drugs may sometimes produce serious
results — mineral oil sprays in the nose may produce a very
serious type of chronic pneumonia and the long-continued use
of magnesium may produce serious calcium depletion.

Dr. Franklin Wright (Minneapolis) : About 35 years ago.
when I studied dermatology, about 400 different drugs had
been reported as producing eruptions on the skin. In the last
few years our American pharmacists have outdone themselves
in supplying good drugs. I have had no experience with barbital
skin eruptions; but had an experience with barbital which I
would like to report. I did a prostatectomy and in four days
the patient was sitting up in bed. His physician came in on
the fifth day and ordered albargene (a barbital compound)
5-grain tablets, one tablet at 4 p. m., one at 7 p. m., and one
at 11 p. m. At 3 o’clock the next morning the hospital called
me. I found the patient with a pulse of 150 and I thought
he would not live until daylight. I ordered hypodermoclysis,
and filled him with strychnine, and he gradually got better.
Now at the end of six weeks he is still in a wheel chair, mak-
ing a very slow recovery.

I believe that his collapse was due to barbital contained in
the albargene.

Dr. R. T. LaVake (Minneapolis) : I agree with Dr. Gardner
that this is a very important subject. I suppose few use the
barbiturates more than the obstetrician. We have used pento-
barbital in practically every labor since it came upon the mar-
ket. In this period we have seen only three or four cases of
mild dermatitis due to its use. It seems to me that the crux
of the matter lies in warning against the continuance of the
drug at the first untoward sign. To my mind, we should nor
deprive patients of the benefits of the barbiturates through the
exaggeration of their danger.

I agree thoroughly with Dr. Roberts that the indiscriminate
sale of these drugs without prescription should not be allowed.

If I am not mistaken, three of the four fatal cases reported
in this papier were found to have a bronchopneumonia at
autopsy. It would suggest itself to me that these cases might
be interpreted as very sick people who happened to receive bar-
biturates. I would like to ask if it was supposed that the
bronchopneumonia was a result of the barbiturates?

Dr. C. B. Wright (Minneapolis) : I would like to ask Dr.
Sweitzer whether any of these patients showed any other evi-
dence of allergy, or whether in the literature there is any indi-
cation that these people are allergic to other drugs. In allergies,
the dosage is not so important as the degree of allergic tendency
of the individual.

Dr. Paul O’Leary (Rochester) : There are two points I
should like to discuss in regard to eruptions from the barbituric
acid derivatives. The first is the so-called delayed reaction, in
which the eruption may not appear until three to five days
after the drug has been stopped. The cutaneous picture of
this type of eruption is similar to that described by Dr.
Sweitzer. I was surprised to hear the comments of the previous
discussors on the rarity of eruptions from the barbiturates,
because in dermatological practice during the past five or six
years these manifestations of intolerance to the drug have been
quite common. Perhaps the recent efforts of the manufacturers
to produce remedies that are apparently less toxic than the
original preparations account for the scarcity of these reactions
now in general practice and surgical work.

The second point which I wish to bring out is illustrated by
the recent work of Wise and Wile and their co-workers,
who endeavored to study the role of allergy in the production
of these lesions. Both of these investigators excised a plaque of
dermatitis which had developed following the ingestion of a
barbiturate, and made a full-thickness graft of this plaque on
an area where the eruption had previously not appeared. The
excised normal skin was grafted over the area where the derma-
titis developed, and from which the plaque had been excised.
On administering a barbiturate within a week after the graft,
the eruption re-appeared in the patch of dermatitis that was
transplanted. However, if several months were allowed to elapse,
the grafted area soon lost its sensitivity; likewise, the normal
skin which had been transplanted to the area of dermatitis did
not develop the dermatitis, although the dermatitis tended to
develop in other areas. It would appear, therefore, that the
sensitivity is not a localized affair in the sense of a localized
allergic area, but is rather of a systemic nature.

Dr. C. B. Drake (St. Paul) : I have run across skin reactions
following the use of luminal in just two instances. One was an
elderly patient at the City Hospital who, following the taking
of about 1 Vz grains of luminal for several nights, developed a
severe dermatitis with extensive petechial hemorrhages. He
recovered and later, through an error, was given luminal again,
and went through the same process. The other instance was in
a private patient who developed a macular eruption from one
small dose of luminal.

In this connection I wish to report what was apparently an
unusual experience I had last winter from the use of quini-
dine. An elderly woman was given two grains of quinidine after
dinner one night because of extrasystoles. In the early morning
hours she awoke with severe burning in her skin, and when I
saw her she had a generalized erythema and later even petechial
hemorrhages in both legs. General desquamation followed in-
volving the palms and soles. Inasmuch as she had had a small
dose of luminal the two preceding nights, I was unconvinced
that the quinidine was the cause of the dermatitis. Two weeks
later one grain of quinidine produced the same symptoms, al-
though in milder form. I assured myself that the druggist had
made no mistake in the prescription, and had a laboratory con-
firm the identity of the drug. This patient had taken quinine
as a young woman without any untoward effect. She had, how-
ever, suffered from a severe dermatitis some years ago follow-
ing the use of some hair tonic which I imagine may have con-
tained some quinine. An interesting aftermath of her recent
experience was the appearance of irregular ridges across the
nails of fingers and toes, which was doubtless the result of the
effect of the cutaneous reaction on the matrix of the nails. This
evidently is a very unusual instance of sensitiveness to quini-
dine, as the drug is used so extensively, and the skin special-
ists I have questioned have none of them had a similar
experience.

Dr. R. D. Mussey (Rochester) : I just want to add a word
to Dr. LaVake’s discussion. We have been using these drugs
for analgesia in confinement cases since 1929, and I think Dr.
O’Leary will bear me out that his group has not been called in
at any time on account of an eruption due to the barbiturates.

I think Dr. Sweitzer’s paper is very timely, and that one
should use the barbiturates with care; but I do not think we
ought to throw this medication aside because of an occasional

THE JOURNAL-LANCET

case of this sort. I am sure the average patient in labor can
take this medication without any appreciable number of them
developing drug eruption.

Dr. H. E. Michelson (Minneapolis) : I am heartily in
accord with the gentlemen who have suggested that the sale
of barbiturics should be definitely controlled by law. The
change of psyche due to the long-continued use of these drugs
is much more serious than the rare cutaneous involvement that
Dr. Sweitzer has reported. When an eruption does occur the
external treatment is essentially that of any dermatitis and in-
ternally the use of alkalis.

Dr. Thomas S. Roberts (Minneapolis): In its broader
application this is a subject of much more than passing inter-
est. While the cutaneous reactions following the administra-
tion of barbiturates to persons with allergic sensibilities, espe-
cially those in impaired health, may be serious or even fatal,
as described by Dr. Sweitzer, the subject of the general use of
these drugs is of much wider and more vital importance. Thou-
sands and thousands of people, with or without the advice of
physicians, are taking regularly one or another of the various
barbiturate preparations, frequently with deleterious effects and
not uncommonly with disastrous results. In this, and in most
states, these drugs are sold over the drugstore counter without
restriction and conscientious druggists are worried and appalled
at the extent to which the evil has grown. Barbiturates are all
habit-forming and their consumption has become almost a
national evil.

The regular taking of even small doses of the barbiturates
and their special administration in large doses produces, in ad-
dition to the sedative effect, a suspension of the coordination of
both the mind and body. The extent of these effects varies of
course with the susceptibility of the individual; but it not in-
frequently results in chronic cases in the disorganization of the
mental faculties and a muscular incoordination suggestive of
locomotor ataxia. In the more common cases the mind is con-
fused, the speech thickened, and muscular movements in gen-
eral are disordered and clumsy — much like an intoxicated per-
son. The normal personality is lost. The mental condition
may even simulate insanity with homicidal or suicidal intent.
One case that came under my notice was committed to an asy-
lum after attempting to shoot his wife; but made a speedy re-
covery after the withdrawal of the drug — much to the surprise
of the attendants, who were not aware of the cause. Another
patient, after taking 10 grains of veronal three times daily for
a short period, escaped and ran amuck armed with a brick with
which he threatened all who interfered. ITe returned to normal
after suspension of the drug. A business man of large in-
terests lost the ability to dictate a letter, to look after his affairs,
became almost helpless physically, had retention of the urine
so that the use of a catheter became necessary; but recovered
slowly after the daily doses of veronal were discontinued. Cases
of this kind could be multiplied many times from my own ex-
perience; but it would take too much time to recount them
here. Suffice it to say, that they have led me to feel and to
believe that the profession is handling (in the case of barbitur-
ates) drugs that are so potent and so habit-forming that they
should be used with very especial care and caution. As soon
as possible, a law should be passed prohibiting the indiscrim-
inate dispensing of these drugs in this state, as has already
been done elsewhere.

Dr. C. B. Wright: It may interest Dr. Roberts to know that
several states have already passed laws restricting the sale of
barbiturates and that such a law is contemplated in Minnesota
if the druggists and pharmacists will cooperate.

Dr. Sweitzer (in closing) : In answer to Dr. Gardner’s

question, we have not seen reactions when the dose of barbitur-
ate has not been over % grain in any twenty-four hours. In
most of our cases, however, the exact dose was not determined,
since the drug was administered by physicians other than our-
selves. Our patients, however, were not seriously ill from
other diseases except the one who developed granulocytopenia.

In reply to Dr. LaVake, we felt that the bronchopneumonia
which was found at autopsy represented a terminal complication,
since no signs of pneumonia were found on the first examination.

As to the question of Dr. C. B. Wright, patients with drug
allergy usually give no history of other personal or familial
allergy.

Our purpose in presenting this paper was to call attention to
the potential dangers of the barbiturates rather than to decry
their proper use by physicians who are alert to these dangers.

R. T. LaVake, M. D.

The meeting adjourned.

SIOUX VALLEY MEDICAL ASSOCIATION
Sioux City, Iowa, January 19 and 20, 1937

Dr. Gilbert Cottam, of Minneapolis, will serve as
toastmaster at the 40th annual meeting of the Sioux
Valley, Medical Association at Sioux City, Iowa, on
January 19 and 20, 1937.

Other speakers are: Karl A. Meyer, M. D., associate
professor of surgery in the Northwestern University
Medical School, Chicago; Joseph L. Baer, M. D., clinical
professor of obstetrics and gynecology in Rush Medical
College of the University of Chicago; Fremont A.
Chandler, M. D., assistant professor of orthopedic sur-
gery in the Northwestern University Medical School;
William F. Braasch, M. D., professor of urology in the
University of Minnesota Graduate School of Medicine
at Rochester, Minn.; Roger L. J. Kennedy, M. D., assist-
ant professor of pediatrics in the University of Minne-
sota Graduate School of Medicine at Rochester; Horace
M. Korns, M. D., associate professor of the theory and
practice of medicine in the University of Iowa College
of Medicine at Iowa City; and Charles W. Poynter, M.
D., professor of antomy and dean of the College of
Medicine of the University of Nebraska at Omaha. Dr.
Poynter will deliver the principal address of the evening
on January 19 (banquet).

Officers of the Sioux Valley Medical Association are:

Frank P. Winkler, M. D., president; Sibley, Iowa.

L. L. Sogge, M. D., vice-president, Windom, Minn.

H. I. Down, M. D., secretary, Sioux City, Iowa.

Walter R. Brock, M. D., treasurer, Sheldon, Iowa.

NEWS ITEMS

Dr. Leonard J. Nilles, who was graduated from the
University of Minnesota Medical School last June, is
now in practice at Rollingstone, Minn.

Dr. George E. Whitson, of Madison, S. D., a gradu-
ate of the University of Minnesota Medical School in
1927, recently was elected president of the Madison
Community Hospital.

Dr. Chester A. Stewart, clinical professor of pedi-
atrics in the University of Minnesota Medical School,
will represent the United States next year at the world-
wide medical conclave in Italy. Dr. Stewart will be the
representative of American pediatrics.

Dr. August E. Bostrom, in practice for several years
at DeSmet, S. D., has accepted a position with the State
Board of Health of Oregon, with offices in Portland.

Dr. J. Arthur Myers, professor of medicine in the
University of Minnesota Medical School was a guest
speaker at the Rocky Mountain Tuberculosis Confer-
ence at Albuquerque, New Mexico.

Dr. Henry E. Michelson, Minneapolis, recently spoke
before the Milwaukee Dermatological Society on "Tu-
berculosis of the Skin.”

Dr. Allan B. Stewart, Owatonna, Minn., was a mem-
ber of the committee in charge of arrangements for

THE JOURNAL-LANCET

the annual tri-city dinner meeting of the Rotary Clubs
of Owatonna, Faribault, and Northfield; the dinner it-
self being held in Faribault.

Dr. C. Francis Ewing, of Wheaton, Minn., won the
championship cup of the golf match sponsored among
members of the Great Northern Railway Surgeons’
Association, of which The Journal-Lancet is the
official publication, at Seattle, Washington, during
October.

Elias P. Lyon, Ph. D., former dean of the University
of Minnesota Medical School was recently honored at a
farewell dinner by the faculty members of the School of
Nursing at the University. Dean and Mrs. Lyon are
now in Florida for the winter.

Dr. John F. Regan, who for the past seven years has
been assistant superintendent of the North Dakota Hos-
pital for the Insane at Jamestown, has resigned to accept
a similar position at the Howard State Hospital in
Providence, Rhode Island.

Dr. Arthur L. Abbett, a recent graduate of the Uni-
versity of Minnesota Medical School, is now attached
to the Civilian Conservation Corps at Camp Badger,
California.

The Northwest District Medical Society of North
Dakota met at Minot on December 3rd, with Dr.
Arthur C. Kerkhof, assistant professor of medicine in
the University of Minnesota School of Medicine, as
guest speaker. Professor Kerkhof’s subject was: "Gastric
Malignancy, Including Gastroscopy and Super-Voltage
Therapy.”

The regular meeting of the Minnesota Academy of
Medicine was held at the Town & Country Club in
Saint Paul on December 9, 1936. Dinner was served at
7:00 p. m., and the meeting was called to order at 8:00
p. m. Guest speaker was Dr. W. L. Benedict, professor
of ophthalmology in the University of Minnesota
Graduate School of Medicine, Rochester. Professor
Benedict spoke on "Episcleritis in Relation to Disease of
the Pelvic Organs.”

The new $250,000 Municipal Hospital at Virginia
was formally opened to visitors during the last week of
November and the early days of December. The super-
intendent is Miss Charlotte J. Garrison.

Dr. Ralph C. Adams, of Bird Island, Minn., was
elected president of the Renville County Medical Society
at its regular election meeting.

Dr. John Hettwer, 67, a retired physician of St.
Paul, Minn., died on November 25, at the home of his
son, Herbert G. Hettwer.

Dr. Herman E. Almquist, 52, who practiced medicine
for 15 years in Minneapolis before moving to the
Pacific Coast, died in Los Angeles, Cal., in November.
Dr. Almquist was a graduate of Macalester College in
St. Paul, and the Loyola University School of Medicine
in Chicago, 111.

Dr. Helen Louise Crawford, roentgenologist at the
Winona General Hospital, Winona, Minn., has returned
from the University of Iowa Hospital at Iowa City,

where she passed the requirements of the American
Board of Radiology.

Dr. Otto Fesenmaier, of New Ulm, Minn., has
located in his home town. He was graduated from the
Marquette University School of Medicine in June, 1936.

The Sharon Lodge, A. F. & A. M., of Willmar,
Minn., will furnish a room in the new Rice Memorial
Hospital of that city, it has been announced.

Dr. E. A. Kilbride, of Worthington, Minn., is the
new president of the Southwestern Minnesota Medical
Society.

Dr. Paul C. Leek, of Austin, Minn., is the new
president of the Mower County Medical Society.

Dr. J. E. Campbell, widely-known South St. Paul
physician, was killed eight miles out of St. Paul on
November 24. Dr. Campbell was the first cheer leader of
the University of Minnesota, from which he was gradu-
ated in 1901. He was a pediatrician.

Dr. E. O. Church, Menno, South Dakota, died sud-
denly on December 3, 1936, of a heart attack. He was
a graduate of the University of Illinois College of
Medicine in 1900. Dr. Church had practiced medicine
in Revillo, South Dakota, for 24 years, and in Menno
for 4 years.

Dr. N. H. Baker, of Fergus Falls, Minn., secretary
of the Park Region Medical Society, reports that the
Society held its annual meeting at Fergus Falls on
December 9, 1936. Dr. J. B. Vail, Henning, was in-
stalled as president; Dr. L. C. Combacker, of Fergus
Falls, was chosen president-elect; Dr. C. J. Lund,
Underwood, was selected vice-president; Dr. T. S.
Paulson, Fergus Falls, was chosen treasurer; and Dr.
Baker was elected secretary. Dr. S. Marx White, of
Minneapolis spoke on "The Early Treatment of Hyper-
tension.”

According to a report received from Dr. C. W.
Froats, retiring secretary, the Red River Valley Medical
Society held its annual meeting on December 8, 1936,
in the Hotel Crookston, at Crookston, Minn., with an
attendance of 37 members and 4 guests. President
W. W. Will, M. D., of the Minnesota State Medical
Association, was a guest speaker, as was also Dr. W. L.
Burnap, of Fergus Falls, Minn., councilor of the 8th
district; and Mr. R. R. Rosell, of the state medical
association’s offices in Saint Paul. Dr. J. L. Delmore,
of Roseau, was elected president for 1937; Dr. C. W.
Froats, of Thief River Falls, was chosen vice president;
Dr. C. L. Oppegaard, of Crookston, was selected
secretary-treasurer; and delegates elected are: Dr. J. F.
Norman, Crookston; Dr. O. E. Locken, Crookston;
their alternates being Dr. H. M. Blegen, Warren; and
Dr. W. F. Mercil, Crookston. Dr. W. G. Paradis,
Crookston, was elected censor for 3 years.

Henry S. Plummer, M. D., chief of the division of
medicine of the Mayo Clinic, and professor of medicine
in the University of Minnesota Graduate School of
Medicine at Rochester, Minn., died at his home in
Rochester on December 31, 1936, at the age of 62. He
was an internationally known authority on exophthalmic
goiter.

THE JOURNAL-LANCET

The Fourth Annual Lecture in the E. Starr Judd
Lectureship in Surgery, established at the University of
Minnesota by the late Dr. E. Starr Judd, will be given
by Dr. Evarts A. Graham, Professor of Surgery, Wash-
ington University School of Medicine, and Surgeon-in-
Chief, Barnes and St. Louis Children’s Hospitals, at
St. Louis, Missouri. The lecture will be held in the
Chemistry Auditorium on the University campus in
Minneapolis on Wednesday, February 3, at 8: 15 p. m.
The subject of Dr. Graham’s lecture will be "Accom-
plishments of Thoracic Surgery and its Present
Problems.”

Dr. E. Sydney Boleyn, secretary of the Washington
County (Minn.) Medical Society, reports that his group
held its extra meeting on September 15 at Stillwater,
Minn., given over to economics. The regular monthly
meeting was held October 13, speaker being Dr. How-
ard Gray, of Rochester; another meeting was held
November 10th, at which Dr. Walter Fansler, of Min-
neapolis, spoke on "Rectal Pathology.” Dr. George Earl
and Mr. Manley Brist, St. Paul, were speakers also.

Dr. Henry J. Leigh, Tower City, N. D., died in
Grand Forks on October 22, 1936, at the age of 70.
He was a graduate of Bennett Medical College in Chi-
cago, 111., in 1891. He had practiced in Sabula, Iowa;
Fort Dodge, Iowa; Carroll, Iowa; Lakefield, Minn.,
from 1909 to 1924; and Tower, N. D., from 1924 to
1936. Dr. Leigh is survived by his widow, Mrs. Agnes
Leigh; two daughters; and one son, Dr. Ralph E. Leigh,
of Grand Forks.

H. R. Hummer, M.D., secretary of the Seventh Dis-
trict Medical Society, Sioux Falls, S. D., reports that
the December meeting of the Society was held on
December 8, with dinner at 6:30 p. m. in the Cataract
Hotel in Sioux Falls. Dr. B. A. Dyar, secretary of the
South Dakota State Medical Association, was guest
speaker. New officers for 1937 were elected. Dr.
Frederick C. De Vail, of Garretson is the new pres-
ident; Dr. N. J. Ness, Sioux Falls, is vice-president;
Dr. H. R. Hummer, Sioux Falls, is secretary; Dr. G. E.
Van Demark, Sioux Falls, censor for one year; Dr.
Charles F. Culver, Sioux Falls, censor for two years;
Dr. E. L. Perkins, Sioux Falls, censor for three years;
Doctors Roy G. Stevens, J. B. Gregg, and L. J. Pankow,
all of Sioux Falls, delegates for two years; and Doctors
M. O. Lanam, J. A. Kittleson, and Goldie Zimmerman,
all of Sioux Falls, alternate delegates.

William F. Snow, M.D., general director of the
American Social Hygiene Association, Inc., New York
City, and author of Individual Prophylaxis in Theory
and Practice as Applied to Syphilis and Gonococcal
Infections in the June, 1936, issue of The Journal-
Lancet, advises that February 3rd, 1937, will be desig-
nated as Social Hygiene Day. Physicians interested in
this aspect of medico-sociological endeavor are urged to
communicate with Dr. Snow at 50 West 50th Street,
New York City.

UNIVERSITY OF MINNESOTA
CENTER FOR CONTINUATION STUDY
POST-GRADUATE MEDICAL INSTITUTE

The Center for Continuation Study of the University
of Minnesota in cooperation with the Medical School
and the Minnesota State Medical Association will offer
a series of post-graduate medical courses for practicing
physicians from January 17 to February 13, 1937. They
are planned primarily for practicing physicians who
desire to spend a short period of time in serious and in-
tensive study in internal medicine, surgery, pediatrics,
obstetrics and gynecology.

Subjects

The first week, from January 17 to January 23, will
be devoted exclusively to instruction in traumatic sur-
gery; the second week, from January 24 to January 30,
to obstetrics and gynecology; the third week, from
January 31 to February 6, to pediatrics; and the fourth
week, from February 7 to February 13, to internal
medicine. It will be possible for any postgraduate
student to enroll in one or more of these courses.
Preference will be given to those enrolling in the entire
series although single week reservations will be wel-
comed. Students are urged to live in the building which
provides splendid facilities for both instruction and
living accommodations. In addition to the full-time
enrolment, a limited number of physicians from the
Twin Cities and vicinity may be accepted for part-time
enrolment.

Program

In planning the courses, the program has been
divided on the basis of regions, systems, or types of dis-
orders. New chairmen will be in charge of each day’s
program and the faculty which will assist them will
function as a unit.

Special Features

New registrations will be completed on each Sunday
prior to the start of the week’s work for those who have
made advance reservations. Students are urged to come
at this time and receive their programs and room as-
signments.

Registration and Tuition Fees

The tuition fee for each week’s course will be $15.00
for full-time enrolment. An advance registration fee
of $3.00 must be sent with the application. This regis-
tration fee will be deducted from the tuition after the
registration is completed. Address all applications or
requests for information to the Director of the Center
for Continuation Study, University of Minnesota,
Minneapolis, Minnesota. The enrolment is limited to
thirty students for each week.

Certificate

Upon satisfactory completion of any one or more
weeks of full-time enrolment a certificate of attendance
will be issued by the Board of Regents of the Univer-
sity of Minnesota upon the recommendation of the
director of the Center and the chairman of the Post-
Graduate Medical Institute.

THE JOURNAL-LANCET

LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS

ON NOVEMBER 7, 1936

(OCTOBER EXAMINATION)

Name

School

Address

Boehrer, John James, Jr. Johns Hopkins U., M.D., 1936 500 Harvard St. S. E., Minneapolis, Minn.

Brink, Donald __U. of Minn., M.B., 1936 St. Barnabas Hospital, Minneapolis, Minn.

Brockman, Helen U. of Minn., M.B., 1933, M.D., 1934 Independence, la.

Burchell, Howard Bertram U. of Toronto, M.D., 1932 Mayo Clinic, Rochester, Minn.

Cady, Joseph Bishop U. of Pa., M.D., 1934 Mayo Clinic, Rochester, Minn.

Canfield, Burt Joseph U. of Minn., M.B., 1936 Miller Hospital, St. Paul, Minn.

Castigliano, Silvio Gordon Rush Med. Col., M.D., 1936 — 736 Lincoln Ave., St. Paul, Minn.

Caveny, Kasper Patrick U. of Minn., M.B., 1936 .. ... Bethesda Hospital, St. Paul, Minn.

Cleveland, William Hatcher Northwestern U., M.B., 1935, M.D., 1936 Mayo Clinic, Rochester, Minn.

Crumpacker, Leo Kyle Northwestern U., M.B., 1934, M.D., 1935 Mayo Clinic, Rochester, Minn.

Cutler, Haydn Harrison Northwestern U., M.B., 1935, M.D., 1936 Mayo Clinic, Rochester, Minn.

Fesenmaier, Otto Bernard Marquette U., M.D., 1936 New Ulm, Minn.

Furey, Ellen Dora U. of Texas, M.D., 1930 Mayo Clinic, Rochester, Minn.

Gilsdorf, Amos Roy U. of Minn., M.B., 1936 Minneapolis Gen. Hosp., Minneapolis, Minn.

Gober, Olin Burr — ... U. of Texas, M.D., 1933 Mayo Clinic, Rochester, Minn.

Graham, Robert Williams Toronto U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Haines, Diedrich Jansen U. of Iowa, M.D., 1934. Mayo Clinic, Rochester, Minn.

Helm, Standiford Northwestern U., M.B., 1935, M.D., 1936 Mayo Clinic, Rochester, Minn.

Heyerdale, William Wentworth La. State U., M.B., 1934, M.D., 1935 Mayo Clinic, Rochester, Minn.

Johnson, Evelyn V. U. of Minn, M.B., 1934, M.D., 1935 . 2600 Vincent Ave. N., Minneapolis, Minn.

Kaufman, Edward John U. of Minn.. M B., 1935, M.D., 1936 1897 Summit Ave., St. Paul, Minn.

Kearney, Rochfort Wynn Northwestern U., M.B., 1935, M.D., 1936 Mayo Clinic, Rochester, Minn.

Korchik, John Peter U. of Manitoba, M.D., 1935 3105 E. Franklin Ave., Minneapolis, Minn.

Lawn, Harold Julius U. of Minn., M.B., 1934, M.D., 1935 1105 W. Broadway, Minneapolis, Minn.

Lawn, Ray Arnold U. of Minn., M B., 1935, M.D., 1936 1105 W. Broadway, Minneapolis, Minn.

Lindberg, Vernon Leslie U of Minn., M.B., 1936 3838 Queen Ave. N., Minneapolis, Minn.

McCree, Dorothybelle U. of Minn., M.B., 1935, M.D., 1936 1897 Summit Ave., St. Paul, Minn.

McKinnon, Daniel Angus, Jr. U. of Pa., M.D., 1933 Mayo Clinic, Rochester, Minn.

Mann, Arthur Seldon, Jr. ._ Med. Col. of Va., M.D., 1934 Mayo Clinic, Rochester, Minn.

Mason, Larkin Keith Tulane U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Neel, Harry Bryan ..._ Johns Hopkins U., M.D., 1932 Mayo Clinic, Rochester, Minn.

Olson, Alton Curtis . ._. U. of Minn., M.B., 1933, M.D., 1934 2425 34th Ave. S., Minneapolis, Minn.

Paine, John Randolph Harvard U., M.D., 1931 41 Clarence St. S. E., Minneapolis, Minn.

Rosenow, Edward Carl, Jr. Harvard U., M.D., 1935. Mayo Clinic, Rochester, Minn.

Rushton, Joseph George ... Rush Med. Col., M.D., 1935 Mayo Clinic, Rochester, Minn.

Schubert, John William U. of Minn., M.B., 1936 Minneapolis Gen. Hosp., Minneapolis, Minn,

Sickler, James Russell Temple U., M.D., 1935 ... _ _ 325 Harvard St. S. E., Minneapolis, Minn.

Siegel, John Sanford U. of Minn., M.B., 1936 St. Mary’s Hospital, Minneapolis, Minn.

Simison, Carl Rush Med. Col., M.D., 1936 Hawley, Minn.

Stromgren, Delph Theodore U. of Minn., M.B., 1936 Miller Hospital, St. Paul, Minn.

Tennison, William James U. of Cincinnati, MB., 1934, M.D., 1935 Mayo Clinic, Rochester, Minn.

Titrud, Leonard Albert U. of Minn., M.B., 1935, M.D., 1936 U. S. P. H. S. Hospital, Lexington, Ky.

Vaughn, Louis Dysart Northwestern U., M.B., 1934, M.D., 1935 Mayo Clinic, Rochester, Minn.

Wenzel, Gilbert Paul U. of Minn., M.B., 1936 Bethesda Hospital, St. Paul, Minn.

Williams, Donald Hugh U. of Manitoba, M.D., 1931 Mayo Clinic, Rochester, Minn.

Wilson, William Doak Vanderbilt U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Woodruff, Robert U. of Minn., M.B., 1936 Minneapolis Gen. Hosp., Minneapolis, Minn.

BY RECIPROCITY

Bray, Kenneth Eben U. of Minn., M.B., 1934, M.D., 1935

Burns, Floyd McKenzie St. Louis U., M.D., 1935

Formanack, Carl Joseph Creighton U., M.D., 1935

Mulligan, Arthur Montgomery U. of Neb., M.D., 1928

Van Winkle, Charlotte C Johns Hopkins U., M.D., 1921

Webster, LuVerne John U. of Wis., M.D., 1933

Co. 1775, Allen Junction, Minn.

. Milan, Minn.

-Otoe, Neb.

. 4040 Grand Ave., Minneapolis, Minn.
.Williston Road, R. 2, Hopkins, Minn,
Walker Sanatorium, Walker, Minn.

NATIONAL BOARD CREDENTIALS

Archer, George Ferguson, Jr

Fischer, Milton Schnell

Kahler, James Elias

Sheppard, Charles Goodnow

Vanderbilt U., M. D., 1934 Mayo Clinic, Rochester, Minn.

U. of Pa., M. D., 1933 c/o H. L. Fischer, 1767 First National Bank

Bldg., St. Paul, Minn.

Col. of Med. Evang., M. D., 1936 Mayo Clinic, Rochester, Minn.

U. of Minn., M. B., 1935, M. D., 1936 1214 7th St. S. E., Minneapolis, Minn.

A Review of 1936 Literature
on General Medicine*

J. O. Arnson, M. D.

Bismarck, North Dakota

IT IS a difficult task to review the medical literature
of 1936 and report the important features of medical
progress in a concise form, in order that the prac-
titioner may benefit from the knowledge contributed by
the authors. Medical literature has grown so voluminous,
and matters of little consequence are discussed at great
length in many journals — therefore, the reviewer finds
himself obliged to choose the points which, in his esti-
mation, will be of particular value and interest to the
average medical man. This review purposes to give the
reader a broad view of the entire field of literature dur-
ing 1936 with emphasis on the contributions which will
determine progress in medicine. Necessarily, many im-
portant facts will be omitted and details which might
be interesting will be neglected; but with the references
appended, those who are interested in further pursuing
the investigation of any subject commented upon will
be able to do so.

The various types of arthritis have attracted the
attention of essayists and investigators during 1936.
Schnabel and Fetter of the Philadelphia General Hos-
pital report continued favorable results, in the gonor-
rheal type of arthritis, from the use of artificial fever
therapy. This method of treatment has been of great
value in the treatment of Sydenham’s chorea. Hyper-
pyrexia in Sydenham’s chorea with the aid of protein
shock treatment (intravenous typhoid vaccine) has also
given good results.1

Rheumatoid arthritis continues to be a therapeutic
problem. Rinehart of San Francisco reports an interest-

*Prepared expressly for the 67th anniversary issue of THE
JOURNAL-LANCET.

ing relationship between rheumatoid arthritis and rheu-
matic fever. It was noted that deficiency of vitamin C
was apparently given as a causal factor in some cases
that were classified as rheumatoid arthritis. From in-
vestigations it was suggested that vitamin C deficiency
may be a predisposing factor in other types of arthritis
by producing a locus of decreased resistance. The
characteristic atrophic changes in the skeleton, muscles
and skin, seen in rheumatoid arthritis, are seen in chronic
vitamin C deficiency."

Inasmuch as the treatment of chronic arthritis is a
prolonged process, the economic situation of many pa-
tients demands that home treatment be carried out.
Coulter of Chicago plans an excellent regime for home
treatment, emphasizing heat, massage and exercise, to
increase blood flow.3

In connection with the treatment of chronic arthritis,
it is interesting to note the report of Schkurov on 219
cases of chronic rheumatic polyarthritis, in 116 of which
parathyroidectomy was performed. A fairly large per-
centage of good results was obtained in his cases. The
treatment, however, is not presented as a cure but is
only one contribution in the numerous measures in the
prophylactic and active treatment of these conditions.
The procedure is not recommended until further in-
vestigations are pursued.4

RHEUMATIC FEVER: Inasmuch as the role of
tonsillar infection as an etiologic factor in the pro-
duction of rheumatic fever has long held an important
place in the ideas of the medical profession, it is timely
to call their attention to the review, "The Influence Of
The Tonsils On Rheumatic Infection In Children” by

THE JOURNAL-LANCET

Albert D. Kaiser, Rochester, New York. There has
been considerable doubt as to the exact relationship of
the tonsils to rheumatic fever. Frequently infection in
the tonsils precedes rheumatism. On the other hand,
many children subject to tonsillitis or sore throat do not
show evidences of rheumatic disease. He made separate
studies of three large groups of children which justify
the opinion that tonsils have definite influence on the
incidence of rheumatic disease in children. He concludes
that the tonsils should be removed in every rheumatic
child. The article is recommended for complete read-
ing.10

"The Effects Of Winter On A Chronic Rheumatic
Condition,” is discussed by J. Barnes Burt of Devon-
shire, England. The geographic distribution of rheu-
matism reveals a rarity in hot, dry climates — common
incidence was noted in the temperate zones and an ab-
sence in dry, cold climates. Lack of exercise, over-
indulgence in food and insufficient sweating are con-
tributory factors to this increased incidence of chronic
rheumatic conditions in cold weather.11

INFLUENZA: Pettit, Mudd and Pepper of Phil-

adelphia, review the status of influenza virus. They
conclude that the virus which has been the primary
etiologic agent of human influenza, in widely separated
areas of the world during recent years, appears to be a
single immunologic entity. They show that both active
and passive immunization of animals against this virus
is possible. These facts offer encouragement for the
ultimate control of influenza. This should stimulate
the efforts of the workers in preventive medicine in the
perfection of a practicable means of immunization be-
fore the coming of the next pandemic."

MEASLES: Gunther Paschlau of Berlin reports

further encouraging results in the use of placental ex-
tract in measles prophylaxis. He advises the use of ten
cubic centimeters of placental extract in nurslings and
from fifteen to twenty cubic centimeters in older child-
ren.0

McGavran reported a limited number of cases in the
prevention and treatment of measles with immune glo-
bulin. It appears that the use of immune globulin is
another advance in the prevention of measles. A per-
son should remember that the immunity is passive and
temporary.7

POLIOMYELITIS: Progress in dealing with this

disease has been restricted to the apparently unsuccess-
ful attempts of workers to develop a vaccine which
would produce a lasting immunity. Kolmer of Temple
University reviews his work and reports success in im-
munizing forty-two monkeys with a living but attenuated
vaccine, carrying four per cent emulsions of spinal cord
in one per cent solutions of sodium ricinoleate. Over
ten thousand children were immunized with the vaccine
with apparently good results. He states that no person
receiving the three doses had contracted the disease, but
ten receiving one or two doses had done so.8

J. P. Leake reports twelve cases in which poliomyelitis
followed injections of the treated virus, administered

to establish immunity against the natural disease. Re-
ports of Leake make it apparent that further use of
such a living virus is unjustifiable and should not be em-
ployed until the objectionable features that Leake re-
ports are overcome.0

TULAREMIA: Lewis B. Flinn of Wilmington,

Delaware, reports the use of a specific anti-serum in the
treatment of tularemia. He reports thirty-two patients
with clinical tularemia, of whom none died, all receiving
anti-serum. His report is very encouraging in that it
will be a valuable adjunct in the treatment of this dis-
ease. lL>

EPIDEMIC PLEURODYNIA: Kirkwood and

Stoll of Sumner, Illinois, give an excellent report on this
condition, which has been so prevalent throughout the
country. A typical case presents an abrupt onset with-
out any premonitory symptoms, with acute severe pain in
the region of the diaphragm, lower thoracic wall or the
epigastrium. Occasionally distention may appear in
the upper abdomen. Rapid and shallow respirations
accompany and headaches and backaches are noted. The
temperature rises to 101 to 104. In twenty-four to
thirty-six hours the severe pain disappears. Occasionally
a second paroxysm will occur in one to two days, but
rarely a third. They report the prognosis excellent and
the treatment is symptomatic. Strapping of the chest
and the administration of quinine are recommended.
This condition evidently seems to be synonymous with
acute diaphragmatic pleurisy. 1,1

PNEUMONIA: The progress in the treatment of

pneumonia lies wholly within the province of further
development of specific sera for the various types. It is
apparent that Type One gives by far the best results to
specific serum therapy. There is some improvement
over the death rate in the use of Type Two serum in
Type Two pneumonia. The following contributions cover
the new developments in serum therapy in detail.14

Pneumococci are now separated according to classi-
fication of Cooper into thirty-two specific serologic types.
Of these one, two, three, five, seven and eight constitute
seventy-five per cent of all cases of pneumonia. In in-
fants and children of pre-school age, Types Fourteen and
Six are the most frequent. Type One anti-pneumo-
coccous serum gives the best results — Type Two not
quite so good. Serums are also available for Types
Five, Seven and Eight. No success has been obtained
in producing an anti-serum which is effective against
Type Three.

Howard, in reference to pneumothorax treatment of
lobar pneumonia, is of the opinion it does not offer any
particular advantages over other types of treatment.

TUBERCULOSIS: The observations of Myers,

Harrington, Stewart and Wulff, of the University
of Minnesota, note the importance of careful observa-
tion of individuals, particularly children, with first in-
fection type of tuberculosis. It is felt that their studies
should be read in detail by all practitioners because of
their daily contact with this type of infection.10

THE JOURNAL-LANCET

In order to appreciate further the relationship of the
childhood infection type and the adult type of pul-
monary tuberculosis, the reviewer recommends Arvid
Wallgren’s contribution, which should be read by every-
one interested in the treatment and control of tuber-
culosis.10

Regarding the progress made in the treatment of
tuberculosis, it is interesting to note the greater appli-
cation of surgical measures. It, manifestly, has had in-
creasing success in many cases. The tendency is to em-
ploy surgical measures in greater numbers of cases. For
instance, the evulsion of the phrenic nerve and artificial
pneumothorax are being advocated in early lesions and
collapse therapy, by means of thoracoplasty, more fre-
quently.

BCG Vaccination In Western Europe — G. Gregory
Kayne of London, discusses the vaccination against
tuberculosis with attenuated tubercle bacilli in great de-
tail. One is attempted to conclude that with further
developments and further trial, if the vaccine produces
increased resistance to tuberculosis, its use in children
of families with open pulmonary tuberculosis would be
justified.17

BRONCHIAL ASTHMA: The most important

advance in the treatment of bronchial asthma during
the past year has been the use of helium inhalations.
The value of helium therapy is based upon the decreased
effort of the respiratory tract, in breathing, due to the
decreased weight of the volume of inhaled air. Marked
relief has been obtained in paroxysms of bronchial as-
thma which did not respond to the usual measures of
treatment. Thirty per cent helium mixture replacing
the nitrogen in the usual atmosphere with an oxygen
concentration of twenty per cent is the type of mixture
which is used. This gives a density thirty-three per cent
of air.18

The Use Of Mandelic Acid In The Treatment Of
Urinary Tract Infections : Rosenheim published his

paper on the "Use Of Mandelic Acid In The Treatment
Of Urinary Infections,” in May, 1935, and further
contributions have been made, particularly by Helm-
holz and Osterberg of the Mayo Clinic; and they call
attention to the great value of this preparation in treat-
ing bacillary infections of the urinary tract of which
colon bacillus is the most predominant etiological factor.
The effects of mandelic acid on the cocci have not been
sufficiently studied; but Helmholz reports that several
strains of staphylococci are about as susceptible to man-
delic acid as the colon group. He also reports that sev-
eral patients have been apparently cured of strepto-
coccus urinary infections with mandelic acid. The oral
administration of sodium mandelate will give .25 to I °/o
concentrations in the urine. A PH of 5 to 5.7 concen-
tration of the urine is necessary.19

ARTERIOSCLEROSIS: Howard B. Sprague,

Massachusetts General Hospital, reports that the etio-
logical factors in degenerative vascular disease are as
follows:

(1) Food — increased deposit of cholesterol in scler-
otic arteries indicates that foods with high
cholesterol content should be eliminated.

(2) The use of tobacco: tobacco causes vaso-con-
striction and peripheral vaso-constriction may
be the primary mechanism of essential hyper-
tension.

(3) Alcohol in itself does not produce arterio-
sclerosis. The lack of judgment induced by
alcohol may promote excesses in eating.

(4) Arteriolar sclerosis.

(5) Hereditary susceptibility.

(6) Increased tempo of life is questionably a factor.

(7) Increased incidence in males may be due to en-
docrine factors not known at the present time.

Dr. Sprague’s conclusions are that the cause of de-
generative vascular disease is unknown but the problem
is being more clearly defined by chemical analyses of
the vessels and study of experimental arteriosclerosis.2"

Chemical Aspects of Arteriosclerosis were studied by
R. S. Austin and Pearl M. Zeek of the Cincinnati Gen-
eral Hospital. They found there is more alcohol-ether
soluble material and increased calcium in sclerotic aorta
than in the normal. These alcohol-ether soluble mater-
ials were cholesterol, cholesterol esters, fatty acids and
small amounts of phospholipids. They explain the in-
filtration of lipids into the wall of the aorta by an in-
creased cholesterol content of the serum and an infiltra-
tion of the lipids into the wall during systole. In age
certain changes in the colloid character of the elastic
tissue of the artery occurs so that the lipids may be
bound or precipitated. Besides age, any condition which
influences blood pressure or which disturbs the choles-
terol metabolism or causes disease of elastic tissue, may
be operative.21

Consideration of the recent developments in the treat-
ment of hypertension would not be complete without
reference to the development that has taken place in the
neuro-surgical field. At the University of Michigan
and at the Mayo Clinic, Rochester, Minnesota, apparent-
ly good results have been obtained in selected cases of
hypertension. Adson, Craig and Brown of Rochester,
Minnesota, conclude from their experiences that defi-
nite results have been obtained by extensive operative
procedures, consisting of (1) bilateral ventral rhizotomy
of the thoracic and lumbar roots, extending from the
sixth thoracic to the second lumbar inclusive, and, (2)
subdiaphragmatic splanchnic resections with removal of
the upper two lumbar ganglia and resection of the
suprarenal gland. They report that the latter operation
may be more effective in controlling symptoms of essen-
tial hypertension than the former. A limited number of
patients failed to respond and some obtained clinical
improvement without much decrease in the blood pres-
sure, some of these having had a recurrence of their old
symptoms and the high blood pressure. They feel the
immediate results have justified the treatment. They
are encouraged to continue operative measures in the
hope that better selection of cases may be made.34

THE JOURNAL-LANCET

Nature Of Peripheral Resistance In Arterial Hyper-
tension With Special Reference To The Vascular Motor
System : Prinzmetal and Wilson of Harvard Univer-

sity carried on an investigation regarding the following
questions:

1. Is the increased peripheral resistance in hyper-
tension generalized throughout the systemic cir-
culation or confined to the splanchnic area?

2. To what extent are the vessels responsible for
the increased peripheral resistance capable of
dilatation?

3. What part is played by the vasomotor nerves in
the maintenance of the increased peripheral re-
sistance?

They found that increased vascular resistance in the
different types of hypertension was not confined to the
splanchnic area, but was generalized throughout the
systemic circulation. They also found that the blood
vessels are capable of considerable dilatation and the in-
creased resistance is due to a hypertonic state and not
to organic changes in the vessel walls. They concluded
that this hypertonus is not of vasomotor origin but is,
in all probability, an intrinsic spasm of the blood vessels
themselves. These conclusions apply to all the types of
hypertension — namely, benign, malignant and the so-
called renal hypertension, which is associated with acute
and chronic glomerulonephritis and chronic pyeloneph-
ritis. They conclude that normal vasomotor activity is
superimposed on intrinsic vascular hypertonus. Their
opinion is that surgical procedures aiming at the relief
of high blood pressure, by sympathectomy, do not
abolish the vascular hypertonus which is fundamentally
responsible for hypertension.-*0

Chemoprophylaxis of Poliomyelitis: Schultz and

Gebhard make a progress report on the prophylaxis of
poliomyelitis by the treatment of the nasopharynx. It is
recognized that the olfactory nerve is the portal of en-
trance of poliomyelitis virus. They studied a number
of solutions and their conclusion was that 1% picric
acid in physiological saline was the most suitable, for
two reasons — first, because its effectiveness, in protecting
the mucous membranes from invasion by the virus, has
been established and, secondly, because it is harmless
and non-irritating. They suggest that the solution be
applied by means of a spray on three successive or al-
ternate days and thereafter once every week or ten days
during the period of an epidemic. Since the solution
should be thoroughly applied to the olfactory area, it is
desirable to have the treatments carried out under the
supervision of a competent physician, preferably a nose
and throat specialist, who would consider the anatomic
conditions which might ordinarily interfere with making
the necessary contact with this area.2'

Peptic Ulcer Therapy : Kellogg and Mettier of San
Francisco report their conclusions in a study of secondary
anemias due to prolonged bleeding in peptic ulcer. They
present data on the influence of alkalinization of the
gastro-intestinal tract on the regeneration of blood by
dietary iron. They found that the bone marrow failed

to respond to the ingestion of dietary iron while the
patients were undergoing alkaline therapy and on with-
drawal of alkalies increase in concentration of hemo-
globin occurred. Increase in the number of erythrocytes
and reticulocytes occurred soon after the addition of iron
rich diet to the alkaline regime. They conclude that
alkalinization of the upper part of the gastro-intestinal
tract interferes with the utilization of dietary iron for
the synthesis of hemoglobin, but not with the utilization
of material necessary for the formation of the cell
structure.2-*

Acne and Carbohydrates: Crawford and Swartz of

the Harvard University Medical School, offer a very
interesting observation on carbohydrate metabolism in
acne. Their conclusions are that the previous general
belief that carbohydrate metabolism is a factor in the
production of acne vulgaris furunculosis is fallible.
They found patients with acne furunculosis have low
blood sugars and normal dextrose tolerance tests — they
improved on diet high in carbohydrates and intravenous
dextrose injection. Fifty per cent of their patients
showed definite improvement — twenty per cent slight
improvement and none were worse. The results of their
experiments intimate that a high carbohydrate diet is
not inimical to the welfare of patients with acne, but
other types of foods, or perhaps specific foods, are more
to be incriminated as factors in cases of acne than the
long abused carbohydrates.24

New Methods Of Medical Treatment Of Schizo-
phrenia: L. De Meduna of Budapest, Hungary, reports
very interesting and apparently excellent results in favor-
ably altering the course of schizophrenia by artificially
producing epileptiform convulsions. Convulsions were
produced by intramuscular injections of twenty-five per
cent oily solution of camphor, gradually increasing the
dose from eight to thirty cubic centimeters. Metrazol in
ten per cent solution intravenously, in doses from three
to six or seven cubic centimeters was also used. The
short duration of the experiments (one year) has pre-
vented him from drawing far-reaching conclusions. He
states that some of the cures may be due to incidental
spontaneous remission. However, he emphasizes two
points — first, that the percentage of cures that he has
obtained far exceeds the number of spontaneous remis-
sions recorded in the literature and, secondly, there were
relapses in which the prompt application of convulsive
therapy lead to remission on the day following the con-
vulsion.23

Hypoglycemic State In The Treatment Of Schizo-
phrenia: Bernard Glueck of Ossining, New York, re-

ports the results of deliberately induced hypoglycemic
state in insulin shock in the treatment of schizophrenia.
This form of therapy was introduced at Professor Potzl’s
Clinic in Vienna in 1933, and since has been extensively
employed in private and public mental hospitals in
Europe. He reports a group of seventy-five patients of
which forty-eight per cent achieved a complete recovery
— total failure occurred in eighteen of the seventy-five
cases. In the remaining twenty-one, definite improve-
ment was noted.26

THE JOURNAL-LANCET

Recent Advances In The Study Of Viruses And Virus
Diseases'. The reviewer recommends to those interested
in this subject, which is one of great importance and
significance, that they take the time to peruse and study
the article by Thomas M. Rivers of New York, pub-
lished in The Journal of the American Medical Associa-
tion of July 18th — volume 107 — pages 206 to 210.

Dr. Rivers discusses at length the recent advances in
knowledge concerning all types of virous diseases and
discusses the status of vaccine and serum therapy in these
conditions. The article is of such a nature that it is
d fficult to abstract in a short paragraph.

Diseases Of The Ductless Glands: The relationship

of endocrinology to general medicine has been increasing
in interest by leaps and bounds the past several years
and 1936 has contributed some very momentous ad-
vances in the study of the endocrines. The development
of the knowledge regarding the hormones of the pitui-
tary and ovaries is well known for the revolutionary
effect they have had upon the treatment of gynecological
lesions, especially ovarian dysfunction and dysmenorrhea.
The advances in the addition to our knowledge of the
thymus and pineal glands, as they are being worked out
by Adolph M. Hanson, of Faribault, Minnesota, offer
some very interesting possibilities in their application to
medical problems. Dr. Hanson states that the thymus
glands of young milk-fed calves, up to four weeks of
age, and killed within six hours after the last feeding,
are particularly rich in an iodine reducing substance
which is most likely glutathione. Glutathione consists
of three amino-acids — glutamic acid, glycine and cys-
teine. Glutathione injected into rats in similar pro-
portions to the amounts of iodine reducing substance in
thymus extract, Hanson estimated, as glutathione, re-
veals the same biologic effect. It seems that one func-
tion of the thymus may be that of supplying large
amounts of glutathione in early life to care for the de-
mands of rapid growth and development and possibly to
take care of the normal cell growth and repair by smaller
amounts later in life.27

Hanson also states that pineal extract, when injected
intra-peritoneally, in succeeding generations of white
rats of the Wistar strain, produces dwarfism, physical
an sexual precocity. While it retards and limits bod)’
growth, it speeds up development, the gonadal develop-
ment compared with the size of the animal being out-
standing.

PROTAMINE INSULIN: The development of

protamine insulin is perhaps one of the greatest ad-
vances that has occurred in medicine during the past
year. It was discovered by Hagedorn of Copenhagen.
This insulin compound is absorbed slowly due to the
fact that it is combined with a basic substance, the pro-
tamines. Hagedorn used the monoprotamines obtained
from the sperm of the rainbow trout. When the reaction
of this protamine insulin was adjusted to a PH of 7.3,
a precipitate took place. This substance was of constant
insulin concentration and when injected into the bodv
there was a steady and prolonged absorption of the in-
sulin. The use of protamine insulin makes it possible

for the average diabetic to receive but one injection of
insulin a day. The insulin is gradually absorbed, and
its effect from one injection has been observed for as
long as fourteen hours. Hagedorn’s results have been
confirmed by numerous observers in this country. One
to five days are necessary for the average patient to
change from regular to protamine insulin. To accom-
plish the use of one insulin dose a day, it is advisable to
give a dose of regular insulin, plus a dose of protamine
insulin, before breakfast. In changing from the regu-
lar to protamine insulin the same number of units of
regular insulin are given before breakfast, combined with
an amount of protamine insulin equal to the quantity
usually given during the rest of the day. Insulin reactions
may occur with protamine insulin and careful adjustment
of the dosage of protamine insulin must be made. Re-
actions, however, are usually milder than with regular
insulin.

With the recent preparations of American manufac-
turers, to which zinc or calcium has been added, the
action is prolonged for more than twenty-four hours.
These preparations do not vary as much in effect as
those without the zinc or calcium and they can be kept
without deterioration for several weeks. At this writing
protamine insulin is not available on the market but will
be soon.33

CRYSTALLINE INSULIN: M. Paul Mains

and McMullen of Chicago give an excellent review of
the subject "Crystalline Insulin as Developed by Dr.
Melville Sahyun of Detroit” and confirm Dr. Sahyun’s
observation. Regarding potency, crystalline insulin is
fully as potent as the regular type. With both types
of insulin equally as potent, any difference in their
actions is to be attributed to differences in their rates of
absorption. During the entire course of the investiga-
tion only five instances of insulin reactions were noted,
and in none of them did the patient become comatose.
They report one individual who had frequent reactions
with regular insulin, coma coming on almost immediately
and before he had time to summon aid or take carbo-
hydrates. These disappeared on the administration of
crystalline insulin. The apparently slow onset of hypo-
glycemia with crystalline insulin is a distinct advantage,
inasmuch as it allows the patient time to ingest carbo-
hydrates and thus prevent coma. None of the other
patients required any treatment for their hypoglycemia,
the reactions being very mild. One of the characteristics
of crystalline insulin is the delayed absorption — for in-
stance, a dose given before breakfast is absorbed so
slowly that the blood sugar is not lowered until 1 1 A. M.
and the blood sugar for the remainder of the day is
maintained at a fairly constant level. The rate of ab-
sorption of crystalline insulin is dependent on some fac-
tor in the body, possibly the PH. The advantages of
crystalline insulin are summarized as follows: it is stable
at room temperature; it is equally potent with regular
insulin; it shows slower absorption and a more prolonged
reaction than ordinary insulin. Severe infections, or
acidosis, favor a more rapid absorption. Delayed ab-
sorption prevents insulin reactions, even when the fast-

THE JOURNAL-LANCET

ing blood-sugar is low. A single morning dose remains
in effect during the succeeding night. One daily large
dose of crystalline insulin will control the blood sugar
of patients usually requiring two or more doses of regu-
lar insulin daily and maintain the patient aglycosur:c.JS

PERNICIOUS ANEMIA: The continued study of
pernicious anemia has resulted in some progress in the
refinement of liver extract and the discovery of its pres-
ence in other organs besides the stomach and liver. Unto
Uotila of the University of Helsinki1’1' made prepara-
tions from the lowest part of the small intestines, just
above the ileocecal junction. The effect of extracts ob-
tained from the ileum was about fifty to sixty per cent,
calculated according to the reticulocyte reaction, of that
exercised by dry stomach powder.

Schemensky, of Kustrin, Germany, reports treatment
of pernicious anemia with powdered colon of hogs with
excellent results.'10

In recent experimental work on the etiology of per-
nicious anemia, Wakerlin and Bruner, of the University
of Louisville, have found evidence of the anti-anemic
substance in human urine. Their work consisted in the
injection of specimens of urine from six normal subjects
into pigeons and the reticulocyte response observed.
Their results indicated that significant increases in the
reticulocyte percentage occurred following injection of
small doses of urine. Other workers have reported
erythropoietic activity of normal urine when adminis-
tered to rats and guinea pigs.'11

Efforts to determine the chemical nature of the anti-
anemic principle have not met with definite success, al-
though progress has been made. Julius Schultz, of Ann
Arbor, Michigan, concludes that previous to 1935 it was
believed the anto-anemic principle had a nitrogenous
base. Dakin has since shown that it perhaps is a gluco-

samine peptid derived from some mucin-like substance.
Further progress will be made more rapidly in the future
when better methods of testing products are found.32

References

1. Annals Int. Med. 9:398-404, October, 1935.

2. Annals Int. Med. 9:671-689, December, 1935.

3. J. Lab. Clin. Med. 21:497-502, February, 1936.

4. J. Bone dc Joint Surg. 17:571-576, July, 1935.

5. J A. M. A. 106:890-892, March 14, 1936.

6. Munchen. Med. Wchnschr. 83:564-566, April 3, 1936.

7. J. A. M. A. 106:1781-1783. May 23, 1936.

8. J. A. M. A. 105:1956-1963, December 14, 1935.

9. J. A. M. A. 105:2152, December 28, 1935.

10. J. Lab. Qc Clin. Med. 21:609-616, March, 1936.

11. Practitioner 132:62-69. January, 1936.

12. Delaware State M. J. 7:219-222, November, 1935.

13. Illinois M. J. 69:29-33, January, 1936.

14. Cecil (N. Y. C.) New York State J. Med. 3 5:1 124-1 129,
November, 193 5. John Fleming — Quart. J. Med. 5:105-117,
January, 1936. Theodore J. Abernethy, New York State J. Med.
36:627-634, April 15, 1936. Cecil, Plummer and McCall — Am.
J. M. Sc. 191:305-31 9, March, 1936.

15. Am Rev. Tuberc. 37:631-643, December, 1935.

16. Journal-Lancet 56:237-244, May, 1936.

17. Am. Rev. Tuberc. July, 1936.

18. Annals Int. Med. 9:6-739-765.

19. Rosenheim M. L. Lancet 1:1032*1037, May 4, 1935.
He'mholz, H. F. and Osterberg, A. E. — Jour. LJrol. 35:

86-92, January, 1 936.

20. New England J. Med. 213-659-662, October, 1935.

21. J. Med. 17:6-10, March, 1936.

22. California QC West. Med. 245 — No. 2, August, 1 936.

23. Archives Int. Med. 58:278-284. August, 1936.

24. Archives of Dermatology QC Syphilology 3 3:1035-1041,
June, 1936.

25. Archives Neurology QC Psychiatry 35:361-363, February,
1936.

26. J. A. M. A. 107:1029-1031, Sept. 26, 1936.

27. The Role of the Thymus and Pineal Glands in Growth fid
Development. Rountree, Clark, Steinberg, Einhorn and Hanson.
New York State Journal of Medicine. 36:18, Sept. 15, 1936.

28. J. A. M. A. 107:959-962, Sept. 19, 1936.

29. Acta. Med. Scandinav. 89:50-56 — 1936.

30. Zetschrift F. Klin. Med. 128:428-438. Aug. 17, 1935.

31. Archives Int. Med. 57:1032, May, 1936.

3 2. Am. J. Digestive Diseases and Nutrition — III, 6:405-412.
3 3. Hagedorn, Jensen, Krarup, and Wodstrup. Protamine
Insulinate. J. A. M A. 106-177. Jan. 18, 1936.

Protamine Insulin — Elliott P. Joslin, Nelson’s Loose Leaf Medicine,
1936.

34. Sur. Gyn. fid Obs. 314-330, February, 1936.

3 5. J. Clinical Investigation 15:63-83, January, 1936.

A Review of 1936 Literature on Obstetrics
and Gynecology*

P. R. Billingsley, M. D., F. A. C. S.

Sioux Falls, South Dakota

IN THE preparation of this review of current litera-
ture, the limitation of space has been kept in mind,
and an endeavor has been made to choose those
articles which seem to have the greatest practical im-
portance. Such a plan of necessity passes by many re-
ports which may later prove to be invaluable, but which
at present only seem to have an academic interest.

Obstetrics

The determination of sex by the method of Dorn and
Sugarman (evidence of spermatogenesis in the testes of
immature male rabbits when injected with the urine of
pregnant women) has been investigated by Mathieu and
Palmer, and by Pommerenke and Rogers, both reports

•Prepared expressly for the 67th anniversary issue of THE

JOURNAL-LANCET

showing an inability to confirm this work. Schumacher
critically evaluates all the theories of sex determination
that have been advanced from Galen to date, to show
the weakness of each, and to leave the question in status
quo.

In the matter of prenatal care, there are several papers
which discuss the effect of diet upon mother and
child and upon the course of the pregnancy, all of which
seem to emphasize the importance of a widely-generalized
menu which will automatically insure an adequate vita-
min intake, rather than a rigid insistence upon certain
specified foods. In general, these papers assert the value
of a wide variety of food, plus milk (or medicinal cal-
cium) , plus cod liver oil.

THE JOURNAL-LANCET

The not uncommon occurrence of biliary colic during
pregnancy gives interest to a report by Reigel, Ravdin,
Morrison, and Potter. The gallbladder bile of 34
women at term was analyzed, the cholesterol concentra-
tion being usually increased, and the bile salt concen-
tration being invariably decreased. These findings are
what would be expected in the early stages of calculus
formation.

Observations on the period of pregnancy by Obata
would indicate that 280 days, or thereabouts, is the ex-
ception. In 10,000 pregnant women at his hospital,
pregnancy ran from 264 to 297 days, with only 3.8 per
cent delivered in 280 days. Among 30 women who had
a definitely known date of conception, pregnancy con-
tinued from 233 to 288 days.

The Ascheim-Zondek reaction as a test for pregnancy
is the subject of several papers. The production of
ovulation in immature female rats and female rabbits
and the production of follicle rupture in mature female
rabbits (Friedman) are the methods commonly used.
Davy and Sevringhaus had an accuracy of 90 °/c in 425
cases, the 10 per cent of inaccuracy representing both
false positives and false negatives. The cause of error
was rarely a matter of technique or of interpretation,
but is felt by the authors to be inherent in the test. Much
better results are reported by Hansen and Gram in a
series of 997 cases, with an initial inaccuracy of 1.48
per cent. Mills reports 213 cases (using' the Friedman
modification) with an inaccuracy of 3.3 per cent. In
all of these reports an analysis of the failures will usually
show some form of pelvic pathology in the mother
(uterine and ovarian tumors and infections), while it is
less frequent to find fetal pathology as a cause. On the
other hand, the test may remain positive for as long as
three months after death of the ovum. A further report
on the value of the ovipositor change in the female
Japanese bitterling as a test for pregnancy showed four
failures in 3 1 tests. Another report concerning this
method gave 12 failures in 21 tests known to be preg-
nant, was positive in 4 of 7 non-pregnant women, and
was also sometimes positive in the male and after the
menopause. All of which emphasizes the need for cor-
relation between the clinical and laboratory findings.

Those papers which deal with the X-ray diagnosis of
obstetric problems are chiefly concerned in sounding a
note of warning against relying too much on this method
of determining disproportion, or of making a diagnosis
of a fetal monstrosity.

The treatment of habitual and threatened abortion is
considered by several writers, and while the number of
cases is necessarily small, they give renewed emphasis to
the probable value of thyroid extract and lutein hor-
mone (corpus luteum, progestin) in prevention. In the
treatment of the various types of abortion in progress
(incomplete, septic), there are reports of large series
of cases from Milwaukee, Boston, Birmingham, and
Emory University, in which a conservative regimen was
followed, with a good deal of reliance on the newer
ergot preparations as a means of emptying the uterus,

and employing digital or instrumental curettage only
after other methods failed. These reports offer low
mortality figures as further argument in support of con-
servatism in treating abortion, an attitude which would
seem to be gaining in its general acceptance. On the
other hand, Carroll offers an interesting report of 106
cases of abortion (all types) which were treated by
emptying the uterus at once and inserting carbon in the
uterine cavity, with a shortened convalesence, lessened
toxemia, and no mortality.

The matter of therapeutic abortion comes up for dis-
cussion in several papers, as it relates to tuberculosis,
heart disease, nephritis, the toxemias, and neurologic
and psychiatric disorders. Without attempting a criti-
cal evaluation of these papers, it can nevertheless be said
that this most vexsome problem is about where it has
been for some time, with the emphasis placed upon con-
servatism in the borderline cases, but with renewed insist-
ence upon the need for radical interference in a small
minority of cases of severely advanced disease. But
each case is an individual problem without any precise
rules for guidance. DeLee offers a critical comment in
which he states that in general he has not receded from
the radical stand he took many years ago with regard
to tuberculosis. As to the technique of therapeutic
abortion, a paper by Robinson and others testifies to
their failure to induce labor by the use of estrin when
the fetus was alive, though they report 80 per cent
efficiency in cases of death of the fetus, or missed abor-
tion. A hopeful field of use for estrin is in uterine in-
ertia, where the response is often quite dramatic.

The various writers who have discussed the relation-
ship between various types of acute and chronic heart
disease (apart from the question of therapeutic abor-
tion) have been insistent in speaking of the desirability
for a closer cooperation between the obstetrician and
internist in the management of these cases during preg-
nancy and in labor. Every effort should be made ta
build up cardiac reserve during the pregnancy by en-
forced rest, the use of sedatives, digitalis, etc., and
when the test of labor comes one should draw upon this
reserve as little as possible. Little can be done to shorten
the first stage of labor, nor is there any great need for
this, since it is a period of little muscular effort on the
part of the patient. But a good deal can be done dur-
ing the second stage of expulsion to lessen the cardiac
effort by the use of anesthesia (local and general) ,
episiotomy, and the application of forceps. However,
if there is a grade of decompensation that does not
justify labor, then a solution of the problem can be
found in low cervical section done under local anes-
thesia.

A distinctly optimistic viewpoint of the effect of preg-
nancy on pulmonary tuberculosis is taken by Ornstein
and Kovnat. A 33 per cent mortality in a non-pregnant
group was only raised to 36 per cent in a group of preg-
nant women, this increase being almost entirely in the
caseous-pneumonic type of the disease, rather than in
the chronic productive type.

THE JOURNAL-LANCET

An outstanding discussion of the problem of diabetes
and pregnancy is contained in an article by White, who
analyzes the material in Joslin’s clinic, consisting of
257 pregnancies in 180 women over a period of 36
years. The low maternal mortality of 5 per cent before
insulin was unchanged by the advent of insulin. The
hazard to the mother seems to lie mostly in the fields of
toxemia, eclampsia, and a lowered resistance to any in-
fection which may ensue as a result of operative inter-
ference. The use of insulin has definitely increased the
rate of fertility among diabetic women and has lessened
the symptom of amenorrhea so many of them have. In
contrast to the low maternal mortality, there is a very
definite increase in the rate of abortion and stillbirth
among these women, despite the use of insulin.

Irving suggests that the hypochromic anemia of preg-
nancy is due to a depletion of the iron and copper re-
serves of the mother, due to the demands of the grow-
ing fetus. An interesting corollary to this theory is the
statement by Strauss that infants born to mothers with
hypochromic anemia do not have a similar anemia at
birth but are prone to develop it during the first year of
life.

Traut and Kuder offer an explanation of the upper
urinary tract infections occuring during pregnancy. The
idea that the gravid uterus presses upon and hinders the
free flow of urine is not sufficient by itself, for an ana-
logous situation does not develop with uterine fibroids
and cystic ovaries. But when this factor is combined
with the atony of the ureteral musculature and the
ureteral dilatation that they have observed, they arrive at
a reasonable explanation for the incidence of infection in
the poorly-drained renal pelvis. They advise rest, large
amounts of fluid, and the use of alkalis, when combined
with frequent changes of posture from one side to the
other in order to favor drainage of the kidneys. To all
of this Harris recommends the more frequent use of
ureteral catheterization, not so much for the relief of the
present situation as for the prevention of permanent
damage to the kidneys. He allows the catheters to re-
main in situ from four to six days. Trillat advises the
use of autogenous vaccines iri this condition.

What to do with the fibromyomatous uterus in preg-
nancy is discussed by three writers. Studdiford and
Mahon take the view that only rarely do they compli-
cate delivery, and hence are best left alone unless some
critical accident occurs, such as obstruction in labor, or
an acute degeneration in the fibroid. A more radical
view may be taken in the elderly patient where hysterec-
tomy might be considered at the end of the childbearing
On 'the other hand, Rehmann feels that all such
^hould be operated upon in the presence of
others., might regard as of minor sig-
nificance, ©ftrf^kough operation may cause abortion.

papers which deal in a statistical
ice of gonorrhea in pregnancy, and
id nature of the complications that
ther and child as a result of this
emphasis is in the direction of ade-

quate prenatal care and treatment, stressing the need
for repeated and critical examinations in all suspected
cases.

Mathieu and Palmer report on the surgical cure of
two cases of chorionepithelioma. In each there was a
history of the passing of a hydatid mole two and three
months prior, and in each case the diagnosis was war-
ranted by the finding of anterior pituitary-like hormone
in the urine through the use of the Friedman test.
Brindeau and others make a report on 27 cases of mole,
in 4 of which chorionepithelioma developed. They do
not feel that the persistence of pituitary-like hormone
(Friedman test) in the urine is pathognomonic of malig-
nancy following a mole, but they do place much faith
in failure of the luteinizing hormone to disappear from
the blood. They run frequent titrations for this sub-
stance for some time after expulsion of a mole, and if
it does not show a decreasing curve, a diagnosis of
chorionepithelioma is made. In the four cases they re-
port the diagnosis was confirmed microscopically.

As noted above, the treatment of abortion has varied
from time to time, but at present there is a definite
trend toward conservatism. A problem of surpassing
importance which has plagued the obstetrician in like
manner is that of the management of eclampsia. The
pendulum has swung from radicalism to conservatism
and back again, just as in abortion; but it can definitely
be said at present that some modification of the con-
servative Strogonoff regime seems to offer the best out-
look for these patients when viewed in the cold light of
mortality figures. As usual, the literature of the past
year brings out many papers dealing with this problem
in its many phases of etiology, pathogenesis, and treat-
ment; and it is impossible to discuss them all in a criti-
cal way. Nor is it necessary to recite the general prin-
ciples of conservative treatment by the Strogonoff
method. Various writers have reported their varied ex-
periences during the past year, and have outlined their
own individual modification of the method. All agree
on the value of rest, freedom from stimuli, and the use
of morphine or other sedatives, plus catharsis, accurate
control of fluid intake, and a careful study of the blood
chemistry and renal function as a factor in prognosis
and in the determination of an opportune time for the
induction of labor.

When it becomes imperative to secure the termination
of labor (either because of an unfavorable trend of
events during the pregnancy, or because of the onset
of convulsions during the labor) , there can be little doubt
that a conservative method of vaginal delivery is super-
ior to abdominal section. The colpeurynter is of great
value in starting labor and of great value in hastening
dilatation when labor has started, and can be followed by
episiotomy and version or forceps as a means of short-
ening the second stage. In some cases, vaginal hysterot-
omy may well be the best method of delivery. All of
this is a generalization of what the writer feels is the
trend of opinion today.

More specifically, some interesting things are noted.
The "cold test,” as devised by Hines and Brown, has been

THE JOURNAL-LANCET

used by Randall and others at the Mayo Clinic in 104
cases, as an index of liability for the development of
toxemia. A normal blood pressure reading at rest is
first made, the other arm immersed in water at a tem-
perature of 5° C. for 60 seconds, followed by two-minute
blood pressure readings till normal is again reached. A
prolonged elevation of pressure may indicate suscepti-
bility to toxemia. And there is a report by McGee on
the use of ephedrine in controlling convulsions. Para-
doxically, the ephedrine seems to help in affording a
compensatory elevation of blood pressure, which has
been previously depressed by the use of barbiturates.
At the Cincinatti General Hospital there have been 121
consecutive cases of eclampsia treated with veratrum
viride, with a mortality of 9.92 per cent. And finally,
there has been some interesting theorizing on the origin
of eclampsia. In a normal patient, there is a fall in the
prolan and a rise in the estrin during the last trimester
of pregnancy; but in toxemia these figures are reversed
and there is a persistence of the high prolan figure.
These observations may be correlated in some way with
what has been noted in microscopic examination of the
pituitary of eclampsia patients, in that there is a pro-
liferation of basophile cells in the posterior lobe. This
in turn may be linked-up with the development of pres-
sor substance from the posterior lobe.

Practically all of the foregoing notes refer to questions
that come up during the period of pregnancy. The
matter of labor is now to be discussed.

Caldwell and others at Columbia have studied the
mechanism of engagement and rotation by means of
stereoscopic films. They conclude that a primary trans-
verse position at the beginning of engagement is most
common, and primary anterior and primary posterior
positions less so. They also conclude that the fetal
head is not usually perpendicular to the plane of the
inlet (synclitism) , but lateral flexion is more the rule
(giving asynclitism, with the posterior parietal bone
presenting) . They think that rotation is accomplished
by the uterine contractions imparting a spiral movement
to the fetus as it slips over the angle formed by the uter-
ine wall and the slope of the pelvis.

A simple method of measuring the true conjugate is
offered by Weitzner. A, metal ruler is placed perpen-
dicularly over the sacrum and is included in a film made
in the lateral position. The length of the conjugate
can then be laid over on this ruler and read directly.
Ball and Marchbanks have devised an instrument with
a chart which traces directly the X-ray outlines of the
fetal head and pelvic inlet, and lets one read directly
their respective circumferences.

There have been several conflicting analyses of labor
in young women and old women, and also comparisons
between primiparas and multiparas. These reports seem
to indicate that there is an increased fetal death among
the multiparas, and a greater maternal hazard in the
young primiparas. But as stated, the reports are con-
flicting.

Obstetricians have always been interested in the prob-
able cause of the onset of labor. With the development

of the newer knowledge regarding the pituitary and its
control of ovarian function, there has been some stimu-
lating theorizing carried out in this field, and some ex-
perimental work also. But it is not yet clear what the
relationship may be between the pituitary (posterior lobe
pressor substance) , the anterior pituitary-like substance
in the urine of pregnant women, and the ovarian hor-
mones (estrin and progestin) insofar as initiating labor
is concerned. Suffice to say, there is good clinical evi-
dence that estrin is of value in starting pains when the
fetus is dead (as in the treatment of abortion), and
estrin is of value in uterine inertia.

There is recent and renewed interest in the function
and value of the bag of waters in labor, and a number
of papers have been written on this subject. There are
five major objections to early rupture of the membranes:
injury to the fetal head, prolapse of the cord, infection,
cervical lacerations, and prolongation of labor. Most of
these articles seem to minimize the importance of these
objections, and particularly stress the fact that labor
really seems to be shortened thereby. DeLee criticizes
these papers from the main viewpoint that the bag pro-
tects the child’s head. Those of us who have had the
unpleasant experience of taking care of intracranial
birth injuries will probably sympathize with his attitude.

Anesthesia and analgesia in labor deserve more than a
passing paragraph; but the question has been well
answered by someone who has remarked that the ideal
reagent has not yet been discovered. The second stage
of labor, now and for a long time past, has been well
taken care of by some form of inhalation anesthesia;
but we have yet to secure acceptable results during the
hours of dilatation. Testimony to this effect is found in
the great number of reports during the past year, most
of which deal with the various types of barbiturates.
Some investigators have modified the original Gwathmey
method by using a barbiturate in place of the morphine
(but continuing the rectal administration of ether) ; and
others simply use the barbiturates alone, supplemented
by inhalation anesthesia. One report deals with dilaudid
and scopalamine. It is difficult to look over these reports
and feel that any one method stands out as superior to
all others. The most valid objection to the use of the
barbiturates (aside from their relative failure to produce
amnesia and analgesia) , is the fact that they produce
excitation, restlessness, and unruliness in some people,
and demand greater watchfulness than is the case with
the Gwathmey method as originally developed.

In the field of operative obstetrics there are interest-
ing papers on funnel pelvis, fibroids in labor, rupture of
the uterus, the treatment of posterior positions, and
forceps. But Caesarean section occupies the center of
interest, and here again only a summary of trends can
be discussed. There are numerous reports from large
obstetric clinics, statistical in nature, which record grati-
fyingly-Iow mortality figures. And in these reports the
operative indications are restricted and rigid in their
application. But in the general surgical field, which
still comprises the larger fraction of cases, there is still
too much latitude in the indications and too large a

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mortality figure when the results are tabulated. Ideally,
this whole problem should be in the hands of the ob-
stetrician; but such an objective is still a long way off,
and until that millenium arrives it will be necessary for
the surgeon and patient each to guard against the ease
with which this operation may be done. A second per-
tinent observation is this: that there is a definite tend-
ency to adopt the low cervical section as the method of
choice. The general surgeon is still performing the
classical operation, but the obstetrician and gynecologist
is turning toward the somewhat more difficult cervical
operation as the method of choice. A third thing to be
noted is that the treatment of placenta praevia has been
slowly changing in the last twenty years, and to an in-
creasing degree is Caesarean section being done for this
condition.

Infection is still the most important question in the
pucrperium. There are interesting papers to be read
but there are no outstanding contributions to our know-
ledge of this disease. Stout at Johns Hopkins has ana-
lyzed the incidence of infection in the home as con-
trasted with the maternity hospital, and concludes that
the home is twice as dangerous as the hospital. Watson
emphasizes a three-fold need, in the detection of
carriers, the use of masks by the attendants, and the
isolation of infected cases. Lash at the Cook County
Hospital discusses treatment and urges especially the
value of blood transfusions and the early use of anti-
streptococcic serum. Colebrook, on the other hand,
believes that such serum may possibly have harmful
effects upon the patient in disturbing her own immuniz-
ing processes, and advises conservatism in its use until
there is better evidence in experimental animals that
streptococcic infections are helped by its use.

Gynecology

In the preparation of the above notes on obstetrics an
attempt was made to limit the material to those subjects
that have the greatest practical interest, since obstetrics
is still in the hands of the general practitioner to a large
extent and will probably remain there. In the field of
gynecology it would seem even more important to
choose only a few subjects for review, and those that
are connected with general practice.

The field of endocrinology as it relates to gynecology
has been productive of more papers than any other sub-
ject in the past year. For the student, attempting to
orient himself in this maze of information, there are two
chief difficulties. The first is that the entire problem
is in process of development, and hence there are
many conflicting reports and conclusions, and one is at
a loss to know what is authentic. The second is the
matter of terminology. As always, uniformity of names
is the last stage in development. To assist somewhat in
helping one over these humps, it may be well to con-
dense some abstracts which have appeared in the Year
Book of Obstetrics and Gynecology.

"The bisexual gonadotropic hormone which activates
the ovaries and testes, has been demonstrated by R. T.
Frank in the blood and urine. Before puberty, small

amounts of this hormone are noted in the blood and
urine of children and adolescents. The hormone brings
about the trophic growth of the genitals. At puberty,
greater amounts are demonstrable, causing full activa-
tion of the sex glands. In the healthy adult female a
cyclic activity of the prepituitary lobe is manifested by
the cyclic blood and urinary curve obtained. After im-
pregnation and throughout pregnancy an increase of
from 100 to 200 times the amount found in the non-
pregnant woman, is noted in the blood and urine. At
the menopause the prepituitary cycle ceases. In one
group (50 per cent) a permanent increase of a gonado-
tropic hormone is noted in the blood and urine; in the
other, none is demonstrable. No clinical differences in
these persons are noted. Functional diseases of the fe-
male genital tract appear due to disturbances of the
prepituitary cycle. With present methods this cannot
always be demonstrated by blood and urine hormone
studies. In the male there is no evidence of a prepitui-
tary cycle or of a senile condition corresponding to the
menopause.

"The female and male sex glands produce distinctive
hormones, which have been recovered from the blood
and urine. A substance apparently identical with the
testis hormone is found in the female; estrogenic sub-
stance is found in the male.

"In the normal, mature, fertile woman, two hormones
are secreted by the ovary: the estrogenic factor, which
circulates each month in increasing concentration in the
blood stream until the onset of menstruation, with a
typical urinary curve of excretion, and the progestational
factor, as yet not demonstrated in the blood but found
cyclically-distributed in the urine. In pregnancy a
higher level of the estrogenic factor is noted in the blood
after the eighth week, and a disproportionately greater
increase in the quantities excreted in the urine (placen-
tal effect) .

"Normal genital function in the female is dependent
upon synchronism of prepituitary, estrogenic, and
progestational blood cycles (with corresponding, char-
acteristic excretory curves) . Functional diseases, as has
been shown by blood and urinary studies, are due either
to underfunction or overfunction of the ovaries. Dis-
turbances of function in most instances are primarily
referable to disturbances of the prepituitary cycle.

"The testis hormone has been demonstrated in the
blood and urine. No cycle has been found, and little
correlation between male functional diseases and changes
in the humoral balance as yet has been discovered. Or-
ganic disease in the male can produce changes in the
excretion of gonadotropic principle.”

Further explanation of some of the above statements
can be found in another quotation.

"There is a group of estrogenic substances which may
be subdivided into those active in castrates, and those
active only in animals with intact gonads (gonadotropic
substances) . The latter group may be subdivided into
those of pituitary origin and those of placental origin.
Some or all of these are found to occur in pregnancy
blood and urine, the placenta, the ovary, and the pitui-

THE JOURNAL-LANCET

tary. In addition to these, there is in the female the
luteal hormone, a product of the ovary; and in the male,
the testis hormone, presumably a product of the inter-
stitial cells of the testis.

"Although different forms of estrogenic substance have
been obtained in crystalline form, it is a fact of special
significance that the bulk of estrogenic substance in
fresh urine occurs in some organic combination, as yet
unknown. Gonadotropic principles that have to be con-
sidered are (1) the maturity hormone complex of the
anterior lobe; (2) the anterior pituitary-like gonado-
tropic hormone of placenta, pregnancy blood, and urine;
and (3) an anterior lobe product found in the urine in
certain menopausal states, in the urine of castrates, and
occasionally in normal urine.

"Since discovery of the gonad-stimulating factor called
'prolan’ in pregnancy urine by Ascheim and Zondek,
there has been much discussion as to whether this sub-
stance is identical with the anterior or lobe product, and,
if identical, whether the hormone found in the placenta,
blood, and urine is produced by the anterior pituitary or
is produced also by the placenta. Results of experiments
in hypophysectomized rats show that the anterior
pituitary-like factor cannot replace the real anterior
pituitary substance.

"It has been proved by Zondek that the urine of cas-
trates and of women in the menopause may contain the
principle which Zondek calls 'prolan A.’

"It seems necessary at the present time to postulate two
hypophyseal hormones (gonadotropic) , one that stimu-
lates follicles and one that luteinizes the theca and ma-
ture granulosa.”

While all of the above may seem more theoretical
than practical, nevertheless it is being reproduced here,
for only by an understanding of these theories can one
trace a path through all of the assertions that are being
made regarding the hormonal treatment of obstetric and
gynecologic problems.

There have been many reports which deal with car-
cinoma of the uterus, most of them concerning cervical
carcinoma. Several writers have again discussed the role
that trauma plays in pathogenesis, and again make a
plea for the adequate treatment of the lacerated cervix,
chronic endocervicitis, and the so-called cervical erosion
as a preventive measure. Some attempt has been made
to link up pituitary function with the production of can-
cer because of the twin facts that the pituitary secretion
can produce changes in the cervical mucosa in experi-
mental animals, and because 80 per cent of genital can-
cers show anterior pituitary-like hormone in the urine,
whereas extragenital cancers show no such hormone;
but so far it is felt that these facts express a secondary
relationship.

As to diagnosis, several points need emphasis. The
development of the colposcope in the hands of the
specialist has proved a distinct aid in the early diagnosis
of suspected lesions. Good visualization, in magnified
form, afforded by this method, will serve to at least
make us suspect malignancy earlier than heretofore.
And the observation that carcinoma cells do not con-

tain glycogen, and therefore will not take an iodine
stain, should make the general practictioner more alert
in using this simple test. Warning is given, though,
that this test is not infallible, and there can be false
negatives and false positives. The admitted fallibility
of the iodine test and the colposcope will then serve in-
directly to emphasize the paramount importance of
microscopic examination in all suspected lesions.

In treatment, there seems to be general agreement in
that trend of late years which places radiation with ra-
dium at the front in treating cervical carcinomas, where-
as radiation and surgery combined offer the best chance
in adenocarcinoma of the fundus. By corollary, several
writers have discussed the desirability of total hysterecto-
my for benign pelvic pathology, as compared to subtotal
hysterectomy, the argument being advanced that the re-
maining cervical stump in the latter operation offers an
increased incidence in the development of carcinoma, and
this fact more than offsets the slightly higher surgical
risk that is inherent in the complete operation. But
this seems to be largely an opinion with few statistics to
back it up. A most comprehensive report comes from
the Marie Curie Clinic in London. A total of 728
cases in 10 years is analyzed. Five hundred of these
could be classified histologically as to the degree of
malignancy. It is an interesting fact that the rate of
local cure for three-year survivors did not show more
than a 15 per cent variation between the various groups.
In all cases radium was used, and in only a very small
proportion was supplementary X-ray radiation used.
The second important conclusion is that there was an
88.8 per cent cure in the 90 cases which could be called
operable or borderline. Of the 500 cases classified, 10
per cent were adenocarcinoma. A. Lacassagne (Paris)
at the Fourth International Congress for Radiology
stated that it still remains to be shown whether hysterec-
tomy after intracavitary radiation is superior to radiation
alone. That leaves the question of surgery still up in
the air.

Possibly the two commonest menstrual disorders are
dysmenorrhea and functional menorrhagia. Stone offers
a note on the treatment of the former, and suggests that
the proven value of cervical dilatation in a certain per
cent of cases merits consideration, and recommends that
the use of a No. 5 Hegar dilator in the office during
the intermenstrual period be carried out. He states that
the results are just as good as those following a more
complete dilatation under anesthesia at the hospital.
There are several reports dealing with the treatment of
functional bleeding in young girls and at the menopause,
with excellent results from the use of anterior pituitary-
like substances. It is thought that the effect is obtained
by a stimulation of the progestin factor, which has been
inhibited by the prolonged action of the follicular hor-
mone.

The role that the chronically-infected cervix plays in
the production of pelvic and general disease is not
definite; but most writers feel that there is a degree of
causal relationship, and hence recommend that we at-
tempt to clear up these infections. The widespread use

THE JOURNAL-LANCET

of the cautery prompts several reports, one of which
stresses the value of fractional office treatments as
opposed to a single hospital treatment in lessening the
possibility of producing stenosis. The treatment of
gonorrheal vulvovaginitis in children by the Lewis
method is reported on by Miller (who used theelin) and
by TeLinde and Brawner (who used amniotin). Both
writers report over one-half of their cases cured, but
there is a large percentage of failure. The latter writers
believe that suppository medication is more efficient than
by hypodermic use. Witherspoon at Tulane is unable
to corroborate Lewis’ reports of a large percentage of
cures after a year’s trial of the method, and feels that
there is a further theoretical argument against the
method in that the use of these substances may inhibit
ovarian development later in life. Abramson reports
good results in adult gonorrhea in treating 50 cases with
ultra-violet light. Diathermy and fever therapy have
been used by others with good results, and Sanders and
Sellers at Tulane testify to the worth of the Elliott bag
in treating adnexal pathology.

The conservative management of persistent adnexo-
peritonitis is the subject of a report by Cooke at Gal-
veston. The use of anterior and posterior colpotomy
has given excellent results. Laparotomy had such a high
mortality that it has been abandoned as a method.
A few cases were treated by small multiple abdominal
incisions and drainage where abscesses were close to the
surface. Secondary operation through the abdomen,
following several weeks after vaginal drainage, has like-
wise been abandoned because of the great technical diffi-
culties, and because those that were not operated upon
had a much better after-course. This report strengthens
the growing feeling that here, also, conservatism pays
dividends.

Trichomonas infections have been treated by an
endless number of methods, which testifies to the rela-
tive value of all of these methods. An ideal method of
treatment has not been found. Cornell calls attention
to the need of examining the husband for prostatic in-
fection in those cases which resist treatment or recur.

In those cases of sterility in which the question of the
patency of the uterine tubes is to be investigated, the
Rubin method of insufflation can be used, or an opaque
oil and the X-ray can be used to visualize the tubes.
Several reports call attention to occasional untoward
events that may follow the latter method. These may
be the introduction of infection, the escape of oil into
the venous circulation, the production of an ectopic preg-
nancy, or the collapse and subsequent atresia of what
was a normal tube. For these reasons the method
should be used with caution (perhaps by the fractional
method or Hyams) . In most cases, the simpler Rubin
method would seem to suffice.

It is impossible to read the various reports relating to
contraception by the method based upon the theory of
Knaus and Ogino and feel that this method is absolute-
ly reliable. For example, Weinstock (in Germany) re-
ports on observations made upon 416 women in whom
pregnancy followed from a single coitus. He analyzes
their menstrual cycles, and concludes that while there is
a definite tendency for the fertile period to occur from
the fifth to the tenth day of the cycle, yet this is only
relative and experience indicates that there is really no
sterile period within the menstrual cycle. This and other
reports are so conflicting in their conclusions that one
would do well to avoid endorsing "rhythm” control until
our data are more reliable.

A Review of 1936 Literature
on Surgery

E. G. Balsam, M. D.

Billings, Montana

NO SUCH improvements or surgical departures
as Harvey’s discovery of the circulation, the
work of Holmes, Semmelweis, Lister or Pasteur
in asepsis or antisepsis, Long’s or Morton’s invention of
ether, Halsted’s use of rubber gloves or Roentgen’s de-
tection of the X-ray, have evolved through the past
year. However, a multitude of smaller and less revolu-
tionary, yet definitely progressive, changes have been
apparent through a casual but comprehensive review of
the surgical literature of the past year.

In the following pages is a compilation of the most
significant articles, chosen because they reflect advancing
concepts or practices in the field of surgery. Undoubt-

•Prepared expressly for the 67th anniversary issue of THE
JOURNAL-LANCET.

edly, many other papers deserve inclusion; and would
have been included, were space not so limited.

General Considerations

Anesthetics: Cyclopropane or trimethylene was first
prepared in 1882, and was first used as an anesthetic in
1929. Waters and Schmidt have reported favorably on
its use in 2,000 cases. In extra-abdominal cases, they
found only 13 deaths in 600 operations, whereas there
were 23 in an equal number of operations when ether
was used, and 22 in an equal number with ethylene.
Size and his associates, during 1935 and 1936 at the
Lahey Clinic, used it successfully in 184 cases. In 124
of these cases operative measures involved the chest.
This appears to be the field to which cyclopropane is

THE JOURNAL-LANCET

most applicable. Further, Wood reports good results
in over 900 cases in which cyclopropane and fluid
avertin were used.

Aver tin, an intravenous anesthetic, was used 3,338
times at the Methodist Hospital of Indianapolis prior
to October, 1935. Mueller continues to say that it is
satisfactory for all types of surgery. The chief danger
was respiratory depression which is combatted by an
open airway, oxygen and carbon dioxide inhalations, caf-
feine sodiobenzoate and coramine. No deaths were
directly attributable to the anesthetic. Gaudy and
Wibauw discuss avertin principally in an article con-
cerning 25,000 operations using intravenous anesthesia.
They conclude that, as a result of its great margin of
security, and its possibility of small and progressive
dosage, surgeons should become more familiar with its
use.

Antiseptics — After 16 months’ observation and use of
azochloramid, Goldberger found it highly successful in
the antiseptic treatment of 351 cases of various types of
surgical infection. Azochloramid is a chlorine com-
pound with the chemical name N-N-dichlorazodicar-
bonamidine. Its marked stability should restore waning
enthusiasm for the Carrel-Dakin technic of treating in-
fected wounds antiseptically. Goldberger proved its
stability with a potency titration test occupying one
year’s time. Young, of the University of Rochester, ob-
tained excellent and, at times, spectacular results in the
treatment of a large variety of surgical infections with
azochloramid. Both the healing period and hospital
stay were decidedly reduced and no significant or un-
toward reactions occurred. Azochloramid is slow to re-
act with organic matter, remains available so long that
dressings need be changed only once in 24 or 48 hours,
and is probably least irritating of all chlorine compounds
so far used.

New Instruments: Suture needles — Sheehan has de-
vised a screw cap for the head of the needle. A strand
of the suture is fitted firmly into the cap. Thus only a
single thickness of suture passes through the tissue as it
is sutured. The cap is discarded with the end of the
suture when the suture is too short for use. Vogel
threads his hypodermic needle with fishgut or a wire
filament. With a stock of this wire in his hypodermic
case and using a long morphine needle, he has sutured
wounds more easily than with the ordinary surgical
needle. The most elaborate invention was made by
Nelson. It consists of a hollow needle and handle which
has a wheel for propelling and a knife for cutting the
suture. When the end of the material has been placed
under the wheel in the handle and after the needle has
been passed through the tissue to be sutured, the oper-
ator by turning the wheel forces the material out beyond
the needle. Then, through grasping and holding the
end of the material and by withdrawing the needle, the
operator by pressing the knife can sever the material
at any desired length.

Procedures: Ethylene Encephalography — Since 1919,
air has been used to replace spinal fluid. However, re-

cently, ethylene has been used at the University of
California in 100 cases. Brain tumors, epilepsy and the
effects of brain injuries have been the pathological con-
ditions principally involved. Ethylene has a mildly
sedative effect on some cases, reduces hospitalization and
is absorbed after a few hours.

Gastroscope — In 1932, Wolf and Schindler first per-
fected the flexible gastroscope now in use. However,
it was not until the latter part of 1935 that Tucker in-
vented the flexible forceps and perfected the technic for
use in removing foreign bodies from the stomach. With
the use of a sheathed flexible forceps dispensing with
the previously used rigid open-end gastroscope, the pa-
tient can be placed in the upright or semi-upright posi-
tion after the forceps is in position and gravity carries
the foreign body to the greater curvature of the stomach
where it is easily accessible.

Carey of the University of Minnesota states that the
flexible gastroscope is the only instrument yet devised
which gives a true picture of the living stomach in health
and disease. It is his view that the gastroscope is not a
substitute for roentgen methods, but rather, an adjunct
to them. By direct gastroscopic examination many ques-
tionable diagnoses can be cleared up which otherwise
would have to be established by repeated physical, X-ray
or blood examination, or by exploratory laparotomy.

Large, Slow, Drip, Blood Transfusions — Believing
that an anemic patient who needs a transfusion requires
more than the usual 500 cc., Marriot and Kerwick, of
London, increased the amount to an average of five
pints. This amount was given by multiple donors and
was administered by a drip method over an average
period of 29 hours. General results were characterized
as encouraging and some described as so dramatic and
extraordinary that they appeared miraculous occurred
in 87 such transfusions. In one case, 1 1 pints of blood
were given over a period of 62 hours. In experiments
with rabbits, Boycott and Oakley showed that there is
little danger of overloading the circulatory system if
massive blood transfusions are given slowly enough.

Needle (Aspiration) Biopsy — According to Ball, the
diagnostic possibilities are much greater when the macro-
scopic and bacteriologic examination of the aspirated
material is extended to include sectioning and staining
of solid elements present. This method of obtaining
tissue for biopsy has been used in every part of the body
including prostate, bone, lung, breast, vertebral column
and endometrium. The biopsy should be continued only
until about two or three cubic centimeters of material
are aspirated. Bits of tissue are teased from the blood
clot and together are put in 10 per cent solution of
formaldehyde for fixation.

Head and Neck

Eye — Modern treatment of retinal detachment, ac-
cording to Arruga has completely changed the prog-
nosis. Generally the surgical outcome is more favorable
in young people as a result of the more rapid cicatriza-
tion. Of 300 cases reported by this author, 164 were
cured. Kadlicky reports 25 successfully-operated cases

THE JOURNAL-LANCET

of (detached retina in a series of 45 at the eye clinic in
Prague. This author attempts not only to close the tear
in the retina; but also to make a barrier between the
normal and diseased retina by a series of electrocoagula-
tion punctures. He uses a needle with a 2 mm. point
which is bent at right angles. This needle is insulated
with a rubber tubing so that only the bent point is free.
The author devised an electrode of stainless steel to
prevent oxidization.

Pharynx — Shallow describes a one-stage closed method
for the treatment of pharyngeal diverticula. In a series
of 76 such operations, there were only two deaths, and
in 74 recovery was complete. None of the cases was
complicated by mediastinitis and none required post-
operative esophageal dilatation. Torek has said, "Thirty
years ago the mortality was very high with the one-stage
procedure, but in the last five years, 60 cases have been
recorded with a mortality of only one.”

Larynx — Garfin reports a study of 202 unselected
and consecutive cases of cancer of the larynx observed
at the Collis P. Huntington Memorial Hospital of
Boston over 14 years prior to 1933. In the opinion of
this author, surgical removal of the growth in the early,
operative, intrinsic type offers a good chance of per-
manent cure. In certain types of not entirely operable
tumors which are highly radiosensitive, the combination
of surgery and irradiation has yielded good results. In
far-advanced cases with metastases the author relies en-
tirely on irradiation for temporary relief. Of 19 patients
with proved cancer who were subjected to operation, seven
are living and well, the longest survival being 1554
years, and the shortest, three years. Garfin concludes
that if radiotherapy can be shown to produce as high a
percentage of permanent cures as surgery, it will be a
safer method of treatment than operation.

Esophagus — Eggers, in a concise article on technic,
describes the different operations used for esophageal
cancer. Under radical surgical treatment, he first des-
cribes the technic for treatment of carcinoma of the
cervical portion of the esophagus. One healed case is
shown following complete resection of the larynx, upper
esophagus and hypopharynx. His second procedure is
applicable to the thoracic portion of the esophagus and
embraces both a cervical and posterior thoracic approach
together with a gastrostomy connection to the upper
esophageal stump. Finally, carcinoma of the lower
esophagus is subjected to one of the following three
operations described in this paper: (1) abdominal

method of esophagogastrostomy; (2) transthoracic
method of esophagogastrostomy; and (3) abdomino-
thoracic operation.

Brain and Nervous System

Brain Surgery — An editorial in the July issue of
Surgery, Gynecology and Obstetrics states that Mr.
Cairns’ study of 157 patients with verified intracranial
tumors operated upon in 1926 and 1927 by Dr. Cushing,
describes the condition of each patient seven to nine
years after operation, Sixty-three patients were still

alive and 37 of those were living useful lives. The
illuminating longest-known survival figures which Dr.
Eisenhardt has added to Mr. Cairns’ tables showing a
four-year plus survival for a glioblastoma and a seven-
year plus survival for a medulloblastoma, make one
feel that a surgeon is scarcely justified in refusing
operation because a tumor is presumably malignant and
the surgical exposure is known to have a high percentage
of postoperative fatalities.

On August 31, 1931, Dr. Gardner performed an ex-
cision of the right cerebral hemisphere according to a
case report by O Brien of Canton, Ohio. The patient s
convalescence was indeed gratifying. She was able to
return to her home and family, later to assume the
duties of her household. The deformity existing prior to
the operation, left hemiparesis, slight facial asymmetry
and sensory disturbance, remained with her to the end.
Her memory for recent and past events was good and
she read constantly in spite of her eye difficulty. The
sense of smell on the right side was lost, because the
right olfactory bulb was destroyed. The sense of hearing
in the right ear with the audiometer was undisturbed. She
took the usual interest in her children, and attended very
well to her household duties. She inquired about, and
was anxious to know, all the details of her operation.

November 29, 1935, while about her home, she tripped
and fell a distance of about 20 feet. She was able to
get up and go about for a few days when she collapsed.
In spite of temporary improvement from trephining, she
was bedridden, decidedly apathetic, with involuntaries,
and was aroused only with great difficulty, giving the
appearance of one decerebrated. She died March 4,
1936. Five years of happiness with her family were pro-
vided this patient through removal of the right cerebral
hemisphere. This is the longest known survival of such
an operation.

Facial Nerve Repair — Shambaugh remarks that Duel
and Tickle have carved themselves immortal niches in
otologic surgery through their operative treatment of
facial paralysis. Concerning the technic, Duel and Tickle
emphasize the necessity of meticulous asepsis. The nerve
is exposed, beginning at the stylomastoid foramen and
working up to the horizontal semicircular canal. In cases
of Bell’s palsy, the wound is closed at once. When a
graft is inserted, a temporary bloodless field is obtained
by normal saline at 120° F. Dental gold foil is placed
over the graft, and perforated rubber tissue is placed
over this to prevent the gauze’s adhering; then the
wound is lightly packed with gauze moistened in nor-
mal saline. Closure is permitted when suppuration has
ceased. Galvanic stimulation of the paralyzed muscles
for a few minutes twice a week helps to keep up the
tone of the muscle. When a nerve graft is used, perfect
facial expression can never be hoped for, although the
result is far better than has been obtained by any other
method. When the nerve is only decompressed with slit-
ting of the sheath, a perfect result can be anticipated.
While approximately 80 per cent of patients with Bell s
palsy make a perfect, spontaneous recovery in four to

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six weeks, in 20 per cent partial recovery occurs only
after three to 12 months.

Sympathetic Nervous System — White, in discussing
Raynaud’s disease, points out that in his series of cases
the recurrence of vasospasm completely vitiated the early
postoperative improvement in four patients and caused
reclassification of the others as only mediocre in results.
Denervated smooth muscle remains sensitive to the cir-
culating sympathomimetric hormones epinephrin and
sympathin. Not only does smooth muscle remain sensi-
tive, but it becomes hypersensitive. A lasting vasodilata-
tion can be obtained only when adrenal secretion is
abolished. Observations over a period of one and one-
half years have demonstrated that the lasting increase
of blood flow in the arm after this operation can be as
great as in the leg. He also finds that in scleroderma
and sclerodactylia, improvement of circulation has been
followed by an arrest in the advance of the disease, and
by an improvement in function of the hand. In the late
stages of poliomyelitis, increasing the circulation of the
paralyzed leg may be of value for two conditions: for
trophic lesions and for increasing bone-growth in the
legs. The author recommends sympathetic ganglionec-
tomy only in the rheumatoid type of arthritis when it
is desirable to improve circulation per se in the cold,
moist extremities. Hyperhidrosis or excessive sweating of
the hands can be stopped by sympathectomy. Lumbar
ganglionectomy should be reserved for those rare in-
stances of Buerger’s disease in which, after the para-
lyzed peripheral nerves have regenerated, vasospasm
again becomes a complicating factor. He believes that
clinical evidence reported by Adson, Craig and Brown,
by Page and Heuer, and by Peet, constitute fairly con-
vincing proof that sympathectomy can cause a worth-
while reduction in blood pressure in certain favorable
cases of essential and malignant hypertension. In con-
clusion, he brings out the fact that sympathectomy in
Hirschsprung’s disease of suitable types is consistently
effective, but presacral neurectomy is not a sound method
for improving the function of a paralyzed bladder.
Sympathectomy for spastic paralysis is now conceded to
be totally illogical.

One of Adson’s recent papers discusses many other
conditions in which surgery of the sympathetic nervous
system is indicated. The relief obtained in dysmenorrhea
from resection of the presacral nerves is the result of
the interruption of nerve fibers carrying sensation of
pain, vasomotor stimuli and motor stimuli to the uter-
ine muscles. Patients who have spina bifida occulta with
neurotrophic changes occasionally develop indolent ulcers
of the soles. Lumbar sympathectomy has been employed
very effectively in improving the circulation and healing
the ulcers. Sympathectomy is indicated for angina pec-
toris when the patients present vasomotor phenomena,
and when they otherwise would be compelled to con-
tinue medical treatment for years. Though numerous
surgical procedures have been introduced for the relief
of the pain of angina pectoris, such procedures are not
indicated when medical measures are adequate.

Thoracic Surgery

Bronchoscopy — Increasing use of the bronchoscope is
responsible for many advances in thoracic surgery. Myer-
son reports that more than 150 patients either known
to have pulmonary tuberculosis or else strongly sus-
pected of having this disease, have been examined with
the bronchoscope by members of the otolaryngologic
service of Sea View Hospital. This author’s experience
has proved that bronchoscopy is not only permissible,
but at times necessary, and can be done on such patients
without harm. As a rule, patients with acute tuberculosis
should not be bronchoscoped. Certain findings appear
with relative frequency in tuberculous cases of long
standing, such as fibrotic and cicatricial changes both
within and outside the bronchi.

Bronchiectasis — According to Bohrer, four lobectomies
were done for bronchiectasis; two boys aged seven and
nine years, and two girls each 1 1 years old. He believes
that children withstand lobectomy as well as, or better
than, adults. Graham states that the opinion has grown
steadily stronger in recent years that children with severe
bronchiectases should be subjected to the operation of
lobectomy for the double reason that they bear the
operation well and may be spared a life of more or less
invalidism. Operative mortalities have dropped to re-
spectable figures in properly-selected cases. Overholt re-
ports two cases of pneumonectomy performed for sup-
purative diseases of the lung living and well. Mason of
England reports six patients suffering with extensive
unilateral bronchiectasis treated by pneumonectomy. All
of these patients were between the ages of seven and
18 years. At the time of publication of the report four
patients were living and well.

T uberculosis — Coryllos summarizes this surgery as fol-
lows: the principal surgical methods besides pneumo-
thorax which are used to effecf collapse of tuberculous
portions of the lung are: intrapleural pneumonolysis,
closed (Jacobaeus) or open; extrapleural apicolysis with
packing or plombe; interruption of the phrenic nerve
either temporarily (crushing) or permanently (avul-
sion) ; and thoracoplasty, partial or complete. Other pro-
cedures such as scalenotomy, thoracoplasty with packing
(Casper), multiple intercostal neurotomy (Alexander),
and pneumocavernolysis (Neuhof) are of secondary
importance, if any. In the first rank of present-day col-
lapse methods are pneumothorax and thoracoplasty.
Other methods are to be used only to supplement them,
and can never substitute for them.

Lung Abscess — Pulmonary suppurations, at one time
considered hopeless, are now often cured by surgical
treatment. Galli classifies them as (1) simple abscess,
(2) fetid abscess, (3) chronic suppuration, (4) pulmon-
ary gangrene, and (5) pulmonary abscess secondary to
bronchiectasis. Medical treatment does not seem war-
ranted, except possibly in the amebic form. Abscesses
which heal under medical treatment are usually of the
simple variety which may heal spontaneously. Pneumo-
thorax is rarely beneficial; in fact, it may be very
dangerous because a fatal empyema may develop.
Phrenico-exeresis is of no value alone but may be of

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aid in other surgical attacks on abscesses near the base
of the lung. Thoracoplasty is of value, not in the treat-
ment of the abscess, but in the attack on the bronchiec-
tasis often secondary to abscess. Neuhof and Touroff
report 37 operative cases of acute abscess of the lung.
In these cases there was one operative death. Twenty-
five show an end-result of complete recovery.

Diaphragmatic Hernia — Harrington states that the
incidence of diaphragmatic hernia is no greater now
than 20 years ago. However, at the Mayo Clinic 30
cases were recognized clinically, and 19 were treated
surgically in the period from 1900 to 1925, and 197
cases were recognized, and 105 were treated surgically
in the period from 1925 to 1935. The only type of
diaphragmatic hernia that may be treated conservatively
is hernia through the esophageal hiatus, in which only
a small portion of the cardiac end of the stomach is in-
volved. In 105 cases operated upon, there were only
seven postoperative deaths. Eight patients were treated
palliatively by interruption of the phrenic nerve. Of 90
patients who recovered from radical operative repair, 88
have been completely relieved, and two have had a re-
currence of symptoms and the hernia.

Mediastinal Tumors — Andrus and Heuer remark that
as more and more successful results have appeared in
the literature, it has become evident that in all such
cases the advisability of surgery should be considered.
To be sure, in certain groups such as the lymphosar-
coma, or in Hodgkins disease, surgery has little or noth-
ing to offer except as a diagnostic aid. But in most of
the others the operative results have become increasingly
more satisfactory, and in many definite benefit, varying
from relief of symptoms to spectacular cure, has been
obtained.

Pulmonary Carcinoma — In speaking of primary car-
cinoma of the bronchus, Graham states that up to the
present time the evidence regarding effective treatment
by either radium or X-ray has not been very convincing.
Wide surgical removal offers the best chance of re-
covery. Lobectomy probably will be found not sufficiently
radical. Total removal of the lung has the advantage of
permitting the removal of enlarged mediastinal nodes,
and a closer approach to the trachea. Reported cases
and the author’s personal experience indicate that total
pneumonectomy is technically possible and practical.

Pneumonectomy — Reinhoff maintains that certain im-
provements in the technic of pneumonectomy, as well as
in preoperative preparation and postoperative care, have
been made in the past two years. The material on which
his conclusions are based consisted of ten cases in which
total pneumonectomy was performed and 20 in which
thoracic exploration provided an opportunity for the
observation of technical methods. Overholt states that
one lobe or an entire lung on one side can be removed
successfully. Twenty-three cases of proved primary can-
cer of the lung form the nucleus of his report. Meta-
static lesions were found in six patients, and two addi-
tional patients were rejected for operation as a result of
poor general condition. The remaining 18 were sub-
jected to thoracic exploration. Mediastinal infiltration

was found in seven. In two, lobectomy and in six,
pneumonectomy was performed. There were three opera-
tive fatalities. At the time of his report, three patients
treated by pneumonectomy were living; one 20 months
and another 14 months after the operation.

Cardiac Surgery

Intravenous Evipal for Acute Coronary Occlusion —
Donath, of Vienna, gave slow intravenous injections of
evipal to six patients suffering intensely from acute
coronary occlusions and to one with severe coronary
sclerosis whose symptoms resembled angina pectoris.
Each of the patients fell into a profound sleep, lasting
from one-half to ten hours, and awakened with the pain
considerably abated. Dosages varied from 1 J/2 to 2 cc.
of ten per cent sodium evipan. Each cubic centimeter
was injected over a two to three minute period. In two
cases a fall in blood pressure was noted as a warning
sign.

Traumatic Cardiac Surgery — Mayer states that over
a two-year period, seven cases of injury to the heart and
pericardium were treated in the Louisville City Hospital.
Five patients recovered and two died. Death in one case
was due to hemorrhage, and the author feels that an
autotransfusion might have saved this patient. Two
patients recovered without operation. Five patients re-
quired major surgical treatment. In four the heart was
injured. A transpleural approach utilizing modifications
of Spangaros’ incision was used in all but one patient.

Thyroidectomy for Heart Disease — Clark, Means and
Sprague report the results of total thyroidectomy per-
formed on 21 patients with cardiac disease at the Massa-
chusetts General Hospital from July, 1933, to May,
1935. Of these patients, 19 had congestive failure and
only two had angina pectoris. The operation was consid-
ered worth-while in only about one-fourth of the entire
series. The relatively poor results were due largely to
difficulty in the selection of the cases. At first, too
severe cases were chosen. Of the cases which were well
selected and managed, worth-while results were obtained,
at least temporarily, in 50 per cent. The authors believe
that the effects of the operation must be studied fur-
ther before its value in the treatment of heart disease
can be determined definitely.

Adhesive Pericarditis — The first surgical cure of this
condition in America, according to White, was obtained
in the case of a 15-year-old girl, who, in 1928, was sub-
jected to an anterior pericardial resection with removal
of a band compressing the inferior vena cava. White
has reviewed the literature and reports 15 cases of
chronic constrictive pericarditis or Pick’s disease treated
by pericardial resection. Six deaths from various causes
occurred in this series. The so-called Delorme operation
is the only cure for Pick’s disease. Cases of chronic con-
strictive pericarditis have a poor prognosis for health
unless they are suitable for and are treated by operation.

Suppurative Pericarditis — Shipley has found that up
to January 1, 1934, 227 cases of suppurative pericarditis
had been reported. His article describes the present con-
dition of six of the seven who recovered from the opera-

THE JOURNAL-LANCET

tion for drainage of his total 12 cases. There is
abundant proof that the operation may be followed by
no clinical evidences of serious interference with cardiac
function. The author collected from the literature 39
cases in which at least one year had elapsed since the
pericardiotomy. Of the author’s seven patients who re-
covered after the operation, six have been traced. Five
have no clinical evidences of disability. The author con-
cludes that the lower anterior approach is better than
the higher parasternal approach at the level of the
fourth and fifth costal cartilages. Moore, however, be-
lieves that when the pericardial infection follows a left-
sided empyema, a left-sided posterior approach to the
pericardium is the procedure of choice. Moore reports a
case in which recovery resulted after the establishment
of drainage by this route.

Abdominal Surgery

Preoperative Decompression — This is a problem that
has for some time occupied the attention of McNealy
and Lichtenstein of Northwestern University. Obvious
to the gastroenterologist is the fact that a stomach
properly prepared preoperatively for gastrojejunostomy
will react better to the actual operation than a dilated
stomach, thq walls of which are thickened and edema-
tous, and where the pyloric orifice is occluded. The
McNealy-Lichtenstein method of preparation for gastro-
jejunostomy is essentially this: the stomach at the out-
set is evacuated of gross contents by a stomach pump,
so that undigested food particles will not later interfere
with suction. Continuous aspiration is then instituted.

Subtotal Gastrectomy for Peptic Ulcer — Selecting
statistics from the literature, Blahd, of Cleveland, com-
piled a series of 5,572 carefully followed-up cases of
gastroenterostomy in which a total of 71.7 per cent of
cures were reported. The results in different series
varied from 47 to 90 per cent. On the other hand, in
3,122 cases of gastric resection collected from 16 dif-
ferent clinics, the percentage of permanent cures fel!
within a higher and much narrower range, namely: from
82 to 98 per cent. Blahd’s arguments in favor of sub-
total gastrectomy, as compared with the more conserva-
tive operations of gastroenterostomy and various pyloro-
plasties result from the facts that subtotal gastrectomy
is the only procedure which will consistently, in his
opinion, bring about a permanent cure for peptic ulcer,
and that in certain types of ulcer, medical treatment is
foredoomed to failure.

Regional Ileitis — Since Crohn, Ginzburg and Oppen-
heimer first described the entity known as regional
ileitis or enteritis an increasing number of cases have
appeared in the literature. In advanced cases the in-
volved loops of lumen roentgenologically resemble a
cotton string. This Kantor calls the "string sign.”
Finally, during 1936, in connection with the report of
eight cases, Meyer and Rosi outline treatment of the
condition as follows: "The treatment of regional enter-
itis varies with the phase of the pathological process.
Acute regional enteritis limited to the bowel and not
associated with thickening of the mesentery may resolve

spontaneously. If, however, the mesentery is thickened
and indurated, it is probable that ulceration of the
mucosa has extended into the mesentery; spontaneous
resolution is less likely to occur, and a short-circuiting
operation or a resection is indicated. Chronic regional
enteritis with stenosis is best treated by resection or a
short-circuiting operation. When complicated by an
external intestinal fistula, resection of the involved bowel
with the fistulous tract is necessary to close the fistula.”

Idiopathic Ulcerative Colitis — McKittrick and Miller
report on a series of 149 cases of chronic idiopathic
ulcerative colitis seen during the past 20 years in the
wards of the Massachusetts General Hospital. The
patients were all studied with particular reference to
the value of, and indications for, surgical treatment.
The authors believe that the only surgical procedure
indicated in ulcerative colitis is one which will give com-
plete rest to the affected bowel segment by diverting
the fecal stream externally proximal to the disease.
Ileostomy is the operation of choice. Preceded and fol-
lowed by blood transfusions, it is frequently a life-saving
procedure. Approximately 40 per cent of the patients
surviving ileostomy will later require removal of the
diseased colon. The results after subtotal colectomy are
excellent. In the 149 cases reviewed, there were 27
deaths, a mortality of 18 per cent.

Resection of the Liver — Moller reports the case of a
woman, 29 years old. Over a period of ten years she
had been subjected to repeated laparotomies for recur-
rent ovarian tumors with secondary malignant degenera-
tion. A liver metastasis the size of a fist was removed
by resection of the liver. Six years after the operation
on the liver the patient was able to work and showed
no signs of recurrence or metastases. Microscopic exam-
ination showed all of the tumors to be granulosa-cell
carcinomas.

Amebic Hepatic Abscess — According to Joslyn of St.
Louis, who reports two successful aspirations of amebic
liver abscesses, there are many advantages to treatment
by this method over surgery. In reported series of cases,
the surgical mortality has ranged well over 50 per cent.
Once the diagnosis has been established, the patient is
bridged across two beds in such a position that the part
of the abscess nearest the surface will be in the most
dependent position. A large-gage needle is then inserted
into the area where the abscess has "pointed,” usually
the tenth intercostal space, and just through the wall
of the abscess. The point of the needle is then in the
most dependent portion of the abscess and in position
to evacuate the contents of the lesion entirely. This
needle is connected to a Wangensteen suction apparatus.
A second large needle is then inserted into the abscess
at any other point, and is connected to an ordinary
gravity flask containing 1:2,500 emetine solution. The
circuit is opened and the entire contents of the abscess
are flushed out. In such a manner one evacuation is
deemed sufficient. Several hundred cubic centimeters of
the emetine solution are left within the cavity.

Acute Gall Bladder — Taylor, of Indianapolis, has
made an analysis of 129 consecutive cases of acute gall

THE JOURNAL-LANCET

bladder grouped according to their morphological find-
ings as (1) acute edematous, (2) acute suppurative and
(3) acute gangrenous. The mortality for the entire
series was 16.3 per cent. Patients operated upon the
first four days after acute onset gave a mortality of
approximately five per cent. Of those operated upon
five or more days after onset, 23.8 per cent died. In
this entire series, if the patient was operated upon dur-
ing the first four days of his acute disease, the chances
of death were about 1 to 20. On the other hand, if
the decision was made to allow the gall bladder to
"cool” or if, failing in this, it was operated upon
five days or more after acute onset, the chances were
one to five that the patient would die. In view of this
uncertainty and the high mortalities resulting from a
waiting policy, prompt operation is indicated. No case
is so urgent that preoperative administration of adequate
amounts of glucose can be neglected.

Acute Hemorrhagic Pancreatitis — Experience with
acute pancreatitis suggests to Dean Lewis, of Johns
Hopkins University, that if a differential diagnosis
could be made between peritonitis due to perforation
and pancreatitis, it would be wiser to delay immediate
operation. In 76 cases cared for between 1926 and 1934
by Walzel of Graz, 30 were treated between 1926 and
1928. Of these, 26 died, a mortality of 86.6 per cent.
The remaining 46 were operated upon between 1929
and 1934; of these, 13 died, a mortality of 28.3 per
cent. Walzel therefore concluded that in doubtful
cases an exploratory laparotomy should be done. If pan-
creatitis is found, the operation continues only if a
common duct stone is found, in which event, drainage
and choledochotomy are done; or if acute phlegmanous
cholecystitis is discovered, in which case cholecystostomy
is indicated. Lewis admonishes all surgeons to employ
glucose solutions with great care, because the intra-
venous administration of glucose in hemorrhagic pan-
creatitis might increase the existing damage by stimulat-
ing further flow of the pancreatic juice.

Injection T reatment of Hernia — Harris and White
conducted an investigation involving 100 consecutive
cases of hernia injected in the Out-Patient Department
of the Mount Zion Hospital of San Francisco. All
cases were treated successfully, without any serious
complication. Results of their study show that this
method may be advocated as a valuable adjunct to the
surgical armamentarium. Modern solutions used for the
injection treatment are based on the principle of pro-
ducing new fibroblastic tissue, without local injury or
danger from toxic absorption. If a hernia is completely
reducible, this method is applicable to any patient who
can be fitted with a truss which will maintain complete
reduction during active treatment. The evidence sub-
mitted should suffice to convince the profession that
this method of treatment is worthy of a thorough and
impartial investigation.

Gynecological Surgery

Hysteroscopy: Its Technic and Results — It is Ham-
ant’s and Durand’s opinion that hysteroscopy has be-

come a most important diagnostic procedure for every
gynecologist. Hysteroscopy is contra-indicated in fixed
retrodisplacements of the uterus, pregnancy, periuterine
inflammations, and profuse metrorrhagia. The chief
difficulty in hysteroscopy is not the technic, but the in-
terpretation of the images. The authors present 22
illustrations in color to show their findings in normal
and pathological conditions.

Orarian Grafts — Hot flashes which constitute abla-
tion symptoms in young women recovering from hys-
terectomy and bilateral oophorectomy can be relieved in
a large number of cases by autotransplantation of
ovarian tissue, reports Shaw, of the University of
Southern California. He describes the operative technic
as follows: a piece of ovarian tissue appearing normal
is excised from the interior of the ovary when the speci-
men is removed. This is laid on a gauze pack on the
instrument tray, and cut with a sharp scalpel into bits
of two or three millimeters in diameter so that vascu-
larization will be favored. The material is next wrapped
in a gauze sponge and placed in a bowl of warm saline
solution, where it remains until the peritoneum has been
closed. He then raises by blunt dissection the fascia of
one of the rectus muscles near the midpoint of the in-
cision, with care exercised to prevent bleeding. The
fibers of the muscle are then separated bluntly to re-
ceive the graft, and the opening in the muscle is closed
with No. "O” catgut, the suture being placed loosely.
Of 53 cases properly traced, only 13 got no relief from
ablation symptoms. Binet believes that the chief indi-
cation for ovarian, grafts is the prevention rather than
the treatment of disturbances caused by surgical castra-
tion. Removal of the genital organs of women is fol-
lowed by more or less serious disturbances in 75 per
cent of cases. According to Tuffier, autoplastic grafts
take in 67 per cent of cases. Autoplastic grafting is, of
course, superior to either homoplastic or heteroplastic
grafting.

Cancer of the Cerux — Tyrone, of Tulane University,
attributes to the use of the Schiller test and the colpo-
scope the early diagnosis and salvation by hysterectomy
of 158 women. These patients were examined before
subjective symptoms of cervical carcinoma appeared. The
Schiller test consists of painting the portio vaginalis
with Lugol’s solution. Cancerous lesions stain lightly or
not at all. The colposcope is a microscopic or telescopic
arrangement of lenses by which it is possible to study
cell changes without removing any tissue. Tyrone be-
lieves that every woman within the limits of the cancer
age should be given the Schiller test and examined with
the colposcope at least once a year.

Genito-urinary Surgery

Prostatic Surgery: Its Present Status — After perform-
ing transurethral resections in 100 cases, Laidley and
Earlam conclude that transurethral resection is the
operation of choice for median-bar and the best pallia-
tive treatment for prostatic carcinoma. In general, the
authors believe that unsatisfactory results are to be at-
tributed not to the operation, but to failure to perform

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it efficiently. They are not yet convinced, however, that
transurethral resection is as surgically sound as open
prostatectomy for the patient in good condition with a
considerable life expectancy and a median-to-large
adenomatous prostate. Mathe and Ballesca, after study-
ing 237 cases of prostatic hypertrophy, conclude that
when properly done, transurethral resection is followed
by less shock and associated with much less risk of com-
plications than prostatectomy. Voelcker, too, is con-
vinced that not all problems of prostatic surgery will
be solved by the transvesical method alone.

M al-development and Mal-descent of the Testes —
Dorf treated 14 boys ranging from six to 13 years of
age who showed mal-development or mal-descent of the
testes. The gonadotropic anterior pituitary-like hormone
obtained from the urine of pregnant women was used.
The treatment was begun after puberty. Of eight cases
of undescended testes, all but one in which there was
mechanical obstruction responded to the administration
of the hormone. The author believes that operation
should not be done until hormone therapy has been
tried for one year without success. In the cases of mal-
development, under hormone therapy, with thyroid when
indicated, the testes increased in size; the scrotum filled
out and progressed toward normal development; un-
descended testes increased in size and descended; the
penis enlarged in size and thickness; pubic hair appeared,
the epididymides and prostate were stimulated; a con-
genital hernia, if present, sometimes became corrected,
and the general mental aspect changed.

Injection Treatment of Hydrocele — Krug reports sat-
isfactory results from injection of primary hydrocele
with sodium morrhuate in 10 cases. Krug’s technic,
which is applicable to office use, is described in part as
follows: by the use of a small syringe and needle, 1.2
cc. of a total volume of 2.5 cc. of a two per cent solu-
tion of procaine is used to secure anesthesia of the skin.
Then a 19-gage needle is pushed beneath the skin in
the subcutaneous tissue for about an inch, and then
into the hydrocele sac, which is emptied as completely
as possible. The remaining anesthetic solution in the
small syringe is injected into the sac through the large
needle and is spread about inside the sac by gentle
manipulation. Again by the use of the small syringe
and needle, 3 cc. of a five per cent sodium morrhuate
with benzyl alcohol is injected into the sac through the
large needle which is then withdrawn. The scrotum is
gently manipulated to spread the solution and the light
suspensory applied. Following the injection, the patient
is ordered to bed for the remainder of that and the
following day. In three to four weeks, accumulation of
fluid may indicate a second injection.

Fractures

Ambulatory Treatment of Femoral Neck Fractures —
From Chicago has come a technic for the ambulatory
treatment of fractures of the neck of the femur devised
by Apfelbach and Aries. These authors report their tech-
nic as follows: all patients entering the female fracture
service with acute fractures are given a quarter-grain of

morphine sulphate and placed in Buck’s extension by
skin traction. This immediately relieves the muscle
spasm and pain, thus combatting shock. A roentgeno-
gram is taken with a portable machine and the diag-
nosis is confirmed or corrected. When the patient has
recuperated sufficiently, usually five or six days after
the fracture has occurred, she is placed in a stockinette
fabric on a Hawley table and anesthetized with ether.
Whitman’s closed manipulative reduction is performed.
The fragments are artificially impacted by the Cotton
method. All bony prominences are padded with sheet
wadding and felt, and a snugly fitting plaster cast is
applied. The cast extends from the toes of the affected
side to the sixth rib on the opposite side. A metal walk-
ing-iron is incorporated in the cast. The cast is finished
with the limb in abduction. An inexpensive light weight,
shoe-elevation is constructed of several thicknesses of
celotex, covered with a thin rubber matting and clamped
to the patient’s old shoe. A roentgenogram is taken
when the case becomes dry and, if the position is sat-
isfactory, the patient is taught to walk with the aid of
crutches. Among the authors’ impressions of this form
of treatment are the following: by obtaining accurate
apposition of fragments with impaction, the patient can
advantageously be made ambulatory. Seventeen, or 77
per cent, of fractures of the neck of the femur in this
series of 22 selected cases have united. Thirty degrees
of abduction with sufficient; inversion to cause a disap-
pearance of the lesser trochanter from the anteropos-
terior film is the optimum position in reduction. The
average time of hospitalization has been reduced from
110 days to 30 days.

Ambulatory Treatment for Fractures of the Femoral
Shaft — In this new method, presented by Anderson,
four Steinman pins or Kirschner wires are inserted, two
in the region of the greater trochanter in the proximal
fragment, and two in the distal fragment. The upper-
most half-pin is inserted obliquely in a distal and medial
direction from a point about the center of the lateral
aspect of the greater trochanter. The half-pin clamp is
held parallel to the thigh. The oblique hole in the lower
end of the clamp provides the guiding agency for the
insertion of the second short pin, which is inserted into
the shaft at an angle to the trochanteric half-pin. Both
half-pins should completely transfix the femur. A distal
transfixion is made at the superior border of the con-
dyles; however, to supply positive fixation, this distal
insertion is supplemented with a second pin or wire
through the shaft at a point about two inches above the
lower transfixion. It should not be placed parallel with
but at a slight angle to the axis of the first distal trans-
fixion. This double pair of transfixions not only supplies
skeletal traction and countertraction, but provides means
for separate and direct management of each fragment.
Traction for reduction can be supplied by a fracture
table or a specially-designed sling for femoral fractures.
When reduction has been checked roentgenologically,
the plaster is snugly applied from the iliac crest down
to a few inches below the knee. Plaster over the patella
and posterior to the knee joint is at once cut out.

I'HH JOURNAL-LANCET

A Review of 1936 Literature
on Proctology

Walter A. Fansler, M.D., F.A.C.S.**
Minneapolis, Minnesota

IT IS the purpose of this review briefly to call atten-
tion to the advancements made during the year in
the field of proctology. No attempt is made to give
a complete resume of all the literature, but rather to
select the material which offers some new or improved
ideas. On the subject of anatomy, Nesselrod1 has pre-
sented an exhaustive article on the lymphatics of the
pelvis. Anyone wishing to review the possibilities of
spread of malignancy or infection in this region can
well read this article with profit. Likewise, Morgan8
presents a very painstaking work on the anatomy and
embryology of the anal canal. Agranulocytosis, or agran-
ulocytic angina, is the subject of many articles. The
occurrence of rectal lesions in this condition is seldom
mentioned. It may, however, be the only external lesion
present. A sluggish-appearing ulcer with a necrotic base
should always make one suspicious, especially in a
patient who seems constitutionally ill.

It seems to me there has been little new offered on
the subject of hemorrhoids. Articles have to do mostly
with the use of sclerosing injections. To my mind it is
doubtful if these "new” formulas offer any particular
advantage over those already in use. In this connection
may be mentioned the employment of various injections
to prevent postoperative pain. These are usually peri-
rectal injections of various anesthetic substances in an
oily base. These are of value in selected cases, but their
indiscriminate use is to be condemned, as pointed out by
Gorsch2 and Simmons3, and Kilbourne4.

The occurrence of rectal and rectosigmoidal endo-
metriosis is reviewed by Rosser3. It is well to remember
that when this condition occurs in the bowel wall, it
may produce an ulcerative lesion which from its appear-
ance alone cannot be differentiated from rectal carci-
noma. The fact that the mass seems largely extra-rectal
may make one suspicious; but a biopsy is the only way
of making a positive diagnosis.

Lymphogranuloma inguinale is voluminously dealt
with. Treatment insofar as the rectal manifestations are
concerned, is relatively unsatisfactory. Because of dif-
ference in the lymphatic drainage from the genital or-
gans of the male and female, the preponderance of
rectal lesions (ulceration and stricture) occurs in the
female. The majority of cases will show a positive Frei
test; but it may be necessary to try several different
antigens before getting a positive reaction (Martin6).
The majority of rectal strictures, thought in the past
due to syphilis, are doubtless due to this condition. Per-
manent colostomy may be necessary in some of these
patients.

^Prepared expressly for the 67th Anniversary issue of THE
JOURNAL-LANCET.

** Assistant Professor of Surgery, University of Minnesota.

There is increasing literature upon the treatment of
fissure in ano by ambulant methods, making use of
anes.hetic solutions producing prolonged anesthesia.
Daniels' describes this method in detail. This treatment
is based on the theory that with dilation and relaxation
of the anal canal and the relief of pain, the fissure can
be healed by local treatment, and surgery avoided. I
believe that this is quite correct in some cases; but I am
convinced that time will show that a not inconsider-
able number of these cases will recur, and that surgery
is still frequently indicated. This is particularly true
when we consider that very often there is other rectal
pathology present which requires surgery, in which case
there is no advantage in dealing with the fissure medi-
cally.

To my mind there has not been the slightest advance
made in the treatment of pruritus ani, which (in my
opinion) is a symptom complex rather than a disease
entity. It should be realized that the causes of this con-
dition are many, and that these causes must be sought
out in each case individually, if the best results are to
be achieved. Further, that it is often impossible perma-
nently to remove the cause of the condition, and that
with a recurrence of the underlying factor, the pruritus
also recurs. If we cease to search for a universal "cure”
and concentrate more upon the management of the con-
dition by the patient, himself — after doing what we can
locally — results will be better and the confidence of the
patient retained.

There was nothing of note during 1936 in connection
with the treatment of anorectal fistula. The subject of
ulcerative colitis seems to be as much in dispute as ever.
There does, however, seem to be some points of com-
mon agreement as to the clinical findings and course of
the disease, even though the etiology may not be agreed
upon. In other words, in many cases the patient when
he presents himself to the physician is often suffering
from an ulcerative condition of the colon, which is a
secondary infectious process, the original cause of the
infection having disappeared. Treatment then is best
based on this premise. Now we also recognize the dis-
ease "regional colitis” where only a definite segment of
the bowel is involved. Probably some of the cases of
diffuse colitis begin as a "regional colitis.” Regional
ileitis, likewise, comes in. for considerable comment. In
the past, no doubt, many of these cases were overlooked.
At present, the consensus seems to be that the surgical
removal of the diseased segment of bowel is the best
form of therapy, if the patient’s condition warrants it.

The writings on precancerous and cancerous lesions
of the colon and rectum are legion. The fact that many
cancers do develop from adenomas has long been gen-
erally accepted. Buie and Brust9 present an excellent

THE JOURNAL-LANCET

resume on this subject. There is a tendency in most quar-
ters to do a greater number of one-stage abdominal
perineal resection for radical removal of rectal carci-
nomas, though this operation should be reserved for
patients without obstructive symptoms, and whose gen-
eral physical condition is average or better. Multiple-
stage procedure for colonic cancer is generally accepted.
The more general use of nasal suction, as developed by
Wangensteen, has been a definite contribution toward
the reduction of the mortality rate. The use of electro-
coagulation or fulguration of stenosing lesions has
offered a wider field for the adequate treatment by
radium application (Bowing and Frick11). Attention is
called to the use of electro-coagulation in the treatment
of cancerous and precancerous lesions of the rectum and
rectosigmoid (Straus10) as palliation in inoperable
lesions and as a curative method in very early lesions
it is of value. A statistical review of carcinoma by
Dixon1 J gives an actual statistical report of what can
really be expected under proper management of cases of
this type.

BIBLIOGRAPHY

1 An Anatomic Restudy of the Pelvic Lymphatics, J. Peerman
Nesselrod, Annals of Surgery, Vol. 104, No. 5, Nov., 1936.

2. Further Observations in Oil Soluble Anesthetics in Proctol-
ogy, R. V. Gorsch, The Medicine World, Vol. 54, No. 12, pp
777-779. Dec., 1936.

3 The Elimination of Pain Following Hemorrhoidectomy, N. J.
Simmons, New England Journal of Medicine, 214:20-22, Jan. 2,
1936.

4. Local Anesthetics Producing Prolonged Anesthesia, N. J.
Kilbourne. S. G. O. 62, 590-604, March, 1936.

5. Rectal and Recto-Sigmoidal Endometriosis ( Adenomyomata ) ,
C. Rosser. Dallas Medical Journal, 22, 32-33, March, 1936.

6. Clinical .°u vey cf Lymphogranuloma Inguinale, C. F. Martin
American Journal Digestive Diseases and Nutrition 2, 741-743,
February, 1936.

7. Anal Fissure and Spasm and Anal Stenosis. E. A. Daniel.
American Journal, Digestive Diseases and Nutrition, Vol. 3. No.
10. p 775, Dec., 1936.

8. Surgical Anatomy of the Anal Canal and Rectum, C. N.
Morgan, Post Graduate Medical Journal, 12:287-300, August,
1936.

9. Solitary Adenoma of the Rectum and Lower Sigmoid. L. A.
Buie and J. C. M. Brust, Transactions, American Proctologic
Society, 36:57-67, 1935.

10. New Methods and Results in Treatment by Surgical D a-
thermy (Electrical Coagula'tion ) , A. A. Strauss, Journal American
Medical Association, 106:285-286, January 25. 1936.

11. Preoperative Radium Treatment, H. H. Bowing and R. E.
Frick, American Journal Roent. 34:766-769, December, 1935.

12. Surgical Procedure of the Colon, 1935. C. F. Dixon, Pro-
ceedings of the Staff Meeting of the Mayo Clinic, Vol. 11, No.
49, Dec. 2, 1936.

A Review of 1936 Literature on Ear, Nose,
Throat and Bronchoscopy

Kenneth A. Phelps, M. D.:i:*

Minneapolis, Minn.

Otology

DURING 1936 many workers have continued
their investigation of the physiology and the
pathology of hearing. Polvogt found numerous
pathological changes in ears which had normal hearing,
most of these changes being in the middle ear. This
proves again that normal hearing may exist in spite of
certain changes in the drum or middle ear. The Wever
Bray apparatus has been experimented with in labora-
tories at Harvard, John Hopkins, University of Minne-
sota, and other institutions and further knowledge con-
cerning tone localization, in the cochlea, has been ob-
tained.

The program for the reclamation of the moderately
deafened child, as outlined by Fowler, consists of: (1)
routine group tests to discover these children, (2)
treatment when indicated must be insisted upon, (3)
lip-reading begun early, (4) front seat in school and
classes for the severely deafened.

Menier’s disease has been treated by dehydration with
good results by some and doubtful results by others.
McMurry reports eleven cases treated by Dandy’s oper-
ation of section of the vestibular branch of the auditory
nerve. Eight were completely relieved. Davis advises

•Prepared especially for the 67th anniversary issue of THE
JOURNAL-LANCET, and read before the Hennepin County
Medical Society, January 27, 1937.

••Assistant Professor of Otology, Rhinology, and Laryngology,
University of Minnesota.

operation on the vestibule of the labyrinth, as being
less formidable; and reports six cases satisfactorily
treated in this manner.

Aural vertigo or Menier’s syndrome is relieved, accord-
ing to McMurry, by removal of foci of infection,
forbidding tobacco and alcohol, and treating the
Eustachian tube, or by Furstenberg’s diet.

One important subject in otology is the testing of
hearing. The necessity for precise measurement of hear-
ing has produced many devices for this purpose. The
most recent are the electric audiometers. These instru-
ments should produce pure tones of the desired pitch
and intensity, all controllable by the examiner. Graphs
are made which chart the acuity of hearing by air and
bone conduction. The percentage of hearing-loss is ob-
tainable and may have considerable importance as the
basis for damages in compensation cases. Such instru-
ments can be used to test the hearing of groups of in-
dividuals, as school children, and those with defects of
hearing can be discovered.

The audiometer is not necessary for diagnostic pur-
poses. It offers a convenient method of testing hearing.

Sound-proof rooms can be built in noisy down-town
offices at a fairly reasonable cost, and make testing of
hearing more accurate. Jones and Knudson believe that
from a practical standpoint, since most hearing tests are
carried on in a noisy place, the results are quite com-
parable without a sound-proof room.

THE JOURNAL-LANCET

These diagnostic instruments are frequently manu-
factured by the same companies which make devices for
aiding the hearing. The commercial concern has sales-
men calling themselves audiometrists, who test hearing
and prescribe hearing devices — similar to the optometrist
examining vision and prescribing glasses. This situation
has given rise to a new problem in the practice of otolo-
gy. The otogram is of little value without the clinical
history and a complete examination of the patient.
Patients who need medical attention, and can be helped
by it, will inevitably be missed when they are examined
and treated by a non-medical person. Shambough re-
ports many such cases and makes a strong argument for
the otologist’s rather than the layman’s diagnosing and
prescribing for the deaf.

Regarding hearing aids: Harting and Newhart of the
University of Minnesota have examined these devices
in the physics laboratory and find that the claims made
by the manufacturer are not always substantiated. The
authors propose a test of sentence intelligibility, though
they state that practical trial of the instrument by the
patient is advisable.

The literature of the past year has many references
to suppurative diseases of the ear. In general, the well-
established methods of treatment have not been changed.
The relationship of sinusitis to otitis media has been em-
phasized by Cullum; the importance of otitis media in
infancy and its relationship to intestinal intoxication is
discussed by Litschkus. Lemaitre believes otitis media
due to pneumococcus Type No. 3, is of increasing fre-
quency, and points out its treacherous nature, particular-
ly the absent symptoms of mastoiditis.

Mastoiditis, as usual, occupies a large amount of space
in the literature. The technique of operation seems
settled for acute mastoiditis; but the term complete
mastoidectomy rather than simple mastoidectomy, seems
to be coming into more general use. For chronic mas-
toiditis, most authors advise that local treatment be tried,
and agree that attic or peripheral perforations of the
drum indicate some danger of complications, while the
risk in central perforation is negligible. The Bondy
type of modified radical operations is advised by some
(Shambough) .

The complications of mastoiditis are considered in de-
tail by many authors. Boise reports on extradural in-
flammation and states that 90% of the complications
are due to direct extension from the mastoid.

Petrositis is now a well-recognized condition, and there
are numerous reports of cases successfully treated. The
operative procedure is not yet standardized; but the
majority of men seem to follow Friesner in both indica-
tions for and technique of surgery.

Thrombosis of the lateral sinus is discussed by Dunn
and Cowan, who state that surgery is indicated. Stone
and Berger report on thrombosis of the sinus complicat-
ing thrombosis of the jugular vein. Other authors re-
port their results, but the old problem of when to ligate
the jugular vein, if at all, the diagnostic value of spinal
fluid cultures, and when to employ transfusions, are not
settled so that there is unanimity of opinion.

The surgical repair of the facial nerve is reported by
Martin of San Francisco, who followed the technique
brought out by Duel and Ballance. He states that mus-
cular movement returns; but not always emotional con-
trol. The frontalis muscle and the function of the chor-
da tympani do not return to normal. Sullivan of Toronto
believes that such operations should not be done until
six months after the paralysis occurs, spasm being thus
avoided. Other men disagree, and report their cases
to prove that the sooner the operation is done, the better
will be the results.

Intracranial complications of ear diseases are discussed
by many writers. No important addition has been made
to the existing knowledge of prevention or cure.

The Nose and Nasal Sinuses

The recognition of the part played by the mucin in
nasal and sinus diseases, which is largely due to Hild-
ing’s work, has changed some of the older ideas con-
cerning these conditions. Fenton and Larsell, after five
years of investigation, conclude that almost any prepara-
tion, not of isotonic strength, applied to the surface of
the sinus or nasal mucosa, acts as an irritant.

The treatment of allergic rhinitis by ionization, has
advocates who report large series of successful results,
while others, notably Dean, have found microscopic
changes in the mucosa which show atrophy and fibrosis
and therefore advise against it. The general opinion
seems to be that ionization will give relief but should be
used only in those cases which do not respond to the
usual treatment of the allergist.

The question of the sinuses’ acting as a focus of in-
fection has received considerable attention. Mitchell
believes they often are a focus in children. The treat-
ment of children’s sinus in general should be conserva-
tive, but some authors, as Pirez, advise operation more
frequently, particularly in asthmatics. Burman advises
an elaborate treatment both locally and generally. He
advises proper diet, hygiene, restriction of salts, ad-
ministers calcium, viosterol, parathyroid extract, and
antogenous vaccines. Locally a spray of cocain and
ephedrine, suction and oily sprays. For the acute stage
he uses hot foot baths, hot liquids, citrus fruits, powder
of ipecac and opium, atropine in small doses and
salicylates, steam inhalations and radiant heat. Leroux
believes Americans pay too much attention to diet and
not enough to climate.

Cook and Grove found sinusitis to be an etiologic
factor in 92% of 240 cases of asthma. Manges now
X-rays the sinus routinely in all non-tuberculous chest
cases, and finds sinusitis in 60% of the cases. He also
finds that 85% of the sinus cases have pulmonary dis-
eases.

Kartogener and Ulrich report on the relationship be-
tween sinusitis and bronchiectasis, and find it to be
definite: bronchiectasis occurs after sinusitis, and sinusitis
occurs after bronchiectasis.

Parfitt cites 1000 psychiatric patients, in 818 of whom
sinusitis was found, and striking results were obtained
by treatment.

THE JOURNAL-LANCET

Ocular and orbital diseases may be related to sinusitis.
Sargnon believes that removal of the posterior tip of
the middle turbinate reduces the retinal circulation, and
cases of retrobulbar neuritis so treated obtain benefit,
due to reduction of arterial blood pressure in the retina.
Many authors, Dunnington, Fisher, and others, believe
most cases of retrobulbar neuritis are due to multiple
sclerosis, and advise against operation on the sinuses.

Intracranial complications from sinus diseases are
discussed by numerous authors, and many cases are
presented, but nothing new has appeared in this year’s
literature.

The common cold is again a subject of many articles,
one of the most interesting being by Browning and
Glasgow, who conclude that 60% of the people have
two or three colds every year. Colds are due to some
agent not harbored by those attacked, e. g., the Eskimos.
The agent is a filter passing virus. Ordinary organisms
found in the nose may play a part in colds and certain-
ly do in the complications. Climate has little to do with
colds, though sudden changes in the weather have a
relation to colds; individual living habits are of no im-
portance as a cause of colds; nasal douches and mouth
washes are not of prophylactic value. Vaccines do not
help prevent colds; only gross dietetic errors are a factor.
Tonsillectomy and nasal operations have no effect.
Therapeutic experiments were conducted on university
students; 75% of the group were given codeine and pa-
paverin, and reported improvement in a day. Thirty-five
per cent of the other group, who thought they were re-
ceiving the same treatment, also reported improvement.

The Pharynx

Lillie discusses granular pharyngitis, the type found
following tonsillectomy, and reports the best results by
administration of iodides by mouth. He believes X-ray,
local applications, and operative removal of pharyngeal
lymphatic hypertrophies to be disappointing.

Roy reports his method of treating residual lymphoid
tissue in the nasopharynx, advising trichloracetic acid
applied on a wire through a rubber Eustachian catheter.

The tonsil,, as usual, is the subject of many articles.
The field, from embryology on, is covered and nothing
really new has been brought forth. Pollitzu writes on
"The Pediatrician Looks at the Tonsil,” and he gives the
indications for tonsillectomy as "repeated attacks of ton-
sillitis, increasing in severity with or without systemic
disturbances.” He concludes that infected tonsils are a
factor in causing rheumatic fever, scarlet fever, and
chronic heart diseases; but tonsillectomy militates against
the incidence of bronchitis, pneumonia, and sinusitis.

Advanced cancer of the pharynx is treated by the
Coutard X-ray technique, in most parts of the world,
and reports from numerous places are encouraging.
Radium is usually used in conjunction with the X-ray.
Martin and McNatten report 140 cases with a 20 to
30-months’ cure in 29%. The percentage of cures is
higher in women than in men. The histologic type
seems of little influence in the prognosis. Zippinger and
Steuart Harrison report 150 cases and a 27-month cure

in 17%. Duffy reported 176 cases of cancer of the
tonsils over a ten-year period with 18% cured for three
years. To the reviewer these figures are indicative of
real progress in the treatment of cancer. Perhaps the
day will come when cancer can really be controlled.

The Larynx

The same method of treatment, referred to above,
has been used for cancer of the larynx with probably
better results. Most writers still feel that surgery fol-
lowed by radiation is the best treatment for intrinsic
cancer of the larynx, that is, for cancer that can be re-
moved by operation, even though the operation is a
total laryngectomy.

Numerous articles have appeared dealing with the
diagnosis and treatment of laryngeal disease, mostly
case reports. Nothing of unusual importance has been
noted.

Esophagoscopy and Bronchoscopy

The flexible gastroscope is being used more frequent-
ly, according to the numerous reports in this year’s
literature. It can be passed about as easily as a stomach
tube, and a very good view obtained of the gastric
mucosa. No operative work, such as removing foreign
bodies or biopsies, can be done through this instrument,
as it is a closed tube. For this purpose the open tube
must be used.

This instrument has demonstrated that gastritis is of
frequent occurrence (Schindler) . This lesion is not so
easily diagnosed by any other means. Eusterman be-
lieves that gastritis deserves more serious consideration
as an underlying factor in gastric diseases, such as
pseudo-ulcers, nervous indigestion, gastrotoxic hemor-
rhage, and gastrogenic diarrhea. He also believes numer-
ous symptoms may arise from gastritis, but cautions
against over-enthusiasm on the part of the gastroscopist,
and advises that the gastritis problem will be solved only
"by careful appraisal of all facts through team-work on
the part of the clinician, laboratory worker, and the
surgeon.”

Some writers, as Jackson, express the opinion that
gastroscopy will become a routine in every gastro-
enterologist’s study of patients with gastric symptoms.
He warns against passing the instrument without
thorough preliminary knowledge of the condition of the
esophagus.

The reports in the field of esophagoscopy have dealt
with numerous subjects as: the Plummer-Vinson syn-
drome, McGibbons believing the anemia is probably
secondary to the dysphagia. Diaphragmatic hernia may
occur in conjunction with other diseases of the esopha-
gus, according to Vinson, who reports cases of hernia
associated with strictures or spasm of the esophagus.
Pitkins reports a case of stricture of the esophagus due
to lactic acid. He points out the danger of mistakes
in preparing infant-feeding mixtures.

Cancer of the esophagus is discussed by numerous
authors, who call attention to the well-known fact that

THK JOURNAL-LANCET

most of these cases are first diagnosed when the disease
is advanced.

The use of the bronchoscope for diagnostic purposes
is much more frequent than ever before. Many authors
dealing with its diagnostic possibilities, such as Gerlingo,
who discusses hemoptysis. Morlock reports a series of
benign tumors. Kramer, Kernan, and Jackson all re-
port cases af adenoma of the bronchus. This tumor is
difficult to diagnose by section, but is clinically benign,
for most cases recover following removal of the tumor,
and no recurrence develops.

Cancer of the bronchus and lung is apparently in-
creasing in frequency. The bronchoscope aids in its
early diagnosis and treatment, though X-ray and radium
still offer the best treatment. Some cases of removal
of the whole lobe or the whole lung are on record, and
surgery may eventually be the solution of treating
cancer of the lung.

Bronchoscopy in tuberculosis is teaching us something
about tuberculosis of the bronchi. Stenosis of the
bronchi and its relationship to collapse therapy is dis-
cussed by Phelps and Cohen, who believe bronchiectasis

in the tuberculous individual is often due to bronchial
stenosis, and is not true tuberculous bronchiectasis.
Bronchoscopy is not contra-indicated in tuberculosis, as
shown by their report of over one hundred bron-
choscopies performed at Glen Lake Sanatorium.

The value of bronchoscopy in treating pulmonary ab-
scess is the subject of articles by Pinchin, Knight, Ker-
nan, Soulas, and others. They agree that the abscesses
connected with the bronchus, and of not-too-long stand-
ing, are the ones in which bronchoscopic treatment is
most successful.

As usual, foreign bodies are frequently reported.
Jackson’s new book is based on over 3000 such cases in
his own experience. While foreign bodies continue to
be an important part of bronchoscopy, the largest field
is now considered to be its diagnostic and therapeutic
possibilities in diseases of the lung.

The report of Barach, on the use of helium mixed
with oxygen to relieve obstructive dyspnoea, is very in-
teresting. He reports good results in status asthmaticus
also.

A Review of 1936 Literature
on Ophthalmology*

Charles Wilbur Rucker, M. D.**

Minneapolis, Minn.

RECENT advances in ophthalmology of general
interest are few. A review of the literature re-
veals the usual modifications of the various
operations for strabismus, detachment of the retina,
glaucoma and cataract, that will in turn be modified still
further next year. Medical treatment has elicited less
comment. There are a fair number of reports of un-
usual cases and of descriptions of disease. While these
works are necessary steps in the development of an art,
they need not concern one outside the specialty. Of
fundamental importance are articles by Ranson and
Magoun, and Scala and Spiegel, on the location of the
afferent light reflex that will eventually lead to a better
understanding of the pupillary reflexes; of reports by
Poljak on the minute structure of the retina in primates;
and by Carl Behr on the septal system of the optic nerve.
Notwithstanding their ultimate value, their clinical im-
portance does not warrant discussion here.

There are a few topics of more general interest in
which there has been progress and which have aroused
some comment. Of these, I have chosen to discuss three:
a new cause of cataract, invisible spectacles, and the
cross-eyed child.

Within the past two years a new cause for cataract
has confronted the ophthalmologist — dinitrophenol. The
drug itself is not new. Its effect on the metabolic rate
of dogs was studied by Gibbs and Reichert 45 years ago.

^Prepared expressly for the 67th anniversary issue of THE
JOURNAL-LANCET, and read before the Hennepin County
Medicai Society, January 27, 1937.

* ^Instructor in Ophthalmology, University of Minnesota Medical
School.

During the war it caused so many poisonings and deaths
among French munitions workers that special pharma-
cological studies were made at that time. Since 1933
Tainter and Cutter of San Francisco have published a
number of studies on its use as a metabolic stimulant.
They found that it could stimulate the consumption of
oxygen to ten times its basal value, and that it caused
oxidation of both carbohydrates and fats. They showed
that when it was given in daily doses of 3 to 5 mg., pa-
tients lost weight without having to take the trouble of
restricting their diets. Although they observed no un-
desirable effects, these authors and also editorial writers
in The Journal of the American Medical Association
warned against the uncontrolled administration of the
drug. Commercial concerns supplied it under various
trade names to be sold in drug stores as a reducing
agent. Soon cases of toxicity were encountered and
there began to appear in the literature reports of deaths
from its use.

Early in 1935, a few patients who had been taking
dinitrophenol began to get cataracts, and during the
following year about fifty cases were reported. This
was an unexpected complication — blindness as a result
of slimming. The opacities in the lens begin beneath
the capsule, spread through the cortex, and then the
nucleus. The change is frequently quite rapid, the lens
becoming completely opaque within a period of a few
weeks. When the cataracts progress rapidly, there is
apt to be a complicating glaucoma. The cataractous
changes in the lens are a late manifestation of poison-

THE JOURNAL-LANCET

ing. In one reported series they occurred on an average
of 15 months after the drug was first taken, and an
average of 7 months after its use was discontinued. The
cataracts, if uncomplicated by glaucoma, can be ex-
tracted by the usual operative methods with as good
return of visual acuity as after extraction of other types
of cataract.

Contact lenses, the so-called "invisible spectacles,” have
received considerable publicity during the past year,
partly originating from the optical companies, partly
from a few ambitious optometrists, and partly from
health columns in the daily press. They are thin shells
of glass worn on the surface of the eye, behind the lids.
Physiological salt solution is used to fill the space be-
tween the glass and the eye.

These lenses are designed to be worn for the cor-
rection of irregular or high degrees of astigmatism or
high myopia, especially when ordinary spectacles are not
practicable. They have been most popular with actors
and speakers who have large refractive errors, and who
do not wish to be seen wearing glasses. In most cases
they can be worn with comfort only for a few hours at
a time. Putting one on and taking it off requires some
skill, and is usually done over a bed where dropping will
not break the thin shell of glass. A new one costs about
$50.00.

Contact lenses were made in Germany fifty years ago,
the first ones of blown glass. Later, methods of grind-
ing them out of hard glass were devised, and now they
are fitted with trial sets of ten or more sample lenses of
various curvatures, and the exact dimensions determined
for each individual. Dallos has had contact lenses
molded over casts made of the living eye, obtaining
comfortable fits in asymmetrical or sensitive eyes. At
present, contact lenses are not entirely satisfactory, and
some persons who can see better with them, cannot wear
them comfortably. Their field of usefulness is dis-
tinctly limited.

The care of the cross-eyed child continues to elicit its
share of published articles. While the causes of stra-
bismus remain uncertain, progress is being made in its
treatment. During recent years many kinds of eye
exercises have been tried, and now enough well-controlled
work has been done with them in the large clinics to en-
able one to estimate their relative value. New instru-
ments have been invented to aid in these exercises or to
produce still other more complicated forms. The next
few years will determine their relative merits. At pres-
ent these fancy new instruments are most popular with
the non-medical refractionists.

Modern ophthalmologists agree that the treatment of
strabismus should be based on an outline about as
follows:

1. Optical treatment. 3. Orthoptic treatment.

2. Treatment of amblyopia. 4. Operative treatment.

1. Refractive errors are corrected by proper glasses
with the object of giving to each eye its best vision.
Abraham suggests ignoring hypermetropia of less than
three diopters and astigmatism of less than one-and-one-

half. Certainly a minor correction in a lens has little
effect on strabismus.

2. Amblyopia, the poor vision in the squinting eye,
is corrected as far as possible with glasses. An attempt
is made to improve vision through use by covering the
better eye and forcing the poorer eye to do the seeing
By this method in children three to four years of age,
good vision can be developed in an amblyopic eye within
a period of a few months. In older children years may
be required for the same result.

3. The place for orthoptic training is subject to much
disagreement. It includes forms of treatment which
aim at establishing binocular and stereoscopic vision.
By its methods the two eyes learn to work together. Be-
cause it requires much time and patience it is not as fully
utilized as it might be by the busy ophthalmologist.

4. Operative treatment seems to be regarded by most
authors as a last resort. Methods most advocated at
present are recession of the attachment for weakening
the effect of a muscle, and resection or advancement of
the opposing muscle to strengthen it. All these oper-
ations can be graded and their results calculated in ad-
vance with fair accuracy. The chief disagreement over
operative treatment arises as to the best time for per-
forming it, whether between the ages of 3 and 6, or at
adolescence. If one may judge from published reports,
the earlier age is becoming more and more popular. In
general, squints of more than 20 degrees in children
will require operation; those of less than 20 degrees may-
be helped or cured by orthoptics.

Perhaps the best course to follow in the light of the
knowledge available at present, is to give the cross-eyed
child proper glasses, and the best vision possible in the
squinting eye. After some orthoptic training, unless
there is great and rapid improvement, lengthen or
shorten the proper extra-ocular muscles, and then in-
stitute orthoptic training. The plan of watchful wait-
ing in the hope that the patient may outgrow his squint
is wrong. A small proportion of cross-eyed children do
grow up with straight eyes without any treatment, but
often at the expense of one poor eye and a lack of
stereopsis. We have little knowledge of the factors
that lead to these spontaneous cures.

There are a number of reasons for preferring to treat
the children before the age of six. Vision can often be
brought to normal limits within a few months. Orthop-
tic exercises are most effective at that age if the child
will cooperate. Operation can be performed satisfac-
torily. It is not fair to a child to send him to school
with an eye turned out of line. Children are notoriously
cruel, and their jeers of "cross-eye” cause more misery
than most of us realize.

Of the three topics herein discussed, the first is of
only passing interest for dinitrophenol cataract should
not be encountered in future years when the drug prob-
ably will not be used. Contact lenses have had a wave
of publicity which is now subsiding. The care of the
cross-eyed child is a problem that will be with us for a
long time. The ophthalmologist’s ideal is to get the
eyes straight before the child begins school.

THE JOURNAL-LANCET

Progress In Pediatrics*

As Recorded in The Journal-Lancet and Minnesota Medicine

Chester A. Stewart, M. D.**

Minneapolis, Minnesota

THE following excerpts selected from arti-
cles published in The Journal-Lancet
about five decades ago portray a few cur-
rent and accepted views and practices of the
physicians of that period, as well as some of their
baffling unsolved problems.

Journal-Lancet, 1881-85

Miscellaneous Subjects

“Concerning the ravages of that fearful disease,
consumption, much has been done towards ex-
terminating the germ, where it exists in child-
birth, by rendering gymnastical exercises, swim-
ming and singing obligatory, ventilation and heat-
ing in schools, prohibiting child labor in factories,
and exercising a wholesome scrutiny and control
over large manufacturing institutions where ob-
noxious substances are used. It is only in the
Lhiited States that the disease, summer complaint,
takes away so many little ones ; and it is for the
reason that the majority of the parents ignore the
fact of the susceptibility of cow’s milk in absorb-
ing all foul gases and that, therefore, if they are
not thoroughly sure about the source from which
it is derived, it is the most dangerous thing to give
children, especially in warm weather.”

“Now as to the origins of true malarial disease.
I think it may be assumed that their source is in
the soil, which may impart a portion of its fungi
to adjacent stagnant water, where they may be
in very active form, but if the water is not drunk,
it can do no harm, for the sporules will sink in
the water as fast as they mature and die, and so
can not be dried and then wafted to neighboring
localities to infect the people; but, if under the
influence of a long drv spell, the water recedes
and leaves the shore to be sun dried, then the
dried spores of the fungi may become light
enough to be transported by air currents, and
inaugurate an endemic disease of malarial origin.
It is that disease called “trembles” when applied
to cows, and “milk sickness” when applied to
those who drank milk of the diseased cows,
originated in the soil and contaminated stagnant
waters of the prairies, which the cattle drank, and
that the germs passed into the milk to reproduce
the disease in the drinkers.”

Vaccination

“There are several methods used in vaccinating,
and several ingenious instruments invented for

•Prepared expressly for the 67th Anniversary issue of THE
JOURNAL-LANCET.

••Department of Pediatrics, University of Minnesota, Min-
neapolis.

vaccinating. In selecting a point on the arm, the
region over the insertion of the deltoid, is the best,
on account of the integument at that point, being
kept more at rest than any other, because there
are no muscular movements going on underneath,
during the motions of the arm. The method prac-
ticed, consists in moistening the ivory point, if
points are used, and when the virus is softened,
smear it on the place selected, or if cones or
crusts are used reduce the virus to the consistency
of milk, and with the point of an ordinary thumb
lancet, smear it in the same manner, and then
passing the fingers and thumb of the left hand
around the patient’s arm, draw the skin tense
transversely, and make fifteen to twenty-five
scratches in the cuticle.”

Diphtheria

“During the year last past I have had oppor-
tunity to observe 26 cases of malignant diphtheria,
and some 15 or 20 cases of sore throat occurring
in the same, or neighboring families, under cir-
cumstances peculiarly adapted to show its conta-
giousness. The above cases, though not numerous,
would seem to point so far as they go : ( 1 ) That
diphtheria is at least sometimes contagious.
(2) That there may be very mild cases of diph-
theria occurring even in the same family with the
most malignant ones.”

Meningitis

“The treatment of meningitis is important, and
if employed early, the true character of the
malady being early recognized, is satisfactory and
attended with good results.

“Cases with violent onset will generally be
treated without blood-letting, although. I believe
this would be most efficient treatment in such
cases, if practiced in the congestive stage, but we
of more modern times make so little use of this
sheet anchor remedy of the older school of prac-
titioners, that we doubtlessly deprive our patient,
in some cases, of the more potent remedy by the
modern substitute by means of arterial sedatives
and depressants.

“If called in the early stage it will generally be
advisable to give a mild cathartic. If the pulse
be accelerated and firm under the finger some
arterial sedative should be given, and I prefer
verat. virid (Norwood’s), for with this you can
bring the heart’s action to any desired state and

THE JOURNAL-LANCET

hold it there as long as you deem advisable, weak-
ening arterial tension hence active congestion of
the cerebral capillaries. Apply cold to the head
in the form of ice bags or bladders filled with
ice. Iodid. Potas. should be commenced early and
continued, the object being, at first, by it to pre-
vent effusion and after effusion to promote its
absorption.

“There is a brain trouble occurring in the course
of gastro-intestinal diseases of infancy and child-
hood, that is regarded by many and spoken of
and treated as meningeal inflammation, with effu-
sion. This effusion is not of inflammatory origin,
but is due to increased capacity in the cranial
cavity ; from atrophied and wasted cerebral sub-
stances, and as a result we have congestion of the
cerebral sinuses and veins ; together with effusion.

It is eminently important that the physician
should comprehend the true pathology of this
class of cases; for if he should regard them as a
true meningeal inflammation and proceed to treat
them as such they will most certainly prove fatal,
while if they be treated as a state of exhaustion,
giving freely of brandy, ammonia, quinia and
concentrated liquid nourishment, he will often
restore his little patient to health, after friends
and all had relinquished the last hope of re-
covery.”

Heliotherapy

“We are pleased to see that the profession is
beginning to appreciate the great part which the
sunbeam plays in promoting health, and now, it
is not at all unusual to hear of patients being
regularly subjected to sun baths for the purpose
of restoring the victims of etiolation. Attention
had already been directed to the subject, when
Kilpatrick's blueglass craze broke out and dis-
gusted the profession with the folly and credulity
of the public, and the whole matter of sunbeam
treatment was abandoned.

“Now, however, when the epidemic blueglass
nonsense has gone the way of all similar fashion-
able follies, there is some prospect of reviving
the rational treatment of anemic conditions by the
sun bath, and numerous physicians are availing
themselves of that potent factor in the treatment
of anemia. Let the anemic lady’s couch, or the
child’s crib be wheeled to the window, where in
the state of perfect nudity, the sun can blaze in
and thoroughly tan the hide and rubify the blood.”

Rickets

“With a history of constipation, together with
a flabbiness of the muscular tissues, taken in
connection with a cough which is troublesome we

are justified in a diagnosis of rachitis, and espe-
cially so since we cannot find any other disease.

“As to treatment, I advise keeping the child in
warm fresh air moistened a little with steam. The
child should be washed twice daily in cold water
with perhaps a little salt added. Then the baby
should be weaned, for the character of the
mother’s milk has probably something to do with
rachitis. Farinaceous food such as barley or oat-
meal mixed with boi'ed cow’s milk may be gradu-
ally substituted for the breast milk. It is thought
by some that a superabundance of lactic acid in
the stomach and intestines may prevent the bones
from reaching their normal development, and the
theory which explains this by the lac-tubes being
washed out is a very plausible one. So too much
milk is injurious by forming too much lactic acid.
I generally do not give much medicine provided
I can harden and toughen the baby by cold water
bathing and proper food. Cod liver oil may be
added in the winter to increase nutrition.”

Germ Theory of Disease

“Why do different epidemic diseases vary in
their intensity and fatality? The gentlemen who
have so lately discovered that all these are caused
by certain known and recognized bacillus, bac-
teria, or something of that sort might explain the
reason why. Possibly these micro-beasts of prey
are more ravenous, active or malignant at one
time than another. We must all swallow Mr.
Koch’s or some other foreign gentleman’s theory
or be classed as ignorant, slow fogies. The past
is strewn with forgotten dogmas and theories.
Some of them were as brilliant as this, and ran
away with some of the greatest minds.”

Since the time the preceding articles were pub-
lished great changes have taken place. Many of
the views and medical practices of the compara-
tively recent past have been abandoned, and many
of the problems of former days have been solved.
Accompanying these changes medical publications
have become progressively more scientific, and
deal frequently with an increasing variety of
topics unheard of by physicians who practiced a
generation or so ago. More recent developments,
views, practices, trends of thought and remaining
unsolved problems may be illustrated by the fol-
lowing excerpts selected from papers which ap-
peared in The Journal-Lancet and in Minne-
sota Medicine during 1933-4-5.

In these few excerpts selected from recent
articles we find discussions of topics such as vita-
mins, pH, disturbance of the permeability of cell
membranes as related to the abnormal “convulsive

THE JOURNAL-LANCET

reactivity’’ of epileptics, scarlet fever immuniza-
tion, and the Dick test ; all of which were un-
known to the medical profession until compara-
tively recent times. These few selections, to which
many more could he added, seem to illustrate how
medical science has advanced in a relatively short
period.

At the present time advances in medical science
are being accomplished, apparently, with increas-
ing rapidity, thus the physician needs correspond-
ingly increasing facilities for keeping himself in-
formed.

Journal-Lancet and Minnesota Medicine

1933-35

Vitamins

"Great advances have been made in the past few
years regarding the chemical nature of the vita-
mins. At least four have been isolated in chem-
ically pure form and two of these have been
synthesized in the laboratory. Vitamins A, B, C,
and D have been isolated and vitamins A and C
have been synthesized.

"Vitamin A is found to he one half a molecule
of beta-carotene as follows

Infections of the Genito-Urinary Tract

"The administration of large amount of fluid
and the bringing about of a urinary acidity suffi-
cient to inhibit bacterial growth make an ideal
combination, during the acute stage, with which
to wash out the passages and prevent further
growth of organisms in them.

“In more chronic cases my experience indicates
that methenamine, used under controlled condi-
tions. offers better chances of success than any
of the other antiseptics. Gillespie has recently
studied the bactericidal effect of Pyridium and
Serenium, two newly introduced urinary antisep-
tics, and has not been able to show that they would
be likely to be of any value in the treatment of
infections with the colon bacillus. Experiments
with methenamine in vitro, have shown that the
degree of acidity is of utmost importance in suc-
cessful treatment. Without accurate control of
urinary acidity, methenamine may be of no more

use than so much water. At a pH of 6.0 and with
a concentration of methenamine of 0.5 per cent,
not enough antiseptic power developed in urine
to kill the colon bacillus after 24 hours, but
at a pH of 5.0 and one tenth the concentration
just named, all organisms were killed within that
time, and the same concentration rendered the
urine sterile in six hours. By means of methyl
red paper, which turns bright red at a pH of
5.5 and below, it is possible to determine whether
urinary acidity is sufficient to split methenamine
rapidly enough to produce bacteriostasis or even
bacteriolysis in six to eight hours. Whether this
suffices to clear up the infection, only trial will
tell. If it will not, it is probable that urinary stasis
is present in the system, and the cause of the
stasis should he determined, if possible, by com-
plete urologic examination.”

Epilepsy

"That an inherent deficiency of this type (a
disturbance in cell membrane permeability) may
conceivably account for the abnormal “convulsive
reactivity” of the epileptic person is further sug-
gested by the circumstances, that most factors
which favor the occurrence of seizures are also
known to increase permeability of cell mem-
branes ; whereas, agents such as anesthetics and
narcotics which cause their cessation, have the
opposite effect. Should this conception prove on
further study to be sound as regards its essential
features, it is probable that a much more effective
form of therapy than any now available will be
developed from more deliberate attempts to cor-
rect or compensate for the existing defect.”

Scarlet Fever Immunization

“No case of scarlet fever has occurred in the
student nurses in the Central School of Nursing
among those who had negative skin tests or who
were immunized with five doses of scarlet toxin
(Dick’s), with the exception of a case in a student
nurse who had had scarlet fever in childhood,
whose Dick test was negative and who. therefore,
had not been immunized. One case out of 690
nurses gives a rate of 1.4 per 1000. During the
same period, there were seven cases of scarlet
fever in a group of 619 affiliating nurses who had
neither been Dick tested nor immunized. This
gives a rate of 11.3 per 1000, eight times the inci-
dence in the regular nurses who had been tested
and immunized.”

Vitamin A and Visual Acuity

“Vitamin A deficiency of sufficient degree to
produce the well known and outspoken symptoms

THE JOURNAL-LANCET

CHRONOLOGIC ORDER OF THE APPEARANCE IN THE JOURNAL LANCET AND IN MINNESOTA
MEDICINE OF SELECTED NEW TOPICS OF IMPORTANCE IN PEDIATRICS

of this deficiency is rare in this country. We have
no good idea of the prevalence of a moderate
deficiency of this vitamin. In searching for a
clinical measure of moderate vitamin A deficiency
it occurred to us that night blindness might serve
such a purpose. By means of a photometer we
have determined the speed of recovery of acuity
of vision after exposure to bright light. We have
found that 20 per cent of the children applying to
our children's hospital for treatment have a loss of
visual acuity in the dark, and that the acuity of
vision can be restored by cod liver oil administra-
tion. We believe that we have established the
validity of this procedure as a method of determin-
ing vitamin A deficiency. We would attach no
special significance to the incidence figures we
have obtained up to now, except possibly that they
permit us to state that in this particular class of
children, moderate deficiency of vitamin A is
relatively common. From this finding we would
not draw the inference that vitamin A concen-
trates are indicated routinely in the every day
feeding of children. It is our opinion that a good
diet will supply an adequate amount of vitamin

A, and that, ordinarily, the use of a good diet is
the better method of obtaining this vitamin.”

Since 1881, the Journal-Lancet has served
uninterruptedly to place new knowledge and dis-
coveries at the disposal of the doctors of the
Northwest, and in this capacity it was joined by
Minnesota Medicine in 1918. The services these
two journals have rendered in the past in
augmenting the dissemination of knowledge to
the physicians of the north central states and else-
where is illustrated by the following chart in
which is recorded the chronological order of the
appearance in each of these two journals of
selected new topics and discoveries of special
pediatric importance.

This chart discloses only a limited part of the
important educational services these two publica-
tions have rendered in the. past and in view of
rapidity with which advances in medical sciences
are being made, these two journals will doubt-
lessly became increasingly indispensible sources
of post-graduate medical information in the
future.

THE JOURNAL-LANCET

A Student Health Opportunity*

E. Lee Shrader, M. D.**

St. Louis, Mo.

MEDICINE has always been concerned with the
sick; not the well. Most of the teaching in
medical schools is still predominantly concerned
with the care of the sick. And even throughout the pro-
fession as a whole there still exists a much keener interest
in sickness than in health and its preservation. The atti-
tude of the average practitioner of medicine, today, to-
ward illness which fails to present very obvious devia-
tions from the median norm, is rather passive. And
patients with these unclassified symptom syndromes are
quickly dismissed with little or no constructive advice
for the alleviation of their problems. Our present con-
cept of human function, although great, have been
accumulated incidentally or accidentally in, and pri-
marily to aid in, our search for a cure or a better
treatment of disease rather than a maintenance of
health. The use of our knowledge of human function
to preserve health is a relatively recent development.
In brief, such was, and largely is today, the viewpoint
of medicine both in professional teaching and practice.

As a more abundant knowledge of human disease has
accumulated, a modest number of direct or indirect
methods of prevention or control have appeared. Their
effectiveness has depended largely upon the amount
known about the specific nature of the disease, the
peculiar mode of invasion and the exact manner of
devitalization of the human body. It is in the realm of
infectious diseases that prevention has been most suc-
cessful. This phase of disease control began with the
work of Pasteur, and has been rapidly and brilliantly
expanded both in the investigative field and the practice
of medicine by such workers as Koch, Lord Lister, and
many others. Infectious disease control is based upon the
protection of large masses of the population from the
etiological agent by its elimination from human contact
or its destruction; by mass immunization; by specific
cures of those ill; but not by any precise individualiza-
tion of health principles for any particular person. The
average citizen today, all too frequently, does not
appreciate how sanitation destroys the causative agent of
disease by the purification of water, by rendering sewage
innocuous, by preservation of food, and by protecting
him from insect carriers of disease; nor how effectively
by quarantine, physical inspection, by the exclusion of
dangerous cases of illness at ports of entry, or by the
study of, and the promulugation of, preventive programs
against domestic diseases, the United States Public
Health Service protects the nation from epidemics of
such diseases as bubonic plague, cholera, undulant
fever, psitticosis, and the like. So also, do the local
health departments contribute their "bit” in the sani-

•Presidential address. Seventeenth Annual Meeting, American
Student Health Association, Washington, D. C., December 30,

1936.

••Director, St. Louis University Student Health Service, St.
Louis, Missouri.

tary campaign against infectious diseases. It is now
within our power to make smallpox, diphtheria, typhoid
fever and tetanus clinical curiosities by mass immuniza-
tion. In clinical medicine cures by antitoxins and sera,
in biochemistry and nutrition triumphs over pellagra,
scurvy, and others have also added to the conservation
and prolongation of life.

The profession and the public have accepted many
recognized principles of disease control or prevention
with great scepticism and indifference, particularly in
their early practical application. Medical history abounds
with these incidents. The introduction of smallpox vac-
cination by Jenner produced bitter antagonism in medi-
cal circles and even today is often violently opposed by
some of the public. One need not mention the abuse
and vituperation with which Pasteur’s theories were at
first received. So, we see, there is still much to be done
for a more thorough application of our present knowl-
edge for the conservation of life both professionally and
educationally, and still much more for medicine to do in
the realm of those still unconquered infectious diseases.

In clinical medicine there has been some progress
made in the conservation of life. Persistent investiga-
tion has defined specific modes of treatment, although
not preventive or curative, in Addison’s disease, per-
nicious anemia, and diabetes. In a great many other
infections and illnesses while no specific cure or control
has been elaborated, better understanding of human
pathological processes has shown it feasible to apply
general principles commonly called "good nursing care”
to increase the natural human resistance with gratifying
results. In a few instances, the correlation of nutrition
and pathology, as in typhoid fever, has provided an
effective dietary program, reducing the length of the
illness by at least one-half and increasing the chances
for life many fold. In fact, today it is not uncommon
for a typhoid patient to be in better health upon recov-
ery than he was prior to his infection. Thus illustrating
that a knowledge of the mode of human devitalization
by an infectious disease makes effective mass methods
of treatment, although not specific, for life conservation.

In general, however, outside of the realm of infec-
tious disease, medicine has achieved only indifferent re-
sults in prevention and control of sickness. Better treat-
ment, earlier diagnosis, and the periodic health examina-
tion have been hopefully applied, but with somewhat
depressing achievements; and yet this is not surprising
when we remember that we have applied pathological
methods of detection to human biological problems
which probably have their origin in physiological devia-
tions from the median norm.

Improved clinical treatment has been accompanied by
ever-increasing effectiveness in clinical diagnosis and vice
versa. Each has been a corollary of the other. Among

THE JOURNAL-LANCET

the various methods of more exact diagnosis sought and
developed, one only need mention the X-ray, bacterio-
logical and serological laboratories, the clinical use of
biochemical methods in the study of blood and other
body fluids and excreta. Today, the use of these aids to
early diagnosis is a very common practice while half a
century ago it was rare. The earlier the diagnosis the
more successful is the treatment. An excellent example
of this is in the case of tuberculosis. Where detected
in the asymptomatic stage, the cure is almost a certainty.
Not only have better methods of diagnosis increased
our ability to detect early disease; but they have focused
our attention on the human mechanism as a whole. This
has led medical men to think of, and to include the
entire human body in, their diagnostic search for path-
ology. When one has a pain in the abdomen the medi-
cal practitioner does not limit his study to the investi-
gation of the abdomen or questions about the diet. For
he knows that neurological derangement, pulmonary
pathology, vascular diseases, and many other things may
be the cause of the patient’s complaints. And, in turn,
this has again increased the possibilities of early diag-
nosis. Because earlier diagnosis has been possible and
because treatment has been more successful in earlier
stages of disease, medical minds have been eager to
make diagnoses in asymptomatic stages of illnesses. This
has suggested the periodic health survey, to determine
the presence or absence of that ambiguous concept we
call health.

In the past few years, the periodic health examination
has been well-advertised and well-practiced. Its principle
is early detection of pathology for the purpose of arrest-
ing it early, or delaying its rate of progress. It has been
applied most enthusiastically in insurance and industrial
medicine and student health services. The best statisti-
cal claims for its successful application are in insurance
medicine. Several years ago, the Life Extension Institute
reported an astonishingly lower death-rate among life
insurance policy-holders who received the periodic health
examination as compared with those who did not. I
question the validity of these claims. For these examina-
tions were offered to policy-holders; but were not arbi-
trarily forced on one group and denied the other. The
policy-holder who was not health-minded or already ill
and under medical care probably did not avail himself
of the examination. While on the other hand those who
accepted it were probably much more healthy and, there-
fore more health-minded than the average. I think it
has been a useful principle and has done much good
but I question whether its value is as great as the sta-
tistical claims for it would indicate. It has made us
aware pathology often exists long before the patient is
symptomatically conscious of it. When the health audit
reveals familiar pathological syndromes for which a cure
or treatment is known, it is decidedly beneficial. But
all too frequently the findings are too incomplete, con-
flicting, or inconclusive to be pathologically classified,
for they are not entirely pathological; but are in that
as yet unexplored twilight zone where functional and
structural changes intermingle.

From a biological viewpoint, functional changes from
the median must be conceived as preceding structural
deviations. Whether such disturbances originate as bio-
chemical, or in a more gross physiological way, is still
speculative. Speculative, however, only because of a
lack of definite evidence to support our thoughts. We
do not know exactly how or when persistent median
func.ional deviations will or do evolve into definite path-
ology. Our ability to visualize and classify impending
clinical trends has not kept pace with our diagnostic
art. We have pushed back the frontier of illness from
the gross to those more subtle asymptomatic and finally
to the hazy and as yet ill-defined meeting ground of
structure and function. We are still structurally not
functionally-minded. We are still more interested in
illness and are only now become health-conscious. Our
clinical methods of investigating disease (or health if
you wish) are still designed to disclose established path-
ology. They need more physiological refinement to
clarify the twilight zone where function and structure
meet.

I think this thought can be more clearly illustrated by
a study of vital statistic tables. As the mortality from
infectious, nutritional and other diseases has decreased
to lower ranks in the lists of the causes of death,
the so-called degenerative diseases have progressively
marched upward to higher and higher ranks. The entire
public health and preventive medical program, including
the periodic health examination have not contributed
very much to the prevention or control of these degen-
erative diseases.

It would seem that the etiological factors in vascular
disease, duodenal ulcer, gallbladder disease, renal stones
and a host of similar human health problems, must be
both intrinsic and extrinsic to the individual. The in-
herent weakness would seem to be hereditary, congeni-
tal and constitutional, the environmental related to cus-
toms, habits, and occupations. There would appear to
be, however, no sharp division between the intrinsic and
extrinsic, for I think it is quite clear that each may
influence the other. Their evaluation awaits better
physiological diagnostic technic, and better vision of
their implications in clinical physiology.

Certain approaches to this field of human biology
have already been made. Perhaps the work of Draper,
Kretchmer, and others on the constitutional relations of
man to disease is more significant than has been real-
ized. Perhaps we should heed Holmes’ advice on how
to live a long life. The investigations of Pearl indicate
that heredity is astonishingly significant in those per-
sons who live long lives and are free from premature
degenerative diseases and vice versa. He even goes so
far as to hint that given a good heredity background
for longevity, our bad habits will have a most insignifi-
cant effect on our chances of becoming an octogen-
arian. Possibly more intense medical interest in the
social, vocational and occupational influences on human
function would provide useful information about the
extrinsic causation of degenerative disease.

THE JOURNAL-LANCET

This potential field of medicine should have a peculiar
interest for the student health physician. The death
curve from degenerative diseases starts its upward rise
slightly before the age of 30. The age of college stu-
dents is only a few years less. Should there not be
some evidence at the college-age level which should in-
dicate future health trends? Could not intensive clinical
physiological study of college students be valuable in
establishing a clearer insight into the significance of
early median functional deviations? Is there any future
health meaning in a slight persistent or recurring albu-
minuria or glycosuria, sub-clinical elevations or depres-
sions of blood pressure, undue fatigue, vague gastric
ulcer-"like” syndromes, abnormalities of nutrition and
a host of other clinical pictures found in student health
records; clinical pictures never clearly classified, despite
an honest, earnest effort to do so? Should it not be
possible for this information to be used intelligently in
preparing a specific health program for a specific indi-
vidual with a specific heredity, a specific constitutional
mosaic, in a specific social, occupational situation for a

longer, more successful, more healthful life? For exam-
ple, if given a certain type of personality, a medical
career may exact a great deal more vitality than one
of law or commerce and finance, and jeopardize either
health or success or both. It is not enough for us to
await the advent of actual pathology before giving ad-
vice for the prolongation of life. This problem should
be attacked when still functional. In order that the stu-
dent health physician can intelligently and accurately
direct his efforts toward the study of degenerative proc-
esses in their early median norm deviations, it is not
enough that he be a specialist in clinical physiology and
medicine of the college years. He must broaden his
clinical and biological knowledge to include a keen
appreciation of the clinical pathological picture of de-
generative disease as it occurs at the older ages.

In other words, the future in health practice and
teaching must include a program for specific planning
of health and hygiene habits for specific personalities
with specific problems in a specific environment of life.

BOOK NOTICES

FROM THE COMMONWEALTH FUND
Rural Health Practice, by HARRY S. MUSTARD, M D.: 1st
edition, heavy red cloth, gold-stamped. 578 pages plus index,
31 tables. 28 figures: New York City: The Commonwealth

Fund: 1936. Price #4.00.

In this book, rural health matters are discussed under the
topics: vital statistics, school health service, maternity and child
hygiene, communicable diseases, syphilis, tuberculosis and rural
sanitation. The author advocates organization of county health
units under state health departments as the ideal approach to
all these problems. Cooperation between these groups and
local practitioners or health units is strongly recommended.
However, no definite integration of the family physicians in
such a program is outlined.

Though embracing many admirable features, this volume
depicts the socio-economic views championed by the Common
wealth Fund and the foundations, all of which are inimical to
organized medicine. It should be borne in mind that such
recent movements as the county health unit, first organized in
1908 or 1911, are not accredited with adding 12 years to human
longevity during the past quarter century. Nor is such a recent
trend responsible for making the United States the most health-
ful of all civilized countries. These accomplishments are
properly attributed to our present system of medical practice.
Should state and county health departments threaten the life
of a profession which has stood the test of centuries and con-
tributed more to human life and happiness than any other?
This is the dominant challenge of this book.

EDUCATION IN AMERICA

The Higher Learning in America, by ROBERT MAYNARD
HUTCHINS, Ph. D.; second edition, 119 pages, no illustra-
tions, no index, three-quarter boards, library labels: New Haven,
Connecticut: The Yale University Press: 1936. Price, #2.00.

This book comprises the 1936 Storrs Lectures of Yale
University, given this year by the president of the University
of Chicago. It is the first truly penetrating analysis of present-
day education in America that has appeared; and to say that
it is admirable is to understate its excellence.

President Hutchins leaves no stone unturned in his search
for the ultimate objective of the higher learning; neither does
he shrink from cracking heads when heads ought to be cracked.

Professors are arraigned as unemotionally as are alumni — and
in late years, it has been exceedingly difficult to discover which
of the two groups is most detrimental to the true ideal of the
university.

The only criticism The Journal-Lancet has to offer is that
this little volume will not be read extensively enough. It is a
pity, for such agile but effective dissections of our educational
dilemma do not appear every week.

POPULAR EDITION OF CLENDENING

Health Chats, by LOGAN CLENDENING, M. D.; first editio.i
in book form, heavy green fabrikoid, gold-stamped, 3 90 pages,
no index, no bibliography, line cut illustrations; Philadelphia:
The David McKay Company: 1936. Price, #2.50.

This is the popular edition of Logan Clendening’s news-
paper articles which he has been writing for the King Features
Syndicate, and which are familiar to all physicians. The work
is new in the sense that these articles have been collected and
put in book-form; otherwise, they are not new.

It is impossible to present an encompassing review of this
volume, because Dr. Clendening has actually produced a medi-
cal potpourri. The reader may thrust his attention in at any
point, and pull out a spicy plum. Nearly every subject imagin-
able is mentioned; few, of course, are treated at any length.

The style is felicitous and the content is sound. The
Journal-Lancet is willing to recommend this volume.

FORGOTTEN MEN OF SCIENCE

Trail-Blazers of Science, by MARTIN GUMPERT, M. D.; first
American edition, cloth, 306 pages plus index; New York City:
Funk Sc Wagnalls Company: 1936. Price, #2.50.

This is not a new book, but it is new to America. The author
is a German scientist who is living in this country, and shortly
will become a naturalized citizen.

Herein the reader will find the story of Max Joseph
Pettenkofer, who swallowed cholera bacilli, yet lived. Herein,
too, is the tale of Robert Mayer, who evolved the law of the
conservation of energy. Jean LaMarck, held by some to be
the true founder of the revolutionary theory, is presented in this
volume. There is a section devoted to Harvey Cushing, fore-
most American brain surgeon.

The book recounts the experiences of world scientists who
for one cause or another (usually abysmal bigotry and ignor-
ance) were compelled to pursue their research under duress and
privation. It is in this respect a unique volume. While not
exhaustive, it is scientifically and historically accurate. The
Journal-Lancet is able to recommend this popular volume.

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

Dr. J. A. Myers
Dr. J. F. D. Cook,

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

EDITORIAL BOARD

Chairman,

Dr. A. W. Skelsey, Dr. E. G. Balsam -

BOARD OF EDITORS

Great Northern Railway Surgeons’ Assn.
American Student Health Association
Minneapolis Clinical Club

Board of Editors
Associate Editors

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

Dr. J. A. Evert
Dr. W. A. Fansler
Dr. W. E. Forsythe
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback

Dr. E. D. Hitchcock
Dr. S. M. Hohf
Dr. R. J . Jackson
Dr. A. Karsted
Dr. Martin Nordland
Dr. I. C. Ohlmacher
Dr. K. A. Phelps

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley
Dr. C. A. Stewart

Dr. J . L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M. D., 1859-1931 W. L. Klein. 1851.1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., February, 1937

SIXTY-SIX YEARS

It is with satisfaction that The Journal-Lancet calls
at ention in this anniversary number to the completion
of sixty-six years of medical journalism in Minnesota.
In the sixtieth anniversary number, dated February 1,
1931, Dr. Vyiiham Davis, of St. Paul, who was for many
years associated with Dr. Alex J. Stone in the editorial
management of 7 he Northwestern Lancet, outlined
briefly the connection between the present Journal-
Lancet and the first medical journal in this state. The
facts herewith cited are from Dr. Davis’ account.

Dr. Alex J. Stone in 1870 published the first number
of the monthly journal of twenty-four pages, called
The Northwestern Medical and Surgical Journal. Thar
Minnesota could arrogate to itself the title "Northwest-
tern” seems odd to us now, when we contemplate the great
states and populations in the thousands of miles of em-
pire lying to the north and west of the Twin Cities. At
that time, however, the only other state in the region
was Oregon, which had been admitted to the Union in
1859, the year following the admission of Minnesota as
a state. It was not until 1889, i. e., nineteen years after
the event we celebrate, that North and South Dakota,
Montana and Washington were admitted as states of
the Union; and Idaho was admitted in 1890.

At the time, settlement was sparse, communications
difficult and slow, a railroad had only recently come
through from Chicago, and Minnesota had a population
of less than half-a-million people. Dr. Stone carried

on this primitive and struggling journal for two years,
when Dr. H. C. Hand of St. Paul and Dr. H. H.
Kimball, of Minneapolis, took it over and carried it for
two years longer, i. e., until June of 1874, when as Dr.
Davis said, "It died of inanition, starved by a lack of
subscribers and advertisements. Realizing how few
must have been its subscribers, and looking over the
scanty advertising, it is remarkable that it survived for
four years.”

The next medical journal to appear in Minnesota was
The Northwestern Lancet, the first number appearing
October 1, 1881. It appeared semi-monthly, was owned
and edited by Dr. Jay Owens, of St. Paul, who turned
over the editorship to Dr. C. B. Witherle, of St. Paul,
in November, 1884. Dr. Stone reappears in this his-
tory through his purchase of The Northwestern Lancet
in September of 1886. Later, as will be shown, The
Northwestern Lancet became The Journal-Lancet,
and it is through Dr. Stone that the complete succession
of The Northwestern Medical and Surgical Journal of
1870, through The Northwestern Lancet to The Jour-
nal-Lancet, becomes established.

Almost immediately after his acquisition, Dr. Stone
turned over the active work of editing the journal to the
associate editor, Dr. William Davis. This arrangement
continued through the year 1899. During 1900, Dr.
Howard Lankester, of St. Paul, acted as associate editor,
and in 1901 the thirty years of service of Dr. William
A. Jones, of Minneapolis, as editor, began. In 1912 the

THE JOURNAL-LANCET

title was changed from Northwestern Lancet to The
Journal-Lancet, in order that the name of the first, the
pioneer journal, might be included. The long and
notable service of Dr. Jones as editor has been memorial-
ized by Dr. Arthur S. Hamilton in The Journal-
Lancet of February 1, 1931; and this same number has
a remarkable portrait of Dr. Jones, who died on Jan-
uary 15th of that year. Dr. Hamilton brings out well
the character of the man; his clinical acumen, his
abounding friendliness and helpfulness, his easy diction
and ready wit, his forceful personality, his love of music
and of work. During the thirty years of his incum-
bency the editorials of Dr. Jones were eagerly sought
and widely read, although the journal served the in-
terests and special medical activities of a limited geo-
graphical area.

With the death of Dr. Jones, the present board of
editors, with Dr. J. A. Myers as chairman and editor-
in-chief, has carried on with a determination to make
The Journal-Lancet more and more a force for good
medical journalism in the territory it serves. A notable
departure has been the issuance of special numbers on
timely and well-chosen topics designed to bring before
the practitioner in medicine the latest knowledge in the
field by able exponents. The titles of these special num-
bers need not be enumerated. The idea has been well
received and widely acclaimed, and the publication of
these special timely numbers will be continued.

If The Journal-Lancet were a woman, it would
by now be trying to hide its age. Being what it is, its
pride grows with each anniversary, and its editor-in-
chief and board of editors resolve anew that each year
shall see a more and more effective service to its con-
stituency.

S. M. W.

ANNUAL REVIEW OF LITERATURE

In this issue, The Journal-Lancet presents for the
first time in us history an annual review of the past
year’s medical literature in most of the chief fields of
medicine. There is a review of general medicine, of
obstetrics and gynecology, of surgery, of proctology, of
the car, nose, throat, and bronchoscopy, of ophthamol-
ogy, and of pediatrics.

This is the first time such a review has been con-
sidered by The Journal-Lancet, or, for that matter,
by any state medical journal within the knowledge of the
editors. But the idea is sound, and the value of these
reviews cannot be underestimated.

They do not, of course, seek to displace in any manner
the customary medical article published in the journals
of the country. It is felt that by offering to the readers
of The Journal-Lancet an opportunity to learn of
the many important advances made in medicine during
1936, these reviews serve a definite purpose which more
than justifies the time and labor expended in their
preparation.

Neither are these reviews exhaustive in scope. With
so limited space available, it is folly to assume that all
the advances made during one year’s time, and reported
in hundreds of journals, can be compressed within the
covers of a single issue of The Journal-Lancet. How-
ever, since the fields covered by these reviews have been
evaluated so circumspectly by the reviewers, it is be-
lieved that the most salient articles have been included,
even though it may have been necessary to slight many
minor and relatively unimportant articles in each field.

Many readers will agree with the editors that these
reviews are almost unique in the periphery of the state
medical journal, and that the practice of presenting
them is a valuable service to the physician.

J. A. M.

DO WHAT YOU CAN

Physicians, wherever they are or whither they go, are
frequently embarrassed by the lack of some instrument
or equipment that would appear indispensable in a given
emergency.

When our forces entered the World War, there was
naturally much confusion in the beginning due to haste.
In From a Surgeon’s Journal are related some of the
vexing problems that confronted medical staffs when
they arrived at their assignments before the necessary
working supplies.

At a conference in Paris, Harvey Cushing suggested a
motto "Do what you can, with what you’ve got, right
where you are.” Why isn’t that a good rule to live by
at all times? It’s an actual and practical religion. Con-
scientious devotion to the principles of our profession
cadis for that very thing under all circumstances. Pres-
ence at an accident where first aid kit and other tools
are lacking, is no excuse for helpless inactivity. Here
is a test in the application of empty-handed ingenuity
to the saving of a life. Pioneer resourcefulness even
before the patient can be moved may determine the out-
come. It is nice to have rubber gloves, X-ray and lab-
oratory reports, but whether or not, we are still fulfill-
ing our duty when we do what we can, where we are
with what we hare.

A. E. H.

OSCAR E. LOCKEN, M. D.

With the death of Dr. Oscar E. Locken of Crooksto
the family, associates, community, and the medical pr
fession have sustained a loss that cannot be fully re-
placed.

To his family as husband and father he was what
every family man should desire to be. In his practice
he was not only a student of medicine, but possessed
those rare characteristics which combine to make him a
valuable man not only to his patients but especially to
his associates with whom he worked. In addition to his
devotion to his family, associates and patients, he found
time to render invaluable service to the affairs of his

THE JOURNAL-LANCET

community. During his six years as mayor of Crooks-
ton, he was an active mayor and instituted changes of
permanent value to the city. He served for three years
as city health officer and during this time sacrificed
much time and energy in improving the health conditions
of his home city.

Nor were his energies and sacrifices confined to his
own immediate community. He was rapidly becoming
one of the most valuable medical men so far as health
and the practice of medicine was concerned.

He served as vice president of the Minnesota Public
Health Association for several years. During this time
his ability as a public speaker and his ingenuity in
handling practical problems in the relation of the medical
profession to the public were well demonstrated. Per-
haps no medical man in the state possessed so rare
judgment in convincing the public that their medical
problems and those of the medical profession were
synonymous. His speech before the assembled county
commissioners stressing the patient-physician relation-
ship, marked him as a most valuable liaison official for
the promotion of this idea. This speech was used
throughout the state for the instruction of county com-
missioners and others who had charge of federal or
state medical aid.

He was a member of the state planning board com-
mittee on social economics and a member of the board
of certification of public health nurses. Last year a new
office was created in the State Medical Society. This
new office was speaker of the house of delegates. On
account of his sense of justice, fairness, general know-
ledge of medical matters, good judgment, ability to
make decisions quickly, and express his ideas without
hesitation, he was unanimously chosen as the first man
to hold this office.

His success in filling this newly created office during
the past year, not only gave the association the assurance
that it should be continued, but that he should be the
occupant of this office so long as he wished to retain it.

Dr. Locken was 45 years old. He died Monday,
January 18th after an illness of ten days with pneu-
monia. He was a member of the North West Clinic
of Crookston, of which he was one of the founders in
1920. He leaves a wife, one son, two daughters.
Funeral held at Crookston, January 21, 1937.

SOCIETIES

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of November 11, 1936

The Minnesota Academy of Medicine held its regular
monthly meeting at the Town & Country Club on Wednesday
evening, November 11, 1936. The meeting was called to order
by the President, Dr. Thomas S. Roberts. There were 47
members and 1 guest present.

Minutes of the October meeting were read and approved.

Upon ballot the following men were elected as candidates
for Active Membership in the Academy:

Dr. E. A. Regnier Minneapolis

Dr. Justus Ohage St. Paul

D.'. Gordon A. Kamman St. Paul

Dr. Carl B. Drake read the following Memorial to Dr. H T.
Nippert and a motion was passed that it be spread upon the
records of the Academy and a copy sent to the family.

Dr. HENRY THEODORE NIPPERT, known to his more
intimate friends as Nip, was born in Heilbron, Wurtemberg,
Germany, on February 12, 1868, the son of Reverend Dr. Lou s
Nippert and Adelaid Lindemann Nippert. His father was an
American citizen and was sent to Germany by the Methodist
Church to promote Methodism in Germany and Switzerland.
Htnry Nippert received his early education at Frankfurt-on-
Ma n, graduating from the gymnasium at the age of seventeen,
which accounts for his somewhat German accent and his fre-
quently having been taken for a German. On the family’s
return to America in 1886, he came to Minneapolis w’here his
brother, the late Dr. Louis Nippert, had already begun prac-
tice and obtained a job as a drugstore clerk which position he
held for a year and a half. He then moved to Cincinnati and
a^ter two years of study obtained the degree of Ph. G. from
the Cincinnati College of Pharmacy. Soon thereafter he began
the study of Medicine at the Miami Medical College, a depart-
ment o^ the University of Cincinnati, where he was graduated
in 1891. He took his internship at the Cincinnati General
Hospital.

On August 2, 1893, Henry Nippert was married to Bertha
Elizabeth Wendt, of Newport, Kentucky, and began practice
in St. Paul. That same year he joined the Ramsey Countv
Medical Society and was president of the Society in 1916. For
twenty-five years he had a medical service at the Ancker Hos-
pital and gave clinics to students of the Hamline and Univer-
sity Medical Schools, resigning from the staff in 1919 in favor
of younoer members of the profession. Henry Nippert joined
the Minnesota Academy of Medicine in 1916 and read his
thes s "Empyema in Infancy and Childhood” on May 10,
1916, the paper having been published in the St. Paul Medica'
Journal the same year (Vol. 18, p. 270, 1916).

Henry Nippert died on July 4th, 1936, while taking a swim
at his summer home on Big Sand Lake. He is survived by his
widow; three daughters. Mrs. Vernon D. E. Smith and Mrs
John B. McGrath of St. Paul, and M’-s. Arnulf Ueland of
Minn^anolis. a son, Carl L. Nippert, of St. Paul; two brothers.
Dr. Edward Nippert of Los Angeles and Judge Alfred K.
N onert, of Cincinnati; three sisters. Mrs. Loirs Hemlings of
Seattle, and the Misses Eleanor and Mary Nippert of Cin-
cinnati.

Henry Nippert had a very high degree of personal integrity.
He was exceedingly frank with his patients where the limita-
tions of therapy were obvious and in every way was a very
practical man. H s patients, who, particularly in his early
vears of practice were largely among the German element of
St. Paul, trusted hun and regarded him as a friend because of
the real sympathy he showed them.

One of his outstanding qualities was h's keen sense of humor.
He loved a practical ioke and could always see the humorous
side of a situation. He was a convivial soul.

He loved the country and enjoyed to the utmost the summer
months sDent at his cabin on Big Sand Lake in northern Min-
nesota with his family.

Although he never contributed a great deal to medical
societies, he was a regular attendant and made staunch friends
among his colleagues. He was tolerant of those who held
oninions differing from his own and was most considerate of
those younger and less experienced in the practice of medicine.

His philosophy towards life, his devotion to his country,
friends and profession are well portrayed in the account of his
life written by himself some time before his death, which was
read at his funeral and published in the August number of the
State Journal.

The Minnesota Academy of Medicine has lost one of its

THE JOURNAL-LANCET

best loved members. The society’s sincere sympathy is ex-
tended to his bereaved family.

(Signed) The Committee:

Frank E. Burch,

Wm. Davis,

Carl B. Drake, Chairman.

The scientific program followed.

ASEPTIC URETERO-SIGMOIDOSTOMY

A New Method Providing Definite Asepsis in Respect to Both
Fecal and Urinous Soiling
by

Frederic E. B. Foley,

ST. PAUL, MINNESOTA

Synopsis

There is no general agreement concerning the importance of
fecal soiling in operations for anastomosis of ureter with bowel.
It is certain this factor is of some consequence and may on
occasions determine a fatal outcome.

Avoidance of fecal soiling may be of importance in one or
both of two ways. First of these is prevention of infection of
the peritoneum and the risk of peritonitis incident to it.
Second, and perhaps of greater importance as an object of
asepsis, is prevention of infection of tissues at the site of anas-
tomosis and impairment of repair processes incident to it. In
the repair process of union between the ureter and the layers
of bowel wall, primary union with absence of inflammatory in-
filtration and cicatrization resulting from infection should be
considered desirable for production of a functioning one-way
valve and avoidance of urinary obstruction by contraction of the
stoma.

Most writers have appeared to think of "aseptic anastomosis"
in terms only of avoiding contamination by bowel content and
have appeared to regard soiling by urine content as of no im-
portance. There is no assurance that soiling by infected urine
does not have importance similar to that of fecal soiling and in
these same ways.

Coffey’s description of his "Technic No. 3” refers to it as
an aseptic method. Quite obviously neither this method nor
Higgins’ extension of it is aseptic. In both methods a "trans-
fixion suture" embracing ureter and bowel walls is tied tightlv
and establishes a fistulous communication by sloughing through
both walls. In placing this suture it passes into and out of
both ureter and bowel lumina and contaminates the site of
union with both ureter and bowel contents.

The method of Poth more closely approximates definite
asepsis but does not give positive protection in this direction.
Description and illustration of the method as employed in ex-
perimental animals shows it to be entirely too troublesome and
cumbersome for clinical use.

The method described here and illustrated by lantern slides is
definitely aseptic in respect of both fecal and urinous soiling.
It involves use of a newly devised and very simple snare or
guillotine instrument within the bowel lumen. With the bowel
submucosa exposed by longitudinal incision of the muscularis
the limited end of ureter, pushing a small invaginated tent of
bowel submucosa before it, is inserted into the snare. The two
structures are held in the grip of the snare while the ureter is
imbedded in the bowel wall by suture and the abdomen closed,
all of which is accomplished without even a suture needle pene-
trating the lumen of either bowel or ureter. After an interval
of time allowed for the tissue spaces at the site of transplant
to become sealed off, a cutting current is supplied to the in-
strument as the snare amputates within the bowel lumen the
ligated ureter end and invaginated tent of bowel submucosa
covering it, thus establishing the uretero-intestinal communica-
tion.

The instrument and method have been employed in one case
reported in summary as follows:

Ancker Hospital No. A 450 096. The patient was a female,
aged 62. There was extensive carcinoma of urethra with in-
vasion of vesical neck and trigone. Complete retention of urine
was present; and there was diminished phthalein excretion, also
nitrogen retention. Excretory urography showed normal pelves

and ureters. The urethra was dilated and constant drainage
with an indwelling catheter improved the renal function and
general condition. Irradiation with radium element gave no
favorable effect.

Bilateral transplantation of the ureters with a view to total
cystectomy was determined upon.

On Dec. 3, 1935, the right ureter was transplanted by the
method described. The procedure was executed with perfect
facility. The submucosal tent and ureter end were amputated
four hours later. Urine came from the bowel on the third
day. General condition was excellent on the eleventh day.
Temperature elevation and signs of bronchopneumonia were
evident on the twelfth day. The patient died of broncho-
pneumonia on the fifteenth day.

Postmortem examination showed excellent healing and union
at the site of transplant, no peritoneal exudate or infiltration
and no dilatation of the ureter or kidney pelvis.

Discussion

Dr. Arnold Schwyzer (St. Paul) : This method looks

quite typical of Dr. Foley — it is neat in conception. Neverthe-
less the other methods are less complicated and gave me good
results. I wonder whether with this instrument we would not
get a stricture through the cauterization of the end of the
ureter. I think for those of us who have operated much on
the large intestine, a fine thread running through the mucosa
of the gut would not mean very great danger of spreading in-
fection, especially as long as there is drainage along the thread
right into the gut. In order to avoid a stricture at the ureteral
opening I have cut the ureter on a slant. The side with the
tip was placed toward the lumen of the gut. In this way it
somewhat protects the opening (for the first days). Again I
wonder whether it would not be possible to have any mis-
hap with this method. The patient might move around while
the instrument is in place. Another question comes up: whether
the end of the ureter protrudes far enough into the gut to in-
sure against a certain amount of retraction which will follow.
Notwithstanding these uncertainties, which practical experience
has to decide, the procedure has neat asepsis to its credit.

Dr. Foley (in closing) : By way of reply to Dr. Schwyzer’s
criticism of the method I want to say that it is not cumbersome.
By comparison with the usual method of transplanting the
ureter to bowel, this instrument and method actually facilitate
the procedure. Having the ligated end of ureter held trans-
fixed to the bowel wall in the grip of the instrument is consider-
ably more convenient than inserting it through a stab opening
in the submucosa and then placing the fixation sutures without
the ureter held in place.

Dr. Schwyzer refers to the results of uretero-sigmoidostomy
by usual methods as perfectly satisfactory. This opinion is not
generally shared. The immediate operative mortality is out of
proportion to the magnitude of the procedure. Most reports
are based on cases in which operation has been performed ac-
cording to a uniform technic planned to establish a functioning
one-way valve. In spite of a uniform method being employed
in the cases of a series, the results among the cases are not
uniformly good. There is considerable evidence to show that
the eventual end result depends on whether or not a good
functioning one-way valve has been produced by operation. In
the presence of satisfactory valve function the ureter and pelvis
do not dilate, the kidney does not become infected and functions
normally; in the absence of valve function or in the presence
of cicatrization or obstruction at this site the ureter and pelvis
dilate, the kidney becomes infected and finally functionless It
seems to me not unlikely that infection of tissues at the site of
transplant is an important factor in determining whether or not
a functioning valve will result. With cicatrization and scarring
the result of infection, I would expect either a poorly-functioning
valve or obstruction. An aseptic method may diminish the in-
cidence of peritonitis; but its real value, if any, appears to me
to lie in avoiding infection of the site of transplant, and in-
flammatory thickening of the valve-forming tissues incident to
this infection. Such changes occurring with non-aseptic methods
appear to be probably responsible for the poor results.

THE JOURNAL-LANCET

I have offered the method at this time and without sub-
stantial clinical experience to endorse it, because I do not have
opportunity for animal experimentation and only a very small
clinical material, and in the hope that others with better oppor-
tunity than mine in these directions will undertake to determine
what the value and uses of the method may be.

EXTENSIVE THROMBOPHLEBITIS COMPLICAT-
ING MASTOIDITIS

Drs. Martin Nordland and Walter E. Camp

MINNEAPOLIS

Lantern slides were shown to demonstrate the anatomy and
the operative procedures involved. (Paper to be published in
full later.)

Summary

During the past year the authors had the privilege of seeing
two cases of extensive thrombophlebitis of the cranial venous
sinuses and internal jugular vein, complicating acute mastoidi-
tis. One of these cases died and the other recovered. The
cases are reported in detail because of the interesting problems
in diagnosis and pathogenesis.

Sinus thrombophlebitis is one of the most common compli-
cations of mastoiditis. The incidence of this complication in
both acute and chronic mastoiditis, as reported in several large
series of rases in the literature, is about 3.5 per cent. The
thrombos s may be manifest, latent or develop postoperatively.
Both of our cases were of the manifest type, i. e., present at the
time of operation. In one case there was definite evidence of
thrombosis at the time of operation. In the other, the diag-
nosis was suspected because of the clinical findings and X-ray
studies, but was not confirmed until operation. In one of the
cases the thrombosis was of the retrograde type extending
against the blood current; in the other it extended with the
blood current into the internal jugular vein down as far as the
subclavian vein.

The first case was that of a man 44 years of age, who came
for examination December 9, 1935, complaining of a sore
throat and earache in the right ear. His illness had begun
three days previous, with sudden onset of fever, vomiting and
diarrhea, sore throat and earache. Examination showed an
acute bilateral follicular tonsillitis with exudate on both tonsils.
The right ear drum was congested, edematous and showed a
spontaneous rupture with serosanguinous exudate. There was
tenderness over the mastoid and tenderness over the glands of
the neck on each side. Temperature was 101.5°. Three days
later he developed severe chills which lasted for four days.
Following the chills he developed pain in the chest and right
hip. He was placed in a hospital where he was treated by his
family physician, until January 10, 1936 (about one month
following the onset of his illness), when he was again seen.

During his stay in the hospital he had had continuous head-
ache for two weeks, having a typical septic temperature the
first week ranging from normal in the morning to 102° to 103°
in the late afternoon. Chills were frequent but not daily. Ex-
amination at this time showed a purulent exudate from the
right ear, the drum was thickened, but not bulging. There
was no mastoid tenderness, but there was tenderness over both
jugulars. The patient stated that there had been some swelling
in the right neck which had now receded. There was pain in
the right hip, but no swelling. Ophthalmoscopic examination
showed bilateral papilledema of about three diopters with small
petechial hemorrhages in both retinae. White blood count was
20,000 with 86 per cent neutrophiles. X-ray of the mastoids
showed dense bilateral sclerosis of all cells and was of little help
in diagnosis. Blood culture after six days was negative. Spinal
puncture showed a marked increase in intracranial pressure.
The fluid was not clear, with 43 cells per cu. mm. Tobey-
Ayers test was positive on the right, showing occlusion of the
right lateral sinus or jugular vein.

A diagnosis of subacute mastoiditis, right ear, with sinus
thrombophlebitis, septicemia, and probable brain abscess was
made, and on January 12, 1936, the internal jugular was ex-
posed and ligated and the right mastoid was explored. The

cortex and mastoid cells were sclerotic, the mastoid antrum was
small and filled with pus and granulations. A small perisinus
abscess was found on the lateral sinus near the bulb. Aspira-
tion of the sinus with a large needle showed no blood in the
sinus. The lateral sinus was widely exposed and opened. A
large clot extending down to the bulb and upward and back-
ward beyond the knee was removed. Free bleeding was ob-
tained from above, but not from below.

Following the operation there was definite improvement for
about one week. The fever remained normal except on two
occasions when there was a rise to 100°, but no chills. Severe
pain in the head returned and he became listless at times. On
one occasion he complained of temporary diplopia. The papil-
ledema showed no improvement and neurological examination
showed absence of left abdominal reflex and slight ptosis of the
left eyelid. A tentative diagnosis of brain abscess, right temporo-
sphenoidal lobe was made and exploration advised. On January
28th trephine and exploration of the right temporosphenoida!
area failed to reveal any abscess. The patient failed rapidly and
died about six hours following the operation. The autopsy-
findings were essentially negative except for a large thrombus
filling completely the right lateral and sigmoid sinuses.

The interesting features in this case are:

First, — The early onset of the clinical signs of sepsis sug-
gesting an early bacteremia and probably also an early throm-
bophlebitis of the right sigmoid sinus. The "head” or oldest
segment of the thrombus was found in the jugular bulb. Pri-
mary thrombophlebitis of the jugular bulb is rare and probably
occurs directly by extension of infection through the floor of
the middle ear cavity.

Second,- — The retrograde extension of the thrombophlebitis
against the blood stream after thrombectomy and ligation of the
internal jugular vein.

Third, — The early and persistent increase of intracranial
pressure with marked papilledema and clinical signs suggesting
brain abscess.

The second case was that of a woman 46 years of age who
was brought to the hospital in an ambulance on March 13,
1936. Her illness had begun one month before with a severe
"head cold” and a pain in her left ear which lasted about five
days. There was no history of discharge. The earache sub-
sided but she continued to complain of tenderness behind the
left ear and in the left temporal region. For three weeks pre-
vious to admission she had had daily chills and fever, headache,
nausea, and vomiting. There had been pain, tenderness and
conspicuous swelling of the left side of the neck for the past
ten days. Examination on March 16th, 1936, revealed tender-
ness and diffuse swelling of the left neck extending from the
mastoid to the clavicle. The left ear drum was normal. X-ray
of both mastoids showed second degree involvement of the left
mastoid. Ophthalmoscopic examination showed bilateral papi!
ledema of about four diopters with a few small retinal hemor-
rhages. Urinalysis showed a large quantity of sugar and ace-
tone, with some diacetic acid. Blood sugar was 236 mgms.
Blood culture was negative after 48 hours’ growth. Spinal
fluid was essentially negative except for markedly increased
pressure. Tobey-Ayer test positive. White blood cells 14,000.

A diagnosis of masked subacute mastoiditis, left ear, with
sinus thrombophlebitis was made, and operation advised.

On March 19th the left mastoid was opened. The cells were
necrotic and filled with purulent exudate and granulations.
Lateral sinus was exposed and found filled with a large throm-
bus extending from the torcula to the bulb of the jugular. A
transverse incision down through the superficial layer of the
deep cervical fascia revealed a large abscess of the neck with
complete necrosis of the left jugular vein. Drainage was es-
tablished and a slow but steady improvement occurred. The
urine became sugar-free and blood sugar returned to normal
one week following the operation. The papilledema gradually
subsided and on April 17th, 1936, the corrected vision was
20/20 when the patient seemed fully recovered.

The interesting features of this case are:

THE JOURNAL-LANCET

First, — The development of an advanced mastoiditis without
perforation of the tympanic membrane. There was tenderness
over the mastoid, but no external swelling.

Second, — The massive thrombophlebitis beginning in the
lateral sinus and extending with the blood stream to involve the
entire jugular vein.

Third, — Complete recovery without complication.

Discussion

Dr. C. N. Spratt (Minneapolis): In my experience lateral
sinus thrombosis has not been a serious complication in mas-
toiditis. In the thirty years in which I did ear work, twenty-
one cases of sinus involvement or approximately 7 per cent of
the mastoids operated on had this complication. There were
four deaths in this series. Two of these were associated with
meningitis and the other two were uncomplicated. This gives
a death rate in the latter, of approximately 10 per cent. In both
of these fatal cases the condition had been unrecognized and
was of long duration and the jugular veins in each case were
completely occluded. Of the twenty-one cases, the jugular vein
was ligated in fifteen. There are certain errors of diagnosis if
one relies upon the blood culture, as it is well known that cases
of pneumonia, typhoid, endocarditis, etc., may give positive
cultures where there is no lateral sinus thrombosis; and, on the
other hand, many cases of lateral sinus thrombosis give negative
blood cultures, as the thrombus may be a mural one and sterile.

Dr A E. Smith, (Minneapolis): There was considerable
sclerosis of the mastoid cells in the first case. Was there a
h-story of ear trouble there?

Dr. Camp: No, there was no history of previous abscess.

Dr. A. R Colvin (St. Paul): We have at the Ancker

Hospital at present a man whom I saw twenty-seven years ago
with a condition due to sigmoid sinus thrombosis, which seems
worth reporting as a discussion to Drs. Camp and Nordland’s
paper When first seen by me, he was unconscious, with evi-
dences of pyemia, i. e . suppurating knee and shoulder joints,
abscess of his chest wall. He had a malodorous discharge from
his right ear and although tender over the mastoid process there
was neither swelling nor redness of this region; there was ten-
derness along the course of the internal jugular vein. On open-
ing the vein pus escaped and it was found that the pus was in
a sertion of the vein walled off by cndophlebitis at about the
middle of its course On opening the mastoid, pus escaped;
and on opening the sinus pus also escaped. The knee and
shoulder joints were drained of pus, as was the abscess in the
chest wall The patient recovered and is now in the hospital
for other ailments.

The question of papilledema from venous obstruction due to
sinus thrombosis was demonstrated in the case of a young
woman who was suffering from severe headache and blindness,
these dating back to a febrile illness of a year previously. She
was operated upon by a colleague under the supposition that she
had a brain tumor At the operation, the bleeding from the
bone was so profuse that death ensued. Autopsy revealed
obliteration of all of the major dural sinuses, with here and
there small pockets in the sinus at the entrance of the diploic
veins. The thrombosis in this instance was due to infection
not going on to suppuration; the blindness was evidently due
to the long-continued venous obstruction.

The third case was a child of three years who was suffering
from bilateral mastoid suppuration — neglected. The left mas-
toid cells were drained of pus and his condition improved.
Shortly, however, it was necessary to drain the opposite mastoid.
After this, however, his symptoms not improving, a diagnosis
of sigmoid sinus phlebitis was made and of the right — last side
operated. On opening this sinus, however, thrombosis was not
found and it was necessary to pack it. Later he became sud-
denly unconscious and blind and finally a red streak appeared
over the course of the internal jugular vein on the side of the
first operation. The boy’s condition was desperate but it was
concluded that he had sinus and jugular vein thrombosis. On
exposing the vein it was found to be adherent to its sheath,
thus indicating at least a phlebitis. However, even if it were
(because of the soft nature of the thrombus) impossible to say
positively that the vein contained a thrombus, still all the other

indications pointed to this and on opening the vein a clot ex-
tending from above and dichotomously extending into the sub-
clavian vein was removed. Because of the child’s precarious
condition at this time the sinus was not explored through the
old operative wound. However, the boy recovered. All the
facial veins became dilated. This was twenty-six years ago and
he is still living.

I report these cases as demonstrating the variable kinds and
results of sinus thrombosis.

The meeting adjourned.

R. T. LaVake, M. D.

Secretary.

NEWS ITEMS

Dr. James L. McCarthy, of Butte, Montana, died of
a heart attack at his home in Butte on December 20,
1936. He was buried in Holy Cross cemetery in Butte
on December 24.

Dr. F. E. Boyd, of Armour, South Dakota, has as-
sociated himself in practice with Dr. W. A. Delaney,
of Mitchell, S. D.

Mitchell, South Dakota, has a new Medical Arts
Building, at present housing 8 physicians and 4 dentists.

Dr. W. H. Gilsdorf, of New England, North Dakota,
has enrolled in the special ophthalmology short course
offered by the Minneapolis General Hospital. Dr. S. B.
Seitz, of Minneapolis, will conduct Dr. Gilsdorf’s prac-
tice in the interim.

Dr. Phillip Graham Reedy, 54, former major in the
United States Army Medical Corps, and first white
child born at Fort Totten, North Dakota, died on
December 19 at Fargo, North Dakota. Death was
accidental.

Dr. E. A. Hofer has purchased the practice and equip-
ment of Dr. H. E. Jenkinson, of Wessington Springs,
South Dakota, who recently retired because of ill health.

Dr. Edward Otis Church, 64, a graduate of the
University of Illinois College of Medicine, Class of
1900, and a native of South Dakota since 1884, died at
Watertown, South Dakota, on December 3, 1936.

Dr. R. T. Rohwer, of Mitchell, South Dakota, who
has practiced internal medicine in that city for the past
7 years, has removed to Sioux City, Iowa, where he
will join Dr. R. J. Harrington.

Dr. Alvirdo W. Pearson, former University of Min-
nesota student, has accepted the position of resident
physician in the Merced General Hospital in Merced,
California.

Dr. Adolph M. Hanson, of Faribault, Minn., has
been named an associate in research of the Philadelphia
Institute for Medical Research. Dr. Hanson, who is
known for his research work with the thymus and pineal
glands, will continue to work and live in Faribault.

Officers and members of the Medical Association of
Montana convened at Billings, Montana, on December

THE JOURNAL-LANCET

13, 1936, to discuss plans for the state convention of
the Association to be held at Great Falls on July 12, 13,
and 14, 1937.

The South Dakota Public Health Association held its
annual meeting at Madison on January 24, in the
Dudley-Stewart Hotel. This was a continuation meet-
ing from October 20, 1936.

The Board of Regents of the South Dakota State
University has petitioned the State Legislature to pro-
vide sufficient appropriations to bring the state medical
school up to the standards laid down by the Council on
Medical Education and Hospitals of the American
Medical Association.

Dr. H. F. Hansen, of Vermillion, South Dakota, has
been elected president of the Yankton District Medical
Society of South Dakota.

Dr. Halvor Holte, 79, for many years a physician in
Crookston, Minnesota, died on January 2, 1937, in
Bethesda Hospital in Crookston.

Plans for a municipal hospital to cost about #47,0C0
and to have a 26-bed capacity, have been completed bv
Park River, North Dakota, officials in consonance with
the Federal Government.

Dr. J. C. Dunn, of Lewistown, Montana, has been
appointed county health officer for a term of one year
by the Fergus County commissioners. He has filled this
office for several years.

Dr. Carl G. Swendseen, of Minneapolis, has been
named chief of staff of the Swedish Hospital in Minne-
apolis succeeding Dr. Swan G. Wright.

Dr. Kenneth L. Bray, of Biwabkik, Minnesota, a
graduate of the University of Minnesota Medical School
in 1934, is now associated with Doctors Hanson and
Houston in Park Rapids, Minnesota.

Dr. L. F. Wasson, formerly of Battle Lake, Minne-
sota, has taken over the practice of the late Dr. A. O.
Flom, at Chisago City, Minnesota.

Dr. G. E. Hertel, of Austin, Minnesota, has been
elected president of the staff of St. Olaf’s Hospital in
Austin.

Dr. J. A. Roy, mayor of Red Lake Falls. Minnesota,
has been elected a member of the Board of Trustees of
the Minnesota Public Health Association.

Dr. Arthur M. Mulligan has inaugurated practice in
medicine and surgery in the Iron Exchange Building at
Brainerd, Minnesota.

Dr. George H. Olds, a graduate of the University of
Minnesota Medical School, has become associated with
Dr. B. J. Gallagher, of Waseca, Minnesota, in the First
National Bank Building.

Dr. V. A. Mokler, of Wentworth, South Dakota, is
the new president of the Third District Medical Society
in South Dakota. Dr. George E. Whitson, of Madison,
is vice president; Dr. Clarence E. Sherwood, of Madison,
is secretary-treasurer; Dr. H. A. Miller, of Brookings,

is state convention delegate; and Dr. Myron Tank, of
Brookings, is a new member of the board of censors.

Miss Carrie E. Haugen, 37, of Virginia, Minnesota,
is the newly-chosen superintendent of the Staples Muni-
cipal Hospital, Staples, Minnesota.

Dr. Charles N. Spratt addressed the King County
Medical Society at Seattle, Washington on January
18th. During his stay there, he showed his motion
pictures on Eye Operations before the Puget Sound
Academy of Ophthalmology.

The Extension Division of the University of Minne-
sota announces a lecture and demonstration course in
X-ray diagnosis to be given by Dr. Leo G. Rigler and
his associates at the University Hospital beginning
Thursday, February 11 from 6:20 to 8:00 P. M. and
continuing once each week for sixteen weeks. Anyone
interested should communicate with the Extension
Division, University of Minnesota.

Dr. B. S. Adams, of Hibbing, Minnesota has been
elected president of the Range Medical Society. Dr.
H. N. Sutherland, Ely, is the vice president; Dr. F. FL
McFarland, Chisholm, is secretary; and Dr. J. Arnold
Malmstrom and Dr. R. A. Salter, of Virginia, are
members of the board of censors.

Dr. Evarts A. Graham, professor of surgery in
Washington University School of Medicine at Saint
Louis, Missouri, will deliver the annual Judd lecture in
the chemistry auditorium of the University of Minne-
sota on "Accomplishments of Thoracic Surgery,” Wed-
nesday, Feb. 3. His address commences at 8:15 p. m.

Dr. R. M. Baker, of Sturgis, South Dakota, was
elected president of the Black Hills Medical Society on
December 17, 1936. Dr. P. P. Ewald, of Lead, was
chosen vice president; Dr. R. A. Jernstrom, Rapid City,
was elected secretary-treasurer; and Dr. Henry David-
son presented a paper, "Pneumonia.”

Dr. M. J. Flom, of Zumbrota, Minn., was elected
president of the Goodhue County Medical Society re-
cently. Dr. R. B. Graves, Red Wing, is vice president;
Dr. M. W. Smith, Red Wing, is delegate to the state
medical association meeting; Dr. E. H. Juers, Red Wing,
is secretary; and Doctors A. E. Johnson and A. W.
Jones, of Red Wing, and M. W. Williams, of Cannon
Falls, are members of the board of censors.

Dr. George Richards, Watertown, South Dakota, is
the new president of the Watertown District Medical
Society, succeeding Dr. M. C. Jorgenson. Dr. A. Einar
Johnson, of Watertown, was re-elected secretary-treas-
urer. Dr. O. S. Randall, Watertown, is vice president;
Dr. Jorgenson is delegate to the state medical conven-
tion, with Dr. G. B. Vaughn, Castlewood, as his alter-
nate. Doctors H. W. Sherwood, Doland; and A. H.
Christensen, Clark, are members of the board of censors.

Dr. J. A. Myers, Minneapolis, spoke on January 12
and 13, before the students and faculty of South Dakota
State College at Brookings. On January 12, Dr.
Myers also addressed the District Medical Society at

THE JOURNAL-LANCET

Brookings; and he also talked before the students of the
Indian school at Flandrau, South Dakota; and the
Brookings Rotary Club. On January 20, Dr. Myers
presented a paper before the joint session of the Phila-
delphia Medical Society and the Pennsylvania Tuber-
culosis Association, in Philadelphia.

A beautiful new infirmary unit, part of a 8300,000
Public Works Administration project, has been added
to the North Dakota State Tuberculosis Sanitorium at
San Haven, of Which Charles MacLachlan, M. D.,
is superintendent. The addition now brings the total
capacity of the sanitorium to 43 1 patients. Occupation
of the new unit must wait until the state legislature
provides funds for the equipping and maintenance of
the infirmary from the time of opening to the end of
the current biennium (June 30, 1937). The new build-
ing itself will house 126 patients; and there are about
200 on the waiting list.

Two more cases of illegal medical practice were con-
cluded in the last days of December, according to
Julian F. DuBois, M. D., of St. Paul, Minn., secretary
of the Minnesota State Board of Medical Examiners.
Hilda Andrews, 30, a South Dakota woman practicing
healing in Worthington, Minn., without a license, was
sentenced to 60 days in jail by Judge Charles A. Flinn,
of Worthington. Sentence was suspended after she
returned to her home in South Dakota. The sentenced
woman was using "The Brooking Methods of Ectylotic
Ablution”, the equipment coming from one "Doctor”
Brooking, of Sioux City, Iowa.

On December 21, Ethel Planque (alias Ethel Benson),
52, was sentenced by Judge Frank E. Reed, of Minne-
apolis, to from one to 15 years in the State Reformatory
for Women at Shakopee, Minn. She pleaded guilty on
December 19 to manslaughter after a 19 year old Min-
neapolis girl succumbed on December 4 to an abortion
performed by the guilty woman.

At the close of the last academic year, Dr. E. P.
Lyon, Dean of the Medical School, retired from active
service at the University of Minnesota. During his ad-
ministration, covering a period of twenty-three years,
the Medical School exhibited steady and continued
growth. As a fitting tribute to his stimulating leader-
ship, the alumni and faculty of the Medical School pro-
posed to establish in his honor the Elias Potter Lyon
Medical Lectureship in Medicine at the University, the
fund for this purpose to be raised through subscriptions
by alumni, faculty, students, and friends. The response
to this proposal has been enthusiastic and generous. Any-
one who welcomes the opportunity of contributing to
the Lyon Lectureship fund before the project is closed
may send his donation to the Office of the Comptroller
of the University of Minnesota.

Through the co-operation of Mr. C. A. Johnson,
county attorney of Blue Earth County, the Minnesota
State Board of Medical Examiners succeeded in banish-
ing one Henry Jeffrey, an Indian quack, from the state
for one year. Fined $100.00 and a suspended sentence of
90 days in jail by Judge L. H. Morse, of Mankato,
Jeffrey was warned absolutely to refrain from practicing

healing in Minnesota.

Julian F. DuBois, M.D., of St. Paul, Minn., secre-
tary of the Minnesota State Board of Medical Exam-
iners, advises The Journal-Lancet that the license of
Frederick H. Moss, M.D., of New Richland, Minn.,
has been revoked because of his alleged habitual addic-
tion to narcotics. Dr. Moss was graduated from the
University of Minnesota Medical School in 1927. Dr.
DuBois also reports that William M. Chowning, M.D.,
63, of Minneapolis, has forfeited his license to practice
medicine in Minnesota by order of the Board. Dr.
Chowning was convicted of abortion on April 24, 1936,
in the Hennepin County District Court.

MISCELLANEOUS

Grand Forks Adopts A Fracture Regulation

In an editorial published in The Journal-Lancet,
January 1st, 1936 the Chicago Ambulance and Fracture
Ordinance was printed. The editorial suggested that
this ordinance should be shown to city officials with the
hope that other cities might adopt a similar regulation
for the protection of citizens who may receive fractures.
Recently the Board of City Commissioners of Grand
Forks, North Dakota has approved and adopted the
following regulation:

PUBLIC HEALTH REGULATION NO. 525

The Board of Health judge it necessary for the public health
and safety of inhabitants to prevent further damage to an in-
jured person after an accident.

No person, firm or corporation shall operate or cause to be
operated any ambulance, public or private, or any other vehicle
commonly used for the transportation or conveyance of the sick
or injured, without having such vehicle equipped with a set of
simple first aid and splint appliances approved by the board of
health and having in attendance at all times such vehicle is in
use a person who has obtained a certificate of fitness as an am-
bulance attendant from the board of health.

Any person desiring a certificate as an ambulance attendant
shall make application in writing therefore to the board of
health. Before the issuance of any such certificate the applicant
therefore must present evidence of his qualifications to fill such
position and must demonstrate to the satisfaction of the board
of health his ability to render emergency first aid and to apply
approved splints to arm and leg fractures.

This regulation shall take effect and be in force from and
after its approval by the Board of City Commissioners.

E. C. Haagenson, City Health Office.

Approved and Adopted Dec. 23, 1936,

Attest:

[SEAL]

CHAS. J. EV ANSON, City Auditor.

E. A. FLADLAND, President Board of City
Commissioners, Grand Forks, North Dakota.

(Jan. 12, 1937)

This regulation like the Chicago Ordinance does not
specify special splints which permit the application of
traction during transportation such as the Thomas-
Murray hinged ring splint for the arm or the Keller-
Blake hinged half-ring splint for the thigh or leg, but
the splints used must be of a type approved by the board
of health and the ambulance attendants must under-
stand their use. The board of health will undoubtedly
only approve modern methods and splints. This regu-
lation should be a protection to the citizens of Grand
Forks and a model for adoption by other cities.

Respiratory Allergy

The Incidence of Other Associated Manifestations
French K. Hansel, M. D., M. S.**

St. Louis, Mo.

AMONG the various manifestations of allergy,
those which concern the upper and lower res-
piratory tracts (perennial nasal allergy, hay
fever, asthma, and allergic bronchitis) are the most com-
monly encountered. Other common manifestations of
allergy, such as urticaria, eczema, angioneurotic edema,
gastrointestinal allergy and allergic headache are fre-
quently associated with the respiratory symptoms. (Ap-
proximately 70 per cent in the past and present history:
more than 50 per cent in the present history.)

One of the most important characteristics of the
allergic individual therefore is the tendency to exhibit
more than one manifestation of allergy. Certain mani-
festations of allergy, such as infantile colic, eczema, and
urticaria may appear in early infancy, to be followed
later by the nasal manifestations and asthma. Early
manifestations may disappear and at some time later in
life there may be a reappearance of the same or different
manifestations. The patient may acquire asthma and the
nasal manifestations of allergy in infancy and childhood,
and they may persist throughout life. In general, there
is a tendency for certain manifestations to shift from
one type to another. It is always the predominating
manifestation which characterizes the clinical picture and
for which the patient seeks relief. The patient who has
the nasal manifestations of allergy usually gives a his-
tory of having had other manifestations in the past
which disappeared or he has other manifestations accom-
panying the nasal symptoms. Occasionally the nasal
symptoms may become very mild when some other mani-
festation predominates the clinical picture.

^Prepared expressly for the special Allergy issue of THE
JOURNAL-LANCET. From the Department of Otolaryngology,
Washington University School of Medicine, Oscar Johnson In-
stitute, and McMillan Hospital.

** Assistant Professor of Clinical Otolaryngology, Washington
University.

In a group of cases of allergy in children reported by
Peshkin1, he found that other allergy was associated
with the principal manifestations as follows: 22 per cent
of the patients with asthma had eczema; 7 per cent
had urticaria; and 2 per cent had angioneurotic
edema. In children, eczema frequently begins in infancy
and usually precedes the onset of asthma by one to
seven years. In a group of 2,063 cases observed by
Rackemann and Colmes", other allergy was reported as
follows: with hay fever, 37 per cent, practically all of
which were asthma; with asthma, 28 per cent, most of
which were hay fever; with eczema in adults, 50 per
cent; with eczema in children, 16 per cent; with urti-
caria, 15 per cent. The average percentage of other
allergy in the entire group was 27 per cent. In children
with eczema and in urticaria at all ages, Rackemann1
noted that the incidence of other allergy was lower. In
100 cases of gastrointestinal food allergy reported by
Rowe, the incidence of other allergy was stated as fol-
lows: asthma, 13 per cent; hay fever, 20 per cent; skin
manifestations, 32 per cent; and migraine, 36 per cent.
In 83 cases of asthma caused by food allergy, reported
by Rowe4, other allergy occurred as follows: hay fever,
17 per cent; skin manifestations, 40 per cent; migraine,
36 per cent; and abdominal allergy, 20 per cent. In 86
cases of migraine reported by Rowe5 as due to food
allergy, the incidence of other manifestations was as fol-
lows: asthma, 12 per cent; hay fever, 17 per cent; skin
manifestations, 43 per cent, and abdominal allergy, 64
per cent. In a group of 205 patients of all ages reported
by Bray*’, there was a history of other allergy in 42 per
cent. Bray also reported that in 300 successive cases of
asthma in children, 36 per cent gave a past or present
history of eczema; 37 per cent of urticaria; 9 per cent
of prurigo; 7 per cent of migraine; 5 per cent of hay
fever; and 5 per cent of enuresis.

THE JOURNAL-LANCET

In 220 cases of nasal allergy in adults", we found the
incidence of other allergy as follows: gastrointestinal
allergy, 55 per cent; headache, 43.6 per cent; hay fever,
27.7 per cent; urticaria, 26.8 per cent; asthma, 25.5 per
cent; angioneurotic edema, 18.2 per cent; eczema, 12.3
per cent; and bronchitis, 10.9 per cent.

The occurrence of other allergy in the group of 220
patients with the nasal manifestations is shown in Tables
I and II. In only 36, or 16.4 per cent, of 220 cases was
there an absence of this history. The combined consid-
eration of the family history and the history of the
occurrence of other manifestations of allergy should in-
dicate the immediate possibility of the individual being
allergic in more than 90 per cent of the cases. The time
of the occurrence and the incidence of the various other
manifestations in relation to the nasal symptoms are
tabulated in Table II. In 55, or 25 per cent, of the cases,
one or more manifestations of other allergy occurred
during infancy and childhood. In four cases it occurred
early in life and did not reappear with the nasal symp-
toms. In 23 cases the patients had other allergy from
early life, both preceding and accompanying the nasal
manifestations. In many cases some types of allergy per-
sisted throughout. In other instances, there was a shift-
ing from one manifestation to another. In Table III
these 55 cases are tabulated as to age, incidence in
decades, and the age of onset of the nasal manifesta-
tions. Forty of the 55 patients were between the ages of
15 and 30 years, and in 32, or 58 per cent, the onset of
the nasal symptoms occurred in infancy and childhood.
In six, or 11 per cent, they appeared at puberty, and
in 17, or 31 per cent, the nasal symptoms appeared after
the age of puberty.

TABLE I

Occurrence of Other Manifestations of Allergy

(Adults)

Early in life only 4

Early, preceding, and accompanying nasal allergy 23

Early and accompanying nasal allergy 28

Preceding nasal allergy only 6

Preceding and accompanying nasal allergy 57

Accompanying nasal allergy only 66

No other allergy at any time 36

Total 220

TABLE III

Patients With Other Manifestations of Allergy
In Infancy and Early Childhood

Age of Patients Number

15-20 20

21-30 20

31-40 9

41-50 5

51-60 1

Age of Onset

0-2 9

2-10 23

10-15 6

16 or over 17

As shown in Table I, six patients had other manifesta-
tions which disappeared before the onset of the nasal
and in 57 cases other allergy both preceded and accom-
panied the nasal. In 118, or 53.6 per cent, of the cases,
therefore, other allergy preceded at various times the on-
set of the nasal. In 66 cases, or 30 per cent, other
allergy only accompanied the nasal manifestations, but
in 174, or 79.1 per cent, including that which had
already been present and still remained, other allergy
accompanied the nasal symptoms. As already mentioned,
there is a tendency to shifting from one manifestation to
another. Sometimes the nasal symptoms temporarily or
permanently disappear while other manifestations pre-
dominate the clinical picture. The incidence and time of
appearance of the various types of allergy in relation to
the onset of the nasal symptoms are tabulated in Table
II. In the past and present history, 484 different mani-
festations appeared in 220 cases, an average of 2.8 per
patient. In order of their incidence, the various mani-
festations appeared as follows: gastrointestinal, 121;
headache, 96; hay fever, 61; urticaria, 59; asthma, 56;
angioneurotic edema, 40; eczema, 27; and bronchitis, 24.
Of the total of 484 manifestations, 410, or slightly less
than two per patient, remained and accompanied the
nasal symptoms. Some patients showed as many as six
different manifestations at various times in the past and
present history. There is a tendency for certain types to

TABLE II

Incidence and Occurrence of Other Allergy — Past and Present (Adults)

G. I. Headache Hayfever Urt. Asthma Angio. Eczema Bron. Total

Early 7 0 0 10 5 0 10 7 34

Early, pre. & accom. 2001 10206

Early and accom. 15 201 3021 24

Preceding 27 1 12 6462 40

Pre. & accom. 11 18 10 13 4 . 2 3 2 63

Accompanying 89 69 50 22 37 34 4 12 317

Total 121 96 61 59~ 56 40 ~27 24 484

% incidence in 220 cases 55.0 43.6 27.7 26.8 25.5 18.2 12.3 10.9

Total accompanying _117 89 60 37 45 36 11 15 410

Total pre. which

disappeared 4 7 .1 22 11 4 16 9

THE JOURNAL-LANCET

be associated. The incidence of other manifestations of
allergy which accompanied the nasal symptoms was as
follows: gastrointestinal, 117; headache, 89; hay fever,
60; asthma, 45; urticaria, 37; angioneurotic edema, 36;
bronchitis, 15; and eczema, 11. Of the total of 484 mani-
festations, 410 remained and 74 disappeared. These
manifestations disappeared, respectively, as follows: urti-
caria, 22; eczema, 16; asthma, 11; bronchitis, 9; head-
ache, 7; gastrointestinal allergy, 4; angioneurotic edema,
4; and hay fever, 1.

In this group of 220 cases, 36 had no other allergy
at any time. Twenty-three of the patients were male and
13 were female. It is difficult to explain the absence of
other allergy in a larger percentage of the males. There
was no difference between these cases and those with
other allergy as to age incidence, or to the skin reactions.

In 200 cases of nasal allergy in children, the incidence
of other allergy was as follows: asthma, 69.5 per cent;
gastrointestinal allergy, 33.5 per cent; eczema, 32.5 per
cent; headache, 10 per cent; urticaria, 23 per cent; hay
fever, 22.5 per cent; angioneurotic edema, 6 per cent;
bronchitis, 4 per cent.

In our group of 200 children with the nasal mani-
festations of allergy, we found an incidence of other
allergy which was much higher than that reported by
other observers. The higher incidence of asthma may be
accounted for by the fact that it was considered as a
separate manifestation. Perhaps nasal allergy should be
considered as a pare of the asthma because in all chil-
dren with asthma the nasal manifestations always accom-
pany it. In only nine of 200 children, as shown in Table
IV, was there an absence of other allergy in the past or
present history. In this group the manifestations con-
sidered as early were those which appeared in infancy,
before the age of two years. In 85 of the 200 children,
the onset of other allergy occurred in infancy. In nine
instances other allergy which appeared in infancy dis-
appeared and did not recur. In 22 instances other allergy
appeared in infancy, persisted throughout and accom-
panied the nasal symptoms. In 53 instances other allergy
appeared in infancy, disappeared and recurred again
with the nasal symptoms. These were not always the
same manifestations; for example, the eczema in infancy
was often replaced by urticaria or some other manifesta-
tion. In ten instances other allergy preceded and accom-

panied the nasal manifestations. In 95 instances other
allergy only accompanied the nasal symptoms. There
were in all, therefore, a total of 85 instances of other
allergy in infancy; a total of 34 preceding the nasal
symptoms after infancy and 180 accompanying the nasal
manifestations. The incidence and the time of appear-
ance of the various other manifestations in relation to
the nasal symptoms are shown in Table V. In the past
and present history of 200 patients, the various mani-
festations appeared in 400 instances in the following
order: asthma, 139; gastrointestinal, 67; eczema, 63;
urticaria, 46; hay fever, 43; headache, 20; angioneurotic
edema, 12; and bronchitis, 8. Of the total of 400
manifestations, 80 disappeared and 320 remained in the
following order: asthma, 139; gastrointestinal, 45; hay
fever, 45; urticaria, 30; eczema, 29; headache, 19; angio-
neurotic edema, 10; and bronchitis, 3. In order of
their importance, various manifestations disappeared, as
follows: eczema, 34; gastrointestinal, 22; urticaria, 16;
bronchitis, 5; and headache, 2. There was no change
in the asthma and hay fever occurrence. While there
was a tendency for such manifestations as eczema, gas-
trointestinal symptoms, and urticaria to disappear, in
general, however, there was a tendency for these mani-
festations to be replaced by others. The gastrointestinal
diseases which occurred in early life were mostly of the
nature of infantile colic, while the disturbances which
accompanied the nasal symptoms were characterized by
pain, nausea, vomiting, gas, and diarrhea. Of all the
manifestations, eczema is the most frequent to subside,
but it is often replaced by other manifestations.

TABLE IV

Occurrence of Other Manifestations of Allergy
Past and Present (Children)

Early only 9

Early and preceding only 1

Early, preceding and accompanying 22

Early and accompanying 53

Preceding only 1

Preceding and accompanying 10

Accompanying only 95

No other allergy at any time 9

Total , 200

TABLE V

Incidence and Occurrence of Other Manifestations of Allergy Past and Present — (Children)

Asthma

G. I.

Eczema

Urt.

Hay Fever

Headache

Angio.

Bron.

Total

Early

Early, preceding & accom

. 0

Early and accompanying

Preceding

Preceding & accom

. 0

Accom panJy in g ,

139

277

Total past and present

.139

400

% incidence in 200 cases

69.5

33.5

32.5

22.5

Total accompanying

139

320

THE JOURNAL-LANCET

The diagnosis and treatment of the nasal manifesta-
tions of allergy in adults and children are problems
which, therefore, do not entirely concern the nose and
paranasal sinuses, but other associated respiratory allergy
such as hay fever and asthma as well. In addition to the
respiratory manifestations as a whole, other associated
allergy, such as the skin manifestations, gastrointestinal
allergy, and allergic headache, is also frequently present.

Table VI shows the relative incidence of the various
types of respiratory allergy and the percentage incidence
of other allergy associated with them in the past and
present history. Among the respiratory forms of allergy,
it is noteworthy that approximately 27 per cent of the
patients with nasal symptoms also have hay fever, and
about 20 per cent have asthma. Taking the respiratory
form as a group, about 75 per cent give a past or present
history of other associated allergy, such as the skin,
gastrointestinal, and headache types. Only about 25 per
cent of the cases of respiratory allergy, therefore, do not
have other associated allergy. It is noteworthy that in
practically all of the patients with respiratory allergy,
the associated allergy accompanied it. Only a few pa-
tients, therefore, gave a history of other allergy in the
past history only.

TABLE VI

Other Allergy Associated with Nasal

Manifestations

ADULTS

Total

No other
allergy

Associated

allergy

Nasal allergy

128

58.2%

36 28.1%

92 71.9%

Hay Fever ... ....

4.0

4 44.4

5 55.6

Nasal Allergy and

hay fever

17.3

9 23.7

29 76.3

Nasal Allergy and

asthma

14.5

6 19.0

26 81.0

Nasal Allergy, Hay

fever and asthma

6.0

1 7.7

12 92.3

220

56 25.6%

164 74.4%

CHILDREN

Nasal allergy

26.0%

10 19.2%

42 80.8%

Hay fever

2.0

2 50.0

Nasal allergy and

Hay fever

2.5

2 40.0

3 60.0

Nasal allergy and

Asthma

49.5

35 35.4

64 64.6

Nasal allergy, Hay

fever and asthma

20.0

15 37.5

25 62.5

200

64 32.0%

136 68.0%

Table VI also shows the various respiratory types and
the percentage incidence of associated allergy in 200
children. It is noteworthy that only 30 per cent had nasal
symptoms alone and that 70 per cent had nasal symp-
toms and asthma. The relative incidence of hay fever
in the entire group was 25 per cent. Taking the group
as a whole, 32 per cent had only respiratory allergy and
68 per cent had other allergy associated with it in the
past and present history. In these children this associated
allergy occurred in the present history in approximately

50 per cent, while in about 18 per cent the associated
allergy occurred only in the past history. This past
allergy manifested itself chiefly in infancy in the form
of eczema, urticaria and gastrointestinal colic.

On the basis of these statistical data, it is evident that
the nasal manifestations of allergy occur in the absence
of any other allergy in only about 25 per cent to 32 per
cent. In the remaining 68 to 75 per cent, therefore, hay
fever, asthma, skin and gastrointestinal manifestations,
and allergic headache complicate the clinical picture.

TABLE VII

Skin Reactions to Allergens in 220 Adults

Pollens 2

Inhalants 11

Foods 19

Pollens and foods 8

Inhalants and foods 103

Pollens, inhalants and foods 57

Negative 20

Total 220

Skin Reactions to Allergens in 165 Children

Pollens 7

Inhalants 20

Foods 14

Pollens and inhalants.... 18

Pollens and foods 7

Inhalants and foods 34

Pollens, inhalants and foods 25

Negative 40

Total 165

The positive skin reactions obtained in 220 adults with
respiratory allergy are shown in Table VII. On the
whole, the positive intracutaneous reactions obtained to
pollens, other inhalants, and foods were quite compara-
ble to the various types of respiratory allergy with their
associated manifestations, as shown in Table VI. Sixty-
seven patients showed positive reactions to pollens and
60 of these patients had hay faver of the tree, grass, or
ragweed type. It is noteworthy that only two patients
reacted to pollen alone. Eight also reacted to foods and
57 to inhalants and foods. A total of 171 patients re-
acted to inhalants other than pollen and 187 reacted to
foods. About ten per cent of all patients gave negative
skin reactions.

Among 165 children with respiratory allergy, positive
reactions were obtained in 125, or approximately 75 per
cent, by the scratch method. Fifty-seven patients showed
reactions to pollens. Only 7 reacted to pollens alone.
The remaining 50 also reacted to inhalants, to foods, or
to inhalants and foods, as shown in Table VII. Among
the 165 patients, 97 reacted to inhalants other than
pollens and 80 reacted to foods. Clinical sensitivity to
foods in children occurs in about 60 to 70 per cent or
more of the cases. It is apparent, therefore, that skin
tests by the scratch method with foods fail to show posi-
tive reactions in at least 50 per cent of those who are
actually sensitive to foods.

THE JOURNAL-LANCET

Summary

These studies on the association of the various mani-
festations of allergy show the common occurrence of this
condition in multiple rather than in single form. The
patient usually presents himself for diagnosis and treat-
ment for that manifestation which predominates the
clinical picture. Associated manifestations of lesser im-
portance, therefore, should not be overlooked. The pa-
tient with perennial nasal symptoms of allergy may have
hay fever in the spring, summer, or fall. The hay fever
symptoms may predominate the clinical picture while
the nonseasonal symptoms may be mild or severe. If
mild, attacks may be considered as acute rhinitis. Pa-
tients with perennial nasal symptoms may have asthma
either with hay fever or only during the winter months.
It is important to emphasize also that allergic bronchitis
not infrequently accompanies nasal allergy during the
winter months without any very definite evidence of true
asthma. The nasal manifestations of allergy in children
are frequently overlooked unless associated with asthma.
The patient whose respiratory symptoms consist only of
hay fever may have allergic headache or gastrointestinal
allergy or some form of skin allergy at other times of
the year. Gastrointestinal allergy or allergic headache
may, on the other hand, appear as the predominating

symptom. Nasal symptoms may be associated in mild
degree. The diagnosis of nasal allergy is always good
presumptive evidence that these other manifestations are
also of an allergic nature. Such manifestations as allergic
headache, gastrointestinal allergy, and skin allergy are
most frequently caused by hypersensitiveness to foods.
The association of these manifestations with the respira-
tory types of allergy always suggests very strongly that
foods also play an important part as etiologic factors.
From these studies it is evident, therefore, that most
allergic patients are affected with multiple manifestations
all of which must be considered in the clinical picture
from the standpoint of diagnosis as well as treatment.

References

1. Peshkin, M. M.: Asthma in Children. II. The Incidence and
Significance of Eczema, Urticaria and Angioneurotic Edema, Am.
J. Dis. Child., 32:862, 1926.

2. Colmes, A. Qc Rackemann, F. M.: Studies in Asthma. IX.
Cough As a Manifestation of Human Hypersensitiveness, J. A.
M. A., 95:192, 1930.

3. Rackemann, F. M.: Clinical Allergy, Asthma, and Hay Fever,
New York, 1933, The Macmillan Co., p. 133.

4. Rowe, A. H.: Gastrointestinal Food Allergy. A Study Based
on 100 Cases, J. Allergy, 1:172, 1930.

5. Rowe, A. H.: Food Allergy, Philadelphia, 1931, Lea and
Febiger.

6. Bray, G. W.: Recent Advances in Allergy, Philadelphia,

1934, P. Blakiston’s Son. Inc.

7. Hansel, F. K.: Allergy of the Nose and Paranasal Sinuses.
A Monograph on the Subject of Allergy As Related to Otolaryn-
gology, 1936, C. V. Mosby Co., St. Louis.

Asthma and Allergic Rhinitis from Molds

An Analysis of Ninety Cases

Samuel M. Feinberg, M. D.**

Chicago

THE study of fungi has received comparatively
little attention among medical bacteriologists and
has found no great place in the curricula of
medical schools. This attitude has been principally due
to the fact that infectious diseases in man due to fungi,
although of great importance, are of too infrequent
occurrence to engage the sustained interest of the medi-
cal mind. The realization that fungi may produce dis-
ease in ways other than infection, that is, by the pro-
duction of reactions of hypersensitiveness, has increased
our interest in these organisms in recent years.

For a long time allergic manifestations have been
known to occur as a result of infection with certain
fungi, particularly tricophyton and monilia. Our discus-
sion here, however, will not take up this phase of the
subject. The thesis of the present communication deals
with the observation that there are large numbers of
instances of respiratory allergy, consisting of either
vasomotor rhinitis, cough or asthma, or combinations of

*This paper is the fifth of a series entitled ''Studies on the Re-
lation of Microorganisms to Allergy.” From the Allergy Clinic.
Department of Medicine, and the Department of Bacteriology,
Northwestern University Medical School.

** Assistant Professor of Medicine, Northwestern University
Medical School; Attending Physician, Cook County Hospital.

these, due to allergic reactions from the inhaled spores
of non-pathogenic fungi constantly present in the
general atmosphere. A number of reports concerning
mold allergy have appeared in the literature. Since
these papers have been reviewed in our earlier publica-
tions1’ 2' 3’ 4 no attempts will be made to refer to them
here.

Many of our colleagues present resistance in accept-
ing the above contention, probably because they do not
realize the ubiquity of fungus spores in the air and
because, having been taught so little about fungi in the
medical school, they think only in terms of infection-
producing organisms. It is our contention that it is
neither illogical nor unreasonable to suspect fungi as
causes of hay fever and asthma. Let us look at the
evidence.

1. For over two years we have been exposing cul-
ture plates and microscope slides to the outdoor air1.
Our results show that there are numerous spores of
molds in the air, on many occasions exceeding the pollen
counts at the height of the season of the latter. The
spores are to be found at all times of the year in vary-
ing numbers and varieties.

THE JOURNAL-LANCET

2. Spores are the reproductive elements — the seeds —
of molds. In general we have been impressed with the
allergy-producing potency of the reproductive parts of
plants and animals, such as nuts, egg, pollen, cotton-
seed, poppyseed, peas and beans.

3. Their light weight and small size enables these
spores to be come widespread, and to easily reach our
respiratory mucosa. The general resistance of molds
and spores to temperature and other weather changes
insures an air contamination practically all times of the
year. These fungi originate from growing and dead
vegetation and from the soil.

An analysis of 90 consecutive cases of hay fever and
asthma due to fungi is presented here. These are all
private patients, and although more instances of mold
allergy were available we have chosen for this report
only those from more recent files. This group does not
include a large number of patients who were sensitive
to yeasts' but not to other fungi. Neither does it in-
clude several instances of eczema in which the inhaled
spores of non-pathogenic fungi appeared to be the cause,
nor instances of urticaria or hyperesthetic rhinitis due
to the absorption from trichophyton infection.

Several clinical observations are of interest in this
group. The age of these patients shows a preponder-
ance among children, even more striking than among
other types of allergy. The following are the findings:
TABLE I

Number of

Age in Years Patients

1-10

11-20

21-30

31-40

41.50

51-60 1

61-70 1

More striking still are the ages at which the symp-
toms first began:

TABLE II

Age at Onset of ' Number of

Symptoms Patients

MO 70

11-20 11

41-50 I 0

51-60 - 1

61-70 1

Of the 90 patients, 52 were males and 38 females.
In 26, vasomotor rhinitis was the only complaint. Only
9 had asthma as the sole complaint, while 55 had both
nasal and asthmatic symptoms. The question of asso:
ciated allergy is worthy of note. Mold allergy alone was
present in 25. Only 7 patients had an associated allergy
other than pollen, while 58 patients had definite pollen
allergy.

The time of year in which the symptoms occurred
varied in different patients, but in general could be
divided into three groups. One group, comprising only
a small minority, had their symptoms the year round.
A second group, consisting of a larger number, had
their symptoms practically confined to the summer
months, but close inquiry showed a discrepancy be-
tween the pollen, season and the season of their symp-

toms. The third group, and by far the largest, is com-
posed of those whose symptoms occur either mostly dur-
ing the summer, with slight attacks during the winter
months or occur perennially with a tendency to aggrava-
tion in the summer. The great tendency for summer
symptoms in those who have mold allergy is accounted
by the decidedly greater contamination of the air with
tungus spores during that time.’1

Diagnosis

How are these patients to be diagnosed? In the first
place, the history is important. Decidedly suspicious is
a history of hay fever or asthma occurring in the sum-
mer or aggravated then in a patient who does not react
to pollen or whose season of symptoms does not agree
with the particular pollen to which he reacts. Attacks
occurring more on warm, windy days (not explained by
pollen in the individual instance), in musty rooms, in
a damp basement, or in a hayloft are suspicious facts.

The diagnostic tests are, of course, important. Scratch
tests are made usually with the killed powdered dry
pellicle of the mold.4 Potent liquid extracts may also be
used. The reactions are of the immediate type as seen
with pollen and similar allergy. They have the usual
characteristics of wheal, erythema and itching, and need
no other interpretation than that used in ordinary aller-
gic tests. Some delayed reactions have also been seen,
but these will not be discussed here. In questionable
cases the intradermal test may be used. If the scratch
test has been negative, intradermal tests with the 1:1,000
extracts may be made.

The next question that arises is — which molds should
be used in testing? There are thousands of species of
molds in the air and the problem in different communi-
ties no doubt differs to some extent. What we are pro-
posing here is, of course, not the final answer to the
diagnosis of mold allergy in all parts of the country nor
even in the middle west. As others become interested
in this phase of allergy a great deal of new data will
be added. In the meanwhile, however, we suggest that
on the basis of our experience as to frequency of air
contamination and frequency of reaction the following
molds would constitute a practical list for the average
worker:

Alternaria
Aspergillus
Chaetomium
Hormodendrum
Monilia sitophila
Monilia albicans

Mucor

Penicillium

Fusaria

Trichoderma

Trichophyton

Yeast

Mold extracts, in order to be potent and productive
of good reactions, must be carefully prepared from the
species producing many spores and carefully cultured to
obtain the maximum number of spores. Failure to ob-
serve these and other details in the preparation of mold
extracts has resulted in the past in some commercial
specimens giving few or weak reactions. This has ac-
counted for a good deal of the failures and skepticism
in the past with respect to the frequent existence of mold
allergy.

THE JOURNAL-LANCET

Treatment

With respect to the need for active treatment mold
allergy can be compared to pollen allergy. As a matter
of fact the necessity for treatment in the mold cases is
even more definite than in the pollen cases. In the latter
a change of locality may produce relief. Mold-sensitive
individuals will probably have greater difficulty in avoid-
ing the cause of their trouble.

The principles of desensitization with mold extracts
differ in no way from those of pollen desensitization.
Beginning with small doses, usually with 0.1 cc. of a
1:10,000 or a 1:100,000 extract, increases are made to
approximately 1.0 cc. and then changed to stronger con-
centrations. In most instances the final dose in our pa-
tients has been about 1.0 cc. of a 1:100 extract. Sev-
eral mold extracts may be combined. Systemic or local
reactions occur and the same precautions must be used
as in other types of desensitization. If possible, it is best
to begin treatment during the winter, but treatment
may be begun at any time, as soon as the diagnosis is
made.

The types of molds to be used in treatment depend
on the reactions of the individual, the concentration of
the particular types of spores in the air and the particu-
lar or special exposures of the patient. The most com-
mon fungus that is employed in our therapeutic work
is alternaria. Aspergillus, penicillium, hormodendrum,
monilia and mucor extracts are also frequently used.

The results of desensitization treatment in 60 of these
patients are presented. This group includes the 28
treated patients who were reported in an earlier paper.''
A large number of the patients treated with mold ex-
tracts also received other desensitization treatment, par-
ticularly pollen. In reporting the results here it is to be
emphasized that: (1) Only those patients are included
in whom molds were definitely established as a sole or
additional cause of their symptoms. (2) In spite of the
fact that other desensitization treatment was frequently
employed, the effects of the mold desensitization, as
followed by daily air analysis, is here evaluated. The re-
sults were as follows:

25 patients had 90 to 100 per cent relief.

23 patients had 75 per cent relief.

9 patients had 50 per cent relief.

3 patients had little or no relief.

Some of the seasonal cases have now been treated for
two or more seasons and the results of the second sea-
son usually are better than that of the first. A fair
proportion of the patients cited here have been pre-
viously treated by others, and a few by myself, with
other types of treatment, particularly pollen, with either
partial or complete failure.

The histories of two or three representative patients
will serve to illustrate some of the salient points in con-
nection with this group:

Case 1. Mrs. M. E. L., 61 years of age, was seen in
consultation at the hospital in September, 1935. The
history was that she had had chronic asthma for four
years, had had complete examinations, including blood

chemistry, gastric and fecal analysis, chest and gastro-
intestinal X-rays, with negative results. She had been
completely tested with allergens by four different but
all competent men, three of whom were allergists. All
tests had been negative. She was using several hypoder-
mics of adrenalin daily. She had had various forms of
treatment, including vaccine therapy, with no results.
Her asthma had been present the year round, but had
been somewhat worse in the summer. The remainder of
the history was irrelevant.

Because of her age at the onset of the asthma the
first impression gained was that we were dealing prob-
ably with an infectious asthma. But because of previ-
ous experience with occasional individuals who develop
allergy at an advanced age it was decided to regard this
patient as allergic until proved otherwise. No attempt
was made to repeat the tests performed by our predeces-
sors. Suspecting that probably the only tests not made
were those with fungi, we made tests with the latter
only. Much to our surprise a number of very strongly
positive reactions were obtained by scratch tests.

For desensitization the molds which were regarded as
the most likely to be incriminated were selected and
combined in a treatment mixture. These included alter-
naria, aspergillus, penicillium, chaetomium and mucor.
Treatment was begun on September 9, 1935, with 0.05
cc. of a 1:100,000 extract. This was continued through-
out the year. On one occasion she had a systemic re-
action following an injection. Freedom from asthma has
been practically complete after the first two months of
treatment.

Case 2. J. B., a 21-year-old medical student, was seen
on July 27, 1929, giving a history of asthma and vaso-
motor rhinitis since infancy. Although his symptoms
occurred chiefly in summer, he also had lesser symp-
toms the rest of the year. At the age of six he had a
tonsillectomy-adenoidectomy. He had pneumonia and
diphtheria as an infant. A history of allergy in the
family was definite. Tests showed moderate reactions to
the following: cat hair, dog hair, cattle hair, rabbit hair,
feathers and two or three foods. There was a very strong
reaction to yeast. The grass and ragweed pollen reactions
were questionable. The foods, including yeast, were
eliminated from the diet, and the epidermals avoided
as much as possible.

Off and on from the fall of 1929 to the spring of
1933 the patient was treated with pollen and with house
dust extract. The winter symptoms were improved but
each summer from 1929 to 1933 inclusive he was ob-
served to experience a marked aggravation of his symp-
toms beginning in July and continuing until late fall.
From the spring of 1933 until the spring of 1935 he
had no treatment and his symptoms recurred as they had
previously. In the spring of 1935, during the process
of reviewing some old records, the findings recited above
impressed us as suspicious of meld allergy. The particu-
lar points which were regarded as suggestive, as had
also been found in other patients of this type, were the
seasonal tendency (especially between pollen seasons)

THE JOURNAL-LANCET

and the presence of allergy to yeast. The patient was
requested to return, and tests with both pollen and fungi
were made at this time. The pollen tests were again
border-line or negative. Reactions to fungi, however,
were many and marked. By scratch tests some of the
wheals exceeded an inch in diameter.

Several of the fungi were selected for treatment. That
summer he experienced some relief, although consider-
able symptoms were still present. In the spring of 1936
treatment was again started, adding two other varieties
of fungi to the mixture. The results this year were de-
cidedly improved over the preceding year. It was defi-
nitely certain that the treatment with mold extracts had
a specific desensitizing effect.

Case 3. Herbert G., aged 22, of El Paso, Texas, pre-
sented himself on May 25, 1934, complaining of asthma
of 15 years’ duration. He had had tests for allergy in
1926 with the finding of some food reactors. A year in
the mountains of New Mexico had temporarily im-
proved his asthma. A nasal septum was operated upon
in 1923 and nasal polyps were removed later. The
father and maternal grandfather have asthma. A
younger brother has hay fever due to Bermuda grass,
and a sister has asthma from horses.

Examinations showed the usual findings of asthma
and vasomotor rhinitis. Skin tests showed a slight re-
action to mushroom and very marked reactions to sev-
eral fungi and yeast. Treatment was instituted with an

extract of yeast and alternaria and was carried on for
about a year. The improvement was rapid and marked
and recent examination indicates that the patient has
remained practically symptom-free.

Summary

Air-borne spores of fungi constitute an important
group of causes of allergy of the respiratory tract —
asthma and hay fever. There is a decided tendency to-
ward seasonal aggravation in this type of allergy. A
series of 90 cases of mold hypersensitiveness are an-
alyzed, of which 60 have been treated with the specific
fungus extracts with satisfactory results in most of them.
Mold allergy is not a rarity but is a common entity,
and in our experience in this part of the country it
ranks next to pollen as a cause of inhalant allergy. With
proper study as to the type and variety causing the pa-
tient’s symptoms and a proper survey of his own com-
munity there is no reason why any physician cannot
manage this group as well as he has learned to manage
the pollen cases.

References

1. Feinberg, S. M. dC Little, H. T.: Studies on the Relat on of
Microorganisms to Allergy. III. A Year’s Survey of Dady Mold
Spore Content of the Air, J. Allergy. 7: 149 (Jan.), 1936.

2. Feinberg, S. M. &L Little, H. T.: Studies on the Relation
of Microorganisms to Allergy. II. Role of Yeasts in Allergy, J.
Allergy, 6: 564 (Sept.), 1935.

3. Feinberg. S. M.: Seasonal Hay Fever and Asthma Due to
Molds. J. A. M. A.

4. Feinberg, S. M.: Mold Allergy: Its Importance n Asthma
and Hay Fever, Wisconsin M. J., 34: 254 (April), 1935.

Asthma*

A Syndrome, Not A Clinical Entity

Robert W. Lamson, Ph. D., M. D.**

Los Angeles, Calif.

TWO OPPOSING concepts relative to asthma de-
serve study. The first is that all patients present-
ing the classical signs and symptoms have a simi-
lar etiology, often erroneously referred to as allergic
asthma; the second, that there are many causes for
paroxysms of dyspnea and wheezing. The former would
make no fundamental distinction between the asthma
in one who had been a "hard rock” miner for many
years and in the infant who manifests similar signs upon
his first ingestion of egg. The latter concept, however,
would admit that there are many conditions, basically
quite different from each other, which may initiate an
identical syndrome. Even normal man, by forced expira-
tion, may duplicate some of these signs. Often one hears
this criticism of a colleague, "He shows little interest in
the patient after he has made the diagnosis.” At the
other end of the scale stands the polytherapist who em-
ploys numerous therapeutic agents for each sign and

’Prepared expressly for the special Allergy issue of THF

JOURNAL-LANCET.

’’Professor of Preventive Medicine and Public Health, Univer-
city of Southern California.

symptom, with little regard for the causative factor. Be-
tween these two extremes lies the optimum pathway. If
one extreme or the other is unavoidable, I would direct
your attention toward the first, for reasons to be
explained.

There are certain well established criteria of allergic
asthma which are too often ignored; especially by those
who make no distinction between the types of paroxys-
mal dyspnea. A brief discussion of these diagnostic land-
marks will furnish a basis for subsequent considerations.
Allergic asthma may appear early in life, often as croup,
and frequently follows or may be associated with,
eczema or nasal symptoms. It tends to recur, alternat-
ing with remissions — occasionally of years’ duration. As
previously indicated, the history discloses that one or
more allergic conditions, hay fever, eczema, hives and
possibly migraine, have been experienced by the patient.
In one, a resistant eczema may miraculously clear up
when "asthma” recurs; in another patient, the two con-
ditions always coexist. What physician does not know
a number of patients who "catch cold” before each at-

THE JOURNAL-LANCET

tack of asthma? Many of these "colds” are manifesta-
tions of a vasomotor rhinitis, not infrequently on a
pollen basis, and if they were less atypical they would be
designated as hay fever. Although the lungs are the re-
acting organs in all types of asthma, it is difficult to
believe that the response is limited to this tissue. In the
allergic individual, a specific cause may be demonstrated
by clinical or laboratory tests; although one is seldom
able to support all the assumptions made by the patient.
Removal of the incriminated substances from the pa-
tient’s environment may completely control the attacks.
If this procedure is impossible, desensitization treatment
may be equally successful.

I shall give little consideration to the physical find-
ings during an attack. These art only occasionally path-
ognomonic, and were this not true the differential diag-
nosis would offer no problem.

In the interval between attacks, the victim of allergic
asthma may be normal by physical and other examina-
tions. In asthma of other types residual findings may be
incorrectly interpreted as sequelae of allergic asthma. For
example, examination of one known to have recurrent
paroxysmal dyspnea may reveal the signs of pulmonary
tuberculosis. To some, this is sufficient basis for the
contention that asthma "runs into tuberculosis.” Care-
ful study of the history may disclose that the patient
was tuberculous many years before the first attack of
asthma. The latter is then but the result of the tubercu-
lous process. This relationship might be summarized by
the following: Many patients with pulmonary tubercu-
losis develop the asthmatic syndrome. Patients who have
had considerable asthma are no more likely than nor-
mal to subsequently develop pulmonary tuberculosis. It
must be added that the latter diagnosis is often sus-
pected, but rarely confirmed — even at postmortem. Other
sequelae, notably bronchiectasis, have been diagnosed
antemortem, but are not often confirmed at necropsy.

No physical type of individual and no particular race,
seems resistant to allergic asthma nor to any other type
of paroxysmal dyspnea. The older concept, that asthma
is a neurosis, undoubtedly arose from a misinterpreta-
tion as to cause and effect.

Routine laboratory examinations, such as blood serol-
ogy, blood counts, sputum and urine tests, yield little
that is pathognomonic of allergic asthma, but they may
furnisli important clues to other types of paroxysmal
dyspnea. I hasten to add that I am aware of the empha-
sis given by some to the eosinophiles in blood and
sputum.

The roentgenographic study is another examination,
the significance of which is controversial. In spite of this,
there is surprisingly little pertinent data in the litera-
ture. At my solicitation, Dr. Carter* has undertaken a
study of the X-ray films of 500 patients with paroxys-
mal dyspnea. We have separated these patients into
decades according to the age when the last film was
taken. Within that particular decade they were further

*Dr. Ray Carter, Roentgenologist, Los Angeles County General
Hospital.

subdivided on the basis of duration of dyspnea. To give
the maximum significance to this factor, we consider the
duration to represent the total lapsed time from the first
attack to the date of the most recent film. During such
a period certain of the patients may have had symptoms
for but a few hours, but any pathologic process might
have continued without the patient’s knowledge. The
films of more than 400 patients have been reviewed, but
the study is far from completed. We have, however,
noted certain trends which may not necessarily represent
Dr. Carter’s final conclusions. It appears that years of
paroxysmal dyspnea may leave few, if any, signs detect-
able by X-ray, nor does it seem to make much differ-
ence at what age of life it occurred. There is a tendency
to a low diaphragm with relative sparseness of pulmon-
ary detail and a rather small and less tortuous aorta
than normal for the age group — those past 50 years of
age. The patients showing marked abnormalities belong
in that group where the pathology antedates the first
attack of paroxysmal dyspnea. It is imperative, there-
fore, that some roentgenologic examination be done on
all patients with "asthma.” Essentially negative findings
are expected in the allergic group, but it is invaluable
in disclosing the cause for other types of paroxysmal
dyspnea.

Until recently there was general acceptance of the
theory that heredity played an important part in allergic
asthma. There was, however, considerable difference of
opinion as to the percentage of patients who had a posi-
tive family history of one or more allergic conditions.
One group was too ready to accept the patient’s state-
ment relative to these conditions in his ancestors, and
probably also to accept migraine or any severe sick head-
ache as a progenitor of asthma in the patient. Other
observers do not accept the unqualified statement of the
patient and are inclined to minimize a history of
"asthma” during the last few weeks of life of the 85-
year-old grandparent. It seems that a bilateral positive
family history predisposes to an earlier onset and to a
greater percentage of such offspring developing allergic
conditions than does a unilateral allergic history. In each
instance the vast majority of the true allergic patients
developed the condition before the age of 40 or 45 years.
A negative family history is not pathognomonic of non-
allergic asthma, nor does if exclude the allergic type.

One may justifiably ask, "Will not the pathology
settle the question?” If it could do so the answer would
be a little late to be of greatest value to the particular
patient. Longevity is supposed to be a characteristic of
allergic asthma: in fact, many patients dread the pro-
tracted nature of the condition and would welcome an
early demise. We find, however, in insurance statistics,
statements to the effect that asthmatic patients tend to
have an expectancy of but a few years if they are having
asthmatic symptoms on or about the time of insurance
examination. There are approximately 50 case reports,
with necropsy findings, in the literature of the world
covering a period of approximately 50 years. I have
analyzed these raw data where the age of onset and

THE JOURNAL-LANCET

duration could be determined. It was found that 12 per
cent had had paroxysmal dyspnea no more than one
year, and a total of 44 per cent died within four years
after onset. In a much larger series (137 patients), now
in press, Dr. Butt and myself found that 17 per cent
and 38 per cent respectively had dyspnea only for the
short period indicated above. If the need for differential
diagnosis was not evident before, it should be after con-
sidering these raw data. We hope to report in some de-
tail the pathology in 48 patients of this series. These
results may be summarized as follows: No single, or
even several, factors confirm a diagnosis of allergic
asthma, and in many instances the pathology was less
typical in proven allergic asthma than in certain patients
quite definitely of the nonallergic type. Here also the
sequelae of the former group, in other organs, are not
outstanding. Primary pathology in the circulatory sys-
tem not infrequently induces asthma. In our series with
necropsies we determined the cause of dyspnea to be:
cardiovascular in 31 per cent, distortion of thorax and
tracheal obstruction in 5 per cent, pneumoconiosis 10
per cent, pulmonary tuberculosis 5 per cent etc. There
was a residuum of 24 per cent in whom we could not
exclude the diagnosis of allergic asthma. Were the data
more complete, I am confident that some of these would
be excluded from this group.

Those who have previously reviewed the published
case reports, as well as ourselves, admit that no more
than 30 per cent of these represent asthma in the strict
sense. There is, however, little unity of opinion as to
which cases shall be thus classified.

It is commonly believed that a therapeutic test with
epinephrine or other drug will distinguish between the
types of paroxysmal dyspnea. This has failed in all but
the rare instance. In fact, epinephrine may give more
relief in one with typical cardiac dyspnea than in an
equally typical allergic patient. It appears that hyper-
reactivity to ordinary doses of one or more drugs may be
expected in those who have had any type of paroxysmal
dyspnea.

The literature concerning asthma, and my own ex-
perience, furnish ample support for the following con-
tention. Asthmatic symptoms may be initiated on a
cardiovascular, on a pulmonary and on a mechanical as
well as an allergic basis. The symptoms and signs are so
nearly identical that the diagnosis of allergic asthma may
be made not once but often several times on each patient
regardless of the primary factors.

The practical features of this problem are not alone
academic ones; although it is of some satisfaction to
know what condition one is treating. Of equal impor-
tance to the allergist should be an interest in eliminating
some of the abuses of allergic testing. A case in point
was a 51-year-old male diagnosed asthma by five dif-
ferent physicians in a period of six years. He had twice
been subjected to allergic tests, and on one occasion was
told he was sensitive to 12 foods. Epinephrine had been
used to control severe dyspnea. No roentgenologic exam-
ination had been done: it is too frequently considered

unnecessary in "typical asthma.” Being rather methodi-
cal, I placed him in front of a fluoroscope and discovered
a large round pulsating mass in the region of the arch
of the aorta. Blood serology confirmed the diagnosis, and
he was referred to a colleague for treatment of the luetic
condition. The "asthma” improved markedly and he lived
an additional five years before the aneurysm ruptured.
Within a month after first seeing that individual, I was
called in consultation on an identical "asthmatic pa-
tient,” one who was also relieved by epinephrine. In
arteriosclerotic heart disease with hypertension, before
the patient has developed other signs of a circulatory
dysfunction, one may have attacks of "asthma.” Such in-
dividuals are too frequently subjected to allergic tests,
and too much is likely to be read into some of the tests.
When such findings fail to solve the problem it is no
wonder that allergic tests are condemned. If I correctly
understand the pathology it is unlikely that the sputum
or other excretion contains a specific asthmagenic organ-
ism. Since someone has to pay for allergic tests, for
autogenous vaccines and for all refinements in diagnosis
and treatment, they should be carried out only when in-
dicated. It may seem too elementary to repeat the time-
worn phrase "a careful history, and the knowledge of
how to use the facts thus obtained, is the most valuable
aid in diagnosis.” No one can deny that, first, some cases
cannot be classified, and second, that the percentage of
correct diagnoses among those with paroxysmal dyspnea
should be materially improved. A step in the latter direc-
tion might be to employ the term paroxysmal dyspnea
instead of "asthma,” and then qualify it to indicate the
etiologic or other type. These concepts are not new and
they find adequate support in practically all standard
texts, not only those in the field of allergy but in those
relating to diseases of the chest and to general medicine.

Summary

1. The term "asthma” as now employed has no more
significance than the terms fever, cough or headache.
Paroxysmal dyspnea is more suggestive of the charac-
teristic signs and commits one to no particular etiology.

2. A great variety of circulatory dysfunctions — arterio-
sclerosis, hypertension, luetic aortitis with or without
aneurysm, pulmonary sclerosis, etc., — may indicate the
asthma syndrome. Numerous authors emphasize the sig-
nificance of an aortic reflex in the production of bron-
chial spasm in such conditions.

3. An equally large number of pulmonary conditions
— tumor masses in the chest; distortion of the thorax and
its contained structures as in Pott’s disease; fibrosis as in
pneumoconiosis, pulmonary tuberculosis and chronic
bronchitis; and hypertrophic emphysema may cause at-
tacks of asthma not readily distinguished from those
occurring on a cardiovascular basis.

4. Allergic asthma seems to stand somewhat apart;
although the symptoms during the attack are similar to,
if not indistinguishable from those in the preceding
groups. Sequelae, such as diseases of the heart and dis-
eases of the lungs, are not common in this type of

THE JOURNAL-LANCET

paroxysmal dyspnea — life insurance statistics notwith-
standing. The duration of the condition is notably long.
Statistics to the contrary are usually based on incorrect
evaluation of cause and effect.

5. In allergic asthma, physical, laboratory and roent-
genologic findings tend to be essentially normal between
attacks for the age group concerned. These diagnostic
aids are invaluable in disclosing etiologic factors in other
types of paroxysmal dyspnea. The most valuable single
aid, not excepting allergic tests, is the history. The age
when "asthma” first began and the presence or absence
of other definitely allergic conditions, the sequence in
which diseases of the heart or of the lungs and asthma
appeared, are significant points in diagnosis. No rule
should be inflexible, but the age 45 tends to be the
upper limit for the onset of allergic asthma.

6. Differential diagnosis of these conditions has more
than academic interest. It should prevent the misuse of
allergic tests, save the patient or someone, considerable
time, expense and inconvenience. Prognosis on any other
basis is apt to be erroneous. The entire routine of treat-
ment may and should be modified in keeping with the
etiologic factors. Large doses of opiates might be well
tolerated by one group and be contraindicated in the
allergic type. It might be well to exclude aneurysm be-
fore using large doses of epinephrine or too drastic
physiotherapy. Preventive measures and regulation of the
patient’s life also should be modified according to the
primary condition. There is a good bit of evidence that
many of those in the circulatory group do not survive
more than five years after onset of paroxysmal dyspnea.

Serum Allergy*

Louis Tuft, M. D.
Philadelphia, Pa.

THE TERM, serum allergy, is employed to desig-
nate a condition of hypersensitiveness or altered
reactivity existing in relation to foreign serum
when the latter is brought into contact with human
tissue cells. Individuals possessing this type of sensitive-
ness or allergy are likely to develop reactions of variable
severity upon the injection of foreign serum. When such
reactions do occur, they are known as serum reactions.
Their occurrence first gained clinical recognition after
the introduction of diphtheria antitoxin into clinical use
in 1890. Since then and especially in the past 15 or 20
years, they have appeared with increasing frequency.
The cause of the reaction was attributed at first to the
antitoxin portion of the serum. However, it soon be-
came evident that this could not be the cause, since
similar reactions could be produced by the administra-
tion of normal horse serum. The remarkable therapeu-
tic effects of diphtheria antitoxin stimulated the use of
many other serums in clinical medicine and accounts in
part for the increased incidence of serum reactions. Be-
cause of the frequency with which these serums are be-
ing employed, it seemed worth while to present to the
practitioner some of the more pertinent facts relating to
serum allergy in the hope that they might aid either in
preventing serum reactions entirely or in lessening their
severity. Because of its almost universal employment in
the preparation of various types of immune serum, the
antigen which is almost always responsible for serum
allergy is horse serum; hence, any reference to the term
serum, unless otherwise specified, should be interpreted
as indicating horse serum.

The most common type of reaction occurring after the
introduction of foreign serum into an individual who

•Prepared expressly for the special Allergy issue of THE

JOURNALLANCET.

has not been previously sensitized, is a delayed type,
occurring as a rule six to ten days after the injection
and never endangering the life of the patient. This type
of reaction is known as serum disease or serum sickness.
Its most characteristic symptoms in order of their usual
appearance are: fever, an urticarial type of skin erup-
tion, enlargement of the lymphatic glands and poly-
arthritis. These symptoms last four to six days on an
average and disappear, leaving no trace of their presence.

This type of serum reaction is practically a normal
phenomenon. If sufficient serum is employed and the
administration is by the intravenous route, it can be in-
duced in nearly every human being. For this reason, the
incidence and severity of the reactions which occur after
serum injection is extremely variable and dependent up-
on the character of the serum employed, the amount
given and the route of administration. Thus, raw un-
concentrated serums provoke a greater number and
severer type of serum reaction than highly concentrated
preparations like diphtheria or tetanus antitoxin in
which an effort is made during the process of concentra-
tion to separate out the antibody-containing globulin
fraction and to remove as much as possible of those ex-
traneous proteins which are likely to cause reactions. The
type of bacteria used for the production of the immune
serum also seems to influence the incidence and severity
of reactions. Thus, antistreptococcic or antipneumococcic
serums are more serious offenders in this respect than
are serums prepared against diphtheria or tetanus toxins.
This difference does not seem to depend entirely upon
our inability to concentrate the former serums as well as
the latter. The nature of the organism itself seems to
determine to some extent the degree of serum sickness
which its antiserum provokes.

THE JOURNAL-LANCET

The amount of serum injected and the route of ad-
ministration are likewise important factors controlling
the incidence and the character of serum reactions. Thus,
the larger the amount of serum injected, the more likely
is it to cause reaction; likewise, reactions are more prone
to occur after intravenous injection than from any other
route of administration.

Except for the discomfort to the patient, delayed
serum reactions usually are entirely innocuous. They sel-
dom occasion difficulty either in diagnosis or treatment.
The history of serum injection and the characteristic
symptoms and signs occurring after a definite incuba-
tion period of at least six days serve adequately as cri-
teria for diagnostic differentiation.

Treatment is entirely symptomatic. The repeated use
of small doses of adrenalin by injection may be valuable
to relieve intense itching, in addition to antipruritic
lotions applied locally. The internal administration of
ephedrine may be of similar value. Salicylates are help-
ful in patients with marked joint pains. Attempts to
prevent the onset of a delayed serum reaction are sel-
dom of value. Ephedrine, adrenalin and calcium are the
drugs most widely used but there is little evidence to
indicate that these drugs are of prophylactic value.
Purification and concentration of immune serums have
accomplished more toward reducing the severity of the
symptoms than any other measures.

Just why this type of serum reaction occurs is still
an unsolved mystery. The appearance of circulating
antibodies, especially precipitins and anaphylactic anti-
bodies, coincident with or shortly after the appearance
of symptoms suggested to Von Pirquet and Schick that
the serum reaction was the result of interaction between
the injected antigen (horse serum) and the antibodies
which they stimulated. Further experimental investiga-
tion has cast doubt upon this theory, since Tuft and
Ramsdell have shown that the serum sickness which fol-
lows the injection of normal horse serum is not associ-
ated with appreciable amounts of circulating antibodies
and yet may be just as severe in intensity. It is very
likely that this reaction does represent an attempt on
the part of the body to rid itself of the injected antigen.
Whether this is attended by an antigen-antibody reac-
tion responsible for the symptoms of serum sickness
awaits experimental demonstration.

As previously mentioned, the delayed type of serum
reaction disappears in a few days and leaves no obvious
trace of its presence. In a certain proportion of these
patients, it is possible to demonstrate positive skin re-
actions to horse serum after the disappearance of the
symptoms of the serum reaction. These skin reactions
vary in degree and may persist for months or years
afterward. They constitute evidence of what may be
designated as acquired or induced serum hypersensitive-
ness or allergy. This sensitiveness may be confined only
to the skin or it may likewise involve the other tissue

cells. Individuals who possess such sensitiveness and par-
ticularly those whose general tissue cells are affected, are
much more susceptible to the induction of reactions from
serum injection than the normal or non-allergic person.
Injection of serum into such individuals (called second-
ary injection or re-injection) is likely to produce a much
severer type of reaction within a space of time which is
less than the incubation period of the ordinary delayed
type of serum sickness. If the reaction comes on im-
mediately, it is termed an immediate serum reaction (of
the secondary type). When it occurs after a few hours
and within three days, it is called an accelerated serum
reaction. The symptomatology of these secondary reac-
tions is similar to that of serum sickness, except that
they are more intense and distressing. Symptoms of
shock may occur in the severer types and fatality may
result, although it is rather uncommon. Urticaria and
angioneurotic edema form a prominent part of these re-
actions. In the immediate types, signs of prostration or
shock may be present. Unusual symptoms may also be
noted, as for example, hemorrhage from the bowel;
hematuria; edema of the larynx, sufficient to require
tracheotomy; severe local purpuric eruptions or severe
local Arthus-like necrotic reactions at the site in which
the serum was reinjected.

Secondary serum reactions, whether immediate or
accelerated, occur only after the reinjection of serum in-
to patients previously sensitized to horse serum by a pri-
mary injection. Such sensitization may result either from
previous injection of immune serum or more frequently
from toxin-antitoxin administration. Sensitization does
not develop necessarily in every patient who receives
serum. A great deal depends upon the nature of the
primary serum, the amount given, the route of admin-
istration and the capacity of the injected individual to
acquire sensitization. It is much more frequent, however,
in those who develop serum sickness. That these indi-
viduals also are more likely to develop reactions upon
reinjection is indicated in the following study reported
by Gordon and Creswell:

Incidence of Serum Reactions After Therapeutic

Serum Inj

ECTION

Percentage
Of Serum

History of Previous Injection

Number

Reactions

None

1750

Therapeutic serum only

151

Diphtheria Toxin-antitoxin

556

74.1

Reactions were much more frequent in patients who
received a primary injection of therapeutic serum or in
those who had toxin-antitoxin than in those who had
never received any form of serum. They also found that
reactions from immune serum given after toxin-antitoxin
injection were generally more severe and included more

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immediate types of reaction, than occurred in either of
the other two groups. These observations were corrobo-
rated in a study of serum sensitization after toxin-
antitoxin reported in 1932 by Tuft, in which it was
shown that after the administration of diphtheria toxin-
antitoxin containing minute amounts of horse serum,
sensitization of a varying degree occurred in 27.9 per
cent of the children. This sensitization affected not only
the skin but also other body tissues and was much more
likely to occur in children who were allergic themselves
or came of allergic families. Information obtained by
means of questionnaires sent to pediatricians indicated
that reinjection of therapeutic serums into children who
had previously received toxin-antitoxin produced serum
reactions, often of a severe type, in approximately 50
per cent, in spite of the fact that tetanus antitoxin and
to a lesser extent diphtheria antitoxin constituted the
principal serums used for injection.

Secondary serum reactions occurring after reinjection,
especially the immediate type, possess certain resem-
blances to the anaphylactic reactions in the guinea pig.
In both instances, there is a period of incubation after
the initial sensitizing dose and the reaction occurs upon
reinjection only after the completion of this incubation
period. In both instances, the reaction is severe and may
be fatal. Because of this similarity, some writers con-
sider the secondary serum reaction an example of an
anaphylactic reaction in the human being. The most im-
portant objections to that viewpoint are the lack of
adequate proof that such reactions are the result of
antigen-antibody reaction as in the guinea pig and also
the failure of desensitization methods in the human.
While these objections seem valid from an academic
standpoint, nevertheless the reaction occurring after re-
injection probably represents the closest prototype in the
human being to anaphylaxis in the guinea pig and is
possibly similar in its mechanism.

The reactions thus far discussed represent the most
common type of serum reactions and occur either in nor-
mal individuals or in those who have an induced serum
hypersensitiveness. Both serum disease and the second-
ary serum reactions after reinjection have many features
in common. Their incidence and severity are dependent
upon similar factors; their symptomatology is similar ex-
cept that in the latter type they usually are more severe
and distressing. Fatality may occur in the latter type but
is uncommon. As a contrast to these reactions is one
which occurs in an individual who has never previously
received a sensitizing injection of serum and yet is mark-
edly sensitive to horse serum. Such hypersensitiveness is
spoken of as primary, natural or atopic serum allergy.
It nearly always occurs in individuals who have the in-
herited or atopic type of allergy or have an allergic
family history. They frequently have allergic asthma
and often possess a concomitant sensitiveness to horse
dander of such a degree that they cannot go near a
horse without manifesting either coryzal or asthmatic
symptoms — hence, the use of the term "horse-asthmatic.”

The introduction or primary injection of serum into
these individuals, even in small amounts, is likely to be
followed by an extremely severe or even fatal type of
serum reaction known as primary or atopic serum reac-
tion. It differs both in severity and symptoms from the
secondary type of serum reaction or serum sickness.
Fortunately it is very uncommon. Definite statistical
data as to its incidence is not available although it has
been estimated by Park that fatal reactions of this type
occur approximately only once in every seventy thou-
sand individuals injected. Although most of these indi-
viduals are horse-asthmatic, a very small percentage have
no allergic manifestations at all.

The symptoms of this reaction begin almost immedi-
ately after the administration of the serum. Almost be-
fore the needle is withdrawn, local itching and edema
(or in intravenous cases, general burning) develop.
These are followed in rapid order by a generalized
urticarial eruption, sneezing, itching of the throat, swell-
ing of the face, neck and extremities, cough, constric-
tion in the chest or definite and marked asthma. These
symptoms are similar to those of other allergic disorders
and differ from those of ordinary serum sickness or sec-
ondary serum reactions, since in the latter coryza and
asthma are conspicuously absent. In the severer type,
signs of collapse quickly ensue and death may result
within a few minutes after the serum administration
or be delayed for several hours. If the reaction does not
terminate fatally, the symptoms may simulate those of
serum sickness at once or after a short interval.

The mechanism of the primary or atopic type of
serum reaction is similar to that which occurs in other
allergic conditions of the natural or atopic type — name-
ly, the result of interaction between the allergen (horse
serum) and the circulating allergic antibody (reagin)
present in large amounts in the patient’s blood. The re-
action which ensues is that of allergic shock and affects
primarily the specifically sensitized cells located in cer-
tain tissues or shock organs e. g. respiratory mucosa) .
It differs from the secondary serum reactions in the
same manner as anaphylactic reactions in the lower ani-
mal differ from the allergic or atopic reactions of the
human being.

Appreciation of the possible occurrence of these types
of serum reactions is extremely important from a prac-
tical standpoint, whenever it is necessary to administer
any type of foreign serum to a patient. Recognition of
the presence of serum sensitiveness can be made usually
without difficulty and should be done in every instance.
The fear of possible serum reaction should never under
any circumstances prevent the administration of serum
to any patient who requires it. Serum reactions occur on
the whole too infrequently to warrant its restriction.

On the other hand, therapeutic serums should not be
given indiscriminately or with the thought that their ad-
ministration can produce no ill-effects other than that
of a mild serum sickness. This is especially true of
tetanus antitoxin given for prophylactic purposes. This
preparation has been so refined and concentrated that

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only a comparatively small amount ( 1 cc.) need be ad- tions by hospital residents or practitioners to children
ministered. While the injection of this amount in a nor- with puncture wounds. Institution of proper prophylactic

mal individual produces serum sickness in only a small measures would have been successful in many instances

percentage of individuals (8 per cent, according to either in preventing serum reactions entirely or in re-

NX eaver), its administration to children previously ducing their severity or, in rare instances, in preventing

sensitized by toxin-antitoxin produces a greater number a fatal outcome. Such precautionary measures are in-
of reactions, some of which may be extremely severe or eluded in the following outline of procedure, suggested

alarming. It is not at all uncommon to obtain a history by the author for use by the practitioner in every patient

of severe serum reactions produced by prophylactic in- to whom foreign serum of any type is to be admin-
jections of tetanus antitoxin given without due precau- istered:

OUTLINE OF PROCEDURE FOR SERUM ADMINISTRATION

DIAGNOSTIC STUDY

History

Inquire for: ( 1 ) The presence of asthma, hay fever, eczema, migraine, etc., in pat ent or patient’s
family. If patient has asthma, determine whether this occurs in the presence of horses. (2) Previous
injection of immune serum (e. g., tetanus antitoxin) or of diphtheria toxin-antitoxin (3 injections).

Skin Test

Routine in every patient. Inject intracutaneously 0.02 cc. (1 /50) of either horse serum or immune
serum diluted 1-10 with either buffered or normal saline solution. In patients who are horse-asthmatic
use a 1-100 dilution. Read reaction in 10 minutes and record as negative, slight, moderate or marked,
depending upon size of wheal and surrounding area of redness.

Eye Test

To bo performed only when skin test is positive. Instill one drop of serum into conjunctival sac and
watch for reaction (inflammatory) occurring within 10 minutes. Whole horse serum, normal or immune,
can be employed in adults giving slight positive reaction; 1-10 dilution in children or in adults with
moderate or marked positive skin reactions and 1-100 dilution in horse-asthmatics or in patients giving
positive allergic history and marked positive skin tests. One drop of adrenalin (1-1000) instilled into
eye allays any severe reaction.

PROCEDURE

Skin Test Negative,
History Negative

Serum administration safe by any route.

Delayed reaction or serum sickness may occur but is never fatal.

Skin Test Negative,
History Positive

Serum administration nearly always safe. Administer serum slowly and have adrenalin ready to be
administered in doses of 0.25 to 0.5 cc., if signs of immediate reaction (itching or burning of skin,
or constriction of chest) appear.

Skin Test Positive,
Eye Test Negative

Immediate reaction possible especially if serum is to be given intravenously. If history is positive, avoid
intravenous injection when possible or employ heterologous serum. If latter is not obtainable, attempt
"desensitization” with spaced injections, coincident or combined with adrenaln injection. It is usually 1
possible to administer total quantity of serum in this way without the production of serious serum
reaction.

Skin Test Positive,
Eye Test Positive

Immediate serum reaction extremely likely and may be severe or dangerous, especially in asthmatic |
patient. Avoid serum injection or employ heterologous type. Attempts at desensitization likely to fail be- 1
cause sufficient serum cannot be given without inducing immediate reaction. It should never be attempted
in "horse-asthmatics. ”

METHOD OF 'DESENSITIZATION” IN SERUM-SENSITIVE PATIENTS

Serum to Be Given
Subcutaneously or
Intramuscularly

1. Inject subcutaneously 0.3 cc. (5 minims) adrenalin chloride 1-1000 and at the same time 0.05 cc.
( 1 / 2 0 ) of serum.

2. Repeat serum injection at one-half hour intervals giving in order 0.1 cc., 0.2 cc., 0.5 cc., 1.0 cc.,
2.0 cc., 4.0 cc., until total amount is given.

3. Repeat adrenalin injection (0.3 cc.) at hourly intervals until all the serum has been administered.
Increase dose to 0.5 or 1.0 cc. if signs of serum reaction occur. Adrenalin may be given in same
syringe as serum. Dosage should be modified in children according to their age.

Serum to Be Given
Intravenously

1. Proceed as above, giving small doses subcutaneously until 1.0 cc. dose of serum has been given. Use
same adrenalin dosage and continue at hourly intervals until all the serum has been administered.

2. One-half hour after subcutaneous injection of 1.0 cc. dose, inject slowly 0.1 cc. of serum diluted
to 1 cc. with normal saline and given intravenously. Repeat at one-half hour intervals giving in
order 0.2 cc. diluted to 1 cc., 0.5 cc. diluted to 1 cc., 1 cc., 2 cc., 4 cc., etc., until all the serum
is administered.

3. If there is the least sign of a reaction (dyspnoea, palpitation, itching or burning of the skin) dis- j
continue injection immediately and inject adrenalin (0.3 to 0.5 cc.) depending upon severity of
symptoms. After these symptoms disappear, start injections again but at a much lower level.

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By employing the procedures just outlined, it should
be possible to detect the presence of serum sensitiveness
in nearly all instances and to prevent or minimize the
severity of serum reactions. It must be remembered,
however, that too much reliance cannot be placed upon
these methods of so-called "desensitization.” Fatalities
have occurred in patients who received a second injec-
tion of serum (usually intravenously) after methods of
"desensitization” had been instituted. Serum-sensitive
patients should be watched carefully for any untoward
symptoms or signs and treatment discontinued as soon
as they appear. If an immediate reaction occurs in spite
of precaution, it should be treated actively by prompt
and repeated injections of adrenalin in sufficiently large
amounts to overcome the acute symptoms.

Conclusions

In spite of the greater concentration and refinement
of therapeutic serums, the incidence and severity of
serum reactions, particularly of the secondary type,
seems to have increased considerably in recent years.
This is due largely to the presence of serum sensitiza-
tion or allergy induced in individuals by a previous in-
jection of either toxin-antitoxin (equine) or therapeutic
serum. By employing diagnostic and prophylactic meth-
ods similar to those herein outlined, it should be possi-
ble to recognize the existence of serum sensitization in
practically every instance and to institute proper pre-
cautionary measures. This would accomplish much to-
ward minimizing any discomforts and dangers incident
to serum therapy.

The Treatment of Bacterial Allergy

Grafton Tyler Brown, B.S., M. D., F.A.C.P.
Washington, D. C.

AS THE diagnosis of bacterial allergy has been
dealt with in a recent paper1, this article will
be limited to a discussion of the specific treat-
ment of bacterial allergy.

Where definitely positive reactions are obtained to
cutaneous tests with stock bacterial proteins, gratifying
results can usually be obtained from proper treatment
with stock polyvalent vaccines, or autogenous vaccines
or vaccine-filtrates, of the corresponding organisms.
When definite reactions occur with two or more differ-
ent bacterial proteins, the vaccines of the reacting organ-
isms are mixed in equal proportions for treatment pur-
poses. Stock and autogenous vaccines may be combined
in the same mixture.

Stock polyvalent vaccines, and autogenous vaccines
or vaccine-filtrates, are made preferably in a concentra-
tion of 5 billion (5000 million) organisms per cubic
centimeter, in order that the maximum doses necessary
for the best results, may be attained. These strong vac-
cines may be used undiluted for treating the less sensi-
tive patients. Such vaccines, however, are too strong for
the early doses in patients who are sufficiently sensitive
to give definitely positive reactions to "scratch” tests
with bacterial proteins, or who manifest focal or con-
stitutional symptoms from the diagnostic intradermal
vaccine tests. It becomes necessary, therefore, to dilute
these strong vaccines ten times, to a concentration of
500 million organisms per cubic centimeter. In some
cases, notably in arthritis, the concentrated vaccines must
be diluted one hundred times, to a strength of only 50
million organisms per cubic centimeter. For the sake of
convenience, vaccines or vaccine-filtrates containing 5000
million organisms per cubic centimeter will be spoken

•Prepared expressly for the special Allergy issue of THE

JOURNALLANCET.

of in this article as strong vaccines; vaccines containing
500 million per cubic centimeter will be termed weak;
and those containing 50 million per cubic centimeter,
very weak. Sterile normal salt solution containing 0.4
per cent phenol or tricresol is used as diluent, nine parts
of diluent being added to one part of vaccine to make
the next weaker vaccine.

For those patients who give positive cutaneous re-
actions to the dried bacterial proteins, or who report
focal or constitutional symptoms from the intradermal
vaccine tests, treatment is started with a dose of about
50 million organisms or 0.1 cc. of weak vaccine. The
dose of the weak vaccine is usually increased by 0.1
cc. each time until a dose of 0.9 cc. is reached; then a
change is made to the strong vaccine with a dose of
0.1 cc., which is the equivalent of 1.0 cc. of the weak
vaccine. The strong vaccine is then increased by about
0.05 cc. each time to a maximum of 2.0 cc. or 10 bil-
lion organisms. These progressively increasing doses are
administered at weekly intervals, or never oftener than
every five days. It is preferable to alternate the arms
for the inoculations.

If, for some reason, a patient’s treatments are inter-
rupted, it becomes necessary to decide what dose to give
when they are resumed. If approximately two weeks
have elapsed since the last treatment, it is best to repeat
the same dose. If approximately three weeks have
elapsed, it is advisable to go back to the dose of the
next to the last treatment, and so on. In other words,
the number of doses to count back is one less than the
number of weeks that have elapsed since the last treat-
ment.

The treatments are stopped when the maximum dose
is reached, providing the patient is clinically well, and

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is also desensitized, as indicated by failure to react on
repetition of the previously positive bacterial skin tests.
If further treatment is indicated, the maximum dose of
vaccine should be repeated at weekly intervals, and with
lessening local reactions, the interval between the doses
may be gradually widened to a maximum of one month.

It is desirable to obtain a satisfactory local reaction
from each injection of the vaccine, namely, some re-
action about the site of the inoculation which persists
for a period of forty-eight hours. The patient is in-
structed to examine his arm carefully the next day about
twenty-four hours after each treatment, and again the
second day about forty-eight hours following the inocu-
lation, to see whether there is a pink spot on the arm,
and if so, about how large it is each day; also to note
whether there is any swelling, itching, fever, hardness,
or soreness of the arm both days. This information on
the local reaction is used in properly regulating the next
succeeding dose. I always endeavor to increase the doses
so as to maintain a satisfactory local reaction. For exam-
ple, if a dose or increase of' 0.1 cc. gives a forty-eight
hour local reaction, the next dose is increased by 0.1
cc., and so on. If, however, a dose or increase of 0.1 cc.
gives only a twenty-four hour reaction that is gone en-
tirely in forty-eight hours, the next dose should be in-
creased by 0.15 cc.; whereas if a dose or increase of
0.1 cc. gives no local reaction whatever at either the
twenty-four or forty-eight hour periods, the next dose
should be increased by 0.2 cc. If any dose produces a
severe local reaction, that is, one extending below the
elbow or into the axilla, this same dose should be re-
peated for the next treatment, or even reduced a little.
If any individual treatment produces what seems to be
a focal or constitutional reaction, in the form of an
aggravation of allergic symptoms during the forty-eight
hour period following the injection, the next dose should
be reduced to the size of the one before it which failed
to produce such reaction, or at least half-way between
the constitutionally reacting dose and the preceding one;
and from then on, the doses should be increased more
cautiously.

Tuberculin syringes should be used for accurately
measuring all vaccine doses up to 1.0 cc., as it is fre-
quently necessary to increase the doses by only 0.01,
0.02, or 0.03 cc. each time. In judging how much to
increase the doses, it is helpful to inquire whether the
local reaction from the last treatment was more, the
same, or less than the reaction from the treatment just
preceding that one.

It hardly seems worthwhile to call attention to the
necessity for absolute sterility of all vaccines, hypoder-
mic syringes and needles, but this is important, as an
infected or abscessed arm is an unpleasant episode in
an otherwise placid course of inoculations. Ordinary
tincture of iodine diluted with an equal quantity of
ethyl alcohol makes a satisfactory antiseptic solution for
sterilizing the skin surface just prior to the injection.

There is one type of constitutional reaction that occa-
sionally occurs in bacterial vaccine therapy, which is
never encountered in treatment with food, animal epi-
dermal, pollen, or other types of protein extracts. This
distinctive type of constitutional reaction is more likely
to occur following the larger doses of strong vaccine,
and manifests itself within an hour, or at most several
hours, following the injection. It takes the form of a
chill, accompanied by fever which may be quite high,
with malaise, and even generalized aching, thus simulat-
ing quite closely an attack of grippe or influenza. After
a few hours, however, the temperature returns to nor-
mal, and by the next day the patient has usually fully
recovered except for a feeling of weakness which soon
passes off. Treatment of these shock reactions consists
of the oral administration of ephedrine, or ephedrine
and amytal, and rest in bed during the brief febrile
stage.

This relatively uncommon type of constitutional re-
action is apparently due to accidental injection of some
or all of the vaccine dose into a blood vessel, and is, as
we would expect, usually attended by a smaller local
reaction, or even none at all. Although such a reaction
may not be dangerous, it is decidedly unpleasant, and
may cause a nervous patient to terminate the treatments
abruptly. The way to prevent these bacterial protein
shock reactions is to keep the vaccine from directly
entering the bloodstream. Because of its lack of vascu-
larity, the best site for the treatment injections is in the
outer part of the upper arm, about midway between
shoulder and elbow. After the hypodermic needle has
been inserted subcutaneously, and before any of the vac-
cine is injected, the piston should be sharply retracted
to see if any blood comes back into the syringe. If
blood appears, the needle should be withdrawn and in-
serted in another spot, and the piston retraction re-
peated, before the dose of vaccine is actually injected.
The vaccine should be injected slowly, and with the
larger doses, the piston should be retracted several times
during the course of the injection to make sure that
the tip of the needle has not slipped into a small blood
vessel.

In addition to specific vaccine therapy, foci of infec-
tion any place in the body should be removed as com-
pletely as possible. All abscessed teeth should be ex-
tracted. In some cases, all devitalized teeth should also
be extracted even though the X-rays show no evidence
of periapical bone destruction, as practically all pulp-
less teeth are infected. Chronically diseased tonsils
should be enucleated. Infected sinuses should be drained.
Chronic endocervicitis should be treated by cauteriza-
tion, and the infected prostate gland should be mas-
saged. Patients with abnormal intestinal flora should be
given sodium ricinoleate, followed by acidophilus milk
and lactose, or lacto-dextrin.

When a definitely positive reaction is obtained to a
von Pirquet test, treatment with tuberculin is indicated,
provided that the presence of active tuberculosis has
been carefully ruled out. The method of treating with

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tuberculin is the same as that already described for bac-
terial vaccines, except that much weaker dilutions are
usually required. Using as diluent, sterile distilled water
containing 0.2 per cent tricresol, 1 to 10, 1:100, 1:1,000,
1:10,000, 1:100,000, and 1:1,100,000 dilutions can be
prepared from sterile undiluted tuberculin (O. T.)
human type, which is commercially available in 1 cc.
rubber-capped vials. There are two ways of determin-
ing the initial dose of tuberculin. One is by the size
of the diagnostic reaction from a scratch test with un-
diluted tuberculin, namely, if a plus two (fi) reaction,
the treatment may be started safely with 0.1 cc. of a
1:1,000 dilution of tuberculin; if a plus three (t+f)
reaction, the treatment may be initiated with 0.1 cc. of
a 1:10,000 dilution; if a plus four (tttt) reac-
tion, treatment may be begun with 0.1 cc. of a
1:100,000 dilution, and so on. The other way of find-
ing the initial dose is by testing the individual patient
with the various tuberculin dilutions, and then using for
the first treatment, 0.1 cc. of the strongest dilution
which fails to react any more than the control test. The
doses of all tuberculin dilutions weaker than 1 to 100
are increased in the same manner as weak vaccines.
Doses of the 1 to 100 tuberculin dilution are increased
in the same way as strong vaccines, namely, by about
0.05 cc. each time. On reaching the 1 to 10 dilution,
however, the doses are increased each time by only 0.01
cc., or a multiple thereof, depending upon the reaction
from the preceding treatment. The undiluted tuberculin
is never used for treatment purposes.

Case Reports

A few illustrative cases will now be briefly reported.

R. C., a boy of 6 years, was brought to me with
asthma, which he had developed at the age of 3, fol-
lowing scarlet fever. He never had asthma without a
cold, but was very susceptible to colds, especially in the
winter. He also had sneezing and running of the nose
in the summer, which his parents described as hay-
fever. He coughed a good deal with his asthmatic at-
tacks, some of which were severe enough to require
epinephrine hypodermically. Thorough skin testing was
done, including tests with pollens and bacterial proteins,
but with completely negative results. This patient was
first treated with a stock mixed respiratory vaccine, but
as the asthmatic attacks recurred in spite of these in-
oculations, cultures were taken from his nasal secretions
and sputum during an attack. Staphylococcus aureus,
Streptococcus hemolvticus, and Streptococcus viridans
were isolated and used for the preparation of autogen-
ous vaccines. Intradermal tests with these three auto-
genous vaccines, gave a marked reaction to Strepto-
coccus hemolyticus, a moderate reaction to Staphylo-
coccus aureus, and no reaction to Streptococcus viridans.
Treatment was instituted with a mixture of the two
reacting vaccines, starting with a dose of 0.05 cc. of
strong vaccine, which was gradually increased at weekly
intervals. These injections were continued over a con-
siderable period of time until the supply of his auto-

genous vaccines was exhausted. A polyvalent vaccine-
filtrate mixture containing the three types of organisms
found in his original cultures, was then substituted and
continued to a maximum dose of 2.0 cc. of strong vac-
cine. A number of times during the course of these in-
jections, both autogenous and stock polyvalent, increases
in dosage were followed by temporary aggravation of
colds or asthma. Four years after this patient was dis-
charged completely well, he reported that he had re-
mained entirely free of asthma and colds since the
termination of the vaccine treatment.

Mrs. P., 28 years of age, was referred to me because
of arthritis, urticaria and severe angioneurotic edema,
which had started some eight months before, following
the extraction of an abscessed tooth. At various intervals
after that, four other abscessed teeth had also been ex-
tracted. Her trouble started with swelling of the fin-
gers, and then the toes and heels were affected. The
joints became red and swollen, and were very painful.
The swelling would stay a day or two in one joint and
then jump to another. Her elbows and larger joints were
not involved until later, and they were not so badly
swollen. Two or three weeks after the trouble started,
her lips became swollen, and the swelling gradually
spread to other parts of her face. At times her eye-
lids were swollen shut. The swellings stung, and were
very sensitive. Her body finally became practically cov-
ered with hives of various sizes, which lasted about ten
days. When I first saw this patient, the swellings in-
volved principally her eyes and mouth, although she
still had some on her body. Her arms, legs, and body
itched a great deal. At one time she had a very large
swelling in her throat, which was relieved by an injec-
tion of epinephrine. I also found it necessary to admin-
ister epinephrine on three different occasions, for the
relief of marked swelling about her mouth. She had not
been entirely free of urticaria or angioneurotic edema
at any time during the preceding eight months. She
stated that eating chocolate made her break out in pim-
ples. Her skin tests were all negative with the exception
of a delayed positive reaction to chocolate, and a mildly
positive reaction to orris root. She was advised to elimi-
nate chocolate from her diet, and to avoid the use of
cosmetics containing orris root. Cultures from the roots
and sockets of the last two teeth extracted showed
Streptococcus hemolyticus and Streptococcus viridans.
When tested intradermally with autogenous vaccines of
these organisms, she gave enormous reactions. The re-
action to Streptococcus hemolyticus was 4 inches in
diameter, and viridans was 2 inches across. She was
treated with these vaccines in gradually increasing doses,
and the arthritis, urticaria and angioneurotic edema dis-
appeared. This patient was so well that she voluntarily
discontinued her treatments before reaching a maximum
dose, but reported over three years later that she had
had no recurrence of the arthritis or angioneurotic
edema, although she still had an occasional small hive.

Mrs. G., 43 years old, was referred to me with angio-
neurotic edema, affecting principally her lips. The

100

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trouble had started six years before, with attacks of
swelling about the eyes, and an urticarial rash on the
neck and various parts of the body. She had had a
great many of these attacks at varying intervals; but in
the preceding year they had occurred much more fre-
quently, and her lips had become affected. The attacks
came on quite suddenly. The first symptoms noted were
itching and burning of her lips. Then the lips would
swell for several hours, until they were two or three
times their natural size. They then looked as if they
were filled with water, similar to a large blister. This
swelling was accompanied with a feeling of tightness,
and at times intense pain. After a certain amount of
swelling, the lips would break open and discharge a
sticky fluid which would dry and form crusts. When
the lips would break, the tightness would be relieved,
but naturally they were very sore afterwards. These at-
tacks would last about a week, and her nervous sys-
tem was considerably upset by them. She thought that
the trouble was due to eating sea food, but cutaneous
and intracutaneous tests for protein sensitization were
all completely negative. Her upper left first molar was
the only devitalized tooth. Even though there was
no radiographic evidence of pathology, this devitalized
tooth was extracted, and cultures from the roots and
socket showed Staphylococcus pyogenes aureus in pure
culture. She was given injections of an autogenous vac-
cine prepared from the tooth cultures, starting with a
dose of 50 million organisms and working up to a maxi-
mum of 1.5 cc. of strong vaccine. As a result, this pa-
tient was discharged well, about nine years ago, and has
had no angioneurotic edema since.

Miss M., aged 17 years, was first seen at home with
the most severe generalized eczema that I have ever en-
countered. This skin trouble had developed two years
previously, and had been moist from the start. Innu-
merable prescriptions had been tried, and also X-ray
treatments, but without any relief. When the eczema
was bad she had fever, and there was scarcely any part
of her body that was not involved. When I first saw
her, she was confined to the bed with a temperature of
101% and was broken out from head to foot. Examina-
tion revealed pus exuding from her ears, vagina and
other orifices. Her scalp was affected also. The hair was
matted down, and eventually all of it fell out. A defi-
nitely unpleasant odor was noted upon entering the sick
room. The correct dermatological diagnosis was prob-
ably infectious eczematoid dermatitis. Cultures from her
skin revealed Staphylococcus pyogenes aureus in pure

culture, and an autogenous vaccine was prepared from
this organism. Treatment was started with a dose of
100 million organisms, and was progressively increased
at weekly intervals. After her skin cleared sufficiently,
she was tested with foods and a number of environ-
mental substances, but with completely negative results.
The vaccine treatments were continued until she was en-
tirely free of skin trouble and had grown a healthy
head of hair, at which time she stopped the treatments
of her own accord. Nearly two years later, she came
back with a recurrence of the old skin trouble, although
in a much milder form. Staphylococcus aureus was
again cultured from her skin, and autogenous vaccine
injections gave the same gratifying results in clearing up
the eczema.

J. R., a boy aged 15 years, was brought to me with
typical migraine of five years’ duration. These head-
aches had been occurring on an average of once a week.
The attacks came on suddenly, yet the patient knew
when they were about to begin, as objects which he
looked at seemed not quite clear preceding these head-
aches. There was a flickering before his eyes, and he
saw lights of different colors. He would lie down in a
darkened room with his eyes closed, and the colored
lights would pass off in about twenty minutes, leaving
him with a headache which usually centered over the
right eye and lasted several hours. Several doctors, in-
cluding an ophthalmologist and a neurologist, had been
unable to find any cause for the migraine. Skin tests
were all negative, but cultures of his stool revealed large
numbers of Streptococcus hemolyticus, and an autogen-
ous vaccine was prepared from this organism. An intra-
dermal test with the Streptococcus hemolyticus vaccine
gave a moderately positive reaction, and treatment was
started with a dose of 50 million organisms. The doses
were gradually increased, and as a result of these injec-
tions the migraine headaches disappeared.

Summary

When any of the allergic diseases, namely, asthma,
perennial hay-fever, urticaria, angioneurotic edema,
eczema, or migraine headaches are due to bacterial
sensitization, they can be successfully treated with vac-
cines or vaccine-filtrates. The specific vaccine treatment
of bacterial allergy is described, and illustrated with a
few case reports.

REFERENCE

1. Brown, G. T.: The Diagnosis of Bacterial Allergy, South.
M. J., 27: 856 (October), 1934.

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101

The Control of Allergic Manifestations

By Phenyl-PropanoPAmine ( Propadrin ) Hydrochloride

J. H. Black, M. D.**

Dallas, Texas

PHENYL - PROPANOL - AMINE is a primary
amine, an analogue of ephedrine having the for-
mula phenyl- l-amino-2-propanol-l — Co H-, C H
O H-C H (NH-J CH3 and its hydrochloride is mar-
keted under the trade name of Propadrin Hydro-
chloride.

Since this drug is an analogue of ephedrine it has
been offered for use in the same field of therapy. The
present study, carried on during the autumn of 1936,
was undertaken to determine its value in the relief of
acute allergic reactions.

There were 131 patients studied, divided into the
following groups: asthma 45, seasonal hay fever 60,
perennial hay fever 18, urticaria and angio-neurotic
edema 8.

The persons with asthma, without regard to their
etiologic factors, were given the drug for relief while
their examination was going on or in order to control
or prevent attacks during treatment. The seasonal hay
fever patients all were sensitive to ragweed pollen and
approximately half of these had had no pollen therapy
or were being given co-seasonal treatment, while the
others, in spite of pollen treatment, needed added re-
lief. Those suffering with perennial hay fever were
given the drug for relief of symptoms while their exam-
ination was progressing. All those with urticaria and
angio-neurotic edema were having constant or nearly
continuous eruption and were given the drug to control
the symptoms.

It was expected that the preparation, because of its
similarity to ephedrine, would have a similar action, so
it was used in the same manner as we have used the
latter drug. In the larger number of patients it was
used to relieve symptoms present. In others it was used
in an attempt to prevent recurrence of frequent, peri-
odically recurring attacks.

Through the courtesy of the manufacturer, the drug
was supplied in capsules for oral use, and in aqueous
and oily solution, and in jelly for intra-nasal applica-
tion. The jelly was not used in the nose of the hay fever
patients because I have always felt that patients seldom
get the material high enough in the nose to give relief
from swelling of the mucosa there and that subsidence
of swelling there is essential to adequate drainage of
sinuses and comfort of the patient. Ten hay fever pa-
tients were given an aqueous solution of the drug
(one per cent) for use as nasal drops, and five used an
oily solution in the same concentration. All other pa-
tients used the drug in capsule. Capsules were used al-
most to the exclusion of other forms of medication

^Prepared expressly for the special Allergy issue of THE

JOURNAL-LANCET.

**Professor of Preventive Medicine, Baylor University.

because I have believed, in using ephedrine, that relief
obtained in hay fever by capsules lasted longer and was
more complete when obtained and made unnecessary fre-
quently repeated instillation into the nostrils, which,
after a time, may cause considerable irritation.

Patients using the solutions in the nose were in-
structed to repeat instillation every two hours if re-
quired. Those using capsules were given 24 milligrams
every three .hours if necessary and doses of 48 milli-
grams were given to many.

The hay fever patients who used the aqueous and
oily solutions in the nose reported results entirely com-
parable to those of ephedrine. As well as could be de-
termined, the degree of relief is the same and there
were as many complaints of pain after its use. One
patient, accustomed to the use of a synthetic ephedrine,
thought it better than the propadrin. The number of
patients in this group was so small that conclusions can
be only tentative.

In patients suffering from asthma and hay fever the
drug by mouth was found to have apparently the same
efficacy in relief of attacks as does ephedrine. Of the
45 patients with asthma, 26 had been using ephedrine
(usually with a barbiturate) and of these, four stated
they got better relief from ephedrine, while 15 believed
the reverse was true. The other seven could see no dif-
ference in the amount of relief obtained. The 19 who
had not used ephedrine could not make their own com-
parison but our opinion was that the relief from a single
dose came as quickly, was as definite, and lasted as
long as did a single dose of ephedrine.

One very definite advantage in the use of propadrin
was the absence of nervousness and insomnia. These
symptoms, so common after the use of ephedrine, were
seen in only three patients, and this made it possible to
use propadrin at regular intervals over long periods of
time, in this manner securing results that could not be
got from ephedrine. In othe? words, a single dose of
one drug seemed to be no more efficacious than the
other, but by its continued use many patients had relief
from propadrin which could not be got except by con-
tinued use of ephedrine. This could not be done, as a
rule, because of the unpleasant effects.

Many asthmatic patients obtained relief from doses
of 48 mgm who had no benefit at all from smaller
amounts. Even the larger doses failed to relieve severe
attacks but many attacks could be controlled by 48
mgm every three hours, which dosage could be main-
tained without ill effect. The action of the drug is rela-
tively short. Three hours seems to be the limit of effec-
tiveness and doses given that often produce no evidence

102

THE JOURNAL-LANCET

of accumulative effect. As a preventive measure it could
be administered at bed time without fear of insomnia,
but since its action was not prolonged we did not find
it preventing attacks in the early morning hours. Forty-
eight mgm doses were given to children six to eight
years of age without any unpleasant effect.

The patients suffering from urticaria and angio-neu-
rotic edema reported very satisfactory relief. The ability
to use the drug at regular intervals over long periods of
time was particularly valuable in these patients. We
have not been able to keep this type of patient free of
symptoms with other medication but consistently good
results have been had from propadrin.

The ill effects or unpleasant reactions of the drug
were few. Two patients complained of nausea without
vomiting after several doses. Three thought their ner-
vousness was slightly increased. None developed in-
somnia, even after several doses of 48 mgm at three-
hour intervals. Urinary retention was not noted in any.
Blood pressure readings were made before and after ad-
ministration of a single 48 mgm dose of the drug. In
41 consecutive patients, without regard to age, but with-
out hypertension, all showed variation not exceeding 15
millimeters systolic and no change in the diastolic pres-
sure. Five patients who each used a total of eight doses
of 48 mgm each — a total of 384 mgm — in two days
showed no change greater than 10 millimeters in their
systolic blood pressure when taken near the close of

the second day. In one patient with hypertension there
was a drop two hours after a single 24 mgm dose from
170 to 160 systolic with no change in diastolic pressure.
There were no other patients with hypertension in this
group.

Discussion

No attempt has been made to discuss in per cent the
amount of relief experienced by these patients. Since
ephedrine is so generally used and its value and limita-
tions so well known we have felt that the amount of
relief could be best expressed as compared to that se-
cured by the use of ephedrine.

While the relief obtained from a single dose is no
more than that produced by ephedrine the absence of
nervousness and insomnia make it possible to use pro-
padrin at frequent regular intervals and obviates the
necessity of combining with it a sedative. Used in this
manner the results are definitely better than can be ob-
tained by the usual irregular use of ephedrine.

Propadrin by mouth at regular intervals gives more
prolonged relief than can be secured by intra-nasal use
in solution.

The use of propadrin every three or four hours gave
more relief to the patients suffering with urticaria and
angio-neurotic edema than any other medication we have
found.

Allergy in General Medicine

Hal M. Davison, M. D.**

Mason I. Lowance, M. D.***
and

Crawford F. Barnett, M. D.****

Atlanta, Ga.

A FEW years ago we were invited to address this
society on the subject of allergy in general
medicine. On being so honored again, we ac-
cepted, because there is enough new in allergy to justify
further discussion.

In our former paper we gave a resume of allergy in
general, a discussion of anaphylaxis and antianaphylaxis
in animals, and drew an analogy between these reac-
tions and those occurring in humans. We discussed the
occurrence of the so-called skin reagin present in the
blood of allergic individuals and the process of passive
transfer. Attention was called to the general allergic
phenomena of smooth-muscle spasm, edema, increased
capillary permeability, itching, increased secretion of
mucus, cellular changes, with an increased passage of
cells into the tissues, with eosinophilia.

There is not space in this paper to go into a discus-

♦Read before the annual meeting of the Southern Student
Health Association, held at Atlanta, Georgia, June 8, 1936.

♦♦ Associate in Medicine, Emory University, Atlanta, Ga.
♦♦^Assistant in Medicine, Emory University. «.

♦ ♦♦♦Assistant in Medicine, Emery University.

sion of the allergens, nor into the various divisions of
allergy. We wish to mention, however, the types of
allergy, which may be briefly divided as follows:

1. Atopy, which includes those forms of allergy which
are supposed to be controlled by heredity, and char-
acterized by specific, circulating antibodies called
reagins. This includes asthma, allergic coryza, and
certain forms of skin lesions, e. g., urticaria and aller-
gic dermatitis.

2. Contact allergy, that form of allergy which occurs in
humans after an exposure by contact to various sub-
stances; after an interval of time, the allergic reac-
tion may be precipitated by further exposure to the
sensitizing substance. Skin reagins do not exist in
the serum of patients suffering only from this type of
allergy.

3. Drug idiosyncrasies, that type of allergy in which
there is an unusual reaction produced by the injec-
tion or ingestion of non-toxic doses of a drug, or by

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103

the application of a drug to the mucous membrane or
to the skin.

4. Bacterial allergy, sometimes called the tuberculin type
of allergy, that form of allergic reaction caused by
an injection or infection following a sensitization of
the individual by a previous injection or infection. It
is characterized by the presence of allergic manifesta-
tions, mainly in the nature of a delayed subcutaneous
reaction following injection of the proteid of the
offending bacteria and by a focal reaction at the site
of infection distant from the point of injection or at
the sites of former injections.

5. Serum sickness, that form of allergy which occurs in
about 90 per cent of white persons following the in-
jection of a foreign blood serum.

6. Physical allergy, that form of allergy produced by
such physical agents as light, heat, cold, or mechani-
cal irritations in amounts ordinarily harmless to
humans.

Attention was called to the fact that allergic indi-
viduals may be in a state of allergic equilibrium, during
which time they may come in contact with allergens
without demonstration of symptoms, and that there are
certain precipitating factors or "trigger elements” that
disturb this equilibrium and allow symptoms to mani-
fest themselves.

A discussion of heredity was given. We may state here
that certain members of the allergic society are attempt-
ing to prove that allergy is not hereditary. It is still an
open question.

During the past few years many more symptoms for-
merly unexplained have been shown to be allergic in cer-
tain patients. It is our object today to give a list of
these various manifestations that affect the different
anatomical and physiological systems of the body, and
to give a brief discussion of some of the newer methods
of diagnosis.

The main allergic manifestations that have been dem-
onstrated in the various systems are as follows:

1. Central Nervous System.

(a) Allergic headaches, without typical migrainous
symptoms.

(b) Migraine.

(d) Psychic disturbances, personality changes.

(e) Neuralgia.

(f) Transient paralyses.

2. Eyes.

(a) Eczema and edema of the lids.

(b) Conjunctivitis, with or without accompanying
allergic coryza (hay fever) .

(d) Edema of the head of the optic nerve.

(e) Keratitis and ophthalmia produced by specific
sensitiveness.

3. Nose and Accessory Sinuses.

(a) Recurring attacks of allergic coryza (hay
fever) , simulating head colds.

(b) Vasomotor rhinitis.

(d) Polypoid swelling in the sinuses.

4. Bronchi and Lungs.

(a) Allergic coughs.

(b) Asthmatic bronchitis.

(d) Transitory edema in the lung tissue.

(e) Croup.

5. Gastro-Intestinal Tract.

(a) Canker sores in the mouth.

(b) Acute gastro-enteritis, with nausea, vomiting,
diarrhea, and pain.

(c) Acute pain like cholecystitis and certain other
right abdominal symptoms in the region of the
liver, with or without slight jaundice.

(d) Peptic ulcers.

(e) Mucous colitis.

(f) Essential hemorrhages.

(g) Pylorospasm and possibly certain cases of py-
loric stenosis in the new-born.

6. Cardiovascular System.

(a) Hypertension.

(b) Hypotension.

(d) Buerger’s disease.

(e) Anginal pain.

7. Genito-Urinary System.

(a) Hemorrhagic nephritis.

(b) Renal colic, produced by spasm or edema in the
ureters.

(d) Cystitis and irritable bladder.

(e) Enuresis.

(f) Dysmenorrhea.

8. Skin.

(a) Eczema and various other dermatoses.

(b) Urticaria.

(d) Purpura.

(e) Erythema nodosum.

(f) Erythema.

(g) Itching over the body.

(h) Pruritus ani and vulvae.

9. Joints, Tendons, Muscles.

(a) Arthritis.

(b) Intermittent hydrarthroses.

(d) Muscular pains about over the body.

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10. General Manifestations.

(a) Fever without other allergic manifestations.

(b) Allergic shock.

i. Subnormal temperature.

ii. Slow pulse.

iii. Lowered blood pressure.

iv. Prolonged coagulation time.

v. Increased non-proteid nitrogen in the blood.

vi. Decreased blood chlorides, calcium, and
phosphorus.

vii. Leukopenia.

We realize that the following discussion is not orderly
and is quite disconnected, but for the sake of brevity
we cannot make a full discussion, and can only men-
tion certain new and interesting points relative to the
various manifestations listed above.

Formerly it was considered that of the headaches only
typical migraine might in some cases be allergic. It has
been proven that many headaches without nausea and
without disturbance of the speech center are allergic in
origin.

In the treatment of allergic headaches or migraine,
the patient should remain at rest in a dark room with
an ice cap on the head. A saline laxative should be given
to clear the gastro-intestinal tract of possibly offending
foods. In addition to this, the patient may be given
aspirin or a capsule containing acetanilid, pyramidon,
and codeine, or ephedrine and amytal mav be given. If
the patient is vomiting, an injection of an ampoule of
novaldin may be given intramuscularly. Gynergen, /i
cc. to 1 cc. intramuscularly, may also be used.

Cases of cerebral allergy consisting of epileptiform
seizures, psychic disturbances, transient paralyses, are
comparatively rare, but no doubt many of these cases
in the past have not been diagnosed accurately, or have
been overlooked. We wish to call your attention to some
of the cases we have seen in the last three years.

One case was a boy in preparatory school, who fell
on the football field and was brought in for examina-
tion. Nothing was found to account for his attack. It
was thought that he had stumbled and hit his head on
the ground, thus producing concussion. Later on, he had
other attacks, which were finally proven to be allergic.
This boy, while on a visit to another city, had a diagnosis
of brain tumor, and was advised to see a brain surgeon
at once. We were called, and advised adrenalin, the use
of ephedrine and amytal, and the intravenous injection
of calcium chloride. The patient recovered at once.

A girl student in a South Carolina preparatory school
came complaining of nervousness, headache, inability to
speak, and numbness with partial paralysis. We made a
provisional diagnosis of hysteria, but upon going into
the case further, discovered a marked family history of
allergy, and skin tests showed marked reactions to many
inhalants and foods. This patient has had no more
attacks.

A young lawyer complained of attacks of headache,
dizziness, followed in one instance by unconsciousness,
and in others by weakness and inability to say what he

wished to say. He had discovered for himself that his
attacks followed the ingestion of eggs and sea food.

No doubt other cases have passed by us unrecognized.

In treating allergy of the nose and accessory sinuses,
the surgeons have become much more careful about the
use of operative treatment. It has been proven that many
cases with symptoms simulating sinus disease or of
polyps in the sinuses may be allergic in origin. The
work of Alexander and of Hansel of St. Louis has
shown that ionization is not the proper treatment for
allergic coryza, that in some cases it actually does harm,
and that it does not prevent return of symptoms within
a few weeks or a few months.

It has been shown in the last few years that foods
often play a part in the production of allergic coryza.
Previously, patients with seasonal allergic coryza had
been treated only by injections of pollen extracts. Rinkel
and others have been instrumental in determining that
many cases of season allergic coryza free of symptoms
and adequately treated by the pollen extracts develop
severe symptoms when eating foods to which they are
sensitive. These foods do not cause symptoms at times
other than the pollen season. Other inhalants than
pollens to which a patient is sensitive may also cause
symptoms during the pollinating season and not at other
times. It is necessary, therefore, to use small amounts
of other inhalants, such as house dust, orris root, ani-
mal and fowl epithelial extracts with the pollen extracts
for treatment, and during the season to omit from the
diet foods to which the patient has proven sensitive.

Asthma

It is desirable to treat every asthmatic individual
early, to prevent the changes which are produced by
asthmatic attacks, that is, emphysema, chronic bron-
chitis, and bronchiectasis. Bray, of London, has called
our attention to the fact that asthma in infants and
young children is somewhat different from that occur-
ring in older children and adults. The attacks of asthma
simulate bronchitis with wheezing; fever is practically
always present, and may vary from one degree to three
or four degrees. This fact has led many physicians to
diagnose as bronchitis, bronchial pneumonia, or asthmatic
bronchitis in infants and small children what was really
a true allergic asthma. These patients should be tested
and treated from the allergic standpoint.

We believe that every asthmatic should have a roent-
genologic examination of the lungs. Tubercular infec-
tion exists in only an exceedingly small percentage of
patients with asthma, but in certain cases the physical
signs of tuberculosis are so masked by signs of asthma
that the condition is overlooked. In children, the roent-
genograms will sometimes show the existence of enlarged
tracheobronchial nodes, and in certain cases roentgen-ray
therapy through the hilum will cause the disappearance
of these nodes and relief of asthmatic attacks.

Bivings, of Atlanta, was the first to show that croup
is often caused by sensitivity to foods. This croup is
entirely prevented by omitting from the diet the offend-
ing foods, and attacks are quickly relieved by the ad-
ministration of ephedrine or adrenalin.

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105

Digestive Tract

Henry of Memphis has shown that definite symptoms
of gall bladder disease, at times with jaundice, may
occur after the ingestion of foods to which the patient
is sensitive.

Eyermann, of St. Louis, and others have conclusively
shown that certain peptic ulcers are caused by sensitiza-
tion to foods, and that these ulcers are cured by omitting
from the diet the offending foods.

Genito-Urinary Tract

We have seen cases of allergic nephritis occurring to-
gether with urticaria, angio-neurotic edema, swelling,
and pain about the joints, and at times a purpura. Some
of these cases are very severe, showing actual hemor-
rhages in the skin, and under the skin, and some of
them eventually die.

We have seen a few cases of pain in the bladder, with
the urine free of albumen and any signs of infection,
which were proved to be caused by the ingestion of cer-
tain foods.

Hypertension

Rinkel, of St. Louis, has shown that certain cases of
essential hypertension are relieved by omitting from the
diet articles of food to which the patient is sensitive,
and that the blood pressure may be immediately raised
to its former height by adding these foods to the diet.
Rinkel tells of one case in which, following a clinical
food test, the blood pressure was raised to a much higher
point than formerly existed, and there followed a hemor-
rhagic nephritis and marked edema.

Eczema and Other Dermatoses
Stroud, of St. Louis, has called our attention to the
fact that dermatoses produced by dye in clothing are
now assuming importance from an industrial standpoint
in the cases of workmen handling the clothing or en-
gaged in its manufacture, and that certain stores had
been sued by customers who had bought clothing which
caused dermatoses. According to Stroud’s account, dam-
ages were awarded the customer in some instances, al-
though neither the store nor the manufacturer was
culpable.

Urticaria

General Causes:

1. Sensitivity to foods or contactants or to drugs.
Balyeat makes the statement that 90 per cent of urti-
caria cases not due to foods are due to the ingestion
of coal-tar products. We believe this estimate too
high.

2. Focal infections.

3. Intestinal toxemias.

4. Endocrine dyscrasias.

5. Combination of the above agents.

There often exists in these cases a hypochlorhydria or
anacidity.

Especially in the female should the endocrine history
be studied. Many cases of urticaria and angio-neurotic
edema occurring at the menopause or with menstrual
irregularities are relieved by the administration of theelin
or theelin and antuitrin S. There has been one case of

urticaria reported due to the sensitization of the patient
to her own menstrual flow. This patient gave a positive
skin reaction to the extract of the menstrual flow, and
was relieved by injection of this extract. Other patients
have been shown to be sensitive to certain hormones,
such as antuitrin S and theelin.

For the non-specific treatment of urticaria we mention
the following:

Adrenalin, the injection of adrenalin and ephedrine
together, ephedrin and amytal, a capsule of aspirin,
ephedrin, amytal, and codeine, the intravenous injection
of calcium chloride, sodium thiosulphate, or hydro-
chloric acid. The best sedative is chloral hydrate; next,
the subcutaneous injection of sodium luminal. Some
patients are relieved by the administration of pancreatic
extract by mouth. Others have been relieved by the sub-
cutaneous and intravenous injection of 5 per cent pep-
tone, and by the use of the coliform vaccine of Coke.
Still others have been relieved by the subcutaneous or
intravenous injection of distilled water as advised by
Schatz. For local relief, 2 per cent menthol ointment,
vinegar and soda baths are helpful.

Purpura

Certain cases of purpura and cases showing the clini-
cal manifestations of purpura with joint symptoms have
been definitely proven to be due to the ingestion of
foods.

Pruritus

Certain cases of pruritus ani and pruritus vulvae have
been proved to be due to foods, chocolate being the most
frequent offender.

Arthritis

There is no doubt that certain cases simulating arth-
ritis and fibrositis are due to sensitivity to foods. We
have had opportunity to observe closely one patient in
whom pain and edema around various joints of the body
occurred, edema about the tendon sheaths with pro-
duction of a friction rub simulating pleurisy, after in-
gestion of chocolate.

The serum reaction of painful and swollen joints is
well known, and we have seen this occur in practically
all joints of the body, including the temporomandibular
joint. In one patient this latter joint was so severely
affected that there was a question of the presence of
tetanus.

Fever

Different physicians have reported the prolonged oc-
currence of fever proved to be due to sensitivity to foods,
and relieved by omitting these foods from the diet.

We have already discussed in a former paper the
diagnosis of allergy through history, physical examina-
tion, laboratory tests, roentgenologic examination, and
skin tests. Details of these will be omitted here. We have
also discussed conjunctival tests, nasal tests, and the test-
ing of infants and very ill patients by passive transfer.
Patch tests for contact allergy have also been described.

We wish to say here that limiting too strictly the
number of tests made is one of the most frequent hin-
drances to correct diagnosis and treatment.

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It has been determined by clinical experience that skin
tests are almost 100 per cent perfect for sensitivity to
the inhalants, but are probably no more than 50 per cent
perfect for sensitivity to foods. It has proven impossi-
ble to produce clinical reactions by feeding some of the
foods to which the patient gives a strong skin test, and
other foods giving no skin reaction at all to the test
may produce strong clinical reactions when fed to the
patient. This has necessitated the use of other methods
for determining food sensitivity in a practical manner.
The Leukopenic Index of Vaughan
Vaughan and others have shown that when a food to
which a person is sensitive is ingested, there is usually
produced a leukopenia instead of the usual leukocytosis
following ingestion of ordinary foods. The method in
general is as follows:

The patient fasts for at least five hours. He is then
given a fairly large quantity of the suspected food, pre-
pared in such a manner that it can be easily absorbed.
The food should be taken in five minutes’ time. A leuko-
cyte count is made just before the food is taken, then
every 20 minutes or every 30 minutes (according to
various methods) for three or four times. A graph of
the counts is plotted, using for a base line the original
count. Different investigators have worked out the in-
terpretation of the various curves obtained.

The use of the clinical history of the patient, the
results of the food skin tests, and the results of the
leukopenic index combined have proven to be about 90
per cent perfect in determining sensitivity to foods.

It has been also shown that when a patient eats food
in the manner described for the leukopenic index, very
often an immediate clinical allergic reaction is produced.
This is called the clinical food test, and, when positive,
is one of the most useful of all the tests.

Treatment

The treatment of allergic conditions may be divided
generally into two approaches, specific and non-specific.
Specific therapy consists of:

1. Avoidance of offending substances.

(a) Foods as indicated by the tests.

(b) Inhalants shown to be positive for the patient.

2. Injection of extracts of inhalants with which contact
cannot be avoided, and which are most important in
the individual case.

Non-specific treatment consists of:

1. Avoidance of so-called "trigger elements” or precipi-
tating factors, such as humidity, cold, night air, emo-
tional upsets, infections, toxemias.

2. General treatment of the patient from the standpoint
of mental hygiene, physical hygiene, nutrition, and
the like.

3. Drug therapy, varying with the different manifesta-
tions, but consisting mostly of the use of adrenalin,
ephedrine, synthetic preparations such as neosyneph-
rin and benzedrine; the use of a 1-100 solution of
adrenalin by inhalation for asthma; the iodides and
arsenic orally or intravenously.

4. Non-specific proteid therapy, such as the use of pep-
tone and histamine.

5. Ether anesthesia, usually by rectal instillation of ether

and oil for status asthmaticus.

6. Vaccines.

7. Intrabronchial injection of iodized oil for the relief

of asthma.

8. Inhalation of helium and oxygen for relief of asthma.

In certain cases of asthma it may be necessary to use

morphine or some derivative of morphine, but most
allergists believe that the use of morphine with adrenalin
is dangerous, and that it should be used only with great
care.

In any case of allergy in which other treatments have
failed, the physician is justified in trying blood transfu-
sion. This measure is not without its danger, and it is
preferable that the donor be starved for 24 hours before-
hand to be sure that his blood will contain as little as
possible of food elements to which the patient might be
sensitive.

Pregnancies and intercurrent diseases give no contra-
indication for the treatment of allergic diseases.

Causes of failure are, in general, as follows:

1. Incomplete testing.

2. Insufficient hyposensitization by using too weak
solutions of the allergens or by not using them long
enough.

3. Using too strong solutions of the allergens and
producing symptoms by injection.

4. Failure to take into consideration precipitating
factors.

5. Non-co-operation on the part of the patient.

Prognosis

As a whole, the prognosis in allergic diseases is much
better than that in other chronic diseases. We believe
that the causes of more than 70 per cent of cases of
asthma may be diagnosed, and a large percentage of
these cases can be either completely relieved or partially
relieved. Certainly a fair percentage of those not spe-
cifically diagnosed can be helped by non-specific treat-
ment. More than 80 per cent of cases of non-seasonal
allergic coryza can be diagnosed, and more than 90 per
cent of the cases of seasonal allergic coryza can be diag-
nosed. Practically all of these diagnosed allergic coryza
cases can be given enough relief to make the treatment
worth the patient’s while.

In cases of asthma and of allergic coryza, we believe
it is wise for the patient to take treatment over a mini-
mum of one year, and preferably for three years.

We cannot give such an accurate estimate of prog-
noses in other forms of allergy. Practically all the few
cases of cerebral allergy that we have seen have been
diagnosed and relieved. A fair percentage of the allergic
headaches and most of the cases of urticaria have been
relieved by either specific or non-specific treatment. With
the other forms of skin lesions we have not been so
fortunate.

In general, the outlook has grown brighter for allergic
diseases as the years have added knowledge concerning
the production of symptoms, and have produced better
extracts for testing and treatment and better methods
for the relief of symptoms by non-specific medication.

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107

Surgery of the Tonsils

From the Anatomic Point of Vieiv

Joseph H. Kler, M.D.*

New Brunswick, N. J.

SURGERY of the tonsils has been discussed so fre-
quently that it seems almost out of place to try
to interest anyone in such a protean subject as
tonsils and tonsillectomy. Certainly it is devoid of the
spectacular but it can be a most interesting and fascinat-
ing surgical procedure.

Rutgers University freshmen are thoroughly exam-
ined. During these examinations we see the results of
tonsillectomies done in our average communities. Most
are done by general practitioners, some by general sur-
geons and few by properly trained otolaryngologists.
If we judge this operation by the completeness of re-
moval, symmetry of structures of the throat and lack
of injury to adjacent structures we find rather few good
tonsillectomies.

There are many reasons for this, including Mother
Nature, who was most unkind to the tonsils in leaving
them so exposed to the vicissitudes of bacteria and the
medical profession. Had nature placed them deeper in
the tissues of the neck, tonsil surgery would be a defi-
nitely accepted major surgical procedure. As it is to-
day, it is "only a tonsillectomy” that "can be done by
anyone” including the quack. So many instruments are
on the market that are supposed to do everything per-
fectly. Each manufacturer guarantees his product to
remove the tonsil in one fell swoop and leave all other
structures uninjured. These factors are the principal
reasons for unsatisfactory tonsil surgery by the profes-
sion. We can expect no better results until tonsillectomy
is considered a major surgical procedure. To do so, the
otolaryngologist must place tonsil surgery on a plane
that is scientifically correct and to be so it must be
based on sound surgical principles which respect ana-
tomic structures. Only then will uniformly good results
be assured.

The tonsil is a modified cylindrical mass of lymphoid
tissue, situated in the tonsil recess, having a hood-like
appearance superiorly and blending with the plica tri-
anularis inferiorly. Its deep surface is enclosed in a
fibrous capsule and its free surface is covered to a vary-
ing degree by prolongations of the capsule called plicae,
over which lies a layer of mucous membrane. The tonsil
arises1 in the ventral part of the second inner branch-
ial groove. During the third month, epithelium grows
into the underlying connective tissue in the form of a
hollow bud. This forms a crypt from which secondary
buds and crypts develop. Lymphoid cells wander into
this structure from the neighboring blood vessels and
epithelium. Distinct lymph follicles with germinal cen-
ters are formed by the third month after birth. These

•Infirmary, Rutgers University, New Brunswick, N. J.

lymph nodules continue as germinal centers' as long
as the tonsil remains normal. However, when the tonsil
becomes irritated the germinal centers quickly become
reaction centers. If the irritation is severe enough, only
phagocytosing reticular cells are produced. When the
tonsil must be a reaction center too long it becomes a
definite menace.

If we could only approximate the faucial pillars the
tonsil would be more nearly like a typical lymph node —
a mass of lymphoid tissue completely enclosed in a cap-
sule. But Nature split these pillars and the free ends
of the capsule became prolonged and inserted them-
selves into the free margins of the pillars and into the
lateral aspect of the base of the tongue. Fowler and
Todd3 consider the capsule an artefact but if we con-
sider the capsule proper and the muscle fascia of the
tonsil fossa as one entity and call both layers of fibro-
elastic connective tissue the capsule, these structures will
have greater surgical significance. The tonsillar layer is
firmly attached to the tonsil by various trabeculae. One
of the trabeculae is so large that it practically divides
the tonsil into a larger upper lobe and a smaller inferior
lobe. This may well represent the hilum of the tonsil.
The other layer of the capsule is closely adherent to the
palatoglossus and palatopharyngeus muscles. The two
layers of the capsule are held together very loosely at
the upper pole and quite firmly at the base. However,
Wood4 found firm longitudinal attachments between the
two layers of the capsule which ran in the direction of
the muscle fibers. Below the equator, at the hilum of the
tonsil, the two layers of the capsule are firmly attached
to each other by fibrous bands, blood vessels, lymph
vessels, nerves and the tonsillopharyngeus muscle de-
scribed by Fowler and Todd3. This muscle consists of
fibers from the lateral part of the palatopharyngeus
muscle. Its size varies greatly. Jason° found that repair
within tonsils occurs as an ingrowth of granulation tis-
sue from the capsule, trabeculae or marginal sub-
epithelial connective tissue. Thus we may have distor-
tion of the normal produced by tonsillar as well as peri-
tonsillar infections and scar tissue may bind the two lay-
ers firmly at any points.

The histology of the plicae is of great surgical im-
portance. The posterior and semilunar plicae have little
lymphoid issue. The lymphoid tissue found has few
deep crypts — altogether unlike that of the faucial ton-
sil. Unless there is much lymphoid overgrowth, both
plicae should be preserved. The semilunar plica is of
particular importance in the post-operative cosmetic re-
sult. The triangular plica is much larger and contains
lymphoid tissue which resembles that found in the

108

THE JOURNAL-LANCET

faucial tonsil. Fetterolf1' described it as arising from the
free margin of the anterior pillar as a triangular fold
whose apex blends with the palate while the base is in-
serted broadly into the lateral aspect of the tongue. The
tonsil blends with this plica and we find typical tonsil
crypts in its lymphoid tissue. There may be depressions
or tonsillar fossae between the lymphoid tissue of the
plicae and the tonsil mass proper. The superior fossa is
most constant, the anterior next most constant, and the
posterior least constant. Sasaki' recommends naming the
superior fossa. This seems unnecessary since the fossae
have no anatomic significance and should have no sur-
gical importance because they are intratonsillar furrows.

The arteries of the tonsil are characterized by an un-
usually thick tunica elastica internas. This permits them
to contract effectively when severed. Scar tissue in the
capsule may interfere with this mechanism. The ton-
sillar arteries are all ultimately branches of the external
carotid artery. Brunner and Schenerer', among many
others, emphasize that all types of variations in the
location, number and origin of these vessels mav be
found. Fetterolf’ pointed out the most frequent points
of entrance into the tonsil of these various branches.
Therefore, surgically we have superiorly a small branch
of the descending palatine entering the tonsil. Birket10
also reports a small branch from the small meningeal
entering at this point. These vessels rarely produce
bleeding either at operation or after. Anteriorly a small
branch of the dorsal lingual enters the tonsil just below
the equator. Usually it is small, but in tonsils that have
had repeated infections this artery may be quite large
and can be seen just inside the anterior pillar. Posteriorly
a moderate sized branch of the ascending pharyngeal
enters the tonsil just posterior and inferior to the hilum
of the tonsil. This vessel is seen in the posterior recess
of the palatopharyngeus muscle. Even though this is a
small vessel it is frequently injured and frequently
causes annoying hemorrhage. Inferiorly we have a group
of arteries. They are tonsillar branches of the external
maxillary, dorsal lingual and the ascending palatine.
The arteries entering the lower lobe are usually the
largest. They all course upward in the plica triangu-
laris and enter the tonsil at the hilum, as a rule. If the
plica is removed at its insertion these vessels contract
well and very little bleeding takes place.

The venous drainage is by a plexus of veins in the
wall of the recess. The largest vein starts at the upper
pole and courses downward practically in the midline of
the recess. Frequently this vein is found between the
two layers of the capsule and when so found it is very
easily injured. These veins join veins from the epig-
lottis and tongue to form a large trunk which joins the
pharyngeal plexus of veins.

A typical lymph node has afferent and efferent
lymphatic channels. Recent studies seem to disprove
the presence of afferent channels to the tonsil.22,
23, 24. However, the lymphatics of the tonsil10 are con-
nected with the adjacent areas of mucosa in the
pharynx, mouth and lower part of the nasal cavity.

They pass chiefly to the upper cervical lymph nodes.
One of these nodes is situated just behind the angle of
the jaw beneath the anterior edge of the sternomastoid
muscle. It is called the tonsillar lymph gland by Wood.

The sensory nerve supply is very abundant.11 The
most important branches comes from the glossopharyn-
geal nerve and the sphenopalatine ganglion. Most of
these branches enter the tonsil at the hilum. There are
also several branches from the posterior palatine nerve
which supply the upper lobe of the tonsil.

The tonsillar recess is formed by the palatoglossus
and palatopharyngeus muscles and limited superiorly by
the soft palate. The function of the two muscles is to
control the soft palate although the palatoglossus muscle
plays a minor role. The palatopharyngeus muscle is very
important. Fowler and Todd describe it as an inner
sheath of muscular fibers disposed vertically forming
a continuous layer around the pharynx between the sub-
mucosa and the superior constrictor. Above it is at-
tached to the soft palate, Eustachian tube and base of
the skull. Below the fibers lose themselves in the upper
esophageal wall. This muscle may be reinforced by the
stylopharyngeus. The lateral part of this muscle is of
particular interest. It arises from the soft palate as far
laterally as the hammular process. A reduplication of it
forms the posterior pillar. In front the muscle merges
with the buccopharyngeal fascia. The tonsillopharyngeus
muscle is composed of muscle fibers from the lateral
portion of the palatopharyngeus muscle which pierce
the two layers of the capsule to enter the tonsil at the
hilum.

At the extreme lower pole the palatoglossus
and palatopharyngeus muscles are quite thin. They are
joined here by the tendons of the muscles attached to
the styloid process. The lingual and glossopharyngeal
nerves are also quite superficial in this area.

Even though mild injury of the faucial pillars usu-
ally produces no symptoms, every effort should be made
to preserve them intact. Dorrance12 reports repairing a
post-tonsillectomy stricture of the oropharynx. It is not
unusual to see retractions of the soft palate, due to
destruction of the posterior pillar, which produce defi-
nite but not unbearable symptoms. Frequently we see
speech defects as the result of destruction of pillars
and the soft palate. Lyons13 states that the quality of
sounds produced depends upon the ability of the tongue
and velum to stop the air column as needed. Any ob-
struction or abnormality in the mouth or pharynx may
cause a speech defect of some degree. Makuen14 also
points out the effect upon speech of various post-
tonsillectomy abnormalities of the pillars and soft pal-
ate. Pillars are most frequently injured by the inju-
dicious use of any guillotine type of instrument. How-
ever, the snare can produce extensive injury to the
posterior pillar if the tonsil has not been properly dis-
sected. Injury of the deeper layer of the capsule is
always potentially dangerous. As long as the capsule is
intact it is an excellent barrier to the spread of infec-
tion. Comer13 reports a case of cavernous sinus throm-

THE JOURNAL-LANCET

109

bosis in a child following a tonsillectomy with a Sluder
instrument. In this case there was an injury of the cap-
sule. Schaeffer and Carmack found seven cases of fatal
hemorrhage occurring at or shortly after tonsillectomy
due to injury of aberrant or anomalously placed internal
carotid arteries. Salinger and Pearlman10, in a very
exhaustive study of hemorrhage from pharyngeal and
peritonsillar abscesses, found that the internal carotid
artery is closer to the posterior pharyngeal wall than any
large vessel. The internal carotid artery normally makes
several curves in its course in the neck which may be-
come exaggerated into tortuosities that will bring it into
close proximity with the pharyngeal mucosa. True
aneurysm of the internal carotid artery is rare but it is
frequently the site of aneurysmal dilatations due to
trauma or infection. We may add that if the deeper
layer of the capsule is left intact, severe hemorrhage
from severed tonsillar arteries is uncommon because the
fibroelastic connective tissue of the capsule assists the
tunica elastica of the severed arteries to seal off the
lumen. Kenn1' reports less bleeding in the guillotine
tonsillectomy in children. This is due as much to the
separation of the two layers of the capsule as to the
crushing effect of the dull blade.

One of our confreres--' reports cutting off a long
styloid process, which encroached upon the tonsil cap-
sule, with a Sluder tonsillectome.

It would seem quite reasonable to conclude that care-
ful dissection under direct vision should always prevent
injury to the pillars, soft palate, aberrant or anomalously
placed internal carotid arteries and if carefully done it
should uniformly prevent injury to the muscle layer of
the capsule.

It would be most presumptuous of me to try to tell
you how to remove tonsils. Skillern18 recommends the
LaForce tonsillectome in all cases except those too diffi-
cult for this method. The tags to be removed with a
snare. Mathews11' recommends the dissection and snare
method, making his incision before grasping the tonsil
with a forcep. Colson1’0 strongly recommends the suc-
tion tonsillectomy but states that it has the disadvan-
tages of the Sluder in that it cannot be used in all in-
stances. Dutrow-1 believes the dissection and snare
method to be the best because it is applicable in all
cases. And so we could go on almost endlessly. Each
one is convinced that his method is the very best. It is
the best if it is scientifically correct and if it uniformly
assures good results. To be scientifically correct it must

be based on sound surgical principles which respect ana-
tomic structures. No instrument made can possibly have
surgical judgment, nor can any one instrument be ex-
pected to remove a tonsil completely if we recall the
variations in the size, shape and position of the tonsil
and its relation to surrounding structures. Any method
can be considered a good method if in the hands of the
reasonably skilled surgeon:

1. The entire tonsil structure will be removed;

2. All other structures will remain uninjured;

3. After operation the throat will be symmetrical, and

4. If the method is simple, rapid and applicable in
all cases to permit the operator to develop proficiency
and thus give him a sense of security so necessary in
surgery.

Bibliography

1. Bailey and Miller: Text Boole of Embryology, Wm. Wood
6C Co.

2. Hoepke, H.: Function of Healthy and Diseased Tonsils,

Ztschr. f. Laryng., Rhin., Otol., 22: 1, 1932.

3. Fowler, R. Qc Todd, T.: The Muscular Attachments of the
Tonsil, J. A. M. A., 90: 1610 (May 19), 1928.

4. Wood, G. B.: The Peritonsillar Spaces, Arch. Otolaryng.,
20: 837 (Dec.), 1934.

5. Jason, R. S.: Pathologic Changes in the Human Palatine

Tonsil.

6. Fetterolf. G.: The Anatomy and Relations of the Tonsil in
the Hardened Body, with Special Reference to the Proper Con-
ception of the Plica Triangularis, the Princioles and Practice of
Tonsil Enucleation as Based Thereon, Am. J. of Med. Sciences,
Vol. 144 (1932).

7. Sasaki. M.: Fossa Supratonsillaris, Arch. f. Ohrenh, Nasen-u,
Kehlkopfh, 134: 89, 1933.

8. Brunner, H.: Structure of Arteries and Veins in the Ton-
sillar Capsule, Monatschr. f. Ohrenh. 66: 1335, 1932.

9. Brunner, H. 6C Schinerer, J.: Arteries of the Palatine Ton-
sils, Monatschr. f. Ohrenh, 66: 1 180, 1932.

10. Birkett, H.: In The Nose. Throat and Ear and Its Dis-
eases, by Jackson and Coates, Saunders Co.

11. Trotter, H.: Local Anesthesia in Tonsillectomy, Arch. Oto-
laryngol, 15; 435 (Mar.), 1932.

12. Dorrance, G.: Treatment of Strictures of the Oropharynx,
Arch. Otolaryng., 14: 731 (Dec.). 1931.

13. Lyons, D. : Relationship of Oral and Pharyngeal Abnor-

malities to Speech, Arch. Otolaryngol, 1 5: 734 (May), 1932.

14. Makuen, G : Relation of the Tonsil Operation to the Soft
Palate and Voice, Transactions of the Am. Laryngol. Assoc., 1911.

15. Comer, M.: Cavernus Sinus Thrombosis in a Child Fol-
lowing Tonsillectomy, Arch. Otolaryngol, 13: (May), 1931.

16. Salinger &£. Pearlman: Hemorrhage from Pharyngeal and

Peritonsillar Abscesses, Arch. Otolaryng.. 18: 464 (Oct.), 1933.

17. Keen, J.: Abnormal Hemorrhage After Tonsil and Adeno:d
Operation, J. Laryngol. QC Otol., 46: 297, 1931.

18. Skillern, S.: The Last Word in Tonsillectomy, Va. Med.
Monthly, 1928.

19. Mathews, J.: Tonsillectomy, J. A. M. A., 66: (Feb. 12).
1916.

20. Colson, Z.: Suction Tonsillectomy, New England J. Med.,
May, 1932.

21. Dutrow: Arch. Otolaryng.. 9: 5, 1929.

110

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Burbot Liver Oil As An Antirachitic

(Preliminary Study)

Thomas Myers, M. D.*

St. Paul, Minn.

THE valuable role played by cod liver oil as an
antirachitic substance was discovered empirically
by British and Scandinavian fishermen centuries
before vitamin D was recognized as the specific factor.
Its use in rickets was first reported by Schuette in 1824,
although its specific value remained unrecognized for
almost a century.

During the past decade considerable effort has been
expended in developing preparations containing vitamin
D in greater concentration than is exhibited by cod liver
oil, thus increasing potency and palatability. Beginning
with irradiated ergosterol, which offered an artificially
prepared vitamin D, and extending down into halibut
liver oil, as well as the oils from various other sea fish,
numerous workers have labored to perfect concentrates
which would provide both A and D vitamins of high
potency in small bulk. Until very recently, oils of
therapeutic value had been obtained only from fish of
marine origin.

While most inland fish possess these vitamins in small
amounts, it was not until 1922 that McCollum1 demon-
strated that the liver oil of the burbot, a fish commonly
found in our northern lakes, exhibited antirachitic
qualities of high order, as well as the power to over-

•Instructor in Pediatrics, University of Minnesota.

come xerophthalmia effectively. In 1922, Glow and
Marlott-’ used burbot liver oil on rachitic rats, and con-
cluded that it was eight times as effective as cod liver
oil. In 1932, Nelson, Tolle and Jamieson'1 investigating
the burbot for the U. S. Bureau of Fisheries, stated
that in experimental rickets, its liver oil was from three
to four times as potent in vitamin D, and from four to
ten times in vitamin A, as in good grades of cod liver oil-

The burbot, or lawyer fish ( lota maculosa), is the
only fresh water relative of the cod, being found
abundantly in the majority of the northern rivers and
lakes of this continent. It occurs in New England, the
Great Lakes region, north to the Arctic sea, and is also
found in northern Europe and Siberia. It is assumed
that the burbot, at one time a salt water fish, remained
in the residual waters when the sea receded from the
North American continent, and became adjusted to
fresh water conditions. The burbot is found in enor-
mous numbers in the Lake of the Woods, where it
breeds prolifically, and is very destructive to game fish.
It weighs about three pounds, ten per cent of which is
represented by the liver. This yields from 30% to
60% of oil. The vitamin content of burbot liver oil has
been assayed at 4500 units of vitamin A, and 640 units
of vitamin D per gram, or about eight times greater
than the requirements for cod liver oil as stated by the
Council on Pharmacy and Chemistry of the American
Medical Association.

The medicinal application of burbot liver oil finds its
most useful place in the treatment and prevention of
rickets. While the growth-stimulating, anti-infective
and anti-xerophthalmic qualities of its vitamin A content
are of considerable value, the tendency for rickets to
occur in over 50% of infants in temperate climes, un-
less vitamin D is included in the diet very early in life,
lends emphasis to the benefits associated with it in that
connection. It is now considered an essential part of
every infant’s regimen to add an ample amount of
vitamin D after the first month. Human and cow’s
milk have been demonstrated as insufficient protection
against rickets. Egg yolk possesses a small and vary-
ing amount of this factor. Assimilation and storage of
calcium and phosphorus cannot be adequately performed
unless additional vitamin D is provided, and the delicate
balance between these elements is easily upset in in-
fancy unless this stabilizing factor is added. Tonney4
has shown that growth, normal dentition, proper posture,
and resistance to infection are all affected when vitamin
D is lacking. Harris0 states that the most reliable

THE JOURNAL-LANCET

111

weapon in the treatment of rickets is vitamin D, as
found in cod liver oil; exposure to sunshine is insufficient
protection. Many observers have concluded that vita-
min D is likewise necessary in older children and adults,
for the purpose of promoting skeletal growth, prevent-
ing dental caries, and as a prophylactic during preg-
nancy, against maternal demineralization.

In order to test the rickets-preventing qualities of
burbot liver oil, fifty infants at the age of one to two
months were given oil in doses of ten minims once daily.
In the cases of a few premature infants, or where clin-
ical bone changes suggestive of developing rickets oc-
curred, the dose was increased to ten minims twice a day.
The infants were selected at random from those attend-
ing an infant welfare clinic, and came from families in
very modest economic circumstances or receiving direct
relief. In all cases, however, the infants made normal
gains and developed satisfactorily while under observa-
tion, for periods varying between six months and one
year. In no case did definite clinical rickets occur.
Attempt was made to have an X-ray taken of a wrist
in each case, but it was difficult to persuade the mothers
to bring their infants to the X-ray laboratory in all
cases. Fourteen of the completed group were X-rayed,
and in none was rickets demonstrable. In this con-
nection it may be worthwhile to refer to the statements
of Shelling and Hopper1’, and also Park and Eliot' on
the inadvisability of interpreting the usual clinical signs,
such as thickening of epiphyses, cranio tabes, beading
of the ribs, etc., as pathognomonic of rickets unless the
X-ray films are also positive. Park and Eliot state that
the diagnosis of the early stage of rickets is often diffi-
cult, and that to differentiate between active and cured

rickets may be impossible without X-ray. The roentgen
film is of more importance than calcium and phosphorus
determinations in the blood serum, as normal levels are
reached soon after treatment is begun. Such determi-
nations were made on a few of the infants observed in
this study, with normal findings. The accompanying
X-rays are part of a series, all showing no indications of
rickets.

Summary

1. Burbot liver oil has been presented as the first cod
liver oil substitute to be made from fresh water fish.
It possesses a potency approximately eight times that of
cod liver oil.

2. In a small series of cases, burbot liver oil gave
satisfactory anti-rachitic protection. While no definite
conclusions should be drawn from so limited a stud)’,
the possibilities of this preparation are worthy of further
investigation.

Bibliography

1. McCollum, E. V.: Studies on Experimental Rickets, Jour.
Biol. Chem. 53:293, Aug., 1922.

2. Glow, B. and Marlott, A.: The Antirachitic factor in burbot
liver oil. Industrial and Engineering Chemistry 21:281, Mar., 1929.

3. Nelson, E. M., Tolle, C. D., and Jamieson, G. S.: Chemical
Physical Properties of Burbot liver Oil. Vol. 1, Investigational
Report No. 12, Bureau of Fisheries, U. S. Dept, of Commerce,
1932.

4. Tonney, Fred O.: Vitamin D in Child Health, Am. J. Pub.
Health, 26:7, July, 1936.

5. Harris, H. A.: Cod Liver Oil and the Vitamina in relation
to Bone Growth ami Rickets. Am. J. Med. Sc. 181:453, April,
1931.

6. Shelling, D. H., and Hopper, K. B.: Calcium and Phos-
phorus Studies XII, Bull. Johns Hopkins Hosp. 58:140, March,
1936.

7. Eliot, M. M., and Park, Edw. A.: Rickets. Practice of

Pediatrics (Brennemann) Vol. 1, Chap. 36, P. 48.

112

THE JOURNAL-LANCET

The Name of the Doctor

Arthur N. Collins, A. B., M. D., F. A. C. S.
Duluth, Minn.

MEMBERS of the Northern Minnesota Medical
Association and Guests, Ladies and Gentle-
men:

It is with deep gratitude that I appear before you
on this occasion to acknowledge the high honor con-
ferred upon me when you elected me your president.
In taking my place in the list of honored physicians who
have led the way for me as presiding officers in this
vigorous organization, I cannot but feel a keen sense of
pride and a feeling of warm friendship for all its mem-
bers. It is my hope that the Northern Minnesota Medi-
cal Association will grow larger and broader each year;
larger, in the sense of increasing yearly attendance, and
broader, in that each member will come to know his
practicing confreres better and to find himself in greater
sympathy with them. It is this last sentiment which fur-
nishes the keynote for my remarks.

In this day, it is no small blessing that we belong to
a profession of such vast accomplishments and far-
reaching beneficence. Were we responsible for all this
ourselves there might be just cause for exultation. But
it is an inheritance for the greater part. Most of the
glory belongs to our predecessors. Our traditions have
been woven from the finest fibre found in our profes-
sional forefathers. Medicine today is the product of the
past and the foundation of the future.

In the past it was an infinitude of dogma and opin-
ion. In the present it is beset my incursions of economic
difficulties in bringing the best of present day scientific
medicine to all classes of our people. In the future,
medicine will be more and more scientific, but how
much of the old will suffer disproof and be sloughed
off from the curriculum of the past and of the present,
remains to be seen. Certain it is, however, that the high
ideals which have sprung from the fine characters of
our predecessors will endure through the generations of
physicians who will follow us. Atavism, or reversion to
a former type, will indeed be far removed from a pro-
fession which has shown itself to be so virile and for-
ward-looking as the medical profession. Progress in heal-
ing the sick is our tradition.

This great tradition, our dearest possession, is like a
mighty tree grown straight. The younger generation is
reared beneath it, the mature thrive in its environs and
the old die with its stalwart form still in full view.

Every thinking physician realizes before he has prac-
ticed many years that this inheritance has come to him
through no virtue of his own, and he may feel his un-
worthiness in having it thrust upon him. But he is pow-
erless to ward it off and must accept it. It was created

*Read before the Annual Session of the Northern Minnesota
Medical Association, held at Fergus Falls, Minnesota, August 31-
September 1, 1936. Presidential address.

for him by those who preceded him and it was presented
to him by an invisible hand at the time he received his
diploma. Progress must be his watchword.

Volumes have been written on the good deeds of the
doctor. He hears it at banquets and in the church. He
is reminded often that he has adopted an honorable
profession. He begins to feel pride in it and he tries
to merit the honor that goes with it.

Listen to Robert Louis Stevenson’s Eulogy of the
Doctor: "There are men and classes of men that stand
above the common herd; the soldier, the sailor, the
shepherd not infrequently, the artist rarely, rarelier still
the clergyman, the physician almost as a rule. He is
the flower of our civilization and when that stage of man
is done with, only to be marvelled at in history he will
be thought to have shared but little in the defects of
the period and to have most notably exhibited the vir-
tues of the race. Generosity he has, such as is possible
only to those who practice an art and never to those
who drive a trade; discretion, tested by a hundred
secrets; tact, tried in a thousand embarrassments; and
what are more important, Herculean cheerfulness and
courage. So it is, that he brings air and cheer into the
sick room and often enough, though not so often as he
desires, brings healing.”

The name of the doctor is buoyed up and sustained
by public opinion. He can maintain it thus, if he is
faithful to his trust. His sincerity is his safeguard. He
can make mistakes, as all men do, and be forgiven. He
is human, and all his neighbors allow for that. He has
his faults, as all have, but these are overlooked by a
generous public. Surely no man could start his career
with factors more in his favor, for the doctor has a good
name.

But, how about his regard for his fellow practition-
ers? Does he admit they have ability equal to his own,
or will he say that competition is keen and that reputa-
tions must suffer? Will he be tolerant of professional
mistakes he might discover in others? Or will he call
attention to such mistakes? Does he think, because
Doctor Newman comes to practice in Pleasantville after
Doctor Olderman, that he is the better physician? Was
Tennyson, because he came after Shelley, therefore, the
greater poet? Let us see, with such a concrete situa-
tion at hand, what befalls him.

The doctor finds himself at the crossroads. Which way
shall he take? No power on earth could make him
accuse a legitimate confrere, the maker of a mistake,
as being a quack, a crook, a criminal or a scoundrel!
But he might just suggest, partly to show his superior
knowledge, partly from his position of security, that
there was a mistake made. It is often difficult to decide

THE JOURNAL-LANCET

113

at the crossroads. A malpractice suit might result from
his words or from his attitude. If he could only re-
member at such a time what was said about doctors at
the banquet and the pride he felt at that time! Was it
meant for him only, or for other doctors, too, including
the one who made the mistake?

While he is choosing his course in this critical mo-
ment, let us see what experience has taught in such mat-
ters. If a malpractice suit is started, he will no doubt
be called upon to testify and if he "downs a competi-
tor” in this way he may have temporary exaltation. But
how can this endure in a man who has felt pride at the
banquet-talk about doctors? Are his professional friends
beginning to distrust him, or is this merely his imagina-
tion? Was that remark he may have overheard, indica-
tive of distrust on the part of his patient? It might be
imagination. But is the type of his work deteriorating?
Doesn’t he tend to work alone? Doesn’t he know of
another doctor in the same situation who became a
"down and outer,” an abortionist and a dealer in nar-
cotics? The name of the doctor is what matters.

He has been watching the doctor who made the mis-
take. Both went to the same medical school and both
received the same teaching. They are not friends now.
That mistake and the lawsuit have fostered an inferi-
ority complex in the "doctor of the mistake.” He feels
his confreres regard his work as of poor quality. He
may feel they believe him guilty of wrong doing. The
situation is so changed! He was once so cheerful and
on such good terms with his fellow practitioners! Now
he wonders whether the worry of medical practice is
worth while. Unless helped and cheered by his confreres
he may develop a mild form of melancholia reflecting
detriment not only to himself but to his family and his
entire professional following.

Each of the physicians, in an episode of this character,
can with justification devoutly wish such a nightmare
obliterated from the minds of all men, including them-
selves. It is not merely the name of doctor A or of doc-
tor B which matters so much, but the name of the doctor
in a larger sense, that name which belongs to all of us,
which suffers, doctors warring against each other in the
courts and before the public eye!

It would be in keeping with good sense to remind
ourselves, from time to time, that whereas we rejoice in
our ability to bring comfort and healing into the lives
of our patients, we have also a solemn civil responsibility
to them and to the public, and it behooves us to review
for our own good this civil responsibility in some of its
tenets which directly concern us. Every physician should
possess in his library and keep ready at hand a volume
on this subject. He should read it from time to time,
and thoroughly digest its teachings. His civil responsi-
bility in the conduct of his practice is indeed no minor
matter.

Here are a few important phrases concerning the civil
responsibility of the physician taken from a competent
authority (Mitchell of Massachusetts) : One who en

gages to undertake the performance of any duty, trust
or employment agrees to do it with honesty, skill and
assiduity. Errors of omission are treated with greater
leniency by the courts than errors of commission. Physi-
cians and surgeons must use ordinary care regardless of
whether they were compensated or not. The law in this
country does not distinguish between physicians and
surgeons.

Where the patient does not co-operate with his physi-
cian, thereby injuring himself by his own wilful or
negligent conduct, he cannot hold the practitioner re-
sponsible for the results to which he contributed and it
makes no difference whether or not the patient was pre-
vented from following the physician’s directions because
of his condition. The burden of showing a want of the
necessary skill must be proved at the trial by the patient
in order to secure judgment against the physician. On
the other hand the burden of proving contributory
negligence is on the defendant.

The law says that where a person knows the dangers
incidental to certain undertakings, he is, by law, deemed
to have assumed the risk, and consequently cannot com-
plain if injury results. From this it would seem that a
physician and surgeon can forestall malpractice suits
against himself by warning the patient of unpleasant
possibilities and expressly stipulating with him that in
such a contingency he shall not be answerable. It is
always best to tell the patient that a perfect result is by
no means certain.

It is well to emphasize the matter of care and skill;
an erroneous diagnosis does not necessarily give a right
of action to the injured party, but must have been the
result of negligence or a want of skill on the part of the
physician, though a wrong diagnosis followed by im-
proper treatment is good ground for an action for mal-
practice.

The performance of a surgical operation on a patient
whose consent has not been obtained will render the
operator liable to damages to that person. The patient
must be the final arbiter as to whether he shall take his
chances with the operation, or take his chances living
without it. Such is the natural right of the individual,
which the law recognizes as a legal one. Consent, there-
fore, of an individual, must be either expressly or im-
pliedly given before a surgeon has the right to operate.

During an operation already authorized, new condi-
tions may be discovered or may develop in the most un-
expected manner and in such emergency-cases the physi-
cian will be justified in performing an operation with-
out any consent, if the operation is necessary and ex-
pedient. The burden of proving that the operation was
not justified by consent of the proper person rests upon
the plaintiff. The law will presume, until contrary proof
has been adduced by the patient, that care and skill were
used by the physician in his treatment and the burden
of proof is upon the plaintiff to show that the physician
was negligent or unskilful.

All our experiences are made up of two elements: first,
the outward circumstance, and second, the inward in-

114

THE JOURNAL-LANCET

terpretation. Are we, at all times, competent to sit in
judgment of the motives of our brother practitioners?
Tolerance is born in some men, absent in others, and
is difficult to cultivate by many. We should guard
against self-complacency. We should seek new values in
tolerance and co-operation. We are unselfish so far as
our general group is concerned. The next step is to apply
this quality individually and to stand up for our brother
physician. We may not have fallen below the standards
of our predecessors, but is it clear that we are above
them in clarity of vision and bigness of purpose? Hu-
manity has been on this planet many thousands of years.
Our brain is apparently as large as that of the man of
the ice ages. Is our soul no greater?

The doctor, if he prays at all, let him say: make me
a competent guardian of the health of my patients and
make me charitable toward any shortcomings of my fel-
low practitioner, even as he is charitable toward me,
and should he stumble and fall, give me wisdom and
courage to lend him a helping hand.

Then as we carry on in our work from day to day
let us remember these sturdy lines fromb Robert Burns:

For a’ that and a’ that,

Their dignities, and a’ that,

The pith o’ sense and pride o’ worth
Are higher rank than a’ that.

The Use of the Vaginal Douche

In Clinical Gynecology

David W. Tovey, M. D., F. A. C. S.*

New York, N. Y.

THE selection of a suitable douche preparation is
a matter of great concern to the clinician who
treats a variety of cases of vaginal infections.
While it is true that many vaginal symptoms can only
be cleared up by the removal of deep-seated causes, the
therapeutic vaginal douche serves as an important ad-
juvant in the treatment of these cases; and in minor
infections a surprising number of cases appear to be
cured if the proper technic is used, and a suitable douche
preparation is employed.

Two major problems confront the clinician in the
selection of a douche preparation.

The first problem is to find one that has powerful
antiseptic and cleansing properties when in contact with
the vaginal mucosae and cervix. The solution must be
potent enough so that a douche prescribed twice daily
will prevent the development of bacterial infection and
maintain the curative gains obtained from office treat-
ment.

On the other hand the second problem is that the
preparation used must not be harsh or irritating even if
used in much stronger dilution than prescribed. With
the recognized carelessness of so many patients in the
matter of dosage, — as witness the numerous cases
appearing for treatment with vaginal irritation or in-
flammation due to the use of caustic or toxic douches —
the importance of this safety factor need hardly be em-
phasized.

In over a hundred cases in which I have used a douche
preparation composed of boric acid, zinc sulphate (dry),
salicylic acid, phenol, menthol, thymol, and eucalyptol,

•Clinical Professor of Gynecology and Obstetrics, New York
Polyclinic Medical School and Hospital, Fellow American Associa-
tion of Obstetricians, Gynecologists and Abdominal Surgeons.

good results have been obtained without a single
case cf burning or irritation. This combination is
not only antiseptic, but it is soothing and healing. It
readily dissolves thick tenacious mucus, and affords the
patient a sense of cleanliness and well being which was
commented on by all patients using it. The preparation
gives markedly better results than any of the newer
vaginal antiseptics such as sodium perborate prepara-
tions, etc., which have been so widely advertised lately.

Illustrative of the typical cases encountered in every-
day practice are these case histories selected from those
under consideration in this series:

Case 1 — 45 years old.

This patient has one child, and has had three mis-
carriages. She shows a negative Wassermann.

There is a six-year history of leukorrhea.

Upon examination, her cervix is eroded and enlarged,
and exquisitely tender on both sides. The uterus is re-
troverted.

Cervicitis and salpingitis present.

Her treatment consisted in douches twice a day over
a period of four weeks, during which several copper-
ionization treatments were given. Great relief after four
weeks.

Case 2 — 30 years old.

This patient complained of pain in the back, leukor-
rhea and constipation.

Menses started at twelve years, and were regular
until two months ago.

Examination showed the vagina reddened and in-
flamed and the uterus enlarged; and smears when ex-
amined in the pathological laboratory showed tricho-
monads.

THE JOURNAL-LANCET

115

The diagnosis: pregnancy and trichomonas vaginalis.

A two weeks course of treatment consisting in douches
twice a day relieved the discharge and afforded the
patient perfect comfort.

A routine check-up after eight weeks showed no re-
currence of the infection.

Case 3 — 39 years old.

The patient complained of a profuse discharge and
severe burning and itching in the vagina.

Menses started at 12 years. Last menses four weeks
ago flowed two weeks.

The patient had had no miscarriages and no child.

Upon examination the vagina appeared very inflamed,
the uterus enlarged and retroverted, the cervix swollen
and eroded.

Diagnosis was cervicitis, retroversion, metritis, vagini-
tis and gonorrhea.

The patient was under treatment for five months,
during which time douches were used every day
in addition to the causative treatment. The douches
greatly relieved the burning and purulent discharge,
and aided in the treatment of the gonorrhea, as well as
affording the patient relief and comfort.

Case 4 — 42 years old.

Profuse vaginal discharge for over a year (since last
menses) was complained of.

The patient had no child and has menopause
symptoms.

Upon examination the vagina appeared inflamed, the
cervix was not eroded. Pathological laboratory exami-
nation of smears showed no trichomonads, but colon
bacilli and Bacillus faecalis.

Diagnosis: vaginitis and menopause.

Tepid douches every other day gave relief and stopped
the discharge.

Case 5 — 21 years old.

This patient’s history: menses at 13 years, with a
history of difficulty at that time and a Caesarian section
for placenta previa.

The uterus was adherent and posterior, the cervix
small and eroded, the vagina inflamed.

Diagnosis was retroversion adherent, vaginitis and
cervicitis.

Copper ionization therapy cleared up the cervical con-
dition after eight treatments. Douches were used every
day, and the cervicitis and vaginitis were relieved in three
weeks.

Case 6 — 37 years old.

This patient complained of pain in the back, burning
and itching in the vagina, with a profuse discharge.

Examination showed the cervix not eroded, retrover-
sion adherent, the vagina and vulva inflamed.

Diagnosis; retroversion adherent, vaginitis with prur-
itus vulvae.

This patient was seen every week for a period of
eight weeks, during which time a douche was used
every other day. At the end of the eight weeks the
patient was discharged, the symptoms of infection hav-
ing disappeared.

Case 7 — 39 years old.

This patient had two children.

Menses at 1 1 years. She had had leukorrhea since
the last baby, but no pain or particular discomfort.

Examination showed the cervix severely lacerated and
eroded, with the vagina inflamed.

After diagnosis of cervicitis and vaginitis, the patient
was treated with copper ionization, coupled with daily
douches, which relieved the discharge after six weeks.

The patient was seen again two months after being
discharged, and there was no vaginal inflammation or
evidence of cervical infection.

* * * *

It was surprising to note the number of cases where
this simple treatment resulted in curing chronic condi-
tions where we had thought that the best that could be
experienced would be symptomatic relief.

The technic used was to have the patient in the re-
cumbent position with the douche bag at an elevation
of approximately four feet. A gallon1 of the solution
was used, the dosage being eight teaspoonfuls to the
gallon of warm water. After office treatment the patients
were instructed to use this treatment twice a day, and
report back at least once a week. A course of treatment
of three to four weeks was found sufficient in most of
the cases, and after this course of treatment the patient
was warned against the use of a daily douche. It has
been our experience that a great deal of harm is often
done through the use of too frequent douches, and we
have recommended the routine use of a douche not
more than two times a week after the vaginal condition
is normal.

Vaginitis, cervical erosions, cervicitis, and endocer-
vicitis, pruritus vulvae, and leukorrhea responded to the
treatment. Because it so readily dissolves thick tenacious
mucus, this douche preparation is particularly valuable
in preparing for vaginal operations, and pre- and post-
partum treatment. I use it as a routine follow-up after
cauterization and copper ionization therapy- in the
treatment of cervical pathology. It seems to aid mater-
ially in promoting healing.

In the treatment of gonorrhea the regular use of warm
douches of this preparation lessens materially the puru-
lent discharge and gives the patient a sense of cleanli-
ness and well being, in addition to providing relief from
the itching and irritation. The patient should be
cautioned to have the douche bag at a very low eleva-
tion to prevent upward spread of the infection.

In vulvitis where focal infection of the urethra,
Skene’s or Bartholin’s glands is at fault, the douche
will relieve the symptoms and prevent a spread of the
infection while basic treatment is directed at the cause.

Jacoby3 reports success in the treatment of pruritus
vulvae in which no definite etiologic cause is apparent,
through the use of subcutaneous perivulvar alcohol in-
jections.

The douche treatment of leukorrhea is naturally
symptomatic. The exceptional solvent and cleansing

116

THE JOURNAL-LANCET

powers of this preparation of boric acid, zinc sulphate
(dry)> salicylic acid, phenol, menthol, thymol and
eucalyptol, will loosen and remove even the thickest and
most tenacious mucus plugs and strands. It is particu-
larly valuable in treating leukorrhea because it thorough-
ly deodorizes and leaves the patient without self-con-
sciousness. If, as it is said,4 about seventy-five per cent
of the gynecologist’s patients visit him because of leu-
korrhea, it can readily be seen how important it is to
provide symptomatic relief while treating the underlying
cause.

It is interesting to note that in three cases of colitis,
enemas of the solution diluted one teaspoon ful to the
quart not only provided relief from the pain and dis-
comfort caused by the colitis, but seemed to exert a
marked healing effect. I am carrying my observations
in this direction further.

Summary

(1) The douche treatment of vaginal infections is
valuable in clearing up a variety of chronic conditions,
and as an adjuvant in the curative treatment of deep-
seated vaginal infections.

(2) A preparation composed of boric acid, zinc
sulphate (dry), salicylic acid, phenol, menthol, thy-
mol and eucalyptol, provides for all practical purposes
an ideal douche solution.

(3) In using the douche and prescribing for home
treatment, emphasis should be placed on the use of at
least a gallon of solution, and after the condition has
responded to treatment, the patient should be warned
against too frequent douching.

Bibliography

1. Miller, Jeff; Clinical Gynecology (Mosby 6c Co., 1932).

2 Tovey, D. W.; American Medicine; November, 1932.

3. Jacoby, Adolph; American Jour. Obs. Qc Gyn.; 29:604, 1935.

4. Kostmayer, H. W. ; Southern Med. Jour. 28:931, 1935.

BOOK NOTICES

PHARMACEUTICAL CHEMISTRY

A Text-Book of Inorganic Pharmaceutical Chemistry, by CHARLES
H. ROGERS. D.Sc. (Pharm.); 2nd edition, revised, heavy
cloth, gold-stamped. 724 pages, 5 5 engravings; Philadelphia;
Lea 8c Febiger, Inc.: 1936. Price, #7.00.

The physician does not see many works on pharmaceutical
chemistry after he leaves medical school. It were better that he
did, for medicine is more and more appealing to the chemist
for the solution of many problems which in other years seemed
to demand surgical or medical treatment.

Dr. Rogers, the newly-elected dean of the College of Phar-
macy of the University of Minnesota, and professor of pharma-
ceutical chemistry, has done a thorough revision of his stand-
ard text. The 11th decennial revision of the U. S. Pharma-
copoeia and the 6th revision of The National Formulary, both
issued in June, 1936, demanded that many changes be made in
all pharmaceutical texts. Dean Rogers has altered the material
on tests for identity, assays, pharmaceutical preparations, phar-
macological actions, etc. The latest processes in commercial
programs for producing chemical compounds are presented.

This is an excellent pharmaceutical chemistry text, not in-
tended to replace any works on general chemistry; it is now
thoroughly up-to-date. The general physician will find it very
helpful to him: it will sharpen his perception, and add to his
knowledge.

ENDOCRINE SYMPOSIUM

The Medical Clinics of North America. Volume 20, Number 2;
St. Louis Number, September. 1936: 3 50 pages. 24 illustrations,
grey cloth, gold-stamped; Philadelphia: The W. B. Saunders
Company: 1936. Price, yearly issue from July 1936 to May
1937, paper, #12.00; cloth, #16.00.

This is the St. Louis number of the justly-famous Medical
Clinics. It contains such treatises as Cyril M. MacBryde’s
on Borderline Endocrine Disturbances, Max Deutch’s on The
Diagnosis and Treatment of Endocrine Infantilism, Harold
A. Bulger’s Endocrine Obesity, and Louis F. Aitken’s Diag-
nosis and T reatment of Hyperinsulinism. David P. Barr and
Kurt Mansbacher have an article on The Treatment of
Pituitary Insufficiency and Hyperfunction.

These clinics appear regularly in bound form, and are now
too well-known to evoke extended comment. In most cases, the
material contained in them is much in advance of similar work
offered in current medical journals and books; and the treatment
given the subjects by their authors is exhaustive. The book
will be very valuable to the endocrinologist.

BALYEAT on allergy

Allergic Diseases: Their Diagnosis and Treatment, by RAY M.
BALYEAT, M.D.; 4th edition, 132 illustrations, 48 5 pages plus
index, green pebbled cloth; Philadelphia: The F. A. Davis Com-
pany: 1936. Price, 36.00.

The well-known allergist and head of the Balyeat Clinic in
Oklahoma City presents here a revision of his standard text
which appeared a number of years ago. Naturally, the more
recent phases of allergy are given first attention. The use of
iodized oil, for example, in cases of intractable asthma, is dis-
cussed at length; and the great advances made in the study of
allergy in dermatology and gastroenterology are covered by
Balyeat rather carefully. As in the first and subsequent edi-
tions, there is a history of the subject itself; but it is not
exhaustive. The index is good, and the illustrations are well-
chosen.

NEW OBSTETRICS TEXT

A Textbook of Obstetrics, by EDWARD A. SCHUMANN, A.B .
M.D. , first edition, 780 pages, and 581 illustrations on 497
figures; Philadelphia: The W. B. Saunders Company: 1936.

Price, 36.50.

This is strictly a text. By that is meant that few historical
aspects of the subject are offered, and no unproved or untried
theories are discussed. The volume does present, however, the
anatomy of the female reproductive organs, a short description
cf the fertilization of the ovum, the growth of the fetus and
its physiology. Section II concerns pregnancy; Section III is
given over to the mechanism of labor; Section IV to obstetri-
cal pathology; Section V to the pathology of labor; Section VI
to the accidents of labor: and Section VII to operative obstet-
rics. It is a pleasure to behold the illustrations by Olive
Stoner and A. L. Comrie.

Professor Schumann has produced an excellent short ob-
stetrics textbook, which it is a pleasure to recommend. Its mod-
est cost is a surprise.

A BEAUTIFUL MEDICINE BOOK
The Practice of Medicine, by JONATHAN CAMPBELL MEAK-
INS, M.D., LL.D.; 1st edition, red cloth, gold-stamped, 1,310
pages plus index, 50 5 illustrations, of which 3 5 are in color:
Saint Louis, Missouri: The C. V. Mosby Company: 1936. Price,
310.00.

This is a volume which it is a delight to recommend. It is
outstanding in every way; but particularly so in the manner in
which the author has chosen to use the pictorial method of
enlightenment. This is a book primarily intended for the gen-
eral practitioner and the medical student; and the specialist is
therefore slighted in the interests of more extended inclusion in
the field of general medicine. This is admirable. Enough texts
have been written for the specialist; too many "medicine" books,
in fact, have leaned heavily toward the favored specialty of the
author concerned.

The author is professor and director of the department of
medicine of McGill University in Montreal, Canada.

The Official Journal of the

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South Dakota State Medical Association The Sioux Valley Medical Association American Student Health Association

Montana State Medical Association Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman , Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

Dr. J . O. Arnson
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Dt. Frank I. Darrow
Dr. H. S. Diehl
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Dr. J. A. Evert
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BOARD OF EDITORS

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Dr. A. S. Rider
Dr. T. F. Riggs
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Dr. C. A. Stewart

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LANCET PUBLISHING CO., Publishers

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84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., March, 1937

THE INCREASING SCOPE OF ALLERGY

Few discoveries in biology have had a greater in-
fluence upon clinical medicine than the phenomena of
anaphylaxis. Following closely upon this discovery at
the turn of the present century astute observers began
to explain on this basis certain maladies to which the
human race has long been subject and for which no
satisfactory relief measures had yet been devised.
Meltzer in 1910 called attention to the similarity of
anaphylactic shock induced in guinea pigs and the
paroxysm of bronchial asthma occurring in human
beings. Koessler independently of Meltzer concurrent-
ly made a similar observation and in 1913 reported a
case of asthma caused by hypersusceptibility to hen’s
eggs. Although subsequent investigations have uncovered
technical differences in the mechanism of allergic mani-
festations of human beings and anaphylactic shock ex-
perimentally induced in guinea pigs, it must be admitted
that they are at least very similar. Notwithstanding
the technical differences involved, allergy in human
beings depends as does anaphylaxis upon the develop-
ment of a peculiar hypersensitiveness to foreign sub-
stances. Whereas anaphylaxis in animals is experiment-
ally induced only with foreign proteins, allergic shock
in human beings occurs with protein and non-protein
substances.

With proof of the allergic basis of true bronchial
asthma, investigators soon reported other conditions due
to hypersensitiveness. Hay fever, eczema, uriticaria,

angioneurotic edema, vasomotor rhinitis, migraine, cer-
tain forms of dermatitis, and certain gastro-intestinal
reactions seem definitely established as syndromes of al-
lergy. The scope is constantly increasing and the care-
ful clinician is finding it necessary to consider it in de-
termining the etiology of an ever increasing number of
conditions. It is perhaps proper to consider the possi
bility of allergic reaction in all the organs and tissues of
the body. When no other obvious cause can be demon-
strated and particularly if the altered physiology is of
the functional type, it is not unreasonable to seek the
etiology in hypersensitiveness to some foreign agent.
The discovery of the substance responsible for the clin-
ical manifestation often taxes the ingenuity of the medi-
cal observer to the utmost, but in the main such labor
as it involves is properly rewarded.

R. V. Ellis, M. D.

THE WHOLE PICTURE

A recent clinical experience re-emphasizes the need
of the broadest possible base of general knowledge; also
that intimate familiarity with a limited field may make
the observer a very valuable agent in uncovering diffi-
cult diagnoses. However, both the experienced general
observers and the highly trained technical experts must
apply their respective "high power” faculties only after
utilizing every possible "low power” estimate.

This is the experience: A highly strung rheumatoid
arthritic woman died after six years of complaint, pro-

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longed bouts of fever with moderate sweats, a period of
an exaggerated skin reaction (variously diagnosed) ; an
almost complete remission of the "arthritis” leaving a
few small joints moderately spindled but not stiff; a
terminal illness with high fever, prostration, marked leu-
kocytosis and a myelogenous leukaemic blood picture.
At various times she looked like the picture of subacute
bacterial endocarditis despite successive negative blood
cultures; and both early and late, as well as at postmor-
tem, she did not have an enlarged spleen.

The immediate autopsy opinion was "myelogenous
leukemia, with areas of leukaemic infiltration, liver, kid-
ney, etc.” However, when these infiltrations were sub-
jected to the closest scrutiny and the literature is care-
fully reviewed, they are found to be pyaemic abscesses,
with certain small vessels plugged with masses of staphy-
lococci. More complete blood and marrow studies place
their respective reactions in the category of "a leukae-
moid reaction.” This was apparently an allergic reaction
in a woman strongly sensitized; and probably against a
bacterial antigen. The patient was probably right:
"Everything I ever got in the way of 'shots’ (and she
had not a few) made me worse; it caused my skin
trouble,” she alleged. The clinical lead of subacute bac-
terial endocarditis was also close to correct. So-called
periarteritis nodosa,1 and related infections in blood ves-
sel walls (arteritis)-’ are certainly near akin to that more
common entity that dislodges emboli to infarct various
organs and areas.

This sequence is briefly recited to emphasize the need
of holding to whole picture in focus, rather than by in-
viting distortion by too intimate a view of any of its
parts. He who looks must ever "tune in” by vigilant
reading of current literature.

E. L. T.

Noteworthy Articles

1. Spiegel. Rose: "Clinical Aspects of Periarteritis Nodosa."

Arch, of Int. Med., Vol. 58 (Dec.) 1936, p. 993.

2. Wegener, H. (Breslau): "Uber Generalisierte Septische

Gefas Erkrankungen." Verhandlung Der Pathologischen Gesell-
schraft (Gustof Fischer), Jena 1937, p. 202.

READING WITH EMPHASIS

Some people mark up the books they read, often
underlining sentences and bracketing entire paragraphs.
Destructive vandalism we say with one accord. But
wait a minute: whose books are we talking about? If
they belong to a library or some other person, that’s one
thing, and we still agree; but if they belong to the
reader, that’s quite another matter. Is there any better
way of expressing approval or disapproval of the written
word than by making just such notations of acceptance
or rejection at the very time; and what else in heaven’s
name are book margins for?

We know an Osler of early vintage with pencilings
all over the landscape depicting additional observations
made by the great teacher on his hospital rounds the
very day they were jotted down. Don’t try to tell the
owner of that book that it is disfigured. Not only does
it have the added information but a wealth of inspira-
tional value. It brings back the circumstances of the

case, the very ward in which the patient lay, the charm
of the master as he patted a shoulder here and took
the arm of another there in conducting his group of
students from one bed to another. That book is illu-
mined with precious memories. It is wear and all these
little indications of use that testify to a book’s worth
and often enhance its value.

A. E. H.

HEALTH AT FLANDREAU INDIAN
SCHOOL

The Flandreau Indian Vocational High School lo-
cated at Flandreau, South Dakota, had its origin in
1872. It was then known as the Riggs School, named
after the missionary who established it. In the early
days of this school, the teaching was done by the use of
charts and pictures in an attempt to interest the students
in their work. There were no formal grades; in fact, it
was not until 1898 that the first class graduated from
the ninth grade. At present this school has approxi-
mately four hundred and fifty Indian girls and boys
enrolled, and there are nearly sixty persons on the teach-
ing and maintenance staff. Approximately one hundred
students are graduated each year. The present super-
intendent, Byron J. Brophy, is a true educator and he
has been influential in bringing about many of the mod-
ern activities on the campus.

In company with the physician in charge of health
work, one is especially impressed with his knowledge
of the health of each student. He knows the students
by their first names and manifests a most unusual
personal interest in them. He has their confidence;
he not only teaches some of their courses but is avail-
able for numerous personal interviews. This physician
is Dr. A. S. Rider, who carries on a large general
practice, including much major surgery, in Flandreau.
For thirty years he has devoted a great deal of time to
the Indian school and at present through his efforts the
health conditions on the campus closely approach the
ideal. Every student has been vaccinated against small-
pox; they have all been immunized against diptheria
and typhoid fever; every student has had the tuberculin
test, and all positive reactors have had X-ray films made
of their chests. Dr. Rider has detected a number of
cases of clinical tuberculosis by this method before sig-
nificant symptoms were present. All with acute illness,
injuries, etc.,- are immediately admitted to the campus
hospital, where Dr. Rider with a staff of nurses and
technicians provide immediate and excellent care.
Through his wide experience of thirty years in this work,
Dr. Rider has become expert on special health problems
among the Indians. Every physician who happens to be
in or pass near Flandreau, South Dakota, should visit
this institution, not only to see the fine educational work
that is being provided for the Indian youth and their
response and appreciation, but also the unique health
activities which Dr. Rider has developed for them.

J. A. M.

THE JOURNAL-LANCET

119

SOCIETIES

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of December 9, 1936

The regular monthly meeting of the Minnesota
Academy of Medicine was held at the Town and
Country Club on Wednesday evening, December 9th,
1936. The meeting was called to order by the President,
Dr. Thomas S. Roberts, at 8 p. m.

There were 47 members and one guest present.

Minutes of the November meeting were read and
approved.

The Secretary read a letter of resignation from Dr.
John T. Rogers, a past President of the Academy. The
Secretary stated that the Executive Committee had
voted and recommended to the Academy that Dr.
Rogers’ name be placed on the Honorary Membership
list. This recommendation was passed unanimously.

The following officers were elected for 1937:

President — Dr. E. M. Jones, St. Paul.

Vice-President — Dr. R. T. LaVake, Minneapolis.

Secretary-Treasurer — Dr. Albert Schulze, St. Paul.

Dr. Roberts asked the newly-elected President to take
the Chair, and Dr. Jones expressed his appreciation of
the honor accorded him in this election.

The scientific program followed.

EPISCLERITIS AND ITS RELATION TO DISEASE OF
THE FEMALE PELVIC ORGANS
By

William L. Benedict, M.D.

Section on Ophthalmology, The Mayo Clinic
Rochester, Minn.

Dr. Benedict read his Inaugural Thesis on the above
subject.

A bstract

■ Episcleritis and scleritis appear in various form as acute, in
termittent or chronic affections of one or both eyes. The dis-
ease attacks only adult persons and is' more common in women
than in men. The superficial forms and some of the inter
mittent forms of the disease are not harmful to sight even
though they persist over many years. The deeper forms of the
disease affecting the sclera and uvea lead to permanent changes
in the coats of the eyeball. Some forms are very painful during
the stage of inflammation. Repeated attacks of scleritis lead to
thinning of the sclera, the appearance of slate-colored areas in
the anterior sclera where inflammatory nodules have been situ-
ated, staphylomata in the ciliary zone, and sclerosing keratitis.

| Through changes in the uvea, the lens and vitreous become
cloudy and in some cases secondary glaucoma leads to blindness.

The etiology of the disease has been attributed to tubercu-
losis, syphilis, gout, leprosy, focal infection, and disturbances
of menstruation. It has long been known that episcleritis is
associated with uterine disorders and is prone to occur in adult
females who are subject to disturbed menstruation. Histopath-
ologic studies have confirmed the diagnosis of tuberculosis in
many eyes enucleated because of grave effects of severe scleritis.
Some oculists have stated that nearly all cases of episcleritis and
all cases of nodular scleritis are due to tuberculosis, but neither
pathologic examination nor clinical experience offers adequate
confirmation of this assumption.

Studies of a series of cases of scleritis in women in whom
a relation between the attacks and disturbances of menstrua-
tion could be established showed that the cervix and uterus
were foci of infection. Bacteriologic studies revealed a green-

producing streptococcus as the offending organism in all cases.
In cases where this relationship could be established, attempts
to correct the uterine disorder were made. In some cases the
cervix was cauterized; in others, hysterectomy was done. Im-
provement in the eye condition invariably followed operation.
Recurrences were rare and in most instances mild.

Discussion

Dr. Frank Burch, St. Paul: I am sure I speak not oniy for
the ophthalmolcgical group of this Academy but for all the
members in welcoming Dr. Benedict into the organization, and
also thanking him for again emphasizing the relation of eye
diseases to general diseases. Dr. Benedict has made a real con-
tribution along several different lines establishing such relation-
ships, particularly the relation of prostatitis to iritis. In this
thesis he has added to the fact that episcleritis is not only
more prevalent in women, but that it has a definite cause in
pelvic infections. Most of us do not see cases of episcleritis
frequently. In other intraocular inflammations, as well as in
episcleritis, we are beginning to learn in our studies of their
etiology that we sometimes have to go far afield in order to
direct the proper treatment. Practically all of our treatment
heretofore was local, aided by non-specific vaccines, foreign pro-
tein therapy, etc. From my own experience, where this relation-
ship of episcleritis with pelvic infection has been established, I
have not been able to get any results from vaccines. Patients
were improved or cured when referred to the gynecologist and
received proper treatment. I believe Dr. Benedict’s thesis is an
important contribution and that he has established a rational
basis for treatment of episcleritis.

Dr. C. N. Spratt, Minneapolis: Dr. Benedict has not men-
tioned the names of two men who have done considerable work
on the etiology of scleritis. Both of these, Verhoeff and Stock,
came to the conclusion that it was a form of tuberculosis.
While I was house officer under the former at the Massachu-
setts Eye and Ear Infirmary, and at Freiberg, where I have seen
the work of the latter, I was much impressed with their find-
ings. Verhoeff had done considerable microscopic work and in
addition to this Stock had injected the ear vein of rabbits
with cultures of tubercle bacilli and had found that lesions of
the choroid, uvea and sclera had followed which were very simi
lar to conditions observed in humans. In 1911, I reported a
series of cases of scleritis treated with tuberculin before the
Minnesota Medical Society. All of thise had been given, pre-
vious to treatment, a focal, general and local reaction to tubercu-
lin. All of these patients recovered. Some time after this a
patient under tuberculin treatment had a lighting-up of a pul-
monary condition, and since then I have discontinued its use
in ali r.i3es. Verhoeff likewise has discontinued the use of tu
Lerculin and relies entirely upon hygienic measures.

I rely entirely upon the application of the Shahan thermo-
phore in the treatment of these cases. One application of this
instrument at a temperature of 145° F. for one minute has
been followed by cure within ten days to two weeks. This tem-
perature causes no permanent damage to the tissues of the eye
Recurrences do occur in a few cases and it would not seem
that hysterectomy would be called for. Vaccines and foreign
protein therapy have not been employed in any cases under
observation.

Dr. Benedict, in closing: One can not consider the dis-
eases of scleritis and episcleritis without recognizing several dif-
ferent forms of the disease. Some individuals who are neurorc
in temperament have a mild episcleral injection, sometimes diag
nosed as conjunctivitis, which lasts for a few days and then
disappears. That condition is known as episcleritis fugax. It
probably is not due to infection. It has been assumed that it
is due to some endocrine disturbance. We have no pathological
proof of this. There is also an episcleritis which involves only
the superficial tissues of the eye and occurs in the menstrual
periods. It is noted in the textbooks of Weeks, Fox, de Schwein-
itz and others. Exacerbations have been noted at menstrual
periods or at missed menstrual periods and are interpreted as
vicarious menstruation. The etiology of tuberculosis has been
brought into the discussion. Some years ago Dr. Knight and I

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reported on two eyes which had been removed. In those two
patients there was no clinical evidence of tuberculosis but the
pathological picture was that of tuberculosis. We know only too
well that the pathological appearance of tuberculosis is mixed
so much with the pathological appearance of local granulomas
and some systemic diseases that it is difficult for the pathologist
to distinguish a difference.

Whether the uveal tract is involved secondarily or whether it
is a coincident infection with lesions in the sclera has given rise
to considerable discussion. As I said in my paper, it is not
clearly established whether this is a single infection which is
transmitted to the uveal tract or whether it is a separate infec-
tion. The lesions in the eye are histologically similar to tubercu-
losis and frequently attributed to focal infection, and our studies
have shown that a green-producing streptococcus will produce
such a lesion. We have been unable to find any bacterium aside
from streptococcus which would produce such a lesion.

I have at hand case histories collected during the past 20
years — 37 cases in all — in which amputation of the cervix or
hysterectomy was performed. In no case was hysterectomy per-
formed only because of infection in the eye itself; but where
there was evidence of uterine infection. The infection in the
sclera usually disappeared within three days from the time the
operation was performed and it never recurred.

I have used the thermophore for its local effect to reduce in-
flammation in the eye. At temperatures of 140° to 160° the
thermophore is kept in contact with the sclerotic nodule long
enough to produce local reaction without necrosis. After a few
days the inflammatory lesion will disappear, but that is by no
means a cure. So long as the source of the disturbance has
not been removed there is no question but what recurrences will
take place, though at irregular intervals.

Peculiarly enough, our clinical observation has shown that
all through the child-bearing period there may be no evidence of
scleritis, particularly during the periods of pregnancy and
lactation.

It is impossible to conceive of episcleritis as being a local
disease of the eye. Simply to treat the local disease (and there
are many ways of getting rid of the local reaction) has abso-
lutely no influence on the cause of the disease; and to assume
that getting rid of the local lesion in any way gets rid of the
origin of the disease is to blind one’s self to the facts. Epi-
scleritis is evidence of disease somewhere else in the body. The
clinical observation that inflammation of the eye subsided after
the removal of an infected uterus led us to believe that here
was a source of infection that was just as potent as infection of
the teeth. Cultures of teeth, tonsils and pelvic organs (uterus
in women and prostate in men) always gave us the same tvpe
of streptococcus. Therefore, we had reason to believe that if a
woman had recurrent attacks of episcleritis and if there was no
question about the virulence of streptococci in the pelvic organs,
we were justified in removing the uterus.

* * *

AGRANULOCYTOSIS

Alfred Hoff, M.D.

St. Paul

Dr. Alfred Hoff, of St. Paul, read a paper on the above
subject. Slides and charts were shown and cases reported.

A bstract

In 1922, Werner Schultz described a highly fatal syndrome
which he regarded as a new and distinct clinical entity and for
which he proposed the term "Agranulocytosis.” Subsequent
terminology by various writers included Agranulocytic Angina,
Idiopathic Neutropenia, Malignant Neutropenia, and Primary
Granulocytopenia.

It occurred mostly in elderly women and was characterized
by necrotizing lesions in the mouth, pharynx, rectum and
vagina, and was associated with fever, marked prostration and
a profound leucopenia with complete or near complete absence
of granulocytes in the circulating blood, but with little, if any,
anemia or reduction in the blood platelets.

Since then much discussion has arisen as to whether or not
it really constituted a new or a distinct clinical entity.

Surveys of the medical literature by numerous writers —
among whom especially to be mentioned are Thomas Fitz-
Hugh, Jr., and Roberts and Kracke — indicate that prior to his
original description there were only three reports which at the
present time would be classified as agranulocytosis: (1) by

Brown in 1902, "A Fatal Case of Acute Primary Pharyngitis
with Extreme Leukopenia "; (2) one by Schwartz in 1904,

"A Case of Extreme Leucopenia”; and (3) one by Tuerck in
1907, "Septic Disease with Atrophy of the Entire Granulocytic
System."

According to Fitz-Hugh, Brown believed that his case was
identical with those of Phlegmon of the Pharynx reported by
Senator in 1888.

Kracke and Parker stated that "it was responsible for morp
than 1500 deaths in the United States alone in the three-year
period ending in 1934.” They give a comprehensive review of
the literature in an excellent article appearing in the Journal of
the American Medical Association (Sept. 21, 1935) entitled
"The Relationship of Drug Therapy to Agranulocytosis.” The
salient features in the etiological approach were summarized and
the accumulative evidence incriminating amidopyrine as a
causative factor given.

Leucopenia and granulopenia are frequent accompaniments of
many diseased states, such as the leucopenic phase of an acute
leukemia, pernicious anemia, aplastic anemia and certain infec-
tious diseases such as typhoid and typhus fever, et cetera. How-
ever, in these the clinical features may be and often are dis-
tinctive and serve to make diagnosis possible.

Fitz-Hugh and Krumbhaar in 1932 reported the pathologi-
cal changes found in the bone marrow in three fatal cases and
stated that the marrow of the bones examined in one case con-
tained active hemopoietic areas filled with myelocytes, pro-
myelocytes and myeloblasts, while the peripheral blood con-
tained only 200 w.b.c. per cu. m.m. In the other two cases
there was likewise absence of myeloid aplasia. They suggested
a condition of maturation arrest as an explanation for the
paucity of the circulating granulocytes.

Henry Jackson, Jr., in a recent article, agrees with this view-
point and in addition to 27 of his own cases coming to autopsy
cites 1 1 cases analyzed by Custer in which "there are marked
proliferation of the myeloblasts with failure of these cells to
mature, while the other elements of the bone marrow were un-
disturbed.”

Therefore, neither marked anemia nor thrombopenia are fea-
tures of this disease. If one permits a severe anemia or hemor-
rhages in the skin to enter into the clinical picture, the diag-
nosis of agranulocytosis becomes hopelessly confused with other
tvpes of bone marrow insufficiency and especially with the acute
phase of aleukemic leukemia whose symptoms in every other
respect may be identical.

The present concept of agranulocytosis holds that it is due
to a depressed condition of the bone marrow in which a selec-
tive failure of the myelocytic function occurs, causing a com-
plete or a near complete disappearance of the granulocytes in
the blood stream. The granulocytes protect the body against
bacterial invasion and with their disappearance active immunity
is lost and local bacterial invasion takes place in the form of
necrotic lesions in the mouth, pharynx and rectum. General
septic invasion results unless timely granulocytic recovery takes
place. However, general sepsis may be so abrupt as to preclude
the possibility of timely granulocytic response, thus resulting in
the acute fulminant type with an invariably fatal outcome.

Four cases were presented with one recovery and three deaths.
Autopsy was obtained in one case.

Slides were presented, showing the course, with frequent
w.b.c. and differential counts, as well as more infrequent r.b.c.
counts and Hb. determinations and the treatment employed.

Two cases followed the regular prolonged use of allonal. One
case that died was in the hospital for a different ailment and
developed an acute fulminant agranulocytosis after the daily use
of two allonal tablets for 3 1 days. One case followed the use of
dinitrophenol.

Allonal, according to its manufacturers, is allylisopropyl-
barbituric acid chemically fused with amidopyrine in the pro-

THE JOURNAL-LANCET

121

portion of 1: 1-2/3. It enjoys considerable popularity as a pain-
relieving and sleep-inducing drug, both among physicians and
the laity, and in consequence is extensively used. Ordinarily it
may be administered with unquestioned safety. I had one pa-
tient who took two, sometimes three, tablets every night for
four years without demonstrable injury. But the accumulated
evidence against amidopyrine-containing drugs is such as to
warrant the statement that its prolonged use in the occasional
sensitized individual may result in agranulocytosis and death.
There is no exact method for accurately determining such sensi-
tivity and, as a result, where its use is unduly prolonged it
becomes necessary to check up such patients with frequent total
and differential white blood cell counts for evidence of leuco-
penia and granulopenia and also to exert our best efforts to
prevent its indiscriminate use among the laity.

Discussion

Dr. C. E. Connor, St. Paul: Our present interest in this
entity dates from 1922, when Schultz described it as we have
it today. Dr. Pepper, of the University of Pennsylvania, re
cently gave an historical resume in which he mentioned the
fact that MacKenzie in 1880 referred to Gubler as having first
described agranulocytosis in 1857; Trousseau, in 1865, differ-
entiated it from other anginas. Pepper thought they were de-
scribing what we know today as agranulocytosis; if so, the dis-
ease was lost sight of until Schultz brought it to our atten-
tion again.

The differential diagnosis from other types of malignant
neutropenia, particularly acute leukemia, Vincent's angina, acute
streptococcic sore throat and diphtheria, depends largely on
laboratory methods, especially the differential blood counts and
smears and cultures of the throat. There is nothing pathog
nomonic about the local lesion.

Dr. Hoff, in closing: This disease seems to be more of a
private hospital disease than a city hospital disease. In a ser-
vice of about 25 years at the Ancker Hospital I cannot recall
ever having seen a case of agranulocytosis in that hospital. Pos-
sibly public hospital patients do not indulge in prolonged self-
medication with the drugs of this group. Allonal is being used
a great deal and this possibility of doing damage should be
recognized.

* * *

The meeting adjourned.

R. T. LaVake, Secretary.

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB
Meeting November 12, 1936
President, Dr. Donald McCarthy, in the Chair
COLON STREPTOCOCCUS MENINGITIS FOLLOW-
ING COLON RESECTION
James Kerr Anderson, M.D., F.A.C.S.

Walter A. Fansler, M.D., F.A.C.S.

Patient — Married, female, aged 63, referred by Dr. E. J.
Hill, first seen June, 1936.

Complaint — For the past two months has had a peculiar
aching feeling in the rectum, which has been gradually get-
ting worse. Slight bleeding has been noted on several occasions
but has always occurred after a constipated movement. No
diarrhea, mucus or change in the bowel habit. She had noted
a difficulty in completely emptying the bowel and would have
to return to the toilet to complete the act. Slight returnable
protrusion from the anus for the past few weeks.

Family History — Negative.

Past History — Childhood diseases only. Three full term
pregnancies, otherwise negative.

Physical Examination — Essentially negative except for the
rectum, and a soft systolic blow at the apex. Carcinoma of
the rectum, just above the ano-rectal junction involving one-
fourth of the circumference. Neither inguinal nodes or liver
polpable.

Laboratory — On admission to Northwestern Hospital, urine
negative. Blood creatinine 2.01 mgm. per 100 c.c., urea nitrogen

22.42 mgm. per 100 c.c. Hemoglobin 75 per cent, red count
4,020,000; white count 7500. Wassermann negative.

Growth removed at operation graded two by Dr. Margaret
Smith. The growth extended 4 cm. along the wall from the
ano-rectal junction and involved about one-quarter of the cir-
cumference. No glands demonstrated in specimen. Growth
ulcerated and edges undermined.

Operation — June 19, 1936, under gas-ether anesthesia, one
stage abdominal-perineal procedure. Midline colostomy. No
metastases demonstrated at operation. The coccyx was not re-
moved as part of the posterior procedure. Patient left the table
in fair condition. Glucose was given intravenously during the
latter part of the procedure.

Postoperative Course

Whole blood transfusion, citrate method, the afternoon of
surgery. Rather stormy postoperative course for four days.
Blood pressure remained well over 100 systolic, temperature at
times to 104° F. and continuously above 99° F. Pulse to 120,
respirations 20-30. Slight abdominal distention controlled with
nasal suction. Some coarse rales in the right upper lobe which
persisted. No cough or sputum. Given oxygen therapy for
three days.

The fifth day postoperatively the temperature started down
and varied from 99° F. to 102° F. for the next 16 days,
never to normal. During this interval the pulse was about 90
and the respirations remained at 20. The colostomy was viable
and functioned on the fourth day, the posterior wound pack
was removed on the fourth day which may account for the
slight drop in the temperature at that time. Irrigations were
started in the posterior wound and carried out twice daily.
There was no evidence of more than ordinary infection in the
posterior wound at any time and the granulating surface ap-
peared healthy.

During this interval the patient complained of feeling quite
tired, weak and exhausted, but there were no findings except
those mentioned in the chest and operative fields. A generous
diet and supportive therapy were carried out. The appetite at
all times was poor. The patient was catheterized for one week,
then able to void. She made slow progress for 15 days, the
chest condition did not clear up and the posterior wound
caused her much discomfort. The anterior wound healed nicely
about the stoma.

During the extremely hot spell in July (1936) when the
outside temperature was 1 10, exactly three weeks after her sur-
gery, her temperature suddenly in the afternoon rose to 106''
F. and pulse to 120. Her condition appeared unchanged and
she did not offer any new complaints. She was given general
therapy for the lowering of temperature, including fans, ice
packs and later an electric cooling unit, by which the room
temperature was lowered to 70° F. Her temperature remained
elevated and she became irrational at times, but when rational
did not offer any particular complaints. During the periods of
irrationalism she had involuntary urination. The chest find-
ings had not changed nor increased, the white count the day
following this temperature rise was 8,800 and the following
day, 11,400. The temperature varied from 103° F. and 105° F.,
the pulse between 110 and 120, and the respirations between
20 and 30, until the day before exitus when they were 40.
The urine showed some pus and red cells but less than on
previous examinations, during the period of catheterization.

The above condition persisted for six days. Owing to the
fact that nothing definite could be found to account for this
sudden rise in temperature and the hospitals in the city were
crowded with cases of heat prostration and exhaustion, it was
felt that she was suffering from the heat. Fluids were given
under the skin and by nasal tube as she would not take suffi-
cient quantity by mouth. The periods of irrationalism increased
in length and now when rational she complained of being un-
able to concentrate and that she could not see as well as
previously. Four days after this temperature rise there were
evidences of meningeal irritation, some stiffness of the neck
and spasticity of the arms and hyperirritibility, noted and re-
ported by the nurse. Kernig’s sign was positive the following

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morning and spinal puncture was done, revealing a thick,
creamy fluid which had to be aspirated, and which had a defi-
nite fecal odor. The laboratory examination of the aspirated
fluid revealed a gram negative bacillus and a gram positive
coccus in pairs and chains in great numbers. Dr. H. B. Han-
nah saw the patient in consultation but advised against a
spinal lavage.

She expired about ten hours after the spinal puncture. The
relatives would not consent to any sort of a post-mortem exam-
ination.

The question in this case is how the infection reached the
meninges. The patient was not given a spinal anesthetic, which
is the usual anesthetic in our cases, and the coccyx was not re-
moved, which is usually done in order to give more room for
the posterior dissection. She had a definite ether bronchitis with
a possible low grade pneumonia. (Chest plates were not taken.)
Blood cultures were not taken at any time. When the meninges
were invaded is also questionable, possibly the day that the
temperature rose to 106° F. and was thought to be due to
the heat. Spinal puncture at this time might have revealed in-
fection but to us was not indicated until 24 hours before death.

As we look back on the case possibly the stupor and the
complaints relative to the eyes should have aroused suspicion
of spinal irritation. Most likely the infection was blood born
and accounts for her tired feeling and the inability for her to
pick up strength. Possibly a blood culture would have aided
us. After the meninges were invaded, of course, the course was
rapid. A blood stream infection, which no doubt was present,
may have been the result of some necrosis in the posterior
wound, although drainage was adequate and the wound ap-
peared healthy. The colon bacillus grows rapidly, overgrowing
other organisms and could not have been present long, pos-
sibly six days.

This case is one of those in which the malignancy was com-
pletely removed with the gland-bearing area, with little diffi-
culty and should have been one to add to the statistics of cured
cases, had not this complication arisen.

In looking over the literature of meningitis caused by the
colon group, practically all of the cases are in young children.
The nose and throat specialists report cases following mastoid-
ectomy but in most the portal of entry has not been determined.
The disease is comparatively rare, in 1500 cases analyzed by
Neal only seven cases were due to this organism and to 1925
there were only 44 cases in the literature. Barron, in a careful
study of 42 cases of meningitis, 39 under three months of age,
found 14 due to the colon bacillus. Tesdal reports a cure in
one adult case. Ratcliff reports one case in 789 in Glasgow
Royal Hospital due to the colon bacillus. He found the middle
ear the most common focus. No recoveries were reported and
treatment was of no avail.

LITERATURE

A Case of Meningitis in a New-born Infant Due to a Slow
Lactose Fermenting Organism. Belonging to the Colon Bacillus
Group; Mulhern and Seelye: Journal Lab. 6C Clinical Med., Vol.
21, No. 8. p. 793.

Meningitis Caused by Bacilli of the Colon Group; J. B. Neal;
Am. Jour. Med. Sciences. Vol. 172, p. 740.

Cured Meningitis Caused by Bacterium Coli Commune; Acta
Medica Scandinavia. Tesdal, Vol. 83. 1934. Supp. 57.

A Case of B. Coli Meningitis; T. A. Ratcliff: Lancet, 1: 1274,
1935; Barron. M. Am. J. Med. Sci., 1918, 156, 358.

FURTHER REPORT ON A CASE OF HYPERADREN-
ALISM AND HYPERTENSION TREATED
BY BILATERAL ADRENAL
RESECTION
Dr. S. R. Maxeiner

A year ago I reported before this organization a patient
upon whom we did a unilateral adrenal resection for a very
malignant hypertension, following the work of D’Corsay. At
that time I told you that we were going to do the other side
and would report subsequent progress.

In reviewing the literature, I found much written on adren-
alism and hypertension, in fact, all of the phases of the dis-
ease of the adrenals, but there is one classification by Rown-

tree1 which I thought was interesting, to which we might refer
briefly in which he classifies the diseases of the adrenal gland
as follows:

"Hyperf unction:

Cortical (syndrome genitosurrenale) , gives rise to:

1. Congenital pseudohermaphroditism.

2. Infantile pubertas praecox.

3. Adult virilism and hirsutism.

Medullary, may be associated with:

1. Neuroblastoma with multiple metastases to the liver
and bones.

2. Benign ganglioneuroma.

3. Paraganglioma with intermittent paroxysmal hyper-
tension or permanent hypertension.

Hypofunction:

Suprarenal insufficiency (hyposuprarenalism) .

Addison’s disease.”

In looking through the literature I found a case similar to
this one reported by Chazette2 in an article from Paris, a
woman 62 years of age who complained of palpitation, and
breathlessness. Examination revealed her blood pressure to be
260 150. Subsequently she became worse, had some symptoms
of cardiac failure and at that time her blood pressure was
320 190. This patient succumbed and autopsy revealed that
the right suprarenal capsule weighed 7 grams and the left
weighed 20 grams. In discussion, he states that death occurs
within a few days and is characterized by a neo-formation of
the suprarenal medulla without any tendency to become gen-
eralized. There is also a syndrome of suprarenal hyperfunction
characterized by permanent hypertension with a tendency to-
ward paroxysmal elevations.

This patient came to the Veterans’ Hospital in 1933. He
had attacks of pressure over his heart and a feeling as though
it would stop, with pain in the left shoulder. This started be-
fore his discharge from the Army. In 1926 he was refused life
insurance because of his heart and hypertension.

In 1933, pulse was 125 and regular, blood pressure 210/140,
and electrocardiogram showed tachycardia with depression of
the S. T. phase in derivation ii and iii. Urinalysis was nega-
tive and blood Wassermann was negative. Basal metabolic rate
ranged from plus 10 to plus 29. Relative size of heart, 43 per
cent.

Diagnoses: (1) Hyperthyroidism.

(2) Hypertension.

(3) Tachycardia.

In February, 1933, a subtotal bilateral thyroidectomy was
performed in which a total of 3 1 grams was removed. Micro-
scopic diagnosis revealed a hyperplastic goiter intensively treated
with Lugol’s.

Fourteen months later he returned, complaining of symptoms
similar to those in 1933. Pulse was 102 and radials were
sclerosed. Examination of the eyes showed fundus findings of
hypertension and marked change in the past year.

In 1935, heart and kidneys were in excellent condition. His
basal metabolic rate ranged from plus 78 to plus 116. X-ray
of the sella revealed the sella turcica to be slightly enlarged,
1.5 by 1.2 centimeters. Because the patient seemed to approach
the suprarenal type of hypertension it was recommended that
an attack be made upon the suprarenal glands and on April
3, 1935, the left suprarenal was resected through a kidney in-
cision, approximately five-sixths of the gland being removed.
The patient made a moderately stormy convalescence but his
blood pressure promptly fell to 120 to 140 and remained sta-
tionary during the course of the next two or three months.

The pathologist’s examination of the removed specimen re-
vealed a gland weighing 7 grams with a bright yellow nodule,
8 millimeters in diameter imbedded in the substance of the
gland. The nodule was made up of rounded and oval cortical
type of adrenal cells. Diagnosis was, adenoma, cortical type,
benign. Part of the periadrenal fat was studied for sympathetic
fibers and were quickly demonstrated in abundance.

The patient was observed until June, 1936. His basal
metabolism had dropped to normal following his operation and
has never been above plus 10 since that time. His blood pres-

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123

sure, however, gradually crept up to 210/150. Electrocardio-
gram showed increased depression of the S. T. phase. Eye
grounds showed some edema but no hemorrhage.

On June 12, 1936, the other adrenal was resected, four-fifths
of the gland being removed through a kidney incision. The
amount of removed gland weighed 6.5 grams and revealed no
pathologic changes. During operation the stellate sympathetic
ganglion was uncovered and was resected.

Sixty days postoperatively the patient has shown a marked
improvement in the S. T. phase, he feels clinically greatly im-
proved, has gained weight and his symptoms of oppression,
headache and pericardial distress have been almost entirely
alleviated. The patient’s blood pressure in December, 1936, is
160/110. Basal metabolism is minus 12 with a very great im-
provement in his clinical symptoms together with improvement
in his electrocardiogram. This represents a fall up to this time
of 110 millimeters in the systolic pressure.

BIBLIOGRAPHY

1. Rowntree, Leonard G. 6z Ball. Ralph G.: Diseases of the
Suprarenal Glands, Endocrinology (May-June), 1933.

2. Chazette, R.: Contribution to the Study of Hyperfunction
of the Suprarenals, Thesis, Paris, 1931.

* * *

Dr. Thomas Ziskin: (by invitation) This case presented
some unusual features and, as Dr. Maxeiner stated, from the
history — it does not seem to fit in with any specific class of
hyperadrenal cases. We thought of a possible cortical tumor
at first but it did not seem to fit in definitely with this con-
dition as he had no signs or symptoms of hypervirilism. We
thought of a medullary involvement of the adrenal but he did
not have the paroxysmal type of hypertension usually found
with this condition. Then again, there was the unusual feature
of the extremely high B. M. R.

In looking over many of the cases reported in the literature
I have found no case in which an extremely high B. M. R. is
reported in these conditions. His B. M. R. was over 100 on
several tests and after the first operation it came down to nor-
mal and has remained so ever since and is normal at present
also while his hypertension has come back. It went back, as
you noted on the chart, to 275 before the second operation and
then came down again. His blood pressure taken today was
200 160, so you can see that it has come back some more since
we last took it about two months ago, but the patient says he
feels much better, the electrocardiagrams taken at various times
show the effect of the drop in blood pressure and even today
the electrocardiagram looks much better than it did before the
second operation or the first operation.

To go briefly into some of the theories as to why surgery
may be indicated in these conditions we must go back to the
first work of Crile. Crile started this work several years ago
and first removed a portion of one adrenal. He found his
results were not very good with this and then he started re-
moving portions of both adrenals and did this for quite a
while and then found his results here were also not as satis-
factory as he wished them to be, and then he began to cut
the splanchnics. This procedure was also used by Adson of
Rochester who has done a considerable number of cases and
who now sections portions of the splanchnic nerves together with
resection of the adrenal glands.

Lately Crile has advanced another theory and has adopted a
new method of procedure. In his studies in Africa on wild
animals he reasoned that there should be a difference in the
energy creating power of the various types of animals. He be-
lieved that the lion, which is a hyperkinetic, powerful animal,
should have a comparatively larger sympathetic mechanism
than the alligator which is a hypokinetic type, and studying
these various types of animals and comparing them he proved
that this theory was correct. He did find comparatively greater
sympathetic plexes and ganglia in the animals of the type of the
lion than he found in the alligator. As a result of these
findings he is now cutting the celiac ganglion and removing
also the aortic plexus, stripping the aorta of its nerve supply
and he feels now that this is the operation of choice. He has
operated on several cases, about 25 so far, and he claims that

the results are more promising than the previous operation of
cutting the splanchnics together with resection of the adrenals.
Crile believes it does not make much difference as to some of
the factors in regard to the operation — he believes that good
results can be obtained in older people and far advanced cases
as well as in some of the younger people. Adson believes
that the operation should not be performed in men over 45
years old or in patients where there has been marked arterial,
cardiac or kidney changes.

There has been some work reported recently by Princmetal,
Friedman and Wilson at the meeting of the American Heart
Association in which they state there is no physiological evi-
dence for the separation into organic and functional types
of hypertension, or for the assumption that renal hypertension
is due to vasomotor hypertonus and that surgical measures
aiming at relief of high blood pressure by sympathectomy do
not abolish the vascular hypertonus that is fundamentally res-
ponsible for hypertension. They experimented on patients
with hypertension and say that increased blood flow in response
to heat and reaction hyperemia were equal in degree in that of
hypertensions and normals. They say that sympathetic vaso-
dilation produced by the heat test produces no greater increase
in blood flow in subjects with hypertension than in normals, sug-
gesting that vascular tonus is not of vasomotor origin. Patients
with coarctation of the aorta, however, showed a greater in-
crease in blood flow in response to heat tests than do controls
or patients with hypertension. This, to them, demonstrates
that vasoconstriction of sympathetic origin is present in the
upper extremities in coarctation of the aorta and affords in-
direct evidence that hypertonus in generalized hypertension is
not of vasomotor origin. Anesthetized with procaine vasomotor
nerves of the arm produce the same increase in blood flow in
normal subjects and patients with hypertension, proving that
vascular hypertonus is independent of vasomotor nerves and
must be regarded as spasm of the blood vessels themselves.

Of course, this is somewhat different than the theories that
we have been following in the study of these cases.

Another interesting piece of work was reported last week at
the Central Society of Clinical Research in Chicago by Gold-
blatt. He produced persistent hypertension in dogs and in
monkeys by partially clamping of the main renal arteries. He
believes the ischemic kidney directly responsible for the for-
mation or accumulation of an hypothetical substance in the
kidney which causes this hypertension. Then, by removing
the adrenals he was able to control this hypertension. He be-
lieves that this hypothetical pressor substance in some way-
sensitized the adrenal glands in the production of hypertension.

We see, therefore, that the subject of hypertension is still
far from settled both as to etiology and treatment. The ex-
perimental work quoted would tend to show that the adrenal
is a great factor in the production of hypertension but whether
the surgical approach to the treatment of hypertension will
finally be definitely established as of lasting value is still a
mooted question.

Dr. F. R. Sedgley: (by invitation) During the recent

progress of this case my role has been chiefly that of an in-
terested by-stander. Being unaware that my name was on the
program I had expected to continue in that role this evening.

The case has been so thoroughly presented that anything I
might say would necessarily have to be in the nature of a
repetition. My thought about it at the moment is that we
have a surgical and physiological experiment under way. On
the theory of a relationship between the adrenals and hyper-
tension, and in this case the added factor of an excessive meta-
bolic rate, we have extensively resected both adrenal glands,
which have been reported histologically normal.

To date the patient appears not only unharmed, but meas-
ured by his former symptoms of severe headaches, inability
for sustained exertion, and a generalized debility, he seems
clinically somewhat improved. Although his metabolic rate
is about normal, his hypertension is still marked. Therefore,
the outcome of this experiment will require considerably more
time to arrive at its real significance, or value.

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Dr. E. T. Bell: This is an ordinary case of essential or
primary hypertension. It is not hyperadrenalism. We have a
well defined syndrome of hyperadrenalism which is due to a
tumor of the adrenal medulla. This tumor produces paroxys-
mal hypertension by excessive secretion of the adrenalin. The
disease may be cured by removal of the tumor. I have ex-
amined the adrenals from several hundred cases of primary
hypertension and have never seen any anatomic changes in
them.

After any major operation there is a period of a couple of
months in which the blood pressure falls and the patient im-
proves no matter what the operation is. Why that should be.
I do not know. I once saw a patient with primary hypertension
improve markedly for about two months after an operation
for uterine myomas, but the blood pressure then returned to
its previous high level. I do not think that the improvement
in this case will be permanent.

Dr. H. L. Ulrich: I just want to emphasize one or two
items. The English have tried to correlate the diastolic pres-
sure and manifestations of headaches in hypertension. Usually
any pressure over HO diastolic will give you a headache. Was
there any study of this kind made in this patient? Cerebral
spinal pressure will rise with the rise in diastolic pressures. In
reference to the elctrocardiogram, of course, a man who is
having a blood pressure of 220 or 230 may show evidence of
coronary insufficiency. We are still where we were twenty years
ago — we do not know the case of essential hypertension. There
is no question but that these people live on a different physio-
logical level. I do not know that we ought to tamper with
that physiological level. We can reduce their pressure — there
are various other experimental things we can do to them. All
we are studying, however, is their physiology, we are not ex-
plaining hypertension.

Dr. Norman Johnson: I want to ask the X-ray men if
any work has been done in an attempt to reproduce the sur-
gical extirpation of the adrenals thru X-ray therapy. Is it
possible to use the X-ray as a therapeutic measure for depress-
ing the adrenals?

Dr. Malcolm Hanson: There has been quite a bit of work
done as far as the X-ray treatment of hypertension is con-
cerned. As in any specialty, X-ray has been used quite as a
"cure-all” and there is no question but that there are certain
people who have responded favorably to the X-ray treatments
for hypertension but the impression you get from the literature
is that the response has been very temporary.

Dr. S R Maxeiner: I wish to thank the different dis-
cussors for the part they have taken. We presented this case
because we had used all of our Staff members and called in
outside consultants. Each one had made a thorough study of
this individual and we thought it might be one of those cases
which would respond to an attack on the adrenals. I wish to
thank Doctors Thomas Ziskin, M. Nathanson, Frank Sedglev
and other members of our Staff who were of assistance in the
study of this patient.

I report this case, not to advocate this operation, but I feel
this is a study group and these are the things we can discuss
with profit to all of us.

CONTROVERSIAL ASPECTS OF THE TREATMENT
OF CARCINOMA OF THE BREAST
(Abstract of a Presentation before the
Minneapolis Clinical Club)

Orwood J. Campbell, M. D.

The speaker reviewed briefly the development of the present
day radical amputation of the breast for carcinoma. It is his
opinion that except for the work of Handley who demonstrated
the pathway of metastases and the desirability of wide excision
of fascia, no important advance in technic has been made since
that developed by Halstead and Willy Meyer.

Surgeons differ in the amount of skin routinely removed.
No definite rules can be laid down to determine the correct
amount. The size of the tumor, its duration, and the presence
or absence of skin attachment are factors which must be con-

sidered in determining the amount to be removed in any given
case. Local recurrences may reasonably be charged to the
operator so that in case of doubt he must elect to remove the
larger amount of skin. In the vast majority of cases the skin
flaps can be closed primarily.

The type of the incision is not important provided it observes
certain fundamental principles. It should be planned to fit
the patient and to observe the principle that the tumor must
be in the center of the block of tissue removed. It should make
provision for skin to cover the axilla completely and should be
placed as low as compatible with an adequate exposure of
the axilla.

The speaker believes that the practice of preserving the
pectoral muscles is undesirable because of the added difficulty-
in obtaining exposure for a careful dissection of the axilla and
because lymph born metastases have been demonstrated in pec-
toral fascia. The pectoralis minor may be stripped of its fascia
and resutured to prevent scar tissue contracture about the
axillary vessels.

Whether the operation should be performed by the use of the
scalpel or the endothermic knife is a matter of personal prefer-
ence. An incision made by the endotherm which does not en-
compass the limits of the disease gives no better chance of
success than one made by sharp dissection. The speaker uses
the endotherm rarely and then only for hemostasis of small
bleeding points. It is never used in the axilla.

Because of the admittedly poor results obtained in cases in-
volving axillary extension, there are those who would abandon
radical amputation completely and confine the operation to
simple removal of the breast. Such a philosophy of defeatism
is unjustifiable. The radical amputation properly performed
need be scarcely more deforming than simple amputation and
when the axillary metastases are few and early, does yield an
appreciable percentage of well patients who would otherwise
succumb to the disease.

Rather than to abandon radical surgery, the speaker believes
that the criteria of operability should be narrowed. Only
earlier and more favorable cases should receive radical ampu-
tation. Even though they may be the only demonstrable
metasteses, extensive axillary involvement marks the case as one
in which palliation is the only reasonable expectation and may
be as successfully achieved by radiation alone.

Radiation is challenging surgery as the most effective thera-
peutic agent in early and operable cases. Particularly in
England many competent men elect to use it in place of
surgery. Unfortunately, comparative statistics are not yet
available upon which to judge its efficacy. Small series have
yielded results which if not quite as good, closely approximate
the results obtained by radical amputation.

Because most carcinomas of the breast are radioresistant, in-
terstitial radiation is more effective than surface radiation.
With either the element or radon, a sterilizing dose can be
given if the radiation is accurately placed with respect to the
tumor tissue. The difficulty of localizing such tumor tissue in
the breast and of irradiating the axillary nodes by the accurate
approximation of radon or the element has been the greatest
handicap to the method.

Surface radiation by high voltage roentgen therapy is proper-
ly an adjunct to interstitial radiation. Except in the case of the
most radiosensitive types of tumors, such as acute inflammatory
carcinoma, the speaker does not believe that X-ray radiation
alone should be depended upon to control the lesion. Most
radiologists prefer to use frequent small doses.

A sharp difference in opinion is registered with respect to
the efficacy of postoperative radiation. The preponderate
opinion as reflected in the literature favors its use. Comparative
statistics show a 5 to 10% improvement over cases treated by
surgery alone.

However, there are other series which fail to show this ad-
vantage and which have led to the opinion that postoperative
radiation is without value. The speaker favors its use for those
cases in which axillary metastases are demonstrated at operation.

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125

Preoperative radiation is not extensively practiced as a routine
procedure and yet is probably more reasonable than post-
operative radiation. It should be used in all cases which
approach the borderline of operability.

From the standpoint of curability, the speaker does not be-
lieve that an inoperable lesion can be converted into an operable
one by radiation. However, many bulky carcinomas too large
to be controlled by radiation can be devitalized and reduced in
size to permit operative removal as a palliative procedure.

Surface radiation by X-ray is extremely useful in dealing
with skin metastases and most valuable in controlling the pain
of bone metastases. Under its influence, pathological fractures
have been known to heal and to permit normal function and
weight bearing.

The speaker concluded by expressing the feeling that the
true picture of the curability of cancer rests somewhere between
the contentions of the optimists and enthusiasts and those of
the defeatists. The education of the laity is making itself
felt in the higher percentage of early and operable lesions seen
by the surgeon. Radiation shows more promise of further
development than does surgery but at the present time in early
and operable cases the radical amputation is still the better
treatment.

DISCUSSION

Dr. Russell Wright Morse: I think that on a subject
like this, one can best speak from personal experience rather
than from statistics. The cases that come to us for treatment
postoperatively, immediately after operation, represent a very
unsatisfactory group for treatment, because we are faced with
a serious problem. If we treat these cases mildly we may find
that they will come back in a very short time with local re-
currence. In order to actually eradicate cancerous tissue I
think it is necessary to give a dose which is almost lethal to
normal tissue and from which the normal tissue will recover
with difficulty. I have not yet come to the point where I am
willing to do this on every case routinely. If we produce this
change in the soft tissues over the chest using 200,000 kilovolts
with from one to two millimeters of copper filtration we are
almost uniformly going to get a pleuritis and pneumonitis as
a result of the X-ray. The patient recovers from this but has
a period of disability from six to eight months in which there
is discomfort and a sense of constriction in the chest. How-
ever, he does recover and I have never seen any late bad effect.

The group that comes back with recurrence locally is a much
better group to treat because we know that we can eradicate any
individual area of tumor in the chest wall in the majority of
cases. Usually, the area which is treated remains free from
malignancy afterward. I am not able to speak for the results
which have been obtained with the higher voltage.

Dr. Malcolm Hanson: This has been a very interesting
summary of this problem. I think cancer of the breast is one
of the dark pages in medicine. Anything you can offer is well
taken. To review the statistics for a long period of time it
would be hard to evaluate some of these statistics. You should
take into consideration the surgery, the type of surgery that is
done, where the postoperative radiation is done and the type of
radiation, how much is done and over what period, etc., before
evaluating the value of radiation.

There is one thing I think you can evaluate from these
statistics fairly reasonably now and that is that your results are
about, I would say, 5% to 15% better in surgery followed bv
radiation or a combination of surgery and radiation. Per-
sonally, I believe that the combination of the two in the large
series of carcinoma of the breast offer the best results at this
time. There is one type that I think is definitely a radiation
problem and that is the very sensitive tumor. Coutard gives
these patients five test doses over a period of six to seven days,
and will give them 200 roentgens per day. If it is a tumor
that responds very rapidly that tumor is a radiation problem

and he says that the statistics from surgery on that type of
tumor are very poor. I think in these cases it would be well
to give them a preoperative dose of radiation, sort of a test
dose, — if they do not respond, operate upon them around
fourteen days after their radiation has started. At that time
you can operate upon them without difficulty and then prob-
ably give them postoperative radiation.

As far as high voltage is concerned, I think we should have
a larger number of cases and that these cases should be carried
on for a longer period of time to determine exactly what the
effect is in higher voltage. We also know that in many of
these tumors it is necessary to give, for instance, nine to ten
times the erethemia dose. We will have to wait to know ulti-
mately to determine exactly what our effect is going to be with
high voltage.

Dr. J. M. Hayes: As Dr. Hanson has said the treatment of
cancer of the breast has been one of the dark pages of medicine.

The comprehensive report of Dean Lewis presented before
the American Surgical Association, gives us something serious
to think about regarding this condition. His report covers a
period of forty-three years and figuring the results by decades,
the recent decades apparently do not show any great progress
in our ultimate results.

The fact that more than 10% of these cases are living after

a period of ten years does not speak well for the established

methods of handling this condition. As Lewis has well shown,
statistics must be figured from many angles in order to give
us a definite knowledge as to what really are our end results.
One may draw the conclusion from McNeally’s report, on the
local removal of the breast cancer, that this method gives re-
sults equal to those obtained by all other combined methods.
The fact is that when the growth has once spread from the

original site our chances of cure are not bright.

I once had an opportunity of examining several of these
resected specimens in which the surgeon and pathologist re-
ported no palpable glands outside of the original site. Study-
ing these closely with a magnifying glass revealed many glands
not much larger than the head of a pin, yet proved to be
malignant. Our greatest difficulty is that we are not getting
these cases early enough for cures. I have been especially in-
terested in Harrington’s report. It is, no doubt, from such a
large number of cases well supervised that we get our most
reliable statistics. His reports seem to substantiate the state-
ment of Dean Lewis: "The very questionable effect of radia-
tion.” Lewis says, the inevitable fluctuation in the results of
treatment of breast tumor is probably due to the type of neo-
plasm and the indeterminable extent of the disease. My ob-
servations, including my fifteen years of service in the out-
patient department of the University Hospital have strengthened
my belief in the above statements.

I recently reviewed twelve cases with metasatic lesions fol-
lowing radical removal of the breast cancer. Two were in the
spine; one in the pelvis; three in the pleura; one on the cer-
vical glands on the opposite side; two in glands on the same
side; one beneath the scapula; one between the ribs beneath
the site of the original lesion after prolonged treatment with
X-ray and one in the ribs on the same side. Apparently earlier
surgery alone would have headed off the disease in these cases.

The educational campaign has not yet accomplished what was
expected of it in getting these patients in for early treatment.

Dr. E. T. Bell: A paper by Nathanson and Welch in the
American Journal of Cancer; 1936, Vol. 28, page 40, gives a
follow-up study of 150 cases of cancer of the breast from
several Boston Hospitals. The patients were treated chiefly by
surgery, but many had X-ray treatment also. The authors
show a survival curve rather than five-year cures. About 33%
survived 5 years; 22%, 7 years; 11%, 10 years; and 6% for
13 years. Nearly all of the women ultimately die from the
cancer.

About three-fourths of the women have involvement of the
axillary lymph nodes when they first consult a surgeon.

126

THE JOURNAL-LANCET

NEWS ITEMS

Dr. J. R. Byrne, a graduate of Creighton University
of Omaha, has established practice at Edgemont, S. D.

Dr. C. T. Olson of Wyndmere, N. D., who has been
seriously ill at Passavant Hospital in Chicago, is mak-
ing a rapid recovery.

Dr. H. H. James, of the Murray Hospital Clinic at
Butte, Montana, left January 22 for Spokane where he
delivered an address on "Cancer and Its Treatment”
before the Mendel Scientific Society of Gonzaga Univer-
sity.

The Fort Harrison Veterans’ Hospital at Helena,
Montana, was reopened February 15th. The institution
was renovated after earthquake damage.

Dr. L. F. Hawkinson was elected chief-of-staff of St.
Joseph’s Hospital, Brainerd. Other officers are Dr. C.
E. Anderson, vice-chief; Dr. O. E. Hubbard, secretary-
treasurer.

Dr. N. O. Pearce, past president of the Hennepin
County Medical Society, was elected president of the
Hennepin County Tuberculosis Association at its recent
meeting. Dr. Stephen Baxter was named vice-president,
and Dr. William H. Aurand, re-elected secretary.

Officers and committees of the Fillmore-Houston-
Dodge County Medical Society were elected at their
meeting of January 13, at the Mayo Clinic.

Dr. E. C. Smith, Mission, South Dakota, died at his
home a few weeks ago of pneumonia. He was 77 years
old, and had been health officer in Todd County for
many years.

Dr. L. H. Fligman, Helena, Montana, presided at the
meeting of the Montana division of the American Col-
lege of Physicians held February 13th, at Great Falls.
A scientific program followed the dinner. Physicians
from Billings, Missoula, Helena, and Great Falls,
attended.

Dr. I. D. Clark, Jr., son of Dr. and Mrs. I. D. Clark
of Fargo, N. D., arrived at Bismarck January 18, to be-
come associated with the Roan and Strauss Clinic of that
city. Previous to this time Dr. Clark, Jr., has been a
member of the staff of the state school for the feeble-
minded at Grafton.

Dr. Louis O’Brien, son of the late Dr. T. O’Brien,
who practiced in Wahpeton, N. D., for 46 years, has
formed a partnership with Dr. J. H. Hoskins of that
village.

Dr. George Sutton, former fellow in the Mayo
Foundation, died suddenly of a heart ailment at his
home in San Francisco, January 31, on the eve of his
fifty-first birth anniversary. Dr. Sutton was born in
Prior Lake, Minnesota, and received his B. S., M. D.,
and M. S. degrees from the University of Minnesota.

The Sixth District Medical Society held a meeting
at St. Joseph’s Hospital at Mitchell, South Dakota,
February 8th. The new officers for 1937 are Dr.
Robert A. Weber, president; Dr. J. H. Lloyd, vice pres-
ident; Dr. F. E. Boyd, secretary and treasurer; Dr. O. J.
Mabee, censor; and Drs. E. W. Jones, and W. R. Ball,
delegates.

Dr. W. M. Dummer, physician at Fairfax, Minnesota,
since 1923, died February 3. Although only 50 years
old, Dr. Dummer had been failing in health for several
years, and was forced to retire from active practice last
April. After graduation from Northwestern Univer-
sity in 1918, he established practice at Farmington,
Minnesota, where he remained until moving to Fairfax.

At a meeting of the Upper Mississippi Medical
Society held in Brainerd, January 23, Dr. Z. E. House,
of Cass Lake, was elected president. Other officers are:
Dr. B. W. Kelly, Aitkin, first vice-president; Dr. Mary
Ghostlay, of Puposky, second vice-president; Dr. T. C.
Davis, of Wadena, third vice-president, and Dr. G. I.
Badeaux, of Brainerd, secretary and treasurer.

At the regular meeting of the Mount Powell Medical
Society of Montana, held December 21, 1936, at Warm
Springs, Montana State Hospital for the Insane, the
following officers were elected for 1937: Dr. T. J. Kar-
gacin, president; Dr. Leo P. Martin, vice president; Dr.
Lawrence G. Dunlap, secretary; Dr. John J. Malee,
treasurer; Dr. W. E. Long, Dr. H. A. Bolton and Dr.
A. J. Willits, censors. Delegates to the state medical
convention are: Dr. L. G. Dunlap and Dr. Frank I.
Terrill; alternates are Dr. T. J. Kargacin and Dr. Leo
P. Martin.

Dr. Joseph E. Schaefer was elected president of the
Steele County Medical Society during its recent meeting
in that city. Other officers of the society are Dr.
Benedik Melby, Blooming Prairie, vice-president; Dr.
C. T. McEnaney of Owatonna, secretary-treasurer; Dr.
L. V. Berghs, Owatonna, delegate to the Minnesota
Medical Society; Dr. C. L. Farabaugh, Owatonna, al-
ternate, and Dr. J. A. McIntyre, Owatonna, censor.
Dr. H. Mark of the Minnesota Tuberculosis Sanator-
ium at Walker, was guest speaker.

Dr. Eugene Kibbey Green, 67 years old, well-known
Minneapolis physician and surgeon, died on January
22 in Pasadena, California. Dr. Green, a past president
of the Hennepin County Medical Society, had been ill
for a year and had gone to California with his wife to
rest. Born in Minneapolis, Dr. Green was graduated
from the University of Minnesota in 1903. He was a
member of the university faculty for some time, and
later became one of the owners of the Franklin Hospital,
formerly known as Hillcrest Hospital.

He was president of the Hennepin County Medical
Society in 1918, a member of the house of delegates of
the Minnesota State Medical Association, of the Amer-
ican Medical Association, and of the American College
of Surgeons.

THE JOURNAL-LANCET

127

Dr. S. A. Slater left Worthington Wednesday, Feb-
ruary 10th, for New York City, where he will attend a
national tuberculosis clinic.

Dr. W. A. Douglas, 73, a resident of Lamberton,
Minnesota, for 24 years, died February 5th, following
a long illness.

Doctor O. I. Refsdal, of Austin, Minnesota, died on
January 14, 1937, in Austin. He had practiced for
some years in Hayfield, Minnesota.

The Washington County Medical Society held its
regular monthly meeting in its Stillwater club rooms,
Tuesday, February 9th. Dr. M. W. Wheeler, of St.
Paul, was guest speaker.

Dr. E. C. Smith, Mission, S. D., died from an attack
of pneumonia January 20. He had practiced at Fort
Randall, and Lake Andes, and at one time was official
physician for the Barnum and Bailey circus. The body
was taken to Keokuk, Iowa, for burial.

Floyd W. Burns, M. D., 61, a graduate of the Uni-
versity of Minnesota and the University of Chicago
Medical School, and a captain in the medical corps
during the World War, was buried in Oakland Cem-
etery, Saint Paul, Minnesota, on January 22, 1937.

Doctor Charles B. Lenont of Virginia, Minnesota,
and Doctor Edward N. Peterson, of the More Hospital
in Eveleth, Minnesota, established on February 1 the
Lenont-Peterson Clinic in Virginia. Cost of the clinic
was between $25,000 and $30,000.

Doctor T. R. Vye, of Laurel, Montana, was named
chief of the staff of Saint Vincent Hospital of Billings,
Montana, on January 11, 1937. Doctor Frank Dunkle
is vice president, and Doctor H. T. Caraway is secre-
tary. Both are of Billings. Doctor Phillip Griffin, of
Billings, is retiring chief.

Carl William Forsberg, M. D., Ph. D., instructor in
pathology at the University of Minnesota Medical
School, died on February 21, 1937, in University Hos-
pital. His degree was obtained from the University in
1922; but he was a member of the South Dakota State
Medical Association. He practiced in Sioux Falls from
1927 to 1933.

At a meeting of the Blue Earth County Medical So
ciety held at the Mankato Clinic on January 18, 1937,
Dr. Charles Koenigsberger, Mankato, Minn., was elected
president; Dr. J. C. Vezina, Mapleton, Minn., was
elected vice-president; and Dr. George E. Penn, of
Mankato, was elected secretary and treasurer.

John Engstad, M. D., 78, a graduate of Rush Medical
College of the University of Chicago, and a physician
for more than 50 years, died at Grand Forks, North
Dakota, on February 19, 1937. Doctor Engstad

founded the first private hospital in the Northwest; it
is now known as the Deaconess Hospital in Minne-
apolis. He was a member of the American Medical
Editors and Authors Association.

Dr. John P. Rhoads, prominent Montana pioneer,
died January 27, at the home of his daughter, Mrs.
C. L. Morris, of Laurel. Dr. Rhoads had lived in
Montana, since 1882, and had an active part in the
forming of the state’s early history. He was 86 years
old.

On Tuesday, March 2nd, at 8:15 p. m. Dr. Henry
E. Sigerist will give the William W. Root Alpha Omega
Alpha Lecture at the medical sciences amphitheater at
the University of Minnesota. The subject for his talk
will be "Leprosy and Plague in the Middle Ages.”

The outline of the program of the annual meeting
of the Montana State Medical Association meeting,
which will be held at Great Falls July 11 to 14, is as
follows: July 11, child welfare; July 12, 13, Montana
State Health Association; July 14, Academy of Oto-
laryngology and Ophthalmology. This meeting will be
followed by the annual meeting of the Pacific North-
west Medical Association on July 15, 16, 17, 1937.

Dr. Owen King was elected president of the Aber-
deen District Medical Society, when 28 members
gathered at their annual meeting January 26, at Aber-
deen. Other officers elected were; Dr. T. P. Ranney,
vice-president; Dr. J. D. Alway, secretary-treasurer;
Dr. B. C. Murdy, Dr. J. L. Calene, and Dr. W. D.
Farrell, delegates to represent the society at various
medical conventions. Alternate delegates were Dr.
E. E. Stephens, Dr. J. F. Adams, and Dr. H. I. King.

Dr. W. A. Gerrish, Jamestown, N. D., president of
the North Dakota State Medical Association, was guest
speaker at the monthly dinner meeting of the Cass
County Medical Society held January 29. The new
officers of the society for 1937 are: Dr. J. C. Swanson,
Fargo, president; Dr. H. J. Fortin, Fargo, vice-president;
Dr. E. M. Watson, Fargo, secretary-treasurer; and Dr.
J. F. Hanna, Fargo, censor for three years. Delegates
to the state convention will be Drs. A. M. Limburg,
R. E. Pray, and R. B. Bray, all of Fargo, with Drs.
W. G. Brown and G. A. Pages of Fargo, and J. B.
James of Page, as alternates. Dr. Pray, Dr. K. E.
Darrow, Dr. Bray and Dr. W. H. Long discussed clin-
ical case reports.

On February 5, 1937, Doctor J. Arthur Myers, pro-
fessor of preventive medicine in the University of Min-
nesota Medical School, spoke before the Fargo Anti-
Tuberculosis Association. On February 8 Professor
Myers spoke at the Minneapolis Y. M. C. A.; on Feb-
ruary 9 he addressed the Tenth District Nurses’ As-
sociation at the Sacred Heart Hospital in Eau Claire,
Wisconsin; and on the evening of the same day he
addressed the Chippewa County Medical Society in
Chippewa Falls, Wisconsin. On February 22, Doctor
Myers was the principal speaker at the combined meet-
ing of the Colorado Tuberculosis Association and the
Denver Sanatorium Association at the Denver Univer-
sity Club; and on February 24, he spoke before the
scientific forum of the Minneapolis Public Library on
"The Breath of Life.”

128

THE JOURNAL-LANCET

Twenty-five years of pioneering in medical education
in North Dakota were publicly recognized when friends
and associates attended a testimonial dinner given for
Dean H. E. French at Grand Forks on February 5.
Speakers who paid tribute to the veteran University of
North Dakota dean of the School of Medicine included
two former students, Dr. John S. Lundy, of the Mayo
Clinic, and Dr. C. R. Tompkins, of Grafton, N. D.

Seven persons were licenced to practice medicine and
surgery in the state of North Dakota by the State
Board of Medical Examiners on January 11, 1937. They
are as follows: Dr. Fred E. Kolb, Granville; Dr.
Christian G. Johnson, Rugby; Dr. Harriet Bixby, Bis-
marck; Dr. Erwin Edward Stephens, Eureka; Dr. Louis
T. O’Brien, Wahpeton; Dr. Ralph Vinjie, Hillsboro;
and Dr. Lenier A. Lodmell, Grand Forks.

At a meeting of the Stutsman County Medical So-
ciety at Jamestown, North Dakota, February 4th, Dr.
Harry Fortin, of Fargo, gave a very interesting paper
on "Fractures.” The new officers for 1937 are: Dr.
J. L. Conrad, Jamestown, president; Dr. W. E. Long-
streth, Kensal, vice-president; Dr. Bertha Brainard, re-
tiring president, secretary-treasurer; Dr. Floyd O.
Woodward, Jamestown, delegate; and Dr. T. L. DePuy,
Jamestown, alternate.

William A. O'Brien, M. D., associate professor of
pathology and preventive medicine in the University of
Minnesota Medical School at Minneapolis, is the speak-
er for the Minnesota State Medical Association’s radio
broadcasts for March, over Station WCCO (810 kilo-
cycles, 370.2 meters) . The broadcasts are given each
Thursday afternoon at 2:30 p. m. On March 4 the
subject is: "Parents & Children”; on March 11 it is:
"Dementia Praecox”; on March 18 it is: "Pneumonia”;
on March 25 it is: "Periodontia.”

Dr. Carl A. Feige, 58, died January 26 after an ill-
ness of two months. Spending the early days of his
practice in Kansas City, Dr. Feige came to South
Dakota in 1924. After being in Iroquois and Huron,
he settled in Canova, in 1928. Dr. Feige was appointed
a member of the State Board of Medical Examiners by
Governor Green, and was re-appointed to the post by
Governor Berry. Of a very public-spirited nature, Dr.
Feige took great interest in the community affairs. As
a member of the town council and mayor for several
years, he helped in the building of the town park. He
was a Master Mason, a member of the Consistory, and
a Shriner.

The American College of Surgeons will hold a sec-
tional meeting at Seattle, Washington, on March 31,
April 1, and 2, 1937. The following states and province
will participate: Washington, Oregon, Idaho, Montana,
British Columbia. According to the program scheduled,
the meeting should be of great interest to all physicians
and hospital superintendents, and everyone is invited to
attend. There will be no registration fee. A general
outline of the program will include: technical and scien-

tific exhibits; hospital conferences; round table dis-
cussions; medical motion pictures; special clinics on
cancer, fracture, and eye, ear, nose and throat, and a
dinner for fellows of the College. Headquarters will
be at the Olympic Hotel.

Julian F. DuBois, M. D., secretary of the Minnesota
State Board of Medical Examiners, Saint Paul, Min-
nesota, advises The Journal-Lancet that on February
2, 1937, Judge Levi M. Hall, of the District Court of
Minneapolis, sentenced one Mary Lovold (alias Mary
Gaslin), 71, to a term not to exceed 4 years in the
Woman’s Reformatory at Shakopee, Minnesota. The
person named pleaded guilty on November 31, 1936,
to performing a criminal abortion on a 28-year old girl
of Princeton, Minnesota. The girl is still at the Min-
neapolis General Hospital, unable to receive medical
treatment because of persistent abscesses. Judge Hall
suspended sentence on the guilty woman because she
is suffering from carcinoma, placing her in the custody
of a Hennepin County probation officer.

Dr. C. L. Sherman, of Luverne, Minnesota, was
named president of the Sioux Valley Medical Associa-
tion at the closing session of their annual meeting, which
was held at Sioux City, January 19 and 20, 1937. Other
officers include: Dr. N. J. Nessa, Sioux Falls, S. D.,
vice-president; Dr. H. I. Down, Sioux City, re-elected
secretary; Dr. Walter Brock, Sheldon, Iowa, re-elected
treasurer. Dr. H. J. Brackney, of Sheldon, and Dr.
W. H. Halloran, of Jackson, Minnesota, were re-elected
to the board of censors, while Dr. W. F. Bushnell of
Elk Point, S. D., was named to the board to succeed
Dr. Nessa. One of the features of the meeting was the
presentation of honorary certificates to the physicians
who have been members of the association for more than
twenty-five years. The presentation was made by Dr.
W. R. Brock of Sheldon, who was introduced by the
toastmaster, Dr. Gilbert Cottam, of Minneapolis.

A one day Congress of Allied Professions and a
Northwest Industrial Medical Conference will be feat-
ures of the annual meeting of the Minnesota State
Medical Association, which will be held in the St. Paul
Auditorium, May 2 to 5, 1937. Discussion of current
social and economic problems from the point of view
of the various professions will occupy the morning pro-
gram. The afternoon will be devoted to addresses by
officials of Washington and representatives connected
with the social security program.

An extensive exhibit section is planned. Included in
this list will be: the prehistoric girl discovered by A. E.
Jenks, Ph. D., professor of anthropology at the Univer-
sity of Minnesota; a cancer exhibit, in cooperation with
the American Society for the Control of Cancer; en-
docrinology, by Dr. L. F. Hawkinson of Brainerd; hand
infections, Dr. Hamlin Mattson, Minneapolis; ophthal-
mology and otolaryngology, Dr. Frank E. Burch, St.
Paul; and many others. An entire hour each morning
and afternoon during the three days will be devoted to
inspection of exhibits and scientific demonstrations.

This issue, devoted exclusively to the subject of Tuberculosis, is
published in conjunction with the National Tuberculosis Association.

INTRODUCTION

MAN, TUBERCULOSIS AND SUPERSTITION

Kendall Emerson, M. D.*

New York City

THE figure of Samuel Pepys, famous diarist of the 1660’s, walking home with a rabbit’s foot
in one pocket and a copy of Hooke’s Book of Microscopy in the other, still stalks the pages
of our daily lives.

Man looks out on the world about him, clutching Science with one hand, anxious for its benefits,
yet clinging firmly with the other to the superstition of the ages.

Tuberculosis is conquerable. Causes are known. Methods of transmission are known. Treat-
ments are known. Man is the great unknown quantity — man with all his negativing attitudes and his
ridiculous mental impediments.

It is the doctor’s high mission — indeed, his first mission — to strip him of these "rabbits’ feet,” not
always so obvious as the furred little legs of our woodland friends, however, because civilization’s veneer
has dressed them up more subtly. But the "rabbits’ feet” are there, nevertheless. And they must be
taken out of man’s pocket and man’s mind.

Then he will be free to value his body as he should.

And that bright day will have arrived when the tiny tubercle bacillus is discovered as it starts its
career of destruction rather than as it completes it.

•Managing Director, National Tuberculosis Association.

130

THE JOURNAL-LANCET

Errors in the Diagnosis of Pulmonary Tuberculosis

J. O. Arnson, M.D.**

Bismarck, North Dakota

WE ARE well aware of the difficulties attend-
ant upon the early diagnosis of tuberculosis,
and with the increasing knowledge which
medical science has given us, more cases of early tubercu-
losis come under treatment every year. During the past
ten years, specialists in sanatoria observe that the gen-
eral practitioner is sending for treatment more cases of
early and fewer cases of advanced tuberculosis. This
healthful state of affairs demonstrates the increasing
diagnostic ability of the medical profession. Some time
ago I heard a group of people interested in tuberculosis
work state that, with the "modern armamentarium,’’
tuberculosis is more-readily diagnosed and earlier recog-
nized; which, with increasing public interest, is true.

Of the modern means available for diagnosis, the
X-ray is perhaps the most important. A great deal of
reliance is placed on X-ray diagnosis of tuberculosis,
and rightly so, because without the X-ray we would
often be handicapped in this work. Yet, it must be borne
in mind that the X-ray is an accessory to the examina-
tion; however, a necessary one; and the clinical history,
physical findings, temperature and pulse records, sputum
examinations and tuberculin tests play an important and
often deciding role in making a correct diagnosis.

Even in advanced types of disease it has been our
experience to find the X-ray fallible, leading us astray,
if we place too much dependence upon it. Realizing the
great chance of error in placing too great reliance on
the X-ray film, we would like to call your attention to
a group of conditions in which the X-ray findings are
confusing and in which other methods of examination
are essential.

Lobar Pneumonia

It sometimes occurs in the course of a lobar pneu-
monia, particularly if the course is atypical and resolu-
tion is delayed, that the question arises as to whether or
not tuberculosis is present. Active cases of pulmonary
tuberculosis may develop any of the types of pneumonia.
In this event, X-ray plates may prove confusing. In lobar
pneumonia the consolidation is not always uniform
throughout the affected lobes. During resolution, absorp-
tion does not occur at the same rate in all parts of the
consolidated area with the result that the shadow pro-
duced is mottled. If plates are taken fairly late during
the period of resolution, areas of early and more com-
plete resolution will show such variations of aeration
that cavitation may be simulated. It is clear, then, that
the X-ray plate may show lesions very characteristic of
tuberculous infiltration and even cavitation. This error

•Presented before the Rocky Mountain Tuberculosis Conference,
Albuquerque, N. Mex., September 29, 1936.

••From the medical service, Quain and Ramstad Clinic, Bis-
marck, N. D.

may be avoided by continuous observation. If the path-
ology is produced by pneumonia, the infiltration clears
in a few weeks and other corroborating evidences of
tuberculosis are absent.1' 2 (Fig. 1.)

Bronchopneumonia

In this condition, the X-ray will show soft, mottled
shadows in one or more lobes, and if the lesion is con-
fined to an upper lobe, the simulation of tuberculosis
will be greater. However, if bronchopneumonia is con-
fined to one lobe, it usually chooses one of the lowers.
The differentiation between a simple, slowly-resolving
bronchopneumonia and tuberculous infiltration depends
on the absence of positive tuberculous findings and the
fact that bronchopneumonia clears in ten days to three
weeks, while tuberculosis requires much longer. (Figs.
2 and 3.)

Suppurative Bronchopneumonia

The severer types of this infection are not so likely
to be mistaken for tuberculosis because of the great
density of the shadows; but less severe cases show
smaller and fainter infiltrations, and when these are
situated in the upper lobes, they may lead to a suspicion
of tuberculosis. To make a definite differentiation, re-
peated X-ray examinations are indicated.

Gangrenous Bronchopneumonia

This condition is the early stage or precursor of lung
abscess, and presents a dense, homogeneous shadow
which, when located in an upper lobe, may simulate
early exudative tuberculosis. Gangrenous bronchopneu-
monia is recognized by the foul sputum which is per-
sistently negative for tubercle bacilli and the early cavitv
formation which occurs in from ten days to two weeks.
(Fig- 4-)

Tuberculous bronchopneumonia may simulate the
early stage of lung abscess, when it is a single localized
lesion, but when it occurs diffusely through the lung, it
cannot be differentiated from lobular or suppurative
bronchopneumonia except by its course and clinical
findings.

Abscess of the Lung

In the earliest stage, pulmonary abscess is not differ-
ent from any other localized consolidation. The site of
predilection is the apex of one of the lower lobes or
the axillary and anterior portion of the upper lobes.
(Fig. 5.) The course, that is rapid cavity formation in
ten days to two weeks, and the location, help to distin-
guish the lesion. Greater difficulty in differentiation
occurs when a tuberculous cavity is found in a lower

THE JOURNAL-LANCET

A. B.

FIGURE 1

A. Resolving bronchopneumonia showing areas of infiltration in right upper which resemble tubercu-
losis. Annular shadows present simulating caviation.

B. Same chest three weeks later shows complete resolution. Sputum negative for tubercle bacilli.

A. B.

FIGURE 2

A. Resolvfng lobar pneumonia simulating massive tuberculous infiltration.

B. Same chest three weeks later showing compkete resolution. This case had a history of joint tuberculosis.
Sputum persistently negative for tubercle bacilli.

132

THE JOURNAL-LANCET

A B

FIGURE 3

A. Tuberculous infiltration left upper lobe simulating broncho-pneumonia.

B. Same chest three months later shows resolution.

Sputum negative for tubercle bacilli.

FIGURE 4

Gangrenous bronchopneumonia in right upper lobe showing
early stage of cavity (abscess) formation.

lobe, which sometimes occurs. (Fig. 6.) However, con-
tinuous clinical observation and repeated sputum exam-
inations make the diagnosis clear.

Bronchiectasis

Bronchiectasis has frequently led to difficulties in its
clinical recognition, and instances are known when tu-

FIGURE 5

Abscess of lung showing typical situation in upper portion of
left lower lobe.

berculosis has been suspected and diagnosed. The X-ray
film made after lipiodol instillation makes the diagnosis
certain. There are, however, instances when tuberculosis
may produce areas of localized bronchiectasis. In long
standing chronic types of pulmonary tuberculosis, bron-
chiectasis may occur in the tissue adjacent to the lesion.

THE JOURNAL-LANCET

133

FIGURE 6

Tuberculous infiltration with cavity in right lower lobe, simu-
lating gangrenous bronchopneumonia with abscess. Sputum posi-
tive for tubercle bacilli.

In these cases, bronchial dilatations persist. They are
often large and irregular, and are confined to the area
involved by the tuberculous lesion.

Silicosis and Anthracosis
In these lesions, we have had no experience, but in
mining and quarrying regions where these conditions
are common, it is recognized that at times they are
readily confused with pulmonary tuberculosis. In such
instances clinical observations are the deciding factors
in making the diagnosis.'3

Streptothricosis, Sporotrichosis, and Leptothrix
Infections

In these diseases, the pathology is that of a granu-
loma which produces either a localized or a diffuse pneu-
monic process, and in the diffuse type differentiation
from tuberculosis by the X-ray is impossible. Many of
these cases are diagnosed and treated as tuberculosis.
The differentiation can only be certain by recovering
the causative organism or the tubercle bacillus from the
sputum.4

Syphilis

Syphilis of the lung is characterized by an interstitial
fibrosis and is so rare that its consideration is nearly
unnecessary. The only confusion we have had called to
our attention was due to the unusual enthusiasm of
some syphilographer. Most of the errors in this category-
corn e from diagnosing tuberculosis as syphilis. It must
be remembered that tuberculosis can be present in a
person who has a positive Wassermann from syphilis,
a fact upon which some enthusiastic clinicians place too
little credence.

Neoplasms

Neoplasms of the lung or bronchi cause confusion
because of the pathologic changes which occur in the
lung tissue as a result of obstruction to a bronchus. The
density of the lung thus obstructed may frequently lead
to a suspicion of tuberculosis. In many instances, how-
ever, the collapse of the lung can be readily seen and a
correct interpretation can be made early and readily.
The error in confusing this type of collapse with a
tuberculous lesion was more frequently made in the
early days of chest roentgenography, but with increasing
knowledge and better interpretation it rarely occurs.

In infiltrating types of carcinoma and diffuse carci-
nomatosis, the differentiation is not so easy and many of

FIGURE 7

A. Density in right middle lobe due to collapse from obstruction of bronchus by neoplasm.

B. Lipiodol injection in same case reveals obstruction of right middle bronchus.

134

THE JOURNAL-LANCET

FIGURE 10

Congenital cystic disease of right lung showing areas of mas-
sive collapse and the walls of the cysts as coarse trabeculations.

from malnutrition and general physical debility, with
superficial observation the error in diagnosing tubercu-
losis may easily occur. The X-ray findings which show
areas of collapse and coarse trabeculations, the walls of
the cysts, are characteristic. This, with consistently nega-
tive tuberculosis findings, should make the diagnosis.
(Fig. 10)

In conclusion, we would emphasize the necessity of
careful and detailed study and constant observation in
cases of obscure pulmonary lesions. In spite of the confi-
dence which has rightly been placed in the "modern
armamentarium” in the fight against tuberculosis, par-
ticularly the X-ray, let us sound a warning that it is a
fallible ally, and that painstaking clinical observations
and sound clinical judgment still are the most impor-
tant factors in arriving at a correct diagnosis.

By following these precepts we will make fewer errors
in the diagnosis of pulmonary tuberculosis.

References

1. Ude, Walter H.: Roentgenologic Studies in Early Pneu-

monia. American Journal Roentgenology and Radium Therapy,
1931, 26: 691-695.

2. Schnack, A. G.: Pneumonia, Roentgenologically Considered.
Radiology, 1932, 19: 177-182.

3. Habbe, J. E. : Silicotuberculosis, Roentgenologic Aspects of
the Differential Diagnosis. Wisconsin Journal of Medicine, 1936,
35: 349-353.

Hawes, John B.: Silicosis. New England Journal of Medicine,
1936, 215: 143-145.

Jonsson, Gunnar: Some Roentgenological Observations Regard-
ing Pulmonary Silicosis in Porcelain Workers. Acta Radiologica,
1935, 16: 431-437.

Lanza, A. J.: Silicosis from the Public Health and Economic
Viewpoint. Annals of Internal Medicine, 1936, 10: 174-178.

Sayers, R. R., and Jones, R. R.: Silicosis and Its Control.
Surgery, Gynecology and Obstetrics, 1936, 62: 464-473.

Sporotrichosis. Oxford Medicine, 1936, 5 No. 2, p. 422.

4. Norris, G. M., and Landis, H. R. M.: Diseases of the
Chest. Ed. 4, Philadelphia, W. B. Saunders Co., 1929, pp. 442-
446, 453-455.

Page, Irving H.: Streptothrix Necrotic Bronchopneumonia. Ar-
chives of Internal Medicine, 1928, 41: 127-136.

FIGURE 8

Infiltrating type of carcinoma of lung simulating extensive tu-
berculous infiltration. Sputum negative for tubercle bacilli. Malig-
nancy proved at autopsy.

FIGURE 9

Extensive malignant infiltration of right lung.

these are confused with tuberculosis for varying periods,
until the course of the disease indicates the correct diag-
nosis. (Figs. 7, 8 and 9)

Cystic Disease of the Lung

This condition, which is unusually rare, is important
in relation to the subject we are discussing because one
case which came to our attention had been under treat-
ment for tuberculosis for several years. Especially when
the victims of cystic disease of the lung are suffering

THE JOURNAL-LANCET

135

Indications and Contraindications for Bronchoscopy*

In the M anagement of Pulmonary Tuberculosis

Porter P. Vinson, M.D.

Richmond, Va.

THE MORE general employment of bronchoscopy
in the management of pulmonary diseases raises
the question as to the indications and contraindi-
cations for this examination in patients suffering from
pulmonary tuberculosis. Although opinions vary as to
the indications for bronchoscopy in the patient with
tuberculosis, there seems to be general agreement that
direct visualization of the tracheobronchial tree should
not be made a routine examination in patients suffering
from this disease. Bronchoscopy can be performed with
a minimal amount of discomfort and very little risk,
but when it is employed in the patient with pulmonary
tuberculosis, complications which arise thereafter may be
attributed to the passage of the bronchoscope. It would
seem advisable, therefore, to limit bronchoscopy in the
patient with pulmonary tuberculosis to the examination
and treatment of those lesions which cannot be diag-
nosed and relieved by more conservative measures.

It hardly is necessary to say that unless the patient’s
general condition is critical as the result of tuberculosis,
bronchoscopic examination is required when a foreign
body is present or thought to be present in the air pass-
ages. It would not seem wise, however, to recommend
bronchoscopy in such a patient even for the removal of
a foreign body from the air passages, if the foreign
body had teen aspirated during the terminal stages of
the disease.

Although tuberculosis in the lungs is infrequently
associated with malignant disease, carcinoma of the
trachea or bronchi may develop in the tuberculous
patient. Without bronchoscopy, this complication can-
not be diagnosed and differentiated from hyperplastic
tuberculosis with the formation of tumor. Whenever
tracheal or bronchial obstruction is evident in the patient
with tuberculosis, bronchoscopy is indicated to determine
the character of the obstructing lesion.

The majority of tuberculous lesions in the tracheo-
bronchial tree are associated with the presence of bacilli
of tuberculosis in the sputum, although tuberculosis in-
volving the hilar area and resembling primary carcinoma
of a bronchus is a notable exception. Many of these
lesions represent tuberculosis of the hilar lymph nodes
with ulceration into the lumen of a bronchus. Bacilli of
tuberculosis are rarely found in the sputum of these
patients, and the diagnosis of tuberculosis is made from
the microscopic study of tissue removed bronchoscopi-
cally from an infiltrated or ulcerated bronchus. At times
no ulceration or infiltration is evident in the wall of
the bronchus in this type of lesion and, when such is
the case, the removal of tissue for microscopic examina-
tion is inadvisable. The fact that infiltration of the

•Prepared expressly for the special Tuberculosis issue of THE

JOURNAL-LANCET.

bronchial wall is not observed suggests that the under-
lying lesion is tuberculous. When a malignant lesion is
demonstrable by roentgenoscopic study, bronchoscopy
almost always reveals evidence of infiltration or ulcera-
tion of the bronchial wall.

The presence of a foreign body, particularly a pul-
monary calculus, may produce the signs, symptoms and
roentgenoscopic appearance of a hilar tuberculous lesion,
and repeated bronchoscopic examination may be required
to demonstrate and remove the cause of the inflamma-
tory disease. When the foreign body is embedded in a
mass of inflammatory tissue, the differentiation of this
type of lesion from tuberculosis or malignant disease
is especially difficult.

Bronchoscopy may be required to determine the source
of bleeding from the lungs when tuberculosis is present
in both lungs and collapse therapy is contemplated. In
many instances, ordinary methods of examination are in-
adequate to locate the origin of the hemorrhage.

Ulceration of the larynx resembling tuberculous in-
filtration is not a contraindication to bronchoscopy if
bacilli of tuberculosis are not present in the sputum.
Simple laryngeal ulceration resulting from the traumatic
effect of excessive cough may resemble tuberculous
laryngitis, and this type of ulceration is not aggravated
by the careful introduction of a bronchoscope. If an
associated pulmonary lesion cannot be diagnosed without
direct inspection of the tracheobronchial tree, broncho-
scopic examination should be made.

Because of beneficial results obtained from the bron-
choscopic aspiration of pulmonary abscess one may be
tempted to employ similar treatment in pulmonary
tuberculosis with cavitation. Although this type of treat-
ment cannot be condemned as hazardous and without
value, it probably is an unwise procedure. Many cavities
in the lung due to tuberculosis resemble those resulting
from pulmonary abscess and, before bronchoscopic ex-
amination is undertaken, careful study of the sputum
for bacilli of tuberculosis should be made in all patients
having expectoration of secretion.

With or without bronchoscopy the injection of medi-
cated solutions into the tracheobronchial tree in patients
suffering from pulmonary tuberculosis is a practice
which should be discouraged. There is little evidence to
support the belief that local application of drugs is bene-
ficial in any tuberculous lesion. Recent reports of dis-
astrous results following the injection or aspiration of
various oils into the respiratory tract should be sufficient
warning that their employment in the diagnosis and
treatment of any type of pulmonary disease should be
made with caution.

136

THE JOURNAL-LANCET

Conclusions

Bronchoscopy should not be carried out as a routine
procedure in patients suffering from pulmonary tubercu-
losis. Definite indications for direct inspection of the
tracheobronchial tree in the patient with tuberculosis
are enumerated. Before bronchoscopic examination is
undertaken the sputum should be examined for the pres-
ence of bacilli of tuberculosis in all patients having secre-
tion from the tracheobronchial tree. The bronchoscopic
aspiration of cavities resulting from pulmonary tubercu-
losis is not considered a wise procedure. Local treatment

of tuberculous lesions by means of drugs or medicated
solutions is not advisable. The injection of oils, either
plain or medicated, for the diagnosis and treatment of
any type of pulmonary lesion should be made with
caution.

Bibliography

1. Davis, K. S.: Roentgenographic changes following the intro-
duction of mineral oil into lung. Radiology, 26: 131-137 (Feb.),
1936.

2. Firth, J. O.: Iodism. Jour. Am. Med. Assn., 100: 110 (Jan.
14), 1933.

3. Goldstein, D. W.: Fatal iododerma following injection of

iodized oil for pulmonary diagnosis. Jour. Am. Med. Assn., 106:
1659 (May 9), 1936.

The Youth Sector*

In the Fight Against Tuberculosis

William J. Ryan, M.D.**

Pomona, N. Y.

IT IS obvious from the subject which has been
assigned to me, namely, "What Examination Meth-
ods Are Recommended or Discouraged,” in the
case-finding of tuberculosis among the young, that no
standards have yet been generally adopted. This fact
was fully realized two years ago by Dr. Charles H.
Keene, of Buffalo, then president of the American
Association of School Physicians, when he appointed a
committee, known as "The Committee on Tuberculosis
of the American Association of School Physicians,” the
membership consisting of Dr. J. Arthur Myers, of Min-
neapolis, as chairman; Dr. Esmond R. Long, of the
Henry Phipps Institute, Philadelphia; Dr. H. D. Lees,
also of Philadelphia; Dr. Wm. Paul Brown, of Albany,
N. Y., and myself.

The purpose of this committee was to formulate stand-
ards in the examination of school and college students
for tuberculosis with the idea that such standards might
be adopted throughout the country. The group met dur-
ing the annual meeting of the National Tuberculosis
Association at Saranac Lake in 1935, and again during a
similar meeting which was held last month in New
Orleans. The recommendations adopted by this commit-
tee were published in the December, 1935, issue of The
School Physician’s Bulletin, and a further report will
soon appear in the monthly bulletin of the National
Tuberculosis Association. I refer to this committee, be-
cause the methods to be discussed here will consist in
the main of those recommended by that group.

It is now generally accepted that the tuberculin test-
ing of students, regardless of age, followed by the

•Presented at the Annual Conference of the State and Local
Committees on Tuberculosis and Public Health, State Charities Aid
Association, Hotel Biltmore, New York City, May 20, 1936.
••Medical Director, Summit Park Sanatorium, Pomona, N. Y.

X-raying of the reactors with the use of celluloid films,
is the ideal procedure. We are, however, cognizant that
the ideal program cannot be carried out completely in
every community for various reasons, such as a lack of
sufficient funds, trained personnel, or even because of
fanatical opposition. However, in regard to the pro-
miscuous X-raying of children and high school students
without first screening-out the negatives by tuberculin
testing is, in my mind, both unscientific and an unneces-
sary waste of funds; it is unscientific because we know
that certain X-ray shadows which are on the borderline
of pathology may be significant in the presence of a
positive tuberculin reaction; while, on the other hand,
they may be disregarded if the tuberculin test is nega-
tive, and those of us who have had experience in the
interpretation of chest films of the young, realize how
difficult it often is to evaluate the significance of slight
X-ray shadows and, without knowing whether or not
that person is sensitive to tuberculin, we are frequently
in a still greater quandary. We feel that the procedure
of promiscuous X-raying is an unnecessary waste of time
and funds, because in certain communities as many as
75 per cent of students will be found negative to tubercu-
lin, and in such cases, except for the occasional one, the
X-ray film serves no purpose.

There are some who will claim that consent for the
tuberculin testing cannot be obtained in their communi-
ties; I feel, however, that with the proper education of
the public, the school authorities and school faculty, to-
gether with good cooperation from the medical profes-
sion, that from 80 per cent to 85 per cent of consents
should be obtained. Some may retort that they are un-
able to educate their public, that they cannot obtain the
necessary cooperation from the school officials and

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137

medical profession. My only answer is that the fault
more likely lies with the workers themselves than with
the people of their community; that human nature varies
but little in different sections of the country; and that
public health workers who experience such difficulties
should first look to themselves and improve on their own
technique in education and approach.

As to the type of the testing material; the committee
recommends that the purified protein derivative, known
as the P.P.D., should be the tuberculin of choice. The
advantages are, first: similar doses are constant in
potency and stability, whereas with the O.T., the best of
them vary in strength due to conditions of manu-
facture. We recently had the experience of several

-| j 1 1- reactions with old tuberculin from a most

reliable laboratory, although the same measured dose
from the same laboratory had, in former years, been
administered to thousands of children with but a very
few severe reactions. We have also been told that many
preparations of old tuberculin, furnished by city and
state laboratories, as well as commercial, are too weak
to give satisfactory results. Again, it has been demon-
strated by Plunkett, Siegal and others, that the per-
centage of reactors with the average test dose of P.P.D.
is higher than with old tuberculin. The disadvantage of
the P.P.D. is the need for more than one dose. Con-
sent for the administration of more than one test com-
plicates the survey, particularly in the public school
studies. Long has recently informed us that a single-
dose method which is practical will probably soon be
found. Another disadvantage of the use of the purified
protein derivative is its cost.

X-RAY: The ideal method is the use of celluloid
films with the high milliampere equipment and short
exposures. This, however, can be done only by trans-
portation of the students to hospitals or sanatoria. Our
own experience has demonstrated the great value of
such a procedure, and our trend is constantly in that
direction. Films with a portable X-ray apparatus are
not yet entirely satisfactory, due to the long exposure
time, resulting in heart or body movement. It is hoped
that manufacturers will be able to furnish us with high-
power portable equipment for this type of work. How-
ever, with care in technique, films with portable equip-
ment are fairly satisfactory in perhaps 90 per cent of
cases. It should, however, be understood that where there
is a questionable shadow seen on the portable film, the
patient should be re-X-rayed with the use of a high-
power machine.

The committee has sanctioned the use of the so-called
"rapid X-ray method” with paper films for large com-
munities where time and expense are factors. While
such films are not yet universally recognized as equal
to the standard, transparent celluloid, it is the opinion
of the committee that they are sufficiently satisfactory
for recommendation when circumstances warrant their
use.

The speaker has had no experience with the use of
fluoroscopy in the routine detection of pulmonary lesions
in the student. My impression, however, as the result
of considerable fluoroscopic experience in sanatorium
regime, is that many early, less-dense lesions might easily
escape detection under the fluoroscopic screen, although
some workers, notably Fellows, of the Metropolitan Life
Insurance Company, report very gratifying results.
While fluoroscopy is far better than no study at all,
we are inclined to refrain at present from recommend-
ing this as a routine procedure to the exclusion of the
X-ray film until further convincing data of its value
is available.

And finally, I will digress for a moment from the
assigned topic and briefly comment on the relative value
of this work; I am for it, especially among the older
groups. We have examined upwards of 13,000 children
during the past six years, and expect to continue. How-
ever, I am wondering if the present enthusiasm for this
school study, which is now sweeping the country, may
not in some communities at least, especially where funds,
personnel and time are limited, be overshadowing and
causing to be pushed in the background the investiga-
tion for our fundamental source of tuberculosis, namely,
the contacts. It is among the latter group that the rich-
est harvest of our efforts will be reaped, and I am frank
to admit that if all of our contacts were as thoroughly
followed-through in the past as we are doing at pres-
ent, the number of new cases discovered in the schools
would be considerably less. If we would compare the
percentage of newly-discovered cases among our exam-
ined contacts, I am certain that it will far outweigh
those found among the apparently healthy school chil-
dren. Let us first ask ourselves, "Are we doing this job
completely?”

This idea of examining school children is an excellent
one and, wherever possible, should be encouraged and
continued; but let us first thoroughly till the fertile
field and reap the maximum harvest from our known
contacts before we venture to spade the more barren
soil of investigating the average apparently well group.

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The Willard Bequest

W hat Form Should It Take ?

An Expression of Opinion from the Wisconsin
Anti-Tuberculosis Association

Hoyt E. Dearholt, M. D.,* and Staff

Milwaukee, Wisconsin

Foreword — Several years prior to her death, the
public-spirited widow of a public-spirited Wisconsin
physician drafted a will which set up a substantial sum
of money to be used by the trustees of her county’s
tuberculosis sanatorium for r the erection, construction,
and equipment of a children’s preventorium , being a
sanatorium for the prevention and care of tuberculosis
among children.” Between the drawing of the will and
its admission to probate, much change of mind had
occurred among physicians, social workers and the
trustees themselves concerning the efficiency of domi-
ciliary care of rr pre-tuberculosis children” as a practicable
means of preventing tuberculosis as a deadly and dis-
abling disease later in life.

The Wisconsin Anti-Tuberculosis Association was
asked to assist the trustees and the court and the fol-
lowing brief was read into the record. It has seemed to
the editors that it will be interesting to The Journal-
Lancet readers, partly on account of local references,
but rather more as an epitomization of responsible but
disinterested social planning.

Since its organization in 1908, the Wisconsin Anti-
Tuberculosis Association has been actively interested in
the establishment and efficient operation of Wisconsin
sanatoria. As a matter of fact, only because of its year
in and year out efforts have many Wisconsin institu-
tions come to be built at all. Once they have been estab-
lished, the Wisconsin Anti-Tuberculosis Association has
felt an obligation to help sanatorium administrators
keep their institutions abreast of the best current
thought regarding the treatment and cure of tubercu-
losis.

Realizing this interest, and realizing, too, the special-
ized knowledge and resources of the Wisconsin Anti-
Tuberculosis Association, the trustees of Mount View
Sanatorium heve kept the Wisconsin Anti-Tuberculosis
Association informed of developments in regard to the
Willard bequest, and have appealed to it for informa-
tion and advice. Several staff workers of the Wisconsin
Anti-Tuberculosis Association have given considerable
thought and discussion to the question of how the letter
and spirit of Mrs. Willard’s bequest can best be met —
as well as the needs of Marathon County — and the pres-
ent brief is an attempt to summarize our discussion and
opinion.

Three Proposals for Fulfilling Bequest

Three general proposals for use of the fund appear

•Executive Secretary, Wisconsin Anti-Tuberculosis Association.

to be most under discussion. Each will be discussed in
turn.

(1) Use of all of the bequest in the building of a
preventorium on conventional lines; and of as large a
capacity as the funds will permit.

(2) Use of all or part of the bequest for improv-
ing the physical set-up of Mount View Sanatorium —
that is, needed surgical facilities, central heating plant,
etc.

(3) Use of all or part of the fund in developing a
tuberculosis prevention program among all Marathon
County children, rather than a selected few whom a pre-
ventorium of the old-fashioned type could benefit.

I. The Preventorium

The terms of Mrs. Willard’s will are that the "fund
be used for the erection, construction, and equipment
of a Children’s Preventorium, being a sanatorium for
the prevention and cure of tuberculosis among children,”
etc., and that "should such share of the residue [of the
estate] be insufficient to properly erect and construct
such a Children’s Preventorium,” the fund be used for
the maintenance and improvement of Mount View
Sanatorium.

From the terms of her will, Mrs. Willard’s funda-
mental interest was obviously in the "prevention and
cure of tuberculosis among children.” Tuberculosis
among children is a subject about which there exists
even today much confusion in thinking, not only as to
what treatment is necessary, but as to what the condition
itself is.

There are two or three sharply distinct types of
"tuberculous” children.

First, there are the children with a bone or joint
tuberculosis. Europe has many of these, due, perhaps,
to the fact that bovine tuberculosis, which is believed re-
sponsible for much of this extra-pulmonary form of the
disease, is so generally prevalent across the ocean; states
like Wisconsin now have comparatively little. The prob-
able number of such children’s cases in Marathon
County is too small to justify special capital construc-
tion, especially since adequate facilities are available at
the State General Hospital at Madison and in the Mil-
waukee Children’s Hospital.

Children With "Adult Type” Disease

Second, children with active disease of the so-called
"adult pulmonary type” — that is, tuberculosis as it is
commonly understood. Children do not appear to be so

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139

susceptible to pulmonary tuberculosis as late teen-age
adolescents or young adults, or even middle-aged adults.
Thus, last year in Wisconsin, only 35 children in the
entire state between five and 15 died from tuberculosis,
about two-thirds of these from pulmonary tuberculosis.
Between 15 and 25, 156 died; between 25 and 35, 210;
between 35 and 45, 187, etc.

Treatment of these children, authorities pretty gener-
ally agree today, should be little different from that for
adults with "adult type” pulmonary tuberculosis — that
is, sanatorium bed rest, with chest surgery when indi-
cated. Children should, however, be kept in a separate
wing or corridor of the sanatorium. Children are not
adults; they need separate environment, different care
and guidance. The mixing of sick children with sick
adults in a sanatorium is undesirable physically and
morally.

"Pre-tuberculous” Children

Third, the so-called "pre-tuberculous” children — that
is, children without active lung disease, but with some
initial infection as indicated by a positive reaction to
the tuberculin skin test. These constitute the vast ma-
jority of children usually treated in preventoria. (Inci-
dentally, they also comprise more than 15 per cent of
all Wisconsin children of high school age.) They may
or may not come from tuberculous homes, though chil-
dren placed in preventoria are usually those who are
"run-down” physically or who would otherwise remain
in contact with an active case of the disease in their own
home.

What should be done with these children? A few
years ago, when Mrs. Willard’s will was drawn, institu-
tional treatment over a period of months or years for
children who had been intimately exposed to tuberculosis
seemed the most promising way of safeguarding their
future. Moreover, the difference between first infection
among children and subsequent "adult type” tubercu-
lous disease which, as stated above, occasionally mani-
fests itself among them, was not clearly understood.

But scientific knowledge in the field of tuberculosis,
particularly childhood tuberculosis, has grown tremen-
dously during the last half dozen years. Our concepts
of the disease as it manifests itself among children have
become clarified; our concepts of proper control meas-
ures have changed proportionately. Much research work
has been done, old emphases shifted.

Today, for example, most authorities question whether
expensive preventorium care is necessary or even advisa-
ble for children infected but not diseased. Some "build-
ing-up” benefit, without doubt, is afforded the child.
But is the benefit permanent enough to justify the ex-
pense? many investigators ask. In most cases, upon dis-
charge a year or two later, they answer, the child steps
right back into the unfavorable home environment from
which he was removed, and the "building-up” is largely
lost.

The experience of Minneapolis may be cited. For
many years this city maintained one of the outstanding

preventoria of the country, Lymanhurst. It was aban-
doned a few years ago. In a recent article in T he
American Review of Tuberculosis, its director, Dr. J. A.
Myers, one of the most distinguished authorities in the
country on childhood tuberculosis, describes, with some
of his colleagues, a study of 155 children with first-
infection type of tuberculosis who had been observed
over a period of several years, some since 1921. They
write: "The first group consists of those whom we sent
to sanatoria; the second, of those sent to a special
school (Lymanhurst) ; and the third, of those who re-
mained at home with no treatment except that every
effort was made to break the contact when an open case
of tuberculosis existed in the home or among other close
associates. . . . Among the 136 traced, we are unable to
see any difference in the course of the disease, regard-
less of whether the children were treated as strict bed-
patients, were sent to a special school, or remained as
active as any normal child is in its home.”

Summing up their findings, these investigators report
that as far as primary tuberculosis (first-infection type)
is concerned, "we have not been able to obtain any evi-
dence to show that hospitalization, special schools,
camps, or any other form of treatment except breaking
contact with tubercle bacilli, has any particular influ-
ence upon the later development of reinfection type dis-
ease” (that is, adult type disease).

Other Considerations

Three or four other observations should be made re-
garding preventorium or other institutional care of chil-
dren infected but not diseased.

They should not be mixed with children with adult
type disease. Children, more than adults, are difficult to
keep segregated in their own rooms. To mix diseased
with non-diseased children — as is more or less inevita-
ble in an old-type preventorium if and when the dis-
tinction between these two very different groups is for-
gotten— is thoroughly bad practice. In fact, undesirable
as is the mixing of children with "adult type” disease
and grown-ups with active adult disease, this mixing
of actively diseased children with merely infected chil-
dren is even worse. Therefore, when and if a preven-
torium were built for Marathon County’s "pre-tubercu-
lous” children, some facilities would still have to be
worked out for children with active "adult type” disease.

The temptation in preventoria is to hold children too
long. Instances have been known where children have
been kept far beyond any reasonable need on the child’s
part in order that beds might remain filled and per
capitas down. The superintendent and nurses grow fond
of their children and rationalize their desires not to part
with them. And then there is a tendency of all of us to
remain rutted in well-worn grooves.

Again, when the child is finally discharged, he all
too often, as suggested above, drops back into a home
environment not one whit better than when he was re-
moved from it, and most of the benefits of his expen-
sive preventorium care speedily become dissipated. The

140

THE JOURNAL-LANCET

root of the trouble — an active case in the family circle —
has remained untouched; the problem tackled from the
wrong end.

Expensive — But Benefits Limited to Few

Finally — and foremost — many investigators are com-
ing to feel that while the preventorium (in its old-
fashioned sense) may be mildly beneficial to the child,
it is a questionable investment for society in that it is
not the most effective use of the funds. Preventorium
care in Wisconsin costs from $12.00 a week up. A year’s
care of a child with infection but not disease therefore
costs at least $625.00. At an average stay of one year,
30 such children could be cared for each year in a
30-bed institution (which is probably the maximum size
that can be built for $50,000.00) ; at an average stay
of six months, 60 — in either case at a yearly main-
tenance cost of approximately $20,000.00. By the 1930
census, Marathon County had 24,552 children under 15
years of age. On the basis of tuberculin skin reactions
found by the Wisconsin Anti-Tuberculosis Association,
in some 25,000 tests over the state, Marathon County
may be estimated to have approximately 2,000 children
who have been infected with tubercle bacilli. Only some
60 of these, we see, or three per cent, could be given
preventorium care (in its usual sense) in a single year;
the rest would get nothing from the funds expended
for the construction and maintenance of the preven-
torium, not even diagnostic study to see whether any-
thing was needed.

In short, then, this is the indictment of the tradi-
tional type of preventoria now made by many public
health workers: expensive care of dubious value for the
few, nothing whatever for the many. This may, of
course, be an extreme and sweeping point of view; pre-
ventorium care, even of the conventional type, still has
its advocates.* In certain cases, where parents absolutely
refuse sanatorium care and cannot be educated to main-
tain sanitary standards, protracted preventorium care
for the children may not only be justified, we believe,
but recommended. Even here, however, every effort
should first be made, through intelligent public health
nursing or social service, to get the active case isolated,
and to raise the standard of the home; and rather than
preventorium care, a good foster home should, we feel,
be sought.

All in all, a preventorium of the traditional type,
built and designed primarily for treatment, appears to
have but limited and somewhat questionable value today.
A few years hence, it may quite conceivably become a
"white elephant” on the hands of Marathon Countv.**
This would, indeed, be an unhappy issue of Mrs. Wil-
lard’s bequest, and a memorial we would all regret. It

*In the Prendergast Preventorium, in Boston, perhaps the most
conspicuous example of a successful preventorium of the tradition-
al type, much of the success is attributed to its out-patient social
service program — a feature most old-fashioned preventoria com-
pletely lack.

••In this connection, it may be noted that while Wisconsin has
a continuous waiting list for adult beds, in spite of a declining
death-rate and continually augmented capacities, children’s beds
in the preventoria and preventorium sections of our sanatoria show
vacancies right along.

would seem to us, therefore, that an obligation rests
on everybody who is, directly or indirectly, a trustee of
the Willard funds to try to work out a program which
embraces the preventorium idea, in accordance with
Mrs. Willard’s wishes and will, but designed in such a
way as to avoid the traditional faults and shortcom-
ings of the old-style preventorium. The key to such a
solution, we believe, lies in a somewhat liberalized in-
terpretation of the term "preventorium” — not as an in-
stitution built and equipped primarily to treat children
(as formerly conceived), but rather to study, diagnose
and guide them into the proper channels for whatever
treatment, if any, is needed. Such a possible program is
presented below under III.

II. Improved Physical Set-up for Mount View
Sanatorium

Suggestions, we understand, have been made that
part, or perhaps all of the money, be devoted toward
improving the physical set-up of Mount View Sana-
torium. Surgical facilities have been mentioned as a
crying need of the institution, a central heating plant,
etc.

We of the Wisconsin Anti-Tuberculosio Association
feel that such a diversion of the Willard bequest would
be both unhappy and unwise. We do not deny the
need for improved physical apparatus at the sanatorium.
But this is a need that should be met by the taxpayers
of Marathon County as a matter of course. We feel
confident, too, that the taxpayers will willingly meet
these needs if properly presented to them. To "plough
under” the splendid gift of Mrs. Willard in routine
capital equipment would not only be contrary to the
spirit and intent of the gift, we believe, but it would
prevent the development of other and much needed
work in line with the terms of the bequest — that is,
treatment and cure of tuberculosis among children, and
it would have, too, we fear, an effect that none of us
would like to contribute toward — the discouragement of
other prospective donors not only in Marathon County
but elsewhere in Wisconsin and the nation from similar
generous and high-minded gifts.

III. An Alternate Program: A Preventorium Unit
With Out-Patient Service

By the terms of the will, a preventorium of some
type is called for. Now the word "preventorium” means
an institution to prevent — tuberculosis, that is. The
word "sanatorium” means an institution to cure —
tuberculosis. We believe that any program of prevention
should embrace not merely a favored 30 or 60 children
each year, but all, if possible, of the 25,000 Marathon
County youngsters under 15. Domiciliary care for these
25,000 is out of the question. Nor is there reason for
it. But diagnostic attention is possible for all of these
25,000 children or at least the 17,000 between five and
15 who go to school. Under the terms of the Willard
bequest, we believe it is possible for Marathon County
to set up and maintain a far-reaching and notable
tuberculosis prevention campaign among all its children.

THE JOURNAL-LANCET

141

This would center around a "preventorium” nucleus —
not a "preventorium” in its old-fashioned sense of a
treatment institution but rather in the more modern
sense — a clearing house for the study and guidance of
cases. We do not propose rejecting the preventorium
idea; what we propose is to bring it into conformity
with 1936 knowledge and technique in the field of child-
hood tuberculosis. In other words, not a preventorium
in its old, narrow sense; rather a preventorium in an
up-to-date, scientific sense.

The "Screening Method”

A simple and relatively inexpensive technique is avail-
able today for finding early tuberculosis among large
groups of apparently healthy youth. This is commonly
known as the "screening” method. Each child or young
adult is given a tuberculin skin test on the forearm. In
the hands of a skilled physician, and when the children
are lined up by a nurse or social worker who keeps
needles sterilized, each test requires less than a minute.
At the end of 48 hours, the tests are read. If tubercle
bacilli have entered the body, a reaction in the form of
a reddened area appears, disappearing a few days later.
The test is entirely harmless and generally causes the
patient less discomfort than a vaccination.

If the reaction appears, it means simply that tubercle
bacilli have entered the body. An X-ray of such a
child’s chest reveals to the experienced eye of a tubercu-
losis diagnostician the scarred field of an old battle be-
tween, on the one hand, the forces of tuberculous dis-
ease, the tubercle bacilli, and, on the other hand, the
resistive forces of the body. In the great majority of
cases, the body wins. The bacilli gain the toe-hold known
as "infection,” but they are unable to do anything more.

Disease may, however, be present in addition to in-
fection. The tuberculin test does not tell. The X-ray,
properly taken and read, and correlated with other
study and findings, does tell. Every positive reaction,
therefore, particularly among children and young adults,
should be followed by an X-ray of the chest to see
whether any disease is present in addition to infection.

Studies done by Wisconsin Anti-Tuberculosis Asso-
ciation physicians on thousands of Wisconsin children
indicate that 10 to 25 per cent of all high school young-
sters in this state are reactors. Since tuberculosis infec-
tion is the absolute pre-requisite for tuberculous disease,
and since the tuberculin skin test, properly administered,
is an almost infallible indicator of tuberculous infec-
tion, the remaining 75 to 90 per cent may therefore be
"screened” out as needing no further diagnostic study
for the time being. (A year later, or two years later, of
course, another skin test should be done on children who
fail to react.)

X-Rays for Positive Reactors

The 10 to 25 per cent who react should have an
X-ray of the chest to determine whether any damage
is present. In the majority of these, as stated above, the
disease is apparently "stopped dead.” Such children usu-
ally need nothing more than an occasional check-up by

X-ray, and, of course, normally intelligent parental
supervision.

A minority of the tuberculin reactors will need in-
tensive diagnostic study — temperature and pulse study,
urinalysis, blood sedimentation, serial X-rays, repeated
physical examinations, animal inoculations, sputum tests,
etc., in order to demonstrate or disprove the presence
of tuberculous disease. Some few will be found with
active disease of the "adult type”; for these, sanatorium
care in a children’s unit of a sanatorium is advisable.
A larger number probably may need a supervised family
and school life, possibly in a foster home, with periodic
check-ups. Whenever a child comes from a home having
as one of its members an active case, that case should
be segregated, if possible, in a sanatorium, not the child
in a preventorium. Sanatorium care is beneficial for the
curative effect on the patient; but far more important
is its preventive value in isolating the carrier of infec-
tion and his education in sanitary precautions.

Recommended: (1) A Case-Study Unit

We therefore recommend that part of the Willard
bequest be spent for the construction and equipment of
a preventorium unit at the Mount View Sanatorium,
with not more than 12 beds of the observation hospital
type. Such a unit could well be serviced by the present
medical, X-ray and laboratory facilities of Mount View
Sanatorium. A unit of this type — purely for case study,
cases then to be referred either to the sanatorium it-
self, to a hospital, to a supervised home, or whatever it
may be — should cost not more than $25,000.00.

Recommended: (2) An Out-Patient Program

The balance of the bequest we would recommend be
set up as a Lee M. Willard Fund, the interest and prin-
cipal of which is to be spent on an out-patient service
connected with the study and guidance unit. The two,
in fact, would be but halves of the whole. We would
suggest that the entire sum be budgeted to finance a
15-year tuberculosis-prevention demonstration in Mara-
thon County, a certain definite amount, with accruing
interest on the balance, to be spent each year. A budget
of $3,000.00 a year should pay for a program of tu-
berculin testing, to be done with the co-operation of
the Marathon County Medical Society, the State Board
of Health, the Wisconsin Anti-Tuberculosis Association,
or all three, in schools throughout the county, including
the city of Wausau, new pupils being tested each year
as well as non-reactors of previous years; for X-rays of
positive reactors; and — not least — hospital social service,
to get active cases out of the home and into the sana-
torium, to educate the parents to the particular needs of
their children, to secure periodic check-ups, etc. We be-
lieve that a trained home visitor, devoting her full time
to visits and case work on tuberculous families, could
accomplish far more toward preventing tuberculosis by
uncovering active cases and safeguarding infected but
not diseased children than a dozen of the old-type "pre-
ventorium” beds.

Such a plan should, of course, be worked out care-
fully by a committee representing local medical men and

142

THE JOURNAL-LANCET

civic organizations as well as representatives of the sana-
torium and the state and local tuberculosis organiza-
tions. Above all, we would urge that no absolutely
inflexible program be established; rather that a tenta-
tive working schedule be set up and followed, with a
definite provision for a fresh appraisal of aims, methods
and results after a five-year interval. Concepts may
change in the future as well as in the past.

Summary

In short, then, this is the recommendation of the Wis-
consin Anti-Tuberculosis Association: (1) that the en-
tire bequest should not be spent for a treatment build-
ing alone — a building which even now would have but
limited value, and might in the near future become a
"white elephant"; (2) that the money should not be
swallowed up in capital improvements for Mount View
which can and should be obtained as routine appropria-
tions for the operation and upkeep of the institution;
but that rather (3) it should be spent in a unique and
forward-looking adventure in prevention, rather than
treatment. In accordance with the terms of the bequest,
as well as the needs of Marathon County, the latter
plan would entail some expense for a small preventorium
unit for study and guidance of cases, but only for one-
third to one-half the amount of the fund. The remain-
der would be set aside for endowing or at least financing
the employment of human intelligence in finding and
preventing tuberculosis in a program closely correlated
with and centering around this preventorium unit. As
one writer has well said, "Endowed brains can adapt
themselves to changing needs; brick and mortar cannot."

Such a program, we readily grant, cannot be as easily
conceived, planned or carried out as the building of a
preventorium on conventional lines, or the use of the
Willard funds for capital improvements at the sana-
torium. But it is a venture that would bring attention
to Mount View and Marathon County throughout the
country for far-seeing and statesmanlike planning. And
it is a program, too, that would constitute a unique and
enduring memorial to the high life and generous mind
of Dr. and Mrs. Willard.

Addenda

In connection with the present discussion and with
particular reference to footnote on page 140, the fol-
lowing quotation from a paper presented at the 1935
National Tuberculosis Association annual meeting, "Are
the Preventorium and Summer Camp Worth While?”*
by Dr. J. B. Hawes, II, of Boston, Mass., is of interest.
Dr. Hawes is president of the Boston Tuberculosis
Association which operates the Prendergast Preventori-
um— an institution which has attracted attention as per-
haps the most successful preventorium of the traditional
type.

"I feel, therefore, as a result of these two surveys and
an intensive study of the situation necessary for me in
the preparation of this paper, more strongly than ever
that the preventorium and the summer camp are dis-

•Transactions of National Tuberculosis Association, 1935.

tinctly worth while and that they afford one of the most
potent means of education at our disposal, providing
always that it is not merely the present health of the
child that we are striving for but rather the condition
of that child five, ten or more years afterwards and
indeed for the rest of his life that the preventorium
and summer camp is concerned with. Miss Billings once
asked me how long after the child’s discharge should
he be kept under supervision and receive periodical ex-
amination. 'Until the child dies of old age,’ was my
quite proper answer.

"If every summer camp and every preventorium will
maintain this attitude and will insist that the six months’
or year’s stay at the preventorium or two to three
months’ stay at the summer camp means also that the
nurse or follow-up worker goes into the child’s home,
takes active measures to remove the source of infection,
sees that the other children are examined, instructs the
parents in home hygiene and sees that after discharge
these lessons are continued, no one, I am sure, will pos-
sibly doubt their educational value in our campaign
against tuberculosis.”

In the May number of the Hoosier Health Herald,
Dr. Paul D. Crimm of Evansville, Ind., the retiring
president of the Indiana Tuberculosis Association and
superintendent of Boehne Sanatorium, makes some in-
teresting comments on the use of hospitals or preventoria
for the care of children with fully calcified and inactive
lesions in the lungs. He says, "A preventorium caring
for children with inactive disease for a period of six
months to two years is an institution spending money
without doing much good for the prevention of tubercu-
losis. In the last analysis, they are only running a hotel
for under-privileged children, which is, of course, com-
mendable, but not far enough reaching in our campaign
against this disease. In my experience, most of the chil-
dren between the ages of five and 15 who enter these
preventoriums are apparently arrested, or nearly so, be-
fore they enter the institution.

"I know intimately a preventorium which existed
from 1929 to 1933 and during this five-year period ad-
mitted and discharged only 287 children. In 1934 the
same preventorium was turned into a diagnostic and
educational institution where the average length of stay
was 30 days, and from 1934 to 1936 (a period of two
years) 835 children were admitted and discharged.
Fifty per cent of these children had a primary infec-
tion, or childhood tuberculosis. So far none of these
children have ever been returned as a case of active
pulmonary tuberculosis. Educational interest aroused in
the minds of the parents who had children in this in-
stitution, and educational follow-up work among both
parents and children should prevent them from return-
ing to some sanatorium later in life between the ages of
15 and 35.”*

Postscript — At this writing it appears that the end
sought by the Wisconsin Anti-Tuberculosis Association

•Bulletin of the National Tuberculosis Association, August, ’36.

THE JOURNAL-LANCET

143

— the setting up of a major portion of the fund for a
case-finding and follow-up program among the appar-
ently healthy but tubercidosis-infected children of the
entire county — has been lost. A brick and mortar pro-
gram has been decided upon, embracing a 20-bed pre-
ventorium unit, a much-needed surgical division for the
sanatorium, and a central heating plant to service the
sanatorium, preventorium and nurses’ home. By present
architect’s plans, little if any money will, therefore, be
available for out-patient work.

Fortunately, a small rather than a large preventorium
structure is being planned. Fortunately, too, the archi-
tects— aware of the growing change in scientific view-
point toward the efficacy of old-fashioned preventorium
treatment — are drawing their plans so as to make the
unit adaptable in the future, if desired, for patients with
adult type pulmonary disease.

A small achievement , perhaps. But to build a house
takes a few months; to build a new concept in people’s
minds, many years.

Teen Age Tuberculosis

S. B. Kalar, M. D .**

Ames, Iowa

THE interest of the National Tuberculosis Asso-
ciation in school health work is based primarily
upon the accepted conclusions of Pirquet, Cal-
mette, Opie and others to the effect that tuberculosis
infection, to a large extent, octurs in childhood, the in-
cidence rising with age up to adult life, when from 50
per cent to 95 per cent of the population may be in-
fected.

Coupled with this hypothesis is another, that any-
thing that increases or maintains the normal resistance
of the child will help to prevent a breakdown with active
tuberculosis later in life.

Most deaths from tuberculosis take place between the
ages of 15 and 45. It is a mistake, however, to suppose
that tuberculosis is an adult disease. These deaths in
adolescence and adult life are the harvest of a disease
which has been planted years before. Dr. W. L. Rath-
bun says: "In our high school and junior high school
students, one-half of the cases of pulmonary tubercu-
losis have signs of latent childhood tuberculosis. This
childhood type of tuberculosis is found in only between
three or four per cent of the total school population in
our country, which means that 50 per cent of the cases
of pulmonary tuberculosis developing during the 'teens’
is in this small group.” He further says, "I believe that
75 per cent of the potential cases of pulmonary tubercu-
losis that will develop the disease during, or just before
the 'teens,’ are included in a group of children compris-
ing those with childhood tuberculosis, their brothers and
sisters, and other known contacts without demonstrable
signs of the disease.”

In a radio talk under the auspices of the Chicago
Tuberculosis Institute, Dr. S. Sinclair Snider, associate
member of the Chicago Pediatric Society, said, "The
point deserving particular emphasis is that most of the
adult type of tuberculosis during the 'teen age’ and ac-
companied by such a high mortality rate is going to
occur in that group of children that come from a tu-
berculosis environment.”

•Read at meeting of Iowa Tuberculosis Association, Ft. Dodge,
Iowa, March 19, 1936.

••Department of Hygiene, Iowa State College.

Tuberculosis is not a swiftly attacking and a swiftly
receding disease. Tuberculosis is usually long-lasting and
chronic. Tuberculosis is a contact, an environmental dis-
ease. To prevent deaths from tuberculosis, attention
must be paid to the "seeding-time,” which is usually the
early years of childhood.

Children living in a home where a careless person has
tuberculosis are in unusual danger because they are al-
most continuously exposed to large "doses” of tubercle
bacilli.

When a moderate number of tubercle bacilli are taken
into the lung for the first time, the infected person has
few or no symptoms, and the tubercle bacilli are finally
imprisoned in the glands located around the larger
bronchial tubes. This type of tuberculosis is called the
first infection type; or, since the first infection usually
takes place in childhood, it is also called the childhood
type of tuberculosis. Following such an infection, the
average child enjoys a period of good health. Lime salts
are gradually deposited in the infected glands and the
X-ray film shows these glands to be calcified. Living
tubercle bacilli have been found in glands that have
been calcified for 10, 20, or even 30 years.

After an individual has passed the adolescent period,
calcified lesions in the lung are evidences of an old
tuberculous process that has probably healed. Calcified
lesions in children, however, indicate tuberculous dis-
ease; and children with this condition need careful
supervision until the years of adolescence have passed
and healing is assured. Much can be done to strengthen
a child’s resistance so that he will not develop a serious
lesion. A periodic check-up on his health will help to
safeguard him against the tragedy of learning some day
that he has a lung disease well established before any
symptoms have appeared.

After a period of quiet as far as activity in the glands
is concerned, many persons develop tuberculous infec-
tion, not in the glands, but in the lung itself. This type
of lung or pulmonary tuberculosis is called the adult
type, since it usually occurs in later life.

144

THE JOURNAL-LANCET

It is all too common when search is made by school
physicians in high schools and colleges to find students
with beginning adult type of tuberculosis playing on the
football or basketball teams. This is a dangerous situa-
tion because the symptoms, if present at all, may be so
slight as to excite no alarm. As a result of indifference,
the disease is allowed to progress to a serious stage. A
case of early tuberculosis treated promptly and ade-
quately has an excellent chance of getting well, but once
the disease is entrenched it is difficult to cure.

There are three very important facts about tubercu-
losis of boys and girls of high school and college age.

First. The infection is very apt to develop insidiously,
to creep up on the boy or girl; and by the time the
individual shows symptoms of disease such as cough,
expectoration, fever, and loss of weight, the disease
process may be advanced and cure is difficult. Cases have
been reported in which the X-ray showed a gradually
developing lung process for seven years before the child
showed any symptoms of infection.

Second. Perhaps because it is usually discovered late,
or perhaps because boys and girls of high school and
college age lack resistance to tuberculosis, the death rate
among those developing the adult type of tuberculosis
is very high. In 1900, the mortality tables for all ages
showed that tuberculosis caused more deaths than any
other disease. In 1930, again considering all ages, tu-
berculosis ranked seventh as a cause of death. How-
ever, if we consider the ages between 10 years and 35
years, tuberculosis still ranks far above any other disease.

The seriousness of the adult type of tuberculosis can
be seen from the fact that out of 110 children found by
the Massachusetts Department of Public Health in its
school clinics to have this form of the disease, 23 per
cent were dead within three to seven years.

Third. The disease is more frequent and the death
rate much higher in adolescent girls than in boys of the
same age. The Massachusetts study has shown almost
three times as many girls as boys with this type of dis-
ease. A further study of the Massachusetts survey and
the Massachusetts death rate shows that one out of every
three young women, who die between the ages of 15 and
30, dies of tuberculosis.

The conclusion that the spread of tuberculosis in the
community is in great part the result of slowly pro-
gressive household epidemics, which often transmits the
disease by contagion from one generation to another,
seems rather well established.

Tuberculosis being a contact, an environmental dis-
ease, it has occurred to me that the much closer contact
in the family of the girls who are confined to the house,
assisting with housework, coming in frequent contact
and helping care for tuberculous (often not known to
be tuberculous) members of the family, thus exposed
to continuous "doses” of tubercle bacilli, while the boys
of the same household are out of doors or away at work,
might be a factor in the greater frequency of the adult
type of the disease, and the higher mortality rate in the
'teen age’ girl.

In our state of Iowa, during the decade 1921-1930,
deaths from tuberculosis numbered 10,045. In 1934,
there were 619 deaths from tuberculosis, which means
that in 1934 there were nearly two deaths per day. If, as
has been shown, there are nine active cases of tubercu-
losis for each annual death, these 619 deaths in Iowa
in 1934 mean that we have 5,571 active cases. Iowa
has 696 beds for tuberculosis. Deducting 696 from the
5,571 active cases, we have 4,875 active cases, many of
whom no doubt are living in families with children.
Many of these active cases are probably not even recog-
nized as tuberculous, and all of them are potential in-
fectors of our youth.

During the period 1928-1932, among Iowa children of
high school age, there were —

217 deaths from tuberculosis.

108 deaths from influenza.

28 deaths from epidemic meningitis.

27 deaths from purulent septicemia.

19 deaths from scarlet fever.

77 deaths from all other diseases.

This totals 492 deaths, of which 217 were from
tuberculosis. Thus, from this quite recent report cover-
ing a five-year period, we find that tuberculosis caused
nearly one out of every two deaths from Iowa children
of high school age.

Such figures as these from the Massachusetts De-
partment of Health and the Department of Health of
Iowa, are rather terrifying and lead us at once to con-
sider the problem of prevention.

Perhaps the greatest single weapon that has been
given us in the last few years in our fight against
tuberculosis has been the general use in large groups
of more adequate methods of early diagnosis and case-
finding. This has been accomplished by tuberculin test-
ing and X-raying.

It is no longer necessary for us to speak in a vague
way about the tuberculosis problem in a high school in
a certain district in our community. We can go into that
school and in a few days or weeks tell exactly how
much tuberculosis there is in it. We can locate the
homes where there are open cases, and can locate the
infected contacts. We have, in fact, a simple way to
unfold the complete picture of tuberculosis in this group.

One of the first contributions on this subject was a
survey made in Philadelphia by the Phipps Institute,
three years prior to 1929. They found in the age group
14 to 19 years of age, of 1,422 white children tested,
83 per cent were tuberculin positive, and of 1,066 posi-
tive reactors 3.6 per cent showed latent or active infil-
trating lesions of the lung parenchyma in the X-ray. In
a survey of school children in Massachusetts in 1926,
Chadwick found one per cent infiltrating lesions in 877
children age 14 to 15 years. More recent figures from
the Red Book area in Brooklyn show that out of 1,325
white children age 15 to 19 years, X-rayed with paper
films in 1933, .8 per cent showed important tuberculous
lesions.

THE JOURNAL-LANCET

145

These figures indicate that on an average we can ex-
pect to find one per cent to three per cent of serious
tuberculosis in children of high school age.

Dr. Lee H. Ferguson reports that in a survey made
in high schools of Cleveland, 35 per cent were found to
react positively to tuberculin.

In the age group 15 to 19 years in Cleveland in 1933
were approximately 83,571 white children and the
Health Station records 435 cases, or 0.5 per cent of pul-
monary tuberculosis.

Dr. Ferguson says, "As it does not seem probable we
are getting more than one-half to one-third of the cases,
we can safely say that in our white high schools in
Cleveland about one per cent to 1.5 per cent have seri-
ous lesions at the present time.”

In the fall of 1933, the tuberculosis committee of the
American Student Health Association conducted a sur-
vey of tuberculosis and tuberculin testing in 1 1 institu-
tions of the United States. Out of seven institutions
having an active tuberculosis program, the incidence of
tuberculosis varied from three active cases per 1.000 to
13 cases per 1,000. The average for the entire group
was 6.7 active cases of tuberculosis per 1,000. Of all
the institutions reporting, Minnesota can be taken as
most typical. Here they have had a program, including
tuberculin testing and X-raying for several years. In
1932-33, the results of tuberculin testing showed 25 per
cent positive reactors, and they found 4.3 cases of adult
pulmonary tuberculosis per 1,000.

Since 1931, the University of Michigan has carried
on a yearly tuberculin testing of all freshmen women,
and all women students with positive skin tests have had
the chest X-rayed. An average of about four active cases
of pulmonary tuberculosis per 1,000 has been found
each year among the entering women students.

The east has a more serious tuberculosis problem
than we of the middle west. In all probability there will
be great variations in these percentages, depending on
the locality in which a survey may be made, but these
figures are sufficiently accurate to show that we have a
very definite and serious menace from tuberculosis at
the high school age. We are carrying over into colleges

exactly the same problem which we face in the high
schools and I fear that we are not meeting it adequately
in either place.

It is well recognized that early cases of pulmonary
tuberculosis often give no symptoms or physical signs
and that diagnosis of the disease in a stage favorable
for treatment depends to a very great extent upon the
widespread use of X-ray facilities.

Dr. David Zacks, in a report on pulmonary tubercu-
losis in adolescence in the ten-year program of Massa-
chusetts, says, "The X-ray is the most important single
factor in the discovery of tuberculosis in the 'teen age.’ ”

Dr. Zacks also states that rales, on the average, ap-
peared 2.6 years after the lesion had been demonstrated
by the X-ray. Cough and expectoration appeared on the
average, three years after the X-ray evidence.

In an article entitled "Value and Limitations of X-ray
in the Diagnosis of Chest Diseases,” The Journal-
Lancet, April 1, 1935, Dr. J. Arthur Myers says,
"Obviously, the X-rav film cost must be reduced to
about the same basis as ordinary laboratory work so that
it can be figured as a part of a general examination
without materially increasing its cost. Periodic films of
the chests of apparently healthy persons, for the purpose
of identifying unrecognized cases, are absolutely essen-
tial to the rapid control of tuberculosis in this country.”

It seems to me that the foundation for the solution
of this menace to our youth is to be found in a wider
dissemination of accurate knowledge of tuberculosis.

We need the co-operation of the parents in the home
and this must be obtained by education. School doctors
should have better training in this disease; teachers and
nurses in their training courses must be given modern
concepts of tuberculosis; hygiene courses in schools and
colleges must be planned so as to interest our pupils in
tuberculosis as an individual and community problem.
Add to this an active program of tuberculosis testing
and X-raying in our schools and colleges, together with
a close follow-up on all cases, and we have at our dis-
posal the means necessary to save the terrific toll which
tuberculosis takes in this group of 'teen age.’

The Human Factor*

In the Control of Tuberculosis

L. E. Smith, M.D.

Louisville, Ky.

CONTROL of tuberculosis is within our reach.
Its accomplishment does not depend upon the
discovery of some perfect remedy capable of
working magic in therapeutic realms. Neither does it
depend upon some wonderful procedure capable of
hedging our children about with a resistance invulnera-

•Prepared expressly for the special Tuberculosis issue of THE

JOURNAL-LANCET.

ble to the tubercle germ. It does, however, depend upon
the acquisition of certain fundamental facts and the
intelligent application of fundamental principles of dis-
ease prevention and health promotion.

It is not within the scope of this article to discuss or
review the history of tuberculosis. Neither is it intended
to review progressive developments in the treatment of

146

THE JOURNAL-LANCET

the disease. Our purpose is rather to point out some of
the reasons why we have not done more to bring this
controllable, preventable, and curable disease completely
under our control.

As far back as we are able to find reliable records
of human achievements, the devastating effects of tu-
berculosis stand out with appalling significance. Whether
it was called the "white plague,” the "consuming dis-
ease,” "consumption,” or by its more modern name,
"tuberculosis,” makes little difference, because it has re-
mained the same destructive human enemy, respecting
no age, but attacking all ages as well as all ranks of
people. While the hovel and the homes of those living
on lower economic levels have suffered most, yet this
disease has been called the plague of kings. It has
wrested crowns from the brows of monarchs as well as
paled the cheeks of beautiful queens. Truly it has been,
and is now, "no respecter of person.”

Some 2300 years ago, a great Greek physician, the
father of medicine, called attention to the treatment
best-fitted to the victims of tuberculosis. He prescribed
a tent on a mountain side, a goat and rest. This meant
quiet isolation, fresh air, good food and rest. More than
20 precious centuries passed and millions of lives were
sacrificed on the altar of ignorance, indifference, care-
lessness and neglect before the value of rest, as the out-
standing factor in tuberculosis control, was demonstrated
and accepted in this country.

During the dark periods of human history, disease
was looked upon with terror and interpreted as a form
of punishment visited upon its victims by Providence
for disobedience to divine law. The human race was
groping helplessly in the dark and crying out to the
deities of its many races and tribes for relief from
devastating plagues and sundry ills which were destroy-
ing countless numbers from year to year.

Tuberculosis was not among the spectacular diseases
of this dark and terrible period. It was a slow-moving
epidemic, taking heavy toll of human life and leaving
the blight of disease upon friends and associates of its
victims. Perhaps it was this phase of the disease that
led Hippocrates to note that it was a family disease and,
no doubt, to the conclusion that tuberculosis was in-
herited.

Almost 20 centuries have passed since the Galilean
Physician spoke to a group of his followers in these
precious words: "Ye shall know the truth and the truth
shall make you free.” And yet we find that only a
small portion of our people today have learned, and
applied the great truth concerning the way of life.

More than 50 years have gone by since the pioneer
in the epidemiology of tuberculosis gave the medical
world the fundamental principles essential to the control
of tuberculosis. His was no guess work, for Dr. Koch
had so thoroughly worked out the problem that his
postulates are still considered outstanding landmarks in
the epidemiology of the "white plague.”

We might recount the various steps taken by many
other scientists of note as they added their contribu-
tions from year to year. The facts as to them, as well

as to the modern methods of preventing, finding, con-
trolling and treating tuberculosis, are common knowl-
edge. We are also familiar with the great decline, in
recent years, in the death rate from tuberculosis, and
are often led to believe tuberculosis is no longer a major
problem. When we examine the figures, however, we
find a different story.

In looking over the records in Kentucky we find
2,010 deaths from tuberculosis in 1935. Tuberculosis
stood fourth from the top of the list as a taker of life,
but it occupied second place in the list of preventable
diseases. When we analyze the deaths, between the ages
of ten and 50 years, due to the four leading causes in
Kentucky during 1935, we find that tuberculosis was
responsible for 1,213 of them. Accidents, with 974
deaths, comes next; heart disease, with 720 deaths, is
third; and pneumonia, with 550 deaths, follows. So, in
Kentucky, after all these years and in spite of all our
knowledge, tuberculosis is still "Public Enemy No. 1.”
Does this distressing situation exist today because we
ire powerless to change it? Have we been misled in
ronsidering tuberculosis a preventable disease? Is our
slogan, "No Tuberculosis Without the Tubercle Bacil-
lus,” untrue? Have we been in error when we consid-
ered tuberculosis to be controllable? Are we wrong when
we say, in the face of the tremendous tuberculosis death
figures, that tuberculosis is curable? The answer to all
these questions is "No.”

Dr. E. L. Bishop, director of health, Tennessee Val-
ley Authority, said, in a recent address before the Ken-
tucky Conference of Social Workers in Louisville:

In the opinion of a conservative epidemiologist,
the ultimate conquest of tuberculosis is quite with-
in our grasp, provided the present rate of inter-
ference with transmission can be accelerated by
more complete application of methods now known.
This statement contains much food for thought. It
places the responsibility squarely on our shoulders. The
goal of tuberculosis control is within our reach, pro-
vided we persistently and intelligently use the dependa-
ble material and tested methods now available.

Perhaps we are not going too far when we admit
that after all these years tuberculosis is still "Public
Enemy No. 1”; not because we have failed to find a
specific remedy; not because we have failed to find the
long sought for immunizing agent capable of fortifying
possible victims of tuberculosis against the possibility of
infection; not because we are not able to provide suffi-
cient sanatoria to furnish the required one bed per
death; but because we have failed to do what could have
been done with the equipment available to us. We have
failed because the human factor in the control of tu-
berculosis has inadequately utilized the available ma'
terial and forces against our great enemy.

Fear is an element that plays a large part on the
human side of tuberculosis control. It prevents many
from informing themselves concerning this disease. They
think of it as if it were a family trait inherited from
their unfortunate ancestors. They speak of it in a whis-
per, lest someone should hear them and spread per-

THE JOURNAL-LANCET

147

nicious gossip among their neighbors. They assure physi-
cians, social workers and representatives of health or-
ganizations that there is no tuberculosis in their families
and stubbornly refuse to permit the use of any tests or
measures designed to reveal the presence of tuberculosis.
They usually wait until they are clinically ill before they
come to the physician for help, and then they are often
in the advanced stages of tuberculosis.

Dr. John B. Naive, of Knoxville, Tennessee, recently
reported 37 patients, 20 years of age and under, enter-
ing Beverly Hills Sanatorium within a two-year period.
Of these, 22 were far-advanced; 12 were moderately-
advanced, while only three were incipient cases. Thirty-
four of these patients (all but the three early cases)
had tubercle germs in their sputa at the time of admis
sion. Thus we see that 34 out of 37 cases were spread-
ing infection among their associates long before they
came under competent care.

We are familiar with the difficulties confronting
us when we attempt to apply modern methods in tu-
berculosis control to the masses, and yet we can never
hope to approach our goal of tuberculosis control any
other way. Often when tuberculosis is found early, the
physician is handicapped because the frightened patient,
or some member of the family, utterly refuses to co-
operate or even permit adequate treatment to be given.

Education will open the eyes of the ignorant masses,
and, as the story of health and the possibilities of tu-
berculosis prevention, control and treatment is told to
them in a language they can understand, they will em-
brace it with open arms, for they, too, want to live. The
light of facts will banish fear.

Selfishness is another element capable of blocking a
tuberculosis control program. Since much of our tubercu-
losis is found among those who live on the lower eco-
nomic levels, tuberculosis control programs are often
hindered, and at times prevented, because of inadequate
funds.

Those who are interested in seeing tuberculosis con-
trolled find it necessary to persuade taxpayers and offi-
cials that funds used for this purpose are legitimate
expenditures and will guarantee ample returns by re-
duction of taxes for the care of orphans, indigents and
institutions, as well as make life safer for those not yet
infected. Physicians must be ever conscious of their dual
personalities. They are physicians when duty calls, but
citizens always. When acting in the capacity of citi-
zens, professional ethics should not prevent them from
discharging their duties of citizenship to the fullest
extent.

Indifference often plays more than a minor role in
obstructing tuberculosis control programs. Those with a
meager knowledge concerning the early symptoms of
tuberculosis are apt to pay little attention to the warn-
ings voiced by health workers and social agencies in-
terested in the early diagnosis and treatment of tubercu-
losis. Again, it is quite natural for those who are not
familiar with the infectious nature of tuberculosis to
ignore all pleas for adequate protection from the spread-

ers who are constantly sowing the seed of death among
their companions.

Indifference on the part of some practicing physi-
cians is often a hindrance to tuberculosis control. After
more than 20 years of intensive education and in spite
of all aids to early diagnosis available to the profession,
we still find that too many of our cases are diagnosed
after delays of months, or even years. There can be but
little, if any, reasonable excuse, other than failure of
the patients to consult physicians early, for delay in
early diagnosis of tuberculosis. To overcome this diffi-
culty, health officials, educators and laymen have joined
hands in a great campaign to educate the public to
the significance of the danger signs of early tubercu-
losis and to emphasize the importance of consulting the
physician early. An educated public will consult physi-
cians early, and up-to-date physicians will use all avail-
able methods and equipment to detect the presence of
tuberculous infection, as well as clinical tuberculosis, at
the earliest possible moment.

Ignorance contributes much to the defeat of many
tuberculosis control programs. When people know, they
are apt to think. When they think, they usually act;
and action is what really counts. It has been wisely said,
"Knowing what to do, is knowledge; knowing how to do

it, is skill; and DOING IT, THAT IS SUCCESS.”

We are not so much in need of more knowledge, but
we do need to apply, intelligently and in the fullest
possible measure, the knowledge we now have in the
wise solution of our tuberculosis problems.

The great gap between what we know and what we
do, should be closed up.

The National Tuberculosis Association was organized
in 1904, in an effort to close this gap. State and local
associations were organized everywhere. An enlightening
educational program was launched on a large scale.

In suggesting briefly a valuable tuberculosis control
program, in the light of present day knowledge con-
cerning tuberculosis, we may assume that our states and
communities have effective organizations, and that vital
statistics are available for intelligent use in convincing
the public of the significance of the tuberculosis prob-
lem. We may also assume that available literature for
educational programs is widely and wisely used.

We are entirely within our rights in insisting that an
adequate health educational program — that is, one
adapted to the individual needs, be a conspicuous part
of the regular schedule of every educational institution,
from the kindergarten up to and through the university,
with special emphasis on tuberculosis.

Every group should have adequate health supervision
by a competent staff of workers. Tuberculin testing,
X-ray follow-ups, home visitation, isolation and adequate
treatment should be applied in a practical way and cover
all the communities from which pupils are gathered.

Teachers, bus drivers, janitors, food handlers and all
employees coming in contact with pupils should be
proven free from infectious tuberculosis by the tubercu-
lin test and X-ray. Examiners should always remember
there may be no symptoms in early tuberculosis.

148

THE JOURNAL-LANCET

Family physicians should be the vitalizing force in
such control programs. They are the guardians of health
and should not hesitate to accept and discharge the re-
sponsibility placed upon them. They should be prepared
to take charge of children in every case revealing the
presence of tuberculous infection. They should recog-
nize their opportunity to render valuable and lasting
service by piloting infected children through the stormy
seas of youth and adolescence, to the calmer waters of
mature years, where discretion and intelligence should
make the remainder of the voyage comparatively safe.

Physicians should ever be aware of the fact that all
tuberculosis is serious. They should not forget that all
those now filling consumptives’ graves were at one time
early cases. They should never be content until the
source of every infection is located and treated. Isola-
tion of spreaders should become a universal practice and
every contact of every spreader should be sought for
and treated. Physicians and health workers have a defi-
nite obligation to those found ill; they also have an
obligation to society, and should not be content until
both obligations are discharged in the most creditable
manner possible.

There can be no effective tuberculosis control pro-
gram without the co-operation of physicians. In the
words of Dr. Robert B. Kerr of Manchester, New
Hampshire:

The physician is not only a practitioner of the
art and science of medicine. He is a citizen of the
community in which he lives. He is almost always

an influential and respected citizen. He should be
interested in the welfare of the community at large.
He should be active in every proper procedure for
the control and prevention of tuberculosis. Every
movement for the prevention of disease and the
promotion of good health, particularly among
children, should receive his interest and support.
The physician should be a teacher of preventive
medicine. In his teachings he should always empha-
size the importance of periodic health examinations
even for individuals in apparent good health. He,
more than anyone else, knows the tragic ending to
physical conditions which caught early and treated
could have been prevented.

The medical profession has always been the leader in
all of the efforts for the prevention of disease and the
betterment of mankind. In every such movement, the
leadership and inspiration of some physician or group of
physicians have always been the motive power behind it.

The responsibilities of the physician are many, yet not
without compensations. To have saved life; to have pre-
vented disease; to have eased human suffering; to have
made the community in which one lives better because
of one’s presence and service there — all these bring to
the physician lasting satisfaction.

To have been true to the ideals of his profession and
to know that he has met in full his obligations for
active participation in the cure and prevention of tu-
berculosis brings to the physician a reward beyond
money and beyond price.

Sick, Broke and Footloose*

H. E. Kleinschmidt, M.D.**

New York City

AT LEAST one type of citizen in the United
States stubbornly defies regimentation, classifi-
cation, or control. He is the tuberculous tran-
sient who has come west seeking a climatic cure, ex-
hausted his resources and now wanders from place to
place on foot, on brake rods, or in a dilapidated auto.
In jungles, shacks and flophouses he pauses when he
must. He has lost his claim as a resident of the home
town he deserted, and is not welcomed as a resident
elsewhere, since he is regarded as a "bum” without visi-
ble means of support, but with a very visible need of
relief. He is not, in the main, getting well of his con-
sumption— salubrious climate notwithstanding. In many
instances he is accompanied by his worried wife and
half-starved children. Worst of all, he is a prolific
sower of the seed that causes tuberculosis, for even the
respectable, cautious resident cannot escape contact with

*Prepared expressly for the special Tuberculosis issue of THE
JOURNAL-LANCET.

**Director, Health Education, National Tuberculosis Ass’n.

him directly or indirectly at the filling station, restau-
rant, tourist camp and lodging-house.

No census has been taken of tuberculous wanderers,
but a conservative estimate, based on observations of
transient officers, is that their number exceeds 1,000 in
the states of Colorado, Arizona, New Mexico, Western
Texas and Southern California. This number, however,
includes only the obvious consumptives — -obvious, that is,
to the non-medical social worker. If a more thorough
and precise case-finding search were made, including
X-ray examinations, the army of indigent tuberculous
in the Southwest would doubtless exceed 5, GOO.

The problem is an old one; at the very beginning of
the tuberculosis movement the National Tuberculosis
Association supported a vigorous "get-well-at-home”
campaign because even then the distress of consumptives
stranded far away from home called loudly for relief.
The campaign succeeded only in small measure, so firmly
had the magic of climate taken root in the mind, not

THE JOURNAL-LANCET

149

only of the common man, but also the physician. Cli-
mate does have therapeutic value; but only as a supple-
ment to the more rational treatment of rest, good
hygiene and medical care. To sacrifice home comfort,
economic security and decent care for the elusive promise
of climate is more risky than hunting gold in Alaska.

Attention is again being focused on the plight of the
tuberculous transient. This came about through the
activities of transient shelters hastily set up by the
Emergency Relief Administration three years ago in an
effort to "freeze” the army of aimless wanderers. Natu-
rally, the sick were separated from the well in these
shelters, and soon it was found that about one-third of
the sick were tuberculous. These were segregated in such
special buildings as were readily available. In Nogales,
Arizona, for example, an old military barrack used
during the Mexican border dispute was utilized. Medi-
cal service was secured from the adjoining town, nurses
were employed, and shortly "tuberculosis units” were
running full-blast.

With make-shift equipment and labor drawn from
among transients not too sick to work, these units per-
formed a heroic and very creditable service. Some of
them were almost completely self-contained; they shel-
tered patients, maintained a farm, killed and dressed
their own beef, manufactured crude coffins and buried
their dead. Social workers investigated each case care-
fully, returned some patients to their homes, placed the
families of others in shelters, and in numerous ways
helped to solve individual problems. Best of all, some
500 patients known to have tuberculosis in communica-
ble form, were taken out of circulation, so to speak,
and given at least the first essentials for recovery, name-
ly, bed rest and nourishing food. The service cost
averaged less than $1.00 per patient per day. Perhaps
no relief money was ever better spent, from a social
viewpoint, than the thrifty sums contributed for the
maintenance of tuberculosis units.

When, last fall, the time came for the Federal gov-
ernment to liquidate its transient service, consternation
spread among the workers in charge of sick transients.
There was no hope of transferring the activity to state
or local budgets. No other alternative seemed open ex-
cept to turn the sick out into the desert.

Fortunately, the fine work of tuberculosis units at-
tracted the favorable attention of WPA officials. A
small unexpended fund was found, and a temporary
stay of the threatened demobilization was granted. At
the same time, however, the intake of new patients was
stopped, and only existing beds were continued.

In this emergency the National Tuberculosis Associa-
tion, in the spring of 1936, called a conference in
Santa Fe to consider the problem. Health officers, tu-
berculosis executives, and transient workers met for two
days to analyze the situation. A representative of the
United States Public Health Service was present and
participated in the discussions. The complexity and im-
mensity of the transient problem in general seemed at
first so overwhelming that every measure proposed led
to greater confusion. Very wisely, however, this group

decided to limit its consideration to the tuberculous
transient as a spreader of a communicable disease.

Tuberculosis is undeniably a communicable disease
and, as Disraeli said years ago, the first obligation of
any government is to safeguard the health of its people.
The emphasis was placed, not so much on the distress-
ing need of sick individuals, as upon the opportunity
of protecting the public in general.

Since a person with a communicable disease creates
an inter-state problem when he crosses state borders, the
consensus was that the control of tuberculosis among
transients is a function the Federal government might
perform better than the several states; but that the final
responsibility for many of these cases must rest on the
states from which the tuberculous transients come.

Whoever assumes the task of controlling the spread
of disease through indigent transients, the question as
to how this shall be done remains to perplex the most
experienced health and social workers. Forcible detention
is in bad odor — tuberculosis is not yet regarded by the
public as seriously as leprosy, for example. Deportation
to point of origin would not solve the larger problem
and for some patients who have the fixed idea that their
very lives depend upon living in this or that climate, it
would be inhumanly cruel to send them home, wrong
though they might be. To erect sanatoria in resort areas
would result in luring persons from all parts of the
country, and thus aggravate the evil. Families would
come with them and, not being eligible as patients,
would be dumped upon the mercy of social agencies in
cities and towns nearby, already swamped with appeals
from their own people.

One proposal made is that colonies be established in
the great open spaces for entire families. But the states
where they would be most likely to settle are least able
to support such an enterprise and the Federal govern-
ment can hardly be expected to finance it, at least not
until the broad problem of transiency is tackled through
sweeping legislation such as that proposed in the Tram-
mell-Wilcox bill recently before Congress. Self-support
of such a colony is a fatuous hope, and it seems un-
likely that many families would consent to be herded
together in that manner. And if such colonies, because
of good management and by providing attractive living
conditions should succeed, we would again be confronted
by the problem of preventing the influx of families from
all over the country who had better remain where they
are.

At present the United States Public Health Service
is studying the situation to see what facilities are avail-
able. The situation is probably not as hopeless as it
might have been a few years ago. One advantage is that
the country generally is now better equipped to care
for its tuberculous residents near at home. Another ad-
vantage not to be had a few years ago are modern
weapons that are now used to combat tuberculosis. Iso-
lation of the carriers in sanatoria is, of course, the crux
of the situation, but there are also new developments in
diagnosis and treatment which make the control of tu-

150

THE JOURNAL-LANCET

berculous transients, even in the absence of adequate
beds, more workable than some years ago. For example,
collapse surgery enables the otherwise bed-ridden patient
to carry on light work, and this treatment also renders
him bacillus-free which means that he promptly ceases
to be a danger to others. Fifty per cent or more of all
tuberculous patients can be successfully "collapsed,”
and so-called ambulatory pneumothorax treatment is
now an accepted procedure. There are furthermore
better methods of case finding. It would not be Utopian
to propose that all transients be X-rayed, which would
lead to the discovery not only of obvious cases, but also
of those in the earlier stages who by prompt action could
soon be restored to health.

Meantime there is need for a vigorous educational
campaign in areas from which most of the transients
come, to point out the futility of bartering the chance

to get well for the flimsy promise of a climatic cure. The
National Tuberculosis Association was enjoined by the
Santa Fe Conference to lead such a campaign. Another
necessary reform needed is the radical revision of state
settlement laws. The present system is an archaic one,
uncoordinated, chaotic, and often working unjust hard-
ships on residents and newcomers. Among the groups
giving attention to this problem are: the American Pub-
lic Welfare Association, the National Committee on
Care of Transient and Homeless, and the Continuing
Committee of the Inter-State Conference on Transients
and Settlement Laws.

"No home is safe until every home is safe,” is an old
slogan used by tuberculosis associations. Until we have
come to grips with the tuberculous transient, we cannot
hope to guarantee safety to the rest of American citizens.

Comparative Study of Tuberculosis
Among Insane Persons

H. E. Hilleboe, M.D.**

St. Paul, Minn.

SUCCESSFUL and permanent control of tubercu-
losis in state institutions in Minnesota is depend-
ent upon the proper execution of two related
procedures: First, routine examination for tuberculosis
of all new inmates and employees by means of the Man-
toux test and X-ray, in addition to the regular medical
examination; second, careful supervision and medical
examination at definite intervals of all known cases of
the disease resident in the institution, and adequate iso-
lation of the infective and potentially infective tubercu-
lous inmates. Only by employing such methods routinely
can the incidence of tuberculous cases and deaths be
reduced. The purpose of this paper is to present results
of the first procedure mentioned, the routine admission
examination for tuberculosis of 1,566 persons committed
to the three admitting hospitals for the insane at Fergus
Falls, Rochester, and St. Peter during the calendar year
1936.

The Minnesota State Board of Control, which is re-
sponsible for the care of state wards, interested itself
in a survey in the winter of 1934-35 to determine the
incidence of tuberculous infection and disease as a pre-
liminary step in the development of a permanent plan
of control for all state institutions. This survey was
carried out by the medical staff of the Minnesota State
Sanatorium and resulted in the identification of several
hundred cases of reinfection (or adult type) tuberculosis
among the 15,994 inmates and 2,400 employees exam-

•Presented before the Trudeau Society, Minneapolis, Minn., on
January 29, 193 7, and the Lymanhurst Medical Staff, February
23, 1937.

••Director, Division of Tuberculosis, Minnesota State Board
of Control, St. Paul, Minn.

ined. Following this survey, the Division of Tubercu-
losis of the State Board of Control set up a system of
admission and follow-up examinations which went into
effect January 1, 1936.

The usual diagnostic procedures are employed in the
examination for tuberculous disease of all newly-admitted
persons. The Mantoux test (using old tuberculin) is
applied and all positive reactors are X-rayed. The X-ray
plates are interpreted by the medical staff of the State
Sanatorium. This point is of importance in the compari-
son of the incidence of positive X-ray findings in the
survey group and the group of patients admitted during
1936. All plates were read by the same group of
physicians.

The material used for this comparative study has
been obtained from two sources. First, the Mantoux
test and X-ray results on 8,969 insane inmates who
were examined during the survey of 1935; second, the
Mantoux test and X-ray results on 1,566 insane persons
admitted to hospitals for the insane during 1936. It is
to be noted that the inmates examined in the survey
had been in residence for different periods of time, and
that no routine procedure for the diagnosis of tubercu-
lous infection -nd disease was in force prior to the sur-
vey. Persons w o recover from their mental disease fre-
quently do so within a period of a year, and accord-
ingly are discharged. The remainder of the inmates usu-
ally spend the rest of their lives in these institutions.
Any comparison made between these two sets of data
must be qualified by these facts. In other words, the
second group represents the type of people who are

THE JOURNAL-LANCET

151

TABLE 1

Distribution of Mantoux reactions and X-ray findings by age group and sex of 8,969 inmates of institutions for the insane, in
Minnesota: 1935; 1,566 admissions to three hospitals for insane, in Minnesota: 1936.

NUMBER

PER CENT

1935 Survey Cases

1936 Admitted Cases

1935 Survey Cases

1936 Admitted Cases

Mantoux

Test

X-Rays of
Positive
Reactors

Mantoux

Test

X-Rays of
Positive
Reactors

X-Rays of

Mantoux Positive

Test Reactors

Mantoux

Test

X-Rays of
Positive
Reactors

-a

0 c

C at

c 2

•- 0

0 tn

o 3

Sex Age Group

•o

0) U

u 0 H

c o

C 4)

‘55

— a

c a

‘3

~ a £ a

‘3

.£ a

.£ a 2

^ a

.5 a

£ a 2

MALE—

“f-

S £

*i ^ at

-H H

at >-

a h

at > o

S >*

-H

0> >s

41 >> 0

ahh

15-24

206

134

5.8

25-44

1710

1506

799

166

361

238

37 10

9.7

4.2

2.8

45-64 ... -

2169

1954

1057

219

271

224

57 18

11.2

9.9

8.0

6.6

65-[-

909

742

383

113

182

106

17 10

15.2

12.5

9.4

5.5

Unknown ... .

—

19.2

—

Total

5031

4362

2324

515

939

626

121 38

11.8

10.2

6.1

4.1

FEMALE—

15-24

133

7 2

6.8

6.4

2.5

25-44 .....

1302

1085

566

149

237

144

27 1 1

13.7

11.5

7.5

4.6

45-64

- 1780

1518

811

182

180

130

38 8

10.2

6.2

4.4

65-|-

698

553

265

1 1 1

11 8

17.5

13.9

12.3

7.2

3 __

15.8

Total ..

3938

3265

1691

440

628

382

86 29

13.5

11.2

7.6

4.6

BOTH SEXES—

15-24

339

224

112

175

1 1 2

9.4

6.2

2.8

i.i

25-44

3012

2591

1365

315

598

382

64 21

12.2

10.5

5.5

3.5

45-64

3949

3472

1868

401

450

354

95 26

11.5

10.1

7.3

5.8

65-|-

1607

1295

648

210

293

171

28 18

16.2

13.0

10.5

6.1

Unknown _

—

T otal

8969

7627

4015

955

1566

1008

207 67

12.5

10.7

69.0*

22*

7.1*

4.9*

•Corrected rates.

admitted to institutions

for the insane having

selec-

to compare one group

of persons

in which 20 per

cent

five factor other than that they are insane. The first
group represents the same type of people with the ex-
ception that this group has definitely been in contact,
both known and unknown, with cases of tuberculosis in
institutions, besides any contact in their homes before
admission.

Table 1 shows the distribution of Mantoux reactions
and X-ray findings by age group and sex of 8,969 in-
mates of the institutions for the insane in Minnesota as
found in the survey completed in the spring of 1935.
Of the total number examined, 56 per cent of the per-
sons were males, and 44 per cent females. The age
groups were originally set up on the basis of ten-year
groupings, that is, 15-24, 25-34, 35-44, et cetera. But
it was found that certain of the age groups could be
combined because of the fact that the incidence of
positive reactors and positive X-ray findings did not
differ greatly within the smaller groups. Four per cent
of the males were in the age group 15-24; 34 per cent
in the age group 25-44; 43 per cent in the age group
45-64; 18 per cent in the age group 65 years of age
and over, and only one per cent were of undetermined
age. The females are distributed in practically the same
proportions as the males by age groups. This makes it
possible to combine the data for males and females
into one group for comparative purposes without dis-
torting the distributions. It obviously would be unfair

of the cases were under 24 years of age, and 80 per
cent 25 years and over, with another group in which
80 per cent were under 24 and only 20 per cent 25
years and over. Having similar proportions in similar
age groups makes comparisons valid and reasonable.

The age group 15-24 was considered separately be-
cause of the interest that everyone has in this "teen”
age and early adult age group in which the tuberculosis
mortality rate is usually very high. The next age group
used was 25-44; the next, 45-64; and finally, 65 years
of age and over. It is interesting to note that several
of the inmates in this last group were between 80 and
90 years of age. In the 5,031 male inmates who were
tuberculin tested, those in the age group 15-24 showed
65 per cent positive reactions; in the 25-44 year old age
group, 88 per cent had positive reactions; in the 45-64
year old group, 90 per cent had positive reactions; in
those over 65, 82 per cent had positive reactions. It is
to be remembered that a large proportion of these pa-
tients had been in residence in the institutions for sev-
eral years.

The female inmates who were tuberculin tested did
not differ significantly from the males in the incidence
of positive reactions by age groups. Of the females
tested in the 15-24 year old group, 68 per cent were
positive; in the 25-44 year old group, 83 per cent were
positive; in the 45-64 year old group, 85 per cent were

152

THE JOURNAL-LANCET

positive; and in those over 65 years of age, 79 per cent
were positive.

When the X-ray findings on the group of positive
reactors to the Mantoux test were considered, it was
observed that the incidence of first infection (or child-
hood-type) tuberculosis by X-ray represented by calci-
fied hilum glands or Ghon tubercles in this series, was
53 per cent for all ages with a slightly higher percent-
age in the age group 45-64 years for both males and
females. That is, approximately 53 per cent of all the
positive reactors showed evidence of first infection type
of tuberculosis by X-ray as the only X-ray evidence
characteristic of tuberculosis.

By reinfection type tuberculosis is meant definite evi-
dence of parenchymal infiltration characteristic of either
minimal, moderate or far advanced pulmonary tubercu-
losis. When reinfection type tuberculosis is mentioned,
this refers only to X-ray evidence, as the clinical diag-
nosis of reinfection type tuberculosis is dependent up-
on other medical factors such as history, physical and
laboratory findings. In the male inmates in the age
group 15-24, nine per cent showed reinfection type
tuberculosis by X-ray. In the age group 25-44, 1 1 per
cent showed reinfection type tuberculosis; in the age
group 45-64, 11.2 per cent; and in the age group 65
years and over, 15.2 per cent.

In the female inmates in the age group 15-24, ten
per cent reinfection type of tuberculosis was found in
the positive reactors. In the age group 25-44, 13.7 per
cent; in the age group 45-64, 12 per cent; and in the
age group 65 years of age and older, 17.5 per cent. It
will be noted that the females, in the 25-44 year old
group and the 65 year old and over group, had a
slightly higher incidence of reinfection type tuberculosis
among the positive reactors than the males, although
this is of doubtful significance.

When the number of diagnoses of reinfection type
tuberculosis is considered in relation to the total num-
ber Mantoux tested, instead of in relation to the number
of positive reactors, it is seen that in the male in-
mates age group 15-24 there are 206 persons, of whom

5.8 per cent have reinfection type tuberculosis; in the
age group 25-44, the incidence is 9.7 per cent in the
1,710 persons. In the age group 45-64, the incidence is

9.9 per cent in the 2,169 persons; and in the 909 per-
sons in the age group 65 years and over, 12.5 per cent
have reinfection type tuberculosis. The data for the
females do not differ materially from those of the
males.

Table 1 shows also the distribution of Mantoux re-
actions and X-ray findings of 1,566 commitments to
three hospitals for the insane in Minnesota in 1936,
which represents examinations on 95 per cent of all
commitments. Of males in the age group 15-24 were
included ten per cent of the cases, 38 per cent were in
the age group 25-44, 29 per cent in the age group
45-64, 19 per cent in the age group 65 years and over,
and the ages of four per cent were undetermined. The

females were distributed similarly by age-group with the
exception of the 15-24 year old group which included
13 per cent of the cases instead of ten per cent as in
the males. It is unusual to have such similar distribu-
tions of age groups in the males and females in an un-
selected group of the population whose only common
bond is insanity and that, of course, not by choice.
There were 60 per cent males and 40 per cent females.

In the newly-admitted male inmates Mantoux tested
in the age group 15-24, 43 per cent were positive; in
the age group 25-44, 66 per cent were positive; in the
age group 45-64, 83 per cent were positive; and in the
age group 65 years and over, 58 per cent were positive.
It is to be noted that these persons were Mantoux
tested upon arrival at the institutions before there was
any opportunity for contamination with tubercle bacilli
through institutional contact.

The newly-admitted female inmates show a similar
distribution of positive reactions by age group, with the
exception of the age group 45-64, in which only 72 per
cent were positive, as compared with 83 per cent posi-
tive in the males of similar age. The number of in-
mates in these two age groups, however, were relatively
small, 180 and 271 respectively.

The X-ray findings of the positive reactors in the
newly-admitted patients are of interest. Of the males
in the age group 15-24, first infection tuberculosis was
shown in only ten per cent; in the age group 25-44,
16 per cent; in the age group 45-64, 25 per cent; and
in the age group 65 years and over, only 16 per cent of
first infection type tuberculosis alone by X-ray was de-
monstrated. Of the females in the age group 15-24, first
infection type tuberculosis was seen in 23 per cent; in
the age group 25-44, 19 per cent; in the age group
45-64, 29 per cent; and in the age group 65 years and
over, again only 17 per cent showed first infection type
tuberculosis by X-ray. In considering the number of
positive reactors who showed reinfection type tubercu-
losis by X-ray, it is observed that in the age group
15-24, there were no reinfection type cases; in the age
group 25-44, 4.2 per cent had reinfection type tubercu-
losis; in the age group 45-64, eight per cent; and in the
age group 65 years and over, 9.4 per cent. Of the
females with positive reactions to the tuberculin test, in
the age group 15-24, 6.4 per cent showed evidence of
reinfection type tuberculosis; in the age group 25-44,
7.6 per cent; in the age group 45-64, 6.2 per cent; and
in the age group 65 years of age and over, 12.3 per cent
showed evidence of reinfection type tuberculosis.

In considering the number of diagnoses of reinfection
type tuberculosis in relation to the total number of
persons Mantoux tested instead of the number of posi-
tive reactors in each age group, some interesting per-
centages were observed. Of the males in the age group
15-24, no reinfection type cases were found; in the age
group 25-44, 2.8 per cent had reinfection type tubercu-
losis; in the age group 45-64, 6.6 per cent; and in the
age group 65 years and over, only 5.5 per cent. In the
females, the distribution was not unlike that of the

THE JOURNAL-LANCET

153

males with the exception of those 65 years old and over,
of whom 7.2 per cent showed evidence of adult type
tuberculosis.

For purposes of comparison, the males and females
in the survey cases may be combined into one group be-
cause their age group distributions are similar and the
Mantoux test and X-ray findings in the males and
females by age groups are not significantly different,
and can reasonably be grouped together. This is also
true of the newly-admitted cases in regard to sex, age,
tuberculin reaction, and X-ray findings.

In comparing the number of positive reactors to the
tuberculin test in the age group 15-24, there were 25 per
cent less positive reactions in newly-admitted cases than
in the survey cases; in the age group 25-44, 22 per cent
less; in the age group 45-64, only nine per cent less;
and 23 per cent less in the age group 65 and over. It
is not unreasonable to assume that the survey group
was similarly less infected on first admission to the in-
stitutions, and that the relatively higher incidence of
tuberculous infection as demonstrated by the positive
tuberculin test during the survey could be attributed in
part to institutional contact with infectious cases of
tuberculosis.

Further evidence to strengthen this contention is
shown when the number of persons with first infection
type tuberculosis is examined in the two groups. In con-
trasting the newly-admitted cases with the survey cases,
in the age group 15-24, there was 35 per cent less first
infection type tuberculosis in the newly-admitted group;
in the age group 25-44, 36 per cent less; in the age
group 45-64, 27 per cent less; and in the age group 65
and over, 34 per cent less cases of first infection type
tuberculosis.

The most noteworthy differences become apparent in
the relative incidences of reinfection type of tubercu-
losis. Comparing the survey and the newly-admitted in-
mates, in the age group 15-24, there was a decrease
from 6.2 to 1.1 per cent; in the age group 25-44, from
10.5 to 3.5 per cent; in the age group 45-64, from 10.1
to 5.8 per cent; and in the age group 65 years old and
over, from 13.0 to 6.1 per cent. In other words, the per-
centage of cases of reinfection type tuberculosis found
in the newly-admitted inmates was less than one-half of
the percentage of cases in inmates who had been in resi-
dence in the institution. This strikingly demonstrates the
need for, as well as the value of, routine examination for
tuberculosis in state institutions, particularly for the in-
sane.

In comparing the total number of survey cases with
the total number of newly-admitted cases, statistical cor-
rections must be made because of the differences in age
group distributions. These corrections are obtained by
arbitrarily using the population of the survey cases as a
standard population and applying the percentages of
positive reactors and X-ray findings in both the survey
and newly-admitted cases to this population by respec-
tive age groups. The rates thus obtained are directly
comparable, other things being equal.

After statistical correction of rates, the survey cases
showed 85 per cent positive reactions to the tuberculin
test, while the newly-admitted were only 69.0 per cent
positive. First infection type tuberculosis was found in
53 per cent of the positive reactors in the survey group,
while only 22 per cent had first infection type tubercu-
losis in the newly-admitted group. Reinfection type tu-
berculosis was found in 12.5 per cent of the positive
reactors in the survey cases, while only 7.1 per cent was
found in the newly-admitted group.

These differences are so striking that it is hardly
necessary to mention that they are statistically signifi-
cantly different.

In absolute numbers, it is observed that actually 67
cases of reinfection type tuberculosis were discovered by
routine tuberculin testing and X-ray examination of
1,566 newly-admitted insane persons at the time of their
commitment to an institution. Of these 67 cases, 45 per
cent were minimal, 25 per cent moderately advanced,
and 30 per cent were far advanced by X-ray. The ma-
jority were early cases and ones most likely to become
arrested under careful medical supervision. Five of the
cases had positive sputum and were immediately iso-
lated. These persons came from various counties in the
state and were not originally concentrated in one par-
ticular section.

A dual function is performed by identifying these
persons with reinfection type tuberculosis on admission
to a state institution; first, medical care becomes avail-
able— second, isolation from uninfected inmates is pos-
sible. The unfortunate inmate, who labors under the
double liability of both insanity and tuberculosis, can
be given adequate medical supervision and care from
the start, and, if indicated, remedial treatment for
whichever of his impairments is remediable. By isolation
of the infectious newly-admitted cases, the second objec-
tive is gained. That is, spread of the disease among un-
infected inmates in the general wards is prevented. This
is a real threat when one considers the intimate con-
tact resulting from overcrowding among 9,000 insane
people, the majority of whom are incapable of carrying
out the simplest principles of personal hygiene and
cleanliness.

The question of follow-up of inmates with tubercu-
losis in the institutions, their medical care and isolation
will not be discussed at this time. That is a major prob-
lem in itself. Suffice it to say that effective methods are
being employed to provide isolation and segregation of
tuberculous inmates as well as special facilities for hos-
pitalization. It is planned to re-test all the inmates in
residence in 1937 who were negative to the tuberculin
test during the survey in 1935. This work will be fin-
ished in the summer of 1937 and should throw addi-
tional light on the effectiveness of the barriers that have
been set up to stop the spread of tuberculosis in state
institutions.

The logical sequence to a comprehensive tuberculosis
survey of inmates of state institutions in Minnesota has
been the development and execution of a system of

154

THE JOURNAL-LANCET

routine examinations for tuberculosis which already are
showing measurable benefits and productive results.

This relatively inexpensive procedure is of paramount
importance from a public health point of view and
should result in definite economies for the state in the
institutional care of its wards, in actual savings in hu-
man life, and in higher standards of public welfare.

Conclusions

( 1 ) The distributions of positive tuberculin reactions
and X-ray findings by sex and age groups have been
shown in a group of inmates of institutions for the in-
sane in Minnesota — first, in 1,566 newly-admitted per-
sons, and second, in 8,969 persons surveyed after a con-
siderable period of residence.

(2) The survey cases showed 85 per cent positive re-
actions to the tuberculin test, while the newly-admitted
cases were orily 69.0 per cent positive (corrected rate).

(3) First infection type tuberculosis was found in 53
per cent of the positive reactors in the survey group.

while only 22 per cent (corrected rate) had first infec-
tion tuberculosis in the newly-admitted group.

(4) Reinfection type tuberculosis was found in 12.5
per cent of the positive reactors in the survey cases, while
only 7.1 per cent (corrected rates) had reinfection tu-
berculosis in the newly-admitted group.

(5) A striking difference is demonstrated in the rela-
tive incidence of reinfection type tuberculosis in the total
number of survey cases, 10.7 per cent, when compared
with the incidence in the total number of newly-
admitted cases, 4.9 per cent (corrected rate) — an actual
decrease of 5.8 per cent, and a relative decrease of 54
per cent.

(6) As a result of routine Mantoux tests and X-ray
examination of newly-admitted inmates, two objectives
in the control of tuberculosis in state institutions have
been gained, the early recognition of tuberculosis in
newly-admitted inmates and the early isolation of infec-
tious cases, which results in the prevention of the spread
of the disease to uninfected individuals.

The Present Status of B. C* G* Vaccination*

W. P. Larson, M.D.**

Minneapolis, Minn.

DURING the past 15 years, voluminous litera-
ture has accumulated on the subject of im-
munity in tuberculosis resulting from vaccina-
tion with B.C.G. The work of Calmette is too well
known to necessitate an extended discussion of B.C.G.
vaccination. In the interests of context, it may be
pointed out that Calmette and Guerin cultivated a
bovine strain of the tubercle bacillus on glycerine-bile
potato for a period of about 13 years, during which time
the organism lost its pathogenicity. After determining
the organism was no longer pathogenic, Calmette tested
its immunizing properties by injecting the living culture
into beeves. He found that the animals developed no
tuberculous lesions as a result of the injections and,
furthermore, he observed that these cattle would now
withstand an intravenous injection of virulent bovine
organisms without developing lesions. Calmette believed,
therefore, that the bacillus of Calmette and Guerin
(B.C.G.) might be used as an immunizing agent not
only for cattle, but for man as well.

The foundation for this work was laid a number
of years previously by Behring, who injected a virulent
human strain of the tubercle bacillus into young beeves.
He found that the human strain of the bacillus failed
to produce progressive tuberculosis when inoculated
intravenously into cattle. Only mild retrogressive lesions
were observed which tended to calcify. Behring found

•Prepared expressly for the special Tuberculosis issue of THE
JOURNAL-LANCET.

••Professor and Head, Department of Bacteriology, University
of Minnesota.

further that animals which had been injected intra-
venously with a living human strain would resist infec-
ton by a virulent bovine strain when the latter was given
after the animals became tuberculin positive. Unfortu-
nately, when the animals which had been inoculated
with the human strain came to lactation, living tubercle
bacilli of the human type could be demonstrated in
the milk. This naturally militated against the practical
application of this procedure. Behring then attempted
to effect the same result by using an avian strain, since
the latter is not pathogenic for man. The avian strain,
however, failed to confer an immunity in cattle.

The fact that the human strain appeared in the milk
of the animals that came to lactation shows that the
organism is somewhat pathogenic for cattle, since they
would not have been able to pass the mammary gland
without first having produced a lesion. It is improba-
ble that a non-pathogenic organism can establish itself
for more than a brief period in the animal body.

During the past 40 years many investigators have
shown that experimental laboratory animals may be pro-
tected for short periods by vaccination with killed cul-
tures. Animals thus protected usually outlive control
animals by a few weeks; in some cases, by several
months. Complete protection, however, has seldom, if
ever, been achieved.

During the years 1927 and 1928, the writer, in con-
junction with Evans, conducted an experiment for the
Illinois Department of Agriculture at Springfield on

THE JOURNAL-LANCET

155

the possibility of protecting cattle against tuberculosis,
using the method recommended by Calmette. A strain
of B.C.G. was kindly supplied us by Dr. Calmette, and
a group of 40 animals vaccinated according to Cal-
mette’s specifications. The animals selected for the ex-
periment varied in age from a few months to about
three years. They were all obtained from tuberculin-
free areas and given the tuberculin test before being
sent to the experimental farm. The animals were each
given 100 mg of B.C.G. subcutaneously. A short time
after the tuberculin test became positive, there was in-
troduced into the herd a group of reactors known to
be "spreaders.” At the same time, a group of 20 tubercu-
lin-negative cattle were introduced as controls. The ex-
periment now embraced some 60 head of cattle which
were maintained in a 20 acre enclosure. During the
entire course of the experiment, the herd was fed on
dry feed and had access to a common water trough.
Approximately 18 months after the introduction of the
infected cattle, the entire group was autopsied. Every
animal in the experiment was found to be infected with
tuberculosis. The lesions in the vaccinated group were
as extensive as in the control group. This experiment
may be open to the criticism that the animals were too
heavily exposed. We attempted to duplicate conditions
on the average midwest farm as far as possible, in order
to determine the value of the B.C.G. vaccination under
natural farm conditions. The conclusions of our experi-
ment were naturally that B.C.G. vaccination was of no
value in protecting against bovine tuberculosis under
natural conditions of exposure.

Rankin, who also conducted vaccination experiments
on cattle, reports somewhat more favorable results than
our own. In a group of animals vaccinated with B.C.G.
and later injected intravenously with 5 mg of a virulent
bovine strain, he found that only 20 per cent of the
vaccinated animals showed macroscopic lesions, whereas
95 per cent of the non-vaccinated developed such lesions.
On the other hand, 80 per cent of the vaccinated ani-
mals did show microscopic lesions. Rankin’s work, there-
fore, seems to indicate that there is very little protec-
tion afforded by B.C.G. vaccination when the animals
were later tested by intravenous inoculation of the
virulent organism, although the lesions produced were
somewhat less extensive than in the controls.

In another series of experiments, Rankin exposed the
vaccinated animals to natural infection following B.C.G.
vaccination. In this group, 92 per cent of the non-
vaccinated animals developed Tuberculosis, while only
34 per cent of the vaccinated developed tuberculosis.
The time of exposure is obviously an important factor
in experiments such as these. Rankin exposed his ani-
mals for a period of time varying from four to eleven
months. A further six months’ exposure would, no doubt,
have given a much higher percentage of tuberculosis
among the vaccinated animals. As the disease spreads,
exposure becomes heavier and more continuous until
finally all the animals become infected, as was the case
in our experiment. The time exposure element undoubt-

edly explains the difference in results between Rankin’s
experiments and our own.

Watson likewise reports unsatisfactory results in his
efforts to establish a protective immunity in cattle.

In view of the uniformly negative results obtained on
cattle vaccinated with B.C.G., there is little reason to
expect marked success in vaccinating humans by this
method.

The fact seems to be well established that immunity
to tuberculosis exists only so long as living tubercle
bacilli remain in the body. Gay suggests the term "non-
sterilization immunity” for this type of resistance. Soon
after the bacilli disappear from the body, or the lesions
heal, the immunity, which at best is of low order, is
lost.

Confident of the innocuity of B.C.G., which is now
universally accepted, Calmette proceeded to vaccinate
children on a large scale. He recommended peroral vac-
cination, which was administered to the infant during
the first ten days of life before it had had an oppor-
tunity to become exposed to virulent organisms. It was
soon found, however, that only about six per cent of
the children so vaccinated became tuberculin-positive,
and the method was, therefore, abandoned in favor of
the subcutaneous or the intracutaneous methods of ad-
ministration. Most children became tuberculin-positive
following the vaccination by the parenteral route; the
individuals thus vaccinated remain tuberculin-positive
from two to six years. This probably represents the
maximum period of immunity which would result fol-
lowing vaccination. Calmette recommends that children
be revaccinated at the ages of three, seven and fifteen
years respectively. These recommendations evidently are
not based on experience, as there are no results upon
which such conclusions could be based, and hence they
should be regarded merely as suggestions. In spite of the
fact that approximately one and a half million children
have been vaccinated during the past 15 years either by
the peroral or parenteral routes, conclusive evidence that
vaccination possesses merit is still lacking.

There are numerous reports in literature, in addi-
tion to those of Calmette, in which the authors conclude
that B.C.G. vaccination has been of definite value in
protecting against tuberculosis. With the exception of
the reports of Heimbeck and Wallgreen, the evidence
submitted in support of such conclusions fails to carry
conviction.

Calmette reports a lower non-tuberculous death rate
among the vaccinated than in the general population.
He states that the non-tuberculous mortality rate among
the vaccinated has been found to be as low as 50 per
cent of that of the general population. Lampadarious
and Stravropoulos, who vaccinated approximately 7,000
children, found that the non-tuberculous mortality
among the vaccinated was 2.8 per cent, while among
the non-vaccinated it was 21.7 per cent. Such a lower-
ing of the non-tuberculous mortality rate among the
vaccinated is difficult to comprehend. There remains a
suspicion that the vaccinated and control groups were

156

THE JOURNAL-LANCET

not comparable in all respects. On the other hand, Park
observed a higher non-tuberculous mortality rate among
the vaccinated than in the general population.

The work of Heimbeck represents one of the best
controlled studies which has been reported. Heimbeck’s
material comprised 1,434 probationary nurses. Forty-six
and a half per cent of these nurses entered the hospital
with a positive tuberculin test, while 53.5 per cent were
negative. None of the nurses who were tuberculin-
positive at the time they entered their hospital training
died of tuberculosis during the training period, while
there was a mortality of 3.5 per cent of the tuberculin-
negative nurses. Of the group which remained negative
after B.C.G. vaccination, 1.8 per cent died, while the
mortality rate among those who became positive as a
result of vaccination was only 0.37 per cent. The work
of Heimbeck, therefore, seems to indicate the tubercu-
lin-positive nurse is more resistant to tuberculosis than
is her tuberculin-negative comrade.

Wallgreen, of Goteborg, Sweden, vaccinated 355
children by the intracutaneous route. None of these
children was exposed to tuberculosis until after they had
become definitely tuberculin-positive. The organization
of the municipal dispensary at Goteborg gives Wall-
green access to all cases of tuberculosis in the city. Of
230 vaccinated children who had become allergic as a
result of B.C.G. vaccination, and later exposed to
tuberculosis in the home, only two have died, neither of
whom showed signs of tuberculosis at autopsy. Wall-
green’s results, like those of Heimbeck, would seem to
indicate that there is some temporary value from vac-
cination. If these results could be shown to be due
solely to the vaccination, its value could not be ques-
tioned. However, in a group such as this, which is con-
trolled by a well organized dispensary, the educational
side of prophylaxis has no doubt not been neglected.

It is a well established immunologic principle that
little can be expected in the way of prophylactic vac-
cination against those infections which do not terminate
in an immunity. In other words, one may expect a

result from vaccination in those infections which are
followed by immunity. Thus, one would expect to be
able to protect against typhoid fever, since this disease
is one of a number which leaves a life-long immunity
following convalescence. Indeed, vaccination is partiallv
successful against typhoid fever, but the immunity ob-
tained following vaccination is not comparable to the
immunity which results from the infection. The im-
munity following typhoid vaccination is probably not of
more than two or three years’ duration. Tuberculosis,
on the other hand, does not confer a high degree of
immunity. It is a common observation in the autopsy
room to see active tuberculosis in a case where healed
lesions exist; and it is not uncommon to see active and
spreading lesions exist where others are healing.

It is evident, therefore, that active tuberculosis lends
only a temporary and probably very low grade im-
munity. In view of the fact that immunization of ex-
perimental animals has been most disappointing, there
is no reason to expect that the results in humans should
be more favorable. The effects of sanitation and educa-
tion may readily be credited to the effect of vaccination,
an effect which is unobtainable in experimental animals.
In view of the fact that a million and a half children
in various parts of the world have already been vacci-
nated against tuberculosis with B.C.G., we would do
well to await the outcome of this work before proceed-
ing too hurriedly with a general vaccination program.
The only place in which vaccination could possibly be
justified in the light of our present knowledge would be
under conditions such as those of Heimbeck, where it
is desired to protect a group for a limited period of
time. Under the most favorable conditions, there is little
reason to expect that the protection, if any, is of more
than a few months’ duration.

Successful vaccination against tuberculosis involves
the paradox of using a virulent organism — in order that
it may establish and maintain itself in the host — and
yet one that will not produce infection. Such a strain
has, as yet, not appeared upon the horizon.

Some Thoughts on Tuberculosis of Fascia andMuscle

Charles K. Petter, M. D.**

Oak Terrace, Minnesota .

A PATIENT with multiple tuberculosis lesions of
fascial compartments and of the skin, who came
under my observation about a year ago and
whose case is reported herewith, led to a review of the
literature and a rather critical analysis of reports of
fascial and muscular tuberculosis. This report consists of
a case summary and an attempt to evaluate the various

•Presented at Semi-monthly Clinical Conference, Glen Lake
Sanatorium, Dec. 9, 193 5.

••Glen Lake Sanatorium, Oak Terrace, Minnesota, and Depart-
ment of Surgery, University of Minnesota, Minneapolis, Minnesota.

descriptions of tuberculosis of fascia and muscle which
were collected in connection with this case study.

The patient was a white male, age 27, admitted to
Glen Lake Sanatorium, July 10, 1934, with far-advanced
pulmonary tuberculosis. Sputum was positive and daily
temperature varied between 98.2 and 99.8° (F) . There
was no evidence of extra pulmonary tuberculosis on
physical examination.

About August 15th, he began to complain of pain
in the region of the right elbow, which was not severe

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and occurred only upon resuming motion after a period
of rest. During the next four weeks an area of swell-
ing appeared proximal and medial to elbow, which was
somewhat fluctuant, not hot or tender, and showing no
skin change.

FIGURE 1

Swelling anterior to tendo Achilles due to mass of tuberculous
granulation tissue in fascial compartment.

Swelling which appeared proximal to right elbow; operative find-
ings shown in Figure 7.

During September, several skin lesions appeared on
the fingers and toes, which were diagnosed as tubercu-
losis of the skin. In November, aching over extensor
surface of forearm occurred and an elliptical swelling
6x4 cm. appeared. The skin was not changed, nor at-
tached to the mass and not reddened, but was locally
warm.

was not grossly abnormal. In February, 1935, a small
swelling appeared just below and anterior to each mal-
leolus, on the right foot. These were tender, boggy, and
warm, but not reddened or attached to the skin (Fig-
ure 4) .

FIGURE 4

Right foot, showing fascial lesions below malleoli.

FIGURE 2

Fascial lesion on right forearm (see also Figure 5).

In the latter part of December, pain on dorsi flexion
of the right ankle developed, followed by limitation of
motion and later by a constant pain "back of the
ankle” accompanied by a bulging mass anterior to the
tendo-achilles, posterior to the lateral malleolus. This
swelling was tender and warm but the overlying skin

During this period the patient had had no apprecia-
ble change in his general body temperature, nor in his
general regime, which consisted of bed rest, carbon arc
irradiation and local heat (infra-red and hot baths) to
the affected parts, including the skin lesions.

Treatment: On January 15, 1935, the lesion on right
forearm was incised, and a large mass of peculiar
gelatinous-appearing granulation tissue was found in the

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intermuscular septum between the extensor carpi radialis
and the brachio-radialis muscles (Figure 5). This was re-

FIGURE 5

Operative findings in lesion of right forearm.

moved and the wound closed, later breaking down.

The lesion anterior to the tendo-achilles was similarly
exposed on January 28, and a large mass of the same
gelatinous appearing granulation tissue with some
watery exudate removed from the fascial compartment
anterior to the tendon. This was thoroughly cleaned-

FIGURE 6

Findings at operation, right foot (see Figure 3).

and sutured after swabbing with iodine.

A mass of the same type of granulation tissue was re-
moved from the intermuscular space between the medial
head of the triceps brachii and the extensor carpi radi-
alis longus on February 5th. Because of the tunneling

FIGURE 7

Operative findings in lesion shown in Figure 1. A cross section
of arm shows extent to which the disease process extended under
triceps.

necessary to remove all of the granulation tissue, this
wound was left open, but healed well after a few weeks.

On March 1 1th, the lesion below the lateral mal-
leolus was incised and curetted. The medial lesion was
not incised until some time later.

In July of 1935, the wound on right forearm which
had closed and reopened several times after the original
evacuation was reopened and a pocket of granulation
tissue found in the proximal extremity of the wound,
probably overlooked at the first procedure. This was
removed, and the wound sutured, healing in a relatively
short time.

Post-operatively, these lesions were all treated by in-
tense heat therapy in the form of infra-red irradiation
and hot baths, and the skin as well as the facial lesions
are now healed.

Because of the frequent co-existence of tuberculosis
in the kidney with similar lesions in the organs of loco-
motion, a guinea pig was inoculated with six specimens
of urine from this man. No tuberculosis developed
in this guinea pig.

Tissue removed from the facial lesions showed
tubercle formation on section and some of the gran-
ulation tissue injected into a guinea pig produced tuber-
culosis in the pig. The skin biopsies showed tubercle
formation on section.

Discussion: ' Tuberculosis of the fascia is generally
described as an extension cf the disease from a bone,
joint or infected lymph gland, and cases of this type
constitute most of those reported prior to 1916. The
case just described is one of so-called "Primary” or
hematogenous infection and a review of the literature
reveals but few such cases reported. Blackburn1 has
reported one such case and describes the pathology as,
". . . bacilli pass through the blood stream and find
lodgement in fascia. In this form the connective tissue
is usually transferred into a mass of granulation
tissue . . .”.

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159

Tuberculous involvement of fascia by direct extension
is a very different problem from the primary lesion.
The latter is relatively benign, and yields readily to sur-
gical treatment. This, however, must consist of com-
plete evacuation of the diseased areas, and not partial
aspiration followed by injection of iodoform into the
lesion, as has been the practice in the past.

In considering the relatively few reports of tubercu-
lous fastitis and the correspondingly greater amount of
literature on tuberculosis of the muscle, one is impressed
by the fact that many so-called cases of muscle tuber-
culosis are after all fascial tuberculosis. Skeletal mus-
cle fibers are surrounded by fine connective tissue, the
muscle bundles by a heavier sheath, and the separate
muscles by fascial sheaths of very dense white fibrous
tissue. In these connective tissue spaces run the blood
vessels,' and here also occur the tuberculous processes
which may extend to invade other spaces and ultimately
destroy the muscle fibers by toxin and interruption of
blood supply.

It is with hesitation I suggest that muscular tuber-
culosis and fascial tuberculosis are two terms applied to
the same process. Yet, since connective tissue septa
of varying degrees of fineness constitute a part of every
muscle, and since the blood vessels in the muscle occur
in these connective tissue spaces, and since the tuber-
culous granulation tissue forms in these same spaces it
seems that tuberculosis of fascia covers the whole field.
Mitchell'* in 1908 stated "the origin and extension is
in connective tissue; therefore, there is no true tuber-
culosis of muscle” and Plantard4 states "tubercle has
never been described in the muscle fiber.” When the
so-called fascial lesion extends, the center of the granu-
lating mass may become necrotic and the periphery
sclerotic forming an abscess. As the nutrition of the
muscle is interfered with, a resulting cirrhosis or atrophy
will occur. These changes make up the three "types”
of muscular tuberculosis described in the German and
French literature, namely (1) nodular (tuberculous
granulation tissue), (2) abscess and, (3) cirrhotic type.
Rather than distinct types, these are probably manifes-
tations of different stages of the same process.

Many of the reported cases of fascial tuberculosis
from 1899 to 1905 contain reference to "cysts under
Pouparts” filled with pus, from which fascial nodules
and abscesses arose. The descriptions are as a rule not
good, and leave one wondering if the cysts referred to
ate not psoas abscesses pointing below Pouparts. We
have seen two cases of this type with invasion of the
fascial planes to the mid-thigh. References to the "cys-

tic” type of fascial lesions may be found in the older
text books on surgery, such as in Senn’s Principles of
Surgery, 1890, and in a few German articles of the
same decade.

Muscle tuberculosis was first described in 1886 by
Habermaas and Muller, each reporting a case. Since
that time there have been 55 additional cases reported
in the German, French and Italian literature, with five
by American authors.

A review of the orthopedic cases treated at Glen
Lake Sanatorium reveals only this one case of tuber-
culosis of the fascia, and no proven case of so-called
tuberculosis of muscle. The incidence then would be

0.015% of all our tuberculous patients, or 0.3% of the
orthopedic series, including lesions of bones and joints,
tendon sheaths and bursae.

Summary:

1. A case of "Primary” multiple tuberculous lesions
of fascia is reported, in which healing took place fol-
lowing surgical evacuation.

2. The lesions developed simultaneously with a "crop”
of skin lesions, as the result of a hematogenous dis-
semination.

3. At the time of this report, the patient has shown
no evidence of other extra-pulmonary tuberculosis, and
is just beginning to clear his pulmonary lesion (after
18 months).

4. So-called tuberculosis of muscle is truely a tuber-
culosis of the fascial sheaths or septa of the muscle,
since tubercle formation in muscle fiber has never been
observed.

5. "Primary” tuberculosis of the fascia occurred once
in 309 cases of orthopedic tuberculosis (0.3%), and
6180 cases of all types of tuberculosis (0.015%).

Bibliography

1. Blackburn, J. N., Tuberculosis of Fascia — Southern Med.
Jr. — 14:556-57, July, 1921.

2. Maximow — Textbook of Histology, W. B. Saunders Co.,
Philadelphia.

3. Mitchell, J. F. — Tuberculosis of Muscles, Tendons and
Fascia — Trans. 6th Internat. Confer, on Tuberculosis. Vol. 2,
Sec. 3, P. 280 (1908).

4. Plantard — Paris Thesis, 1901.

5. Milch, H. — So-called ’Primary’ Tuberculosis of Muscle

Am. Jr. Med. Sc., 188:410, Sept., 1934.

6. Plummer, W. W., Sanes, S., and Smith, W. S. — Hemato-
genous Tuberculosis of Skeletal Muscle Am. Jr. Bone and Joint

Surg. — 16:631-639, July, 1934.

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Newer Concepts in the Epidemiology of Tuberculosis

Hilbert Mark, M. D.*

St. Paul, Minn.

WITHIN the past decade, the therapy of pul-
monary tuberculosis has made rapid strides,
but only because of the improved and finer
methods of diagnosis of the disease at its inception. With
this ability for diagnosing early tuberculosis has come
an enlightenment in the concept of this disease in its
entirety. Pulmonary tuberculosis has been divided into
two main groups: primary complex, or what is generally
known as childhood type of tuberculosis; and reinfec-
tion, or adult type. The primary complex is that body
reaction which takes place when tubercle bacilli invade
a host for the first time with the formation of one or
more tubercles. The cells of the host are then altered
so that future invasion of the bacilli may produce a more
ulcerative type of disease, the production of which will
depend upon the balance of resistance of the host
against mass infection. The border between primary
and reinfection disease is very narrow, so that at times
it is difficult to know where one leaves off and the other
begins. In primary groups, the mortality rate is exceed-
ing low and thereby influences the prognosis and ther-
apy.

A large percentage of this group will heal with little
or no X-ray clinical evidence. Sometimes, on subsequent
examination, Ghon tubercle, calcified glands, or fibroid
areas may be found roentgenologically. The remainder,
at sometime or other during the life of the host, will
show reinfection either from an exogenous or an endo-
genous source.

The disease resulting from the tubercle bacillus in-
vasion in a previously-infected individual, or from the
breakdown of a primary complex (freeing of tubercle
bacilli causing an extension from an inner source) is
called reinfection tuberculosis. The development of re-
infection is, as a general rule, insidious, so that there is
an average period of two and one-half years between the
onset of the parenchymal lesion and the first symptom.
Because of this silent development of the disease, 90 °/c
of all patients entering Minnesota sanatoria today have
moderately to far-advanced disease.

No longer can primary disease be treated as a benign
infection with no consequential or subsequent serious-
ness; no longer can this stage of tuberculosis be passed
up with a sigh of relief, but it should be placed in its
proper category and continuous subsequent attention
given to it. Only then can this phase of tuberculous
pathology be regarded without serious intent.

Of special seriousness is the prognosis of the individ-
ual— especially under the age of three and past puberty
— who has recently become infected and continues to re-
main in an intimate circle of infection. The addition
of the exogenous infectious agents continuously intro-

•Tuberculosis Epidemiologist, Minnesota State Sanatorium,
Ah*gwah-ching, Minnesota.

duced on top of a recent pathologically active primary
complex will increase the mass infection as compared to
the resistance of the particular host. This type of danger
is seen occasionally in the child from three years to
puberty who reveals evidence of reinfection tubercu-
losis. It is also shown in nurses having a negative Man-
toux reaction on entrance to hospital training and break-
ing down within a relatively short length of time with
disseminating type of tuberculosis.

From the foregoing statements, four main points can
be accepted as our guide for adequate epidemiology to
control future tuberculous infection and reinfection:

1. Tuberculosis is a contagious disease, especially in-
fectious in intimate circles, such as family groups, office
groups, school rooms, and the like.

2. Reinfection occurs only in a previously-infected in-
dividual either from an exogenous or endogenous source.

3. Reinfection type of tuberculosis is an insidious dis-
ease, and there may be a period of years between the
period of reinfection and the period of disease. The
primary complex may become latent and even fairly
well walled-off, yet in this area, there may be and usually
are, living tubercle bacilli.

4. There is an average period of two and one-half
years from the first parenchymal lesion of reinfection
tuberculosis to the first symptom. As a consequence,
the patient at the time he sees his physician, has devel-
oped a disease which is usually far advanced and one of
serious intent. The main objectives in the proper pre-
vention of tuberculous infection would be:

a. Break contact; that is, isolate the open infectious
cases so that other members of the intimate circle are
spared the necessity of further exposure.

b. Tuberculin tests of intimate contacts. The method
generally used is the Mantoux test or intradermal
method, whereby 1/10 of cc. of 1-1000 diluted O. T.
is used. There are also other products on the market
which are quite satisfactory which may be used to ad-
vantage in a physicians office when only a few tests are
given at a time. Through this method, the extent of
the spread is known.

c. X-ray of positive reactors, excepting those falling
into the age group of from three to puberty. The
omission of this age group is purely one of economy
based on statistics derived from a ten-year study of the
Lymanhurst Clinic by Myers and Stewart. Only a few
reinfections were found. It is felt that children in this
group handle infection and disease remarkably well.
However, should there be any clinical evidence or con-
tinued massive infection, then these children like-wise
should also be X-rayed. Children under three reacting
to the test should be re-checked by X-ray every 3-6

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months until their third year. Children and adults of
fourteen or over should be X-rayed at least yearly until
they reached the age of 35-40 years, at which time the
X-ray check-up may be spread over longer periods de-
pending upon the general condition of the individual
and previous X-ray findings.

Early tuberculosis should be treated promptly accord-
ing to the latest methods. Advanced disease requires
special attention and methods. In this way, it can be
said that cases of tuberculosis resulting from intimate
exposure, which take place in the greatest number of
cases, would be diagnosed at their inception. As a result
of this early diagnosis, the disease is found before the
lesions have ulcerated and, therefore, before it develops
into infectious type of tuberculosis. The subsequent
results, naturally, will be far more successful than treat-
ing far advanced or complicated disease, both as far as
the patient himself and his family are concerned. With
these points, it is the thought and principle of the
Minnesota State Sanatorium that the family physician
and the sanatorium itself should work hand in hand in
the development of a program that will control the dis-
ease. The State Sanatorium likewise believes in a sys-
tem of decentralized care of the tuberculous so con-
ducted that the sanatorium becomes a hospital for the
care of the following:

1. Positive sputum cases until such cases cease to be
infectious.

2. Incorrigible cases which because of the character
of the individual may in time become of serious intent,
not only to the individual but also to his family and to
his community wherein he resides.

3. Cases of complicated tuberculosis needing special
treatment beyond the individual’s economic reach.

The local physician would then be responsible for:

1. Non-infectious types of pulmonary tuberculosis
such as primary complex, pleurisies, early non-ulcerative
cases, and the like.

2. Observation cases.

3. Post-sanatorium cases, such as those needing con-
tinued pneumothorax refills, continued rest care, and
continued observation.

Local hospitals can be utilized for those patients who
are non-infectious and who are needing only a relatively
short period of hospitalization. From an economic point
of view, certainly, it will be better to follow along these
lines, since the cost of maintenance at a sanatorium is
much greater over a long period of time than the cost
of maintenance and care at home. From the patient’s
point of view, this plan will be to his liking. It will

either replace or reduce the length of his stay at the

sanatorium, and reduce or nullify his menace to the

family. Under such a plan, the sanatorium field phy-
sician, now doing mostly epidemiological work, will then
become a traveling consultant and liaison officer between
the sanatorium group and the family physicians hand-
ling the so-called out patient department of the sana-
torium.

The success of such a program will depend upon the
interest taken by the family physician in the original
case finding, testing, and the subsequent follow-up of the
intimate contacts, and the care of the tuberculous cases
discharged from the sanatorium.

The Problem of Developing A Student
Health Service

Florence Brown Sherbon, A. M., M. D.**

Lawrence, Kan.

I The Philosophy of Health. The philosophy of
the moment seems to be the philosophy of the
♦ whole. It seems to me important that we should
fit all thinking into the picture of an integrated uni-
verse— an organic cosmic whole. Science tells us that
apparently this whole consists of units of force, perhaps
positive and negative electricity (whatever that may be) ,
arranged in minute atomic patterns. Atoms, in turn, re-
late themselves with each other in obedience to occult
compulsions to form a super-pattern, apparently implicit
in infinity and eternity, and revealing itself through time
and space in the bewildering phenomena of life, of
worlds, of suns and of galaxies, which now appear with-
in the mere scrap of the infinite cosmos of which our
senses make us increasingly aware.

•Read at the South Central Section Meeting of the American
Student Health Association at Lincoln, Nebraska, April 18, 1936.
••Students’ Health Service, University of Kansas.

The philosophy of wholeness — of the integration, if
not the identity, of the hereditary pattern with environ-
ment (meaning by environment the sum-total of experi-
ence and relationship with the external world) , in a
word, the philosophy of relativity — is leavening and uni-
fying every aspect of human thinking and behavior.

To my mind, then, the basic "problem” involved in
developing a student health service is that of initial per-
spective— seeing health as a quality of the whole. Thus
only can every effort be made to contribute to the sym-
metrical and optimal growth and development of body,
mind and personality. The characteristic which distin-
guishes the organism — any organism let us say the stu-
dent in whom we are interested — is the wholeness of
response of every part of him to every experience. Pub-
lic school educators are seeing this, more or less gen-
erally, and primary education is refreshingly becoming

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a matter of directed living, rather than formalized in-
struction.

Too generally, however, higher education is still for-
malized and departmentalized. Scholastic subjects are
still so pigeonholed and so divorced from the personal
life of the student, it is probably not very far from the
truth to say that the average college instructor still sees
students as so many containers full or empty of mathe-
matics, chemistry, or Latin nouns. Indeed, the instructor
is commonly employed on a basis of his specific ability
to fill the mental void alike of all with mathematical
facts, chemical facts — and Latin nouns. With such spe-
cialized and circumscribed contact the instructor has
little opportunity to see the student as a total person-
ality. Few faculty advisors, even, are equipped by train-
ing or intuition to see the close relationship between
academic work and fatigue, economic security, emotional
strain, and nutrition.

One of the first persons to see the individual as a
whole was the social case worker. Consciously or un-
consciously, every successful social worker is a Gestalt
psychologist. The case work method is modifying the
technic of every effort for human betterment. The physi-
cian in his office, the personnel director in industry, the
directors of progressive education schools — all keep
more or less complete case records of their clienteles.
The nursery school, which is perhaps the most nearly
perfect example of correct educational method which we
have, keeps very detailed and continuous record of every
aspect of the child, his experience, and his environmental
surroundings.

The public school is adopting, one by one, the items
of the conventional case record, and adds to its staff
school nurses, school physicians, dental hygienists, physi-
cal education directors, recreation directors, and visiting
teachers. Very commonly, however, there is little ma-
chinery for routine integration of all these potential
data into a unified picture of each child’s personality.
It is the problem child only which rates such attention
after he has become a problem.

What is true of the public school is true to even
greater extent of colleges and universities. A few highly-
privileged schools are giving their students enriched liv-
ing in lieu of lock-step learning. All institutions of
higher learning are becoming humanized and are offer-
ing students many helps formerly unknown. Orientation
week, physical examinations, mental tests, social deans,
faculty advisors, official dormitories, student health ser-
vices— all operate in the direction of unification of the
life of the student. Probably most educators are in sym-
pathy with the principle of individualizing education. To
an even greater degree than in the common school, how-
ever, the parts of the student coming to the attention
of the indicated agencies are assembled and integrated
as a total personality picture only when and after he has
become a definite problem.

II. Need for Unification. Our primary interest, as a
group, should be to determine where a student health
service fits organically into a modern scheme of educa-

tion through directed living. In order to be concrete,
let us review the experience of the average student as he
comes to the average campus and see what the situation
suggests.

First the student brings with him certain academic
credentials certifying to the status of his capacity for
receiving into certain compartments of his mind addi-
tional standardized information on mathematics, chem-
istry, and Latin nouns: this and nothing more! Under
present conditions, standardization is probably necessary
and provides large economies of time and money, al-
though it frequently operates against the individual.
Certain institutions such as Antioch College, Reed Col-
lege, Bennington College, and a few others, require
certificates of physical fitness and extensive personality
data for admission, and in such schools unified case
records are kept. In most schools, however, the stu-
dent appears with the required transcript in his hand,
pays his fee, and the college proceeds after its own fash-
ion to make his acquaintance. His high school transcript
is filed in the college office. If the college provides a
medical examination, record of the same is filed in the
office of the examining physician who indicates that cer-
tain students are to be excused from physical education
for medical reasons. The physical education department
takes measurements and posture rating of the student
and files these away to serve somewhat in determining
his activity program. The results of the mental tests are
apt to find their way to the files of the department of
psychology. I speak feelingly of this because I know
from experience how time-consuming and difficult it is
to assemble a case record of any given student, even a
problem student, under such a system.

As far as my information goes, there are few schools
in which all this information is assembled routinely and
made serviceable to every student and used as a basis
for guidance except in cases of outstanding deviations
such as compel specific attention. The average student
more or less muddles through, succeeding — and he usu-
ally does succeed to some degree, but with tremendous
waste — because of his own initiative and ability to in-
tegrate and organize rather than because of any specific
all-round guidance from the school.

III. The Role of the Student Health Service in Uni-
fication of Education. Now what does this have to do
with the student health service? Simply this: of all the
campus agencies dealing with the life of the student, the
health service logically has the most intimate contacts
with his personal life and has the most to contribute to
the integration of the curriculum with health and per-
sonality. To be sure, copies of the many and various
findings of the health service should go straight to the
administrative office which is the ultimate unifying
agency, but let us see what the health service can do
to further this end.

To go back to our freshman with his transcript in his
hand, we would like to see a copy of his medical exam-
ination clipped to it, and both records should go to the
department of physical education (which should be part
of the health service and has no excuse for being out-

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163

side of a broadly conceived health service) as a guide
in formulating his activity program. His structural find-
ings and activity program should also be added to the
cumulative record, which may now go to a member or
the health service whom we shall designate as the mental
hygienist, personal councilor, or some other relevant
title. While this official should have psychiatric train-
ing because of the definite number of psycho-pathologies
found in any sample of population — such implications
should be kept entirely in the background, and the per-
son should function chiefly as an understanding con-
fidant who serves principally as a clearing-house of the
emotions, the repository of worries, uncertainties, doubts,
hopes and ambitions. On this first occasion we should
like to see him obtain a record of vocational leanings
and aptitudes; of financial and social status. To this
intimate personal history may be added any tests of per-
sonality traits, tastes, culture and intelligence suggested
by his judgment. He will consult the medical and physi-
cal findings, and in the end add to the growing record
such summary and evaluation as will serve further to
interpret the student to all those-and-sundry who are
supposed to serve his welfare.

Having run the gamut of evaluation, the student may
finally approach his academic advisor, who is now, with
these data before him, and not until now, in a position
intelligently to assist the student to plan his scholastic
work. We hope that the social deans also will scrutinize
each case record and assist each student personally,
according to his need, to find a congenial social group
and assist him to plan for balanced cultural and recrea-
tional life. The personal councilor certainly should co-
operate in this, particularly in immediately identifying
those students lacking in social aptitudes and needing
specific social guidance.

IV. The Role of the Student Health Service in the
Continued Direction of Living. The student having
established personal working relationship with the health
service the next immediate duty of the service is that of
supervision of conditions under which the student lives.
The institution should feel obligated to the parents and
to the student to provide living conditions of a salutary
character. This means inspection of rooming houses,
official, organized and private, as to sanitation, heat,
light and ventilation. Having made up a list of approved
rooms, the health service should next concern itself with
food. No other one thing is so vital to the young adult
as is his nutrition. All eating places, official or private,
catering to students, should be inspected and rated as to
sanitation, health of the food handlers, quality and bal-
ance of food, and an official list of approved tables
should be prepared.

The foregoing procedures take care, fairly well, of
the personal situation of the student. The institution now
has a further obligation to provide a class-room setting
which shall not injure his health. We will probably
agree that most schools might advantageously be super-
vised by the trained personnel of the health service as
to the heating, ventilation and lighting of class-rooms,

laboratories and libraries; also as to toilet facilities, rest
rooms, water, cleanliness, and comfortable seating.

All this settling and adjustment takes time. At last,
however, we will assume that our student is occupying
a good room, eating at a good table, carrying a reason-
able and individualized schedule of exercise and work,
and is sitting in airy, clean class-rooms. Does the health
service have anything further to do? Verily, a-plenty!
the medical staff now settles down to follow up the
deviates, to examine and dispose of its screenings. In any
unit of several hundred to several thousand students
there will be found those suffering from infected sinuses,
tonsils and appendices; from hyper-and hypo-thyroidism
and other glandular derangements; allergies; constipa-
tion; menstrual disorders; there will be tuberculin posi-
tives to be X-rayed and followed up; there will be
damaged hearts; there will be underweight and obesity;
there will be defects of vision and hearing; there will be
defects of locomotion; teeth will need attention; there
will be immunizations to give. The full duty of the
medical service will not be discharged until every
remediable defect has been removed.

In addition to this, the maintenance of dispensary
service for the care of injuries and minor ailments con-
sumes a prodigious amount of time, but it is one of the
most important functions of the health service both as
a preventive measure, and as providing opportunity for
individual health instruction.

The provision of up-to-date hospital care and medical
and surgical care for sick students is expensive but, in
many local situations, an indispensable item of the health
care of the student. In epidemics it is a life-saving mat-
ter. The organization and maintenance of hospital care
is difficult, complex, and the variety of difficulties and
scope of difficulties differ in each situation.

Nor are we through listing the duties of the health
service. The most far-reaching and constructive of its
manifold duties is that of health education. The student
comes in more or less competent physically and more or
less intelligent about his body. We may examine him,
direct him, protect him as long as he is under our par-
ticular care. If we do not, at the same time, communi-
cate to him an enthusiasm for health and craving for
enlightenment, we have only made of him an auto-
maton. We have only partly done our job. How to
arouse this enthusiasm and impart this enlightenment is
a perpetual challenge to any health service. Up-to-date,
vitalized, factual instruction must be supplemented by
continuous personal conference and by the stimulation
of personal interest and personal responsibility for his
own welfare on the part of every student.

Nor is this all! Having come thus far — the sorting
of the findings will draw the service, willy-nilly, into
problems of social life. The venereal diseases are appro-
priately termed "social disease” and they are found on
every campus. There is the problem of sexual promiscu-
ity with its inevitable trail of accidental pregnancies and
social disaster. There is the no-man’s land of the sex
life of the unmarried young adult which might appro-
priately be taken over by the health service for study

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and some measure of guidance. Sex is essentially and
basically a matter of physiology and psychology — a prob-
lem in psycho-biology — and only secondarily a matter of
manners and morals. The student comes to college at
the height of the mating urge. Why in Heaven’s name
should this not be frankly-recognized? Why should not
the college help to orient him in this intrusive and im-
portant aspect of life, and extend to him understanding
and such guidance as we know how to give? Granting
this should be done, is there on any campus a more
logical agency for the purpose than the health service?
The sex life of the student, no matter how disciplined
he may be (and how few are disciplined in personal
control of any sort!), ramifies through and permeates
his emotional, mental, and physical existence; nothing
is of so much importance to his future happiness as that
he shall find balance, poise, and inspiration. The general
ignoring of this fact is one of the greatest deficiencies
of our whole educational system.

The personal councilor will find himself drawn into
many other sorts of social situations in this analysis of
emotional difficulties — he will find himself co-operating
earnestly with many campus agencies in the effort to
provide normal social and recreational life.

It would seem that at last we have the "whole” stu-
dent before us, and that the health service must have
discharged every possible duty toward him. The trouble
is that by this time many questions have opened up
for which there is only a partial answer or no answer.
So, in addition to the comprehensive program here out-
lined, we will have to impose upon the health service the
perpetual obligation to investigate, experiment, and
report.

It is interesting to look through the Proceedings of
the American Student Health Association and see the
nice balance which has obtained from the beginning in
the presentation of authoritative papers upon medical
subjects: symposiums on administration and integration
of college health work and especially, with increasing
frequency, reports of investigation and research in the
many unsolved subjects of interest.

V. The Practical Aspects of the Development of a
Health Service. Having the possible scope of a student
health service freshly in mind, it is discouraging to real-
ize that the ideal, completely unified service probably
does not ye-t exist, although it would seem to be closely
approximated in the endowed progressive education col-
leges and in the Universities of Michigan and Leland
Stanford, the Teachers’ Colleges of Towson, Maryland;
Ellenberg, Washington; and doubtless in many other
universities and colleges of whose complete programs the
writer is in ignorance.

The first practical problem is how to make a start.
One gathers from reading The Proceedings that actu-
ally any interested individual may make a start. One
can build the outlines of a complete service about the
needs of any student. Take the instance which I happen
to have observed, of an obese girl discovered in a nutri-
tion class — solving her situation involved a medical
examination and diagnosis with glandular and dietetic

treatment; structural examination with supervised exer-
cise; a conference with a mental hygienist over the mat-
ter of an inferiority complex; with the social dean over
recreation; and a consultation with her academic advisor
over capitalizing really outstanding mental ability, and,
last but not least, a conference with the clothing instruc-
tor over the matter of becoming dress. The end result
is a splendid woman now occupying a position upon the
faculty of her alma mater. In this particular instance
the integrated service was not to be had except piece-
meal— the integrated result was due to the wise percep-
tion of the particular advisors.

Any interested official may make an initial start by
merely talking — talking until he has attracted a group
of persons who are sympathetic and willing to co-operate.
I do not mean to be so naive as to say that anyone at
any time may succeed in perpetuating his start. Times
must be "ripe”; moments must be "psychological.” It
never does any harm to try, however, and, unexpectedly,
the iron does become hot, the moment is propitious.

In The Proceedings of 1931 of the American Student
Health Service Association, the Committee on Correla-
tion of Physical Welfare Activities lists in its report 11
different college and university departments which are
in whole or in part interested in health and are perform-
ing fragmentary services. The committee makes the fol-
lowing suggestions as to how to make a start with
recommendations as to ultimate organization:

"... it is suggested that correlation of these widely
scattered services be obtained through the organization
... of an Advisory Health Council or Advisory Com-
mittee on Health — this council or committee being com-
posed of representatives appointed yearly from the 11
or more departments interested in health. This Council
or Committee should in no sense be an administrative
uni:, but simply an advisory and correlating unit.”

The establishment of an advisory committee having
been accomplished, this committee should proceed to
study the campus situation. The report mentioned goes
on to say:

"The activities and interests of the Student Health
Service, the department of Physical Education, the de-
partment of Intramural Sports and Recreational Activi-
ties, the department of Hygiene, the department of
Mental Hygiene, the department of Intercollegiate Ath-
letics, and the Rooming House Inspection Service are
all so closely related that it is suggested that they be
administratively unified in a Division of Health and
Recreation, the director of which will be directly re-
sponsible to the president of the institution.”

The secret of success of such a council or committee
is that the chairman shall have the vision of the whole
and that the members of the committee shall be imbued
with enthusiasm for health and enthusiasm for student
welfare. The initiative in securing the formation of such
a committee can be taken by any member of any depart-
ment (via the administrative head of the institution, of
course) .

After the committee is formed, it should spread out a
plan for an ideal health service, taking any compre-

THE JOURNAL-LANCET

165

hensive existing plan or making up one of its own, and
then it should see what component factors may be avail-
able, and especially it should study the matter of integra-
tion, and the matter of filling in the weakest and the
most salient places.

Leadership will naturally inhere in the strongest focus
of interest in health. If the strongest unit in organiza-
tion, equipment and interest and the oldest in service
is the department of physical education, it may happen
that the first medical examination may be in the nature
of a hasty examination of hearts preliminary to enroll-
ment in gymnasium work and competitive athletic
events. Mere human interest in the screenings should
lead to ultimate extension of the medical examination
service, and I have seen it so happen. An intelligent
structural examination leads to a strong realization of
the need of medical service.

If the school of home economics is doing vitalized
teaching, the resultant interest in the nutrition of indi-
vidual students will show states of nutrition which are so
linked up with physical conditions of medical implica-
tion, with curriculum load, with emotional stress, that
the full Health Service program could be demanded
and, given leadership, might come trailing in the wake
of a course in nutrition and the chemistry of food. Case
study of any one class or any one group may set the
pattern and act as leaven which sooner or later will give
character to the organization pattern of the institution.

VI. The Difficulties. One of the first difficulties and
one which usually forever limits, hampers and restricts
the realization of the ideal is the cost. There is just one
universal rule of successful procedure in the develop-
ment of anything new and that is go just as far as
possible without definite funds. Exhaust volunteer effort,
and manage somehow to make initial demonstrations as
to the exigencies of the situation and the technic of pro-
cedure. It is altogether right that public money should
be expended only upon well-defined and non-experimental
bases. Subsidies, even, can appropriately be used for
investigation and demonstration only after the local in-
terest has crystallized to the extent of clearly defining
the situation and with the definite certainty of co-
operation and support. In our own University of Kansas
we have a brilliant example of this sequence in the evo-
lution of the medical service. I have personally seen it
grow from the hasty routine heart examination men-
tioned and a six-bed fire-trap of a cottage hospital ser-
viced by a part-time local physician; pass through two
terrifying flu epidemics, to arrive eventually at so com-
plete a demonstration of need and so convincing a plan,
that one of the finest hospitals in the country, built by
voluntary subsidy, stands upon our campus.

Having assembled such parts or fragments of health
service as may be contributed by the departments repre-
sented in the advisory health council, and having deter-
mined whether this service, partial as it must be at first,
will be extended to all, or to selected students only,
means for financially supplementing volunteer service
will have to be considered. If, as is usually the case, it
is medical service which is lacking, means must be found

for raising a small fund, by donation, subscription or
subsidy, to command some part of the time of a local
physician. Probably the great majority of student health
services start with a part-time medical service. After the
value of such a service has been demonstrated to the
student, he will usually be willing and in the end may
be required personally to pay for part or all of value
received.

Intelligence tests can commonly be commandeered
from the departments of psychology and education. The
personal councilor must have his advance agent in the
wisely selected faculty advisor. The physical education
department is usually fairly well equipped and the mem-
bers of the staff are usually co-operative in contributing
their share of physical evaluation, but are not always
willing to sacrifice enough of their historically en-
trenched independence to become incorporated in an in-
tegrated program. (Also, athletics may dominate the
other aspects of physical education and the "education”
factor may trail far behind the "glory of Alma Mater.”)

One of the real essentials which it is difficult to
secure from volunteer sources is competent and suffi-
cient clerical service for making the tabulations and
unified records which furnish the very framework of
support and the machinery for the functioning of the
entire project. Now and then the various records, if
carefully planned and carefully kept, may be used as
thesis or project material by students in statistics or
educational research. It is worthwhile to consult instruc-
tors in such courses and see what arrangements may be
made in this direction. The possible utilization of the
time of scholarship students will occur to all. It occa-
sionally happens that the head of one of the "15 depart-
ments” will find it possible to contribute part of the
time of a departmental secretary.

One of the first essentials of even a fragmentary
health service is the nurse. Dispensary service frequently
starts with one trained nurse, who refers individual
cases, as indicated, to local physicians for personally paid
service. Money must be raised any way possible for the
initial demonstration, after which the nurse becomes as
much a matter-of-course staff member as the teacher of
English or French.

All of this, of course, is greatly facilitated when the
head of the institution has a vision of the whole and,
especially, if he has back of him an enlightened gov-
erning board. The real challenge to individual initiative
and resourcefulness comes when the executive head and
executive board must be "sold to the idea.” Very care-
ful, clear and definite units of demonstration, with clear
outlines of purpose and plan will then be necessary —
and a course in the psychology of salesmanship will help
much!

As to personnel — again the necessary procedure is
from the volunteer to the paid. Since the character of
the personnel determines explicitly the character and
success of the work, the selection, especially of persons
in key positions, is critically important. It is essential
that the head or even the temporary leader shall have a
broad perspective of the whole field, that he shall be a

166

THE JOURNAL-LANCET

person as free as is humanly possible from prejudices
and peculiarities. Technical and scientific preparation of
a high order are, of course, fundamental. Preparation,
however, must never overshadow personality. It is often
much easier to command the preparation than the de-
sirable personality, as will be apparent if one thinks of
the members of any medical graduating class.

As to whether the head should preferably be the
psychiatric councilor, the college physician who is usu-
ally also the medical examiner, the head of physical
education, or the personal hygiene teacher — unhesitat-
ingly I say it should be the one having the broadest
perspective and the most thoroughgoing scientific prepa-
ration plus quality of leadership. Actually all four of
these officials frequently have, perhaps all should have,
medical degrees. A determining factor may be the par-
ticular physical location of the service. If the offices and
equipment are located in the students’ hospital, the
medical head of the hospital is the logical director of
the service. In this case, the advisory council may have
to watch that interest in diagnosis and treatment of dis-
eases does not overshadow health education and con-
servation of personality.

If the head of physical education is medically trained,
he may have by far the best perspective, and it not in-
frequently happens that the entire health service, with
the exception of care of actual illness, may in the be-
ginning be housed in the gymnasium. In some very good
health services, the office of the college physician and
the dispensary will be found here.

A medically-trained psychiatrist should be the best
prepared of all properly to evaluate all the factors de-
termining the success or lack of success of each and
every student.

On the other hand, the health education specialist
may have not only perspective, but have the most effec-
tive personal contact, and should have an aggressively
constructive point of view and have peculiar interest in
"positive health.”

CASE REPORT

A CASE OF UNRESOLVED STREPTOCOCCIC
PNEUMONIA

This patient, 21 years old, male, six feet one inch tall,
normal weight 170 pounds, was operated on for acute appendi-
citis under local anesthesia, in another city. During his con-
valescence he developed a pneumonia of the right lung. Resolu-
tion did not take place. Exploratory punctures were made but
no pus was found. His condition did not improve. The opera-
tion was performed early in April, 1935, and in May he was
brought to his home in this city and placed under the care of
a physician, who had him under observation during the sum-
mer, and in August turned the case over to me as one of
tuberculosis.

I found the patient in bed, propped up with pillows. He
was extremely emaciated, and unable to sit erect without sup-
port. The entire right lung was absolutely dull to percussion
and only a few breath sounds could be heard.

The left lung was clear and the pulse of fair strength. He
had a frequent cough, only slightly productive. Appetite poor.

So there you are! At least all should co-operate as
one person, and the advisory council should be the tail
which balances and stabilizes the kite. After all, con-
tinuous forward movement is rare. Spurts of enthusiasm
on the part of newly-established committees is apt to
be followed by periods of lethargy and inactivity when
the energy of the leaders is drawn into compelling per-
sonal channels, or when the real leader may drop out,
or when things seem to be going very well and the
council takes a well-earned sleep!

This situation may easily lead to disaster. It must not
be forgotten for one moment that the thing we are con-
sidering ramifies into the entire life of the entire cam-
pus. It should be as vital, as perpetual, as evident as is
the beating of the heart or the breathing of the lungs,
and ever and always it must be kept balanced. If the
quality of health education slumps, or the personal
councilor sees a grand opportunity to collect psycho-
analytic data for a report, a screw drops out of the
machine, and engine trouble starts. Ever the objective
must be a unity — a "whole.”

Summary

The thing of primary importance is the seeing that
health is a quality of the whole personality. Every part
of every organism responds to every experience. Each
individual fits into his environment as an organic part
of an organized universe. Life should be a search for
unity.

Education is becoming directed living rather than
formalized instruction. The student health service must
promote this scheme of integrated living by taking care
of student environment and by evaluating the student
physically, mentally and emotionally and by realizing a
unified picture of him which may serve as a guide in
directing his academic program. It should carry on re-
search. It should assume ever-increasing importance in
the field of higher education in applying scientific
knowledge to personal, practical living.

He was held under observation for two or three days, during
which time he ran a typically hectic fever. Subnormal in the
morning, his temperature would rise in the late afternoon to
102.5 to 103.5 F., followed by a drenching sweat. After this
period of observation, he was taken to the hospital for further
examination. X-ray confirmed the physical findings. The right
lung was seen to be completely solid. His weight was now 97
pounds. His sputum showed a pure culture of streptococci.
Following these tests he was returned home.

In view of the failure of preceding therapeutic efforts, I de-
cided to use a streptococcus vaccine, prepared for intravenous
administration. The results were dramatic. A short time after
the first injection he had what, from his description, was a
rather severe reaction consisting chiefly of a chill and a
"loosening of the cough.” The following day his temperature
was less and his sweat was moderate. The third or fourth day
the afternoon temperature was normal. Five or six injections
were given at intervals varying from three days at first to a
week for the last two. His appetite returned and in a month
his lung was cleaned up. In October he was about the streets
and his weight was up to 160.

Inasmuch as this case was treated at home, and in rather a
poor home, accurate daily reports were not kept. The interval

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167

FIRST: From viewpoint of diagnosis the affected lung was
more solid than would be ordinarily the case in the tuberculosis
of sufficient severity to have produced the hectic fever, emacia-
tion, and the accompanying conditions.

SECOND: The use of streptococcic vaccine was logical and
in this instance startlingly successful.

C. C. Wallin, M.D.,

above. Lewistown, Mont.

LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS

ON FEBRUARY 6, 1937
(JANUARY EXAMINATION)

Name School Address

Aanes, Aimer Russell __ U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Adams, Richard Charles Queens U., M. D., 1931 Mayo Clinic, Rochester, Minn.

Allen, Herbert Benjamin U. of Minn., M. B., 1936 Northwestern Hospital, Minneapolis, Minn.

Anderson, Wallace Everett U. of Minn., M. B., 1933, M. D., 1934 Midway Hospital, St. Paul, Minn.

Autry, Daniel Hill U. of Ark., M. D., 1934 Mayo Clinic, Rochester, Minn.

Benson, Kenelm Winslow U. of Pa., M. D., 1934 Mayo Clinic, Rochester, Minn.

Benton, Paul C U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Berman, Lawrence U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Brown, Milton G. U. of Minn., M. B., 1926, M. D., 1927 1789 Munster St.. St. Paul, Minn.

Brussell, Albert Sinai U. of Minn., M. B., 1933, M. D., 1936 Co. 1774, V. C. C., Rochester, Minn.

Bushard, Wilfred Joseph U of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Butler, Raleigh Virgil U of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Chermak, Francis Gordon U of Minn., M. B., 1936 St. Mary’s Hospital, Minneapolis, Minn.

Cowan, George Morterud U of Minn., M. B., 1936 St. Mary’s Hospital, Duluth, Minn.

Davies, Benjamin Paul U. of Kansas, M. D., 1 93 1 University Hospital, Minneapolis, Minn.

Dearing, William H., Jr U. of Pa., M. D., 1934 Mayo Clinic, Rochester, Minn.

Deters, Donald Cummings U of Minn., M. B., 1936 Broadlawns Gen. Hospital, Des Moines, la

Enroth, Oscar Ernest U of Minn., M. B., 1936 Bethesda Hospital, St. Paul, Minn.

Ershler, Irving Geo. Wash. U., M. D., 1931 Mpls. Gen. Hospital, Minneapolis, Minn.

Frank, Leonard Charles U of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Friedell, George . U. of Minn., M. B., 1936 Ancker Hospital, St. Paul, Minn.

Gorenflo, Leila Ann Rush Med. Col., M. D., 1935 Cass Lake. Minn.

Gregg, Robert Ober Syracuse U., M. D., 1934 Mayo Clinic, Rochester, Minn.

Hall, Harry Benjamin U. of Minn., M. B., 1935, M. D., 1936 University Hospital, Minneapolis, Minn.

Hammerstad, Lynn M U. of Minn., M. B., 1935 Heron Lake, Minn.

Hendrick, John Alexander, Jr. Tulane U., M. D., 1935 Mayo Clinic, Rochester, Minn.

Hertz, Charles Schaeffer .U. of Pa., M. D., 1934 Mayo Clinic, Rochester, Minn.

Jensen, Russell Maben Northwestern U., M. B., 1935, M. D , 1936 Mayo Clinic, Rochester, Minn.

Kern, Maximilian Christian Creighton U., M. D., 1936 Gillette State Hospital, St. Paul, Minn.

Kooiker, Clarence U. of Minn., M. B., 1936 . Swedish Hospital, Minneapolis, Minn.

Lloyd, Samuel Joseph Johns Hopkins, M. D., 1934 Mayo Clinic, Rochester, Minn.

Lovelace, William Randolph Harvard U., M. D., 1934 Mayo Clinic, Rochester, Minn.

Matthews, Morgan Whitsitt Tulane U., M. D., 1927 Mayo Clinic, Rochester, Minn.

Mecray, Paul Mulford, Jr U. of Pa., M. D., 1934 Mayo Clinic, Rochester, Minn.

Moore, Ferrall Harmon U. of Neb., M. D., 1932 Mayo Clinic, Rochester, Minn.

Mundell, Benjamin James Georgetown U., M. D., 1934 Mayo Clinic, Rochester, Minn.

Noran, Harold H U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Ransom, H. Robert U. of Minn., M. B., 1936 University Hospital, Minneapolis, Minn.

Rasmussen, Theodore Brown U. of Minn., M. B., 1934, M. D., 1935 Mayo Clinic, Rochester, Minn.

Reed, Paul U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Regan, James Francis U. of Chicago, M. D., 1934 Mayo Clinic, Rochester, Minn.

Richardson, Frank Lloyd U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn

Sawyer, Malcolm Herbert Northwestern U., M. B., 1935, M. D., 1936 Mayo Clinic, Rochester, Minn.

Seitz, Sherwood Bretz Northwestern U., M. B., 1935, M. D., 1936 Fairview Hospital, Minneapolis, Minn.

Seljeskog, Sigsbee R. U. of Minn., M. B., 1936. M. D., 1936 5237 42nd Ave. S.. Minneapolis, Minn.

Shandorf, James Frederick U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Smith, Frederick Abbott U. of Minn., M. B., 1936 St. Barnabas Hospital, Minneapolis, Minn.

Snyder, John Mendenhall U. of Pa., M. D., 1934 Mayo Clinic, Rochester, Minn.

Spittler, Russell O. U. of Minn., M. B., 1932, M. D., 1933 5013 Bryant Ave. S., Minneapolis, Minn.

Stanford, Charles Edward U. of Wisconsin, M. D., 1934 515 Delaware St. S. E., Minneapolis, Minn.

Swingle, Hugh Franklin, Jr Duke U., M. D., 1935 Mayo Clinic, Rochester. Minn.

Thysell, Desmond Milton U. of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Varco, Richard Lynn I J of Minn., M. B., 1936 Mpls. Gen. Hospital, Minneapolis, Minn.

Wood, George Howard ___ U. of Cincinnati,, M. B., 1934, M. D., 1935 State Hospital. Rochester. Minn.

Wrork, Donald Holly Northwestern U., M. B., 1934, M. D , 1935 Mayo Clinic, Rochester, Minn.

BY RECIPROCITY

Miller, Joseph Matthew Columbia U., M. D., 1935 Mayo Clinic, Rochester, Minn.

Plowman, Elven Theodore U. of Iowa, M. D., 1930 . — - Marble, Minn.

NATIONAL BOARD CREDENTIALS

Smith, Stanley Joseph Northwestern U., M. D., 1931 Eveleth, Minn.

between injections of the vaccine were determined by the con-
dition of the patient as it presented, rather than by fixed
schedule. Other treatment consisted only of rest, fresh air, and
proper nourishment.

Conclusions

There are two obvious conclusions to be drawn from the

JOURNAL

Represents the
MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

The Official Journal of the

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American Student Health Association
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EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

BOARD OF EDITORS

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Dr. J. A. Evert
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Dr. W. E. Forsythe
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Dr. S. M. Hohf
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Dr. A. S. Rider
Dr. T. F. Riggs
Dr. E. J. Simons
Dr. J. H. Simons
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Dr. C. A. Stewart

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Secretary

LANCET PUBLISHING CO., Publishers

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84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., April, 1937

Early Diagnosis and the Eradication of Tuberculosis

For some years this country has witnessed an increas-
ingly successful campaign aimed at the eradication of
tuberculosis in cattle. "Eradication” is the word, and the
United States Department of Agriculture has not hesi-
tated to use it. The physician, dealing with tuberculosis
in man, has been more cautious, speaking of control
rather than eradication, just as he avoids the use of
"cure” and uses "arrest.”

The phenomenal success of the cattle anti-tuberculosis
campaign should be an object-lesson to physicians. It is
based upon two principles, viz., that tuberculosis is a
contagious disease and that removal of infected cattle
will stop the disease at its source.

It is now apparent that eradication of tuberculosis in
man, in communities that will make a comparable effort,
is by no means an unreasonable goal. Methods quite
analogous to that used in cattle are available for man,
and available in a state of great refinement. Early dis-
covery, early treatment, early education to prevent in-

fection of contacts, will accomplish everything achieved
by early discovery and slaughter in cattle. Reach the
people and find the cases and spread of the disease can
be prevented. The crux is early diagnosis.

During the month of April the tuberculosis associa-
tions all over our country are emphasizing the serious-
ness of that age-old disease that still carries off the
flower of our nation. They are urging people to see their
family physicians for thorough examination, including
chest X-rays, if they seem to be indicated. Radio broad-
casting, public addresses, motion pictures, window dis-
plays and posters are all being offered the public. If
one form of attack does not succeed, they hope another
will. This year’s Early Diagnosis Campaign offers an-
other chance for the fine co-operation of Tuberculosis
Societies and physicians all over our country.

Esmond R. Long, M.D.,

President,

National Tuberculosis Association.

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169

AN IMPRESSIVE TEACHER

Those who attended Harvard at the turn of the
century will never forget Fred Shattuck. When he
popped into the arena of the Massachusetts General
Hospital to give a clinical lecture, the air was fairly elec-
trified by his dynamic personality. The coat tails of his
cutaway, that often found such difficulty in keeping up
with him during ward rounds, subsided as his theatrical
entrance came to a momentary standstill before the pa-
tient who had been wheeled in for demonstration. If his
catapult arrival a la May Robson in the first scene of
"The Rejuvenation of Aunt Mary,” did not impress
the assembled multitude, there still was the inescapable
matter of a very red vest to dazzle the eye.

From the colorful setting the amphitheater resounded
with the opening sentence designed to insure attention
by its sudden and dramatic explosion: "Gentlemen, this
man escaped the surgeon’s knife like the bird the snare
of the fowler.” He went on to relate how the patient
had been admitted to the surgical section because of pain
in the upper right abdominal quadrant and was about to
have a gall bladder operation, when a herpes labialis
appeared. The students were further informed concern-
ing the pulse, a slight elevation of temperature, and some
stiffness of the muscles about the neck.

After sallies back and forth, he enthusiastically ap-
pealed for a recognition of what he would have them see
in this picture. With out-stretched hands he pirouetted
about, pleading for someone to venture a diagnosis; and
a pointing finger finally came to a standstill in the face
of a post-graduate student, vulnerably exposed on a front
seat: "You, Sir!”

The astonished P. G. resolved to try his luck with the
roulette ball that had so unexpectedly fallen in his lap
and modestly suggested that it might be cerebrospinal
meningitis.

"What kind? What kind? Simple or tuberculous?"

Falteringly the P. G. offered the opinion that it was
simple.

"Why? Why? Why? I agree with you; I agree with
you; but give a reason for the faith that is within you.”
Stumped to be sure (for the particular answer wanted) ;
but not to this day have we forgotten the lesson he
would teach: that herpes labialis is indicative of an acute
rather than a chronic disease.

A. E. H.

THE COLD COMPRESS

The cold compress is a valuable but much neglected
remedy. Priessnitz was a farmer and Kneipp was a
Catholic priest. Neither of them had a medical educa-
tion in the ordinary meaning of the term; but they be-
came lesser apostles, so to speak, of modern hydro-
therapy. It was Professor Winternitz of Vienna who
worked out the reason for their getting results and
placed the whole matter on a scientific basis. The time
of exposure, relative temperature of the recipient’s body

surface to the water, and the force of the accompanying
mechanical stimulus were found to be the three most im-
portant factors. Kneipp’s barefoot walking through the
dew laden morning grass had been ridiculed, but Winter-
nitz found that it had an effect so remote as to influence
the very capillaries of the brain.

The Priessmtze umschlage have been applied to all
parts of the body for a variety of conditions such as local
fever, pain, insomnia, and to affect metabolic changes
by circulatory stimulation or stasis. Because of the oft
shown negligence by nurses for the time element, it may
be well to instruct them about the difference in results
obtained from active and passive reactions. In cases of
acute laryngitis they should first apply around the neck
a properly folded linen napkin, that has been wrung out
of cold water; next to this, a dry napkin; and lastly,
something of woolen kind, all snugly pinned. The ac-
tive reaction takes place in fifty minutes at which time
the compress will be found hot, and the procedure must
now be repeated unless the passive results be desired.

A. E. H.

JOHN E. ENGSTAD

1858 - 1937

Another veteran has fallen and left an empty space
in the rapidly thinning ranks of the pioneer physicians
of North Dakota. Dr. J. E. Engstad of Grand Forks
North Dakota, was born in Christiania (Oslo) Norway
May 4th, 1858; and while yet a mere child came with
his parents to America and settled at Holman, Wiscon-
sin. He passed away at Grand Forks, North Dakota,
February 19th, 1937, in the hospital he founded forty-
six years ago. He received his medical degree from
Rush Medical College, Chicago, in 1885. Being a
pioneer in fact as in spirit, he heard and answered the
call of the West and came to the then territory of
Dakota, where in his early years of practice he did much
hard pioneer work on its prairies.

Dr. Engstad was never too old to be a student. That
he might give his patients the best of which he was cap-
able, he made regular visits to the leading clinics at
home and abroad, thus perfecting himself in the pro-
fession he loved so well. In this way he became widely-
known and was recognized as an authority on many
branches of medical lore. He was a charter member of
the North Dakota Medical Association, and in 1888
was elected its secretary. He was also a member of the
local and national medical societies and for eight years
operated St. Luke’s Hospital, the first of its kind in the
state. He brought to Grand Forks the first X-ray
machine and the first blood pressue instrument to be
used in the state, both of which are now in the State
Historical Museum at Bismarck.

Dr. Engstad was a ready and versatile writer on med-
ical and surgical subjects, his articles appearing in the
leading professional journals of the country, and was a
member of the American Medical Editors and Authors
Association. He was also a frequent contributor to the

170

THE JOURNAL-LANCET

lay press on a variety of subjects of more or less general
interest. He was of a mechanical bent of mind and
being ambidextrous, developed a surgical technic that
was outstanding. In this connection, he devised means
and methods that have become the common property of
the profession. His keen, intuitive mind could sense the
fitness of things and shed light on obscure or intricate
conditions. To this in large measure was due his re-
sourcefulness and skill as a surgeon. In an age marked
by individualism, it was inevitable that steel would meet
steel, but these trivial clashes, important as they seemed
at the time, when viewed in the mellowing perspective
of half-a-hundred years, appear as mere love-pats that
brought to the fore the best of brain energy and service.

Dr. Engstad was a lover of the beautiful in nature
and in art. He traveled far, and in his trip around the
world made a collection of rare and beautiful paintings
and objects of art that were sources of pleasure and
satisfaction not only to himself and family, but to the
community as well; for he delighted in sharing with
others the treasured fruit of his gathering.

Dr. Engstad was the most genial of companions,
warm and sympathetic in his friendships, devoted to his
home and family, kind and considerate to his patients
and true to the faith of his fathers. As we pay this
parting tribute, the freed pioneering spirit with the for-
ward look, signals back:

"Say not good-night, but in some brighter clime
Bid me good-morning.”

J. Grassick, M. D.

Grand Forks, N. D.

SOCIETIES

MINNESOTA STATE MEDICAL
ASSOCIATION

Annual Meeting, St. Paul, May 3, 4, and 5, 1937

A large public health meeting will be one of the
features of the 84th Annual Meeting of the Minnesota
State Medical Association to be held at the St. Paul
Auditorium, May 3, 4 and 5.

The meeting is scheduled for Tuesday evening in the
Auditorium Theater.

Rev. Alphonse M. Schwitalla, S. J., St. Louis, Mis-
souri, president of the Catholic Hospital Association
and dean of the St. Louis University Medical School
will appear on the program; also Dr. Nathan B. Van
Etten, New York City, speaker of the House of Dele-
gates of the American Medical Association; Dr. R. A.
Vonderlehr, Washington, D. C., assistant surgeon gen-
eral, United States Public Health Service, and Dr.
Morris Fishbein, Chicago, editor of The Journal of the
American Medical Association.

Dr. Van Etten will speak on "The Medical Citizen.”
He will also speak before a general session of the As-
sociation Tuesday afternoon in connection with a sym-
posium on medical economics. At that time his subject
will be "Medical Care for All Americans,” and Dr.
Maxwell J. Lick, Erie, Pennsylvania, president of the

Dr. Maxwell J. Lick Rev. Alphonse M. Schwitalla, S. J.

Erie, Pa. St. Louis, Mo.

Medical Society of the State of Pennsylvania, will speak
on "The Doctor Looks at Social Security.”

"Quacks of the Last Year” will be Dr. Fishbein’s sub-
ject at the public health meeting. Both Dr. Fishbein
and Rev. Schwitalla will take an active part in the
Congress of Allied Professions to be held throughout
Monday in connection with the annual meeting.

Dr. Lick will also be one of the speakers for the
Northwest Industrial Medical Conference to occupy
the third day of the meeting. Talks on subjects es-
pecially pertaining to medicine in industry will form the
third day of the scientific program. Medical and sur-
gical sections, which will hold separate sessions during
the first two days of the meeting will unite for this pro-
gram. The Conference has also been designated as the
annual meeting of the Great Northern Railroad Sur-
geons because of the important topics to be discussed.

Clinics Monday and Tuesday mornings will begin
the program on those days. There will be several ques-
tion panels on various subjects also included on the pro-
gram. An hour’s time each morning and afternoon will
be devoted to inspection of exhibits and scientific demon-
strations.

OFFICIAL CALL

SOUTH DAKOTA STATE MEDICAL
ASSOCIATION

To the officers and members of the South Dakota
State Medical Association:

The Fifty-sixth Annual Session of the South Dakota
State Medical Association will be held in Rapid City,
S. D. from Monday, May 24, to Wednesday, 26, 1937.

Headquarters Alex Johnson Hotel.

The Council will convene on Monday, May 24 at
4:00 P. M. Alex Johnson Hotel.

The House of Delegates will convene on Monday,
May 24, at 7:00 P. M. Alex Johnson Hotel.

The Scientific program will open on Tuesday, May
25, at Alex Johnson Hotel.

Annual Banquet May 25, 7:00 P. M., Alex Johnson
Hotel.

Second meeting of House of Delegates May 25, fol-
lowing banquet, at 10:00 P. M.

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171

Wednesday, May 26, Program — Drive through the
interesting portion of the Hills. Luncheon at Noon
with a program at Sanator.

Wednesday, May 26, Second meeting of Council.
6:30 A. M. Breakfast. Alex Johnson Hotel.

J. L. Stewart, M. D., President
Nemo, S. D.

H. R. Kenaston, M. D., Chairman Council
Bonesteel, S. D.

Attest:

J. F. D. Cook, M. D., Sec’y-Treas.

Langford, S. D., April first, 1937.

TENTATIVE PROGRAM
THE SOUTH DAKOTA STATE MEDICAL
ASSOCIATION
Rapid City, May 24, 25, 26, 1937
Headquarters — Alex Johnson Hotel

MONDAY, MAY 24—

4:00 P. M. First meeting of Council.

■7:00 P. M. First meeting House of Delegates.

TUESDAY, MAY 25, Scientific program.

8:00 A. M. Medical Clinic — "Biliary tract diseases.”
Albert Markley Snell, M. D., Rochester,

9:00 A. M.

10:00 A.M.
10:15 A.M.

11:15 A. M.

Minn.

Orthopedic Clinic — "Fractures of Neck
Femur,” Myron Ornell Henry, M. D.,
Minneapolis, Minn.

15 minutes intermission — Visit exhibits.
Surgical Clinic — "Cancer of the Colon,
Sigmoid and Rectum,” Claude Frank
Dixon, M. D., Rochester, Minn.

Pediatric Clinic — "Nutritional Problems
in Childhood.” George Edward Robertson,
M. D., Omaha, Neb.

NOON

1:30 P. M.

2:20 P. M.
3:10 P.M.

4:00 P. M.
4:15 P.M.

5:05 P.M.

Paper — "Roentgenologic Diagnosis of
Gastro-intestinal Disease.” Harry Mathew
Weber, M. D., Rochester, Minn.

Paper — "Acute Abdomen,” Claude Frank
Dixon, M. D., Rochester, Minn.

Paper — "Some Diagnostic and Therapeu-
tic Problems Presented by the Jaundiced
Patient,” Albert Markley Snell, M. D.,
Rochester, Minn.

15 minutes intermission — Visit Exhibits.
Paper — "Feeding Problems in Infancy,”
George Edward Robertson, M. D.,
Omaha, Neb.

Paper — "Use of Bone Chips in Surgery,”
Myron Ornell Henry, M. D.,
Minneapolis, Minn.

* * * *

7:00 P. M. Abbual Banquet. Alex Johnson Hotel.
10:00 P. M. SECOND meeting of House of Dele-
gates. (Following Banquet)

WEDNESDAY, MAY 2<>-

6:30 A.M. Second meeting of Council.

Breakfast — Alex Johnson Hotel.

8:00 A. M. Trip through the most scenic parts of the
Black Hills. Ladies to participate.

12:00 NOON. Luncheon.

1:30 P. M. "The Institutional Care of Tuberculosis
in South Dakota,” Floyd S. Coslett,
M. D., Superintendent State Sanatorium,
Sanator, S. D.

2:00 P. M. Paper — "Surgery of Pulmonary Tuber-
culosis,” Thomas James Kinsella, M. D.,
Minneapolis, Minn.

3:00 P. M. Clinic — "Roentgenologic Manifestations
of Tuberculosis of the Gastro-intestinal
Tract.” Harry Mathew Weber, M. D.,
Rochester, Minn.

=S= =)= * *

PROGRAM COMMITTEE
R. E. Jernstrom, M. D., Rapid City, S. D.

D. L. Kegaries, M. D., Rapid City, S. D.

J. L. Stewart, M. D., Nemo, S. D.

J. F. D. Cook, M. D., Secretary, Langford, S. D.
LOCAL COMMITTEES

Room Reservations and Registration —

E. W. Minty, M. D., Rapid City
Exhibits — D. L. Kegaries, M. D. and F. W. Stevenson,
M. D., Rapid City

Scenic Trip— R. J. Jackson, M. D., Rapid City
Banquet — N. T. Owen, M. D. and R. E. Jernstrom,
M. D., Rapid City
Clinicians:

Dr. Snell — D. L. Kegaries and E. W. Minty
Dr. Henry — W. E. Morse and N. T. Owen
Dr. Robertson — J. D. Bailey and F. J. Radusch
Dr. Dixon — W. A. Dawley and F. W. Minty
MAKE YOUR HOTEL RESERVATIONS EARLY
THROUGH THE LOCAL COMMITTEE.

J. F. D. Cook, M. D., Secretary
Langford, S. D., April 1, 1937

TENTATIVE PROGRAM
SOUTH DAKOTA ACADEMY OF
OPHTHALMOLOGY AND
OTOLARYNGOLOGY
RAPID CITY, SOUTH DAKOTA,

MAY 25th, 1937.

Headquarters Alex Johnson Hotel
Meeting Place — Auditorium — Dakota Power Co.

OFFICERS

A. Einar Johnson, M. D., President Watertown, S. D.

T. C. Nilsson, M. D., Vice-President Sioux Falls, S. D.

H. L. Saylor, M. D., Secretary Huron, S. D.

SCIENTIFIC PROGRAM

9:00 A. M. "Diagnosis and Surgical Treatment of Strabis-
mus.” Avery D. Pragen, M. D., Rochester,
Minn.

10:00 A. M. "Moot Questions in Cataract Surgery.”

J. J. Hompes, M. D., Lincoln, Neb.

11:00 A. M. "Significance of Chronic Hoarseness.”

Harry B. Stokes, M. D., Omaha, Neb.

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THE JOURNAL-LANCET

WOMEN’S AUXILIARY
to the

SOUTH DAKOTA STATE MEDICAL
ASSOCIATION
1910—1937

The Women’s Auxiliary will meet at Rapid City,
South Dakota, May 24-25-26, 1937 at the time of the
State Medical Association meeting. Greetings to the
members and friends of the South Dakota State Medi-
cal Auxiliary.

It is indeed a pleasure to welcome you to the twenty-
seventh annual meeting and particularly so because we
shall meet again in our beloved Black Hills, where the
Medical Auxiliary had its beginning.

Let us make this an occasion for rejoicing, not only
because of our past achievements but because of the
opportunity it presents for planning bigger and better
things in the future.

Sincerely,

Florence B. Nessa, President
Sioux Falls, S. D.

TENTATIVE PROGRAM
for the

NORTH DAKOTA STATE MEDICAL
ASSOCIATION
ANNUAL MEETING
To Be Held in

Grand Forks, May 16, 17, 18.

The 50th annual meeting of the North Dakota State
Medical Association will be held at Grand Forks in the
new auditorium of Central High School on May 16, 17,
and 18, 1937. Commercial and scientific exhibits will
be held on the lower floor, and those who desire booth
space at this meeting should communicate with Doctor
R. E. Leigh, 101 North 3rd Street in Grand Forks, who
is chairman of exhibits.

Speakers on the program will include: Doctor Donald
C. Balfour, Rochester, Minn.; Doctor Robert Daniel
Mussey, of Rochester, Minn.; Doctor George Albert
Williamson, of St. Paul, Minn.; Doctor E. L. Tuohy, of
Duluth, Minn.; and Doctor John Silas Lundy, of
Rochester, Minn.

Members of the North Dakota State Medical As-
sociation who are on the program comprise these phy-
sicians: Doctor H. Milton Berg, of Bismarck; Doctor
Kent Darrow, of Fargo; Doctor Willard Arthur
Wright, of Williston; Doctor Reuben Herman Wald-
schmidt, of Bismarck; Doctor William H. Long, of
Fargo; Doctor Reinhold O. Goehl, of Grand Forks;
Doctor William Crane Nichols, of Fargo; Doctor Glenn
William Toomey, of Devil’s Lake; and Doctor A. D.
McCannel, of Minot.

The House of Delegates will meet at 2:00 P. M. on
May 16. The scientific program will commence at 9:00
A. M. on May 17. The annual banquet will be at
6:30 P. M. on May 17. Other entertainment has been
scheduled.

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB

Thursday, December 10, 1936
Dr. Donald McCarthy, President
* * *

CASE HISTORY AND DIAGNOSIS
ADENOCARCINOMA OF THE PARATHYROID
GLAND WITH HYPERPARATHYROIDISM
Dr. Norman Johnson

On August 6, 1935, Mr. Geo. C. presented at my office at
the instigation of a benefit organization to determine whether
he was both totally and permanently disabled. He was then 48
years of age, a railroad engineer, who had been unable to work
since June, 1933. He complained as follows:

For two years there had been a gradual and progressive
muscular weakness which began with pain in his feet on walk-
ing and with weakness in his back. At the present time he
required a cane to steady himself when he walked and reported
that in the dark he could not get about. He also recited that
in the last few years his eyesight had begun to fail and his
hearing to become less acute. He can read with glasses but he
cannot see across the street. The eye movements are sometimes
difficult and painful and he complains of aching of the eyes
and of transient attacks of dizziness. He reports tenderness in
all of his joints and along the bones and a loss of weight from
a normal at 195 pounds to his present weight of 142. He is
also troubled with nocturia three or four times, and on some
nights, every hour, and with some frequency during the day.
His strength has so diminished that he can no longer carry a
market basket from the store. He ceased ordinary work in
June, 1933, because he was no longer able to pull himself into
the cab. After a> few drinks on New Year’s Eve in 1934 he
admits that he was absolutely "down and out” and the con-
dition has gradually been getting worse since.

In his past history are two important periods of hospitaliza-
tion. In 1925 he was a robust individual carrying about 200
pounds, well distributed over a five feet 1 1 inches height.
Shortly after, he began having attacks of severe colicky pain,
several hours in duration, usually in the left flank or left abdo-
men. These attacks were not frequent but were definitely dis-
abling. During one of these attacks in early December, 1931,
following an investigation by cystoscope and X-ray, he did
pass a kidney stone about the size of a pea. Because of a
finding of RBC and WBC, hyalin and granular casts, and of
X-ray evidence indicating stones in the kidney, he was hospi-
talized and operated on December 8, 1931. Though most of
his pain had been on the left side, the right kidney was re-
moved. He was discharged December 23, 1931. The hospital
chart for this period shows the following significant findings:

URINE:

Eleven urinalyses recorded.

Specific gravity 1007 to 1014 in all.

Albumin — Present in several, none in last three.

Sugar — None.

Microscopic — Occasional hyalin casts and granular casts. No
RBC after December 11. Intermittent finding of WBC. One
week p.o. there were 30-40 pus cells. Two weeks p.o. 1-2 WBC.
BLOOD AND BLOOD CHEMISTRY:

Hemoglobin — 97 per cent.

WBC— 12,900.

Creatinin — 2.34 mgs. 2nd day p.o.; 1.92 mgs. 3rd day p.o.

Urea — 39.9 mgs. 2nd day p.o.; 46.2 mgs. 3rd day p.o.

PATHOLOGICAL REPORT:

Kidney — 15x7x4 cm. Dilatation in the upper pole. Calices
contained fine and coarse granular material and stones. Thick-
ening of the capsule. Congested glomeruli. Thickening and
hyalinization of Bowman’s capsule. Cloudy swelling of the
tubules.

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173

PATHOLOGICAL DIAGNOSIS:

Parenchymatous degeneration.

Diffuse interstitial fibrosis.

Obliteration of the medium and smaller vessels.

Hyaline degeneration.

Post-Operative Notes

He was said to have had nephritis in the remaining kidney
with edema of the feet and ankles which was considered per-
manent at the time. He was discharged weighing 145 pounds,
having had a temperature fluctuation between normal and
100.2, even up to the day of discharge.

The patient states that he made a good recovery following
this operation, was able to return to his work, and felt quite
well until the present complaint began with painful feet and
weakness in the back muscles some time early in the year 1933.

His second hospitalization in different hands occurred be-
tween February 17 and March 30 of 1935. This entry was be-
cause of marked physical weakness and a severe anemia of the
secondary type. Physical examination at this time failed to re-
veal any cause for weakness. There was marked muscle wasting
and pallor of the membranes. He had great difficulty in sleep-
ing, voided frequently at night, and on six occasions vomited.

Laboratory Reports

BLOOD:

Averaged a little over 3,000,000 red cells with hemoglobin
between 60 and 70 per cent. No report on morphology of the
cells.

BMR:

Minus 9.

WASSERMANN:

Kolmer and Kline negative.

X-RAY:

By fluoroscope only — therefore no record except by written
report. The following findings were perhaps noteworthy. "A
triangular shadow in the upper chest having its apex at the
aorta and its base toward the neck. Heart and chest otherwise
clear.’ Barium by the mouth showed some pyloro-spasm and
pressure, probably from an extrinsic source, along the lesser
curvature of the duodenum. There was retention of barium.
Colon enema was negative.

URINALYSES:

Negative except for persistent low gravity — 1004 being the
highest.

Physical Examination

Enlargement of the neck noticed for eight months. A nodule
present in the right lower thyroid lobe. Systolic bruit at the
apex. Blood pressure 138/106. Pulse 88, regular. Pain and
tenderness both insteps, both ankles, backs of the legs and
knees. Had excellent appetite. Voided frequently at night.
Great difficulty in sleeping. Pulse averaged from 70 to 90 dur-
ing his hospital stay. Temperature as high as 99.4. Was given
ventriculin grams X t.i.d. and liver extract (1 ampule) every
other day as the only medication. Discharged without improve-
ment in the blood or any of his symptoms. Apparently no
attempt was made to study blood chemistry, kidney function,
or to follow up the X-ray findings of the shadow in the upper
chest and the deformity in the stomach.

Six weeks later his hemoglobin was 60, RBC 3,100,000,
leucocytes 9,200. Urine showed RBC and WBC, three plus
albumin. Sugar reduced with nine drops and polyuria was re-
ported. A diagnosis was then made of nephritis of the remain-
ing kidney and of "diabetes encephalitis.”

One month later he was somewhat improved but still showed
sugar in the urine. The hemoglobin was 70, red count
4,000,000. Hospitalization at this time was refused. Two
months later he reported to me for the first time and was
hospitalized by me from October 29 to November 2 for study

The complaints were essentially those of the past several
years, only more severe. In the order of importance in the
patient s mind, they were as follows. Tremendous muscular
weakness and loss of weight from 200 pounds to 142. Difficul-
ties in locomotion resembling an ataxic paraplegia. Spasms of
dizziness or giddiness and visual difficulties. It was also brought

out that his original height of five feet 11 had shrunk to about
five feet eight when measured in his slippers. There was a
noticeable kyphos and some anterior bowing of his lower
extremities.

Physical Examination

He stands with his feet wide apart and when he walks he
helps himself with his eyes on the ground and a cane extended
laterally. There is noteworthy muscle atrophy fairly evenly dis-
tributed throughout. The skin shows a papular acne-form out-
break over the chest but is otherwise negative. The nails are
negative. Pupils react to light and distance. Ophthalmoscopic
examination shows a retina beyond reproach though the
arteries perhaps are smaller than normal. They are not tortu-
ous or beaded and the arterio-venous crossings are not obliter-
ated. There was no evidence of retinitis, old hemorrhage, or
exudate. The optic discs on both sides are very pale and very
sharply defined, resembling the primary optic atrophy of lues.
Though nystagmus was once seen by me I was unable on
several occasions to elicit it again. The glandular system, with
the exception of the thyroid, seemed negative. Ears were nor-
mal, mouth normal. A mastoid scar appears on the left. The
right tonsil is present. There is not much tissue in the tonsillar
fossa on the opposite side. Tongue moves in the midline and
is normal. Patient is edentulous. Membranes somewhat pale.
Pressure over all the joints and most of the long bones pro-
duces tenderness. The heart was of normal size and shape. A
short, sharp, systolic murmur was heard over the apex. Blood
pressure was 122 to 130/80. In the three months elapsing be-
tween the first office visit and the hospitalization, the adenoma-
tous development in the region of the right lower thyroid pole
had enlarged noticeably. There was no tremor of the fingers.
Pulse rate remained within normal limits. The chest was clear
to all forms of physical examination except for the evidence
that the tumor in the thyroid area extended below the right
clavicle. There was marked tenderness to pressure applied over
the left twelfth rib; whether because of pressure on the bone
or on the kidney beneath could not be determined. The abdo-
men was negative to all investigation. Neurological tests on all
four extremities for reflexes, position and muscle sense, sensa-
tion, clonus, Babinski, and vibration sense were normal except
for a diminished vibration sense in the right leg. There was no
asteriognosis; finger-nose test was well performed. No joint
swellings appeared. There was a good check reaction in the
muscles of the upper arm. The Romberg was slightly positive
but was thought to be due to muscle weakness rather than to
definite interruption of continuity in the central nervous system.

Laboratory

RENAL FUNCTION:

Urea nitrogen — 37.8 mgs.

Creatinin — 1.22 mgs.

P.S.P. Test — One hour — 130 c.c 20%

Second hour — 130 c.c. 10.6%

Total 30.6%

The entrance urinalysis showed a gravity of 1023, alkaline
reaction, albumin 1 plus, sugar none.

Microscopic — A few hyalin and 8-10 granular casts, 30-40
WBC. Pus in clumps.

This is the only record of a specific gravity appearing above
1014 in any hospital record since 1931. On the following day
specific gravity was 1013. The other findings were the same
A two-hour water concentration test was well performed and
well carried out. Specific gravity ranged between 1011 and 1014.
The night specimen averaged 1012. Volume showed 1594 c.c.
by day against 1120 c.c. by night.

BLOOD:

Hemoglobin — 72 per cent.

RBC— 3,400,000.

WBC— 8450.

Seventy-six per cent polys; 19 lymphocytes, two large monos,
two baso, one eosin.

Morphology not characteristic of pernicious anemia.

Fasting blood sugar was 80 mgs. per 100 c.c.

174

THE JOURNAL-LANCET

CLINICAL COURSE:

Temperature varied from normal to 99.4 each afternoon
Pulse rate between 80 and 90. He had not vomited in several
months and needed no attention from the nurses except for
help in getting from place to place.

COMMENTS:

Syphilis seems definitely to have been ruled out. There was
the failure to find lesions or history in the patient, a normal
family history, repeated negative blood serology, a lack of evi-
dence of any C.N.S. involvement. Lumbar puncture was not
done. It seems apparent that his remaining kidney was deficient
in function as evidenced by an elevated urea, a diminished
P.S.P. excretion, an inability to concentrate, and the micro-
scopic findings in the sediment.

X-RAY:

Because of overlying gas a single flat plate of the abdomen
did not demonstrate the remaining kidney well. However, no
stone was apparent and the outline of the kidney seemed
normal. A single film of his chest revealed the shadow previ-
ously reported in the upper substernal area, triangular in shape,
its base toward the neck, apex at the aorta. This shadow is
thought to be due to an enlarged thyroid with displacement
downward, compression of the trachea on the right side, and
tracheal displacement to the left. Near the right axilla, at the
level of the third and fourth ribs, was a shadow at first re-
ported as metastatic malignancy, later thought to be due to
bone cyst. Osteoporosis was not noted. No X-ray of the stom-
ach was made.

DIAGNOSIS:

The anemia is unexplained unless it be due to a renal de-
ficiency more severe than the present investigation has revealed.
The anemia has been remarkably constant over a period of
years and did not respond to liver therapy. The vomiting might
have been due to urea retention but there has been no history
of headache. The loss of weight and height, the remarkable
muscle wasting with ataxic gait in the absence of evidence of
central nervous system damage, the inability to prove lues in
spite of apparent primary optic atrophy, and the previous his-
tory of kidney stone, all are unexplained by any adequate
diagnosis except hyperparathyroidism. It then seems possible
that this supposed adenoma of the right lower thyroid pole
may be in fact a parathyroid tumor: or that hyper-functioning
of the parathyroid does exist from glands not located by X-ray
or palpation. In support of this belief, a blood calcium was
done, revealing a level of 13.38 mgs. per 100 c.c., which is
approximately 33 per cent above normal. The phosphorus was
reported to be 3.46 mgs., distinctly a low normal, though not
definitely in the abnormal field. However, in long standing
cases it has been reported that the low phosphorus tends to
return to a more normal figure. Since it was not my privilege
to superintend or advise treatment, but merely to report the
cause of disability, I had unwillingly to allow this patient to
depart and had no knowledge of him until one year later.

Subsequent Course

In the Mayo Clinic Bulletin for September 30, 1936, Dr.
A. M. Snell reported a case of hyperparathyroidism operated
at the Clinic. I immediately communicated with him, believing
the case to be the same as the one I have just described. Dr.
Snell confirmed my suspicions and with the greatest of gen-
erosity1 he has supplied me with all of the Clinic records, in-
cluding photographs and X-ray material, in order that I may
complete this report. This patient entered the Clinic December
26, 1935. In addition to the previously described complaints,
he added a sensation of choking in his throat and the element
of pain was more obvious than in previous investigations.
Physical examination was not far different from that previously
described. Polyuria to the amount of three liters a day was
present. The entrance urine showed a specific gravity of 1014
with two plus albumin, no sugar, occasional pus cell. The blood
showed 11.9 mgs. per 100 c.c. of hemoglobin; 3,100,000 RBC;
7200 WBC; polys 49; monos 2.5; lymphocytes 33; eosinophiles
15.5. The blood urea was 40 mgs.; chlorides 619 mgs.; the
C02 combining power 43.8 per cent; blood calcium was 14.9
mgs.; phosphorus 2.6 mgs.; phosphatase 24.0; free hydrochloric

acid 32 units; total acid 40 units; blood Wassermann was nega-
tive. No explanation for the eosinophilia has been offered.

A urea clearance test was done, resulting in 11.0 c.c. and
sulphate clearance 6.2 c.c., both indicating a greatly reduced
renal function. A basal metabolic rate was plus 15. The X-ray
showed osteoporosis with possible cystic rib changes and spon-
taneous healed fractures of the ribs. There was a miliary
osteoporosis of the skull. The ataxic gait was thought to be
due solely to weakness. It was graded three. Dr. Wilder sug-
gested the anemia to be due to replacement of the bone marrow
by connective tissue.

On December 30, Dr. C. W. Mayo removed the cervical
tumor. It is described as an orange size adenoma of the right
inferior thyroid pole, discrete, substernal, and retrotracheal.
Over it lay a network of veins. It looked different than the
usual thyroid adenoma, was soft and a little cystic. The cut
surfaces looked like chocolate. A part of the right lower
thyroid lobe was removed with the tumor. There was no evi-
dence of tumor on the left and no resection was done on that
side. Pathological report of the specimen was as follows:
WEIGHT:

Parathyroid gland, 101 grams, measuring 6x5x5 cm.

Portion of the right lobe, thyroid, 30 grams, 7x3x3 cm.
PATHOLOGICAL DIAGNOSIS:

Colloid thyroid.

Adenocarcinoma of parathyroid gland, graded one.

POST OPERATIVE COURSE:

No tetany existed but some parasthesias were reported. The
calcium dropped to eight mgs. The phosphatase remained high.

The urea on December 30, the day of operation, was 40 mgs.

The urea on January 3, 1936, was 70 mgs.

The urea on January 4, 1936, was 58 mgs.

The calcium on December 28 was 14.9 mgs.

The calcium on December 31 was 10.6 mgs.

The calcium on January 2, 1936, was 8.8 mgs.

The calcium on January 3, 1936, was 8.2 mgs.

The calcium on January 8, 1936, was 8.1 mgs.

Basal metabolic rate on January 7, 1936, had risen to plus
18. Some Lugol’s was given but eventually it was discontinued.

The patient was discharged to his home and again reported
six months later on July 22, 1936. He then demonstrated an
ataxia, graded one, a gain of 40 pounds in weight, a normal
blood, and a serum calcium of 9.4 mgs. The phosphatase was
normal. X-ray of the long bones was interpreted to show re-
classification. His chief complaint was that of painful feet and
he exhibited tenderness along the longitudinal arches.

The parathyroid tumor removed at this operation is said
by the Cliniq to be the largest tumor as yet reported in the
literature. In 1936, Dr. Webb reported one about two-thirds
this size, and Cope has reported one which weighed 53 grams.
Apparently the operation has produced in this patient a re-
markable recovery but it is not likely that the damage to the
remaining kidney will be greatly improved and the prognosis
for the future must be guarded inasmuch as age and intercur-
rent infections may add to the damage already present in the
kidney, where the tubules are probably heavily laden with cal-
cium deposits.

Through the kindness of Dr. Snell and the Mayo Clinic
I am enabled to show their photographs of this case.

- Discussion

Dr. Leo G. Rigler: This is a very interesting case report
and brings to mind a similar case at the University Hospital
which is being studied by Dr. Richard Johnson: a woman
came into the out-patient department complaining of head-
aches. She was examined repeatedly and it was found she had
a positive Wassermann with other findings which indicated a
diagnosis of syphilis, and treatment was started. It was also
found that one of her breasts had been removed some ten ot
12 years before, and she had some glands in her axilla. She
was sent in for examination of the chest to determine whether
or not she had metastasis, not knowing from our records
whether the tumor was carcinoma or not. X-rays of the lungs
revealed tuberculosis and then she was sent in for X-rav ex-
amination of the skull because in almost every case of head-

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175

ache we take an X-ray of the skull. It was found she had
three areas in the skull which looked much like the metastases
which one would get in carcinoma of the breast. She then dis-
appeared, although she was recommended for X-ray treatment.
When she returned it was found that someone else had re-
moved these axillary glands and these had proved to be tubercu-
lous. We finally obtained a report of her breast amputation
and found she had had a carcinoma. It appeared, therefore,
that she had carcinoma, syphilis and tuberculosis. X-ray treat-
ment was started to the skull under the assumption that these
were metastases from the carcinoma of the breast.

A film of the pelvis was made which revealed that she had
a very large cyst in the ilium which did not look like a
metastasis. The picture of the pelvis was entirely different from
that of metastasis, having a marked granular appearance. We
took films of her entire spine, found numerous kidney stones
and, what is more remarkable, an osteoblastic process through-
out the thoracic spine, but in addition this marked granular
appearance. Her calcium at that time was practically normal,
her phosphorus was not decreased. The appearance of the
skeleton was so typical that we felt certain she was suffering
from hyperparathyroidism in spite of the normal blood findings.

Her blood calcium later rose and it got up to 14.5, well
above the normal. With that in mind, further examination was
done, and finally a very small nodule was palpated in her neck.
She was operated upon and a good-sized tumor of the para-
thyroid was removed, following which her calcium dropped to
normal. Her bone changes have hardly disappeared at all.
There is a little change in the skull, but her skeleton has re-
mained very much the same. Her general apparance is very
much improved. She still has a moderately active tuberculosis
in both lungs and definite clinical syphilis. I thought it was a
very interesting case because of the combination of carcinoma,
syphilis, tuberculosis, and, finally, hyperparathyroidism.

Dr. Walter Fink: May I ask if the Mayo Clinic threw any
light on the primary atrophy you spoke of?

Dr. Norman Johnson: They did not mention it except that
in the examination of July 22, 1936, it had apparently dis-
appeared. It was probably due to his anemia and was not a
primary atrophy but merely resembled one.

Dr. Douglas P. Head: Isn’t it true that you cannot de-
pend on the blood calcium in these cases, that many of them
will have normal blood findings and yet show increased urinary
excretion values? ,

Dr. Norman Johnson: The blood calcium depends on a
great many variable things. It depends on the amount of cal-
cium and phosphorus taken in daily and upon the ability of
the individual to absorb that intake and upon the reservoir of
these minerals which may be well stocked or badly depleted.
Therefore, it is rather unwise to base too much upon a single
finding. Whenever you do get a calcium above 12 mgs. per
100 c.c. and at the same time a phosphorus below three mgs.,
it is probably of great significance and hyperparathyroidism
should be considered. On the other hand, if either of these
two blood elements is normal and the other one deviates in the
proper direction, it is also unwise to overlook the possibility
of hyperparathyroidism.

Dr. Leo G. Rigler: I think the muscular weakness here
particularly should be thought of. That should be emphasized
as a very important factor in early diagnosis. Ballin, who saw
many cases of hyperparathyroidism, used a muscle tone test as
an important factor in early diagnosis.

Dr. Douglas P. Head: Did you have a picture of the spine
taken?

Dr. Norman Johnson: X-rays at Rochester of the spine
showed a marked diffuse osteoporosis.

Dr. Douglas P. Head: How do the X-ray men feel about
the relatively common cysts involving only the mandible? How
often are they associated with hyperparathyroidism?

Dr. Leo G. Rigler: In the case I described, the patient also
had a systic area in the mandible which we had diagnosed
from the X-ray examination as a giant cell tumor. A cancer
quack burned this out so we could not get any sections to
determine what it was. It no doubt was one of these cysts which

might occur in the mandible just as well as anywhere else.
Ballin had a number of cases that had been sent in as solitary
cysts but on careful examination other cysts were found else-
where in the skeleton.

ABSTRACT

ROENTGEN DIAGNOSIS OF OCCLUSION OF THE
SMALLER BRONCHI
Leo G. Rigler, M.D.

While stenosis of the larger bronchi has been studied in-
tensively both from the clinical and roentgenologic point of
view, stenosis of the smaller bronchi has had relatively little
attention. The bronchi beyond the second bifurcation are rather
frequently occluded, most commonly in association with bron-
chial asthma, but also as a secondary finding in chronic emphy-
sema, unresolved pneumonia, tuberculosis, syphilis of the lung,
pneumoconiosis or as a result of other chronic inflammatory
processes.

The occlusion of these smaller bronchi may occur in three
possible ways. First, there may be a partial obliteration of the
lumen due to an actual hypertrophy of the bronchial mucosa
with infolding and extension into the lumen. This occurs
rather rarely in asthma. The second is by far the most com-
mon form of occlusion and is due to the accumulation of
mucous plugs in the smaller bronchi which eventually become
hyalinized and produce complete obliteration. This is very fre-
quent in bronchial asthma. The third is by actual infiltration
of the outer bronchial wall from parenchymal processes of an
inflammatory nature and compression of the bronchi in this
fashion.

The occlusion of these bronchi may be demonstrated bv
bronchography with iodized oil. Great care must be exercised
in the technique of the examination so that sufficient time
elapses between the time the oil is given and the time the
films are made so that there will be an opportunity for the oil
to reach the smaller bronchi. If the technical factors are cor-
rect, however, and certain areas of the lung field do not show
any iodized oil or if certain bronchi fail to fill completely
while other bronchi in the immediate neighborhood are filled,
it is reasonable to conclude that an actual occlusion of the
lumen is present. These findings are most commonly seen in
asthma, but may be found in other chronic conditions. Many
patients present themselves with clinical roentgenologic find-
ings suggestive of bronchiectasis. When bronchography is done
on these patients, frequently no dilatations of the bronchi are
found. If these films are carefully examined, however, it will
often be shown that actual occlusion of the bronchi is present
and this may explain the patient’s symptoms.

The importance of this finding in asthma is largely prog
nostic. Extensive obliteration of the bronchial lumina is of
serious import in cases of bronchial asthma. In other types of
cases the demonstration of occlusion of the smaller bronchi by
roentgenography may be the only indication of the actual lesion
which is present.

Discussion

Dr. F. W. Wittich: I would like to have Dr. Rigler tell
us his experiences with the thinner iodized oil in determining
just how much the bronchi are stenosed. Therapeutically, one
seems to get better results by giving 15 or 20 c.c. lipiodine-
Ciba, first filling up the smaller bronchi and then following
with a like amount of the heavier oil, lipidol or iodochloral.
If adrenal is given prior to the introduction of the oil and
observed fluoroscopically, the oil will be seen to frequently
descend farther into the small branches after apparently stop-
ping rather abruptly in one of the larger branches, thus rul-
ing out a permanent occlusion, from whatever cause besides
spasm. With this method and a plate taken immediately which
shows rather abrupt or rounded endings of the bronchi, the
evidence, of course, would be much stronger for a permanent
occlusion whether from mucous plugs, hypertrophy or cicatri-
cial stenosis. Sacculations are not unusual in chronic respiratory
allergy.

Dr. Douglas P. Head: Have you had any case that showed
atelectasis?

176

THE JOURNAL-LANCET

Dr. Leo G. Rigler: In regard to Iipiodine, I have tried to
use a thin oil. The objection is that it enters the alveoli too
readily and obscures the field so that it is difficult to see the
bronchi. There is no doubt that some of the thin oil will get
by in some of the small bronchi and reach the alveoli.

The question of atelectasis is a very interesting one. The
atelectasis that we get in asthma is very different from the
massive atelectasis we like to talk about. In asthma it is lobular
and patchy. In addition to that, in the asthmatic there is a
great deal of emphysema which neutralizes the effect of these
atelectatic patches. Furthermore, as I said, the bronchi are not
completely occluded as they must be in order to get much
atelectasis.

Lawrence R. Boies, M. D.
Secretary

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE

Meeting of January 13, 1937

The Annual Meeting of the Minnesota Academy of Medi-
cine was held at the Town & Country Club on Wednesday
etening, January 13th, 1937. The meeting was called to order
at 8 o clock by the President, Dr. E. M. Jones.

There were 53 members and 4 guests present.

Reading of the minutes and all other business was dispensed
with and Dr. Jones turned the meeting over to the essayist of
the evening.

THOMAS S. ROBERTS, Minneapolis, retiring Presi-
dent then said he would depart from the usual custom of ad-
dressing the Academy on some scientific subject and talk about
his hobby instead. Dr. Roberts gave a most interesting and
entertaining Review of the Bird Life of Minnesota; illustrated
with slides and colored movies.”

The meeting adjourned.

A. G. Schulze, M. D., Secretary

NEWS ITEMS

The new director of the Hennepin County Tubercu-
losis Association is Dr. E. J. Lillehei, of Robbinsdale,
Minn.

Dr. H. G. Irvine, of Minneapolis, is the new president
of the Minneapolis Council of Boy Scouts of America.

Dr. W. C. Hills has moved from Newell to Sioux
Falls.

Doctor John F. Briggs, of Saint Paul, Minnesota, has
returned from a trip to Europe, and has resumed his
practice.

Doctor Kenneth Sherman, formerly of Passavant
Hospital in Chicago, Illinois, has resigned from that
institution to enter practice at Sturgis, South Dakota.

Dr. A. W. Pasek, of Duluth, a graduate of the Uni-
versity of Minnesota Medical School, has announced
that he will inaugurate practice at Lismore, Minn.

Doctor Harry Whlliam Arndt has opened his new
office in the Nunn Building at Detroit Lakes, Minne-
sota. Doctor Arndt formerly practiced at Frazee.

Dr. M. J. Lindahl, formerly of Jasper, Minn., has
moved his office to Pipestone, where he is located in the
Pipestone National Bank Building.

Dr. J. P. Greaves, formerly of Sherwood, N. D., has
inaugurated his own practice at Great Falls, Mont. For
the past six years, Dr. Greaves has been associated with
Dr. Coulter of that city.

The Richland County Medical Society of North
Dakota unanimously adopted a resolution petitioning
the county commissioners to discontinue the county
doctor system and adopt a minimum fee-schedule for
indigent cases.

Dr. Ted L. Havlicek has become associated with Dr.
Ray E. Lemley, of Rapid City, South Dakota. Pre-
vious to this time Dr. Havlicek had been a member of
the staff at Sanator, S. D.

Dr. Stanley J. Smith, of Chicago, recently joined the
staff of the More Hospital at Eveleth, Minnesota. He
is a graduate of the Northwestern University Medical
School and for the past five years has been a member of
the faculty of Loyola University.

Dr. R. D. Gardner, formerly of the More Hospital
staff, Eveleth, Minnesota, and who has been associated
with the Hopkins Clinic at Cleveland, Ohio, for the
past number of years, was recently named head of that
institution by the directors.

Arrangements are under way at Crookston, Minne-
sota, for a voluntary subscription fund with which to
erect a memorial to the late Dr. O. E. Locken, medical
leader and former mayor of that city.

F. O. Hanson, superintendent of the Swedish
Hospital in Minneapolis, has been re-elected president
of the Minneapolis Hospital Council. Others likewise
returned to office are: Harry Brown, Northwestern Hos-
pital, who is vice-president; Sister Anna Berglund,
Deaconess Hospital, who is treasurer; and Rebecca
Peterson, Saint Andrew’s Hospital, who is secretary.

The new $82,000 municipal hospital at Brookings,
South Dakota, has just been completed. Modern in
every detail, the hospital is one of the finest in the
northwest. Miss Lavine Nelson is superintendent, and
R. Magni Davidson is chief-of-staff.

Doctor Kenneth L. Bray, who was graduated from
the University of Minnesota Medical School in 1934,
is now associated with Doctors Hanson and Houston at
Park Rapids, Minnesota.

Dr. Lars J. Hauge, for the past 32 years a physician
of Howard, S. D., died at the age of 76 in Howard in
November. Dr. Hauge was a graduate of the old Sioux
City (Iowa) College of Medicine; but prior to that had
been a minister in the Norwegian Lutheran Church.

Doctor Martin C. Berheim, of Hawley, Minnesota,
was a member of the University of Minnesota’s post-
graduate medical institute during January. Doctor
Berheim was graduated from the Medical School of the
University in 1920.

Doctor Stanley S. Chunn, a graduate of the Univer-
sity of Minnesota Medical School in 1927, is now in
practice at 123 V2 West Main Street in Pipestone,
Minnesota.

Doctor John Arnold Malmstrom, health officer of
Virginia, Minnesota, has resigned, and Doctor David
Marcellus Parker, formerly a Civilian Conservation
Corps physician, has been named as his successor.

THE JOURNAL-LANCET

177

Doctor Ramey M. Baker, 31, of Sturgis, South Dako-
ta, died at St. John’s Hospital in Rapid City on March
2, 1937. Doctor Baker was graduated from the Univer-
sity of Nebraska College of Medicine in 1931, coming
to Sturgis in 1933.

Doctor Friede Van Dalsem, 92, pioneer physician of
Beadle County, South Dakota, died in Huron during
March. She is survived by four children and one sister.

Cascade County is one of the three counties in Mon-
tana maintaining a full-time city-county health depart-
ment. The chief is Doctor Frank L. Watkins, who is
also health officer for Great Falls, Montana.

A Charles Mix County health unit advisory committee
has been formed by Docter Pierre Romeo Pinard, of
Wagner, South Dakota. This committee supersedes
the old county board of health, and will be affiliated
with both the state board of health and the United
States Public Health Service of Washington, D. C.

Leila Ann Gorenflo, M. D., a graduate of Rush Med-
ical College of the University of Chicago in the class
of 1935, will commence practice at the Endion Hotel
in Cass Lake, Minnesota. She has completed her in-
terneship at the Los Angeles County General Hospital
in California.

Dr. L. H. Cady, of Minneapolis, succeeds Dr. Wal-
ter Ude as chairman of the staff of Saint Andrew’s
Hospital in Minneapolis. Dr. J. T. LaPierre is vice
chairman, and Dr. Stanley Roberts is secretary.

Dr. Donald F. Fitzgerald, of Minneapolis, has been
named chairman of the Saint Barnabas Hospital staff;
Dr. Julius Johnson is vice chairman; Dr. H. D. Diess-
ner is secretary-treasurer; and Dr. J. S. Reynolds is a
member of the executive committee.

Dr. H. D. Nagel has established a hospital at
Waconia, Minn. In addition to the rooms formerly used
for his office, Dr. Nagel has taken more space and is
operating a ten-bed hospital with a modern operating
room and kitchen.

Dr. Leo R. Prins, a graduate of the University of
Minnesota School of Medicine, and formerly of St.
Paul, is now associated with the surgical and medical
clinic at Albert Lea, Minn.

Dr. Ellis Giere, formerly of Rochester, Minn., has
been named head of the Fort Peck Hospital at Fort
Peck, Mont. Dr. Carl Eklund, of Minneapolis, will be
assistant to Dr. Giere in his new position.

Dr. Kenneth F. Maxcy, head of the department of
preventive medicine and public health at the Univer-
sity of Minnesota, was selected as one of the scientific
directors of the International Health Division of the
Rockefeller Foundation.

Dr. R. R. Hendrickson, superintendent and medical
director of Fair Oaks Lodge Tuberculosis Sanitorium at
Wadena, has resigned, effective May 1st, to enter pri-
vate practice in that city.

Dr. James B. Carey was elected president of the staff
at Eitel Hospital, Minneapolis, at the annual banquet
held at Hotel Radisson. Dr. William B. Roberts was
named vice president, and Dr. Frank R. Hirshfield,
secretary.

A new Indian hospital with a nurses’ home, a doc-
tors’ residence and a six-car garage, has just been com-
pleted at Sisseton, S. D., at a cost of $185,000. Miss
Feme Rumsey is superintendent of nurses.

Doctor Henry E. Sigerist, professor of the history of
medicine at Johns Hopkins University in Baltimore,
Maryland, went on record as favoring health insurance
at Rochester, Minnesota, on March 1, 1937. Professor
Sigerist, a graduate of the University of Zurich Faculty
of Medicine in 1917, said: "I know the profession
opposes health insurance; but I think it is unavoidable,
and that it will come. It is impossible to avoid it.”

Fifty hospital superintendents and assistants from
various Minnesota cities gathered at the University of
Minnesota on March 18 for the first hospital adminis-
tration short course ever offered. The course lasted 3
days, and was sponsored by the Minnesota Hospital
Association and the University of Minnesota Center for
Continuation Study. Doctor Bert Wilmer Caldwell,
executive secretary of the American Hospital Associa-
tion, attended.

Doctor E. C, Smith, 77, passed away on January 9,
1937, at Winner, South Dakota. Doctor Smith, a
pioneer physician of South Dakota, was president of
the Rosebud District Medical Society, and health officer
for Todd County, at the time of his death. He was a
member of the South Dakota State Medical Association
and of the Sioux Valley Medical Association. He was in
practice at Mission, South Dakota.

The regular semi-annual mid-winter meeting of the
Montana Academy of Oto-ophthalmology was held in
Butte, February 21 and 22, under the presidency of
Dr. Edward S. Murphy of Missoula. The mid-summer
meeting will be held concurrently with the Pacific North-
west Medical Society in Great Falls in July. Dr. Arthur
L. Weisgerber of Great Falls was elected president, and
Dr. A. W. Morse was reelected secretary-treasurer.

Among the Montana eye and ear surgeons who at-
tended the Los Angeles Research Study Club post-
graduate course the last two weeks of January were Drs.
William J. Marshall, of Missoula, W. R. Morrison of
Billings, and L. G. Dunlap, Anaconda.

On February 13, 1937, the eleven Montana fellows
of the American College of Physicians met in Great
Falls for the purpose of discussing the advisability of a
closer organization which would further the cause of
scientific internal medicine. It was decided that the
organization should be known as the Montana Society
of Internists and that its membership should be limited
to fellows of the American College of Physicians. The
governor for Montana, Dr. L. H. Fligman, was con-
tinued in the office of chairman of the proposed society.
Dr. H. C. Watts was elected to serve as secretary. It
is planned to hold a meeting at least once yearly at
which time a program of general scientific interest will
be arranged. The date has not yet been set but it will
be so fixed as not to interfere with the annual meeting
of the American College of Physicians.

178

THE JOURNAL-LANCET

J. F. D. Cook, M. D., secretary of the Third District
Medical Society of South Dakota reports that the
March meeting was held at Brookings in the Dudley
Hotel. Doctor Eivind Klaveness, of St. Paul, Minne-
sota, spoke on "Grenz Rays: Their Origin and Ther-
apeutic Use.” The April meeting of the society will
meet on April 1, in Madison, with Doctor J. C. Ohl-
macher, dean of the University of South Dakota Med-
ical School, speaking on "Pathology and Laboratory
Tests: Their Significance” and "The Treatment of
Kidney Conditions.”

A special program of lectures and demonstrations in
surgery and medicine will be held under the direction
of the Mayo Foundation at Rochester, Minn., from
April 5 to 9, inclusive. Mornings will be devoted to
surgical and medical clinics. In the afternoons and
evenings, in addition to climco-pathologic conferences,
symposiums will be conducted on urology, cardiology,
gastro-enterology, dermatology, endocrinology, diseases
of the colon and rectum, orthopedics and arthritis.
Visiting physicians will be welcome guests.

Captain A. H. Robnett, M. D., of the U. S. Navy,
Great Lakes, Illinois, announces that examinations will
begin on May 10 for graduates of Class "A” medical
schools who wish to become assistant surgeons in the
U. S. Navy. Accepted graduates will be given a post-
graduate medical course at the Navy Medical School
in Washington, D. C. Physicians interested should
address: Bureau of Medicine & Surgery, U. S. Navy
Department, Washington, D. C.

Benjamin Hobson Frayser, M. D., 50, chief of the
surgical staff of the Fort Harrison, Montana, Veterans'
Administration Facility, until 1931, died at Lexington,
Kentucky, on March 5, 1937. Doctor Frayser was
graduated from the medical department of the Lincoln
Memorial University in Knoxville, Tennessee, in 1909.

Doctor Elmer G. Balsam, secretary of the Medical
Association of Montana, has announced the following
committee chairmen for the state medical convention at
Great Falls on July 12, 13, and 14, 1937: General chair-
man: Doctor Martin Larson of Great Falls; general
vice-chairman: Doctor Faus Peter Silvernale, of Great
Falls; general secretary: Doctor Laurence Laurie

Howard, of Great Falls. Doctor Charles J. Bresee,
Great Falls, is in charge of publicity; Doctor Fred Lee
Anderson, Great Falls, heads the hotels and transpor-
tation group; Doctor Silvernale will conduct registration;
Doctor Ernest Dexter Hitchcock, Great Falls, will serve
as entertainment chairman; and Doctor Larson will
arrange the program. The meeting of the Montana
body will be followed by a three-day meeting of the
Pacific Northwest Medical Society.

The South Dakota State Board of Health receives
numerous requests from Todd and Campbell Counties
asking that a doctor locate in these communities. Todd
County has been without the services of a physician
since the death of Dr. Smith several months ago. The
population is 6,463 with approximately half of this
number Indian. Campbell County has a population of

5,634 and has been without a doctor for five months.
Should the proposed medical relief program become
operative, these counties would be excellent locations
for progressive doctors.

Dr. E. R. Crow, of Arlington, reports that the Scott-
Carver County Medical Society held a meeting at Mud-
baden Sanitarium, January 11th, in conjunction with
the Minnesota Valley Dental Study Club. The meet-
ing was devoted to a discussion of economics and legis-
lative matters of interest to both groups. Speakers for
the medical society were Dr. L. L. Sogge of Windom,
and Mr. Manley Brist of St. Paul. Introduced by Dr.
D. W. Wilson, of Belle Plaine, were guest speakers of
the dental society: Drs. Clayton Swanson and Louis
Weiss, of Minneapolis.

BOOK NOTICES

KINESIOLOGIC EXERCISES

The Kinesiology of Corrective Exercises, by GERTRUDE HAW-
LEY, M.A.; 1st edition, cloth, 268 pages. 107 engravings,
bibliography; Philadelphia: Lea 8c Febiger, Inc.: 1937. Price,
£2.75.

The stated purpose of the book is to provide a practical text
in kinesiology for the use of students, teachers, and physio-
therapists specializing in the field of corrective exercise.

Part one, consisting of eight chapters, is devoted to a review
of anatomy and pathology of the bones and joints, and is well-
documented with bibliographies. Part two has nine chapters
devoted to corrective exercises and positions. There is no bibli-
ography for part two, which is technical material describing in
detail exercises used by the writer in the practice of physio-
therapy.

Descriptions of specific exercises are careful and thorough,
often illustrated with clear outline drawings to constitute a
comprehensive treatment of the subject.

The book is very readable and constitutes a valuable addi-
tion to the literature on technique of corrective exercise. It is
recommended for teachers of physical education, for students
working toward teaching credentials in this field, for administra-
tors of secondary schools and colleges, and for others interested
in physiotherapy.

The author is assistant director of the women's gymnasium
of Leland Stanford University in Palo Alto, California.

Helen B. Pryor, M.D., Director,
Physical Education for Women,
Leland Stanford University,

Palo Alto, California.

GUEDEL ON ANESTHESIA

Inhalation Anesthesia, by ARTHUR E. GUEDEL, M.D., with a
foreword by RALPH M. WATERS M.D.: 1st edition, cloth.
182 pages, index, illustrated; New York: The Macmillan Com-
pany: 1936. Price, £2.50.

This thoughtful book is just off the press. The dedication
is touching and most appropriate. The brief preface is full of
real meaning: The foreword by Waters is a stellar tribute to
what the author has done for the teaching of anesthesia. The
material in the book itself is excellent. It reads smoothly, con-
cisely, and with authority. There can be no better presentation
of the mechanism of inhalation anesthesia than has been accom-
plished in the 12 pages of the first chapter. The diagrams very
clearly show the stages and signs of anesthesia, and help greatly
in understanding the picture. The second part on "Anesthedc
Accidents” is superb. The author is associate clinical professor
of surgery in the University of Southern California Medical
School.

John W. Shuman, M.D.,
Associate Professor of Medicine,
College of Medical Evangelists,
Los Angeles, California.

Clinical Changes Produced by Diarrhea
And Their Restitution

Lee Forrest Hill, M. D.

Des Moines, Iowa

ALTHOUGH the mortality rate from the diar-
rheal diseases has undergone a remarkable de-
cline in the last quarter of a century, still the
problem of saving life from these causes continues to be
of frequent occurrence in the practices of the general
practitioner and the pediatrician. In recent years con-
siderable information has been added to our knowledge
of the changes produced in the body by diarrhea, and
methods have been developed for correcting these
changes, which, when effectively carried out, have been
demonstrated capable of reducing the mortality in the
severest types of cases from around seventy per cent to
as low as twenty or thirty per cent.

The etiologic factors concerned in the production of
diarrhea are far from being on a clear-cut and readily
classifiable basis. No attempt will be made here to en-
ter into a detailed discussion of this phase of the subject,
since regardless of the cause, the resulting changes and
the treatment demanded, are essentially the same. It is
possible, however, to divide the diarrheal diseases into
two rather distinct groups; the one has a specific bac-
terial etiology in which the intestinal wall itself is in-
vaded and blood and pus characteristically appear in the
stools, and to which the terms infectious diarrhea, or
dysentery, or acute colitis are commonly applied; the
other constitutes the remaining types of diarrhea in
which the contents of the intestinal tract are involved
and in which a multiplicity of etiologic factors are con-
cerned. As Marriott1 has pointed out, diarrhea should
not be looked upon as a disease entity in itself, but as a
symptom resulting from a variety of causes.

•Prepared expressly for the special Pediatric issue of THE

JOURNAL-LANCET

In private practice, parenteral and enteral infections
undoubtedly account for a majority of the diarrheas en-
countered. In the late summer and fall months there
usually occur, in this part of the country at least, mild
epidemics of gastro-enteritis characterized by an acute
pharyngitis, vomiting, fever and diarrhea of varying in-
tensity. Healthy breast-fed and bottle infants as well as
older children are likely to be attacked if exposure occurs.
Occasionally, a severe case is encountered in which
there are vomiting, convulsions, and such a marked fluid-
loss that serious changes, to be described later, result.
Climatic conditions are undoubtedly responsible in some
way for the prevalence of bacterial life during this sea-
son, which either directly or indirectly by toxic action,
has a predilection for the intestinal tract; whereas in the
winter months the prevailing type of bacterial activity is
largely confined to the respiratory tract. While excessive
heat and humidity may be capable of depressing the di-
gestive function to the point of initiating a diarrhea here
and there, nevertheless the role played by these factors is
decidedly subordinate to infection as a cause of the so-
called "summer diarrheas.” Numerous investigators have
conducted bacteriologic studies of stools in attempts to
isolate the offending organisms, but the varieties of bac-
teria responsible have been almost as numerous as the
investigators themselves, so that no justifiable conclusion
on this point can be made at present. It should be
understood that such a statement does not apply to
bacillary dysentery where the specific bacterial etiology
has been established for many years. It may, however,
be difficult to differentiate bacillary dysentery from epi-
demic enteritis at the onset, before the characteristic
stools of the former have made their appearance.

180

THE JOURNAL-LANCET

Aside from this group of diarrheas occurring epi-
demically in the autumn months, parenteral infections,
particularly of the nose, throat, and ears, are frequently
the underlying factor in gastro-intestinal disturbances
occurring at any season of the year. Recently a month-
old baby came under observation because of a suddenly-
developed diarrhea. The crying and fretfulness could
easily have been attributed to colic, since the temperature
was normal; but one ear drum was found to be bulging,
and upon incision, pus was obtained. Jeans and Floyd-’
and Marriott'5 have drawn attention to a special type
of parenteral infection in which symptoms resembling
cholera infantum have been shown to be secondary to an
otitis media or mastoiditis or both. Such a syndrome
is largely confined to undernourished institutional in-
fants, and is seldom seen in private practice.

Other parenteral infections may also precipitate a
complicating diarrhea; but in general there is less likeli-
hood of this development occurring when the infection
is located in some other part of the body than the
rhinopharyngeal and otitic region; for instance, in the
kidney or lung.

Important as are enteral and parenteral infections in
the production of diarrhea, the impression must not be
given that all diarrheas arise from these causes. Over-
feeding or unsuitable milk mixtures may cause intestinal
indigestion in infants, and underfeeding may result in
diarrheal type of stools. Prematurely or newly-born in-
fants who of necessity are deprived of breast milk, and
constitutionally weak infants as well as infants suffering
from malnutrition, comprise a group in whom the diges-
tive capacity is limited. Spoiled food is less a factor in
recent years than formerly, since most parents even in
the poorest of circumstances have learned the important-
ance of boiling milk and of keeping it in suitable con-
dition. The widespread popularity of evaporated milk
has also accomplished much in this direction. Mechani-
cally indigestable foods, gastro-intestinal allergy and
gastro-enterospasm are further causes which occasionally
are responsible for intestinal indigestion.

In all cases of diarrhea it is desirable to determine the
underlying cause, since this may have an important bear-
ing upon the subsequent management of the case. From
what has been said it is obvious that a most careful
physical examination, including examination of the ears
with an electric otoscope, is essential if parenteral in-
fections are to be located and properly treated.

The modus operandi by which diarrhea is brought
about from the various causes enumerated above has
long been a baffling problem, and indeed has not been
entirely settled up to the present time. All the food
elements at one time or another have been blamed.
Finkelstein thought fermentation of carbohydrates was
at fault, and devised protein milk (one of the most val-
uable contributions ever made to infant feeding) , to
counteract its effects. In recent years Marriott and his
co-workers at St. Louis have advanced the theory that
many of the diarrheas of infancy are the result of the
growth of organisms in the upper intestinal tract which
are normally present only in the lower bowel. A decrease

in gastric acidity favors the migration of colon bacilli to
the upper intestine. Gastric acidity has been shown to be
decreased in infection, and in weak undernourished in-
fants. Cow’s milk with its higher buffer capacity neu-
tralizes the acid of the gastric juice, which may be one
reason why artificially-fed infants have a greater tend-
ency to diarrhea than breast-fed infants.

The harmful effects of colon bacilli growing in the
small intestine and stomach may be produced by the
elaboration of toxic material such as histamine, or an
actual invasion of the body by the bacilli may occur.
Casparis4 has suggested that guanidine formed in the
course of severe diarrheas and circulating in the blood
stream may be partially responsible for the toxic symp-
toms, and recommends administration of calcium to
counteract its harmful effects. Nedzel ’ advances the in-
teresting theory that the cause of summer diarrhea (ex-
cluding the cases definitely connected with pathogenic
organisms) is due to a disturbed balance of the auton-
omic nervous system occasioned by extreme heat. Thus
it is apparent that the underlying factors responsible for
the initiation of the non-specific type of diarrheas are
many, and that the manner in which these factors op-
erate to bring about the diarrheas is in many instances
only theoretically explainable. The results of diarrhea,
however, are fortunately fairly well understood.

Clinical changes result from diarrhea only when the
diarrhea is of a severe type. Mild types of diarrhea pro-
duce little or no evidence of illness beyond fretfulness.
Fever and vomiting may be present, but interest in sur-
roundings is maintained and color and tissue turgor are
undisturbed. However, transition from the mild to the
severe type frequently occurs with startling rapidity. In
a few hours the patient may become apathetic and gray-
ish, with sunken eyes, rapid pulse, and poor tissue tur-
gor. Convulsions may occur, fever becomes high, and
the lips assume a cherry-red hue, while the respiration
becomes deep and pauseless. Continuation of the symp-
toms results in coma and death. It should be emphasized
here that the mild type of diarrhea should not be taken
too hghtly as something of little significance which a
dose of castor oil will relieve. A day or two of correctly
prescribed simple therapy at the onset of the disturb-
ance may prevent the necessity of weeks of complicated
and drastic measures later on in neglected or badly man-
aged cases. The time-honored custom of administering
a physic whenever the bowels become loose should be
mentioned only to be condemned. The intestine is
already irritated, and what is to be gained by further
irritation? More water is removed from the body at a
time when the paramount objective should be to main-
tain the supply. Withholding food for twelve to twenty-
four hours and giving water and weak tea solution in as
large quantities as will be accepted is the logical method
of treatment of a diarrhea at its onset. When food is
begun it should be weakened sufficiently to be tolerated
by the disturbed digestive function, and additions should
be made gradually and under careful observation for
evidences of return of the symptoms of indigestion. Pro
tein milk is usually a very satisfactory type of food to

THE JOURNAL-LANCET

181

start after the initial period of starvation. It should not
be used longer than forty-eight hours without the addi-
tion of carbohydrate, because of the risk of establishing
a proteolytic indigestion which is characterized by very
foul-smelling brownish liquid stools. Many infants who
have a diarrhea tendency on correctly constructed milk
formulae can be fed successfully on protein milk with
added carbohydrate for considerable periods of time.

The symptoms produced by a severe type of diarrhea
are usually described under the terms of "alimentary in-
toxication,” or "intestinal toxemia.” Marriott, Hart-
mann, and Senn1’ state that these symptoms "are the
secondary results of disturbance in the chemical equi-
librium of the body brought about as the result of loss
of water, salts and organic material by way of the gastro-
intestinal tract and that the development of the clinical
picture of intoxication depends more upon the degree
and severity of the diarrhea than upon the nature of the
underlying cause. Any severe diarrhea, whether occur-
ring as the result of enteral or parenteral infection, or
other causes, may be associated with the development of
symptoms of intoxication.”

For purposes of discussion, the clinical changes enter-
ing into the picture of alimentary intoxication may be
further sub-divided into athrepsia, anhydremia and de-
hydration, acidosis, and toxicosis. Such changes may be
present in various combinations in the individual patient,
depending upon the severity and duration of the di-
arrhea; or in very severe prolonged cases all the changes
may be present.

Athrepsia, or starvation, results from failure to assim-
ilate sufficient food to provide for the fuel needs of the
body. Underfeeding, vomiting, and diarrhea are the
contributing factors. Under such conditions the body
tissues are consumed to provide fuel, and in prolonged
cases this process continues until the familiar picture of
"the little old man” is presented. Marriott1 estimates
that as much as 25 to 50 per cent of the fat, 50 per
cent of the ingested carbohydrate, and 15 per cent of
the protein may fail of absorption in the presence of
diarrhea.

Whenever loss of water from diarrheal stools exceeds
in amount the utilizable intake, dehydration or desicca-
tion of the body begins. Intercellular fluid provides a
reservoir which tends to maintain a normal blood volume
as long as possible, but with continued loss of water this
supply becomes exhausted and anhydremia or concentra-
tion of the blood occurs. The decrease in the fluidity of
the blood impairs the circulation, and lessens the urinary
output, factors which contribute to the upsetting of the
normal acid-base balance, as will be discussed later. From
the clinical viewpoint, it is important that the symptoms
of dehydration be recognized as early as possible. It is
the onset of this condition which causes the patient to
change from an attitude of lively interest to one of
apathy. He no longer desires to be up and about, or if
an infant, he ceases his usual active motions. The color
becomes grayish, the tongue and mucous membrane are
dry, and the skin lacks its usual resiliency. The eyes
have a sunken appearance, and the pulse rate is fast.

Urination is scanty. Loss in weight in an infant may be
as much as a pound in twenty-four hours. Such a pic-
ture does not demand the giving of purges, enemas, and
drugs, but the giving of water immediately and in suffi-
cient amount to restore the blood volume and inter-
cellular fluid to the normal content. Furthermore, water
administration must be continued by whatever route
necessary to equalize the loss and maintain the supply in
the body. Prompt recognition of the symptoms of de-
hydration at their onset may make it possible to restore
body fluids by relatively simple means, such as hypo-
dermoclysis of 500 to 1,000 cubic centimeters of sterile
physiologic salt solution, thus preventing the further
development of more serious changes in the body not
so easily correctable.

Clinically, acidosis is recognized by the type of breath-
ing. The deep, pauseless, "air hunger” type of respira-
tion is an expression of the effort being made by the
body to rid itself of excess acid. Several factors combine
to bring about acidosis in severe cases of diarrhea and
anhydremia. In the first place an actual loss of minerals
occurs in the diarrheal stools, and since base ions pre-
dominate over acid ions in the intestinal secretions, the
ultimate effect of diarrhea is a reduction in the bicar-
bonate content of the blood plasma. Normally the urine
serves as one of the efficient mechanisms for acid-base
regulation, by excreting excess acids neutralized by am-
monium salts. However, as has been noted, in anhydre-
mia the urine output is greatly reduced, so that this
mechanism becomes ineffective and acids remain in the
body to reduce further the bicarbonate. Lactic acid col-
lects in the tissues because of the impaired circulation
and anoxemia, and ketone acids may be formed as a
result of incomplete combustion of the fats secondary
to the partial starvation going on in severe diarrhea.
These are the more important factors which combine to
deplete the alkali reserve of the body, sometimes to
such an extent that chemical analysis shows the bicar-
bonate to be less than one-fifth of its normal amount.

Patients with severe diarrhea may manifest only signs
of anhydremia and acidosis; but frequently toxic symp-
toms are also present. These are chiefly fever and con-
vulsions. Occasionally one sees a fulminating case of
diarrhea in which the toxemia is so great that death
results in a few hours from the toxemia. One such case
came under observation only recently. A two-year-old
child became ill in the evening with fever, enteritis, and
convulsions. Death occurred the following morning in
spite of vigorous therapy. Autopsy showed only con-
gestion and inflammation of the entire intestinal tract.

The therapeutic indications for restitution of the clin-
ical changes brought about by severe diarrhea are clear-
cut, and must be adequately met if the lives of these
patients are to be saved. The acidosis and anhydremia
of diarrhea presents an emergency no less great than
the emergency of acidotic coma in diabetes. Fluid-loss
must be replaced, and the supply maintained day after
day so that blood volume and intercellular fluid may be
restored and kept at normal levels. Loss in weight must
not be permitted to occur. Minerals must be supplied in

182

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adequate amounts to replace those lost in the intestinal
secretions, and a normal balance must be maintained.
The diarrhea must be brought under control as rapidly
as possible and nutritional needs must be met as soon as
digestive function permits.

Fluids may be administered by mouth, subcutaneously,
intraperitoneally, intravenously and by venoclysis. In
severe diarrhea, it may be necessary to employ all these
routes. The amount of fluid lost from the body in some
diarrheas is frankly amazing. Several cases may be cited
to illustrate this point. A three weeks-old infant was
brought into the hospital one evening weighing five
pounds and fourteen ounces. During the night 500
cubic centimeters of fluid were given subcutaneously and
six ounces were consumed by mouth. The next morning
the weight was five pounds and ten ounces, a net loss of
four ounces. A premature infant weighing four pounds
developed a diarrhea with as many as twenty-two stools
in twenty-four hours. In the twenty-four hour interval,
a total of 1081 cubic centimeters were given subcu-
taneously and by mouth, with a net loss in weight of
three and one- half ounces. A five year-old child entered
the hospital with a severe enteritis, with marked anhy-
dremia and acidosis. The total quantity of fluid admin-
istered in the subsequent eight days was 2150 cubic centi-
meters intravenously, 7,900 cubic centimeters subcu-
taneously, and 140 ounces by mouth. Only by the ad-
ministration of these large volumes of fluid could the
symptoms of dehydration be overcome.

Venoclysis must be considered the most efficient of the
routes for parenteral administration of fluid; but the
technical difficulties attendant upon this method make
it of limited value, particularly in infants. For those
who are interested, a technic of this procedure has been
described by Spinek in the issue of the Journal of
Pediatrics, and Karelitz in the March 1937 issue of the
same journal.

The peritoneal cavity provides an easily accessible
and efficient route for the administration of fluids, and
with reasonable regard for asepsis, this method may be
carried out in the home. The needle is inserted in the
mid-line or slightly to the left about an inch below the
navel, and pushed through the abdominal wall in an
oblique manner upwardly, in order to avoid any chance
of puncturing the bladder. The contra-indications ate
distention and adhesive peritonitis. From 150 to 400
cubic centimeters, depending upon the age and size of
the patient, may be given once or twice daily. Glucose
solution should not be given intraperitoneally because ic
produces a sterile peritonitis.

Intravenous administration of fluids provides the
quickest and most efficient route for restoring fluids and
minerals. In infants and young children it is usually
necessary to cut down on one of the veins in the anti-
cubital fossa or in the ankle just anterior to the internal
malleolus. The longitudinal sinus should be used only
when other sites fail, or when one has had a great deal
of experience in using this route.

No comments concerning the subcutaneous adminis-
tration of fluid are necessary other than to warn against

the use of glucose in stronger dilutions than five per
cent, since irritation of tissues and sloughs are occa-
sionally encountered by higher concentrations. When
needles are placed bilaterally in the thighs and axillary
regions, and fluid is allowed to run in slowly, surpris-
ingly large quantities can be given in the course of a few
hours with very little discomfort. Frequently it is our
custom to give as much as 1,00 cubic centimeters to an
infant during the night without disturbing sleep.

Hartmann' has described very clearly the various
types of fluids which are necessary to restore the changes
brought about by severe diarrhea. Practically, only four
solutions need be considered. These are physiologic salt
solution, glucose solution, Hartmann’s solution and
blood.

Physiologic salt solution is the least effective of any
of these solutions. In our own experience, it is seldom
used, being replaced by glucose and Hartmann’s solu-
tions. In mild degrees of dehydration, it may suffice to
restore blood volume and tissue fluids, and by re-estab-
lishing urinary flow permit acid elimination through the
normal kidney mechanism. However, in severe dehydra-
tion and acidosis its use is contra-indicated, because
chloride ions are already in excess in the blood plasma,
and the injections of more chloride directly into the
blood stream may increase the already existing acidosis.

In severe dehydration glucose, given intravenously, is
indicated. It may be given in a ten or twenty per cent
solution, and in a dosage of twenty cubic centimeters pet
kilogram of body weight. Two or more injections daily
may be necessary. In addition to replacing lost fluid,
glucose acts as a diuretic, overcomes ketosis, and fur-
nishes a certain amount of food, which may be of value
if athrepsia is present to any degree.

The combined use of ten per cent glucose and Hart-
mann’s solution, administered intravenously or by veno-
clysis, is the measure of choice in correcting anhydremia
and acidosis. Hartmann’s solution is available in the
market under the name of physiological buffer salts solu-
tion, or as lactate, Ringer’s solution. The solution is a
mixture of neutral sodium lactate and the chlorides of
sodium, calcium, and potassium. It is effective-in either
acidosis or alkalosis, even where previous chemical de-
terminations of the blood have not been done. The con-
version of sodium lactate into bicarbonate proceeds at a
rate sufficiently slow to prevent the danger of shifting
from acidosis to alkalosis, such as sometimes occurs when
sodium bicarbonate is the solution injected. By means
of this solution, then, minerals lost in the intestinal
secretions can be replaced and the soda bicarbonate is
restored to normal levels. It may be given intraoeri-
toneally and subcutaneously, as well as intravenously and
by venoclysis. In a severe diarrhea exhibiting symptoms
of dehydration and acidosis, the procedure would be to
give twenty cubic centimeters per kilogram of Hart-
mann’s solution in ten per cent glucose intravenously,
and either repeat this amount one or more times dailv
in single injections, or by the continuous drip method,
run in three to six drops per minute. From 150 to 400
cubic centimeters of Hartmann’s solution would be

THE JOURNAL-LANCET

183

given intraperitoneally and from 500 to 1,000 cubic cen-
timeters subcutaneously, these amounts to be replen-
ished as rapidly as absorption occurs.

Molar’s sodium lactate in isotonic solution is some-
what more effective in correcting a severe acidosis, but
ordinarily it is not necessary to use both types of solu-
tons.

The value of one or more blood transfusions in these
seriously ill patients to supplement the fluid and mineral
administration should not be overlooked. Particularly
is this desirable when athrepsia and anemia have resulted
from a prolonged diarrhea. Blood transfusions should
not be given until the dehydration has been overcome.

Drugs find little place in the management of the di-
arrheas. Paregoric in suitable dosage may be used for
relief of tenseness, and adrenalin or caffeine may be
necessary as stimulants in collapse.

Feeding is a problem which merits some attention. In
acute diarrhea, if of any severity, all food should be
stopped for a period of twelve to twenty-four hours. Par-
ents readily grasp the point if it is suggested that the
way to put out a fire is to withhold fuel and put on
water. After the period of starvation, protein milk is
begun in quantities and dilution suitable to the age and
condition of the infant. Powdered protein milk is avail-
able on the market, and when four level packed table-
spoons are dissolved in twelve ounces of water the pro-
portions of Finkelstein’s original Eiweissmilch are ob-
tained; i. e., fat, 2.2 per cent, carbohydrate, 2.0 per cent,
and protein, 3.3 per cent. Such a food is not readily
attacked by the fermenting type of bacteria, and yields
about twelve calories to the ounce. Carbohydrate in the
form of corn syrup or dextri-maltose should be added
after forty-eight hours of protein milk feeding. When
improvement in the diarrhea occurs a gradual shift to
some form of acidified milk should be made, either
skimmed lactic acid milk, acidified evaporated milk, or
buttermilk. No attempt can be made to meet caloric
requirements in the early stages of the diarrhea; rather
the concentration of the food must be adjusted to meet
digestive tolerance.

No discussion of the dietary management of diarrhea
would be complete without reference to the raw apple
diet. This method of treatment was first used in Ger-
many some twenty years ago. It has had extensive trial
in this country and most of the reports are favorable. It
has been satisfactory in our experience. Essentially the
method consists of giving from one to four tablespoons
of grated ripe raw apple (including the skin) every two
hours day and night for forty-eight hours. Nothing elSfc
is given by mouth except water or weak tea solution.

Parenteral fluid administration is given as indicated to
prevent or overcome dehydration. The exact substance
in the apple which is responsible for the beneficial results
has not been definitely determined, but the measure is
worth a trial in suitable cases.

Summary

1. Diarrhea still occurs with sufficient frequency and
seriousness to be one of the major problems among the
illnesses of infants and children.

2. Except for bacillary dysentery, diarrhea is a func-
tional rather than an anatomic disturbance and is the
result of various etiologic factors.

3. Determination of the cause of the diarrhea is im-
portant so that treatment of the underlying factors, such
as a parenteral infection (otitis media), may not be
overlooked.

4. Mild diarrhea produced no significant clinical
changes.

5. Appropriate treatment of mild diarrhea may pre-
vent the sudden development of severe symptoms.

6. Purging is not only of no value in the treatment
of diarrhea, but may be harmful.

7. Severe diarrhea results in clinical changes described
by the terms, dehydration, anhydremia, acidosis, tox-
emia, and if prolonged, athrepsia.

8. Restitution of such changes requires the replacement
and maintenance of the fluid and mineral balance of
the blood plasma and tissues of the body.

9. The quantity of fluid necessary to prevent dehydra-
tion may be very large, and may require parenteral ad-
ministration by all routes.

10. Protein milk, acidified milk, and raw apple are
suggested as measures to be used in dietary manage-
ment.

Bibliography

1. Marriott. W. McK.: Infant Nutrition, C. V. Mosby Com-

pany, St. Louis, 193 5.

2. Jeans, P. C., and Floyd, M. L.: Upper respiratory infec-

tion as cause of cholera infantum. Jour. Am. Med. Assn.,
Ixxxvii: 220-223 (July 24) 1926.

3. Marriott. W. McK.: Further observations concerning nature

of nutritional disturbances. Laryngoscope, xxxv: 592-593 (August)
1925.

4. Dodd, K., Minot, A. S., and Casparis, H.: Guanidine as a

factor in alimentary intoxication in infants. Am. Jour. Dis. Child.,
xliii: 1-9 (January) 1932.

5. Nedzel, A. J. : The role of splanchoperipheral balance in
etiology of diarrhea. Illinois Med. Jour., lxix: 549-559 (June)
1936.

6. Marriott, W. McK., Hartmann, A. F., and Senn, M. J. E.:
Observations on nature and treatment of diarrhea and associated
systemic disturbances. Jour. Ped., iii: 181-191 (July) 1933.

7. Hartmann, A. F. : Theory and practice of parenteral fluid
administration. Jour. Am. Med. Assn., ciii: 1349-1354 (Novem-
ber 3) 1934.

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THE JOURNAL-LANCET

Observations on Pneumonia in Childhood*

Edward Dyer Anderson, M.D.**

Minneapolis, Minnesota

IN THIS paper I wish to discuss some of the aspects
of pneumonia that have seemed particularly interest-
ing to me, some of the mistakes that I have made
and the lessons they have taught me, with some con-
clusions that I have arrived at in my practice.

First, as to some of the unusual diagnostic problems
which we meet in pneumonia in childhood.

When in medical school, I thought that it was always
easy to make a definite diagnosis of either broncho or
lobar pneumonia. I believed that there would never
be any question as to with which type of pneumonia one
was dealing. I expected always to have the involvement
of a whole lobe with massive physical findings in lobar
pneumonia, and numerous scattered small areas in
bronchopneumonia. Also, if I were dealing with lobar
pneumonia, I expected to have a typical maintained-tem-
perature curve, while in bronchopneumonia I would have
an absolutely different type; namely, an irregular curve.
Although in the majority of cases one can make a defi-
nite diagnosis as to which type of pneumonia one is deal-
ing with, nevertheless, this is not always true. The
temperature curves do not always go as expected. Also,
in bronchopneumonia you rarely have small scattered
areas, but more often, have one area which may be
large or small. I have seen more than one case in
which I never was able to state definitely which type of
pneumonia was present.

It has been often said that as we become older we
become more tolerant of our fellow men. I believe this
is particularly true of physicians regarding their fellow
practitioners. As we grow older we learn how fallible
we are, and that the mistakes which we used to think of
with such scorn when made by other physicians, can be
so easily made by ourselves. When first starting the
practice of medicine, I remember how I used to raise my
eyebrows when I learned of some case where a doctor
had made a diagnosis of pneumonia and the next day
the child was well, with temperature normal, respi-
rations normal and the child "raring” to get up. Well,
I don’t raise my eyebrows any more, because more than
once I have seen a child with temperature of 103-105,
respirations of 40-60, cough, grunting respirations and
physical findings in the chest showing fine sub-crepitant
rales, and have told the parents that the child was very
sick with pneumonia and that it probably would be
seriously ill for several days, and then on coming to see
the child the next day, have found the parents sitting on
him trying to keep him in bed, and all symptoms and
physical findings gone. Whether these cases are pneu-

•Presented before the Hennepin County Medical Society,
Dec. 1936 and prepared expressly for the special Pediatric issue of
THE JOURNAL LANCET.

••Instructor in Pediatrics, University of Minnesota Medical
School.

monia of very short duration, or are due to asthma
occurring during an acute upper respiratory infection, or
whether they are cases of capillary bronchitis, one often
cannot say. I do know they occur, and they have fooled
me more than once.

Then there is the case of lobar pneumonia which we
so frequently see where no physical signs appear until
the third, fourth, or fifth day. In fact, there are many
cases where physical findings never appear, and the
X-ray alone confirms our clinical diagnosis. We should
not necessarily feel that we are poor diagnosticians when
we fail to hear signs in the chest in the first few days
of an illness in which the clinical and X-ray findings are
unmistakably those of pneumonia. In such a case, the
involvement may be so located in the chest that the
findings are not transmitted to the surface where we can
hear them.

Another condition which has always been of interest
to me is that type of pneumonia in which the child
does not seem to be particularly sick. This type is
usually a bronchopneumonia and is most frequently seen
in the late spring or summer. The child runs a very
low-grade temperature, has little or no toxicity and
is with difficulty kept in bed. Even though these child-
ren are really only slightly ill, there may be physical and
X-ray findings showing involvement of a considerable
area of lung tissue.

The frequency with which lobar pneumonia in child-
ren may give the clinical picture of appendicitis has
been noted many times. I wish only to emphasize again
its frequency and to call attention to the extreme care
that one must take in ruling out pneumonia in every
case of appendicitis in children before performing an
appendectomy.

Another condition which we occasionally meet in
lobar pneumonia in children which requires diagnostic
care is the case which simulates meningitis. Not in-
frequently, we see a child with all the clinical findings
and symptoms of meningitis, who has only a meningis-
mus along with his pneumonia. In this case, X-ray and
spinal puncture will rule out meningitis.

Otitis media, abdominal distention and empyema
are frequent complications of pneumonia in children.
The first, otitis media, is extremely common, particularly
in the lobar type. It often occurs without causing pain
to the child. Certainly one should examine daily the
ear drums of every child ill with pneumonia. In a
large percentage of cases, the otitis media clears up
spontaneously without rupture of the drum or para-
centesis. I personally never open the drum unless there
is severe pain or mastoid tenderness, or unless there is
definite bulging. Even in these cases when rupture of
the drum has taken place or paracentesis is done, the

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185

drainage usually stops soon after the pneumonia clears
up.

Abdominal distention is a common and most trouble-
some complication. When severe and prolonged, it is
usually a bad prognostic sign. Nasal suction has proved
to be a most valuable method of treating this complica-
tion, and is usually far superior to the old methods of
hot stupes and repeated enemas.

Empyema is one of the most dreaded complications
that we meet. The best method of treating this condition
is still under dispute. As is well known, long before the
work done by the empyema commission during the war,
Dr. Holt called attention to the high mortality in
children in whom open drainage was done during the
acute pneumonia. He advocated that conservative
treatment be used until the acute stage of the pneumonia
was well passed. After the war, the accepted method of
treatment of empyema in both adults and children
was to use either aspiration or the closed method of
drainage. Several years ago, some authors advocated the
use of repeated aspirations alone, and felt that the major-
ity of cases in children could be cured without the use
of closed drainage or rib resection. I do not believe that
these authors at the present time are as enthusiastic
about the use of this procedure as the sole method of
treatment as they formerly were. It is a method of ex-
treme value during the acute stage of pneumonia, and in
some cases of empyema one is able to use it alone with
complete cure. However, in the majority of cases more
radical procedures are necessary to cure the empyema
completely.

For several years closed drainage was considered to be
the method of choice in the treatment of those cases of
empyema in children where aspiration alone was not
sufficient. In my experience the closed method of drain-
age has proven most unsatisfactory in the majority of
eases, and in most instances has been a flat failure. It
is almost impossible to get a really air-tight system in
ehildren for any length of time. They are so active,
■vriggle, twist and squirm so much, that in a short time
:here is leakage around the tube. Also, the fluid usually
becomes so thick that it will not drain adequately through
i catheter or tube.

The method of closed drainage is unquestionably of
/alue in those cases in which inadequate drainage is ob-
ained by aspiration, but where the child is too ill to
ittempt rib resection. In some instances the closed
nethod will serve to cure completely the empyema.
Towever, in my experience this is usually not the case,
ind after the child has gained sufficient strength, rib
esection has to be resorted to.

The method of procedure which I most commonly
ise today is as follows: if empyema develops, I use

tspiration during the acute pneumonia, repeating this
procedure as often as is found necessary to reduce pres-
ure symptoms. Aspiration is continued until the acute
cage of pneumonia is passed, or until I am convinced
hat the empyema is cured or that the fluid is going to
ontinue to form or until the fluid becomes so thick that

it can no longer adequately be aspirated through a needle.
Within at least a week or ten days from the time one
considers the acute pneumonia to be over, one can deter-
mine whether the empyema is subsiding. When this
decision is made and aspiration is not adequate, if the
child is in good general condition, a rib resection is
done. If the child is not in condition to stand rib re-
section, a large catheter is introduced into the chest
cavity by the trochar method. Effort is made to avoid
leakage around the catheter, and also to prevent too-
rapid drainage of the fluid at first; so as to avoid too
rapid change of pressure in the chest with resultant cir-
culatory difficulties. For the first 24 or 48 hours, the
catheter is connected up with a negative pressure ap-
paratus, for perhaps, for this length of time there may
be little or no leakage around the wound. Usually at
the end of this time the negative pressure apparatus is
disconnected and sterile dressings placed over the
catheter. Suction with a syringe or washing with
Dakin’s solution or normal salt solution to prevent
clogging of the tube is sometimes of value.

In some instances the empyema clears up. However,
in the majority of cases it does not, as adequate drain-
age cannot be obtained in this way. Nevertheless, the
child has usually gained in general strength, and when
one sees that adequate drainage is not being obtained,
rib resection is done.

There is often a tendency for all of us to forget the
value of rest in the treatment of pneumonia. I think
we all agree that this is the most dreaded thing to be
obtained in the treatment of this disease. Certainly I
have become convinced that this is more important than
anything I can do for a child ill with pneumonia. Yet
I realize that I myself, have at times in the past, been
instrumental in keeping the child from getting the thing
it needed most. In my zeal to do something to help, I
have ordered procedures, medications, food and fluids
to an extent that has made it impossible for the child to
get adequate rest. There was a time when I thought
that if a child with pneumonia had a high temperature,
that it must be combatted, and I endeavored to keep it
down. My usual order was that if the temperature was
above 102, tepid body packs or alcohol or tepid sponges
should be applied every hour. I am convinced now that
in the majority of cases this is not only unnecessary but
actually harmful. It means disturbing the child every
hour, often waking him up from a sleep, and besides
this in most instances, the child hates hydrotherapy in
any form and cries and fights and exhausts himself.
The only time I use hydrotherapy at the present time
is when I think the temperature is causing discomfort
and restlessness. Otherwise, regardless of the tempera-
ture, I do not use it.

Another instance of meddlesome therapy is the pro-
miscuous use of enemas in children with pneumonia.
These are given either to reduce temperature or to cause
evacuation of the bowels. Children almost invariably
resent enemas and fight against them to the point of
exhaustion. There are of course times when they must
be used, but mild cathartics will usually take care of

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bowel elimination without the exhaustion caused by
enemas.

It is of course, important that adequate food be given
to a child suffering with a prolonged illness, but the
average case of pneumonia in a child does not last more
than a week at the most and I think it is unnecessary
and unwise to force food in any great amount during
this time. In the past, children with pneumonia who
would not take food were often tubed so that their cal-
oric intake was kept up. Personally, I think that this
is a most pernicious procedure in most cases. The strug-
gle which the child puts up against this procedure can
often be of greater harm than value obtained from the
food.

The question of giving fluids to children with pneu-
monia is an important one. I realize perfectly the value
and importance of an adequate fluid intake in infants
and children suffering with pneumonia. However, the
value has been so emphasized in the last few years, that
I think we sometimes overdo it. I feel that fluids should
be pushed but within reason. The child should not be
disturbed every few minutes to give it fluids. An
attempt to give food, fluids, and medications all at about
the same time should be made so that there is not con-
stant disturbance of the patient. Except in unusual
cases, the average youngster will get sufficient if fluid is
offered every two hours during the day, and only when it
awakens in the night. I believe it is more important to
have a record kept of the amount of rest and sleep the
child gets than it is to chart the food and fluid intake.

The value of serum therapy in the treatment of
lobar pneumonia in children is still a question to be
decided. Several writers up to the present time have
felt, because of the comparatively low mortality rate of
lobar pneumonia in children, the difficulty of getting
material for typing of the organism; the difficulty of in-

travenous therapy in children; the severity of serum re-
actions; that serum therapy was not practical. It seems
to me that until we have had a great deal more work
done upon this subject, no definite decision can be
made. However, the increasing number of reports of
the excellent results obtained in the use of pneumonia
serum in adults should make us hopeful that it will
prove of definite value in children.

It is true that present evidence indicates that there is
a great difference in the incidence of the different types
of pneumococci in children under 12 years compared to
adults. Types I and II are much less frequent in child-
ren, and Type IV much more common at the present
time. The use of serum therapy is particularly efficient
in cases where Types I and II are the infecting organism.
Nevertheless, with increased knowledge of the various
types which make up Group IV, and with improvement
in the potency of serum, we can look forward with hope
to the use of serum therapy in children.

Material for typing can be obtained in most children
by use of laryngeal swabs or by gastric aspiration. With
the development of the Neufeld method, early determi-
nation of the type of pneumococci can be made at the
present time. Where one has access to adequate labora-
tory help, one should endeavor to determine early in the
disease what organism is the cause of the pneumonia and
if it is found to be a Type I or II pneumococcus, serum
therapy should be used in the cases which clinically in-
dicate any degree of virulence.

Although serum therapy in the treatment of lobar
pneumonia in children may never hold the place which it
will in adults, nevertheless, it does offer in many in-
stances a distinct advance in our method of combating
this disease, and I believe in the future will be of even
greater value.

Asphyxia Neonatorum

Roy E. Swanson, Ph.D., M.D.**
Minneapolis, Minn.

THE first and most important event that should
occur at the completion of the birth of a baby is
the establishment of respiration. This should
most happily be followed by crying, which, forcing air
against a partly-closed glottis must aid in the opening of
the atelectatic new-born lung. Henderson1 asks the
question "Why does the baby begin to breathe?” and
aptly states that the purpose is clear but the means
obscure.

A considerable number of terms appear in the litera-
ture in relation to the asphyxiated states in the newborn.
The term asphyxia (meaning suffocation) is loosely ap-

•Prepared expressly for the special Pediatric issue of THE
JOURNAL-LANCET.

* ’Assistant Professor of Obstetrics and Gynecology, University
of Minnesota Medical School, Minneapolis

plied as a general term, all causes included. Previous
to the 18th century, asphyxia meant no pulsation in an
artery, in particular below a tourniquet. In the 18th
century, it applied mostly to drowning, and soon after,
it included death from strangulation and noxious gases.
Obstetrically speaking, in its present day usage, we apply
it to any baby who fails to breathe at birth, irrespective
of cause. Various more specific terms such as apnea,
acapnia, anoxemia, hyperpnea, etc., are avoided in this
paper in order not to confuse the average reader into
whose hands the bulk of this work falls.

The controversy in the literature regarding the roles
played by oxygen and carbon dioxide in the causation
and cure of this condition is unfortunate. It has been
implied that an accumulation of CCT, is as much a cause

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187

of death as lack of O. It further has been assumed
that a deficiency of O killed by producing an excess of
CO-. Haldane and Priesdey’s classical demonstration
proved that CO-, rather than O, is the chief immediate
factor in respiration. Oxygen has been proven not to be
a respiratory stimulant, although minor degrees of
oxygen-want increase respiration, and profound levels
of oxygen-want cause absence of respiration. Whatever
the tests for CO- tension in the blood show, the prac-
tical answer is that the use of CO- and O has proven
to be of untold value in the establishment of respiration
in asphyxia neonatorum. After respiration is established,
O becomes the main requirement.

The mortality rate in the first 15 minutes of life is
said to be as great as in any subsequent month. It is
said that approximately one in twenty babies die in the
first 24 hours of life. Asphyxia plays a large part in
these deaths, both as a primary as well as a secondary
cause. In states with an increasing degree of oxygen-
lack, consciousness is lost, respirations cease, the heart
beats more and more slowly, and soon a complete col-
lapse of muscle tone is reached resulting in death from
asphyxia1. The ill effects of asphyxia are not limited to
the respiration alone, since true respiration is, according
to Henderson, a process occuring fundamentally in the
tissues. A lack of oxygen produces tissue death, rupture
of vessels and hemorrhage even without the trauma of
labor (cesarean section). Unfortunately, in autopsy
reports on these babies, hemorrhage (cerebral) is many
times the principal pathological finding and the under-
lying causative factors are disregarded. Haldane has
said that oxygen-lack not only stops the machine but
wrecks the machinery.

The Causes of Asphyxia Neonatorum

The most simple and inclusive list of causes of
respiratory failure in the newborn (asphyxia neona-
torum) is given by Moncrieff in The Ldncet. He lists
them as follows:

A. Central Causes:

1. Immaturity of the respiratory center.

2. Damage to the center (increased intracranial
pressure, edema, hemorrhage.)

3. Narcosis (morphine, nitrous oxide, ether, bar-
biturates.)

4. Chemical factors (oxygen lack, CO- excess.)

5. Circulatory (in utero) , cord disturbances, etc.

B. Peripheral Causes :

1. Obstruction to the air ways.

Premature inspiration.

2. Delayed expansion of lung (atelectasis.)

3. Muscular feebleness.

4. Circulatory failure (profound collapse of muscle
tone.)

The triad, cerebral hemorrhage, prematurity, and
asphyxia represents the greatest causes of post and neo-
natal death. In a recent study (Robbins) in a Minne-

apolis hospital, approximately 50% of these deaths were
in premature infants. When one realizes the immatur-
ity of the centers and the ease with which the premature
tissues are injured, this is not at all surprising. It seems
obvious that, in spite of the improved pediatric care
given to prematures, no great advancement can be ob-
tained in this group without better obstetrical results in
the prevention of premature births. The major patho-
logical process in 50% of premature deaths is cerebral
hemorrhage.

Damage to the brain centers, in spite of the fact that
the newborn’s skull is well fitted to withstand increased
pressure by virtue of its fontanelles, sutures and yielding
brain, is common (Cushing) , even in spontaneous labors.
Hemsoth & Canavan3 showed microscopic hemorrhage
in sections through the medulla oblongata sufficient to
cause death in a group of unselected infant autopsies.
During the expulsion of the fetus a tremendous differ-
ence in pressure may exist up to 250 mm. in excess of
atmospheric pressure. The uterus thus causing an in-
creased positive pressure to the fetus in utero, and an
excess negative pressure to the head. This latter may at
times occur very suddenly. This may result in edema or
hemorrhage within the skull, with resultant damage to
the center. Excess compression, traction and rotation
result in similar injury. Rapid extraction of the after-
coming head, without a generous episiotomy or excessive
pressure on the after-coming head from above produces
even worse injury. The careful use of low forceps after
the head has been on the floor for a reasonable time like-
wise may prevent these injuries.

Opiates are being used much less frequently in labor
in the teaching clinics of this country. Their use is be-
ing more restricted for rest to the laboring woman rather
than for analgesia. Shute & Davis4 at the Chicago
Lying-In Hospital show that infants born within one or
after six hours subsequent to the use of morphine in the
mother, show little if any narcotic effect. Between these
hours only 50% are affected to any great degree. Mor-
phine may be safe in their opinion if adequate means of
resuscitation are at hand. Irving5 states that children
born from mothers who have received neither analgesic
nor anesthetic drugs, breathed immediately after birth
in 98.1% of cases. He further states that with the use
of nitrous oxide oxygen mixture and ether, 80%
breathed at once. In cases where barbiturates were used,
50 to 65% breathed at once. Eastman0 believes that
chloroform has no demonstrable effect on oxygen sat-
uration of the fetal blood, but its use may be injurious
to the mother; that ether produces slight depression of
the oxygen saturation, although not sufficient ordinarily
to cause injury. Nitrous oxide oxygen mixtures 85 to 15
or weaker and for periods of less than five minutes reg-
ularly cause moderate degrees of fetal distress, but in
the normal full term, the infant is apparently not
harmed. When nitrous oxide and qxygen in concentra-
tions 90 to 10 or stronger are used over periods in excess
of five minutes, marked degrees of fetal distress are pro-
duced in about one out of three cases and occasionally
profound asphyxia neonatorum results. It is wise when

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using nitrous oxide oxygen mixtures never to go below
15 per cent oxygen mixtures before the birth of the
baby. Do not allow maternal cyanosis to become evident.
If deeper anaesthesia is needed, ether should be added or
substituted for the gas in the interests of the baby. Eth-
ylene may possibly be safer, but it is more explosive and
many delivery rooms are not properly insulated for its
use. The more recently used gas, cyclopropane, in mix-
tures up to 50 per cent with oxygen, appears to offer the
best g.v> so far for obstetrical use, where profound re-
laxation is not required.

The use of various barbiturates has been steadily in-
creasing in labor. There is much divergence of opinion
regarding their action on the fetus and infant. Anima'
experiments by Berutti' with dial, veronal, luminal,
somnifen, evipal and pernocton show that the placenta
(in these animals) is very permeable to these drugs.
More so to luminal and less so to evipal. These drugs
passed to the fetus within fifteen minutes and reached
a maximum in five hours. DeLee comments that many
babies are somnolent and poor nursers after labors med-
icated with barbiturates, for as long as 36 hours, and
that they probably delay complete opening of the lung
for as long as a week. Lewis1', reporting on a large
series of cases where morphine, scopolamine and the bar-
biturates were used in labor, found very few babies nar
cotized from the latter. When a combination was used,
the incidence of narcotized babies increased about five
times. He comments on the fact that the traumatism of
labor is the most important factor influencing this nar-
cosis. Danforth9 favors scopolamine and nembutal and
he, like his colleague, Galloway93, states that no fetal
deaths could be attributed to their use. Randall of the
Mayo Clinic10 reports the successful use of pentobar-
bital sodium without fetal distress. Darchman & Shir11
report a high incidence of asphyxia with sodium amytal.
Many reports from England and the continent are fa-
vorable with a variable amount of asphyxia. It is quite
generally thought that morphine causes more asphyxia
than do the barbiturates.

The establishment of respiration in the new born is
thought to be accomplished by chemical rather than by-
physical factors. Eastman12 found the CCT tension in
the asphyxiated infant to be twice that of the normal
baby. He believes that the use of CCT for resuscitation
is superfluous and even harmful, since there is already
an existing acidosis. The oxygen content of the feta!
blood in asphyxia, he states, is so low as to be inad-
equate. He believes that the fetus in utero is definitely
less sensitive to CCL. In profound asphyxia, he finds
the CO2 content lowered as a result of replacement by
large amounts of lactic acid. Henderson has advocated
the use of CCL and O as a means of establishing respira-
tion for many years and his work has gained a large
following both here and abroad. There is no doubt
that inadequate oxygen as well as excess CCL is very
injurious to the higher centers.

It is now well-established that the fetus in utero makes
distinct rhythmic respiratory movements weeks and
months before birth, These movements are ineffective

in expanding the lung. This fact has impressed Hen-
derson11 very much in elaborating his muscle tonus
theory on respiration, metabolism and circulation. At
birth, external stimuli increases muscle tone. Without
muscle tone, blood would stagnate in the tissues and
circulation would fail. Henderson’s first experiments
with dogs thirty years ago proved that over-ventilation
killed. Collapse consisted in a failure of circulation
rather than of the heart. The injury was to the venous
return due to a complete failure of muscle tonus. In
situations where we have disturbances of the cord from
knots, coiling and prolapse, we promptly get a condition
of oxygen want with subsequent collapse of circulation.
Vagus action gives us a slower and slower heart until it
ceases to beat. A slowing heart is more dangerous than
a rapid one. In conditions disturbing placental circula-
tion, such as placenta praevia, ablatio, rupture of the
uterus, tears of the cord, toxemias and syphilis with their
impaired placental interchange, circulatory disturbances
become serious. Abnormalities of uterine contraction,
excess stimulation with pituitrin, excess bearing down, all
may produce profound circulatory disturbances from
injury to the centers in utero.

Peripheral causes which are of the most moment to
us are obstructions to the air way by meconium, mucus,
blood and amniotic fluid; premature attempts at inspira-
tion and delayed expansion of the lung. Muscular feeble-
ness and circulatory failure complete the picture. The
diagnosis of atelectasis is sometimes difficult. Breath
sounds, if present, may help. X-ray, where respiration
is established, is of aid. Attacks of cyanosis, with irreg-
ular breathing, constant accumulations of mucus are
noted. Atelectasis as a primary condition is probably
a grossly exaggerated post-natal cause of death. It has
been used many times to cover up unknown causes14.

Treatment

In the intelligent treatment of asphyxia neonatorum,
i: is first necessary to establish in one’s mind the degree
of asphyxia. Is the child merely depressed, borderline
or dying1'1? For many years asphyxia neonatorum has
been divided into asphyxia livida and asphyxia pallida.
The general idea being that they are degrees of the
depth or length of the oxygen lack. It may also be
postulated that these two types represent degrees of
injury. Thus the observer, in outlining his contemplated
plan of procedure in any given case, should attempt to
evaluate the primary cause of the asphyxia. Is it due
to anaesthesia, drugs, obstruction, atelectasis, injury or
some unknown factor?

Before discussing the detailed treatment of asphyxia
neonatorum, a brief review of three important phenom-
enon in respiration will be reviewed.

Resistance to respiration will result in a decrease of 0
and an increase of COL> in the blood. As a result, the
respiratory center will be stimulated and the resulting
hyperventilation will wash out the CO-j excess. If the
resistance prevents hyperventilation, an adequate de-
crease in CO^ is not obtained. The resulting acidosis
may be balanced by an increase in the total CCL in the
blood as carbonates10. Henderson’s1 ‘ experiments with

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189

dogs, kept in atmospheres of increased CCL tension,
showed an adjustment of the respiratory center in these
animals to the change. A return of the animal to nor-
mal COj tensions, produced asphyxia for long periods
and frequently death from oxygen lack.

Bohrls has shown (Bohr phenomenon) that hyper-
ventilation will wash out CCL to a much greater degree
than it will increase the oxygen saturation of the blood.
Oxygen in the alveolar air, under ordinary pressure, will
saturate the blood as well as when a considerable increase
in oxygen tension exists. If the CCL tension is main-
tained and the alveolar oxygen tension much reduced,
the blood will lose its oxyhemoglobin saturation and
cyanosis will result. If the alveolar oxygen remains the
same and the COL. tension is markedly reduced, cyanosis
v/ill disappear. With a low COj tension, oxygen is not
freely broken off from oxyhemoglobin, and the tissues
suffer even though the oxygen tension of the blood is
high. The disappearance of cyanosis ushers in a more
serious situation to threaten the life of the patient. It is
essential to maintain a proper CO_> tension in the blood
and alveolar air.

The Hering-Breuer1*’ reflex is based on vagus action.
Distention of the lung stimulates nerve endings in such
a way that inspiration is halted and expiration initiated.
Deflation in turn stimulates nerve endings to the end
that expiration is stopped and inspiration begun. Thus
inspiration causes expiration and vice versa. This reflex
makes the use of intratracheal insufflation most logical.

The treatment of the average case of delayed breath-
ing should be successful if the following principles are
observed:

1. Extreme gentleness.

2. Clear air passages with a bulb or trap aspirator.

3. External warmth.

4. Establish drainage by posture.

5. Avoid severe external stimuli.

6. Forward traction of the tongue.

7. Determine absence or presence of pharyngeal
reflexes.

8. Have CO^ and O mixtures, under controllable
pressure, available.

9. Avoid suspension by the feet if cerebral hem-
orrhage is suspected.

10. Limit asphyxia to as short a time as possible.

If respiration does not start and all of the above
principles have been followed, more drastic methods
must be used. These will depend upon the equipment
at hand.

1. Mouth to mouth breathing. This method has been
superseded by more scientific methods. The only reason
for its existence is its immediate availability. It still,
however, has many advocates.

2. Drinker respirator. This machine is expensive and
is not always available. It requires valuable time to
place the baby and close the cover. Attendants in the
delivery room are not always well informed in its use.
The amount of negative pressure necessary to inflate the

atelectatic lung in the newborn is not always reached.
This machine has not lived up to expectations in the
newborn.

3. Inhalation of CCL (5 to 7 per cent) and O with a
mask as advocated by Henderson & HaggardJI). Slight
positive pressure is maintained and the mask is raised
15 to 20 times a minute.

4. The intratracheal catheter. This can be placed
either by touch or by direct vision with a pharyngo-
scope'-’1. This method is superior to all others since it
assures patency of the air way and permits introduction
of COj and O mixtures under pressure. This may ini-
tiate respiration because of the Hering-Breuer reflex
and assures one of a pressure sufficient to dilate the lung.
It assures one of lung ventilation without respiratory
movement. Its more frequent use is urged.

5. Drugs. Adrenalin, alpha lobelin, and coramine are
the three most commonly used drugs. They are most
frequently used as a last resort and are usually disap-
pointing.

Summary

1. The cause and treatment of asphyxia neonatorum,
a term loosely applied to all babies not breathing at
birth, is discussed. The views of many writers are in-
cluded.

2. Certain phenomena of respiration are reviewed
with the hope that we may be better able to evaluate
various recommended procedures.

3. The use of CCT and O mixtures are of great
assistance in the establishment of respiration in the new-
born and should be available in all delivery rooms and
nurseries.

4. Mechanical machines have a greater place in main-
taining respiration than they have in initiating it.

5. Intratracheal insufflation with COo and O under
controlled pressure should be more universally used.

6. Drugs for stimulating respiration are frequently
disappointing.

7. Gentleness in resuscitation is recommended.

8. The best treatment for asphyxia neonatorum is its
prevention.

Bibliography

1. Henderson, Yandell, Science 85:89, Jan. 22, 1937.

2. Moncrieff, Lancet 1:531, March 9, 1935; :595, March 16,
1935; : 664, March 23, 1935; :736, March 30, 1935.

3. Hemsoth Qc Canavan, Am. J. Obs. Qc Gyn. 23:471, 1932.

4. Shute Qc Davis, S. G. O. 57:727, 1933.

5. Irving, S. G. O. 58:1, 1934.

6. Eastman, Am. J. Obs. Qc Gyn. 31:563, 1936.

7. Berutti, Ginacologia 2:407, May 1936.

8. Lewis, South. M. J. 29:178, Feb. 1936.

9. Danforth, Med. Rec. Qc Ann. 30:717, May 1936.

9a. Galloway, J. A. M. A. 106:505, 1936.

10. Randall, Texas State J. Med. 32:385, Oct. 1936.

11. Darchman Qc Shir, Am. J. Obs. Qc Gyn. 32:97, July, 1936.

12. Eastman, Bull. Johns Hopkins Hosp. 50:39, 1932.

13. Henderson, Science, 85:89, Jan. 22, 1937; 83:399, May
1, 1936.

14. Liff, Am. J. Obs. Qc Gyn., 32:286.

15. Brown, Canada Med. Asso. J. 28:75, 1933.

16. Brown, Canada Med. Asso. J. 28:176, 1933.

17. Henderson, J. Biol. Chem. 33:333, 1918.

18. Bohr, Centralbl. of Physio. 16:22, 1903.

19. Haldane, Respiration, Yale University Press: 193 3.

20. Henderson Qc Haggard, J. A. M. A. 96:495, 1931.

21. Flagg, J. A. M. A. 91:789, 1928.

190

THE JOURNAL-LANCET

The Management and Feeding of the
Premature Infant

Albert V. Stoesser, M.D., Ph.D.**

Minneapolis, Minn.

PREMATURITY refers to infants who are horn
before the 36th week of gestation and weigh less
than 5J4 pounds (2,500 grams) and who usually
differ anatomically and physiologically from normal
full-term infants. Infants having a low birth weight
are not necessarily premature, as the smaller size may
be an inherited characteristic; nor are all infants who
have been delivered prematurely necessarily below the
average weight of full-term infants. In general, however,
prematurely born infants and immature full-term in-
fants who are small at birth require special care. In the
following paragraphs the term premature is used to
include immature full-term infants, as well as infants
born prematurely, coming under the weight classifica-
tion cited above.

Premature infants, because of underdevelopment, are
at a great disadvantage when compared to normal
infants. Due to shorter intra-uterine life, they show
under-development of their heat-regulating mechanism.
The body temperature tends to fall below normal on
slight exposure to cold, and to rise above normal due
to high surrounding temperatures. Where the surround-
ing temperature is not subject to careful regulation,
daily variation of body temperature of as much as
5°F. has been observed.

The respiratory center is also underdeveloped, which
accounts for the large incidence of respiratory failure,
and for the frequency of irregular respirations punc-
tuated with long periods of apnea (transient cessation
of respiration). These periods may be so long at times
as to lead to death from suffocation. Sometimes,
however, the apnea of premature infants may be due
to intracranial hemorrhage involving the respiratory
center, rather than to underdevelopment.

As a corollary of an immature gastrointestinal tract
the digestive capacity of premature infants is low; intes-
tinal motility is impaired, and absorption of food is poor.
Normal digestive enzymes may be present in reduced
amount. The gastric capacity of the premature baby is
likely to be disproportionately small and per unit of
weight the food and food accessory requirements are
greater than those of the normal full-term infant.

In view of these illustrations of physical immaturity,
it naturally follows that the premature infant’s ability
to adjust to a feeding formula and to cope with infec-
tion is much less than that of the full-term normal
infant. With these two factors in mind, the Pediatric
staff of the Minneapolis General Hospital has worked

•From the Pediatric Division of the Department of Pediatrics,
University of Minnesota, at the Minneapolis General Hospital, and
prepared expressly for the special Pediatric issue of THE JOUR-
NAL-LANCET.

••Assistant Professor of Pediatrics, University of Minnesota.

out a schedule for the care of the premature infant
which has given very satisfactory results in that the mor-
tality rate of these infants has been consistently drop-
ping from year to year. This is very clearly shown in
Table I which reveals that a rather small number (6.6
per cent) of premature babies now die after the forty-
eighth hour of life. In order to present in a practical
way the program which has given these results it was
thought best to offer suggestions in the form outlined
below.

Reception of the Premature Infant

Prematurity is an emergency condition and is fre-
quently precipitate. Preparedness at the time of birth
frequently means the difference between life and death
to the infant. Two things are of predominant impor-
tance: (1) prevention of chilling or exposure over too
long periods of time and (2) asepsis. When the possi-
bility of premature birth is suspected, one must be
prepared. In the nursery the heating unit of the incu-
bator (or whatever equipment is employed) is turned
on as soon as word is received from the physician. A
design for a premature incubator is shown in the accom-
panying illustrations. (Figures 1, 2, 3 and 4).

This equipment is simple and inexpensive. It con-
sists of a white enameled wooden box, supported on four
legs with roller casters. When the cover is down, the
size of the opening in it may be regulated by sliding
panels. The head end of the bassinet in the incubator
may be lowered to facilitate the removal of mucus from
the infant’s respiratory passages. The temperature is
controlled by a thermostat and humidity may be added
at any time. All of this is obtained in a rather compact
portable apparatus.

When the temperature of the incubator and bassinet
reaches 100°F., the heating unit is turned off but the
temperature is not allowed to fall below 98°F. When
the baby arrives the temperature is adjusted so as to
maintain body temperatures between 98° and 99.6°F.
The heating capacity of the incubator should be such
that this can be attained.

In the obstetrical delivery room the baby should be
immediately placed in a warm receiving blanket or in
sterile absorbent cotton covered with two layers of
gauze, and if his condition permits, and there is no
maternal emergency, the cord should be allowed to
pulsate for two or three minutes before ligation, during
which time it will receive an additional 1 to 2 ounces
(30 to 60 cc.) of blood. The baby is placed in the
prepared bassinet. The cord may then be tied. A soft
absorbent diaper is folded and placed at the buttocks
to catch meconium and urine. This is changed as
required.

THE JOURNAL-LANCET

Figure 1. The premature incubator with cover lowered. The
sliding panels for the opening in the cover are shown.

Great care should be taken at delivery to remove
mucus from the air passages by carefully wiping the
nose and mouth with a piece of soft gauze. The head
should be held dependent so that secretions and mucus
which have accumulated in the respiratory passages may
escape.

Premature infants should not be bathed during the
first day or two. It is preferable to cleanse small infants
with warm liquid petrolatum or olive oil. The genital
and anal regions should be carefully cleansed with
sterile water, avoiding trauma.

During the first sixteen hours the baby is observed
frequently by the nurse. Orders should be given to
notify the physician immediately if cyanosis, irregular
respiration, convulsions, pallor or hemorrhage develop.
Resuscitation may be efficiently performed within the
bassinet.

Maintaining the Body Temperature of
the Premature Infant

Unless otherwise ordered by the physician, the tem-
perature is taken just before feeding time and not more
often than every four hours. The body temperature of
the premature infant should be maintained between 98°
and 99.6°F. and always recorded. Body temperatures
lower than 98°F. over long periods of time are probably
more hazardous than those slightly above 100°F.

The room temperature should be between 72° and
80°F. and the incubator temperature should be 80° and
86JF. or more, depending in each case on the amount
of heat necessary to maintain the premature infant’s

Figure 2. The incubator with cover raised. The rod and
ratchet combination shown on the right permits lowering or raising
of the head end of the bassinet. The thermostat for automatic
regulation of the temperature is also visible.

body temperature as stated previously. The higher tem-
perature of the bassinet is necessary for the smaller
infants. Regulation of incubator temperature is effected
by thermostatic control, by turning on and off the elec-
tric heating units or lights, by lowering the cover or
by hot water bottles, depending upon the type of
incubator employed.

The humidity of the room or the incubator is like-
wise of paramount importance. Relative humidity
should be kept between 45 and 55% saturation — par-
ticularly in the case of very small premature babies.

Room or incubator temperature and humidity should
be recorded at the request of the physician.

No premature infant should be removed from pre-
mature care until it can maintain a normal temperature
at all times with the heating unit entirely turned off.
This must be considered before a premature infant is
discharged.

In view of the many external surroundings which
require regulation, a special room should be reserved for
the use of the premature baby. In the hospital this is
frequently possible and in the home every effort should
be made to provide isolation and the desired physical
surroundings.

Treatment of Asphyxia

All premature infants should be carefully watched for
cyanotic attacks during the first days of life, as such
attacks may develop suddenly and without warning.

192

THE JOURNAL-LANCET

Figure 3. The front of the incubator. The position of the
humidifier is shown. It is turned1 on or off by the middle 6witch
which has a pilot or safety light attachment.

Infants below 3.3 pounds (1500 grams) must be
watched very closely. If cyanosis develops shortly after
birth the first thought is the removal of mucus.

Mucus is removed from the throat and mouth most
effectively by aspirating with a soft rubber ear syringe
or a soft rubber catheter attached to a syringe for suc-
tion. The mouth is not swabbed out with gauze, as a
slight abrasion of the mucous membrane might occur.

To remove mucus or amniotic fluid from the larynx,
trachea, or bronchii, the infant is held with the head
dependent, the trachea and larynx are gently stroked
toward the mouth and suction is applied to the pharynx.

If the premature infant does not begin to breathe
after removal of any obstruction of the air passages,
oxygen with 5 to 10% carbon dioxide may be advan-
tageously used, administered by nasal catheter. Rate of
flow should be between 60 and 120 bubbles per minute.
The infant size Drinker respirator has been tried with
little success.

Artificial respiration without undue trauma may be
employed. For this purpose the infant should be sus-
pended by the feet, the forehead resting lightly on the
bed or table, so as to deflect the chin and straighten out

Figure 4. The floor of the incubator. The four electric heating
units and the two lights controlled by the thermostat, and the
opening for the vapor from the humidifier are shown.

the trachea, and then the chest is compressed between
the thumb of the right hand resting on the back and
the four fingers of the same hand resting on the anterior
wall of the chest. The act should be repeated from 15
to 30 times a minute by compressing and suddenly relax-
ing the chest wall.

Careless handling and traumatizing the infant, or too
rapid performance of artificial respiration, is productive
of more harm than good and must, therefore, be
avoided.

If the premature infant is cyanotic but breathing,
insert a small nasal catheter into the nostril so that the
tip of the catheter extends to the edge of the soft palate,
and give a mixture of 5 to 10% carbon dioxide in
oxygen continuously until cyanosis is relieved. It may
be desirable to repeat this procedure at regular inter-
vals for several days in case cyanosis persists. Avoid
irritation of the nostril.

One minim of epinephrine (1:1000) may be given
every hour to the very small infants, until they show
definite signs of activity. That may be for three or four
days and then the dose may be increased to a maximum
of 3 minims every four hours. Some very weak pre-
mature infants may require 3 minims every four hours
routinely until they are quite definitely active; then
every eight hours, every twelve hours, finally, every
twenty-four hours until discontinued by the physician.
The adrenal glands are probably not very active in
these very small premature babies.

THE JOURNAL-LANCET

193

TABLE I. MORTALITY RATE OF PREMATURE INFANTS
Six Year Period — Minneapolis General Hospital

Year

1930-1931*

1931-1932*

1932-1933*

1933-1934*

1934-1935*

1935-1936*

Total Number of
Prematures

148

155

139

145

146

120

No. of Deaths —

No.

Av.Wt.

No.

Av.Wt

No.

Av.Wt.

No.

Av.Wt.

No.

Av.Wt.

Av.W't.

Less than 1 hr.

4.7

1505

3.1

1160

8.6

960

11.7

1069

3.4

1153

2.5

1222

1 hr. to 1 6 hr.

12.1

1553

14.0

1126

14 0

1158

10.5

1526

1 1.6

1443

11.7

1505

16 hr. to 48 hr.

6.0

1489

3.7

1820

4.4

1372

2.8

1240

4.1

1332

5.8

1924

Total up to 48 hr.

22.8

20.8

27.0

25.0

19.1

20.0

48 hr. to 10 days

23.0

2255

18.0

2237

3.5

1915

0.7

1425

3.4

1723

3.3

1590

More than 10 days

15.0

2197

27.0

2194

3.5

2033

6.9

1662

4.9

1694

3.3

1907

Total over 48 hr.

38.0

45.0

7.0

1 1

7.6

8.3

6.6

Grand Total

60.8

102

65.8

34.0

32.6

27.4

26.6

•July first to July first.

Any evidence of asphyxia or cyanosis at any time
should be reported to the attending physician im-
mediately.

Intracranial Hemorrhage

If there is evidence of intracranial hemorrhage or
hemorrhagic disease of the newborn, whole or citrated
blood warmed must be given deep subcutaneously or
intramuscularly at once, 1 3 to 1 ounce ( 10 to 30 cc.)
— depending upon the size of the baby. This blood
need not be grouped or matched if given intramuscu-
larly, but should be Wassermann negative. This will be
administered by the physician but the set-up should be
ready. If bleeding persists, the procedure is repeated
every 24 hours for two to three days.

Hemorrhages from the skin, mouth, rectum and geni-
talia, especially between the third and sixth day after
birth should be reported to the physician immediately.

Care of the Eyes

One per cent silver nitrate solution or 15 per cent
argyrol is used of course to prevent ophthalmia neona-
torum. This should be followed by normal saline solu-
tion instilled in the eyes. Not infrequently the applica-
tion of silver nitrate will result in some inflammatory
reaction of the conjunctiva in the first 6 to 12 hours
after its application. This occurs more frequently in
premature infants than in full-term infants and is
usually relieved by cold applications. It is not to be
confused with the more serious specific ophthalmia
which develops on the second or third day. In case of
doubt a microscopic examination of the purulent dis-
charge should be made.

In all cases an old silver nitrate solution which has
undergone decomposition should be avoided, as such
solutions are far more likely to irritate the sensitive
conjunctiva.

Care of the Mouth and Nose

Every effort must be made to avoid trauma of the
.iiucous membranes of the nose and mouth because of
the danger of secondary infections. After the third or

fourth day the anterior portion of the nostril may be
gently cleaned with small pieces of absorbent cotton.

Prevention of Respiratory and Skin
Infections

Upper respiratory infection, with complications, is
one of the chief causes of mortality in premature babies.
The nurse or mother in attendance must pay strict
attention to even the slightest detail.

Anyone with upper respiratory infections, however
slight, should avoid all contact with the premature
infant.

Scrupulous care of the hands of nurses, doctors, or
those attending the premature baby must be observed
before handling the baby, and especially before feeding.
The hands should be soaped several times, rinsed thor-
oughly between each soaping. The hands should not be
washed and then the mask adjusted or the door opened.

Masks must be made, or obtained, and changed fre-
quently. The mask is to be worn over mouth and nose.

If the baby develops any evidence of respiratory infec-
tion or any skin lesion, isolate it at once. Skin lesions,
especially impetigo contagiosa, must be carefully exam-
ined and then may be treated by the nurse or mother
under the direction of the physician. Silver nitrate (15
per cent), gentian violet (5 per cent in alcohol), tinc-
ture of merthiolate (1:1000) and/or ammoniated mer-
cury (2 per cent) have all been used with success. The
physician should leave orders that any sudden spread of
the lesions must be reported at once.

Birth Weight Loss

Loss of body-weight during the first few days of life
occurs so constantly in full-term infants that moderate
losses must be considered physiological. This is also true
of premature infants but their loss is relatively greater
than that of the full-term infants and they regain their
birth weight more slowly, frequently requiring three
weeks or more.

The loss in weight of premature babies should not
average more than 7 to 8 °/o of the birth weight.

194

THE JOURNAL-LANCET

TABLE II. SUMMARY OF THE DATA FROM A CLINICAL EVALUATION OF PREMATURE FEEDING FORMULAE

Below

2,000 Grams

Over

2,000 Grams

FEEDING FORMULAE

Breast Milk
With Casec

Evap. Milk
Mixture

Skim. Milk
Olive Oil**

Breast Milk
With Casec

Evap. Milk
Mixture

Skim. Milk
Olive Oil**

Number of Cases

1 2

Birth Weight in Grams ..

1812*

1798

1741

2370

2347

2247

Minimum Weight

1685

1679

1639

2249

2207

2120

Total Initial Weight Loss

125

114

100

121

140

127

Day of Minimum Weight

Day Birth Weight Regained

Caloric Intake per Kilogram on That Day

124

134

108

114

117

Discharge Weight in Grams

2634

2680

2710

2732

2721

2696

Day of Discharge

Caloric Intake per Kilogram on That Day

143

156

147

137

138

146

Average Weight Gain in Grams per Day

•Except for number of cases all figures are averages.

Total Fluids

After the first few days the total fluid intake must
he maintained at from one-sixth to one-eighth of the
body weight; in each 24 hours. The sum of the water
and milk intake is used to determine the total fluid
intake.

Fluids (Water) and Feeding

Although modifications may be made by the physi-
cian, it has been found to be highly satisfactory to per-
mit the premature infant to rest for the first 16 hours
of life during which time no fluid or feeding is offered.

Prematures weighing 3.3 pounds ( 1,500 grams) or
less. Water is given at the end of the sixteen hour rest
period. Offer 10 cc. (2 teaspoonfuls) every 2 hours
during the remainder of the first day and thereafter
every four hours. Increase the amount offered by 2 cc.
each feeding until 1 Yi ounces (45 cc.) are offered.
When this volume is reached, decrease by 1 cc. with
each administration until 1 ounce (30 cc.) is offered.
This decrease in water must be made because the milk
feedings are gradually being increased.

If breast milk is available, begin the second day by
offering 5 cc. (1 teaspoonful) of boiled breast
(human) milk with 2 per cent calcium caseinate
(Casec) every 4 hours and increase by 1 cc. with each
administration until about 1% ounces (50 cc.) are
offered. Any further increase or more rapid increase
in feeding depends upon the progress made. Where
breast milk is routinely available and stored under asep-
tic conditions, this may be used without additional
boiling. The addition of calcium caseinate to the breast
milk has been found to definitely reduce the number of
cases in which frequent liquid stools have developed,
and has led to a most satisfactory and consistent daily
gain in weight.

Where breast milk is not available, either one of two
formulae may be used with little fear that the premature
infant will not be able to adapt itself to the feeding.

••The new feeding called olac.

A mixture consisting of equal parts of unsweetened
evaporated milk and water with the addition of three
per cent dextri-maltose has given good results. However,
recently a new preparation has been tried and the re-
sponse of the premature baby to it equals or even sur-
passes that of breast milk. This response may be observed
in Table II which is a summary of the data obtained
after eighteen months clinical trial of the new formula.
A complete analysis of this data will be presented in
another communication.

The new mixture is composed of a combination of
skimmed milk, virgin olive oil, calcium caseinate and
dextri-maltose with a small amount of halibut liver oil.
Its composition is based on the observations of Holt,
Tow and Marriott in connection with the absorption of
fat and the assimilation of protein in the premature
infant. Since it can be obtained now in the dry or
powdered form*, it may be employed in a dilution of
1 ounce of the powder to 5 ounces of previously boiled
cooled water, the caloric value of this being approxi-
mately the same as the boiled breast milk with the two
per cent calcium caseinate.

Little can be expected in the way of increasing weight
until about 45 calories per pound (90 calories per kilo-
gram) are administered. Later the infant will require
approximately 50 to 55 calories per pound of body
weight and after the first month as much as 60 calories
per pound may be needed. In exceptional cases it may
be necessary -to feed 80 to 100 calories per pound, but
in such cases these infants are markedly underweight
for their fetal age. In the present routine of feeding
not much attention is paid to the total calories. The
idea that so many calories per pound or per kilogram
should be given has been overemphasized. A good plan
is to feed the premature baby an amount sufficient for
an adequate and consistent gain in weight.

Prematures weighing between 3.3 and 4.4 pounds
(1,500 to 2,000 grams). Begin by giving water at the

•Prepared by Mead Johnson &C Co., Evansville, Indiana, and
identified as Olac.

THE JOURNAL-LANCET

195

end of the 16 hour rest period. Offer 2 teaspoonfuls
( 10 cc.) of water every 2 hours for the remainder of the
first day and thereafter every 4 hours. Increase by 2 cc.
with each administration until almost 2 ounces (55 cc.)
are offered; then decrease by 2 cc. until 1 ounce (30 cc.)
is offered.

Begin on the second day by giving 2 teaspoonfuls
(10 cc.) of boiled breast milk with 2 per cent calcium
caseinate, or the skimmed milk-olive oil mixture every
4 hours and increase by 1 cc. with each administration
until 2 ounces (60 cc.) are reached. Any further in-
crease or any more rapid increase requires an order by
the physician.

Prematures weighing 4.4 pounds (2,000 grams) and
more. Begin by giving water at the end of the 16 hour
rest period. Start with 3 teaspoonfuls (15 cc.) of water
every 2 hours for the remainder of the first day and
thereafter every 4 hours. Increase by 2 cc. with each
subsequent administration until 2 ounces (60 cc.) are
offered; then decrease by 3 cc. each feeding until 1
ounce (30 cc.) is given.

On the second day, offer one-half ounce (15 cc.) of
boiled breast milk formula, or if necessary the supple-
mental feeding every four hours and increase by 2 cc.
with each feeding until 1 x/z ounces (45 cc.) are offered.
The amount offered is then increased by 5 cc. daily, to
2)4 ounces (75 cc.) . Following this, additional changes
in the feeding depend upon the progress of the case and
must be ordered by the physician. Reference to Table
III will probably help to avoid any confusion which
may arise in connection with the routine of feeding
outlined above.

The infants weighing between 2,000 and 2,500 grams
may frequently be able to nurse quite early at the breast.
Weighing before and after nursing is of paramount im-
portance to determine how much milk has been received.
In all cases of prematurity an effort should be made to
promote maternal lactation. If the infant is initially too
weak to nurse, the breasts should be hand expressed or
emptied with a breast pump at regular intervals.

The best test of satisfactory and adequate feeding is
a steady gain in weight. The physician should be noti-
fied each morning as to whether the infant will take or
needs an increase in feeding. Weigh once during the
first 24 hours, then every day for three days and there-
after every third day or twice a week. If the baby has
lost in weight, it must be weighed daily until it has again
made a good gain in weight.

Feeding Time Schedule

After the second day water is given every four hours
five or six times a day; milk is given two hours after the
water feeding every four hours, usually six times a day.

5 A. M.— Milk
7 A. M.— Water
9 A. M.— Milk
11 A. M.— Water
1 P. M.— Milk
3 P. M.— Water

6 A. M.— Milk
8 A. M.— Water
10 A. M.— Milk
12 Noon — Water
2 P. M.— Milk
4 P. M.— Water

5 P. M.— Milk
7 P. M. — Water
9 P. M.— Milk
11 P. M.— Water
1 A. M.— Milk

6 P. M.— Milk
8 P. M.— Water
10 P. M.— Milk
12 P. M.— Water
2 A. M.— Milk

This schedule shows five water feedings and six milk
feedings daily. It has the advantage over six water feed-
ings and six milk feedings in that it permits the pre-
mature to have a little rest period during the night.

Additional Fluids

From the second to the fourth day after birth it is
often desirable to give 3 1/3 to 5 ounces (100 to
150 cc.) of Ringer’s solution (physiological saline) or
Hartmann’s solution by hypodermoclysis, using the
inner aspect of the leg just above the knee for the site
of the injection. This should be administered very
slowly, preferably by continuous drip. This is a good
method for reaching the required fluid intake if the
baby is losing rapidly in weight during the first few
days of life. The only objection is that it may disturb
the infant.

Whole Blood

Many physicians administer whole blood to all pre-
mature infants early on the second day of life. When
this procedure is performed, 1/3 ounce (10 cc.) is given
to small babies and up to 1 ounce (30 cc.) to the larger
babies. The blood is injected deep subcutaneously into
the back below the scapulae.

Repeatedly observations have been made that the pre-
mature infants who cannot take adequate feeding and
who are not gaining satisfactorily in weight may be
benefited by receiving additional whole blood. The phy-
sician may find that this procedure will often put an end
to a refractory period during which there has been little
or no gain in weight.

Methods of Giving Water and Milk

Three methods are commonly employed:

1. Catheter or tube method is frequently used.

2. Medicine dropper (protected by rubber tip) is
used occasionally. The Breck feeder may be tried
but it has the disadvantage of allowing too rapid
feeding.

3. Bottle feeding is used but conservation of the
baby’s strength then is to be considered.

Many babies weighing less than 4.4 pounds (2,000
grams) must be fed by catheter. If this is done a
Number 10 or 12 soft French catheter, for small pre-
matures, and a Number 14 French catheter, for larger
prematures is employed. Catheter may be marked with
silver nitrate four inches from the tip. The sterile
catheter or tube is carefully passed, not allowing it to
go beyond the four-inch mark. There should be a
catheter for each infant. The baby may be supported
in a semi-recumbent position, and after becoming quiet
is slowly fed. When the procedure is completed, the
tube is kinked and removed quickly. The infant is sup-
ported in the sitting position in the crib to allow for the
expulsion of any air. The baby is watched carefully at

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TABLE III.

ROUTINE OF FEEDING FOR
PREMATURE INFANTS

THE

Milk — cc.

Water — cc.

Milk — cc.

Water — cc.

1 2 3

First Day: Sixth Day:

1st F.

2nd F.

16th hour

3rd F.

18th hour

4th F.

20th hour

5th F.

22nd

hour

1 5

6th F.

—

Second

Day:

Seventh

Day:

1st F.

2nd F.

3rd F.

4th F.

5th F.

6th F.

—

6th F.

—

Third Day:

Eighth

Day

1st F.

2nd F.

3rd F.

4th F.

5th F.

6th F.

—

6th F.

—

■ —

Fourth

Day

Ninth Day:

1 st F.

1st F.

2nd F.

3rd F.

4th F.

5th F.

6th F.

—

6th F.

—

Fifth Day:

Tenth Day:

1st F.

1 st F.

2nd F.

3rd F.

4th F.

5th F.

6th F.

—

6th F.

—

Eleventh Day:

F — Feeding. Further increases in feeding

depend upon progress made.

1 — Prematures 3.3 lbs. (1500 grams) or less.

2 — Prematures 3.3 and 4.4 lbs. (1500-2000 grams).

3 — Prematures 4.4 lbs. (2000 grams) and more.

the time of feeding and for a while after the tube is
removed to see if it is going to regurgitate. If regurgi-
tation should occur, the head and shoulders are lowered
at once and the baby is turned face downward. The
regurgitated milk is wiped from the mouth and face and
the baby is re-fed 15 to 20 minutes later. This nursing
care is one of the most important factors in preventing
otitis media and bronchopneumonia due to aspiration.

Babies weighing over 4.4 pounds (2,000 grams) may
often be fed by medicine dropper. Patience and care
on the part of the nurse are prerequisites to success.
Drop by drop the fluid is placed on the dorsum of the
tongue, trickles down, and is swallowed. Babies usually
begin to nurse from the bottle when they approach 5
pounds (2,300 grams) in weight.

Milk or water should not accumulate in the pharynx.
It should be ascertained that the baby is swallowing. The
accumulation of milk or water in the pharynx will
strangle the infant and aspiration is inevitable. This is
highly undesirable and often results in aspiration
pneumonia.

Gastrointestinal Disturbances

If regurgitation or vomiting occurs, no further in-
creases in feeding are made. It may actually be neces-
sary to decrease the volume of feeding and increase the

number of feedings. This will be determined by the
physician.

The physician should always leave an order to be
notified immediately if diarrhea (frequent, watery
stools) makes its appearance. This condition requires an
increase in the fluid intake and Hartmann’s solution is
given by hyperdermoclysis. Weak tea or one-half
strength Hartmann’s solution may be employed in place
of all feedings for 12 to 24 hours, after which feeding
is again started by using small amounts of the breast
milk — calcium caseinate (casec) preparation, or the
skimmed milk-olive oil formula (olac) , and gradually
increasing the volume.

If there is no improvement, whole blood is given deep
subcutaneously on the second day. Do not temporize.
Repeat Hartmann’s solution by slow, continuous infu-
sion, giving about 3 1 3 ounces ( 100 cc.) to small pre-
matures and as much as 6 ounces (200 cc.) to the large
infants.

If the premature baby is not gaining in weight and
the stools continue to be loose, weigh daily until there
is a weight increase, and normal stools.

Vitamin Requirements

After 10 days or as late as 14 days, premature infants
which reach or are between 3.3 and 4.4 pounds (1,500
and 2,000 grams) should receive 5 drops of oleum
percomorphum, 50% or of viosteral in halibut liver
Oil twice daily. This is increased to 10 drops twice a
day. Pure strained orange juice (one teaspoonful) is
also given twice a day.

Premature infants which reach or are 4.4 pounds
(2,000 grams) or more in weight, will receive oleum
percomorphum, 50% or a standardized cod liver oil.
If the former is used the amounts given are as indicated
in the paragraph above. If cod liver oil is used, start
with an amount equivalent to one-half teaspoonful twice
daily and increase to one teaspoon ful twice a day. As
long as the infant receives feedings by tube, the cod
liver oil can be added to the milk, but after the feedings
are given by bottle, the cod liver oil should be adminis-
tered separately. About 1 to 2 teaspoonfuls (5 to 10 cc.)
of orange juice is offered twice a day.

If vomiting or diarrhea occurs, stop antirachitic and
antiscorbutic preparations immediately for the time
being.

Anemia

Premature babies tend to develop a low hemoglobin
very readily. A hemoglobin determination should be
made no later than the fifth week of life, and if low,
should be repeated weekly. Some form of iron adminis-
tration should be followed, beginning at the latest by
the fifth week of life.

Liver extract and ""or ferric ammonium citrate with or
without copper sulphate have given a very satisfactory
response. The infant may receive each day 1 cc. of a
10 per cent solution of ferri et ammonii citras for each
pound or 2 cc. for each kilogram of body weight, and

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197

Zz cc. of a 0.5 per cent solution of cupri sulphas per
pound or 1 cc. of 0.5 per cent solution per kilogram of
body weight. Both preparations are placed in the breast
milk or in the feeding formula. The copper may be
discontinued after a short period of administration. It
may be given again later.

Suggestions Regarding Discharge From
the Hospital

Before discharge the premature should be carefully
examined and should be free from respiratory infections
and skin lesions. The physician may desire a final hemo-
globin for the records and may possibly order X-rays
of the long bones, and of the bones of the hand in order
to be sure that there is no bony evidence of syphilis.

The infant should be able to nurse from the mother’s
breast or to take expressed breast milk or the artificial
feeding formulae, easily from the bottle. The mother
can be asked to come in a few days before discharge in
order to determine ho>v well the infant nurses at the
breast. If an artificial feeding is ordered, it must be
remembered that as the amount of milk per feeding
increases it may be necessary to order more feedings
rather than to continue to increase the amount of milk

each feeding, as stomach capacity may be limited. This
can be done by substituting milk for some of the water
feedings given during the day. As a result, in some
instances the infant will be fed every three hours. A
little water should then be given between feedings.

Directions must be given the mother for the adminis-
tration of standardized cod liver oil or any especially
potent antirachitic, and orange juice. If oleum perco-
morphum is available, it is to be preferred to cod liver
oil, because of smaller dosage.

Conclusions

Cardinal points in the management and feeding of
the premature infant in the order of their importance
are:

1. Intelligent nursing care on the part of the nurse
or mother.

2. Maintenance of proper environment from the
moment of birth.

3. Prevention of upper respiratory infections and skin
disorders.

4. Establishment and maintenance of adequate fluid
intake and feeding.

A Few Common Dermatoses of Infancy
and Childhood*

Carl W. Laymon, M.D.**

Minneapolis

THE purpose of this paper is to briefly discuss a
few of the most common cutaneous disorders of
childhood especially from the standpoint of ther-
apy as carried out by dermatologists in this vicinity. In
an attempt to learn "just what to do and when to do it”
regarding the frequent dermatoses which confront the
practitioner almost daily, one is usually confused by the
multitude of therapeutic agents mentioned in the com-
mon pediatric or dermatologic texts and is left without
a definite, acceptable form of therapy to follow. Wher-
ever possible references will be cited for more detailed
discussions of the condition in question since a com-
plete exposition, even of therapeutic procedures alone,
cannot be given.

MacKee and Cipollaro1 partially prefaced their recent
text on skin diseases in children as follows: "The der-
matoses of infancy and childhood are interesting and im-
portant for several reasons. There are in the first place
a number of cutaneous affections that are seen only in
infancy or childhood; a few are peculiar to adolescence.

*From the Division of Dermatology, University of Minnesota,
H. E. Michelson, M.D., Director; and the Dermatology Service,
Minneapolis General Hospital, S. E. Sweitzer, M.D., Chief, and
prepared expressly for the special Pediatric issue of THE JOUR-
NAL-LANCET.

••Instructor of Medicine, University of Minnesota.

Many of the chronic adult dermatoses begin in early
life. By detecting these conditions in the early stage of
evolution much can be done to prevent future suffering
and disfigurement. Finally, most of the skin diseases
common to adults are also encountered frequently in
children, but the eruption complex is likely to be modi-
fied by factors peculiar to youth.”

Eczema

It seems essential to cease being satisfied with the
vague diagnosis "eczema” both for advance in the solu-
tion of the "eczema problem” and for the management
of the individual case. Within the past few years a few
definite and distinct conditions have been separated from
the general eczema group, among which are atopic der-
matitis, contact dermatitis, seborrheic dermatitis and
certain mycotic infections. Eczematous mycotic infec-
tions and contact dermatitis do not present a great prob-
lem in infancy and childhood since they are much less
frequently seen than in the adult. Although seborrheic
dermatitis is far from a rarity especially in infancy —
atopic dermatitis of the infantile and childhood type still
defies analysis both as to etiology and therapy in a large
number of cases. The term disseminated neuroderma-

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Figure 1. Pustular scabetic lesions on the soles of an infant.

titis, weeping and exudative in infants and chronic and
lichenified in older children, is regarded as synonomous
with atopic dermatitis. This disease occurs in atopic
(hay fever and asthma) families and is distinct from
acute or chronic eczema of the contact type.

The clinical picture of infantile eczema is well known.
At first the infant presents a papulovesicular eruption
on the cheeks which may extend to the outer aspects of
the legs, forearms, wrists and forehead. There may be
irregular areas of erythema and a tendency to wheal
formation. The eczema in severe cases may become gen-
eralized and assume the appearance of an erythroderma.
Many infants with atopic dermatitis recover completely
by the end of the second year. Other cases continue
into childhood usually in the form of infiltrated, licheni-
fied pruritic, plaques in the antecubital and popliteal
spaces and on the face and sides of the neck.

It would seem that from the association of atopic der-
matitis with other allergic diseases such as hay fever
and asthma, the family history of allergic disease, and
the frequent positive findings in scratch and/or intra-
dermal testing that the logical therapeutic approach lies
in attempting to eliminate as far as possible those spe-
cific allergens suspected as being etiologically important.
Furthermore the "specific” or "allergic” attack of the
problem would appear less complicated in infancy and
early childhood on account of the fewer contacts with
food or inhalant substances prone to sensitize the pa-
tient. The diet of the infant is much less complex than
that of the adult and studies have shown that environ-

Figure 2. Multiple ruptured bullae in impetigo neonatorum.

mental (inhalant) allergens play an increasingly impor-
tant role with the aging of the child as compared to food
in infants. Hill2 found that scratch tests to environ-
mental allergens were positive in only 10% of 38 ecze-
matous infants under 1 year of age, while the percent-
age rose to 50 in 49 children from 2 to 12 years of age.
Peck1 obtained similar results. Hill and Sulzberger4
traced the evolution of atopic dermatitis from its begin-
ning, through infancy, childhood and adult life. Based
on skin tests egg, wheat, and milk were the most com-
mon reactors during the first year of life. Reactions to
inhalant allergens were rare but of these silk was ap-
parently the most important. In childhood (2 to 12
years) reactions to inhalants were more frequent coincid-
ing with the previously mentioned findings of Hill and
Peck. While in many cases removal of the specific sub-
stances to which the patient reacted positively on skin
testing, cured or improved the dermatitis this was not
true in all instances. Peck found that elimination diets
were of practical value only in the infantile cases.

Factors other than allergic ones undoubtedly are in-
fluential in the pathogenesis of atopic dermatitis. In a
review of allergy in dermatology Sulzberger'1 called at-
tention to the observations of Pehu and Woringer that
50 to 90% of eczematous infants show positive wheal
reactions to skin tests with egg white. Many of these
can be shown to possess specific reagins to egg by means
of the Prausnitz-Kustner method of passive transfer. Yet
many of these infants have never been exposed to egg
white and even admitting sensitization in utero many

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199

infants show no exacerbation of the eczematous process
when egg is fed. The significance of reactions to egg
white in atopic eczematous infants has never been satis-
factorily explained.

Without denying the importance of the allergic study
and managements of atopic dermatitis in infancy and
childhood it is my impression that most practitioners
will in general secure the best results from intelligent
dermatologic therapy. Even the best trained allergists
and dermatologists with every means of cutaneous test-
ing at their command frequently encounter great diffi-
culty in the alleviation of this condition and are forced
to admit that the allergic approach is of definite value
in the exception rather than the rule. Specific desensi-
tization as yet is usually unsuccessful in atopic derma-
titis.

Certain fundamental measures are prerequisite to the
successful management of all eczematous individuals. By
far the best results are obtained when the patient is hos-
pitalized. Rest and relief from pruritis are essential. In
certain instances sedation is necessary, bearing in mind
however that opium and its derivatives are contraindi-
cated regardless of the severity of the itching. In infants
especially a properly adjusted splint to prevent bending
the arm at the elbow is necessary to make scratching
impossible. Medications containing local anesthetics are
potent contact sensitizers and should be used only with
caution.

In the acute, erythematous oozing phase moist com-
presses of saturated boric acid solution or dilutions of
1:10 of Burow’s solution are of the greatest service. As
the acuity subsides mild "shake” lotions such as calamine
are of value. In chronic, sluggish or Iichenified areas
ichthyol (3-5%), naftalan (5-10%) or crude coal tar
(1-5%) incorporated in zinc paste (Lassar’s paste with-
out salicylic acid) are frequently efficacious. Although
my experience with the so-called "white tar” has not
been great, the impression has been gained that it is
inferior to ordinary crude coal tar. Extremely stimulat-
ing preparations such as strong tar pastes or varnishes,
sulfur, chrysarobin, ammoniated mercury, etc., must be
used with care lest intense aggravation of the process
result. Proper application of a medicament is as im-
portant as the drug itself and thorough instructions
should be given to the patient. Pastes should be cleansed
off with olive oil before fresh applications are made.
Soap and water as a general rule prove aggravating to
eczematous skins.

Specialized methods of therapy such as X-rays are not
within the scope of this discussion. In the therapy of
eczema it is far better to know well the basic actions
and proper application of a few appropriate remedies
than to know a little or nothing about a large number
of prescriptions. The physician who follows this prin-
ciple will alleviate or cure cases which have defied a
multitude of therapeutic agents given without exact
knowledge of their properties.

Scabies

The clinical picture of scabies is constituted by two
chief elements: (a) the burrow and inflammatory

changes caused directly by the acarus scabiei and (b)
lesions caused indirectly by scratching, secondary infec-
tion, etc. The result is a multiform picture which in
itself enables the well trained eye to diagnose a typical
case without difficulty.

The female acarus is chiefly responsible for the symp-
tomatic eruption in scabies, the male taking little part in
the burrowing into the skin. The latter process results in
the characteristic scabetic lesion, the burrow in which the
parasite lays her eggs and deposits excreta. The thinnest
parts of the skin are usually selected such as the webs
between the fingers, the flexor surfaces of the wrists,
axillae, abdominal wall and genitalia especially in the
male. In individuals of poor personal hygiene no part
of the body is exempt in cases of long duration, although
as a rule the head, face and back are spared. In infants
special attention should be paid to the palms and soles,
since lesions are not infrequently found in those loca-
tions. Moreover the usual rule that the face is unin-
volved does not hold true in infants, infection taking
place from contact with the mother’s breast.

As the parasite enters the epidermis, inflammatory
changes are the consequence, usually in the form of a
small papule, vesicle or pustule. In children especially a
pustular or impetiginous eruption on the hands should
always suggest scabies. The characteristic burrow, which
is an irregular, sinuous or rarely a straight line in the
skin is not always found. In a recent article Stokes8
emphasized the examination of the skin with a hand lens
for detection of these lesions. In addition to the above
lesions excoriations, impetiginous or ecthymatous infec-
tions, wheals and secondary eczematization may be seen.
Acute inflammatory cutaneous changes with scabies are
much more easily provoked in children, hence pustular
complications are more frequent than in the adult.

As a rule the proper treatment of scabies is both
simple and effective. Most antiscabetic medications con-
tain parasiticides such as sulfur, betanaphthol, or balsam
of Peru frequently combined with an abrasive such as
potassium carbonate. A thorough soap and water bath
to open the burrows is essential to the success of any
form of therapy in scabies. The U.S.P. compound
sulfur ointment (Wilkinson’s ointment) is highly ef-
fective though messy, malodorous and somewhat irritat-
ing. Although used in full strength for older children,
it should be diluted one half with zinc paste for use in
infants and young children. Following the preliminary
bath the ointment is applied from the neck to the feet
(never on the face) . In the case of average severity in
a patient with good hygiene 3 daily applications are
usually sufficient. The treatment is furnished with a
second cleansing bath. The subsequent irritation which
often follows the use of Wjlkinson’s ointment is soothed
by a bland preparation such as zinc paste. In patients
who have severe scabies or whose personal hygiene is
not good, such as those who are treated in a large city
hospital dispensary practice the time of treatment is ex-
tended to six days. Sweitzer and Tedder7 and later
Sweitzer8 reported favorable results with the use of
pyrethrum ointment in a large number of cases of

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THE JOURNAL-LANCET

scabies treated at the Minneapolis General Hospital.
Fantus and Cornbleer* recently reviewed the treatment
of scabies as carried out in the Cook County Hospital:

All clothing that has been in contact with the skin
during the course of the disease must be boiled, laun
dered or dry cleaned (which means a thorough immer-
sion in naphtha) . The patient should take a prolonged
warm bath, thoroughly scrubbing with soap and brush.
After drying the skin the remedy is applied to the entire
skin below the clavicles. Sulfur ointment, preferably
diluted, is to be used night and morning for a total of
six times. Then the bath is repeated and the clothes
worn during the treatment should be boiled, laundered
or dry cleaned. The "clean up” is the most important
part of the treatment and also the most difficult to get
carried out thoroughly, as well as the most expensive.
For children, one-half or one-fourth the strength of the
ointment used for adults should be prescribed. For those
who have an idiosyncrasy against sulfur, 5 or 10% beta-
naphthol ointment should be resorted to. "One day-
cures, ” such as the Danish treatment, are apt to be too
irritative.

Continuance of the itching means (a) that the
treatment was not thorough enough, (b) reinfestation
from contacts, (c) residual irritation of the skin, pos-
sibly aggravated by the treatment, or (d) habit forma-
tion.

(a) To exclude the first possibility, one may repeat
the treatment, which should always suffice.

(b) Infested contacts must be eliminated by treat-
ment of these, or otherwise.

(c) Residual irritation requires that the skin be
soothed by calamine lotion or other bland application,
or by 10% borated cold cream if it is excessively dry.
If there is much trauma or if there are many raw areas
from wild scratching, these should be cared for even
before instituting measures for the scabies itself. Colloid
baths and calamine lotion or liniment help to prepare a
badly scratched and traumatized skin for the more spe-
cific and irritating scabies ointment. For pus infections,
half strength ammoniated mercury ointment may be
used after sponging with mercury bichloride solution to
remove the crusts.

(d) Habit requires psychotherapy, possibly plus cal-
amine lotion as a placebo.

Stoke’s method as recently outlined is as follows:

First Night: Bathe with hot water and soap, soaking
well and scrubbing all burrows and pimples open with
brush. Rub in ointment over whole body except face and
scalp. Special attention to hands, arm pits, waist, nip-
ples, groin and genitals (external) .

Next Morning: Rub ointment again, without bath.
Wear same underwear.

Second Morning: Bathe thoroughly, do not apply

ointment, powder the body with borated talcum all over.
Then put on fresh underwear. Have all bedding
changed (sheets, pillow cases) .

Send blankets and everyday suit to dry cleaner.

Send linen and underwear to laundry.

Return to the office one week from today.

Use no more ointment unless ordered.

Stokes stated that almost any preparation containing
Peru balsam or volatile sulfides or ether or betanaphthol
in concentration of not less than 10% for adults would
be effective. These percentages should be as a rule re-
duced one half for infants and children.

Regardless of the type of medication used it must be
remembered that the patient does not cease to itch im-
mediately upon the death of the acarus and subsequent
courses of parasiticidal preparations should not be re-
peated for a week or two until the irritated skin has an
opportunity to quiet down. The treatment of all the
affected members in a family is important to prevent
repeated transference of the disease.

Impetigo Contagiosa

Impetigo is one of the most frequent cutaneous affec-
tions encountered in children and may in infants become
extremely severe, occasionally terminating fatally. In
the common form the lesions begin as vesicles or bullae,
the contents of which are rapidly transformed into pus.
The secretion then dries, forming at first honey-yellow
crusts which seem to be "stuck on” the skin. These
later become reddish-brown or brown from blood, pus.
and dirt. The lesions, which arise as a result of strepto-
cocci being implanted in the skin, are located as a rule
on the exposed surfaces of the body such as the face,
hands and knees. The eruption may vary considerably
in extent and severity.

The poorly named pemphigus neonatorum is not a
separate disease but in reality a bullous infantile variant
of impetigo contagiosa. The eruption begins in the first
week or two of life usually about the thighs, buttocks
or back, frequently spreading to the extremities and
face. The bullae arise rapidly and often in great num-
bers and easily rupture to leave large areas of raw de-
nuded skin in the widespread cases. The disease may
assume epidemic form in hospitals and in such epidemics
fatalities often result.

In impetigo contagiosa the type of treatment depends
largely upon the stage of the disease when the patient
is seen. When large numbers of adherent crusts are
present they are best removed by softening, mildly anti-
septic ointments such as 2 or 3% ammoniated mercury,
diachylon or boric acid. Such therapy in itself may
bring about a cure. In the bullous stage and after the
crusts have been thoroughly removed, painting the bases
of the lesions with 10% silver nitrate or a 5% aqeous
solution of gentian violet is efficacious. Children suffer-
ing with impetigo must of course be excluded from
school.

In the bullous form in infants strict isolation tech-
nique must be enforced especially in hospitals. The
bullae may be carefully clipped and the bases painted
with 5% silver nitrate or gentian violet. Ointments as a
rule are not well tolerated. Leiner’s lotion containing
Yz% salicylic acid and 1 to 3% cinnibar is frequently
beneficial.

THE JOURNAL-LANCET

201

Figure 3. Hemangioma of the face.

Urticaria

The most important variety of urticaria encountered
in infants and children is the papular type or lichen
urticatus. Its onset is, as a rule, during the first year of
life. The characteristic lesions are small yellowish-red or
pale red pruritis vesico-papules distributed most fre-
quently on the extensor surfaces of the extremities and
occasionally on the face and trunk. The papular lesions
may or may not be accompanied by ordinary, evanescent,
urticarial wheals. Constitutional symptoms, except those
resulting from loss of sleep in a few cases, are lacking
although secondary excoriations and eczematization are
not uncommon.

In a thorough study of the condition Walzer and
Grolnick1" investigated especially the allergic aspects of
papular urticaria. Specific (elimination) therapy based
on skin tests was of no avail. Likewise nonspecific mea-
sures, such as removal of foci of infection physiotherapy
and removal of skin irritation produced no improvement.
The prognosis as to duration and cure must be guarded,
although the condition usually disappears spontaneously
in a later childhood or at puberty. Personal experience11
with papular urticaria coincides with that of Walzer and
Grolnick.

Figure 4. The same lesion a year later after therapy with
carbon dioxide snow.

are thoroughly shielded with lead. Doses of 800 to
1200 R frequently produce desiccation and disappearance
of the verruca in from 3 to 5 weeks.

The flat type of wart (verruca plana juvenilis) is es-
pecially common in children, though also seen in adults.
The lesions are usually from 1-3 mm. in diameter, just
perceptibly raised above the plane of the surrounding
skin, and are either color of normal integument, grav
or brown. They appear often in great numbers upon
the faces of children, especially along lines of irritation.
As in other warts, their development, duration and dis-
appearance are erratic. The administration of protiodide
of mercury by mouth may effect a cure. Touching the
lesions with an extremely fine desiccating current may
achieve a satisfactory result although the procedure is
rather tedious if the number of lesions is great. Sulphars-
phenamine intravenously in doses of .1 gram per 25
pounds body weight has been used with varying degrees
of success14, 16, 17. Since its administration is not without
danger it should be used only after other means have
failed. Both local18 and intramuscular111 injections of
bismuth compounds have been advocated in the treat-
ment of warts.

Verrucae

Warts rarely present diagnostic difficulty, although
their treatment when they occur in certain locations such
as the soles or under and about the nails, occasionally
tries the acumen of the most skillful therapist. Destruc-
tive measures such as cauterization or electro-desiccation
offer the most reliable and most easily controlled means
of cure of common warts in the usual locations. Chem-
ical agents such as salicylic, nitric and trichloracetic
acids, though not entirely condemned, are less depend-
able and more difficult to control. Plantar, sub-ungual,
and peri-ungual verrucae lend themselves less readily to
destructive measures on account of inaccessibility
(nails) and subsequent morbidity due to pain (soles).
Nevertheless such methods are entirely acceptable12,13.
Irradiation in the form of unfiltered X-rays is successful
in a fair percentage of these cases14,15. In carrying out
such treatment the lesion is exposed as much as possible
by cutting away the nail or, in the case of plantar warts
the overlying callous. The surrounding normal tissues

Hemangiomas

As is the case in verrucae, vascular nevi present more
of a therapeutic than diagnostic problem. The various
types of hemangiomas depend upon a congenital hyper-
plasia of a circumscribed area of the cutaneous vascular
system. The clinical lesion is thus dependent upon the
size of the affected vessels. In the flat so-called "port
wine stain” or nevus flammeus there is a superficial
plexus of dilated capillaries; in hemangioma simplex or
"strawberry mark” large vessels are involved; and in the
cavernous hemangioma there are extremely large dilated
blood spaces of either arterial or venous origin or both.
No organ or area in the body is exempt from involve-
ment in hemangiomas20. Cutaneous lesions are especially
frequent about the face, head and arms. Although either
sex is affected the lesions are more common in females.

Port wine nevi are best left alone since all manner of
therapy has been attempted with very little success.
X-rays and radium in dosages within the margins of
safety will not eradicate these nevi, and dire results have

202

THE JOURNAL-LANCET

resulted from such therapy. At the cancer institute of
the University of Minnesota recently a young man was
treated for a highly malignant squamous cell carcinoma
originating within an area of radiodermatitis which fol-
lowed the treatment of a nevus flammeus.

Strawberry nevi do not afford such a gloomy outlook.
Carbon dioxide snow repeatedly applied to the lesion in
doses of 10 to 30 seconds often results in great improve-
ment or cure. Subsequent applications should not be
made until all reaction from the previous treatment has
subsided and improvement is no longer occurring. The
final result of course is a scar which, however, is usually
white, soft, flat and supple.

Cavernous hemangiomas vary greatly in surface size,
depth, and appearance. The cutaneous aspect is not
always a true guide as to their exact extent. Surgical
excision is not frequently feasible on account of the
danger of severe hemorrhage and the inability to ac-
curately determine the entire extent of the growth.
Other therapeutic methods consist in (1) irradiation"1
and (2) the injection of sclerosing fluids1’".

In general the older the child the less response may
be expected from irradiation on account of the maturity
of the cells making up the nevus. Cavernous hemangio-
mas overlying bone may cause erosion. For these rea-
sons therapy should be instituted as soon as possible
after birth rather than delayed until the infant or child
is old enough to co-operate better with the physician.
When the lesion begins to grow cure is more difficult
to effect.

At the University of Minnesota irradiation in the
form of low voltage X-rays is used frequently in the
treatment of these nevi. Doses of 500-600 R either un-
filtered or through 1 or 2 mm. of aluminum are given
and the effect noted. Only after improvement has
ceased (usually after several months) is such a dose
repeated, and even then rarely over two treatments are
administered. Radon implants are occasionally used
about cavernous hemangiomas of the mucosae.

The sclerosing agents in most frequent use are sodium
morrhuate (5%) and absolute alcohol. In the former
an attempt is made to enter the dilated blood space and
inject a few minims of the solution, the exact amount
depending upon its size. Injections are repeated after
the reaction has subsided and the lesion is not changing.

This method is used more frequently in older children or
adults or in case irradiation has failed to obliterate the
lesion. No attempt is made to penetrate the vessels in
using alcohol. In certain instances the resulting inflam-
matory reaction following the repeated injection of 3-8
minims of alcohol eventually leads to fibrosis and ulti-
mate shrinkage of the nevus. In all injection methods
improvement is slow and the patient should be warned
that many months will be required to achieve a satis-
factory result. A perfect result, especially from the
cosmetic standpoint, should not be promised.

Carbon dioxide snow is also of service in the eradica-
tion of purple discoloration on the surface of cavernous
hemangiomas which sometimes remains even after the
deep blood vessels have been obliterated.

Literature

1. MacKee, George; and Cipolloro, A. C. : Skin Diseases in

Children, New York, Paul B. Hoeber, Inc., 1937.

2. Hill, Lewis Webb: Sensitivity to Environmental Allergens in
Infantile Eczema, New England J. Med., 214:135, July 25, 1935.

3. Peck, Samuel: Eczema of Infancy and Childhood, New

York State J. Med., 34:1, Nov. 15, 1935.

4. Hill, Lewis Webb; and Sulzberger, Marion: Evolution of

Atopic Dermatitis, Arch. Dermat. &C Syph., 32:451, Sept. 1 93 5.

5. Sulberger, Marion B.: Allergy in Dermatology, J. Allergy

7:385, May 1936.

6. Stokes, John: Scabies Among the Well-To-Do. JAMA.
106:674, Feb. 29, 1936.

7. Sweitzer, S. E. ; and Tedder, James: Pyrethrum in the

Treatment of Scabies, Minn. Med., 18:793.

8. Sweitzer, S. E.; Scabies: Further Observations on Its Treat-

ment With Pyrethrum Ointment, J. Lancet 56:467, Sept. 1936.

9. Fantus, B. ; and Cornbleet, T.: The Therapy of Parasitic

Dermatoses, JAMA, 108:553, Feb. 13, 1937.

10. Walzer. A.; and Grolnick, M.: The Relation of Papular

Urticaria and Prurigo Mitis to Allergy, J. Allergy, 5:240, 1934.

11. Laymon, Carl W.: Urticaria, J. Lancet, 52:29, Jan. 1937.

12. Eller. J. J.: Plantar Warts, Callosities and Corns, A. J.
Surg., 29:444, Sept. 1935.

13. Lewis, George M.: Verruca Plantaris, N. Y. State J. Med.,

35:869. Sept. 1. 1935.

14. Osborne, E. D.; and Putnam, E. D.: Treatment of Warts,
Radiology, 16:340, March 1931.

15. Mackee, George M.: X-ray and Radium in the Treatment

of Diseases of the Skin, Philadelphia, Lea and Febiger, 1927,

p. 612.

16. Sutton, R. L.: Sulpharsphenamine in the Treatment of

Warts, JAMA. 87:1 127, Oct. 2, 1926.

17. Allington, H. W.: Sulpharsphenamine in the Treatment of

Warts, Arch. Dermat. 6c Syph., 29:687, May 1934.

18. Shellow, Harold: Treatment of Verrucae by Local Injec-

tions of Bismuth, III. Med. J., 66:332, Oct. 1934.

19. Lurie, S. A.: Verrucae Vulgares (Palmar and Plantar),

Arch. Dermat. 6c Syph., 26:95, July 1932.

20. Hemangiomata, Bull, of Staff Meeting U. of M. Hosp.,
18:254, April 5. 1934.

21. Eastland, William H.: The Treatment of Nevus Vascularis,
South. Med. J., 27:802, Sept. 1934.

22. Andrews, Geo. C. ; and Kelly, R. J.: Treatment of Vas-

cular Nevi by Injection of Sclerosing Solutions, Arch. Dermat Qc
Syph., 26:92, July, 1932.

The Trend of Mortality in Insured Children*

Karl W. Anderson, M.D.**

Minneapolis, Minn.

THERE can be no question that life insurance
companies have made a definite contribution to
the field of medicine, both from a prognostic and
a therapeutic standpoint, and through them the medical

•Prepared expressly for the special Pediatric issue of THE
JOURNAL-LANCET.

••Assistant Medical Director, Northwestern National Life In-
surance Company.

profession has had called to its attention certain con-
tinuous changes in both the therapeutic and diagnostic
fields, and some fallacious beliefs have been corrected.

Some of these beliefs were due to the fact that the
individual doctor would develop his ideas and practices
as a result of his personal experience, and based his con-

THE JOURNAL-LANCET

203

elusions on a very inadequate number of cases. In his
whole lifetime the doctor may not see sufficient cases in
any one field for a proper statistical study. However,
through the various organizations with which the doctor
is associated, a sufficient number of cases have been re-
corded by mutual co-operation so that results are being
studied in larger groups, and in this way the purely per-
sonal viewpoint is being gradually discounted.

Medicine has more and more realized the importance
of proper statistical study. Long ago the insurance com-
panies adopted the statistical method as an aid in solving
many of their problems. However, it is only compara-
tively recently that this medium has been used in med-
ical science. Now it is being applied in all its fields of
endeavor, and the result is that medicin; has at last a
very formidable instrument in evaluating the various
types of treatments for the many diagnoses that are now
being made.

One of the things that life insurance companies
worked out was the life expectancy table for the average
American newborn. The life expectancy in the United
States has been extended greatly in the past quarter of a
century. In 1900 the newborn in the United States had
an average life expectancy of 39 years, and in 1935 this
had been extended to 59 years. We have been able to
obtain this information through biometric science. On
further study it has been proven that practically all this
improvement has been taking place at the younger ages,
particularly in the first few years of life. From the
available data now there is a serious question as to
whether adults who live to be age 40 have not a shorter
life expectancy than in the past. While there has been
a very marked improvement in the death rate in the
communicable diseases, particularly in children, this has
been offset by the very large and steady increase of
deaths due to diseases of the cardiovascular system.

In the past it has been estimated that 80 per cent of
the population died before the age of 40. Now 80 per
cent live to be 40 years of age and over. More people,
therefore, are living to ages above 40, and naturally a
greater number are subject to diseases of the cardio-
vascular system. Yet, in the light of the marked increase
in a number of diseases in this group, there has been
little improvement in their treatment. It is now appar-
ent that our problem is twofold: first, to continue the
improvement in mortality in the younger ages; and sec-
ond, to develop some means by which the cardiovascular
diseases can be combated, as they are now the most
common cause of death.

In this paper I am particularly interested in the for-
mer group — that is, the mortality of childern up to age
15 — and I should like to speculate as to the reasons for
the splendid conservation of life since the turn of the
century in this group, and as to whether or not there is
going to be any marked change in the trend in child
mortality in the future.

In mentioning a few of the factors that have been
responsible for the improvement in this group in the
past, although not necessarily mentioning them in their
right proportions, one must first consider the economic

situation in this country. There has been a steady im-
provement in wage scales and living and working con-
ditions of the masses, so that the average family has had
more money to spend in child care — medically and so-
cially. Second, one must realize that the geographic and
climatic conditions in this country, as a whole, are con-
ducive to healthful living. Third, the educational system
available to the masses from the beginning has made it
possible for the average individual to appreciate the
value of the medical treatments and preventative mea-
sures available. Fourth, I believe that the heterogeneous
mating of pioneer stock in this country has been a very
large factor, but has seldom been given any recognition.
As a rule, only the healthy individuals dared to migrate
to this country, as it took sturdy men and women to
stand the hardships of pioneering. Naturally, this type
was bound to produce healthier children.

There are other factors that should be considered, but
I have mentioned only some of the more obvious ones,
and have left for the last the one which is probably the
most important — that is, the relentless war waged upon
communicable diseases by the medical profession, its
branches and allied sciences. However, the battle is not
won, nor has there been a truce declared. Every child
who dies is proof of our imperfect knowledge, our care-
lessness of purpose, and of the fact that there is yet
considerable work to be done in the medical world and
by public health education. This is made particularly
evident when we consider the unnecessary deaths that are
occurring each day in industrial sections of the United
States, as there has been a tremendous difference be-
tween the mortality in this group and the mortality
among children from the better homes. A study of the
statistical material of insurance companies has brought
this forcefully to our attention.

One of the most valuable sources of information that
the medical profession has is the study of necropsy ma-
terial. This probably has been more effective than any
other single factor in increasing the knowledge of the
medical profession, and second only to that in impor-
tance is the information obtained in the statistical studies
of various groups of diseases causing death. Therefore
the statistician is a most valuable ally to the medical
profession, and is a medium through which much knowl-
edge has been developed. The statistician, using ana-
lytical methods, has been able to show us the various
trends of mortality in the past, and to prognosticate the
future rather accurately.

Life insurance companies were one of the first to ap-
preciate the value and scientific application of biometrics
to their medical problems. Through their actuarial and
medical departments they were able to develop much
needed information that has been helpful in insurance
selection, and also to the medical profession. By com-
bining their materials the life insurance companies have
been able to obtain a sufficient number of cases in the
various disease groups so that they can be studied in
an effectively significant fashion. The Joint Committee
from the Association of Life Insurance Medical Di-
rectors and the Actuarial Society of America have been

204

THE JOURNAL-LANCET

studying this combined material, and have been able to
show not only the trend of mortality of various diseases
and their effect on the longevity that the various diseases
have, but also the fallacy of many of our medical prac-
tices and beliefs.

The average doctor does not have an opportunity to
study his patients over a long period of time. The usual
illness is of only short duration, and people getting over
the effects of an operation are soon discharged from the
doctor’s care as cured according to his records. Therefore
he does not fully or always realize the effect that these
illnesses and operations might have upon the future
health of the individual, and it is only by studying large
groups that we find the answer to some of these ques-
tions.

Most of the large clinics, hospitals, and universities
have or are developing statistical departments, and those
that have such a department would not dispense with
them any more than they would with the necropsy de-
partment. As a result of this widespread use of statis-
tical methods, most of us now have developed an atti-
tude of watchful waiting, reserving our opinions on new
therapeutic measures until their value has been proved
or disproved by this cold analysis. The prophylactic
value of the diphtheria immunization, smallpox vaccine,
and typhoid inoculations, has been confirmed statis-
tically. There is still considerable doubt, however, con-
cerning the value of the treatment and preventive mea-
sures in other contagious diseases, such as mumps,
whooping cough, and scarlet fever. The newer treat-
ments for these conditions must have statistical confirma-
tion before one can be sure of them.

In studying the mortality figures in the United States
registration area from 1900 to 1936, one can appreciate
how much has been accomplished during these years.
Chart I shows, among other things, that the rate of
communicable diseases has decreased from approximately
400 deaths per 100,000 in 1900 to 96.5 in 1934. This is
in the registered population of the United States as a
whole, and differs from what would be expected if one
considered only the insured lives of children. It would
also be different if one compared it with the insured
lives of children outside of those of the industrial grade.

There are two types of insurance sold for children,
and in discussing insured children’s lives and their mor-
tality one must keep these two types of insurance clearly
in mind. One is the so-called "regular” business, mean-
ing the usual policy sold by companies on a standard
basis to parents or guardians whose children live in a
good environment, and where their social and economic
situation is above the average. These policies are usually
sold in amounts of $1,000 or more. The second group is
the so-called "industrial” type, and the insurance is gen-
erally in small denominations — $100 to $500. These
latter children are usually living in the metropolitan
areas of the larger cities, and in this environment we
find a greater number of undernourished children living
in crowded unhygienic surroundings. Often their parents
are foreign-born, first generation immigrants. The first
group are better protected against the elements and dis-

ease, and therefore are less subject to accidents and com-
municable diseases. In this group, as would be expected,
there is a much better mortality than in the industrial
grade.

We have no large compilation of figures as yet to
study in the first group, but we hope that in the next
year a joint study by most of the companies selling chil-
dren’s policies will be available. However, in a recent
analysis by the Northwestern National Life on all their
children’s policies sold between 1925 and 1935, in which
approximately 19,100 lives were insured, some interesting
data were obtained. This company does not sell indus-
trial business. Table 2 shows the number of exposures
and the deaths by ages. It also shows the mortality per
100,000 when this material is statistically treated on that
basis. The average mortality experience on Northwestern
National Life’s children’s policies issued between 1925
and 1934 at ages 1 day through age 14 is 101 per
100,000. If we exclude those issued between age 1 day
to 1 year and include only those issued between ages 1
through 14 years, the experience of the Northwestern
National is improved to 80 per 100,000. This compares
favorably with the experience of other companies writ-
ing practically the same type of business. This figure
naturally is considerably lower than would be expected
for the same age group of children in this country as
a whole, as this class is without doubt a selected group.
They come from the better type of homes in which there
is more financial stability, as illustrated by the fact that
the greater number of these policies are taken on the
more expensive forms, particularly the 20 Payment Life,
and for at least $1,000. Keeping these facts well in
mind, and considering the comparison between this type
of insurance and the industrial type of insurance, the
mortality figures in the industrial group naturally will
show a marked increase.

Chart 3 shows the mortality for 1936 of the industrial
business issued by the Metropolitan Life Insurance Com-
pany. It is a more comprehensive study, as it shows
the causes of death as well as the mortality. But in
order to compare similar ages one would have to change
the Northwestern National figures from 1 day through
14 years to 1 year through 14 years. In the industrial
business of the Metropolitan the total mortality for 1936
was 260.5 deaths per 100,000, in comparison with the
Northwestern National Life experience of 80 deaths per
100,000 in the same age group. There are many factors
that must be considered in making the comparison. The
Northwestern National policies are sold to a more urban
population, and the people living in the midwestem
states have a much better mortality than those living in
the eastern states. However, even keeping these factors
in mind, the difference indicated in the comparison is
entirely too great. It is evident that these children need
a new deal, in spite of the marked improvement in
mortality in the past 25 years. Another interesting fact
to be noted in studying this chart is that five times more
deaths occurred in 1936 in childern 5 years or younger
than occurred in children from 5 to 14 years of age, so
it becomes evident that the greatest problem at the pres-

THE JOURNAL-LANCET

205

CHART I

Death rate DEATH RATES IiJ UNITED STATES DEATH REGISTRATION AREA Death rate

ent time is with the younger ages, particularly in the
first two years of life.

The most common causes of death in 1936 for the
Metropolitan Life Insurance group were influenza and
pneumonia, and when one studies the statistics of these
two diseases for the past 21 years one cannot help but
realize that there has been practically no improvement
in their mortality. Another thing of interest is the fact
that whooping cough up to age 5 is the largest single
cause of death in the communicable disease group. I
believe that the medical profession and the population
as a whole do not realize the high rate of death that is
associated with whooping cough, and that the improve-
ment in mortality in this disease has not been in propor-
tion to that found in other infectious diseases.

Accidents will always be a major problem, even
though in the younger ages most of these accidents could
be prevented by a little more thoughtfulness exhibited

by adults in charge of children. These points should be
emphasized more in the public health publications, pop-
ular magazines, and daily papers.

CHART II

Northwestern National Life Insurance Company’s Juvenile
Mortality Experience

Northwestern National Life’s Data

Attained

Age

Exposed

Deaths

Death Rate per
100,000

1969

660

2354

510

2574

271

3062

229

3603

111

4247

141

4663

129

5205

5617

5916

6779

7137

7696

8316

—

8972

206

THE JOURNAL-LANCET

CHART III

Death Rate per 100,000 From Specified Causes of Death.
Ages Under 15 Years

Metropolitan Life Insurance Company, Weekly Premium-Paying
Industrial Business, 1936.

Cause of Death

Death Rate

per 100,000

Under 1 5

Under 5

5 to 9

10 to 14

All Causes

260.5

600.0

147.8

116.6

Typhoid Fever

Measles

2.6

7.0

1.7

Scarlet Fever .

5.1

7.3

6.4

2.4

Whooping Cough

5.1

17.8

—

Diphtheria .

Influenza and

4.9

9.5

5.2

1.4

Pneumonia

64 4

191.1

19 2

13 6

Influenza
Pneumonia — -

9.7

25.1

4.2

3.5

All forms

54.7

166.0

15.0

10.1

Cancer — all forms

2.7

3 8

2.3

2.4

Diabetes Mellitus
Diseases of the

1.1

1.5

1.3

Heart

Diarrhea and

8.2

4.9

6.7

11.9

Enteritis

21.0

73.9

1.6

Appendicitis

9.7

9.8

9.6

Suicides

—

Homicides

Accidents, Total

34.1

48.7

32.5

24.9

Auto Accidents

12.0

13.1

14.0

9.2

Chart 4 shows the mortality for the Metropolitan Life
Insurance Company’s weekly premium-paying industrial
business from 1911 to 1935. It presents a still more
comprehensive study. It shows the mortality for all
causes and the figures for the individual diseases. A
progressive improvement is evident in most diseases, in-
cluding pneumonia and influenza, with the exception of
those of the upper respiratory tract. There has not,
however, been a very striking improvement in pneumonia
and influenza. The diseases of the pharynx, tonsils,
mastoids, and ear show no improvement from 1911 to
1935, and it is very hard to understand why this is true.
It makes one wonder whether or not the usual treat-
ment of these conditions should be continued. The most
common treatment in the past for these conditions has
been the tonsillectomy. It again raises the question as
to whether or not the wholesale removal of tonsils, as
has been done in this country in the past, is justified.
I do not believe the question of the advisability of the

CHART IV

Standardized Death Rates per 100,000 From Specified Causes of Death. Ages 1 to 14 Years
Metropolitan Life Insurance Company. Weekly Premium-Paying Industrial Business

1911 to 1935

Year

All

Causes

Typhoid

Fever

Measles

Scarlet

Fever

Whooping

Cough

Diphtheria

Tuberculosis
(All forms)

1935

207.7

6.7

7.5

4.5

6.5

1 1 .8

1934

213.7

1.3

7.5

7.1

6.3

6.5

13.9

1933

210.8

1.3

4.1

6.8

3.8

7.6

1 4.1

1932

225.6

1.5

4.5

7.4

5.3

1 1.2

15.9

1931

264.9

1.9

8.1

8.2

6.0

12.5

18.4

1930

269.7

1 .9

6.9

6.4

6.3

16.1

20.4

1 929

319.8

1.7

7.0

6.7

9.4

23.9

21.8

1928

319.5

2.3

12.0

6.4

8.1

25.9

21.6

1927

309.7

4.0

9.1

7.2

8.8

27.3

23.1

1926

363.8

3.3

22.4

8.5

14.8

25.3

27.1

1 925

332.6

3.8

6.9

8.1

10.3

26.7

25.0

1924

358.6

3.6

1 5.7

10.3

10.6

33.9

27.9

1923

394.9

4.7

25.3

1 1 .3

15.8

42.8

28.3

1922

396.4

4.6

1 3.6

1 2.6

9.0

51.1

29.4

1 921

433.1

6.2

9.4

18.1

13.3

66.1

32.3

1920

511.1

6.2

25.1

1 5.4

21.5

61.0

40.8

1919

502.9

6.3

10.1

9.9

9.6

56.4

45.3

1918

803.5

10.5

23.6

8.6

31.7

51.8

53.6

1917

558.9

10.4

30.3

14.7

16.2

66.1

53.4

1916

546.9

10.8

29.4

10.4

19.3

58.3

54.9

1915

493.6

10.6

17.5

1 2.4

16.0

60.3

55.3

1914

544.5

14.1

20.9

26.3

19.7

72.5

59.3

1913

594.1

16.6

36.9

34 3

20.0

77.3

60.2

1912

562.6

15.7

23.5

26.1

17.3

69.7

58.8

1911

623.7

17.8

34.0

35.4

23.9

78.6

63.5

Diseases of

Diseases of the

Dis. of Pharynx

Accidents!

Automobile

Influenza or Pneumonia!

Y ear

the Ear

Mastoid Process

and Tonsils

(Total)

Accidents

5 to 9 Yrs.

10 to 14 Yrs.

1 935

3.0

2.1

5.8

28.0

1 2.1

21.9

14.0

1934

2.8

1 .9

5.2

31.3

13.2

17.0

1 1.0

1 933

2.8

2.3

6.1

30.2

1 3.4

21.2

1 1.9

1 932

2.7

2.0

5.9

31.7

1 3.5

19.8

14.7

1931

2.5

1.8

6.3

35.0

16.1

21.3

14.3

1930

2.3

2.0

5.9

37.3

16.3

20.9

1 3.1

1 929

2.9

1.7

5.9

42.1

18.1

30.6

18.3

1928

2.5

2.1

6.2

41.5

17.1

28.0

18.4

1927

2.5

1.7

6.6

45.3

18.2

24.9

14.3

1926

2.7

1.5

5.9

42.3

17.3

25.2

16.8

1 925

2.3

1.3

6.0

45.3

17.4

26.5

19.1

1924

3.0

1.5

5.7

46.9

17.2

23.6

16.0

1 923

2.7

1.6

5.6

44.9

17.1

28.0

19.7

1922

2.7

1.1

6.2

47.9

17.0

29.3

19.3

1921

2.7

1.5

8.4

47.9

15.7

30.4

17.9

1 920

2.9

1.6

6.7

48.0

15.6

49.6

32.6

1919

2.1

6.6

52.2

14.7

72.3

53.8

1918

2.6

5.5

53.4

13.7

199.6

158.9

1917

2.8

5.6

53.9

1 1.6

31.9

1 9.5

1916

2.8

4.2

46.6

9.5

36.0

19.1

1915

2.9

4.5

45.1

7.2

33.1

16.8

1914

3.1

3.9

44.9

6.1

34.4

16.6

1913

3.0

4.1

46.5

5.2

41.0

15.7

1912

2.3

3.5

43.5

3.8

33.9

15.4

1911

3.2

3.0

44.3

2.3

41.5

19.6

•Not available. t Standardized rates for ages 5 to 14.

JThese are "age specific” rates. Standardized rates not available at this time.

THE JOURNAL-LANCET

207

tonsillectomy as a general procedure will be settled until
controlled groups, one group of those who have had
their tonsils removed and the other of those who have
not, have been studied statistically.

The steady decline in mortality in the industrial cases
from 623.6 to 207.7 per 100,000 is comparable to the
general decline that one would expect from studying

Chart I. This is the group which will be benefited most
by the social legislation now being enacted. With the
decrease of child labor that is now taking place, and the
improvement in the social and economic situation of the
industrial people in this country, we have a right to
expect that these factors will be reflected in a much
better mortality in the future.

The Prevention of Whooping Cough "

E. J. Huenekens, M.D.**

Minneapolis, Minn.

MODERN medicine is stressing more and more
the prevention of disease. This is especially
true of diseases of infancy and childhood,
including the so-called contagious diseases. Physicians
are gradually adapting themselves to the idea that the
family doctor has other functions besides taking care of
the sick; though one still hears an occasional old-fash-
ioned doctor query, "Why vaccinate against small pox
or inoculate against diphtheria when there is no
epidemic?”

Well established procedures in the prevention of con-
tagious diseases, are vaccination against small pox, the
use of toxoid to prevent diphtheria, and vaccine to pre-
vent typhoid. Two comparatively new procedures are
clamoring for consideration, the administration of scarlet
toxin to prevent scarlet fever and pertussis vaccine for
whooping cough.

Pertussis vaccine has been in use for a number of
years and its efficacy has been confirmed both by lab-
oratory experiments and clinical evidence. Huenekens1
was able to demonstrate that pertussis vaccine produces
immune bodies, as shown by the complement fixation
test; freshly prepared vaccine was the most effective.
Later Mishulow, Oldenbusch, and Scholl2 showed that
old pertussis vaccine, properly prepared, preserved, and
stored, retains its potency for several years. Unfor-
tunately, their work is not wholly conclusive because it
was performed on rabbits and not on human beings.

It has been contended that pertussis vaccine would
protect against only one strain of the Bordet-Gengou
bacillus, but Leslie and Gardner3 present evidence that
the pertussis bacillus is a uniform species without fixed
types.

The most favorable and best controlled clinical ob-
servations come from Madsen4, who reports two epi-
demics in the Faroe Islands. The isolated position of
these islands cause the whooping-cough epidemics to
appear in waves, separated by quite long intervals
entirely free from whooping cough. In the 1923-1924
epidemic, 2,094 individuals were vaccinated, and 627
received no vaccine. The prophylactic effect of the
vaccine was practically nil, but the mortality in the non-
vaccinated group was twelve times that in the vaccinated,

•Prepared expressly for the special Pediatric issue of THE

JOURNAL-LANCET.

••Clinical Professor of Pediatrics, University of Minnesota.

and the disease in the latter group was much milder and
of shorter duration.

In a second epidemic in 1929, the results were more
striking. Of the 1,832 vaccinated individuals, 458 did
not contract the disease, and only one died; while of
the 446 nonvaccinated, only eight escaped pertussis, and
eight died. The mortality was thirty times greater in
the nonvaccinated group, and there were sixteen times
as many severe cases.

TABLE I

Madsen’s Analysis of 1929 Epidemic

1,83 2 Vaccinated

446 Nonvaccinated

Not attacked

458

Mild cases

1,336

225

Moderate cases

170

Severe cases

Fatal cases

The vaccine used was from the State Serum Institute
in Copenhagen, where it is always made from several
recently cultivated strains of Bordet-Gengou bacilli;
forty-eight-hour blood agar cultures are emulsified in
physiologic salt solution containing 1 per cent formal-
dehyde and numbering ten billion bacilli per cubic
centimeter.

According to Madsen, the favorable results were due
to the following facts:

1. The vaccine was made from young strains.

2. The dose was rather large, twenty-two billion
bacteria.

3. The vaccination was completed shortly before the
onset of the epidemic; i. e., at a time when the
titer of antibodies produced by the vaccine is
highest.

If we had no other evidence, these reports of Madsen
would justify the use of pertussis vaccine, partly to pre-
vent the disease, but especially to reduce the mortality
of pertussis and to decrease its severity.

Favorable as is this report it does not solve the prob-
lem of permanent immunization. We must give credit
to Sauer5 not only for being the first to attempt this
but also for his apparent success. He prepares his vac-
cine largely according to the Danish State Serum Insti-
tute specifications, the principal difference being that he
uses human blood for his blood agar culture plates. His
technique follows: 8 cc. of bacillus pertussis vaccine

208

THE JOURNAL-LANCET

(1 cc. equals 10 billion bacteria) made from recently
isolated, strongly hemolytic strains grown on Bordet-
Gengou medium made with freshly defibrinated human
blood, is injected subcutaneously in three weekly (bi-
lateral) doses of 1 cc., 1.5 cc. and 1.5 cc. respectively.
The reactions to this procedure are comparatively mild:
an occasional rise in temperature, temporary local re-
actions (redness, induration and tenderness) and sub-
cutaneous nodules which may persist for a few weeks at
the site of each injection. Since we have no test of
immunity in pertussis comparable to the Schick and
Dick test, the efficacy of this procedure must be judged
entirely by the clinical results.

In a recent round table discussion on the prophylaxis
and treatment of whooping cough1’ the latest and most
comprehensive figures are available. Sauer reported on
a total of 2474 cases. (See Table II.)

TABLE II

Immunization With Authorized Commercial Vaccine

Injected Exposed Failed

Evanston Health Department

(1933)

865

familial

outside

Private patients (1932)

627

familial

outside

Three orphanages (1932)

252

’’Cradle” infants under 2
( 1932-33) 6 cc.

mo.

400

familial

outside

( 1934) 6 cc. .

330

2,474

219

Of 219 children definitely exposed to pertussis, 22 or
approximately 10% contracted the disease. Kendrick of
the Michigan Department of Health gave the prelim-
inary figures of a three year study of the value of per-
tussis vaccine in the prevention of whooping cough.
(See Table III.)

Kendrick used approximately the dosage advised by-
Sauer but her vaccine was not made from media en-
riched by human blood but more according to the
method originated by Madsen. This Michigan study
showed that 12.7% of the vaccine-injected group de-
veloped pertussis while 74.5% of control group de-
veloped the disease.

The report on Krueger’s Pertussis U.B.A. (Commer-

cial) disclosed that, of 119 vaccinated children 53 or
approximately 45% developed pertussis. On the basis
of these figures it would seem less effective in prophy-
laxis than either Sauer’s or Madsen’s vaccine.

There has been a tendency during the past year to
encourage the distinction that Sauer’s vaccine is espe-
cially adapted for prophylaxis while Krueger’s vaccine
is more effective in therapy. It would seem that the
vaccine which is finally judged to be more effective in
prophylaxis should also be better therapeutically and
vice versa.

Sauer advocates that during the four-month period
while the child is developing his active immunity no
other immunizations should be administered. One could
imagine that a severe case of measles or scarlet fever
wth high temperature and prostration might interfere
with the production of immunity by pertussis vaccine.
But that the slow non-incapacitating immunization by-
diphtheria toxoid or pertussis vaccine should interfere
with each other is rather a strain on our credulity and
contrary to our experience with other immunological
processes.

Summary

It may be said that while the final word on the value
of pertussis vaccine in prophylaxis must await the pass-
age of time, we have now enough evidence of its value
to recommend it to our patients as a safe procedure of
sufficient value to warrant an extensive clinical trial.

Either Sauer’s or Madsen’s vaccine should be given
weekly in doses of 2 cc., 3 cc. and 3 cc. (Vi in each
arm.) The reactions are comparatively mild. Ten per
cent of children thus immunized may contract whoop-
ing cough in a mild form when exposed to the disease
compared to 75% of nonvaccinated children.

Bibliography

1. Huenekens, E. J.: Am. J. Dis. Child 14:226, 1917; and
Am. J. Dis. Child. 16:30, 1918.

2. Mishulow, L.; Oldenbusch, C.; and Scholl, M.: J. Infect.

Dis. 41:169, 1927.

3. Leslie, P. H.; and Gardner. A. D.: J. Hyg. 31:423, 1931.

4. Madsen, T. : Boston M. Si S. J. 192:50, 1925; and J. A.
M. A. 101:187, 1933.

5. Sauer, L.: J. A. M. A. 100:239, 1933; and J. A. M. A.
101:1449, 1933.

6. Round Table Discussion on Prophylaxis 6C Treatment of
Whooping Cough: J. Pediat. 9:116, 1936.

TABLE III

Whooping Cough Prevention Study
Total in Study April 15, 1936 — 2,285
Exposures and Cases in Study Series to Date, April 15, 1936

Kind of Exposure

VACCINE-INJECTED GROUP

CONTROL GROUP

TOTALS

History

Exposed

Cases

Exposed

Cases

Exposed

Cases

Number

% of

Number

% of

Number

% of

Exposed

Definite

15.0

80.5

132

50.75

Indefinite

5.5

52.9

' 106

28.30

None

Totals

118

12.7

149

111

74.5

267

126

47.2

Per Cent of
Total Cases

11.9

88d

100.0

THE JOURNAL-LANCET

209

Growing Feet*

Edward T. Evans, M.D.**
Minneapolis, Minn.

A CONSIDERATION of the growing foot re-
quires an understanding of the fundamentals of
development, namely hereditary, embryonic, and
early life factors. The foot you possess in adult life is,
excepting extraneous influence, the foc-t you were born
with and a reflection of maternal or paternal heritage.

Hereditary Factors

One may quite frequently use the designation, "type
foot.” By this we mean a foot, which at first glance,
obviously falls into one of several categories. We all
recognize the so called "peasant” type of foot, also
commonly known as the German or Scandinavian type
of foot. This is notoriously rather broad-heeled with
a tendency to some flattening of the long arch, moderate
pronation, and broad anterior arch with a considerable
amount of subcutaneous fat and fibrous tissue-padding.
Another common type of foot is the thin, relatively
small, finely molded "aristocratic” type commonly met
with in the petite French. The negroid foot is a classical
example of a type foot, in that it is a long foot with
a narrow heel but unusually flat longitudinal arch with
considerable pronation through the anterior tarsal area
and with a broad anterior arch, not, however, possessed
of much subcutaneous fat or padding.

All gradations of these extremes, of what might
almost be termed "pathological” types, may be met
with.

Of course the ideal type of foot, at least, as ideal as
the human foot may be, is one exemplified by a reason-
ably good longitudinal arch, narrow, well-molded heel,
and anterior arch sufficiently broad for good support,
hut well-padded though not inclined to chubbiness.

In a paper as short as this, it is impossible to consider
all the features of the foot. Basically, the human foot
is not an excellent weight-bearing organ, although it
has adapted itself well to the environment in the process
of evolution. There is a tendency in many feet to carry
over attributes of the primitive prehensile organ. Nota-
ble among these tendencies is tbe frequency with which
we encounter a short first metatarsal, the so-called
metatarsus atavicus, which may in later life prove a
disturbing factor in proper weight-bearing and lead to
the development of anterior metatarsal disorders and
hallux valgus.

Suffice to say that one must appreciate the fact that
the type of foot is hereditary, and treatment of its dis-
orders must take cognizance of this fact lest one be too
optimistic in prognosis and relief.

In addition to the hereditary qualities of the type
foot, one should, of course, mention the congenital trait

•Prepared expressly for the special Pediatric issue of THE

JOURNAL-LANCET.

••Assistant Professor of Orthopedic Surgery, University of

Minnesota.

in the clubfoot case. I have in mind the case record in
which a maternal grand-aunt had bilateral extreme club-
foot, and the present generation has only a very mild
adduction deformity of the forefoot, but very definitely
a congenital deformity requiring radical procedure for
its correction.

Embryonic and Foetal Features

Clubfoot has been mentioned above. This is, of course,
a congenital deformity and a subject by itself which will
not be discussed in this paper.

The foetal position of the child may result in the
development of an apparent deformity noted at birth.
This must be carefully analyzed to rule out true con-
genital deformity, but a careful examination of the foot
as a whole, irrespective of its apparent deformity will
usually convince one of the fact that prolonged main-
tenance of a fixed position in utero has caused the con-
dition. Treatment should be directed to the correction
of the position by careful and easy manipulation over
a period of time, stretching out the contracted tissues
and allowing the previously stretched-out tissues to re-
gain their tone and activity. This is an acquired, not
a congenital, deformity.

The presence of a spina bifida, even an occult spina
bifida, associated with a paralysis of the extensor and
everting mechanism of the foot so that a paralytic club-
foot results must not be overlooked. Treatment here,
with the exception of treatment of spina bifida, is
directed to maintenance of normal position, the preven-
tion of increasing deformity, and in later years, stabiliz-
ing procedures to maintain a fixed functional position.

The Baby’s Foot

For the most part, the normal baby’s foot at birth
falls into two types; either a long thin type of foot in
the baby of long bones without much fatty tissue, or the
short, chubby type of foot so frequently seen with the
chubby type of infant. It is frequently impossible to
determine at birth whether the foot possesses maternal
or paternal characteristics.

Assuming that the child will grow to early childhood
without rickets or other debilitating disease affecting the
development of the bony structure or normal soft tissue
support, the child’s foot will develop almost willy-nilly
along hereditary lines.

Early weight-bearing is not to be frowned upon pro-
viding that weight-bearing is not productive of excessive
stress or strain. At first weight-bearing, almost every
infant’s foot presents considerable pronation, but it is
only by active use that the tone of the supporting struc-
tures can be developed.

In this respect, it is a common observation that the
child will toe in, thereby assuming a position of maxi-

210

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mum support. Frequently the parent will consult her
physician because her baby is pigeon-toed. Most of these
children are assuming a sensible position which gives
them maximum support, because otherwise there would
be considerable strain as a result of the weight-bearing
line falling internal to the longitudinal arch. As long as
the child persists in walking pigeon-toed, the probabili-
ties are that no active treatment at that time is indicated.

One must appreciate the fact that the bony structure
in the infant’s foot is not firm until the child is about
twelve years of age, and that it will develop normally
along hereditary lines if given the opportunity, provid-
ing there are no extraneous factors operating. The in-
discriminate use of firm supports, especially steel arches,
should be frowned upon for several reasons. In the
first place, treatment should be directed toward the
maintenance of proper stance and the development of
proper soft tissue tone through exercise and training. In
the second place, the indiscriminate use of firm supports,
while it may apparently mold the foot into proper
shape, tends to weaken the soft tissue supports and make
the patient dependent forever upon artificial support. In
the third place, heavy supports inhibit the child’s activ-
ity and prohibit the normal development of the child in
physical activity with other youngsters.

It seems to me that there has been altogether too
much tendency on the part of attending physicians to
cater to the mother’s desires for a shapely foot at the
expense of the normal development of the foot. This is
especially true when the mother appreciates the fact
that the child’s foot possesses either maternal or pater-
nal characteristics, not disabling, which she would like
to eradicate. The sacrifice of the child’s normal de-
velopment to this bit of vanity, should be frowned upon.
One might as well take the infant and perform a sur-
gical operation upon its nose in an effort to eradicate
the type of nose with which it was born.

Parents should be instructed that their child has a
type of foot and that it should be allowed to deveolp
normally with attention to the development of soft
tissue support rather than shapeliness, providing of
course, that this or that particular type of foot will be
adequate to future use as it develops.

The Pathological Longitudinal Arch

As a result of rickets or debilitating disease, an other-
wise normal foot may have so lost the tone of its sup-
porting soft tissue that artificial support is necessary for
its rehabilitation, lest serious developmental changes
occur. I have in mind a case of a young boy of three
and one-half years who, though he developed his ability
to walk normally prior to a severe pneumonia, sub-
sequent to his pneumonia found great difficulty in walk-
ing and continually complained of pain in his feet.
Examination in relaxation showed a perfectly normal
contour of the foot with all the potentialities of proper
weight-bearing. On weight-bearing, however, marked
pronation occurred and it was almost impossible for the
youngster actively to invert his foot. It was obvious that

at his age exercise alone would be insufficient. He was
fitted with steel arch supports and wedged heels which
held the feet in proper weight-bearing position and
allowed him to actively exercise his feet in this position.
As soon as complete maintenance of position is possible,
these supports will be gradually discarded. But it is only
in this type of case that arch supports should be applied
to an otherwise normal foot.

There are, of course, those cases which early in life
show the hereditary characteristics of a severe flatfoot.
The parent may bring this child in with the request that
something be done to prevent, if possible, the develop-
ment of a foot such as he or she has suffered with.
When the parent gives a history of this type of foot
being inadequate, then and then only is one justified
in attempting treatment to prevent a like experience in
the child. I do not believe that the type of foot can be
changed, but I do believe that a carefully supervised
course of treatment over a period of years may so de-
velop the supporting structures of the foot that it is not
subjected to damaging stress and strain with resulting
discom fort.

Such a course of treatment in the extreme case may
combine the use of wedged heels, built up longitudinal
arches, preferably flexible, and the institution of simple
exercises which are not too complicated for the child
to carry on. Such exercises should, if possible, be made
a matter of play in the very young, and a matter of
discipline in the older child so that eventually the main-
tenance of proper stance becomes a matter of habit.

There are some cases of flatfoot which are so extreme
that they are resistant to exercise treatment. In this
condition steel arch supports may prove necessary, but
their use should always be accompanied by exercise,
because all too often the discarding of steel arches later
in life results in a resumption of the hereditary position.
In some of these cases, it early becomes obvious that
the treatment has little if any effect. In these, rare
indeed, operative methods of correction may prove
necessary. The large number of operations proposed for
this type of severe flatfoot indicates that the success of
the operative procedure is questionable. Transposition
of the posterior tibiai insertion, together with stabiliza-
tion of the internal aspect of the tarsus, has proved the
most reliable procedure. The operative procedures vary,
however, from section of the os calcis to change the
weight-bearing line, to radical sub-astragalar arthrodesis
with wedge resections of the tarsal and anterior tarsal
areas. Such operative procedures obviously result in
rigidity of the foot though they may improve the weight-
bearing line and give good functional results. Their use
is, as stated, rarely indicated and only after all conserva-
tive treatment has been exhausted.

When a severe flatfoot is painful it may react by the
development of spasm of the everting mechanism of the
foot and the extensor mechanism of the toes, and be
accompanied by secondary joint changes, all of which
result in the development of a rigid, spastic, flatfoot.
This type of foot may be seen during early adolescence,
although it occurs more commonly in early adult life.

THE JOURNAL-LANCET

211

Its presence requires immediate active treatment consist-
ing of manipulation of the foot under general anesthesia
into an overcorrected position and fixation of the foot
in plaster in this position until the contracted tissues
have stretched out and the previously stretched-out
tissues have had an opportunity to resume their normal
tone and pain has subsided. The after-treatment con-
sists in the maintenance of normal position by means of
rigid arch supports and the utilization of active physio-
therapy to restore the supporting mechanism of the foot.
It is this type of case which, because of the marked
contractions, occasionally requires peroneal section in
order to effect correction.

It is our belief at the University Clinic that a short
tendon Achilles is a female characteristic which may
be apparent in the very early years of life. Certain it
is that we frequently find young girls of eight, nine, or
ten years with a tendency to pronation so marked that
they stand with their feet turned outward at right
angles to each other. These cases invariably present a
limitation of dorsiflexion of the ankle when the foot is
held in the mid position. And any attempt to have the
child walk "Indian fashion” with its toes straight ahead
causes poor general posture and strain of the calf
muscles. We have shocked many a mother by suggest-
ing that she fit her nine or ten year-old child to oxfords
with Cuban heels, but it is our experience that this
frequently corrects the condition, much to the delight of
the child. Apropos of this belief, we are of the opinion
that high heels are worn by women, not as a matter of
style for satisfaction of their vanity, but rather as a
matter of comfort demanded by this female charac-
teristic.

One is frequently asked to express an opinion on the
presence of an abnormal protuberance over the inner
aspect of the longitudinal arch. This is usually caused
by an accessory scaphoid which, though it is unsightly,
seldom needs active treatment in the child unless other
conditions of the foot indicate active treatment. After
the bony development of the foot is complete, this en-
largement may be cut down if demanded although at
that age the child has usually adjusted itself to the
condition and the mother is no longer so desirous of its
removal.

X-ray examination of the foot in the young adolescent
complaining of pain in the longitudinal arch may reveal
the presence of osteochondritis of the scaphoid bone,
more commonly called Kohler’s disease. This may re-
quire, in an aggravated case, the wearing of a plaster
boot until the acute process subsides.

X-rays may also reveal the presence of a destructive
lesion of the accessory scaphoid similar to an epiphysitis
which should perhaps more properly be called an apo-
physitis similar to that process involving the posterior
tip of the os calcis which is known as apophysitis. Pre-
vention of abnormal pressure over a period of time
results in eventual cure in all cases, although some de-
formity of the bone structure itself may persist.

Pathological Conditions of the Forefoot
Including the Metatarsal Arch

Web toes are a common congenital anomaly which
call for no treatment providing the deformity is not
extreme, unless plastic surgery is demanded for cosmetic
reasons. X-rays should always be taken prior to surgery
to determine whether or not complete bony structure is
present upon the basis of which a good functional end
result might be expected. One frequently finds marked
abnormalities of the bony structure which would vitiate
a good surgical result. Hammer toe is another common
condition. This may occasionally be overcome by allow-
ing the child to go barefoot for a summer with strict
attention to the active correction of the toes at each
step. Otherwise surgical correction of the deformity
is indicated after bony development is complete if the
condition is troublesome. Early procedures in this type
of case are not attended with happy results because of
the persistence of the tendency to deformity.

Before considering the anterior metatarsal conditions,
may I disillusion you of the common conception that
there is an anterior arch at the heads of the metatarsals.
The arch is formed by the bony configuration of the
shafts of the metatarsal but a section taken through the
heads of the metatarsals will show that they lie in the
same plane. Most so called anterior arch difficulties
result from conditions which alter the supporting mech-
anism of the anterior foot and destroy its "gripping
power.” At each step the normal foot simulates the
normal plantar reflex and assumes, to some extent, a
gripping position. States of malnutrition, localized pain-
ful lesions, and other factors may result in weakness or
atrophy of this supporting mechanism so that sustained
effort of the forefoot is diminished and strain is thrown
upon the ligaments or metatarsal heads. The anterior
arch does not fall, it broadens. This is particularly true
in that type of foot associated with the short first meta-
tarsal mentioned above. Here, the head of the first
metatarsal, by reason of its abnormal position, does not
bear its normal share of weight-bearing and an abnormal
amount of weight bearing is thrown upon the heads of
the second and third metatarsals. Mechanical support
of the forefoot, utilizing especially added support just
behind the head of the first metatarsal, is productive of
almost immediate relief. The shoes should have firm
soles to make the internal supports effective. If the con-
dition is allowed to persist, painful contraction of the
extensors of the toes associated with flexion of the distal
phalanges and the development of irritated areas and
callouses and corns, is not unusual. Treatment should,
therefore, be directed to support of the area together
with development of the supporting soft tissue mech-
anism of the foot. The common exercises of picking up
marbles, walking in sand, etc., are of value.

Shoes

It would seem almost unnecessary to have to go into
the question of shoes in a paper of this type and yet
our patients frequently ask us what the proper type of
shoe for a growing child should be. In my opinion,

212

THE JOURNAL-LANCET

unless specifically indicated, the use of a sensible, well-
fitting shoe with adequate toe space and adequate length
is all that is necessary. The shoes should, of course, be
reasonably flexible to allow proper exercise of the foot
in walking. It should fit well enough so that no friction
occurs, resulting in excoriation or blisters. They need
not be expensive or fancy.

For the child who has a tendency to flatfoot, there
are many shoes on the market which have a slightly
wedged heel and built-in longitudinal arch which gives
support without sacrificing muscular development. I
should again like to mention that rather frequently you
may find it wise to place an adolescent girl in Cuban or
military heel shoes.

It is almost impossible for any mother to take her
child into the average shoe store without obtaining all
sorts of advice as to how her child’s feet should develop.
And almost never do these commercial houses fail to
attempt to sell some type of corrective apparatus with-

out any conception of the normal development of the
child’s foot. It would seem their sole purpose is the
advancement of their sales without regard to the true
needs of the child. The lay public should be warned
that the assumption of a medical or orthopaedic-sound-
ing name as a trade mark, is not a certification of the
value of the article by the profession.

Conclusions

1. An understanding of the normal hereditary and
developmental factors is necessary for proper consid-
eration of the child’s foot.

2. Artificial means of support should never be used
unless it is obvious that functional development of the
foot cannot be accomplished.

3. Certain pathological states should be recognized
and treated accordingly during the developmental age
of the foot.

State Medicine in Minnesota

C. B. Young, M.D.

J. Arthur Myers, M.D.*

Minneapolis, Minn.

FOR many years we have been reading much about
state medicine. At first we heard the older prac-
titioners sadly prophesying the doom of the private
physician. Next, professional social workers began ad-
vancing plans and schemes whereby the state would
simply take over the practice of medicine and every
physician would be reduced to the status of a state
employee. Now, high school students and various lay
organizations are earnestly debating the subject, and
many people seem to be confirmed in the belief that
the millineum is here and that they have only "to ask
and they shall receive.” However, when asked who is
to pay for this medical service they vaguely reply, "The
Government.” The purpose of this paper is to point out
dispassionately and fairly just what the various govern-
mental units are already paying toward medical care
for the people of Minnesota; and to determine, if pos-
sible, just how much and where governmental medicine
has increased during the past ten years. It is obvious
that state medicine is not coming; it is already here, and
has been here for more than seventy years. The govern-
ment has long accepted the responsibility for the care
of the indigent, the insane, the deaf, the blind, the
feeble-minded, and within the last thirty years, the epi-
leptic and tuberculous. The criteria for eligibility to free
medical care by the government’s institutions have always
been, first, defectives and persons who are a menace to
the health and welfare of organized society, and second,
indigents and persons of the very lowest income levels.
These criteria are still prevalent in state and county

^Professor of Preventive Medicine, University of Minnesota.

institutions but have been almost entirely disregarded by
federal institutions. A possible explanantion for this is
the very excellent Veteran’s Lobby that has been main-
tained in Washington for the past sixteen years.

In Minnesota we have four governmental units ac-
tively engaged in the practice of medicine, i. e.: federal,
state, county, and city. The federal government by con-
gressional action1 has assumed the care of disabled vet-
erans regardless of their financial condition. The total
cost of maintaining the two Veterans Hospitals2 in this
state increased from $790,391 in 1925 to $1,194,728 in
1935, an increase of 51 %. The sum allocated for med-
ical care is less than ten per cent of the total amount —
$13,697,934* — spent for benefits to veterans of all wars
for medical care, compensation, insurance and pensions
in 1935. The federal government also provides medical
care for the Indians4 in this state, and the total cost of
this service was $55,000 in 1925 and $209,000 in 1935,
an increase of 280%. The Indian population5 of Minne-
sota increased from 14,300 in 1925 to 15,283 in 1935, an
increase of almost seven per cent. In August, 1935, an
infirmary with a capacity of 117 beds for the care and
treatment of tuberculous Indians was opened at Ah-
gwah-ching0. This building is maintained by the State
Sanitorium and the federal government reimburses the
State at the rate of two dollars per day for each patient.

In 1933, by establishing the Civilian Conservation
Corps, the federal government assumed the cost of med-
ical services for approximately ten thousand additional
persons in our state. These civilians were provided with
medical and hospital service totaling about $490,000'

THE JOURNAL-LANCET

213

for the fiscal year ending June 30, 1936. This figure is
based on the number of camps in Minnesota and the
total expenditures for medical purposes in the entire
Civilian Conservation Corps.

The Federal Transient Division was established in
November, 1933, and continued for about two and a
half years when it was disbanded and the camps con-
verted into WPA*- work camps. The Transient Divi-
sion provided complete medical and dental care for the
homeless, including dentures, glasses, trusses, etc. The
total cost of medical service provided by the Transient
Division8 in Minnesota was $52,769 in 1934, and for
the year 1935, $95,207. Under WPA° regulations
workmen are given treatment for injuries incurred while
on duty only, and this treatment is provided by private
physicians who are paid on a fee-basis from WPA
funds.

In 1863, the Minnesota State Legislature author-
ized10 the Governor to place, not to exceed twenty-five,
indigent insane in the Iowa State Hospital. Three years
later, the Legislature11 appropriated a sum of money to
establish a hospital for the insane, and the first institu-
tion of its kind in Minnesota was opened in an old
hotel building at St. Peter the same year. Gradually,
as the state grew to maturity, more institutions were
built until now, we have three hospitals and three asy-
lums for the care and treatment of the insane. At the
present time, contracts have been let for another hos-
pital at Moose Lake and it is expected to be completed
within the next two years. Each of these institutions
has a full time resident medical staff plus a consulting
staff of private physicians who donate their services.

The average number of patients in insane hospitals
and asylums for the year ending June 30, 1936, was
9,544 and the total expenditures were $2,088,78712. Ten
years ago, 7,197 insane persons were hospitalized at a
total cost of $1,802,294'". During the ten year period
the average number of insane persons in institutions in-
creased 32.6%, but the cost increased only 15.9%. Min-
nesota’s population14 increased 5.8% over the same
period. For the fiscal year 1926, 25.8% of the patients
were classed as pay and part-pay and contributed
11.3%1-’ of the total maintenance costs. A decade later,
21.7% of the patients paid 7 V2 %16 of the total ex-
penditures. In other words, the care of the insane was
88.7% socialized in 1926, and 92.5% in 1936. It seems
reasonable to conclude from the above figures that the
care of the insane is slowly approaching complete social-
ization, and that the total number of insane persons in
the state institutions is increasing much more rapidly
than the rate of normal population increase.

Although the care of the deaf, the blind, and the
feeble-minded is more educational than medical, the
underlying causes of the conditions are in most cases of
a medical nature. It is interesting to note that the first
legislation authorizing1' the hospitalization and educa-
tion of defectives was in 1858, tbe same year that Min-
nesota was admitted to the Union. However, it was not
until five years later that the Minnesota Institution for

the Education of the Deaf and Dumb was opened at
Faribault with eight pupils in attendance. Growth has
been rather slow and for the fiscal year 1926, the aver-
age attendance was 261. The total maintenance cost for
the year was $151,1 121S. Ten years later, the average
attendance was 314 — an increase of 20% — but the total
expenditures were $164, 7391" — an increase of only 9%.
Minnesota law-" requires that deaf or dumb children
between the ages of six and twenty years attend the
state school or an equivalent private school until dis-
charged by the superintendent with the approval of the
State Board of Control. The state school is entirely
free except for postage, clothing, and transportation.

In 186421, the name of the Faribault school was
changed to the Minnesota Institution for the Deaf,
Dumb, and Blind; and the first class of blind was ad-
mitted in 1866. The school'- for the blind is free to
all children who are unable to attend public schools be-
cause of defective vision. In 1926, with ninety-nine stu-
dents in attendance during the school year, the total
maintenance costs were $ 106,8 1 423. A decade later, 126
students attended the school, but the total costs had
decreased to $93 ,9 1 524. The Division of the Blind also
provides relief, higher education and assistance in find-
ing work to the needy blind. During the past decade
the relief needs of the blind have greatly increased, and
the total amount spent for relief and education of the
blind increased from $147, 2342-1 in 1926, to $204, 45824
in 1936, an increase of 38.8%. The 1935 Legislature-"
appropriated approximately $125,000, to match an equal
grant by the Social Security Board, for the care and
rehabilitation of the blind. However, the Division of
the Blind has not received the federal grant because the
Minnesota Law does not conform to federal require-
ments. The law will probably be amended at the 1937
session of the State Legislature.

In 1879, the Legislature authorized'0 a further ex-
pansion of the Faribault school and a department for
the care of the feeble-minded was organized on an ex-
perimental basis. Two years later2', it was made a reg-
ular division of the school and money was appropriated
for a separate building. The School for the Feeble-
minded and Colony for Epileptics, as it is now called,
has grown rapidly and is now the largest state institu-
tion with an average population of 2,312 for the fiscal
year 1936. The total expenditures for that year were
$529, 64828, as compared with $607,944-’" a decade be-
fore, a decrease of 12.8%. Until 1925, the epileptics
were cared for at Faribault, but in that year a colony
for epileptics was opened at Cambridge. It is the
state’s newest institution and its growth has been very
rapid, but there are still more applications than va-
cancies. The total expenditures for the fiscal year 1926,
were $35,76830, but ten years later, they were $207,-
73431, an increase of 483%. However, this does not
give a true idea of the actual increase in the cost of car-
ing for the epileptics because in 1926, the colony at
Cambridge was just getting started and most of the
epileptics were still being cared for at Faribault. Com-
bined expenditures for the two institutions increased

214

THE JOURNAL-LANCET

about fourteen per cent for the decade and the average
number of feeble-minded and epileptic in both institu-
tions increased from 2,013 in 1926, to 3,185 in 1936, an
increase of 58%.

Minnesota has the honor and distinction of being the
first state in the Union to provide state* funds for the
hospitalization of indigent crippled children. In 1897,
the Legislature appropriated $5,000'*-’ to be used to hos-
pitalize indigent crippled children in the City and
County Hospital at St. Paul. Ten years later, the Gil-
lette State Hospital for crippled children was author-
ized'*'*, but it was not opened until 1911. The medical
staff is composed of the foremost orthopedic surgeons
and specialists of the Twin Cities who all donate their
services. Total maintenance costs were $223, 563'*'* for
the fiscal year 1926, and $224,740'*'' a decade later and
the average hospital population was 233 in 1926, and
240 in 1936. In addition, $44,088'**’ was utilized by the
Department of Education to provide vocational training
for physically handicapped children for the fiscal year
1926, and $51,139'*’ for the fiscal year 1936. By pro-
vision of the Social Security Act of 1935'*s, an annual
sum of approximately fifty thousand dollars was granted
to Minnesota for the care of crippled children, partic-
ularly those from rural and economically distressed
areas. By action of the State Board of Control the
Division of Crippled Children was created to locate and
keep permanent records of all crippled children in the
state. The director of the division also assumes leader-
ship in conducting twelve orthopedic diagnostic clinics
a year at various cities in the state to examine and ar-
range hospitalization for needy children in that locality.
These clinics are held in cooperation with the local med-
ical societies or other interested welfare organizations.
Five public health nurses and two physio-therapy nurses
have been secured to do the follow-up work and to assist
in conducting these clinics.

It should be emphasized that there has been no change
in eligibility requirements and this program can in no
way be construed as an invasion of the private practice
of medicine. It has resulted in a marked reduction of
heretofore long waiting lists and therefore provides
better and more satisfactory service to the indigent
crippled child.

Minnesota by organizing a State Department of
Health in 1872'*!>, was the third state on the Union to
establish governmental health protection and regulation.
The State Board of Health consists of nine members
appointed by the governor for terms of three years
each. The terms of three members expire each year, and
all members serve without pay. This board by regular
meetings and through its executive secretary, the state
health officer, regulate and enforce the various health
laws of the State. They may also draft reasonable reg-
ulations for the preservation of the public health, which,
after being approved by the attorney general and duly
published, have the authority of law.

In 1926, the total cost of the State Department of
Health was $205, 67540, a per capita cost of $0,087.

Even this amount is not all chargeable to the taxpayers
of this state, because the Federal Government contrib-
uted $18,099 and miscellaneous collections of the de-
partment were $13,493. Ten years later, the gross ex-
penditures of the Health Department were $321,415",
an increase of 56%. However, this increase is more
apparent than real, because several State Departments
have been transferred to the Health Department. The
largest of these, the Division of Hotel Inspection, was
formerly under the jurisdiction of the State Securities
Commission. The expenses of this division, amounting
to approximately thirty-five thousand dollars each year,
cannot therefore be considered as an addition to the cost
of state health. In 1933, laws4-’ regulating and licensing
plumbers were passed by the Legislature and this new
function was added to the administrative division of
the Health Department. License and inspection fees
more than pay the administrative cost of the new divi-
sion. The stream pollution survey formerly was carried
on by the conservation department. The federal govern-
ment under terms of the Social Security Act granted
Minnesota $78,1384'* for the fiscal year 1936, to be used
to extend and improve public health functions. This
amount is only about half of the total amount possible
under maximum provisions of the Act. It is apparent
that, in spite of a gross increase in the Health Depart-
ment budget, the actual expenditures of state money is
about the same in 1936 as in 1926.

Perhaps the least known but certainly not the least
important of our state health agencies is the Livestock
Sanitary Board. This board, formed in 1903, is de-
signed to eradicate diseases of livestock that directly or
indirectly affect man. The chief problem has been, of
course, tuberculosis in cattle. Exactly how much this
work has contributed to our marked decrease in the tu-
berculosis death rate in man is difficult to say, but it
must be considerable. Thousands of tuberculous cattle
have been slaughtered, each of these being a potential
dispenser of millions of tubercle bacilli. For the past
two years, Minnesota has been an officially accredited
area44 — this simply means that practically all herds in
the state have been tested and the incidence of tubercu-
losis is less than .5%. Glanders in horses and rabies have
also been practically eliminated through efforts of the
Livestock Sanitary Board. In 1926, this board under-
took plans to eliminate Bang’s disease in cattle. Milk
containing bacillus abortus is known to cause undulant
fever in man and the only practical method of entirely
eliminating this disease lies in completely eradicating it
in cattle, swine, and goats. In 1934, the federal govern-
ment, in cooperation with the Livestock Sanitary Board,
began an extensive program to control Bang’s disease.
The work is progressing satisfactorily and before many
years we may look forward to the complete elimination
of Bang’s disease. For the fiscal year 1926, the division
operated on a budget of $488,0964°, but a decade later
the total expenditure was only $153, 53341’, a decrease
of 68%. However, the federal government expended
approximately $226, 0004' for the fiscal year 1926, and
$1,174,215 for the fiscal year 1936, for these same pur-

THE JOURNAL-LANCET

215

poses. Total expenditures, therefore, increased 85.9%.

A state sanitorium for consumptives was authorized
in 19034s, but the institution was not opened until five
years later. At the present time the State Sanitorium
is a fine modern institution with a capacity of 480 beds
including the Indian Infirmary which was opened in
August, 1935. In addition to the tuberculous Indians in
Minnesota, the State Sanitorium cares for patients from
the forty-six unorganized counties and also supervises
epidemological work in these counties. The total main-
tenance cost for the fiscal year 1926 was $ 194,8 164!\ A
decade later, the total cost had increased $194,816 to
$305,64 L’°. The approximate percentage distribution’’1
of income for the State Sanitorium for the year 1936
was as follows: counties 42%, Indian Bureau 18%,
federal transients 1.15%, pay-patients 3%, the state
29%, and miscellaneous 5%. In addition to the state
institution, we have fourteen county sanitoria"* with a
bed capacity at the present time of 1,793, making a total
of 2,073 beds available for the hospitalization of tuber-
culous persons. For the past two years there has been
empty beds in almost every sanitorium in the state.
However, if all our known methods of diagnosis were
utilized to their maximum extent on every individual in
the state, these beds would in all probability be more
than filled. Although figures from all the county sani-
toria are not available for the year 1925, the approxi-
mate total maintenance cost of the fourteen county sani-
toria was $1,253,000. The 1935 cost was $l,341,975’:t,
an increase of about 7%. There has been, however, an
increase of 82% in the amount of state aid paid these
sanitoria during the same period. In 1925, the total state
aid paid to county sanitoria was $237,995 l4, or about
19% of the aggregate maintenance costs. In 1935,
$436, 097”-’, or about 30% of the total expense was paid
by the state. This shift in costs toward the state is due
entirely to the increased number of free patients, because
the state is obligated by law51’ to reimburse the county
sanitoria at the rate of $5 per week for each pa-
tient. Hilleboe’" in his report to the Board of Control
for the fiscal year 1936 makes the following pertinent
statement: "The percentage distribution of income by
sanitoria has changed considerably in the last five years.
In 1931, 50.5% of the total income came from the sani-
torium district and 16.4% came from state aid for resi-
dent cases. In 1935, 62% of the income came from the
sanitorium district and 30% from state aid for resident
cases. It is to be noted that the proportionate cost is
shifting more and more to the county and to the state,
and that the state particularly has had quite a marked
increase in the cost of care of tuberculous individuals
because of the fact that the patients are no longer able
to pay for their care, or even to partially pay for their
care in the majority of cases.” We believe that it is safe
to say that the care and treatment of tuberculosis in
Minnesota is between 95 and 98 per cent socialized at
the present time. It is probable that this represents an
approximate maximum under existing laws and eligibility
requirements. In 1925, 92.8%r>s of the Hennepin Coun-
ty health expense was for the Glen Lake Sanitorium and

13.4%’,:' of the Minneapolis Health Department’s bud-
get was used for tuberculosis control work. Although
the county portion of maintaining Glen Lake Sanitorium
had increased 9% in 1935, the relative amount spent on
tuberculosis in Hennepin County was only 83% of the
total health budget. In Minneapolis, the Health Depart-
ment expended 20.8%'’° of its budget on tuberculosis
control work or nearly double the 1925 expenditure.
Because of the marked increase in medical aid to indi-
gents, only 29% of the total (city and county) health
expenditures was for tuberculosis in 1935, as compared
to 46% in 1925. The per capita cost of tuberculosis in
Hennepin County was $0.91 in 1925, and $0.89 in 1935.
No figures are available for the Ramsey County Sani-
torium because it is a part of Ancker Hospital, but the
Health Department in St. Paul expended 16.2%t’1 of
its budget on tuberculosis control work in 1926 and
13.4%l>2 in 1935. In St. Louis County, 72 %6-3 of the
county health expenditure was for the treatment and
control of tuberculosis in 1925, but only 34%04 in 1935.
However, the per capita costs were $0.87 in 1925, and
$0.95 in 1935. All of the above figures represent local
costs only and therefore do not include state aid. The
total cost of governmental control and treatment of tu-
berculosis in Minnesota was approximately one and a
half million dollars in 1925, and $1,690,000 in 1935.
This represents a per capita cost of $0.60 in 1925, and
$0.64 in 1935. These figures do not include the cost of
caring for tuberculous individuals in the Veterans Hos-
pital and in our state institutions for the insane, feeble-
minded, epileptic, etc., as that cost is a part of the reg-
ular maintenance expense of the institution.

University Hospital, now called the Minnesota Gen-
eral Hospital, has always been primarily a teaching
institution. Its secondary purpose is to provide medical
services to the indigent of our rural counties that have
no local facilities. Prior to the depression, local physi-
cians cared for the indigent in their own community and
sent only unusual cases, and patients requiring surgery
to the University. Gradually as the depression wore on,
more and more patients were sent to the University. The
hospital has been enlarged from a capacity of 155 in
1925 to 325 in 1935. In addition a large out-patient
department cares for thousands of ambulant cases each
year. The total operating costs of the University Hos-
pital increased from $230, 590''’’ for the fiscal year 1925,
to $606, 225M' for the fiscal year 1933, an increase of
163%. In 1925, claims totaling $132,382 were filed, of
which one half was paid by the counties and the other
half from the state’s general revunue fund. A decade
later, claims totaling $351,161 were filed, and $340,580
collected. Some counties are delinquent in the payment
of their share of the cost, so that actual payments in any
one year may be more or less than the claims filed.

The direct responsibility for the care of the indigent
sick rests upon the county commissioners in places where
the county system is used, and upon the township’s
supervisors where that system exists. Of course, the com-
missioners may delegate the responsibility to special
boards or commissions. City governments may also ac-

216

THE JOURNAL-LANCET

cept this responsibility, and it is usually delegated to a
board of public welfare appointed by the mayor.

Locken'’7 recently conducted a survey of all the coun-
ties of the state and found that twenty-six have estab-
lished a fee-basis plan where all the physicians partici-
pate in the care of the indigent. The patient simply
calls his own physician and the physician presents a bill
to the county for services rendered. These twenty-six
counties report the system working with reasonable
satisfaction. Fifteen other counties use a fee-basis sys-
tem, but it is unsatisfactory due to the fact that the
township officers are notoriously difficult to reach for
authorization. Eleven counties report that the county
physician contract plan is in effect and that in nearly
every case medical care is regarded as unsatisfactory by
the local physicians. Eight counties have a combination
of county physicians and fee-basis plan and four report
satisfaction and four dissatisfaction. There are a few
counties that have no provision at all for the medical
care of indigents other than the LJniversity Hospital.
At the present time there are about forty thousand fam-
ilies on direct relief and WPACi), and about thirty-five
thousand persons receiving old age pensions in the
rural counties of the state. These people must be cared
for when sick, and if the local physicians are not com-
pensated by the county on a fee-basis, the physicians ate
duty bound to care for them gratis. When one out of
every five or six families is on relief in a community, the
burden upon the local physicians is unquestionably un-
fair. In 1935, physicians and dentists of the rural
counties received $9 1 7,521 70 from the State Emergency
Relief Administration for medical care of relief clients.
This method of providing medical care has been dis-
continued and the burden returned to the counties and
other local units. The obvious solution is for all rural
counties to adopt the fee-basis plan.

Urban counties, Hennepin, Ramsey, and St. Louis,
have entirely different systems for the care of their in-
digent, and these systems have evolved through a process
of adaption to local conditions, both geographic and
political. The City of Minneapolis has maintained a
City Hospital for almost thirty-five years. It is closely
connected with the Medical School of the State Univer-
sity and three of its department heads are full time
members of the Medical School faculty. Residencies are
at a premium and thus it is possible, with the aid of a
large visiting staff of physicians, to staff the entire hos-
pital at almost no cost to the City. Ramsey County and
the City of St. Paul have operated Ancker Hospital
under a joint partnership plan since 1889. This insti-
tution is also used for teaching purposes and is staffed
by physicians volunteering their services. St. Louis
County is far from the Medical School and there is no
real reason for a large centralized teaching institution,
and therefore, relief clients are cared for in their own
homes by private physicians who are paid by the county
on a fee-basis. We shall attempt to compare the costs of
medical care for the indigent in these three counties.
The City of Minneapolis and rural Hennepin County
have entirely separate arrangements for the care of in-

digent sick, but the care of the tuberculous and prac-
tically all the specialized welfare activities (except Pub-
lic relief) are financed from county funds. We shall
first discuss the health and welfare expenditures of Hen-
nepin County'1 in 1935 as compared to 1925.

HEBBEP IB COUUTY
County funds only

1926 1935

Pig. I

The accompanying chart (Fig. I) shows clearly that
the 98% increase in the health and welfare budget is
largely due to welfare expenditures (216% increase),
and not to health expenditures (22% increase). Prob-
ably a more accurate comparison would be on a per
capita basis. The population of Hennepin County in-
creased approximately fifteen per cent during the ten-
year period. The total health expenditures from county
funds was $0.95 per capita in the year 1925, and $1.01
in 1935. In addition, the SERA paid private physicians
and dentists a total of $ 1 6,53 1 ‘ “ for medical and dental
services to relief clients of rural Hennepin County, as
they are not eligible for care at Minneapolis General
Hospital. There has been no new county health pro-
gram started during the ten-year period. Welfare ex-
penditures''5, however, increased from $0.65 per capita
in 1925, to $1.76 per capita in 1935. Much of this in-
crease is due to old age pensions and mothers’ aid.

Before discussing the costs of health and welfare ac-
tivities for the City of Minneapolis, we should like to
call your attention to a few facts relating to the number
of persons dependent upon government funds for their
very existence. Ten years ago, the number of persons
on relief was, at the most, about one thousand families
per year. Each year following the memorable stock mar-
ket crash, the relief load mounted higher and higher
until in January, 1935, more than 24,00074 cases were
registered on the Minneapolis relief rolls. It is difficult
to estimate the number of people dependent upon relief
but it probably exceeded 100,000 or somewhat more than
one-fifth of the total population of the City of Minne-
apolis. At the present time the relief rolls are greatly
reduced, but when WPA1'' workers are added to the ex-
isting relief case load, we find that there are still about
20,000 families and single persons dependent upon gov-
ernment relief in one form or another. There are also
about ten thousand persons receiving old age pensions.
Thus we know that in spite of recovery there are still
between eighty and ninety thousand persons in the City
of Minneapolis that must receive free medical care and
hospitalization in case of serious illness. How many

THE JOURNAL-LANCET

217

more families there are with incomes of less than $1,000
per year we do not attempt to guess. The total amount
spent for welfare (public relief) in the City of Minne-
apolis7'1 for the year 1925 was $570,968, a per capita
cost of $1.34. Ten years later, the amount had in-
creased 1452% to the astonishing figure of $8,863,681,
a per capita cost of $18.10.

CITY 0? MMEAPOLIS
Federal. State k City Funds

Fig. II*

The accompanying diagram (Fig. II) shows graph-
ically the tremendous increase of welfare expenditures in
relation to the total city expenditures. We have not been
concerned as to where the city gets its money, but it
might be interesting to know that all except $80,000 of
the amount spent on public relief was either borrowed
(bond issue) or received from state and federal relief
agencies. The total amount' ' spent for health increased
from $486,399 (1.14 per capita) in 1925 to $1,076,817
($2.19 per capita) in 1935, an increase of 121%. Gen-
eral Hospital7* has borne almost the entire burden of
caring for relief clients and its total maintenance cost
has increased 268% from $212,331 ($0.50 per capita)
in 1925, to $781,197 ($1.50 per capita) in 1935.
Although General Hospital accounted for 72% of the
total amount spent by the city government for health in
1935, the other 28% is perhaps more important to
the average citizen, because he gets a definite amount
of protection for his tax money. This is not the place to
discuss the activities of the Health Department, but it
suffices to say that Minneapolis rated 930 points out of
a possible 1,000 in a survey conducted by the American
Public Health Association and the United States Cham-
ber of Commerce for the year 1934. The total cost of
the Health Department79 increased from $122,871 in
1925, to $146,996 in 1935, an increase of 19%. How-
ever, the city’s population increased 15% and thus the
per capita cost was twenty-nine cents in 1925 and thirty
cents in 1935. Maintenance costs of Lymanhurst Health
Center*0 — under Health Department supervision — de-
creased 32%, a per capita reduction from eleven cents
in 1925, to six cents in 1935. Part of the reason for this
reduction is the fact that the personnel of the Cardiac
Convalescent Hospital was furnished by ERA*1 and
WPA*- and thus labor costs are not included in the
above figures.

There were fifty-nine school nurses and ten part time
school physicians employed by the Minneapolis schools83
at a total cost of $103,475 for the year 1925, a pet

capita cost of twenty-four cents. In 1935, filty-nine
nurses and twelve physicians were employed at a total
cost of $116,190, a per capita cost of twenty-four cents.

In addition to the amount spent by the city govern-
ment for the various medical services, the community
fund84 expended $146,108 for free clinics, nursing serv-
ices and dental care of children in 1925, and $192,257
in the year 1935, an increase of 31%. However, the
relative proportion of the total fund spent for medical
care was 15% in 1925, and 13% in 1935.

At the present time — January 1937 — there are about
fifteen thousand cases on WPA and direct relief and
about four thousand persons receiving old age pensions
in Ramsey County. Therefore, as in Hennepin County,
approximately one-fifth of the total population of Ram-
sey County is receiving government relief in one form or
another. Because the Ramsey County Board of Public
Welfare80 receives funds from both city and county as
well as state and federal assistance, we have compared
only health and welfare expenditures (Fig. Ill) in 1935
with similar expenditures in 1925. Expenditures for
medical aid to the poor and care of the indigent tu-
berculous increased 69% during the ten-year period,
from $510,943 ($1.91 per capita) in 1925, to $865,700
($2.81 per capita) in 1935. This sum in 1935 included
salary of five county physicians and approximately sev-
enteen thousand dollars paid to private dentists on a
fee-basis for dental care of relief clients.

RAJ1S2T C0U1TY 4 SAIAT PAUL
Health k Welfare Lxpecd ituree
City, County. State k Federal Funds

Welfare expenditures increased from $209,271 ($0.78
per capita) in 1925, to $6,869,412 ($22.35 per capita) in
1935, an increase of over three thousand per cent. Non-
relief health expenditures decreased considerably during
the same decade. The St. Paul Health Bureau80 de-
creased expenses from $141,622 (fifty-three cents per
capita) in 1926, to only $95,992 (thirty-one cents per
capita) in 1935, a decrease of 39%. The school health87
program also reduced expenditures from $48,627
(eighteen cents per capita) in 1925, to $34,404 (twelve
cents per capita) in 1935, a decrease of 25%. In addi-
tion, the St. Paul Community Chest88 classified $72,545
as medical expenditures in 1925, and $61,887 in 1935.

St. Louis County has approximately twelve thousand
cases on WPA and direct relief and thirty-two hundred
persons receiving old age pensions or somewhat more
than one-fifth of the total population.

218

THE JOURNAL-LANCET

SAINT LOO IS COUNTY
County, Stat« k Federal Fund*

1926 1936

Fig. n

Total health expenditures89 (Fig. IV) increased
154% during the past decade from $246,808 ($1.21 per
capita) in 1925, to $626,330 ($2.77 per capita) in 1935.
These figures do not include school health because prac-
tically all of the range cities maintain their own school
physician and dentist from local funds. Welfare ex-
penditures90 increased 1,169*' h from $355,786 ($1.73
per capita) in 1925, to $4,514,141 ($19.97 per capita)
in 1935.

Summarizing91 health and welfare expenditures for
the three urban counties, we find that Hennepin County
spent $1.98 per capita for health in 1925, and $3.24 per
capita in 1935. Ramsey County health expenditures to-
taled $2.66 per capita in 1925, and $3.24 per capita in
1935. Excluding school health, St. Louis County ex-
pended $1.21 per capita in 1925 and $2.77 per capita in
1935. Even allowing twenty-four cents per capita for
school health (the Minneapolis cost) we find that the
per capita cost of medical care in St. Louis County is
still somewhat less than in Hennepin and Ramsey
Counties. This fact would seem to indicate that the fee-
basis method of providing medical care to relief clients
is no more expensive than the centralized hospital system
used in Minneapolis and St. Paul.

Welfare expenditures for Hennepin County were
$1.99 per capita in 1925, and $19.86 per capita in 1935.
Ramsey County spent $0.78 per capita for direct relief
in 1925, and $22.35 per capita for direct and work relief
in 1935. St. Louis County welfare expenditures were
$1.73 per capita in 1925, and $19.97 in 1935. These per
capita costs will all be still higher in 1936 and 1937 be-
cause of the increased cost of WPA and also because of
liberalized old age pensions. These figures are all based
on total expenditures for relief and work relief from
county, state, and federal funds.

The above chart (Fig. V) gives comparative expend-
itures of the various governmental health units for the
years 1926 and 1936. According to the report of the
White House Committee on Costs of Medical Care92,
the American people spend approximately four per cent
of their total incomes each year for all forms of med-
ical care. This figure remains fairly constant year after
year in good times and bad. In 1926, the total value of
goods and services 93 produced in Minnesota was slightly
more than one and a half billion dollars. Four per cent
of this amount is sixty million dollars or the approxi-

mate cost of all forms of medical care in our state. For
the fiscal year 1926, government medical care in Min-
nesota totaled approximately seven million dollars or
about eleven per cent of the aggregate sum. Ten years
later, the value of goods and services produced was
about one billion, one hundred million dollars91 and
nearly one-fifth of our total population was receiving
government relief. On the above basis, the total cost of
medical care in Minnesota would be approximately
forty-four million dollars, of which about twelve and a
half million, or twenty-eight per cent, was provided by
the various governmental agencies and institutions. This
shift is certainly significant if it is a permanent change
in our method of providing medical care.

We have tried to point out as accurately and as
fairly as possible the extent of state medicine in Min-
nesota at the present time as compared with a decade
ago. Conclusions from these findings, whatever they
may be, are most important only insofar as they relate
to the future of organized medicine. There is no doubt
that governmental responsibility for the medical care of
a certain proportion of our people has increased tremen-
dously during these past ten years. We believe, however,
that this increase is fundamentally due to the distress-
ing economic conditions that have prevailed in this state
and nation for the past seven years. It depends largely
upon one’s personal economic views whether or not he
believes that the present conditions are to be permanent
or temporary. Almost everyone will agree that if unem-
ployment could be completely eliminated, we would have
no problem of socialized medicine. However, as long as
from one-sixth to one- fifth of our total population re-
mains dependent upon government relief in one form or
another, they will demand and receive free medical
care. How will that care be given in the future? Prob-
ably about the same as it is now, with perhaps some
increase in the use of the fee-basis plan for indigent care,
especially in the rural counties.

While the underlying principles of professional rela-
tionship to the community have scarcely changed at all
during the last decade, organized medicine itself has
made some progress toward better medical care for all,
whether rich or poor. Perhaps the most significant is the
development of the community health center, of which
Lymanhurst Health Center in Minneapolis is an ex-
cellent example. The movement is still in its embryonic
stage, there being only one in Minnesota, but there are
several in other states. These centers are primarily in-
terested in diagnosis and preventive medicine, such as
Mantoux testing, vaccination and innoculation, etc. At
present, they function largely as tuberculosis control
centers, but are beginning to include control of venereal
diseases and preventable heart diseases in children. These
centers are staffed by leading private physicians who
serve gratuitously. This plan is generally approved by
organized medicine and by the United States Public
Health Service. Some believe that these centers are the
opening wedge for complete socialization of medicine.
Whether they are or not depends entirely upon organ-
ized medicine itself. Under present conditions of man-

THE JOURNAL-LANCET

219

TOTAL MEDICAL EXPENDITURES
MINNESOTA - IN THOUSANDS OF DOLLARS

FISCAL TEAR 1926
FISCAL TEAR 1936 ■■

• FISCAL TEAR 1926 - 1936

CALENDAR TEAR 1926
CALENDAR TEAR 1935

FIGURE V

agement and control, we do not believe there is any such
danger. It is quite possible that these centers will some
day be the center of medical knowledge in the com-
munity, serving not only the indigent population but
the medical profession as well. Such a center, with the
cooperation of the physicians of the district could be
made a very effective educational aid in any community,
urban or rural.

Another significant development of the past few years
is hospital insurance. For a small monthly sum the

individual may protect himself from hospital bills to the
extent of twenty-one free hospital days. The policy'
holder is also entitled to free operating room service,
routine laboratory examination, ordinary drugs and sur-
gical dressings, the association also defrays 25% of the
cost of all special diagnostic procedures. The contract
does not provide for the physicians’ fees, and, of course,
the individual has a free choice of physicians. As a means
of lessening the burden of costs of medical care to the
average individual, hospital insurance is proving its

220

THE JOURNAL-LANCET

TABLE VI

URBAN HEALTH EXPENDITURES

Hennepin,

Ramsey, St. Louis Counties

Hennepin

1925

1935

Examining Insane
Public Health Nurses

$ 17,851

$ 14.852
8.709

State Institutions

1 3.000

67.387

Sanatorium

416.000

454.800

General Hospital

212.332

781.198

Health Department

122,871

146,996

Lymanhurst

47.789

32.433

School Health

103.407

116,190

Total Health

$933,250

Ramsey

Medical Aid incl
Ancker H.

Health Bureau
School Health
Total Health
* St. Louis

Health Department
Medical Aid
Sanatorium
Total Health

$510,943

141,622

48,627

$701,192

$ 23.004
45,089
178.715

$246,808

$865,700

95,992

36,404

$998,092

$ 25,570
385,656
215,104

$626,330

worth, but it has the disadvantage of any insurance in
that it applies only to the provident and therefore has
no effect on our problem of indigent medical care.

In conclusion, we wish to say that we are neither ad-
vocating generalized, socialized medicine nor condemn-
ing state medicine as it exists today. We have tried to
present the facts as they are at the present time and
readers are invited to draw their own conclusions as to
whether or not we are traveling along the road toward
complete socialization of medicine in Minnesota.

References

1 Public laws enacted on and after March 20, 1933, and Ex-
ecutive Orders issued pursuant thereto governing the granting of
benefits to veterans, etc. Government Printing Office, 193 4.

2-3 Personal communication — S. M. Moore, Veterans Admin-
istration. Washington, D. C.. October 27, 1936.

4-5. Personal communications — Commissioner of Indian Affairs,
Department of Interior, VC^ashington, D. C., January 7, 1936,

November 27, 1936.

6. Eighteenth Biennial Report — Minnesota State Board of
Control — 1935-1936, p. 264.

7 Personal communication — Office of the Director, Emergency
Conservation Work, Washington, D. C., December 4, 1936.

8. Personal communication — L. P. Zimmerman. Minnesota
State Relief Agency, St. Paul, Minnesota. November 10, 1936.

9. Personal communication — Victor Christgau, Works Progress
Administration. St. Paul, Minnesota.

10. Minnesota General Laws 1863 Chapter VIII. pp. 41. 42.

11. Statutes of Minnesota — Revision 1866 — Chapter XV, Sec-
tions 1-19. pp. 201-207.

12. State Auditor's Biennial Report, Minnesota 1935-1 936, pp
20. 24. 25.

13. State Auditor’s Biennial Report, Minnesota 1925-1926, pp.
240-241.

14. Personal communication — Bureau of Census, Department of
Commerce, Washington, D. C., November 23, 1936.

15. Thirteenth B ennial Report, Minnesota State Board of Con-
trol— 1925-1926, p. 166.

16. Eighteenth Bennial Report, Minnesota State Board of Con-
trol— 1935-1936, p. 21.

17. Minnesota Public Statutes, 1849-1858, Chapter 23, para-
graph 44-58.

18. State Auditor’s Biennial Report, Minnesota, 1925-1926, p.
242.

19. State Auditor’s Biennial Report, Minnesota, 193 5-1936, p.

24.

20. Mason’s Minnesota Statutes, 1927, Article 4615.

21. Eighteenth Biennial Report, Minnesota, 1935-1936, p. 212.

22. Mason’s Minnesota Statutes, 1927, Article 4615.

23. State Auditor’s Biennial Report, Minnesota, 1925-1926, pp.
236, 242.

24. State Auditor’s Biennial Report, Minnesota, 193 5-193 6, pp.
20, 24.

25. Laws of Minnesota 1935, Chapter 320, Section 13, p. 589.

26. Minnesota General Laws, 1879, Chapter 31, Sections 4-5-6,
p. 39.

27. Minnesota General Laws, 1881, Chapter 146, p. 189.

28. State Auditor’s Biennial Report, Minnesota, 193 5-1936, p.

25.

29-30. State Auditor’s Biennial Report, Minnesota, 1925-1926,
p. 242.

31. State Auditor’s Biennial Report, Minnesota, 193 5-1936,
p. 24.

32. Eighteenth Biennial Report, Minnesota State Board of Con-

trol. 1935-1936, p. 267.

3 3. Mason’s Minnesota Statutes. 1927,
3 4. State Auditor’s Biennial Report,
p. 244.

3 5. State Auditor’s Biennial Report,
p. 24.

36. State
p. 245.

37. State

Auditor’s

Auditor's

Biennial Report,
Biennial Report,

p. 27.

Article 4547.

innesota,

Minnesota,

1925-1926.

1935-1936,

1925-1926,

1935-1936,

38. Federal Social Security Act of 193 5. Title V.

3 9. Department of Health, Minnesota Year Book,

40. State Auditor’s Biennial Report, Minnesota,
pp. 235. 236.

41. State Auditor’s Biennial Report, Minnesota,

p. 22.

1 933.

1925-1926,

1935-1936,

42. General Laws of Minnesota. 1933, Chapter 349.

43. State Auditor's Biennial Report, Minnesota, 1935-1 936,

p. 22.

44. Mason's Minnesota Statutes of 1927, Section 5416, 5417,
5418.

45. State Auditor’s Biennial Report, Minnesota, 1925-1926,

p. 224.

46. State Auditor’s Biennial Report, Minnesota, 193 5-1936,

p. 22.

47. Personal Communication — Dr. L. S. Englerth, Livestock
Sanitary Board, St. Paul, Minnesota.

48. General Laws of Minnesota, 1903, Chapter 316, pp. 559-

562.

49. State Auditor’s Biennial Report, Minnesota. 1925-1926,

p. 244.

50. State Auditor’s Biennial Report, Minnesota, 1935-1936,

p. 26.

5 1. Personal communication H. A. Burns, M. D., Ah-Gwah-

Ching, Minnesota, March 3, 193 7.

52-5 3. Annual Report. Minnesota Tuberculosis Sanitoria, Un-
der Supervision of the State Board of Control, year ending Dec.

31, 1935, Table IV.

54. State Auditor’s Biennial Report, Minnesota, 1925-1926,

p. 219.

55. State Auditor’s Biennial Report, Minnesota, 1935-1936,

p. 646.

56. Mason’s Statutes, 1927. Article 708.

5 7. Eighteenth Biennial Report, Minnesota State Board of
Control, 1935-1936, p. 69.

58. Personal communication — F. Cholgren, Deputy Auditor,
Hennepin County, October 27, 1936.

59-60. Annual Report, Division of Public Health. Board of
Public Welfare, Minneapolis, F. E. Harrington, M.D., Commis-
sioner of Health, 193 5.

61- 86. Annual Report, Department of Public Safety, Bureau
of Health, St. Paul, 1926.

62- 86. Annual Report, Department of Public Safety, Bureau
of Health. St. Paul, 1935.

63- 64. Personal communication — County Auditor, St. Louis
County, Minnesota, November. 1936.

65-66. Personal communication — Dr. L. D. Coffman, Univer-
sity of Minnesota, November. 1936.

67. Personal communication — Dr. O. E. Locker. Crookston.
Minnesota, "Medical Care for the Indigent” — Speech before Coun-
ty Commissioners Conference of Minnesota, February 28, 1936.

68- 70. 72-74. Personal Communication — L. P. Zimmerman,
State Relief Agency. St. Paul. Minnesota. Nov. 1 0. 1 936.

69- 75. Personal communication — Victor Christgau, Works

Progress Administration. St. Paul, November, 1936.

71-73. Personal communication — F. Cholgren, Deputy Auditor,
Hennepin County, October 27, 1936.

76. Personal communication — City Comptroller, Minneapolis,
November, 1936.

77. General Hospitals, Health Department, Lymanhurst,

School Health.

78. Personal communication — A. C. Bolstad, Secretary, Board
of Public Welfare. Minneapolis, November, 193 6.

79-80. Annual Report. Division of Public Health, Board of
Public Welfare, Minneapolis, F. E. Harrington, Commissioner of
Health. 193 5.

81. Emergency Relief Administration.

82. Works Progress Administration.

83. Personal communication — C. A. Reed, Superintendent of
Schools, Minneapolis, Minnesota.

84. Personal communication — Community Fund, Minneapolis,
Minnesota.

85. Annual Report, Board of Control, 1925, and Board of
Public Welfare of Ramsey County and City of St. Paul, 193 5.

86. See 61, 62.

87. Personal Communication — Superintendent of Schools, St.
Paul, Minnesota.

88. Personal communication — Pierce Atwater, St. Paul Com-
munity Chest, 404 Wilder Bldg., St. Paul, Minn.. Dec. 10, 1936.

89-90. Personal communication — St. Louis County Auditor and
the St. Louis County Auditor’s Report, 1935, also letter from L.
P. Zimmerman, dated Dec. 20, 1936.

91. See Table VI.

92. Medical Care for the American People White House

Committee Report, 1932.

93. Report of Minnesota State Planning Board, Part I, Plate 17.

94. Estimate, exact figures not availble for 1936.

THE JOURNAL-LANCET

221

Vitamin C and Tuberculosis

Charles K. Petter, M. D.*

Oak Terrace, Minn.

AN ABUNDANCE of literature has appeared
in the last few years relative to the influence of
vitamin C in both clinical and experimental
tuberculosis.1' A review of this material reveals many
interesting and pertinent facts. The purpose of the pres-
ent paper is simply to analyze the published reports and
to add a report of our experience with vitamin C feed-
ing.

Guinea pigs on vitamin C deficient diets show de-
creased resistance to tuberculous infection and disease.
Greene and his co-workers1' found a shortened survival
period and decrease in body weight of infected guinea
pigs, also demonstrating that generalized tuberculosis
develops more rapidly in chronic vitamin C deficiency.
De Savitsch, et al la found smaller lesions and greater
increase in weight in animals inoculated with tubercle
bacilli and fed vitamin C than in the inoculated and un-
treated controls.

From the standpoint of intestinal tuberculosis, Smith10
produced intestinal ulcers in infected animals deprived
of the vitamins found in cod liver oil and tomato juice
(vitamins A, B, C, and D). McConkey and Smith'1
conclude that the feeding of tuberculous sputum to
guinea pigs was not the sole cause of intestinal ulcers.
Their control animals fed adequate vitamin C developed
ulcers in only two instances, as compared with 26 in the
C deficient group. This same protection against the
development of intestinal ulcers was demonstrated in
guinea pigs on adequate vitamin C, by Hou.1G Animals
infected with tuberculosis and allowed to develop scurvy
show more tuberculosis than the control guinea pigs.

Clinically vitamin C deficiency is definitely demon-
strable in all forms of tuberculosis, most marked in the
febrile and destructive forms of the disease. While
simply supplying adequate vitamin C will not complete-
ly reverse destructive processes of tuberculosis, the work
of Hasselbach,2, '*• 4 Heise and Martin,1 Schroeder,s
Stepp et al ,14 Stub-Christensen,1'1 and Grant12 show def-
initely that treatment with vitamin C has certain en-
couraging prospects in connection with tuberculosis in
all forms.

Bronkhorst1 1 demonstrated that vitamin C in con-
junction with cod liver oil and ultraviolet was attended
by unusually good response in cases of intestinal tuber-
culosis. Body weight increased and the blood picture
and general condition improved. Grant12 has shown
that the addition of vitamin C to an adequate diet in-
creases the resistance to tuberculosis, while — interesting-
ly— the addition of vitamin D to a C deficient diet
lowers the resistance. Therefore more than calcium and
vitamin D are necessary in tuberculosis, and vitanvn C
is the answer. Excess of D, with normal or reduced

*Glen Lake Sanatorium. Oak Terrace, Minnesota and Instructor
in Surgery, University of Minnesota, Minneapolis, Minnesota.

calcium, tends to cause a spread of tuberculosis while a
balance between vitamin C and D and calcium changes
a reduced resistance to the level of a natural immunity
or increased resistance. Lawrason Brown 1!l advocates
a diet high in vitamin C with dicalcium phosphate and
restricted sodium chloride, in the treatment of pulmonary
tuberculosis.

The material for the present study is made up of 49
adults and 24 children, each one of whom was afflicted
with some form of tuberculosis. The adult group was
made up of 30 males and 19 females, ages ranging from
20 to 79 years. Bone tuberculosis was present in 7 in-
dividuals, bone and renal in 2 and renal in 1. Twenty-
nine presented far advanced, seven moderately advanced
and four minimal pulmonary tuberculosis. Ten boys
and fourteen girls with ages ranging from three to five
years made up the childhood group. Of these, thirteen
presented osseous tuberculosis, while the remaining
eleven were individuals afflicted with childhood type of
tuberculosis and were 10 per cent or more under the
standard weight for age and height.

Before beginning the feeding of vitamin C, part of
the group was tested to determine the amount of cevi-
tamic acid being eliminated each day. The urinary
content of this vitamin was determined by the method
of Tillmans and Hirsch2" using dichlor-phenol-indo-
phenol as an indicator in titration. Our findings from
these determinations showed a daily elimination of from
3.6 to 8.74 mgni. of cevitamic acid which is far below
the accepted normal of about 20 mgm. for an individ-
ual on an adequate diet. The general diet of these
patients was supposedly balanced and adequate in vita-
mins, as figured on paper, and calculated to yield from
2800 to 3000 calories.

Vitamin C was administered, in this study, in a choco-
Iate-malt-milk base. This preparation, cal-c-malt,f con-
tains 50 milligrams of chemically pure cevitamic acid
and 7/2 grains of dibasic calcium phosphate in two
heaping teaspoonfuls or 20 gm. This amount was given
three times daily in a seven ounce glass of milk.

The patients then received, in addition to their gen-
eral diets, an additional 654 calories per day, and 150
mgm. of vitamin C. This feeding was continued for an
average of 21 days ( 1 1 to 30) until the urinary output
of vitamin C reached, in those tested, an average
level of 18.3 mgm. per day. At this point the amount
of vitamin C per feeding was reduced and maintained
at from 75 to 100 mgm., the urinary output averaging
about the same as before (18.3). After four to six
weeks of this feeding, the cal-c-malt was discontinued
and only the glass of milk given. As a result the urinary
vitamin C output dropped to below 14, and the body
weight showed a tendency to fall off in most cases, al-

t Hoffmann-LaRoche, Inc., supplied rhe cal-c*malt used in this
work.

222

THE JOURNAL-LANCET

though some patients maintained their increased weight
and a few showed continued gain.

The most striking observation following the feeding
of the vitamin C was the increase in urinary output ot
this substance. Next, as is shown in the accompanying
charts (Figures 1, 2, 3, 4, 5) was the increase in body
weight, probably due to the increased caloric intake,
followed by some declines when the feeding was with-
drawn. There was a greater tendency for weight in-
crease and maintenance than for weight drop.11 In the
adult group the weight changes ranged from a loss of
one pound to a gain of twenty in the far advanced
group, from — 1 to — 13 in the moderately advanced,
and — 1 to — 10 in the minimal pulmonary group. The
bone cases showed an average of 3.5 pounds increase,
although the range was from a 3 pound loss to a 12
pound gain. Changes in weight after the special
feedings were stopped are shown as dotted lines in
Chart 3, and range from a 3 pound loss to a 3 pound
gain.

The children who were 10 per cent or more under-
weight showed weight gains ranging from 1 to 18 pounds
or an average of 3.6 while those with bone lesions
averaged 2.3 pounds increase.

A third observation not graphically demonstrable was
the expression of the patients’ general feeling of well
being. The adults, particularly, in the majority of in-
stances, volunteered the statement that they felt gen-
erally better while on the special feeding. A resume of
the X-ray and clinical findings in the adult group is
shown in Table 2.

Comments

1. A preparation containing chemically pure vitamin
C, dibasic calcium phosphate, and a sugar-cocoa-milk

WEIGHT CHART

103 *

#G815C M U

GC -tt-a

children: -

CHILDHOOD TUBERCULOSIS

Figure 1. Weight Charts of Children, 10% or more under-
weight, who were given cal-c-malt.

(Base Tine in each case represents weight at time cal-c-malt
feeding was started Weight tendency during previous three
months is shown at left, and weight changes during this study at
right of point where curve crosses base line).

base supplying also vitamin B! and BL> has been adminis-
tered to a group of tuberculous individuals.

2. This preparation as given in milk supplied 150
mgm. of vitamin C per day and added 654 calories to
the regular diets.

3. Of the 49 adults treated, 30 showed definite im-
provement, 12 no change, and 7 are definitely worse.

WEIGHT CHART

Figure 2. Weight Charts of Children with bone tuberculosis
who were given cal-c-malt.

(Base line and curves have same significance as in Fig. 1.)

WEIGHT CHART

121k#

#558GT19

U8\ #

#6098 E--39-MA

95*

*6102-F17

100# NO GAIN
#3220-?21-M.A.

ADULTS - SOME
TUBERCULOSIS

Figure 3. Weight charts of adult bone cases who were given
cal-c-malt.

(Base line and curves have same significance as in Fig. 1.)

TABLE I.

WEIGHT CHANGE

—

-+-

Average

Far Advanced
Pulmonary

-1-3.

Moderately Advanced
Pulmonary

-f-4.

Minimal

Pulmonary

-+-4.

Bone

Adult

— 3

-+-3.5

Childhood

Tuberculosis

1 to 18

-+-3.6

Bone

Children

— 1

-+-2.3

Showing range of weight changes and average gain
in pounds for each class of patients receiving cal-c-’nalt.

THE JOURNAL-LANCET

223

■WEIGHT CHART WEIGHT CHART

TABLE 2.

No.

DISEASE

Improved

Unch’ged

Worse

Minimal Pulmonary

Mod. Advanced Pulm.

Far Advanced Pulm.

Bone Tuberculosis

Bone 6c Renal Tb.

TOTAL

Condition of adult patients based on clinical and
Roentgen findings. Comparison made with findings 4
to 6 months before.

4. The children showed improvement in weight and
general condition in 21, no change in 1 bone case and
slight increase in bone destruction in 2 bone cases.

5. Elimination of cevitamic acid was found to be be-
low normal in cases of advanced tuberculosis and was
brought up to normal by feeding this vitamin in doses
of 150 mgm. per day.

6. These observations were recorded over a relatively
short period of time, and are presented so those in-
terested may draw their own conclusions.

Bibliography

1. Heise and Martin: Ascorbic Acid Metabolism in Tubercu-

losis. Proc. Soc. Exp. Biol, and Med., 1936, 34:642.

2. Hasselbach: Vitamin C und Lungentuberkulose, Zeitschr. f.
T uberkulose, 1936, 75:336.

3. Hasselbach: Das Vitamin C-Defizit bei Tuberkuloesen.

Deutsch. Med. Wochenschr., 1936, 62:924.

4. Hasselbach: Die Rolle der Vit.imine bei der Behandlung der

Tuberkulose. Deutsch. Tuberkulose-Blatt, 1936, 10:186.

5. McConkey and Smith: Relation of Vitamin C Deficiency to

■WEIGHT

CHART

14 1#

# 5791-F-33-FA

lO** *

#5562 F 23 M A

\ ^

13H #

# 5872 -F24-FA

1121* \/
#5b25-F-29-FA

#5849T-19

ll7*^fel90_-FJ8- MIN

* 6407-F-23-MA

<t)\ ft

0 #b356-F-55

^ #Sbb7-F21-mN

10 ll#

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98#"

*■ 2I55-F-23

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Z'"

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no* *

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ADULT FEMALES
RULMONAR7 TUBERCULOSIS

121#

#G3b7 - F-49 -M A.

Figure 5. Weight charts of adult female pulmonary cases who
were given cal c-malt.

(Base line and curves have same significance as in Fig. 4.)

Intestinal Tuberculosis in Guinea Pig. J. Exper. Med., 193 3,
58:503.

6. Greene, Steiner and Kramer: Role of Chronic Vitamin C

Deficiency in Pathogenesis of Tuberculosis in Guinea Pig. Amer.
Review of Tuberculosis, 1936, 33:585.

7. Horesh and Russell: Observations on Growth and State of

Nutrition of Premature Infants given an Antirachitic and Anti-
scorbutic Food. Ohio State Med. Jour., 193 5, 31:339, through
J. A. M. A.. 1935. 105:79.

8. Schroeder: Die Ausscheidung der Ascorbinsaeure im ge-

sunden und kranken Organismus. Klin. Wochenschr., 193 5,
14:484.

224

THE JOURNAL-LANCET

9. Hess: Infantile Scurvy: V. A. Study of its Pathogenesis.

Am. J. Dis. Child., 1917, 14:337.

10. Smith: Address before National Tuberculosis Association,

11. Mayer and Kugelmass: Basic (Vitamin) Feeding in Tu-

berculosis, Preliminary Report. J.A.M.A., 1929, 93:1856.

12. Grant: Effect of Rachitic Diets on Experimental Tubercu-
losis: Effects of Disturbing Optimal Ratio between Calcium. Vi-

tamin C and Vitamin D. Am. Rev. Tuber., 1930, 21:1 15.

1 3. Stub-Christensen : Diatetilc und Tuberkulose unter beson-

derer Beruecksichtigung des Kalkstoffwechsels und der Bedeutung
der Vitamine. Hospitalstidende, 1951, 74:157.

1 4. Stepp, Kuehnau and Schroeder: Die Vitamine und ihre

klinische Anwendung, 1936, Stuttgart. Page 85.

15. DeSavitsch, Stewart, Hanson and Walsh: The Influence

of Orange Juice on Experimental Tuberculosis in Guinea Pigs.
Nat. Tuberc. Assoc. Trans. 1934, 30:130.

16. Hou: Vitamin C and Its Relation to Disease. Shanghai
Med. News 1935, No# 29.

17. Bronkhorst: Roentgenologische Untersuchung bei Tuber-

kulose des Dickdarms und ihre Bedeutung fuer die Klinik. Nederl.
Tijdschr. v. Geneeskunde, 1936, No. 12, 1310.

18. Editorial: Vitamin C and Tuberculosis. J. A. M. A. *936,

107:1225. 10-10-36.

19. Brown: The Present Status of the Treatment of Pulmonary
Tuberculosis. Ann. Int. Med., 1936, 10:147.

20. Tillmans, J. and Hirsch: Ueber das Vitamin C. Biothem.
Ztschr. 1932, 250:312.

The Cultural Side of A Doctor’s Life*

J. G. Parsons, M.D.

Crookston, Minnesota

i i f~W y HAT indefinable something called Culture”
I like to think of as affording a familiarity
JL. with and an appreciation of, things that are
worthwhile — the ability to know good men and good
things when you see them, or at least to know where
they may be found, to the end that life may be en-
riched and enjoyed.

Obviously, the greater the range of acquaintance with
things having a worthwhile content, the greater the pos-
sibility of extraction, whether we are in the realm of
literature, art, music, philosophy, or what not. How-
ever, it seems to me that the doctor, by the nature of his
position in society, where he ranks as a member of a
learned profession, and by his constant practice in
evaluating diagnostic data and the personalities of pa-
tients, is in an atmosphere peculiarly adapted for the
development of culture.

Whether he thinks this art of worthwhile-ness is
worthwhile and is, or should be, willing to put forth
the effort necessary to its acquisition, is not the princi-
pal object of our consideration.

The ever-increasing complexity of medical lore makes
it impossible to keep up, except in epitome, with medical
literature. This has caused many a younger member of
the profession to neglect the cultural side of his life and
to make himself the slave of Minerva Medica, to the ex-
clusion of many of the other things which make for the
larger life, and to which he is entitled.

No one realized this more than Osier, who so often
in his essays and addresses called attention to the im-
portance of a "Liberal Education,” and pointed out how
it may be acquired. Becoming educated is a lifelong
process, to be worked out with such tools as one learns
to use during his preliminary training in school and
college. Unfortunately, there is so little time available
in the usual premedical curricula, and, more fortunately,
so little stress laid upon the cultural background which
a doctor ought to have, that he finds himself, after sev-
eral years of intensive study of the science and art of
medicine, rather out of touch with what may be called
general culture. He needs to acquire the habit of self

•Read at Grand Forks Medical Society, Jan. 1935.

culture, which is the only true education, and to become
worthy of his title of Doctor — a learned man.

I know of no greater cultural asset to any physician
than an acquaintance with Osier’s essays and addresses.
Permit me to quote a bit of advice which he gave to
medical students:

"A liberal education may be had at a very slight cost
of time and money. Well-filled though the day may be
with appointed tasks, to make the best possible use of
your one, or your ten talents, rest not satisfied with this
professional training, but try to get the education, if not
of a scholar, at least of a gentleman. Before going to
sleep, read for half an hour, and in the morning have a
book open on your dressing table. You will be sur-
prised to find how much can be accomplished in the
course of a year. I have put down a list of ten books
which you may make close friends. There are others;
studied carefully in your student days these will help
in the inner education of which I speak.

1 — Old and New Testament. 2 — Shakespeare. 3 —
Montaigne. 4 — Plutarch’s Lives. 5 — Marcus Aurelius.
6 — Epictetus. 7 — Religio Medici. 8 — Don Quixote. .

9 — Emerson. 10 — Oliver Wendell Holmes — Breakfast

Table Series.”

I have quoted this bit of Osier for the dual purpose
of illustrating how highly such a master regarded gen-
eral culture, and his insistence that it is within the reach
of everyone who thinks it is worth while to acquire it.

The list of books given by Osier is suggestive. It may
not make the same appeal to everyone, but it is signifi-
cant that it offers to the medical man material which,
ordinarily, in the rush of scientific reading which he, at
least, is supposed to be doing, he is liable to neglect.
It serves as an introduction to the general reading which
makes for culture.

Poetry, drama, biography, essays and philosophy, are
recommended as essentials of what Osier believed to be
the education of a gentleman, and which every physician
should possess. I take it that most of us feel the need
of supplemental education, realizing that our preliminary
schooling was abruptly ended by the intensive study of
medicine which was so exacting in its demands that there

THE JOURNAL-LANCET

225

vvas little or no time left for cultural subjects. Since en-
gaging in practice there have hardly been hours enough
in the day to get in all that might be desired in the way
of reading or otherwise acquiring the things we feel we
need. We may well take to heart the advice of Osier
in appropriating a few minutes daily to this end.

It has seemed to me that there are approaches which
are especially favorable to the medical practitioner who
desires to broaden his intellectual horizon, in the writings
of medical authors and in other literature which is
filled with medical allusions. As one reads, listens to a
lecture or a concert-actual or by radio, he inevitably en-
counters things which suggest limitations of his know-
ledge, which may be remedied. The notebook habit, as
suggested by Abbe Dimnet, is an excellent means of re-
minding one what is to be done.

Let us suppose that we encounter some foreign names
or expressions. We may not have had a preliminary
education which has introduced us to other languages
than our own, save the minimum amount of Latin re-
quired for the study of medicine. We may not be es-
pecially interested in the acquiring of an extensive know-
ledge of this kind, but it is easily possible by the Oslerian
method to learn the Greek alphabet and to avoid speak-
ing of "adenomatas” and other "phenomenas.” We
may well spend some time in acquiring a fair reading
knowledge of one or more modern languages, and at
least learn the correct pronounciation of names and
terms commonly used. It is worth while knowing that
Gigli is not pronounced "giggly” though such a sen-
sation may be evoked. There is really no excuse for re-
ferring to the great psycho-analyst as "Frood,” the father
of bacteriology as "Pastoor,” or the author of the famous
work on ophthalmology as "Fewkes.” Any good med-
ical dictionary can set us right as far as these things
are concerned.

However, there is something more of value in the
satisfaction to be had from the ability to read an article
in the original. This satisfaction is but a type of the
values which inhere in all efforts at the attainment and
acquirement of culture, of any kind. The physician may
have these if he sets sufficient store on them, and is will-
ing to follow Osier’s advice to insist upon taking a little
time each day in which to develop inner resources. He
may be encouraged to cultivate this habit by reminding
himself that in order to really enjoy the society of cul-
tivated people he must, as it were, "speak their lang-
uage.” Not only is this desirable for his own satisfaction,
but rather a part of his duty to society, in particular
"the blessed company” of those who in any community,
large or small, who stand for the finer things of life and
are to a degree responsible for their preservation and
encouragement.

Let me personally testify to the value of membership
in a small group of people whose tastes are culturally in-
clined, and who meet for the discussion of topics of
various kinds introduced by well prepared papers. This
is an excellent corrective to the one sidedness of all the
members of the group, including the doctors.

As working tools, to be kept bright by constant use,
let there be some good dictionaries, including French,
German, and Italian, and such others as occasion may
demand.

One may not be especially interested in early English
literature, but I venture to state that reading Chaucer’s
"Canterbury Tales” for the particular purpose of noting
his frequent references to the medical lore of that period
will prove interesting, and incidentaly lead to an appre-
ciation of this literary gem. The medical allusions of
Rabelais, himself a physician, add a zeal to the reading
of "Gargantu et Pantagruel.”

So we might make mention of Conan Doyle, War-
wick Deeping, Oliver W. Holmes, S. Weir Mitchell,
and others among the writers of fiction whom every
physician should number among his friends.

Among the essayists whom it will pay a physician to
peruse are such men as Holmes, not only for his "Break-
fast Table,” recommended by Osier, but for his medical
essays — a source of delight to one who will take the
time to read them. His essay "On the Contagiousness
of Puerperal Fever” is a classic. So also we find profit-
able Weir Mitchell, famous both as a novelist and a
neurologist; Joseph Collins, whose "A Doctor Looks at
Literature” and other essays, cannot fail to make an
appeal to doctors, and Walsh, whose fame as a de-
fender of the faith in his historical writings is so well
known throughout the Catholic world.

The reading of medical history opens a wide field
for reading a variety of literary works by physicians..
We, of the profession are justly proud of their con-
tributions. I discussed this in an article published some
years ago, mentioning such names as Rabelais, Thomas
Browne, Oliver Goldsmith, Keats, John Locke and
several others including Wm. Drummond, whose poems
in French-Canadian dialect are so delightful.

So we may be led into the fields of general history,
ethnology and anthropology. For example; the bearing
of malarial infection brought home after foreign con-
quests, on the decline and fall of the Roman Empire;
the relation of caravan routes of trade and of the
Crusades to epidemics of the plague; the part played by
Mohammedan civilization in preserving the achievements
of science and medicine; the weakening of native races
by miscegenation and their death rate from the white
man’s diseases to which there was no established im-
munity; all these suggest an exploration of fields which
add to our breadth of culture.

The spectre of bureaucratic and socialized medicine
which is rising out of our present economic and political
situation makes it imperative for us to pay serious atten-
tion to sociology and economics if we we are to offer an
intelligent resistance to the schemes of social theorists
who lack the background of medicine. It is hardly
necessary to point out the importance of something more
than a superficial knowledge of psychology. The suc-
cessful practice of the profession demands that; but to
qualify for the leadership which is expected of us de-
mands that we know about such things as intelligence

226

THE JOURNAL-LANCET

quotients, the inheritance of mental defects, mass psy-
chology and the like.

An interest in philosophy, such as may he gained hy
reading Gomperz’ "Greek Thinkers,” recommended by
Osier, or Will Durant’s "The Story of Philosophy,” is
but another accomplishment which fits in with the sug-
gestion of "speaking the language” of cultivated people.
If only as a matter of professional pride it is worth
while to read something of John Locke, physician.

While medical men are not usually concerned with
theology, it is an inspiration to know that Albert
Schweitzer, regarded as one of the great outstanding
figures in the modern religious world, is a physician,
taking up medicine in order to become a medical mis-
sionary in Africa after having achieved a world wide
reputation as a theologian, and an equally great one as
an organist and the preeminent authority of the music
of Bach.

Speaking of music leads to the suggestion that the
doctor is entitled to an appreciation of great music.
With so much of it as is now available on the radio, one
cheats himself out of a great source of enjoyment if he
does not take the time to know something of the great
composers and their work, the stories of the great operas
and the work of great musical artists. Good music is as
cheap as raucous, barbaric jazz. Cultured people prefer
it.

What has been said of music applies equally to art.
Feeling a sense of pride in the anatomist, R. Tait
McKenzie, an authority on physical education and re-
nowned as an American sculptor, or having an interest
in the anatomical drawings of Leonardo da Vinci may be
the portals through which we may enter the temple of
art, there to receive the inspiration and satisfaction which
comes from an appreciation of beauty.

If we mention drama, might we not make an approach
to reading the modern drama (assuming, of course, that
every cultured person requires urging to read Shake-
speare) by reading the plays of Arthur Schnitzler,
Viennese physician!

Time forbids further elaboration of the thesis that the
doctor should be a cultured man. The few suggestions
which have been made have been offered as an appeal
to doctors to consider the importance of balancing their

interests — to add to their sources of enjoyment — to add
to their equipment for usefulness, by developing the
habit of culture. The inner resources which a man has
are the most dependable, in spite of economic upsets and
social changes.

To the younger man of the profession it means the
storing-up of riches of the soul that enhance in value,
like life insurance, the years to come. To those of us who
are older, it means a source of satisfaction to take the
place of the more strenuous exercise which may, perhaps,
have taken too much of our time in earlier years.

The laity always have regarded the doctor as a
learned man, as implied in the good old Latin word
Doctus. He is looked up to, with the preacher, the
teacher and the lawyer as a member of a "learned”
profession. We owe it to them as well as to ourselves
to be in fact what they expect us to be.

I like to think of culture as an investment. The time
and energy required for the building up the reserve of
this "indefinable something” calls for regular deposits —
premiums, if you please. The investment is sound. The
bank never goes "broke.” Of course, like all other in-
vestments it calls for sound judgment — better a diversi-
fication of securities than putting "all eggs in one basket”
— but I fancy it is a better dividend-payer than most of
our investments have proven to be. It has often been
objected that the busy doctor has no time to devote to
such things; which is about as pathetic an alibi as is
referring to them contemptuously as "high-brow stuff.”

Those of us who have had the privilege of close
acquaintance with some of the great men of our pro-
fession have observed that despite for greater demands
upon their time than most of us, they have found time
for just the sort of thing we have been discussing. They
thought it worthwhile.

One of the New Testament parables is about a "pearl
of great price.” To obtain it, everything else was sacri-
ficed. It is not expected that every doctor will be a con-
noisseur of pearls to that extent; but it is within the
power of us all to make a collection of smaller gems,
which in the aggregate will give us wealth which brings
satisfaction — an enrichment of life which is eminently
"worth while.”

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

Great Northern Railway Surgeons’ Assn
American Student Health Association
Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dt. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

BOARD OF EDITORS

Dr. J . A. Evert
Dr. W. A. Fansler
Dr. W. E. Forsythe
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback

Dr. E. D. Hitchcock
Dr. S. M. Hohf
Dr. R. J. Jackson
Dr. A. Karsted
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley
Dr. C. A. Stewart

Dr. J. L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO, Publishers

W. A. Jones, M. D, 1859-1931 W. L. Klein, 1851.1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn, May, 1937

A SIGNIFICANT MEETING IN
NORTH DAKOTA

Members of the North Dakota Medical Association
may well be proud of its accomplishments during the
first half century of its existence. It takes strong hearts
to venture into new territory and blaze the trail. It
takes courage to lay the foundation of any structure.
Beginnings are arduous, prosaic, and often discouraging.
But here we are with the corner stone secure, the super-
structure well under way, and a machinery that has
been functioning smoothly for five decades. Members
of the association are no longer isolated pioneers prac-
ticing under the difficulties that handicapped the found-
ers. On the contrary, they are enjoying the benefits of
the cementing influence that such organization brought
about; and scientific information and equipment that
were unheard of in those early years are theirs to com-
mand.

Men of North Dakota, from the vantage point of
opportunity on which fifty years of wise administration
have placed you, it is yours now to carry on. You in
turn are stretching your hands into the future with the
power to mold the destinies of the group in years to
come. We feel sure that the 50th annual meeting to be
held at Grand Forks on May 16, 17, and 18 will be an
outstanding success.

SOUTH DAKOTA MEETING

As elsewhere indicated the Fifty-sixth Annual Session
of the South Dakota State Medical Association will be
held in Rapid City May 24, 25, and 26, 1937 with head-
quarters at the Alex Johnson Hotel.

The scientific program was published in full in the
April issue and certainly is very inviting, covering as it
does a large range of practical interest to the average
busy practitioner.

Organized medicine serves to set up standards, rules
of conduct, and principles of ethics. Each member of
the profession owes it to himself and to the organization
to give time and thought to the formulation of such
rules and regulations as shall redound to the honor and
best interests of his group. With changing times and
legislative enactments it has become necessary for the
physician to keep abreast not only with medicine but
also with legislation, judicial decisions, and social regu-
lations. The state association, through its various officers
and committees, is prepared to discuss these matters
with the membership and act as a clearing house for the
dissemination of knowledge when new demands are
made. Never was it more important than now for
physicians to attend association meetings.

A. E. H.

228

THE JOURNAL-LANCET

ANNUAL PEDIATRIC ISSUE

In accordance with the custom that has been observed
for the past few years, the May issue of The Journal-
Lancet is devoted particularly to the field of Pediatrics.
It brings to its readers a variety of subjects dealing with
an important part of each physician s private practice.
This special issue of The Journal-Lancet is an ex-
pression of a desire to aid physicians in the care and
treatment of infants and children.

THE SOCIALIZATION OF MEDICINE

Physicians who are not aware of the degree to which
the practice of medicine has already been socialized
doubtlessly will be surprised, and possibly disturbed by
pertinent facts published in this special number of The
Journal-Lancet, which reveal how firmly and deeply
this change is rooted in Minnesota, and how prolifically
it is growing.

Although the development of preferred alternatives
for the socialization of medicine obviously transcends in-
dividual ability, nevertheless the suggestion is offered
that adequate medical care will be quite generally avail-
able to patients with limited resources when legislative
bodies provide state medical associations with funds
which official representatives of these responsible or-
ganizations can use for the special purpose of partially
compensating physicians for professional services they
are now unable to render without financial assistance.
This suggested alternative for the drift toward pure
socialization extends to legislatures the privilege of sub-
sidizing splendid humanitarian programs fostered and
supervised by major component units of the American
Medical Association whose individual members are
acquainted with local needs that reasonable aid should
enable them to supply. This plan permits the public
to assist the profession in making adequate medical care
universally available. Consequently it probably deserves
to be considered "Public Aid to Medicine” rather than
"The Socialization of Medicine.”

Doubtlessly methods superior to the one that has been
briefly outlined can be devised for enlisting the public
and the profession in a cooperative and mutually bene-
ficial venture which preserves for patients with limited
resources the ptivilege not only of selecting the physician
they prefer, but also of receiving private attention. If
the development and promotion of plans which favor
the attainment of these objectives is desired, necessary
leadership probably can be recruited from the ranks of
the profession provided State Medical Associations avail
themselves of the services of physicians, who, through
their publications, have demonstrated a profound know-
ledge of the drift toward the socialization of medicine.

C. A. S.

- A NEW PLAN

We desire to call the attention of every medical prac-
titioner to a series of editorials by Mr. E. H. Bobst,
which richly deserve the attentive perusal of every
physician.

Mr. Bobst presents very pertinent, and well deserved
criticisms of efforts made by the medical profession and
different pharmaceutical houses to publicize medicine,
and bring more patients to the physicians and fewer
patrons to patent medicine vendors, quacks and char-
letons.

Mr. Bobst offers definite, practical advice as to
methods to be pursued in bringing medicine, both as an
art and science, before practically everyone in the
United States, and stands ready to "start the ball roll-
ing” by pledging his company to contribute $20,000.00
annually for five years toward an annual fund of
$400,000.00, to be contributed by ethical pharmaceu-
tical houses, and turned over to the A. M. A. without
strings of any sort being attached. The said amount to
be used for publicizing medicine. He outlines very
thoroughly plans for bringing this campaign to our
people over a nation-wide radio hook-up, which, with
fees of advertising experts to handle said program, to-
gether with talent and radio expenses, he estimates to
cost $400,000.00 for forty weeks in each year. He
further is most convincing in his argument that this con-
templated program is entirely ethical, and that in it
also will be found our most effective means of combat-
ing attempts to introduce socialized or state medicine.

Do not fail to read these editorials by Mr. Bobst,
which may be obtained in a reprint by addressing him
at Nutley, N. J., in order that you may be prepared
to intelligently discuss and assist in completing the good
work so well begun by Mr. Bobst.

W. A. G.

SOCIETIES

PROGRAM OF THE
NORTH DAKOTA STATE MEDICAL
ASSOCIATION

50th Annual Session at Grand Forks, N. D.
May 16, 17, and 18th, 1937

House of Delegates meets Sunday, May
SUNDAY, MAY 16-

House of Delegates meets at 2 P. M.

Concert in New High School Auditorium by the
University Faculty of Music at 8:30 P. M. Public
Invited.

MONDAY, MAY 17, 1937—9:00 A. M.

"Treatment of Burns,” with demonstration of the
Rapid Tanning Method by Natural Color Motion
Pictures. W. A. Wright, M. D., Williston, N. D.
"Problems in the Diagnosis and Treatment of Gastro-
intestinal Hemorrhage.” D. C. Balfour, M. D.,
Rochester, Minn.

"Cancer.” H. M. Berg, M. D., Bismarck, N. D.
"Fractures of the Upper Extremity.” Geo. A.
Williamson, M. D., St. Paul, Minn.

THE JOURNAL-LANCET

229

SPECIAL GOLDEN JUBILEE PROGRAM. In
charge of Dr. James Grassick, Grand Forks, N. D.
NOON RECESS-

AFTERNOON SESSION— 1:30 P. M.

"Bone Marrow,” Its Vital Importance to the Body.
E. L. Tuohy, M. D., Duluth, Minn.

"The Management of Nephritis,” W. H. Long, M.D.,
Fargo, N. D.

"Initial Care and Treatment of Accidental Injuries,”
R. H. Waldschmidt, M. D., Bismarck, N. D.
ANNUAL BANQUET
HOTEL DAKOTA— 6:30 P. M.

President’s Address, W. A. Gerrish, M. D.,
Jamestown, N. D.

Guest Speaker, E. L. Tuohy, M. D., Duluth, Minn.
TUESDAY, MAY 18, 1937—

"Course, Conduct and Complications of Pregnancy
among Physicians Wives.” R. D. Mussey, M. D.,
Rochester, Minn.

"Anesthesia and Relief of Pain by the Genera!
Practitioner.” John S. Lundy, M. D., Rochester,

Minn.

"Problems in the Diagnosis of Obstruction in the
Bowel.” Kent Darrow, M. D., Fargo, N. D.

"A Discussion of Protamine Insulin.” R. O. Goehl,
M. D., Grand Forks, N. D.

NOON RECESS—

During Noon Recess the North Dakota Health Offi-
cers Association will hold a luncheon beginning at
12:15.

Address by Dr. C. C. Applewhite, Surgeon, U. S.
Public Health Service, Chicago, 111., "Present Trends
in Public Health Administration.”

AFTERNOON SESSION—

Symposium On Venereal Disease.

1. "Public Health Aspects of the Control of the
Venereal Diseases,” H. G. Irvine, M. D., Con-
sultant in Venereal Diseases in the Minnesota
Department of Health, Minneapolis, Minn.

2. "Present Status of the Treatment of Gonorrhea
in the Male.” L. W. Larson, M. D., Bismarck,
N. D.

3. "Treatment of Syphilis,” Paul O’Leary, M. D.,
Rochester, Minn.

4. "Developments in Communicable Diseases Con
trol,” K. F. Maxcy, M. D., Director Department
of Preventive Medicine and Public Health, Uni-
versity of Minnesota, Minneapolis, Minn.

SPECIAL PROGRAM
NORTH DAKOTA ACADEMY OF
OPHTHALMOLOGY AND
OTOLARYNGOLOGY
at Hotel Dakota, May 17, 1937
LUNCH AND ADDRESS— 12:30
Dr. Arthur E. Smith, Los Angeles, California.
"Reconstructive and Plastic Oral Surgery.”

The North Dakota Health Officers’ Association
Annual Conference, Grand Forks,
Tuesday, May 18th.

This conference is open to all physicians and thev
are urged to attend. A splendid program has been ar-
ranged. It should be of practical value to all physicians,
whatever their interests in public health problems may
be.

The Symposium on Venereal Diseases will include
papers of a practical nature on the treatment of both
syphilis and gonorrhea.

Please note that this conference will be held after the
sessions of the State Medical Association have closed.
We hope that all who plan to go to Grand Forks will
arrange to stay over for this conference Tuesday after-
noon.

L. W. Larson, M.D.

President

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB

Meeting of January 20, 1937
DR. DONALD McCARTHY, Presiding
ANNUAL SENIOR MEMBER PROGRAM
Arranged by DR. S. R. MAXEINER
AUTOPLASTIC NERVE GRAFT IN FACIAL
PARALYSIS
Dr. Kenneth A. Phelps

My purpose in presenting this subject is primarily to call
attention of this group to the work done by Ballance and Duel
in establishing experimentally and clinically that restoration of
continuity of the facial nerve is the only satisfactory means of
dealing with facial palsy, in all but exceptional cases. That this
work is not thoroly familiar to general surgeons is shown by
a paper read in 1935 before The Western Surgical Association
by Loyal Davis. In this paper on The Surgical Treatment of
Facial Paralysis no mention is made of Ballance and Duel's
articles. Davis’ paper deals with facial transplants and nerve
anastomoses only, though the statement is made, "end to end
suture is the ideal treatment, but it is a difficult and serious
procedure in the course of the facial nerve within the facial
canal.” Adson says in discussion: "Wait six months for spon-
taneous regeneration, and if positive the nerve is cut, wait six
weeks after the wound is healed before operating.”

Following the anastomosis, association movements of the face
are present; in moving the tongue when the hypoglossal is
used, or the shoulder when the spinal accessory is used. At
times paralysis of the muscles supplied by the anastomosed
nerve results.

In order to work on the problem of facial palsy. Sir Charles
Ballance of London, came to this country in 1931, at the age
of 76, after he had retired from practice. He joined Dr. Arthur
Duel of New York City, who was 61 at the time, and in a
laboratory at Dr. Duel’s country home they conducted experi-
ments on animals, mostly monkeys. It is with sincere respect
that I pay tribute to these gentlemen — both having died a few
months apart in 1936.

Ballance and Duel published the results of their experiments
in 1932. They first did the anastomosis operation. Later, in
order to discover the effect on a nerve graft, they cut a seg-
ment out of the facial nerve and replaced it in the bony facial
canal, some times with the ends reversed. Next they used
other nerves, sensory or motor, for the graft, and in all cases
they found that the function of the facial nerve returned. First
the face became symmetrical, due to the restoration of the
normal muscle tone. Second, voluntary control appeared, and
third to return were symmetrical movements induced by emo-
tional stimuli.

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With the fact established that the facial nerve could be
repaired by merely placing one or more grafts in the bony
canal between its cut ends, without suturing, they went on to
determine when to operate on a case of facial paralysis.

Recovery is spontaneous in many cases of facial palsy follow-
ing mastoid surgery. Particularly those in which the paralysis
appears some time following the operation. Most of these never
have reaction to regeneration. In other cases, with reaction to
degeneration, changes in the galvanic responses enable the ob-
server to recognize the moment recovery begins. If faradic con-
tractibility has long been lost, no one can foretell spontaneous
recovery, and immediate operation is advisable. The nerve
should be exposed and any pressure removed, such as a frag
ment of bone pressing on the nerve. The nerve sheath should
be slit, thus doing a decompression. This results in complete
recovery while the best that can be hoped for without operation
is partial recovery. If the nerve is found to have been cut, a
graft can be inserted. If there is no galvanic response present,
it means the muscle fibers are atrophied completely and no
operation is advised.

If the facial palsy is not traumatic in origin, as Bell’s palsy,
Duel advises operation when the faradic response is persistently
absent for two or three days, meticulous asepsis is required.

In cases of facial palsy due to fracture or gunshot wounds,
the same advice is given, providing one knows where the nerve
is injured so it could be decompressed. Otherwise anastomosis
is advisable. Even in this situation, some of Duel’s disciples
believe that repair of the nerve is possible without anastomosis.

The presence of suppuration is no contraindication to opera-
tion.

In 1934 Duel reported 69 operated cases. Twenty-nine were
decompressions and forty were grafts. The length of the graft
averaged 20 mm., the shortest 7 mm., and the longest 40 mm.
He noted in the decompression cases that the return of the
faradic response occurred in a few weeks but in the graft cases
it took several months. This difference he explained as being
due to the time required for the degeneration of the fresh
graft, which is necessary before new axons could grow through
it into the distal part of the nerve which is already degener-
ated. Hence, he now advises that the graft be prepared by
letting it degenerate 2 or 3 weeks before using it. In 30 cases
so handled he found the time of response around !4 to Zz of
that formerly required. He even tried homoplastic grafts
(same blood group) and in 5 cases all were satisfactory.

Technique of the operation consists of exposing the facial
nerve from the stylo mastoid foramen to the geniculate gang-
lion, doing a radical mastoidectomy if necessary to get proper
exposure. The nerve to be used as a graft, anterior femoral
cutaneous, is cut three weeks before, and one or more seg-
ments of the degenerated end are placed between the cut ends
of the facial nerve. The graft is protected by gold foil and the
wound packed with gauze strips soaked in saline solution. Daily
dressings are required.

Sullivan of Toronto advises waiting six months before placing
the graft to avoid the occurrence of spontaneous spasms, but
others disagree with him and state better results are obtained
by the earliest possible operation.

Duel and Tickle in 1936 reported on 120 cases operated.
They state perfect facial expression does not return but the
results are far better than by any other method of treatment.

Case Report

Mr. E, age 35, was operated upon for acute left mastoiditis
February 23, 1935. During the operation a large sequestrum
was removed which involved the entire tip of the mastoid
process. Upon removal of the anesthetic mask a complete left
facial paralysis was observed.

March 9, 1935, mastoid cavity reopened. The posterior canal
wall was taken down and a break in the nerve was found in
the descending portion about 15 mm. in length. The lower
end of the cut nerve was found at the stylo mastoid foramen.
With the assistance of Dr. Zierold, a piece of an intercostal
nerve was obtained. Two strands of it were placed between the
freshened cut ends of the facial nerve and a piece of muscle
was transplanted to form a bed for the graft. Gold foil was

placed on the graft, and upon this some pieces of rubber
sponge, held in place by saline moistened gauze strips.

The pleura was perforated at the removal of the graft and
some chest pain with respiratory difficulty was present for a
few days, no temperature.

The wound was dressed daily, replacing the moist gauze
packs and removing the pieces of sponge. March 23, the gold
foil was removed and the graft could be seen covered with
healthy granulations. A plastic closure of the wound was done
March 25, 1935.

The patient had to wear protecting goggles because of his
inability to close the left eye. He went home and on Sep-
tember 5, 1935, twitching of the angle of the mouth was seen
on closure of the left eye.

March 29, 1936, great improvement. Can close eyes and
move cheek and mouth. Discarded protective goggles. Ear
dry and hearing serviceable.

Discussion

Dr. O. J. Campbell: I would like to ask Dr. Phelps what
results these men obtained with their cablegrafts. In general
surgery we have found that if there is a defect in a peripheral
nerve, the results obtained by transplanting nerve, the so-called
cablegrafts, are not very satisfactory. If good results are ob-
tained in transplanting nerves for the repair of injured facial
nerves, I am wondering if the preservation of the bony canal
is not the important factor in helping to direct the newly
developing axones.

Dr. R. C. Webb: At the meeting of the Western Surgical
Association in 1933 Dr. Loyal Davis discussed the transplanta-
tion of nerves and the scar formation in the distal end of the
peripheral nerve which may cause an apparent failure of the
graft. It is then necessary to resect this scar and resuture in
order to permit the continuation of the growth of the nerve.
I would like to ask Dr. Phelps if there had been any failures
in his studies of these short grafts and if so, what were the
causes of the failures.

Dr. Kenneth A. Phelps: In dealing with facial nerve you
have a bony canal, rather a small definite place, and when you
put the graft in the canal it stays pretty nearly in contact with
both ends of the injured nerve, as Dr. Campbell suggested.
This is a great advantage, I think, over dealing with nerves in
soft tissue. Drs. Duel and Ballance have not had to do any
secondary operations and their results have been phenomenally
good. The percentage of satisfactory results has been very high

RECENT ADVANCEMENT IN THE TREATMENT
OF DIABETES*

Archie H. Beard, M. D.

During the last five years our conception of etiology, physiol-
ogy, and treatment of diabetes has changed completely. Today
we are standing on the threshold of a new era in diabetes. The
Banting era, which we are just leaving, was a great advance-
ment. During the last fourteen years, diabetics have gained
hope, food, and strength. Insulin has given life to their dry
bones and tissues until, at the present time, they are a group
of people nearly as strong as the normal individual.

Our greatest problem has been the treatment of complica-
tions. Diabetic coma has been undiagnosed and carelessly
treated by many physicians during a period when we should
have had a decrease in this severe complication. With the use
of protamine insulin we hope for greater results especially in
our previously diagnosed cases. The severe diabetics probably
will receive the greatest share of this new discovery. Before
we discuss treatment in detail, there are other things that
should be reviewed.

In regard to etiology, the newer research indicates that all
cases of diabetes are genetic and possibly pituitary in origin
If we had not been able to prolong the life of the diabetic with
the use of insulin, the duration of their lives would have been
so short that data of family histories would never have been
complete. The actual evidence that diabetes is hereditary rests
primarily on four facts:

*Presented January 20, 1937, to the Minneapolis Clinical Club,
Minneapolis, Minnesota.

THE JOURNAL-LANCET

23 1

1. The almost simultaneous development of diabetes in
similar twins.

2. The greater occurrence of diabetes in diabetic families
than in normal families.

3. The demonstration of the Mendelian recessive ratios
in a large series of cases selected at random.

4. The occurrence of diabetes in latent cases.

In regard to the first statement little need be said except
that statistics have shown 70% of similar twins develop diabetes
at the same time in comparison to only 12% of dissimilar
twins. In regard to the second statement, diabetes occurs nearly
seven times more often in the parents and siblings of diabetics
than in the relatives of non-diabetic patients. In regard to the
third statement, or the Mendelian ratios, we expect 100% of
the offsprings of two diabetic individuals to become diabetics;
in the cross between a diabetic and a hereditary carrier, 50%;
in the cross between hereditary carriers, 25%. However, this
does not always occur, but at least we can state that diabetic
individuals develop in a definite ratio, and the further an off-
spring is from the original diabetic the less opportunity he has
to develop the disease. If my time were not so short, I would
discuss this more fully. However, we realize this does not cover
all the possible etiological factors in diabetes.

Endocrine functions are known to be controlled by the Men-
delian recessive genes, e. g. dwarfism in mice and cretinism in
humans. Houssay has suggested two possible complications that
might control the pancreas, first, hyperactivity and second, hypo-
activity of the pituitary gland. Hyperactivity of the pituitary
gland, theoretically, is associated with an excess of the dia-
betogenic factor of Houssay, whereas hypoactivity of the pitu-
itary gland is consistent with a lack of the pancreatropic hor-
mone of Anselmino and Hoffman. Evidences of both hyper-
activity and hypoactivity can be found in clinical cases of dia-
betes. The hyperactivity is suggested by the over growth that
occurs in 90% of our diabetic children prior to the onset of the
disease. This occurs at the age when hyperactivity of the pitu-
itary gland is most pronounced, as for example between the
ages of six and twelve and again at the age of fifty, when
diabetes in elderly people is likely to develop. In contrast to
this, obesity in the adult and dwarfism in some diabetic chil-
dren suggest hypofunctioning of the pituitary gland. Hyper-
activity of the pituitary gland is associated with the more severe
clinical case of diabetes, and hypoactivity with the milder form.

In regard to treatment, all of us have seen many forms
arise, but the fundamental principles are the same, namely:

1. To maintain weight, or, if the patient is a child, to
promote the normal rate of growth and development.

2. To keep the urine practically free from sugar, and
maintain the blood sugar at normal levels.

3. To control fat metabolism.

4. To prevent acidosis.

In regard to dietary treatment, it depends to a great extent
upon the severity and the age of the patient. With a co-
operative adult diabetic over fifty years of age treatment has
never been difficult, and the end results usually have been good.
The end results with a severe and young diabetic have been
less satisfactory; consequently, many forms of dietary treat-
ment have been used. This concerns principally the division of
the diet into its various parts, namely, carbohydrates, proteins,
and fats rather than total calories. Today it is generally rec-
ognized that the average adult over fifty years of age will main-
tain a normal weight provided he receives 30 calories per kilo-
gram body weight. The child will grow at a normal rate if he
receives 100 calories per kilogram body weight during infancy,
gradually decreasing this to 45 calories during adolescence and
to 35 calories during early adult life. Every possible variation
of carbohydrates, proteins, and fats has been used for the severe
diabetic. There has been brought forth the use of low carbo-
hydrate and high fat ratios; moderate carbohydrate, moderate
protein, and moderate fat ratios; high carbohydrate and low fa:
ratios; and high protein and low protein ratios. Probably the
happiest end results for an adult patient is a carbohydrate
value between 100 to 200 grams. The child generally is hap-
piest when he receives between 150 to 250 grams, and a 214:1

or 3:1 carbohydrate-fat ratio. It is relatively an easy problem
to get a diabetic patient sugar-free if one to two hourly speci-
mens are collected for examination unless acidosis is present.
We are interested mainly in attempting to have the patient
have, also, a relatively low blood sugar. For that reason fasting
blood sugars are taken if the patient is not using insulin, and
blood sugars at eleven-thirty in the morning if the patient is
using insulin. This has been shown to be the best times at
which to determine blood sugar levels. In the Banting era our
greatest problem was to keep the patient from developing peaks
of hyperglycemia and periods of hypoglycemia. It was difficult
to keep the patient sugar-free and maintain the blood sugar at
a fairly normal level. This was true especially of the severe
diabetic. The new protamine, however, has revolutionized our
treatment, and the severe diabetic will benefit mostly from the
use of this new material. As a rule the youthful and severe
cases show an elevated fasting blood sugar well over 300 mgs.
After the third year the blood sugar is inclined to be some-
what stable, and, as a result, the disease is apt to show no
further increase in severity as indicated by the fasting hyper-
glycemia. With regular insulin it became customary to give a
dose of insulin between ten o’clock at night and midnight or
at five o’clock in the morning. The first method resulted in an
abrupt fall of the blood sugar to hypoglycemic levels followed
by a spontaneous rise, so that, even with this extra dose of
insulin, the fasting blood sugar was relatively high. Insulin
given at five o’clock in the morning, or earlier, controlled night
hyperglycemia, but it was very inconvenient. Therefore, we
realize that our next improvement in the treatment of this
disease lies in developing a relatively stable level for the blood
sugars through the twenty-four hour period. This was Dr.
Hagedorn’s theory.

I shall not go into the principles and the development of this
material. All of you appreciate what protamine insulinate is.
With protamine we have been able to develop a hydrogen-ion
concentration of 7.3 compared to approximately 2.5 to 4.0
(usually 3.0 to 3.5) of our regular insulin. Therefore,
protamine insulin appears ta remain in the body nearly twice
as long as regular insulin, or, in other words, it is not absorbed
as rapidly. The drop in the blood sugars is more gradual,
consequently, the rise is more gradual. As a result, insulin
reactions are reduced a great deal. However, protamine insulin
can never replace regular insulin when rapid absorption is
needed as in diabetic coma and infections. Protamine is
principally a material to be used in the treatment of
diabetes when complications are not present. Furthermore, it
cannot replace regular insulin in the treatment of severe dia
betes and coma. At first we used regular insulin in the morn-
ing when we wanted rapid absorption, and protamine insulin
in the evening. In that way we attempted to have the patient
awaken with a normal fasting blood sugar. Many of those
individuals who had to take four to five injections of regular
insulin a day are now able to reduce their injections to two or
three a day. In milder cases, in some instances, patients have
been able to take a larger amount in one injection, and remain
relatively sugar-free for twenty-four hours.

Apparently diabetes is increasing throughout the world, and
especially in the United States. At least the statistics from
all the large diabetic centers, e. g. Joslins’ clinic, the large hos-
pitals in the East, and the Mayo Clinic, show a constant increase
in the number of cases in the last ten years.

Our patients are living longer with this disease, and, na-
turally, complications are bound to arise. In many instances
a diabetic’s death is attributed to a disease other than diabetes.
The most serious complication with which we have to deal is
still diabetic coma. There is a peculiar feeling among the laity,
and especially among some diabetics, that the treatment of dia-
betes does not pay. Those of us who saw the diabetics in the
days before the Banting era realize the seriousness of (I) the
intercurrent crisis of coma, (2) the severe loss of weight and
strength, and the failure of growth in young individuals, (3)
the loss of resistance and death from septicemia, snd (4) pre-
mature aging. On going into these factors in a superficial way,
I might state that diabetic acidosis still occurs more often than

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it should, and that it occurs most frequently in severe diabetes.
Insulin has changed the picture entirely, and has reduced the
total mortality of severe coma from nearly 100% to 14% in
the entire Joslin coma series, or 1% in his patients who have
had the disease over fifteen years of age. The causes of coma
usually are (1) breaking the diet, (2) omission of insulin, (3)
infections, and (4) diseases of glycogen storage bodies, e. g.,
extensive diseases of the skin, liver, and muscles. We now have
to add a new factor (5) endocrine imbalance. This has been
noted especially by Bertran, who has suggested the greater in-
creasing frequency of diabetic coma during pregnancy and
catamenia. At this period the individual is inclined to have a
relatively low alkali reserve and a low blood sugar, even as
low as 190 mgs. This is merely to warn against the inter -
currence of acidosis during pregnancy, and particularly to warn
the patient of the extra care and re-adjustment of insulin which
may be necessary at the time of catamenia. First, there can be
no question or doubt that insulin given in the first twenty-four
hours and in large and divided doses, ranging from 10 to 1,000
units, is still an essential part of our treatment. Recently it
has been brought to my attention that some diabetic clinicians
feel that diabetic acidosis should be eradicated with not more
than 50 units of insulin. This is not the opinion of other
men, including myself, and I wish to emphasize this fact. Sec-
ond, the results from diabetic acidosis, also, depend upon com-
bating the dehydration. 1500 to 8,000 cc. of normal saline
generally should be given the first six hours, and, on genera!
principles, it cannot be over done. Third, frequent gastric
lavage and enemas to counteract loss of gastro-intestinal tone
is very essential. Fourth, concentrated glucose, 50%, or con-
centrated salt solution, 10%, may counteract renal retention
Fifth, adrenalin and rarely blood transfusions are of use in
circulatory collapse. Sixth, 100 grams of glucose should be
given by mouth, if possible, the first twelve hours.

The argument over the use of alkalis to prevent increasing
acidosis is again being brought forth. Joslin’s series show a
mortality of 0.7 of 1% in treated diabetics. This has not been
improved upon by the statistics of the Mayo Clinic, although
that organization has shown very good results with a combina-
tion with or without alkali therapy. Hartman, however, criti-
cises the non use of alkalis. In diabetic children especially he
uses racemic sodium lactate, although his series show a mor-
tality rate eighteen times that of Joslin's series, or nearly 13%.
In the University Hospital we rarely have used alkali therapy
except in severe and prolonged cases in dehydrated individuals
when we felt alkalis might be of some value. As long as our
mortality rate remains as low as it has in the past we feel justi-
fied in not using alkalis. It has been Joslin’s theory that the
harm was not especially from the use of alkalis, but was in the
false sense of security given by the rapid rise of the alkali re-
serve, and, in doing so, the fundamental fault, or lack of using
insulin, has been overlooked. It has been shown that in the
patients treated without alkali, one could expect a rise of only
12 volume per cent in eight hours. Hartman has advocated
the use of only 2 units of insulin per kilogram body weight,
and none for six hours afterwards. We feel this is not sufficient
in severe acidosis, and in some instances we have used as high
as 14 units per kilogram body weight. Thus the old question
of the use or non use of alkalis, which was lost after insulin
was discovered, again has come forward. The hypoglycemia,
or another of the difficulties in the treatment of diabetes,
should be eliminated with the use of the new protamine insulin.
If hypoglycmia should occur with protamine, it must be re-
membered that it takes possibly a larger amount of carbo-
hydrates over a prolonged period to keep the patient from re-
turning to the insulin reaction.

A severe diabetic is apt to develop skin lesions, which in-
cludes the new disease described by Michelson and Laymon,
Necrobiosis Lipoidica Diabeticorum. I shall not go into this
in detail because it has been discussed frequently in this region
due to the wide recognition these two men have in dermatology.
I wish to state, however, that it seems to be due to fatty
degeneration of connective tissues followed by deposits of
lipoids. In some areas these lesions become necrotic, and appear

to be what approaches actual gangrene. It will be interesting
to see if the use of increased carbohydrates under a new regime
of lower blood fats and low blood cholesterols will control this
condition.

I do not wish to discuss the subject of dwarnsm tonight,
but this remains an essential part of the treatment by the
pediatrician, who must be certain that his patients grow and
develop normally. There is a certain percentage of them that
will not do so under any regime, and this probably occurs
when there is a hypoactivity of the pituitary gland and lack of
growth hormones, and is not due to a definite under nutrition
Houssay has demonstrated in one diabetic dwarf, on whom he
was able to perform an autopsy, that there were actual scars
in the pituitary gland, which probably had some definite rela-
tionship to the lack of pancreatropic hormone, which is thought
to produce diabetes, as well as a lack of growth hormones,
which, also, produced dwarfism in that individual. The use of
thyroid and pituitary gland extract has not always been
successful.

Another interesting complication is the enlargement of the
liver, which recently has been reported in many juvenile dia-
betics. In some instances the liver has been felt as low as the
iliac crest. These patients are apt to have a pronounced pro-
tuberance of the abdomen. They present serious problems
because they are very unstable, and they are liable to develop
frequent attacks of insulin reactions and diabetic acidosis. The
cause of the enlargement is not definitely known; theoretically
it may be due to an excess of fat or to an excess of glycogen
deposited in an abnormal fashion in the liver. Most autopsies
have shown fatty infiltration of the liver. Liver function tests
reveal very little. However, the relation of free cholesteral to
cholesteral ester has been reported lower in the experimental
animal; therefore, the function of fat metabolism in the liver
may be defective. Best and Hershey have reported excellent
results in the use of cholin, lecithin, or whole pancreas. The
most remarkable results, however, have been reported by Han-
son, a co-worker of Hagedorn, who has noted the disappear-
ance of the enlargement of the liver after the use of protamine
insulin. I, also, have been one case in which this has occurred,
and Dr. Platou has reported to me a similar case in his private
series. Time, only, will tell whether or not protamine alters
the fat metabolism or increases the storage rate of glycogen. At
present the liver and the ductless glands are bee hives for ex-
perimental activity in diabetes.

Joslin states an analysis of the long duration cases gives a
picture of the end results of severe diabetes. He reports that
in his juvenile series he finds 5% have survived fifteen or more
years of the disease. Of this series 4 have died, 19% have
had coma at various times, 43% show evidence of arterio-
sclerotic vessels, 28% have retarded growth and development,
8% have had infections, none have had tuberculosis, 6% have
had cataracts, and 6 % have had neuritis. It is still his con-
clusion that excessive fat is the cause of these degenerative
changes. He hopes to control this condition with the use of
protamine and a higher carbohydrate and lower fat diet than
he has used in the past.

Another factor which has been brought to my attention this
last year is the unfavorable effect of diabetes complicating
pregnancy, not resulting as much in paternal mortality, which,
fortunately, is low, nor in the grave progression of the disease
in the mother, but in the rather frequent occurrence of acci-
dents to the fetus as a result of toxemia, eclampsia, coma, and
hypoglycemia. In Joslin’s series of 271 pregnancies between the
years 1898 and 1935, he found practically one-half of the
cases had been in the pre-insulin era and one-half in the insulin
era. It is surprising to find only slight improvement of the
insulin over the pre-insulin days. He found stillbirths have
dropped from 29% to only 25%, and miscarriages and abor-
tions from 22% to 16%. Therefore, we are concerned with
the investigation and manner in which diabetes contributes to
these conditions. Early abortions and miscarriages generally
are attributed to the disease itself for its incidence is three
times more frequent among diabetic patients with hyper-
glycemia and glycosuria than in the controlled cases. We

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233

realize the impregnated ovum is implanted in that portion of
the uterus which has the richest supply of glycogen, and this
may be the reason for miscarriages occurring early in uncon-
trolled cases. Toxemia and eclampsia occur fifty times more
often in the diabetic than in the normal mother. This is most
common in the younger mothers who are severe cases. The
severity of the disease rather than its control seems to favor
the occurrence of this complication. Stillbirths, also, occur
relatively frequent. For years the obstetrical-diabetic literature
has contained accounts of the large number of cases in which
the over developed, macerated fetus has been born to the dia-
betic mother. We realize, also, that this is not an unfailing
characteristic of diabetes. However, the fact that one-half of
the pregnancies ended successfully prior to the general use of
insulin shows without further comment that insulin has not
been of great value. The cause of this over development, which
is characteristic of so many diabetic pregnancies, has never
been quite clear. It is natural that it should be attributed to
over nutrition and the elevation of the blood sugar and blood
fat, but this is not the case in Joslins' series. It is true that all
these factors need further investigation, but a new and interest-
ing clue has been found in the reports of G. V. Smith and
O. W. Smith. They have demonstrated an excess of prolan
is characteristic of the toxemia of pregnancy, and that it is
likely to be more frequent in the toxemia of the diabetic preg-
nancies. Schneider and Hoopes have demonstrated that injec-
tions of prolan in animals gave the picture we have in diabetes,
namely over development, death, and maceration of giant rat
and rabbit fetuses. Smiths’ work has been under way for at
least a year. Three of their nine clinical cases showed a defi-
nite increase of serum prolan while the remaining six had
normal prolan. All three of these mothers were delivered of
a giant type of fetus. Thus two definite forward steps have
been reported. First, Titus decided to deliver these patients
prematurely, therefore, anticipating the death of the fetus
in utero. This has been unsatisfactory, and we know that all
these patients are not predestined to develop this complication.
Therefore, we have no positive way of telling when it will and
will not occur. As yet I am not thoroughly convinced that it
is the treatment of choice to do a Caesarean delivery on these
individuals as is being advocated by some physicians and clinics
throughout the country. Smiths’ work has to be carried further
before we come to definite conclusions. Second, congenital diffi-
culties, hypoglycemia and asphyxia, most frequently occur in
the prenatal child. Congenital difficulties are beyond thera-
peutic control, and they may be genetic in origin. However, it
is interesting to note that Wagner has found there is a grear
increase in number of congenital anomalies in the true juvenile
diabetic patient. Hypoglycemia may be a serious complication
in the neonatal period. It may be due to a maternal over dose
of insulin or to an over production of fetal islet tissue. As-
phyxia in a diabetic child is a real problem, and it is to be
feared greatly if the patient has had prolonged labor due to the
large size of the baby. Furthermore, insulin is capable of pro-
ducing cerebral edema. Last, and most important, is the fact
that the alkali reserve, measured by the plasma combining
power, is lower in the diabetic offspring than in that of the
non-diabetic. It certainly remains for the diabetic mother to
make more frequent calls to her physician during her preg-
nancy. It must be impressed upon her that she should be
checked more often the first three months of her pregnancy
because of nausea and vomiting, with re-adjustment of her diet,
in order to prevent spontaneous abortion. Possibly the use of
hourly feedings of carbohydrates, or the use of 5% glucose
by rectum, or the use of 5 % to 10% glucose intravenously,
may be necessary. During this period the mother’s urine
should be tested every two to six hours, and the necessary
amount of insulin should be given accordingly. If nausea and
vomiting do not occur in the first three months, the patient’s
regime should be carried on as formerly. In the second three
months we are interested especially in the low renal threshold
and the increased requirements for food. Here the amount of
insulin must be changed according to blood sugar estimates
alone. In the beginning of the last three months, acidosis must

be watched closeiy. by this time the basal metabolic rate is
increased perhaps 20%, and a definite caloric intake is neces-
sary. The baby needs 50 grams of glucose daily, and the ad-
ministration for this has to be made in the patient’s diet. Labor,
also, increases the characteristic changes of the last three
months, namely the elevated metabolism and the depletion of
glycogen. If normal labor is selected, the patient requires con-
stant attention because she is a potential coma case. As a rule
150 to 300 grams of carbohydrates introduced by some method
and insulin determined according to the blood sugar and uri-
nalysis are absolutely necessary. If Caesarean section is chosen
there is no special danger of acidosis, but there is the danger
of hypoglycemia. Therefore, the blood sugars must be watched
carefully again, preferably maintaining them between 150 to
200 mgs. per 100 cc. of blood. This patient must be treated as
any surgical case with urinalyses, blood sugars, and insulin
accordingly every three hours following the operation. Failure
of normal lactation is another characteristic of the diabetic
mother. This is due, possibly, to the lack of oestrin, or the
specific lack of lactogenic hormone of the pituitary gland. This
failure does not appear to develop by diet because it has oc-
curred when patients have received as high as 3,000 calories.

Therefore, within the last year the problem of diabetes has
extended from the life of the internist to that of the derma-
tologist, pediatrician, surgeon, and obstetrician. Our diabetics
are living longer; consequently, they are gradually entering into
fields other than that of the internist.

Eli Lilly & Company made this investigation possible by
graciously furnishing the protamine.

References

1. White: Can. Med. Asb. J., 1936, Vol. 35: 1 53.

2. Hagedorn. Jensen, Krarup and Wodstrup: J. Am. Med.

Ass., 1936. Vol. 106:177.

3. Raat, White, Marble and Stotz: J. Am. Ass., 1936, Vol.
106:180.

4. Hartman: Arch, of Int. Med., 1935, Vol. 56:413.

5. Best and Hersey: J. Physiol., 1932, Vol. 75:49.

6. Joslin: The Treatment of Diabetes Mellitus. Fifth Edition,
Lea and Febiger. 193 5

7. Eastman, Gceling, DeLawder: Bull. Johns Hopkins Hosp..
1933. Vol. 53:246.

Discussion

Dr. R. T. LaVake: This has been a very interesting paper
My practical experience in diabetics associated with pregnancy
has been limited to four cases. The responsibility rests upon
the obstetrician to recognize these cases immediately. They
should then be referred to the internist for treatment.

In spite of everything that could be done in two out of the
four cases that I spoke of, they went into coma and aborted
It seems to me that it cannot be too strongly emphasized that
the treatment of diabetes is so complicated, that the obstetrician
should not attempt to take care of these cases without the
assistance of the internist.

Dr. R. Swanson: I would like to ask Dr. Beard a few

questions. He did not mention sterility in diabetic women.

Isn’t the pancreas of the fetus supposed to carry the diabetic
woman to term?

Caesarian section is as yet not the accepted method of treat-
ment for diabetics in this section.

Dr. A. Beard: Before the days of insulin many of our dia-
betic women were sterile. With the use of insulin diabetic
women, being normal in growth and development, are begin-
ning to take their place along with normal women. We see
this quite frequently in our dispensary.

The question of whether or not the pancreas of the fetus is
able to carry the mother through is a great problem. The fetus
has enough to do to take care of itself, and it does not have

enough insulin available in its small gland to take care of the

mother. This is the time when the mother might go into

acidosis. That varies from day to day as time goes on, and

it is for that reason the mother must be seen often.

In regard to Caesarian section in the diabetic mother, I do
not feel it is necessary to consider it except in certain instances
where a mother has a small pelvis and has a large child, and
the possibility that she may go into protracted labor. At the
present time there is no reason from the diabetic side of the

234

THE JOURNAL-LANCET

picture, if the patient is watched carefully, why she should have
a Caesarian section in every instance.

SHALL I RAISE MY BOY TO BE A DOCTOR?

Edward Dyer Anderson, M. D.

Summary-

In this paper the author discusses the factors which, to his
mind, make the practice of medicine at the present time an
attractive career for his son. He then outlines what changes he
feels will come in the practice of medicine in the coming years
and what medicine as a career will offer to a young man. His
conclusion is that regardless of the probable changes which will
occur, medicine will still be an interesting worthwhile and
attractive career.

Lawrence R. Boies, M. D.

Secretary.

NORTH DAKOTA MEDICAL BOARD OF
REGISTRATION
DOCKET OF CASES: 1936

Case No. 1 : This person had been practicing medicine in

this state during 1935 and 1936, although his license had been
previously revoked by the Board. An investigator was em-
ployed, proceedings had with state's attorney, and joint meeting
held of local doctors in that area: Result, man left the state.

Case No. 2: Started to practice first as a faith-healer, then

added medicine. Has now agreed to abandon the practice of
medicine.

Case No. 3: Practiced under the all-embracing title of

naturopath, and obtained some following in that village. Has
now left the state.

Case No. -4: A midwife and irregular practitioner. State's

attorney investigated and intervened, with result that the
woman promised to cease operations.

Case No. 5: A regular medical doctor, but picked his town

and started work without first receiving the state license. Mat-
ter taken up by attorney, and the man agreed not to practice
further until receiving his legal license. (The Board has at
times been confronted with the problem of having to deal with
not only the above type of case, but also those cases where
some regularly-licensed physician or group of physicians bring
in a man and permit him to start to work before first receiving
the state license. Then again there is the man, yet non-licensed,
but intending to settle in this Land of Goodly Promise and
Wealth; who is even perhaps married, and who perhaps buys
an interest in a practice, or possibly a drug store and a home,
who, when called upon by the Board for his misdemeanor, puts
up the heart-breaking plea that he has invested his all in that
given town, and that he should be allowed to continue prac-
ticing until he has taken the state board examination, even
though he is not at all certain that he can pass.)

Case No. 6: A flamboyant follower of the Glass system.

Arrested and bound over to the District Court for practicing
medicine.

Case No. 7: At another town. Some activity by an ir-

regular, not classified under the title of those working under
another type of board. Investigation by the local physicians
requested.

Case No. 8: This should be docketed under the heading

of plurals. In one of the larger towns of the state. To a great
extent the outcome will depend upon the interest and the activ-
ity of the regular physicians of that town.

Case No. 9: A faith-healer, with a very large following

and a lucrative return. Does not directly prescribe medicine,
although advocating certain drugs. Under investigation.

Case No. 10: Tried and convicted of murder in second

degree, due to an alleged operation. Yet on appeal.

Case No. 11: A person bearing different names. Arrested

on charge of criminal abortion. Bound over for trial.

Case No. 12: A woman. Alleged that she was operating

a hospital and administering drugs, although not even a regis-
tered nurse. To date, not sufficient evidence to initiate pro-
ceedings.

Case No. 13: A combination group of so-called naturo-

paths, advertising and practicing medicine. Upon action, left
town.

Case No. 14: Complaint made that this osteopath was prac-

tically doing general medical practice. Under investigation.

Case No. 15: Hearing heard for revocation of license. See

final paragraph of this paper.

Case No. 16: A decided irregular, in the limelight for

some time. Was convicted some years ago for violating the
Medical Practice Act. Very much in evidence during legislative
sessions. Now under investigation.

Case No. 17: Small-town irregular practitioner. Has re-

cently moved to a farm. He is going to leave the state.

Case No. 18: Non-ethical practitioner, but other men in

that area suggest he be given a chance to improve, upon warn-
ing of his standing.

Case No. 19: A noted offender, and one who was made

to leave Minnesota a few years ago. Charged with using an
instrument to procure an abortion, he is now out on bail. An
irregular of the worst type.

NOTA BENE

It should be carefully noted that charges based partly on
hearsay, cannot in court be admitted as evidence, and under
such conditions any endeavor to prosecute and fine or imprison
the designated offender entails unnecessary expense upon the
Board and might result in the affair’s being dismissed by the
court. Some attorneys and also some interested physicians are
instrumental in defeating well-meant efforts of the medical
board to disqualify non-ethical practitioners and also the efforts
of the Board to take action in cases of decided violation of the
Medical Practice Act. In a rfcent case wherein the defendant
physician certainly seemed to have deserved the complaint
alleged against him, and also to have merited the cancellation
of the license, the Board considered that it could not act defi-
nitely at the time, due to the fact that in the course of the
hearings some hearsay evidence was infected into the testimony,
thus partly nullifying the Board’s proposed action. However, in
that case, as some actual evidence was introduced proving non-
ethical practice ( but not in direct line with the original charges
or the wording of the Law) the case may again be opened up.
The powers of the Board could be increased through legislative
action along the following lines: (1) By increasing the penalty

for a second offense of violation of the Medical Practice Act.
A bout two years ago a bill seeking this object was passed, but
unfortunately was vetoed by Governor Welford. An illustra-
tion of how such a desired bill would work might be cited in
the case of a notorious irregular who a few years ago was fined
a small amount, plus jail confinement; later arranged with the
judge that if released from some of the confinement, he would
leave the state. Soon thereafter bobbed up in another part of
the state, again under charge for a very serious offense. It was
desired by the Board in the original case of that man, to make
the charge of obtaining money under false pretenses (which
he certainly did), but the presiding judge would permit the
lighter charge only, i. e., of practicing medicine without a
license. One-town irregulars or those who move from place to
place generally get enough money from the gullible public to
pay one fine after another.

Proposed Law No. 2: To give the Board greater powers

in proceedings to revoke the license of an offending physician
or surgeon.

MINNESOTA STATE BOARD OF MEDICAL
EXAMINERS

Julian F. DuBois, M.D., Secretary
St. Paul, Minnesota
DOCKET OF CASES

ILLEGAL LIQUOR PRESCRIPTIONS. The Minnesota
State Board of Medical Examiners cautions all physicians
against issuing illegal prescriptions for liquor, after appearance
before the Board of Mr. William Mahoney, state liquor control
commissioner, on November 27, 1936. Commissioner Mahoney
reported that a number of physicians had been writing out

THE JOURNAL-LANCET

235

hundreds of prescriptions for liquor, and that these particular
prescriptions were not issued in good faith. Some were even
blank, to be completed by the druggist. Four physicians, two
druggists, and one veterinarian were haled before the Board
on February 6, 1937. All concerned admitted guilt, and the
four physicans were reprimanded by the Board. It is the
opinion of the Board that it is not necessary to remind physi-
cians that the indiscriminate issuance of liquor prescriptions is
a violation of the law; and all physicians are asked to do their
part in living up to this law.

STATE OF MINNESOTA ex rel KNUTE H. LUROSS
versus BASIC SCIENCE BOARD. On February 5, 1937,
Judge M. A. Brattland, of the District Court of Polk County,
Minnesota, made an order sustaining the demurrer interposed
by the Basic Science Board in the action whereby Knute H.
Luross attempted to secure a basic science certificate without
examination. Judge Brattland gave Luross a stay of 30 days
to perfect an appeal to the Minnesota Supreme Court. No
such an appeal has been taken. Luross was found guilty in
March 1936 of practicing healing without a basic science cer-
tificate. He was sentenced to a term of six months in the
county jail. This sentence was suspended on the condition
that he cease practicing healing until licensed. The Basic
Science Board was represented by the then Attorney-General
Harry H. Peterson, William S. Ervin, and Roy C. Frank,
assistant attorney-generals.

STATE OF MINNESOTA versus R. A. McHALE.
On March 23, 1937, one R. A. McHale, 38 years old, was
convicted of practicing healing without a basic science certificate,
at Milaca, Minnesota. On March 16. 1937, McHale filed an
affidavit of prejudice against Judge D. M. Cameron, of District
Court, who promptly referred the case for trial to Judge
Anton Thompson, Fergus Falls, who was holding court at
Milaca at that time. At the conclusion of this trial, Judge
Thompson sentenced McHale to a term of four months hard
labor in the Long Prairie jail (Todd County) . McHale came
to Long Prairie in 1936, setting himself up to be a chiro-
practor. He examined patients, administered manual manipu-
lation and light treatments, furnished salve and pills for the
treatment of diseases. Some patients paid 82.00 per treatment;
others $10.00. The State of Minnesota was represented by
Mr. J. Norman Peterson, county attorney of Todd County; and
by Mr. Manley Brist, of St. Paul, who was appointed assistant
county attorney of Todd County for purposes of the trial
The Board thanks Mr. Peterson, and Judge Cameron for his
prompt reference of the case.

STATE OF MINNESOTA versus JEANNE MARTIN.
alias ESTHER G. MARCOE) TALBOT. On March 5,
1937, one Jeanne Martin, alias Esther (Marcoe) Talbot, 32
years of age, pleaded guilty to an indictment charging her with
the crime of abortion. On April 1, 1937, the defendant was
sentenced to a term not to exceed four years in the Women’s
Reformatory at Shakopee, Minnesota. Evidence by the Min-
neapolis Police Department indicated that the woman had per-
formed in excess of 75 abortions, and that she had been per-
forming abortions for two years. She collected about $1,500
for this unlawful work. After examination by two physicians,
however, it was deemed unwise to incarcerate the prisioner be-
cause of her physical condition, although she had done nothing
to improve her health prior to her arrest. The defendant was
married in 1931 to James Edward Talbot, and the two have
been living in Minneapolis under the name of Martin. The
woman was placed on probation for four years in charge of the
probation officer of Hennepin County, due to her unsatisfactory
physical condition. The Board thanks the Minneapolis Police
Department for its commendable work in this case.

TO PHYSICIANS OF SOUTH DAKOTA
FROM THE BLACK HILLS MEDICAL
SOCIETY

Fellow Physicians:

Probably most of the physicians of the state have al-
ready visited Rapid City, the convention home for 1937.

To those who have not, we wish to say that your visit
here will be more than the usual routine of high-class
papers and discussions. We feel that in the Hills
we have a certain community of interest that does not
exist elsewhere. Our Black Hills region, standing as it
does surrounded by a wide plain has certain features all
its own, and so has to offer to the visitor something en-
tirely different from anything surrounding it. Our Black
Hills Medical Society is limited by topographical rather
than geographical boundaries. At the same time each
community has something distinctive to offer the visitor,
the forests, the mines, the thermal springs, sugar refinery,
vast caves, are a few of the many attractions. The con-
vention city itself lies snuggled in the eastern embrace
of the mountains and provides hotel facilities unsur-
passed by any city of its size in the entire west. The
Black Hills are yours; come out and get acquainted with
them.

NEWS ITEMS

Funeral services for Dr. Joseph D. Freed, 85, of
Goodwin, South Dakota, who died on March 27 at
Watertown, were held in Goodwin on March 30.

Dr. George T. Joyce, 58, of Rochester, Minn., was
buried on March 31, 1937, in Saint John’s Cemetery
in Rochester.

Hereafter, the Anoka State Asylum at Anoka, Min-
nesota, will be known as the Anoka State Hospital,
according to Dr. Milburn Watts Kemp, superintendent.

Joyce W. Baldwin, credit manager of the Deaconess
Hospital in Great Falls, Montana, has been named first
assistant superintendent of the hospital.

Dr. Herbert H. James, of Butte, Montana, was a
recent visitor to the northwest sectional meeting of the
American College of Surgeons in Seattle, Washington.

Dr. Albert David Brewer, of Bozeman, Montana, has
returned to that city from Berkeley, California, where he
took a six weeks’ course in public health work.

Dr. Albert Harold Reiswig, formerly of Fairmount,
North Dakota, is now in practice at Wahpeton, North
Dakota, taking over Dr. W. John Pangman’s practice.

Dr. Charles E. Lyght, director of the Student Health
Service at Carleton College, Northfield, Minn., was re-
cently notified of his election as an associate of the
American College of Physicians.

More than 1,600 individuals in Rolette County,
North Dakota have been given Mantoux tests,
according to Doctor Milton Greengard, of Rolla, head
of the county tuberculosis survey.

According to Doctor Emmett Adolph Doles, president
of the Hill County Medical Society, Havre, Montana,
that city is in danger of a smallpox epidemic unless
vaccinations are speedily done.

The South Dakota State Senate on March 2 killed
two proposals to permit the State Board of Charities and
Corrections to build an additional insane hospital at
Watertown.

236

THE JOURNAL-LANCET

Dr. Francis Elmo Kibler, a graduate of the Univer-
sity of Colorado School of Medicine in 1933, is now
associated with the Austin Clinic at Austin, Minnesota.

Dr. Mvron O. Henry, of Minneapolis, was a guest
speaker at the meeting of the Park Region Medical
Society at Alexandria, Minn., on April 14, 1937.

State Senator Clifford I. Oliver, M. D., of Grace-
ville, Minn., had an article in The Minneapolis Trib-
une on Sunday, April 11, called "Goodbye! Country
Doctor”!

Dr. Rudolph John Ferlic, a graduate of the Creighton
University School of Medicine at Omaha, Nebraska,
in 1935, and a native of Butte, Montana, is in practice
at Panama, Iowa.

Bids were opened in St. Paul, Minn., on March 30
for the construction of the new state hospital for the
insane to be erected at Moose Lake, Minn. About 600
or 700 men will be employed in the project.

Dr. John S. Burton, who has completed his interne-
ship at the Minneapolis General Hospital, has taken
over the practice of Dr. Albert William Shaw, of Buhl,
Minn., who is retiring after 38 years of practice.

Dr. Ernest J. Hofer, of Freeman, South Dakota, a
graduate of the University of Illinois College of Medi-
cine in 1932, has established practice at Iroquois, South
Dakota.

Dr. Paul Reed, of the Minneapolis General Hospital,
a graduate of the University of Minnesota School of
Medicine in March 1936; will associate with Dr. Victor
A. Mulligan at Langdon, North Dakota.

Dr. Bernard S. Clark, formerly of Lead, South Da-
kota, a graduate of the Washington University School
of Medicine in St. Louis, Missouri, is now in practice in
Spokane, Washington.

Robert M. Catey, son of Mr. and Mrs. William
Catey, of Mobridge, South Dakota, took his degree in
medicine from the University of Chicago on March 16,
1937. He will interne at a Chicago hospital.

A $75,000 hospital is hoped for in Malta, Phillips
County, Montana. Citizens are trying to induce the
board of county commissioners to issue $40,000 in bonds,
and to obtain $35,000 as a WPA grant.

Dr. Julio Raymond Soltero, of Lewistown, Montana,
has been named health officer for Fergus County to re-
place Dr. John C. Dunn, who now heads the state hos-
pital at Warm Springs.

Dr. William Wallace Holleman, of Corsica, South
Dakota, a graduate of the University of Illinois College
of Medicine in 1933, will open a new hospital in Corsica.

Dr. Louis William Allard, of Billings, opened a two-
dav free clinic for crippled children under 16 years of
age at Saint James Hospital in Butte, Montana, March.
15 and 16.

Dr. W. A. Fansler, Minneapolis, read a paper en-
titled "Carcinoma of the Rectum and Colon” before
the Mount Powell Medical Society, Butte, Montana,
April 30.

Doctor Christopher Roy Dukart, of Richardton,
North Dakota, has gone to Chicago, Illinois, for post-
graduate work. Doctor Dukart’s practice is being car-
ried on temporarily by another physician.

N. E. Davis, of Columbus, Ohio, secretary of the
National Board of Hospitals of the Methodist Episco-
pal Church, recently inspected the Methodist State
Hospital in Mitchell, South Dakota.

United States Representative Fred Hildebrandt, of
Watertown, South Dakota, has introduced a bill into
Congress which would authorize construction of a 100-
bed hospital for veterans in Eastern South Dakota.

The Veterans’ Administration at Washington, D. C.,
will open bids on May 11 for the construction of a new
surgical unit at Battle Mountain Sanatarium at Hot
Springs, South Dakota.

The American Medical Golfing Association will hold
its twenty-third annual tournament at beautiful Seaview
Country Club, Atlantic City, New Jersey, on Monday,
June 7, 1937.

Louis William Shodaire, Los Angeles, California, has
donated to the Montana Children’s Home at Helena,
cash and real estate to the value of $200,000 to be used
for the construction and operation of a hospital for
crippled children.

Heart disease took 141.1 persons per 100,000 in
North Dakota in 1932 and 1934; and cancer was second
with 76.1 persons per 100,000 population, according to
J. M. Gillette, Ph. D., professor of sociology in the
University of North Dakota.

Dr. Walter F. Muir, a recent graduate of the Uni-
versity of Minnesota School of Medicine, has taken over
the practice of Dr. Lee Bey Greene, Edgeley, North
Dakota, who is ill in the Northern Pacific Hospital in
St. Paul, Minnesota.

Dr. Kano Ikeda, associate professor of pathology in
the University of Minnesota; and Otto Theodore
Walter, A. B., M. S.. Ph. D., professor of biology at
Macalester College in St. Paul, Minn., are in charge
of a new course in medical technology to be offered in
that institution.

Dr. Stanton Lovre, a native of Watertown, South
Dakota, was married to Miss Frances Anderson of
Lincoln, Nebraska, on March 25. Dr. Lovre, a graduate
of the University of Nebraska College of Medicine in
1936, will open practice at Alma, Nebraska.

Dr. Floyd Coslett, formerly superintendent of the
State Sanatorium, Sanator, has accepted a position at
West Rutland, Mass., in the Veterans’ Hospital. Dr.
T. L. Havlicek, assistant at Sanator has gone to Denver
to act as regional director in the Veterans’ Hospital
there.

Doctor Otto William Yoerg was elected president of
the Minneapolis Surgical Society on March 4. Doctor
Edward A. Regnier was elected vice president; Doctor
Harvey Nelson was chosen secretary-treasurer; and
Doctors Daniel A. MacDonald and William A Hanson
were selected as executive council members. Membership
in this body is limited to 50.

THE JOURNAL-LANCET

237

Bids were accepted on April 10 for a new $40,000
hospital at Wolf Point, Montana, to be operated by the
Trinity Hospital Association. It will be of fireproof
face brick, steam-heated, with terazzo and asphalt floors,
and will contain a freight elevator.

Dr. J. Vincent Sherwood, of Doland, South Dakota,
a graduate of the University of Minnesota School of
Medicine in 1929, is the new superintendent of the
South Dakota State Tuberculosis Sanatorium at San-
ator, South Dakota.

Dr. Frank L. Watkins, city health officer of Great
Falls, Montana, and health officer of Cascade County,
announces that 379 children in the county outside of
those in the Great Falls High School, have been given
Mantoux tests.

Dr. John C. Dunn, of Lewistown, Montana, a grad-
uate of the Northwestern University Medical School in
1902, has been named Acting Superintendent of the
Warm Springs State Hospital by Governor Roy E.
Ayers.

Custer County in South Dakota has a new nurse,
hired for a period of 3 months, commencing April 1.
Funds were secured from the South Dakota State Board
of Health, Custer County commissioners, and from the
sale of Christmas seals.

Bids will be opened early in May for a $90,000 chil-
dren’s preventorium to be erected at Wausau, Wisconsin.
It will have a capacity of 20 beds. (See "The Willard
Bequest,’’ by Hoyt E. Dearhart, M. D., in The Jour-
nal-Lancet, April 1937, p. 138.)

Dr. Royal V. Sherman, a graduate of the University
of Minnesota Medical School in 1931, will join the
Northwestern Clinic at Crookston, Minn. He formerly
was associated with the Bratrud Clinic at Thief River
Falls.

John Barton, vice-president of the Northwest Security
National Bank of Madison, has been named treasurer of
the South Dakota section of the American Society for
the Control of Cancer by Dr. Clarence E. Sherwood, of
Madison.

Dr. Hugo Mella, of the Veterans’ Administration
Facility at St. Cloud, Minn., announces the appointment

Dr James S. Glotfelty, of Clarinda, Iowa; and Dr.
Harold Lawn, formerly of Ely, Minnesota, as associate
physicians at the veterans’ hospital.

Dr. George E. Cardie, formerly of Ah-Gwah-Ching,
Minn., will take over the practice of Dr. Earl F. Jamie-
son, of Brainerd, while Dr. Jamieson is in Chicago for
a postgraduate course in ophthalmology and otolaryngol-
ogy at the University of Illinois College of Medicine.

The Montana State Board of Medical Examiners has
licensed these physicians: Dr. S. S. Graff, of Butte;
Dr. W. C. Robinson, of Cutts, Alberta, Canada; and
Dr. Wayne Gordon, of Billings. Drs. Rowland G.
Scherer, Bozeman; Orval A. Bosshardt, Lyman, Wy-
oming; Paul R. Ensign, Butte; Harry G. Drew, Albion,
Nebraska; Earl H. Brown, of Lewistown; and James S.
Gravly, of Butte, received reciprocity diplomas.

Dr. Charles T. Granger, Rochester, Minn., county
physician for Olmsted County, has published Auld Lang
Syne, a book of 5 short stories. One of them, "The
Saga of a Country Doctor,” appeared as a serial in The
St. Paul Pioneer-Press.

South Dakota physicians were grieved to learn of the
death of Dr. Milber Brink, 86, at Boyden, Iowa, during
March. For many years Dr. Brink owned lands in Wal-
worth County, South Dakota; and for a time he owned
the Bank of Granville in South Dakota.

Doctor Fred Floyd Keene, Doctor Jesse Walter Foster,
and Doctor E. A. Hofer conducted a scarlet fever clinic
on March 5 for the students of Wessington Springs,
South Dakota, in collaboration with Superintendent of
Schools Barrett Lowe, of Wessington Springs.

A campaign for $10,000 for the Methodist State
Hospital at Mitchell, South Dakota, has been announed
by Reverend P. O. Bunt, executive secretary of the hos-
pital’s board of directors. No such campaign has been
made since 1918 by this hospital.

Dr. Hovald K. Helseth, Litchville, North Dakota, a
graduate of the University of Minnesota Medical
School in 1930; and Dr. Carl A. Eckhardt, formerly
associated with Dr. Arthur F. Bratrud, of Minneapolis,
have associated with Dr. Edward Bratrud, of the Brat-
rud Clinic and Hospital in Thief River Falls, Minn.

Dr. Paul W. Giessler and Dr. John F. Pohl, recently
of Boston, Massachusetts, have established partnership
at 1945 Medical Arts Building in Minneapolis. Dr.
Giessler was graduated from the University of Minne-
sota School of Medicine, where he is associate professor
of orthopedic surgery in 1913; Dr. Pohl in 1929.

Dr. Frank Woodford Stevenson, of the Midwest
Clinic at Rapid City, South Dakota, was married on
March 6 in Minneapolis to Miss Esther Arndt, of Min-
neapolis. Dr. Stevenson is a graduate of the University
of Minnesota and Rush Medical College of the Univer-
sity of Chicago.

On May first, Montana will wage war on gophers,
marmots, and other rodents in an effort to stamp out
the bubonic plague, according to Dr. William F. Cogs-
well, Helena, secretary of the State Board of Health.
The Federal government has supplied $3,000 for a
truck, laboratory, and equipment.

Montana physicians are mourning Dr. Harris A. Bol-
ton, superintendent of the Warm Springs State Hos-
pital, who died on March 18. Dr. Bolton came to
Montana in 1911, shortly after his graduation from the
Baltimore College of Physicians and Surgeons. In 1929
he was named to the position he held at his death.

On April 5, President John A. Evert, President-elect
William Smith, and Secretary E. G. Balsam, of the
Medical Association of Montana, visited the Murrav
Clinic in Butte on the occasion of the clinic’s 30th anni-
versary. Next day the three physicians visited Warm
Springs, Galen, Deer Lodge, and Anaconda, all in
Montana.

238

THE JOURNAL-LANCET

Dr. William F. Cogswell, Helena, Montana, secre-
tary of the Montana State Board of Health, returned
on April 14 from Washington, D. C., where, with Dr.
Albert J. Chesley, secretary of the Minnesota State
Board of Health, he attended a conference on social
security.

Hillard Herman Holm, M. D., city health officer of
Glencoe, Minnesota, and a graduate of the University
of Minnesota Medical School in 1919, has a case of his
described in the April issue of the Des Moines maga-
zine, Look . Doctor Holm separated what the press
called "Siamese twins” (xiphopagi) in 1927, the oper-
ation being a success, although one member died in
March, 1936.

The radio schedule of the Minnesota State Medical
Association for May (WCCO: 810 kilocycles) is at
9:45 a. m. every Saturday morning. Subjects, by Dr.
William A. O’Brien, are as follows: May 1, "Child
Health Day”; May 8, "Minnesota State Medical As-
sociation”; May 15, "Some Major Health Problems”;
May 22, "Nervous Exhaustion”; May 29, "Artificial
Dentures.”

The annual spring clinic of the Yellowstone Valley
Medical Society will be held May 3rd in Billings, Mon-
tana. President John A. Evert, Glendive, head of the
Medical Association of Montana, will be a guest; and
Dr. George Wilkins Swift, of Seattle, Washington, will
speak. Dry clinics and fracture films will be shown in
the morning, while local members will read papers in the
afternoon.

The Annual Address in the University of Minnesota
Cancer Institute Lectureship will be presented by Dr.
Robert S. Stone of the University of California, on
Tuesday evening, May 4, at 8:15 p. m. in the Medical
Sciences Amphitheater. The title of Dr. Stone’s lecture
will be "Theoretical and Practical Considerations of
Super-voltage X-rays, Neutrons and Artificial Radio-
active Substances for Treatment of Cancer.”

Alumni of the Johns Hopkins University School of
Medicine at Baltimore, Maryland, held their annual
meeting at the Minneapolis Club in Minneapolis on
Saturday evening, April 10, 1937. Johns Hopkins alumni
from Iowa, Minnesota, North and South Dakota, and
Western Wisconsin were in attendance. Between 40 and
50 were present. The meeting was addressed by Alan
Mason Chesney, M. D., Sc. D., associate professor of
medicine and dean of the Johns Hopkins School of
Medicine. A talking film of the late William H. Welch,
M. D., was shown.

On April 7, Dr. J. A. Myers addressed the Post-
Graduate Conference of the Wayne County Medical
Society in Detroit, Michigan; on April 12 the Convoca-
tion at the University of North Dakota, Grand Forks,
the District Medical Society and the Business and Pro-
fessional Women and Parent-Teachers’ Association; on
April 15 the Camp Release Medical Society at Dawson,
Minnesota; on April 20 the annual meeting of the Illi-
nois Tuberculosis Association, Rockford, Convocation of
Rockford College, and the Winnebago County Tubercu-
losis Association.

Major General Frank T. Hines, administrator of the
Veterans’ Bureau in Washington, D. C., has advised
Secretary of State Goldie Wells that South Dakota
will "receive careful consideration” in the development
of any future construction program for war veterans’
hospitals; but that all available funds have already been
specifically allocated.

BOOK NOTICES

HANDBOOK ON OTOLARYNGOLOGY

Physical Therapeutic Methods in Otolaryngology, by ABRAHAM
R. HOLLENDER. M D.; first edition, heavy cloth, gold-
stamped. 442 pages, 189 illustrations: Saint Louis, Missouri:
The C. V. Mosby Company: 1937. Price, #6.00.

This useful handbook follows the symposium plan, wherein
the greater part is the work of the author, himself widely ex-
perienced in physical therapeutic measures in otolaryngology;
and the rest contributed by 10 well-known specialists who have
devoted special attention to the subjects assigned to them.

As stated in the preface, the main body of the book con-
siders the clinical problems encountered in everyday practice.
Only a small portion is given up to the fundamentals, for such
readers as must acquire a grounding to insure correct employ-
ment of the various therapeutic aids.

From the foregoing it will be seen that the aim of the book
is essentially practical, to furn sh the accepted procedures of
physical therapy as an adjunct to the use of routine and other
treatment in otolaryngology. It bears all the evidence of use-
fulness in this direction, evaluating and adjusting the various
tried and adopted measures to the special field under con
sideration. It should prove very helpful to those who want the ■ ■
facts quickly furnished in practical form.

The chapter on hearing aids is contributed by Horace
Newhart, M. D., of Minneapolis, and is a model of terseness
and completeness, giving an outline of all essential information,
with the authority of one who has devoted much thought and
study to the subject, and who is well-recognized everywhere for
his authoritative standing in that field of his work.

While the volume is intended primarily for the practical use
of the specialist, it is one which can be read profitably by any
practitioner. One needs to know about these things, if only to
furnish a working knowledge for intelligent discussion. The
book can be cordially recommended.

Gilbert Cottam,- M. D., j j
Minneapolis, Minn.

ZONDEK ON THE ENDOCRINES

Diseases of the Endocrines, by HERMAN ZONDEK. M.D.: 3rd
edition, revised, translated by CARL PRAUSNITZ, M.D.. blue
cloth, gold-stamped. 492 pages, 168 illustrations; Baltimore:
William Wood 6C Company: 1936. Price, #11.00.

Endocrinology is becoming increasingly important to the gen-
eral practitioner. This volume represents the current transla-
tion of the author’s book, and follows on general lines the last
German edition which appeared in 1926. The present edition
was prepared and concluded in England.

The recent advances in the knowledge of the physiology and
pathology of internal secretions are accounted for, and essen
tial points are altered when necessary. The author supplements
the known clinical data with his experience. Although this sub
ject still contains much unexplored territory, the author cor-
relates the advances already made and consolidates them so
that this volume remains a book for the clinician. The subject
matter is arranged according to diseases.

A number of fundamental hypotheses, some of which were
derived from the author’s personal work, are contained in the
book, and give it its special outlook. This edition is a most
important contribution to the science of endocrinology It
should be noted, however, that the author is Herman Zondek
not the somewhat more famous Bernhardt Zondek of the
Aschheim-Zondek test.

Hilbert Mark, M.D.

Saint Paul, Minnesota

The Schilling Hemogram In Acute Infections

W. H. Griffith, M.D.*

Huron, So. Dak.

THE treatment of acute infections constitutes a
major portion of the work in nearly every field of
medicine. Therefore, anything which will aid in
the management of these cases should be of interest to
the specialist as well as the general practitioner. Every
acute infection is a struggle between the infectious pro-
cess on one hand and the defensive forces of the body,
on the other hand. It is important to know at all times
just how this struggle is progressing, and the relative
strength of the opposing forces.

In mild cases, the clinical picture may give all the in-
formation that is needed, but in the more severe cases
we must use every possible means to follow the progress
of the disease so that we may have a proper basis for
therapy and prognosis.

Routine leucocyte and differential counts have been
the most common laboratory examinations in acute in-
fections but they do not tell the whole story. At times
they may even be misleading. During recent years there
has been a great deal of interest in a modified differen-
tial count called the Schilling hemogram. It is claimed
that it is possible by this method to differentiate between
a normal blood, a moderately severe infection, and an
infection that is likely to have a fatal outcome. Further-
more, it is claimed that examinations of the blood from
day to day give the most accurate picture of the progress
of the case. Hundreds of articles have been written
about the Schilling hemogram, nearly all of them attest-
ing its value; but still it is slow in coming into general
use.

This may be due to a natural skepticism on the part
of those who have not had first-hand contact with the

•From the Huron Clinic, Huron, South Dakota.

work, and also to some confusion resulting from numer-
ous modifications, and variations in terminology.

Sometime ago we began an attempt to evaluate the
Schilling hemogram for ourselves by comparing the con-
clusions from the blood findings with the later develop-
ments in each case. We now have records of 923 exam-
inations in 625 cases, covering a wide range of condi-
tions. (All cases are from the private practice of the
members of the staff of the Huron Clinic.) This series,
although not large, has been sufficient to convince us that
the Schilling hemogram should be made a part of the
examination in every case which is serious enough to
warrant careful study.

It was thought that a brief review of the subject to-
gether with some reference to our own impressions
might be of interest.

The work of Schilling was based on observations of
Arneth published in 19041. It had been known that
acute infections usually stimulate the formation of new
leucocytes, or at least, that they increase in numbers in
the blood stream. Arneth believed that these new cells
could be identified by their appearance and that the
proportion of new cells was of greater significance than
the total number of leucocytes. The increase in cells is
principally in the polymorphonuclears and so Arneth
devoted his attention to them. He believed that the age
of a polymorphonuclear neutrophile was indicated by
the degree of lobulation; i. e., the number of segments
in the nucleus. On this basis he divided these cells into
five groups. In Group I he placed those having a
sausage-shaped or irregular nucleus all in one segment.
In Group II he placed those with a nucleus with two
segments, and so on. Some hematologists have objected

240

THE JOURNAL-LANCET

to the idea that a cell with a bi-lobed nucleus is neces-
sarily younger than one with three lobes"; but there can
be no denying the fact that the cells in Groups I and II
become relatively increased in infections. Arneth tabu-
lated his groups from left to right on the page, and so
an increase in the first groups, i. e., the more immature
cells, has come to be spoken of as a "shift to the left.”

Schilling'* attempted to simplify the Arneth count, us-
ing a slightly different classification of cells, and placing
more emphasis on differentiation of the types of im-
mature forms. He divides the neutrophiles into true
principal groups, the segmented and the non-segmented
cells; i. e., the mature and immature forms. The Schil-
ling index is simply the ratio of the number of cells in
these two groups. In normal blood it is a small frac-
tion; that is, there are several times as many mature
lobulated cells as there are immature non-segmented
ones. With the development of an infection this ratio
changes promptly and profoundly. For instance, in an
acute otitis media or an acute appendicitis of only a few
hours duration, the non-segmented or immature cells
will have increased until they may be equal in numbers
to the segmented ones. With the two types in equal
numbers, the ratio will be 1 to 1 and we say the Schil-
ling index is 1. If the infection progresses, the index will
rise to 2 or 3 and in overwhelming infections such as
septicemia, peritonitis or meningitis, it will rise to 5 or 10
or even higher. It may be well to point out here that
the Schilling hemogram is a complete blood study using
the methods of Schilling, while the Schilling index is the
ratio of segmented to non-segmented cells, and is only
a part of the complete hemogram. The Schilling index
is practically the same as the staff count and the fila-
ment, non-filament count.

With the more severe infections, we have several
types of immature cells appearing and they are of great
significance. The first is the myelocyte, exactly the same
cell that we find in myelogenous leukemia. The second
type is the juvenile, which corresponds to the meta-
myelocyte of some authors. It has a U-shaped or twist-
ed nucleus with open, less dense structure than that of
the mature cells. It is intermediate between the myelo-
cyte and the next type, the staff or stab cell. The stab
cell differs from the mature segmented cells only in that
its nucleus is all in one segment. The stab cells are the
first to increase. In fact, a small rise may occur with
such non-infectious conditions as ruptured ectopic preg-
nancy or intestinal obstruction, severe pain, or even
faradic stimulation4. The presence of a leucocytosis with
only a slight increase in stab cells serves a valuable aid in
distinguishing such conditions from acute inflammations.

The appearance of juveniles and myelocytes in the
blood is of such significance that another index has been
proposed, making use of them. This is the lethal index ’,
the ratio of myelocytes to segmenters, or if there are no
myelocytes, then the ratio of half the juveniles to the
segmenters. When this index reaches one, and the Schil-
ling index is 4.5 or more, it is said to point to a fatal
outcome within about 48 hours. We have had only five
cases in which the lethal index reached 1 or higher. All

course of the temperature, leucocyte count, and Schilling Index
during the course of the illness. The Schilling Index rose until
the crisis, after which it dropped sharply, while the white blood
count showed comparatively little change.

have terminated fatally although not all within 48
hours.*

We may now consider briefly the usual blood changes
in some of the more common forms of illness. Pneu-
monia serves well to illustrate the relative significance of
the leucocyte count and the Schilling index. Chart I
shows the course of the temperature, daily leucocyte
count, and daily Schilling index in an uncomplicated
pneumonia in a boy of six, admitted to the hospital two
days following the onset. Note that the variations in the
white-cell count have little relation to the course of the
disease, while the Schilling index rises steadily until the
time of the crisis, after which it drops sharply. Of
course, the greater the rise, the more unfavorable is the
prognosis, especially when accompanied by a large pro-
portion of myelocytes. A failure of the index to drop
with the crisis, or a secondary rise would indicate some
complication.

Case 2 is a pneumococcus meningitis, type 3, in a child
of four years. The first blood examination indicated a
severe infection. The next two showed the condition
becoming worse while the fourth showed a temporary
improvement. The fifth examination showed a marked
turn for the worse although there was little change in
the clinical picture. The child died about thirty-six hours
later. In these virulent infections it is not unusual to
find a marked change in the blood picture, with little
apparent cause, only to have the patient’s general condi-
tion show a decided change within a short time.

The next case, Case 3, is an example of an extremely
virulent infection with low resistance. It is a peritonitis

* Since this was written we have seen two cases recover, although
the blood picture in each had indicated a bad prognosis. Both
were patients with streptococcus infection and were treated with
prontosil. We believe his to be of some significance.

THE JOURNAL-LANCET

241

Figure 2. Meningitis Due to Pneumococcus Type III, With
Fatal Termination. The temperature, leucocyte counts. Schilling
Index and Lethal Index are shown. The patient received anti-
pneumococcus serum containing heterophile antibody. This may
account for the temporary improvement shown from the third to
the fifth days.

secondary to a perforated duodenal ulcer. Only a mir-
acle could save a patient with a blood picture like that
found on the last two examinations. His general condi-
tion although far from good, would have led one to

fffi 00
tOfiOO

stooo

H Jl

mil

lin

•

,1.

t a 3
Days

Figure 3. Peritonitis Following Perforation of Duodenal Ulcer.
The blood picture on the second day gave a bad prognosis which
became more certain on the following days.

believe that he had some chance of recovery.

Case 4 is typhoid in a girl of eight years. It is of in-
terest because it shows a high Schilling index accompa-
nied by the usual low white count, and the Schilling
rose as the white count dropped. The leucocytosis in the
later stages was due to a pyelitis.

We have been particularly interested in the blood
findings in acute otitis media and mastoiditis. Our series
includes sixty-two cases. Most of them had several blood

242

THE JOURNAL-LANCET

gradually and the white cell count rose.

examinations and all had at least one X-ray. I shall not
attempt to analyze them except in a general way. It
must be remembered that the hemogram is a measure of
the virulence or activity of an infection rather than of
the amount of mastoid involvement. The onset of the
otitis in most cases was rapid. In many of them the first
examination showed evidence of a fairly severe infection,
and in some, the X-ray already showed evidence of in-
volvement of the mastoid. Under treatment, most of
them subsided into a relatively sub-acute stage, although
the invasion of the mastoid might continue. The tem-
perature, leucocyte count and Schilling all were usually
lower during this period. A failure of the Schilling
index to drop would naturally be further indication for
surgical treatment, if the clinical and X-ray findings
pointed that way. The same would be true of a sec-
ondary rise in the Schilling index later in the course of
the disease. The blood findings are of great value in
judging the importance of complications which may
develop. Such conditions as septicemia, sinus throm-
bosis, brain abscess, or meningitis, will immediately pro-
duce a blood picture characteristic of such severe in-
fections.

Acute sinus infections will show some shift in the
Schilling hemogram. Sub-acute or chronic infections,
and in fact, all important focal infections will show a
rise in the Schilling index usually with some increase in
large lymphocytes, and no leucocytosis, The hemogram

may aid in determining the importance of focal infec-
tion in individual cases.

No discussion of this subject would be complete with-
out some mention of acute appendicitis. In eighty-five
cases we have had the opportunity of comparing our
blood findings with the evidence of infection shown in
the microscopic sections of the appendix. Four cases had
normal Schillings and showed no acute inflammation in
the appendix. Twenty-two showed a slight elevation.
About half of these had normal appendices and the rest
showed sub-acute inflammation (as shown by the find-
ing of only a few scattered polymorphonuclears in the
appendix) with three exceptions to be noted.

Of the forty-nine with high Schillings, all but one
showed acute inflammation. The most pronounced dis-
crepancy was in the three cases where the blood showed
evidence of only slight infection and the appendix was
found to be gangrenous. Similar experience had been
noted by Crocher and Valentine, and it seemed like
more than a coincidence. One possible explanation is
that the gangrene is due, not to a different type of in-
fection, but to the more or less accidental occurrence of
thrombosis of blood vessels in the appendix. In this
way gangrene could be produced by a relatively minor
infection and until the infection spread, there might be
little systemic evidence of its presence. So it happens
that although the hemogram is a big help in the diag-
nosis of appendicitis, it does not relieve one from the
necessity of being constantly on guard against gangren-
ous appendicitis.

There are numerous other types of infections in which
the hemogram is of interest, but the foregoing account
may give some idea of the possibilities with this type of
examination.

Summary

The Schilling hemogram is a blood study using the
methods of Schilling. The Schilling index is an impor-
tant part of the hemogram. It is concerned with the
polymorphonuclear cells, and is the ratio of immature to
mature cells of this group. The hemogram gives reliable
evidence as to the presence or absence of infection and
the virulence of an infection if present. It has impor-
tant diagnostic and prognostic significance.

References

1. Arneth, J.: Die Neutrophilen Weissen Blutkorpeichen bei

Infectionskraukheiten. 1904 — Gustav Fischer.

2. Fitz-Hugh, Thomas Jr. The Age of the Leucocyte in Re-
lation to Infection, Journal of Laboratory and Clinical Medicine.
Vol. XVII, P^ge 975, July, 1932.

3. Schilling, V.: The Blood Picture (Gradwohl), 1929, C. V.
Mosby Co.

4. Healy, J. C., Sweet, M. H., and Chillingworth, F. P.: Effect
of Vibratory Stimulation on the Neutrophilic Index. Annals of
Internal Medicine, Vol. IX, Page 123, August, 1935.

5. Crocher. W. J. and Valentine. E. H.: Hemography in

Diagnosis, Prognosis and Treatment. Journal of Laboratory and
Clinical Medicine, Vol. 20, Page 172, November. 1934.

THE JOURNAL-LANCET

243

Benefactions of Surgery to Man

Owen H. Wangensteen, M.D.f
Minneapolis, Minn.

IX A MOMENT of weakness f yielded to
the request of Dr. Mann and his committee
to give this address, which assumed an obliga-
tion I now find it necessary to discharge. T wo
months and more ago it was easy to promise ;
now, I find it difficult to pay. Greatly appreciative
of the honor owing to my profession in having
the accomplishments of surgery included in this
series of lectures, I ventured to accept this trust
with a duteous but self-mistrustful spirit.

The healing art of medicine, it has been said,
is the oldest of all the arts. Hipi>ocrates, the
Father of Medicine, referred to it as “the art.”
I11 sponsoring this discussion relating to Medical
Science and Human Welfare, Sigma Xi obvi-
ously places upon medicine the stamp of scien-
tific approval as well. Reverberations of discus-
sions amongst medical men as to whether medi-
cine is art or science may even have reached your
ears. We can, however, at the outset, with the
greatest candor admit that in the relatively short
span of years, during which time medicine could
lay any justifiable claim to being a science, only
during this time, has palpable progress been made
in the healing art. It is to the steady growth
of knowledge and science on a broad base and to
the more general employment of the scientific
method in the solution of its problems that medi-
cine owes whatever distinction it enjoys.

My responsibility in this program is to present
the role that surgery plays in the treatment of
disease. And not lightly do 1 regard this honor,
for, time was, not so long ago, when little of
surgery was deemed scientific. Lord Moynihan
relates that as recently as 1800 when, following
several refusals, a charter was granted the dis-
banded company of surgeons of London, Lord
Thurston is reported to have said in the House
of Lords, when the bill had succeeded in the
Commons : “There is no more science in surgery
than in butchery.” To this invective, Mr. ( bin-
ning, a surgeon, appropriately replied : “Then,
my lord, I heartily pray that your lordship may
break his leg and have only a butcher to set it.”
Surgery or chirurgery is a derivative of two
greek words which literally translated mean hand
work or handicraft. A surgeon may then be
defined as a manual laborer in a Greek dress.
Representatives of the guild of surgeons have
not infrequently been rash enough to speak of
the art of surgery and one of our distinguished

*A scmi-popular lecture sponsored by the Minnesota Chapter
of Sigma Xi, illustrated by lantern slides and given at the
Northrup Memorial Auditorium, January 31, 1936. Reprinted
with permission from the September, 1936, issue of The Sxgtna
Xi Quarterly.

jChief, Department of Surgery, University of Minnesota.

contemporary votaries has been so bold as to
describe surgery, "The Queen of the Arts.” Now
one need not gossip much in the medical “sewing-
circle,” the confessional in which the sins of
one's neighbor are adequately confessed, to learn
that surgeons are not universally held in the
high esteem to which we may pretend. Very few
institutions of human inventions have departed
so little from the original spirit of the founder
as the sewing-circle. There, we may find and
hear ourselves scornfully described as carpenters
and mere technicians. It would perhaps be a
little unjust for us to take offense at the re-
proach implied in this designation, for many of
us find, in the artistry of work well done, con-
siderable satisfaction, and we are not sensitive
or ashamed over employing our hands in the
service of our brains. So, whether a surgeon
be a tradesman, an artisan or artist is apparently
a matter of divided opinion. It is interesting,
however, to reflect that whatever of ancient
medicine has lived and proved useful in our day
is essentially surgical in origin. Whereas, in the
time of Hippocrates, medicine and surgery were
one and the same healing art, when we again
hear of them after the turn of the twelfth cen-
tury, surgery has assumed the servant role of
handmaiden to medicine.

And thus, well into the middle of the seven-
teenth century we find medical men divided into
three groups : the superior physician attended and
prescribed for patients and with others of his
kind concerned himself over theoretical and
abstract philosophic exercises relating to disease
but of which they made very few accurate or
careful observations and knew in consequence
but little. At the lower end of the scale was the
barber-surgeon or the surgeon of the short-robe
of whose duties the present barber-pole is sym-
bolic. He shaved the monks and bled them usu-
ally five times a year. In civil practice when
blood had to be shed in the performance of an
urgently indicated cutting operation, the barber-
surgeon did it. He was wholly unschooled except
for the knowledge and skill he acquired in the
apprenticeship of his calling. He was usually
an itinerant, finding it occasionally more con-
venient to his personal safety to be at some dis-
tance, when the patient did poorly following his
desperate acts of mercy. In the middle, between
these two groups, equally hated by both was the
surgeon of the long robe whose essential duty
was that of dressing and treating wounds.
Eventually the surgeons strengthened their band
by taking into company the barber-surgeons. It
is a matter of common admission that in Queen

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THE JOURNAL-LANCET

Figure 1. Surgeons were originally blood-letters who shaved
the monks, and bled them 5 times yearly.

Elizabeth’s time when consultations were held
between physicians and surgeons that the latter
frequently awaited the decision of the physicians
outside the sick room as to whether the service
of the surgeon would be needed. Oh, what
mockery and deception there was in the ostenta-
tion of learning displayed by these pompous
pedants, the physicians ! Moreover their hypoc-
risy has been fully avenged in that no tangible
good of their deliberations has survived the
wreck of time and descended to our day. Little
wonder that Sydenham, a more modern Hip-
pocrates, counselled “Don Quixote” as the best
text on medicine of his time. When Boerhaave,
one of the most illustrious and distinguished phy-
sicians of the eighteenth century, died he left
behind him an elegant brochure, the title page
of which declared that it contained all the secrets
of medicine. When the volume was opened,
every page except one was blank. On it was
written, “Keep the head cool, the feet warm and
the bowels open.” This legacy of Boerhaave to
suffering humanity was the product of blind ad-
herence for centuries to authority influenced only
by theoretical philosophical abstractions.

O Clio, Muse of history ! May it never again
be your duty to record in the annals of medicine
that men have disdained the skill of the hand
and the observations of the eye as being unworthy
of the attention of men of learning. May medi-
cine always remain free from the fetters of
tradition and authority and the philosophic ex-
ercises of the mind uninterested in ascertaining
what is fact.

The Development of Surgery

To attempt to tell you in sixty minutes of how
..i.rgery has benefited man through the centuries
is admittedly a difficult task. My duty is some-
what lightened, however, in that up until about
sixty years ago the chief anxiety of surgery was
with the treatment of wounds. In the intervening

years, surgery has emerged from a handicraft
concerned with wound management to occupy an
important position in the treatment of disease.
It is with this latter significant chapter of surgery
that we are here concerned. Before reviewing
some of the accomplishments of surgery attained
by modern methods, let us briefly peep into the
common practices prevalent well up toward the
middle of the nineteenth century.

Anesthesia and asepsis were unknown. Bac-
teriology had never been heard of. ( )f the Hotel
Dieu the great municipal hospital of Baris and
probably the oldest hospital in existence in the
world, J. C. Warren writes:

“In the surgical ward there were, on January
6, 1776, 273 patients, there being but 106 beds
in the ward. The walls were soiled with expec-
torations and the floors with evacuations of the
bowels and bladders, as also with blood and dis-
charges from the wounds. The wood-supply and
the washing were kept in this ward, and every
afternoon there was also an out-patient clinic.
There were four rows of beds in a ward 34 feet
wide, and the report states: ‘It is difficult to
maintain the purity of the air on account of the
blood and pus that stain the floor, which it is
impossible to clean, owing to the crowding of the
beds.’ (Tenon’s Committee)

“In the St. Jerome. Ward more operations
were performed than in any other ward in
Europe. It was placed almost directly over the
deadhouse, the odors of which were quite per-
ceptible. This ward accommodated about 20 beds
and an out-patient department. The capacity of
the hospital was 2,500 beds, but during the cold
season as many as 4,800 patients were in the
hospital at one time. On the straw beds there
were sometimes four or five patients called
‘agonisans.’ These patients were not only the
moribund, but also those whose sphincters were
beyond control. These beds were only occasion-
ally wiped with a cloth, and the straw was rarely
changed. On extraordinary occasions the pa-
tients were placed in tiers one above another, so
that some were reached only by a ladder. There
were no stoves, the wards being warmed only
by the presence of the patients.”

How the world has moved on since that day!
not only in things medical but in the art of knowl-
edge of sanitation, plumbing, heating, ventilation,
architecture, and a score of other matters which
bear directly upon the comfort of hospital pa-
tients. The growth of science has created wealth,
convenience and luxury — much of which we can
all enjoy. This picture of a hospital scene was
probably not overdrawn and was likely fairly
typical of what prevailed where patients were
brought together in groups until antiseptic prac-
tices revolutionized surgery.

The only operations performed were those of

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245

necessity — to save life and when pain was no
longer tolerable, as in the presence of a stone in
the bladder. In the cutting for the relief of
this disorder, the surgeons of the day had de-
veloped considerable proficiency. The bladder
would be sounded to make certain of the pres-
ence of a calculus. The lithotomist would make
an incision in the perineum and in a minute he
would exhibit the extricated precious stone. Speed
was the primary consideration. Amputation of an
injured or mortified extremity was another opera-
tion which the surgeons had learned to do with
dispatch. The lightning-like swiftness of these
men in their work has been the object of con-
stant marvel. I have been told of a surgeon
of the pre-anesthetic era who in his rash haste
in the amputation of a thigh removed as well
two fingers of his assistant and both testes of
the patient — all in the space of 26 seconds. Since
the time of Ambrose Pare (1552), the employ-
ment of the ligature in amputations for the con-
trol of hemorrhage had become universal prac-
tice. Before, the flow of blood from the extremity
had been staunched by the use of heated irons,
it being hoped that the arrest of hemorrhage
would occur through the clotting of the blood in
the seared vessel.

War played an important role in the develop-
ment of early surgery. Crude and imperfect as
were obviously the ministrations of the surgeons
of this time, their services on the battle field were
held in high esteem by kings, generals and
soldiers alike. The examples of Ambrose Pare
and of Barron Larrey afford striking illustra-
tions of the happy influence which the military
surgeon of an earlier day exerted over the minds
of soldiers in time of war. inspiring confidence
in their leaders and assuring them of greater
security and safety when struck down by accident
or disease. When the French Surgeon Pare ap-
peared at Metz, the soldiers of Charles V, ex-
hausted by fatigue and hunger, crowded around
the great surgeon exclaiming, “We have no longer
any fear of dying even if we should be wounded ;
Pare our friend is among us.” And Larrey who
accompanied Napoleon through all his campaigns
was loved by the soldiers, and Bonaparte de-
clared him the most honest and upright man he
had ever known. I^arrey must have been a most
kind and thoughtful man, yet, perusal of his
books affords no description of the untold suf-
fering borne by these men during operative pro-
cedures. On one day, he amputated more than
200 limbs upon the field of battle— all without
anesthesia. How he and his soldiers must have
steeled themselves for such ordeals ! More than
a century earlier Pare had expressed the opinion
that surgery, though perhaps incomplete, had
attained a state of perfection, unlikely ever to

Figure 2. When the great Ambrose Pare (1510-1 590) finished
an amputation, he ligatured the arteries, instead of cauterizing
them, as had been done before his time.

be improved upon. Vain man has again, from
time to time, uttered such futile and frivolous
prophecies, only to be in turn outdone and humili-
ated by his successors.

Anesthesia

The horror of an operation without the bene-
ficent agency of anesthesia is terrible to contem-
plate. Very few persons are probably now alive
who were eye witnesses to such distressed scenes.
The advent of administration of ether for the
alleviation of pain, an American invention by the
dentist Morton in 1846, was one of the great
medical triumphs of all time. At the scene of its
first supervised trial at the Massachusetts Gen-
eral Hospital in Boston on October 16, 1846,
John Collins Warren, the operating surgeon, on
conclusion of the successful experiment, spoke
these prophetic words, “Gentlemen, this is no
humbug.”

Never in the history of medicine has a thera-
peutic principle been so quickly put into practice.
Man had long hoped for such an antidote for
pain but it had seemed to be a celestial blessing
not to be attained in an earthly existence. Oliver
Wendell Holmes, our physician-poet, for whom
medical men in particular have an especial afifec-
tion coined the word anesthesia — without feeling.
And so the excruciating pain of operation was
steeped in oblivion to remain only upon the
scarred memories of sufferers and witnesses.
Opposition was encountered to the introduction
of anesthesia in Scotland where Simpson in
Edinburgh advocated the use of chloroform to
assuage the pain of child-birth. Scotch theo-
logians of the stamp of John Knox proclaimed
from the pulpit that the pain of child-birth was
a punishment to be borne in the spirit of meek-
ness and that the administration of anesthetics
was an irreverent attempt to circumvent the man-
dates of the divine power. Scripture was freely
quoted in the support of this contention. It had

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hccn related of Simpson that he would have given
both his bible and his Shakespeare for a copy of
Oliver and Boyd's fact-containing almanac; vet,
lie knew his bible, too, and used the same weapon
in defense when lie referred his opponents to
the twenty-first verse of the second chapter of
Genesis, “and the Lord caused a deep sleep to
fall upon Adam and he slept and he took one
of his ribs and closed up the flesh thereof."
Simpson eventually triumphed and when Queen
Victoria permitted the use of chloroform at the
time Prince Leopold was born in 1863 all opposi-
tion broke down.

Holmes and Semmelweiss and the Contagion
of Puerperal Fever

Considerable impetus was lent to surgery in
the development of anesthesia. Patients more
willingly sought relief from disorders which
threatened life and operations became more fre-
quent. Apart from the obliteration of the pain
factor during operation permitting of greater
care and deliberation on the part of the surgeon,
the results were the same. Wounds suppurated ;
blood poisoning, erysipelas and hospital gangrene
followed the surgeons about and thwarted their
every effort. The mortality of even trivial opera-
tions was prohibitive. It is related of Sir Astley
Cooper, the most celebrated surgeon of his time
in London, that when requested by King George
IN', that he remove a simple wen from the king's
bead that his agitation knew no bounds. Cooper’s
anxiety and fear lest erysipelas should supervene
seem scarcely compensated by the baronetcy
which the king bestowed upon him as a reward
for the successful issue of the operation.

Sepsis was the curse of surgery. The forecast
that surgery had reached its zenith was more
frequently heard from authoritative persons.
Suppuration was apparently a natural and un-
avoidable sequence of operation. When the
evidence of inflammation was limited to the site
of operation without the menacing portent of
centripetal spread, the appearance of an abun-
dance of yellow exudate was acclaimed as “laud-
able pus.” Nicholas Pirogoff, a Russian military
surgeon of many campaigns, who had number-
less occasions to feel the futility of his own art
in dealing with suppuration was moved to write a
dissertation upon “Fortune in Surgery” in which
he stated that “the influence of the surgeon, the
therapeutic resources and mechanical dexterity
are of no importance ; the results of an opera-
tion are dependent entirely upon chance.”

However, even before Pirogoff made this re-
signed pronouncement, Oliver Wendell Holmes
had squarely put the blame upon the doctors
themselves — at least as far as the tragedies of
suppuration attending child-bed fever were con-
cerned. The disease known as puerperal fever,
he said in 1843, is contagious insofar as it is

carried from patient to patient bv physicians and
nurses. 1 he storm of protest and resentment pro- 1
voked amongst physicians can be readily im-
agined. The doctors Hodge and Meigs, professors
of obstetrics in Philadelphia, took largely upon (
themselves the defense of the innocence of phy- !
sicians in such matters. The denunciations heaped
upon Holmes were multiple.

Let us for a minute examine Holmes' serious- |
ness. He said :

“Let it be remembered that persons arc noth-
ing in this matter, lx-ttcr that twenty pamphleteers
should be silenced, or as many professors un- i
seated, than that one mother’s life should be
taken. There is no quarrel here between men.
but there is deadly incompatibility and exterm-
inating warfare between doctrines. ... If I am
wrong, let me be put down by such a rebuke as
no rash declaimer has received since there has
been a public opinion in the medical profession
of America; if I am right, let doctrines which
lead to professional homicide be no longer taught
from the chair of those two great Institutions.
Indifference will not do here; our Journalists and
Committees have no right to take up their pages
with minute anatomy and tediously detailed cases, |
while it is a question whether or not the “black-
death" of child-bed is to be scattered broadcast 1
by the agency of the mother’s friend and ad-
viser. Let the men who mould opinions look to '
it; if there is any voluntary blindness, any in-
terested oversight, any culpable negligence, even,
in such a matter, and the facts shall reach the
public ear; the pestilence-carrier of the lying-in
chamber must look to God for pardon, for man
will never forgive him.”

Holmes was not certain of the manner in which
this pestilence was carried. His views may be
summarized as follows :

“I shall not enter into any dispute about the
particular mode of infection, whether it be by
the atmosphere the physician carries about him
into the sick-chamber, or by the direct applica-
tion of the virus to the absorbing surfaces with
which his hand comes in contact. Many facts
and opinions are in favor of each of these modes
of transmission. But it is obvious that in the
majority of cases it must be impossible to decide
by which of these channels the disease is con-
veyed, from the nature of the intercourse between
tbe physician and the patient."

In 1847, Semmelweiss, a 28 year old assistant
in the obstetrical clinic at Vienna, saw in a post-
mortem wound of the finger sustained by his
friend Kolletcha at the necropsy of a parturient
woman, which caused his friend’s death with
findings similar to those observed in women dying
of child-bed fever, a source for the contagion.
He asked tbe students who participated in post-
mortem examinations, to wash their hands in

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247

chloride of lime before aiding with the duties
of the lying-in chamber. Semmelweiss quickly
demonstrated to his own satisfaction and that of
some of his colleagues that the contagion was
carried directly upon the hands of the attendants.
Youth must bear its yoke. His superiors refused
to take any notice of his claims. Impetuous and
intolerant of criticism, Semmelweiss directed his
energies into channels which led to his dismissal
with lost opportunity. His earnestness is certainly
to be admired. Said Semmelweiss :

“Should the professors not soon consent to
have their medical students and interns instructed
in my methods ; should the administration con-
tinue to tolerate the epidemics of puerperal fever
in the hospitals, 1 will direct myself to the public
in order to secure proper protection for those to
be confined. I will say: Father of the family!
Do you know what it means to call a medical
attendant for your wife at child-birth? It means
that you put a hazard to life in the way of your
wife and unborn child. If you do not wish to be-
come a widower, and if you do not wish your
unborn child injected with a lethal poison, and
should your children not wish to lose their moth-
er, go buy yourself a little calcium chloride; pour
a little water on to dissolve it, and do not permit
the physician or the midwife to make an internal
examination of your wife until they have care-
fully washed their hands in the chlorine water.
But do not blame the physician or the midwife for
this threat to your wife’s life. The responsibility
lies with the professor of obstetrics who taught
them and who failed to indicate that the resorp-
tion fever may be avoided by preventing infection
from without. ... 1 hope that the public will
prove more capable of being instructed than the
professors of obstetrics !”

Prophets have been stoned in places other than
Jerusalem. Semmelweiss has already lived longer
in his name than in his body, a distinction which
most of us shall not achieve. When futurity has
antiquated the present, time will still smile kindly
on the courage and glory of this man whom her
contemporaries ignored. Their curses have long
since ceased their din upon his ears. We need
the example of men like Semmelweiss more than
they need our praise.

Antisepsis

Working quietly but feverishly in his labora-
tory in France was a chemist, Louis Pasteur, the
medical Moses who was to revolutionize medi-
cine and surgery and lead it out of the bondage
and fear of suppuration. Life had confronted
him with a number of practical tasks. With a
genius for taking infinite pains, he had been able
to solve the mystery of tartaric acid by demon-
strating the presence of two tartars with the same
chemical formula — one with laevorotatorv, the
other with dextrorotatory behavior toward a plane

Figure 3. Lord Lister’s (1827-1912) famous carbolic acid
atmospheric spray in action at an operation.

of polarized light. In turn, he discovered that
micro-organisms were the cause of the spoiling
of beers and wine, and that a parasite was re-
sponsible for the catastrophies in the silk in-
dustries of southern France. These studies led
him into an investigation of the nature of
chicken-cholera, anthrax, and the general prob-
lem of infection. He crushed for good and all
the doctrine of spontaneous generation and his
successful vaccination of hydrophobia crowned
his achievements. This man of humble origin did
his best work after he had been stricken down
with apoplexy at 46. Fortune dealt kindly with our
medical Moses ; for he lived to get more than
a glimpse of the promised land from Mount
Pisgah. He crossed the Jordan and when he
died in 1895, the world acclaimed him as the
greatest public benefactor of all time. He had
kept the covenant.

The torch lit by Pasteur was to burn brightly
in the hands of Lister, our surgical Joshua. He
it was who by the application of antiseptics to
the skin demonstrated that incisions could be
made and that wounds would heal without the
anticipated consequence of suppuration. For cen-
turies, inflammation had continuously harassed
the surgeons and frustrated their efforts. It is
not amazing, therefore, that this new prophet,
though his divinations were true, like Cassandra,
was not believed. The walls of age-long pre-
judice were not to topple and fall like those of
Jericho. The exultant shout of victory over all
opposition was delayed well up toward the close
of the last century.

The New Science of Bacteriology

In brief, this is the story of the origin of
present-day surgery. The microscope and the
employment of aniline dyes taught us, in the new
medical science of bacteriology why wounds
suppurated. Man then quickly developed tech-
nical procedures which have gradually made it

248

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possible to invade and attack disease-processes
in ever)' body cavity and almost every tissue. The
growth of medical knowledge during the time
which parallels the discovery and development
of bacteriology has been unprecedented in the
annals of medical history. An ever increasing
Hood of illumination has penetrated into the
mysterious darkness of disease. A small faint
source of flickering light, in which one groped
blindly about, unable to read or see the cause of
disease had suddenly become incandescent and
brilliantly bright. The lamp lit by Koch, the
father of bacteriology, has continued to burn, but
the light has not always been so luminous, and
has been inadequate to permit of satisfactory
vision in the dim recesses of many diseases.

Within a few years, a score of bacterial dis-
eases which had defied probing and understand-
ing by the tedious, inexact, and inaccurate
methods of noting the symptoms present and
the tissue-effects produced, became clarified. The
employment of a new approach to old problems
had succeeded overnight in differentiating with
precise methods what centuries of speculation and
plodding effort had failed to do.

The studies in pathological anatomy by John
Hunter, Bichat, Laennec. Louis, Baillie, and
later of Rokitansky and Virchow, together with
the contributions of physiologists of the mark
of Johannes Muller, Magendie, Claude Bernard,
and Helmholtz had greatly enriched the stores
of medical knowledge, but these innovations had
influenced the practice of medicine but slightly,
to these anatomic and physiologic contributions,
the new bacteriological discoveries lent better
understanding and increased importance ; the re-
sults of previous morphological and physiological
studies took on new meaning and their relation to
the practice of medicine and as avenues for en-
larging and extending the horizon of medical
thought, became quickly apparent. The sig-
nificance of the momentum afforded to already
existing medical knowledge and the impetus lent
to further exploration into the obscurities of
medicine by the new science of bacteriology can-
not be over estimated. Never before in the his-
tory of man had disease been seen and read with
the crystalline clairvoyance made possible by this
new tool. Medical journals multiplied to record
the successive discoveries and conquests. New
approaches to obscure problems created new and
unfamiliar specialties of practice and brought
into being new sciences to assail disease in the
interphases between chemistry, physics, and ma-
thematics. Never before had the yield been so
plenteous and laborers for the vineyard came
forward in numbers with their various talents
for the harvest.

The New Surgery

The role of surgery in the elaboration of

knowledge concerning disease has been an im-
portant one. The therapeutic triumphs over
dread afflictions once believed to be beyond
remedy have been manifold. To enumerate many
of them here would be impossible and wearisome.

It may not be out of place, however, to retell
the story of some of these victories and to re-
count briefly the manner in which surgery works j
and attains its ends today.

It is very fitting that one of the first applica- I
tions to which the instrument of the new surgery j
was put was the relief of suffering women. So I
much of the exhausting drudgery of the daily .
tasks of life and the painful misery of woman's I
lot is borne in silent complacence that one feels I
a sense of gratification in this chivalry, however I
accidental it might have been.

The first aggressions into the abdomen under j
the auspices of antiseptic surgery were directed ]
toward the removal of ovarian cysts which fre- I
quently distressed and incapacited women as I
much on account of the size of the tumor as be- I
cause of pain. Even before the days of anesthesia I
and antisepsis, however, Ephraim McDowell, a I
bold pioneer of the West, in 1809, in Danville, I
Kentucky, had succeeded in removing a large I
ovarian cyst from the abdomen of Mrs. Craw- I
ford. Eight times in 13 trials, success attended I
the fearless efforts of this intrepid surgical ex- I
plorer.

In 1879, loyal admirers keenly impressed with I
the significance of McDowell’s contribution I
erected a monument in his honor with the in-
scription: “Honor to whom honor is due.’' It is
eminently just that within the past year a monu-
ment has also been erected in memory of the i
courage and resolute fortitude of the patient, Jane
Todd Crawford.

The great pioneer work of Marion Sims in
the aid of women, suffering from the presence of I
abnormal fistulous communications with bowel or
bladder, which unfortunate accident occasionally
attends precipitous child-birth was notably accel-
erated and advanced in the hands of the new
surgery. The surgeon became bolder and invaded
the hitherto unexplored domain of the vermi-
form appendix, the large and small intestine — |
even excising diseased portions of the stomach.
Simultaneously, surgical attacks were directed
with startling success upon concretions that
formed in the gall bladder, kidney and urinary
bladder, which had long been familiar and fre-
quent causes of much human misery not sus-
ceptible of relief by ordinary medical measures.
Even use of the hypodermic syringe employed in
the administration of medicines to assuage the
severity of such painful seizures was not with-

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249

out its attended dangers until asepsis became the
vogue.

Technical developments grew apace and more
drastic operative procedures requiring greater
Jare and deliberation could be done without seri-
ous risk. In 1866 Samuel Cross had said that
the danger of hemorrhage was so great in oper-
ating upon goiter that only a fool would be in-
duced to try it. By 1880 partial excision of the
enlarged thyroid for the relief of mechanical
obstruction to breathing was a common occur-
rence in surgical clinics. With the development of
cerebral localization — -a product of experimental
surgical research and refinements in neurological
diagnosis which indicated that definite areas in
the brain directly correlate with certain peri-
pheral nerves — with this knowledge came suc-
cessful surgical intervention for the relief of in-
creased intracranial pressure caused by brain
tumors. Tumors of the spinal cord and its cover-
ings proved even more amenable to surgery. By
1906, knowledge concerning the incompatibilities
of blood groups and the technical features of
transferring blood from one individual to an-
other had been sufficiently worked out that blood
transfusion — a therapeutic agency which had
been taken up and discarded many times in the
preceding 250 years because of the fatalities at-
tending its use — became a reality. Transfusion of
blood had superseded promiscuous blood letting
as a remedial measure. Developments in surgery
have created a demand for elaboration of other
anesthetic agents and today we have local,
regional, and intravenous anesthetic agents as
well as a host of vapors which may be inhaled
to allay the pain of operation. Emulating the
principle of looking into the eye by means of
reflected light, introduced by Helmholtz, endo-
scopic technique and instruments were quickly
developed to look into practically every natural
orifice of the body. With the aid of the X-rays,
surgeons have recently developed methods of
visualizing the urinary and biliary tracts by the
introduction of a solution into a superficial vein.
Surgeons have injected air into the spinal canal
and ventricular system of the brain to afford
the contrast in density which permits of better
localization of tumors by the use of X-rays.
Surgery of the extremities no longer concerned
itself alone with the removal of dead or dying tis-
sue. Broken bones in which one of the fragments
projected through the skin when treated in accord
ance with the precepts of Lister, now ceased to
carry such a formidable threat to life. Opera-
tions upon the delicate and intricate structure of
the eye, a branch of surgery in which Albert V.
Graefe, even before the days of antisepsis, had
performed works of wonder, repairing failing
vision — such operations now became even more
successful in the hands of many ophthalmic sur-

geons who were followers of Listerism. The
power to work miracles had descended upon
many disciples and in many lands, persons with
dimmed vision were to be privileged again to
know what a pleasant thing it is “for the eyes
to behold the sun.”

With the development of means of admin-
istering anesthesia by overhead pressure to com-
bat the subatmospheric pressure normally pres-
ent in the pleural cavity, the thorax, the last
strong-hold of the large body cavities to resist
invasion of the surgeon, surrendered. And ex-
periences gained in the war have made the cor-
rection of deformities the special concern of
the plastic surgeon.

In these pages, I have occasionally described
under the more inclusive caption of medicine the
activities of the surgeon. The great growth of
information in the biologic field has made it
impossible for any one man to master equally
all of the ramifications of medical knowledge and
practice — let alone make any contributions to the
patrimony of biologic science. The number of
specialists in the medical field has now become
so large as to impose a great task on any one
who should attempt to enumerate them all. The
problem of relating and taking advantage of
gains in skill and knowledge possessed by any
of these groups by the others is obviously an
intricate and difficult problem. Today, divisions
in practical medicine are based essentially on
mastery of diagnostic and therapeutic agencies.
The activities of the surgeon are no longer
dictated by physicians who would limit their func-
tion to the care of wounds, ulcers, fractures, dis-
locations and operations of necessity. The sur-
geon has become a physician in the field of his
interest. Today physicians and surgeons stand
side by side not as master and servant but more
as willing helpmates linked together hy the bonds
of a sacred duty combining different talents and
responsibilities but similar interests in the care
of the sick.

Surgery Then and Now

The contrast afforded in the preparation for and
conduct of an operation in the pre-antiseptic era
and that of present day practice is startling.
Then, surgeons washed their hands after opera-
tion instead of before. The surgeon took his in-
struments out of his case much as a plumber
removes his tools from his kit. Without more
ado, he put them out on the table, took off his
street-coat, and when in the hospital, donned a
frock-coat which usually hung on its owner’s
hook in the operating room. The sleeves and
other parts of this garb often bore too obvious
traces of previous encounters with free hemor-
rhage. It was customary to put out only a pair of
hemostats with which to close the mouths of
bleeding vessels before they were secured with

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ligatures. Marine sponges taken from the same
kit were put out on the table and were employed
to sponge up the blood accumulating in the
wound. The surgeon frequently carried his
sutures and needles in the lapel of his operating
frock. It was not uncommon practice for the
surgeon to taper the thread in the manner em-
ployed by a seamstress who points the tip of
the thread with her lips before attempting to pass
it through the eye of the needle. Though Lister
had addressed the International Medical Con-
gress which met in Philadelphia in 1876 upon the
subject of antiseptic surgery, his words fell upon
deaf ears. Some of the most celebrated surgeons
in the country, as a last gesture before the skin
incision was made, continued to strop the blades
of their knives on their boots or the heels of
their shoes. Many a spectacular surgeon between
cuts, reposed the blade of his knife, pirate-fash-
ion, between his teeth. Instruments accidentally
dropped on the floor were replaced on the table
bv any bystander, for immediate use. An inter-
ested spectator was occasionally asked to put
his hand into the wound and examine the tissue
under consideration. However dreadful and in-
credible these practices may seem to you now, it
is even more strange to recollect that such methods
prevailed amongst the most respected of the
surgical profession in this and other countries
until in the early eighties when the momentum
of the precepts of Lister ism crushed all opposi-
tion. Following the assault upon President Gar-
field in 1881, he was attended by two of Amer-
ica’s best known surgeons of the time, who to-
gether with the other medical attendants probed
the bullet wound with their fingers and catheters.
An antiseptic dressing was applied to the wound,
but there is no suggestion that other precautions
were observed to avoid infection of the wound.
There remains but little doubt that these maneu-
vers and the failure to heed the warning uttered
by Lister in this country five years before were
of major consequence in bringing about Gar-
field’s death somewhat more than two months
following the receipt of the injury. Here and
there, however, as late as 1900 the doctor refused
soap and water for the cleansing of his hands
offered him by the widwife. before going into
the lying-in chamber, saying, “No, thank you,
1 washed my hands just before I tied up my
horse.”

The late W. W. Keen states that at the second
battle of Bull Run he had charge of a caravan
of 36 wagons of medical supplies. Eleven of this
number carried only alcohol, brandy, and wine
for the injured — indeed a very liberal portion of
the medical supplies. We have no testimony that
the generous internal administration of this rem-
edy accomplished very much. Had that medica-
ment been employed externally as the good

Samaritan used it in binding up the wounds of
the man who fell amongst thieves “pouring in
oil and wine” how many lives would have been
saved. How this parable might have been cited
for the instruction of surgeons as well as lawyers!

Lister believed that the danger lurked in the
air and devised a carbolic acid dressing to ex- I
elude the putrefactive influence of the atmos- ;
phere and sprayed the operating room and the ,
field of operation generously with a solution of
dilute carbolic acid during the operation. It was '
soon learned that the air itself was the least im- t
portant source of the contagion — that the pa-
tient's skin, the hands of the surgeon and his I
assistants, the instruments, linen and gauze must
all be rendered as sterile as possible. Thermal
sterilization quickly replaced the chemical. Par- I
ticipants in the operation donned sterile gowns
and added the wearing of sterilized rubber gloves 1
to meticulous mechanical cleansing of the hands j
for the added safety of the patient and finally it
was appreciated that wearing of masks covering I
mouth and nose was highly essential in order
to preclude droplet infection of the wound. Sur-
gery, however, was not born full-fledged like t
Minerva, the goddess of the handicrafts. From ,
year to year new methods and techniques have
caused surgery to exhibit improvement similar to ■
that manifested in our motor cars over 5 or 10
year periods.

A third year medical student or a student
nurse who has had the opportunity of witnessing
operations but whose hand has never poised a
scalpel would be a far safer surgeon than the ,
best of that period, despite serious lack of ex- .
perience and skill. The hospital with its present
day appointments is equally as changed as is the
surgeon. A person in no small measure re-
sponsible for the improvement in its atmosphere
is the nurse. The role of the nurse in the care |
of the sick and particularly of surgical patients |
is a most important one. When one contemplates J
the Betsy Prig or Sairey Gamp of Dickens’
time, he cannot fail to recognize the extent of
the reformation which has simultaneously oc-
curred in nursing. The movement which Florence ;
Nightingale set in motion in Scutari during the
Crimean war, for the aid of ill and injured
soldiers will keep her memory bright forever.
Only since Lister and Florence Nightingale have
hospitals become true havens for the sick. Be- ‘
fore Lister, the patient accepted chances with no 1
more promise than those afforded gamblers at
Monte Carlo. Today, the risk of almost every 1
operative procedure can be reasonably gauged
and the patient can decide whether the gain is
worth the hazard.

The new surgery created and brought the
modern hospital into being. Despite all our
striving for uniformity and attempts at stand- ,

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251

ardization, every hospital, as Harvey Cushing
has so well said, has a personality all its own —
an intangible quality, let us hope that is always
an asset. This character represents usually a
combination of individualities rather than in-
dividual accomplishments. To this fusion, all who
have worked in the hospital, no matter how lowly
his position, brings his contribution. The stu-
dent nurses, their superiors, the orderlies, the
clerical, force, social service workers, students,
house-officers, and staff — these help to mould the
personality of a hospital — in which expressions,
Axel, the orderly, who takes pride in the giving
of a fine enema or Charlie, elevator operator who
dressed the Christmas trees since the hospital was
built and still comes back to discharge this func-
tion after retirement and helpful Fred Hamilton,
hospital engineer ; the foot-weary instrument
nurse who continues to pass hemostats to the
less agreeable and somewhat imperious surgeon ;
the over-worked, underpaid and faithful secre-
tary who labors in and out of season without
complaint to write the letters and type the papers
of her chief ; loyal assistants who lend patient
and attentive ears to the inquiries of the sick
and their relatives after a hard day’s work in
the operating room and who still have energy
and enthusiasm to pursue an investigation in the
experimental laboratory in their few hours of
leisure — these noble men and women who live
and love their work and bring to their jobs their
very best effort — they help to mould the spirit
of a hospital as much as the senior staff or the
hospital director who tells us how much money
we may spend. The ward-maid, anxious over the
personal comforts of the patients of her charge,
worries about the old man with the hip whom
Dr. Cole operated upon yesterday, and the
baby with the cleft-palate repaired by Dr. Ritchie.
She wonders whether the window left open may
have been the reason that John in 407 failed to
recover from his operation. To the hospital
superintendent falls the more important but less
interesting task of worrying about the per-diem
cost. One may well, with the poet, inquire, “In
the sweet ear of nature, whose song is the best?”

Trends in Surgery

Over and over again, time has demonstrated
that the borders of medicine and surgery are not
fixed but subject to constant change. We are
continually striving to find means of treating
surgically diseases which are refractory to medi-
cal management. At the same time, an uninter-
rupted and restless search is always on for more
conservative agents which may adequately re-
place satisfactory but more energetic operative
intervention. These imaginative pursuits and
dreams of physicians and surgeons are often
matters of stern reality to the patient afflicted
with an internal disorder for which medicine can

do nothing, as well as to the patient faced with
the prospect of operation for the relief of his
complaint. The one asks, “May not an opera-
tion help me?” The other, “Can not the same
result be accomplished without operation?" These
two opposed activities of the surgeon — -greater
conservatism in the management of diseases al-
ready amenable to operative intervention ; and
aggression bordering on radicalism in diseases
refractory to any known extent — these activi-
ties are always in progress like the changes in
a reversible chemical reaction.

We find the surgeon on the one hand excising
a portion or all of the stomach or colon or re-
moving an entire lung for cancer, extirpating
the urinary bladder similarly affected and trans-
planting the ureters into the bowel, as well as
entering the skull and removing generous por-
tions of the brain when the seat of a malignant
tumor ; we find him removing almost all the ribs
on one side of the chest in order to obtain mech-
anical compression for the diseased lung and stop
the ravages of tuberculosis when bed rest and
medical measures have failed.

We find him so bold as to excise liberal por-
tions of the sympathetic nervous system to secure
relief of pain and an improved peripheral cir-
culation in patients with spastic contraction of
their blood vessels where gangrene is threaten-
ing. This same rash endeavor he applies occa-
sionally to physiologic spastic types of bowel
obstruction and even constipation. And now we
find him attempting to relieve the menacing
threats of high blood pressure with its conse-
quences by removing portions of the sympathetic
nerves and the adrenal gland. No portion of the
human anatomy seems to have withstood the
force of his invasion. He is found removing
small tumors in the pancreas that produce insulin
in excess and cause its owner to have lethargy
and convulsions — tumors whose presence had
long been noted but which were generally be-
lieved to be without significance. We find him
trying to revive patients, who stand on the brink
of death from the rare but appalling disaster of
pulmonary embolism, in which a blood clot
loosens during convalescence after operation and
propagates itself as a thrombus obstructing the
pulmonary artery, making respiration ineffectual.

Mandl, an enterprising young surgeon in Vien-
na, solved the mystery of multiple bone cysts
with associated parathyroid tumors which con-
dition had long intrigued pathologists by excising
a parathyroid tumor and arresting the disease-
process. We find the surgeon now the strong
right arm of the endocrinologist in attacks upon
tumors of glands such as the adrenal, hypophysis,
ovary and testis which affect body growth and
development as well as personality. This ro-
mantic activity of the surgeon promises to be one

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of the most dramatic and fruitful of all his
labors. My colleague, Dr. McQuarrie, will later
•elaborate the role of the surgeon in this most
fascinating province of medicine.

At the same time, this intrepid and somewhat
reckless fellow, the surgeon, will be found in-
jecting sclerosing solutions into varicose veins to
obliterate them instead of excising them as he
was wont to do a few decades earlier. We find
him attempting to cure hernias as well as hem-
orrhoids by injection rather than by operation.
Truly, the hypodermic needle threatens to be
mightier than the scalpel in the treatment of
many surgical disorders. We find him aspirating
gas and fluid from the distended stomach and
upper reaches of the intestinal canal by an
inlying duodenal tube to afford relief of obstruc-
tion without operation ; or clipping off portions
of the prostate gland which projects into the blad-
der causing urinary retention in aging men.

Strange as it may seem to you, the surgeon
often appears to find in the successes of these
strategic lesser surgical triumphs greater cause
for rejoicing than in the more brilliant and color-
ful victories of bold aggressions for he knows
that they are purchased with less risk of life and
cost patients less apprehension.

Unsolved Problems

Tn addition to the anxieties, trials and tribula-
tions of his work which tend to make of the
surgeon a modest man, any inclination to vanity
or pride is short-lived, in that the surgeon is
daily reminded of the many diseases for which
his art can do nothing and in which he is but
a passive spectator. The scourges of cancer and
infection take yearly a large toll of lives despite
the best effort on the part of physicians and sur-
geons. To be certain, the surgeon has his suc-
cesses, but when he reckons his losses, he is
dismayed to see how large the winnings of
Death have been. With the many attacks launched
upon the problem of cancer from every approach,
one may hope soon to hear that this strong-hold
of disease has yielded. Whereas the precepts of
Pasteur and Lister have made it feasible to ex-
plore practically every body cavity with impunity,
when the surgeon is confronted with established
infection, the problem is essentially the same as
it was before the days of Lister. Virulent spread-
ing infections are as dangerous today as then.
The surgeon in dealing with infection can only
incise a localized collection of pus as in
abscess or prophylactically prevent extension of
infection into a larger space as is best exemplified
in the early removal of an inflamed appendix.
When infection is spreading whether it be in
the arm, the brain, or the lung, the surgeon can
only do harm by intervention and must resign
himself to supporting the natural defenses of
the body, of which my colleague, Dr. Bell, will

later speak at length. The patient must grimly
fight out the battle with the infection with little
or no specific help from his surgeon. Ambrose
Pare recognized the limitations of surgery ; he
said, “I treated him, but God healed him.”

As one reads the expressed hopes kindled in
the breast of medical men by the rapid bacteri-
ological discoveries of the eighties and nineties ■
and the first few years of this century, he might
be led to believe that a specific treatment would
soon be available for every bacterial disease.
Suddenly, however, the triumphant exploits of
the bacteriologist seemed to have reached an
impasse and no new great victories have been
won. Yet, it is to the development of bacteri- ■
ologic and pharmacologic aids that we must look
for more light in onr fight upon infections. Much
of what has been accomplished, in the eyes of
the pre-Listerian era is as much a mircle as the
granting of vision to the blind Bartimaeus. i
Asepsis is the birthright of the present genera-
tion of physicians and surgeons. We take a just j
pride in it, but until we have enlarged this heri-
tage, how can we feel proud? We must look to ;
our laurels for posterity will find no lasting sat- 1
isfaction in our achievement and that she will
greatly improve upon our possessions one may j
write down not as a prediction but as a foregone ;
conclusion. Our accomplishment by contrast with
that of our antecedents may entitle us to feel I
like Brobdingnagians — but that exhilaration can
be only short-lived, for, by comparison, the
achievements of our successors will prove us to
be mere Lilliputians.

Buried in the literary catacombs of the volumes
which occupy7 the shelves of our libraries un-
doubtedly lie suggestions which if properly syn-
thesized and co-ordinated would shed luminous
light on our unsolved problems of infection and
cancer. Were these volumes to be more worn by
us than byr time, the likelihood of important dis-
coveries through the conversion of known fact': \
into ideas would be greatly enhanced. We must
often wait patiently and long for the discerning
dreams of a Joseph or a Daniel who will be able
to make such syntheses or lead us by a path ye1
unknown, directly to the solution of such prob
lems as those presented by cancer and infection.

The Role of Experimental Surgery

How anesthesia and asepsis reformed surgery
is a revelation ; how in turn the new surgery
improved medicine, afforded abundant opportun
ity for observation of disease-processes and sup
plied new methods of bringing relief to mai
suffering from serious bodily disorders are bu
natural consequences of that great stimulus. Tb
most significant advances in medicine are nov
coming about through the employment of sur
gery" in the experimental study and investigatioi
of disease. The anatomical structure of organ

THE JOURNAL-LANCET

253

could he studied upon the dead body, but how
these organs function is only to be ascertained
during life. The new surgery served this ob-
jective admirably, and played an important role
in the development of our knowledge of diges-
tion, the circulation, respiration and the function
of the ductless glands. How Harvey by animal
experimentation proved that the blood circulates,
even before the rise and development of the new
physics and chemistry, attests the great sig-
nificance of the experimental method in the study
of normal function. For centuries speculation
had been rife as to what the relationship was
between the heart, the lungs, and blood vessels.
These disputations had only succeeded in com-
plicating and confusing the issue. A few simple
experiments in the hands of an accurate observer
brought enlightenment that left no room for fur-
ther argumentation.

How much sooner Lister would have suc-
ceeded in dispelling the cloak of ignorance had
he employed the advantages of animal experi-
mentation. John Hunter recognized the superi-
ority of the experimental method over logic. To
Edward Jenner, of smallpox vaccination fame,
Hunter said, “Try the experiment, don’t think.”
Rationalization too often proves deceptive, not
because the logic is fallacious, but rather because
the knowledge of the factual data bearing on the
matter is incomplete or the initial premises them-
selves may be wrong. History has repeatedly
taught how apparently sound reasoning and de-
duction have led us astray. If all the factual
data bearing on an issue were known and avail-
able to the one attempting its rationalization, a
logician who would take the time to become
thoroughly acquainted with the subject under
discussion could deliver a satisfactory and ac-
curate answer to any question propounded him.
Direct experimentation will always have an im-
portant place in all human activity. How specu-
lation and vacuous arguments have retarded
human progress ! The crucial test of experiment
deletes our textbooks of medical and surgical
barnacles and ancient errors that have been re-
copied for generations.

The few years which have run through the
hour glass of time within the experience of the
youngest of this audience have witnessed two
innovations of experimental surgery that have
brought life and happiness to thousands of homes
throughout the world. In 1921, Frederick Bant-
ing, an orthopedic surgeon in London, Ontario,
abandoned his practice, convinced that the internal
secretion of the pancreas could be isolated by
eliminating the confusing influence of the diges-
tive secretions of the same gland. In his imagina-
tion, known facts were built into an idea. Within
a few months together with helpful colleagues,
he had succeeded. His name has since become

a household word to be cherished in gratitude
in homes where insulin helps diabetics to live and
lead more normal lives. To the hands and
creative mind of the pathologist, George Whipple,
experimental surgery furnished the means of
attacking the problem of blood regeneration in
anemia. What Whipple learned of the value of
liver as a dietary measure in the repair of blood
loss was put to practical use by Minot and
Murphy. Today in consequence, persons afflicted
with the hitherto invariably fatal pernicious ane-
mia can, with the aid of liver, live normal lives.
Only homes which lost a mother or father or
other dear one a short time before this dis-
covery was made can fully appreciate the bles-
sings of this new knowledge denied them, but
enjoyed by others.

Yet, we hear prejudiced people raising their
voices against animal experimentation. In this
and other municipalities, there is a self-styled
“animal rescue league” which takes homeless
dogs ofif the street and asphyxiates those which
are not claimed. What deception there is in this
disguise — the voice of Jacob, to be sure, but the
hand of Esau! To kill without purpose — no
savage barbarism could be more cruel than this !
When man no longer slays animals for food
or clothing or holds them subservient to his will,
the significance of truths learned in animal ex-
periments will fully justify their performance
for the protection and prolongation of human
life. One of the most valued instruments in the
relentless search for the cause and alleviation of
disease is the experimental method. Matters of
such vital importance to health and happiness can-
not be left to chance. Biological research em-
ploying the scientific method must go on ; its dis-
coveries and benefits are available to all men
irrespective of creed or birth or whether rich or
poor; through its agency more lives are saved
than all the wars of all the ages have thrown
away. Like a divining rod, the experimental
method wrests truths from nature, which would
otherwise percolate for centuries through the
slow filters of time.

The Future of Surgery

What of the future of surgery? Any child
who can speak can ask questions which none
of us can answer. Just now, endocrinology in
its broad aspect, in which activity surgery plays
an important role, seems to hold forth a promise
almost equal to that of bacteriology of 60 years
ago. Whether advances in surgery will be made
at a snail-like pace or in rapid strides will be
determined not alone by discoveries in medicine
as a whole but by developments in genera!
biology and the physical sciences. The two
greatest benefactions of surgery to man are in
reality gifts of chemistry to surgery. To be
sure, ether and nitrous oxide inhalations were

254

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mere chemical playthings of the lecture hall until
surgeons demonstrated their great value in the
relief of pain. The value of chemical antiseptics
and asepsis in the prevention of infection were
wholly unknown till empirical trial and the dis-
covery of micro-organisms declared their true
worth. Anesthesia made operations possible ; an-
tisepsis and asepsis have made them safe. Dis-
covery of the X-rays by Roentgen and of radio
activity by Becquerel and of radium by the
Curies have been a great boon to medicine — gifts
from physics. The new science of bacteriology
was essentially an outgrowth of chemistry, mi-
croscopy (physics) and medicine. No man can,
like Francis Bacon, take all knowledge for his
province. It is, however, still true that some of
our most valuable and useful information in the
warfare on disease is to he learned at outposts
stationed in the interphases of activity between
greater medicine and our biological and physical
sister sciences. Only through the activity of alert
eyes and minds scanning the horizon in these
interphases, will the great lag between discovery
and application become a less common occurrence.

Surgery, long a parasite on the common stores
of knowledge, now has its own contribution to
make. Recognition of the importance of the
experimental laboratory for all workers in the
field of clinical medicine is rapidly gaining
ground. We have been accustomed to hear that
the hospital wards are the laboratories of phy-
sicians and surgeons. No — accurate observations
may be made there and occasionally significant
rationalizations may he made from such obser-
vations ; only in the experimental laboratory,
however, may the factors which bear on the
observation he varied and a true analysis of its
significance he reached. The crucial test of direct
experimentation will serve to avoid the pitfalls
of rationalization on incomplete factual data.
The pedantry of authority has given way before
the testimony of fact.

The interests of greater medicine, I cannot
believe, will be best served by the complete with-
drawal of groups such as anatomists and phys-
iologists into the tranquil detachment of scholas-
tic seclusion afforded by their laboratories. The
great stimulus of enthusiasm gained by daily
first-hand contact with unsolved problems can
scarcely reach them there. Amidst the arduous
responsibilities of service and practice, Vesalius,
Pare, Harvey, Hunter, Jenner, I-aennec, Koch,
and Lister — among the most illustrious men
in medicine of all times — still found time to
prosecute fruitful researches. At the same time,
the clinical investigator intent upon the divert-
ing and time consuming occupation of his daily
tasks may awaken to find himself the victim of a
circumstance which befell Commander Peary,
who while together with his companions on one

of his Arctic explorations, found after some days
that while they walked eight miles a day on a
sheet of ice, they were being carried back ten
miles by the current of the water. The vitalizing ,
influence of stimulating teachers and investiga- I
tors is becoming more generally recognized as
transcending in importance all other material
wealth of medical schools and institutions. The |
most valuable possession of a university, said
the late William Osier in an address to medical
students on this campus 44 years ago, are the I
names of the inspiring teachers of its faculty, I

The surgeon, one occasionally hears it said, is I
a calloused individual who places little value on
human life. If those who think so could only I
know the anguish, despair, and self-reproach of
the surgeon with a knowing conscience, who feels 1
that something which he did or failed to do. had
a part in bringing an illness to an unhappy end- |
ing, how much more often the surgeon would
be pitied than censured.

The reassuring expressions of grateful pa-
tients more than reward surgeons for the hours fi
of haunting anxieties which it is their lot to i
hear. The irrepressible joy and delight of chil-
dren once sick and now restored to normal liv- ■
ing. the restoration of health to the weary and
suffering through the benisons of surgery — these
are the best paymasters of the surgeon and sat-
isfactions which he cherishes in his memory as
among the most worth-while of life’s treasures, j
With his pre-occupation of mind the surgeon may
not learn much of life. But he is privileged to •
hear from the lips of people from every walk of
life and read often in their anxious and despair- 1
ing faces what to them is most worth-while. How
much it is to be regretted that it is not in the
possession but in its pursuit that the greatest value
is put on health.

If advances in our knowledge concerning dis-
ease should make much of present day surgery |
unnecessary, the surgeon would be the first to
welcome such an occurrence. For despite the
painlessness of operations, he sees in the dis-
tressed faces of persons about to come under the
knife, unexpressed fears relating to the anesthetic
and the operation. How can lie but wish that
patients could be spared these anxieties? How-
ever much the surgeon may desire that relief
could be afforded without recourse to operation,
and however surgery may change with the devel-
opments in greater medicine, it is quite safe to
predict that there will be always a need for the
services of surgeons. The vermiform appendix
with its bad anatomical arrangement, which man
gives no sign of outgrowing, will, when ob-
structed, probably always need excision ; congeni-
tal and acquired deformities will necessitate
operation for their correction, and automobile
accidents appear to supply a constant field of

THE JOURNAL-LANCET

255

Figure 4. "Many more people, therefore, gain the crest of the
bridge of life . ”

activity for the surgeon. Yes, there are diseases
yet unnamed for which surgery will be necessary !

The surgery of the future will integrate itself
more closely with the problems of the social order.
Forward looking man no longer labels the dissec-
tion of dead bodies as a sacrilege. He has learned
that information secured therefrom redounds at
once to his own gain. Anesthesia is no longer
looked upon as an impious attempt to thwart
divine will, and the great significance of animal
experimentation for the welfare of man is being
more generally recognized and appreciated. Ster-
ilization of the socially unfit, which would burden
society with progeny of an undesirable kind, is
certainly not far off.

Search for a fountain which would restore
youth to aging men has not been an occupation
peculiar to Ponce de Leons and the dreams of
poets. Surgical explorers who have gone in this
quest have met the same fate which befell Ponce
de Leon. The death of persons in the prime of
life from a defect in a single tissue, whose bodies
are otherwise sound, is as wanton desolation of
human life as the discard of a good automobile
with a plug in its gasoline line. The function of
medicine and surgery appears to be rather with
the prevention of and salvage from occurrences
of this sort. Whereas more people live to be old,
there appears to be no good proof that people live
to be older. The conjoint forces of public health
and pediatrics have largely done away with the
scourges which decimated the lives of infants and
children. Many more people, therefore, gain the
crest of the bridge of life (see Figure 4), but the
mortality beyond, because of the enormous toll
taken by the degenerative diseases of increasing
age, still continues.

Though we hear much said about the stress and
tension of modern life and its causative relation-
ship to premature death in the useful period of
middle life, there is but slender evidence to indi-

Figure 5. " . . . greater numbers shall come to their graves

'in a full age. like a shock of corn cometh in, in his season’. ”

cate, in the main, that man will live longer if he
rusts out than if he wears out. And the joys and
satisfactions gained in the knowledge of work
well done are numbered amongst the pleasures
that will not be foregone. It is apparently no
longer true that the equanimity of a Methuselah,
whose only chronicle was long life, will assure
longivity. After Mathuselah had lived more than
400 years, an angel is said to have appeared
before him with the suggestion that he build
himself a house for he was yet to live more than
500 years. The chronicler relates that Methuselah
felt the promise not worth the effort. Raymond
Pearl has observed, however, that nonagenarians
and centenarians as a group are uniformly char-
acterized by a calm and equable temperament.
Old age creeps daily upon us and will not be
deferred. We see his mark upon another’s brow
more readily than upon our own. There seems but
little likelihood that man will ever succeed in
prolonging life greatly beyond its period of use-
fulness. It appears to be a law of life that when
vital energies wane, death is near. Having eaten
of the tree of knowledge, was not man driven
out of the garden of Eden “lest he put forth his
hand and take also of the tree of life, and eat,
and live forever?”

The surgery of the future will continue to re-
late itself to man’s needs so that men may lead
more full, complete and useful lives, and greater
numbers shall come to their graves “in a full age.
like a shock of corn cometh in, in his season.”
Surgeons will strive to relieve suffering, to repair
injuries and save life. And when life is only a
burden and medicine can bring no relief, when
the social order recognizes the right of the indi-
vidual to release from such distress, he can be
helped on to a peaceful sleep in which there is no
remembrance of painful things.

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Conclusions

No panoramic view of the benefactions of
surgery to man are contained in these remarks.
Rather an attempt has been made to indicate the
manner in which surgery, once an heroic remedy
for a desperate ailment and concerned largely
with the management of wounds, has come to en-
joy an important position in the treatment of
disease. The history of surgery teaches the im-
portant lesson that a single fact evolved from
accurate observation is of more utility than an
entire system of speculative invention. Facts built
into ideas by the creative power of imagination,
that all important coefficient of the mind, estab-

lishes truths, overthrows false doctrines, and
destroys the tyranny and frost of custom and
dogma. You may have been unable from these
comments to decide whether surgery is a trade,
craft, art, or science. Leonardo da Vinci, one of
the world's most resplendent figures of all time,
recognized no greaj difference between handi-
craft, art, and science. The surgeon worthy of the
name combines in liberal measure the love of
humanity, science and craft. However one may
choose to designate the activities of the surgeon,
it has been my pleasure and privilege to relate
something of the most beneficent achievements
for mankind in the annals of man.

Medical Care of University Students

Warren E. Forsythe, M.D.*

Ann Arbor, Michigan

THE medical care of special groups of people is a
chapter in the history of medicine. Under a wide
range of variation in policy and program, college
students in the United States have received medical care
as a special group since 1859. In that year the first
American college physician, Dr. Edward Hitchcock, was
appointed at Amherst, following reports by President
Stearns from which the following is quoted:

"The breaking down of the health of the stu-
dents, especially in the spring of the year, which is
exceedingly common, involving the necessity of leav-
ing college in many instances, and crippling the
energies and destroying the prospects of not a few
who remain, is in my opinion wholly unnecessary if
proper measures could be taken to prevent it.”1
The program inaugurated by Dr. Hitchcock might
well be followed today. The American Student Health
Association now lists over one hundred member depart-
ments in colleges interested in student health work.
About five hundred formal papers have been published
dealing with the medical aspects of the problem and a
national conference held in 1931 issued a comprehensive
report' on college hygiene. Many reports of surveys
have been made.3

The college programs have varied greatly, but usually
have included attention to teaching, sanitation, physical
education, and student illness. The strictly medical care
of the sick under college auspices has been most subject
to professional criticism. In the writer’s judgment, re-
sponsibility for strictly clinical service to sick students
should be assumed by the college only because certain
necessities in the situation are not being met otherwise.
The college has responsibility to parents and to the
state for custody of students; students learn best by
actual experience the methods of good scientific medical
care; since the prevention of much illness requires early
attention to beginning processes, students should have

♦ {Director, Health Service, University of Michigan, Ann Arbor.

access to medical advice with the least possible hindrance,
such as fear of costs; also the educational experience of
worthy students should not be allowed to terminate be-
cause of the element of large expense for major illness.
When these conditions can be satisfied otherwise, the
college administrators will probably be glad to confine
their hygiene programs to work characterized by the
term health education. It is fair and proper to ask to
what extent these clinical activities should now be
allowed to retard the development of the primary health
education features of a program in college hygiene.

At the University of Michigan the program has been
outstanding because of provision for very generous clin-
ical service, centralized and supported upon a basis of
distributed cost to students. The University Health
Service was inaugurated by Dr. Howard H. Cummings
in 1913 and it rapidly expanded to provide for prac-
tically complete medical care of these students.

It provides unlimited out patient service with attention
of all specialties, including psychiatry, allergy, usual
X-rays, ordinary drugs, dressings, laboratory, etc. Room
calls are made at small charges to the patient. Bed care
is extended for thirty days in any school year with
emergency operations and all medical service. Charges
are made for special nurses and expensive drugs. Eye
glasses are provided at special prices, as are elective serv-
ices not available in the department.

Fifty persons are on the staff. Sixteen physicians are
about equally divided between full time and part time
status. The general physicians are on full time, do some
teaching, and several are medical advisers to particular
groups of students.

Because of many years of work with a fairly complete
organization, the accumulated data and experience
should be reliable in determining questions of illness and
related problems for a population of young adults. As

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25 7

TABLE No. I.

Requested Services at Intervals for Regular Sessions.
Rates per 1,000 Students Enrolled

Items

Office clinic visits

Patients

Room calls

Hospital and Infirmary patients — MEN

Hospital and Infirmary patients — WOMEN

Deaths — all causes, in Ann Arbor and elsewhere

♦Prescriptions filled

Refractions

X-ray examinations

Physiotherapy treatments „

Consultations — Mental Hygiene

Major operations — general anaesthesia

Laboratory determinations

Tonsil and sub-mucous operations — local anaesthesia

Total Enrollment (entitled to service) not rates

♦Undetermined amount of drugs dispensed in offices also.

School Year Rates — Summer Session Not Included

1913-14 1917-18 1921-22

2,946 4,949 5,335

703 711 728

73 110 153

1.1 1.5 .9

349 715

126

184

4 6

155 418

5,520 4,579 8,1 13

1925-26

1929-30

1933-34

4,041

6,517

1 1,613

775

855

941

206

146

145

1 30

128

210

148

179

238

1.3

260

828

1,542

105

1 30

165

104

255

460

871

949

142

1,569

540

1,049

1,621

8,594

8,833

7,314

an over view of this experience, some data and discus-
sions are given herewith.

Health Examination — New Students

The health program for students at the University of
Michigan starts with an entrance examination. This de-
termines possible contagions and serves as a basis for the
physician’s advice regarding desirable programs for in-
dividual students. Defects are recognized and contruc-
tive health measures suggested. Last fall the entrance
examination included a routine chest X-ray film, and
for several years has included a tuberculin test for
women. The health evaluation of entering students is
difficult, even with our complete tabulations. About 75%
of them are rated as having good health appearance,
health weight, satisfactory all live teeth, not obviously
vulnerable personality, good vision, freedom from nerv-
ousness, and freedom from previous infection with tu-
berculosis. About two per thousand are refused admis-
sion because of active tuberculosis; practically none for
other reasons.

Hernia, organic hearts, hemorrhoids, and glycosuria
are found for about one per cent. Fifty per cent have
had tonsillectomy; thirty per cent are classed as allergic;
fifteen per cent are unvaccinated; and one in ten has a
history of appendicitis. About one half of the girls have
varying dysmenorrhea.

The follow-up of these entering students assures a fair
degree of correction of, or attention to defects. The
amount of correction depends upon student finances,
persistence in securing contacts, personality of medical
adviser, and the like. The health program for women
students includes resident nurses in the dormitories.

Periodic Examinations

The modern public health program has accepted the
annual health examination as a basic element in its pro-
gram. The success of this project in the general popula-

tion has probably been all that could reasonably be ex-
pected. The annual examination and health conference
have had considerable emphasis in some college pro-
grams, and were required of all students here during a
five-year period. The required examination was discon-
tinued here, however, because of insufficient staff and
facilities to do it properly and meet a heavy demand for
clinic service. Also, the careful entrance examination
and the accessible clinic brought to light most of the
readily detectable physical defects. More recently, the
annual check-up has been promoted as a voluntary or
incidental project, and it appears to be gaining as a
requested service. In the writer’s judgment, it is time
for colleges seriously to require that each student clear
annually with a department which can make a careful
evaluation of physical and emotional status; upon this
determination continued residence would depend. With
this in mind, a study of four hundred students showed
about 25% who might reasonably be held for corrective
work.

Our students gain an average of five to ten pounds
during their first year. On the basis of judgments of
students and physicians about 5 per cent have worse
health after college entrance, and 35 per cent have im-
proved health. About 50 per cent receive X-ray exam-
inations of their lungs during four years here, and 25
per cent of upper-class students are so examined an-
nually. Albumin in the urine is found much more fre-
quently at the entrance examination than later.

Since the work at Michigan has been outstanding in
the provision of care for illness to students during resi-
dence, its data should be significant as to the medical
needs of young adults. Trend data are given in Tables
I and II, for five year intervals, which appear to be
typical of data for intervening years.

The amount of illness in freshmen, as compared to
other classes, and the sex differences are apparently not
very significant. Table No. Ill gives the analysis of

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TABLE No. II

DIAGNOSES SELECTED AT INTERVALS — Regular Sessions.
Annual Rates per 1,000 Students Enrolled.

Diagnoses result from requested services.

Diagnoses

Upper respiratory infections — Men
Upper respiratory infections — Women
Appendicitis, acute

Contagions

Scabies

Epidermophytosis

Tuberculosis of lungs active

Constipation

Gonorrhea

Syphilis

Pneumonia

Diabetes

Fractures

Reactions psychiatrically classifiable

Otitis media acute
Sinusitis acute
Vincent’s angina
Glycosuria

School Year Rates — Summer Session Not Included

1913-14

1917-18

1921-22

1925-26

1929-30

1 933-3-

488

937

885

668

738

1,101

289

694

631

514

659

85 )

182

1.5

2.2

2.5

1 5

1 3

1.5

1.2

1.5

2.2

1 1

TABLE No. III.

ILLNESS RATIOS BY CLASSES AND SEX.

Based upon records of eight recent years of about 8,000 men and
3,000 women freshmen. Decreased numbers for upper classes.
Ratios relate to freshmen men as one.

Groups

Illness Item

Freshmen

Sophomores

J uniors

Seniors

Men

W omen

Men

Women

Men

Women

Men

Women

1 otal patients

1.0

.99

.97

.99

.93

.98

.89

Dispensary calls

1.0

1.24

.86

1.04

.86

.94

.89

.95

Had room calls

1.0

1.42

1.02

1.36

1.06

1.38

1.06

1.32

Acute U. R 1 diagnoses

1.0

.80

1 .08

.85

1.16

.85

1.12

.75

Infirmary and Hospital patients

1.0

.66

.78

.82

.78

.87

.76

Infirmary and Hospital days ... ..

1.0

1.02

.99

1.14

1.07

1.63

1.11

1.32

data for many years on this question as ratios of the first
year’s experience.

Finances

The departmental annual budget has increased grad-
ually from about $10,000 to $125,000. This does not
pay for building overhead nor for refer service from the
University Hospital. It does, however, provide for
some teaching as an offset against these non-budgeted
services to students. The budget is provided from stu-
dent tuition. There are small earnings which deducted
give the net expense rates shown in Table No. IV.

1. Includes dispensary nursing, general supplies,
and equipment, excluding drugs.

2. Significant earnings here — Gross equal double
amount.

3. Significant earnings here — Gross equal four
times amount.

Based upon our estimates of cost, this very complete
service to groups of 10,000 at student age could be sup-
plied annually under average social conditions for $21.00
per person. Service rendered through the department
for one year was evaluated at the usual private practice
rates and thus estimated, it would have cost two and
a half times as much.

Salaries averaged about 75%, hospital expense 20%,
and supplies and equipment 5 -j-%, for a typical year.

Hospitalizations

Even with one half the desired number of easily avail-
able infirmary beds, about 20% of our students are hos-
pitalized each year. The average stay is 4 to 5 days since
most conditions are early processes, put to bed for pre-
vention and to give best attention. Table No. VI indi-
cates types of illness most frequently responsible for hos-
pitalization of our students.

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259

TABLE IV.

ANNUAL EXPENSE RATES

Regular Session per 1,000 Students Enrolled — 5 Year Intervals.

Net Cost

School Year

Rates — Summer Session

Not Included

1913-14

1917-18

1921-22

1 925-26

1929-30

1 93 3-34

All service

$2,1 18

$4,039

$5,646

$6,539

$9,425

$14,103

4,469

3.295

5,754

9,21 1

Hospital service

181

2,009

2,875

2,372

2,994

Salaries and wages

1 1 5

2,820

2,998

3,716

6,102

9,926

Equipment and all supplies

760

437

709

846

898

1,133

Drugs (only)

—

217

441

Earnings (not cost) .

128

329

409

622

405

Expense per clinic service — not rates

$.66

$71

$.93

$.98

$.86

TABLE V.

BUDGET DISTRIBUTION
Net 1931-32

UNIT

COSTS

Percent of
Total

Per

Patient

Per

Service

General physicians

21.0

$2.80

$.30

Infirmary service

15.0

12.65

2.65 (day)

Mental hygiene

1 3.0

23.05

1.70

Administration

1 I .0

1 .45

.90

Hospital care non-infirmary

8.0

52.10

5.90 (day)

1. Dispensary

6.3

.85

.10

X-ray

6.2

1.95

Pharmacy ....

4.5

.60

.05

Entrance examinations

2.9

1 .05

Surgeon

2.4

.90

Laboratory

2.0

.20

Sensitization

1.0

3.15

.80

Physiotherapy

1.8

1 .65

.30

2. Ophthalmology

1.5

1.55

.50

Hospital out-patient service

0.8

.65

Dermatology

0.8

.35

3. Otolaryngology

0.6

.25

Dental

0.4

.45

Refer service at the University Hospital provided care
for psychiatric situations until about 1930, when a stall
unit was added. Students are now evaluated for person-
ality upon entering college and their future experience
shows high validity in the rating. The program in men-
tal hygiene has been largely confined to attention to
cases which total 10% of the student enrollment an-
nually. Of these cases about half request the service on
their own initiative. The interviews average 18 per pa-
tient, 8 of which are with the patient himself. The other
interviews are with interested persons such as faculty,
relatives, etc.

About half of the situations are maladjustments not
significantly clinical; a third are psychoneurotic; and
psychoses average about 2%. A fourth of the situations
are acute and urgent and 75% are disposed of in the
first year. It is possible to treat 70% of all cases with
85% satisfactory result. A fourth of the cases are not
severe, but disabling and amenable to help. Suicide in-
dications are present in 6% of the cases.

The leading basic situations in order of frequency
which bring students for this service are excitability and
tensioned response, worry over school work, poor orienta-
tion, instability and over-impulsiveness, physical disturb-

TABLE No. VI.

HOSPITALIZED CONDITIONS — SELECTED.

Regular Session 1934-35 —

-Combined Sexes.

Condition

Number

487

Percent

100

Reactions, psychiatrically classifiable

Others

331

1,272

ances and residual states, over-sensitivity, and im-
maturity.

Physical health, male or female, college department,
or intellectual rating seem to have no significant relation
to cases.

Allergy

For about seven years, one staff member has given
attention to sensitization and has used the scratch test
for two hundred materials as routine testing. Over 6%
of the men and women, nearly 4,000 students, have been
so tested.

Strong reactions were as follows, to pollens 31%, to
foods 13%, to epidermals 9%, to bacteria about 2%
and miscellaneous the same. There were no reactions
in 33%. Intradermal tests were advised for 58%. Cases
were mostly refers and others selected upon the basis of
history in new students. One hundred students with
entirely negative histories gave essentially negative re-
actions.

In the treatment of four hundred cases of hay fever,
the patients later reported in percentage of improvement,
the value of the treatments, as shown in Table No. VII.

Refractions

About 15% of these students receive complete eye
refractions annually as a result of requests which come
without particular stimulation. There is no significant
sex difference. About 35% are first refractions as a
result of which glasses are advised for 88%. Of those

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TABLE No. VII — HAY FEVER TREATMENTS
Percentage Improvement. Averages of Five Year Records.
402 Cases.

Percentage Improvement
(Patient estimate)

100 per cent

75 per cent

50 per cent

Some, but less than 50 per cent
None

Percentage
Of Cases
11.

61.

82.

18.

requesting first refraction, 96 % complain of symptoms.
Compound hyperopic astigmatism makes up 38% of
over 15,000 diagnoses of refraction errors and is fol-
lowed in order by simple hyperopia 18-!—%, compound
myopic astigmatism 18 — %, simple myopia 13%, mixed
astigmatism 6%, simple hyperopic astigmatism 5%, and
simple myopic astigmatism 2%.

Tuberculosis

The trend rate for active pulmonary tuberculosis has
remained at about two per thousand enrolled students
annually. This steady rate with the general decline of
the disease is explained by the increased emphasis on
early case finding. Considerable study of experience with
this disease has been made.

An analysis of cases for a recent five year period
shows over 60% minimal at first recognition. That
checks well with the findings of routine chest X-rays of
all new students last fall. Cases by departments rank,
in order of frequency, in medicine, graduate, engineer-
ing, dentistry, law, and literary. There is almost ten
times as much active tuberculosis among students from
overseas, particularly Chinese, as in the native group.
College freshmen have less disease than transfers and
other older new students.

The search for cases mostly in the clinic during seven
recent years has resulted in a gradual annual increased
use of chest X-rays. The annual percentage of chest
X-ray for the total student body has increased in seven
years from 15% to 41% for women, and from 5% to
25% for men.

The early readings of 3,300 flat chest films of entering
students for lungs last fall are indicated in Table No.
VIII. Developments during the year indicate little
change in the validity of these findings.

The death rate given in Table No. I are not over a
third of the rate for the same age group in the general
population and deaths have been counted for all persons
enrolled regardless of where, when, or why the death
resulted. This favorable rate may be partly the result
of the health program, although other special factors
must be considered. Since the control of the student
use of automobiles, accidental death rates have been
lower.

Contagions

The usual contagious diseases are not a very serious
problem in this student group, which is largely urban
and has apparently previously acquired a high degree
of immunity. Vaccination is required of all.

TABLE No. VIII.

Preliminary Readings of a Rapid X-Ray Survey of Intrathoracic
Tuberculosis on *,300 Student Entrants.

Rates are per 1,000 examined Fall 193 5 •

Items

Men

Women

Rate

1. Gohn’s tubercle 51 55

2. Calcification, parenchymal, other than Gohn’s 12 6

3. Pleural calcification 0 0

4. Hilar calcification 53

5. Hilar and mediastinal glands T.B. non-calcified 1 0

6 Parenchymal infiltration 8 7

( Cavity ( l case ) ( 1 case)

8. Except as above (not calcified parenchymal

1,1 (1 case ) ( 1 case)

Total 133 123

*X-ray examination of all new students the fall of 1936, gave
essentially the same results.

Reports

Regular reports feature selected items monthly and
give more complete data annually. Many requests for
special data are received, and papers by staff members
have dealt largely with statistical summaries from de-
partmental records. From some such tabulations, cer-
tain relationships appear to exist.

About one half of the students report annually for
attention for an average of two upper respiratory infec-
tions each; men more than women. No relationship can
be shown between the incidence of such infections and
attacks of acute appendicitis. No significant difference
in any of the many other items of a complete medical
history and examination could be shown between per-
sons reporting at the clinic for maximum number of
colds and those reporting for none. The condition of
tonsils seems to have more relation to enlarged cervical
lymph glands than have decayed teeth or history of
devitalized teeth. Many tabulations fail to reveal any
very significant factor in dysmenorrhoea. The presence
or absence of tonsils in our students as a whole seems to
be a determining factor in no other important question
of health.

Students on scholastic probation have more hospital-
ization, more room calls, more tonsils, and less history
of allergy than control groups.

One finds no statistical evidence of improved health
for men students taking a two hour a week required
program in physical education. After an average of five
years following tonsil operations done here, the patients
reported improvement in 80% of the cases; 55% re-
ported improvement after sub-mucous resections. Infant
nursing or bottle feeding history could not be shown to
make any difference in the health of men students
studied.

The analysis of 107 recent cases of pneumonia shows
absence of leucocytosis to be of no prognostic value in
ncn-complicated cases, X-ray and physical signs may
reveal bronchopneumonia without fever, and clinical

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261

signs may antedate X-ray confirmation by as much as
two days.

Problems

In consideration of one’s ideals it may be said that
there are many problems in the department, but viewed
from other angles one might defend the position that
there is none of major concern.

The rapidly increased demand upon the department
for the highest type of extensive clinical service has lim-
ited the program of health education and health pro-
motion. The development of a sufficient staff and ad-
equate space for the desired program of annual, time
consuming, personal, health examinations and confer-
ences is yet to be realized here.

The continued growth of requested service in old and
new fields has made it so far impossible for us to say
how much modern medical service is needed for a pop-
ulation of comparatively healthy young adults. Lack
of building space, budget limitations, and inadequate
measures of values, may be listed also as problems.

Conclusions

Twenty years of experience seem to have established
a student health clinic at the University of Michigan
as a satisfactory method of handling medical problems
for its student group.

The University-controlled clinic meets several health
necessities in a student population for which provision is
not otherwise made.

Clinical data from years of experience are summarized
covering a wide range of considerations.

The desirable future development of such departments
in colleges should be in the direction of the objectives
for which such institutions are primarily maintained.

References

1. Hitchcock, Dr. Edw. "Hygiene at Amherst College" read
before Am. Publ. Health Assn., Chicago, Sept. 26. 1877.

2. Proceedings Nat’l Conference on College Hygiene Nat’l

Health Council, 50 West 50th St., New York, 1931.

3. Noteworthy are: A. The Status of Hygiene Programs in In-

stitutions of Higher Education in the U. S.. Storey, 1927. — Stan-
ford Press. B« Health Service in Am. Colleges 6C Univ’s — For-
sythe, Univ. Mich. Bull., 1926. C University and College Stu-
dent Health Services — Bureau of Medical Economics, Am. Med.
Assn., 1936.

Aural and Nasal Problems in General Practice

Frank L. Bryant, M.D.**

Minneapolis, Minnesota

Cerumen

AS A GENERAL RULE, the patient who has
wax periodically removed presents no special
problem. Occasionally, one does see a patient
with small ear canals, in which the cerumen has become
very dry and impacted. Ordinary syringing in this in-
stance has no effect; and attempts to remove it by curet
or ear-spoon are too painful. More often, it cannot be
done. With such a patient, it is better to instruct him
to use softening drops three or four times daily for two
or three days before a removal is attempted. Once the
cerumen is softened, it is easily removed by syringing
it out with warm water. One may use either warmed
olive oil, or a prescription containing sodium bicarbonate
Gr. xx in equal parts of glycerine-and-water to make
one ounce. After removal of the bulk of the wax, the
ear drum should be examined to determine its condition.
Sometimes, a small flake of wax may adhere to the tym-
panic membrane, thus impairing the hearing until such
time as it is removed. Patients of this type should be
advised to have more frequent check-ups, in order to
preclude a recurrence of such a condition.

Foreign Bodies

Most foreign bodies (if they are lying free in the
ear canal) can be removed by syringing the canal, or by
a small tenaculum alligator ear forcep. But if someone

• Read before the Lyon-Lincoln Counties Medical Society at
Tyler, Minn., Nov. 24, 1936.

** Instructor in Otolaryngology, University of Minnesota Med-
ical School.

in the patient’s home has attempted to remove the
oft ending object, there may be so much trauma and
edema that the object has become impacted. Further
attempts may be too painful, no matter how much care
is exercised by the physician. In such a patient, it is
necessary to give a general anesthetic; and this is espe-
cially imperative in children. Under such narcosis, re-
moval of a foreign body is greatly facilitated, and good
opportunity to examine the ear drum for possible injury
is presented. If the foreign body is alive (i. c.: an in-
sect) , it may be removed by irrigation, since an insect
often clings to the ear’s canal wall, where water will
easily reach it. A one-half per cent solution of liquor
cresolis saponatus ( lysol) should be instilled; or a
pledget of cotton saturated with chloroform should be
placed in the outer one-third of the canal. Chloroform
should never be poured directly into the ear canal: it
is too painful. A solution of one gram of glycerine
with three drops of phenol likewise can be employed.

If, however, the foreign body has been pushed through
the ear drum, a retro-auricular incision should be made.
Removal is then done more easily through the site of
the perforation.

Eczema

Eczema is a fairly common condition. It is not pain-
ful; but it often annoys the patient greatly, and may
thus predispose toward more serious conditions. The
patient may present himself with the ear canals in an
irritated or inflamed state; it is even possible that in an
effort to relieve the itching, he has perforated the ear

262

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drum with a sharp instrument. The indiscriminate use
of a toothpick, bobby-pin, or proprietary ear oils, etc.,
may favor the development of a fungus infection. When
a general examination to determine the presence or ab-
sence of allergy, intestinal conditions, and kidney dis-
ease, is not done, these two prescriptions may be helpful:
Ling. Amm. Hydrarg. 5 °/c

Sig.: Apply to ear canals b. i. d.

Phenolis gr. VIII.

Acid salicylate Aristol ad. gr. X.

Lanolin, ung. Zn. oxidi ad. IV.

Fungus Infection

The use of ear oil, as has been stated, often predis-
poses to more serious conditions. The patient has an
itching in the ears, and complains of a sensation of full-
ness, and a discharge. Examination reveals the discharge
to be a brown, a black, or a yellow color, possessing a
sweet, sickening odor. This can readily be cleansed by
using alcohol-soaked cotton applicators. Painting the ear
canals at intervals of two to three days with AgNCL,
5 per cent to 10 per cent, or with one of the germicidal
tinctures, is usually curative. The patient obviously must
discontinue his home treatment wtih ear oils, and he
must prevent the accumulation of moisture in the ear
canals through washing, etc.

Furunculosis

Boils of the ear canal, with diffuse inflammation, are
very painful. Sometimes, this condition is mistakenly
called mastoid infection because it is deep-seated and
severe. The patient with furunculosis usually offers a
negative history of upper respiratory infection; more
likely, he has been swimming in water which was high
in bacterial content, or he has been irritating his ear
canal with a match, toothpick, etc. An examination re-
veals an inflamed ear canal which is almost completely
closed, and which will not permit the insertion of even a
small ear speculum. Any manipulation of the auricle
is extremely painful. This is due to the swelling of the
sub-dermal tissues, and to extension down between the
cartilaginous tissues of the external ear canal.

T rcatment. Avoid an incision, if it is at all possible.
If the inflammation is diffuse, hot epsom salts com-
presses are indicated. A small gauze wick saturated with
cresatin, icthyoldine, or camphor phenol, is inserted very
gently and cautiously. The otologist may not be able to
insert the packing very far the first time. Any secre-
tion should be gently removed at least twice daily, and
drops instilled; or a clean medicated pack should be re-
inserted. Foreign protein injections are helpful. The
patient should be instructed to use a liquid diet, because
chewing aggravates the pain, owing to movement of the
condyle of the mandible. If the patient has had two or
three attacks, the staphylococcus toxoid in graduated
doses is a helpful prophylactic measure. Some have used
an autogenous staphylococcus vaccine with success.

Acute Otitis Media

This condition may result from external or internal
causes. Some of the common causes are: a perforating

injury to the car drum, skull fractures, re-infection
through an old unhealed perforation, etc. Internal
causes may be an extension via the Eustachian tube from
an upper respiratory infection, severe nasal douching,
acute infectious diseases, influenza, or tonsillitis.

Symptoms are a stuffiness in the ear which may range
to deafness, a gradually-increasing throbbing pain, echo-
ing in the ear when the patient talks, and fever and
malaise. Examination reveals an ear drum diffusely
reddened, with obliteration of the normal landmarks.
Insertion of the ear speculum gives no increase in the
pain. If there is a definite redness and a bulging,
myringotomy is immediately indicated. The opening is
best made under a general anesthetic. The patient
should be kept in bed under the prescription of a light
diet and such general measures as are indicated. If the
nose and throat show involvement, as they very often do,
such treatment should be done as is needed. Occasion-
ally, the otologist encounters a patient after the eardrum
has ruptured; and in this instance, the discharge must
be removed in order to determine the size and location
of the perforation. In a great many cases it will be
small; here a myringotomy should be done. This will
permit a more unimpeded flow of discharge, and will also
minimize further destruction of the tympanic membrane.
It will also allow better restoration of the eardrum after
healing commences.

Treatment during the acute stage consists of instilla-
tions, irrigations, or dry wiping with cotton applicators.
The "dry wipe" method is favored by many otologists.
It must be done regularly and thoroughly if any success
is to be achieved through it. Often, the physician will
leave a small pledget of cotton in the ear canal; this
must be removed and changed before it becomes sat-
urated. If it remains in the ear canal long enough to
become saturated with the purulent discharge, it there-
after functions as a very definite barrier to satisfactory
drainage.

The clinical course of a patient with acute otitis media
runs from two to twelve days or more. It may resolve
completely within this period, or it may extend a few
days longer. If the patient gradually exhibits less dis-
charge, sleeps more restfully, and requires little or no
analgesics, one may assume that the healing process is
in action. If, however, after ten to fourteen days, the
examination reveals an angry-red eardrum, and if a defi-
nite pulsation is seen in the middle ear when the pus
has been thoroughly cleansed, the prognosis will be less
favorable.

If the discharge appears to "well up” while the physi-
cian is observing the tympanic membrane, a diagnosis
of mastoiditis may be made safely. The physician ought
also to watch for redness and swelling in the posterior
superior portion of the osseous section of the ear canal,
for these are the two earliest signs of extension of infec-
tion into the mastoid. It is dangerous to wait for a
drooping ear, a prominent ear, or for pain and ten-
derness over the mastoid tip in arriving at a diagnosis.
If these signs do occur, the diagnosis is only the more
obvious. The X-ray at this time should show a variable

1 K

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263

amount of bone destruction; and dependent upon these
and other general findings, the physician should be able
to judge whether or not the condition is a surgical or
non-surgical mastoiditis. If the patient, in spite of mas-
toid involvement, shows no pain of any consequence, if
he has little or no fever, and if his general condition
is good, the physician is justified in waiting; but it
should be watchful waiting.

If, on the other hand, pain occurs and is not relieved
by the usual doses of codeine or morphine, if the patient
is restless and sleeps poorly, and is in general sick, sur-
gery is called for. It is true that many patients who are
not operated upon do recover from the acute condition,
and apparently return to health. The fact that they
seemingly return to health is emphasized, for too often
their ears continue to discharge. These individuals form
the legion of patients who have what is called a "chronic
running ear,” or who have exacerbations of ear-aches
concomitant with discharge.

These are the patients who gradually lose their hear-
ing, who are forced to be careful about catching cold,
who may occasionally display polyps and granulation
tissue in the ear canal, and in whom the usual ear drops
have little or no effect — certainly not a permanent effect.
It is these patients who should have had a mastoidecto-
my at the time of the acute condition.

Significance of Chronic Running Ears
The physician ought to assume that every patient who
has a chronic purulent discharge from the middle ear
(either continuous or rather periodic) , and who has
almost a complete loss of the ear drum, has a chronic
mastoiditis. Any patient who complains of pain, and
who has chronic otitis media, is a patient demanding
careful and repeated examinations. A patient exhibit-
ing a purulent discharge in which the otologist can feel
a gritty substance likewise must be thoughtfully ob-
served. The ear drum and the middle ear cavity serve
as excellent diagnostic indices to the state of affairs ob-
taining. There are, in general, three types of perfora-
tions: central, marginal, and ShrapnclI’s. They arc of
importance as indicated below:

1. Central perforations occur in the center part of
the membrana tensa of the ear drum. Such a
perforation as a rule offers a better prognosis for
conservative management. Two prescriptions
which may be used are these:

(Calot’s solution)
Guaiacol

1.0

Creosote _ .... ...

. 5.0

Iodoform

10.0

Sulphuric ether

30.0

Olive oil

. .70.0

Misce et signa: guttac V
into ear b. i. d.

Acidi borici 2.0

Spiritus Vini Rect. 70%, q. s. 30.0

Misce et signa: guttae X
into ear b. i. d.

If upon examination, disease in the nose, throat,

or sinuses is discovered, suitable and adequate
treatment should be instituted.

2. Marginal perforations (or peripheral perfora-
tions) usually indicate an osteitis at the partic-
ular site of the periphery. There is often a grow-
ing-inward of the skin from the ear canal at the
expense of the mucous membrane of the middle
ear. Cholesteatomata subsequently form, due to
the inability of desquamated skin to come out.
Several cholesteatomata may form; these in ad-
dition to the osteitis may constitute sufficient in-
dication for mastoid surgery.

In some patients, examination will show almost
a complete loss of the tympanic membrane, with
granulation tissue and purulent exudate. The
history of repeated exacerbations of mastoid in-
flammation substantiated by changes in the X-ray
of the area means surgery is the only expedient.

3. Perforation in Shrapnell’s membrane (the mem-
brane flaccida) is often indicative of an inflam-
matory process extending over the entire middle
ear. Frequently the onset is insidious, being dis-
covered only after a very careful routine exam-
ination. Conservative treatment is of doubtful
value in this type; often a patient with such a
condition must ultimately undergo mastoid sur-
gery before cure is achieved.

Infections of the Nose and Sinuses

In the consideration of the management of a sinus
disease, a review of the anatomy and physiology of the
nose is important to a better understanding. A few
essentials may be pointed out here.

The nose is the chief portal through which air reaches
the lungs. It is therefore situated at a crucial location,
and being so situated, it has two important functions in
this relation to perform: that of an (a) air-conditioner,
and that of an (b) air-filter.

The internal configuration of the nose is peculiarly
adapted to these functions. The air column is not
straight; but is rather irregular and curved. The air it-
self as it passes through the nose is broken up into nu-
merous eddies and currents by the formation of the tur-
binates and the septum. It therefore comes into contact
with much more of the surface area of the mucous mem-
brane. Nevertheless, the greater part of the air inspired
is not fit for use by the lungs; just as food ingested is
not ready for use by the body until it has been digested.
The air is conditioned — that is to say, it is warmed and
moistened. Each of us remembers how the nose becomes
stuffy in a hot, dry room. In an effort to impart enough
moisture to the too-dry air being inspired, the turbinates
enlarge at the expense of the nasal space. Each of us
can remember having what we once called a "runny
nose,” after having been out in the cold air for a period
of time. In this particular instance, the air is so cold
that all the moisture given off cannot be evaporated and
utilized; and hence, collected. If the nose be examined
at this time, the turbinates will be very red, indicating

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the efforts of these structures to warm the air and insure
a more abundant secretion.

Most of us, also, can remember how clear the atmos-
phere seems, and how clear the nose seems, after a heavy
rain on a summer’s day. In this case, the temperature
probably is from 70 to 80 degrees, and the relative hu-
midity at least 40 to 50, possibly higher. Optimum con-
ditions exist. The nose has little actual work to do.
The temperature of the air is what we should call
"almost normal”; that is, for ideal metabolic require-
ments. Now, the normal temperature of the turbinates
is about 90 degrees, and if the humidity of the atmos-
phere is from 40 to 60, it permits the turbinates to re-
cede, allowing freer nasal breathing.

The turbinates are covered with a ciliated epithelium.
Dust particles, bacteria and pollen which are too minute
to be enmeshed in the hairs or the vibrissae acting as the
first line of defense just inside the vestibule, are filtered
out by these cilia. The nasal cilia have a wave-like, rip-
pling action; they are partially covered by a layer of
protective mucous, and function best in a temperature
of from 70 to 90 degrees. Lower temperatures and dry
air gradually reduce their activity, thus permitting less-
ened efficiency.

It is likewise true that a diseased organ is a less effi-
cient one. Hence, particular emphasis should be placed
upon this phase in the treatment of all nasal conditions.

From the foregoing, it is possible to appreciate the
responsibility of the nose to the lungs, as well as to the
throat, trachea, and bronchi.

When disease exists in the nose, the symptoms arc of
course those due to an altered physiology. That is (a) ,
changes in the discharge; it may be too scanty, too
heavy, or too thick, ranging from mucoid to catarrhal or
purulent; (b) changes in the nasal space, stuffiness to
complete stoppage, either temporary or transitory, or
more or less permanent; (c) changes due to swelling of
tissues, and backing-up of the secretion; head-ache,
neuralgias and, (d) , reflex disturbances arising from
pressure.

A diagnosis should be made only after a careful his-
tory has been secured. This history should include in-
formation regarding (a) the nasal discharge — character,
amount, and duration, (b) nasal obstruction — the de-

gree, side of, and duration, (c) head-ache — location, se-
verity, relation to nasal discharge, and to nasal stuffiness,
(d) frequency of upper respiratory infection — i. c.:
colds, sore throats, and pharyngo-tracheobronchitis.

A rhinoscopic examination with a focused reflected
light, a posterior rhinoscopy (using a suitable mirror in
the mouth) and trans-illumination of the sinuses should
be done routinely.

Many physicians believe that if a patient has a chronic
sinus infection, pain must be present. It is true that
pain usually is a complaint in a patient with an acute
sinus infection. Nasal discharge and nasal obstruction
occupy second and third places, respectively, in the symp-
tomatology. In chronic sinus disease, however, a nasal
discharge which is usually mucopurulent and persistent,
is the outstanding complaint; in fact, this is really the
so-called "catarrh” of the nose of our grandfathers’ day.
Second in incidence is nasal stuffiness or obstruction un-
relieved or only temporarily helped by nasal oils or local
nasal treatment.

When a patient with a chronic sinus infection catches
a severe cold in the head, the sinus infection is thereby
exacerbated, and pain occurs. Pain at this time becomes
sharp and more severe; and it is in a closer relationship
to the nerve supply of the sinus primarily involved.
When the middle turbinate becomes inflamed and swol-
len to such extent that it presses against both the septum
and the inferior turbinate, obliterating the middle
meatus (which is the drainage zone for the frontal max-
illary and anterior ethmoid group of sinus cells) , the pa-
tient complains of a dull, constant head-ache, relieved
somewhat by acetysal, or by removing some of the dis-
charge.

Conservative and supportive treatment should be in-
stituted in those patients with acute sinus infections.
Moist heated compresses, various forms of fever therapy,
suction drainage, and general symptomatic treatment,
form the main aids. Surgical interference should be re-
stricted to simple drainage procedure when indicated.

On the other hand, in those patients who have a long
standing chronic sinus infection, where marked changes
in both the nasal cavity and in the sinuses have occurred,
only a thorough exenteration will effect a cure.

THE JOURNAL-LANCET

26?

Silicosis and Other Dust Diseases

Albert E. Russell, M.D., F.A.C.P.**

Washington, D. C.

THE public today is no longer mystified when it
hears silicosis mentioned; however, it is frequent-
ly spoken of as "the new disease.” As a matter
of fact, diseases due to dust and to lead are the oldest
known occupational diseases. We find references to
them in literature before the Christian era, and there is
a classical description of silicosis more than 200 years
old. Apparently, there is less silicosis today in propor-
tion to the number of industrial workers than there has
ever been; however, it is more widely-known tiian at
any time in history. There are two reasons for this latter
fact; one is that the public is more health-conscious than
ever before, and second, silicosis has become such a
medico-legal problem in the last few years as to merit
wide publicity. There is scarcely a large city in the
United States that has not had a siege of silicosis suits.

The disease "silicosis” is a condition of the lungs due
to the inhalation of particulate silica dust. It will occur
anywhere that prolonged exposure to silica dust takes
place. The extent of the disease depends on several
things, the most important of which are extent and
length of exposure, and type of dust. The presence
of a latent tuberculous infection is a great factor in the
course of the disease and in its prognosis. Silicosis is sel-
dom a fatal disease without being complicated by tuber-
culosis; and when tuberculosis is present the physical
and clinical picture is quite different from simple, un-
complicated silicosis.

Occurrence

The most abundant constituent of the minerals and
rocks that make up the earth’s crust is silica; most of
this, however, is in a combined form. Quartz is the most
common form of free or uncombined silica, and occurs
in granite, flint, schist, sandstone, quartzite and other
rocks. It is a hard mineral and is resistant to the action
of reagents. Many ores are found in rock that consists
largely of quartz; this is particularly true of gold. Opal,
amethyst, chalcedony, onyx, agate, carnelian, and other
semi-precious stones are forms of quartz.

When we consider that silica is so abundant in the
earth’s crust, it is not surprising that the silica hazard is
so widespread in industry. It is met with in occupations
in mining, quarrying, tunneling, and those connected
with industries concerned with the processing of mineral
products. Some of these are: use of sand and gravel,
stone-dressing, manufacturing of abrasives, sand-blast-
ing, grinding, moulding, ceramic processes, smelting,
refining, etc. The most common forms of silica met with
in industrial processes are crystalline quartz, sandstone,

‘Harold S. Boquist Second Memorial Lecture, given at the
University of Minnesota Medical School on December 3, 193 6.
Approved for publication by the Surgeon. General of the U. S.
Public Health Service Bureau.

••Surgeon, U. S. Public Health Service.

flint, tripoli, diatomaceous earths, and sand. Most of the
industrial dusts are inorganic, and incidentally, they are
the most harmful.

The following list shows the widespread uses of silica
in industry:

Abrasives.

Sand paper.

Sand-blast work.

Metal-buffing.

Sawing and polishing of stone.

Whetstones, grindstones, etc.

Tube mill linings.

Lithographer’s graining sand.

Tooth powders and pastes.

Wood-polishing and finishing.

Refractory uses.

Metallurgical (silicon alloys) .

Smelting (as flux) .

Foundry — mold wash.

Foundry — parting sand.

Chemical industries (lining acid towers).

Filtering medium.

Manufacturing of sodium silicate.

Manufacturing of carborundum.

Paint: as an inert extender.

Mineral fillers.

In fertilizers.

Insecticides.

Rubber filler.

Asphalt (surface mixtures) .

Ceramic (potteries).

Glass.

Manufacturing of chemical apparatus.

Decorative materials (gems, crystals, vases, etc.)

Insulation (rockwool).

Structural materials.

Optical quartz.

The U. S. Bureau of the Census reported that there
were approximately 14,000,000 persons gainfully em-
ployed in the United States in the manufacturing and
mechanical industries in 1930. Bloomfield1, in a recent
survey in a large manufacturing center, showed that
about nine per cent of the industrial workers were em-
ployed in occupations where the silica hazard required
consideration. If his survey is representative of the oc-
cupational distribution of workers, it appears that there
are slightly more than 1,300,000 persons potentially ex-
posed to a silicosis hazard in the manufacturing and
mechanical industries alone. One-fifth of the workers,
or about three million persons, are exposed to inorganic
non-metallic mineral dust.

Etiology of Silicosis

The etiology of silicosis is prolonged exposure to high
concentrations of silica dust. It has been shown that

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silica (SiOo) alone produces more permanent pulmonary
damage than all other elements found in industrial dust.
Originally, the dangerous properties of dust were
thought to be dependent on certain physical character-
istics, such as hardness, sharpness, and angularity of
particles. This theory, however, has been abandoned,
generally, in favor of the chemical action of the dust.

The silica particles in the alveoli stimulate phago-
cytosis. According to Fallon and Banting-1, the particles
are taken up by histiocytes which multiply in the sur-
rounding tissue and migrate into the alveoli, collect the
particles of silica dust and remove them into the lymph-
atic channels and nodes. These cells tend to collect into
aggregates in the lymph channels and nodes, thereby
forming obstructive lesions. In this way there occurs an
accumulation of dust in the intrapulmonary lymphatic
tissue. Apparently silica becomes soluble after being de-
posited in the tissues, and produces cellular proliferation.
It was agreed at the International Silicosis Conference*
that "there is experimental evidence that the solubility
of silica in the tissues is an essential factor in the caus-
ation of silicosis.” In time, the silica particles undergo
a gradual dissolution, and thereby stimulate an excessive
production of fibrous tissue, forming the characteristic
nodule of hyaline fibrous tissue. Degeneration takes
place in the nodules, and the proliferation of fibrous
tissue takes place at the periphery, increasing the size of
the nodule. These nodules coalesce as they increase in
size, and bring about areas of massive fibrosis in the
lung. Grossly, the nodules appear as small pearly bodies
two to three millimeters in diameter, and when cut, pig-
mented foci may be seen on the surface. The lymph
nodes are enlarged and deeply-pigmented, and are
fibrous and indurated. In later stages, large nodules are
formed by the coalescence of smaller ones, and there
are emphysematous areas between them. The lymph
nodes are enlarged and pigmented and present a gritty
sensation on being cut.

Infection of the lung with B. tuberculosis, whether it
occurs before, simultaneously with, or subsequent to, the
development of silicosis, alters and unfavorably in-
fluences the course of the disease.

Kettle4 gives an explanation as to why tubercle bacilli
proliferate in the necrotic center of the silica lesion, nam-
ing the following reasons: "first, the mere mechanical
protection of bacilli during their early lodgement in
the body; second, the rich pabulum furnished to the
disintegrated cells; and third, the stimulating action of
silica on the growth of the bacilli.” It is also well known
that tubercle bacilli grow well in a medium rich in col-
loidal silica. His final opinion as to why silica dust is
dangerous, as far as the production of tuberculosis is
concerned, seems to be that it is not because of the
fibrosis produced by the silica, nor because of the dam-
age which silica does to the lymphatic system, but simply
because of the presence of silica in the lung.

Collis'1 calls our attention to the fact that when ex-
cessive mortality rates from phthisis in dusty occupations
occur, they are always found to be associated with ex-
posure to dust containing crystalline silica. In this con-

nection, the mortality from tuberculosis among granite
workers in Vermont was found to be 1900 per 100,000,
while the mortality of marble workers from the same
cause in the same state is below that of the males in
the general population. The type of work and the
economic conditions of these two groups of workers are
very much the same.

Knowledge of the petrography of dust is necessary in
estimating its effects on workers. The following ex-
amples are good illustrations as to why chemical anal-
yses should not be relied upon solely for this purpose.
The chemical analysis of cement dust indicates that there
is 15.2 per cent silica present, while the petrographic
analysis shows that it contains only 1 per cent of free
silica or quartz. It has not been shown that silicosis
occurs from exposure to cement dust. The chemical
analysis of granite indicates that there is approximately
70 per cent silica present in it, while by petrographic
analysis only 30 per cent of quartz is found. During
recent years much attention has been given to the role of
sericite, a potassium aluminum silicate in the form of a
secondary mica, as the damaging element in silica dust.
It has been definitely proven, experimentally, that it is
not the harmful element in dust.

The reported absence of silicosis in the Kolar gold
mines in Mysore province in India were cited as a sup-
port to the sericite theory. The absence of silicosis
among the workers was reported to be due to the absence
of sericite in the gold-bearing rock, in contrast to the
great incidence of silicosis in South Africa where sericite
is present. Dr. S. Rubba Sao, Mysore Government med-
ical officer, reports that the free silica in the Kolar rock
is only 5 to 20 per cent, as compared with 43 to 98 per
cent in the South African rock. Dr. Sao reported that
silicosis was found among the underground workers, and
sent X-ray films and pathological specimens to the South
African Institute, where the diagnoses were confirmed.
Obviously the disease would develop much more slowly
as would be expected when we consider the low silica
content of the Kolar rock, and also that the mines arc
reported to be well-ventilated.

Irvin1’ showed that sericite can remain in the lung,
lymphatic or subcutaneous tissue for a year without pro-
ducing anything but a foreign-body reaction and show
no evidence of physical change in the tissue fluids. He
also found fibers of sericite in the pulmonary lymph
glands of non-silicotic individuals, and they were not
associated with any fibrosis. Fallon and Banting' also
found that the tissue reaction to sericite is comparable
to that produced by innocuous substances, but not to
that of free silica.

Concentration and size of the dust particles is a part
of the etiology of silicosis and ranks with equal im-
portance to the chemistry of dust. It is necessary to
know the concentration of a dust before a definite de-
cision can be made that such a dust is harmless. A toxic
dust in low concentration may not produce a disabling
silicosis, but when the threshold of tolerance is passed,
the disease will develop at a rate proportionate to the
concentration and the percentage of free silica present

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267

in the dust. In the Vermont granite plants, it required
about 15 years for silicosis to become established and a
longer period before disability became evident unless
tuberculosis became a complicating factor.

So far as the size of the particles is concerned, it is
apparent that in order for any given dust to produce in-
jury, it must gain access to the parenchyma of the lungs,
the site where the harmful effects of the dust take place.
All of the particles of inhaled dust do not gain access
to the lungs, and are not necessarily retained in case
they do reach the alveoli. The respiratory system has
been provided with certain equipment for the purpose
of keeping out foreign matter. Dust particles that gain
access to the alveoli may be coughed up before being
removed by phagocytosis. Several have shown that it
is rare to find a particle of dust in the lungs of de-
ceased persons that is more than ten microns in diameter,
and that the majority of them are considerably smaller.
This is possibly due to the fact that the number of
particles larger than ten microns in dust is small when
the lower size range is considered. Gravity causes a more
rapid settling of suspensions of the larger-sized par-
ticles, also, these particles are easier to catch with the
respiratory protective equipment. It is obvious that we
must concern ourselves with particles that are less than
ten microns in diameter.

Clinical and X-Ray Characteristics
of Silicosis

When considering the clinical aspects of silicosis, it
is necessary to bear in mind that it occurs in uncompli-
cated form (simple silicosis) , and with infection. The
latter is almost invariably tuberculosis. The physical
and clinical aspects of the disease will be quite different
in each case. Uncomplicated silicosis is not accom-
panied by toxemia, and the course of the disease is quite
different when tuberculosis is absent. The patient may-
be able to continue his work and usual routine without
much inconvenience. He is usually well-nourished and
apparently healthy, unless in an advanced stage of the
disease.

Physical examination will reveal some limitation of
chest expansion; and unless the patient has engaged in
athletics, the extent of limitation is usually in propor-
tion to the length of service. The restriction of expan-
sion was found to be symmetrical, in contradistinction to
the asymmetry found in pulmonary tuberculosis, un-
complicated by silicosis.

Dyspnea is usually the first complaint, and is quite
constant in silicosis, increasing with length of exposure.
It was my experience in the study of the Vermont
granite workers that if silicosis was well-established, and
the worker changed to non-dusty occupations, the
dyspnea increased as time went on. Pains in the chest
were a common complaint; however, none was of suffi-
cient severity to warrant the consultation of a physician.

Patients with uncomplicated silicosis usually have a
non-productive cough, which seems to cause them no in-
convenience. They do have frequent colds, however.
Physical examinations usually revealed a general im-

pairment of resonance over the chest, the intensity vary-
ing as a rule with the length of dust exposure. This
finding is consistent with the character of the generalized
fibrosis of the lungs in silicosis. The fibrosis of tuber-
culosis is localized over the infected area, whereas the
fiibrosis of silicosis is general throughout the lungs. It
is easy to overlook the impaired resonance, since it is
general, and there are no local areas to afford a contrast
in percussion note, as is the case in tuberculosis and
pneumonia.

In my cases of granite-cutters there was no marked
change to any particular variety of breath sounds in un-
complicated silicosis. There was, however, a general
softening (or "soft pedal” effect) on all the breath
sounds, which naturally accentuated the vesicular type
of breathing. Riddells states that "The commonest
change is in intensity. Breath sounds in silicosis tend
to be distant or blanketed.” Rales were absent in un-
complicated cases. No toxemia was present, which is
accounted for by the absence of infection.

Silicosis Complicated by Tuberculosis

Our experience with the granite-cutters in Vermont
led us to the conclusion that workers who have a latent
tuberculosis become disabled with silicosis earlier than
the average individual. The rate of development of
silicosis seemed to be more rapid, and the tuberculosis
complication came about when they were yet young men.
This was not the case in persons who had developed
silicosis in the usual manner. The average age of this
latter group was 49. The course of tuberculosis in this
instance was more rapid and went to an early fatal ter-
mination. The average duration of illness was about
15 months.9

Early Manifestations of Infection

Silicosis with beginning tuberculous infection is not
easy to diagnose with X-ray methods alone. Advanced
silicosis and early tuberculous complication may give
similar appearances in the X-ray film; however, when
tuberculosis has advanced, the picture is quite different.
It was our experience that the patient complained of
fatigue, rapid loss of weight and strength, night sweats,
increase in dyspnea, more severe pains in the chest and
often a very painful pleurisy (in some instances requir-
ing opiates to alleviate) , and an afternoon rise in tem-
perature. The cough was usually more severe and be-
came productive. In our cases it was easy to find tubercle
bacilli in the sputum when the above symptoms were
present; many of the patients had hemoptysis, and
later in the disease there were frank hemorrhages from
the lung. Several died from severe pulmonary hem-
orrhages. As the disease advanced it presented no great
differences from those fulminating types of uncompli-
cated tuberculosis.

The physical signs of tuberculosis complicating sili-
cosis presented variations from those in uncomplicated
cases, inasmuch as general pulmonary fibrosis already
existed. When consolidation and cavitation occurred, the
signs were similar to the usual case of tuberculosis. The

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latent or post-tussic rale was constant and not unlike the
same valuable sign of uncomplicated tuberculosis.

It is necessary in the diagnosis of silicosis to take into
consideration:

( 1) The employment history in detail.

(2) Symptoms and physical signs.

(3) Radiological findings.

X-ray gives more evidence of pneumoconiosis than any
other single method of diagnosis. In fact, no diagnosis
of silicosis is complete without it. X-ray characteristics
are so pronounced that it may easily become a habit to
omit other procedures in the diagnosis. The physical
examination is very important in this respect. There are
other pulmonary conditions which may closely resemble
silicosis, and care must be taken in all cases to establish
a history of exposure to silica dust.

The X-ray characteristics of silicosis may resemble
asbestosis, mycotic infections of the lung, and also mili-
ary tuberculosis and tuberculous broncho-pneumonia, as
well as passive congestion of the lung and bilateral
bronchiectasis. Certain metastatic malignant conditions
ot the lung may show a resemblance to silicosis by
X-ray. Occasionally X-ray films of silicosis will show
a deviation from the usual picture. This emphasizes the
importance of the history of the patient. His whole
occupational life should be accounted for in detail and
particularly those occupations in which there was dust
exposure.

X-Ray Characteristics

When the pathology of silicosis is taken into con-
sideration, it; can readily be seen that an X-ray of the
chest will show a generalized fibrosis. The dust is de-
posited in the lymph channels and nodes along the
bronchioles, bronchi and hilus, and naturally the path-
ology of the disease will be located in these same places.
The body’s response to silica dust is the formation of
fibrous tissue, and this is indicated on the X-ray as a
generalized thickening of shadows in the parenchymal
portions of the lung. There is a predominance of shad-
ows in the lower middle portions and on the right side.
I he dust enters the lung in a downward direction, and
reaches the lower middle portions before it is arrested
on the moist walls of the bronchi and bronchioles.
Therefore, very little dust reaches the apical portions.
The right bronchus is larger than the left and enters
the lung at about a 24-degree angle, whereas the left
bronchus, the smaller one, enters at an angle of about
45 degrees, and the dust is more readily arrested by im-
pingement against moist walls of the pulmonary struc-
tures before it reaches the bronchioles. Riddell,8 in
speaking of nodular shadows says, "It tends to be rather
evenly distributed throughout the lung fields, but pri-
marily appears in the mid-zones about the lung roots
and is often of greater intensity on the right side.” It
was my experience at autopsy to find very dense pleural
adhesions. In one case where there was exposure of only
three years, there were marked adhesions. We found
evidence of adhesions marked by irregularity of the
diaphragm in many cases and it was quite consistent

in the more advanced cases. This is evident in the
X-rays reproduced in Bulletin 187.

Briefly stated, the X-ray appearance of an early
(first stage) case of silicosis is as follows: There is an
increase of the linear shadows radiating from the hilus,
and in the course of these, there occur discrete densities
indicative of nodule formation. The apical portions are
usually clear.

In the second stage, there is a further increase in the
bilateral markings and in the number and size of the
discrete nodular shadows. There may be evidence of
confluence of the nodules. Evidence of pleural adhesions
may occur, shown by irregularity of the diaphragm.

In the third stage, there is marked accentuation and
confluence of the above-mentioned shadows, and there
may be massive areas of consolidation and irregularity
of the diaphragm.

Silicosis Complicated by Tuberculosis

Tuberculosis may become a complication in any stage.
It occurs with increasing frequency as the disease ad-
vances. Bohme10 observed a group of 300 patients with
silicosis. He found that after five years more than one-
half of them had died, and that 72 per cent of the
deaths were due to pulmonary tuberculosis. The X-ray
findings usually show an accentuation of the markings
described above with a loss of their distinct character or
lineation. There is a tendency to flocculence, and areas
of conglomeration and consolidation form as the disease
progresses. There may be cavitation in advanced stages.
Pleural changes may be shown on the X-ray film. The
tuberculous lesion is not always in the apical portion,
as in uncomplicated tuberculosis. The majority of the
early lesions in our cases were in the lower portions, and
often on the right side.

Anthraco-Silicosis

An interesting phase of silicosis is found in anthra-
cite coal workers, where the disease is modified by the
presence of coal dust. The clinical and roentgeno-
logical findings have much in common with ordinary
silicosis, yet there is some variation from the complete
picture. The association of emphysema with silicosis
and the prevalence of barrel-chested workers are not
common among the usual silicosis cases.

According to Dreessen and Jones11 anthraco-silicosis
(miners’ asthma) is an occupational disease characterized
by silicotic fibrosis, excessive retention of carbonaceous
material, and emphysema. It renders the sufferer sus-
ceptible to ' tuberculosis in later life, as does ordinary
silicosis.

These patients have shortness of breath, cough and
pains in the chest. Later on in the disease there is
weakness, gastric distress, and hemoptysis. There is de-
creased chest expansion, clubbing of finger nails, pro-
longed expiration. In more advanced cases, or when
infection occurs, there are noted persistent rales, loss of
weight, cardiac defects and cyanosis.

Twenty-seven hundred and eleven active workers were
studied and practically all the personnel of three repre-
sentative mines. Six hundred sixteen, or 22.7 per cent,

THE JOURNAL-LANCET

260

SCHEME OF X-RAY INTERPRETATIONS

(SILICOSIS)

LUNG FIELD APPEARANCE

Normal Lung Markings or first
degree exaggeration of Linear
Pulmonic Markings

u h 7 ' 7v'."

Second degree exaggeration7
7of linear pulmonic markings

with or. without beading

■ ■■ . / / ./ / ,■ :: /

^First degree diffuse
ground glass or grainy i
appearance, not obliter-,
ating linear markings

LINEAR PHASE

GRANULAR PHASE

T T x X X X X X A

» « W > i i

Second degree diffuse
ground glass or grainy j
appearance, obliterating
linear markings-

• First degree disseminated :
; nodules up to size of

X - R ay

interpretation

USUAL

FIBROSIS

COMMENC ING

GENERALIZED

FIBROSIS

GENERALIZED
FIBROSIS 14-

NOD ULAR PHASE

CONGLOMERATE PHASE

GENERALIZED
FIBROSIS 24*

^.^Conglomerate v/ith any of the^C
•#^(above manifestations (E.G. ||'

*nodulo-conglomerate)moderate. *

^or marked emphysema usually ^

W present ^ \

« W 1 * ”

Figure No. 1 . Assymmetrical distribution of shadows, unilateral increase of markings, and
less discrete or coalescing shadows (mottling), imply complicating pulmonary infection and modify
any of the phases illustrated above.

GENERALIZED
FIBROSIS 3-jf-

were found to be affected witb antbraco-silicosis. Clini-
cal pulmonary tuberculosis was found in 15 per cent of
the early cases, and in 43 per cent of the late well-
established cases. The incidence of tuberculosis in the
controls, and those essentially negative for anthraco-
silicosis, was found to be one and two per cent, respective-
ly, which is about the same as would be found in the
general population.

It was the opinion of these investigators that tubercu-
losis complicating anthraco-silicosis was of a milder type
than that ordinarily seen in silicosis. I am inclined to
agree with them inasmuch as tuberculosis has not been
generally associated with anthracosis in the minds of
physicians and the public in general. The presence of
emphysema, bronchitis and anthracosis makes it more
difficult to diagnose tuberculosis than in uncomplicated
cases.

Latent Silicosis

One of the unusual characteristics of silicosis as a non-
bacterial disease is its progress after cessation of dust
exposure. If the disease is well-established, its course
and prognosis seem to be altered very little by the re-
moval of the worker to a non-dusty occupation. It is
questionable if the cases of early silicosis without in-
fection exhibit this characteristic; however, more data
are needed to substantiate this opinion.

In the cases of more advanced silicosis, a change in
occupation did not seem to lessen materially the chances
of escaping a final tuberculous complication. This was
exemplified in the case of granite manufacturers, most of
whom had been stone-cutters before starting in business
for themselves, and evidently had silicosis. These
manufacturers have had only intermittent exposure, and
this to the general atmosphere of the plant since they

270

THE JOURNAL-LANCET

THRET MALE GROUPS.

Figure no. 2.

stopped cutting stone. In most instances, their social
and economic conditions were better than that of cutters,
which, incidentally, was above the average for industrial
workers.

It was possible for us to observe in the granite study
2-1 cases who had worked in the industry a number of
years and then had taken up trades where there was no
further dust exposure. The following table summarizes
our findings in these cases. The X-rays of most of these
workers are shown in U. S. Public Health Service
Bulletin 187.

The latency of silicosis has been referred to by other
investigators. The South African workers found that
"a steady fall over a period of years in dust concentra-
tion is not associated with the corresponding fall in the
silicosis incidence.”1 J

Dr. Pancoast1'1 presents a case of advanced pneumo-
coniosis in a quartz miner who had been exposed to dust
for eight years. He had been out of the mining in-
dustry for ten years, yet the X-ray showed entensive
pneumoconiosis with irregularities of the diaphragm,
and by fluoroscope he found the diaphragm restricted
on each side. There was, perhaps, a tuberculous in-
fection intervening at the time.

Britton14 reports two cases of workers who had been
exposed to dust between seven and eight years. They
changed occupations and had been away from siliceous
dust for eight or nine years. They developed pulmonary
symptoms and were found to be suffering from silicosis
and tuberculosis. Tattersall10 also observed cases of
latent silicosis in his studies: "Some of the men (rock-
drillers) , moreover, had changed their occupation for
various reasons quite apart from health; but in due
course the inevitable dyspnea came on. One man, for
instance, worked eight years regularly with rock drills,
from 1906 to 1914, then joined the Army, was passed
as A-l; but in spite of his open-air life, dyspnea came on
in 1918, and from then until his death six years later
his illness was a typical case of silicosis.”

The Effects of Other Dusts

A summary of the effects of dust other than free
silica is given below:

Asbestos: Merewether11’ gives results of a very ex-

haustive study on the subject of asbestosis. He defines
asbestosis as a specific occupational disease of the lungs

TABLE 1.

Summary of cutlers, groups A and B, previously exposed to granite dust, but later employed in nondusty trades*

Case

No.

Age

Years in
Granite

Occupation Since Leaving
Granite

Years in Such
Occupation

Comment

112

Salesman

Silicosis

299

Night watchman

Silicosis and tuberculosis!

296

Superintendent

Silicosis and tuberculosis!

387

Secretary of union

Silicosis and tuberculosis!

530

Shipping clerk

Silicosis and tuberculosis!

132

Chauffeur

Silicosis and tuberculosis!

289

City clerk

Silicosis and tuberculosis!

440

Farmer

Silicosis and tuberculosis!

379

Farmer

20-*-

Silicosis and tuberculosis!

Employed on farm .

1 1

Adv. silicosis and suspected latent tuberculosis

432

Janitor and fireman ...

Silicosis and tuberculosis!

309

Janitor

Advanced silicosis and tuberculosis!

443

Street cleaner

Silicosis and tuberculosis!

339

18t

Employed on farm

1 5

Silicosis and early tuberculosis

322

Salesman ... _ _ .

Silicosis and advanced tuberculosis!

117

Manufacturer

Silicosis and advanced tuberculosis!

Farmer

Silicosis and extensive tuberculosis in both lungs!

Insurance agent

Silicosis and tuberculosis pneumonia!

t Total years in granite. Returned to industry one year before examination,
! Died of silicosis and tuberculosis.

* From P. H. S. Bulletin No 187.

THE JOURNAL-LANCET

271

caused by the inhalation of asbestos dust, and character-
ized by the progressive development of fibrous tissue.
The symptoms are insidious in their onset and irregular
in their course. They consist mainly of cough and
dyspnea. The roentgenograms show a diffuse ground
glass appearance together with a fine pinhead mottling.
Death usually results from a low grade bronchopneu-
monia, but may be due to lobar pneumonia, bronchitis,
influenza or less often a sub-acute tuberculous infection.
In the lungs of asbestos workers are found asbestos
bodies and spicules. From case histories, he found that
when the dust is highly concentrated, the minimum
period between exposure and production of a serious
degree of asbestosis is approximately seven years, al-
though the average interval is about 1 1 years.

Silicate Dust: Dreessen1 ' has made observations on
several groups of workers who were exposed to dust
containing silicates. These dusts were principally talc
and slate. He concludes that: 1. The silicate dusts of
tremolite talc and slate induce a fine, diffuse, bilateral
fibrosis of the lungs which is definitely demonstrable in
the X-ray. 2. While very dusty conditions prevail in
certain departments of these two stone trades (tremolite
talc and slate) it cannot be said that the resultant pneu-
moconiosis has led to disability.

Portland Cement: A study of the effect of Portland
cement was made by the U. S. Public Health Service
a few years ago. It extended over a period of two and
one-half years.ls No disabling pneumoconiosis was found
to exist among the workers and no evidence was elicit-
ed that exposure to cement dust would reactivate
healed lesions of tuberculosis. Miller, Sayers and Yant10
showed that in 180 days after the injection of cement
dust into the peritoneum of guinea pigs, all the dust and
a large portion of the pigment had disappeared.

Artificial abrasives: Some of these are silicon carbide
(SiC) and aluminum oxide (AL>0;f). They are
products of the electric furnace and are now widely
used, principally in grinding wheels, and have largely
replaced the use of sandstones in grinding. Artificial
abrasive materials are harder than quartz and approach
the diamond in hardness. Neither of these materials
produced massive fibrosis in animals. Peritoneal in-
jections of carborundum showed that the material
apparently is not irritating, and is insoluble, causing no
cellular proliferation. The reaction was considered one
of inertness.20 It has been stated, however, that silicon
carbide did show evidence of activating old tuberculous
lesions in animals.

Gypsum: (CaSo^ZHjO) is widely used in various
parts of the world, principally in making plaster.
Riddell21 found that gypsum dust did not produce
pneumoconiosis or any other harmful effect. Peritoneal
injection of this dust showed that it was absorbed with-
out the formation of scar tissue.

Iron dust: Hematite (Fe^O.-j) is the commonest iron
ore and is reddish in color. Pneumoconiosis produced
by it is commonly called siderosis. It has not been
shown that exposure to pure hematite produces a dis-
abling pulmonary fibrosis; however, rock dust encoun-

tered in iron mining may produce a form of silicosis
with the usual disability.

Carbon dust is the most common one encountered
outside of industry. It occurs in varying quantities in
all cities where coal is used as a fuel. It is an important
constituent of black smoke from any carbonaceous fuel.
The lungs of city dwellers at autopsy invariably show
carbon deposits. The exposure in city air is insufficient
to cause any harmful effect on the lungs. It has been
shown, experimentally, that pure carbon dust from
diamonds, the hardest substance known, is harmless.22
Haldane22 believes that carbon increases the phagocy-
tosis, that it might reduce the potency of quartz and
thereby give a simple and effective preventive for silico-
sis. However, since Haldane set forth this theory, an in-
tensive study has been made of the anthracite coal min-
ers. Dreessen and Jones11 found that the terminal tuber-
culosis in anthraco-silicosis was of the mild, chronic, pro-
liferative type, in contrast to silicosis where the tuber-
culosis is of a more virulent nature. Williams24 found
a similar characteristic in the old and retired coal miners
in South Wales.

Medico-Legal Aspects of Silicosis

The medico-legal situation in recent years regarding
silicosis has been tragic and expensive. It reached the
point where it was very difficult for a worker with sili-
cosis to get compensation. Silicosis had not been in-
cluded in the schedules for compensation in most states,
and claims went to the open courts. There the merits of
the cases were decided by lay juries, most of whom had
heard little if anything about the disease, or had never
seen an X-ray of the chest. There are several instances
where unscrupulous lawyers fomented suits, and many
unmerited awards were made by non-medical juries.
Some industries were bankrupted, and in most instances
the patient had very little left after paying lawyers’ and
experts fees and the other costs of prosecution. Under
many of the better-drawn compensation acts the fees arc
strictly limited and subject to the scrutiny of the com-
pensation commission.

In some states where silicosis is a compensable disease,
the commissioners have recourse to medical boards for
evaluation of the claimant’s condition and extent of dis-
ability, and in this manner the worker and the industry-
are more likely to obtain equity. It also protects the
industry from long and expensive litigation and at the
same time assures to the deserving workers who have
silicosis an opportunity of obtaining compensation in
amounts to commensurate with their condition and dis-
ability.

The situation regarding the silicosis problem is differ-
ent from that relating to other occupational diseases and
to accidents. Several factors must be considered in ap-
proaching the solution of the silicosis compensation
problem. The question of accrued liability is an im-
portant factor, as this disease does not develop in a few
weeks or months but requires a period of several years.
Ordinarily, it does not produce disability until after
many years of exposure. The silicotic who has to change
occupations is confronted with the problem of re-employ-

Ill

I'l IE JOURNAL-LANCE7

TABLE 2.

Tentative Thresholds of Dust Tolerance

Industry

Average Dustiness,
Millions Particles per
Cubic Foot

Amount of
Free Silica

Tentative Threshold,

Millions Particles per
Cubic Foot

Hazards —
Actual and Potential

GRANITE

Cutters

47.5

30-35

Less than 1 0

Silicosis

General atmosphere

30-35

Less than 10

Silicosis (mod. fibrosis)

Less than general atmosphere

30-35

Less than 1 0

Slight fibrosis (no disability)

ANTHRACITE COAL
Rock drillers

241

Less than 5

Anthraco-silicosis

Miners and helpers

480

1.5

Less than 50

Anthraco-silicosis

Transportation

7-233

Less than 1 5

Anthraco-silicosis

BITUMINOUS COAL
Rock drillers

Less than 5

Silicosis

Cement — -

6-8 (raw)

Less than 1 5

Silicosis?

Slate

15-715

Sit. trace to 3

Less than 1 5

Pulmonary fibrosis

Talc . -

5 0-1440

Less than 1 5

Pulmonary fibrosis

Asbestos -

Less than 15-20

Asbestosis

Marble

Over 30

No disability

Cotton Cloth Mfg.

No disability

Silverware Polishing

— 1.7

No disability

Municipal

No disability

mcnt, as his condition which will be diagnosed on pre-
employment examination excludes him from a job in
many instances. On the other hand, the employer is
assuming an accrued liability if he employs a silicotic.
The worker can obtain compensation if it is shown that
his condition has been aggravated. This is a difficult
situation and one that needs serious consideration. A
plan should be worked out whereby the employer would
assume only the portion of liability that accrued in his
plant. Under such a system, the worker could obtain
employment and earn a living wage.

The question of tuberculosis necessitates additional
consideration. Under the present system, if tuberculosis
develops as a complication of silicosis, the industry is
held responsible. When clinical (or active) tuberculosis
is present, disability is also present, varying in extent
with the amount of toxemia present. The prognosis is
not good, and the worker should be removed from em-
ployment and given compensation. As a matter of fact,
less than one in every 1,000 persons in the general popu-
lation will develop tuberculosis, irrespective of industrial
environmental conditions. The rate among industrial
workers, where a silica hazard exists, is from two to five
times as high as in the general population. Seventy-five
per cent of those who have silicosis die of tuberculosis as
a complication. If we can prevent silicosis, we can re-
duce the general tuberculosis rate. If no steps are taken
to prevent silicosis, the tuberculosis rate will increase not
only in industry, but also at home, because of contacts.
The extra cost of such tuberculosis will be greater than
the amount the public would contribute toward a fund
taking care of accrued liability. This seems a logical
way to take care of a difficult situation.

The extent of disability from silicosis cannot be es-
timated accurately from the X-ray alone, and should
not be attempted. The patient’s general condition must

be taken into consideration. Employers should provide
safe atmosphere and employees be allowed to continue
work as long as they are able to do so without further
harm to themselves. Experience in some foreign coun-
tries has shown that it is a great mistake to remove sili-
cotics from work too early. The amount of compensa-
tion received is less than that of their wages, and they
must necessarily lower their standards of living. If they
seek other employment, they are again handicapped be-
cause of their disability and employers are loath to em-
ploy them. Persons with silicosis find it hard to adapt
themselves to work and routine to which they are un-
accustomed. In many places where silicosis is endemic,
there is generally a scarcity of jobs where these unfor-
tunates can be placed. Adequate compensation seems to
be very necessary.

Prevention

Sanitary engineering in the field of industrial hygiene
is a new profession, as is this kind of medical specializa-
tion. The sanitary engineer is the closest ally of the in-
dustrial physician, and an absolute necessity in determin-
ing the working conditions in plants. Establishing of
control measures is largely his duty, as well as mainte-
nance of safe working conditions after preventive equip-
ment has been installed.

In a program of dust control, the extent of existing
hazards as well as the thresholds of danger must be
known, in so far as possible. The limits of tolerance
have been set, tentatively, for several occupations. Some
of these are given in the following table:

The Public Health Service, in its various studies of
workers in dusty trades, did not find significant pul-
monary fibrosis in any trade where the dust exposure was
less than five million particles per cubic foot of air.

Bloomfield2*’ has recommended four general methods
of dust control: 1. Substitution of non-dust producing

THE JOURNAL-LANCET

273

DUST PROBLEM IN GRANITE CUTTING
CAN BE CONTROLLED BY THE USE OF
EFFICIENT LOCAL EXHAUST SYSTEM

FI gu re No . 4 .

processes, or tire use of harmless substances. This pro-
cedure, however, has a rather limited application. One
example of substitution is the use of non-silica parting
compounds in making foundry moulds. It is obvious
that the use of a harmless parting compound instead of
one containing free silica will lessen the hazard to a
considerable extent. 2. The second method consists in
isolating the dusty process. This method has many pos-
sibilities, but unfortunately is not widely used. With
this procedure, the dust-generating process is confined
to a single closed space, and only the workers actually
engaged in the operation are exposed to dust. 3. The
third method, and perhaps the best known, is the prac-
tice of wetting the dust at its source. It was shown that
by wet methods the dust in drilling was reduced from
!>68 to 33 million particles per cubic foot; and in load-
ing, from 636 to 32. Even though these concentrations
are above the threshold of tolerance, the great reduction
in dustiness is worth while. 4. The fourth method is
exhaust ventilation, and is perhaps the most effective.
Fortunately, it has the widest application of all the
methods. Exhaust equipment must be designed for each
particular problem, and when adequate equipment is ob-
tained, its efficiency is then dependent on its proper
maintenance. The following graph shows the effective-
ness of exhaust ventilation applied to stone cutting.

Personal protective measures in the form of masks
and positive pressure air helmets are valuable. There
are several masks of the approved type on the market.
Equipment of this kind must be selected for the specific
problem at hand, inasmuch as these masks are not de-
signed to protect against all of the dusts. They require
constant care and upkeep, and are often misused. In
the case of caustic dust, the mask presents a problem as
moisture precipitates dust on the face and produces skin
burns.

The positive-pressure helmet is suitable only for cer-
tain specific uses. It cannot be used by persons engaged
in an occupation that requires them to move about the
plant. This type of protection from dust is a palliative
measure only, and should never be used as a substitute
for adequate ventilation either local or general.

The selection of employees for dusty trades is most
important; persons who have had prolonged exposure
to tuberculosis should not be placed in an occupation
where they will be exposed to siliceous dust. Likewise,
persons who have a history of excessive respiratory dis-
turbances should be excluded. Those who are below
normal in general physique are not suitable for employ-
ment in dusty trades. Those selected should have phys-
ical examinations at stated intervals or at any time respir-
atory disturbance occurs.

274

THE JOURNAL-LANCET

It is very important that workers exposed to dust be
educated regarding the hazards to which they are sub-
jected. They must know that they share the responsi-
bility of protection with their employer. It is their pri-
mary duty to help keep the ventilation equipment in
proper functioning condition, and the masks and helmets
clean and in order.

Morbidity

Respiratory diseases stand out as the most prominent
thing in the morbidity of workers in dusty trades.

The general manufacturing group may be taken as an
average. It is apparent that granite cutters, anthracite
coal miners, cement workers, and a group of gold miners
have much higher rates of influenza and grippe than the
average.

Mortality

A study of the mortality trend in the United States
reveals that tuberculosis has declined in a most gratify-
ing way, from approximately 200 per 100,000 in 1900,
to 59.5 in 1933. During this period there has been an
increase in certain occupations associated with dust ex-
posure. It has been shown that by sanitary engineering
methods, this industry can be made safe from dust ex-
posure.

The influence of dust on mortality from tuberculosis
is clearly indicated in the following table. New methods
of manufacturing stone, which created excessive dust
by the use of pneumatic tools, were introduced in the
granite industry about the beginning of the present cen-
tury, and the tuberculosis rate has increased rapidly with
their use. The rate has risen in direct proportion to the
length of time during which they have been employed
as follows:

1.5 per 1,000 ... 1890-1894

10.8 per 1,000 1910-1914

19.5 per 1,000 1924-1926*

(* During period of our observations)

A consideration of the mortality statistics of Barre,
Vermont, shows that there has been an excessive death
i ate from pneumonia and other respiratory diseases (tu-
berculosis excluded) during this period.

Public Health Aspects

There are about 15 million workers in manufacturing,
mechanical and mineral industries in the United States.
The control of occupational diseases in this group is
quite a public health problem and can be met. Medicine
and public health, broadly speaking, are greatly ad-
vanced in scientific knowledge and skill. There are
many men of ability in the profession; nevertheless,
they are backward in the application of this knowledge
and skill to the problems of today. We know of meth-
ods of control, and even of elimination, of many con-
tagious as well as occupational diseases. Yet they con-
tinue to occur. Mr. Hastings26 has asked, "Why do we
spend $15,728,925,396 annually for treatment and care
of the sick, and lost wages, and spend less than one-half
of one per cent of this amount for prevention?” New
York State spent $531,808 for compensation in 1934.
The per worker cost for industrial hygiene during the
fiscal year 1936-1937, which is allotted for 21 states hav-

ing over 19,000,000 employees, is $0,015. This is a very
small amount for the many industrial health problems
that exist, but will yield a return much greater in pro-
portion than the amount spent.

The states can, and will, greatly aid in further reduc-
tion of the incidence of tuberculosis with their programs
cf industrial hygiene, which, incidentally, is a good ex-
ample of how knowledge can be applied in the control
of disease.

In the past, only a few states had taken steps to assist
industry to control its hazards. At present, there are 21
industrial hygiene units in states, most of which were
established since the passage of the Social Security Act,
which provided funds for such work. Plans are under
way to establish several more, which will include more
than one-half of the states and approximately 84 per
cent of the industrial population27. We have good rea-
son to expect a marked reduction in the incidence of
tuberculosis in industry through the control of harmful
industrial dusts.

References

1. Bloomfield. J. J.. Johnson. W. Scott. Sayers, R. R.: Potential
problems of industrial hygiene in a typical industrial area. Public ;
Health Bulletin 216, Dec. 1934.

2. Fallon. J. T. and Banting, F. G.: The Cellular Reaction to

Silica. Can. Med. Assn. Jour., 33:404-407, Oct. 1935.

3. Proceedings of the International Silicosis Conference. 1930. ],

4. Kettle, E. H.: Experimental Silicosis, Jour. Ind. Hyg., 1926, |

8:491-495.

5. Collis, E. L.: Industrial Pneumonoconioses, Milroy Lec-

tures, 1915.

6. Irvin, D.: The Experimental Aspects of Silicosis. Ann.

Int. Med. 9:546, Nov. 1935.

7. Fallon, J. T. and Banting, F. G.: Tissue Reactions to Seri* U

cite. Can. Med. Assn. Jour. p. 407, Oct. 1 935.

8. Riddell, A R.: Clinical and Radiological Aspects of Silicosis, •.]
Can. Pub. Health Jour. vol. 27, No. 2, Feb. 1936.

9. Russell, A. E., Britten, R. H., Thompson, L. R.. Bloomfield, |

J. J.: The health of workers in dusty trades. II. Exposure to

siliceous dusts (granite industry). Public Health Bulletin No.
187, July 1929.

10. Bohme, A.: Beit. z. Klin. d. Tuberk. 84-119. Dec. 1933.

11. Dreessen, W. C., and Jones, R. R.: Anthraco-Silicosis. '

given at meeting of Am. Med. Assn., May 1 1, 1936. Journal of

A. M. A., Vol. 107, No. 15, Pp. 1 179-1 185, Oct. 10, 1936.

12. South African Institute of Medical Research. Annual Rc- ii

port, year ending 1925.

13. Pancoast. Henry K.: Roentgenological Studies and Other jl

Fibrosing Conditions of the Lungs. Annals of Clinical Medicine, ]
July, 1923.

14. Britton, James A.: Silicosis, a Modern Factory Hazard.

Jour. Ind. Hyg., Sept., 1924.

15. Tattersall, N.: The Occurrence and Clinical Manifesta* <1

tions of Silicosis Among Hard Ground Workers in Coal Mines. 1
Jour. Ind. Hyg., Nov. 1926.

16. Merewether. E. R. A.: A memorandum on asbestosis.

Tubercle, 15:69, Nov. 1933.

17. Dreessen. W. C. : Effects of certain silicate dusts on the

lungs. Jour. Ind. Hyg., Vol. XV, No. 2, March 1933.

18. Thompson, L. R., Brundage, D. K., Russell, A. E. Bloom- ■
field. J. J.: The health of workers in dusty trades. I. Health of .
workers in a Portland cement plant. Public Health Bulletin No. ( !
176, April 1928.

19. Miller, J. W., Sayers, R. R., and Yant, W. P.: Response ffl

of Peritoneal Tissue to Dusts Introduced as Foreign Bodies.

J. A. M. A. ‘ 103:907-911, Sept. 22, 1934.

20. Gardner, L. U.: Relation of Mineral Dusts to Tubercu* j(

losis. Am. Rev. Tuberc. 7:344, 1923.

21. Riddell, A. R.: Clinical Investigations Into the Effects of

Gypsum, Can. Pub. Health Journal, 25:147, 1934.

22. Gardner, L. U. and Cummings, D. E.: The Reaction to

fine and medium sized quartz and aluminum oxide particles. Sili- j ’
cotic cirrhosis of the liver. Am. Jour. Path., 9:741, 1933.

2 3. Haldane. J. S.: The avoidance of silicosis with dry meth- '

ods of working. J. Chem. Met. and Mining Soc. So. Africa, H
30:54, 1929.

24. Williams, E. M.: The Health of Old and Retired Coal H

Miners in South Wales, Univ. of Wales Press Board, Cardiff, 193 3. |j

25. Bloomfield, J. J.: Some Practical Considerations in Dust ’•

Control. Trans. 24th National Safety Congress, 1935.

26. Hastings, G. A.: Public Relations in the Conquest of Tu- h

berculosis. Proceedings of 27th Annual Meeting of National
Tuberculosis Assn., p. 385, 1931.

27. Adapted from figures of the U. S. Census for 1930.

JOURNAL

Represents the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

The Official Journal of the

North Dakota State Medical Association The Minnesota Academy of Medicine Great Northern Railway Surgeons’ Assn.

South Dakota State Medical Association The Sioux Valley Medical Association American Student Health Association

Montana State Medical Association Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

BOARD OF EDITORS

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. J. A. Evert

Dr. W. A. Fansler
Dr. W. E. Forsythe
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock

Dr. S. M. Hohf
Dr. R. J . Jackson
Dr. A. Karsted
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. A. S. Rider

Dr. T. F. Riggs
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley
Dr. C. A. Stewart
Dr. J . L. Stewart

Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M D., 1859-1931 W. L. Klein, 1851-1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., June, 1937

MONTANA MEETING

The Medical Association of the State of Montana
meets at Great Falls this year, July 11-14. This is the
vacation month of the year. Successful men are disin-
clined to take out-and-out vacations; they like to com-
bine them with some useful purpose; and those who go
to the trouble of arranging programs wisely have this in
mind. July in Montana is perfect, and the attendance
should be good.

There will be a certain note of sadness at this gath-
ering because of the absence of Dr. E. G. Balsam, who
served as secretary for so many years, and who died of
embolism of the right lung in Billings on May 13, 1937,
at the comparatively early age of 53 years. He did much
unselfish work for the profession of Montana and will
certainly be missed.

A. E. H.

IT IS LATER THAN YOU THINK

A preceptor of blessed memory used to say, "Dispose
of matters as they come up, it saves time and thought.”
He had this sentence pasted before him on his desk as
a constant reminder. An old adage has it, "Don’t put
off until tomorrow that which you can do today.” And
now comes a Chinese expression, "It is later than you
think, ’ and while it does not quite paraphrase the for-

mer two, it nevertheless emphasizes with a peculiarly
oriental slant the importance of promptness and punc-
tuality.

The physician must be alert, "on his toes,” ahead of
time if anything. To arrive, even a few minutes after
the baby has been born, is a sad disappointment to all
concerned. In case of a consultation it is considered in-
excusable for one doctor to keep another waiting. But
why in heaven’s name he should be such an infernal
procrastinator in so many other matters we cannot under-
stand. Oh yes, it is a very human trait, very human
indeed. And then of course the physician has been
peculiarly inhibited in so many ways. He never knows
until the very last minute whether he can go on a cher-
ished fishing or convention trip; and so through years
of disappointments of various kinds he becomes accus-
tomed to the futility of planning and neglects certain
matters of vital interest to himself and his family,
always thinking of others. He does not make his Pull-
man and hotel reservations until the very last minute
when he is going on a trip. He fails to review the pro-
visions of his life insurance policies so that alterations
may be made to fit changed needs. And often he dies
intestate. It might be well to have the admonition in
mind that it is later than you think-

A. E. H.

276

THE JOURNAL-LANCET

A STEP FORWARD

South Dakota at last has secured legislation needed
to enforce the testing of all her cattle for tuberculosis.
It is expected that the work of eradicating this disease
from our herds will now proceed and that the state will
soon be listed as an accredited area. I am informed
that this will leave California as the only state not
accredited. This action of our legislature marks an-
other step in the fight against tuberculosis.

The medical profession individually and through the
state medical society has warmly supported this legisla-
tion. Their endorsement and the education of the gen-
eral public have no doubt been helpful in securing its
passage. I suspect, however, that economic pressure was
the effective driving force. The desire to retain federal
financial assistance which was to be withdrawn July 1st,
and the fear of further discrimination against South
Dakota cattle and dairy products, did the trick. One
wonders whether the fight against human tuberculosis
will not proceed along similar lines. Education of the
public about tuberculosis and professional support may
help but when the time comes that the average citizen
and tax payer finds that it is cheaper to prevent tubercu-
losis than to care for its victims, then and perhaps not
until then, will come a demand for a more efficient and
active program than public opinion will support at this
time.

A. S. R.

ELMER G. BALSAM, M.D.

1884-1937

Dr. Elmer G. Balsam, for twenty-one years secretary
of the Medical Association of Montana, died May 13th
in Billings from a pulmonary embolism, following a
thrombo-phlebitis of his left leg.

Dr. Balsam was born in Manistee, Michigan, June
17th, 1884. He was graduated from the University of
Michigan School of Medicine in 1906. After serving an
interneship in the Northern Pacific Beneficial Associa-
tion Hospital in Brainerd, Minnesota, he went to Billings
to practice, and remained there throughout his life. A
general practitioner, he took great pride in being a fam-
ily doctor and often said he would not care to change his
allotted position in the medical field. He had a large
following of loyal patients.

Dr. Balsam was always interested in medical econom-
ics. In this phase of his life work he made many friends
and was one of the best known doctors in the North-
west.

During the World War Dr. Balsam served as medical
aide to Governor Sam Stewart. He was also president
of the Montana Medical Examining Board. At the time
of his death, he was president of the Montana State
Board of Health. He was particularly interested in
preventive medicine, and he was ever on the alert to

Elmer G. Balsam, M.D.

harmonize conflicting interests of individualistic practice
and Board of Health work.

The doctor leaves a family of wife and three boys
who are still of school age. He was well liked by his
confreres in the Medical Association of Montana and his
useful life will be long remembered by them.

J. A. E.

ELIAS P. LYON
1867-1937

With the passing of Dean Lyon so soon after his I
retirement, we recall the opening sentence of his response I
at the testimonial dinner given at the Minnesota Union j
June 10, 1936. "Are, Mr. Toastmaster, President Coff- j
man, Ladies and Gentlemen, Ave, and shall we add ■
morituri Salutemus?” There was something dramatic I
and portentous about this utterance, even though he |
hastened to reverse the gladiator’s salutations to connote, 1
so far as .he was concerned, "We who are about to live, I
salute you.” He added that he ought to have a good 1
time from then on looking at the show, and slyly criti- I
cizing the performers.

Who does not envy the man who can so time his J
strokes, his down-sittings and uprisings, and actually de- j
liver his own obituary to assembled friends and co- I
workers while still in possession of faculties with which j
to do so in a brilliant and an impressive manner?

At another point he said, "I prefer the sententious I
truth of Maeterlinck, 'There are no dead.’ ” This had I
the ring of Osier’s confescio fulei in Science and Imttior - I

THE JOURNAL-LANCET

277

tality, "I trust you will come to the opinion of Cicero,
who had rather be mistaken with Plato than be in the
right with those who deny altogether the life after
death.”

He may have had the influence of his teaching in
mind, and how that would live on after him, because he
took the profession of teaching seriously. He passed out
from time to time typewritten copies of "Why I Teach,”
by Louis Burton Woodard, the last verse of which read:
Because I know that when life’s end I reach
And thence pass through the gates so wide and deep
To what I do not know, save what men TEACH
That the remembrance of me men will keep
Is what I’ve done; and what I have is naught,

I teach. A. E. H.

LEE BEY GREENE
1881-1937

Dr. Lee B. Greene was born at Valparaiso, Ind., April
4th, 1881, and passed away at a St. Paul hospital on
May 3, 1937. His parents, Mr. and Mrs. James L.
Greene, homesteaded near Sheldon, N. Dak., in 1882.
Dr. Greene attended the school at Sheldon, then entered
the North Dakota Agricultural College, receiving his
bachelor of science degree in 1901. He was graduated
from the University of Michigan Medical School in
1905, and took his interneship at the Northern Pacific
Hospital, Brainerd, Minn. He began his practice at
Monango, N. Dak., in 1906, remaining there eight
years; then moving to Edgeley, N. Dak.

In July, 1917, he enlisted in the medical corps, and
was commissioned first lieutenant at Camp Cody; was
sent overseas to become surgeon in the first division with
the rank of captain, serving throughout the Argonne
offensive in that capacity.

He was discharged in April, 1919, and resumed his
practice at Edgeley. At the time of his death he held
the rank of major, in command of the medical detach-
ment of the 164th Infantry, North Dakota National
Guard.

Besides the American Legion, which he served in high
departmental offices, he belonged to the Masonic Order,
to El Zagal Shrine, and the Lions Club.

Dr. Greene took an active interest in organized medi-
cine and was a charter member of the Southern District
Medical Society. He was for years a member of the
Council of the State Medical Association and at the
time of his death first vice-president of the State Associa-
tion.

Dr. Greene was a man of versatile action. He took
an active part in community affairs. Few knew his
many acts of kindness, of the time and substance given
to the needy; but this was his daily service.

Dr. Greene is survived by his wife and two daughters,
Mrs. R. H. Wenzel of St. Paul, and Anne, or Edgeley,
and a brother, Dr. Paul Greene, of Livingston, Mont.
He was buried at Sheldon. Full military honors were
accorded him.

F. W. F.

CASE REPORT

PERFORATIONS OF THE INTESTINE FROM
AN UNUSUAL FOREIGN BODY

J. H. Garberson, M.D., F.A.C.S.

Miles City, Montana

Perforations of the intestine from swallowed foreign bodies
are rare considering the number of such bodies ingested, espe-
cially in childhood. The uniqueness of the causative agent in
this instance, together with the unexpectedness of its discovery,
makes the following case worthy of report.

History: S. E. Male. Admitted August 3, 1935. Age

23. Ranch hand. Family history negative. His own history
negative except for some attacks of abdominal trouble during
the past 18 months, when he had some distress in the right
lower abdomen and nausea. These, three in number, had
always been transient. History of the present attack is that
during the early morning, on the day of admission, he had a
sudden, severe, cramping pain in the abdomen, associated with
nausea but not vomiting. Bowels had not moved since onset.
There were no genito-urinary complaints. During the day, he
had been seen by Doctor Alexander of Forsyth, Montana, who
referred the case to us. His temperature was 100°F. Pulse 98.
Respirations 22. He seemed ill and in considerable pain. White
blood count 15,750. Urinalysis essentially negative except for
a few pus cells. The general examination was essentially nega-
tive. The abdomen was moderately rigid throughout. There
was definite rebound tenderness, and his pain and tenderness
seemed to be definitely localized in the right lower quadrant.
On account of history of previous attacks, which had appar-
ently centered in the right lower quadrant, his leukocyte count,
and moderate temperature, a tentative diagnosis of acute ap-
pendicitis, possibly perforated, was made and operation was
advised and accepted.

as —

This porcupine quill, 2.6 centimeters long and 2 millimeters at
the thickest portion, was found free in the peritoneal cavity. It
had passed through the stomach and transversed the duodenum
before perforating the bowel.

Operative Record: Under ethylene anesthesia, supple-

mented by small amounts of ether, an outer right rectus in-
cision was made. A small amount of purulent fluid was found
free in the peritoneal cavity. The terminal third of the ap-
pendix was definitely reddened and swollen; but there was no
evidence of perforation and it was felt that it was probably nor
the cause of his symptoms, and of the purulent fluid within
the abdomen. However, it was removed because his history
was indicative of previous attacks. The abdominal incision was
enlarged upward and duodenum and pyloric regions were ex-
plored for possible perforated ulcer. There was no evidence of
any ulcer, but in the upper abdomen was found more purulent
fluid which had a definite bile-stained appearance. The gall
bladder and ducts were explored and found negative. The
small bowel was examined inch by inch and about two feet
below the ligament of Treitz, on the anti-mesenteric portion of
the bowel was an area which was thickened, reddened, and, in

278

THE JOURNAL-LANCET

the center, covered with a diphtheritic type of exudate. Gentle
probing of this area disclosed a minute perforation. The per-
foration was closed with sutures of catgut, and the peritoneal
cavity was carefully sponged out and dried. During this process,
a small, yellowish black needle-like object was found free in the
peritoneal cavity. On examination this proved to be a porcu-
pine quill It was 2.6 cms. in length and 2 mms. at its thickest
portion. The abdomen was closed without drainage.

Postoperative Notes: Postoperative course was uneventful,
with the exception of one slight attack of epigastric pain on the
tenth postoperative day, which lasted only a few hours.

On questioning the young man and his father, it was learned
that some two or three days previous to his admission, one of
the ranch dogs had returned with his face literally studded
with porcupine quills. The dog s head had been held between
the spokes of a wagon wheel and with pliers, the quills had
been drawn from his face and nose. Although the patient did
not know how he could possibly have swallowed one of the
quills, he must have, in some manner, ingested it with food or
water. It had passed through the stomach and only after trans-
versing the duodenum and about two feet of the small bowel
had its point lodged, after which, owing to the barbed-like con-
struction of the porcupine quill, perforation was inevitable.

SOCIETIES

TENTATIVE PROGRAM
THE MONTANA STATE MEDICAL
ASSOCIATION

Annual Meeting, Great Falls, July 13-14
I o Be Held in Heisey Memorial
Headquarters: The Rainbow Hotel

On the afternoon of July 13th, 1937, the following
papers will be given:

(1) Presidential Address — Dr. John A. Evert, Glendive,
Mont.

(2) "Treatment of Uterine Myomas,” by Dr. Henry
Schmitz, Chicago, Illinois.

(3) "Conservative Renal Surgery,” by Dr. Roland G.
Scherer, Bozeman, Mont.

(4) "Fractures of the Os Calcis,” by Dr. R. B. Richard-
son, Great Falls Clinic, Great Falls, Mont.

On the evening of July 13th — Meeting of Council
and House of Delegates and a smoker for the men.

On July 14th, 1937, opening at 9:00 A. M. and ex-
tending through the day, the following papers will be
given:

(1) "Fluid Intake in Edematous Patients,” by Dr. F. R.
Schemm, Great Falls Clinic, Great Falls, Mont.

(2) "Paralysis of the Peripheral Nerves of the Upper
Extremity,” by Dr. J. K. Colman, Murray Hospital
Clinic, Butte, Mont.

(3) "Massive Purulent Pericarditis,” by Dr. Fred F.
Attix, Lewistown, Mont.

(4) "Heart Disease in Middle Life,” by Dr. J. H. J.
Upham, President American Medical Assn., Co-
lumbus, Ohio.

(5) "Cancer and Its Treatment With Radium,” by Dr.
H. H. James, F. A. C. S., Murray Hospital Clinic,
Butte, Mont.

(6) "Psychosis Associated With the Involutional
Period,” by Dr. Ernest M. Hammes, Professor

Nervous and Mental Diseases, University of
Minnesota, St. Paul, Minnesota.

(7) "Nephritis in Children,” by Dr. Jessie M. Bier-
man, Helena, Montana.

At 7:30 P. M. July 14th, Annual Banquet of the
Montana State Medical Association with address on
"Changing Times in Medicine,” by Dr. J. H. Upham,
President of the American Medical Association of Co-
lumbus, Ohio.

MINNESOTA STATE MEDICAL
ASSOCIATION

Annual Meeting, St. Paul, Minnesota
May 2, 3, 4, 5, 1937

The 84th annual session of the Minnesota State Medical
Association was unusually successful, both in the attendance
and in the nation-wide attention which its scientific program
attracted.

On Sunday, May 2, the Council met at 9:00 A. M. in the
Lowry Hotel. At 3:00 P. M., the House of Delegates met
in the ballroom, and at 4:30 P. M. on Sunday the reference
committees met for business. At 5:00 P. M. on Sunday the
Council met once more, followed at 7:30 P. M. by the House
of Delegates. Dr. E. H. Skinner, Kansas City, Mo., spoke on
"How the Kansas City Profession is Meeting Social Security
Problems.” Dr. Olin West, Chicago, secretary of the Ameri-
can Medical Association, spoke on "Better Health” activities.

The Council also met on Monday and Tuesday mornings.
With President A. W. Adson, Rochester, presiding, the gen-
eral membership heard Dr. E. H. Skinner, president of the
American Radium Society, deliver the Russell D. Carman Mem-
orial Lecture on "Reflections Upon the Roentgenology of Frac-
tures” Monday at 11:00 A. M., followed by "The Irradiation
Therapy of Tumors With a Consideration of the Possibility
of Super-Voltage X-Rays,” by Dr. Robert Stone, of San Fran-
cisco. On Monday came the famous Congress on Allied Pro-
fessions, where Rev. Alphonse M. Schwitalla, S. J., St. Louis,
president of the Catholic Hospital Association, was to have
spoken. Others were: Dr. Martha Eliot, Washington, D. C.;
C Rufus Rorem, Ph D., of the American Hospital Association;
and Dr. Morris Fishbein, editor of The Journal of the Amer-
ican Medical Association. Dr. Fishbein, however, was not in
attendance.

On Tuesday, May 4, the general assembly heard Dr. John
M. Wheeler, Columbia University, speak on "Important In-
juries About the Eyes”; and Dr. Francis D. Murphy, Mil-
waukee, talk on "Hypertensive Heart Disease.”

On Tuesday afternoon at 1:30 there was a general discussion
on medical problems by Dr. Maxwell J. Lick, president of the
Medical Society of the State of Pennsylvania; Dr. Nathan R
Van Etten, speaker of the House of Delegates of the Ameri-
can Medical Association. That evening there was an Industrial
Dinner at the Hotel Lowry, and a public health meeting in
the St. Paul Auditorium.

On Wednesday morning. May 5, the Northwest Industrial
Medical Conference opened at 8:00 A. M. Dr. J. R. Kuth, I
Duluth, Dr. W. McK. Craig, Rochester, Dr. H. W. Meyer-
ding, Rochester, Dr. Maxwell J. Lick, Erie, Pennsylvania, and
Dr. Wallace Cole, St. Paul, were speakers.

At 10:00 A. M. came the secretary's report and the installa-
tion of officers. At 3:00 P. M. on Wednesday the meeting
was ended by a panel on industrial medicine headed by Dr.
A. W. Adson, Rochester.

Dr. James M. Hayes, Minneapolis, is the new president of
the Minnesota State Medical Association, and will take office
on January 1, 1938. Dr. W. R. McCarthy, St. Paul, is 1st
vice-president; Dr. B. A. Smith, Crosby, is 2nd vice-president:
Dr. E. A. Meyerding, St. Paul, is the re-elected secretary; and
Dr. W. H. Condit, St. Paul, is the treasurer. Dr. W. W.
Will, Bertha, is speaker of the House of Delegates; Dr. Joel
C. Hultkrans, St. Paul, is vice speaker; Dr. Chester A Stew-

THE JOURNAL-LANCET

279

art, Minneapolis; Dr. B. J. Branton, Willmar; Dr. George
Earl, St. Paul; and Dr. Edwin J. Simons, Swanville; are coun-
cillors. Dr. J. T. Christison, St. Paul, is the association’s dele-
gate to the American Medical Association's meeting in At-
lantic City, and Dr. Meyerding is his alternate.

Mrs. W. B. Roberts, Minneapolis, is the new president of
the Minnesota State Medical Association’s Woman’s Auxiliary
for 1937-1938. Mrs. John Dordal, Sacred Heart, is a vice-
president; Mrs. G. E. Hertel, Austin, is auditor; and Mrs.
R. J. Josewski, Stillwater, is treasurer.

MINNESOTA RADIOLOGICAL SOCIETY
Annual Meeting
St. Paul, Minnesota

The annual meeting of the Minnesota Radiological Society
was held in St. Paul, Minnesota, in connection with the meeting
of the Minnesota State Medical Association. The annual Car-
man Lecture was delivered to the general assembly of the
Minnesota State Medical Association by Dr. Edward H. Skin-
ner, of Kansas City, on "Reflections on the Roentgenology of
Fractures.”

Dr. Skinner also addressed the Minnesota Radiological So-
ciety on the subject "Comments upon Early Books upon Elec-
tricity and the Roentgen Ray.”

Dr. Robert S. Stone of San Francisco delivered the annual
Christian Lecture on Cancer before the State Medical Society.
His subject was "Irradiation Therapy of Tumors with a Con-
sideration of the Possibilities of Supervoltage X-rays.” He also
addressed the Minnesota Radiological Society on "The Profes-
sional and Economic Status of the Radiologist."

Officers for the coming year were elected as follows: presi-

dent, Dr. Walter H. Ude, Minneapolis; vice-president, Dr.
Leo G. Rigler, Minneapolis; secretary-treasurer, Dr. Harry
Weber, Rochester.

Leo G. Rigler. M.D.

Secretary-T reasurer.

NORTH DAKOTA STATE MEDICAL
ASSOCIATION
Annual Meeting, Grand Forks
May 16, 17 and 18, 1937

The 50th annual meeting of the North Dakota State Medical
Association opened at Grand Forks on Sunday, May 16; and
most of the morning was devoted to registration. The after-
noon was devoted to scientific exhibits and lectures; but the
same day, Dr. H. P. Rosenberger, Bismarck, was elected
president of the North Dakota Academy of Ophthalmology
and Otolaryngology. Dr. Nelson A. Youngs, Grand Forks,
became vice-president; Dr. F. L. Wicks, Valley City, was
chosen secretary; and Dr. A. D. McCannel, Minot; Dr. Axel
Oftedal, Fargo; and Dr. J. P. Miller, Grand Forks, were
elected counsellors.

Tuesday morning opened with a scientific session in the high
school auditorium at 9:00 A. M. At noon, the North Dakota
Health Officers’ Association met, with Dr. Leonard W. Larson,
Bismarck, presiding. Dr. George U. Ivers, Fargo, was elected
president of this group; Dr. W. A. Wright, Williston, was
chosen vice-president; Dr. Maysil I. Williams, Bismarck, was
elected secretary.

On Tuesday, the North Dakota State Medical Association
elected Dr. William H. Long, of Fargo, to the presidency. Dr.
Long will succeed Dr. Edwin Lincoln Goss, who became presi-
dent at this convention. The new 1st vice-president is Dr. H.
A Brandes, Bismarck. Dr. A. W. Skelsey, Fargo, was re-
named secretary; and Dr. W. W. Wood, Jamestown, was
chosen treasurer again. Dr. Aloysius Patrick Nachtwey, Dick-
inson, is delegate to the American Medical Association meeting
at Atlantic City; and Dr. Clyde Ernest Stackhouse, Bismarck,
is his alternate.

Dr. William Crozier Fawcett, Starkweather; Dr. William
Albert Gerrish, Jamestown; and Dr. Jesse William Bowen,
Dickinson, were recommended to the State Board of Medical

Examiners. Dr. Fawcett also was elected delegate to the Amer-
ican Medical Association’s meeting in behalf of the University
of North Dakota Medical School.

New counsellors are: Dr. George Francis Drew, Devil’s
Lake; Dr. Phillip G. Arzt, Jamestown; Dr. Frederick William
Fergusson, Kulm; and Dr. Albert Edgar Spear, Dickinson.

Of especial interest to physicians attending this 50th anni
versary of the 1st year of the association, was the Golden
Jubilee service held at 11:30 A. M. on Monday, May 17, with
Dr. James Grassick presiding. Dr. Grassick read his paper,
"Fifty Years Ago”; and introduced the five living physicians
who held licenses in North Dakota's territorial days. These
are: Dr. Henry O'Keefe, Grand Forks; Dr. Charles Me

Lachlan, San Haven; Dr. George W. Glaspel, Grafton; Dr.
James Prentiss Aylen, Grafton; and Dr. James Grassick, Grand
Forks.

Mrs. A. W. Ide, St. Paul, Minnesota, presented a report
of the first year of the North Dakota State Medical Associa-
tion, written by her father, the late Dr. J. G. Millspaugh (see
The Journal-Lancet. February 1, 1936, p. 65). Mrs. E. C.
Flaggensen spoke briefly on the trials of a pioneer physician’s
wife.

The North Dakota Academy of Ophthalmology and Oto-
laryngology held its nineteenth annual session at Grand Forks
May 17th, under the presidency of Dr. J. P. Miller. Dr.
Arthur E. Smith of Los Angeles presented an illustrated ad-
dress on "Reconstructive and Plastic Oral Surgery.” Officers
elected included: Dr. H. Rosenberger, Bismarck, president;

Dr. N. A. Youngs, Grand Forks, vice-president; Dr. F. I..
Wicks, Valley City, secretary-treasurer. Counsellors: Dr. A.

D. McCannel, Minot; Dr. J. P. Miller, Grand Forks; Dr.
Axel Oftedal, Fargo.

SOUTH DAKOTA STATE MEDICAL
ASSOCIATION

Annual Meeting, Rapid City, S. D.,

May 24, 25 and 26, 1937

South Dakota physicians gathered at Rapid City for the
56th annual meeting of the association; and about 35 mem-
bers of the Woman's Auxiliary were in attendance concom-
itantly. The House of Delegates convened on Monday eve-
ning, May 24, to elect a committee on nominations, and to
consider other business.

On Tuesday morning, May 25, Dr. Albert M. Snell,
Rochester, Minnesota, associate professor of medicine in the
University of Minnesota Graduate School of Medicine, was
on the program. Dr. Myron O Henry, Minneapolis, instructor
in orthopedic surgery in the University of Minnesota, held a
fracture clinic; and Dr. Claude F. Dixon, Rochester, Minnesota,
associate professor of surgery in the Minnesota graduate school,
spoke. Dr. George Edwin Robertson, Omaha, Nebraska, in-
structor in pediatrics in the University of Nebraska College of
Medicine, was also a speaker.

Tuesday afternoon the same speakers took part in a general
scientific session, with the addition of Dr. Harry M. Weber,
Rochester, Minnesota, instructor in radiology in the University
of Minnesota Graduate School of Medicine.

The joint banquet was held Tuesday evening, with Gov-
ernor and Mrs. Leslie Jensen, Mrs. N. J. Nessa, Sioux Falls,
and Dr. R. J. Jackson, of Rapid City, as special guests. Dr.
J. L. Stewart, Nemo, president of the association, delivered an
address; as did Dr. E. A. Pittenger, Aberdeen, the presi-
dent-elect. Dr. R. G. Leland, Chicago, director of the bureau
of economics of the American Medical Association, was a ban-
quet speaker. Dr. Paul P. Ewald, president of the Black Hills
Medical Society, was toastmaster.

Dr. E. A. Pittenger, chosen president last year, was inaug-
urated into office. Dr. J. F. D. Cook, Langford, the retiring
secretary-treasurer, was elected president for 1938-1939, to take
office at the 1938 convention. Dr. B. A. Dyar, Pierre, becomes
the executive secretary; and Dr. C. E. Sherwood, Madison, is
the secretary-treasurer. Dr. D. S. Baughman, Madison, will
succeed Dr. Sherwood as councillor from the Madison district.

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Dr. J. L. Stewart, Nemo, was elected councillor-at-large, and
the present councillors from the Black Hills, Rosebud, Kings-
bury, and Whetstone districts were re-elected.

On Wednesday morning, the physicians went on a tour of
the Black Hills, and visited the state tuberculosis sanatorium at
Sanator in the afternoon, where Dr. Vincent Sherwood, super-
intendent, was host. Papers were read by Dr. Thomas J. Kin-
sclla, Minneapolis, of Glen Lake Sanatorium, Oak Terrace,
Minnesota; and Dr. Sherwood. Dr. Harry M. Weber, Roches-
ter, Minnesota, conducted a clinic.

Huron, South Dakota, is the meeting-place of the associa-
tion for 1938.

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of February 10, 1937

The regular monthly meeting of the Minnesota Academy of
Medicine was held at the Town S: Country Club on Wednesday
evening, February 10, 1937. Dinner was served at 7 o’clock
and the meeting was called to order at 8 o’clock by the Presi-
dent, Dr. E. M. Jones.

There were 42 members present.

Dr. S. Marx White read the following memorial of the
Necrology Committee:

RICHARD OLDING BEARD was born December 20,
1836, at Tollington Park, Middlesex, England, the son of
Richard and Anne Beard. His father was a manufacturer. He
was educated at Camden House Academy, Brighton, England,
and came to the United States in ioo9, sectnng lusc m
Chicago. He was engaged as book buyer and stock clerk for
two large book concerns for a period of about eight years.
Graduated from the Department of Medicine of the North-
western University in 1882, he came at once to Minneapolis,
Minnesota, where he engaged in the active practice of medicine.
He was Assistant Commissioner of Health from 1886 to 1889.

He was one of the founders of the Medical School of the
University of Minnesota in 1888 and took an active part with
Dean Frank Fairchild Wesbrook in the movement which re-
sulted in the unification of medical teaching in this state at the
University of Minnesota in 1908. He was Secretary of the
Faculty of the Medical School from 1888 to 1903 and from
U06 to 1925, and was Head of the Department of Physiology
from 1888 to 1912. Holding the Professorship of Physiology
in the Medical School from 1888 to 1925, he retired from
active teaching in the latter year, becoming Professor Emeritus.
He founded the School of Nursing at the University of Min-
nesota in 1909. This was the first true University Nursing
School. He was active in the organization of the Centra!
School of Nursing at the University of Minnesota in 1921,
uniting the nursing services of four major hospitals with the
school. He also initiated movements to establish endowment
funds for the Nursing and Medical Schools of the University.

Upon retirement from active duty in the University, he was
engaged in the direction of public health work, serving as
Executive Secretary of the Health Council of the City of
Minneapolis and the County of Hennepin from 1925 to 1932.
During a part of this time, also, he was active as chairman of
a voluntary committee for the promotion of legislation to es-
tablish a psychopathic hospital at the Medical School. Upon
retirement in 1932 from public health work, he devoted him-
self to writing. His death cut short a monumental task to
which he had laid his hands, that of writing a history of the
Mayo Clinic. During the early part of his active life he wrote
many articles for medical journals and later gave addresses
on medical and nursing education and in public health in-
terests in thirty-four states of the Union.

His relation to the Minnesota Academy of Medicine is of
interest at this point. He was a Charter Member in the or-
ganization, founded in 1887. There is some question as to
whether there were 37 or 38 charter members, but there is no
question as to his status as he served as the Minnapolis Secre-
tary until October 1889. During this same period Dr. E. C.
Spencer served as Secretary for St. Paul. By October, 1889

co-secretaries seemed to be no longer necessary and Dr. Beard
was elected Secretary-Trasurer, an office he filled until October.
1903, when he was succeeded by Dr. Arthur W. Dunning.
On October 3, 1906, he was elected President and his presi-
dential address, read at the meeting of November, 1906 was
entitled: "The Relation of Physiological Chemistry and Physio-
logical Microscopy to Medical Practice.” Indicative of the
character of his interests are the titles of the first two papers
he read before the Academy, the first on June 1, 1889, on
"The Causes of Infant Mortality” and the next in 1891, on
"Physiology of Sleep and the Physiological Treatment of In-
somnia.” Dr. Beard was elected to honorary membership in
the Academy on April 15, 1925.

He was a member of Alpha Kappa Kappa fraternity; honor-
ary member of Hennepin County Medical Society, Minnesota
State Medical Association, State Organization of Public Health
Nursing; Fellow of the American Medical Association and the
American Public Health Association; member of the American
Hospital Association; honorary Fellow (formerly Secretary,
Vice-President and President) of the Minnesota Academy of
Medicine; and an honorary member of the National League
of Nursing Education.

Dr. Beard stood foursquare for everything in which he be-
lieved. He was a trenchant speaker and fluent writer with an
unusual command of the English language. His many students
remember well his clean-cut characteristics of speech and action.
He took an effective part in the movement which resulted in
the affiliation of the Mayo Foundation with the University.
Following that, he became the outstanding leader in the develop-
ment of nursing education in Minnesota, a leadership which
has had its effects far beyond the confines of this state. Dying
just a few months short of his 80th birthday and invalided
for the greater part of the last year and a half of his life, he
was unable to complete his last great wish — that it might be he
who should write the first real history of the Mayo Clinic and
its founders. His initiative, unremitting energy and determi-
nation were an example to all.

The Committee:

J. F. Corbett

H. L. Ulrich,

S. Marx White, Chairman

The scientific program followed.

SPINAL CORD TUMOR

E. M. Hammes, M.D.

ST. PAUL

Dr. Hammes reported two cases of spinal cord tumor: (1) a
typical textbook case, and (2) a most atypical case with rapid
onset, a remission of several months, and a sensory level four
dorsal segments lower than the tumor mass.

Case 1. The patient was a female, age 35, and was referred
to us by Dr. W. C. Carroll, St. Paul, on December 12, 1935.
The family and personal histories were negative except for an
appendectomy at the age of 23 and a cholecystectomy at the
age of 28.

In July 1934 she began to have pain in the upper right ab-
dominal quadrant. This manifested itself only at night while
lying down. Because of continued pain and loss of sleep she
lost 28 pounds during the following year. About July 1935,
one year after the onset of her pain, she noticed a slight stiff-
ness in her knees and ankles. Her gait gradually became un-
steady, especially when walking in the dark or with her eyes
closed. This stiffness was more pronounced in her right leg.
About this time she noticed some numbness in her toes which
gradually extended upward to the level of the knees. During
the early part of November the right leg began to tire easily,
and the knee and ankle had a tendency to "give way. ' There
had been some edema of both ankles since the middle of
October.

The pain continued, was aggravated by coughing and sneez-
ing, and on November 3, 1935, an exploratory laparotomy was
performed under spinal anesthesia. Numerous dense adhesions
were severed, but the pain continued.

Neurological examination on December 12, 1935, revealed the

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281

Case 1. Sensation: Over dark band — hyperesthesia. Over

shaded area tactile, pain and temperature sense impaired. Deep

muscle and vibratory sense lost.

following: Cranial nerves and upper extremities negative except
for a slight intention tremor of the right arm The Romberg
was positive with a tendency to fall to the right. She walked
with difficulty and with a definite spastic gait. Both lower ex
tremities were definitely spastic, the right more marked than
the left. Both knee jerks were markedly increased with a bilateral
patellar clonus. Both ankle jerks were definitely increased
with a bilateral ankle clonus. There was a bilateral Babinski.
While lying down she was able to execute the movements with
the left leg more readily than with the right leg. There was
a bilateral ataxia with the knee-heel test. This she executed
with the right leg with great difficulty. There was no evidence
of muscle atrophy, but slight edema with definite pitting of
both ankles. The lower abdominal reflexes were absent; the
upper ones were questionable. Sensation was normal over the
face, both upper extremities, and the chest. On the right side
about two inches above the umbilicus there was a band about
one inch wide extending around the right upper abdomen.
This band was somewhat hyperesthetic to touch and pain as
compared to the left side. Below this there was a small band
where touch and pain and temperature sense were quite normal.
Immediately below this about one inch above the umbilicus and
from there down over the remainder of the right trunk and
right leg, touch, pain, and temperature sense were somewhat
impaired but could be definitely recognized. Over the anterior
surface of the right thigh to a short distance below the knee
there was an indefinite area of hyperesthesia where pin pricks
were quite painful. Over the left trunk from the level of the
umbilicus, over the left trunk and the entire left leg, touch,
pain and temperature sense were impaired but could be recog
nized. Position and deep muscle sense were lost in both lower
extremities. Vibratory sense was lost over both ankles and both
knees, with some inpairment on the pelvic brim.

Her hemoglobin was 78 per cent; blood pressure 122/74;
urine normal. The blood Wassermann was negative.

On January 6, 1936, a lumbar puncture was performed.
The spinal fluid pressure was 14 mm. of mercury with some
evidence of block. The spinal fluid presented a Nonne Froin
syndrome. It was xanthochromatic and coagulated to a solid
mass within thirty minutes. The Wassermann and colloidal
gold tests were negative. Because of the spontaneous coagula-
tion, no further tests could be made. There was no change in
her symptoms following the lumbar puncture.

Roentgenologic studies of the spine were negative.

A diagnosis of non-malignant intradural extramedullary cord
tumor, located on the right side at the level of the eighth dorsal
segmant was made. On January 27, 1936, a Iamenectomy was
performed by Dr. Carroll, and a tumor was found at the level
of the eighth dorsal segment, intradurally and attached to the

Case 2. Sensation: Over shaded area — tactile, pain, tempera

ture, vibratory and deep muscle sense are impaired.

meninges. This was easily removed. It was the size of a large
hazel nut.

The microscopic diagnosis was a meningioma. The patient
made an uneventful convalescence.

Examination on March 6, 1936, was entirely negative except
for some hyperesthesia over both thighs and some subjective
complaint of stiffness of the toes.

Case 2. A male, age 36, a farmer, was referred to us by
Drs. Kalinoff and Brekke, Stillwater, Minnesota, on October
25, 1935.

The family and personal histories were essentially negative.

In October 1934, the patient developed some pain in his left
hip. This was constant for a week and then subsided. About
two weeks later he developed marked attacks of flatulency and
belching. This continued and on November 17, 1934, an
appendectomy was performed, without relief. When he began
to get about following the operation he noticed some weakness
in his legs, especially the right one. He also had some in-
voluntary urination which subsided in two weeks. The weak-
ness in his lower extremities gradually grew worse. About
January 1935, both legs had become so weak and spastic that
he was unable to walk without assistance. He also had a return
of his involuntary urination. This continued until about May
1935. He began to improve so that during July, August and
September he was able to attend to his work on the farm,
plow, run a mower, and walk over a mile daily. Early in Octo-
ber 1935, he had a rapid return of his symptoms. His lower
extremities became spastic with occasional involuntary jerkings,
so that he was unable to walk without assistance. He was un-
able to void and had to be catherized. There was no pain at
any time.

About October 20, 1935, Dr. Kalinoff performed a lumbar
puncture. The spinal fluid was yellowish, the Kolmer and
Kline were negative, Colloidal gold curve 1233443211.

The neurological examination on October 26, 1935, revealed
the following: The pupils were equal and round and responded
to light and accommodation. The fundi were normal. The
fields of vision were normal on rough testing. The eye move-
ments were normal and there was no nystagmus. All other
cranial nerves were normal. Both upper extremities showed
normal reflexes, normal sensation, normal muscle strength, no
ataxia, and no tremors. We were unable to test the Romberg
because he was so spastic and was unable to stand alone. Both
lower extremities were markedly spastic with an occasional jerk-
ing of the musculature. There was a bilateral ataxia with the
knee-heel test. Both knee jerks were markedly increased with
a patellar clonus. Both ankle jerks were markedly increased and
there was a bilateral ankle clonus. There was a bilateral Babinski.
There was no evidence of atrophy or other trophic changes.
He was unable to walk without a cane. The abdominal and

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cremasteric reflexes were absent. Sensation was normal in the
face, both upper extremities, and the upper portion of the
trunk. From two inches above the umbilicus on the right side
over the right half of the abdomen and the entire right leg,
touch, pain, position, and deep muscle sense were impaired.
On the left side from the level of Poupart's ligament down over
the entire left leg there was some sensory impairment. Over
this area the prick of a pin gave him a burning feeling.

A lumbar puncture was performed on October 28th and
revealed the following: The spinal fluid was clear, pressure
8mm. of mercury, no evidence of bloc; 6 cells, a positive globu-
lin, a negative Wassermann, and a colloidal gold curve
1234221000. Quantitative protein 150 mg. per 100 cc. All
other laboratory findings and roentgenologic studies of the en-
tire spine were negative.

Because of the high protein content, an intramedullary cord
tumor was considered, but, in the absence of a spinal bloc and
with the history of a marked remission during the summer of
1935, a diagnosis of multiple sclerosis was made. He was
placed on quinine hydrochloride and triple typhoid vaccine.
His bladder condition improved considerably, but there was no
change in his sensory or motor symptoms. Within a month he
had a return of his bladder symptoms.

On January 10, 1936, the spinal fluid was yellowish, there
was some evidence of bloc, and the quantitative protein was
100 mg. per 100 cc. The sensory level remained constant, and
a diagnosis of an intramedullary cord tumor at the level of
about the seventh dorsal segment was made.

On January 22, 1936, Dr. Robert Earl performed a laminec-
tomy, removing the fourth, fifth and sixth dorsal spinous
processes. The cord appeared anemic, there was no pulsation,
but no evidence of tumor or obstruction could be found. Be-
cause of the marked hemorrhage, further exploration seemed
inadvisable.

The patient had an uneventful convalescence but no im-
provement in his symptoms.

On March 6, 1936, Dr. Earl performed another laminectomy
and removed the second and third dorsal spinous processes. At
the level of the fourth dorsal segment under the second dorsal
spinous process an intra medullary tumor about the size of a
hazelnut was found. This was infiltrated and could not be
removed. A small biopsy revealed that the tumor was a
glioma. The surgical recovery was uneventful, and there was
no improvement in his symptoms. The patient is still alive.

Discussion

Dr. H. Z. Giffin (Rochester): I would like to ask Dr.

Hammes how often he sees a cord tumor that does not cause
pain which is relieved by moving around at night?

Dr. Hammes: The pain is relieved when the patient sits up
and aggravated while in the recumbent posture, because in the
sitting posture the tension of the posterior roots is lessened,
due to the slight flexion of the vertebral column. This relief
I believe occurs only in cord tumors so located that they pro-
duce some direct pressure on the posterior sensory roots.

Dr. Giffin: What percentage of spinal cord tumors do not
have that symptom?

Dr. Hammes: I cannot give the percentage, but we see
many cord tumors in which a change of position has very little
effect, if any, on the pain itself.

Dr. S. Marx White: (Minneapolis): Do you frequently

find cases in which the tumor is located in the upper dorsal
segments and the sensory level indicates a much lower dorsal
segment lesion, such as occurred in your second case?

Dr. Hammes: The marked difference between the sensory
level and the location of the tumor is quite infrequent. In the
second case the tumor was small and intramedullary. The main
pressure was probably exerted on the long posterior fibers,
while the laterally placed sensory fibers escaped. The more
centrally placed fibers, i. c., those nearer the posterior septum,
control sensation in the lower portion of the trunk and lower
extremities. This may explain the marked difference between
the sensory level and the tumor in this case.

Dr. William Davis (St. Paul): I was interested in what
Dr. Hammes said about lying down increasing the pain, and

that the pain was better during the daytime, and that it was
due to pulling on the sensory roots. Wouldn't that explain
what I have noticed in several cases of herpes zoster, that the
patients have less pain when upright, especially in cases of
herpes zoster where the dorsal or lumbar nerves are affected?

Dr. Hammes: I do not know, but that would seem a logical
explanation.

Dr. W. H. Hengstler (St. Paul) : One of the interesting
things about that second case was that the man showed early
bladder involvement. That is an interesting point in the diag-
nosis of intramedullary tumors. They frequently show bladder
involvement before anything else. I think it is an important
thing that he had bladder involvement early in the disease,
from the diagnostic standpoint.

A SUGGESTION IN THE TECHNIC OF
CHOLECYSTECTOMY FOR THE COMPLICATED
CASE OF GALLBLADDER DISEASE

Harry P. Ritchie, M. D.

ST. PAUL

Dr. Harry P. Ritchie, of St. Paul, read a paper on the
above subject, and showed lantern slides of the technic of the
operation.

Abstract

A plan for removal of the gallbladder was suggested for
those cases wherein a risk of injury to structures about the
gallbladder is possible in the attempt at cholecystectomy by the
formal up-down or down-up methods of procedure.

The first step is to split the gallbladder by a median in-
cision, a distance from the dome to a point where the opening
of the systic duct is identified from within. The second step
is to "wing" the gallbladder by two parallel incisions made in
the same direction as the first, and far enough away from the
normal attachments of the gallbladder to the liver to preserve
them completely. The "wings" of the gallbladder are removed.
These two steps leave a situation which can be pictured as a
ladle, the handle of which is the strip of the gallbladder wall
with its mucous membrane lining and its normal attachments
to the liver; the cup of the ladle is the mucous-membrane-
lined base of the gallbladder. The third step is the dissecting
of the mucous membrane of the handle and the cup away from
the wall, thus removing the mucous membrane entirely. The
fourth step is the suturing of the wall of the cup about a
drainage tube and the suturing of the wall of the handle to
diminish raw surfaces and control bleeding.

The main objection to the plan is that, by opening the gall-
bladder so widely, infectious agents are released upon the peri-
toneum. This is a valid objection, which the surgeon must
consider in each case on the question of cholecystotomy and
drainage on the one hand, or the attempt to remove the gall-
bladder by formal methods under difficult and dangerous cir-
cumstances.

The justification for the procedure is found in the studies
of Andrews on the infectious nature of the gallbladder con-
tents. Andrews questions the appropriateness of the term "em-
pyema of the gallbladder.” His studies fit into the clinical
experiences of the writer in sixteen cases of cholecystectomy per-
formed by the above-described method over a period of fifteen
years. In this small series of selected cases, the mortality has
been nil. In only one case was there postoperative concern;
the story' of this case was reported in detail.

Emphasis was made in the plea that such unusual surgery
should not be interpreted as a substitute for formal steps, but
was offered only as an emergency procedure in certain com-
binations of circumstances. The plan meets the surgical prin-
ciple of any cholecystectomy, which is the removal of the mu-
cous membrane of the gallbladder, and eradicates the danger of
injury to the common duct and traumatism to and exposure of
denuded surfaces of the liver.

Discussion

Dr. E. M. Jones (St. Paul): Dr. Ritchie's paper is very
interesting. These severe gallbladder cases often give the sur-
geon a great deal of concern. I recall two cases in particular,
in which it would have been wiser to have followed some such

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283

procedure. In doing a cholecystectomy, the clamps applied to
the cystic duct cut through. It was necessary to apply the
clamps to the cystic artery and the cystic duct and leave the
clamps in situ. Fortunately, both of these patients recovered.

Dr. Ritchie (in closing) : There are causes of obstruction

of the biliary ducts other than surgical traumatism, but the
surgeon is challenged when this condition follows operation.
There are procedures in the literature which remove most of
the wall and mucous membrane, leaving a part of the gall-
bladder with the normal attachments to the liver, just as I
have illustrated. Thorek does so, then destroys the mucous
membrane of the handle and cup with the endotherm, brings
over the falciform ligament and sews it to the outer margin
of the handle. Raymond McNealy iodinizes the mucous mem-
brane after winging the gallbladder and uses the ligament to
protect the peritoneal cavity. Denegre Martin, of New Orleans,
in 1921 and again in 1926, reports a series of cases treated
along similar lines. All of them report satisfactory recoveries.
When I read their reports, I wonder whether I have made a
mountain out of a molehill. But I believe the surgical dissec-
tion of the mucous membrane is founded on proper principle.
As I pointed out in the paper, what I suggest is that an old
gynecological operation be applied to the complicated case of
gallbladder disease.

MALIGNANT HYPERTENSION

Moses Barron, M.D.

MINNEAPOLIS

Abstract

There are several synonyms, such as malignant nephrosclero-
sis, malignant arteriolar sclerosis, malignant phase of essential
hypertension. Essential hypertension is extremely common. It
was first identified after the invention of the sphygmomanom-
eter by von Basch in 1893, separating essential hypertension
from that associated with glomerulonephritis. Volhardt differ-
entiated between "pale” hypertension of nephritis and the "red”
hypertension of the essential type. The former is supposed
to be associated with a pressor substance circulating in the blood
which is liberated in the later stages by the kidney parenchyma.
The latter is the result of arteriosclerotic changes with hyper-
trophy of the elastica and hyalinization in the precapillary
arterioles. Constitution seems to be the only definite etiological
factor so far known. Essential hypertension is not common
before 40; is most common between 50 and 60. The histology
shows a degenerative change in the peripheral arteries and ar-
terioles producing rather rigid tubes and increasing the peri-
pheral resistance. In the early stages there is increased vaso-
motility with marked fluctuation in the blood pressure. This
is elicited by Brown’s "cold” test for early stages of hyper-
tension.

The benign hypertension is a chronic ailment, and may run
for ten to twenty-five years. The termination is either from
congestive heart failure, coronary disease or cerebral hemorrhage.
About ten per cent of the deaths are due to renal insufficiency.
A few of these kidney deaths are due to a gradual obliteration
of individual glomeruli resulting in shrinking of the kidney.
This may go on to renal insufficiency. This type, however,
is not included in malignant hypertension.

Another small group may be the result of a true glomerulo-
nephritis being superimposed upon the benign hypertension.

By malignant hypertension is understood a condition in
which there is usually a history of hypertension, of longer or
shorter duration, upon which there is superimposed a rapidly
developing and progressive renal insufficiency. The blood pres-
sure rises, the patient becomes pale, loses his appetite, develops
weakness, becomes apathetic, sensorium becomes cloudy; there
is usually a complaint of severe headache. Examination shows
i very high blood pressure, very little edema as a rule, more
or less anemia, heart enlarged and pounding, and eye-grounds
show evidence of an angiospastic condition of the blood vessels
with degenerative changes in the retina; the picture is what is
Known as hypertensive neuroretinitis or neuroretinopathy. There
•fften is no congestive heart failure associated with it but there
fnay be mild or even severe degrees of heart failure accompany-

ing the kidney change. It occurs principally in younger per-
sons between thirty and forty-five. The blood chemistry will
show a retention of metabolites and the patient will proceed
rapidly into true uremic coma and will die in uremia, often
in convulsions.

The clinical picture is, therefore, one which starts as a be-
nign hypertension, upon which is superimposed the clinical
findings of a true nephritis which ends in uremia. Patho-
logically the kidneys show lesions other than those from a
glomerulonephritis. There is extensive degeneration often with
necrosis of the arteriolar vessels in the kidney and also end
arteritis which bring about the ischemia of the glomeruli and
the resultant renal insufficiency. Several cases were reported
illustrating the condition.

Discussion

Dr. John F. Noble (St. Paul) : Dr. Barron approached

me just before the meeting and inquired whether or not I was
the only member of the department of pathology present. He
seemed relieved when he found I was the only representative
present. I find his pathological concepts sound and orthodox.
With reference to his clinical description of the red and pale
hypertensive patient, representing respectively the case of ma-
lignant hypertension and the patient with chronic glomerulo-
nephritis, let me say that, while early in the disease this may
be of some value, later when uremia develops, the patients be-
come very anemic in both instances.

I would also like to emphasize the fact that late in the pic-
ture clinical differentiation is very difficult and sometimes even
histologic studies are confusing. Special stains are frequently
necessary to arrive at a correct diagnosis.

The term malignant hypertension is frequently used very
loosely. Dr. Barron has defined malignant hypertension as
having certain definite characteristics, namely, rapid onset of
uremia and typical necrotic lesions in the arterioles of the
kidney. If this term is to be used, I believe some such defini-
tion should be made.

Dr. H. W. Grant (St. Paul) : I think this question is im-
portant from the standpoint of the ophthalmologist because he
is constantly coming in contact with cases of choked disc asso-
ciated with the characteristic general picture of which Dr. Bar-
ron has spoken. Ordinarily it is usual to recognize in exam-
ination of the fundus three types of cases: the arteriosclerotic,
the atheromatous sclerosis, and the essential hypertension in
its various stages. Atheromatous sclerosis may be present from
birth or until sixteen years of age, and then usually has a tend-
ency to disappear until later life. Usually the characteristic
picture of essential hypertension is an infiltration of the vessel
wall. This has a tendency to produce an infiltration of the
arteriovenous crossing, as these vessels have a common outer
coat. Not all changes at the arteriovenous crossings are, how-
ever, of this nature, as some distortion at this point may be
produced by contraction of the arterial wall without any in-
filtration. Following the infiltration of the vessel wall there are
likely to be hemorrhages because of the necrosis which results.
It is much less likely that hemorrhage results in an atheroma-
tous sclerosis because of the actual thickening of the vessel
wall Apparently all cases of choked disc dependent upon
malignant hypertension do not have characteristic findings.
Some are present without headache, which is usually one of
the more pronounced symptoms. They do, however, have the
piling up of fat in the superficial retinal layers probably due
to the fact that the lipoid content of the retina is higher than
that of any other structure of the body, the brain ranking sec-
ond. This fat is likely to be dissolved out in most sections, but
can easily be demonstrated in flat sections of the retina which
are unstained.

Dr. Barron (in closing) : Dr. Noble asks about the question
of the "paleness” in malignant hypertension. I suggested its
cause in the discussion but did not emphasize it enough.
The "paleness” is due, first, to the spastic condition of the
blood vessels, and, second, to the development of the anemia.
It is true that in some cases it is not easy to differentiate
nephritis from malignant hypertension by the microscopic sec-
tions. In a few cases we have true glomerulonephritis super

284

THE JOURNAL-LANCET

imposed upon the benign hypertension. In malignant hyper-
tension there is no evidence of inflammatory changes which can
be seen in glomerulonphritis. The endarteritis is an important
finding emphasized by the authorities and it is not due to in-
flammation.

As to the question about necrosis, we do not believe that
the hyalin change seen in the arterioles of essential hypertension
is a necrotic one. It seems to be due to a certain degenerative
change of the fibers into hyalin material. The staining reaction
is often different from that of necrotic material.

After the scientific program, Dr. Barron showed motion
pictures which he had taken last summer on the Academy's
trip on the Mayo yacht, and also at a picnic which had been
held at Dr. Archa Wilcox’s summer home.

The meeting adjourned. A. G. Schultze. M.D.

Secretary.

Grafton, North Dakota, Passes a Fracture
Ordinance With a Penalty Clause
ORDINANCE NO. 115

An Ordinance Regulating the Equipment and Operation

of Ambulances Within the City of Grafton, North

Dakota.

BE IT ORDAINED by the City Council of the City of

Grafton, North Dakota:

Section 1. No person, firm or corporation shall operate
or cause to be operated any ambulance, public or private, or
any other vehicle commonly used for the transportation or con-
veyance of the sick or injured, without having such vehicle
equipped with a set of simple first aid and splint appliances
approved by the Superintendent of the Board of Health and
having in attendance at all times such vehicle is in use a person
who has obtained a certificate of fitness as an ambulance at-
tendant from the said Superintendent of the Board of Health.

Section 2. Any person desiring a certificate as an ambulance
attendant shall make application in writing therefor to the
Superintendent of the Board of Health. Before the issuance
of any such certificate the applicant therefor must present evi-
dence of his qualifications to fill such position and must dem-
onstrate to the satisfaction of the Superintendent of the Board
of Health his ability to render emergency first aid and to
supply approved splints to arm and leg fractures.

Section 3. Any person violating the provisions of this ordi-
nance shall in each case be subject to a penalty of not less than
Five ($5.00) Dollars nor more than Twenty-five ($25.00) Dol-
lars, and as to the like penalty for each week he shall fail to
comply with the provisions thereof or continue in the violation
of same to be recovered in any Court having jurisdiction.

Section 4. This ordinance shall take effect and be in force
from and after its passage, approval and publication.

First Reading March 1, 1937.

Second Reading and Final Passage April 5, 1937.

Publication April 14, 1937.

Approved this 5th day of April, 1937.

Henry L. Sieg,

Mayor.

Filed in my office this 5th day of April, 1937.

W. F. Schutt,

City Auditor.

MINNESOTA STATE BOARD OF
MEDICAL EXAMINERS
Julian F. DuBois, M.D., Secretary
St. Paul, Minnesota
DOCKET OF CASES

STATE OF MINNESOTA versus JOHN STANLEY,
also known as WILLIAM STANLEY.

STATE OF MINNESOTA versus BILLY STANLEY,
also known as BILLIE STANLEY.

On May 15, 1937, Sheriff Arthur Brown and two deputies,
George Kelly and Arthur Murray, arrested two "Indian
doctors” in Crooked Creek Township, Houston County, Min-

nesota. On May 16 they pleaded guilty before Mr. Jerry
Kenny, a justice of the peace, to selling herbs and drugs, hav-
ing no medicinal value. Billie Stanley, who deposed that she was
the wife of John Stanley's father, was fined the sum of $40.00
and $20.00 costs, which was paid. John Stanley was put on
probation to the sheriff, and both defendants, together with the
husband of Billy Stanley, were given 24 hours by the Court to
leave the State of Minnesota. The two defendants claimed to
be 22 years of age, and to be of Osage and Cherokee ancestry.
They claimed to have been living in Minnesota less than 30
days, and to have been residing near Canton, Minnesota.

The Minnesota State Board of Medical Examiners commends
Sheriff Brown and his deputies, and also Mr. L. L. Roerkohl,
county attorney of Houston County, who handled this case.

NEWS ITEMS

A $50,000 addition to the Kalispell General Hospital
in Kalispell, Montana, will be erected soon.

Dr. Oscar C. Heyerdale, for 38 years associated with
the Rochester State Hospital, operated by the Minnesota
State Board of Control, will retire on July 1.

The Knights of Columbus of Devil’s Lake, North
Dakota, donated $800.00 to Mercy Hospital in Devil’s
Lake on April 26.

Dr. Donald Emerson Hale, a member of the Butte
Clinic, Butte, Montana, spoke before the Butte Ex-
change Club on April 13 on "Modern Surgery.”

Dr. Edward Harold Frost, Willmar, Minnesota, is
the new president of the Great Northern Railway Sur-
geons’ Association.

Dr. A. G. Berger, a graduate of the University of
Minnesota School of Medicine, is the new city quaran-
tine officer for Minneapolis.

Dr. William Edward Macklin, Jr., of Litchfield, Min-
nesota, has moved his offices to the second floor of the
Askeroth Building in Litchfield.

Dr. Robert Wilson Campbell, Cass Lake, Minnesota,
has moved to new offices in the Cass County Hotel
building.

The Right Reverend Bishop Bernard J. Mahoney, of
the Sioux Falls diocese, officiated at the dedication of
the new annex to Saint Joseph’s Hospital in Sioux Falls
on April 14.

Sister M. Jolenta, O. S. B., for 26 years nurse and
supervisor of Saint Alexius Hospital in Bismarck, North
Dakota, died on April 20 in the hospital. She was born
on April 30, 1889, at Buckman, Minnesota.

Dr. Fred Franklin Attix, of Lewistown, Montana,
spoke at a public mass meeting to further the women’s
field campaign against cancer held at the Lewistown
Junior High School on April 28, 1937.

A gift of $36,000 from the Rockefeller Foundation
to be used for research in biology and medicine, has beer
accepted by the Board of Regents of the University oi
Minnesota.

The Northwest District Medical Society of Nortf
Dakota held its monthly meeting in St. Joseph’s Hos
pital at Minot on April 29. Dr. E. M. Ransom, Minot
spoke on "The Diagnosis of Placenta Previa.'

THE JOURNAL-LANCET

285

Dr. Arthur Raymond Zintek, a graduate of the Mar-
quette University School of Medicine in Milwaukee,
Class of 1934, has located in Lancaster, Minnesota, ac-
cording to dispatches.

Dr. John William Campbell, of Fargo, North Da-
cota, who was graduated from the Rush Medical Col-
ege of the University of Chicago in 1897, will locate in
Tutchinson, Minnesota.

Dr. Jacob Thorkelson, of Butte, Montana, was in
Large of examination of pre-school children who expect

0 enter grade school at the next term in Butte. Exam-
nations began on April 26.

More than 3,500 schools in South Dakota have taken
>art in the South Dakota Public Health Association’s
lealth poster contest, representing 45 counties of the

tate.

Dr. Homer Harold Hedemark, of Robbinsdale, Mir,-
iesota, a graduate of the St. Louis University School
if Medicine in 1933, is now a member of the Bratrud
Ilinic at Thief River Falls, Minnesota.

Dr. Robert Hugh Ray, of Garrison, North Dakota,
as been discussing plans with Dr. J. B. Simons and
)r. Edwin J. Simons, of Swanville, Minnesota, for a
ew municipal hospital for Garrison.

There are now 40 public health nurses, subsidized by
ne North Dakota State Health Department, operating
t about 40 counties of the state, according to Dr.
daysil Williams, chief of the department.

Dr. Desmond Thysell, who was graduated from the
Jniversity of Minnesota Medical School in March
937, began work as city physician in the Minneapolis
leneral Hospital on April 1st.

By action of Governor William Langer, May 12 was
eclared National Hospital Day for North Dakota,
lay 12 was the birthday anniversary of Florence
lightingale.

Owing to the fact that medical care for the poor
itients of Codington County in South Dakota cost
>,230.68 during March 1937, the county commissioners
ive decided that a revision in the fee schedule of the
B7 county contract is necessary.

Dr. Russell Aanes, son of Dr. and Mrs. A. M.
anes, of Red Wing, Minnesota, has finished his in-
rnship at General Hospital in Minneapolis, and will
associated temporarily with his father in the Medical
ock clinic in Red Wing.

The South Dakota State Planning Board has sent a
solution favoring amending a bill to authorize a 100-
d veterans’ hospital in Eastern South Dakota. The
>ard s amendment calls for a 175-bed hospital, and an
creased appropriation.

Dr. Herrick John Aldrich, a graduate of the Univer-
y of Minnesota Medical School in 1935, has re-
;ned from the Lake Kabetogama Civilian Conserva-
’n Corps medical unit to enter practice with Dr. John
ancis Briggs, of St. Paul, Minnesota.

Dr. Arthur C. Strachauer, professor of surgery in the

1 edical School of the LJniversity of Minnesota gave
*- public lecture on cancer in conjunction with the

annual meeting of the Iowa State Medical Association
at Sioux City, Iowa May 12th, 1937.

Dr. Joseph T. Newlove, for 41 years a physician at
Minot, N. D., died on April 16. Dr. Newlove was
graduated from the Wayne University College of Medi-
cine in Detroit, Michigan, in 1896. For 20 years he was
a member of the Minot Park Board.

The new government hospital for Indians at Wagner,
South Dakota, was opened on April 3, 1937, by the
Wagner Chamber of Commerce. Dr. George Hopson,
formerly of the Rosebud Agency Indian Hospital, is
superintendent.

Whitney Memorial Building, the new $275,000 wing
of Saint Barnabas Hospital in Minneapolis, was dedi-
cated on April 17 by Bishop Frank A. McElwain and
Bishop Coadjutor Stephen E. Keeler, of the Protestant
Episcopal Church.

Dr. John Thompson Bowers, Bemidji, Minnesota,
dropped dead on the evening of May 20, 1937, at his
residence, Shoreacres, on Lake Bemidji. Dr. Bowers was
graduated from Northwestern University Medical
School in 1908.

Dr. John Patrick Bartle, a graduate of the University
of Manitoba Medical School in 1934, will locate in the
Backes & Johnson Building in Langdon, North Dakota.
He formerly was with the North Dakota State Tuber-
culosis Sanatorium at San Haven.

Dr. Emil Gunvald Ericksen, health officer of Sioux
Falls, South Dakota, told the Sioux Falls Junior Cham-
ber of Commerce how the city health department’s ex-
amination of milk supplies and health tests for food
handlers, are conducted. He spoke before the organiza-
tion on April 29.

The American Student Health Association, for which
The Journal-Lancet is the official journal, announces
its editorial committee for 1937 to be: H. D. Lees,

M.D., University of Pennsylvania; D. F. Smiley. M.D.,
Cornell University; and Ruth E. Boynton, M.D., LJni-
versity of Minnesota.

The post hospitals at Fort Snelling, Minnesota, are
to be altered, with additions to certain structures, accord-
ing to advice from Major Phillip B. Fryer, Quarter-
master Corps, United States War Department, at
Washington, D. C. Major Fryer will open bids after
May 28, 1937.

Dr. George W. Swift, of Seattle, Washington, held
a brain clinic in Anaconda, Montana, before the Mount
Powell Medical Society on April 30. Dr. Walter A.
Fansler, assistant professor of surgery in the University
of Minnesota Medical School at Minneapolis, spoke on
"Carcinoma of the Rectum and Sigmoid.”

Henry Clinton Cooney, M.D., of Princeton, Minne-
sota, founder of Northwestern Hospital in Princeton,
and widely-known throughout Minnesota, was tendered
a dinner at Princeton on April 19 by many friends, on
the occasion of his 75th birthday. Dr. Cooney was grad-
uated from the University of Illinois College of Medi-
cine in 1887, and licensed the same year.

286

THE JOURNAL-LANCET

The nursing schools of the Kennedy Deaconess Hos-
pital in Havre, Montana, the Great Falls Deaconess
Hospital, and the Bozeman Deaconess Hospital in
Bozeman, will be consolidated to form the Consolidated
Deaconess School of Nursing, offering the degree of
Bachelor of Science in Nursing, according to officials.

Dr. Maysil M. Williams, state health officer of the
North Dakota Public Health Department, and a
graduate of the University of Toronto Faculty of Med-
icine in 1921, was elected vice president of the State and
Territorial Health Officers’ Association of America at
Washington, D. C., recently.

Dr. Alphonso James McLaughlin, who was born in
Lyle, Minnesota, in 1876, and who has practiced at
Sioux City, Iowa, for many years, died in Sioux City
on April 18. He was a member of the American Col-
lege of Surgeons, and of the American Urological As-
sociation.

The regular meeting of the Minnesota Academy of
Medicine was held at the Town & Country Club on
May 12, in St. Paul. Dr. J. A. Johnson, Minneapolis,
spoke on "Tumors of the Jejunum;” and a case report,
"Adamantinoma With Cyst of the Lower Jaw,” was
presented by Dr. A. R. Colvin, St. Paul.

Assistant Superintendent B. A. Dyar, M.D., of the
State Board of Health of South Dakota, announces
that a medical care program for standard loan resettle-
ment administration clients became effective in South
Dakota on May 1. It operates through the South
Dakota Farmers’ Aid Corporation, of which Dr. Dyar
is medical supervisor.

The regular monthly meeting of the Northwest Dis-
trict Medical Society was held at Trinity Hospital in
Minot on Thursday, May 27th, 1937. Dinner was
served by the hospital at 6:15 P. M. Dr. Irvine Mc-
Quarrie of the Department of Pediatrics of the Uni-
versity of Minnesota, spoke on the subject of "Con-
vulsive Disorders of Childhood.”

Dr. George Fahr, associate professor of medicine in
the University of Minnesota Medical School at Minne-

apolis, spoke before the Washington County Medical
Society at Stillwater on April 1 1 on "Hypertension.”
Dr. Everett K. Geer, St. Paul, assistant professor of
medicine, interpreted several Mantoux reactions of
students.

Dr. Myron O. Henry, of Minneapolis, was recently
made a member of the Chicago Orthopedic Society and
at the February meeting, which was a joint meeting of
the Chicago Orthopedic Society and Chicago Roentgen
Society, read his inaugural thesis on "Chip Grafts in
Orthopedic Surgery.”

For June, the radio broadcast of the Minnesota State
Medical Association is as follows: June 5, "Avitami-
nosis;” June 12, "Water Cures;” June 19, "Diverti-.
culitis of the Colon;” and June 26, "Calcium and
Denistry.” The speaker is Dr. William A. O’Briean.
associate professor of pathology and preventive medicine
in the University of Minnesota Medical School.

The annual spring conference of the Fourth Dis-
trict Medical Society of South Dakota met at Pierre or
April 16. Dr. Joseph Charles Murphy, Murdo, wa:
elected president; Dr. Isaiah Reed Sallidy, Pierre, wa;
chosen vice president; and Dr. Clarence Edward Rob
bins, Pierre, was voted secretary-treasurer. Dr. Olir
A. Kimball, Murdo, attended the meeting of the Soutl
Dakota State Medical Association at Rapid City or
May 24 as the Society’s delegate.

On Saturday, June 19, Northwestern Hospital o
Minneapolis will hold a reunion and homecoming fo
its former interns. From 8:00 A. M. Saturday to 1 : OC
P. M. there will be clinical and scientific demonstration
in the hospital by the staff; at 3:00 P. M. Saturday the
gathering will take a boat ride on the Donna May
which cruises the Mississippi River under command o .
Captain W. G. Holstrom. Dr. Arthur E. Benjamin
1727 Medical Arts Building, and Dr. William Arthu
Hanson, 1005 Medical Arts Building, Minneapolis, ar
in charge; and would like to have every former inter:
of Northwestern Hospital communicate with them fo.
this celebration.

BOOK NOTICES

A PEDIATRICS SPECIALTY

Reading, Writing and Speech Problems in Children, by SAMUEI
TORREY ORTON, M.D.: 1st edition, grey cloth, library label.
200 pages plus glossary, line cut illustrations; New York City:
The W. W. Norton Company: 1937. Price, #2.00.

Dr. Orton has specialized for many years in psychiatry and
neurology, having been professor of neurology and neuro-
pathology in the Columbia University College of Physicians
and Surgeons until recent years.

His book considers not only the etiology of childhood neuro-
logical disorders, but also the approved methods of treatment
He points out the evils of forced correction by parents. This
book represents Professor Orton’s summarized Thomas W.
Salmon Memorial Lectures given before the New York Acad-
emy of Medicine. The work is not extensive enough to be
called a full-fledged text; but it is useful and its value should
be apparent to every pediatrician.

R. R„ M.D.,

St. Paul, Minnesota.

A VALUABLE PEDIATRICS BOOK

Diseases of the Newborn, by ABRAHAM TOW, M.D.: 1st ed
rion, cloth. 477 pages and 53 illustrations; New York City: Th
Oxford University Press; 1937. Price J16.50.

This volume of 461 pages of text contains practical consic
eration of the general physiology of the new-born, of the cat
and feeding of premature and full term infants, of the disease
and congenital malformation of the skeletal, digestive, respire
tory, genito-urinary, and the nervous system of the new-borr
Chapter's are also devoted to blood dyscrasias, to diseases of th
eye, ear and nose, to infections and septic diseases, to disease
of the skin, and to a few special topics. A total of 58 illustr;
tions and 580 references to the literature are included in th
text.

This volume presents condensed and conservative discussior
of a wide variety of conditions peculiar to new-born infant
It should prove to be a valuable addition to the libraries, pai
ticularly, of physicians who are responsible for the care of th
babies they deliver.

The author is adjunct professor of pediatrics in the Ne
York Polyclinic Medical School & Hospital, New York City.

C. A. Stewart, M.D.

Minneapolis, Minnesot-

Fulminating Laryngotracheo-Bronchitis

Nelson A. Youngs, M.D.*

Philip H. Woutat, M.D.*

Grand Forks, N. D.

FULMINATING laryngotracheobronchitisf is a
non-specific infection of early childhood that at-
tacks the respiratory mucosa, causing respiratory
embarrassment and in a large number of cases, death
from asphyxia. The asphyxia is caused by glottic spasm
and subglottic swelling,1 plus the formation of muco-
purulent plugs in the bronchi. Swelling of the lining
mucosa of the main and secondary bronchi is also a
factor in some cases.

The onset is insidious. These children play and re-
act normally except for a croupy cough, until the slowly
forming obstruction becomes severe enough to cause
oxygen deficiency. Then, with startling rapidity, the
cardinal signs of laryngeal obstruction and anoxemia
develop.

According to Jackson,2 these signs are: ashy-gray
pallor, anxious expression, rapid, labored respirations,
fast pulse, restlessness, supra-sternal retraction, infra-
sternal retraction, and intercostal indrawing.

The seriousness of this condition may be better under-
stood from the fact that of 115 cases reported in the
literature 3’ 5 and 9 to 24 incl- in the past ten years,
plus the four cases we are now reporting, making a
total of 119 fulminating cases, there were 59 deaths.
The ages of these children varied between 10 months
and 9 years. Around fifty per cent occurred in child-
ren 2 years old. Figure I shows the age distribution
and mortality according to age.

t We have arbitrarily accepted fulminating laryngotracheobron-
chitis to be any laryngotracheobronchitis of such severity as to
demand tracheotomy or intubation to prevent asphyxia.

* From Healy, Law, Woutat, Moore Clinic, Grand Forks, N. D.

The dotted line, figure I, represents the number of
cases, while the solid line represents the fatalities accord-
ing to age.

The bacteriology is non-specific. Richards,3 in report-
ing a series of eleven cases, of which seven were fatal,
says, "The streptococcus hemolyticus is the organism
most frequently found. In cases with a superimposed
staphylococcic infection the destruction of the tracheal
mucosa is more marked.”

288

THE JOURNAL-LANCET

In both of our fatal cases, pure cultures of staphylo-
coccus pyogenes albus were recovered from the tracheal
secretions. Beare4 reported a fatal case in which the
staphylococcus was recovered in pure culture from the
blood stream at autopsy.

Report of Cases

Case 1 — M. M., female, aged 2. The patient was
first seen on the evening of February 14, 1934, with a
history of a cold and croupy cough since the preceding
day.

On examination, signs of laryngeal obstruction were
present.

Direct laryngoscopic examination revealed marked
swelling of the vocal cords and a considerable amount
of mucopurulent material in the trachea. The breath-
ing space was inadequate, and a tracheotomy was per-
formed.

Subsequent course was very stormy due to the for-
mation of numerous obstructing bronchial plugs, which
were removed by the following technique:

The patient was laid across the bed with head and
shoulders hanging far enough over the edge to bring
the chest into an inclined position. The operator sat
on a low stool with the patient’s head between his knees.
A small French catheter, with the tip cut off and the
edges rounded, was connected to a record syringe filled
with warm sterile normal saline solution. The tip of
the catheter was then inserted through the tracheotomy
wound as far as the bifurcation and sometimes well into
the main bronchi. From five to ten cc. of normal saline
solution was then injected as the catheter was with-
drawn. Another catheter connected to a suction appa-
ratus was then quickly inserted and the trachea and
main bronchi aspirated. Most of the liquid ran out or
was coughed out during the procedure. The remainder
was removed through the suction apparatus together
with the loosened secretions and plugs. Three or four
such irrigations were sometimes necessary at a sitting to
clear the air passages.

In this manner, obstructing plugs were removed a
total of 43 times over an eleven-day period. We have
been unable to find a similar report of pulmonary irri-
gation used in this condition. We found it to be super-
ior to bronchoscopic removal of plugs in those instances
where the obstruction was due to numerous small par-
ticles. Decannulization was accomplished on the 39th
post-operative day. The patient has remained well
since this time.

Case 2 — N. A., male, aged 4. The patient was first
seen April 12, 1933, with a history of an upper respira-
tory infection and hoarseness since April II. Respira-
tory effort had been slowly increasing since the day
before.

Examination revealed a well-nourished and developed
boy. The temperature was 100° F. by rectum, pulse
rate 130 per minute, and respirations 38 per minute.
The rest of the examination was entirely normal except
for a red throat and signs of laryngeal obstruction.

Direct laryngoscopic examination revealed consider-

able subglottic swelling. The breathing space was in-
adequate and a tracheotomy performed. Although the
time taken for these procedures was not excessive, the
patient was in a critical condition from lack of oxygen
before completion of the tracheotomy.

Although repeated cultures were negative for the
diphtheria bacillus, 20,000 units of antitoxin were
given. Convalescence was complicated by the forma-
tion of mucous plugs which were removed by suction.
Decannulization was accomplished on the thirteenth
postoperative day.

Case 3 — R. J., female, aged 18 months. The patient
was first seen on the evening of December 7, 1934, with
a history of a cold and croupy cough for the past two
days. Since morning, respiratory effort had slowly in-
creased.

On examination, the temperature was found to he
101° F. by rectum, lungs clear, heart normal, and all
the cardinal signs of laryngeal obstruction present.

Direct laryngoscopic examination revealed the pres-
ence of marked inflammatory swelling of the mucosa i
which bled easily. The breathing space was inadequate
and a tracheotomy performed.

Subsequent course for the first twenty-four hours wa*
fairly satisfactory, although symptoms of oxygen wan
were never completely relieved. In spite of every effor
to keep the air passages open, the patient died on thi
third postoperative day.

Repeated tracheal aspirations, steam, expectorants, in
tratracheal oxygen were used, as well as repeated bron
choscopic examinations to rule out obstructing plugs.

Bronchoscopic appearance of the trachea and bronch
was unusual. The mucosa was markedly swollen an<
inflammed, the carina was greatly thickened, and th
mucosa covered with patches of dirty gray scales o i
dried secretions. However, there was nothing larg
enough to remove with a bronchoscopic forceps.

Repeated cultures were reported as pure culture o
staphylococcus pyogenes albus. Permission for autops
was refused.

Case 4 — D. S., male, aged 10 months. The patien ,
was first seen at 11:00 P. M., October 10, 1935, wit
a history of a cold and croupy cough for a few day:

He had felt well enough to play with other members c
the family at supper-time, but at 8:30 P. M. the crou
became worse, and respiratory effort developed. Whe
we saw him he was in extremis, with all the signs c
anoxemia and laryngeal obstruction. Oxygen was at
ministered while a quick tracheotomy was performed.

He responded somewhat after the tracheotomy, bi
the pulse and respirations remained high. All the suj
portive measures at our command such as removal c .
tracheal secretions by frequent suction through a sma 1 i
catheter inserted down to the bifurcation and continuot \
intratracheal oxygen failed. The patient died the ne:
afternoon. His condition at all times was too precarioi
to subject him to a bronchoscopic examination, or irrig.
tions as used in Case 1.

THE JOURNAL-LANCET

289

Post-mortem

Examination of larynx, trachea, and bronchi revealed
only moderately swollen vocal cords with marked sub-
glottic swelling. The entire respiratory tract to the ter-
minal bronchioles contained a large amount of muco-
purulent debris. Pressure on the lung parenchyma, in
many areas, caused thick yellow pus to exude into the
bronchi.

A pure culture of staphylococcus pyogenes albus was
recovered from tracheal secretions before death. Cul-
tures could not be made at the time of autopsy because
the body had been embalmed; but smears showed the
presence of gram-positive coccus forms and no other
organisms.

Treatment

There is no specific treatment for this condition.
The laryngeal obstruction is overcome by either in-
tubation or tracheotomy. Some authorities1 favor in-
tubation because they feel that the formation of bron-
chial plugs is lessened. We feel that tracheotomy-
should be the procedure of choice, unless a trained in-
dividual is at all times available to reinsert or clean the
intubation tube in case it is coughed out or becomes
plugged with secretions.

Some authors’' have found tracheal plugs already
present at the time of tracheotomy. These are easily
removed by bronchoscopic manipulation through the
tracheotomy incision or by lavage as practiced by us
in Case 1.

It is very important that these patients be constantly
watched by a nurse who has been instructed, and can
tecognize early signs of oxygen want. These patients
may pass from a state of relative comfort to one of
extreme oxygen-want in a very short time.

It is very essential that body fluids be maintained;
and if the proper amounts are not taken by mouth,
hypodermoclysis or intravenous therapy must be resorted
to.

Drug therapy has little to offer in the treatment of
this condition. Jackson' recommends alkalies, and
warns against the use of sedatives. Most authors recom-
mend an expectorant.

i Repeated small transfusions are of value because they
increase the body fluids, stimulate the hematopoietic
.->vstem and possibly contain antibodies.

If bronchoscopic inspection shows that a large part
of the obstruction is due to swelling of the mucus mem-
brane, oxygen therapy should be instituted early either
by piping oxygen through a catheter directly into the
tracheotomy tube, or by placing the patient in a tent,
with the amount of oxygen regulated according to
Waters’ technique.8

If bronchoscopic equipment is not available, lavage as
used by us in Case 1 offers the only method that we
know of for removing these obstructing plugs.

Bibliography

1. Baum, H. L. : Acute Laryngotracheobronchitis, J. A. M. A.,
XCI 1097-1102, October 13, 1928.

2. Jackson, C. 6c C. L.: Bronchoscopy, Esophagoscopy 6C Gas-

troscopy, Page 40 3 — 3rd edition — W. B. Saunders Co.

3. Richards, Lyman: Fulminating Laryngotracheobronchitis,

Ann. of Otol., Rhino. 6C Laryngol. XLII 1014-1040, December
1933.

4. Beare, Frank: A Series of Cases Resembling Laryngeal

Diphtheria, The Med. Journal of Australia, :638, May 24,

1930.

5. Johnson, M. C. : Acute Laryngotracheobronchitis in Infants,

Arch. Otolaryngol., 17:230-234, February 1933.

6. Thenbe, C. L.: Acute Non-diphtheritic Obstruction, The New
England J. of Med., 207:740, October 27, 1932.

7. Jackson, C. 6C C. L.: Same as reference No. 2 — page 417.

8. Waters, R. M.: Clinical Aspects of Oxygen Want, The Wis.
Med. J., 20 January 1932.

9. Cultra, G. M. Sc Streit, A. J.: Non-diphtheritic Infectious

Laryngitis, Texas State Journal of Med., 31:364-368, Sept. 1930.

10. Leigh, H.: Sudden Death from Acute Laryngeal Obstruc-

tion of Non-diphtheritic Origin, Southwestern Med. XI 210-213,
May 1927.

11. Seitz, R. P. : Acute Streptococcic Laryngitis in Children,

Calif, dc West Med. XXX, 259-260, April 1929.

12. Kirkpatrick, S. 6C S. M.: Non-diphtheritic Laryngotracheo-

bronchitis, South. M. J. XXVI 287, March 1933.

13. Marks, S. B. : Acute Laryngotracheobronchitis in Children,

Kentucky M. J., 31:381-384, August 1933.

14. Hyde, C I. 6c Ruckman, J.: Acute Infectious Edematous

Laryngitis in Which Recovery Followed Tracheotomy, Arch, of
Ped. XLVIII 124, February 1931.

15. Gittins, T. R.: Membranous Laryngitis 6C Tracheobron-

chitis, Annals O. R. 6C L., 35:1 1 10-1129, December 1926.

16. Strachan, J. G.: Acute Septic Tracheitis, The Can. Med.

Assoc. J. XV 708-711, July 1925.

17. Gittins, T. R.: Laryngitis and Tracheobronchitis in Chil-

dren. Special Reference to Non-diphtheritic Infections, Annals of
O. R. dc L., XLI. 422, June 1932.

18. Schenck, C. P.: Non-diphtheritic Laryngotracheobronchitis,

Texas State J. of Med., XXVII, 493, November 1931.

19. Peeler, C. N.: Acute Non-diphtheritic Laryngitis in Chil-

dren, Southern Med. 6c Surgery, 88:661, October 1926.

20. Codd, A. N.: Obstructive Laryngeal Dyspnea, Annals O.

R. & L., XL. 242, March 1931.

21. Hart, V. K.: Streptococcic Laryngitis Report of a Case

With a Very Rare Complication, Annals of O. R. 6c L., XXXVI,
781, Sept. 1927.

22. Mathew, R. Y.: The Staphylococcus Aureus as the Possible
Cause of a Fatal Disease Simulating Laryngeal Diphtheria, The
Medical Journal of Australia — I, 34-37, Jan. 11, 1930.

23. Bradford, W. L. 6C Leahy, A. D. : Acute Obstructive Lar-

yngitis. American J. Dis. of Children, 40:298-304, August 1930.

24. Champion, A. N.: Acute Stenotic Laryngitis of Infectious

Origin, Tex. State J. of Med., 23:669, February 1928.

Tularemic Pneumonia*

E. G. Hubin, M.D.**
Deerwood, Minnesota

McCOY, of the United States Public Health
Service, reported tularemia as a disease of
rodents in 1911. Ten years later, Edward
Francis, also of the Public Health Service, discovered

^Presented before the Medical Staff of the Lymanhurst Health
.'enter, September 22, 1936.

••Superintendent, Deerwood Sanitorium

several instances of human tularemia, and since then
upwards of 600 cases have been reported. It is a wide-
spread disease, being found in practically all states,
in Canada, and in several foreign countries.

Tularemia is characterized by an acute onset with
chills, fever, headache, vomiting, and prostration. The

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portal of entry is usually a scratch or sore on the hand;
or the germs may gain entrance through the eye, or
through the gastrointestinal tract, or even through the
intact skin. Wild rabbits are the commonest source;
but many other animals, including squirrels, muskrats,
and opossums, have been found infected, as have also
the grouse and horned owl. Handling such animals,
or eating poorly-cooked meat from them, is the mode
of transfer to man. The common wood-tick is also
responsible for numerous cases of human tularemia. It
feeds first on an infected animal, and then passes the
germs on to its human host. The same applies to the
deer fly.

The disease in man is probably always a bacteremia,
the infecting organisms circulating freely in the blood
stream. Any organ of the body may therefore become
secondarily involved, i.e., lungs or nervous system. The
acute stage usually lasts two or three weeks, but dis-
ability is generally prolonged through several months.

Numerous reports of tularemic pneumonia have
appeared in the literature during the past five years.
Some of these complications were found post mortem,
while others were definitely diagnosed before death,
where that occurred, or during the patient’s illness or
convalescence.

In 1931, Permar and Maclachlan reported finding
consolidation, necrosis and thrombosis of the lungs at
autopsy in a patient dying of tularemia with pulmon-
ary symptoms. Sante reported a case in the same year
in which the patient showed small consolidations in
one lung; but with subsequent clearing and recovery.
Bdcterium tularense was recovered from the digital
ulcer, and from the patient’s blood.

Tureen, in 1932, reported another case. His patient
had several small hemoptyses and developed pleura!
effusion, the fluid giving positive agglutination for
B. tularense in high dilution. This patient also re-
covered, but disability persisted for more than three
months.

In 1935, Kavanah gave an excellent report of a
series of 123 cases of tularemia with pulmonary in-
volvement in 16. Pleurisy and effusion occurred in
three of these. There was a mortality rate of 25 per
cent in the pulmonary cases, as compared with only
four per cent for the entire series. Of those recover-
ing, seven per cent were still 25 per cent incapaci-
tated by fatigue and weakness at the end of a year.

Blackford reported 35 cases of tularemia in March
of last year. Seven had a complicating pneumonia, and
three of these died — a mortality of over 40 per cent
as against 11.4 per cent for the series. Seven other
patients of this group had bronchitis, and three had
pleural effusion; so more than 48 per cent of his series
had some complicating pleuro-pulmonary lesion.

The treatment of tularemic pneumonia, like that of
the underlying bacteremia, is largely symptomatic and
supportive. Foshay, of Cincinnati, has developed an
anti-tularense serum which appears promising; but its
use is still in the experimental stage.

Fig. 1. Made from an X-ray film of the chest taken on August
24, 1 935. Shows extensive consolidation middle portion of right
lung; slight infiltration middle portion of left lung.

Case Report

We encountered an interesting case of tularemic .
pneumonia at the Deerwood Sanatorium in the sum-
mer of 1935 in a man, aged 37, suspected of having |
pulmonary tuberculosis. The clinical history and ob-
servations were as follows:

On July 9, 1935, one of the local doctors called us
by telephone stating that he had in his office a very
sick man with a pleural effusion which he thought
might be tuberculous, and for which he wished to
have the patient admitted to the sanatorium at once.
He added that the man also had tularemia. There
was no bed available at the institution at the time; so 1
the doctor was requested to put his patient to bed at
home until such time as we could admit him to the
sanatorium.

On August 24, about 1 Vi months later, the patient
was seen in one of our monthly chest clinics. Physical
examination revealed considerable pathology on the
right, especially anteriorly; so we advised an X-ray
examination. A film taken the same day showed an
inflammatory area occupying roughly the middle half
of the right lung-field, and there were finger-like
shadows extending out from the left hilum into the
left lung-field. While the appearance was atypical for
tuberculosis, it was deemed advisable to admit the
patient for a period of observation. The history ob-
tained on admission and subsequently was as follows:
On June 16, he suddenly developed chills and
sweating attacks. On the following day he felt fever-
ish. Next day he consulted his doctor. Blood was taken

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291

for laboratory tests. About two weeks later, the doctor
tapped his right pleural space, and according to the
patient, withdrew about a quart of fluid. The patient
has but hazy recollections of what happened during
an interval of two weeks or more, except that his fever
continued and that he was very ill. There was some
cough and expectoration, and both had continued to
the date of his admission on August 31st. He had lost
approximately 30 pounds in weight, but had already-
regained ten. There had been two small pulmonary
hemorrhages. He was feeling much better at this
time, but tired very easily and felt much weaker than
before the onset of his illness. There was, in addition
to the cough and expectoration, some pain in the right
lower chest on inspiration. He was also somewhat
dyspneic.

The temperature was but slightly elevated on admis-
sion, and the pulse rate was normal. Physical examina-
tion, aside from the chest findings, was essentially nega-
tive except for a very poor condition of the teeth and
gums. Blood pressure was 122 systolic and 80 diastolic.
The chest examination showed dullness and moderately
coarse rales over the right middle two-third anteriorly,
and similar abnormal sounds in the right interscapular
area and in the right mid-axillary line near the base.
The blood Wassermann test was negative. Agglutina-
tion for B. tularense was present in a dilution of
1:1280 according to a report from the Minnesota De-
partment of Health. Agglutination was absent for the
typhoid and paratyphoid group, and also for Br.
melitensis.

In order to rule out tuberculosis, several sputum
specimens were examined for tubercle bacilli; but all
were negative. A Mantoux test of 1/ 10 mg. of old
tuberculin was made on September 5th. This was defi-
nitely negative. A second intra-dermal test with the
second-strength solution of purified protein derivative
was likewise negative. Another X-ray examination on
September 9th, 16 days after the first film, showed
considerable resolution on the right and also some on
the left. These findings seemed fairly conclusive for
the non-tuberculous nature of the patient’s pulmonary
pathology, and he was, therefore, discharged from the
institution as a resolving tularemic pneumonia and in-
structed to return later for another X-ray check-up.

Before his discharge, a guinea pig had been inocu-
lated with about two cubic centimeters of the patient’s
sputum. The animal died on the sixth day, and autopsy
showed inoculation abscesses and inflammation in the
groins and grayish, miliary lesions in the spleen. This
organ and smears from the abscesses were sent to the
State Department of Health for examination. The re-
port showed that Gram-negative organisms "very sug-
gestive of B. tularense” were found in the smears. Dr.
McDaniel had no hesitation in stating that the guinea
pig had died of tularemia. We were also informed at
this time that pleural fluid withdrawn by the family
physician from this patient in July had resulted in the

Fig. 2. Made from an X-ray film of the chest taken on July
25, 1936. Shows fibrotic band across mid-field with retraction of
heart and mediastinum to right. No evidence of cavity now.

death of an inoculated guinea pig, death being due to
tularemia.

We saw our patient again in November of the same
year, approximately five months after the onset of his
illness. An X-ray examination at this time showed the
lesion on the right reduced to about one-third its origi-
nal size, but very dense and giving the suggestion of
beginning cavity formation. The left side appeared to
be practically clear. The blood showed an agglutination
titer of 1:640. The Mantoux test was repeated and
found negative. The patient still tired easily, and there
was some cough; but he had had no further hemoptyses.

On April 9, 1936, we X-rayed him again. This was
nearly ten months after the onset of his trouble. There
was now a fibrotic area approximately an inch wide
extending across the right midfield with what appeared
like a definite cavity % by 1% inches in diameter just
below it. The agglutination titer was again reported
positive in a dilution of 1:640. The patient was feeling
fairly good and working every day, but he still tired
more than before his illness.

In July, 1936, we saw him again. He still admitted
tiring more readily, and stated that he coughed a little
but did not raise anything. His X-ray film at this time
showed again the fibrosis in the right midfield but no
definite evidence of a cavity. Another Mantoux test was
reported negative. A final film was made on September
5th, 1936, a little more than a year after the first X-ray
examination, and nearly 15 months after the acute on-
set of his illness in June, 1935. This film showed
approximately the same findings as the previous one,

292

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The agglutination titre at this time was atypical in a
dilution of 1:160.

Comment

We report this case because of the problem in diag-
nosis which the patient presented when he first con-
sulted a doctor. It seems remarkable to us that more
than two months after the acute onset of his tularemia,
the patient’s chest still showed so much pathology. Our
patient evidently had the typhoid type of tularemia, as
no primary sore was ever found, so far as we could
ascertain, and no enlargement of lymph nodes appears
to have occurred. There was some contact with rabbits
about two weeks or more before the onset. This seems
to be too long an incubation period, as the average
is approximately three days. He did, however, pick off a
great many wood-ticks from his body a few days before
he became ill; so it appears more likely that his infec-
tion was contracted through a tick-bite. It would seem
important to have tularemia always in mind when at-
tempting a diagnosis in any acute or subacute pulmonary
condition presenting itself to the physician.

References

Francis, E.: Tularemia, Am, J. of Nursing, 34:No. 1, 1934.

Francis, E.: Tularemia, How to Prevent and Control it, Ed.
Health Circular No. 31, III. Dept, of Pub. Health.

McDaniels, H. E.: Tularemia in Illinois, III. Health Quar.,
September, 1931.

Parker. R. R : Tick-caused Tularemia of Man, U. S. Pub. Health
Service, Sta. Cir. No. 3, March, 1933.

Green. R. G.: Epizootiology of Tularemia in Minnesota. Minn.
Med., July, 1936.

Permar. H. H. and MacLachlan, W. W. G.: Tularemic Pneu-

monia, Ann. lnt. Med., 5:687-698, 1931.

Sante, L. R.: Pulmonary Infection in Tularemia: Case Report,
Am. J. Roent., 25:241, Feb., 1931.

Tureen, L. L.: Tularemic Pneumonia, J. A. M. A., 99:1501-
1502, Oct. 29. 1932.

Blackford. S. D.: Pulmonary Lesions in Human Tularemia,

Ann. Int. Med., 5:1421, May, 1932.

Kavanaugh, C. N.: Tularemia: Consideration of 123 Cases with
Observations at Autopsy in One, Arch. Int. Med., 55:61-85, Jan.,
1935.

Blackford. S. D.: Pulmonary Manifestations in Human Tula-

remia, J. A. M. A., 104:891-895, March 16, 1935.

Blackford, S. D. and Wissler, J. E.: Pulmonary Manifestations
in Human Tularemia: a Roentgen Study, J. A. M. A., 104:895-
898. Mar. 16. 1935.

Sloan, L. H., Freedberg, A. S. and Ehrlich, J. C.: Tularemic
Pneumonia, J. A. M. A., 107:117-119, July 1 1, 1936.

Theobromine Calcium Gluconate

In the Treatment of Cardiovascular Disease

Thomas Ziskin, M.D.

Minneapolis, Minn.

THE maintenance of an effective coronary circula-
tion is the prime requisite in the treatment of
cardiovascular disease. Various drugs have been
used for this purpose. The nitrites and iodides were in
favor in the early part of the century; however, because
of their temporary action their use was greatly restricted.
In the past decade the xanthine derivatives, which prev-
iously had been used mainly for their diuretic action,
came into general use in the treatment of cardiovascular
disorders, particularly because of their sustained vaso-
dilator action. It was found also that they relieved the
pain of angina pectoris and were helpful in cardiac
asthma.

Smith, Miller and Graber studied the effect of the
xanthine derivatives experimentally by perfusion experi-
ments on the isolated heart of the rabbit and measured
the increase in the coronary flow as a result of the use
of the various compounds. Recently, Smith, Rathe and
Paul have reported on their clinical experience in the
use of theophylline and theophylline derivatives in the
treatment of coronary artery disease, manifested by con-
gestive failure, paroxysmal dyspnea, angina on effort or
coronary artery occlusion. They summed up their re-
sults over a period of eight years and conclude that these
drugs are valuable therapeutic agents in the treatment of
these conditions.

Theobromine was the first of the xanthine derivative
to be used in the treatment of coronary artery disease,
Askanazy having recommended it in 1895 for cases o
angina pectoris and cardiac asthma. Theophylline de
rivatives have been used extensively during the pas
decade. Theophylline, however, is not readily solubl
in water and its maximum therapeutic effects have bee
delayed because of its slow and incomplete absorptio
from the gastro-intestinal tract. The combination c]
theophylline with ethylene diamine (aminophyllin)
much more soluble and more readily absorbed and it
action, therefore, is more prompt and more intense tha
theophylline. Continued use of theophylline cthyler
diamine, however, may also cause gastric irritation an
in clinical cases it becomes necessary to discontinue i
use when symptoms of gastric irritation occur or to alte
nate its use with some other xanthine derivative which
less irritating to the stomach.

Comparative clinical studies on the effectiveness (
various drugs of the xanthine series have appeared in tl
literature from time to time. Smith, Miller and Grabe
as a result of their perfusion experiments on the isolate
and intact heart of the rabbit, believe that theophyllii
ethylene diamine has a more pronounced effect on tl
coronary circulation than the other xanthine derivative
On the other hand, Gilbert and Fenn using the inta

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293

animal found that theobromine and its salts was more
effective in increasing the coronary flow. Gilbert and
Kerr in a study of eighty-six ambulatory patients with
angina pectoris, who were allowed to continue their reg-
ular activities, made observations on the effect of prep-
arations of theobromine, theophylline and theophylline
ethylene diamine. They found that, clinically, the theo-
bromine preparations were also more effective than ami-
nophyllin in the treatment of angina pectoris.

Recent studies on methods of overcoming gastric irri-
tation caused by certain drugs have been made by Schne-
dorf, Bradley and Ivy. By means of Pavlov stomach
pouches they observed the effects of prolonged adminis-
tration of acetyl salicylic acid and noted a definite in
crease in the gastric secretion. With the addition of
calcium gluconate the increase was not nearly so marked
and with sodium bicarbonate there was a decrease in the
gastric secretion. They believe that the neutralizing and
inhibiting action of calcium gluconate and sodium bi-
carbonate on the titrable acidity of the gastric contents
and on the output of hydrochloric acid may play a defi-
nite role in the ameliorating effects of the substances
upon the degree of gastric irritation and the incidence of
ulceration produced by the prolonged oral administra-
tion of acetyl salicylic acid and other drugs. While the
protective action of sodium bicarbonate may be adequate-
ly explained by a reduction of acid irritation, this is not
true, they say, of calcium gluconate whose protective
action against digestive disturbances appears to be due
also in part to some systemic action of calcium.

Because of the known tendency of theophylline prep-
arations to cause gastric irritation as a result of then-
prolonged use in cardiovascular disease, a study was
made of the effects of a preparation of theobromine cal-
cium gluconate. Fifty-two cases were studied. Among
these were twelve cases of hypertension, eleven cases of
hypertension with cardiac decompensation, seventeen
cases of coronary disease with angina pectoris and twelve
cases of coronary disease with cardiac decompensation.
Thirty-two were bed patients and twenty were ambulant.
Many of these patients had been taking theophylline
ethylene diamine (aminophyllin) before being started on
theobromine calcium gluconate. Other drugs such as
digitalis, were used in conjunction with these prepara-
tions whenever necessary. Theobromine calcium glu-
conate was given in five grain doses three times daily.
This dose was later increased in some patients to ten
grains three times daily. There was not a single instance
of nausea or gastric irritation in any patient from the
use of this preparation. Some of the patients have been

taking this drug continuously now for a period of nine
months. Two patients, who were receiving aminophyllin
and developed nausea and gastric distress, were com-
pletely relieved of their gastric symptoms when changed
to theobromine calcium gluconate. Favorable results
were noted in the majority of these cases in relieving
symptoms of congestive failure, angina and dyspnea and
in some cases the results were very striking. Digitalis
was used in conjunction with theobromine calcium glu-
conate in the cases with congestive failure.

In comparing the effects of aminophyllin with theo-
bromine calcium gluconate on the relief of cardiac symp-
toms more favorable results were noted with the use of
theobromine calcium gluconate. Eight, of the fifty-two
patients, reported greater relief of pain when taking
theobromine calcium gluconate. Twelve patients, who
were taking the theobromine preparation and then
changed to aminophyllin, asked to be put back on theo-
bromine calcium gluconate stating that they received
greater relief of their symptoms when taking this prep-
aration.

No cases of occlusive vascular disease of the extrem-
ities were included in this series, but the use of theo-
bromine preparations in these conditions has been defi-
nitely established and many observers have reported very
favorable results.

Conclusions

Theobromine calcium gluconate is a valuable prepara-
tion in the treatment of cardio-vascular disease.

It may be prescribed over long periods of time without
causing any gastric distress. It is preferable to theophyl-
line ethylene diamine (aminophyllin) for this reason.

In a series of fifty-two cases of heart disease it was
found to be more effective in relieving symptoms than
theophylline ethylene diamine (aminophyllin).

References

Smith, Fred M.; Rathe. Herbert W. and Paul, W. D.: Theoph-
ylline in the Treatment of Disease of the Coronary Arteries, Arch.
Int. Med. 56:1250, 1935.

Askanazy, S.: Klinisches Uber Diuretin, Deutsches Arch. f.

Klin. Med. 56:209, 1895.

Smith, Fred M.; Miller, G. H. and Graber, V. C. : The Effects
of Caffeine Sodium Benzoate, Theobromin Sodiosalicylate, The-
ophyllin and Euphyllin on the Coronary Flow and Cardiac Action
of the Rabbit, J. Clin. Investigation 2:157, 1925.

Gilbert, N. C. and Fenn, G. K.: The Effect of the Purine Base
Diuretics on the Coronary Flow, Arch. Int. Med. 44:118, 1929.

Gilbert, N. C. and Kerr, John Austin: Clinical Results in

Treatment of Angina Pectoris with the Purfne Base Diuretics,
J.A.M.A. 92:201, Jan. 19, 1929.

Schnodorf, J. G.; Bradley, W. B. and Ivy, A. C. : Effect of

Acetylsalicylic Acid Upon Gastric Acidity and the Modifying
Action of Calcium Gluconate and Sodium Bicarbonate, Am. Jour.
Dig. Dis. 6c Nut. 3:239, 1936.

294

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Eyeground Examination As An Aid to Prognosis

In General Medicine

M. F. Fellows, M. D.

Duluth, Minn.

THE purpose of this paper is not to advance any
new or startling discoveries, hut to serve as a re-
minder of one means of examination which should
always be included in any complete examination. It is
one which is omitted perhaps more frequently than any
other. There are many times when examination with the
ophthalmoscope will yield as much information as, if
not more than, the sphygmomanometer or the test-tube.
Too often, the eye is thought of as only a small organ
of the body, separate, unaffected by the diseases which
affect the more distant organs, and it is forgotten that
diseases of the ocular fundus are, as a rule, merely
symptoms of diseases originating elsewhere. It is for-
gotten that the retina and underlying choroid are highly
vascular tissues and that many disturbances of the gen-
eral organism may be noticed there before the disease
has progressed far enough to produce noticeable path-
ology in the less delicate tissues of the body.

Often, the dramatic choking of the discs found asso-
ciated with brain tumor is remembered when the retinal
lesions of general bacterial infections, of blood diseases,
syphilis, tuberculosis and the many other more frequent
and just as important findings are forgotten and not
looked for. Too often, the warning signs flaunted in the
retina in the development of arterio-sclerosis, of hyper-
tensive disease, of Bright’s disease, of diabetes, and the
toxemias of pregnancy are not looked for, and perhaps,
no importance is attached to their presence. If their
presence is recognized, it is frequently passed off as just
another symptom of the disease present and no prog-
nostic importance is attached thereto, thus overlooking
the fact that inasmuch as the condition of the blood
vessels of the retina and choroid is pictured for whoever
may observe it, in almost the same degree is the con-
dition of the blood vessels of the kidneys and other vital
organs of the body so pictured.

In this discussion it will be necessary to limit remarks
to one or two conditions and in these, it will only be
permitted to touch on the most salient points, omitting
any detailed discussion of the pathology. The prognostic
importance of retinal lesions in kidney diseases and in
toxemias of pregnancy will be discussed in the hope that
such discussion may stir up enough interest that who-
ever may be interested will, of his own accord, carry the
study further.

Albuminuric retinitis, as is called, the retinopathy
associated with Bright’s disease, occurs in all forms of
chronic nephritis, but is particularly common in the pri-
mary interstitial type.

*Read before the Annual Session of the Northern Minnesota
Medical Association, held at Fergus Falls, Minnesota, August 31-
September 1, 1936.

The retinal changes which may be found in a case
of albuminuric retinitis may include some or all of the
following: (1) Optic neuritis and retinal edema, which
are shown by a blurring and indistinctness of the disc
margins, usually noticeable first on the upper and lower
margins, and next on the nasal side, the temporal bor-
der being the last alfected. The retinal edema may ex-
tend from two to four disc diameters from the disc mar-
gins. (2) Hemorrhages which may be either striate or
punctate in character, and are usually situated in the
nerve-fibre layer of the retina. (3) Exudates ("cotton-
wool patches”), which are irregular in size and shape.
(4) Small white spots may be found in the macular
region. 1 hese are situated in the deeper layers of the
retina and are more frequent than the so-called (5)
Star-figure” in the macula which is due to fatty de-
posits along the fibres of the retina. (6) The blood
vessels may show increased white stripes along the course
of the arteries. The veins may appear distended while
the arteries seem underfilled. (7) The blurring of the
optic neuritis may become so marked as to simulate a
choked disc , especially when there is an associated edema
of the optic nerve. (8) Detachment of the retina may
occur in the more advanced stages of the disease.

The more gross of these findings may be noted by
anyone who is familiar with the use of the ophthalmo-
scope, and does not require the acumen which is neces-
sary to detect the more border-line changes. In the acute
glomerular nephritis with generalized edema, that of the
retina, according to Wilmer, is the last to disappear, and
may be used to indicate complete recovery, while, on the
other hand, if the condition should progress to the
nephrotic stage, the edema may be seen to increase. In
retinitis from an acute toxic nephritis, such as those
accompanying scarlet fever and pregnancy, when there
is not an underlying chronic nephritis, the prognosis is
considerably better than in the cases associated with the
more chronic condition.

As regards the importance of these changes, Maitland
states, "In the cases in which signs of vascular degen-
eration predominate, the prognosis is always grave, be-
cause the morbid changes in the blood vessels are steadily
progressive, not only in the arteries of the retina, but
also in those of the brain, the kidney, and other parts
of the body — general arteriocapillary fibrosis. On the'
other hand, where the signs of acute toxemia predomi
nate, a favorable prognosis may be given wherever it is
possible to remove the cause of the toxemia.”

Fox has said, "The relationship between kidney dis-
ease and retinitis is not well understood, but the cause
of the ocular disturbance is probably an extension oi
the degenerative changes in the vascular system to the

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29?

small vessels in the tunics of the eyes. The severity of
the eyeground symptoms seems to bear no fixed rela-
tion to the intensity of the renal disease, as the kidney
affection may complete its course without any attention
being directed toward the eyes. On the other hand, while
the retinitis is not an early occurrence in nephritis, it
may be the first recognized, and its importance in this
connection is very great.”

The presence of hypertension and arteriosclerosis in-
creases the complexity of the retinal picture as well as
the severity of the general condition. Both hypertension
and arteriosclerosis may be considered from the stand-
point of each, but there is not time for their considera-
tion here.

Various authorities have given us fairly definite fig-
ures regarding prognosis as to life associated with albu-
minuric retinitis, and it is well worth while noting these
figures and observing how nearly they correspond with
each other. Fuchs stated, "Patients suffering with typi-
cal albuminuric retinitis succumb from their renal dis-
order within one or two years.” Vannady and O’Hare
state, "An advanced retinopathy in chronic glomerular
nephritis usually indicates death within seven months.”
Adam gives the probable length of life after the onset
of an albuminuric retinitis as from two to three years in
90 per cent of the cases. In one group of 38 patients
observed by him, 29 died within one year, four died
from one to two years, and two died in from two to four
years. Three patients observed with the retinitis of preg-
nancy recovered.

Ball states, "Probably 85 per cent of all patients
with albuminuric retinitis die within two years. A few
live for three, four, five, or six years, and exceptional
cases have survived for ten or 12 years.” Fox makes the
statement, "Albuminuric retinitis is of diagnostic im-
portance— and usually indicates a fatal termination in
from six months to two years unless prompt treatment is
instituted.” Terrien and Renard say, "In general, the

kidney lesions parallel the ocular lesions, so that the
prognostic value of renal retinitis is great. One may ex-
pect a severe renal disturbance within a short period, if
one discovers renal retinitis in a person who is, at the
time, in apparently good health.” It will be noted that
the average of these predictions is about 23 months fol-
lowing the onset of an albuminuric retinitis.

Pregnancy is frequently a grave complication in a
patient with a chronic nephritis, and any clinical means
of checking the amount of damage present is of extreme
value. Pregnancy increases the load on the entire vascu-
lar system of the mother, and its effect may be noticed
ophthalmoscopically as the retinal vessels reflect the dam-
age to the smaller blood vessels throughout the body.

The prognosis in the acute toxemias of pregnancy
which produce retinitis is usually good, provided there
is no underlying chronic nephritis. Adam states, "The
albuminuria of eclampsia can give rise to an albumin-
uric retinitis, only when it persists after delivery.” Manes
remarks, "The albuminuric type of retinitis, retinal foci
coincident with nephritis, small retinal hemorrhages, or
white spots around the disc during pregnancy consti-
tute a double jeopardy, i. e., to both vision and life.”

Adam, DeSchweinitz, Peter, all agree that retinitis
developing from an exacerbation of a chronic nephritis
is an absolute indication for the termination of the preg-
nancy in order to prolong the life of the mother. Zent-
mayer’s arbitrary rule is frequently referred to, namely:
If retinitis develops before the six month, the pregnancy
should be terminated. If at the eighth month, carry
patient to full term. Between the sixth and the eighth
months, be guided by the visual disturbances. If the
vision is poor, terminate pregnancy.

This discussion has been, of necessity, brief, but it is
hoped that it may in some way lead to more interest in
the inclusion of fundus examination as a means of de-
termining the course and prognosis of the ordinary con-
duct of clinical cases in daily practice.

Acute Abdominal Symptoms Complicating Diagnosis

With Case Reports
J. L. McLeod, M.D.**

Grand Ra

IN ANY discussion of the differential diagnosis of
the acute abdomen, one always hears of many con-
ditions confined to the abdomen itself which con-
found the practitioner and make accurate diagnosis dif-
ficult. One need only mention stone in the ureter, Dietl’s
crisis, perforated duodenal ulcer, pyelitis, salpingitis,
mesenteric adenitis, ectopic pregnancy, and ovarian cysts
to call to mind a few of the conditions which make the

*Read before the Annual Session of the Northern Minnesota
Medical Association, held at Fergus Falls, Minnesota, August 31-
September 1. 1936.

**The Itasca Clinic.

ids, Minn.

diagnosis by the surgeon anything but an open book.
This paper presents to you briefly four case reports (one
borrowed from Drs. Binet and Engdahl, also of Grand
Rapids) which illustrate the fact that general patho-
logical conditions may, in the early stages, so simulate
the acute abdomen that one must use extreme care not
immediately to classify a case with acute abdominal
symptoms as an acute appendix or some other form of
acute abdomen.

Case I: A. T., male, age 19 years, was admitted to

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the hospital June 15, 1935, stating that he had felt well
until the night before, when he got a sudden pain in
the epigastrium. This pain, in a few hours, localized in
the right lower quadrant and nausea was present. He
reported to the CCC doctor, who transferred him to our
hospital. On admission, his complaints were as stated
except that cramp-like pain was also present in the left
leg and radiated up the left side to the left arm.

On physical examination, the skin showed some
splotches almost like freckles in color, but larger, appear-
ing on arms and legs; external examination was other-
wise normal. Blood pressure was 120 80. The heart
was normal. General condition negative. The abdomen
showed some rigidity in the right lower quadrant, fairly
marked tenderness and rebound tenderness. Rectal exam-
ination demonstrated tenderness in the right lower
quadrant.

Laboratory tests showed a white blood cell count of
12,200, red blood cells 4,100,000, hemoglobin 81 per
cent, urine negative.

The diagnosis was acute appendicitis. The appendix
was removed at once under spinal anaesthesia. Gross in-
spection showed some distention of appendix. There was
no injection. The pathological report was acute catarrhal
appendicitis.

It would seem that the case was clear-cut and surgery
should have closed the story, but on returning from the
operating room, the boy started to vomit, and a few
hours later vomited red blood. On the following day,
the patient commenced passing blood by bowel in fairly
large amounts; the skin demonstrated a shower of
erythematous patches; the hemoglobin dropped from 81
to 76 per cent, the red blood, cells from 4,100,000 to

3.720.000, the white blood cells from 12,000 to 8,000.
On the third day, more blood was passed; on the fourth
day, he not only passed blood, but again vomited it.
Careful requestioning at this time revealed that the boy-
had really been sick on the twelfth, three days before
admission. He had reported this and had shown the
erythematous patches, but these had not been taken
seriously by either patient or physician and were not re-
ported on admission. When no improvement was noted
on the fifth postoperative day, the platelet count was
found to have fallen to 78,000, the red blood cells to

3.000. 000 and the hemoglobin to 70 per cent, decision
was made to use whole blood in small amounts both
intravenously and intramuscularly. Blood from a suit-
able donor was given. The procedure was repeated June
20th, 21st and 22nd. On the twenty-third, the patient
was markedly better. He passed formed stools with very
little blood on the twenty-fourth. Platelet count was
90,000 and his condition steadily improved. He was dis-
charged on June 27th, with a final diagnosis of erythema
multiforme with slight appendiceal involvement.

In discussing this case, one feels that there was an
error in not going into more detail obtaining the initial
history and in not delaying the surgery till some study
had been made of the possibility of a systemic disease
with abdominal symptoms. Chenowith, in Medical News,

March 4, 1905, states, "The matter of diagnosis is one
of grave importance. The attack of colic, the so-called
abdominal crisis of exudative erythema, may easily lead
the inexperienced to make a diagnosis of appendicitis
when no such lesion exists; on the other hand, a more
serious mistake may be made of overlooking the co-
existing appendix trouble, unless it is recognized that
these vasomotor circulatory disturbances do, at times,
result in congestion of, and even hemorrhage into, the
appendix with the result that there may be bacterial
infection and inflammation or actual gangrene of this
organ.” The literature reports many cases where the
abdominal symptoms are present. In this particular in-
stance, inasmuch as our pathologist reported acute
catarrhal appendicitis, there is room for argument as to
whether we might not have left the appendix in situ ,
and given our patient a better chance at recovery. The
fact that the case ended happily for all concerned does
not, however, excuse us for not giving careful thought
to the necessity of ample study pre-operatively. It is to
impress the need of always remembering rare possibili-
ties and also the need of thorough investigation that
this case is presented.

Case II: J. N., male, age 11 years, was admitted to
the hospital May 25, 1936. The patient stated that he .
was well until May 22, 1936, when, at school, he noticed
pain in the lower abdomen with nausea and vomiting.
He went to bed at home, but was quite sick all night.
The next morning he could not stand or walk because
of pain in the lower abdomen and upper thighs. This
was much worse on the right side and the child pre-
sented the slightly flexed thigh frequently seen in acute
appendix. Not improving during the day, he was
brought to the hospital and was first seen at night.

Physical examination showed temperature 100.6°,,
pulse rate 112, respiratory rate 20. Head was normal.
Tonsils we re moderately enlarged and inflamed. The
neck showed a little rigidity. Cervical adenopathy was.
present. Both lungs were clear. The heart was normal.
The abdomen revealed tenderness in region of the navel,
rebound tenderness in McBurney area, marked rigidit)
at times over the whole abdomen. This was absent at
other times.

Laboratory work showed a hemoglobin of 87 per cent
red blood cells 4,530,000, white blood cells 30,200, urine
negative.

Because of neck rigidity, lumbar puncture was done
The flu,id was clear, under normal pressure, with a nor
mal cell count, reported normal from the state labora
tories later. Agglutination tests were later reported nega
five from the state laboratories. An ice bag was placed or
the abdomen and the child was observed 24 hours. A
that time white blood cells numbered 20,000. The abdo
men remained painful and the right leg drawn up slight
ly. Tenderness and rigidity of the right lower quadran
were still present but no mass was apparent. The pair
in the abdomen was bad enough at times to require ;
little morphine, and at this time we started using som<
salicylates. At intervals during the next 24 hours, the

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297

boy would cry and complain to the nurses of his severe
abdominal pains and cramps. Enemas were used and
gave some relief. However, six days after the first
symptoms and three days after admission to the hospi-
tal, some joints in the left hand started swelling and
became painful. On the 29th, white cells numbered
17,200, and the patient, for economic reasons, was dis-
charged for further observation and treatment at home.
Blood smears at this time suggested a possible commenc-
ing myelogenous leukemia.

The patient was again seen one week later after abso-
lute bed rest and salicylates. He was much improved and
able to walk without limping. His joints were neither
sore nor deformed. Pain in the abdomen was all gone
and he was eating fairly well. A marked cardiac mur-
mur had not been present previously but was now
apparent. After five weeks of observation with rest and
salicylates, the boy showed very marked improvement,
the cardiac murmur almost disappeared and the patient
was discharged with a diagnosis of acute rheumatic
fever.

In this case, on superficial examination, the diagnosis
of acute abdomen could readily have been made. The
pain, nausea, vomiting, rigidity and tenderness were all
present. The flexed thigh, the somewhat elevated tem-
perature and even the blood count, which, while high
tnough to be typical of an acute rheumatic fever, was
tot out of keeping with that found in a ruptured appen-
dix, and, seen as they were on the third day of symp-
oms, would have made surgical intervention excusable.

Case III: A white male, age 21 years, according to
he first history, had previously been perfectly well. He
ite a large Sunday dinner at the CCC camp of which
le was a member, and in the afternoon, went to a ball
;ame. During the game, he was suddenly seized with
harp colicky pains in the lower abdomen accompanied
>y nausea. He got out of the stand and over to the
dge of the grounds and vomited. The camp surgeon
^as called immediately and saw him about one-half hour
ater. Upon examination, he found distinct, localized
iain and rigidity in the right lower quadrant. The
tatient was transported to the hospital at once and ad-
mitted at 5 p. m. His general physical examination and
ppearance were essentially negative except that he had
he same abdominal findings as determined by the camp
urgeon. However, his temperature was then 104.6°,
•ulse rate 108, respiratory rate 32, and the leucocyte
ount 6,100, suggesting some condition other than the
pparent appendicitis. It was decided to observe the
atient a little longer. By eight p. m., the temperature
ad fallen to 99.8°, the acute pain had subsided, the
’'hite blood cell count was 5,100, but there was still some
mderness in the abdomen. The next morning, the tem-
erature was 98 and the patient had no complaints. He
ad slept soundly throughout the night. At three p. m.
te patient had a severe chill lasting 35 minutes, followed
y a temperature of 102° and severe pain in the abdo-
men. Then, further details of his history were brought
ut. He had arrived at Fort Snelling about one week

previously with a contingent from his home in Topeka.
The first few days he had had a headache and the third
day some abdominal pain; he was given some pills but
they were not retained. He thought he was upset due
to the cold lunches and candy he had eaten on the jour-
ney. Toward the end of the week, he felt quite well
and was sent out with the contingent for this area,
arriving the day before his present illness. Further ques-
tioning revealed that about a month before leaving home
he had experienced chills. Acting on the new facts
brought out and the presence of chills, a blood smear
was then obtained. Fresh, unstained blood revealed small
round, ring-like and irregular bodies within the red cells,
many of them showing a vibratory motion. Wright-
stained smears showed many small bluish granules with-
in the red cells as well as extra-cellularly. These findings
were thought to be conclusive enough to warrant a diag-
nosis of malaria and quinine therapy was instituted
with prompt relief of symptoms.

The interesting point was that malaria would evi-
dence these symptoms. However, it is known that this
disease presents a large variety of forms and may at
times closely simulate all other known diseases. For in-
stance, there may be malarial pneumonia, meningitis,
pleurisy, neuralgias, rheumatism, otitis media, coryza,
stomach disorders resembling ulcer, appendicitis, diar-
rhea, typhoid, disturbances of vision, pseudo-angina
pectoris, heart murmurs, hepatitis suggesting gallstones,
pyelitis, cystitis, extensive furunculosis and skin erup-
tions.

As a slight digression here, a warning to all prac-
titioners should be given that because of rapid trans-
portation in closed cars and trailers, malaria is carried
north by the Anopheles mosquito and it may affect
native Minnesotans. Furthermore, the swift travel of
people from one section of the country to another makes
it necessary to add this southern disease to the northern
medical worries.

Case IV: D. K., female, age 15 years, was first seen
at home, April 16th, because of severe, colicky, lower,
left, abdominal pain which had come on suddenly. The
pain was so severe the patient lay in bed crying. She was
nauseated, but had not vomited. The abdomen was rigid
over the lower left quadrant. The general examination
was negative as was the past history except for two pre-
vious attacks of chorea. The heart was normal, pulse
rate 100, respirations 22, temperature 102°, hemoglobin
85 per cent, white blood cells 5,100.

An ice bag was applied and the patient put under
observation. Her temperature varied a little. There was
some constipation relieved by enemas, but still the pain
and rigidity continued. Ectopic pregnancy, salpingitis,
and ovarian cyst were clearly in the picture but the his-
tory was against the former, and negative vaginal smears
ruled out the second. Watchful waiting was continued
and at the end of a week, the abdominal pain had dis-
appeared slowly. The girl commenced having an after-
noon temperature up to 103° at three or four p. m., re-
turning to normal about nine p. m. All agglutination

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tests were ordered and were sent April 23rd, May 3rd,
May 4th, and May 13th. They all came back negative.
In spite of the negative tests, the presence of all the
symptoms of undulant fever led us to make such a diag-
nosis and to avoid operative interference.

Simpson says in this connection, "Abdominal pain is
a prominent complaint in about 12 per cent of cases of
undulant fever. This is common early in the course of
the disease. The pain may be generalized or confined to
any one of the abdominal quadrants. There are many
instances on record of needless and perhaps harmful
surgical intervention in cases of undulant fever in which
the abdominal symptoms were a prominent feature of
the disease.”

The negative agglutination was investigated and it
was found that cases are on record in which such a
state of affairs existed. A year before the family had
a cow which "dropped” two calves, was tested and found
to have Bang’s disease, and then was disposed of. No
other contact was proven. Acting on this diagnosis, we
obtained Brucella serum and administered it. The

patient continued to grow worse, but presented every
symptom typical of undulant fever throughout her ill-
ness. It was not until May 20th, more than a month
after the onset of the disease, that she developed a
cardiac murmur and the diagnosis was changed to sub-
acute bacterial endocarditis. Some blood was plated, and
sent to the laboratory to try to culture some germs, but
the laboratory reported no growth. Also, on the 23rd,
petechiae first appeared, and, on the 27th, in spite of
heroic treatment, the girl passed away. This case was
interesting from many angles, but principally to stress
again the variety of general diseases which present local-
ized abdominal symptoms early in their course.

No effort is made in this paper to present any new
or revolutionary medical discoveries. It is presented in
the hope that it will again emphasize the multiple pit-
falls the general practitioner faces in making speedy,
correct diagnoses. Such knowledge will, it is hoped, call
forth even more careful diagnostic practice in Minne-
sota.

Artificial Pneumothorax

A Standard Method of Treatment

J. Arthur Myers, M.D.**
Minneapolis, Minn,
and

Ida Levine, M.D.

Brooklyn, New York

COLLAPSE therapy has been accorded a prom-
inent place in the diagnosis and treatment of
some pulmonary, bronchial and pleural diseases
during the past two or three decades1. The chief meth-
ods employed in lung collapse are artificial pneumo-
thorax, interruption of the phrenic nerve and extra-
pleural thoracoplasty. Of these, the most simple, the
most effective, and certainly the most widely used is
artificial pneumothorax.

Formerly we looked upon artificial pneumothorax as
a drastic procedure, and one that should be employed
only as a last resort. However, it has come to be rec-
ognized as a simple procedure which has passed the ex-
perimental stage and is now looked upon as a standard
method of treatment. Peters2 says: "Artificial pneumo-
thorax is the most efficient of all forms of compression
when a good collapse is possible.” Amberson8 is of the
opinion that when it collapses the lung adequately and
is continued long enough, it restores a majority of the
patients selected who otherwise would be destined for
an early death or at best permanent disability. Slyfield4
says: "This one treatment often makes a difference

between life and death.” The time has arrived when in

’Presented before the 49th Annual Meeting of the North Da-
kota State Medical Association, Jamestown. May 18, 1936.

** From the Departments of Internal Medicine and Preventive
Medicine. University of Minnesota, and the Lymanhurst Health
Center, Minneapolis.

Prepared with the aid of a grant from the Research Fond of
the University of Minnesota.

conjunction with our modern methods of diagnosis it:
use should be greatly extended.

Several different apparatuses have been devised foi.
the administration of artificial pneumothorax. It make
no difference which of them is used as long as it deliver
the gas or air into the pleural cavity at the desired rati
and under manometer reading control. Those whicl
deliver air under low pressure are in common use ii
this country. However, some Italian clinicians find i
more satisfactory to use a simple apparatus which filter
the air and allows it to be sucked into the pleural cavit
by the negative intrathoracic pressure. This procedur
obviates the danger of acute pneumothorax to whic!
Yates5 has called attention.

There was formerly a great deal of discussion as t
the kind of gas to be introduced into the pleural cavit}
Some clung to the view that carbon dioxide should b
used for the initial treatment, since in case of gas eir
bolus this would be very quickly absorbed. Others prt
ferred the use of oxygen for the initial treatment for tli
same reason, although oxygen in the blood stream i
not absorbed as fast as carbon dioxide. Neither of thes
gases is satisfactory for the subsequent refills becaus
they are absorbed from the pleural cavity too rapidh
For the refills, nitrogen was thought to be best bv man
because of its slow absorption rate so that the interv:
between treatments could be long. Observation ht

THE JOURNAL-LANCET

299

shown, however, that ordinary air is adequate, although
it absorbs a little faster than nitrogen because of its
oxygen content, still it is retained in the pleural cavity
for a sufficient length of time. Most physicians use
ordinary air for the initial treatment also. Berlin'1 and
Mcntenegro" are of the opinion that cold gas or air is
irritating to the pleura and, therefore, causes pleural
effusion. They recommend the warming of air either by
the use of a special apparatus or by placing the tube,
through which the air passes, in hot water. However,
we have always administered air at room temperature,
which has proved entirely satisfactory.

Neumann3 believes that 400 to 600 cc. is not too
much air to introduce on the initial treatment. However,
200 to 300 cc. is usually recommended, since with this
amount there is less likelihood of tearing adhesions and
slow collapse of the lung is more desirable. The fre-
quency of refills depends very much upon the individual
patient: one will absorb air from the pleural cavity rap-
idly and another slowly. The more common practice in
this country consists of administering the first refill of
200 to 300 cc. approximately forty-eight hours after
the initial treatment. The second, in three or four days,
and the third approximately a week later. The amount
of air introduced on each of these refills must depend
upon the manometer readings and the physician’s judg-
ment. It is best to discontinue while the intrathoracic
pressure is negative. Patients are usually kept on a week
schedule for some time, after which the intervals are
lengthened depending upon the rate of absorption in the
individual case. Fluoroscopic or X-ray film control is
very desirable at the time of each refill, particularly
when one is considering the lengthening of the interval
between treatments.

Passing a needle through the chest wall, whether for
the purpose of introducing air or aspirating fluid, is
attended by some danger, which together with the various
complications attending artificial pneumothorax treat-
ment, has been discussed elsewhere 9,1°.

Because of so much reserve pulmonary tissue, the
greater part of each lung may be destroyed, and yet,
if the disease can be brought under control, the patient
lives. When bilateral pneumothorax is being considered,
the vital lung capacity of the patient is of considerable
importance. Frisch11 is of the opinion that bilateral
artificial pneumothorax is contraindicated if the vital
capacity is materially reduced. We have used vital ca-
pacity determinations rather extensively in artificial
pneumothorax cases both before and after treatments1"
and have never seen any harm result from the tests but
have often received valuable aid in the guidance of sub-
sequent treatments. Studies on the effects of artificial
pneumothorax on vital capacity have shown that the re-
duction is not consistent with the amount of air intro-
duced into the pleural cavity. Liebermeister13, Frisch
md others11 found the vital capacity is reduced much
less than one would expect from the amount of air
ntroduced into the pleural cavity, that is, the decrease

in the vital capacity is less than the amount of air
introduced.

Dumarest and Delonglj showed that the respiratory
capacity falls rapidly following the collapse of a lung,
in fact, it may equal only one-fourth of the total ca-
pacity before pneumothorax. As the collapse continues,
compensation is established, and the respiratory capacity
gradually returns to the normal. Means and Balboni1<:
have found that all the factors of respiration, gaseous
exchange, carbon dioxide tension, and the mechanical
factors are normal in persons with a collapsed lung.

Basal metabolic rate usually is not altered by artificial
pneumothorax except in cases who have an elevated
metabolism as a result of tuberculosis before the pneu-
mothorax is instituted. In such cases, the metabolic rate
is reduced to normal if the pulmonary lesion is brought
under control by artificial pneumothorax.

Paradoxical as it may seem, when the patient is short
of breath from disease in one lung, collapse of that lung
frequently improves breathing. In fact, the shortness of
breath may completely disappear. Coley1 ‘ and others
are of the opinion that dyspnea in such cases is not
mainly mechanical but is largely due to toxemia.

Following the institution of artificial pneumothorax,
some patients lose weight while others remain stationary
or gain. Loss of weight may be due to lesions elsewhere
in the body such as those of the gastro-intestinal tract,
but often there is no obvious reason for the weight loss.
However, Burrell and Garden13 believe that such loss
in weight may be explained on the basis of diminished
oxygen concentration of the blood which apparently
causes an inefficient combustion of carbohydrates and
fats. As the treatment continues, however, the uncol-
lapsed lung accommodates itself to the altered conditions
and the patient’s body weight begins to increase.

Febrile reactions sometimes occur following the first
few artificial pneumothorax treatments. They were seen
more often when larger amounts of air were introduced
on the initial treatment and with the first few refills. In
such cases, it is believed that more rapid absorption of
toxins immediately after the refills, explains at least
part of the reactions. We have never found it necessarv
to discontinue artificial pneumothorax because of such
reactions, since smaller amounts of air at more frequent
intervals have been sufficient in our cases.

Some changes occur in the blood and the circulatory
system when artificial pneumothorax is begun but they
are harmless and some are definitely beneficial. Ricci19
has called attention to the fact that the anoxemia which
occurs is due to compression of superficial alveoli. He
finds that for about an hour after the refill the blood
sugar is raised and that the anoxemia disappears through
a compensatory increase in the erythrocytes. There is a
temporary acidosis which decreases the alveolar carbon
dioxide tension, but this quickly disappears when small
amounts of air are introduced. When a collapse is per-
formed too suddenly or too extensively, such changes
are more marked. Hirschsohn and Maendl20 found that
the pulmonary circulatory rate can be normal in pneu-

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mothorax but that it depends upon the condition of the
heart muscle and the compensatory action of the lung
function. Bosviel21 observed that the heart usually tol-
erates artificial pneumothorax remarkably well and that
in most cases there is no change of the venous or the
arterial pressure. This is also true when the pneumo-
thorax is bilateral. He strongly advocates taking the
venous pressure in each case, however, since this pres-
sure reveals evidence of cardiac disturbance more clearly
than the arterial pressure and therefore, provides val-
uable data concerning the heart’s ability to support lung
collapse.

Weiss22 found that in the collapsed lungs of dogs and
rabbits, the circulation is lowered by as much as 12 per
cent. In dogs with closed pneumothoraces, the amount
of blood passing through the collapsed lung was approx-
imately 70 per cent of the normal.

Perrin and Drouet23 made studies on pneumothorax
cases which showed that the electrocardiogram may be
modified due to displacement of the heart, but that this
is purely a physiologic modification and should never be
mistaken for evidence of myocardial degeneration.
Bronfin, Simon and Black24 reported the results of an
electrocardiographic study of one hundred and ten cases
treated by artificial pneumothorax. They found the right
ventricle often develops varying degrees of hypertrophy
and are of the opinion that the electrocardiogram is a
valuable aid in prognosis. Hansen and King25 studied
sixty-six patients who had undergone collapse procedures
including pneumothorax, phrenic exeresis, and thora-
coplasty. They state that the evidence obtained sug-
gested that the heart changes are due to alterations in
position influenced more by pleural and mediastinal ad-
hesions than by myocardial factors. Later Hansen and
Maley26 reached a similar conclusion in electrocardio-
graphic studies of fifty-seven patients who had been
treated by thoracoplasty.

Gutstein2' called attention to the increase in the num-
ber of red cells and hemoglobin percentage in favorable
pneumothorax cases and to a decrease in the total white
count, although the lymphocytes and eosinophiles were
increased. Pescatori28 made an experimental study of
eosinophilia to determine whether in pneumothorax
cases it is to be ascribed to an asphycitic state. He came
to the conclusion that pneumothorax reduces the volume
of the bronchial tree which follows or precedes the con-
traction of the elastic network of the lung. He ascribes
the histo-eosinophilia and the eosinophilia of the blood
in pneumothorax cases to this spastic state as well as the
asphyxia. Michels23 found an increase in eosinophiles in
four of seven pneumothorax patients who improved. In
cases without improvement, there was no increase in
eosinophiles. Therefore, he attributes the increase to
autotuberculin action.

That part of the lung which is diseased collapses more
readily than the normal part, for example, when an area
of disease is present in the apex and pleural adhesions
are absent, the introduction of air into the pleural cavity
results in a greater collapse of the apical portion of the

lung. Dumarest30 and others have called attention to
the fact that the elasticity of distention diminishes with
the volume of the alveoli peripheral to the hilum. There-
fore, it is easier to immobilize the apex than the base. It
is also easier to immobilize infiltrated parts because their
retractile capacity is increased. Healthy lung tissue has
a tendency to expand with inspiration because of the
counter pressure of alveolar air due to interference with
expiration by the pressure of the surrounding pneumo-
thorax, therefore, selective collapse is possible. Barlow
has called attention to the fact that in the part of the
lung involved with tuberculosis, there is marked impair-
ment of expansibility while there is little or no diminu-
tion in contractility. However, the tendency to contract
is compensated by an increased tension of the adjacent
healthy lung in its attempt to conform to the shape of
the thoracic cavity, but when one introduces a small
amount of air into a free pleural cavity the total volume
of the lung is reduced with the consequent reduction in
tension, therefore, the lung is free to assume any form.
Thus, selective collapse occurs by localization of air
over the retracted pleura of the diseased areas, and a
small amount of air may cause effective collapse of
lesions scattered through an entire lung.

Partially because of selective collapse, artificial pneu-
mothorax has been found a valuable diagnostic pro-
cedure, especially in diseases of the mediastinum, pleura,
lungs, ribs, and chest wall when obscure conditions exist.
It has been used to determine definitely whether intra-
lobar empyema exists, whether true cavity is present in
the lung, and the mapping out of other pulmonary con-
ditions. When combined with lipiodol, it becomes un-
usually valuable. This subject has been discussed by
such workers as Singer00, Fishberg32, Vallardi33,
Isaacs34, and Sergent and Bordet35.

Artificial pneumothorax has been used by a number
of workers in cases of persistent pleural effusions, par-
ticularly if there is evidence of underlying parenchymal
disease. In such cases a part of the fluid is removed and
replaced with air. If this is not done when the fluid
absorbs, the visceral and parietal layers of pleura usually
become adherent and if progressive parenchymal disease
is present its control by artificial pneumothorax is an
impossibility. In some cases of bronchiectasis, artificial
pneumothorax has been found of great value. However,
in the more extensive cases, adhesions usually are pres-
ent or it is impossible to obtain satisfactory collapse be-
cause of the pathological changes in the tissues. In pul-
monary abscess artificial pneumothorax is rarely indi-
cated in the acute stage, particularly if the abscess lies
near the periphery of the lung. In such cases, frequently
the abscess burrows into the pleural cavity and mixed
infection empyema results. However, in some cases of
pulmonary abscess located more centrally which have
become subacute or chronic and have drained into the
ramification of a bronchus, artificial pneumothorax when
carefully administered may definitely hasten recovery..
Moorman has found artificial pneumothorax valuable
in cases of massive collapse. Usually only one or a few

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301

administrations of air are necessary. In recent years a
number of reports have been made in the medical litera-
ture, showing good results in treating lobar pneumonia
by artificial pneumothorax. Here again usually only a
few administrations of air are necessary.

The most extensive use of artificial pneumothorax has
been in the treatment of pulmonary tuberculosis where
good collapse of the diseased area of a tuberculous lung
results in the closing of cavities, relief from symptoms
such as disappearance of fever, reduction in pulse rate,
increased appetite and disappearance of cough and
sputum. The closing of cavities is purely mechanical,
and the collapse results in blocking of the lymph cir-
culation which prevents the poisonous products con-
tained in the lymph from entering easily into the gen-
eral circulation. The accumulation of the poisons results
in a reaction which stimulates the growth of connective
tissue. There is also a venous stasis which aids in heal-
ing. Gardner315 made a postmortem study of fifteen
cases of pulmonary tuberculosis treated by artificial
pneumothorax and came to the conclusion that perma-
nent anatomic alteration is dependent on the duration
of compression rather than on the degree of pressure
maintained. The alteration consists in the development
of fibrosis in the pleura and connective tissue coats of
the blood vessels and bronchi. This is always accompa-
nied by a lymph stasis. He believes the fibrosis is due
to the retention of metabolic products which cause a
toxic stimulation as well as the pressure. He finds that
the degree of permanent changes in the lung is depend-
ent on the extent and degree of injury by the tuberculous
process.

Even the tubercle bacilli may be injured by the dam-
ming up of their own products of growth. Coryllos3'
states that since the tubercle bacillus is a strict aerobe
requiring large amounts of oxygen for continuation of
life and growth, absence of oxygen interferes with its
development. Collapse therapy decreases the amount of
oxygen available for its growth. He believes that de-
velopment of fibrosis is closely related to anoxemia.

Yoonts did some experimental work on rabbits,
guinea pigs, and a dog in which he produced tubercu-
losis by human and bovine bacilli and studied the effects
of artificial pneumothorax on the lesions. He came to
the conclusion that pneumothorax has a favorable in-
fluence on chronic tuberculosis while in acute exudative
disease it caused more marked caseous destruction and a
more acute course. He found that in the non-caseated
tuberculous processes, fibrosis progresses rapidly. He
believes that tubercle bacilli die in the collapsed lung as
a result of malnutrition.

Dock and Harrison39 found that when the right lung
of the rabbit is collapsed the total volume flow of blood
is not greatly affected, but there is a decrease in the
arterial oxygen content due to mixture of blood from
the normal lung with blood of venous character, which
passes through the unaerated tissues. During the first
few hours after collapse, the lung does not become
atelectatic; however, within a few days the collapsed

lung becomes airless and solid and the proportion of
blood passing through it falls to less than one-fifth of
the total flow. Therefore, they are of the opinion that
since an analogous condition occurs in man, the thera-
peutic value of pulmonary collapse resulting from cir-
culatory changes in the affected lung is due to ischemia.

Friedland40 performed bilateral pneumothorax on
forty-three dogs, cats, and rabbits and found that the
carbon dioxide output, and the oxygen absorption are
diminished. However, the total gas metabolism exceeds
the normal, and the respiratory co-efficient is increased.
The blood pressure is not appreciably increased.

Corper, Simon, and Rensch41 collapsed the right lung
in rabbits shortly after intravenous injection of a sus-
pension of virulent human tubercle bacilli and main-
tained the collapse for a period of one month. They
found that it had no appreciable effect on the size or
number of macroscopic tubercles in the lungs of the
treated animals as compared to the untreated, or in the
collapsed right lungs as compared to the left lungs.

Rolland4J and Roubier43 have proved conclusively that
no harm is done to that part of the lung which is normal
but which may be collapsed in order to secure a suffi-
cient collapse of the diseased area. Lichtenstein44 studied
the sensitivity of tuberculous patients and found that
compression of the lung results in increased allergy. He
finds that the more thorough the compression the
greater the skin reaction. He says: "This again fits in
with the theory that the skin reactivity depends upon
the amount of tuberculo-protein liberated from the
lesion. Apparently the sensitivity may be restored to a
higher level when compression procedures cut down the
circulation of the tuberculo-protein.”

Another paradox in artificial pneumothorax work is the
favorable action which one sometimes sees on the lesion
in the opposite lung. Some believe this is due to slight
immobilization through pressure on the mediastinum.
Betchov4'' says that artificial pneumothorax is never
restricted to one side alone, that the opposite lung is
always somewhat affected; that the pressure against it
may exert a healing influence on the contralateral lung
also. Others are of the opinion that when toxemia from
the more extensive lesion is reduced and disappears, and
when tubercle bacilli are no longer being eliminated
from the lesion, the resisting forces of the body arc
better able to control the lesion in the opposite lung.

The patient in whom artificial pneumothorax is in-
dicated is fortunate, indeed, when no pleural adhesions
are present, but if the disease has existed over a consid-
erable period of time or has become extensive, some
adhesions have usually developed. In fact, Sevier46
found pleural adhesions prevent success of the treatment
in more than 50 per cent of suitable cases. Other work-
ers have made similar observations. Adhesions may vary
from those which completely obliterate the pleural space
to small string-like structures which interfere little or
not at all, with the success of the treatment. Most per-
sons who have had pleural effusion at some previous
time have very extensive adhesions. Many who have

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previously had pneumonia also have numerous adhesions.
Matson et al 4‘, report that adhesions are almost invar-
iably present over cavities. This is an undesirable con-
dition for the end results of artificial pneumothorax
cannot be as satisfactory when adhesions are present.
This subject has been discussed by numerous authors,
such as Pallasse4*, Simon411, Schilb'0, Izzo and Aguilar '1,
and Lucacer ’-.

Enough reports on artificial pneumothorax treatment
are now available to enable one to draw some fairly
definite conclusions as to results obtained. Borelius''"
has shown that approximately 70 per cent of tuberculous
patients without adhesions treated by pneumothorax are
later able to work, whereas only 40 per cent with ad-
hesions are able to do so. Macfie and Alexander ' 1 re-
ported on two hundred cases in whom artificial pneu-
mothorax was attempted. Forty per cent were in the
third stage, 53 per cent in the second stage, and 7 per
cent in the first stage when treatment was begun. They
succeeded in collapsing the lung in 83 per cent; 57 per
cent of this group were alive when the report was made,
whereas only 38 per cent of those in whom treatment
could not be administered were alive.

Maendl55 made a study of 172 patients treated by-
artificial pneumothorax ten years after the first case was
started. In all of these cases, the pneumothorax was
continued two years or longer. He found that 51 per
cent showed no improvement; 49 per cent were im-
proved. Of the total 172, fifteen were cured; sixty-two
able to work, and eighty-five were living. Burnand’6
called attention to a patient treated by artificial pneu-
mothorax for thirty months who later died of another
condition. The postmortem examination showed com-
plete closure of the cavity.

Matson et <j/4' studied the results of artificial pneu-
mothorax on six hundred patients treated by artificial
pneumothorax over a period of twelve years. Eighty-
five of their cases were moderately advanced and 515
far advanced when the treatment was begun. They ob-
tained satisfactory compression in 235, partial or unsat-
isfactory compression in 245, and found no free pleural
space in 120. One hundred and forty-nine of the total
six hundred were clinically well when the report was
made, of whom 114 had satisfactory collapse, 28 partial
or unsatisfactory collapse, and 7 were with no free
pleural space.

Among Rist’s 1,009 cases treated by artificial pneu-
mothorax0‘, 759 had chronic unilateral disease when
the treatment was begun. Over a period of thirteen
years he observed that 387 of the 759 cases were clin-
ically well but that 336 of them were still under treat-
ment. Of the remaining 372, 240 had died. The con-
dition was unchanged in 33 and lesions in the opposite
lung had developed in 99. In the remaining 250, he
found it impossible to produce artificial pneumothorax
because of pleural adhesions. Douglas°s observed 396
patients with reference to fatality with effective and
ineffective collapse. Of the 152 who had effective col-

lapse, 6 per cent were dead, of the 245 with ineffective
collapse, 40.4 per cent were dead.

Poor results have been frequently reported in cavity
cases. Plieninger has shown that cavities located near the
hilum usually are difficult to obliterate. Adler1’0 has found
that a few cases may have their disease continue to pro-
gress under artificial pneumothorax treatment. This is
manifested by enlargement of the cavities, etc. In treat-
ing children, Fechter1’1 found that when cavities arc
present the results are less favorable, in such cases, it
is more difficult to obtain good results with reference to
negative sputum, or disappearance of sputum.

The Committee of the American Sanatorium Associa-
tion on treatment consisting of Douglas, Peters and
others''* reported 360 cases with reference to tubercle
bacilli in the sputum at the termination of artificial
pneumothorax treatment. Of one hundred and fifteen,
whose re-expansion was intentional, 66.1 per cent had
negative sputum. Of two hundred and forty-five, whose
re-expansion was unintentional, 46.9 per cent had nega-
tive sputum. They then observed 405 patients with
reference to sputum at the termination of the treatment
according to condition of the treated lung before col-
lapse. One hundred and fifty-eight of these patients
had considerable cavitation in whom 53.8 per cent had
negative sputum. One hundred and one patients had
moderate cavitation of whom 54.4 per cent were nega-
tive; ninety-seven had slight or no cavitation of whom
64.9 per cent were negative. Forty-nine patients had
pneumonic consolidation of whom 57.2 per cent had
negative sputum. They observed further, 186 living
patients with reference to their condition one or more
years after termination of treatment according to spu-
tum at termination of treatment. Of this number, fifty-
two had positive sputum on termination of whom 42.3
per cent were free from, symptoms. One hundred and
thirty-four had negative or no sputum at the termina-
tion of treatment of whom 85.8 per cent were free from
symptoms. They also report 362 patients with reference
to mortality according to sputum at termination of
treatment. One hundred and sixty-two of them had
positive sputum, 47.5 per cent were dead; two hundred
had negative sputum or none, of whom 1 1 per cent
were dead. Cutler1’- reported a group of cases in which
he points out that in every instance where the disease •
was confined to one lung and a successful collapse was
obtained, the sputum became free from tubercle bacilli.

Artificial pneumothorax treatment has been extended
to the minimal case of progressive pulmonary tubercu-
losis, where excellent results are obtained63. Many pa-
tients who have the treatment instituted when the dis-
ease is minimal and even some with moderately and fat
advanced disease may remain ambulatory throughout
the greater part or all of the course of treatment154.

How long collapse by artificial pneumothorax should
be continued in order to effect good control of the
lesions has been a subject of considerable discussion
Of course, much depends upon the extent of disease
and the progress of the case. If the disease is very ex

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303

tensive and numerous or large cavities are present so
that little normal lung tissue remains, there is some
question whether the lung should ever be allowed to
re-expand. On the other hand, when the disease is
minimal or moderately advanced and multiple or large
cavities are not present, the treatment may be discon-
tinued with a reasonable degree of safety but just when,
is the question that no one can answer with certainty in
any individual case. There are a number of cases on
record who after six months to a year of collapse ther-
apy, discontinued their treatment and have gone on to
excellent recovery. However, there is a general con-
sensus of opinion that such brief periods of treatment
are not adequate. Rist°° says that the habitual practice
of allowing premature re-expansion is frequently disas-
trous. He likens it to throwing a man, who has been
saved from drowning, back into the water. On the
basis of actual observation of 189 patients in whom col-
lapse was instituted between 1919 and 1921 and the
patients traced as late as 1927, Rist and his co-workers
concluded that security cannot be assured before the
fifth year. Rist now maintains collapse for this period
of time with excellent results. Jacquerod06 is of the
opinion that in cases of severe advanced lesions, the
treatment should be continued to the point of more or
less complete fibrous transformation of the entire dis-
eased lung and sometimes for life. In the case of more
recent lesions, however, he believes that the time to allow
re-expansion must depend upon the physician’s judg-
ment. He says, "We never will regret having kept it
up too long, but we often may have to regret that we
stopped it too soon.”

In 45.1 per cent of Hoffschulte’s0' eighty-two pa-
tients, it was impossible to continue pneumothorax as
long as six months; 54.8 per cent were treated for six
months and longer, 36.5 per cent for twelve months and
longer. Of the first group, clinical cures resulted in 5.4
per cent; of the second group 37.7 per cent; and the
third group 43.2 per cent. The sputum became nega-
tive in 18.9 per cent of the first group; 71 per cent of
the second group; 69.9 per cent of the third group.

The Committee of the American Sanatorium Associa-
tionu8 on treatment observed 396 patients with reference
to their condition one or more years after termination of
treatment. Of the total number, 49 were dead one or
two years after treatment. Of the remaining 347, two
to three years after treatment, 19 were dead. Of the
remaining 328, three years and more after treatment, 25
were dead. Of the remaining 303, with the interval un-
known, 15 were dead. They also reported on 348 pa-
tients with reference to sputum at the termination of
treatment according to time of re-expansion. One hun-
dred and seventy whose re-expansion was established
within the first year, 36.4 per cent had negative sputum;
af 99 within the second year, 74.8 per cent were nega-
tive; of 46 whose re-expansion was established within
the third year, 75.8 per cent were negative.

Amberson and Riggins3 traced 165 patients after the
ung had re-expanded who had been treated by pneumo-

thorax for an average of five years. In eighty-nine, the
cavities were permanently closed and 87.6 per cent were
living, while 78.2 per cent of the living were able to
work or lead normal lives. In seventy-six, the cavities
were not completely closed and only 41.6 per cent of
them were living of which 48.6 per cent were able to
live normally. They are of the opinion that the dura-
tion of treatment after the cavities have been closed and
the sputum has become negative, is more important than
the total duration of treatment. Their patients do well
after re-expansion if the cavities were kept closed from
one and one-half to two years, the average total length
of treatment in the most successful cases was from two
to three years.

Pearson' advises that pneumothorax be continued at
least three years. In his series, those who recovered were
treated an average period of four years and four months.
Neumann09 believes the lung should be kept collapsed
as long as is necessary for the formation of connective
or fibrous tissue to replace the diseased tissue. He calls
attention to the work of Ranke and Saugmann, the for-
mer recommending two years and the latter from two
years in acute cases, and three to four years in chronic
cases. Pearson08 observed seventy-eight patients whose
treatment was begun three to five years before his report.
All of his cases were in the third stage and had positive
sputum when treatment was begun. When he traced
them he found that 42 per cent of those in whom pneu-
mothorax was feasible were able to work and 50 per
cent were dead. Of those in whom the treatment was
impossible, only two were able to work and 64 per cent
were dead. He points out that of those with pneumo-
thorax who died, the average length of life was two
and one-half years which was longer than similar un-
treated groups. Peters'0 found in his group of patients
the end results in those having pneumothorax treatment
were approximately twice as good as among those in
whom no pneumothorax was possible. When satisfactory
collapse was obtained, the chances of being alive after
two to fourteen years were almost trebled and the
chances of being in satisfactory condition were exactly
trebled. He emphasizes the significance of bringing
about the disappearance of tubercle bacilli from the spu-
tum when satisfactory pneumothorax is possible. Bur-
nand'1 is of the opinion that the lung should be col-
lapsed for a minimum period of two years.

The Schilling haemogram has been found of value by
such workers as Griesbach'- and Russew73 in observing
the progress of patients on pneumothorax treatment.
Schneider74, Papanicolau and Weiller‘°, Marotta76,
Cutler77, Gripenberg'8, and Maendl'9 and others have
discussed the sedimentation test in artificial pneumo-
thorax. For the most part they find that with clinical
improvement, there is diminution in the red-cell sedi-
mentation values. Although the rate usually becomes
normal when the patient does well on artificial pneumo*
thorax, yet a normal rate is not a sufficient indication to
discontinue artificial pneumothorax.

In all cases, we recommend that the treatment be con-

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tinned for three years. At the end of that time we
neither advise that it be continued nor discontinued. We
know of no way to determine with certainty, when the
disease is so well under control that there is no danger
of subsequent reactivation. We have patients who have
discontinued treatment after a short period of time and
have remained free from symptoms*0. On the other
hand, we have patients whose disease has reactivated
after being on treatment five or more years.

The question often arises as to whether a lung kept
under artificial pneumothorax treatment over a long per-
iod of time will re-expand. If the disease is very exten-
sive the fibrous tissue may become so interwoven
throughout as to prevent expansion when artificial pneu-
mothorax is discontinued. In such cases, it is probably
better that the lung does not re-expand, since there is
always the likelihood of old cavities opening and re-
activation of disease. In some cases with effusion, the
visceral pleura becomes extensively involved and this
prevents the re-expansion of the lung. However, these
cases are not common. A much more frequent and un-
pleasant occurrence is the re-expansion of the lung
through the formation of adhesions before one has com-
pleted the treatment.

When the lung is allowed to re-expand, adhesions
usually form between the parietal and visceral pleura,
thus making the re-institution of artificial pneumothorax
impossible in a high percentage of cases. This is one of
the reasons for continuing the treatment sufficiently long
to insure the control of the disease. In the occasional
case, however, it is possible to re-institute treatment.
Hirschbcrg*1 reports a case of successful resumption, ten
months after the treatment had been discontinued, and
Hutchinson*" recompressed a lung six years and three
months after the last refill.

We no longer look upon artificial pneumothorax as
a drastic procedure; in fact, it has become a standard
method of treatment. To be sure, the procedure is at-
tended by some danger but the accidents such as gas
embolus and spontaneous pneumothorax are so rare as
to be of little significance. Fishberg22 speaks of the
harmlessness of the artificial pneumothorax procedure
when used for diagnostic purposes. Here the procedure
is no different than when it is used therapeutically ex-
cept that in the latter the lung is kept collapsed over a
longer period of time. Peters says: "The complications
of pneumothorax are so few and their percentage so
small as to be negligible.” Rist,,;’ says that the risks of
artificial pneumothorax are negligible when induced to
cure pulmonary tuberculosis. When the lung is allowed
to re-expand the pleural space usually becomes oblit-
erated but this is far better than to allow obliteration to
occur through progression of the disease before treat-
ment is begun. The treatment does not interfere in any
significant way with the heart and the circulation of
blood nor does it result in any harmful blood changes.
It does not interfere seriously with vital lung capacity or
factors of respiration such as gaseous exchange, carbon
dioxide tension, and the mechanical factors are normal

in persons with artificial pneumothorax. In cases who
arc dyspneic from toxemia, the breathing is improved
and other symptoms disappear, in the majority of cases
when the lung is satisfactorily collapsed. Even small
lesions in the opposite lung are often benefited. Arti-
ficial pneumothorax inhibits the proliferation of tubercle
bacilli and stimulates fibrosis. Therefore, the good which
results far offsets the complications and the adhesions
which form when the lung re-expands.

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cosinofilia: Reperti istologici in corso di pneumotoraee. speri-

mentale, Ri vista di Patologia e Clinica della Tubercolosi, Bologna,
September 30, 1930, iv, 725.

29. Michels: Uber Blutuntersuchungen mit besonderer Be-

rucksichtigung der Eosinophiles nach Tuberculin — und Pneumo-
thoraxbehandlung, Beitr. z. Klin. d. Tuberk., 1923, lvii, 13.

30. Dumarest. F.: Sur la physiologic mecanique du pneumo-

thorax, Rev. d. 1. Tuberc., April 1929, x, 177.

31. Singer. J. J.: Diagnostic Pneumothorax, Ann. Clin. Med.,

May 1926, iv, 907.

32. Fishberg. M.: Discernment of Intrathoracic Neoplasma by

Aid of Diagnostic Pneumothorax, Jour. Amer. Med. Assn., Feb-
ruary 26, 1921, lxxvi, 581.

3 3. Vallardi. C.: Del pneumotoraee diagnostics. (cisti da

echinococco del polmone diagnosticata col pneumotoraee artificiale),
II Policlinico, November 27, 1922, xxix, 1561.

34. Isaacs, H. J.: Diagnostic Pneumothorax, Amer. Jour.

Roentgenol., March 1925, jyii, 250.

3 5. Sergent, E. and Bordet. F.: A propos du diagnostic differ-

entiel des pneumothorax enkystes susscissuraux et des grandes
caverncs du sommet, Presse med., July 9, 1924, no. 55, 581.

36. Gardner, L. U.: Pathology of Artificial Pneumothorax in

Pulmonary Tuberculosis, Amer. Rev. Tuberc., January 1925, x,
501.

37. Coryllos. P N.: How Do Rest and Collapse Treatment

Cure Pulmonary Tuberculosis, Jour. Amer. Med. Assn., February

1 18, 1933, c, 480.

38. Yoon, C. : Die Pneumothoraxwirkung auf die Lunge mit

und ohne Tuberkulose. Beitr. z. Klin. d. Tuberk., 1924. lviii, 92.

39. Dock, W. and Harrison, T. R.: Blood Flow Through

Lungs in Experimental Pneumothorax, Amer. Rev. Tuberc., Jan-

< uary 1925, x, 534.

40. Friedland. M.: Die Pathologie des Pneumothorax in Bezug

, zur Frage des intrapleuralen Druckes. Dissertation. Kasan. 1922,

Abstract from Centralbl. f. d. ges. Tuberk. -Forsch., February

1924, xxi, 395.

41. Corper. H. J.. Simon, S. and Rensch, O. B.: Effect of
Artificial Pneumothorax on Pulmonary Tuberculosis in Rabbit,
Amer. Rev. Tuberc., October 1920, iv, 592.

42. Rolland: Evolution anatomique des lesions dans le pou-

mon collabe par le pneumothorax artificiel, Ann. de Med., April

1925. xvii, 327.

43. Roubier: Consequences anatomiques de la compression du

poumon tuberculeux par le pneumothorax artificiel, Presse Med.,
April 1 1, 1925, no. 29, 477.

44. Lichtenstein. M. R. Quantitative Tests on 944 Tubercu-
, lous Adults with TPT (Seibert), Amer. Rev. Tuberc., 1934. xxx,

214.

45. Betchov, N.: Ueber den einfiuss des einseitigen Pneumo-

thorax auf die Spannungsverhaltnisse in der anderen Lunge. Gibt
es uberhaupt eine einseitige collapstherapie?, Schwizerische medi-
zinische Wchnschr., 1921, li, 994.

46. Sevier. J. A.: Modern Methods of Treatment of Pulmo-

, nary Tuberculosis, Jour. Amer. Med. Assn., September 28, 1929.

xciii, 982.

47. Matson. R. W. Matson. R. C. and Bisaillon. M.: Treat-

ment of Pulmonary Tuberculosis by Means of Artificial Pneumo-
thorax, Jour. Amer. Med. Assn., September 1, 1 923. lxxxi, 713.

48. Pallasse, E.: Le pneumothorax artificiel. Ses raisons d’etre,

ses difficulties, son avenir, Prog. Med., November 8, 1924, no. 46,
699.

49. Simon, S.: Effect of Artificial Pneumothorax on Collapsed

Lung. Amer. Rev. Tuberc., 1921-1922, v, 620.

50. Schill. E.: Uber den Einflusz des kunstlichen Pneumo-

1 thorax auf die kontralaterale Lungenhalfte, Zeitschr. f. Tuberk ,
j December 1920, xxxiii, 149.

51. Izzo, Roque A. and Aguilar. Oscar P.: Consideraciones

, sobre el valor que tienen las lesiones del pulmon oquesto como

limitacion del neumotorax artificial, August 21, 1924, xxxi, Part
II, 407.

52. Lucacer, M.: The Immediate Results of Contralateral Pri-

mary Artificial Pneumothorax (Ascoli), Amer. Rev. Tuberc., 1931,

i xxiv, 50.

5 3. Borelius, R.: Kollapsbehanling vid Iungtuberkulos, Hygiea.

Stockholm, April 1 5, 1930, xcii, 292.

54. Macfie, J. D. and Alexander, A. J. P.: Artificial Pneumo-

thorax. Lancet, February 27, 193 2, ccxxii, 450.

5 5. Maendl. H.: Zur Frage der Dauerfolge nach kunstlichem

Pneumothorax. Wien. klin. Wchnschr., October 25, 1923, xxxvi.
756.

56. Burnand. M. R.: Tuberculose cavitaire chronique; pneu-
mothorax artificiel; deces par grippe: autopsie, Bull. d. 1. Soc.

Med. d. Hop., November 21, 1919, xliii, 983.

57. Rist, E.: Results of Artificial Pneumothorax in Pulmonary

Tuberculosis, Amer. Rev. Tuberc., 1927, xv, 294.

58. Douglas. B. H.: Report of the Committee on Treatment.

Trans. National Tuberc. Assn., 1933, 385.

59. Plieninger. T.: Die chirurgische Behandlung der hilus-

nahen Kaverne, Beitr. z. Klin. d. Tuberk., August 1932, lxxx, 291.

60. Adler. Hugo: Uber Aktivierungen der KoIIapslungc

wahrend der Pneumothoraxbehandlung, Zeitschr. f. Tuberk..
Leipzig, May 1931, lx, 434.

61. Fechter, H.: Pneumothoraxbehandlung im Schulalter unter

besonderer Berucksichtigung der Fehlergebnisse, Zeitschr. f. Kin-
derheilkunde, February 14, 1930, xlix, 143.

62. Cutler, J. W.: Ambulatory Pneumothorax and Public

Health, Med. Jour, and Rec., April 19, 1933.

6 3. Myers, J. A. and Levine. Ida: Artificial Pneumothorax in

the Treatment of Progressive Minimal Pulmonary Tuberculosis.
Am. Rev. Tuberc., 1935, xxxi, 518.

64. Myers. J. A.: Collapse Therapy and the Ambulatory Pa-

tient, Jour. Thoracic Surg., 1933, iii, 175.

65. Rist. E.: Quand faut-il interrompre le pneumothorax thera-

peutique? June 14, 1930, Rev. de la Tuberc., October 1930, xi,
915.

66. Jacquerod: Duree et mode de terminaison du traitement

par le pneumothorax artificiel, Presse Med., August 19, 1925,

no. 66, iv.

67. Hoffschulte. F.: Erfahrungen bei kunstlichem Pneumo-

thorax, Zeitschr. f. Tuberk., December 1929, lv, 220.

68. Pearson. S. V.: End-Results of Artificial Pneumothorax.

Brit. Med. Jour., January 9, 1926, No. 3393, 52.

69. Neumann. F.: Artificial Pneumothorax in Pulmonary Tu-

berculosis, Med. Jour, and Rec., June 6, 1928, cxxvii, 601.

70. Peters. Andrew: Artificial Pneumothorax at the Loomis

Sanatorium Over Fourteen Years, Amer. Rev. Tuberc., 1928, xvii,
348.

71. Burnand. R.: Effets anatomiques de la compression par le

pneumothorax sur le poumon tuberculeux. Rev. med. de la Suisse
Rom., December 1917, xxxvii, 729.

72. Griesbach. R.: Das differnzierte weisse Blutbild bei der

Kollapstherapie der Lungentuberkulose, Zeitschr. f. Tuberk., 19 30,
Ivi, 177.

7 3. Russew, R.: Uber die Morphologic des Blutes im Verlaufc

der Pneumothoraxbehandlung bei der Lungentuberkulose, Beitr. z.
Klin. d. Tuberk., 1928, lxviii, 522.

74. Schneider, Mathilde: Bedeutung der Blutsenkungsprobe

beim kunstlichen Pneumothorax, Ztschr. f. Tuberk., July 1 923.
xxxviii, 420.

75. Papanicolau. B. and Weiller. P.: La Vitesse de Sedimon-

tation des Globules Rouges dans La Collapsotherapie, Paris Med-
ical, November 14, 1925, lvii. 400.

76. Marotta. G.: II Comportamento degli Anticorpi nella Tu-

bercolosi polmonare durante la collassoterapia, Riforma Medica,
October 5. 1925, xli, 939.

77. Cutler. J. W.: The Blood-Sedimentation Test in the Man-

agement of the Pneumothorax Patient, Amer. Rev. Tuberc., 1932,
xxvi, 134.

78. Gripenberg, R.: Om blodsankningshastigheten hos Iung-

tuberkulospatienter, behandlade med konstgjord pneumotorax,
Finska Lakaresallskapets Handlingar, November 1925, lxvii, 974.

79. Maendl, H.: Zur Frage der Dauererfolge nach kunst-

lichem Pneumothorax, Beitr. z. Klin. d. Tuberk., 1924, lviii, 29.

80. Myers, J. A.: Artificial Pneumothorax: With Particular

Reference to the Ambulator Patient, Jour. Thoracic Surg., In press.

81. Hirschberg, F. : Pneumothorax artificial reinstitue malgre

dix mois d-interruption de traitement et resorption complete de la
poche gazeuse, Rev. d. 1. Tuberc., February 1928, ix, 73.

82. Hutchinson, R. C. : Recompression of a Tuberculous Lung

by Artificial Pneumothorax after an Interval of More Than Six
Years, Lancet, January 10, 1925, ccviii, 74.

306

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Unit Method of Teaching Hygiene in College

Helen L. Coops, Ph.D., and Laurence B. Chenoweth, M.D.**

Cincinnati, Ohio

IN RECENT YEARS attention has been focusing
on a certain method in education called the unit plan
of study. According to many observers the method
is not new, but goes back to the beginning of the 19th
century when Johann Friedrich Herbart (1776-1841), a
German educational philosopher, proposed a certain
method in presenting a given subject1.

The followers of Herbart divided his method into five
formal steps which they called "formal Herbartian
steps.”2 The steps were (1) preparation, (2) presenta-
tion, (3) association or comparison, (4) generalization
or abstraction, and (5) application.

Various additions and special applications have been
made to the general principle by a number of prominent
educators3.

Various unit plans are being put into operation in the
teaching of various subjects among which is hygiene.
The older methods of teaching hygiene had a tendency
to be ineffective. Many facts were presented to students
which had no practical value. On the other hand, there
were many subjects omitted which may very well have
been included because of interest in them. The unit plan
has been adopted as a device to help vitalize the subject
of hygiene teaching. There are almost as many varia-
tions of the unit plan as there are instructors in the
different institutions. The educational literature shows
frequent references to many variations of the scheme.

One of the main advantages of the unit plan as
usually applied in college hygiene courses is a division of
the subject matter into units. The units should not be
too large, should not include too much material. One
advantage of the unit method in college is that the in-
structor may receive instruction from the student. In
digging up material on so active and growing a subject
as health instruction it is not unusual for a student to
present material which is news to the instructor.

What the Unit Method Is

To quote a recent author, "The central fact of the
unit idea is that content should be studied as complete
meaningful wholes rather than in isolated or unrelated
lessons or bits.”4

The unit system is primarily a point of view in which
the instructor acts as a leader and a joint discoverer with
a class, in search of some desired information. The
older traditional method presented the instructor as a
ring-master who gave out periodic assignments, conduct-
ed drills, and then tested the memorized material. Ac-
cording to the unit method the same material is cov-
ered in classes; but the manner of presentation of sub-
ject matter and its subsequent development is usually
quite different.

♦Presented at the 13th Annual Meeting of the Ohio Student
Health Association, Columbus, Ohio, April 2, 193 7.

♦♦University of Cincinnati, Cincinnati, Ohio.

An example of this method is the modern teaching
of a class in college hygiene. The instructor presents a
series of suggested units, with brief outlines of suggested
developments. The class discusses the units in general,
and the instructor points out interesting and important
features. The outcome of the discussion (if it is prop-
erly led) is the expression of a desire to investigate top-
ics. The instructor may suggest methods and help with
organization of the class into smaller groups of from
three to nine students for separate investigations and
reports. These separate investigations and reports then
lead to further activity if the instructor is skillful in
integrating material and directing its course along the
channels he originally had in mind.

The secret of the method is to make the students
think that they have selected the topics to be investigat-
ed and that their efforts are based upon felt needs for
information. The resulting study is then self-motivating,
becoming both purposeful and meaningful to the stu-
dent. Text-books and other available literature become
source materials in case of need rather than a patent
medicine dose to be taken in gulps of 20 pages each.
Instead of learning the muscles of the body and the var-
ious systems, in isolated learning, the student investigates
the material because he can thus understand more fully
such personal problems as: how to defend himself

against infection, the value and limitation of drugs in
illness, the use of immunizing substances, mental hygiene
and the development of an acceptable personality, the
significance of motor activity in modern life, and many
other subjects of vital importance to the college student
himself.

How a Given Unit Is Presented to a Class

The first step in actual presentation is to appeal to
what students actually know about a given topic and to
get them to express their own feelings concerning their
individual knowledge or experiences.

The next step is to present new and startling informa-
tion concerning the topic. This information should be
interesting and pertinent in order to stimulate their
curiosity and imagination. It should be so stated that
students are personally aroused, either because of a de-
sire to know more or because of the chagrin of ignor-
ance. In all cases such a reaction should be directed
toward activity because of a desire to investigate.

The final step (in presentation) is for the group, in
cooperation with the instructor, to outline tentative
methods of solving the felt problem or project.

Specific examples of subject matter were first given
out of which general topics or trends developed. Subse-
quent investigation or study should revert to the specific,
including detailed analysis and scrutiny,

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307

What an Instructor Docs in
, Preliminary Work

1. He sets up personal goals in terms of the purpose of
the teaching and expected accomplishments. He
should know in general what he expects the class to
learn although he cannot foresee the exact methods
and the details of procedure.

2. He should know as much as possible about his group
— the answer to such questions as:

(a) What general individual characteristics have
students at that age? Individuals vary within the
group, but a twenty-year old student is quite apt to
have typical problems and desires which are due to
his age and stage of physical, mental, and social
development.

(b) What sort of homes do they come from and
what sort of a community do they live in? Are they
comparatively well-to-do or do they come from a
section with low socio-economic status? Factors of
this sort have much to do with health teaching. A
class discussion of the effects of alcohol is far dif-
ferent when the majority of students come from
homes where cocktail drinking is a daily and accept-
ed habit than when students come from conservative
country districts.

3. The instructor should be personally well informed on
his subject, in terms of:

(a) History and details of subject matter.

(b) Recent investigation, research and experi-
mentation.

(c) Source material — either in printed material
or local happenings. A unit on the college health
examination may serve as the basis for investigation
of methods of prevention of common bodily defects.
This may in turn lead to investigation of body
structure in the normal person.

The Place of the Instructor

The instructor should be the person to "set the stage”
for an interesting play. He should have the point of
view that people learn primarily through their own ef-
forts and activity. His job is to guide the process, to
utilize the resources of the college and the community
in making the activity personal and real, to make quick
use of unexpected developments and situations by swing-
ing them into line. His own pre-established objectives
serve as a focus and he merely guides student activity
toward this focus. He somehow should get the class to
realize that his function is:

1. To aid the process of study by giving out any
suggested or requested information.

2. To explain short cuts in the process — because of
his own knowledge and experience.

3. To help organize and correlate these separate ac-
quisition of knowledge.

4. To evaluate individual quality and quantity of
work by periodic quizzes or examinations.

The Main Difficulty in the Unit Method

The most persistent problem is the fact that the in-
structor must have initiative, foresight and ingenuity.

He must have more knowledge of his subject than the
instructor who "keeps ten pages ahead of the class as-
signment.” He must know more of the individual
characteristics and motives of his students than the old
type teacher who was concerned merely with pass-
ing out subject matter. He must be a human being
who is interested in other human beings. He must
think of education as living and not just a text-book
memorization.

There are rewards for this effort. The business of
teaching becomes far more interesting for the instructor
as well as the student. Invariably students work more
willingly and do much more. Subject matter becomes
more vital and related to life — not just the remote and
sterile process that has characterized the teaching of
hygiene in the past.

Examples of Units

The unit may be long or short. A whole course may
be thought of as one unit, or a number of subdivisions
may each serve as such.

In order to make use of a fortuitous circumstance,
malaria, its transmission and prevention may be con-
sidered as a unit. In the autumn of 1936, just after
the opening of a certain university, one of the professors
returned to his work after a long cross-country drive
from California. A week or ten days after his arrival
he came down with a typical case of malaria. He is
well-known and popular and students began to discuss
his case and to marvel at the seriousness of his illness.
The approach was ready made for an instructor who
could seize the opportunity. Interest was manifest in
malaria, which had not visited this campus for a number
of years. To help in the approach, students remarked
that the university’s archaeological expedition which goes
to the site of ancient Troy in Asia Minor every February
and returns in September, came home without any ma-
laria among them. Not only that, but none of them
have had any malaria for many years, and some of them
never at all. This in spite of the fact that malaria is
notoriously prevalent and endemic in Asia Minor.

The objectives of the unit may be outlined somewhat
as follows: (1) to acquaint students with practical and
scientific information concerning the transmission of
malaria, (2) to make a study of the history and present
status of the disease, (3) to learn the personal prophy-
laxis of this disease.

The procedure of study in such a case could be out-
lined somewhat as follows: those students interested in
electing to report on this unit appoint a chairman, who is
not expected to do all the work, but to serve as a co-
ordinator, to bring about cooperation among the stu-
dents working on the unit. One of the members of the
"committee on malaria” assumes the duty of assembling
the main biological facts concerning the malarial mos-
quito. Another looks up the history of malaria, the
scientific facts concerning its transmission and its char-
acteristics. A third volunteers to interview the convalesc-
ing professor. A fourth interviews the director of the
archaeological expedition just returned from Troy. Cer-

308

THE JOURNAL-LANCET

tain definite things are brought out by members of the
group:

1. The teacher returning from the West told of the
long day and night driving required to get back
to the university.

2. It was learned by study that the malarial mosquito
bites mostly after sunset, therefore night-driving
through malarial infested country is especially
hazardous.

3. The archaeological expedition reported

(a) That they lived in well-screened houses.

(b) After sunset they remain indoors.

(d) Year after year they are exposed to malaria,
yet never contract it.

The references concerned in the study are brought to
class and reveal an interesting story: malaria was a pre-
valent disease of the ancients. It probably had much to
do with the decline of ancient Greek and Roman civili-
zations. It was not until recent years (1894) that the
disease was definitely known to be carried by a certain
type of mosquito (discovered by Ross or Grasse?).
Many interesting biological and medical facts about
malaria and the mosquito are brought out and made
practical for the student.

The student should be led to activity; to see the need.-,
of mosquito elimination in his community and, in case
he were traveling in the South, he should follow a
routine which would protect him from the possibility of
contracting malaria.

The story of malaria as an insect-borne disease raises
the question of what other diseases are transmitted by
insects and other units are suggested by the cooperative
work of students and instructor. If the students think
of desirable units, their interest should be recognized
and their suggestions followed. If not, the instructor
should point out what units should naturally follow.

Examples of Unit Teaching in University
Health Courses

1. Personal Hygiene for Women (Dean Katherine D.
Ingle and Dr. Marian A. Boyd.)

Introduction and Unit I

Introduction: Scope of personal hygiene — modern em-
phasis on positive and social viewpoint. Correlated with
facts presented in community hygiene.

Unit I: Heredity, eugenics, and euthenics.

A. Problems of heredity

1. History of study of heredity

2. Laws of heredity.

B. "The way life begins”

C. Heredity v*. environment

D. Eugenics and euthenics

Bibliography

Unit II: The Orientation of the Student in the
Health, Physical Education, and Guidance Programs

A. The guidance program

1. Trend toward individualization

2. Changes in society:

a. Those which have occurred in the past

b. Those which are needed in the future

3. Changes in college curricula

4. Possible modifications in behavior

5. History of personnel viewpoint

6. History of physical education in schools and
colleges

7. History of education for women in the United
States

B. The orientation of the student in fields other than
health

C. Objectives of the physical education and health
programs

1. Individual needs met by physical training

2. Health program (physical examination, classes,
conferences, etc.)

3. Desired results

D. Significance of motor activity in the history of man

1. The evolutionary, recapitulation, and other
theories

2. Classification of motor activities

E. Activity in the various periods of childhood

F. Physical activity on the college level; exercise
problems

Unit III. Defensive health measures

1. Care of skin

a. Structure and function

b. Disease of skin and their prevention

2. The skeletal system — posture, abnormalities of
feet

3. Hygiene of the digestive system

4. Head — eyes, ears, nose, mouth, throat

5. Reproductive system and sex hygiene

6. Endocrine system

7. Circulatory system — heart disease and its pre-
vention

<8. Drugs, useful and harmful
9. Common diseases and their personal prophylaxis
Unit IV: Constructive health measures

1. The newer knowledge of nutrition

2. Physiological aspects of sleep

3. Conservation of vision and hearing

4. Adequate medical and hospital service

5. Problems of physical activity and recreation in
college and later

6. The accident problem

7. Social relations and the problems of mental
hygiene

2. Orientation in health education for freshmen
women (Harriet Rowley)

Steps:

A. Pre-test for background

B. Questionnaire for interest (Students)

C. Appeal to authority (Faculty and others)

D. Study of findings of health examination

3. Sample 6- weeks course to senior men and women
— units (according to expression of personal interest and
desire for information) (Dr. Coops) .

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309

A. New phases of mental hygiene

B. New phases of social hygiene

C. Research and history of medicine and public health

D. Consumers’ Research and buying and legislation

E. Personality in relation to vocational success

Topics selected by students. Instructor directed spe-
cific choice of investigation under each topic

4. Methodology in health education for professional
students (seniors) (Dr. Coops)

Main topic: Actual methods of presenting health
materials to various grade levels and various types of
persons

Appeal to students:

1. You have had various courses containing various
subject matter.

Professional courses: anatomy, physiology, hygiene,
physical diagnosis, etc.

Educational theory: principles, methods, class

management, statistics, etc.

Related courses: speech, psychology, etc.

2. You may soon be in a practical situation where
you will have to integrate all this material. Do
you know how to teach social hygiene in a high
school; could you present a unit on milk to second
grade children; could you present posture effective-
ly in the junior high school? In other words, can
you integrate all you have learned and apply it
practically?

3. Do you know local or national resources of mater-
ials for health teaching? Do you know how to
keep up with things that are happening in the
world? Can you see the field of health education
in terms of educational trends and present-day
American life?

4. Finally, how would you like to go about acquiring
this information? What definite practical measures
can be undertaken that would be of most practical
help to you? How can I, as instructor, be of most
help in the process?

On the basis of these discussions limits were set up by
the class:

1. Definitions, terminology, and administrative re-
lationships of school health education.

2. Source materials — (addresses, prices, and descrip-
tions) Books, periodicals, and pamphlets. Health
organizations; federal and local, private and semi-
private, commercial. Materials other than printed:
visual education, activities in school, home and
community, etc.

3. Certification and training standards: major, minor
and courses for non-specialist. Standards and min-
imum essentials.

4. Opportunity to work out a health curriculum in
selected situation.

5. Work on individual problem selected because of
personal interest or because of felt lack of know-
ledge.

6. Knowledge of contemporary findings — literature of
field and significant recent findings.

Methods: Group investigations (2—4 individuals) —
reports, discussion. Mimeographed summaries.

Bibliography

1. Johann Friedrich Herbart, Outlines of Educational Doctrine
(tr. by A. F, Lange), New York, Macmillan Co., 1901.

2. Chas. de Garmo Herbart and the Herbartians, New York.
Charles Scribners, 1895.

3. See Umstattd, J. G., Secondary School Teaching, Boston,
Ginn & Co., 1937, pp. 147-175.

4. Umstattd, Loc. cit.

Physiological Principles of Importance in Heart
Failure and Its Treatment

Maurice B. Visscher, Ph.D., M.D.**

Minneapolis, Minn.

The heart is of importance only because it
serves to provide the motive power for the circu-
lation of the blood. Consequently, its efficiency as
a machine for doing work is its most important property.
The failing heart is unable to perform as much work as
a normal heart in propelling blood around the circu-
latory system. In order to treat heart failure intelligently
we must know the defect in the heart muscle that is
responsible for its inability to do work.

In any machine the amount of work that can be done
depends upon two factors, the amount of energy avail-
able and the proportion of that energy that can be con-

'"Presented before the Hennepin County Medical Society, Wed-
nesday, January 6, 1937.

**Chief, Department of Physiology, University of Minnesota,
Minneapolis, Minn.

verted to useful work. Machines are never 100 per cent
efficient in converting energy to work, and under the
best conditions the heart is approximately 20 per cent
efficient, that is to say, for every 100 units of energy
liberated in contraction, only 20 are capable of appear-
ing as work. The remainder is dissipated as waste energy
or heat.

In studying the physiology of the failing heart it is
important to know whether its defect lies in an inability
to liberate energy sufficient to carry its load or in a
disability to convert the proper fraction of the energy
to useful work. Experiments have been designed to
determine this question by observation. It is very diffi-
cult, if not impossible, to measure the total energy lib-
erated by the heart beating in situ. By the use of the

310

THE JOURNAL-LANCET

isolated heart in the Starling heart-lung preparation,
however, it is possible to make such measurements where
the oxygen consumption of the preparation can be meas-
ured, and after correcting for the oxygen consumption
of the lungs, the remainder of the metabolism can be
assumed to be that of the heart itself. Extensive studies
by Starling and Visscher, 1927; Clark and White, 1928;
Gremels, 1933; and Decherd and Visscher, 1934; among
others, have shown that the energy liberated in cardiac
contraction is a function of the fiber length. At the be-
ginning of the contraction the fiber length is measured
by the volume of ventricles, the volume at the end of
the diastole, or, in other words, at the moment at which
contraction begins. It is the factor that determines the
energy liberation in the next systole. It has been shown
that in the normal heart the energy liberation is greater
the longer the fibers are at the instant of contraction,
thus the more dilated the ventricles are, the more energy
they are able to liberate.

With respect to clinical physiology, the important
question is as to whether this relationship between the
diastolic ventricular volume and energy liberation holds
in the case of cardiac failure. The observations, particu-
larly of Peters and Visscher, 1936, show that this is
strictly true. It was found that no matter how little work
a heart was able to do after it had failed in the heart-
lung preparation, the total energy consumption at a
given diastolic volume was the same as it was in that
heart when it was working vigorously when fresh and
normal. The failing heart has become a spend-thrift, so
to speak, in its utilization of energy. It can do less and
less work with a given amount of energy with progressive
failure, so that instead of having an efficiency of 20
per cent, that factor may fall to less than one per cent.
In such a case more than 99 per cent of all the energy
the heart puts out in contraction is wasted. Thus it can
be said that the failing heart, at least in the heart-lung
preparation, is simply an inefficient heart.

There are reasons for believing that the situation is
not essentially different in the case of failure in the
clinical sense. The behavior of the heart in the isolated
preparation and in man in failure is similar in several
important respects. First, in that it dilates to accomplish
a constant load of work in both cases. To be sure the
dilation occurs faster in an acute experimental failure
than in man, but this is partly due to the restraining
influence of the pericardium in man, and presumably to
the slower rate at which the process of deterioration
occurs in the intact organism. Furthermore, the similar
actions of drugs in the two cases, to be mentioned later,
gives further evidence that the essential processes are
comparable in the isolated heart and in the intact
organism.

An understanding of the mechanism of failure from
a physiological point of view is chiefly significant to the
clinician in providing a basis for rational therapy. If the
defect in heart failure is a decrease in the mechanical
efficiency of the heart muscle, the obvious aim of treat-
ment should be to restore the efficiency to normal. It is

a matter of observation that imposing heavy loads of
work for long periods of time upon the heart causes it
to lose efficiency. Working at moderate loads, on the
other hand, results in improvement in efficiency after
periods of over-loading. It is apparent, therefore, that
decreasing the load of work imposed on the heart to as
low a figure as possible will give it an opportunity to
recover its efficiency. From a practical point of view it
is the muscular work of the body in movement that calls
for the greatest increases in the work of the heart.
Therefore, muscular exertion must be reduced to a
minimum and the common clinical practice of putting
cardiac patients at strict bed rest finds its justification
from a physiological view point.

An extra load is also thrown upon the heart after in-
gestion of food. Thus, after moderate meals, Grollman
and others have shown that there is a fifty per cent in-
crease in the circulation rate. The association of acute
cardiac episodes with the eating of a hearty meal is
therefore not an accident, and the fatal heart disease
mistaken for acute indigestion has its physiological basis
in the circulatory processes associated with the intake of
food.

The importance of the heart rate upon the efficiency
of the circulation was pointed out by Starling and
Visscher. They showed that the heart was only 60 per
cent as efficient at a rate of 170 as it was at 90 in carry-
ing a given load of work. Thus, other things being
equal, it is physiologically desirable to keep the heart
rate as low as possible, since this factor in itself has such
a profound effect upon efficiency.

The most important practical information at hand re-
lating to the influence of the cardiac drugs upon the
efficiency in the failing heart concerns the mechanism
of action of digitalis. It has been shown by Gremels, and
Peters and Visscher, that the efficiency of doing work
increases markedly in failing hearts treated with digi-
talis glucosides; Gremels used strophanthin and lani-
digin; while Peters and I used scillaren, ouabain, digi-
lanid and strophanthin. These agents are able to increase
the efficiency of the heart as much as 200 per cent and
may restore a failing heart practically to normal in this
respect. The fact that digitalis glucosides are capable of
permitting the heart to do larger amounts of work at a
given energy liberation is obviously of importance to our
view of the way in which digitalis has its therapeutic
action. It is a drug which permits the heart muscle to
carry a given load of work at less cost to itself, and
therefore, with a lower metabolism going on. It requires
less fuel and fewer materials for repair. Any agent which
has such an effect should be useful in the treatment of
the failing heart.

Anesthetics as a rule have a deleterious effect upon
the efficiency of the heart muscle. Sodium amvtal in
anesthetic concentration produces a 40 per cent decrease
in efficiency. Ethyl alcohol comes in the same category.
Its effects have been studied by Peters, Rea, and Gross-
man, who showed that the efficiency decreased markedly
when the concentration of alcohol in the blood was

THE JOURNAL-LANCET

311

greater than 0.2 per cent. Certain agents used as cardiac
stimulants also have a deleterious effect upon the effi-
ciency; conspicuous amongst these is coramine, which,
according to these observations, is certainly not a useful
cardiac tonic, whatever its other effects may be. In this
connection it should be noted that the expression, circu-
latory stimulant, has a very indefinite physiological mean-
ing; and that agents may have useful effects on peri-
pheral circulation and at the same time have deleterious
actions on the heart. Their dangers, however, should be
recognized if they are to be used. Since coramine has a
damaging effect upon heart muscle in the heart-lung
preparation, it seems very doubtful whether it should be
used clinically when the critical factor for the life of a
patient is the efficiency of his heart muscle. If the heart
is not in the state of failure, there would perhaps be no
danger in the administration of substances which them-
selves tend to cause heart failure as coramine does in the
heart-lung preparation.

These physiological studies have pointed to the im-
portance of a consideration of the heart as a machine
for utilizing energy in doing work. As a machine it be-
comes less efficient in failure, and its treatment by such
tonics as the cardiac glucosides results in an improve-
ment in its efficiency. Other factors have become evident
which also point the way to the establishment of con-
ditions under which the heart can recover its lost effi-
ciency and thereby be made more capable of carrying
the loads that are imposed upon it.

References

Clark, A. J. 6c White, A. C. : Jour, of Physiology, 66:185,
1928.

Decherd, G. 6C Visscher, M. B.: Jour, of Experimental Medi-
cine, 59:195, 1 934.

Gremels, H.: Arch. f. exper. Path. u. Pharmakol, 169:689,
1933.

Peters, H. C. ; Rea, C. E. 6C Grossman, J. W.: Proc. of Soc. for
Experimental Bio. 6c Medicine, 34:61, 1936.

Peters, H. C. 6c Visscher, M. B.: Amer. Heart Jour., 2:273,
1936.

Starling, E. H. Sc Visscher, M B.: Jour, of Physiology, 62:243,
1927.

BOOK NOTICES

A MIGHTY WORK

Abortion — Spontaneous and Induced, by FREDERICK J. TAUS-
SIG, M.D.; first edition, heavy cloth, gold-stamped, 526 pages,

146 illustrations, indexed; Saint Louis, Missouri, the C. V.

Mosby Company; 1936; #7.50.

American physicians treat no less than 100,000 cases of abor-
tion annually; but how many cases (both spontaneous and in-
duced) never have the physician’s care?

The C. V. Mosby Company declares, and with truth, that
no greater authority on abortion than Taussig exists. Professor
of clinical obstetrics and gynecology for many years in the
Washington University School of Medicine at Saint Louis,
Taussig has devoted the greater portion of his life to this sub-
ject. He spent two years in the abortion clinics of Russia; and
his collection of data and statistics on the subject is world-
recognized.

This book is the summation of that experience. Every med-
ical aspect of abortion is considered and treated; diagnosis, pre-
vention, and treatment are concisely offered. The social, reli-
gious, and economic considerations are included. It is the first
complete discussion of the subject in any language.

The Journal-Lancet recommends this work without quali-
fication. It is difficult to imagine informed obstetrical practice
without it.

itself. It is significant, too, to see that Professor MacLEOD has
given the neuro-muscular and the central nervous system ex-
tensive revision. The section on circulation (Carter) is re-
vised, and the introductory chapters are new (Peterson). The
index is re-worked, and the references are painstakingly accurate.

This is a text which should be in the physician’s library even
before he receives his diploma and licentiate.

POPULAR OBSTETRICS

Into This Universe, by ALAN FRANK GUTTMACHER. M.D :
first edition, blue cloth, silver-stamped, 342 pages plus bib-
liography and index, 15 illustrations; New York: The Viking

Press: 1937. Price, #2.75.

This book does not differ from several other works on the
subject of obstetrics for the lay reader appearing in recent
years; but it is competent, and it is well-written. Part of it is
devoted to the razing of old superstitions, many of which have
even been fostered by medical men! A pleasing characteristic
of this book is that Dr. Guttmacher frequently quotes illum-
inative points from his own experiences in active practice, a
technic already used to advantage by Chideckel, Robert
Morris, Cushing, and others. The author is an associate in
obstetrics in the Johns Hopkins University School of Medicine.
The work is sound, and would be enjoyed by any lay reader;
and in point of fact, by many physicians, also.

MacLEOD’S PHYSIOLOGY

Physiology in Modern Medicine, by I J R MacLEOD, MB
LL D . D.Sc. ; assisted by PHILIP BARD. EDWARD P
CARTER, J. M. D. OLMSTED. J. M. PETERSON, and N. B.
TAYLOR; 7th edition, 297 illustrations (7 color plates), 1,104
pages plus references and index, heavy green washable cloth,
stamped in gold; St. Louis, Missouri: The C. V. Mosby Com-
pany: 193 5. Price, #8.50.

This is a text which probably every physician, and certainly
every medical student, either owns or hopes to own; for it is
a work which most physicians of today cannot be without.
When the first edition of this text appeared Professor Mac-
Leod was at the University of Toronto in Canada; now he is
in Aberdeen, Scotland. The passing of the years has only made
his work more imminently valuable.

Biochemistry does not play so important a role in this edition
as it has in previous printings; obviously because biochemistry is
no longer ancillary to medicine, but is almost a specialty in

A NEW PHARMACOGNOSY TEXT

Mdieria Medica, Toxicology 6C Pharmacognosy, by WILLIAM
MANSFIELD, A M., Phar.D.; 1st edition, red cloth, stamped
in gold, 202 illustrations, 682 pages plus index; Saint Louis:
The C. V. Mosby Company: 1937. Price #6.75.

This is an admirable text, beautifully suited to the needs of
the physician, for it has not only a good section on toxicology;
but also it conforms to the U. S. Pharmacopoeia XI and The
National Formulary VI. Drugs are classified for ready and
easy reference, descriptions are systemized, and there is a work-
ing photograph of each vegetable and animal drug. And under
each drug is given its Latin name, its abbreviation, English
name, synonym, botanic name, part or parts used, impurities,
assay, ash, habitat, description, constituents, dose, preparations,
properties, uses, and its toxicoligy, if it has any. From this it
may be seen that this is one of the most utilitarian texts ever
produced for the physician in pharmacognosy. The Journal-
Lancet commends the author.

312

THE JOURNAL-LANCET

LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS

ON MAY 1, 1937
(APRIL EXAMINATION)

Name School Address

Aagaard, George Nelson, Jr. U. of Minn., M B., 1936 Mpls. General Hospital, Minneapolis, Minn.

Almas, David Joeseph U. of Minn., M B., 1936 Ancker Hospital, St. Paul, Minn.

Andresen, Karl d’Autremont U. of Minn., M.B., 1936 Ancker Hospital, St. Paul, Minn.

Bachnik, Francis Wilfred U. of Minn., M B., 1936 St. Mary’s Hospital, Duluth, Minn.

Blegen, Halward Martin, Jr. U. of Minn., M B., 1936 Cincinnati Gen. Hospital, Cincinnati, O.

Boland, Edward Ward St. Louis U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Bond, Thomas Arthur U. of Minn., M B., 1936 Ancker Hospital, St. Paul, Minn.

Bjirton, John LeRoy U. of Minn., M B., 1935, M.D., 1936 1844 E. 26th St., Minneapolis, Minn.

Carley, Walter Arthur
Chauncey, Lester Robert _

Clay, Lyman Birney

Coombs, Carl Herman

Cumming, Harry A

Delmore, John Leo, Jr.

Dickson, Douglas Dwight
Dockerty, Malcolm Birt

U. of Minn., M.B., 1936 Ancker Hospital, St. Paul, Minn.

U. of Toronto, M.D., 1934 Mayo Clinic, Rochester, Minn.

U. of Minn., M B., 1936 St. Barnabas Hospital, Minneapolis, Minn.

U. of Minn., M B., 1935, M.D., 1936 St. John’s Hospital, St. Paul, Minn.

U of Minn., M B., 1936 Northwestern Hospital, Minneapolis, Minn.

U. of Minn., M B., 1936 St. Mary’s Hospital, Duluth, Minn.

u. of Neb., M.D., 1935 Mayo Clinic, Rochester, Minn.

Dalhousie U., M.D., 1934 Mayo Clinic, Rochester, Minn.

Dowidat, Raymond William U. of Minn., M.B., 1936 St. Mary’s Hospital, Minneapolis, Minn.

Drachman, Theodore S. __ U. of Minn., M B., 1937 Kings Co. Hospital, Brooklyn, N. Y.

Ellis, Fred Arthur U. of Minn., M B., 1936 1407 Russell Ave. N., Minneapolis, Minn.

Fisketti, Henry U. of Minn., M B, 1936 213 Mesabe Ave., Duluth, Minn.

Fredlund, Melvin L. U. of Minn., M B, 1936 K. C. General Hospital, Kansas City, Mo.

Friedell, Morris Theo. .. U. of Minn., M.B., 1936 Mpls. General Hospital, Minneapolis, Minn.

Gates, Phillip Howe U. of Minn., M B., 1936 Mpls. General Hospital, Minneapolis, Minn.

Halladay, George John U. of Minn., M B., 1936 Northwestern Hospital, Minneapolis, Minn.

Hardiman, John Albert .. U. of Minn., M B., 1937 K. C. General Hospital, Kansas City, Mo.

Hargraves, Malcolm McCallum Ohio State U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Hartnagel, Grant F. U. of Minn., M B, 1936 Milwaukee Co. Hospital, Wauwatosa, Wis.

Hawn, Hugh William U. of Minn., M.B., 1936 Mpls. General Hospital, Minneapolis, Minn.

Hillis, Samuel Joseph Trinity U., M.D., 1904 806 Sheldon Ave., St. Paul, Minn.

Hollister, Clinton Bennett Hale Columbia U., M.D., 1934 4921 — 1st Ave. S., Minneapolis, Minn.

Holman, John Crafford, Jr. Tulane U., M.D., 1934 Mayo Clinic, Rochester, Minn.

Kaiser, George Daniel U. of Minn., M.B., 1936 University Hospital, Minneapolis, Minn.

Lilleberg, Norbert John U. of Minn., M B., 1936 Ancker Hospital, St. Paul, Minn.

Lundblad, Stanley William U. of Minn., M B, 1936 Mpls. General Hospital, Minneapolis, Minn.

McCain, Donovan Legare U. of Minn., M B., 1937 Mpls. General Hospital, Minneapolis, Minn

Marking, George Henry U. of Minn., M.B., 1936 _ Mpls. General Hospital, Minneapolis, Minn.

Marks, Roger Weston U. of Minn., M B., 1936 176 Concord St., St. Paul, Minn.

Mollers, Theodore Peter U. of Minn., M.B., 1936 St. Mary’s Hospital, Minneapolis, Minn.

Neumaier, Arthur Duke U., M.D., 1935 St. Mary’s Hospital, Duluth, Minn.

Nordholm, Vincent William Northwestern U., M B., 1936 Fairview Hospital, Minneapolis, Minn.

Norris, Neil Thomas U. of Minn., M B., 1936 St. Mary’s Hospital, Minneapolis, Minn.

Nuebel, Charles Joseph U. of Minn., M B, 1936 St. Joseph’s Hospital, St. Paul, Minn.

Page, Robert Clinton Syracuse U., M.D., 1933 Mayo Clinic, Rochester, Minn.

Palmer, Harry Allen U. of Minn., M B., 1936 St. Luke’s Hospital, Duluth, Minn.

Paulson, John Albert U. of Minn., M B, 1936 __ 537 Third Ave. N. W., Rochester, Minn.

Penheiter, Donovan Northwestern U., M.B., 1936 Bagley, Minn.

Biwabik, Minn.

Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.

Rokala, Henry Emil U. of Mi nn, M.B., 1936

Rolig, David Howard U. of Minn., M B., 1936

Rosenstiel, Henry Carl .. . U. of 111., M.D., 1935

Rutledge, David Ivan U. of Neb., M.D., 1934

Sandell, Samuel T. U. of Minn., M.B., 1936

Schneidman, Norman Reuben U. of Minn., M B, 1936 1414 — 6th Ave. N., Minneapolis, Minn.

Shapiro, Jesse U. of Minn., M.B., 1936 Ancker Hospital, St. Paul, Minn.

Sheinkopf, Jacob Allan U. of Minn., M B., 1934, M.D., 1935 Co. 712, C.C.C., Grand Marais, Minn.

Skogland, John Edmund U. of Minn., M.B., 1935 412 Delaware St. S. E., Minneapolis, Minn.

Stroebel, Charles Frederick, Jr. Rush Med. Col., M.D., 1937 Northfield, Minn.

Tenner, Robert Johnson U. of Minn., M B., 1937 Mpls. General Hospital, Minneapolis, Minn.

Tisher, Paul Winslow ..U. of Iowa, M.D., 1935 1072 Portland Ave., St. Paul, Minn.

Tweedy, John Archibald U. of Minn., M.B., 1936 352 Main St., Winona, Minn.

Weaver, Delmar Franklin, Jr. U. of Va., M.D., 1932

Whetstone, Stuart Daniel U. of Minn., M.B., 1935, M.D., 1937

Whitney, Richard Aurie U. of Minn., M B, 1936

Whittemore, Dexter Delmont U. of Minn., M B., 1935, M.D., 1936

Wilson, Robert Bruce U. of III., M.D., 1933

BY RECIPROCITY

Behr, Orlo Keely U. of Neb., M.D., 1935

Pellettiere, Edmund Victor .Creighton U., M.D., 1928

Mayo Clinic, Rochester, Minn.
Owatonna, Minn.

Asbury Hospital, Minneapolis, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.

University Hospital, Iowa City, Iowa.
Thief River Falls, Minn.

NATIONAL BOARD CREDENTIALS

Youngman, Robert Armstrong

Harvard U., M.D., 1933

109 N. North Ave., Fairmont, Minn.

Represents the Jh Medical Profession of
MINNESOTA, NORTH DAKOTA, SOUTH DAKOTA and MONTANA

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

Great Northern Railway Surgeons’ Assn.
American Student Health Association
Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman , Board of Editors

Dr. J. F. D. Cook, Dr. A. W. Skelsey, Dr. E. G. Balsam - Associate Editors

Dr. J . O. Arnson
Dr. Ruth E. Boynton
Dr. Frank I. Darrow
Dr H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. J. A. Evert

BOARD OF EDITORS

Dr. W. A. Fansler
Dr. H. E. French
Dr. W. A. Gerrish
Dr. j ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. S. M. Hohf

Dr. R. J . Jackson
Dr. A. Karsted
Dr. H. D. Lees
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. A. S. Rider

Dr. T. F. Riggs
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley
Dr. C. A. Stewart
Dr. J . L. Stewart

Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M.D., 1859-1931 W. L. Klein, 1851-193 1

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., July, 1937

HAIL TO THE CHIEF

The Journal-Lancet takes pride in recording the
honor that has come to the chairman of its editorial
board during the past month. Dr. J. A. Myers was
elected president of the National Tuberculosis Associa-
tion at its annual meeting in Milwaukee during the
first week of June and was also elected president of the
American Academy of Tuberculosis Physicians at the
academy’s annual meeting in Atlantic City the following
week. That’s making it unanimous, wouldn’t you say?

It takes qualification to arrive, work to attain, and
achievement to gain renown. We are indeed happy to
have this well deserved recognition come to one of our
members. Others have served as presidents of the
American College of Physicians, the American Procto-
logical Society, and the American Student Health As-
sociation but Dr. Myers has been chosen to preside over
two national organizations in the same year.

There should be a correlation of tuberculosis physi-
cians in one body making a single national group. This
election may lead to such a consummation. Members of
both organizations have expressed that hope.

A. E. H.

MEDICAL DEFENSE PLAN OF STATE
MEDICAL ASSOCIATIONS

During recent years both the law and the medical
professions have become keenly cognizant of what they

designated corporation practice, i. e., an interference in
the respective fields of their professions, viz.., as regards
law, the practice of many banks (banks) in combination
with their trust departments to aid their patrons draw
wills, act as legal trustees, etc. Now, the pinch either of
an excessive number of attorneys or greatly reduced
revenue to the legal brethren, or both causes, has lately
led to a vigorous attack by the Blackstones against some
of the state medical associations carrying the medical
defense plan, their particular object evidently being
against the Ohio State Medical Society. The medical
journal of that State for June, 1937, advises its member-
ship that owing to the complaints of the past several
years, and particularly the irritation caused since 1935,
said State Society will discontinue as of date June 15,
1937, its medical defense plan; this in deference to the
results of a conference had with a joint committee on
interference, whereby the ruling was made that such
medical defense practice was actually the illegal practice
of law. North Dakota State Medical Association dis-
carded some years ago that form of defense, therefore
is not affected by the ruling, yet the A. M. A. head-
quarters intimate that possibly other state associations
may be interested in this decision.

What organization will next be the conscientious and
mercenary objector against something?

A. W. S.

314

THE JOURNAL-LANCET

THE JOURNAL-LANCET AND THE EARLY
DIAGNOSIS CAMPAIGN

The stress laid upon tuberculosis by the Journal-
Lancet during the past few years has taken into con-
sideration the fact that the Christmas seal of the Na-
tional Tuberculosis Association and some of the pro-
jects it has financed, particularly the Early Diagnosis
Campaign, has stimulated widespread interest in tuber-
culosis, not only among physicians but also in the gen-
eral public. It has frequently been said that education
of the public in the modern aspects of tuberculosis con-
trol has exceeded that of the medical profession. Ob-
viously such a situation should never be permitted to
develop. To be sure, we should not in any way curtail
the educational program for the public but should
support it in every possible manner. At the same time,
there should be made available in concentrated form all
of the newer information for the physician for it is he
who must make the diagnosis, administer the treatment,
and direct the program of prevention. In this: manner,
most can be accomplished in the eradication of any dis-
ease. Therefore, every possible effort has been made to
procure and publish articles which provide all the in-
formation the physician needs. These articles have con-
tained condemnations of procedures at one time used
but now known to be almost worthless or futile, such as
the tuberculosis clinic of former days, which often re-
quired one physician to examine as many as a hundred
persons in a single day.

Emphasis has been placed on the modern diagnostic
procedures, including the tuberculin test as a fine screen,
the X-ray as a coarse screen, followed by adequate
clinical and laboratory examinations to determine diag-
nosis, treatment indications, etc. As a result of bring-
ing the modern viewpoint on tuberculosis control so
frequently to the desks of physicians, large numbers have
adopted them, are using them daily in their offices, and
are thus aiding their communities in the eradication of
tuberculosis. The development of programs and the
actual accomplishments in tuberculosis control in North
and South Dakota, Montana, and the student health
services of America, during the past few years are al-
most unbelievable. More has actually been accom-
plished in these places in the past few years than in the
immediately preceding quarter century.

The best evidence that points toward eradication of
tuberculosis is the definite and persistent decrease in
mortality from tuberculosis, with parallel decreases in
morbidity and infection. Indeed, in places the mortality
from tuberculosis has become so low that we are in
grave danger of having the workers, including physi-
cians, relax their efforts under the impression that the
victory against tuberculosis is practically won. Such an
attitude is extremely dangerous for we must constantly
keep in mind that wherever there has been a death from
chronic pulmonary tuberculosis, there are numerous
associates of the person who has lost his life in whose
bodies cultures of tubercle bacilli have been established.
Every one of these persons is a potential case of clinical

tuberculosis, even though the only finding at present may-
be a positive tuberculin reaction. Thus, our criterion
as to the magnitude of the tuberculosis problem in any
community must no longer be only the mortality rate in
that community but also the incidence of positive tuber-
culin reactors. A very pertinent fact in tuberculosis con-
trol work is that, generally speaking, only positive tuber-
culin reactors develop clinical tuberculosis. Since the
appearance of sensitiveness to tuberculin represents the
beginning of tuberculosis, we can not rest upon our
laurels until this category has definite provisions made
for them.

J. A. M.

SOCIETIES

Annual Session of the
Montana State Medical Association
July 13th and 14th, 1937

r The Most Friendly Meeting You Ever Attended”
Heisey Memorial, Great Falls, Montana
Headquarters — Rainbow Hotel
OFFICIAL CALL
To the Members of the
Montana Medical Association:

The Great Falls meeting will be unique — ours will
afford you a chance to hear many of our own members
and guest speakers of high caliber; that of the Pacific
Northwest, which immediately follows, is unusually
attractive.

As the subjects to be presented are practical, we are
sure you will find them valuable and that you can well
afford to attend for the sake of the programs alone.
Also, it is important for you to get in touch with your
confreres at this time, to contribute your views and to
hear theirs on the many medical and social problems
that now confront us.

Please "make” this meeting.

Fraternally yours,

John A. Evert, M.D.,

President

Thos. L. Hawkins, M.D.,

Secretary-T reasurer

"The Most Friendly Meeting You Ever Attended'’

PROGRAM

Tuesday Afternoon, July 13, 1937

1:30 P. M. Address of Welcome, Hon. Julius J.

Wuerthner, Mayor of Great Falls.

1:40 P. M. Presidential Address, Dr. John A. Evert,
Glendive, Mont.

2:00 P. M. Treatment of Uterine Myomas, Dr.

Henry Schmitz, Chicago, Illinois.

3:00 P. M. Conservative Renal Surgery, Dr. Roland
G. Scherer, Bozeman, Mont.

3:45 P. M. Fractures of Os Calcis, Dr. R. B. Richard-
son, Great Falls Clinic, Great Falls, Mont.

THE JOURNAL-LANCET

315

Wednesday Morning, July 14, 1937
9:00>A. M. Fluid Intake in Edematous Patients, Dr.

F. R. Schemm, Great Falls Clinic, Great
Falls, Mont.

9:50 A. M. Paralysis of the Peripheral Nerves of the
Upper Extremity, Dr. J. K. Colman, Mur-
ray Hospital Clinic, Butte, Montana.
10:50 A. M. Massive Purulent Pericarditis, Dr. Fred F.
Attix, Lewistown, Montana.

Wednesday Afternoon, July 14, 1937
1:15 P. M. Heart Disease in Middle Life, Dr. J. H.

J. Upham, President of American Medical
Association, Columbus, Ohio.

2:15 P. M. Cancer and Its Treatment With Radium,
Dr. H. H. James, F.A.C.S., Murray Hos-
pital Clinic, Butte, Mont.

3:00 P. M. Psychosis Associated With the Involu-
tional Period, Dr. Ernest M. Hammes,
Professor Nervous and Mental Diseases,
University of Minnesota, St. Paul, Minn.
4:00 P. M. Nephritis in Children, Dr. Jessie M. Bier-
man, Director of Child Welfare, State
Board of Health, Helena, Montana.
Annual business meeting and election of
officers.

Wednesday Evening, July 14, 1937
7:30 P. M. Annual Banquet, Palm Room, Rainbow
Hotel.

Addresses by —

Dr. J. H. J. Upham, President of Amer-
ican Medical Association, Columbus, Ohio,
Changing Times in Medicine. Dr. A. J.
Carlson, Professor of Physiology, Univer-
sity of Chicago, Chicago, Illinois, Black
Oxen and Togenburg Goats.

Note: Don’t miss this banquet — we promise some

leal entertainment. Get your tickets when you register.

Cascade County Is Acting as Host to
This Meeting

Hosr and Entertainment Committee — Dr. E. D.
Hitchcock, Chairman, Dr. F. E. Keenan, Dr. F. R.
Schemm, Dr. Thos. F. Walker, Dr. A. L. Gleason, Dr.
F. L. McPhail, Dr. E. M. Larson, Dr. Ivan Allred, Dr.
J. H. Irwin, Dr. P. E. Logan, Dr. J. C. McGregor.
Ladies’ Committee — Mrs. A. F. Longeway.

SPECIAL NOTE

On the three days following our State Meeting, the
Pacific Northwest Medical Association will hold its ses-
sion in Great Falls. All members of the Montana Med-
ical Association are cordially invited to remain for this
meeting.

We suggest that if you expect to attend the latter
meeting that you get in touch with Dr. E. M. Larson
of this city and obtain a ticket at a reduced rate ar-
ranged only for members of our association. If you have
not already obtained a program for the Pacific North-
west Medical Meeting, one will be sent you upon request.

Tentative Program of the
Pacific Northwest Medical Association
Sixteenth Annual Meeting
Great Falls, Montana
July 15, 16, 17, 1937

Great Falls Committee on Arrangements
Dr. E. Martin Larson General Chairman

Dr. Faus. P. Silvernale Vice Chairman (General)

President, Cascade County Medical Society
Dr. L. L. Howard General Secretary

Secretary, Cascade County Medical Society
General Committee — Dr. E. Martin Larson, Chair-
man, Dr. J. H. Irwin, Dr. Thos. F. Walker, Dr. L. L.
Howard, Dr. Faus. P. Silvernale, Dr. C. J. Bresee, Dr.
Charles Little, Dr. F. E. Keenan.

Publicity Committee — Dr. C. J. Bresee, Chairman,
Dr. Clyde Fredrickson.

Hotel and Transportation Committee — Dr. F. E.
Andrews, Chairman, Dr. R. B. Richardson, Dr. J. C.
McGregor, Dr. C. H. Peterson.

Registration and Information Committee — Dr.
Faus. P. Silvernale, Chairman, Dr. L. L. Howard, Mr.
A. J. Breitenstein.

PROGRAM
A. J. Carlson, Ph.D.

Professor of Physiology, University of Chicago

1. "Recent Studies in the Motility of the Colon."

2. "The Problem of Control of the Endocrine
Glands.”

3. "Physiology of the Hypophysis.”

Virgil S. Counseller, M.D.

Head of Section of General Surgery, Mayo Clinic
Associate Professor of Surgery, University of Minnesota

1. "Classification and Surgical Treatment of Adnexal
Tumors.”

2. "The Surgical Treatment of Lesions of the Biliary
Tract.”

3. "The Surgical Management of Congenital Anom-
alies of the Male and Female Generative Organs.”

Norman F. Miller, M.D.

Professor of Obstetrics and Gynecology
University of Michigan

1. "Birth Injuries to the Bladder and Bowel, and
Their Management.”

2. "The Bloody Complications of Obstetrics.”

3. "The Acute Lower Abdomen in the Female.”

L. H. Newburgh, M.D.

Assistant Professor of Internal Medicine
University of Michigan

1. "The Nature and Treatment of Obesity.”

2. "Newer Knowledge of Kidney Diseases.”

3. "Some Aspects of the Problem of Diabetes.”

H. E. Robertson, M.D.

Head of Section of Pathological Anatomy, Mayo Clinic
Professor of Pathology, Mayo Foundation

316

THE JOURNAL-LANCET

1. "Causes and Effects of Various Cirrhoses of the
Liver.”

2. "The Pathological Features of Hypertension and
Coronary Sclerosis.”

3. "The Pathology of Tuberculosis.”

F. C. Rodda, M.D.

Clinical Professor of Pediatrics , University of Minnesota

1. "Management of the Vomiting Child.”

2. "Feeding of Infants.”

3. "The Trend in Pediatrics and What to Do
About It.”

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of March 10, 1937

The regular monthly meeting of the Minnesota Academy of
Medicine was held at the Town & Country Club on Wednes-
day evening, March 10th, 1937. Dinner was served at 7
o’clock and the meeting was called to order at 8 o’clock by the
President, Dr. E. M. Jones.

There were 47 members present.

Minutes of the February meeting were read and approved.

The President called attention to the new screen which Dr
Thomas S. Roberts had presented to the Academy. On behalf
of the members, Dr. Jones said he wished to accept this gift
and express the very deep appreciation of the members to Dr.
Roberts.

The scientific program followed.

PNEUMONIC PATHOLOGY IN THE
UPPER LUNG FIELDS

Lewis M. Daniel, M.D.

Dr. Lewis M. Daniel, Minneapolis, read his Inaugural Thesis
on the above subject.

The purpose of this paper is to present the problem which
confronts us in the differentiation of tuberculous and non-tuber-
culous pulmonary pathology where we have clinically the pic-
ture of prolonged or unresolved broncho pneumonia, and where
the evidence from the laboratory and the X-ray is inconclusive.
I would like to summarize briefly what has been found to be
pertinent in the meager literature on this subject and to review
four rases in point which have been under observation during
the last year.

In the French literature considerable attention has been
given to the transitory shadows of pulmonary consolidation
which, although they are short-lived, present about the same
initial problem in diagnosis. Jeanneret and Fame, in "Revue
de la Tuberculose” December 19331, discussing the subject of
fugacious X-ray shadows, cite several cases in which the dif-
ferential diagnosis between tuberculosis and influenzal broncho-
pneumonia could be made only by studying the manner of reso-
lution as shown in serial X-rays. At the outset this type of
shadow, which they describe as an "Ombre radiologique

fugace,” resembles tuberculous pneumonia. The absence or
mildness of symptoms and the disappearance often in as short !
a period as one week decides the question, but many people, j
according to the writers, have been and are being institutional-
ized for months on the evidence of a single X-ray.

Cain, Oury, et Barnaud, in the Bull, et Mem. de la Societe
medicale des Hopitaux de Paris ( 1932) 2.H cited cases in which
the mode of onset and early symptoms made them hesitate i
between the diagnosis of tuberculous pneumonia and a mild
bronchopneumonia. X-ray evidence distinctly favored tuber-
culosis but a plate taken a month later showed resolution to
have taken place to such an extent that their diagnosis was i
abandoned.

Bernard and Lamy*, writing in the same publication in 1933, I
presented two more such cases in an article entitled "Pneumo-
nies prolongees simulant la tuberculose.” In the first case the
findings one and one-half months after the onset were still |
characteristic of tuberculosis but, because of former experience,
they refused to make a positive diagnosis. At the end of three

months the chest was clear. The second case was almost iden- i

deal Both cases were in the upper lung fields.

The French writers on the subject feel that the sudden onset

of the acute episode is the most important circumstance which
might lead to the diagnosis of a non-tuberculous lesion.

A pertinent article on this subject was written by Dr. R. G.
Allison'1 in 1926. He mentions the struggle of the clinicians i
and the roentgenologists to arrive as early as possible at a posi-
tive diagnosis in chest pathology. An enthusiasm which re-
sulted in many mistakes. He believes that there are many cases l
in which pneumonic processes occur in the upper lung field in
which serial X-rays may reverse the diagnosis favored in the
first X-ray and, furthermore, to quote "A critical review of these
cases, after the end result has been determined, has given no
additional information as to how we may differentiate the tu-
berculous from the non-tuberculous, at the time of the first
examination.”

Case 1. A woman of seventy, whose previous examinations
had shown evidence of healed tuberculosis, caught a cold. A
week later a cough developed and then chills and fever mount-
ing to 103°. She had physical signs characteristic of broncho |
pneumonia and was hospitalized. X-ray taken shortly after her
admission to the hospital showed consolidation of part of the I
upper right lobe and it was interpreted as tuberculous. Her
leucocyte count never went above 8,000 while she was in the
hospital. Sputum examinations were negative. She continued
to have a fever of 99.6° to 100° for a month. A second X-ray
was taken at that time. The upper right lung showed only the
evidence of the old fibrous lesion which had been there before,
but a new area of consolidation extending out from the root of
the right lung was described. From the X-ray it was impos- .
sible to say whether this represented broncho-pneumonia or an ;
extension of tuberculosis. During the next three weeks she was 1
afebrile and improved rapidly in strength so that she was up
and around. A final X-ray, taken two months after the first
one which had so strongly suggested tuberculosis, showed noth-
ing to support this diagnosis.

F-70

M-50 F-20

All had positive tuberculin tests

-All had accelerated sedimentation rates at the outset.

— All had negative sputa at the outset

All had acute onset

M-36

Three had chills and fever with temp, of 102°, which gradually subsided over a period of about
1 month.

Three had moderately severe cough and complained of chest pain.

Mucopurulent sputum. Little or no sputum in any of these

Three showed physical signs of broncho-pneumonia of limited extent.

Coarse rales. No rales. No rales.

W.b.c. 7,200 W.b.c. 12,000 W.b.c. 17,000

P.m.n. 83% P.m.n. 61% P.m.n. 4%

Initial X-Ray Evidence

Tbc. Pneumonia? — in first three cases

Resolved broncho-pneumonia.
No recent tbc.

No symptoms.

Activity resumed.

Final X-Ray Evidence

Fibroid consolidation tbc. ? shadow still disappearing.

Positive sputum No symptoms or signs.

Treatment. Sedimentation normal.

Gain 20 lbs. Working.

Fever for one week.

Slight cough. No pain.

instances I

Increased bronchial sounds
with moist rales.

W.b.c. 17,000
P.m.n. 80%

Fibrotic productive with acute in-
fection superimposed.

Old fibrosis — quiescent.
Sa ny status as before.

No trouble.

THE JOURNAL-LANCET

317

Case 2. The second case is that of a man of fifty, first ex-
amined about a year ago because of a digestive upset. At that
time it ‘was noted that there was tuberculosis in one member of
his family and that he had evidence of an old healed process.
He remained well until May 1936, when he contracted an
acute respiratory infection. He had chills and fever mounting
to 103° at the outset, and considerable prostration. The phys-
ical signs in the chest were absent except for a small area of
bronchia! breathing in the right axilla. The clinical diagnosis
was broncho-pneumonia and it was believed to be limited to a
very small area. One month later he was entirely free from
symptoms. He had had no cough and no fever for about two
weeks. From the fluoroscope it appeared that his pneumonia
had not resolved. An X-ray taken at the time was suggestive
of tuberculosis and the man was sent home to be quiet for a
month to see what changes would develop. This observation
and rest treatment continued for five months. The patient
gained twenty-five pounds and felt better generally than he did
before his illness. He has never had any cough or temperature
since the acute stage of his illness. There has been no change
in his X-ray picture during this period of five months. It
seemed as though we might disregard the X-ray picture; but,
finally, after repeated attempts to get a satisfactory sputum
specimen, we were successful, and found tubercle bacilli.

Case 3. The third case which I wish to summarize is that
of a girl of twenty-two, who, after an acute upper respiratory
infection which continued for two weeks, was X-rayed and ad-
vised that she had tuberculosis and must go to a sanatorium.
At that time she had a mild unproductive cough, a tempera-
ture which rose to about 100° in the afternoon, and she com-
plained of feeling very tired. She had physical signs of bron-
chial breathing in small areas in both the right and left upper
lung fields. Laboratory findings were negative except for a
leucocytosis of 17,000 with 74 per cent p.m.n.’s. (The X-ray
plate taken at that time was shown.) Report on this is as fol-
lows: "Pneumonic consolidation left upper lobe and base of the
right upper lobe. While this lesion has the characteristic ap-
pearance of pneumonic tuberculosis, I believe that further plates
should be made in a few weeks to determine definitely, etc.”
After one month of rest at home she was X-rayed. She had
gained fifteen pounds and had no cough or fever. The X-ray
showed nearly complete resolution of the infiltration of the right
lung, but still considerable remaining in the left upper lobe.
It was felt that some of the lesion was acute pneumonia which
was resolving and it was still impossible to say whether the
remaining consolidation was unresolved pneumonia or tubercu-
losis. In October she felt so well she was allowed to go back
to work. Pictures taken at that time still showed some infiltra-
tion on the left side, but the right side was practically clear.
The roentgenologist felt that the long delay in this resolution
would indicate that the lesion was tuberculous. Clinically, this
girl is well; no fever, no cough, no fatigue, sedimentation rate
normal, hemoglobin 85%, weight 20 pounds more than last
winter.

Case 4. One more case before I attempt to comment. This
is a man of 36 who was seen last February with what appeared
to be post influenzal bronchitis. He recovered completely in
two weeks, or would have perhaps if an X-ray film had not
been made of this chest. Diagnosis: moderately advanced

fibrotic tuberculosis of productive type with evidence of recent
activity. His life and activities were, of course, modified after
this but, from that time to the present, there has not been a
single symptom or complaint which might be related to tubercu-
losis. Periodic X-rays have shown no change except that one
taken in October was reported as showing a tendency to qui-
escence and in another examination made in another city in
November it was thought that the fibrosis was of no signifi-
cance at the present time.

In a chart which is represented here, an attempt is made to
summarize the findings in these four cases.

This recitation of four related cases of pulmonary pathology
is of no importance in the advance of our knowledge in that
field except for the fact that it presents the problem of the in-
ternist who is nor specializing in chest diagnosis, confronted

with contradictory findings, anxious patients and considerable
responsibility.

It is safe to say that the acceptance of first X-ray impressions
in these cases would have been unfortunate. The roentgenolo-
gist suggested subsequent study in his first report.

It must be emphasized that the character of the initial illness
did not furnish any satisfactory indication of the ultimate
outcome.

My third point is that in these four cases, all observed care-
fully in the last year, clinical observation and laboratory find-
ings gave better guidance for the ultimate conduct of these
cases than did the X-ray findings. However, the X-rays were
of course of great value in correlating the clinical conclusions.

Bibliography

1. Rene Jeanneret et F. Fame: Apropos des "ombres radiolo-

giques fugaces.” Revue de la Tuberculose. December 193 3.

2. MM. Leon Bernard et Maurice Lamy: Pneumonies pro-

longees simulant la tuberculose. Bulletins et memoires, Societe
Medicale des Hopitaux de Paris, May 12th, 1933.

3. M. G. Caussade: Apropos des pneumonies prolongees simu-

lant la tuberculose. Ibid. May 26th, 1933.

4. MM. Cain. Oury, et Mile. Barnaud: Pneumococcie pulmo-

naire aigue curable. Image radiologique simulant la broncho-pneu-
monie tuberculeuse. Ibid. November 4th, 1932.

5. R. G. Allison: Resolution in Pneumonic Consolidations.

American Journal of Roentgenology 1926.

THIRTY-TWO YEARS OF PATHOLOGY AND
SURGERY IN ONE INDIVIDUAL
A. R. Colvin, M.D.

ST. PAUL, MINN.

This case is shown and reported to call attention to the re-
cuperative power of the human and the possibilities of surgery
extending over a period of thirty-two years. Briefly enumerated
is a list of conditions and operations.

1. Mastoid suppuration.

2. Opening abscess of jugular vein.

3. Arthrotomy of knee for suppuration.

4. Arthrotomy of shoulder for suppuration.

5. Opening abscess on chest wall.

6. Amputation through thigh for intractable suppura-
tion of knee joint. (Dr. Gilfillan) .

7. Repair amputation stump.

8. Cystoscopies.

9. Ureteral calculi removed.

10. Hemorrhoidectomy.

11. Prostatic abscess following urethritis.

12. Osteotomy of femur from deformity following dis-
location of hip.

13. Tonsillectomy. (Dr. Warren).

14. Herniotomy. (Dr. Hauser).

15. Fracture of femur.

16. Cholecystectomy for cholecystitis with calculi. (Dr.
Hauser) .

17. Bursting open of incision for above.

18. Ruptured wound repaired.

19. Repair of abdominal hernia.

20. Thoracoplasty for pulmonary tuberculosis. (Dr. L.
Daugherty) .

21. Removal of diverticulum of esophagus. (Dr. Greth
Gardiner) .

22. Open cervical abscess.

23. Tracheotomy for tuberculosis of larynx. (Dr.
Gardiner) .

Since two years after the beginning of his surgical life, he
has worked steadily except for an occasional holiday to have
another operation performed. There are some features of his
excursions into surgery which seem worth while relating.

The patient is a male, age 50. He was admitted to Ancker
Hospital on February 7, 1905, in a delirious state. He had a
suppurating shoulder and knee joint and an abscess of his chest
wall. These evidently were localized lesions due to pyemia.
Further investigation revealed suppurating otitis media, with
tenderness over the mastoid process and along the course of
the internal jugular vein. On February 9, 1905, the jugular
vein was exposed and opened and found to contain pus, the

318

THE JOURNAL-LANCET

pus being limited below by proliferating endophlebitis. The
mastoid suppuration was dealt with and the sigmoid sinus con-
tained pus which was limited by proliferating endophlebitis
above, but was continuous with the pus in the vein below. The
suppurating knee and shoulder joints and the abscess in the
chest wall were then opened and drained.

While reviewing once more phlebitis, thrombosis, embolism
and related conditions, one was impressed again with the im-
portance of keeping in mind the variable nature of infections
in their course and consequences, and the manifold reactions of
tissues to infections. It was interesting, for instance, to note
the swing from Hunter’s position that phlebitis is primary to
the position of Virchow that thrombosis is the cause of the
phlebitis, and the swing back again to the opinion now held
that in the great majority of cases the thrombosis is secondary
to the phlebitis and that many of the so-called bland throm-
boses are really due to mild or non-suppurating phlebitis such
as occurs in influenza, pneumonia, postoperative, etc.

Phlebitis with consequent thrombosis can in this sense be
likened to the various grades of arthritis and, indeed, I shall
always remember the patient who came to me after an opera
tion for simple hernia, who, following a postoperative phlebitis,
suffered from multiple non-suppurating granulating arthritis
from which he was permanently crippled. I opened one of the
joints and so demonstrated the granulating character of the
arthritis. In another case, following a suppurating tendon
sheath infection, there developed multiple abscesses in the calf
muscles, with a non-suppurating shoulder and hip joint infec-
tion without demonstrable effusion. This patient recovered,
v/ith some stiffness of both joints.

I recall a mastoid case in which a diagnosis of lateral sinus
phlebitis was made; the upper end of both femurs were in-
volved in suppurative osteomyelitis; the sinus was not opened,
and the boy recovered. The sinus thrombosis quite evidently
was not of the suppurating kind; the osteomyelitis was.

While reflecting on these and other cases, I was impressed
with the infrequency with which the lungs — through which
the micro-organisms have to travel to reach the general circula-
tion— are the subject of inflammatory reaction. McEwen, how-
ever, in his great work on pyogenic diseases of the brain and
spinal cord, divides his cases of sinus infection symptomatically
into: (1) pulmonary; (2) enteric or abdominal; and (3) men-
ingeal. I had one patient, a woman, who, after sinus infection
due to mastoid disease and operation thereon, developed pneu-
monia and empyema in the midst of pregnancy and was de-
livered of a normal child before leaving the hospital. Perhaps
sinus phlebitis is recovered from more often than we know.
Certainly the non-suppurating kind does.

It is instructive that in this man’s case, which we are pre-
senting tonight, the thrombosis was limited by endophlebitis
both in the iugular vein and lateral sinus, thus effectually wall-
ing off an abscess in a section of the vein.

1 he diagnosis of his ureteral stones at a time when urethritis
complicated the picture and X-ray was poorly developed, was
somewhat difficult; he consequently suffered a good deal from
pam in the back and left lower abdomen, and thus had a work-
ing knowledge of kidney pain. Later he began to complain of
kidney pain on the opposite or right loin, which, he said,
was similar to that he had had before on the left side, and
insisted that the right kidney be operated upon. This was, of
course, refused and it was not until some time later that I dis-
covered that his hip on the left side was ankylosed in a faulty
position of flexion of about 35 degrees. An X-ray disclosed a
hip dislocated on the dorsum of the ilium. This dislocation was
due to the position in which he lay for so long with a sup-
purating knee. After observing h is manner of walking it was
seen that with the artificial limb worn with the stump, in a
fixed flexed position, each step was practically a contortion of
his lumbar spine. It was concluded that his pain was due to
a traumatic arthritis or sprain of the spine, and osteotomy
through the base of the neck resulted in a corrected position
of his stump with complete relief of his lumbar pain; and there
has been no recurrence.

Except for the various surgical experiences enumerated, he
has remained well and is now again very insistent on going
back to work, saying that he feels better than he ever did in
his life.

The patient was presented.

Discussion

Dr. William Davis, St. Paul: I am not going to discuss Dr.
Colvin’s case from the surgical standpoint, but wish to make
one or two philosophical observations that came to me as I
listened to the report.

In his lectures on anatomy to our class, Dr. Oliver Wendell
Holmes presented a tattooed man who was covered from head
to foot with tattooing — figures and animals and devices of all
kinds. Dr. Holmes, in commenting on him, very gravely said:
"This man is an example of the tortures that man can inflict
and that man can endure.” To paraphrase Dr. Holmes, this
patient of Dr. Colvin is an example of the operations that the
surgeon can perform and the patient can endure. I think the
patient was extremely fortunate to have fallen into the hands
of a man who could follow him through his checkered career
and relieve him as he went along. (By the way, the tattooed
man turned out to be a fake. His tattoo marks were painted
on the skin. This man is not a fake.)

The meeting adjourned.

A. G. Schulze, M.D.

Secretary.

NEWS ITEMS

Dr. Thomas F. Walker, of Great Falls, Montana,
spoke on "Myelogenous Leukemia” before the Silver
Bow County Medical Society on June 1, 1937.

On the basis of a total bond issue of $5,500 the city
of Bowbells, North Dakota, is rebuilding the old school
annex into a modern municipal hospital.

Dr. Byron Elmer Crawford, Chamberlain, South Da-
kota, has moved his office to the Kramer Building in
Chamberlain.

Dr. William T. Ferris, formerly associated with Dr.
Creighton P. Farnsworth in Chamberlain, South Dakota,
now has his own office over Casey’s Drug Store in Cham-
berlain, and is practicing independently.

Dr. Paul F. W. Rick, a graduate of the University
of Minnesota School of Medicine in April 1937, has
opened offices on the second floor of the Pelovsky Build-
ing in LeCenter, Minnesota.

On Thursday, May 6, Dr. James Charles Shields, of
St. James Hospital in Butte, Montana, spoke before
the Butte Rotary Club on "Some History of Medicine
and Surgery.”

Mr. George H. Bugenhagen, of Minot, North Da-
kota, opened bids on May 18 for the new $40,000 hos-
pital to be erected at Wolf Point, Montana. Mr. Bugen-
hagen designed the new hospital.

In the June issue of The Journal-Lancet, an error
appeared concerning the identity of the incumbent presi-
dent of the Montana State Board of Health. Dr. Lewis
H. Fligman, of Helena, is the present head of that body.

Dr. Frank Ageton Remde, 36 years old, who was
graduated from the Rush Medical College of the Uni-
versity of Chicago in 1933, was slain by an intoxicated
patient in Bottineau, North Dakota, on June 17,

THE JOURNAL-LANCET

319

Dr. John William Campbell, formerly of Fargo,
North Dakota, has located in the suite above the Loe
Electric Shop in Hutchinson, Minnesota.

Dr. Arthur F. Sether, formerly with the Civilian Con-
servation Corps at Grand Rapids, Minnesota, has located
in the Oberle Building in Ruthton, Minnesota.

A new 40-pound electric cauterodyne for use in cases
of cancer of the breast, has been installed in the Murray
Hospital at Butte, Montana.

Dr. John Paul Ritchey, Missoula, Montana, has been
accepted as a fellow of the American College of Phy-
sicians.

Dr. James Henry Roth, a graduate of the Rush Med-
ical College, Chicago, in 1896, is now a member of the
Jamestown Clinic at Jamestown, North Dakota. He
had been a physician in Chicago.

Dr. Clarence Albert Butler, of Egan, South Dakota,
has returned to Lake Preston to practice. He formerly
was mayor of Lake Preston, and president of the Com-
mercial Club, and chairman of the school board.

Dr. Wilfred J. Bushard, of New Ulm, Minnesota, a
graduate of the University of Minnesota Medical School
in 1936, has located in Bird Island, Minnesota, where he
is a visiting member of the staff of Loretta Hospital.

Dr. Charles H. Speir, a graduate of the Wayne Uni-
versity College of Medicine in 1929, and formerly of
Shawano, Wisconsin, is the new chief of the Cass Lake,
Minnesota, Indian hospital.

Wessington, South Dakota, no longer has a physician.
Dr. Wayland Rice, formerly of Wessington, has pur-
chased the practice and equipment of Dr. Frank Elmer
Boyd, of Armour, and will locate there.

Dr. Henry Ulrich, professor of medicine in the Uni-
versity of Minnesota Medical School, is the new presi-
dent of the Hennepin County Medical Society, Minne-
apolis. !

Dr. Benjamin Thane, of Wahpeton, North Dakota,
a graduate of the University of Minnesota Medical
School in 1917, was electrocuted by his own X-ray ma-
chine in Wahpeton while treating a patient on June 17.

Mrs. John Harlan Bridenbaugh, wife of Doctor J. H.
Bridenbaugh, of Billings, Montana, is one of the lead-
ers in the Women’s Field Army, sponsored by the
American Society for the Control of Cancer, in the
Billings area.

Dr. John W. Ward, a graduate of the College of
Physicians and Surgeons of Keokuk, Iowa, in 1880, and
until 1917 a resident of Armour, South Dakota, died
at Titusville, Florida, on April 9, according to dis-
patches. He was buried at Armour on April 15.

Horace Wood, of the North Dakota Farmers’ Mu-
tual Aid Corporation, announces that the medical pro-
gram for resettlement clients ended on June 10. Physi-
cians and hospitals who held unpaid authorizations were
urged to present them immediately for payment.

Dr. Fred Wallace Logan, 63, of Blue Earth, Minne-
sota, died at a Minneapolis hospital in June from heart
disease. Dr. Logan was graduated from the University
of Iowa College of Medicine in 1901, and came to Blue
Earth about 15 years ago.

Dr. John Gartrell Johns, 72, who practiced at Het-
tinger, North Dakota, since 1907, died there in May.
He was graduated from the University of Nashville
Department of Medicine in 1897, and came to the
Dakotas in the 1880’s.

Dr. Edward A. Boyden, professor of anatomy in the
University of Minnesota Medical School, Minneapolis,
was awarded the gold medal for a scientific exhibit at
the 84th annual meeting of the Minnesota State Med-
ical Association. The medal is given by the Southern
Minnesota Medical Association.

Dr. Neil S. Dungay, of Carleton College, Northfield,
Minnesota, presided at the annual meeting of the north
central section of the American Student Health Asso-
ciation at Iowa City, Iowa, in May. Dr. Charles E.
Lyght, director of the student health service at Carleton,
was a speaker.

Dr. Herman William Froehlich, 57, of Minneapolis,
died on June 14 at his home. A graduate of the old
Minneapolis College of Physicians and Surgeons in 1905,
Dr. Froehlich was in charge of the varicose vein clinic
at the Minneapolis General Hospital, and was a trustee
of Concordia College in St. Paul.

Dr. Edwin D. Stoddard, 87, formerly of High Forest
and Stewartville, Minnesota, died at his home in Beverly
Hills, California, recently. Dr. Stoddard came to High
Forest in 1875, and to Stewartville in 1890. He was
graduated from the Northwestern University Medical
School in 1875.

Dr. George Edward, 66, of Canton, Minnesota, a
graduate of the University of Minnesota Medical
School in 1897, died in Rochester on June 3, 1937. Dr.
Edward was a college room mate of the late Dr. Henry
S. Plummer, of Rochester, and was a first lieutenant in
the U. S. Medical Corps during the World War.

Mr. F. D. Hopkins, executive secretary of the Na-
tional Tuberculosis Association, advises The Journal-
Lancet that the 10th conference of the International
Union Against Tuberculosis will be held in Lisbon,
Portugal, September 5 to 9, inclusive; under the chair-
manship of Professor Lopo de Carvalho.

Dr. Agnes Stucke, Garrison, North Dakota, a grad-
uate of the Women’s Medical College of Philadelphia
in 1910, was chairman of the joint conference of crip-
pled children and maternal and child health workers at
Bismarck on June 12. Dr. Stucke represented the State
Medical Advisory Board.

The Silver Bow County Medical Society of Montana
met on May 4, 1937, at Butte, Montana, where a paper,
"The Reticulo-Endothelial System,” written by Dr. Peter
Potter, was read by Dr. Harvey Lee Casebeer, of the
Murray Clinic. The next meeting will be held on
June 1, the guest speaker being Dr. Thomas L. Walker,
of Great Falls, on "Myelogenous Leukemia.”

Doctor Jean Alonzo Curran, who formerly lived in
Cannon Falls, Minnesota, and who took his arts degree
from Carleton College at Northfield, Minnesota, has
been named dean of the Long Island College of Medi-
cine in Brooklyn, N. Y., according to The New York

320

THE JOURNAL-LANCET

Times. Doctor Curran was graduated from the Har-
vard Medical School in 1921.

Doctor J. A. Diamond, of Frederick, South Dakota,
has retired from partnership with Doctor R. G. Arveson
in Frederick, and will make his home with his son,
Doctor Francis Diamond, in Gladstone, Michigan.
Doctor Diamond had been in practice for 21 years in
Frederick, and was a graduate of the Wisconsin College
of Physicians & Surgeons in Milwaukee, Class of 1906.

Dr. Jorgen G. Vigen, of West Los Angeles, Cali-
fornia, died at St. Luke’s Hospital in Fergus Falls, Min-
nesota, on May 1st. Dr. Vigen, 73, came to America
in 1869; and was graduated from the University of
Minnesota Medical School in 1894. He came to Fergus
Falls to practice in 1896, where he remained until 1928.
That year he went to California.

Dr. Dana C. Rood, now of Duluth, Minnesota, re-
cently inspected the old Rood Hospital in Chisholm,
Minnesota, with a view to modernizing it. Dr. Rood has
the assurance of the Oliver Iron Mining Company and
the Snyder Mining Company that these two firms will
cooperate with him in every way possible toward re-
opening this hospital.

Sixty-six public health nurses convened in Great Falls,
Montana, on June first for a two-day conference. Dr.
W. F. Cogswell, of Helena, was the presiding officer;
and physicians taking part were: Dr. Burton Kane Kil-
bourne, Helena; Dr. Frank L. Watkins, Great Falls; Dr.
Francis Lachlan McPhail, of the Great Falls Clinic; and
Dr. Jessie M. Bierman, director of the child welfare
division of the Montana State Board of Health, Helena.

At the annual meeting of the Scott-Carver County
Medical Society at New Prague on June 15, Dr. Charles
F. Cervenka, New Prague, was elected president. The
vice-president is Dr. Earl R. Crow, Arlington; the new
secretary is Dr. Bror F. Pearson, Shakopee; the delegate
is Dr. Milton Boyce Hebeisen, Chaska (Carver) ; and
his alternate is Dr. William Frank Maertz, New Prague.
Dr. Herman M. Juergens, Belle Plaine, is censor. The
v;uest speaker was Dr. Frederick Carl Schuldt, of St.
Paul.

Dr. E. Martin Larson, Great Falls, was elected presi-
dent of the Montana Tuberculosis Association at
Helena on May 15. Dr. W. E. Pierce, Butte, was re-
elected 1st vice president; Mr. J. X. Nenman, Butte,
2nd vice president; and Mr. T. O. Hammond, of
Helena, treasurer. Dr. Frank I. Terrill, Galen, Mon-
tana, and Dr. Frank L. Watkins, Great Falls, are mem-
bers of the executive committee.

Nineteen of 21 medical students completing the pre-
liminary course in the University of South Dakota
School of Medicine have been placed in 4-year medical
colleges, according to Dr. Joseph C. Ohlmacher, dean.
Eight will go to Rush Medical College in Chicago, four
to Northwestern University Medical School in Chicago,
and three to the University of Louisville School of
Medicine. Two go to Washington University in St.
Louis, one to the University of California, and one to
Creighton University in Omaha.

Dr. R. C. Webb, Minneapolis, chief surgeon of the
Great Northern Railway Surgeons’ Association, of which
The Journal-Lancet is the official publication, was j
guest speaker on "Fractures” at the May meeting of the 1
Seventh District Medical Society at Sioux Falls, South (
Dakota, on May 11.

Mrs. Stephen Baxter, Minneapolis, was installed as
president of the Hennepin County Medical Auxiliary in |i
May; and Mrs. R. R. Cranmer was chosen president- !
elect of the auxiliary. Mrs. J. A. Watson is first vice |
president; Mrs. James Johnson is recording secretary;
Mrs. W. G. Beckman is corresponding secretary; Mrs.

J. P. Hiebert is treasurer; Mrs. E. G. Appen is auditor; '
and Mrs. C. E. Willcutt is custodian.

The broadcasting schedule (Station WCCO, each j
Saturday at 9:45 A. M.) of the Minnesota State Med- |j
ical Association for July is as follows: July 3, "Fourth !
of July Injuries”; July 10, "Summer Diets”; July 17, I
"Summer Skin Disorders”; July 24, "Dysentery”; July |
31, "Vitamins and the Teeth.” Dr. William A. O’Brien,
associate professor of pathology and preventive medi-
cine in the University of Minnesota Medical School, is
the speaker.

The North Central District Medical Association of
Montana was organized in May. Dr. Paul O. Neraal,
of Cut Bank, became its first president; Dr. Herman
Frederick Schrader, of Browning, is vice-president; and
Dr. Walter Lynn DuBois, of Conrad, is secretary-treas-
urer. Delegates to the state medical convention at 'i
Butte in July are Dr. Leon John Liest, of Cut Bank;
and Dr. Harry W. Powers, of Conrad. The next meet- !
ing will be in July in Conrad.

The Cass County Medical Society of North Dakota 'l
held its monthly meeting in Fargo on April 26, accord-
ing to Dr. E. M. Watson, secretary. Dr. A. C. Fortney
spoke on "The Treatment of Syphilis;” Dr. W\ F.
Baillie spoke on "Certain Aspects in the Reporting of
Syphilis Cases;” Dr. W. G. Brown discussed "The Med- .
ical Follow-up of the Venereal Disease Patient;” Dr. '
H. J. Skarshaug spoke on "Education in Syphilis;” and
Dr. Frank Darrow spoke on "A Discussion of Certain 1
Phases of Syphilis.”

The annual meeting of the Advisory Board for Med- I
ical Specialties, which is the coordinating board of the
twelve certifying boards in the various specialties, the
Association of Medical Colleges, the American Hospital
Association, the Federation of State Medical Boards of , I
the U. S. A., and the National Board of Medical Ex-
aminers was held at Atlantic City, N. J., on June 6,
1937. The following officers were elected: Willard C.
Rappleye, M.D., president, New York, N. Y.; W. P.
Wherry, M.D., vice-president, Omaha, Neb.; Paul
Titus, M.D., secretary-treasurer, Pittsburgh, Pa.; W. B.
Lancaster, M.D., Boston, Mass.; and R. C. Buerki,
M.D., Madison, Wis., executive committee. Dr. Louis
B. Wilson of Rochester, Minn., the retiring president
of the board, was elected an emeritus member of the
board.

Edwin Lincoln Goss, M.D.

Carrington, North Dakota

President-Elect, North Dakota State Medical Association

Edwin Lincoln Goss, M.D., was born on May 7, 1 86“5 ,
in Grundy County, Illinois. His great grandfather
(Goss) was born in Boston in 1760; and his forbears
on the maternal (Spillman) side came to Virginia with
Captain John Smith.

Dr. Goss attended public school, and then enrolled in
the Northern Illinois Normal and Scientific School at
Dixon, Illinois, in 1886. He taught three winter terms
of school, and entered what was then the College of
Physicians and Surgeons (now the University of Illinois
College of Medicine) in Chicago in the spring of 1889.
He was graduated in 1892, entering practice at Sheffield,
Iowa, the same year.

That year, Dr. Goss married Miss Sarah Augusta
Vincent, by whom he had two sons, Rollin and Robert
Goss. Mrs. Goss died in 1901, and Dr. Goss thereupon
moved to Carrington, North Dakota, where he has since
practiced. In 1905 he married Miss Nellie S. Standish,
by whom he has one daughter.

Dr. Goss entered the Medical Corps of the U. S.
Army on April 19, 1918, at Fort Des Moines, Iowa.
He was discharged on December 6, 1918, at Camp
Devens. He is a Mason and a Shriner.

322

THE JOURNAL-LANCET

Transactions of the North Dakota State Medical

Association - - 193 7

GRAND FORKS, NORTH DAKOTA

OFFICERS AND COMMITTEES

PRESIDENT

W. A. GERR1SH, Jamestown

PRESIDENT-ELECT

E. L. GOSS, M.D Carrington

FIRST VICE-PRESIDENT

W. H. LONG, M.D Fargo

SECOND VICE-PRESIDENT

*L. B. GREENE, M.D Edgeley

SECRETARY

A. W. SKELSEY, M.D Fargo

TREASURER

W. W. WOOD, M.D Jamestown

DELEGATE TO A. M. A.

(1938)

A. P. NACHTWEY, M.D Dickinson

ALTERNATE

(1938)

C. E. STACKHOUSE, M.D. Bismarck

* Deceased May 3, 1937.

COUNCILLORS term

EXPIRES

FIRST DISTRICT

MURDOCK MacGREGOR, M.D., Fargo 1938

SECOND DISTRICT

G. F. DREW, M.D., Devils Lake ... 1937

THIRD DISTRICT

G. M. WILLIAMSON, M.D., Grand Forks 1938

FOURTH DISTRICT

A. R. SORENSON, M.D., Minot 1939

FIFTH DISTRICT

F. L. WICKS, M.D, Valley City 1939

SIXTH DISTRICT

N. O. RAMSTAD, M.D., Bismarck 1938

SEVENTH DISTRICT

P. G. ARZT, M.D., Jamestown 1937

EIGHTH DISTRICT

*L. B. GREENE, M.D., Edgeley. .. _ .1937

NINTH DISTRICT

JOHN CRAWFORD, M.D, New Rockford 1939

TENTH DISTRICT

A. E. SPEAR, M.D., Dickinson 1937

* Deceased May 3, 1937.

HOUSE OF DELEGATES

CASS COUNTY MEDICAL SOCIETY

A. M. LIMBURG, M.D Fargo

R. E. PRAY, M. D Fargo

R. B. BRAY, M.D. Fargo

W. G. BROWN, Alternate .Fargo

G. A. LARSON, M.D., Alternate Fargo

J. B. JAMES, M.D, Alternate Page

DEVILS LAKE MEDICAL SOCIETY

JOHN D. GRAHAM, M.D., Delegate Devils Lake

W. C. FAWCETT, M.D., Alternate Starkweather

GRAND FORKS DISTRICT MEDICAL SOCIETY

FRANK E. WEED, M.D., Delegate Park River

PHIL H. WOUTAT, M.D, Delegate Grand Forks

W. A. LIEBELER, M.D., Alternate Grand Forks

KOTANA MEDICAL SOCIETY

P. G. E. HOEPER, M.D, Delegate Williston

NORTHWEST DISTRICT MEDICAL SOCIETY

F. E. WHEELON, M.D., Delegate Minot

R. W. PENCE, M.D., Delegate Minot

SHEYENNE VALLEY MEDICAL SOCIETY

WILL H. MOORE, M.D., Delegate Valley City

A. C. McDONALD, M.D, Alternate Valley City

SIXTH DISTRICT MEDICAL SOCIETY

H. A. BRANDES, M.D., Delegate Bismarck

O. T. BENSON, M.D, Alternate Glen Ullin

SOUTHERN DISTRICT MEDICAL SOCIETY

F. W. FERGUSSON, M.D, Delegate Kulm

C. H. SHERMAN, M.D, Alternate Oakes

SOUTHWESTERN DISTRICT MEDICAL SOCIETY

A. P. NACHTWEY, M.D, Delegate Dickinson

R. W. RODGERS, M.D, Alternate Dickinson

STUTSMAN COUNTY MEDICAL SOCIETY

F. O. WOODWARD, M.D, Delegate Jamestown

T. L. DePUY, M.D, Alternate Jamestown

TRI-STATE MEDICAL SOCIETY

H. Van de ERVE, M.D, Delegate Carrington

C. G. OWEN, M.D, Alternate Sheyenne

traill-steele county medical society
R. C. LITTLE, M.D, Delegate Mayville

STANDING COMMITTEES

EXECUTIVE COMMITTEE

W. A. GERRISH, M.D, Chairman Jamestown

ALBERT W. SKELSEY, M.D. Fargo

ARCHIE D. McCANNEL, M.D. .... Minot

F. W. FERGUSSON, M.D Kulm

P. G. ARZT, M.D. Jamestown

COMMITTEE ON SCIENTIFIC PROGRAM

A. D. McCANNEL, M.D, Chairman Minot

W. A. GERRISH, M.D Jamestown

A. W. SKELSEY, M.D. Fargo

R. D. CAMPBELL, M.D. _ Grand Forks

J I I MOORE, M.D. Grand Forks

COMMITTEE ON PUBLIC POLICY AND LEGISLATION

L. W. LARSON, M.D, Chairman Bismarck

*L. B. GREENE, M.D Edgeley

FRANK I. DARROW, M.D Fargo

G. M. WILLIAMSON, M.D. ... Grand Forks

JOHN CRAWFORD, M.D New Rockford

ARCHIE D. McCANNEL, M.D. ... Minot

A. P. NACHTWEY, M.D ...Dickinson

COMMITTEE ON MEDICAL EDUCATION

H. E. FRENCH, M.D, Chairman Grand Forks

H. D. BENWELL, M.D . Grand Forks

H. J. FORTIN, M.D Fargo

W. C. FAWCETT, M.D. Starkweather

COMMITTEE ON NECROLOGY

JAMES GRASSICK, M.D, Chairman Grand Forks

W. C. FAWCETT, M.D. Starkweather

F. L. WICKS, M.D... Valley City

COMMITTEE ON HOSPITALS

V. J. LaROSE, M.D, Chairman Bismarck

A. R. SORENSON, M.D. Minot

E. A. PR^VY, M.D. Valley City

COMMITTEE ON PUBLIC HEALTH

MAYSIL WILLIAMS, M.D, Chairman Bismarck

E. G. SASSE, M.D Lidgerwood

B. S. NICKERSON, M.D. . Mandan

D. W. MATTHAEI, M.D. Fessenden

COMMITTEE ON MEDICAL HISTORY

G. M. WILLIAMSON, M.D, Chairman Grand Forks

JAMES GRASSICK, M.D. Grand Forks

JAMES P. AYLEN, M.D. Grafton

THE JOURNAL-LANCET

323

PERMANENT COMMITTEE ON HISTORY

JAMES GRASSICK, M.D. Grand Forks

EDITORIAL COMMITTEE ON The JoURNAL-LaNCET

J. O. ARNSON, M.D., Chairman Bismarck

H. E. FRENCH, M.D. ... Grand Forks

FRANK I. DARROW, M.D Fargo

W. A. GERRISH, M.D. Jamestown

COMMITTEE ON CANCER SURVEY IN NORTH DAKOTA

E. P. QUAIN, M.D., Chairman Bismarck

L W. LARSON, M.D Bismarck

FRANK I DARROW, M. D Fargo

H. E. FRENCH, M.D Grand Forks

RUSSELL GATES, M.D ....Minot

COMMITTEE ON MILITARY AFFAIRS

*L. B. GREENE, M.D., Chairman Edgeley

E. P. QUAIN, M.D Bismarck

F. E. WEED, M.D Park River

COMMITTEE ON TUBERCULOSIS

CHARLES MacLACHLAN, M.D., Chairman San Haven

PAUL H. ROWE, M.D Minot

F. O. WOODWARD, M.D. ... Jamestown

C J. GLASPEL, M.D Grafton

MAYSIL WILLIAMS, M.D ...Bismarck

W. H. LONG, M.D. Fargo

COMMITTEE ON FRACTURES

A. L. CAMERON, M.D., Chairman __ Minot

H. J. FORTIN, M.D. Fargo

W. W. WOOD, M.D. Jamestown

J. W. BOWEN, M.D Dickinson

R. M. WALDSCHMIDT, M.D. Bismarck

PAUL H. BURTON, M.D Fargo

R. D. CAMPBELL, M.D. „ Grand Forks

C. S. JONES, M.D Williston

COMMITTEE ON PUBLIC RELATIONS

FRANK I. DARROW, M.D., Chairman Fargo

J. H. MOORE, M.D. Grand Forks

W. H. BODENSTAB, M.D. Bismarck

J. O. HAYHURST, M.D. RoIIette

A. W. SKELSEY, M.D. Fargo

COMMITTEE ON CARE OF EARLY MENTAL CASES

J. D. CARR, M.D., Chairman .. Jamestown

H. A. BRANDES, M.D. Bismarck

W. A. WRIGHT, M.D _..... Williston

A. D. McCANNEL, M.D Minot

COMMITTEE ON MEDICAL ECONOMICS

H. A. BRANDES, M.D., Chairman Bismarck

A. D. McCANNEL, M.D .. . Minot

ANGUS CAMERON, M.D. Minot

E. A. PRAY, M.D. ...Valley City

W. H. LONG, M.D. Fargo

COMMITTEE ON MATERNAL AND CHILD WELFARE

J. H. MOORE, M.D., Chairman Grand Forks

P. W. FREISE, M.D. Bismarck

E. M. RANSOM, M.D. _ _ _ Minot

J. D. GRAHAM, M.D Devils Lake

J. F. HANNA, M.D .... Fargo

COMMITTEE ON CHILD WELFARE

J. L. CONRAD, M.D., Chairman Jamestown

JAMES P. AYLEN, M.D. Grafton

R. E. PRAY, M.D. Fargo

A. M. BRANDT, M.D. Bismarck

RUTH M. MAHON, M.D. Grand Forks

COMMITTEE ON CRIPPLED CHILDREN

H. J. FORTIN, M.D., Chairman Fargo

V. J. LaROSE, M.D Bismarck

ANGUS CAMERON, M.D. Minot

PAUL H. BURTON, M.D. Fargo

W. W. WOOD, M. D. Jamestown

* Deceased.

PROCEEDINGS
of the

HOUSE OF DELEGATES
of the

FIFTIETH ANNUAL MEETING
of the

NORTH DAKOTA STATE MEDICAL
ASSOCIATION

Sunday, May 16, 1937

The first meeting of the House of Delegates was held at the
Dakotah Hotel, Grand Forks, North Dakota and was called to
order at 2:00 P. M., by the president, Dr. W. A. Gerrish,
Jamestown. Roll CaU

Secretary Skelsey called the roll, and the following delegates,
councillors, and officers responded:

Doctors:

A. M. Limburg, Fargo
J. D. Graham, Devils Lake
W. C. Fawcett, Starkweather
P. H. Woutat, Grand Forks
W. A. Liebeler, Grand Forks
P. G. E. Hoeper, Williston
A. R. Sorenson, Minot
A. L. Cameron, Minot
A. D. McCannel, Minot
Wili H. Moore, Valley City
H. A. Brandes, Bismarck
O. T. Benson, Bismarck

L. W. Larson, Bismarck

F. W. Fergusson, Kulm

A. P. Nachtwey, Dickinson
A. E. Spear, Dickinson
R. C. Little, Mayville
H. Van de Erve, Carrington

E. L. Goss, Carrington
J. P. Aylen, Grafton

C. E. Stackhouse, Bismarck
Paul H. Burton, Fargo
Chas. MacLachlan, San Haven
W. A. Gerrish, Jamestown
A. W. Skelsey, Fargo

M. MacGregor, Fargo

G. F. Drew, Devils Lake

G. M. Williamson, Grand Forks

F. L. Wicks, Valley City

N. O. Ramstad, Bismarck

The president declared a quorum present, and the House duly
constituted for the transaction of business.

Dr. Williamson, Grand Forks, made the motion that inas-
much as a vacancy had been created in the Board of Coun-
cillors due to the death of Dr. Lee B. Greene, of Edgeley,
Dr. N. O. Ramstad be appointed president of the Councillors,
and Dr. F. W. Fergusson, be appointed councillor from the
Southern District.

the motion was duly put by the president, a roll call being
taken on same, which motion was unanimously carried.

Thereafter the president declared that the alternate, Dr.
C. H. Sherman, of Oakes, would be the official delegate from
the Southern District.

Minutes

Secretary Skelsey moved that the minutes of the Forty-ninth
Annual Session as published in The Journal-Lancet, August,
1936, be adopted, and the reading of the minutes omitted.

The motion was seconded by Dr. A. M. Limburg, of Fargo,
and unanimously carried.

Report of the Secretary

Secretary, Dr. A. W. Skelsey, presented the following re-
port:

This session signalizes our Fiftieth Anniversary. As there
may be presented a separate and detailed review giving our
half century’s career, we shall not now relate that history.

For the year ending December 31, 1936, we had 417 mem-
bers. From January 1, 1937, to date 334 persons ha' e paid
their dues.

324

THE JOURNAL-LANCET

Committee Meetings: Several joint meetings with various
committees were held, especially at Bismarck concerning the
Federal Resettlement Administration, and its plans for medical
relief to those thousands of families to be cared for under that
Administration and local welfare boards.

The Journal-Lancet has rendered excellent service, in its
usual form, and also through the several special editions In
these times of financial depression, the State Association has
been fortunate in that a corporation other than our own, has
carried this burden of printing a monthly medical journal.

You, too, doubtless have noticed the number of formerly
nation-wide, high-grade general magazines which have sus-
pended publication. Even now, formerly very staid journals

and newspapers have yielded to the apparent necessity of major-
ing in advertisements, and those often of dubious nature.

Nowadays one almost ceases to be surprised on finding in such
publications as Harper’s Magazine advertisements extolling the
alleged value of books on birth control, and others on sex

affairs freely illustrated — subjects that not so many years ago
were taboo in homes and reading circles.

Economics and North Dakota Physicians: It is unnecessary
to enlarge upon the nation’s plight and the thirty-five billion
dollars’ national debt. In North Dakota, the several contin-
uous droughts have placed the State in bad shape, so much so
that federal, state, and local governments have been providing
sustenance and money to the thousands in need of help. Your
Committee on Medical Economics will give you their report.

Contract Practice in North Dakota: Through the efforts of
the Committee on Medical Economics, agreed rates for reason-
able compensation have been secured to some of the doctors,
and amicable plans effected between certain counties and physi-
cians. Yet several localities continue the old-time city and
county contract practice, plainly indicating a decided lack of
unity among medical men. This subject, and also that of con-
tract practice with cheap fraternal orders and lodges for medical
and other care, could well bear reviewing and some action
thereon.

New Committees: On account of the Federal Social Security
Act, and other developments, the following new committees
have been created:

On Crippled Children;

On Maternal and Child Welfare;

On Child Welfare.

Proposed Re-Districting of Some County Societies: In com-
pliance with the constitution and the by-laws, several months
ago notices were mailed to the councillors and to the local sec-
retaries that this plan might again come before the delegates
and the councillors for further action.

Our Two-Year Medical School: This subject was before our
last annual session. General reference to this type of schools
may be found on page 1540 of the Journal A. M. A. for May
1, 1937. Today you will obtain from the Committee on Medi-
cal Education latest data on this affair. Apparently the A. M.
A. has been straddling the fence. Some of the transactions at
the A. M. A. headquarters appear rather peculiar. For several
years they have been expending money and time, and awarding
their "seal of approval’’ to bakeries, confectioners, and similar
concerns, as recommendations from the A. M. A.'s Committee
on Foods. These awards have covered material which now the
Association decides shall not hereafter be included in the in-
vestigations and awards by said Committee. ( Good Housekeep-
ing has also been another organization in presenting oval-shaped
seals of approval on foods, utensils, etc.) Even if the Federal
Pure Foods and Drugs Act is not sufficiently drastic to protect
the public, can the A. M. A. rightly be considered another
national censor along those lines; in other words, does our own
national medical organization have resources enough to adopt,
follow up, and at intervals check carefully the various products
to which it has already given its approving seal, utilized by
donees for advertising purposes?

And now, after having passed along many seals of merit to
such concerns and articles, and also having incurred expenses
in a field not really belonging to it, the Association has ruled
that our medical school possesses not enough merit, money, and

physical equipment to be recognized longer by that Association.
Yet it is well known and admitted that practically all of the
students from our school have compared very favorably indeed,
in scholarship and later professional success, with students from
larger and financially better-equipped medical institutions. We
admit that our buildings on the Grand Forks campus do not
loom large; that we do not have extensive laboratories, as com- \
pared with some wealthier colleges; and we also admit that our
state financially has been so crippled as to prevent liberal ap-
propriations,— yet for all this, the A. M. A. Council on Medical
Education should admit that scholarship and professional suc-
cess mean much more than elaborate buildings and equipment
therefor.

The Society’s Constitution and By-laws: We are asked to
suggest the possibility of reprinting these. The suggestion
comes, NOT from a Democrat of the aggressive Franklin
Roosevelt type, with his hobby about the U. S. Constitution,
but from one who notices that our document goes back to the
year 1919, and because included in its sixteen pages are about
four pages devoted to medical defense — which plan of defense
was abandoned some years ago. Also, due to the development
of serious economic and socialistic tendencies and actual condi-
tions, your Association has deemed it necessary to create com-
mittees not existing when the document of 1919 was printed
Our present list of committees now totals twenty, a rather large
assignment for North Dakota.

Recent correspondence and a telegram of May 7, 1937, from
the A. M. A. might serve some purpose here:

"Recently, certain attorneys considered that the medical de-
fense plan of some medical societies constitutes the unauthorized
practice of law; that there was held in Washington, D. C.
May, 1937, by the joint committees on professional ethics and
grievances on the unauthorized practice of law, discussions
covering complaint against the Ohio State Medical Society; |
that as a result of said conferences a committee has expressed
the opinion that the operation of medical defense constitutes
the unauthorized practice of law; and that presumably this
opinion will apply to other state associations.”

We answered headquarters that as we do not carry that
form of medical defense, the resolution did not concern us.

If, however, our Constitution and by-laws should be reprinted
and perhaps amended within the next few years, and the ques-
tion of medical defense should arise, the above information
should be remembered.

Nationally: Health conditions generally have been favorable.
However, the whole country has been having forced upon it
several decided mass movements via the federal, state, and
local governments; aided also by the social service uplifters. It
appears that the number of highly-strung people waving banners
and helping circulate tons of literature of that kind, keeps in-
creasing. Not all of these publicity urges and punches are due
entirely to salaried, comfortably-chaired employees clinging fast
to governmental jobs; but they are to some extent fostered and
aided by some physicians. One doctor interested in this form
of noisy campaign explained his attitude and actions by saying
that many women have not enough to do, and that the mass-
movements will help keep thousands of them busy and there-
fore out of mischief. However, the question arises whether
these ever enlarging mass movements and propaganda urges,
while they may relieve the emotional output of those needing
employment and so-called self-expression, may not on the other
hand, cause undue mental distress and phobias in those whose
supposed needs are noisily crusaded by the uplifters via publicity
talks, radios, magazines, newspapers, etc. If we must have all
of this kind of campaigning, why not also freely utilize the
large billboards, high protruding rocks, etc., like unto some of
the religious sects, which by such devices urge the public at
large to be prepared to meet their God. The medical profes-
sion seems to be falling into the plan of regimentation.

Syphilis: In connection with some of these movements, it
was recently suggested by one of our public health officers that
the doctors accept the following plan: free medicine for the
syphilitics, not alone for the indigent, but also for the persons
well able to pay; also, that the doctors’ charge, for such persons

THE JOURNAL-LANCET

325

able to pay, not more than #2.00 or #2.50 at the most, for
each injection. Certainly this is going quite rapidly along the
lines of socialized and regimented practice of medicine. But,
as the proposed plan is not that of an actual practitioner, the
whole affair must be viewed as from the angle of a man, on
salaried governmental payroll, passing along the suggestion from
the salaried man higher up, who too has a cozy salaried chair,
and all traveling expenses paid by the authorities.

A local secretary states that the welfare board in that com-
munity believes arrangements may be made whereby those on
relief, may be dropped for that case, from the existing contract
practice system, so as to take treatments for syphilis at a min-
imum, say of #3.00 per treatment. But why make an exception
for syphilis in case of those on welfare relief? Why not let
all persons on relief, needing medical and obstetrical care,
select their individual doctor and the doctors be paid an agreed,
reasonable compensation? This should be the system in all
counties and towns.

Year 1925 17%
" 1926 34%

" 1927 49%

" 1935 88%

Immunization: The North Dakota State Health Department
circularizes all physicians and sends forms for record, notifying
them that said department can supply, free of charge, smallpox
vaccine and diphtheria toxoid. While not so stated, this could
refer only to strictly indigent cases; but in view of the pro-
cedures now being urged by various agencies other than the
medical profession, physicians should be warned about Fargo's
experience in connection with and for some years following the
implanting of the Commonwealth Foundation there and the
episodes therefrom.

Federal Veterans’ Administration: As private practitioners
you must be interested in the following data from the February,
1937 Ohio State Medical Journal regarding the hospitalization
service of the Federal Veterans’ Administration:

Approximate percentages of hospital admissions to the
Administration’s facilities, of patients with non-service-
connected disabilities, by years:

The medical journal expresses wonder
as to the probable extent of investi-
gations made by the Administration
of those sworn applications for ad-
mission.

It might also be noticed here, thac the Federal Civil Service
Commission reports that as of March 31, 1937, the national
government had 829,193 persons on payrolls.

A. M. A. Committee on Foods: After some years’ expendi-
ture of time and money, the committee has wisely decided to
limit the scope of the foods formerly considered and seals of
merit awarded where deemed worthy. Hence, no longer will
those seals be awarded to the many dozens of ordinary breads
and bakery products, the names of the manufacturers and the
brands having been detailed in the various issues of the Journal
of the A. M. A. These earlier commendations included such
seal-bearing products as Quinx-a-Wink Self-Raising Flour, Tar
Heel Bread, Angel Food Cake, Buy Jimmie (cocoanut bar) ,
Baby Ruth drops (chocolate flavor), Easy Aces candy, etc. A
recent number of the Journal carries an advertisement bearing
the imprint of both the A. M. A. seal and of the oval-shaped
seal of Good Housekeeping, which presumably makes assurance
doubly sure.

Foundation Studies, Questionnaires, etc. on Medical Affairs:
One of the latest publications is that of the American Founda-
tion, created by Bok. It prints the result of its investigations
and the post-mortem inquest. Data obtained through circulars
to the physicians. There are two volumes entitled American
Medicine, sold for #3.50 the set. A lengthy editorial on this
publication will be found in the Journal of the A. M. A. for
May 10, 1937, which deserves your careful perusal.

Care and Relief of Physicians and Their Dependents: The

A. M. A. has again considered this subject, which previously
had been dismissed in a negative way by it. Its present find-
ings are: (a) that few of the proposed projects for the estab-
lishment of clubs or homes, deserve encouragement; ( b ) that it
does not appear1 to be within the province of that organization
to establish homes; (c) that perhaps the formation of an agency
in connection with commercial insurance companies to secure

more advantageous contracts and reductions in rates, might
operate efficiently.

Special Journals Published by the A. M. A.: the Trustees

report a net financial loss in some of the special magazines
issued by our national society; intimate that if the deficit con-
tinues in those groups of journals, they may suspend publication
of those responsible for the larger loss. Even Fiygeia exceeded
its income by a net loss of #14,791.38. While Fiygeia is use-
ful to the medical fraternity through its public contact, so far
as the other specialized non-profit magazines are concerned, the
printing thereof is not only a loss to the A. M. A., but also
is in direct competition with regular medical book and publish-
ing concerns, which are doubtless trying hard to get a living.

The Cults and the Irregulars: Throughout many of the states
the legislative hoppers have been holding dozens of bills seek-
ing to increase not only the scope of the cults already en-
trenched by law, but also such composites as sanipractors,
naturopaths, etc.

The May 1937 number of The Journal-Lancet gives a
record of the N. D. Medical Registration Board and its efforts
to control the irregulars and the non-ethical physicians.

The Diplomate for April 1937, contains a valuable address
by James Grafton Rogers, master of Timothy Dwight College,
Yale University, entitled "The Professions in World Turmoil.”
While this refers to medicine and law, it could well be applied
elsewhere. We hope that we can meet and dispose of these cur-
rent problems according to our abilities and our resources. Out
of all of these conflicts and sufferings, one writer recently made
the heartfelt plea that "efforts be made to find some adjust-
ment beneficial alike to the employer, the employee, and the
public.” All this concerns the physician, his work, and his re-
compense, mentally and financially. For us who live in North
Dakota — an agricultural country and therefore fairly free from
distorted textile labor trouble — about all that we are looking
for are good crops. May your desires be fulfilled.

Before concluding, I wish to state that Mr. L. M. Cohen, of
Minneapolis, was admiring our program. He said he would
be glad for his publishing house, the Lancet Publishing Com-
pany, to furnish us free of cost the program for each year. He
admitted this was an especially nice one and his offer would
not include the gold leaf. I thought this matter should be
brought to your attention, as it would represent a considerable
saving to the Association.

Secretary Skelsey: I have attached to the report the usual
statement of annual receipts.

Albert W. Skelsey, M.D.

Secretary

Dr. Williamson: I would move you that you appoint a
committee to go over the report of the secretary and bring in
recommendations on it.

Dr. W. C. Fawcett, Starkweather: Second the motion.

(Said motion was duly put and unanimously carried.)

President Gerrish: I will appoint on that committee Drs.
Williamson, Fawcett and MacGregor.

Dr. Williamson declined to act, stating that his duties in
connection with the host society were too numerous to make it
possible for him to serve.

Dr. Charles MacLachlan was named in his stead.

President Gerrish called for the report of the president of
the Council.

Dr. N. O. Ramstad stated that inasmuch as he had just been
appointed as such chairman, a, report would be submitted at a
later date.

The report of the treasurer, Dr. W. W. Wood, was dis-
pensed with for the time being, owing to the absence of the
treasurer.

REPORTS OF COUNCILLORS
First District

Since the last meeting of the North Dakota State Medical
Association, the Cass County Medical Society has held seven
meetings, with an average attendance of forty-three members.

The total membership at this time is sixty-seven. Five new
members have been added during the year, one by transfer

326

THE JOURNAL-LANCET

from the Sixth District, and four by formal election to the
society. Two members have left the society, having taken up
practice elsewhere. There have been no deaths.

The scientific programs have been furnished by members of
our own society. A motion picture film was shown and accom-
panied by a lecture by the Lederle Laboratories of New York
City. An obstetrical seminar was held in the early fall.

Various members who attended meetings during the year,
outside of our own society, made reports of such meetings be-
fore the society from time to time. A symposium on fractures
was featured at one session. Syphilis and its relation to public
health was discussed at the last session, at which meeting
visitors from the State Health Department and from the Fargo
Health Department and Cass County Welfare Service, were
present. A purely social meeting, at which the wives and
friends of the doctors were present, was held in December,
1936.

Subjects of an economic nature came up from time to time.
One concerned the relationship of the North Dakota State
Medical Association to the Farmers’ Mutual Aid Corporation
(the Resettlement Administration) . What constitutes an emer-
gency under the provisions of the corporation needs clarification
and should be clarified at the meeting of the State Council and
delegates in order that physicians treating such cases might
share in the financial benefits for the care provided.

A fee schedule for the treatment of the indigent cases of
syphilis has been worked out by a committee of the society and
accepted by the Cass County Welfare Board. It is understood
that the fees are to be provided under the Social Security Act.
Negotiations for fees for follow-up work in syphilis are still
under way.

There has been close contact between the society and the
various welfare groups in the community, through committees,
throughout the year, particularly with the Cass County Tuber-
culosis Association. Special work was directed to case-finding
of tuberculosis among the teachers of the Fargo schools and in
the junior class of the local high school. The society has given
its full cooperation in this work.

Medical care of the Cass County poor still remains one of
our unsolved problems, so far as the Cass County Medical
Society is concerned. The physicians of the rural districts of
the county have entered into an agreement with the County
Welfare Board to furnish medical care in the various town-
ships at the rate of fifty dollars per township per year. Further-
more, the society continues to be embarrassed by having certain
of its members persist in entering into salary contracts with the
Welfare Board in violation of the resolutions adopted in good
faith prohibiting such contracts.

The society is gradually becoming better organized, and due
to the encroachment of socialistic trends, it is evident that great-
er interest is being taken in all questions touching the profession.
In spite, however, of this greater interest and the increasing
awareness of the dangers confronting the profession in these
swiftly-moving times, under the protective cloak of a pater-
nalistic government, are we to be content in winning peace
without victory?

Murdoch MacGregor, M.D.,

Councillor

Second District

The Devils Lake District Medical Society held four meetings
during the year, which were all well attended.

We have had no friction in the society and none of the
members has taken contract work.

Our April meeting was taken over by the State Committee
on Maternal Mortality. Dr. J. H. Moore and Dr. W. E. G.
Lancaster gave papers which were considered very valuable.

At the September meeting we had a paper by Dr. J. A.
Urner of Minneapolis on obstetrical analgesia. Also, Dr.
Kratz gave a paper advocating whole-time district health
officers.

We have lost one member by death, and admitted one mem-
ber, and now have a membership of 28, the same as last year.

G. F. Drew, M.D.,

Councillor

Third District

Regular monthly meetings of the Grand Forks District Medi-
cal Society are held from September to May each year.

The attendance is usually good and programs are of a high
order.

Good fellowship prevails throughout this district society.
Sometimes I think that if it were possible to create some con-
troversy or difference of opinion as to the management of
affairs, more fellows might attend the meetings and every man
practicing in this district might want to be a member. As it
is at present, it is so peaceful and everybody is so happy that the
secretary, although I have been unable to secure his report,
tells me the men are slow in paying their dues; however, they
will pay in time.

We have lost by death two of our older outstanding mem-
bers: Drs. August Eggers and J. E. Engstad, both pioneers in
the practice of medicine. Each had a large circle of friends,
and in the early days a very large practice.

G. M. Williamson, M.D..

Councillor

Fourth District

The Northwestern District Medical Society was made up of
58 paid-up members for the year 1936. Twelve meetings were
held during the year, nine of which were devoted to scientific
programs. The three meetings of the summer months were
held in the picnic grounds of the Country Club, and were of a
social nature and largely attended.

A sincere effort was made to have a worth-while program
for each meeting, and the officers of the society made every
effort to make the meetings interesting and profitable. The
outside speakers brought in were Dr. Wm. White, of the
General Hospital, Minneapolis, Minnesota, who spoke on
fractures; Dr. G. Alfred Dodds, of San Haven, who spoke on
the "Use and Results of Lung Collapse Therapy”; Drs. Freise,
Graham and Moore, who spoke on various aspects of obstet-
rics; Dr. A. C. Kerkhof, of the University of Minnesota, who
spoke on "Gastric Malignancy and its Diagnosis by Means of
the Gastroscope.” The other meetings were addressed by
members of the local society, who, in each instance, presented
a worth-while subject well-prepared.

All of the meetings of the society have been well-attended,
and especially so by out-of-town men. There are a number of
men belonging to this district, who are members but never
attend any of the meetings; and an effort has been made to
reach them and induce them to come, but with little avail.

Seven new members were added to the membership, as fol-
lows:

Dr. Paul Ittkin, Tolley
Dr. Tracy Krogstad, Minot
Dr. R. T. O’Neill, Minot
Dr. Kenneth Malvey, Bottineau
Dr. Wm. J. McGee, Flaxton
Dr. Frank A. Remde, Bottineau
Dr. O. W. Johnson, Rugby

Five members were lost to the society through removal from
the district, namely, Drs. Russell Gates, Cyrus Owen Hansen,
C. W. Robertson, S. J. Hillis, and A. F. Jensen.

During the year of 1936 four doctors were lost through
death:

Dr. O. S. Leedahl, Stanley
Dr. J. T. Newlove, Minot
Dr. A. E. Pierce, Minot
Dr. H. A. Owenson, Arnegard

The society also went on record as favoring re-districting of
the state; believing that it would create better and more effec-
tive district medical societies.

A. R. Sorenson, M.D.,

Councillor

Fifth District

The Sheyenne Valley Medical Society has thirteen members,
having lost two during the past year: Dr. H. K. Helseth,
Litchville, removed to Minnesota; and Dr. J. M. Nelson, Valley
City, located in Montana.

THE JOURNAL-LANCET

327

Four meetings have been held, with case reports and autop-
sy findings being the main topics of discussion. Our aid was
extended to the University Medical School. A number of our
men visited the Stutsman County Medical Society at various
times.

In the Traill-Steele Society territory, there are nine physicians,
all belonging to the society, besides one from Grand Forks
County.

Three regular meetings have been held, with banquet and
program, usually a guest speaker, and talks and discussions by
members.

Topics given attention have been "The Status of our North
Dakota Medical School”; "Fractures”, and "Syphilis.”

The fraternal spirit is fine. The society votes its preference
to remain as now, against consolidation with another district.

F. L. Wicks, M.D.,

Councillor

Sixth District

During the past year, the Sixth District Medical Society
has held four meetings, with an average attendance of 37 mem-
bers, and a total of 25 guests.

New members admitted to the society during the year are:
Drs. A. B. Halliday, Hebron; H. J. Bertheau, Linton; and
John A. Cowan, Bismarck.

There are at present in good standing 59 members with their
1937 dues paid. There is one member living outside of North
Dakota at present, whose dues have not been paid.

Our programs have been good and interesting. An effort
has been made to review important diseases and their treatment,
and also to consider the new ideas in medicine and surgery.
One meeting was devoted to the consideration of fractures and
injuries, the speaker from outside the society being Dr. B. I.
Derauf, St. Paul, who discussed "Fractures of the Humerus.”

Dr. John A. Urner, Minneapolis, at another meeting, gave
us a fine paper on "Analgesia in Obstetrics.” One meeting was
devoted to "Cancer of the Gastro-Intestinal Tract” under the
guidance of the cancer committee.

The members of the society have accepted the plan of the
Economics Committee during the past year, and we feel that
this plan has been a very helpful and useful one to all con-
cerned.

N. O. Ramstad, M.D.,

Councillor

Seventh District

Your councillor begs leave to present the following report for
Stutsman County:

We represent twenty-two active and paid-up members as of
this date. One physician in the county has as yet failed to pay
his dues, so is not included.

We have lost three members during the year: Drs. John F.
Regan, C. V. Lawton, and J. C. Fitzpatrick.

One addition: Dr. Pearl Matthaei, who is on the staff of the
State Hospital.

Six meetings have been held as follows:

October 1, 1936 — Business meeting cleaning up the odds and
ends of the state meeting.

December 2, 1936 — Address by Dr. Schmidt on "Treatment
of Pneumonia and Pernicious Anaemia,” with a film on local
anesthesia in obstetrics.

January 21, 1937 — Film on "Treatment of Hernia,” and
film on "Episiotomy and Repair with Local Anesthesia.”

February 3, 1937 — Address by Dr. Harry Fortin, on "Treat-
ment of Fractures.”

March 4, 1937 — Address by Dr. Orr on "Health and Its
Relationship to Maternal and Infant Welfare.” Film on
"Treatment of Eclampsia” and one on "Examining the Child.”

April 23, 1937 — Address by Dr. R. E. Pray on "Hyper-
insulism”; film on "Rib Resection,” "Treatment of Empyema”;
film on "Breast Feeding.”

Our meetings are always preceded by a dinner, with an
average attendance of seventeeen per meeting.

Last fall the society purchased a film projector, which has
enhanced the attendance and made the meetings more in-
teresting.

Several informal meetings were had with the county and
state welfare boards, resulting in a somewhat better under-
standing. This subject is one which the Executive Committee
will have to deal with this fall.

The subject of re-districting the component county or dis-
tricts was brought up at a recent meeting. There was no dis-
cussion following your councillor’s presentation. It is my opinion
some good will result from a re-grouping in certain areas.

May I bring to the attention of the councillors the question
of a revision of the by-laws. The present set was revised about
twenty years ago. Most copies are obsolete. New ones should
be printed, and all members supplied with the same.

Our society is in good financial standing; harmony prevails;
all are interested in their profession and willing to cooperate
in every way to alleviate the stress of the present economic
situation.

P. G. Arzt, M.D.,

Councillor

Eighth District

The Southern District Medical Society has fourteen paid
members for the year 1937.

There are four other doctors in the district who are eligible,
but who have not paid their dues.

No doctors have entered the district for practice. Dr. L. B.
Greene, Edgeley, was removed by death.

The society held several meetings, with an average attend-
ance.

Dr. Harry Fortin was guest speaker at the May meeting
and gave a very instructive paper on "Fractures of the Hu-
merus.”

F. W. Fergusson, M.D.,

Councillor

Ninth District

(In the absence of Dr. John Crawford, Dr. E. L. Goss read
the following report:)

During the last fiscal year we have had four regular meet-
ings. We have had no outside speakers. We have had our
own members present papers on medical and surgical problems.
Much of the time at our medical meetings was taken up with
the discussion of medical economics.

This society went on record as favoring the re-districting of
the various medical societies of the state.

Our society is on record as against any form of contract
practice except as approved by the State Medical Association.
Our three counties have no contract doctors, and patients have
free choice of doctors.

We have thirteen paid-up members.

John Crawford, M.D.,

Councillor

Tenth District

The Southwestern District Medical Society has lost no mem-
bers during the year, either by death, removal, non-payment
of dues or unethical behavior; but has increased its membership
by one, the new member being Dr. Fred Hamernek, government
physician at Elbow Woods. This gives us twenty-eight mem-
bers in good standing.

In spite of adverse conditions, about which you have all
probably heard more than we have, I am happy to be able to
report one hundred per cent membership for the fourth con-
secutive year.

We have held five meetings, all of which have been well
attended and filled with cheer and good fellowship. At two
of these meetings the society entertained as guests the chairman
and members of the welfare boards of the several counties
which make up the district. We feel that personal contact
with these members of the welfare boards is a big advantage,
both to them and to the doctors.

We have had as guest speakers during the year, Drs. A. D.
McCannel, W. A. Gerrish, W. H. Long, and W. H. Boden-
stab.

A. E. Spear, M.D.,

Councillor

328

THE JOURNAL-LANCET

REPORTS OF COMMITTEES
Executive Committee

President Gerrish: Through some humorous quirk of our
beloved secretary, he has put me down here as chairman of the
Executive Committee, so I will have to give a verbal report.

The Executive Committee met with full attendance, either
three or four times in Bismarck, relative to the welfare work,
and consummating an agreement with this Farm Co-operative.
How poor or how good it is, varies somewhat with your ability
as a collector. Some folks report good results, and some say
they haven’t received any money at all. Personally, in out
clinic the bookkeeper informed me the other day that we were
about six months in arrears, the whole length of the service.
Anyhow, we did the best we could. This thing was organized;
they had it incorporated, and they told us to take it or leave
it, or they would go on a salary basis and get some men to
do it. This is about the extent of our executive committee
work.

May we have the report of the Chairman of the Committee
on Scientific Program?

Committee on Scientific Program

Dr. A. D. McCannel, Minot, chairman of the Committee,
gave the following oral report:

Dr. McCannel: I have no particular report to make, other
than the program which you have in your hands. I might say
that the resolution passed last year stated that the outgoing
president was to be the chairman of the Committee.

I started to do the work, but unfortunately in January I
had to discontinue it, so turned it over to Dr. Williamson of
Grand Forks. I think we should congratulate them on the
splendid program they have arranged.

Committee on Public Policy and Legislation

The report was read before the House of Delegates by the
chairman, Dr. L. W. Larson, and accepted by the House.

Dr. Williamson: I think the House of Delegates and the
residents of North Dakota owe a great deal to Dr. Larson,
and the profession in Bismarck, for what they do during these
sessions. Personally I cannot comprehend all of the time and
effort they spend for the good of the profession.

I want to move at this time a vote of thanks to Dr. Larson
for the efforts he put forth during the last session of the
Legislature.

Dr. G. F. Drew seconded the motion, which was duly put
and carried.

Report of Committee on Medical Education

Dr. H. E. French, Grand Forks, chairman of the committee,
made the following report:

Your Committee on Medical Education would report, in re-
gard to the School of Medicine at the University, that the
school was notified in the latter part of October, 1936, that it
would no longer be recognized as an acceptable medical school
by the Council on Medical Education and Hospitals, this action
without prejudice to students at present enrolled.

Appropriations were made by the last session of the legis-
lature that would approximately double the budget that the
school has had for the last four years, if it is authorized to
continue. Tentative plans are in progress for improvements
made possible by the increased budget, and the plans are be-
fore the Council to be considered at their meeting in June,
1937.

The committee has nothing to report on popular health edu-
cation or graduate opportunities for physicians other than what
it has reported in other years.

H. E. French, M.D.,

Chairman

Treasurer’s Report

Dr. W. W. Wood, treasurer of the Association, gave his
report, which was referred to the councillors for action.

Committee on Hospitals

The chairman, Dr. V. J. LaRose, was not present, and
accordingly no report was given.

Committee on Medical History

Dr. Williamson: On Dr. Skelsey’s desk will be some of the
histories that Dr. Grassick published. There is a lot of good
stuff in it. Many of the young men haven’t that history. I
believe it would be a good book to have in their library. Dr.
Skelsey will have the books on his desk tomorrow and he will
tell you the price of them.*

* $52.25, delivered.

Committee on JOURNAL-LANCET

In the absence of the chairman, Julius O. Arnson, Dr. H.

A. Brandes read the report as follows:

We are pleased to give you a report regarding The Journal- .
Lancet.

So far as we are able to determine, the situation with The
Journal-Lancet and the publishing house is satisfactory. No
adverse criticism of The Journal-Lancet has come to our
attention during the past year.

We do not believe that any change, regarding the attitude
of The Journal of the American Medical Association toward
The Journal-Lancet, and the articles published in it, has
taken place. It is the suggestion of the committee that efforts
be continued to re-establish the reputation of The Journal-
Lancet with the American Medical Association, in order that
the articles published in it will be recognized and reviewed by
The Journal of the American Medical Association. Efforts
along this line are now being carried out and a supplementary
report, regarding this phase of The Journal-Lancet will be
made shortly to the officers of the state society.

Dr. Brandes: For several years, the A. M. A., on the old
plea that we were not carrying ethical advertising, has apparent-
ly deliberately refused to abstract anything from our journal.

It is very high grade now, and should receive some recog- |
nition. I believe that is what Dr. Arnson is referring to.

Committee on Cancer Survey

In the absence of the Chairman, Dr. E. P. Quain, Dr. L. W.
Larson read the following report:

Dr. Quain, chairman of your Committee on Cancer, has
asked me to prepare and deliver this report. Unfortunately
circumstances have made it impossible for him to be very ac- 1
tive during the past year, so the committee has not functioned
as it would have under his active leadership. However, he does
feel that the Committee on Cancer should be continued for
several reasons.

One reason is tfi^t our medical brethren must be made as
cancer-conscious as possible. Symposia, devoted to the subject j
of cancer, should be continued in the future in our district j
medical societies.

It is possible that if federal funds are ever appropriated to
aid in the fight against cancer, refresher courses in tumor
diagnosis can be given, in the same manner as those fostered
by our State Committee on Maternal Welfare. Early diagnosis
and early treatment are still the important weapons in the war
on cancer and it behooves us, as practitioners, to keep pace with
the subject.

The educational campaigns that have been conducted by the
American Society for the Control of Cancer in the past, and
are being contemplated for the future, will tend to inform the
public as to the early signs, the proper treatment of cancer in
general, and the result of recent research. If we are to fore-
stall lay control of a program to decrease the incidence of
death from cancer, which has risen from seventh place to
second place as a cause of death within the past twenty-five
years, we must assume the leadership.

The second reason is that the American Society for the
Control of Cancer is organizing a so-called "field army” of
women, e3ch member of which will pay a dollar a year for a
membership. Seventy cents of each membership fee will be re-
turned to the state organization of the society. It is the plan
and hope of the society that the direction of this campaign, and
the expenditure of the funds received, will be largely in the con-
trol of the organized medical profession. Therefore, it is most
important that a state committee on cancer be made permanent.

The society is very anxious that an educational program, pre-
ferably over the radio, be fostered. We believe that the State

THE JOURNAL-LANCET

329

Medical Association should authorize its Committee on Cancer
to assist the Society for the Control of Cancer in this efficient
means of disseminating knowledge. There is no reason why
it cannot be conducted on an ethical basis, and there are many
reasons why the medical profession should be publicly identified
with such a program. We feel that this subject should be dis-
cussed frankly by the House of Delegates and some decision
arrived at for the future guidance of the Committee on Cancer.

Report of Committee on Military Affairs

Dr. L. B. Greene, chairman of the committee, died on May
3, 1937. Neither of the two remaining members of the com-
mittee was present; accordingly, no report was presented.

President Gerrish called for the report of the Committee on
Tuberculosis. The chairman, Dr. Charles MacLachlan, made
the following remarks:

Dr. Mac Lachlan: We have had difficulty in getting the
members of this committee together. I realize that the meetings
have been called for the State Sanatorium which is situated
near the margin of the state, so it has been difficult for the
men, who are spread all over the state, to get away in sufficient
numbers to constitute a quorum. A large committee was asked
for last year by two members of the committee, when we met in
Jamestown, on account of a feeling, which I agree with in prin-
ciple, that the committee should be large, so that every section
of the state would be included, but that appeared practically
impossible.

I opposed it because it appeared to me to be impossible to
get so many members together at San Haven. We had already
experienced difficulty. But they still clung to the idea that as
many men as possible from different parts of the state should
at some time during the year visit the state sanatorium.

While we had last year a committee of five, we had to wait
until we got to Jamestown to the state meeting to get that
number together.

I propose to the president something that perhaps might be
new in parliamentary rules of order: that if we could get a
committee of three together, in which are a membership con-
stituting perhaps nine or ten, that we might make a rule of
our own. They would constitute a majority, or at least a quor-
um of that committee. He did not think that was quite accord-
ing to Robert’s Rules of Order. However, I still maintain that
any committee, or the majority of any committee, may make its
own rules as to the number that would constitute a quorum.

Our invitations perhaps came out a little late. I grant that;
but we have been so busy in the past year up there and it was
a long winter and the roads were impassable the greater part of
the winter, so I thought perhaps we could get them on their
way to the meeting at Grand Forks; and make a date as of
yesterday for the members of the committee, not all of whom
are on the program as printed. I received notices that it would
be impossible for this one and that one to be present, so when
yesterday came, the president had agreed to come — he is a mem-
ber of every committee — and we were mighty glad to have him
come to San Haven. Dr. Paul Rowe came over, all the way
from Minot, to attend the meeting; so it happened that only
he, the president and myself were there, so according to Dr.
Gerrish’s ruling, we didn’t have a meeting; however, Paul and
I prepared a report, and we have his signature to the report so
far as it has been prepared.

Now Mr. President, I would like to have all of the members
of this committee who are present come to Room 320 in this
hotel as soon as this meeting is over, in order that we may
continue our work.

Unfortunately the names of the members of the committee
are not all on your program. They are Drs. MacLachlan,
Arnson, Williams, Woodward, Pray, Roan, Rowe, Glaspel,
Tooney, and Long. I believe I have mentioned them all and
as many of you as are present, I would like to have you meet
up there and we will continue our work. We have a partly pre-
pared report.

Mr. President, we will report at a later time, after we have
the committee meeting.

President Gerrish: I don’t know all about this Robert’s

Rules of Order; but it strikes me that in order to establish
this rule of three, you have to get a quorum together first.

May we have the report of the Committee on Fractures?

Committee on Fractures

Dr. A. L. Cameron, Minot, chairman of the committee, gave
the following verbal report:

The efforts and work of this committee have consisted in
using its influence through correspondence with different mem-
bers, and through the president, Dr. Gerrish, to arrange with
the program committee to have an outstanding speaker on the
state program on the subject of Fractures, and to that end,
arrangements were made whereby one of our leading members
of the State Medical Society, qualified on fractures, Dr. Wald-
schmidt, of Bismarck, was placed on the program. I think
that was a very happy beginning of the efforts of the fracture
committee.

I might say here, as you well know, that the American Col-
lege of Surgeons has been very active in furthering the better
treatment of fractures, through the organization of the entire
country and has made units, and has appointed chairmen in
each of the states, to carry on the propaganda of the College
of Surgeons.

Here in this state the effort has been made to have an active
member of the College of Surgeons committee in each district
society, and each component society, who himself would serve
as a medium through whom the propaganda of the College of
Surgeons would be furthered.

We have had the organization functioning in this state for
two years, and as you will note, the reports of the councillors
indicate that this work has been carried on very well; that in
most every instance there has been one meeting of the society
during the year devoted to the subject of fractures, and usually
that meeting has been very worth-while, and particularly in
these instances where outside speakers have been obtained.

The question arises in my mind, and I just offer it as a
suggestion — I don’t know whether or not it would be termed
a suggestion — that is whether or not it would not be better
to have rather than two committees functioning in this state,
(one representing the College of Surgeons and one representing
the state organization) whether it wouldn’t be much better to
combine those committees? It could be done very well without
changing the personnel of the committees.

Committee on Medical Economics

Dr. H. A. Brandes, chairman of the committee, gave the
following report:

Adverse farming conditions over a period of several years,
made worse by the disastrous drought of 1936, brought ad-
ditional problems to the committee during the year.

It became evident early in the summer of last year that a
tiemendous demand for assistance would be made upon relief
agencies by our farm population, because of the total loss of
crops over the greater part of the state. This presented a
serious problem with winter ahead and relief funds being rapidly
depleted.

The State Public Welfare Board in August, 1936 informed
us that we could no longer expect them to furnish medical
attention to WPA and Resettlement clients as had been done in
the past, owing to the increasing demands upon the County
Welfare Boards and the lack of funds.

Medical Relief Under Resettlement
Administration

This created for us a serious problem which required immed-
iate action to provide a satisfactory plan to meet the needs for
medical care to farmers on Resettlement rolls.

About this time, the Resettlement Administration recognized
the need for providing medical aid to their clients and sent their
medical director, Dr. R. C. Williams, to the state to survey the
situation and to confer with the State Medical Association.

Our first meeting with Dr. Williams took place the latter
part of August, 1936. He was much interested in the plan
then in effect with county welfare boards, and asked for a copy
of our relief plan and fee schedule. In October the state execu-

330

THE JOURNAL-LANCET

tive committee and the Committee on Medical Economics held
two meetings with him and out of these conferences the present
set-up with the North Dakota Farmers’ Mutual Aid Corpora-
tion was formulated.

The Resettlement Administration accepted, without change,
the relief plan and fee schedule which we had submitted.
Briefly, the plan and schedule of fees are the same as we had
in force with the county welfare boards, and limits medical care
to acute and emergent conditions.

Early in our negotiations, we learned that the act under
which the Resettlement Administration was created made no
provision for medical care and, therefore, no federal money was
available for payment of fees directly to the physician. There
were two ways open to secure funds — the first, through ad-
ditional or supplemental grants to the client and the physician
collects his fees from the client; and second, through a coopera-
tive agency set up by the Resettlement Administration.

It was not possible for us to secure the same arrangement
for the payment of medical bills as we had with the F. E. R. A ,
and such as exists with the county welfare boards.

Realizing it was necessary for us to take immediate steps to
obtain federal funds to provide treatment for Resettlement
clients, and to give assistance to our physicians, especially in the
smaller communities, we decided to deal with a cooperative
agency rather than with the individual client.

We felt that under the conditions that exist in the practice of
medicine in our state, and the present attitude of some of our
farmers, the physician might find it difficult to collect from the
relief client. Under the present arrangement, the physician
knows that when he treats a client he will be paid for his ser-
vices on an agreed schedule of fees, and that he will have no
collection expense.

Your committee was not unmindful of the inherent dangers
of dealing with a medical cooperative when it recommended to
the executive committee the adoption of the understanding or
agreement submitted by the Resettlement Administration. Un-
der the conditions that confronted us last fall, it was imperative
to act quickly and to accept the best plan that it was possible
for us to obtain, and in so doing we hope we have not advanced
the cause of state or socialized medicine.

It is true the articles of incorporation of the North Dakota
Farmers’ Mutual Aid Corporation are drafted along broad
lines, and if carried out, would prove vicious and far-reaching
in their effect on the practice of medicine. This is unfortunate
because we have been assured that it is not the intention of the
Resettlement Administration to exercise the powers granted in
the articles ot incorporation. As we see it, the Corporation wa»
formed to comply with the regulations of the Resettlement Ad-
ministration for the purpose of getting federal funds into out
state to provide medical care to the large farm population on
relief.

There is the remote possibility that the Corporation may
continue to operate after federal funds are withdrawn but this
is not likely to happen, because experiences with similar cooper-
atives or mutual aid societies in our state have shown that they
do not survive, because our farmers do not support them.

The understanding with the North Dakota Farmers’ Mutual
Aid Corporation was subscribed to by the executive committee
on October 19, 1936. The agreement expires at the end of
one year.

Since October of last year, bills for medical care, which in-
cludes hospitalization, drugs, dental care, etc., totaling #204,000
have been allowed, and of this sum #76,000 had been paid.

There has been some delay in mailing out the checks from
the offices of the Resettlement Administration due to shortage
of help, but this has been overcome during the past week, and
we have been promised that the physicians will receive their
checks more promptly in the future.

Dr. W. H. Bodenstab, who was appointed medical supervisor
for the Corporation upon the recommendation of the executive
committee, deserves much credit for maintaining the fine spirit
of cooperation and understanding that exists between the officials
of the Resettlement Administration and organized medicine in
our state. His duties at times are not pleasant, and he is en-

titled to our support in his efforts to keep our profession from
being placed in an unfavorable light.

We do not wish to leave the impression that it is only the
physician who takes advantage of a medical relief program.
During the past four years we have encountered very few in- ,
stances where physicians have been guilty of "chiseling.”

We know, as do the relief agencies, that too many patients
succeed in getting on relief rolls for the sole purpose of ob-
taining medical attention at reduced rates. This practice on
the part of our patients is to be condemned. The relief offi-
cials find it very difficult to prevent this abuse of the medical
relief set-up.

During the year there has been a splendid spirit of coopera-
tion and understanding with the State Public Welfare Board
and many of the county welfare boards. This has done much
to keep our relief program in force. We are especially apprecia-
tive of the many courtesies that have been extended us during
the year by the members and executive secretary of the Public
Welfare Board.

So far as we can learn, there are twelve counties in the state
employing a county physician. This is about the same number
as reported at the last annual meeting.

Mr. Lyman Baker, of the Public Welfare Board, furnished
us with some statistics which should be of interest to the pro-
fession. During the calendar year of 1936, the Public Welfare
Board of North Dakota expended for medical aid #848,829,
and of this sum #367,798 was paid to physicians. According
to the figures, relief expenditures for 1936 totaled #2,490,718,
and 34 per cent of this sum was spent for medical care. These
figures do not include the cost of relief furnished by other
relief agencies, or medical treatment provided by the Resettle-
ment Administration.

Activities Under the Social Security Act: The various health
activities provided for under the Social Security Act have been
organized and are now functioning in our state.

The public health and maternal and child welfare activities
are under the direction of Dr. Maysil Williams, state health
officer, and the crippled children and blind programs are under
the supervision of the Public Welfare Board. We would call
your attention to the reports of the chairman of the standing
committees on these various activities.

Northwest Medical Conference: The chairman of this com-
mittee attended the meeting of the Northwest Medical Con-
ference held in Chicago on February 14th of this year. In at-
tendance at this meeting were more than one hundred and
fifty physicians from the middle western and central states.

Dr. McCannel was scheduled to speak on the subject of
"Medical Care in North Dakota under the Resettlement Ad-
ministration,’’ but owing to illness the assignment was taken
over by your chairman.

The morning session was given over to a symposium for
postgraduate work. A number of state medical associations
are now providing postgraduate and refresher courses for their
members. I believe this association should take steps immed-
iately to interest itself in this field. The afternoon session was
devoted to a discussion on medical economics.

It was my impression there is not a state in the Middle West
that has a medical relief program that compares favorably with
the one in North Dakota.

Except for taxes and death, no one knows what the future
has in store for us. However, it seems that a halt must be
called to relief spending in the very near future, and when
that time comes we in the medical profession must be willing
to cooperate with relief officials to bring about a satisfactory
solution to 'our economic and social problems.

The chairman wishes to express his sincere thanks to the
members of the committee for their work during the year and
especially is he deeply appreciative of the assistance given by
Drs. McCannel and Long in accepting assignments to address
component societies on relief activities.

The committee wishes to thank Doctor Gerrish and the mem-
bers of the executive committee for the cooperation and assist-
ance given during the year.

THE JOURNAL-LANCET

331

The expenses of the committee were $132.77. All bills have
been paid by the chairman. Attached hereto is an itemized
list of expenditures.

Committee on Maternal and Child Welfare

Dr. J. H. Moore, chairman, read the following report:

In this meeting at Grand Forks, May 16-18, 1937, the North
Dakota Committee on Maternal Welfare and Child Health,
begs to submit the following report of its activities.

Following the decision of the North Dakota State Medical
Association at its Jamestown (1936) meeting, that this com-
mittee be made a standing committee of the North Dakota
State Medical Association, and that it include "Child Health”
in its title and activities, President Gerrish re-appointed the
original committee to function during the fiscal year.

Your committee would like to quote from a portion of its
report made to the House of Delegates at Jamestown last year:

"It is obvious that your state committee can function best
only as a directing agency and as a clearing house, and that the
most effective work will be done by the district societies, work-
ing in cooperation with your state committee.”

Our recommendations, in detail, were published in the pro-
ceedings of the House of Delegates and are to be found in
The Journal-Lancet, New Series, Vol. LVI, No. 8, page
422, August, 1936.

In line with this recommendation, your committee proceeded
to arrange its first obstetric seminars or refresher courses, with
the district committees on maternal welfare and child health
directly responsible for each seminar in all of the district socie-
ties visited.

After securing authorization from the North Dakota State
Department of Health, which authorization included the assur-
ance that funds would be supplied from social securiety monies
available for this purpose, your committee selected Doctor John
Urner, associate professor of obstetrics and gynecology in the
University of Minnesota, as clinician, and began the task of
arranging his schedule with the various district committees.
These seminars were conducted by Dr. Urner in Grank Forks,
Grafton, Devils Lake, Fargo and Bismarck, September 15 to 22,
1936 inclusive.

No two district maternal welfare committees followed exactly
the same plan in conducting the seminars. After the seminars
were held, a letter was sent to each participating district medical
society asking for a report from the local maternal welfare com
mittee and inviting criticisms and suggestions. Reports were
received from all and a complete report was filed with the state
health officer for forwarding to the Children’s Bureau at Wash-
ington. This complete report makes interesting reading but,
consisting as it does of some seven typewritten pages, is too
lengthy for the records of this meeting. Your committee has
the entire report in its files and would be glad to furnish it to
any delegate interested. Excerpts from it are as follows:

L "Dr. Urner chose five different obstetrical subjects, name-
ly: 'Toxemias of Pregnancy,’ 'Obstetrical Hemorrhage,’ 'Pre-
natal Care, 'Breast Feeding’ and the 'Management of Abor-
tions.’ All five subjects were exceedingly useful, and were well-
received by the members attending. The whole series acted as
a refresher course to the men who were fortunate enough to
attend.

2. "All the sessions were unique in the large number of
questions asked, and the length of discussion that followed
each paper. The concensus among the medical men seemed to
be that this was one of the most outstanding meetings ever
held here. The only suggestion would be, if possible, to have
perhaps two clinicians conduct such a seminar. This would
tend to make such seminars even more interesting. In our es-
timation, the seminar was a decided success.

3. "Our plan of meeting was to follow the obstetrical case
through to delivery, showing both the normal case and the com-
plications which must be considered. Topics presented were
handled by the local committee, and consisted of prenatal care,
toxemias of pregnancy, early hemorrhages of pregnancy, late
hemorrhages of pregnancy, and post-delivery care of the in-
fant. Cases were presented from the case histories, following
which Dr. Urner presented discussions of the topic. If there

were to be any criticism made of this meeting, it would seem
that it is rather difficult for one speaker, no matter how capable
he is, to preside at meetings conducted over two days’ time.
I would suggest that if we were to conduct another seminar,
we ask the pediatricians to join us.

4. "The meetings were conducted on a very informal basis,
which we feel encourages discussion and we feel that this result
was thoroughly achieved. Our general plan was for one of the
local committee members to present a subject in a rather brief
manner. Following the presentation of the topic, it was dis-
cussed by the attending physicians and was closed by Doctor
Urner. The attendance varied considerably. The first fore-
noon there were fifteen men present. There were thirty-five at
the afternoon sessions. Most of the men came from a consider-
able distance, going home at night and returning for the follow-
ing day, which we felt was indicative of their interest and en-
thusiasm. Although the attendance was not so marked, we
were pleased with the type of physician who manifested an in-
terest in these meetings; that is, the men in the larger towns
who do very little or no obstetrics were not in attendance, but
the men in the rural communities who do considerable obstetrics
were present and were highly interested.”

Your committee has given you these excerpts from the re-
ports of the several district committees to emphasize that we
believe this form of postgraduate instruction in obstetrics is
decidedly worth-while. They indicate how the different societies
at ranged the seminars to suit their particular desires or needs
and such individuality is to be encouraged. We believe that
the effective work of the various district committees should be
encouraged.

Interest in this form of postgraduate instruction is high, and
your committee has received requests for seminars from districts
not yet visited. Whether or not additional seminars can be pre-
sented depends largely upon the availability of funds. We are
at present attempting to work out plans for seminars in at
least three cities of the state in the very near future.

In concluding our report to you at the Jamestown meeting
we stated, "Your committee has not had time to contact all the
district societies of the state.” Nor have we yet had time to
make the personal visitations which our original program called
for. Since the last annual meeting, your committee has pre-
sented an obstetric program before the District Society at
Minot on October 29, 1936, and three members of the com-
mittee appeared on the program.

The work of your state committee would be greatly facilitated
if each district society would appoint a district committee on
maternal welfare and child health. We strongly recommend
that such be done and that such committees: (1) Sponsor ob-
stetrical programs in their own societies at stated intervals; (2)
increase case reports in obstetrics by the members; (3) foster
educational work among lay organizations such as Federated
Women’s Clubs, Parent-Teachers’ organizations and Home-
Makers Clubs, and (4) arrange for obstetric seminars or re-
fresher courses as a part of a program of postgraduate in-
struction in obstetrics for its own. members. To all of these
undertakings your state committee would be glad to lend the
fullest possible degree of cooperation.

In addition1 to eight radio talks, dealing with obstetric sub-
jects, your committee now has available radio talks on "New-
born” and "Infant Feeding.”

We have actively cooperated with the American Committee
on Maternal Welfare, Inc., and have contributed material for
publication under the auspices of the American Committee in
the Department of Maternal Welfare of The American Journal
of Obstetrics and Gynecology. The last article, dealing with
the plans of your state committee, is published in the April,
1937, issue of the above Journal.

There has been an increasing amount of correspondence and
secretarial work necessary to carry on the very limited work of
your committee thusi far, and the expense of this has, to date,
been borne privately. Coupled with this, the members of the
committee have been put to considerable personal expense in
furthering the work of the committee. It is recommended to

332

THE JOURNAL-LANCET

the state association that an appropriation be made to cover the
actual expenses of the committee.

It is further recommended that the personnel of the North
Dakota Committee on Maternal Welfare and Child Health be
increased to include one or more pediatricians, so that the child
health phase of the committee’s work can be given proper em-
phasis.

A very important field of lay education can be developed if
the various local committees on maternal welfare and child
health will furnish speakers to talk on maternal welfare and
child health problems as requested. An example of this is to
be found in the manner in which members of your state com-
mittee have cooperated with several American Legion Auxiliary
Posts during the past year in celebrating Mother’s Day. There
are many other organizations, as indicative above, which would
welcome informative talks on these subjects by members of the
medical profession.

Dr. McCannel: Carrying out the suggestion of Doctor
Moore, I think it would probably be a good thing to combine
the Committees on Maternal and Child Welfare, and Child
Welfare — the two committees would dovetail.

President Gerrish: We have had a lot of correspondence
with these two committees. We weren't able to figure out
where one ends and the other begins. We never were able to
decide why we had the two committees.

Dr. McCannel: We were trying to follow the provisions
of the Social Security Act. These both come under the Depart-
ments of Health.

Dr. Williamson: I move you that you appoint a committee,
with Dr. McCannel as chairman, to get all these things
straightened out.

Dr. McCannel: I was just making a suggestion.

Dr. Moore: I am mighty proud of this committee on Mater-
nal Welfare. These boys worked, and I will put the record
of that committee up against any other committee, unless it is
Dr. Brandes’ committee. However, don’t make that committee
too large, or we can’t get them to work.

President Gerrish: Personally, I have always been opposed
to large committees. They are cumbersome and almost im-
possible to work with. As Dr. MacLachlan says, three is
about the limit of the quorum.

Dr. Williamson: I move that the chairman appoint a com-
mittee on committees, with Dr. McCannel as chairman of that
committee, and get a couple of other fellows familiar with the
procedures. Consolidate them; appoint a committee of three.

Dr. Brandes: Second the motion. (Motion duly put and
unanimously carried) .

Dr. Graham, Devil’s Lake: I think that at this time before
we are through with committee reports, some discussion ought
to be made with regard to Dr. Brandes’ report, especially in
regard to the part dealing with the North Dakota Mutual Aid
Cooperative.

(Drs. Graham, McCannel, Long, Drew, Brandes, Fawcett,
Matthaei, R. C. Little and Ramstad informally entered into the
discussion.)

President Gerrish: On the Auditing Committee, I would
like to appoint Drs. Drew, Sorenson and Wick.

Dr. Williamson: Mr. President, I want to introduce Dr.
Grassick. ( Prolonged applause.)

President Gerrish: Dr. McCannel made the suggestion that
a medical man should be appointed on the State Welfare
Board. If this meets with your approval, I will give it to the
Legislative Committee for action to decide. (No dissenting
voice.)

Dr. Ramstad, have you a report on the re-districting com-
mittee?

Dr. Ramstad: Not at the present time. The councillors
have not met yet. We shall be glad to give you a complete
report afterwards.

President Gerrish: At the last annual meeting we had a
resolution on birth control that was tabled because of the pub-
licity it would bring about. It is the so-called Cass County
resolution. Do you have the resolution as it was read? It was
discussed quite thoroughly at the last meeting, and we put it

on the table until today.

Dr. A. P. Nachtwey: I move that we postpone it for
another year, due to the fact the A. M. A. (year 1936) had
tabled it for another year.

President Gerrish: Why not postpone it indefinitely?

Dr. Nachtwey: All right; I will so amend my motion.

Dr. Limburg: Second the motion. (The motion was duly
put and unanimously carried.)

President Gerrish: Anything on the table, Mr. Secretary?

Secretary Skelsey: There is a letter from the North Dakota
Pharmaceutical Association I received just yesterday, suggesting
affiliation with our society. I may say in this connection that
about a year ago the public relations committee entered into an
agreement with the Greater North Dakota Federation and
allied associations, looking to unity of interests. It was agreed
that our society would pay $25 a year. I am sorry Dr. L. W.
Larson is not here, because he spoke about working with the
Greater North Dakota Federation. (Reads letter from state
secretary of the N. D. Pharmaceutical Association.)

Dr. A. P. Nachtwey: I make a motion that it be referred
to the executive committee for action, and reported to the next
meeting of the House of Delegates.

Dr. Benson: Second the motion. (Motion duly put and
unanimously carried.)

President Gerrish: Another thing I would like to bring up
It seems there will be considerable amount of federal money
brought into the state for the care of syphilitics. I don’t
understand the exact set-up. I think we should have a tem-
porary committee appointed to report during the meeting this
year. There is going to be brought into the state, as I said,
considerable money, and I believe we should get an idea of what
we should do. I would entertain a motion for the appointment
of such a committee.

Dr. Fawcett: I move that the chair appoint a committee of
three.

Dr. Nachtwey: Second the motion. (Motion duly put and
unanimously carried.)

President Gerrish: I will place on that committee Drs. Lar-
son, Graham and Bowen.

President Gerrish: Another thing that I think should come
up, is the the matter of having the Constitution and by-laws
brought up-to-date and reprinted. We have not had a new
edition for many years. They are very incomplete. What
would be your pleasure?

Dr. E. L. Goss, Carrington: I move that they be reprinted.

Dr. Nachtwey: Second the motion. I think the committee
should be appointed with Dr. Williamson as chairman.

Dr. Fawcett: It was drawn up in 1919. I happened to be
one of the committee at the time. Doctor Williamson knows
more about it than any other man in the state. I think a com-
mittee of three should be appointed with Dr. Williamson as
chairman, so I move that a committee of three be appointed,
with authority to act.

President Gerrish: If they are revised, they would have to
bring it up on notice for a year or so.

Dr. Fawcett: It will take a great deal of time to do that,
and if that committee were appointed now, it would be in
shape to make a report a year from now.

President Gerrish: You may correct the Constitution and
take out things that are dead. That is not a revision of the
Constitution. It doesn’t have to be acted on by the Associa-
tion. They are not going to make a new Constitution and
by-laws.

Dr. Fawcett: I think it would be well merely to have them
revised by next year; not reprinted.

Dr. Ayeen: In the matter of changing the Constitution,
something was called to my attention today which I didn't
know before. In the old Constitution, the ex-presidents were
ex officio officers so to speak, of the House of Delegates and
Councillors; but it is omitted from this present one.

President Gerrish: Wasn’t that a typographical error?

Dr. Aylen: It must have been, because most of the ex-
presidents thought all the time they were members of the House
of Delegates.

THE JOURNAL-LANCET

333

Dr. Fawcett: We are members, all of us ex-presidents; but
if it comes to a show-down, we have no vote. We always
have voted and got up and talked more than anybody else. It
should be so stated, as Dr. Aylen says.

Dr. Fawcett: I move that a committee be appointed to
make such corrections in the Constitution as the committee
deems necessary, and be prepared to report at the next annual
meeting.

Dr. Spear: Second the motion. (Motion duly put and un-
animously carried.)

President Gerrish: I will put on that committee Drs.
Williamson, Fawcett and Spear.

Are there any special committees to report, Mr. Secretary?

Is the Auditing Committee ready with its report?

Secretary Skelsey: The Auditing Committee, as I under-
stand it, finds the reports of the Treasurer, the Secretary, and
the bill presented by the Committee on Medical Economics,
correct. The Committee on Medical Economics is allowed a
definite sum annually, and it has used a little over half.

Dr. Benson: Move that the report be accepted.

Dr. Van de Erve: Second the motion. (Motion duly put
and unanimously carried .)

President Gerrish: You all heard the report of Doctor
Cameron, chairman of the Fracture Committee, wherein he
suggested that the State Committee on Fractures, and the one
representing the College of Surgeons, be combined. What is
your pleasure about the Committee on Fractures?

Dr. McCannel: I think the suggestion is a good one. The
College of Surgeons is doing an outstanding work. Last year
to give recognition to the College of Surgeons, I incorporated
in the program the entire fracture committee of the state and
College of Surgeons.

President Gerrish: I still can’t see why we should have only
one. Why should we combine — why should we accept their
committee as ours, or they accept ours?

Dr. Cameron: The College of Surgeons have a very definite
program which they are trying to institute in this state. I can
see no reason why the state organization should not cooperate
with them to extent of accepting their committee.

Dr. McCannel: Why duplicate the work?

Dr. Cameron: That is what I say; why not have the state
committee put their stamp of approval upon the College of
Surgeons’ Committee and work in conjunction with them to
the extent of arranging programs; that is, scientific programs
and exhibits and furthering the propaganda of the College of
Surgeons in connection with the care of fractures, as far as the
hospital set-up is concerned and all those features, and while
the American Medical Association and the State Medical
Association are separate and distinct organizations, yet we arc
all in direct contact with the work of the College of Surgeons,
and we are as much in contact with that as we are with the
American Medical Association.

President Gerrish: What is the pleasure of this group:
shall we combine this committee with that of the American
College of Surgeons?

Dr. Benson: I move that we refer it to the Committee on
Committees.

Dr. Cameron: Second the motion. (Motion duly put and un-
animously carried .)

President Gerrish: Anything else to come before this meet-
ing?

Dr. Woutat: Dr. Moore in his Committee on Maternal and
Child Welfare made some suggestions regarding the perma-
nancy of that committee.

President Gerrish: That is referred to the Committee on
Committees.

Dr. Woutat: He made a further recommendation that in-
asmuch as apparently the Social Security provisions were going
to have considerable money poured in here, and prenatal clinics
possibly be established, to enable this committee to function
accurately, perhaps an appropriation should be made to cover
its expenses.

President Gerrish: That would have to go before the Coun-
cil, where finances are concerned.

We will now entertain a motion to adjourn.

Dr. McCannel: I move we adjourn.

Dr. Nachtwey: Second the motion. (Motion duly put and
unanimously carried.)

Second Meeting
House of Delegates

The adjourned meeting of the House of Delegates was
called to order at 12:30 P. M. on May 17, 1937, by President
Gerrish.

Secretary Skelsey called the roll, and there being no quorum
present, the meeting was adjourned until the completion of the
banquet and evening program.

Third Meeting
House of Delegates

The adjourned meeting of the House of Delegates was called
to order at 11:30 P. M., on May 17, 1937, by President
Gerrish.

Secretary Skelsey called the roll and declared a quorum
present. The following proceedings were had:

President Gerrish: We have a telegram from the Minne-
sota State Medical Association, which reads as follows:

"Members of the Minnesota State Medical Association extend
greetings to members at this annual meeting, and wish them
a bumper crop and medical success.

A. W. Adson, M.D., President.”

Dr. MacGregor: Have all of the societies reported this year?

President Gerrish: All except the Southern Society. It is
the first time, so far as the annual meeting is concerned, that
every one has not reported; that is the annual report. Is Dr.
Fergusson here?

Dr. MacGregor: Could we have authority to declare their
charters vacated, and then let them join another society? I
know a lot of fellows that would like to come to Cass and join
with us.

President Gerrish: I can’t imagine that it is anything like
that, that they have in mind. I think it is economic conditions.
Even the Grand Forks Society is short one hundred dollars in
its remittance; it is twenty members short. Grand Forks us-
ually remits for about sixty, and this year has remitted for
only forty-one. I suppose the Southern District is in very bad
shape financially.

Dr. Williamson: I think myself sometimes it is the fault
of the officers. I told the fellows this is a great opportunity
this year to bring in every man into the society, for the reason
it is the Golden Jubilee.

President Gerrish: May we have the rest of the committee
reports, please. The committee on syphilis: do you have a
report ready?

Dr. L. W. Larson: The committee wasn’t formally appointed;
it is merely tentative, but I believe that a committee on venereal
disease should be made a permanent committee of this society.
It is just a matter of a little time, and there will be a definite
program attempted by the State Health Department. Now I
believe that you should have a strong committee on venereal
disease to confer with the state health officer, and with the
doctor who will undoubtedly be the representative of the
Health Department in venereal disease, so that many difficul-
ties can be ironed out.

You will remember that when the Cass County delegation
or society brought in its report, it showed that that society had
had a meeting, and had appointed a committee to arrange for
a schedule of fees to be accepted by the Welfare Board of Cass
County. Now we find ourselves in the situation of having one
schedule of fees in Cass County, another in Burleigh, and
another one in Grand Forks. I believe there should be a
separate committee on venereal disease to iron out these diffi-
culties.

Dr. Williams tells me that every day they receive letters from
doctors out in the territory requesting information. How are
we going to carry out the program? Are we going to have
some one designated by the state society, or have some one
sent in by the federal government? What kind of records
shall we keep? These are some of the things to come up in
the venereal disease program.

334

THE JOURNAL-LANCET

I think the incoming president should be given authority to
appoint a committee to act as an advisory committee, with the
State Department of Health, on venereal diseases.

President Gerrish: You were the chairman of the commit-
tee, whom I appointed. You spoke about federal funds com-
ing in and we made you chairman.

Is the Committee on Committees ready to report?

Committee on Committees

Dr. A. D. McCannel, chairman of the Committee on Com-
mittees, made the following report:

I don’t know who the other members of the committee are.
However, I talked this over with a number of members of the
profession, and I beg to make this report. If you will look at
the list of the standing committees it will simplify it somewhat.
We make the following suggestions:

Leave the executive committee the same as it is; as well as
the committee on scientific program and the committee on public
policy and legislation.

Eliminate the committee on medical education.

Combine the committee on necrology and medical history.

Eliminate the committee on hospitals. It never functions,
anyway.

Leave the editorial committee as it is.

Leave the cancer survey committee as is.

Eliminate the committee on military affairs.

The committee on tuberculosis remains the same.

The committee on fractures: the state society to recognize the
College of Surgeons, with the committee on fractures as their
spokesman or representative as far as its functions in the state
are concerned.

Eliminate the committee on public relations and on early
mental diseases.

The medical economics committee is to, remain the same.

Have one committee on maternal and child welfare consist-
ing of obstetrics, and a committee on child welfare represent-
ing pediatrics.

Also leave the committee on crippled children.

We will also be very glad to add to the list of standing com-
mittees the committee on venereal disease as suggested by Dr.
Larson.

Dr. Williamson: Why not combine the two committees on
maternal and child welfare?

Dr. McCannel: We have.

Dr. Fawcett: I think it is a great mistake to cut off the
committee on medical education. The school is still running.
Perhaps we could take it off later; but not right at this time.

Dr. McCannel: I move the adoption of this report other
than eliminating the committee on medical education.

Dr. Spear: Second the motion.

( President Gerrish stated the motion, which was duly put
and unanimously carried.)

Dr. L. W. Larson, chairman Committee on P. P. & L.: If
it is in order, I would like to offer this resolution, which has
the approval of the majority of the members of the committee;
some I have not been able to contact, but I feel confident they
would approve. It is as follows:

"Whereas, so many of the problems confronting the State
Welfare Board involve the medical care of the indigent sick,
and

"Whereas, a medical physician as a member of the Welfare
Board could be of inestimable value to the Board in the solu-
tion of these problems, and

"Whereas, there is no physician on the Welfare Board at
the present time, now therefore,

"Be it resolved, that the House of Delegates of the North
Dakota Medical Association in convention assembled in Grand
Forks May 16-18, 1937, does hereby petition His Excellency,
William Langer, Governor, to appoint a medical physician to
the State Welfare Board as soon as the opportunity arises.”

Dr. McCannel: Second the motion.

Dr. Nachtwey: This committee has been quite concerned
about not having a doctor on the Welfare Board. I would
like to ask Dr. McCannel to tell us how important it is to have
a doctor on the Board, inasmuch as you have been there for

the last couple of years. What would be the results to the
profession if we have no representation?

Dr. McCannel: I will be very glad to tell you my im-
pression, being upon the Board.

(The motion was duly put and unanimously carried.)

President Gerrish called for the report of the Re-districting
Committee.

Dr. Fawcett: We thought we had this thing fixed up
pretty well at Aberdeen. This re-districting was to be left as
it is, with the perfect freedom of the men to join where they
wanted. If a doctor wants to remain a member in Cass
County, or if he wants to be a member some other place, that
is all right. I think the files will show that in 1931 we left it
elastic enough; that we don’t need to ask any society to quit,
or we won’t put any society out of business.

Dr. Skelsey read from The Journal-Lancet for 1931,
concerning the re-districting proposition.

Dr. Williamson: If you would name your councillors on a
committee, they could get together and work this thing our.

President Gerrish: I notified the Councillors and the secre-
taries; but there has been no correspondence upon the prac-
ticability of the proposition.

Dr. MacGregor: The society south of us hasn’t had a
meeting this year, and there are a number of doctors there
who would like to join our society because their society is not
active. Can we take those fellows in? They would like to
come into some place where they can attend the meetings.

President Gerrish: Why not have a committee develop a
definite specific plan and send it to the different societies and
have a vote on it, from the members of the society?

Dr. van de Erve: Tri-County voted on that proposition,
and they decided to join with the different societies of their
choice.

President Gerrish: Another way we can do is to let the
societies eliminate themselves that way, if they wish.

Dr. MacGregor: Can’t we eliminate them absolutely, when
they don’t have meetings or make a report, or their society is
not active?

President Gerrish: I presume we could.

Dr. Fawcett: Going back to the meeting of 1931 in Aber-
deen. It explains the whole situation of what we can do and
can’t do, and that has never been revoked. That is elastic
enough so that those down in Richland County can join any
society they wish. I don't think we should have any other
committee; but should go back to that plan.

President Gerrish: My idea would be this: to let each soci-
ety decide whether or not it will continue.

Dr. Fawcett: The trouble that time came up over the
Dickinson and Bismarck districts, and according to the minutes
of the meeting, in the plan we put over at that time, there was
to be no definite line. It was to be a point nearest for the
doctor. Each district was to decide who was to have that man.
If they wished to stay in the society they belonged to for years,
they could have that privilege. I don’t see the necessity of
going into the thing any more, or any more re-districting. As
for the district in Richland County, or the Southern District,
if the men say their society is dead, and that they have no
society, they can come up to Fargo or Jamestown, if they want
to join. If their records are good, let them come in.

Drs. McCannel, Williamson, Wicks and Goss spoke to some
extent on the question before the house.

Dr. Sherman, of the Southern District: As to the suggestion
made by the doctor, down there in our particular instance, it
would so weaken our society that it would have to go out of
existence. We have certain men in our district who are fairly
active now”, who would not belong to any district, they would be
so far away. An arrangement like that is simply going to
wreck our society, so we won’t have any. If it lets men in
the northern part of our district join some other district, it
leaves so few of us down along the border that it wouldn't be
worthwhile. If you make such a revision as this, you will not
have any members in your society or anything else.

President Gerrish: What is your pleasure about this re-
districting?

THE JOURNAL-LANCET

335

Dr. MacGregor: I make a motion that we table it.

Dr. Fawcett: Second the motion. (Motion duly put, and
unanimously carried.)

Dr. MacLachlan: I have endeavored to get the committee
on tuberculosis, consisting of ten members together to sign
this report, and to make any additions or corrections they might
see fit. Now I have this committee report signed by three
members of the committee. I have called meetings and have
been unable to get the members together. This is the report
of the tuberculosis committee. If you wish me to get more
signatures, I shall endeavor to do so.

President Gerrish: The committee report is accepted.

Report of Committee on Tuberculosis

Dr. MacLachlan, chairman of the aforementioned committee,
submitted the following report:

With an application for hospitalization list that at one time
during the year, May 1, 1936 to May 1, 1937 numbered 263,
and with a list of completed registration patients of about 60
to 65, that was pretty constant and somewhat equally divided
as between the sexes, the information department serving by
mail was necessarily overworked in replying to inquiries from
doctors and patients’ families as to when relief might be ob-
tained through admission.

Some relief was obtained through the cooperation of the
superintendents of the Minnesota group of county sanatoria,
particularly at Sunny Rest, Crookston and at Battle Lake,
Minnesota, where between these two alone, as many as four-
teen patients registered at San Haven were at one time or
other given competent service for months while awaiting ad-
mission here; we advised the individual or county, and they en-
tering into the financial contract which would permit this care
until opening appeared at San Haven corresponding to pa-
tients’ registered numbers.

Notwithstanding the fact that infirmary improvements in
the original unit had permitted an increase of space for thirty
additional patients in the winter of 1936, our list of applicants
lengthened; but our hope for real relief had meanwhile been
bolstered by joint action of the federal and state governments
in providing the funds for the construction and equipment of a
third infirmary unit to care for, when furnished, 123 bed pa-
tients.

The construction of this unit necessitated increased equip-
ment for power house service, not all of which has yet been
provided; but which we anticipate will be ere winter’s cold
appears.

Unfortunately, however, the last legislature failed to respond
to our appeal for increased dormitory accommodation for the
fifty or more employes that will be required to care for these
123 bed patients when the new Number Three unit is called
upon to maintain its complement of service. This increased
employe service consists first, of fifteen nurses, a dietitian, a
matron and about thirty diet kitchen and housemaids; the male
additions being one doctor and the necessary male nurses,
janitors and orderlies.

To house these forty-five females, the present nurses’ home
will care for the additional nurses; but for dormitory accommo-
dation for the others, we have been obliged to transport to the
new unit the sixteen male patients hospitalized in the Masonic
Cottage, and remodel it to some extent within to care for a
matron, a dietitian and twenty-eight house and dietary maids,
while for housing the required extra male help, we were forced
to transport eight; female bed patients from another cottage to
another new unit floor and refit the interior for the changed
service.

The institutional service will be greatly improved when the
new unit has been furnished with the equipment ordered under
contract bids, which include not only) beds, bedding and bed-
stand furniture in keeping with the general excellence of con-
struction that prevails throughout the building, with its diet
kitchens on each of four floors, all reaching by continuous cor-
ridors to the electrically-operated elevators that lead to the in-
fit mary’s general kitchen, its rotunda solarium on the roof,
and its capacious sterilizer and morgue in the sub-basement.
Institutional records contain the following facts as to surgery.

May 1, 1935
to

May 1, 1936

CHEST SURGERY

Pneumothorax refills 9,986

Aspirations 44

Phrenic exeresis

Phreniphraxis 13

Scalenotomy 0

Thoroscopy 3

Intra-pleural pneumolysis 18

Rib resection 1

Thoracoplasties 21

GENERAL SURGERY

Appendectomy 0

Cholecystectomy 0

Enterostomy 1

Abdominal exploratory 2

Nephrectomy 0

Bowel resection 0

NOSE AND THROAT

Tonsillectomies 6

Bronchoscopies 6

Superior laryngeal nerve section 1

Mastoid 0

Antrum puncture 0

Tenotomy 0

Sub-mucuous resection 0

Tracheotomy 0

GENITOURINARY

A repair of hydrocele 1

Transurethral prostatectomy 1

Lithotritomy 0

PROCTOLOGY

Injection of hemorrhoids

Rectal fistula

BONE SURGERY

Spinal fusions 0

Open reduction of dislocated hip 0

EXAMINATIONS AND TREATMENTS

May 1. 1936
to

May 1, 1937

10,822

3
11

5
43

6
1
0
0
1
1

4
2
1
1

Cystoscope

Removal of cervical polyp

Cautery of cervix

Biopsy

Incision of abscess

Intratracheal lipiodol injection

Electrocardiograms

Blood transfusions

Curretage

Drainage into lung hernia

Closed pleural drainage

Extra-pleural pneumolysis with

paraffin pack

Open lung drainage

Retrograde urography

Intravenous urograms

Physical examinations

269

274

Gall bladder series

G. I. series

Plates interpreted for outside practitioners

1225

Laboratory

Sputum specimens examined 1454

1703

Urinalyses

836

1124

Blood counts

456

696

Blood sedimentation

Wassermann

271

243

Blood sugars

Pleural fluids examined

Gastric analysis

Stool examinations

Patient population — May 1, 1937 — 295.

Institutional deaths — May 1, 1936 to May 1, 1937 — 35.
Deaths of patients already registered, but occurring in the horn
while awaiting here — 18 reported in 1936

12 reported in 1937 to Tune 8, 1937

336

THE JOURNAL-LANCET

It will be noted that the medical staff has increasingly served
members of the profession through interpretation of X-ray
chest plates and re-mailing the plates to the senders, in most
instances supplying the postage for which the state does not
make provision, and which thus in one year makes a consider-
able drain on our finances. A very few only have been attach-
ing return postage to plates mailed for such service. The staff
is glad to render the service, but return postage should be fur
nished with films mailed.

Physical Improvements of Buildings and Grounds

Marked physical improvements in buildings and grounds have
been accomplished in the past year by way of Infirmary Unit
No. 3 construction and power house already mentioned, besides
stone-bouldered road trenches for drainage, with hundreds of
tons of earth excavation and dirt removal to provide better
drainage.

It is impossible to further particularize and thus encroach on
your time and patience; however, we submit to you the state-
ment for your serious consideration that the institution, all in
all, is worthy of a special visit in order that you may personally
acquaint yourselves with the service it is capable of rendering
the state’s tuberculous, including your patients.

This is the particular reason for the superintendent’s in-
sistence from year to year, while he feels he has been privileged
to serve you and the public as its superintendent, that meetings
of your committee on tuberculosis should be held at San Haven
in order that the members have opportunity to observe its ser-
vice and disseminate the knowledge to their fellows.

Advantage has been taken of federal set-ups to project other
physical improvements in buildings and landscape, including
drainage and sewage sanitation.

(Signed) Charles MacLachlan, M.D., Chairman
C. J. Glaspel, M.D.

Paul H. Rowe, M.D.

G. W. Toomey, M.D.

W. H. Long, M.D.

W. A. Gerrish, M.D.

President Gerrish: We must have a committee on resolu-

tions. I will appoint on that committee Drs. Meredith, Sher-
man and DePuy.

Report of Committee on Secretary’s Report

President Gerrish: We have a report of the Committee on
the Secretary’s Report, which I will read.

"Your committee has read the secretary’s report, and com-
mend it to the close study of each member of the society. We
also commend the secretary for the amount of study and energy
he has devoted to the problems of this Association, and to the
preparation of this report.

(Signed:) W. C. Fawcett, M.D.

C. MacLachlan, M.D.

M. MacGregor, M.D.’’

What do you wish to do with this report, gentlemen?

Dr. MacLachlan: I move its adoption.

Dr. Spear: Second the motion. (Motion duly put and un-
animously carried.)

Secretary Skelsey: We have a resolution here commending
the state institutions:

"Whereas, it is the opinion of the North Dakota State Med-
ical Association that the state charitable institutions in Grafton,
Jamestown, and San Haven have been efficiently and economi-
cally-operated this past1 year, and that the mental and tubercu-
lous patients of the state are receiving the proper care and
scientific treatment, therefore this Association desires, in con-
vention assembled, to express to the superintendents of these
institutions their appreciation, confidence and cooperation.’’

Dr. Sorenson: I move we adopt this resolution.

Dr. McCannel: I move as a substitute, that we turn it over
to the Resolutions Committee and let them bring it in with their
report tomorrow.

Dr. Nachtwey: Second the motion. (Motion duly put and
carried.)

Dr. Brandes: I presume it is in order now to extend an in-
vitation for the next annual meeting. I have the happy privi-
lege to extend to you on behalf of the Sixth District Medical

Society an invitation to hold your meeting next year in Bis-
marck. I have a formal invitation from the City of Bismarck, |
and the secretary of the Sixth District. We have, as you know, ,
ample hotel facilities, and we would be most happy to enter-
tain vou:

"We wish to extend your organization a cordial invitation to
hold your 1938 state meeting in the City of Bismarck.

"It is not necessary for us to enter into a discussion of the
accommodations and conveniences for your satisfactory enter-
tainment at this point.

"We assure you that in the event you come here, you will re-
ceive a cordial welcome and the complete cooperation of the :
people of Bismarck in your plans to make the meeting an out- ]
standing success.

(Signed:)

Bismarck Association of Commerce, by

H. P. Goddard, Secretary.

City of Bismarck by

Obert A. Olson, Mayor.’’

"I have the pleasure of extending to you an invitation to
hold your 1938 convention in Bismarck. The members of the
Sixth District Medical Society assure you that if you accept this
invitation, they will do everything possible to make the con-
vention a memorable one.

(Signed:) L. W. Larson, Secretary
Sixth District Medical Society.”

Dr. Williamson: I move that we go to Bismarck. (Several
seconds were heard; the motion duly put and unanimously
carried.)

President Gerrish: On the nominating committee, I will
appoint Dr. Fergusson, Ramstad and Burton.

Dr. Brandes: There was one recommendation, or suggestion,
made in the Report of the Committee on Cancer in reference
to radio.

I know there are many objections to participating in radio
programs. I think if the matter is given careful attention, the
good advantages that come from radio programs would out-
weigh the disadvantages. I am wondering if some action can't I
be taken on that from year to year. I think we are missing a
fine opportunity to do some constructive work for the North
Dakota State Medical Association.

President Gerrish: I agree with you. We are missing a
good opportunity. It should be done as a society or state
association. They are doing it in Minnesota and other places.

Dr. Brandes: I think the North Dakota State Medical
Association should take some official action. We can’t carry
out this program unless you state that program here in the
state association.

President Gerrish: Will you make that a motion?

Dr. Brandes: I was going to suggest that the report be
turned over to some committee.

Dr. McCannel: I move you that it is the sense of the
House of Delegates that the radio be used in spreading infor-
mation about cancer.

Dr. Woutat: Noticing publications in the A. M. A., the
Minnesota State Medical Association, etc., radio programs
throughout the State of North Dakota, I would think, should
be broadcast with the approval of all pertinent committees of
the North Dakota State Medical Association, and if necessary,
a special committee be appointed to handle that sort of thing.

I believe it has unlimited possibilities regardless of whether it
should be controlled by the Cancer Committee, Maternal Wel-
fare or Public Relations Committees, and if given the proper
publicity, could do as much good as the work done by the
American Medical Association and the Minnesota medical
society on 'publicity, etc. I think the thing should be given due
consideration, and if necessary, a representative from each com-
mittee be put on the committee to direct this work rather than
the thing passed over and put to one committee to settle the
matter.

President Gerrish: That is a good idea. I think there are
other things involved than cancer, and the bulk of the people
arc not so much interested in cancer as they are in other sub-
jects.

THE JOURNAL-LANCET

337

Dr. Sorenson: I think, as Dr. Woutat says, this matter has
unlimited possibilities; but if we are going to leave it to each
committee to put on something, nothing will happen. There
should be a very carefully-selected committee to supervise the
broadcasting. It should be broadcast under the auspices of the
North Dakota State Medical Association. There should be a
committee appointed to handle this, and it should be a very
carefully selected committee.

President Gerrish: I think that is a good idea; possibly a
publicity committee or a public relations committee might be
established.

Dr. Brandes: Now we are going to start all over again;
however, this is a very important subject to be considered, be-
cause if you are going to spread the responsibility of giving
radio programs over a number of committees which don’t have
any technical knowledge about putting on programs, it will be
a failure. I believe the best thing would be to form a new com-
mittee on radio programs, and let that committee then get these
various committees to submit the material to them to broad-
cast. Then, and in that way, supervising them, you will have
a worth-while program.

Dr. Sorenson: I make the motion that we appoint a com-
mittee on public relations to take charge of radio broadcasts.

Dr. Brandes: Second the motion.

Dr. Sorenson: Let the committee decide on their own name.
It was the opinion of the Council that it should be subject to
the supervision of the Council or House of Delegates. If we
appoint a well-chosen committee, I think they would fulfill the
requirements.

(The president re-stated the motion, which was duly put
and unanimously carried.)

A motion was duly made, seconded and carried to adjourn
subject to call.

Fourth Meeting
House of Delegates

The adjourned meeting of the House of Delegates was
called to order by President Gerrish, at 10:30 A. M., on May
18, 1937.

Secretary Skelsey called the roll, and declared a quorum
present.

The following proceedings were had:

Dr. Williamson: Last year, you remember at Jamestown a
resolution was put through to the effect that the outgoing
president should be chairman of the Scientific Committee. I
thought it was a mistake last year, and I know it was a mis-
take. We have always had it before with three on the scien-
tific committee, with the president and secretary ex officio mem-
bers of that committee. I think we had better go back to the
old way of doing it. I make a motion that we do not approve
the minutes as far as the resolutions last year were concerned.

President Gerrish: You wish to make a motion then to re-
peal that resolution?

Dr. Williamson: I will make a motion to repeal it.

Dr. Nachtwey: Second the motion.

(The motion was duly put and unanimously carried.)

President Gerrish: Now will you make a motion as you
would like to have the scientific committee?

Dr. Williamson: I make a motion that the Scientific Com-
mittee be composed of three members of the society in whose
district the meeting is to be held, and the president and secre-
tary of the state association as ex officio members, the same way
that it was before we made the motion last year.

Dr. Nachtwey: Second the motion.

(The motion was duly put and carried.)

President Gerrish: Does the committee on syphilis have

any report?

Dr. Larson: After you decided to make a permanent com-
mittee out of that, we didn’t have a meeting, because I felt it
would be up to the incoming president to appoint members on
that committee, so we haven’t anything to report, Mr. Presi-
dent, except that I think the incoming president should select
that committee with considerable care, because there will be
some matters of policy to be decided that are quite important,
especially if the Surgeon-General of the Public Health Service

goes through with the program and gets more and more money.
We don’t know how much will be in here, and we want to
keep it in the hands of the practicing physician if we can. I
don’t think we need any more of a report than that.

President Gerrish: With that report, is it the idea that it
would be advisable to have another committee on social dis-
eases?

Dr. Larson: Make that a permanent committee. Wasn’t
that decided last night? That was approved, I believe.

President Gerrish: What report have the councillors to

make?

Dr. Williamson: We don’t have to do that; however, noth-
ing happened. We are the most peaceful and harmonious
group you ever saw. They put $200 at the disposition of the
Economics Committee for the next year, and $200 to pay some
other bills of certain committees. The secretary is to notify
them that no expenses will be paid unless authorized.

Dr. Larson: Take for instance, this committee on venereal
disease. If that committee is going to function, they will have
to have a meeting at some central point where everybody can
easily reach it. Do you want to pay their expenses, and if
they have some correspondence, will you take care of that?

Dr. Williamson: My personal idea is that if we have any
essential committee in this society which entails an expense
upon the individual member of that committee to function —
he is donating his time, so the society should be willing to pay
his necessary expense. He pays the same dues as anybody
else. Why should he travel at his own expense?

Dr. MacGregor: We can’t throw the bars down, or there
would be no limit to the expense.

Dr. Fawcett: I think it should be limited to the legislative,
executive and economics.

Considerable discussion followed concerning the advisability
of paying expenses of committee members, but no definite
action was taken.

President Gerrish: We will put Phil Woutat on the com-
mittee for revision of the Constitution.

Dr. Sherman: I have one resolution drawn up here, which
I desire to present at this time:

"Resolved that we wish to express our confidence in the
School of Medicine at the University, and in the value of its
work to the profession, and to the people of the state. Since
the appropriation made by the Legislature of 1937 will en-
able the school to correct its greatest weaknesses, we would
urge the Council on Medical Education and Hospitals to give
it favorable consideration.”

Dr. Fawcett: I move the adoption of this resolution.

Dr. Brandes: Second the motion. (Motion duly put and
unanimously carried.)

Dr. Sherman: At this time, I think it is also appropriate
that we should extend to the Grand Forks District Medical
Society our sincere appreciation for their efforts and success in
carrying out the program commemorating our Fiftieth Anni-
versary, as well as for their splendid hospitality. We also wish
to commend them for the fine scientific program, as well as
the other arrangements incidental to the state meeting.

I move the adoption of this tentative resolution, with the re-
quest that the secretary convey these sentiments to the Grand
Forks District Medical Society.

Dr. MacGregor: Second the motion. (Motion duly put
and unanimously carried.)

President Gerrish: May we have a report as to what we

are doing relative to the irregulars?

On page 234 of The Journal-Lancet, May, 1937, will be
found a detailed report on irregulars and some non-ethical phy-
sicians in North Dakota.

President Gerrish: May we have the report of the nominat-
ing committee?

Report of Nominating Committee
Dr. Fergusson presented the following report:

President: E. L. Goss, M.D., Carrington.

President-elect: W. H. Long, M.D., Fargo.

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THE JOURNAL-LANCET

First-Vice-President: H. A. Brandes, M.D., Bismarck.

Second Vice-President: C. J. Glaspel, M.D., Grafton.

Secretary: A. W. Skelsey, M.D., Fargo.

Treasurer: W. W. Wood, M.D., Jamestown.

Delegate to A. M. A. 1938: A. P. Nachtwey, M.D.,
Dickinson.

Alternate: C. E. Stackhouse, M.D., Bismarck.

Councillors:

Second District: G. F. Drew, M.D., Devils Lake.

Seventh District: P. G. Arzt, M.D., Jamestown.

Eighth District: F. W. Fergusson, M.D., Kulm.

Tenth District: A. E. Spear, M.D., Dickinson.

Dr. Nachtwey: I move the adoption of the report of the
nominating committee.

Dr. Graham: Second the motion. (Motion didy put and un-
animously carried.)

President Gerrish: There is one thing I would like to bring
before you under the head of new business. I think the work
of this Association has become so great that two days is not
enough to give to its workings. I would suggest that we do as
other state societies around are doing, have three days of fore-
noon meetings for scientific work, the afternoons for pleasure
for those who do not have to work in official bodies of the
society and for the work of the Ffouse of Delegates, Coun-
cillors, and what-not, and in that way we would not have to
race around. I think we are large enough now and should
consider seriously giving three days to it. Why not have it so
we have our programs in the mornings, and the afternoons and
evenings for pleasure and other events. When we have to
work all day we can’t half see the exhibits, and some of the
fellows are missing part of the program because they must be
on committees, in the House of Delegates, etc. I think you will
find it will agree with more of the members than you think to
put in three days. The last two or three years our official body
of the society has had an awful time to get things done in the
allotted period.

A motion was made, seconded and carried that the meeting
adjourn.

* * * *

The following committee reports were received subsequent to
the annual meeting.

Crippled Children’s Committee

Dr. H. J. Fortin, Fargo, chairman of the foregoing com-
mittee, submitted the following report:

In North Dakota there has never been a state-wide crippled
children’s program. The needs of the crippled child have been
left chiefly to several philanthropic organizations. Some of the
work has been done in North Dakota, but the majority has
been done in the other nearby states and Canada.

Under the Social Security Act, it enables each state to care
for its crippled children, especially in the rural and urban
areas suffering from economic distress. This includes diagnostic
clinics, medical, surgical and corrective services, also hospitaliza-
tion and after care of the crippled child.

Under the Public Welfare Board, a Children’s Bureau was
established and an advisory committee was appointed to act in
an advisory capacity. The committee consisted of the following:
Drs. Maysil Williams, J. C. Swanson, H. A. Brandes, A. D.
McCannel, and H. J. Fortin.

This committee had two meetings at Bismarck the past year,
at which time the type of crippled child, and services to be
rendered were taken up. There are certain specifications laid
down in the Social Security Act, which must be followed by
the states.

Up to May, 1937 five diagnostic clinics have been held at
Williston, Dickinson, Devils Lake, Mandan and Minot. There
were about 800 children examined at these clinics. There will
be five more diagnostic clinics at Bismarck, Grand Forks, Val-
ley City, Jamestown, and Fargo.

A complete report will be ready at the next meeting, after
all of the children are examined. This will then give some
idea as to the number of children crippled and the types of

deformities found. This is all being tabulated under the
Children’s Bureau, Bismarck, with Miss Theodora Allen in
charge. Any information regarding this work and those en-
titled to treatment can be obtained from the Children’s Bureau.

H. J. Fortin, M.D., Chairman

Committee on Child Welfare

Dr. J. L. Conrad, Jamestown, chairman of the committee,
submitted the following report:

The committee had difficulty in determining its functions,
and in securing contact with the state department of health.
After the return of Dr. August Orr to the state, we held two
conferences with him and one of our members, Dr. Brandt, j
conferred with Dr. Williams, as did Dr. Pray later.

At a meeting of the committee, it was decided that we
arrange for a series of seminars to be held in the larger towns
of the state. The State Department of Health informs us
that there is enough money on hand to finance these meetings.

For these meetings, it is planned to bring into the state
some outstanding pediatrician who will hold a seminar for one
day in each of the eight larger towns of the state. It is hoped
that at those meetings we can have a majority of the men in
that vicinity attend.

It is planned to begin these meetings as soon as the necessary
arrangements can be made.

J. L. Conrad, M.D., Chairman

Committee on Necrology

Dr. James Grassick, Grand Forks, chairman of the com-
mittee, submitted the following report:

As we pay this, our tribute of remembrance to those of our
number who, since last we met, have ceased from labor and are
at rest, hope holds aloft the torch that lights the way, while
love tenderly whispers, this earth may not be all.

An obituary notice of Dr. August Eggers, a past president
of our Association, who practiced in Grand Forks, for over
forty years, appeared in the November, 1936 issue of The
Journal-Lancet, and of Dr. John E. Engstad, an early secre-
tary of the Association, who practiced in Grand Forks for
fifty-two years, in The Journal-Lancet of April, 1937.

HENRY J. LEIGH
1866 — 1936

Dr. H. J. Leigh was born at Millidgeville, 111., June 6, 1866,
and died at Grand Forks, N. D., October 22, 1936. He was
graduated from Bennett College of Eclectic Medicine and Sur-
gery, Chicago, Illinois, in 1891, and was licensed in North
Dakota, January 4, 1924. He had practiced in Sebula, Iowa,
Fort Dodge, Iowa, Carrae, Iowa, and in Lakefield, Minn. He
came to North Dakota in 1924, located at Tower City, and
there continued to practice his profession until shortly before
his death. Dr. Leigh was a fine type of the family physician.

He went in and out among his patients, counseling, directing,
helping; and was beloved by them all. Forty-five years of con-
tinuous faithful practice in the healing act, entitles him to a
place among the favored pioneers. His son, Dr. Ralph E.
Leigh of Grand Forks, is a worthy representative of the pro-
fession and of his honored sire.

HENRY A. OWENSON
1884 — 1936

Dr. H. A. Owenson was born November 11, 1884 in Iowa.

He received his literary education in the schools of his native
state and his medical training in Keokuk, Iowa. He later took
graduate work in Chicago. He was licensed in North Dakota
in 1906, and began practice at Deering, N. D. He later
practiced his profession at Alhambra, California, and in 1928
returned to Minot where he remained for three years, and then
moved to Arnegard where he resided until his death in Sep-
tember, 1936. Dr. Owenson was prominent in local affairs, as
well as in his profession, and supervised his own private hos-
pital at Arnegard. During his later years he was in ill health
and became despondent. While in this condition, he lost his
way amid the mists of life and quietly passed away at his home
in Arnegard.

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339

ALEXANDER KENNETH BLAIR

1880 — 1937

Dr. A. K. Blair was born in Quebec, Canada, in 1880, and
passed away of pneumonia at Hampden, N. D., January 2,
1937. He received a classical education and was graduated in
medicine from McGill University in 1903. He was licensed
in North Dakota in 1912. He practiced his profession respec-
tively in Hampden, N. D., Winnipeg, Man., Minnewaukan,
N. D. and again at Hampden, N. D. Dr. Blair was of
English, Irish and Scottish extraction, and was a splendid type
of the cultured professional gentleman.

He was held in the highest repute as a physician and be
loved for his many sterling qualities of mind and heart by
those who had the pleasure of his acquaintance. If at times
his genial nature swayed his way of life, he never lost his in-
born dignity, and bearing of refinement. Personality shines
through the most perfect of disguises, and Dr. Blair main-
tained his fine sense of propriety to the end.

PHILIP GRAHAM REEDY

1881 — 1936

Dr. P. G. Reedy, born 1881, died at Lisbon, N. D., in 1936.
He was a graduate of the College of Physicians and Surgeons,
University of Illinois, 1910, and was licensed in North Dakota
on July 4, 1913. He practiced for a time at Casselton and
later removed to Lisbon, where he remained until his death.

LOUIS W. MYERS
1881—1937

Dr. L. W. Myers was born in Illinois in 1881, and died at
Los Angeles, California, April 3, 1937. He was graduated in
Chicago in 1905 and was licensed in North Dakota April 12,
1906 as from Bottineau County. After practicing in the state
for ten years, he went to Europe, where he remained nine
months, and made a special study of eye, ear, nose and throat.
On his return he located at Fargo, and was associated with
Dr. Axel Oftedal, and later with the Dakota Clinic. He
moved to Los Angeles, California about seven years ago, where
he remained until the time of his death. He leaves a wife
and three children to mourn his passing.

JOSEPH T. NEWLOVE
1867 — 1937

Dr. J. T. Newlove was born in Ontario, Canada, December
16, 1867, and died at his home in Minot April 6, 1937. He
graduated from Detroit College of Medicine and Surgery in
1896 and was licensed in North Dakota the following year.
He practiced his profession in Towner for many years and did
pioneer work among the settlers in the Mouse River Loop
District. In 1902 he moved to Minot where he remained until
the time of his death.

Dr. Newlove was highly regarded as a family physician
alike by patients and professional associates. He held many
positions of trust, and acquitted himself well in them all. He
was elected president of his local medical society, was a director
of the Pioneer Life Insurance Company, and served on the
Minot Park Board for more than twenty years. The Roose-
velt Zoo was his hobby, and much of its success was due to
his personal supervision. His body was laid away at Towner
among his associates and friends of early days.

LEE B. GREENE
1881—1937

Dr. L. B. Greene of Edgeley, N. D., was born at Valparaiso,
Ind., April 4, 1881; and came with his parents to the Terri-
tory of Dakota in the following year. It will thus be seen that
he was a pioneer in the land where he did his day’s work at a
very early age. He passed away in a St. Paul hospital May 3,
1937. Dr. Greene received his schooling at the Sheldon
schools, and at the N. D. A. C., where he received his
Bachelor of Science degree in 1901. He was graduated in
medicine from the University of Michigan in 1905, and served
his interneship at the Northern Pacific Hospital at Brainerd,
Minn.

He began the practice of medicine at Monango, N. D., later
removing to Edgeley, N. D., where he remained until the time

of his death, less the time spent in the Army during the
World War. In July, 1917, he enlisted in the Medical Corps,
was commissioned first lieutenant at Camp Cody, transferred
to Camp Dix, and sent overseas to become battalion surgeon
in the First Division with the rank of captain, serving through
the Argonne offensive in that capacity. He received honorable
discharge April, 1919; but retained the rank of major in the
medical reserve.

Dr. Greene was public spirited, and took an active interest
in community welfare activities, as well as in state and national
affairs. For two terms he served his city as mayor. He was
a member of the executive committee of Camp Grassick, and
an enthusiastic worker for that institution. He was for a
tetm of three years a member of the North Dakota State
Medical Examining Board. He was organizer and commander
of the medical detachment of the North Dakota National
Guard. He served in high departmental offices of the Ameri-
can Legion and was active in promoting its welfare.

His body was laid to rest with full military honors at
Sheldon, N. D. In the passing of Dr. Greene, the profession
loses an honored member, the country a loyal veteran of the
World War, society an aggressive worker for the public good,
his associates an engaging comrade and a fast friend, and his
family a devoted husband and father.

Public Health Committee

The following report was submitted through the mails by
Dr. Maysil Williams, chairman, subsequent to the annual
meeting:

When this committee reported at your last meeting, the
theme of the discussion was: "What could be expected from
the Social Security Act in improving public health activities
throughout the state?” Since that time, the social security
program has been started, and a brief review of the public
health activities of the year is in order.

The Public Health Department program will be discussed
in reference to State Health Department activities, and the local
health department activities.

In order to qualify for an allocation of funds under Titles
V and VI of the Social Security Act, it was necessary for the
State Health Department to provide as a minimum on a full
time basis the following services:

1. A qualified full time state health officer.

2. Adequate provision for the administrative guidance of
local health services.

3. An acceptable vital statistics service. This should include
an approved plan for the registration of births and deaths and
the prompt forwarding of information thereto, to the Public
Health Service.

4. An acceptable state public health laboratory service.

5. Adequate services for study promotion and supervision of
maternal and child health.

6. Special services for the study, promotion and guidance
of local activities for the control of preventable diseases and
health promotion. This should include an approved plan for
the collection of reports of notifiable diseases and the prompt
forwarding of information relative thereto, to the Public Health
Service.

7. Services for the study, promotion and supervision of en-
vironmental sanitation.

The State Health Department in accepting financial assistance
under the Social Security Act is expected to foster the develop-
ment of satisfactory local health service. Allotment of funds
for the establishment or maintenance of city, county or district
health services are made only when the basis principles of or-
ganization in a community are met, namely, the public health
services of the city, county or district shall be under the direc-
tion of a full time health officer, and when the personnel in-
cludes in addition to the full-time health officer such officers
and clerks as will insure at least a minimum of effective health
service commensurate with the population and health problems
of the area concerned.

In order to fulfill these requirements, certain additions had
to be made to the State Health Department personnel.

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THE JOURNAL-LANCET

1. Division of Child Hygiene and Public Health Nursing.

On July 1, the Division of Child Hygiene was re-established

with Dr. August C. Orr as director of the division, and Miss
Cecilia Eyolfson as supervisor of public health nurses. Miss
Cecilia Eyolfson resigned in October, and was succeeded by
Miss Margrete Skaarup. Dr. Orr was a trainee at the Harvard
School of Public Health from September until February. Itiner-
ant pre-school conference work in rural areas was resumed with
the re-establishment of the division.

During the year, the North Dakota Committee on Maternal
Welfare and Child Health of the state medical society organized
and conducted four seminars on obstetrics for the physicians in
the state. Dr. John Urner, of the University of Minnesota,
was the lecturer. These refresher courses were free to the
physicians of the state and all expense was borne by the State
Health Department.

2. Division of Preventable Diseases.

On September 1, Dr. J. A. Cowan, of Flaxton, was appointed
epidemiologist, and spent three months in the School of Public
Health of the University of Minnesota, returning January 1,
1937, after attending the Conference on Venereal Diseases
called by Surgeon-General Parran in Washington, D. C.,
December 26 to 31.

The distribution of free drugs by the State Health Depart-
ment for the treatment of syphilis was begun January 1. These
drugs are available to all licensed physicians in the state upon
application and the reporting of the case. The organization
of the V. D. program for the state is awaiting the appoint-
ment of a committee from the State Medical Association to
act as an advisory committee to the State Health Department
in formulating plans for North Dakota. Toxoid for diph-
theria immunization, smallpox vaccine, typhoid vaccine and
Mantoux test material, are available free to the physicians of
the state upon application by physicians. The services of the
state epidemiologist are available for investigations in any of
the communicable diseases, including the venereal diseases,
upon the request of a physician through the local county or city
health officers.

3. Division of Laboratories.

The twq public health laboratories at Bismarck and Grand
Forks had some changes and additions to the personnel.
Harriet Bixby, B.A., M.D., replaced A. W. Ecklund, M.S., in
the Bismarck laboratory and Edwin Wicks, B.S., M.S., replaced
K. W. Riley as assistant to Melvin Koons, M.S., in the Grand
Forks laboratory. Additional personnel in the way of tech-
nicians and stenographic help have been added during the
year. The replacing of considerable old equipment in both
laboratories with modern equipment has added much to the
efficiency of the laboratory service, although the Bismarck
laboratory quarters are inadequate for efficient service at this
time.

4. Division of Sanitary Engineering.

In the Division of Sanitary Engineering, two engineers were
added to the staff, and were given special training at the Uni-
versity of Minnesota. One of these engineers devotes his time
to milk sanitation.

5. Division of Vital Statistics.

The demands upon the Division of Vital Statistics have more
than doubled during the year, due to the organization of many
federal programs where birth certificates and vital statistics in-
formation are required.

6. Local Health Service.

Budgets for the North Dakota State Health Department
have never included financial assistance for local health work.
The bulk of the funds available through social security have
been intended to improve local city, county or district health
service. Progress in local health work during the past year has
been slow for various reasons. The laws of North Dakota
make no provision for the combining of local part time county
and city health services into full time country or district health
services. No one county or city in North Dakota with the ex-
ception of Cass and Fargo, Ward and Minot and Grand Forks
and Grand Forks City, has a population or financial resources

that would warrant a full-time county or city health department
at this time. The minimum full-time unit recommended at this
time includes one full-time health officer, one to three public
health nurses, depending upon the population, a sanitary en-
gineer and a clerk. Familiarity with the problems of the state
has convinced us that district health units will be most practical
at this time. A district to consist of several counties with a
full-time health officer in charge, a sanitary engineer and a clerk
in the district office, with a public health nurse in each county.
The present part-time local health officers would function as
at present under the district plan.

Permissive legislation for the organization of full-time county
or district health departments was necessary, and S. B. 187
was introduced at the 1937 legislature; however, opposition
from the anti-medical forces were successful in killing the bill.
This was a decided handicap to the development of local
health service for the next two years. Local participation in
administration and financial support are necessary for the suc-
cess of any full time county or district health service. It is
needless to state that financial participation has been well nigh
impossible in many counties due to conditions incident to
drought and economic distress, although during the year 17
counties organized public health nursing services and provided
some financial support.

After reviewing the activities of the year the committee
recommends the following:

(a) The appointment of a committee from the State Medical
Association to act in an advisory capacity to the State Health
Department in formulating the venereal disease program for
the state.

(b) A careful consideration by the State Medical Associa-
tion of legislation to improve local and state public health ser-
vices.

(c) Interest in knowledge of guidance for and participation
by every member of the state medical society in all local public
health activities in their respective communities.

Respectfully submitted,

Maysil M. Williams, M.D.,

Chairman.

B. S. Nickerson, M.D.

D. W. Matthaei, M.D.

E. G. Sasse, M.D.

PROCEEDINGS OF THE COUNCIL OF THE
NORTH DAKOTA STATE MEDICAL
ASSOCIATION
1937

First Meeting
Monday, May 17

The first meeting of the Council was held in the Dacotah
Hotel, Grand Forks, and was called to order by Secretary
Williamson.

Members present: Drs. Ramstad, MacGregor, Wicks, Soren-
sen, Drew, Spear, Crawford, Williamson.

Owing to the death of Dr. L. B. Greene, president, Dr.
MacGregor moved, seconded by Dr. Wicks, that Dr. N. O.
Ramstad act as president, and that Dr. F. W. Fergusson, Kulm,
act as councilor to fill the vacancy caused by the death of Dr.
Greene. Carried.

Minutes

Moved by Dr. Crawford, seconded by Dr. Spear, that min-
utes of Council as published in The Journal-Lancet, August,
1936, be approved and adopted. Carried.

Report of Auditing Committee

Drs. Drew and Wicks reported that they had examined the
accounts of the treasurer, W. W. Wood, and found them to
be correct. Treasurer’s report attached.

A motion was duly made, seconded and carried unanimously
that the report be accepted and filed.

Moved by Dr. Spear, seconded by Dr. Sorenson, that an
amount not to exceed #200 be allowed to both the Economics
and the Public Relations Committee for the ensuing year;
carried unanimously.

THE JOURNAL-LANCET

341

Moved by Dr. Drew, seconded by Dr. Crawford, that Secre-
tary Skelsey be instructed to notify the chairmen of all com-
mittees that no expenses of any committee will be paid unless
authorized by this council. Motion carried unanimously.

Report of Committee on. THE JOURNAL LANCET

Moved by Dr. MacGregor, seconded by Dr. Fergusson that
The Journal-Lancet be continued as official organ of this
Association for next two years, as per former agreement, and
that we commend the editorial staff and the publishers for the
high type of papers and editorial comments appearing regular-
ly. Carried unanimously.

Moved by Dr. Crawford, seconded by Dr. MacGregor, that
President Ramstad and State Secretary Skelsey be a committee
to select the editorial staff from this association, to the staff of
The Journal-Lancet. Motion carried unanimously.

Resolution in re Lee B. Greene, M.D., Deceased

The following resolution was prepared and presented by
Drs. MacGregor and Sorenson, and adopted:

"WHEREAS, it has pleased Divine Providence to remove
from our midst our respected and beloved co-worker. Dr. Lee

B. Greene, president of the Council, and

"WHEREAS, his wise council will be missed and the
friendly greetings are no more,

"THEREFORE, BE IT RESOLVED, that this Council
feels that it has sustained a great loss in his passing, and that
we extend to members of his family our sincere sympathy, and
that a copy of this resolution be spread upon the minutes of
this meeting.”

President Ramstad reported that Dr. H. A. Wheeler wished
to appear before the Council as regards his non-admission into
the Sixth District Medical Society.

Dr. Wheeler was invited to appear at Council meetings and
ocate his case.

Dr. Wheeler stated that he was associated with Dr. Spielman,
Mandan, in a loose-group arrangement, and presumes that
this Association had something to do with his non-admission;
that he had applied for membership in the Sixth District
Society, and had failed of election; that he desires to be a
member in order that he might hold membership in the State
Association.

Moved by Dr. Sorenson, seconded by Dr. Spear that Dr. C.

C. Smith and any other members from the Sixth District be in-
vited to appear at Council meeting for questioning re this com-
plaint. Motion carried.

A motion was duly made, seconded and carried that the
meeting adjourn until the following day.

* * * *

Second Meeting

When the Council re-convened at 11:30 A. M., Tuesday,
May 18, all members were present, and the following pro-
ceedings were had:

Moved by Dr. Sorenson, seconded by Dr. MacGregor, that
no action be taken at this time in re complaint of Dr. Wheeler
in his appeal re action of the Sixth District Medical Society,
on account of insufficient evidence. Motion carried.

Moved by Dr. MacGregor, seconded by Dr. Crawford, that
the usual amount of #200 be given the Grand Forks Medical
Society to assist in paying expenses of meeting. Motion
carried.

Election of Officers

Moved by Dr. Wicks, seconded by Dr. Sorenson, that Dr.
N. O. Ramstad be elected president. Carried.

Moved by Dr. MacGregor, seconded by Dr. Fergusson, that
Dr. G. M. Williamson be elected secretary. Carried.

There being no further business, the Council adjourned.

George M. Williamson, M.D.,

Secretary

N. O. Ramstad, M.D.,

President

PROCEEDINGS OF THE GENERAL MEETING
of the

NORTH DAKOTA STATE MEDICAL
ASSOCIATION
1937

First Day

Monday, May 17 — Morning

The first general meeting was called to order at 9:00 A. M.,
at the High School Auditorium, with the president, Dr. W. A.
Gerrish, presiding.

Dr. W. A. Wright, of Williston, read a paper on the
"Treatment of Burns,” with a demonstration of the rapid
tanning method by natural color motion pictures.

"Problems in Diagnosis and Treatment of Gastro-Intestinal
Hemorrhage” discussed by Dr. D. C. Balfour, of Rochester,
Minn., using in connection therewith some slides.

Dr. H. M. Berg, of Bismarck, with the use of slides and
manuscript, gave an interesting discussion on "Treatment of
Cancer in Sweden.”

Dr. George A. Williamson, of St. Paul, in an interesting
manner presented a paper and slides on the subject "Fractures
of the Spine.”

President Gerrish: We will now have our special Golden

Jubilee program, under the direction of Dr. Grassick.

This being the Fiftieth Anniversary of Organized Medicine
in North Dakota, the local Committee on Program, of which
Dr. G. M. Williamson was chairman, was of the opinion that
some fitting recognition of the occasion should be given. Acting
on this suggestion Dr. Williamson arranged a program for a
special hour, with Dr. James Grassick in charge. The following
is the outcome.

Golden Jubilee Program

Dr. Grassick: It is very appropriate indeed that we should
hold our anniversary program in such a beautiful temple of
learning, and around an altar that has been dedicated to the
quest for truth. Music is one of the cultural arts that is always
appropriate, for it speaks a common language, and we are very
happy indeed to have with us the Centralian Singers of the
City High School, who will favor us with some numbers. It
gives me pleasure to present them. (Several selections were
rendered.)

I believe you will agree with me that this makes a very fine
setting for the program that is to follow. These sweet young
voices, as yet unmarred by life’s activities, bring to us all,
lessons of hope, cheer, and inspiration.

The profession of medicine is not hedged within narrow or
conventional bounds. It fraternizes with all of the learned
professions. It regards the whole domain of human knowledge
its legitimate field from which it feels free to cull for the relief
of suffering, the prevention of disease and the prolongation of
life. The president of our State University, Dr. J. C. West,
has very graciously given of his time to be with us for a word
of inter-professional greeting. We appreciate this courtesy and
have pleasure in presenting Dr. West, of the University.

Dr. West: Mr. Chairman and Assembled Physicians:

Simply enough, it falls to me, a member of no profession
but with access to all, to bring you the greetings of the pro-
fessions other than your own. They have watched the medical
profession and have been struck with its accomplishments. It
may be that they view them from a different angle or point
of observation than do those within your own profession.
Possibly the outstanding thing they have noticed, apart from
the purely technical aspects of your profession, is your con-
tinued struggle against ignorance and error, which is but adop-
tion and application of the true University Spirit. It is gratify-
ing indeed to observe that the medical profession has in recent
years become truly professionalized.

So in bringing greetings, we do not ignore nor do we min-
imize the tremendous accomplishments of a technical nature;
but we do admire and congratulate you upon your seeking the
professional attitude. A true profession must be in control of
its education; a true profession must be in control of its ethics;

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and a true profession must have control not only of the ad-
mission to practice in the profession, but must also have cor-
rective machinery whereby it may discipline the person that
falls from the code of ethics established by the profession. On
all three of these tests the medical profession is outstanding,
and it is because of the control of these three elements that it
is able to make the progress that we know it has made, and
to promise even greater progress in the future.

And so I bring you greetings, good wishes, fellowship, fra-
ternity, and a prediction of further progress along your own
lines. An eminent statesman once said in dedicating a monu-
ment: "We must dedicate ourselves to the unfinished work.”

I wish I had time to point out some of the unfinished work
for your profession, as seen from the other professions. Time
forbids this and I can only hope that you will share with me
the belief, that this ceremony is not a ceremony in which we
look over our shoulders and think of the things we have done,
and think of closing the books saying, "There is nothing else
to do,” but rather, a dedication supported by fifty years of
splendid service, looking to the next fifty years, to other ac-
complishments, to other services rendered to humanity, and
to new scientific investigations, observations, and practices. And
that, Mr. Chairman, is the thought I have in speaking for
and representing all of the professions, wishing you well and
starting you out on the second half century of your organiza-
tion, representative of a most honorable profession. I thank
you.

Dr. Grassick: We are very happy indeed and honored as

well to have with us Mrs. A. W. Ide, wife of Dr. A. W. Ide,
chief surgeon of the Northern Pacific Railway, of St. Paul, and
daughter of Dr. J. G. Millspaugh, our first president and the
founder of our organization. She has come all the way from
St. Paul, to pay tribute with us, to our fellows of pioneer days.
She is to read extracts from her father’s presidential address
delivered at the first meeting of our Association after state-
hood. Nothing could be more appropriate, for they will show,
as nothing else can, the calibre of this man whom we all honor,
his far-sightedness and his practical idealism. It is with much
pleasure that I present Mrs. A. W. Ide.

Mrs. Ide: Dr. Gerrish, Dr. Grassick, Members and Friends

of the North Dakota Medical Association:

Because of my father’s activity in this organization many
years ago, I feel that it is a great privilege and honor to be
asked to represent him here at this time.

Modesty was one of his virtues, but I am sure he would have
deeply appreciated the tribute paid him today. He followed the
fortunes of this state, particularly those of his fellow prac-
titioners, and he would be proud, were he here today, of the
standards and achievements of this group.

Dr. Grassick deserves, and has had much credit and praise
for his book on North Dakota Medicine, which he published
some ten or twelve years ago, shortly before my father’s death.
As a result of his efforts, much interesting material has been
preserved.

I shall read in part from my father’s address as the first
president of this society.

"Fellow Members of the North Dakota Medical Society:

"Deference to a time-honored custom is my apology for a
few remarks on this occasion.

"My first sentiment is one of gratitude to the members of
this society for the high honor of being named to preside over
your deliberations. Allow me to express my appreciation of
your actions and to indulge the hope that the confidence thereby
implied has not been entirely misplaced.

"This society germinated a few years ago, during the terri-
torial regime, by a fortuitous concourse of medical atoms, or
if you please, in accordance with the evolution hypothesis, in
response to a genuine want, a desire for professional associa-
tion on the part of a number of medical gentlemen in North
Dakota. It was felt that no county or mere local society except
in two or three instances could supply this want. To whom the
inception of the idea was due, I am unable to state. (The
modesty of the man! — Ed.J It certainly was not novel and is
of no interest to us in this connection. However, the gregarious

instinct seems to have been the dominating one, and it is hoped
no baser sentiment will obtain the ascendancy until the nu-
merical idea, at least, has been fully evolved.

"It is, of course, too early in our career to indulge in a retro-
spect or offer a prediction, but I must venture to observe that
when we view our present condition and take into consideration
the many obstacles incident to our situation, and compare it
with the throes attending the birth of similar organizations in
the other states, it seems to me that we have reason to conclude
that both mother and child are doing well. The attendance and
interest in this meeting are gratifying indications of a zeal and
determination on the part of the profession to sustain this or-
ganization. It seems to me that we are emerging from the
woods, from the crucial period in our history; that the omens
are favorable; that the work so far accomplished, though small,
may be pronounced good.

"This society, the profession, and people of the state, and
especially those gentlemen of the profession who were members
of our recent legislature, are to be congratulated that our new
state starts out upon its career with a law regulating the prac-
tice of medicine, equal, if not superior in tone and efficiency to
anything that has yet been enacted. In this connection, too, it
gives me great pleasure to acknowledge the valuable assistance
of Doctor Arthur Sweeney, secretary of the Minnesota State
Board of Medical Examiners, and Dr. John F. Fulton, of Saint
Paul, in the original draft of this instrument.

"But while we thus congratulate ourselves upon the posses-
sion of so excellent and powerful an instrument for good, we
must not forget that the duties and responsibilities incident to
its proper execution rest with our profession, and if we do not
bring to the task a sufficient measure of ability and character,
the blame and disgrace of failure will also rest with us.

"Our worthy governor, in deference to our wishes and in
keeping with his excellent judgment in other matters, has kindly
consented to consider nominations from this society for the
Board, whose duty it will be to enforce the provisions of this
law. This is as it should be. I hope and trust that our action
in this particular will be broad-gauged and such as to dem-
onstrate its wisdom, commending itself to our chief executive,
and thus establishing a valuable precedent.

"A celebrated writer has said that 'whatever tends to elevate
a profession so important as is ours to the welfare of humanity,
necessarily contributes to the benefit of society and the state.’
The relation of cause and effect, as here stated, is, I believe, often
unappreciated or lost sight of by our own number, and very
seldom, if ever, properly recognized by the public. As busv
practitioners, occupied with the routine of our art and en-
grossed with the details of scientific study, we forget that we
have a duty to perform to that profession that has done so
much for us. Let us bear in mind that whatever we can do
towards sustaining this Act, toward securing its wise, firm and
impartial administration, will react through the added dignity
and usefulness of the medical profession of this state, upon our-
selves, and those we serve.

"The direct and only object of this law should be the eleva-
tion of the standard of the medical profession. It is hoped that
no party ambition, unseemly strife, or any other base considera-
tion will permit us to lose sight of this idea.

"The subject of medical ethics is one that this society has
not yet grappled with in a formal way. This is one like the
tariff and civil service in politics, always with us and about
which much is said, but little done. It is one over which, in-
deed, in later days the fiercest battles have been fought, upon
which the most diverse opinions have been held, and about
which the public will not concern itself. I implore your clem-
ency for opening this Pandora’s box in your midst.

"This intensity of feeling, however, is an evidence of the
great importance of the subject to us. Indeed, without regard
for its dictates, all professional spirit and community of interests
as students of science would cease and our calling be reduced
to the level of a trade or vocation.

"Thanks to the ennobling tendency of our study and work,
our profession has been blessed with the most illustrious ex-
amples of men with whom the personal element has been sup-

THE JOURNAL-LANCET

343

pressed and whose lives were devoted to the upbuilding of their
art. This moral development of our profession has always
been a purely spontaneous one, and that, too, in the face of
the fact that the economic or material interests of the individual
has always seemed to be in the opposite direction. Many are
inclined to think that this developmental tendency is so spon-
taneous and contagious that the principle of the golden rule
is all that is necessary to guide us in relation with one another
and the public. If all were indeed actuated by that principle
this would be true. If this were practicable, in our case it
would be solved and all law and governmental restraint would
be superfluous.

"It seems to me on the other hand that the crowding of the
profession at the present day and the material struggle incident
thereto necessitates a refinement of ethical conduct not demand-
ed or dreamed of in earlier times. And so, too, in a new and
sparsely settled, free-for-all country like this, where two or
three, or at most a dozen medical men are perforce brought into
professional contact and business association, without any regard
to congeniality or compatibility, and having 'different views as
to what may be proper and honorable conduct, it seems to be
especially important that there should be some standard fixed
by the profession which would serve as a guide in our more
important relations.

"Gross breaches of professional ethics among educated men
are, I believe, becoming more and more uncommon. This is
due, undoubtedly, to an improved educational standard, the
more exact nature of our science and practice, the more rapid
diffusion of knowledge through our periodic literature, bring-
ing all nearer to the same level of intelligence, to a more just
appreciation of the true office of the physician on the part of
the laity, and especially to the emphasis that is placed upon this
subject at the threshold of our career in the teaching of the
schools.

"As evidence of the improved ethical sentiment and practice
throughout the world, we may note the tone of the medical
press, manifested over the organic act of the American Medical
Association, and broad, markedly, in the ethical resolutions
passed last year by the Congress of German Physicians, in
which are reprobated every kind of public laudation, whether
proceeding from the physician himself, or others, all attempts
to intrude upon the practice of another, especially on the part
of a substitute or consultant, all underbidding in concluding
contracts with sick societies or public institutions, the ordering
of secret remedies, disparaging remarks about another physi-
cian, and in which are laid down ethical directions in regard
to the giving of expert testimony where the good name or rep-
utation of a brother physician is involved.

"While, as I say, it is encouraging to observe these evidences
of improved moral tone and just dealing amongst our fellows,
yet as the professional conscience becomes more enlightened, the
demands become more refined and exacting. Every breach of
this nature affects not only the parties directly interested, but it
has also an injurious influence upon the esteem in which the
entire body of the profession is held. The demerits of one man
beget mistrust and disrespect for the profession as a whole. In
the large cities, where all grades are supposed to exist, these
problems adjust themselves with greater facility. Here, pro-
fessional approval or ostracism is a thing of greater moment.

"It is not my intention to particularize; but rather to call
attention to that most excellent and explicit instrument than
which none better has appeared, the Code of Ethics of the
American Medical Association. My plea is that it may be
indeed as in name our guide, until to the title of doctor of
medicine will attach, if not infallible wisdom, at least the idea
of unimpeachable honor.

"Medical men, as the science advances, are becoming more
and more liberal and tolerant. This is true, I think, of all who
have any right to claim to be educated, whatever their predilec-
tions as to therapeutics. The opinion is prevailing that the
title of physician or doctor of medicine is good enough and
distinctive enough. A few of the sectarian societies have already
dropped their distinctive title. I believe that the essence of the
question lies not so much in what this man oc that man hon-

estly believes, as in the trading upon a meaningless name.
'Quackery consists not so much in ignorance as in dishonesty
and deception.’

"The Royal College of England, one of the most conserv-
ative organizations in the world on this question, eight or ten
years ago, passed the following resolution, to-wit: 'that while
this college has no desires to fetter the opinions of its mem-
l-crs in reference to any theories, they may see fit to adopt in
connection with the practice of medicine, it nevertheless con-
siders it desirable to express its opinion that the assumption or
acceptance, by members of the profession, of designations im-
plying the adoption of special modes of treatment, is opposed
to the principles of the freedom and the dignity of the pro-
fession which should govern the relations of its members to each
other and to the public. The College therefore expects all its
fellows, members, and licentiates will uphold these principles by
discountenancing those who trade upon such designations.’ This
can only mean that so long as no distinctive name or trade-
mark is used, a physician is at liberty to hold to and practice
after any theory of therapeutics he may see fit.

"I believe that the time is inevitably and soon coming when
the principles enunciated by the high medical authority of
England will everywhere prevail.

"I allude to this subject at this time because as I believe, we,
or at least some of our number, are pursuing a more liberal
policy than the Code which we have bound ourselves to respect
will sanction, and are thus placing a stumbling-block in the
way of others and are virtually effacing all ethical barriers. In
proportion as our science becomes more and more exact, and the
state more and more insists upon its mastery, will the realm of
error recede. But until the leaven of knowledge has more thor-
oughly permeated the mass and made it possible for a change
of position, or while the majority so decrees, the only proper
course for the individual is in acquiescence. The folly of such
mongrel association is easily demonstrated to any intelligent
layman. In our zeal to appear fair-minded and without bigotry,
let us beware of stultifying ourselves.”

Dr. Grassick: Previous to the admission of our Territory

into statehood, there were registered in that part which is now
North Dakota upwards of 200 doctors of all classes. A recent
survey shows that only fifteen of those are now living; and of
these we have five with us today on this platform. I will ask
them to stand as I name them, that you may know them for
their worth, and as outstanding members of our profession.
Drs. Chas. MacLachlan, J. P. Aylen, G. W. Glaspel, H. O’-
Keefe, and myself. The others that were unable for various rea-
sons to attend are: Drs. F. N. Burrows, A. Carr, E. I. Don-
ovan, A. Ekern, A. A. Flaten, J. B. Harris, A. T. Horsman,
Thos. C. Patterson, W. H. Welch, and Geo. McIntyre. The
latter, who was elected to affiliated fellowship in the A. M. A.,
sends the following: "As a member and officer of your State
Medical Association in territorial days, and a practitioner in
the State for forty years, I send my greetings on this your
fiftieth anniversary. I am impressed with the calibre of the
pioneer men who were responsible for the organization, and with
their high ideals and lofty purposes. The intervening years have
thinned their ranks, and those who remain deserve well of the
profession. I congratulate the Association on its continued
success and on the fact that there have not been wanting out-
standing men as leaders to guide its destinies through the
years.”

It is said that when Marshal Ney reported to his chief after
the ill-fated retreat from Moscow, Napoleon sternly demanded:
"Where is my rear guard?”

Marshal Ney stood erect and saluting, replied: "Sire, I am
your rear guard.”

With like truth, we may say that this is the rear guard of
that valiant force who went forth to battle against human ills,
on the plains of Dakota in Territorial days.

The committee which had this program in charge thought
that as the wives of the pioneer doctors played such a leading
part in the great drama of "Winning of the West,” they should
have a part in this program, and so I have much pleasure in

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presenting to you a lady who is herself a pioneer, who is the
daughter of pioneers, and who is the wife of a pioneer doctor
of this state, Mrs. E. C. Haagensen, Grand Forks.

Mrs. Haagensen: I think it will be rather difficult to have
the doctors so far away. I am more accustomed to being close
to them.

Whether the year be 1887 or 1937, I am quite sure the doc-
tor's wife was, and now is, in a class by herself. According to
Webster a pioneer is one who goes before to prepare the way.
It has been well said: "For age is not alone of time, or we
should never see, men old and bent at forty; men young at
seventy-three.” After thirty-eight years of experience, this sub-
ject should be right up my alley. During the recent Minnesota
medical meeting, The Minneapolis Journal ran a questionnaire
on this subject, asking if the lives of the wives present had been
sunny, sad, good or bad. How many of those present, if given
a chance to live life over, would choose to marry a doctor?
Foolish questions! People ask them every day! In my short
life, I have learned that you can’t dream yourself into charac-
ter. You must hammer and forge yourself into one.

There is one reply, which doctors use a great deal, and that
is, "That’s professional.” Doctors like gossip as well as others,
but when you ask them about anything, you always meet that
inevitable reply, "That's professional.” Doctors’ wives early
learn not to talk shop. A huge bird came and roosted near
our chimney. I used to wonder why that bird wasn’t more
professional. But now in 1937 it has become so.

We often speak of horse sense even now. But in those ter-
rible blizzards, while the doctor’s wife kept vigil, I well remem-
ber, the horses were responsible for the safety of the physician
many a time. Oh yes, those were wise horses. Even before we
were married, we put the lines in a clip on the dash board,
and the horses kept the road. Life was much more strenuous
then, than it is now.

In order to paint a pioneer picture, I must tell you of one
case. A two-year-old baby boy had fallen into a pig-pen, full
of hungry savage hogs. The mother had rescued what was
left of the child before we arrived. One eye was gone, one ear
was gone, and bites had been taken out of arms and legs. The
mother fainted. The bleeding child was cared for on the kitchen
table. Miraculously, he escaped infection, and is a fine man
today. Too bad the doctor was never paid!

If you marry a doctor, you must be prepared to share him
with humanity. You must learn to live a lot, love a lot, and
laugh a lot. I recall the story of a patient near Cummings.
The doctor had taken her temperature under her arm and
departed, forgetting the thermometer there. In a few days he
returned. She still had the thermometer there and said she
was much better because of the treatment. And there was the
young man, who after having had typhoid, ate an apple, core
and all.

The doctor was angry that day and said, "Why didn't you
bring in the tree, and eat that?”

I well remember opening the front door for a man who was
almost breaking it down. It was midnight and a terrific snow
storm was it> progress. I timidly asked the doctor if it were
the first baby.

"No, the tenth,” he replied, "why wouldn’t he be nervous?”

Some of you recall Dr. E. M. Darrow’s favorite yarn. He
was a fine gentleman, genial and jolly. He said the family
doctor was called into the country to attend a farmer’s maid.

Upon examination he could find no trouble, and said, "You
are not sick; why lie in bed?”

She replied, "They have never paid me, and I’ve gone to bed
to rest it out.”

This antedated the sit-down strike.

Is there any difference now, and then, in the doctor’s home?

The small boy expressed it when he prayed, "God bless the
American home, even if there’s no one in it.”

I am sure it was a doctor, who wound up the alarm clock and
put it on the back porch, while he placed the milk bottle on
the bureau. As a result he missed his morning appointment,
and had no milk for breakfast. So absent-minded, often he

forgets his wife entirely. The pioneer doctor's wife? She took
the grade with him, and made it, too!

An author; a scientist too, has told us he thoroughly be-
lieves that a husband is a present, which from Heaven the wife
receives.

But I seem to hear an occasional pioneer doctor’s wife say:
"You may be gift from Heaven sent; the professor made an
error; ’cwas the other place he meant.”

Dr. Grassick: Just a few words in closing. "Hallow the

Fiftieth Year” were the words of the great Hebrew Law-Giver,
and although thirty-five centuries have elapsed, they still ring
out as clear as the silvery tones of a far off mission-bell, and
it is well.

This is the fiftieth anniversary of organized medicine in
North Dakota, and it is fitting indeed that we take official
notice of the occasion, note some of the social and economic
conditions that made it desirable, recall incidents in the lives of
those who were its sponsors and mark along the way the part
it played in the development of our young commonwealth.

In 1861, when the Territory of Dakota was organized with
a physician as its first governor, what is now North Dakota
had only a mere handful of settlers of white blood; mostly
trappers, voyageurs and adventurers. It was not until the decade
immediately preceding 1887 that the real influx took place; but
what settlers they were! Never had any country a finer group
of men and women than were the pioneers of North Dakota.
They were the cream of the countries from which they came.
Young, strong, progressive, courageous, fearless. They brought
with them as chief assets; strong arms, willing hands and
dauntless hearts, and these they dedicated to the development
of the country of their choice. Into this heritage of the gods,
of a land clean, fresh, fair and free, and among a people gen-
erous, hospitable, warm-hearted and home-loving, came the
pioneer physician who was in no sense less virile, less aggress-
ive or less liberty-loving than the people he served. His trained
mind fitted him for leadership; and in addition to the part he
played as a physician, he in many instances became an active
factor in solving the many social and economic problems inci-
dent to a new country. In 1887, there were in all about 100
graduate physicians in the territory comprising the 70,000
square miles of what is now North Dakota, and some of these
covered without a rival, ground as large as a New England
state. A few may have been "not too learned, but nobly bold”
but the majority were graduates from Eastern schools, and for
various reasons decided to cast their lots in the then picturesque
and colorful West. In the broad acres of our then undeveloped
"Land of the Dacotahs,” there was space enough, freedom
enough, opportunity enough and adventure enough to satisfy
the longings of the most ambitious.

Dreams as such may be baseless and fleeting as the mists of
morning on the one hand, or the foundation on which are
built the best of human accomplishments on the other. They
are in reality the torches that light the way of progress. To see
visions and to dream dreams however is not enough. We must
Raphael-like paint our visions and our dreams. The real pro-
gressives of our age, or of any age, are those who have in-
terpreted their dreams in terms of action; and Dr. J. G. Mills-
paugh, the founder of the North Dakota Medical Association
and its first president, was such a one. He was well fitted for
the task, and in that sense may be said to have had a call to
the work; for preparation is the real call to leadership in any
great undertaking. Like a ranchman of the Bad Lands, who
later became a president of the United States, he came to
the Territory seeking health. While resting and gaining
strength, he had leisure to observe and to think. He recognized
that his fellows in the profession were so many freelances, in-
dividually battling with problems that were common to all, and
making no general advance.

He saw as did Kipling that "The strength of the pack is the
wolf and the strength of the wolf is the pack.” In other words,
that although scouts and skirmishers were all right in their
respective places, organization and cooperation were what were
needed to get the best results. He had a vision of a united
profession with new aims and new ideals, and he set himself

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345

with all the ardor of an enthusiast to make his dreams take on
form and substance; and history records how well he succeeded.
In May 1887, Dr. Millspaugh arranged for a social gathering
in the city of Larimore, of a small group of men with the for-
ward look — Drs. Montgomery, Rounsevel, Murray, Lunde,
Conkey, Engstad, and a few others. Before they parted, an
organization was formed of what in the future was to be
known as the North Dakota State Medical Association. It was
a small beginning, but it had in its structure all the possibilities
and potentialities of organic development. This coterie of de-
voted men planted their ideals in virgin soil, and had the satis-
faction of seeing many of them grow and wax strong; while
others as might be expected, were choked in the dense growth
of primal things; and had to be replanted by future leaders.

In all new countries, the pressing physical problems are the
first to claim attention and demand solution. Homes have to be
built, bodies clothed, feet shod and mouths fed. It is little
wonder therefore that at times, the beautiful and the esthetic
were overshadowed by the customs of the times that the free
spirit of the West seemed to foster. But this was not for long.
The Association as the years came and went, grew mightily
until its influence was felt in every nook and corner of the state
and beyond. In 1890, when it met in annual session at James-
town, it was as fine a representative professional gathering as
could be found anywhere, with a scientific program that would
have done credit to a metropolitan center. While still in the
swaddling clothes of statehood, a new Medical Practice Act,
drafted by the Association’s legislative committee and piloted
through the legislature by Dr. John Montgomery, a charter
member, was considered by competent authorities as a great
advance on previous measures, and one of the best of its kind
in the country.

While these concrete advances were taking place, other
forces were quietly at work. What is so fine as the members
of a great profession meeting in the spirit of brotherhood,
peace and unity, and working to lift standards of life to
higher levels; and what is so beautiful as the members of an
organization reacting to the highest of ideals and laying their
choicest gifts of mind, heart, learning and service on the altar
of human welfare? These intangible, ethical by-products that
cannot well be weighed or measured, but are none the less real
on that account, are among the most valuable contributions our
Association is making to society.

Among the Scottish clans, there was a custom that lends
itself to our purpose. In the old days, every chieftain was the
head of a small army whose individuals worked for him in
times of peace, and were led by him against a neighboring clan
or a common enemy of the country, in times of war. When
the Fiery Cross, the symbol of contest went forth, and the
shrill notes of the pibroch echoed from cliff to cliff, stalwart
kilted Highlanders responded to the call. At the trysting place,
there was the Cairn of Remembrance. Before leaving on a
mission of war, each clansman placed a stone on the Cairn, and
if fortunate enough to return, removed one. In the course of
years, a monument, as rugged as their native hills, was reared,
representative of those who had fallen in defense of country,
clan, or cause; and each stone in the Cairn was a personal con-
tribution. It was a sacred and a hallowed thing, this Cairn of
Remembrance. Sacred to Memory, to Duty, to Honor and to
Truth.

May we not in like manner approach this Fiftieth Anniver-
sary of our Association and as we gather around it, if not as
a Cairn, at least as a Day of Remembrance, reverently and
appreciatively, pay our tribute of memory to those of our
pioneers who gave the best of which they were capable for the
cause of human betterment?

But this is not enough. Let us go forth in the spirit of ad-
venturous truth-seekers and take possession of the vast areas of
unplatted knowledge that invite the plow and harrow of the
pioneer; let us with pick and shovel of the prospector, seek out
and uncover the rich lodes of golden treasures that await our
coming; and as loyal soldiers of the common weal, let us gird
our loins for the battle and go forth against the enemies of
our race that lurk in darkness as well as those that are rampant

at mid-day, and cease not until the going-down of the sun. In
this way, by re-dedicating ourselves to the tasks that lie before
us, we may be deemed worthy representatives of a worthy pro-
fession by those who follow after.

President Gerrish: Doctor Grassick, on behalf of the Asso-
ciation I want to congratulate you and the others who took part
with you, in presenting this timely Anniversary Program.

We will close by singing America.

Afternoon Session

The Association reconvened at 1:30 P. M., and was called
to order by President Gerrish.

Dr. E. L. Tuohy, Duluth, Minn., discussed "Bone Marrow:
Its Vital Importance to the Body.”

Dr. W. H. Long read an interesting paper on "The Man-
agement of Nephritis.”

Dr. R. H. Waldschmidt presented a paper on "Initial Care
and Treatment of Accidental Injuries.”

At this juncture, a fifteen-minute recess was declared to en-
able the members to view the exhibits.

Dr. Arthur E. Smith, Los Angeles, Cal., discussed "Plastic
Surgery,” and in connection therewith showed several reels of
natural-color motion pictures.

The meeting adjourned at 6:15 P. M., to re-convene at 9:00
A. M., on May 18th, 1937.

Evening Session

At 6:30 P. M., the annual banquet was held at the Hotel
Dacotah, following which a program was given, Dr. A. D.
McCannel acting as toastmaster.

The president delivered his address, and the guest speaker
of the evening was Dr. E. L. Tuohy of Duluth, Minn.

Presidential Address

W. A. Gerrish, M.D., Jamestown, N. Dak.

My friends and fellow practitioners: — I bring you
greetings, good will and personal felicitations.

This annual meeting of the North Dakota State
Medical Association brings to a close my tenure of
office as your president. Words fail me in my efforts
to express to you my appreciation of the great privilege
of being your leader during the year that is now draw-
ing to a close. I know of no greater honor that could
come to any physician than to be selected as president
of a state medical association. It is the crowning event
of a physician’s professional life. I also realize that
associated with this high honor, there is a great respon-
sibility, not only to the organization as a body, but to
every individual member thereof. How well I have ful-
filled the great confidence you have reposed in me only
time can judge. I can only say that I have labored with
an eye single to what I believed to be the best interests
of the State Association and its individual members.

Naturally, among my first words on this occasion, I
should express my gratitude for your splendid coopera-
tion. The willing, cheerful and efficient work of our
members, officers and numerous committees is worthy
of most honorable mention.

This is the fiftieth anniversary of organized medicine
in North Dakota. Only recently we jointly celebrated
in Aberdeen the semi-centennial of organized medicine in
the Dakotas. For that reason, we are not attempting a
real celebration.

Progress is not automatic. The world grows better
because there are high-minded souls who wish that it
should, and because they will and dare to take the right
steps to make it better. So we commemorate the efforts
of those great pioneers of medicine, who felt that the

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scheme of human relationship was out of balance, and
capitalizing the gregarious or fellowship instinct and the
altruistic desire to serve, inherent in most men, gave us
organized medicine. To them we acknowledge a debt of
gratitude.

Life’s tale is soon told. The years, which in childhood
loom large as planets, shrink fast as we journey along
life’s highways, and the mile posts move rapidly by, but
whether we be blessed by long careers or short, there are
hours enough if we but use them. No man has done
enough for his fellows. We are ready for the treasures
of new friendships, which make wisdom splendid, offices
and honors beautiful, and offer us never-ending hours
of pleasure. This mutual gathering-together in a great
outpouring of fellowship lends itself well to the cre-
ating of new friendships, and to our greater usefulness
as factors for good in community life.

The finest ideals will not propagate themselves. In
organized medicine we have the happy combination of
ideals plus organization. Individuals may worthily de-
sire to serve and build, to imbibe deeply of friendliness,
tolerance and understanding; but alone they fail to
pierce the armored hide of indifference, selfishness, hate
and bigotry. But with an organization of men similarly
imbued with, and fortified by, an exchange of ideas, mu-
tual helpfulness, and a splendid association which mar-
shals for him an array of leadership, experience, facts
and literature, and binds all together in a perfect union,
he becomes an integral part of a great altruistic force for
human good.

We are a great body with maturing obligations and
of recognized importance in the councils of the con-
tinent. We may be proud of the past, but we grow with
the years. On this anniversary, we think of the fine and
outstanding achievements of a glorious past, but we con-
secrate ourselves to a larger future of helpful service to
humanity.

It is fitting and proper that we bear in remembrance
our members who have responded to the last call during
the past year: — Alexander Keith Blair, Minnewaukan;
August Severin Eggers, Grand Forks; John Evan Eng-
stad, Grand Forks; Lee B. Greene, beloved vice-presi-
dent, Edgeley; Henry J. Leigh, Tower City; Louis W.
Meyers, Fargo; Joseph T. Newlove, Minot; Henry A.
Owenson, Arnegard; and Philip Graham Reedy, recently
of Casselton.

A speaker cannot do anything for the perpetuation of
the glory of extraordinary souls. LeSage was right when
he said that "Their deeds alone can praise them.” No
other praise is of any effect where worthy names are
concerned. It needs but the simple story of deeds faith-
fully performed to create and sustain glory. Memory
brings their smiles, their words, their deeds, and the
memory of their high courage, unselfish devotion, noble
purpose and unbounding love strengthens our resolve
to make our own lives more pure and remembrance cf
our dear ones "Whose lips though silent still speak
through ours,” and who will rejoice if we but bring "the
flower of life to a perfect fruitage.” We leave them in
His keeping, "Who doeth all things well.”

These meetings serve many excellent purposes. They
provide the opportunity for renewal of friendships, for
interchange of ideas, for the taking of inventories of
those abstract possessions which can be neither bought
nor sold. In a world where transportation and communi-
cation are so swift and so certain, we find difficulty in
stopping long enough to determine our position, the dis-
tance we have traveled, or the direction in which we are
tending. Our task today is to achieve perspective, for
we are told "The young have aspirations that never
come to pass; the old have recollections of things that
never happened.”

As I speak to you, I feel very much like a guide in
a museum trying to show to a group of visitors the
treasures of the building, but provided with only a small
box of matches in the way of light. He would strike a
match, hold it for an instant before a picture or a statue
or a case of jewels, and then it would flicker out; anoth-
er match, in the same feeble way, would provide just
the hastiest glimpse of another beautiful and valuable
object. So, in trying to tell you a little of a subject
which is as broad as the world in which we live, I can
only give you a bare and rather kaleidoscopic introduc-
tion. I do it with the hope that something I say will
make you want to know more, and to follow through
some of the roadways of thought to which I can barely
point.

This is not the time for didactic essays or ornate ora-
tions. In these days which are, to use the fine phrase,
"the times that try men’s souls,” the only thing that is
valuable in speech is sincerity, and it is in that spirit
I speak to you for a few minutes on "State Medicine.”

United States doctors have had tough sledding. The
depression was only one of their troubles. Among their
other trials we find: free clinic service has quadrupled
in a decade; medical men now treat gratis 500,000 of
the nation’s daily sick list of 1,250,000.

Pay clinics have had a recent mushroom growth. They
were designed for down-trodden white-collared workers,
and operate on a system of small fees. Doctors must
give their services free, while other employees are paid
Competitors have been chiseling fat slices from the na-
tional medical dollar; osteopathy forty-two million a
year, chiropractic, sixty-three million a year, besides a
living for three thousand naturopaths and ten thousand
Christian Science practitioners. Lesser bad breaks for
the doctor’s pocket book have included free hospitaliza-
tion of veterans and a mass-production contract system
of medicine fostered by insurance companies and com-
pensation clinic work.

And now, with the calling of many prominent pro-
ponents of the socialization of medicine to Washington
during the past year, we may expect renewed action
against organized medicine from the Social Security Act
in amendments to be introduced.

Two widely antagonistic forces are striving for dom-
inance in America. On one side is the desire and ambi-
tion of the individual to live his own life and carry his
own responsibilities and secure the utmost mental and
material development; while on the other is the ambi-

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347

tion to have the people subjected wholly to herd ideas
whether advantageous or otherwise — with only an inner
certitude, a personal sense, necessarily imperfect, that
the way the herd is directed, is also the best way. The
contest is between individuality and regimentation; and
while regimentation with its attendant oppression has
secured high place among decadent nations of Europe,
it will be fought bitterly in an America, which has grown
great through private initiative. The doctor is by nature
and training an individualist, and sometimes so zealous
that he is reluctant even to join his fellows in a common
aim, but there is no field where such an attribute is more
essential than in medicine. With proper professional
equipment and wisdom, the doctor should be free to ex-
ercise his best judgment in his gallant struggle against
disease and death and to bring unhampered all his skill
and experience to succeed in his daily combats with life’s
enemies.

Regimentation on the other hand deprives the average
mind of all chance of growth, and the ambitious men-
tality of all hope of fruition. Simultaneously, it dimin-
ishes that superb efficiency which appears when a person
responds to the normal incentives to happiness and suc-
cess; incentives that arise from an inherent consciousness
of a personal importance in the world of affairs. Such
individualism undoubtedly has often been carried to an
extreme by zealous medical men. In their desire to con-
quer disease and help humanity, they have become the
slaves of charity. They give as always of their services
gladly to the poor. Even before the war, doctors gave
gratuitous medical and surgical treatments to the value
of many thousands of dollars per year per doctor, and
since that catastrophe the profession has been strained
to the utmost in time, service and money. Yet the sal-
aried altruists prate to the doctors about philanthropy —
to doctors, mind you, who almost invented this min-
istry.

The time-honored attitude of the profession toward
the indigent sick is well-known, too well, perhaps, and
often imposed upon by such apostles of regimentation
as the foundations, the salaried altruists, the social
theorists and "charity brokers” who are anxious to en-
large the organizations they conduct, and thus increase
their personal prestige. Many institutions, and at pres-
ent may supervisors in the emergency relief service, vie
with one another to secure a numerical increase in their
"clients” for the enlargement of their personal perqui-
sites and importance. The principle is fallacious and
unworthy. We should as reasonably expect the prisons
and asylums of the state to compete for inmates. Such
ambitions can only result in injury to the personal pride,
self-esteem and lead to moral deterioration of the vic-
tim. A worthy citizen is entitled to adequate aid until
he is competent to carry on, but as soon as possible, the
support should be withdrawn, lest his morale be broken
down, and a chronic dependency established.

The practice of charity is one of the most ancient and
glorious traditions of medicine, but the doctors are
aware that this phase of their calling is not infrequently
misunderstood and abused by the undeserving, for that

charity is pernicious which takes from independence its
proper pride and from mendicity its proper shame. The
abuse of charity leads for the physician to pauperiza-
tion of the body and for the patient to the even more
serious pauperization of the soul. The abuse of charity
moreover arouses the indignation of the doctor, since
every such care of malingering prevents the extension
of legitimate aid to a worthy object. Loss of morale is
an inevitable consequence where high ambitious qualities
are regimented.

The exercise of charity which has always been cher-
ished as a laudable virtue has now become an organized
and remunerative industry in the hands of social
theorists who under the mask of humanity hoodwink
the government, prey upon the doctors, exploit the poor,
and weaken or destroy the virile American traits of self-
respect, resourcefulness and resolution, so that they
themselves may tread the primrose path. With a full
knowledge of these conditions, the medical profession
has been striving to correct social evils, accommodate its
work to the changing face of society; and adapt its prac-
tice to the gradual mechanization and industrialization
of American life. New forms of medical procedure are
being tested in nearly all the states, and unusual plans
for medical service are being introduced. These experi-
ments cover in some degree every aspect of medical work,
and while some are conducted honestly and ethically,
others are devised exclusively for a personal advantage.
Schemes of medical and hospital insurance, free and pay
clinics — medical care for a fixed yearly fee; contract
practice and corporation practice, are the most common
examples.

Corporations, casualty companies and insurance so-
cieties are usually the outgrowth of lay efforts to exploit
the medical man, but in California and Washington, in
Michigan, Massachusetts, Utah, Georgia, Virginia,
Ohio, and other states, sincere efforts are being made to
change the character of professional activity without
a corresponding loss in that quality of competence and
efficiency which stands highest in the world today. Some
of these hundred or more projects under trial by county
societies have been tentatively indorsed by medical au-
thority, and if allowed to develop, will in time find a
proper and satisfactory adjustment.

These methods of careful experimentation, however,
are too slow for the social theorists and salaried altruists
who want the world revamped according to their vapor-
ous fancies while they still are able to enjoy the expected
prestige and financial compensation. They are possibly
aware that the earth is some fifty millions years of age
and alters slowly, but hope nevertheless to bring about
a radical reversal of social conditions in a few intense,
unnatural months. The social theorists have always ex-
isted, but the salaried altruists and the "charity brokers”
are purely modern productions. They belong to that
large company of adventurers who prefer to exploit the
assured, rather than to explore the unknown. Thus they
strive for regimentation of workers, and employers, of
proletarians and scientists, and of physicians, by fiat.
They visualize a large, clean, orderly housekeeping plant

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with themselves at the head and all personal ambitions
and means of development abolished or subordinated to
their personal theories regarding the method and direc-
tion which evolution should pursue and where remunera-
tion could be most worthily and satisfactorily bestowed.

The immediate goal which the professional altruists
hope to attain in medicine is socialization. This is a men-
ace both to medicine and to the public. It is a most im-
portant factor, however, in their plan; for the only social
advance that ever obtained recognition was won by way
of medicine. This is the first step, therefore, in a pur-
pose openly or hesitantly admitted at Washington to kill
our democracy and substitute in its place a collective
form of government, which will reduce the entire pro-
ductive portion of the population to the level of serfs.
This being accomplished, the serfs can be put to work
to support the lazy, the thriftless, the incompetent, and
the subnormal, who are the particular pets and the most
hopeful beneficiaries of the salaried altruists in their ex-
periments. The most ominous feature of this puerile
program is the effect upon the hopeless victim, who is
arbitrarily deprived of pride, ambition, and all incentives
to effort. He is reduced to a soft, sloppy, gelatinous
existence wherein only two primitive desires survive —
to eat and breed. This social subversion was attempted
once before, though very cautiously, by the passage of
the Sheppard-Towner law, which was rejected by sev-
eral states.

Socialization of medicine is state medicine, and the
latest attempt in this present upheaval is the passage
of the Social Security Act. This act has a more plaus-
ible approach and a deeper rouge to hide its vaster
viciousness, its more incisive teeth, and its more dan-
gerous political purpose than its predecessor’s. It is
open, however, to the same objections, and should re-
ceive the same thoughtful and united opposition.

We have no sympathy with paternalism or unwar-
ranted dependence on a grandmotherly state, either in
medicine or commercial affairs. We are a staunch sup-
porter of state rights, of local autonomy, of private ini-
tiative and neighborly cooperation. Bureaucratic admin-
istration is a menace to personal freedom and social
progress, and we may add also that it spells ruin to
medical efficiency.

State medicine cannot change human nature, though
it may alter relations. Independence in medical practice
is an essential to the happiness and prosperity of doctors
and to the advance of scientific medicine, as independ-
ence in citizenship is to the welfare of the government
and this priceless independence gained by prodigious ex-
penditure of blood and treasure should under all circum-
stances be sacredly preserved to the people of these
United States.

In your thinking, start not with purely economic con-
siderations, not with purely materialistic considerations;
but start with fundamental values of medicine. Some of
you have heard the story about a fellow in East Ten-
nessee who was lost in the mountains. He wandered
around, and finally came to a mountaineer’s cabin. An
old fellow was sitting in a cane-bottom chair on the

porch, with an old ten-gallon hat pulled over his eyes,
taking a nap. The traveler called to him and the old
man came down to see what he wanted.

He said, "I want to know how to get to Knoxville
from here.”

The old mountaineer thought a minute and said,
"Well, you go up this here trail, and at the first gulch
you come to at the right, you go down that gulch about
three miles and turn to the right.”

He then got to thinking about how rough the so-
called road was, and said, "No, that won’t do; go over
here about a mile-and-a-half, and take the first gulch
to the left, and go about two miles and turn to the left.”

He recalled that was also rough, and again directed
the traveler a third way, took that back and said, "Look
here, mister, if I was you and was going to Knoxville, I
wouldn’t start from here.”

My plea is that in your thinking about all these
things you are constantly reading about and talked to
about, start from the right place — start with the funda-
mental values of medicine — don’t ever lose sight of the
fact that the work of medicine can be done only by a
qualified, humane, idealistic profession. I have put the
emphasis on profession. Don’t overlook many of the
influences that are persistently at work today, including
some of our so-called philanthropies — and the perils of
philanthropy are very real — whose whole tendency is to
create conditions that will pull medicine down from the
status of a profession. There is nothing that will retard
scientific progress, and destroy the possibility of the
people’s receiving good service more completely than de-
motion of medical practice from a truly professional
status.

You are servants of humanity, and have a humani-
tarian service to perform which can be best accomplished
by organization and cooperation and education.

It is this coming-together of earnest men — each with
his individual experiences, but all with a single engross-
ing purpose — which keeps our beloved science abreast of
the times and ever ready for the next forward step. The
full and candid presentation of our varied experiences —
our mistakes and failures, no less than our successes —
makes possible intelligent comparison, stimulates sugges-
tion and leads to discussion, out of which each of us
surely may gather somewhat of profit.

We want to practice the Golden Rule in our organi-
zation as much as possible; however, we should not be
satisfied with merely doing unto others as we would have
them do unto us or living to let live, but may we as an
organization live to help others. If we but apply this
axiom to our own lives by putting our own house in
order first, then we shall be better able to help our town,
state and nation in a more ideal way.

In carrying out these ideals of service to ourselves
and one another, we unconsciously become one common
happy family working for a common worthy cause.

Cooperation is spelled with two letters — W — E.

There is power in organization for good or for evil.
Good teamwork is an essential factor in any under-
taking.

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349

"What makes that woman look so homely?” asked
one man of another.

The other took a look at the woman and said, "Don’t
know; she has good eyes, a good nose; she has a good
mouth and good cheek bones; she has a good forehead,
but her features don’t seem to understand teamwork.”
My friends, it is time to bring these crowded remarks
to a close. Reject what in them is false; examine what
is doubtful; remember what is true.

SECOND DAY
Tuesday, May 18 — Morning

The Association re-convened, and was called to order at
9:00 A. M., by President Gerrish.

Dr. R. D. Mussey, Rochester, Minn., read a paper on "The
Course, Conduct and Complications of Pregnancy Among Phy-
sicians’ Wives.” He used statistical slides to illustrate his
address.

"Anesthesia and Relief of Pain by the General Practitioner,”
was discussed by Dr. John S. Lundy of Rochester, Minn.

Dr. Kent E. Darrow read a paper on "Problems in the Di-
agnosis of Obstruction in the Bowel.”

Dr. R. O. Goehl presented a paper on "A Discussion of
Protamine Insulin.”

President Gerrish: At this time, I want to thank the So-
ciety for the honor it has bestowed upon me, and for the
hearty, willing cooperation I have received from each and every
member thereof. At this time it gives me great pleasure to
introduce to you your new president, Doctor Goss.

Dr. Goss: This is indeed an honor, gentlemen, to be elected
president of the North Dakota State Medical Association. It
comes after a great many years of waiting. Forty-five years is
a long time to wait; so I am going to tell you young fellows
you had better be prepared when it is thrust upon you.

Another thing that I am going to ask you to do is to attend
every meeting of every local medical society that you possibly
can. You can go whether you have a paper or anything to
say. And be sure to attend the annual medical meeting at
Bismarck next year.

Doctor Gerrish: The program this afternoon will be re-
arranged a little bit. I am telling you now, as some of the
members might be interested in the treatment of syphilis, which
as I understand it, will be the subject discussed this afternoon
by Dr. Paul O’Leary, of Rochester. Dr. O’Leary has to get
away on the early train and he has asked that he be the first
one on the program this afternoon, which change has been
made.

The Fiftieth Annual Session of the North Dakota Medical
Association adjourned at 12:00 Noon.

DISTRICT AND COUNTY ROSTER

CASS COUNTY MEDICAL SOCIETY

PRESIDENT

Swanson, J. C

Fargo

SECRETARY-TREASURER

Watson, E. M

Fargo

Aylen, J. P .....

Grafton

Baillie, W. F

Fargo

Barnes, N. J

Fargo

Boerth, E. H

Buffalo

Borland, V. G

.. Fargo

Bray, R. B.

Fargo

Brown, W. G. .

Brown, R. C.

Fargo

Burton. P. H.

Fargo

Clay, A. 1

.. Fargo

IJarrow, Frank I.

Fargo

Darrow, Kent

Fargo

Dillon, J. G

Fargo

Elofson, C. E

Fargo

Evans, L. J

... New York

Ferguson, W. C

Fargo

Fjelde, J. H.

Fargo

Floew, A. T

Fargo

Fortin, H. J.

Fargo

Fortney, A. C

Fargo

Foster, G. C. . ....

Fargo

Hanna, J . F.

Fargo

Haugen, H.

Fargo

Haugrud, E. M.

Fargo

Haynes, G. H.

Lisbon

Heimark, A. J.

Fargo

Hendrickson, G.

Enderlin

Hunter, G. W.

Fargo

Huntley, H. B.

Kindred

Ivers, G. U.

Fargo

James, J. B.

Page

Jelstrup, C.

Big Lake, Minn.

Joistad, A. H

Fargo

Kaess, A J.

Fargo

Lancaster, W. E.

G Fargo

Larson, G. A.

— . Fargo

Lewis, T. H.

Fargo

Limburg, M.

Fargo

Long, W. H.

Fargo

MacGregor, M.

Fargo

Miller, H. W

Morris, A. C

Fargo

Nichols, A. A.

Fargo

Nichols, W. C. Fargo

Oftedal, A. Fargo

Ostfield, J. R Fargo

Patterson, C. H.

Veterans Hospital, Fargo

Patterson, T. C Lisbon

Pray, R. E Fargo

Richter, E. H Hunter

Rindlaub, Elizabeth Fargo

Rostel, H Fargo

Rothnem, T. P Fargo

Sand, O Fargo

Schatz, G j West Fargo

Sedlak, O. A Fargo

Skarshaug, H. J. Fargo

Stafne, W. A. Fargo

Stolinsky, A. Lisbon

Skelsey, Albert W. Fargo

Swanson, J. C Fargo

Tainter, Rolfe Fargo

Tronnes, N. Fargo

Watson, E. M. Fargo

Weible, R. E Fargo

Winn, W. R Fargo

DEVILS LAKE DISTRICT MEDICAL SOCIETY

PRESIDENT

Fawcett, N. W Devils Lake

SECRETARY-TREASURER
Drew, G. F Devils Lake

Arneson, A. O McVille

Bartle, J. P San Haven

Call, A. M Rugby

Drew, G. F Devils Lake

Dodds, G. A San Haven

Engesather, J. A Brockett

Fawcett, J. C Devils Lake

Fawcett, N. W Devils Lake

Fawcett, W. C Starkweather

Ford, F. W Minnewaukan

Graham, J. D Devils Lake

Greengard, M Cando

Horsman, A. T Devils Lake

Laugeson, L. L San Diego, Calif.

Lees, H. D Philadelphia, Pa.

Lund, A. B Leeds

MacDonald, J. A ». Cando

McGurren, C. J. Devils Lake

McIntosh, G. J Devils Lake

Mattson, R. H McVille

Olafson, K. Cando

Sihler, W. F Devils Lake

Smith, C. Devils Lake

Sedlacek, B. B Ft. Totten

Stickelberger, J Oberon

Toomey, G. W—_ Devils Lake

Verrett, B. B Rollo

Vigeland, J. G Brinsmade

Widmeyer, J. P Rollo

350

THE JOURNAL-LANCET

GRAND

FORKS DISTRICT

MEDICAL SOCIETY

PRESIDENT

Glaspel, G. W. .

Grafton

Needles, A S.

Grand Forks

Liebeler, W. A

Grand Forks

Goehl, R. O

**Grassick, James

Grand Forks
Grand Forks

Orr, August

Panek, A. F

Bismarck

Milton

SECRETARY

Haagensen, E. C.

Grand Forks

Peake, M. F

Grand Forks

Muus, (J. Harold _

Cirand horks

Hardy, N. A

Minto

Quale, V. S.

Grand Forks

TREASURER

Hofto, J. M. .

Grand Forks

Rand, C. C

Crystal

Benwell, H. D

Grand Forks

Irvine, V. S

Landry, L. H.

.... Park River
Walhalla

Ruud, M. B

Rystad, O. H.

Grand Forks
Grand Forks

Alger, 1 G

Grand Forks

Law, H. W. F.

Grand Forks

Stromberg, G. E.

Langdon

Benson, T. Q.

Grand Forks

Leigh, R. E. .

Grand Forks

Thompson, A. Y.

Bentzen, Olaf

Grand Forks

Liebeler, W. A.

Grand Forks

Tompkins, C. R.

Grafton

Benwell, H. D

Grand Forks

Lohrbauer, L. T.

Grand Forks

Vance, R. W

Campbell, R. D.

Grand Forks

McQueen, W. W..

.. Langdon

Wagar, W. D.

Michigan

Countryman, J. E..

Grafton

Mahon, Ruth

Grand Forks

Waldren, H. M., Sr.

Drayton

Countryman, G. L.

Grafton

Miller, J. P.

Grand Forks

Waldren, H. M., Jr.

Drayton

Field, A. B

Forest River

Moore, J. H.

Grand Forks

Weed, F. E.

Park River

Flaten, A. N

Edinburgh

Mulligan, T. ....

Grand Forks

Williamson, G. M. ...
Witherstine, W. H...

Grand Forks

French, H. E ...

Grand Forks

Mulligan, V. A.

Langdon

Grand Forks

Glaspel, C. J

Grafton

Muus, O. H.

Grand Forks

Woutat, P. H

Grand Forks

KOTANA MEDICAL SOCIETY

PRESIDENT
Dochterman, L. B.

AbPlanalp, I. S.

Jones, C. S

Williston

Craven, J. P

Williston

Schwinghamer, E. J

Grenora

Dochterman, L. B.

. . Williston

Skovholt, H. T

W illiston

SECRETARY-TREASURER

Johnson, P. O. C.

...Watford City

Wright, W. A

Williston

AbPlanalp, I. S

. Williston

Hoeper, P. G. E.

Williston

NORTHWEST DISTRICT MEDICAL SOCIETY'

PRESIDENT

Frogner, G. S

Parshall

McGauvran, T. E

Breslich, P. J

Grangaard, H. O.

Ryder

McGee, W. J

Goodman, Robert

Powers Lake

Moffatt, G

Crosby

SECRETARY-TREASURER

Garrison, M. W

Minot

Nelson, L. F

— Bottineau

Pence, J. R

Minot

Gillespie, D. R

Halliday, D. J

Mohall

Kenmare

O’Neill, R. I

Pence, J. R.

Minot

Van Hook

Minot

Pence, R. W

... Minot

Breslich, P. J.

Minot

Hanson, G. C.

Minot

Ransom, E. M.

Minot

** Honorary

Haraldson, O.

Minot

Rollefson, C. J.

Carr, A., Sr

Minot

Hayhurst, J. O.

Rolette

Rowe, P. H.

Minot

Ittkin, Paul

Tolley

Rollie, C. O

Cameron, A. L.

Minot

Johnson, J. A

Bottineau

Smith, J. A

Noonan

Cowan, J. A....

Bismarck

Kermott, L. H.

Minot

Sorenson, A. R.

Minot

Devine, J. L.

Minot

Kolb, F. K.

.... Granville

Seiffert, G. S

Minot

Timm. J. F.

Makoti

Dyson, R. E

Erenfeld, H. M

Minot

Krogstad, L. T

Minot

Wheelon, F. E

Minot

Lampert, M. T

Minot

Weeks, S. A.

Ambrose

Fardy, M. J

Minot

McCannel, A. D.

Minot

Yeomans, T. N

Minot

RICHLAND COUNTY MEDICAL SOCIETY

PRESIDENT

fThane, Benj. Wahpeton

SECRETARY-TREASURER
Hoskins, J. H Wahpeton

Bateman, C. V Wahpeton

f Deceased

Beithon, E. J Hankinson

Durkee, C. E Abercrombie

Hoskins, J. H Wahpeton

Landers, C. H - 2469 N.

Holliston Ave., Altadena, Calif.

Miller, H. H.. Wahpeton

O’Brien, L. T Wahpeton

Olson, C. T Wyndmere

Pangman, W. J

3 550 10th St., Riverside, Calif.

Reiswig, A. H Wahpeton

Rice, C. P Wahpeton

Sasse, E. G _ Lidgerwood

Thompson, A. M. Wahpeton

SHEYENNE VALLEY MEDICAL SOCIETY

PRESIDENT

Zimmerman, S. A ..-.Valley City

SECRETARY-TREASURER
Moore, Will H Valley City

Almklov, L. Cooperstown

Brown, Fred Valley City

Campbell, Wm. Valley City

Macdonald, A. C Valley City

Macdonald, A. W Valley City

Meredith, C. J Valley City

Moore, Will H.. Valley City

Platou, C. A Valley City

Pray, E. A Valley City

Van Houten, J._ Valley City

Westley, M. D.._ Cooperstown

Wicks, F. L Valley City

Zimmerman, S. A Valley City

THE JOURNAL-LANCET

351

SIXTH DISTRICT MEDICAL SOCIETY

PRESIDENT

Constans, G. M Bismarck

SECRETARY-TREASURER
Larson, L. W Bismarck

Arneson, C. A. . Bismarck

Arnson, J. O. Bismarck

Baer, DeWitt Steele

Benson, O. T Glen Ullin

Berg, H. M Bismarck

Bertheau, H. J Linton

Brink, N. O. Bismarck

Bodenstab, W. H. Bismarck

Brandes, H. A. Bismarck

Brandt, A. M. .... Bismarck

Buckingham, T. W. Bismarck

Bunting, F. E. Mandan

Constans, G. M Bismarck

Diven, W. L Bismarck

Eastman, L. G Hazen

Fisher, A. M Bismarck

Fredricks, L. H. Bismarck

Freise, P. W. Bismarck

Gaebe, O. C. New Salem

Gerdes, Maude M

Minneapolis, Minn.

Gordon, W. L Washburn

Griebenow, F. Bismarck

Halliday, A. B. Hebron

Hamilton, E. E. .... .. New Leipzig

Heinzroth, Geo. Turtle Lake

Henderson, R. W Bismarck

Hetzler, A. E. Mandan

LaRose, V. J. Bismarck

Larson, E. J. Underwood

Larson, L. W. ... Bismarck

Lxpp, G. R. Bismarck

Monteith, G. Hazelton

Moyer, L. B. Carson

Nickerson, B. S. Mandan

Owens, P. L. Bismarck

Pierce, W. B. Bismarck

Quain, E. P. Bismarck

Quain, F. D Bismarck

Radi, R. B Bismarck

Ramstad, N. O Bismarck

Rasmusson, F. P Beulah

Rice, P. F Solen

Roan, M. W - Bismarck

Rogne, W. G. McClusky

Rosenberger, H. P Bismarck

Schoregge, C. W. Bismarck

Shepard, W. B Linton

Smith, C. C... Mandan

Smith, L. G Mandan

Spielman, G. Mandan

Stackhouse, C. E Bismarck

Strauss, F. B. Bismarck

Thompson, R. C Wilton

Vonnegut, F. F. Hague

Waldschmidt, R. H. Bismarck

Weston, D. T Mandan

Weyrens, P. J Hebron

Whittemore, A. A Napoleon

Williams, Maysil Bismarck

SOUTHERN DISTRICT MEDICAL SOCIETY

PRESIDENT

Sherman, C. H Oakis

SECRETARY-TREASURER

Lynde, Roy... Ellendale

Fergusson, F. W. Kulm

Grant, G Wishek

Kyle, W. D Havana

Lynde, R. „ Ellendale

Merrett, J. P Marion

Miller, S. - Ellendale

Ribble, G. B LaMoure

Salvage, F. E. LaMoure

Sherman, C. H. Oakes

SOUTHWESTERN DISTRICT MEDICAL SOCIETY

PRESIDENT

Gilsdorf, W. H New England

, SECRETARY-TREASURER
Spear, A. E. Dickinson

Bowen, J. W Dickinson

Bradley, W. C Beach

Chernausek, S. Dickinson

Cornelius, F. J Bowman

Dach, J. L Reeder

Dukart, C. R Richardton

Gilsdorf, W. H. . New England

Gumper, A. J. Dickinson

Gumper, J. B Belfield

Hamernek, F Elbow Woods

Heffron, M. M. Dickinson

Hill, S. W Regent

Law, I. M Halliday

Lemieux, D. Stanley

Lyons, M. W Beach

Maercklein, O. C Mott

Morris, V. G Beach

Murray, K. M. Scranton

Nachtwey, A. P Dickinson

Olesky, E Mott

Patterson, S Rhame

Perkins, G. A. Dickinson

Reichert, H. L Dickinson

Rodgers, R. W Dickinson

Schumacher, N. W. Hettinger

Smith, Oscar Killdeer

Spear, A. E Dickinson

Williams, M. W Hettinger

STUTSMAN COUNTY MEDICAL SOCIETY

PRESIDENT

Conrad, J. L Jamestown

SECRETARY-TREASURER
Brainard, Bertha B. Jamestown

Arzt, P. G Jamestown

Brainard, Bertha B Jamestown

Cabot, S Jamestown

Carr Agnes Thorpe Jamestown

Carr, John D Jamestown

Carpenter, G. S. Jamestown

Conrad, J. L Jamestown

Culbert, M. H Courtney

DePuy, T. L _ Jamestown

Fergusson, V Gackle

Gerrish, W. A Jamestown

Holt, G. H. Jamestown

Karterman, M. R Lake Williams

Longstreth, W. E. J Kensal

Matthaei, Pearl Jamestown

Melzer, S. W Woodworth

Nierling, R Jamestown

Peake, Francis Jamestown

Robertson, C. W. , Jamestown

Sorkness, J Jamestown

Wood, W. W Jamestown

Woodward, F. O Jamestown

TRAILL-STEELE COUNTY MEDICAL SOCIETY

PRESIDENT

Fowlie, J. A Hope

SECRETARY-TREASURER
Vinje, Syver Hillsboro

Cuthbert, W. H Hillsboro

Hjelle, C. A Portland

Kjelland, A. A Hatton

Knutson, O. A Buxton

Little, R. C. Mayville

Odegaard, Bernt Mayville

Rose, N. J Finley

Savre, M. T Northwood

Vinje, Syver Hillsboro

PRESIDENT

Crawford, John. New Rockford

SECRETARY-TREASURER
Hammargren, A. F Harvey

Boyum, P. A. Harvey

TRI-COUNTY MEDICAL SOCIETY

Crawford, John New Rockford

Donker, A. E Carrington

Goss, E. L. Carrington

Hammargren, A. F Harvey

LaPointe, Jos. P Harvey

MacLachlan, C San Haven

Matthaei, D. W Fessenden

Meadows, R. W._ Carrington

Owens, C. G Sheyenne

Seibel, J. J. Harvey

Van de Erve, H Carrington

Westerveldt, A. E Bowden

352 THE JOURNAL-LANCET

ALPHABETICAL ROSTER

AbPlanalp, I. S. Williston

Alger, L. J. Grand Forks

Almklov, L. Cooperstown

Arneson, A. O. McVeille

Arenson, C. A. Bismarck

Arnson, J. O. Bismarck

Arzt, P. G Jamestown

Aylen, J. P. Grafton

Baer, DeW Steele

Baillie, W. F. Fargo

Barnes, N. J. Fargo

Bartle, J. P San Flaven

Bateman, C. V Wahpeton

Beithon, E. J. Hankinson

Benson, O. T. Glen Ullin

Benson, T. Q. Grand Forks

Bentzen, Olaf Grand Forks

Benwell, FI. D Grand Forks

Berg, H. M. Bismarck

Blatherwick, W. E. Van Hook

Bertheau, H. J Linton

Bodenstab, W. Fd. Bismarck

Boertli, E. Buffalo

Borland, V. G Fargo

Bowen, J. W Dickinson

Boyum, P. A. Harvey

Bradley, W. C Beach

Brainard, Bertha Jamestown

Brandes, H. A. Bismarck

Brandt, A. M. .— Bismarck

Bray, R. B Fargo

Breslich, P. J Minoc

Brink, N. O. Bismarck

Brown, Fred Valley City

Brown, R. C. Fargo

Brown, W. G. Fargo

Buckingham, T. W. Bismarck

Bunting, F. E. Mandan

Burton, P. H Fargo

Cabot, G. S. Jamestown

Call, A. M Rugby

Campbell, R. D. Grand Forks

Campbell, W. Valley City

Cameron, A. L Minot

Carpenter, G. S. Jamestown

Carr, Agnes Thorpe Jamestown

Carr, A Minot

Carr, Andy M Minot

Carr, J. D Jamestown

Chernausek, S Dickinson

Clay, A. J Fargo

Conrad, J. L. Jamestown

Constans, G. M Bismarck

Cornelius, F. J Bowman

Countryman, G. L Grafton

Countryman, J. E Grafton

Cowan, J. A Flaxton

Craven, J. P. Williston

Crawford, John New Rockford

Culbert, M. H Courtney

Cuthbert, W. H Hillsboro

Dach, J. L Reeder

Dalager, N. O Anamoose

Darrow, Frank I Fargo

Darrow, K. E , Fargo

DePuy, T. L Jamestown

Devine, J. L._ Minot

Dillon, J. G Fargo

Diven, W. L Bismarck

Dochterman, L. B. Williston

Dodds, G. A. San Haven

* Honorary

Donker, A. E Carrington

Drew, G. F. ... Devils Lake

Dukart, C. R. Richardton

Durkee, C. A. Abercrombie

Dyson, R. E. Minot

Eastman, L. G. Hazen

Elofson, C. E — Fargo

Engesather, J. A. D. Brockett

Ehrenfeld, H. M. Minot

Evans, L. J. New York

Fardy, M. J. Minot

Fawcett, J. C Devils Lake

Fawcett, N. W Devils Lake

Fawcett, W. C. Starkweather

Fergusson, F. W. Kulm

Fergusson, V. O. Gackle

Fergusson, W. C. .... Fargo

Field, A. B. Forest River

Fisher, A. M Bismarck

Fjelde, J. H. Fargo

Flaten, A. N. Edinburgh

Floew, A. T Fargo

Ford, F. W. Minnewaukan

Fortin, H. J Fargo

Fortney, A. C Fargo

Foster, G. C Fargo

Fredricks, L. H. Bismarck

Freise, P. W.. Bismarck

French, H. E. Grand Forks

Frogner, G. S Parshall

Gaebe, O. C. New Salem

Garrison, M. W. Minot

Gerdes, Maude M

.... . Minneapolis, Minn.

Gerrish, W. A. Jamestown

Gillespie, D. R Mohall

Gilsdorf, W. H. New England

Gaspel, G. W. Grafton

Glaspel, C. J Grafton

Goehl, R. O. Grand Forks

Goodman, R. Powers Lake

Gordon, W. L. Washburn

Goss, E. L. Carrington

Graham, J. D. ... . Devils Lake

Grangaard, H. O. Ryder

Grant, G Wishek

*Grassick, James Grand Forks

Greengard, M. .... Cando

Griebenow, F. F. Bismarck

Gumper, A. J Dickinson

Gumper, J. B Belfield

Haagensen, E. C Grand Forks

Halliday, A. B Hebron

Halliday, D. J Kenmare

Halverson, H. L Minot

Hamernekj F. Elbow Woods

Hamilton, E. E __ New Leipzig

Hammargren, A. F Harvey

Hanna, J. F Fargo

Hanson, G. C Minot

Haroldson, O Minot

Hardy, M. A. Minto

Haugen, H. Fargo

Haugrud, E. M Fargo

Hayhurst, J. O Rolette

Haynes, G. H Lisbon

Heffron, M. M Dickinson

Heimark, A. J Fargo

Heinzroth, G. E Turtle Lake

Henderson, R. W Bismarck

Hendrickson, G Enderlin

Hetzler, A. E. .... Mandan

Hill, S. W Regent

Hjelle, C. A Portland

Hoeper, P. G. E Williston

Hofto, J. M Grand Forks

Holt, G. H Jamestown

Horsman, A. T Devils Lake

Hoskins, J. H. Wahpeton

Hunter, G. W. Fargo

Huntley, H. B. Kindred

Irvine, V. S Park River

Ittkin, P. Tolley

I vers, G. U Fargo

James, J. B.. Page

Jelstrup, C Big Lake, Minn.

Johnson, J. A . Bottineau

Johnson, P. O. C Watford City

Joistad, A. H.._ Fargo

Jones, C. S. Williston

Kaess, A. J Fargo

Karterman, M. R. Lake Williams

Kempthorne, C. Minot

Kermott, L. H Minot

Kjelland, A. A Hatton

Knutson, O. A Buxton

Kolb, F. K. Granville

Krogstad, L. T Minot

Lampert, N. T Minot

Lancaster, W. E. G Fargo

Landers, C. H. .... 2469 N.

Holliston Ave., Altadena, Calif.
Landry, L. H. .Walhalla

LaPointe, J. P. Harvey

LaRose, V. J. Bismarck

Larson, E. J Underwood

Larson, G. A Fargo

Larson, L. W. Bismarck

Laugeson, L. L. San Diego, Calif.
Law, H. W. F. Grand Forks

Law, T. M. Halliday

Lees, H. D. Philadelphia, Pa.

Leigh, R. E. Grand Forks

Lemieux, D. . Stanley

Lewis, T. H. Fargo

Liebeler, W. A. .... Grand Forks

Limburg, M Fargo

Lipp, G. R Bismarck

Little, R. C Mayville

Lohrbauer L. T. Grand Forks

Long, W. H Fargo

Longstreth, W. E Kensal

Lyle, W. D Havanna

Lund, A. B Leeds

L.ynde, R Ellendale

Lyons, M. W Beach

McGouvern, T. E Velva

McCannel, A. D. Minot

McGee, W. J Flaxton

McGurren, C. J Devils Lake

McIntosh, J. G Devils Lake

McQueen, W. W. Langdon

Macdonald, A. C Valley City

Macdonald, A. W Valley City

Macdonald, J. A Cando

MacGregor, M Fargo

MacLachlan, C San Haven

Maercklein, O. C Mott

Mahon, R. M Grand Forks

Matthaei, D. W Fessenden

Matthaei, Pearl V Jamestown

Mattson, R. H McVille

THE JOURNAL-LANCET

353

Meadows, R. W Carrington

Melzer, S. W Woodward

Meredith, C. J. Valley City

Merrett, J. P _. Marion

Miller, H. H Wahpeton

Miller, H. W _ Casselton

Miller, J. P Grand Forks

Miller, S Ellendale

Moffatt, G. Crosby

Monteith, G Hazelton

Moore, J. H Grand Forks

Moore, W. H _ Valley City

Morris, A. C Fargo

Morris, V. G Beach

Moyer, L. B Carson

Mulligan, T Grand Forks

Mulligan, V. A Langdon

Murray, K. M Scranton

Muus. FI. O Grand Forks

Nachtwey, A. P. _____ Dickinson

Needles, A. S Grafton

Nelson, L. F Bottineau

Nichols, A. A Fargo

Nichols, W. C Fargo

Nickerson, B. S Mandan

Nierling, R. D Jamestown

O’Brien, L. T Wahpeton

Odegaard, B ___ Mayville

Oftedal, A. Fargo

Olafson, K , Cando

Olesky, E. Mott

Olson, C. T Wyndmere

Orr, August Bismarck

O’Neill, R. T Minot

Ostfield, J. R Fargo

Owens, C. G Sheyenne

Owens, P. L Bismarck

Panek, A. F Milton

Pangman, W. J Riverside, Calif.

Patterson, S Rhame

Patterson, T. C Lisbon

Patterson, C.

Fargo Veterans Flospital, Fargo

Peake, F. M Jamestown

Peake, M. F Grand Forks

Pence, J. R Minot

Pence, R. W Minot

Perkins, G. A Dickinson

Pierce, W. B Bismarck

Platou, C. A Valley City

Pray, E. A Valley City

Pray, R. E Fargo

Quain, E. P Bismarck

Quain, F. D Bismarck

Quale, V. S Grand Forks

Radi, R. B Bismarck

Ramstad, N. O Bismarck

Rand, C. C Crystal

Ransom, E. M Minot

Rasmussen, F. P. ___ Beulah

Reichert, H. L Dickinson

Reiswig, A. FI Wahpeton

Ribble, G. B LaMourc

Rice, C. P Wahpeton

Rice, P. F Solen

Richter, E. FI ___ Flunter

Rindlaub, E. P Fargo

Roan, M. W Bismarck

Robertson, C. W. Jamestown

Rodgers, R. W Dickinson

Rogne, W. G McClusky

Rollefson, C. J Crosby

Rollie, C. O Drake

Rose, N. J Finley

Rosenberger, H. P. Bismarck

Rostel, H Fargo

Rothnem, T. P Fargo

Rowe, P. H._ Minot

Ruud, M. B Grand Forks

Rystad, O. FI. Grand Forks

Salvage, F. E. LaMoure

Sand, O Fargo

Sasse, E. G Lidgerwood

Savre, M. T Northwood

Schatz, G. West Fargo

Schoregge, C. W. Bismarck

Schumacher, N. W. _ Hettinger
Schwinghamer, E. J. Grenora

Sedlacek, B. B __1 Ft. Totten

Sedlak, O. A Fargo

Seibel, J. J Harvey

Seiffert, G. S Minot

Shepard, W. B. Linton

Sherman, C. H Oakes

Sihler, W. F Devils Lake

Skarshaug, H. J Fargo

Skelsey, Albert W Fargo

Skovholt, H. T Williston

Smith, C. Devils Lake

Smith, C. C Mandan

Smith, J. A Noonan

Smith, LeRoy G. Mandan

Smith, O. M Killdeer

Sorenson, A. R Minot

Sorkness, J. Jamestown

Spear, A. E Dickinson

Spielman, G. H Mandan

Stackhouse, C. E Bismarck

Stafne, W. A Fargo

Stickelberger, Josephine Oberon

Stolinsky, A Lisbon

Strauss, F. B Bismarck

Stromberg, G. E Langdon

Swanson, J. C Fargo

Tainter, Rolfe Fargo

Thompson, A. M Wahpeton

Thompson, A. Y Larimore

Thompson, R. C Wilton

Timm, J. F. Makoti

Tompkins, C. R. Grafton

Toomey, G. W Devils Lake

Tronnes, N Fargo

Vance, R. W. Northwood

Van de Erve H Carrington

Van Houten, J Valley City

Verret, B. D Rollo

Vigeland, J. G Brisbane

Vinje, S. Hillsboro

Vonnegut, F. F. Hague

Wagar, W. D Michigan

Waldren, H. M., Jr. . Drayton

Waldren, H. M., Sr. Drayton

Waldschimdt, R. H. Bismarck

Watson, E. M. Fargo

Weed, F. E. Park River

Weeks, S. A Ambrose

Weible, R. E. Fargo

Westervelt, A. E Bowdon

Westley, M. D. Cooperstown

Weston, D. T. Mandan

Weyrens, P. J Hebron

Wheelon, F. E Minot

Whittemore, A. A. Napoleon

Wicks, F. L Valley City

Widmeyer, J. P , Rollo

Williams, Maysil Bismarck

Williams, M. F Hettinger

Williamson, G. M Grand Forks

Winn, W. R. __ Fargo

Witherstine, W. H. Grand Forks

Wood, W. W Jamestown

Woodward, F. O. ____ Jamestown

Woutat, P. H. Grand Forks

Wright, W. A Williston

Yoemans, T. N Minot

Zimmerman, S. A Valley City

The Fiftieth Anniversary of the North Dakota
State Medical Association

A. W. Skelsey, M.D.
Fargo, North Dakota

IN CONNECTION with the proposed celebration,
our historian, Dr. James Grassick, was requested to
give for the anniversary a review of some of the
leading events affecting the medical world during our 50
years of history. He kindly but truthfully replied that
he had already collected much historical data for us,
especially that concerning the State itself, and that now

it was the duty of some others to add their quota. As
he fails to pass along his "torch” to us, we must first
remind you of the very valuable and interesting material
to be found in his first volume of North Dakota Medi-
cine. None of us can equal him in suitable language
and vivid description of the pioneer days. To the
younger medical generation we earnestly commend his

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THE JOURNAL-LANCET

book that they may appreciate fully the lives and the
experiences of those Dakota pioneers.

Now, in contrast, modern hospitals, improved meth-
ods and accessories for treatment of the sick and the
maimed, rapid transportation by automobiles and air-
planes, and concrete roads mean commercial and pro-
fessional death to some of the formerly prosperous small
towns. Stronger competition meets the individual phy-
sician in those smaller locations, due to easier access to
the clinics and the hospitals of the larger towns. Seem-
ingly, the general practitioner is being edged out of the
professional race. So, also, does North Dakota itself en-
counter these changed conditions, in that today by quick
and comfortable modes of transportation the North Da-
kotans travel on to yet larger clinics and to more noted
doctors beyond our borders.

Supplemental to Dr. Grassick’s book, should you de-
sire to consider other events affecting the profession here
and in the country at large, we submit the following
facts for your consideration: In the year 1880 the north-
ern portion of the Territory of Dakota contained 36,305
persons, excluding Indians. In 1887 was created what
now constitutes the State Medical Association. North
Dakota was not legally separated from the southern por-
tion of the Territory until 1889, when there came into
existence the present divisions of North and South Da-
kota. Therefore, our society preceded by two years the
birth of North Dakota. According to the old records,
politically the birth of these twins was accompanied with
great travail; some of the quarrelsome subjects con-
cerned the attempt to intrude into North Dakota the
Louisiana Lottery of national fame, and the attempt
also to introduce strong State prohibition of liquor.

Our present population is about 675,000. We have
no large cities. Agriculture is practically our only re-
source financially, and unless the farmers, upon whom
we are all dependent, can get good prices for their prod-
ucts, we all experience financial distress. On the other
hand, having no large industries, we are fairly free from
the serious labor troubles prevailing in commercial and
textile centres. Owing to the unusually severe droughts
which we have experienced for several years past, very
many thousands of our Dakota families are now "on
relief,” furnished through such agencies as the Federal
Resettlement Administration, the WPA, et cetera. The
former department has been very helpful, coming to the
rescue often where the WPA workers have been released
on account of severe climatic conditions or unassigned
appropriations for the latter class of workers. Through
the aid of our own Committee on Medical Economics
and the efforts of one of our medical men then on the
State Welfare Board we have been able to effect an ar-
rangement with such organizations and certain counties
whereby there has been adopted a minimum fee schedule
for the physicians caring for those on relief. Just at
present, there is no regular doctor on our State Welfare
Board, but we hope some arrangements may be made
for such representation there.

The past half century has greatly modified and en-
larged the fields of medicine. Now there are decided

divisions into such subjects as internal medicine, sur-
gery, gynecology, obstetrics, orthopedics, and other spe-
cialties, with newly created organizations for the careful
examination of persons claiming specialty. For many
years practically all of our states have had medical ex-
amining boards conducting rigorous general medical ex-
aminations, or, in lieu thereof, accepting reciprocal cer-
tificates from states properly accredited. A recent addi-
tion to the plan has been the inclusion of a fourth day
practical examination. We now have the National Board
of Medical Examiners, a body comparable to similar
systems in Great Britain. The fortunate holder of a
diploma from our National Board is usually admitted
to any of our states on reciprocal basis.

Our two-year medical school connected with the Uni-
versity in Grand Forks was organized in 1905. It re-
quires for admission to its first-year class three years of
collegiate work. The total number of students is re-
stricted to between 50 and 60. Nearly all of its grad-
uates have done well in the other medical schools where
they have gone to complete the final two years. They
have succeeded in scholarship as well as professionally.
Due to our very severe droughts of recent years the
medical department has not received from the legisla-
tures all of the appropriations deemed necessary by the
American Medical Association’s Council on Medical Ed-
ucation. That Council has removed our medical school
from its list of approved institutions. Representatives
from our State Medical Association will appear before
that Council in June, 1937, to urge the American Med-
ical Association to modify its action, particularly in view
of the fact that, despite our very straightened circum-
stances, our last legislature increased its appropriations.
Of course large buildings and expensive laboratories are
of great value, but under present conditions in this sec-
tion of the country, scholarship and successful profes-
sional careers should also have much weight with the
Council. Proper acknowledgment is duly accorded to
that national society and to its councils, yet they should
also clearly realize that, even with fairly moderate phys-
ical equipment, the medical schools of a few decades ago
did valuable work and sent out many talented practi-
tioners to successful careers.

Universities, Medical Schools, Foundations
and Endowments

There has been a great change, not only in other sec-
ular education, but also in the field of medicine. The
heavy requirements placed upon medical colleges to fit
them for the highest rating have caused the disappear-
ance of the very low and the medium grade medical
schools. Vast sums of money have been given to private
and collegiate-grade institutions by individuals or have
been secured from trust funds. Most liberal appropria-
tions have been granted by state legislatures, so that now
their medical schools, as well as those of the private or
denominational colleges, have obtained international
recognition. This is a decided contrast to that of only a
few years ago, when foreign authorities gave recognition

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355

to but a few of our schools. A resume of some notable
foundations, gifts and institutions is appropriate here.

John D. Rockefeller, who died May 23, 1937, alone
contributed for educational and other philanthropic pur-
poses a sum amounting to over $530,853,632 from 1855
to 1934. Included in this were gifts as follows:

The University of Chicago $34,708,375, The Rocke-
feller Institute for Medical Research $59,931,891, The
Rockefeller Foundation $182,851,480, The General Ed-
ucation Fund $129,209,167, The Laura Spielman Rocke-
feller Memorial $73,985,313, The Baptist Church, over
$20,000,000. Part of these gifts, as can be seen, went
to medical education or research.

A few decades ago a southern institution with a de-
nominational background was offered a million or two
provided it become secular; the arrangement went
through, and the university now has an imposing group
of medical buildings. The increased wealth and the vast
number of buildings of many of our colleges and uni-
versities are the marvels of the age. Note the attendance
at some of those listed below:

Attendance, 1932

New York University, a private institution . 40,665
Northwestern University, Evanston-

Chicago. Private - 14,562

Boston University. Private 14,611

Carnegie Inst, of Technology. Private . 5,262

College of the City of New York.

Municipal 26,293

Columbia, New York. Private 37,808

Duke University. Private. 99 years old, but
fairly recently endowed by the Duke To-
bacco Estate, $20,000,000 2,658

Emory University. Private. 100 years old, but
removed several years ago from a small town

into Atlanta, Ga. Endowed 2,051

Fordham University. Private 8,754

George Washington University, Washington,

D. C. Private 8,585

Harvard University. Private 8,536

University of Chicago. Private 7,613

University of Pennsylvania. Private 15,800

Western Reserve. Private 9,043

Washington University. Private 7,355

Yale University. Private 5,388

University of Pittsburgh 14,342

Iowa State College of Agr. & Mech. Arts.

State 13,753

State University of California 19,235

State University of Illinois 14,986

State University of Michigan 15,500

State University of Minnesota 13,864

The University of Pittsburgh is now celebrating its
150th birthday, just completing its new home, the Ca-
thedral of Learning, a skyscraper of 42 stories, costing
about $20,000,000. Nearby is its noted medical centre.
Columbia of New York City has its 183rd Commence-
ment. Awards about 4,500 degrees, diplomas and cer-
tificates. The two great medical centres in New York
City are said to represent each an outlay of $50,000,000.

The Regular Medical Profession and the
Irregulars

We continue to have a serious surplus of regular doc-
tors, despite gradually increasing admission and gradua-
tion requirements. Failing to gain admission to our own
medical schools, a large number of students are now
going to Europe for their medical work.

Many of our doctors are affiliated with the local,
state, and national medical organizations. The American
Medical Association now has a membership of 105,460
physicians — the largest in its history. In North Dakota,
out of the total number of regular doctors, our Society
enrolls about 400 annually.

The Eclectic medical system is not now prominent.
They have a medical college in Cincinnati. Homeopathy
has gone off the main highway. When one does encoun-
ter a homeopathic physician, he usually is utilizing reg-
ular medical procedure and medication. There is a
homeopathy medical school in Philadelphia, and one in
New York City. There are now only five state Home-
opathy Medical Examining Boards. Those state uni-
versities which a few decades ago furnished separate
medical schools for homeopaths have abandoned such
distinction and added expenses; about the only vestige
left of this system may be a notice in the catalogue
offering a few lectures on homeopathic medicine.

The only separate college for women medical stu-
dents, so far as we know, is the Woman’s Medical
College in Philadelphia. The past year that institution
graduated 33 women, compared with 213 medical
females from coeducational colleges. The total number
of women practitioners keeps fairly constant. There are
now 1133.

The chiropractors constitute a later eruption from
osteopathy. Alleging that they are the latest scientific
product they doubtless consider themselves of the elect.
Their entire lack of modesty in crying their wares and
their own merits is stated to have been augmented by
the clever advertising section of their "colleges.” The
human spinal column must bring in much cash income
to these sectarians. In violation of the laws under which
they are working, they are trespassing very decidedly
into fields not their own.

The osteopaths have veered greatly from the old-time
definition of their healing art, i. e., that of relieving im-
pinged nerves which caused all diseases. Now they ad-
vertise teaching colleges giving instruction in all sub-
jects to be found in the regular medical schools. They
have been enabled in several states to obtain recognition
giving them practically all of the rights and privileges
of the regular profession.

In practically all states, in and out of legislative sea-
sons, vigorous and politically-influenced attempts are
made by various of these irregulars, attempting to secure
legal recognition of such vagaries as naturopaths, sani-
practors, etc. Much money is spent by them in these
efforts.

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Growth of Wholesale Pharmaceutical
Establishments

While this has in many ways been beneficial to our
profession and also affords efficient and scientific means
of securing biological and other products under Federal
supervision, it has developed a high pressure and very
effective method of getting not only before the doctors
themselves, but also to the public, the dentists and the
irregulars, samples of all types of medication. Not in-
frequently, so far as the physician is concerned, the
pharmacist passes out to the patrons thousands of such
samples duly labeled with copyright or trade names.
The magnitude of mass publicity is well shown by an
advertisement of a large proprietary firm in the Ameri-
can Druggist for May, 1937, stating that the firm will,
during the year, "publish 427,785,583 advertisements in
the consumers’ magazine and newspapers.”

Hospitals have increased greatly in size, numbers, and
superior equipments; they are now more freely utilized
by the public, especially as compared with the patronage
of earlier periods. Economic conditions have induced
them individually and in groups, to offer to the public
for 21 days hospitalization at a yearly cost of $10.00.

Radios affect the medical profession. Utilized very
freely by quacks of all description, from small-fry up to
noted cancer-cure fakers. Offsetting this, to some extent,
have been the discussions by some competent medical
men.

The automobile and the air-plane, as stated above,
have materially changed our mode of life. On the wrong
side of the ledger is the astounding death rate from auto-
mobile accidents; last year the number killed was about
38,000, and to this must be added the many thousands
of accidents due to automobiles.

Birth control, in these very modern and hectic years,
is freely bandied about. Conflicting views arouse angry
discussions and pamphlets. Cass County Medical So-
ciety tackled the proposition and voted in favor of it,
and, in addition, has arranged for local parlors afford-
ing instruction in its technique.

The open and very free discussions about euthanasia
clearly indicates the tendencies of these years. In Eng-
land lately an attempt was made to legalize the practice
of "mercy-deaths,” but the measure failed of adoption
in Parliament. Also, in Nebraska this year, the bill
introduced was squelched.

Mass movements now aim to eradicate diseases of all
types. While the medical profession has always been
alert to help in the cause of preventive medicine, it seems
that in later years there is a tendency toward undue
interference by outside agencies seeking to exploit the
doctors and thus gradually causing friction and appre-
hension regarding probable "state medicine”.

One is told that our population has swung so far
from Victorian restraints and prudery that many are
headed downwards to the lowest depths of immorality.
The nation’s well-meant plan of national prohibition
against liquors did not succeed; hence the saloon, the
booze, and the barmaids are back with us. The for-

merly legally restricted prostitution districts have been
declared inhumane and revolting to mankind as well as
affording nidi for fearsome diseases and later divorces;
therefore, the old-time red light areas have been sub-
merged into the residential and the business blocks. The
movie films and movieland itself have become so extreme
in depicting erratic and erotic lives, that some of the
religious denominations have been compelled to protest,
the Catholic Church especially. Pornographic literature
is allowed to pass through the mails and is avidly public-
ly read by many persons, who only a few years ago would
not be bold enough to do so. Perhaps as a result of these
modern happenings comes from Dr. Parran of the
U. S. Public Health Service and also from the Health
Department of New York City the warnings that very
many thousands of persons are afflicted with syphilis,
and demands of an immediate mass movement against
that disease. They also urge the regimentation of all
physicians and social agencies in the support of the
Federal and local services expected to be given.

Fifty years ago in this country, very few women
smoked, at least publicly. Now, at the risk of being
called upon for exact data, we may feel safe in saying
that at least one-third to one-half of the female sex
openly and defiantly puff some form of tobacco. Thou-
sands and thousands of dollars are spent by manufac-
turers of tobacco, especially of cigarettes, in the most
gorgeous and glamorous manner, to urge on the number
of addicts. At intervals a modern Jeremiah travels
along modern routes, claiming that in "research work”
he had found traces of nicotine in the mammary glands
and the nipples of pregnant and lactating mothers. But
who, after reading and seeing the advertisements describ-
ing the benefits from smoking ensuring guaranteed en-
ergy and "poise”, would object to a slightly nicotinized
maternal lacteal outflow? Indicating the liberal opinions
of these years, the North Dakota legislature has now
withdrawn the former legal restrictions against smoking
in restaurants and other public resorts.

And after these almost 50 years of questionable state
and local prohibition, all intoxicants are permissible here.
We dare not here try to give an estimate of the liquor
habits in this part of the country more than to say that
there are much fewer liquor prescriptions given by doc-
tors now that prohibition is non-existent. As a rule,
however, during the Federal restrictions, there were not
many of our doctors who, by issuing excessive liquor
prescriptions, violated the laws. Now that there are so
many deaths and thousands of accidents due to auto-
mobiles, the National Council of Safety’s slogan is:
"When you drink, don’t drive.”

Federal, state and local laws governing pure foods
and drugs, the sanitation and safety of factories, mines,
etc.; quarantine; child labor regulations; shorter hours
of employment; reporting of contagious diseases; com-
pulsory vaccinations and immunizations; Federal and
local control of narcotics and their distribution have
had their influence on medicine and induced better con-
trol of disease. Tuberculosis, small-pox, diphtheria,
yellow fever and other diseases are not now nearly so

THE JOURNAL-LANCET

357

prevalent. Diabetes, while still one of the leading dis-
eases, has been controlled better since the discovery and
the use of insulin. Syphilis is now being treated by more
modern methods and medications, and here the arsenicals
give most excellent results. Poliomyelitis is yet a serious
menace, especially in epidemics; nor has yet any definite
specific been found for it. Among the diseases heading
the death columns are cancer, heart disorders, pneu-
monia, and appendicitis. The recent advent of sera
treatment in some tyes of the pneumonias seems to offer
hope. The advance in anesthesia, general and local, has
been notable. There are now many surgeons who do
the major portion of their work under spinal anesthesia.
The modern use of the endocrines and the fairly recent
development of the theories regarding the vitamins has

evolved a prodigious amount of literature, including
probably much advertising and exploitation by large
chemical concerns and some physicians. Out of this mass
of claims and advertisements, there have come some
fairly well proved values. As usual, the laity come in
on this with self-medication resulting.

As a substitute for an allegedly great improvement
over the older sedatives, enter the barbiturates backed
with great vigor and advertisements by the proprietary
concerns. From prescriptions and possibly some free
samples the public is now well informed regarding these
drugs, and freely purchases them over the counters.
Drastic legislation should be enforced, to prevent the
indiscriminate use of such drugs. But can the druggist
be reformed?

Epidural and Subdural Hemorrhages

Thomas S. P. Fitch, M.D.

Plainfield, New Jersey

IN COLLEGE ATHLETICS, head injuries are not
at all unusual. The most frequent type encountered is
simple cerebral concussion in which the patient is
merely dazed or shows a transient period of unconscious-
ness.

Fortunately, the grave type of head injury, which we
meet in automobile accidents and industrial accidents, is
not often encountered as a result of competitive sports.
This type is manifested by a sudden and profound coma
which persists and is accompanied by a rapid pulse and
slow but continuous rise of temperature. These patients
do not present signs of increased intracranial pressure
and almost invariably end fatally. At autopsy, multiple
minute punctate hemorrhages are found scattered
throughout the white substance of the brain and fre-
quently small hemorrhages are present in the mid-brain,
pons and medulla.

The treatment of this class of patients at the present
time is entirely unsatisfactory. You are undoubtedly
familiar with the treatment of ordinary head injury,
consisting of simple concussion or contusion of the brain,
by shock measures followed by dehydration and spinal
punctures.

There is a great difference of opinion as to the treat-
ment of these cases. Each exponent of a particular
method claims the best results by his pet theory.

I will skip over this group of cases and dwell upon
the class of epidural and subdural hemorrhages. This
class presents the most serious outlook of the group of
head injuries encountered in college athletics. They are
not extremely rare and should be thought of and care-
fully excluded in all cases coming under the observation
of college physicians.

* Illustrations and portions of this article are reproduced by
express permission of The Journal of the Medical Society of New
Jersey, \ ■ -

I should like to present a short series of such cases as
a clinical talk and attempt to point out significant signs
and symptoms by which these localized hemorrhages can
be diagnosed.

In the entire field of serious head injuries, the recog-
nition and treatment of subdural and epidural hem-
orrhages offers the greatest responsibility to the attend-
ing physician. The physician who recognizes this im-
portant group and proceeds with the proper surgical
treatment will have a great deal of satisfaction. These
cases are often dramatic in their rapid return to con-
sciousness and it is remarkable how function is restored
in these critically ill patients who present themselves with
excruciating headache and perhaps convulsions or hemi-
paresis.

Subdural and epidural hemorrhages will eventually
cause the death of the patient if not treated surgically.
The delayed diagnosis made at autopsy table is a real
tragedy and we can recall such cases with much chagrin.
Many of these cases are lost because the condition is not
thought of.

At times newspaper accounts of the train of events
which have followed an accident very graphically de-
scribe the cardinal symptoms of this condition. We will
read of a patient being taken to a hospital in an uncon-
scious condition and the next day will be told by the
newspaper that the patient has regained consciousness
and is expected to recover. At a later date the newspaper
informs us that a paralysis has occurred and then we
learn that the patient has again lapsed into coma and
finally we read the death notice. This is the typical
sequence of events.

This picture (Figure 1) is taken at autopsy of a
middle-aged gentleman who went to a chiropractor in
Elizabeth. The chiropractor proceeded to adjust his
cervical vertebrae and gave him a severe thrust on the

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Fig. 1. Subdural hemorrhage.

back of his neck. He immediately lost consciousness
and was kept in the office for about an hour until he re-
gained consciousness. He complained of a severe head-
ache but was put in a taxi and sent to his home in
Roselle. That afternoon, he lapsed again into coma and
a regular practitioner was called who immediately sent
him to Muhlenberg Hospital by ambulance. On his
arrival at the Hospital, a head injury was suspected and
1 was called. Before I arrived, the man had died, and
through the courtesy of Dr. Brokaw, the county physi-
cian, I performed the autopsy which shows the condition
pictured here. There is a massive hemorrhage in the
subdural space which shows no lamellation. This case
illustrates several important points: 1st, it shows that a

trivial injury may be the cause of a subdural hem-
orrhage; 2nd, it shows that the force was applied in the
posterior anterior direction of the skull. This is a com-
mon factor; 3rd, it presents the typical lucid interval
which is highly characteristic; 4th, it illustrates the rapid
death which may follow a subdural hemorrhage.

Subdural hemorrhages are most often produced by a
rupture of an unsupported cerebral vein as it leaves the
cortex of the brain to enter the longitudinal sinus in the
region of the vertex. This explains why a blow on the
occiput or the frontal region is most apt to produce these
lesions. It is also important to determine whether the
patient’s head was stationary or in motion at the time of
the impact. It is more apt to occur when the head is
the moving object and is suddenly stopped by the im-
pact against an immovable object. In such a case, the
brain is in motion and the skull is suddenly retarded,
causing the brain to slide in a sagittal direction and
thus tear one of the small emissary veins. I recall a case
of Mr. W. P., 75 years old, admitted to Muhlenberg
Hospital March 14th, 1931, who was struck by an auto-
mobile. He had been stunned; but quickly regained
consciousness. Examination showed abrasion of the left
occipital region and the X-ray showed a linear fracture
of the occipital bone. His spinal fluid pressure was in-
creased and the fluid contained free blood. His right
pupil was dilated and he was unconscious on admission.
His reflexes were increased and he had a bilateral

Fig. 2. Linear fracture across vortex of skull.

Babinski. When I saw him, he was deeply unconscious
and showing Cheyne-Stokes respiration and he died
within a few minutes. Dr. Brokaw again permitted me
to examine his brain and I found a linear fracture of
the left occipital bone extending downward lateral to
the foramen magnum toward the petrous bone. The
left lateral cerebellar lobe showed a contusion about
3 inches in diameter with subarachnoid hemorrhage.
The interesting feature of this autopsy was a contracoup
laceration and contusion of the anterior pole of the right
cerebral hemisphere with a massive subdural hem-
orrhage. This case illustrates very well the mechanism
of the contracoup injuries to the brain. Subdural hem-
orrhage may be due to a laceration of a cortical artery,
as it was in this patient, through a laceration of the
brain. If the bleeding is arterial in origin and especially
if accompanied by a laceration of the brain, the coma
is sudden in onset and the case progresses rapidly to a
fatal termination. If the symptoms progress more
slowly, we can then assume that the origin of the
hematoma is venous in origin.

Dr. B. M. Vance1, from his invaluable experience as
assistant medical examiner of the City of New York,
reports that subdural hemorrhage accounted for 26 °/c
of the deaths of the 507 cases of fractured skull in his
series. In that number, he found a subdural hematoma
of sufficient size to produce increased intracranial
pressure. He records the fracture in these cases most
frequently in the posterior portion of the skull and in
numerous instances there was a contracoup brain injury
causing the hemorrhage. He states that subdural hem-
orrhage below the tentorium is rare and insignificant.
He also calls attention to the relation of contracoup
injuries and the Head being in motion at the moment
of impact. Last spring, I had two boys of the same age
in Muhlenberg Hospital who demonstrated this fact.
One of the boys fell from a limb of a tree while watch-
ing a baseball game and struck his head on a flagstone
beneath the tree. He showed an extensive depressed
fracture in the right parietal region, was deeply uncon-
scious and showed focal signs pointing to the left cer-
ebral hemisphere. The second boy was catching at base-
ball behind the bat and sustained a severe blow in the
right parietal region from a powerful swing of the

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359

Fig. 3. Encephalogram. Normal position of ventricles.

batter. His X-ray showed practically an identical de-
pressed fracture in the right parietal bone. The first
boy ran a very stormy course of coma and a period of
irrationality and irritability before his eventual recovery,
while the second boy dropped unconscious immediately
on receiving the injury but soon recovered consciousness
and made a completely uneventful recovery. In the first
case, the head was in motion and the lad received a
severe contracoup injury, while the second lad’s head
was at rest and the trauma was entirely local and con-
fined to the right side.

Epidural hemorrhage has many points of similarity
with subdural hemorrhage as far as the symptomatology
is concerned. Again quoting Dr. Vance, who reports
that epidural hemorrhage is rare in childern and is most
frequent in patients between 30 and 40 years of age.
The reason for this is that the middle meningeal artery
is not canalized in the skull in early youth. Of epidural
hemorrhage, which constitute about 12% of deaths from
fractured skulls, the middle meningeal artery was the
one most frequently ruptured but the lateral sinus
accounted for some.

This X-ray picture (Figure 2) , is from G. O. V., age
20 years, a parachute jumper of the U. S. Navy, who
was admitted to Middlesex Hospital on June 13th, 1933.
He was riding his motorcycle from Pensacola, Fla., to
the Brooklyn Navy Yard and was upset and hurtled
through the air, head foremost, against a tree. He was
dazed but had recovered consciousness on admission to

Fig. 4. Shift of ventricles in extradural hemorrhage.

the hospital and complained of severe headache. This
X-ray was taken by Dr. Avery with a portable machine.
I saw him two days later and found the patient very
drowsy but could be aroused and was cooperative. He
complained of an excruciating headache in the frontal
region and pain back of his eyes. My examination
showed bilateral choking of his optic discs, contracted
but equal and active pupils, the left abdominal reflex
was easily exhausted, the right remaining active. He
showed a definite weakness of both lower extremities
and positive Babinski. His chart showed his tempera-
ture was 99, pulse 52, respiration 14, which is suggestive
of intracranial pressure. I did a spinal puncture and
to my amazement, the mercury rose to the 50 mm. mark.
The fluid was clear. I withdrew the needle immediately.
It is very unusual to have such a high acute pressure
with a conscious patient. It does occur in chronic pres-
sure of tumors but seldom in acute head injuries. I
immediately took him to the operating room and used
local novocame anesthesia instead of general anesthesia
because of this high intracranial pressure. I made a
horse-shoe incision with the base posterior right over the
depressed fracture area and reflected the skin flap. The
fracture line was exposed with its depression and I made
an osteoplastic flap across the mid-line over the vertex.
On reflecting the bone, a large extradural blood clot
was evacuated from both sides. The patient stated that
there was instant relief of his headache when the bone
flap was elevated and he brightened up and laughed and

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Fig. 5. Fracture crossing middle meningeal artery.

joked with us through the remainder of the operation.
1 scooped out large firm clots from both sides, returned
the bone flap to its place and left two rubber tissue
drains, one on each side. We typed him and that eve-
ning gave him 310 cc. of blood by transfusion. Three
days later, his temperature was 99, pulse 80, respiration
20. The weakness of the extremities was improved and
he was bright and cheerful. Six days later the sutures
were removed and the skin flap had healed by primary
union. Ten days later he was discharged to the Naval
Hospital in Brooklyn in good condition.

Our next case was A. J., 35 years old, admitted to
Muhlenberg Hospital February 11th, 1933, from in-
juries received in an automobile accident. She was
knocked unconscious but had regained consciousness on
her admission to the Hospital and was complaining of
a severe right-sided headache. She was admitted at 2:30
P. M. and I saw her at 10:30 P. M., 8 hours later. She
was very stuporous, but could be aroused and complained
of a severe headache. Her eyes showed a deviation
toward the right. A slight left facial asymmetry. The
left abdominals were absent and the deep reflexes were
increased on the left side. Her spinal fluid pressure
was 28 mm. of Hg., and bloody fluid present. There
was a weakness of the grip of the left hand. My note
on her chart reads, "... with a history of unconscious-
ness immediately following the accident, with recovery
of consciousness, and now lapsing back into coma, I
advise an immediate operation and search for middle
meningeal bleeding.” We had had no X-rays so far,
and we did not delay the operation at that hour to have
them taken. We took her to the operating room im-
mediately and opened the right side of her skull, and
through the first drill hole in the bone a black clot
exuded. On opening further, an extensive extradural
clot was evacuated. I elevated the brain and exposed
the foramen spinosum and plugged it. A fracture was
seen at the base of the skull running into the foramen
spinosum. I opened the dura and a large amount of
bloody cerebro-spinal fluid spurted out. A drain was
inserted and the wound closed in layers. Eight days
after the operation, the sutures were removed and the
wound was completely healed. Her temperature, pulse
and respirations were practically normal throughout.

She made a complete recovery from all her neurological
signs and was discharged 15 days later. I have seen her
in my office several times since and each time she has
no subjective complaints, saying that she believes she
feels better since her injury than she did before it.

The next case was an Italian, who was in an auto-
mobile accident, admitted to Muhlenberg Hospital
November 28th, 1930, unconscious and recovered con-
sciousness within 24 hours. He showed a dilated and
fixed left pupil. His reflexes were all sluggish. Abdom-
inals and Babinski absent and he developed an engorge-
ment of his retinal vessels, ending in papilledema. The
X-ray showed a fracture, crossing the left middle men-
ingeal artery. His spinal fluid pressure was 30 mm. of
Hg. and the fluid was bloody. This man continued to
be irrational and highly irritable for several days, re-
sembling a post-traumatic psychosis, frequently running
up and down the hospital corridor in the abbreviated
hospital nightgown. His spinal fluid pressure showed
no tendency to come down under continued drainage
and dehydration treatment, so I finally decided to op-
erate for middle meningeal hemorrhage on the side of
the fracture and the dilated pupil. The subtemporal
area was exposed and a large extradural clot removed.
The middle meningeal artery was plugged at the for-
amen spinosum. This man returned from the operating
room an entirely different individual. It was difficult to
believe that he was the same man. He was so quiet,
docile and cheerful. He made a good immediate post-
operative recovery. Unfortunately, he became involved
in a series of difficult court trials over the litigation of
his accident and in February, 1932, I was called to see
him. The family said that he had been paralyzed on
the left side of his body and had been unable to leave
his bed for more than a week. I examined him and
found no neurological signs of an organic lesion. The
paralysis had been on the same side of the body as his
head injury and by suggestion therapy, I had him up
walking about on my first visit. I wanted to be certain
that he had no hemorrhage on the opposite side and so
admitted him again to Muhlenberg Hospital for en-
cephalography— (Figure 3). You will see by his picture
that there is no deviation of the ventricles and his spinal
fluid pressure was found to be normal. You can readily
see the importance of this procedure in determining
whether the symptoms in this case were organic and the
value that these pictures are in court.

In this next case,*I applied encephalography as an
early diagnostic procedure. E. L., 32 years old, was ad-
mitted to Muhlenberg Hospital May 18th, 1931. This
boy was riding a motorcycle two days before when he
was involved in an accident in which he was dazed from
a head injury. He got on his motorcycle and returned
home complaining of a severe headache and lapsed into
coma. He recovered from his coma at intervals in the
next two days but each time returning to the unconscious
state. The X-ray of this skull on admission, showed
a fracture in the right side of the skull crossing a middle
meningeal blood vessel groove. This boy had no ab-

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361

Fig. 6. Encephalogram in extradural hemorrhage.

normal neurological signs other than intermittent coma
and we found the spinal fluid pressure increased to 30
mm. of Hg. and blood-tinged fluid present. On dehy-
dration, his spinal fluid pressure came down to 22 but
gradually returned to 26 and he developed edema of
his optic discs. Because of the paucity of focal signs,
I performed an air injection through the lumbar route
and, as you see here, (Figure 4), there is a displacement
of the ventricles toward the left side with a partial
obliteration of the anterior horn of the right lateral
ventricle. I made a temporal opening in his skull and
found a large extradural hemorrhage in the right frontal
region which was evacuated. This boy made a good post-
operative recovery with practically normal temperature
and pulse and was discharged eleven days after his op-
eration and has remained in perfect health to the pres-
ent time.

Our next patient is a girl of 20 years, M. R., who
entered Muhlenberg Hospital February 14th, 1933. She
had been injured in an automobile accident, rendering
her unconscious, and was brought to the Hospital in a
stuporous condition. The patient was drowsy, but could
be aroused. She showed no focal neurological signs. Her
spinal fluid pressure was 18 mm. of Hg. and bloody fluid
present. Her X-ray examination of the skull by Dr.
Boyes, showed a vertical fracture on the left side in the
anterior parietal region (Figure 5), extending from the
vertex to the base. Dehydration treatment and continued
spinal punctures failed to reduce her pressure and on

Fig. 7. Encephalogram in subdural hemorrhage.

the 17th of February she was still complaining of severe
headache in the right parietal region. The left abdom-
inal reflex was more active than the right. Her pupils
were equal and no other neurological signs could be
elicited so I resorted to encephalography and you see
here (Figure 6) that after the air injection there is an
absence of air over the left hemisphere with the shifting
of the ventricles toward the right side. Because of these
findings, in conjunction with the fracture reported by
Dr. Boyer, I took her to the operating room on the 17th.
I made an opening in the left temporal region and on
opening the bone, a large extradural blood clot was
found in the frontal region. I evacuated the clot, elevat-
ed the dura and clipped the middle meningeal artery in
the foramen spinosum. This girl made an uneventful
recovery, running a temperature of not more than 100
post-operatively and was discharged the 31st day after
the operation. She has remained perfectly well until the
present time with the exception of slight numbness in
the second division of the trigeminal nerve which was
inadvertently injured during the exposure of the for-
amen spinosum. There has been no pain connected with
this.

The careful examination of the visual fields may be
of localizing value as in the following case: C. Y. was
referred by Dr. Boyer of Clinton from the N. J. Re-
formatory. The boy had fallen from a truck and had
made a good immediate recovery from what seemed a
trivial head injury. Weeks later he complained of severe

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headaches and appeared apathetic. His eye grounds
showed choked discs and his visual fields demonstrated
a homonymous hemianopsia of the opposite side. Dr.
Boyer sent the boy to the infirmary at Skillman under
Dr. Dan Renner, where I operated upon him on March
8th, 1931. I opened his right temporal region and found
an epidural blood clot. Sixteen days later, on March
24th, he was discharged in good condition. The point
well exemplified by this boy was the importance of tak-
ing the visual fields in localizing the pressure of the
blood clot.

This last case is a patient of Dr. Hegeman’s, who was
injured on August 16th, 1932. While walking on the
road, he was struck by a car. He was unconscious for a
few minutes and was not orientated on admission to
Somerset Hospital. Examination showed a swollen area
over the occiput. The X-ray showed no fracture of the
skull. He was irrational in the early part of his stay in
the hospital, getting out of bed, and appearing in a
dazed condition. His spinal fluid showed the presence
of blood and he complained of headache. On Septem-
ber 1st, 1932, he was discharged mentally clear. On his
return home, his mother states that he was somewhat
irritable and showed clumsiness on the left side of the
body. On October 16th, 1932, he had an attack of
headache and vertigo, with projectile vomiting through
the night. The next morning the patient had a complete
left-sided hemiplegia — the arm more involved than the
leg, and a drooping of the left side of the mouth. The
left pupil was larger than the right. On October 20th,
the patient was taken with a convulsion more marked
on the left side and unconscious for l'/2 hours. I saw
him in consultation with Dr. Hegeman on November
22nd, 1932, at which time he showed a left spastic hemi-
plegia, with no voluntary motion on the left side of
the body. A left central facial weakness and a con-
jugate deviation of the eyes to the left and deviation
of the tongue to the left. There was hypalgesia ana
astereognosis of cortical type on the left side of the
body, more marked in the distal part of the extremities.
Pain and vibratory sense were normal. He obliged us
by going into a Jacksonian convulsion of the left side
with deviation and nystagmus to the left. His spinal
fluid pressure was 18 mm. of Hg. and an air injection
was performed (Figure 7). I diagnosed a subdural hem-
orrhage in the right fronto-parietal region and operated
the next day. A right fronto-parietal osteoplastic flap
was turned down and on reflecting the dura, a large
hematoma with a thick capsule was present over the
right cerebral hemisphere, the greatest volume appearing
in the frontal region. The clot was evacuated and the
membrane removed and the boy made a good post-
operative recovery, the power returning to the upper

and lower extremities and the facial paresis disappeared.
The unusual part of this case was the fact that his
spinal fluid showed a positive Wassermann and this sug-
gests the diagnosis of pachymeningitis hemorrhagica
interna.

Pachymeningitis hemorrhagica interna is a similar
condition which occurs in general paresis, chronic alco-
holism, senile dementia and wasting diseases. This term
is reserved for those cases in which no traumatic history
is obtained. I believe that if a true history were known
the number of these cases would be materially
reduced. The pathological process of these diseases
eventually gives a brain atrophy, so that the cortical
emissary veins are elongated and put under a greater
strain, so that a very trivial injury could rupture them
easily. In addition, these patients have a notoriously
poor memory and their trauma is readily forgotten.

In the differential diagnosis, I will mention only one
condition which is rather rare. That is fat embolism2
which occurs after fractures of the long bones. The
symptoms are similar to the subdural and epidural hem-
orrhages. There is a lucid interval, hemiplegia, mono-
plegia and a rise of temperature. The history of fracture
of the long bones, the absence of marks of cranial
injury, the cutaneous hemorrhages, similar to bacterial
endocarditis, and fat droplets in the sputum and urine
render the diagnosis possible3.

In looking back over these cases, we find that of the
focal signs, probably the most constant is a dilated fixed
pupil. Also the unilateral absence of abdominal and
cremasteric reflexes with a positive Babinski or Oppen-
heim. The central facial weakness, choked discs, and the
increased spinal fluid pressure which does not improve
under dehydration measures. There is a characteristic
type of respiration which resembles that of sound sleep.
The expiratory phase is exaggerated. The coma is apt
to be intermittent. They are mentally dull and drowsy
in the lucid intervals.

In summarizing, I should like to emphasize the fol-
lowing points to guide us: 1st, the lucid interval with
perhaps a trivial injury; 2nd, a careful history of the
circumstances of the accident and the location of the
injury; 3rd, headache, drowziness and coma; 4th, focal
signs, such as dilated pupils, monoplegia, hemiplegia,
visual field defects or Jacksonian attacks; 5th, persistent
increased intracranial pressure; 6th, the value of en-
cephalography as a final court of decision in obscure
cases.

References

1. Vance, B. M., Arch. Surg. May 1927, vol. 14, pp. 10-23-
1092.

2. Vance. B. M., Arch. Surg. Sept. 1931, vol. 23, pp. 426-465.

3. Purvis Stewart, Diag. Nervous Dis., E. Arnold Si Co.,
London, 1931.

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363

Treatment of Pneumonia

Evaluation of Modern Methods

H. Corwin Hinshaw, M.D., Ph.D.**
Rochester, Minnesota

IT IS WISE to pause occasionally and take inven-
tory of our therapeutic armamentarium. Enthusiastic
specific claims are made for several methods of treat-
ment in pneumonia. Protagonists easily leave the erro-
neous impression that their method is of such value that
previously established treatments may be abandoned.

The treatment of pneumonia cannot be standardized,
for pneumonia is not a standard disease. The term
"pneumonia” is a pathologic concept and one essentially
synonymous with pulmonary consolidation. This unique
phenomenon is dependent upon the peculiar course of
acute inflammation in a spongy air-containing organ. It
may be caused by a variety of organisms and may follow
divergent clinical courses.

The erratic and often unpredictable clinical course of
pneumonia renders judgment of therapeutic methods
especially fallacious. The dramatic crisis of lobar pneu-
monia may spontaneously appear very early and be
falsely attributed to efforts at treatment. The result has
been repeated, baseless therapeutic claims. Conversely,
it took more than ten years to prove conclusively to con-
servative physicians the value of specific serum therapy.

Let me, then, very briefly offer opinions on the present
status of several currently popular methods of treatment
for pneumonia:

Oxygen Therapy

Anoxemia is a characteristic feature of most serious
cases of pneumonia. The appearance of cyanosis is clear
evidence of insufficient oxygenation of the blood and is
a definite indication for oxygen therapy. Properly ad-
ministered oxygen can overcome moderate degrees of
anoxemia. The cyanosis, dyspnea, tachycardia and men-
tal symptoms of severe pneumonia are largely due to
anoxemia and resemble those due to oxygen lack in
"mountain sickness” or in experimental oxygen depriva-
tion. The restlessness, delirium, apprehension, and air
hunger of pneumonia may be dramatically relieved by
oxygen. Temperature, pulse and respiration rates are
consistently reduced.

Oxygen is best administered in a modern oxygen tent
which also has the virtue of air-conditioning. Physician
and nurse must clearly understand the construction and
adjustment of the mechanism. It is essential that fre-
quent analysis of the gaseous content of the tent be
made. The technic of analysis is not difficult and may
be accurately carried out by a laboratory technician,
using the convenient apparatus now available.

Oxygen may be administered by nasal catheter when
the oxygen tent is not available. Milder degrees of an-

*Read before the meeting of the Seventh District Medical
Society, Sioux Falls, South Dakota, March 9, 1937.

** Division of Medicine, the Mayo Clinic, Rochester, Minnesota.

oxemia may be overcome by this method. It is simple,
inexpensive, and sometimes surprisingly effective.

Serum Therapy

Serum therapy has passed the experimental stage and
must be accepted as an effective weapon against certain
varieties of pneumonia. It is rarely justifiable to use
antipneumococcus serum without bacteriologic classifica-
tion of the causative organism. The greatest recent ad-
vance in specific therapy has been the perfection of the
rapid, simple Neufeld method of typing pneumococci.
This has been made universally available by the market-
ing of complete typing outfits by several firms.

The effectiveness of Type I antipneumococcus serum
has been well established. Properly used in suitable
cases it may be expected to cut the mortality in half.
Type II antipneumococcus serum appears to be some-
what less effective, but its use is clearly indicated in
Type II pneumonia. With the subdivision of Group IV
into specific types there have appeared other types for
which sera may be prepared.

The cost of serum therapy is the greatest handicap to
its unlimited use in private practice. So far, it has
chiefly been used where special funds were available to
bear this burden. The average case will require from
$100 to $200 worth of serum at present prices.

The effectiveness of serum therapy is multiplied by
early administration, and it is not wise to delay its use
'to see if it should become necessary.” A positive blood
culture of Type I or Type II pneumococci renders
serum therapy nearly obligatory. Sepsis is a common
cause of death in pneumonia, and serum therapy is the
only effective weapon against it.

Artificial Pneumothorax

Pneumothorax treatment of lobar pneumonia remains
in the experimental stage. It has not been accepted by
many conservative physicians. Its use should be restrict-
ed to medical centers and to those thoroughly acquaint-
ed with the technic and complications of artificial pneu-
mothorax. It appears to relieve pleural pain and it is
claimed that artificial crisis may be precipitated. It
should not be used after the third day of lobar pneu-
monia, and it is contraindicated in bilateral disease and
probably in bronchopneumonia.

Medical Diathermy

The early claims of diathermy treatment have not
been realized. It may conspicuously relieve pleural pain,
and its effects seem to be mainly restricted to the chest
wall. It has not been proved that the lung can be sig-
nificantly heated by diathermy. Diathermy appears to
be harmless when properly administered, and if available
may well be tried when pleurisy does not respond to

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simpler measures. There is no proof that the course
of pneumonia is altered, or that the mortality is reduced,
by diathermy.

Chemotherapy

There is reason to hope that chemists and physicians
now engaged in intensive research may yet give us ef-
fective drugs against the pneumococcus. Antistrepto-
coccic drugs are now available for clinical trial, but their
place in medicine remains to be determined.

Postoperative Pneumonia

Pneumonia following surgery is unique in several re-
spects and deserves separate consideration. Surgery
affords opportunity for aspiration and dissemination of
infectious material. At the same time it seriously ham-
pers aeration and pulmonary drainage. In addition to
the usual treatments one must strive to keep the post-
operatively infected lung aerated and drained. During
the first day or two before extensive consolidation has
occurred, aeration is facilitated by voluntary deep breath-
ing exercises and by the forced hyperventilation induced
by inhalation of carbon dioxide. Drainage of the lung
is encouraged by urging voluntary coughing and by re-
ducing the use of sedative drugs as much as possible.
Sometimes a Trendelenburg position for postural drain-
age is indicated.

Nursing Care

The death or survival of the pneumonia patient fre-
quently depends upon the skill and judgment of his

nurse. Physical and mental comfort, minimal handling
and disturbance, symptomatic treatment, maintenance
of fluid balance, control of distention and every effort
to conserve the patient’s natural resources, play signif-
icant roles. Every patient who is seriously ill with pneu-
monia belongs in a hospital whose facilities for study
and care materially increase his chance of survival.

Symptomatic Treatment

The physician’s therapeutic skill is often severely
taxed by efforts to control the symptoms of severe pneu-
monia. Sedatives are often indispensable, for strength
must be conserved. Expectorants are indicated when the
sputum is thick and difficult to dislodge, but they must
be wisely chosen to avoid gastric distress. Digitalis is
indicated only in cardiac failure. Distention must be
controlled by enemas, even laxatives, and, rarely, by
pituitrin. Alcohol may be of some benefit, especially for
aged patients or alcoholics.

Conclusions

Mortality rates in pneumonia may be significantly
reduced by more widespread and judicious use of mod-
ern therapeutic agents. No single method is complete;
"specific” therapy does not release one from the necessity
of using every available symptomatic remedy. Pneu-
monia may be an acute medical emergency and require
the organized services of a modern hospital, laboratory,
and trained nursing staff.

Missed Abortion

W. F. Mercil, M.D.
Crookston, Minnesota

THE general misconception of the meaning of the
term "missed abortion” and its more frequent
occurrence than is usually believed, coupled with
personal observation of some cases in recent years, has
prompted my interest in this subject. In the search of
literature to learn of the experience of others, one finds
few complete articles written on this subject. This dis-
cussion briefly reviews some of the general features of
missed abortion and also reports four cases.

Terminology

Most writers agree to the definition of Duncan, "The
death of the fetus before term with general symptoms
of abortion and failure of the uterus to expel its con-
tents within the usual time.”1 Rongy2 defines it as fol-
lows: "Intrauterine death of the fetus, with its complete
retention and absence of progressive enlargement of the
uterus.” To avoid confusion, it should be remembered
that spontaneous abortion differs in this respect in that
uterine expulsion is usually within a few days, while in
missed abortion it may not occur until many weeks or

•Read before the Annual Session of the Northern Minnesota
Medical Association, held at Fergus Falls, Minnesota, August 31*
September 1, 1936.

months later. It is generally believed that expulsion of
the fetus six weeks after its death is the limit of time
in consideration of the term "spontaneous abortion.”

Etiology

There are two factors concerned in the etiology. Pri-
marily, the death of the fetus has been explained in
many cases to be due to trauma, to the abdominal wall.
However, such evidence is lacking in a great number of
instances. Schwartz3 considers abnormality of the cord
to be of frequent occurrence in such cases. The failure
of the fetal death to occur in many severe types of or-
ganic disease leads one to the belief of some endocrine
unbalance as being a causative factor. Secondarily, the
non-expulsion of the dead fetus has not been satisfac-
torily explained. Lack of uterine muscular irritability,
perhaps caused by ingrowth of chorionic villi into the
muscle wall, has been advanced by some writers as an
etiological consideration.

Medico-legal Significance
The question of abdominal trauma to the pregnant
woman, with subsequent signs of abortion and disappear-
ance of these symptoms with retention of a dead fetus

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365

to be expelled perhaps months later, is one to be kept
in mind by those engaged in expert testimony.

Recurrence

It is interesting to note that few cases have been re-
ported in the literature of the recurrence of this condi-
tion. Litzenberg1 reported one case of missed abortion
occurring twice in two years, as did also Machenhauer1.
In one of the cases which I am reporting, the same
incident occurred. No satisfactory explanation has been
offered why this situation should repeat itself.

Diagnosis and Symptomatology

In the usual history, there occur signs of a threatened
abortion, which subside. The patient has a feeling of
security that the danger of an abortion is passed. Close
observation will reveal that the uterus ceases to enlarge
and that regressive changes occur in the breasts. Also,
cessation of fetal movements and a foul vaginal dis-
charge may cause these patients such concern that they
seek medical advice. The latter symptom has been the
most prominent one in our experience which brings these
cases to the attention of the medical attendant. There
may occur irregular vaginal bleeding, but this symptom
is usually not common. Some authors have also reported
the incidence of a general feeling of malaise and chronic
disability in this class of patient'’. However, the greater
percentage tolerates the dead fetus remarkably well. In
fact, so good has been the health of many that they
may carry the product of conception for years. Smith4
reported two cases, one of 11 years and another of 12
years’ duration. Frequently, the diagnosis can be made
on past history of the patient when one considers that
the size of the fetus passed does not coincide with the
supposed month of pregnancy. A negative Aschheim-
Zondek or Friedman test is also of value. The condition
most frequently mistaken for missed abortion is fibro-
myoma, especially if the tumor is soft and of an even
contour. Amenorrhea may occur for three or four
months, but the subjective symptoms of the first tri-
mester are usually absent.

Prognosis

The outlook is usually good. Spontaneous expulsion
occurs frequently. The fetus is usually macerated, fol-
lowing, perhaps, weeks of foul vaginal discharge. Com-
monly, mummification takes place. This phenomenon
occurred in all of our cases. Of the reports in the litera-
ture, most of the cases have terminated in one of these
two manners. Undoubtedly, in many cases, the uterine
contents would be expelled sooner or later, but, in some
cases, spontaneous expulsion does not take place when
the retained product of conception is well organized and
is strongly adherent to the uterine wall. At times, re-
sorption of the fetal soft tissue alone, or of total absorp-
tion, including the skeletal structures, may take place.
Danforth and Paddock reported one incident of total
absorption of all fetal tissue, with an easily recognized
cord and placenta left intact. Calcification of the fetus
is rare. Smith4 reported a case of calcification of the
uterus, resulting from the fetal bones cutting their way

into the muscular layer. The occurrence of superimposed
pregnancy in missed abortion is extremely rare. Forster’s*’
case was one in which death of the fetus occurred at the
fifth month. A superimposed pregnancy took place the
following month, and nine months later a normal live
fetus and a dead five months’ fetus were delivered by
Caesarian section.

Treatment

In the light of what has already been stated, evacua-
tion of the uterine contents is the first consideration of
therapy. Given a case in which diagnosis is in doubt, it
is best to make two examinations a month apart, noting
definitely the lack of increase or the decrease in size
of the uterus. One may elect to wait for spontaneous
termination when no untoward symptoms arise, or when
close observation can be maintained in a healthy patient.
However, two months’ time of watchful waiting should
be sufficient to accurately determine death of the fetus.

Evacuation of the uterine contents early in pregnancy
can best be accomplished by dilatation and curettage.
This is usually done when the cervix is soft and the
fetus lies on the lower uterine segment. A long, rigid
cervix requires a more radical procedure, vaginal hys-
terotomy. One must bear in mind while doing a dilata-
tion and curettage in missed abortion that the uterine
wall is usually thin and may be easily ruptured. Stein7
reports this incident occurring in one case in which the
fetus had passed into the vesico-uterine space. There
also occurs a more firm fixation of the retained embryo
to the uterine wall, making the incidence of rupture a
strong possibility. When mummification has occurred,
the fixation is apt to be quite firm, and in such instances
repeated curettages may be successful in removing the
fetal tissue. Medical induction of uterine contractions by
the means of castofl oil, quinine and pituitary prepara-
tions are practically useless and some mechanical or
operative intervention is necessary. Results were obtained,
however, by the use of p^tuitrin alone in one of my
cases, due to the fact that some uterine contractions
had occurred before the introduction of the drug. After
the uterus has been emptied, it is well to keep a close
watch on the amount of bleeding, as it has been defi-
nitely shown that severe hemorrhage is more likely to
occur because of poor contractility of the uterine muscle.
Thus a uterine packing is often indicated. Introduction
of bags and manual removal has been the method used
successfully by some.

A new light on therapy has recently been reported by
Robinson8 and his associates. This is the employment of
the estrogenic substances. They report 80 per cent suc-
cessful results in evacuating the uterus in missed abor-
tion by this method. They explain this on the basis of
the sensitizing factor, estrin, which, when given intra-
muscularly, sensitizes the uterus to contract or elicits a
prompt response with pituitrin. They believe the patient
has the discomfort of intramuscular injections, but that
she is immune from the danger of uterine trauma, in-
fection, and hemorrhage. However, the expense of this
product, together with the uncertainty of its successful

366

THE JOURNAL-LANCET

results, makes one hesitate to employ this method
routinely.

Case Reports

Case 1: Mrs. A. L., age 33 years, para two, gravida
three, seen on April 8, 1931, with the history of her
last menstrual period dating January 15, 1931. The cal-
culated date of delivery was October 13, 1931. She had
no complaints, and the size of the uterus corresponded
to three months’ pregnancy. She was seen again June
6th, the uterus approaching the size of a five months’
pregnancy. She had no complaints. At her next visit on
July 23rd, she stated that she had ceased feeling the
fetal movements, and that she twice had had a slight
bloody vaginal discharge with cramps in her lower abdo-
men similar to those at her menses. Examination at this
date revealed a uterus that more nearly approximated a
four months’ pregnancy. There was no history of
trauma dating between these two visits. One week later,
July 30th, she passed a mummified fetus, 12 cm. in
length, corresponding to that of a three and a half
months’ fetus. She has since passed through a normal
pregnancy.

Case 2: Mrs. J. S., age 37, para three, gravida four,
was seen on October 27, 1933, her last menstrual period
occurring on August 26, 1933. Except for nausea and
vomiting, she had been feeling well. The uterus was
slightly enlarged. She was not seen again until December
9th, at which time examination revealed a uterus the
size of a four months’ pregnancy. There were no com-
plaints nor any unusual features of her pregnancy at
this time. The next visit was January 27, 1934, at which
time she stated that she felt well, but had had a slight
bloody vaginal discharge for the past three days with
no pain. The uterus was somewhat smaller than at the
previous visit. On February 17, 1934, she had had a
continuation of the same bleeding, which, in the last
week, had assumed a brownish red color and a foul
odor. Examination revealed a uterus the size of a three
months’ pregnancy, while her menstrual history would
indicate one of about six months. A diagnosis of missed
abortion was made. By dilatation of the cervix and the
use of a placental forcep, the mummified fetus 1 1 cm.
in length was delivered.

Case 3: Same patient. She had felt well when seen
more than a year later on May 23, 1935. Her last men-
strual period occurred on March 15, 1935. The uterus
was slightly enlarged, and a diagnosis of a presumable
pregnancy was made. She was seen again one month
later, June 25th, at which time she had no complaints,

and the uterus was definitely increased to the size of a
three months’ pregnancy. She was not seen again until
three months later, on September 11th, at which time
she stated that she felt well, but had had no signs of
life for the past six weeks, and also that she had begun
to pass a foul reddish-brown discharge from the vagina.
She had slight pains in the lower abdomen at this time.
Examination revealed a uterus the same size as on the
previous visit, and the cervix was found gaping with
membranes presenting. She was hospitalized, given two
injections of pituitrin, and the next day spontaneously
aborted a mummified fetus, similar in size and length
to the previous one. This patient presented much the
same clinical features and result in this pregnancy as
she did in the one preceding.

Case 4: Mrs. H. P., age 31, a primipara, was first
seen on July 15, 1935. Her menstrual periods had been
regular and the last period dated May 5, 1935. Her
past history was negative except for a mild hypothyroid-
ism which was well controlled by thyroid extract. Pre-
vious examinations had revealed a uterus, infantile in
type, and at this examination, a positive diagnosis of
pregnancy from the size of the uterus alone was diffi-
cult. However, at her next visit one month later, the
uterus had enlarged considerably and was then at about
the three months’ size. On October 22nd, she stated that
she felt well and had no complaints. The uterus now
increased to that of a five months’ pregnancy. She was
seen next on November 8th, at which time she stated
that for the past two weeks she had not felt any more
fetal movements. The uterus was apparently the same
size as on the previous visit. Fetal heart sounds were not
heard. On December 12th, after passing a brownish dis-
charge for two days, she spontaneously aborted a mum-
mified leathery fetus of about five months’ size. This
time corresponded to her seventh month of pregnancy.

Bibliography

1. Litzenberg, J. C. : Missed Abortion, Am. J. Obst. dC Gynec.
Vol. 1, No. 5, Feb., 1921.

2. Rongy, A. J. Arluck, S. S.: Surg., Gynec. Qc Obst., Vol. 32
No. 2. Feb., 1921.

3. Schwartz, O. H.: Discussion of Dr. Litzenberg’s paper. Am
J. Obst. Qc Gynec., Vol. 1, No. 5, Feb., 1921.

4. Smith, F. R.: Am. J. Obst. 3c Gynec., 26:896-898, Dec.
1933.

5. Paddock, C. E., Danforth, W. C. : Discussion of Dr. Holmes
paper. Surg., Gynec. Qt Obst., 3 3:435, Oct., 1921.

6. Forster, N. K.: Missed Abortion with Superimposed Preg
nancy. Am. J. Obst. &: Gynec., 27:260, Feb., 1934.

7. Stein, A.: Case of Missed Abortion Presenting Unusual Fea
tures, Med. J. 6c Rec., 126:373, Sept., 1927.

8. Robinson, A. L., Datnow, M. M. Qc Jeffcoate, T. N. A.: In
duction of Labor By Means of Estrogenic Substance, Brit. Med. J.
1:763, Apr., 1935.

Represents the

MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

Great Northern Railway Surgeons’ Assn.
American Student Health Association
Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman , Board of Editors

Dr. A. W. Skelsey, Dr. C. E. Sherwood, Dr. Thomas L. Hawkins - Associate Editors

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. J . F. D. Cook
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

BOARD OF EDITORS

Dr. W. A. Fansler
Dr. H. E. French
Dr. W. A. Gerrish
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. S. M. Hohf

Dr. A. Karsted
Dr. H. D. Lees
Dr. J. C. McGregor
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. J . C. Shirley
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley

Dr. C. A. Stewart
Dr. J. L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M.D., 1859 1931 W. L. Klein, 1851-1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., August, 1937

THE MINNESOTA DEFENSE PLAN

Medical men will have no desire to dispute the de-
cision of committees of the American Bar Association
who decided recently that the medical defense plan of
the Ohio S:ate Medical Society constitutes the un-
authorized practice of law.

The professional ethics of law and medicine have
much in common and their preservation is vitally im-
portant to the welfare and advancement of both.

The Ohio medical association agreed to submit its
case to the Committees on Professional Ethics and
Grievances of the Unauthorized Practice of Law and is,
therefore, bound by their decision.

Other state associations are not so bound but will
readily bow to the decision of the Bar association. The
decision will be accepted as a precedent by which other
defense plans will be judged and attorneys will rightly
refuse to associate themselves with any similar plan.

Minnesota has no medical defense plan, as such, hav-
ing abandoned medical defense as a state association
activity a good many years ago.

Its present plan for aid to members who are threat-
ened with malpractice litigation in no way impinges upon
the practice of law.

Unlike the Ohio plan, the Minnesota plan calls for
no aid in court from the association, no counsel and no
payment of fees of counsel retained by members who
are threatened with suit.

Ohio’s plan, in operation when the case arose, called
for a standing medical defense committee which was to
have the advice and assistance of the general counsel of
the association. The committee was authorized to con-
tribute to the cost of defense, to cooperate in making in-
vestigations and obtaining witnesses, to recommend legal
counsel if requested to do so and to extend such other
aid and support as the committee found to be prac-
ticable and proper.

Although the medical association assumed no obliga-
tion, it ordinarily re-imbursed the defendant physician
for the amount of legal services, provided the counsel
employed cooperated with the committee and the gen-
eral counsel in handling the suit. This cooperation con-
sisted in submission of full facts and information in the
case with copies of briefs and pleadings so that general
counsel could make intelligent and helpful suggestions.
It was not required that the counsel for the defendant
physician follow the suggestions.

Minnesota’s Medical Advisory Committee is merely
advisory. It investigates facts and otherwise assists mem-
ber physicians if such assistance is deemed proper but it
does not provide legal defense for anyone. Its object,
instead, is the avoidance, as far as possible of actual mal-
practice litigation.

In so doing it is regarded by the Bureau of Legal
Medicine of the American Medical Association as en-
tirely within its rights and will not therefore be affected
by the bar association decision. J. A. M.

368

THE JOURNAL-LANCET

THE DOCTOR’S VACATION

Whether you go on a "holiday” or a "vacation” de-
pends largely on the place whence you came. If you are
of British extraction, it is likely that you will tenaciously
cling to the former; and if you are not, you will simply
vacate your usual haunts, cease your daily pursuits, and
seek some divertissement that shall promote forgetfulness
of routine, toil, and care; and build up strength and re-
sistance for the monotonous grind that you must look
forward to upon your return.

To the mind, restricted by the limitations that our
native provincialisms impose, holidays suggest festivities
and dress parades, while vacations are preeminently
periods of change and repose in bathing suits, fishing
togs, and old clothes. If the doctor makes any such dis-
tinction, then his excursions and side trips on attending
conventions satisfy the holiday craving; but for a truly
restful vacation he must get away from telephones, that
have become very exacting in his daily life, and the mod-
ern turmoil that adds exasperation.

Some of our distinguished friends have contrived to
annex as one of the perquisites of their exalted station
in life the right to a sort of de luxe vacation, impres-
sively termed "sabbatical leave.” This might be a pro-
pitious time for the organization of a movement in the
interest of physicians, who are of necessity on duty every
Sunday of the year, to get recognition by some such
high-sounding name. It should somehow point out to
the public the constant vigil of the profession, lest the
multitude begrudge the interlude. Shall we say, "The
doctor is taking his annual sabbath?” A. E. H.

THOMAS MULLIGAN
1877-1937

Another heart has ceased to beat, another noble spirit
has taken its flight and another empty space is left
among the stalwarts of our profession.

Dr. Thomas Mulligan was born in Dublin, Ontario,
March 23, 1877, and passed away at Grand Forks,
North Dakota, July 19, 1937. He was educated in the
public and high schools of Ontario, and graduated from
the medical department of the University of Toronto in
1904. He came to Grand Forks, North Dakota, and
was licensed October 13, 1904. After practicing for two
years he took post-graduate work at London, Edinburgh,
Berlin and Vienna. Returning to Grand Forks he re-
sumed practice and by strict attention to duty became
favorably known over a large area. In 1908 he was
married to Miss Margaret McQuaid of Seaforth, On-
tario, who survives. His home life was exemplary and
beautiful, each through mutual concern contributing to
the others happiness.

Dr. Mulligan was recognized by his professional asso-
ciates as a gentleman of high ideals and worthy pur-
poses. He was above-board, honest and ethical with his
fellows and expected like consideration from others. He
kept himself fully abreast with the latest in medical
progress but never allowed himself to be carried away
by the untested claims of enthusiasts or the visionary

whims of the hour. Dr. Mulligan deserved well of the
profession and he was honored by being elected presi-
dent of the State Medical Association in 1927. He also
served as president of the Grand Forks District Medical
Society. He had been a member of the American College
of Surgeons since 1926. Dr. Mulligan was an engaging
companion, grateful of favors, courteous at all times and
with a fine sense of quaint humor that was contagious.

For the past several years he was less well physically
than has been generally known. As a physician he gave
to his patients the best he had of learning, skill, care,
and sympathy, and received in full measure their con-
fidence and esteem. As his physical energies waned this
earnest and intense application drew heavily on his
reserve. At intervals he found it expedient to get away
from work for periods of rest and recuperation. Like
another valiant knight he would say: "I’m wounded but
not slain. I’ll lay me down and rest a while and then
I’ll rise and fight again.” That was the character of the
man; and from these breathing spells he would come
back refreshed and eager to carry on. Nature, however,
sets her limitations and says, "Thus far shalt thou go.”
When an acute heart attack supervened, the silver cord
gave way and all that was lovable of Doctor Mulligan
departed and he was at rest.

Dr. Mulligan was a splendid type of an American
citizen and physician. He was loyal to his country and
its institutions; upright in dealing with his fellow-men;
public-spirited in community affairs; faithful and gen-
erous to the Church of his choice; devoted to home,
family and friends; and true to the profession he loved
and honored. J. G.

SOCIETIES

Annual Meeting of the
Northern Minnesota Medical Association
Virginia, Minnesota
August 27th and 28th, 1937
Speakers’ Program

1. L. F. Hawkinson, Brainerd — "The Menopause Syn-
drome.”

2. H. D. Harlowe, Virginia — "Bronchoscopy as an
Aid to the General Practitioner.”

3. Gage Clement, Duluth — "X-Ray Therapy in Non-
Malignant Conditions.”

4. Frank Hirschboeck, Duluth — "Heart” (Movie) .

5. C. I. Krantz, Duluth — "Gastro-Intestinal Allergy.”

6. George Earl, St. Paul — "The Comparative Values
of Injection and Surgical Treatment of Herniae.”

7. J. C. Michael, Minneapolis — "Insulin Shock Ther-
apy in Schizophrenia (Dementia Precox).”

8. J. A. Bargen, Rochester — "Conditions Causing In-
testinal Obstruction and Their Management.”

9. H. J. Lillie, Rochester — "Certain Considerations of
the Faucial Tonsil in General Practice.”

10. A. W. Adson, Rochester — "Essential Hypertension;
the Indications For, and the Results of Extensive
Sympathectomy.”

THE JOURNAL-LANCET

369

11. Robert M. Bums, St. Paul — "Rating of Disabilities.”

12. R. G. Leland, Chicago— Director, Bureau of Med-
ical Economics, American Medical Association.

13. B. J. Branton, Willmar — "Medicine: A Cooperative
Business, A Non-Competitive Profession.”

14. Hon. N. H. Debel, St. Paul — "The Physician and
the Workman’s Industrial Commission Compensa-
tion Law.”

15. Philip C. Reynolds, Minneapolis — "The Medical
Witness.”

John F. Fee, Duluth — Discussion.

Banquet Program, August 27th
Toastmaster — Dr. Frank J. Hirschboeck, Duluth.
Address — "The Wonderland of Lake Superior,” J. A.
Merrill, Ph.D., Pres. Emeritus, State Teachers
College, Superior, Wisconsin.

"The Business Side of Medicine” — Dr. R. G. Leland,
Chicago, Director of Bureau of Medical Economics,
American Medical Association.

"The State Medical Association; A Going Concern,”
Dr. A. W. Adson, Rochester, President, Minnesota
State Medical Association.

"President’s Address,” Dr. O. O. Larsen, Detroit Lakes.

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB

Stated Meeting, February 11, 1937.

Dr. Donald McCarthy, Presiding
CAUSE OF THE TOXEMIAS IN PREGNANCY

Dr. R. T. LaVake

At the October 13, 1932, meeting of this Society, I dis-
cussed what seems to me to be the correct theory of the cause
of the toxemias of pregnancy. This discussion appeared in the
November 1st, 1932, issue of The Journal-Lancet. In sum-
mary, it may be stated as follows:

When the spermatozoon impregnates an ovum, an organism
is evolved whose cells may or may not be toxic to the maternal
organism. When toxic, the exotoxins and endotoxins of the
developing cells of the products of conception are the causes
of the toxemias of pregnancy. This is the only theory that
accounts for every clinical manifestation.

After working on blood groupings, agglutinations, etc., etc.,
with no results, I wish to report what I believe to be an im-
portant finding in experimental substantiation of this theory.
It suggested itself that if the fetal and placental cells might
be toxic, that if I obtained placental serum, following delivery,
by squeezing the placenta in a meat squeezer, such serum should
or should not cause an intradermal reaction in the mother ac-
cording as it were toxic or non-toxic.

This has been tried on eight normal cases showing no tox-
emic signs or symptoms and one case of fulminating toxemia.

In the non-toxic cases, absolutely no reaction occurred around
the intradermal bleb.

In the toxic case, a most angry reaction extended for % of
an inch around the bleb.

To my mind, if this reaction proves to be constant, this
may be the last link in proof of the origin of late toxemia, and
may help us in differentiating real pregnancy toxemia from
toxemia based upon a nephritis.

Discussion

Dr. Elmer M. Rusten: Did you use that serum on other
normal pregnancies?

Dr. R. T. LaVake: No, I have not used the placental serum
of one patient on another.

Countless experiments suggest themselves to clear up the
problem. If this theory is correct, the placental cells, if toxic,
should be specific for that particular woman and women of her

cell make-up. To other women they might not be toxic. The
experiments cited are an effort to give an ocular demonstration
that sometimes the products of conception are definitely toxic
to the mother herself and sometimes not; and when toxic,
toxemia of pregnancy may result depending upon toxicity of the
cells, the amount of infarction and necrosis of the placenta, and
the eliminative capacity of the pregnant woman. The work is
practical because, if correct, all measures that will tend to pre-
vent placental infarction will minimize the causes of toxemia
if the cells of the products of conception are toxic to the
mother. If not toxic, no amount of infarction will precipitate
a toxemia. The causes of placental infarction over which we
may exercise control are the prevention of any infection in the
mother such as abscessed teeth, sinuses, common colds, etc.,
and keeping metabolites low.

In very few cases of pre-eclamptic toxemia will you find
absent the following links: some type of focal or general in-
fection and some type of placental change manifested by local-
ized gross color changes in the placenta, or by infarction.

Dr. R. C. Webb: Have you tried this with other tissues

than the placenta, the mother’s serum, or serum from the
child taken at the time?

Dr. R. T. LaVake: I have not tried it with the child’s

serum. I have worked out to my own satisfaction that there is
no association as regards clumping between maternal and foetal
blood. I have been more interested in the part that infection
and consequent placental infarction may play because these
elements lend themselves to prophylactic measures. I am quite
sure from my experiments that no connection exists between
the toxemias of pregnancy and agglutinative reaction between
husband’s, mother’s and child’s blood.

It would be interesting to see what the mother’s serum would
do to the child and to the mother herself. This approach im-
mediately suggests innumerable possibilities of interest and
practical value. I have brought this work before you merely to
stimulate interest in this approach; and to report findings that
suggest that this approach may furnish definite experimental
proof that the causative toxin resides in the products of con-
ception, and that the condition is not basically due to meta-
bolic disturbance in the mother, such as hypoglycemia, etc.

A CLINICAL STUDY OF LOW BACK PAIN OF
PROSTATIC ORIGIN FOLLOWING INJURY
Inaugural Thesis

Ernest R. Anderson, M.D.

MINNEAPOLIS

The incidence of low back pain in the adult male has in-
creased, especially, since the establishment of compensation acts
The employee will attribute the cause of his back trouble to
some action or injury, whether it is slight or severe, occurring
in his work. It is estimated that at the present time the occur-
rence of back pain is twice as frequent in the male as in the
female. A few decades ago the medical profession was con-
cerned with the ubiquitous female complaining of backache. It
is to the credit of gynecology that pelvic diseases have been
recognized as the cause of back pain and scores of women,
relieved. Oliver Wendell Holmes’ definition of a female as a
' species of biped with a pain in the back” is no longer true.

Thirty-one years ago Young, Geraghty and Stevens3 in a
comprehensive study of 358 cases of chronic prostatitis, found
that pain in the back and over the sacrum were the only symp-
toms in 69 cases. Since that time the urologic literature con-
tains several references of chronic prostatitis being the caus-
ative factor in producing back pain.

Low back pain following injury was recognized by Wesson5
as sometimes being due to a chronically-infected prostate gland
and seminal vesicles. Webb4 in 1928 reported a series of such
cases in which the disabling back pains disappeared when the
chronic prostatitis and seminal vesiculitis were cleared up. In
153 cases of low back pain Duncan2 found that chronic infec-
tion was present in the prostate gland in 83 cases and consid-
ered it as the etiologic factor. Chronic prostatitis prolonged
the disability in a number of back injury cases which were
studied and reported by Boies1-

370

THE JOURNAL-LANCET

The importance of chronic prostatitis and seminal vesiculitis
in back injuries will be readily appreciated when the prevalence
of that condition is considered. It is the opinion of Wesson '
that practically all adult males have prostatitis. This may be
questioned, however, as the urologists do not all agree. The
teachers of histology and tissue microscopists find it hard to
obtain sections of normal prostate gland and resort, conse-
quently, to infant glands for material. Nielson", an internist,
reported a series of 200 patients having a variety of symptoms
other than those associated with the genito-urinary system and
found pus in the prostatic secretion in 85 cases. It would seem
that 40 or 50 per cent of the adult males have evidence of an
infection residing in the prostate gland.

The question arises then, "What is the source of the in-
fection in the prostate gland?” For many years it was consid-
ered a complication of gonorrhea in practically all cases. Re-
cent investigators have agreed that chronic inflammation of
the prostate gland and seminal vesicles is produced by the gono-
coccus in about 40 per cent of the cases. The remaining cases
are caused by septicemias or are the metastatic infections of
other foci of infection in the body. In the order of frequency
the chief bacteria that have been isolated from the chronically-
infected prostate glands and seminal vesicles are as follows:
staphylococcus albus, streptococcus pyogenes, colon bacillus and,
occasionally, the gonococcus.

The pathology of the prostate gland when it is cnronically
infected, consists of an increased volume which is due to a
fibrous hyperplasia. There is a periacinous round cell infiltra-
tion which is sometimes combined with a more extensive inter-
stitial infiltration. Dilated orifices of acini are seen throughout
the gland. Small cysts and small hemorrhagic lesions may also
be present.

The prostate gland and seminal vesicles are richly supplied
with nerves from the pelvic plexus which is connected with the
hypogastric parasympathetic plexus. This plexus receives fibres
from rhe tenth dorsal spinal segment to the third sacral. There
are nerve endings of various kinds and ganglion cells scattered
in the interstitial connective tissue of the gland. Head has
shown that visceral stimuli will be referred to the surface of
the body and interpreted as pain in the region which is supplied
with the sensory cutaneous nerves from the same spinal seg-
ment from which the visceral nerves originate. The patient
accepts this physical error of judgment and interprets the
diffusion area of pain as the source of his pain. The pain
originating from stimuli in the prostate gland and seminal
vesicles would have a wide distribution because of connection
with the tenth dorsal spinal segment to the third sacral. Young,
Geraghty and Stevens-* in their analytic study found this to
be true.

Besides having referred pains from the chronically infected
prostate gland and seminal vesicles, the back pains can be
produced by metastatic infection from this focus. A localized
myositis, fibrositis or arthritis can be produced. These condi-
tions will be improved by the eradication of the responsible
focus.

This study is based upon 21 cases which have come under
my observation in my association with Dr. R. C. Webb. These
cases of low back pain have all occurred following injury. The
injury in some cases has been very slight such as stepping off
a trunk, a height of 2Vi feet (case 9), or resulting from a jar
received while riding on a tractor over a board track crossing
(case 1). In others the injury was more severe — such as being
knocked off a 15-foot scaffold and landing on the back (case
21). The severity of the injury did not determine the disa-
bility or the amount of back pain which the individual ex-
perienced.

The age groups at which these cases occurred are as fol-
lows: between 20 and 29 years 2, 30 and 39 years 11, 40 and
49 years 5, 50 and 59 years 3. The largest number of cases
are in the fourth and fifth decades. This is what might be
expected as the incidence of chronic prostatitis and seminal
vesiculitis is high in these age groups.

Pain in the lower part of the back was the chief complaint
offered by these patients. The: pain varied in intensity from a

dull aching, characterized by some as being like a toothache,
to a type that was more severe — sharp and knife-like. The
pain was present in some patients continuously, having no re-
lation to the position they assumed. In others the pain was
relieved by lying down. One patient stated that he obtained
relief when sitting in a chair if he allowed his weight to be
taken by his arms resting on the chair arms (case 14). In all
the cases the pain in the back was aggravated] by bending for-
ward. Walking made the pain worse in 15 of the cases; cough-
ing increased the pain in 8 cases and it is interesting to note
that 5 patients stated their pain felt as if it were "deep in.”

The location of the pain varied considerably throughout the
lower back. The pains were designated as occurring in regions
from the lumbar back down to the buttock. Of the 21 cases
pain occurred in the lumbar area in 3; in the lumbosacral area
in 2; in the sacro-iliac area in 8; in the sacral area in 4; and
in the buttock in 4. In 7 cases leg pains were associated with
the back pains.

The onset of the back pains, in the majority of cases, dated
from the time of the accident. This was true in 14 cases. The
pain had its inception with the alleged injury, having no relation
to whether the injury was severe or minimal as stooping over
(case 19), or twisting of the body (case 4). In 7 cases the back
pains were first noticed some time after the injury. This inter-
val varied in duration from one-half hour to 14 months. In all
the cases the individuals felt that the back pains were the result
of the accident they had sustained.

On physical examination 8 cases presented some findings in
the back. These findings consisted of tender areas located in
different regions, namely ever the sacro-spinalis muscles, over
the spinous processes of the fourth and fifth lumbar vertebrae
or only over the fifth and over the sacrum. In two of the
cases there was a tilting of the back present when the indi-
viduals stood on their feet. Flexion of the back was limited in
4 cases because pain was produced. There was no muscle spasm
of the back muscles found in any of the cases. Roentgeno-
graphic studies were normal in eleven of the cases.

The prostate gland was found to vary in size from about
normal, or slightly larger, to a mass that nearly touched the
sacrum. The size of the gland did not have any relation to
the amount of disability that the individual experienced. One
thing, frequently noted, was that in those individuals complain-
ing of a unilateral back pain the corresponding lobe of the
prostate gland or the corresponding seminal vesicle was en-
larged. On examination of the prostate gland and seminal
vesicles the tenderness present varied a great deal. This sub-
jective symptom is hard to evaluate because the perception of
pain differs in individuals. There was no consistent relation-
ship found between the intensity of the back pains and that
present in the prostate gland and seminal vesicles when they
were examined. It is interesting to note that in a few cases
the individuals volunteered that their back pain was worse
while the prostate gland and seminal vesicles were being ex-
amined.

Unstained cover-glass preparations of the expressed secretion
were examined. The presence of leucocytes was considered as
pathologic. The number of leucocytes present varied and did
not have any relationship to the size of the prostate gland
and seminal vesicles, to the degree of tenderness in them or to
the intensity of the back pains. In 15 cases leucocytes were
found on the first examination, in 3 cases on the second exam-
ination. There was one case that no secretion appeared at the
meatus on the first examination but on the second examination
leucocyte-containing secretion was obtained. In 2 cases leuco-
cytes were found on the third examination.

The back pains of these cases were relieved and disappeared
when treatment was carried on for the chronic infection in the
prostate gland and seminal vesicles. One individual had an im-
mediate relief of the back pains following the first massage.
Severt noticed improvement after the second massage. At the
end of 4 weeks 19 were relieved of their back pains, one case
at the end of 6 weeks and the remaining one at the end of
8 weeks.

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371

There were 5 cases who lost no time from their work, 5 who
lost 7 days or less and 1 1 who lost from 3 weeks to one year.
Half of these cases, with low back pain, had a prolonged disa-
bility due to a condition which is usually considered less serious.
When chronic prostatitis and seminal vesiculitis are not recog-
nized as the causative factors in producing back pains, pro-
longed treatment and prolonged disability increase the expense
to the compensation carriers in such cases. The employee also

suffers because he is forced to endure a back pain which is a

real thing to him. He has often been considered a malingerer
or a neurotic when the chronic prostatitis and seminal vesiculitis
were producing a definite and real pain.

Case Reports

Case 1. G. M., aged 30, a mail handler, was injured July
2, 1933. While riding on a tractor over a board track crossing
he was jarred. At the time he felt a pain on the right side
in the lower part of the back. He continued to work.

He presented himself on July 3, 1933, stating that the pain
in the lower part of the back on the right side was constant

and more severe than it was on the day before. It was very dif-

ficult for him to get out of bed. Walking at first aggravated
the pain but after he had been up awhile the pain did not
increase. The pain was more noticeable on bending forward.

The past history was non-essential.

On examination of the back it was found to be normal. The
prostate gland was enlarged, smooth and very tender. The
right seminal vesicle was enlarged. The smear of the secretion
contained five to ten leucocytes per low power field.

After the first massage he stated that the back felt much
better. He continued doing light work. At the end of two
weeks he was free from back pains.

Case 2. A. A., aged 53, a stower, was injured September
14, 1936, at 10:00 A. M. He was moving a boiler with a
bar. The bar slipped causing him to bend forward suddenly.
On straightening up he felt a pain in the small part of the
back. The pain continued and became worse after sitting down
to eat his lunch.

He presented himself four hours after the accident com-
plaining of a constant pain across the small of the back. The
pain was aggravated upon his bending forward. Walking did
not increase the pain nor did the pain radiate.

The past history was non-essential.

Upon examination the back was found to be normal except
for a slight limitation of flexion caused by pain. There was no
muscle spasm or rigidity in the back muscles. The prostate
gland was enlarged, soft and tender. The first smear was nor-
mal; the second smear of the prostatic secretion contained
leucocytes.

After the second massage he was free from back pains and
so remained. This man continued to work and did not lose
any time from work.

Case 3. O. C., aged 37, a switchman, was injured February
7, 1930. He was caught between a moving boxcar and a plat-
form and was rolled one complete turn. He was examined
shortly after the accident and was found to have some abrasions
over the lower back. Roentgenographic studies of the lumbar
spine and sacroiliac articulations were normal. He returned to
work in ten days.

He presented himself on December 14, 1931 complaining of
pain in the middle of the lower part of the back. The pain
had been present for three weeks. The pain was dull in char-
acter and came on after he had worked for three or four hours.
On occasions he had sharp pains when he straightened up after
he had stooped over. When he arched his back and bent back-
wards he had a sensation of something slipping in the back.
On placing his weight on the right leg the pain in the back
was aggravated.

The past history was non-essential.

Upon examination the back was found to be normal. The
prostate gland was enlarged, soft and tender. The right lobe
of the gland was distinctly more swollen. The smear of the
secretion contained fifty to seventy leucocytes per high power
field, occurring in groups.

The prostate gland was treated. He did not lose any time

from his work. At the end of four weeks he was free from
back pains.

Case 4. F. H., aged 33, an airbrake rackman, was injured
January 4, 1934. His body was twisted when a gasoline engine
which he was cranking "kicked back.” He had pain in the
left side of the lower part of the back immediately and the
back felt stiff.

He presented himself on January 6, 1934 complaining of
having a constant pain in the left side of the lower part of the
back. The pain was made worse by walking. He obtained
relief by lying down.

The past history was non-essential.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
was a tender area over the sacrum and over the lower third of
the left sacro-spinalis muscle. The prostate gland was of normal
size, smooth, firm and slightly tender. The first and second
examinations of the smear of the secretion were normal. On ex-
amination of the third expressed secretion fifteen to twenty
leucocytes per low power field were found.

After treatment of the prostatitis for two weeks the back
was less painful. At the end of six weeks the back pains were
gone. He did not lose any time from his work.

Case 5. H. G. O., aged 34, a telegraph operator, was in-
jured in December 1932. While pulling a loaded four-wheel
truck, his feet slipped causing him to fall backwards landing
on his buttocks. He continued to work. He continued to
have slight pain in the lower part of the back on the left side.
In January 1934 the pain became more severe, especially when
he sat down.

He presented himself May 27, 1935 complaining of having
a constant ache in the lower part of the back on the left side
and in the left buttock. The pain had been more severe for
the last two months. The pain was aggravated by sitting on a
soft cushion or soft seated chair.

The past history was non-essential. He had not had any
venereal disease.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
were no tender areas. The prostate gland was enlarged, smooth
and tender. The left lobe was boggy. The smear of the secre-
tion contained twenty-five to thirty-five leucocytes per low power
field. The coccyx was normal.

He was referred to his local physician who carried on treat-
ment for his chronic prostatitis. Reports were received that he
was free from back pains at the end of three weeks. He did
not lose any time from his work.

Case 6. H. M., aged 47, a brakeman, was injured Decem-
ber 26, 1936 at nine A. M. In stepping over a rail the left
foot slipped and he fell backwards. He got up and continued
to work. Immediately he had a pain in the lower part of the
back. The pain became more severe and he quit work at
eleven thirty A. M. He went to a physician who advised him
to rest. He returned to work December thirtieth.

He presented himself on December 31, 1936 complaining of
having pain in the lower part of the back. The pains did not
radiate. He had cold and warm sensations which went up the
back. In the back of the left thigh he had soreness and he
stated that the thigh felt weak.

The past history was non-essential. He had not had any
venereal disease.

Upon examination the back was found to be normal. There
was no spasm or rigidity of the back muscles. No tender
areas were found. The extremities were normal. The pros-
tate gland was smooth. The left lobe was enlarged and tender.
The smear of the secretion contained eight to ten leucocytes per
high power field.

He was referred to his physician to carry on treatment for
the chronic prostatitis. In two weeks the back pains were gone.
He continued to work from December 30, 1936.

Case 7. A. D., aged 26, a mail handler, was injured June
15, 1931. He jumped off a truck, a distance of five feet,
landing on his feet in a stooped position. He got severe pain
in the small of the back and could not straighten up.

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He presented himself a few hours after the accident complain-
ing of having a constant sharp pain in the middle of the lower
part of the back. The pain was aggravated by bending for-
ward.

The past history was non-essential.

On examination the back was found to be normal except for
an area of tenderness over the fifth lumbar vertebral spine.
There was no muscle spasm or rigidity of the back muscles.
The prostate gland was enlarged, soft and tender. The smear
of the secretion contained ten to fifteen leucocytes per low
power field.

After the first treatment the back felt better. He returned
to work June nineteenth and did not have any pain after that.

Case 8. M. B. H., aged 42, a carpenter, was injured June
14, 1928. He was struck on the head by a pile driver weigh-
ing eighty pounds which fell a distance of twelve feet. The
scalp was lacerated, he was not unconscious. He was off work
for four and a half days. He worked steadily up to January
1932 when he was off for ten days because of pain in the
lower part of the back.

He presented himself on November 9, 1932 complaining of
having a steady stabbing pain in the left side of the lower part
of the back. The pain had been present for the last eleven
months. The pain did not radiate. It was aggravated by
bending forward and by lifting. He was relieved of the pain
by lying down.

The past history was non-essential. He had not had any
venereal disease.

On examination the back was found to be normal. The pain
was located over the left sacroiliac region. There were no
tender areas. The prostate gland was of normal size, smooth
and firm. The smear of the secretion was normal. On the
second examination the prostate gland was slightly enlarged,
smooth and tender. The smear of the secretion contained five
to eight leucocytes per low power field.

The roentgenograms of the lumbar spine and sacro iliac ar-
ticulations were normal.

The back pains were relieved after the second massage. He
was referred to his physician for continued treatment. He re-
turned five months later complaining of pain, of twelve days
duration, in the left side of the lower back. He had not fol-
lowed up the treatment for the chronic prostatitis. Examina-
tion at that time revealed an enlarged, tender prostate gland.
The smear of the secretion contained leucocytes. After treat-
ment of the chronic prostatitis he was relieved of the back pains.

Case 9. P. T., aged 34, an electrician, was injured Septem-
ber 22, 1923. He stepped off a trunk two and a half feet
high and felt a snap in the back. He could not straighten up
and was off work for seven days.

He presented himself on January 25, 1933 complaining of
having a soreness which had been present since the accident in
the small of the back. When he worked in a stooping position
he would get a catch and pulling sensation in the back. The
back had been more sore for the last three weeks.

The past history was non-essential. He had not had any
venereal disease.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
was a tender area over the right sacro-iliac region. The pros-
tate gland was enlarged, smooth and tender. The right lobe
was very tender. The smear of the secretion contained ten to
fifteen leucocytes per low power field.

The roentgenograms of the lumbar spine and the sacro-iliac
articulations were normal.

After treatment for ten days the back felt better. At the
end of three weeks the back pains were relieved. He did not
lose any time from his work.

Case 10. J. M., aged 37, a car cooper, was injured April 12,
1931 at ten A. M. He jumped from the door of a standing
box car landing on both feet. At the time he had a sharp
pain in the left side of the small of the back. The back be
came stiff and he had to quit work at noon because of the pain
and stiffness in his back. The following day he stayed in bed
all day.

He presented himself on April 14, 1930 complaining of pain
in the left side of the small of the back and stiffness of the
back.

On examination flexion and extention of the back were found
to be slightly limited. There was a tender area over the left
sacro-iliac region. The prostate gland was swollen, smooth and
tender. The smear of the secretion contained forty to fifty (
leucocytes per low power field.

The back was greatly improved after the first massage. He
returned to work April eighteenth and remained free from
pain in the back after that time.

Case 11. O. E., aged 53, a stockman and farmer, was in-
jured February 8, 1931. As he was going to sit down he was
thrown against the arm rest of a train coach seat, striking the
right side of the lower back. He had pain in the right side
of the lower back. He had seen seven physicians at different
times on account of his pain. The back had been taped, heat
and massage treatments had been given and he had been sup-
plied with a belt.

He presented himself on March 31, 1931 complaining of
having a constant dull gnawing pain in the lower part of the
back on the right side. The pain awakened him at night.
Walking and bending forward made the pain worse. The pain
did not radiate.

The past history was non-essential. He had not had any |
venereal disease.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. Flexion
of the spine was limited slightly because of producing pain.
There was a tender area over the right sacroiliac region and
over the fourth and fifth lumbar vertebral spines. The pros-
tate gland was markedly enlarged and very tender. The smear
of the secretion contained sixty to eighty leucocytes per low
power field.

The roentgenograms of the lumbar spine and sacro-iliac ar-
ticulations were normal.

After the fourth massage the back began to feel better. At
the end of four weeks the back was much improved.

Case 12. A. F. H., aged 43, a yardmaster, was injured
August 1 and 29, 1931. On August first he felt a twinge on
the right side of the lower part of the back when he was push-
ing a box car. The back remained sore but he continued to
work. On August twenty-ninth when pulling on a switch
handle the back became more painful. The pain gradually be-
came more severe. At times he had sharp knife-like pains in
the back. At intervals he had pain down the back of the right
thigh. On September sixteenth the pain became very severe
and he had to quit work. He was carried to his automobile.

He took mud baths for three days.

He presented himself on September 19, 1931 complaining of
sharp pain on the right side of the lower back. The pain was
aggravated by walking and by bending forward. He had to
walk with the aid of crutches.

The past history was non-essential.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
were no tender areas. The prostate gland was firm, smooth
and tender. There was no secretion obtained on the first mas-
sage. The smear of the second massage was normal. The
smear of the secretion following the third massage contained
thirty-five to fifty leucocytes per low power field.

The back felt better after the second massage. He returned
to work October eighteenth. The back was free from pain.

Case 13. R. B., aged 32, a laborer, was injured August 14,
1933. The bar, which he was using to move a box car, slipped
and he fell to the ground, twisting his body to the right. Im-
mediately he felt a burning sensation in the left side of the
lower back. He continued to work. Two days after the acci-
dent he went to a physician who supplied him with a canvas
belt.

He presented himself on August 21, 1933 complaining of
having pain in the lower part of the back on the left side. The
pain went down the back of the left thigh. The back pains

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373

were aggravated by coughing. He was unable to get out of
bed because of the pain.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
was a tender area over the sacrum. The prostate gland was
flat, soft and tender. The smear of the secretion contained
three to five leucocytes per high power field.

The roentgenograms of the lumbar spine and sacro-iliac ar-
ticulations were normal.

After the second massage the back was much improved. He
returned to work at the end of three weeks, free from back
pains.

Case 14. L. B., aged 35, a coal shed laborer, was injured
May 28, 1936. About one-half hour after wheeling a wheel-
barrow full of coal he began to have a pain in the center of the
lower part of the back. He continued to work. The pain be-
came worse through the day.

He presented himself on May 29, 1936 complaining of a
dull aching in the left side of the lower back which was so
severe that he could not get out of bed. On standing the pain
was felt down the back of both thighs. The pain was aggra-
vated by coughing. In sitting in a chair he was most com-
fortable when he supported his weight on the chair arms with
his arms.

The past history was non-essential.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
were no tender areas. Flexion of the spine was limited about
fifty per cent because of producing pain. The prostate gland
was of normal size, soft and tender. The smear of the secre-
tion contained five to eight leucocytes per high power field.

The roentgenograms of the lumbar spine and the sacroiliac
articulations were normal.

The back pains were relieved by treatment of the chronic
prostatitis. He returned to work at the end of three weeks
free from pain.

Case 15. R. V. B., aged 46, a brakeman, was injured the
first time September 4, 1931. He was thrown from the top of
a box car, landing on his buttocks. The back was X-rayed
and he returned to work in six weeks. After the accident he
had a dull aching in the lower part of the back. In September
1932 he had an attack of sharp pain in the lower part of the
back when he was lifting some freight. He was off work for
five days. On October 29, 1932, with the help of another
brakeman, he bent over to lift a plow beam. When he straight-
ened up he had a sharp pain in the lower part of the back.
He had to quit working.

He presented himself November 7, 1932 complaining of a
constant sharp pain in the lower part of the back when he got
up. The pain was relieved by lying down. The pain was ag-
gravated by walking and by bending forward. He had pains
down the back of the left thigh.

The past history was non-essential. He had had gonorrhea
twenty years ago.

On examination the back .was found to list to the right.
Flexion of the spine was limited fifty per cent because of pro-
ducing pa n. There was no muscle spasm or rigidity of the
back muscles when he laid on his abdomen. There was a
tenderness over the lumbo-sacral and sacral regions. The pros-
tate glanl was enlarged and tender, especially over the left
lobe. The smear of the secretion contained thirty to forty

leucocytes per low power field.

The roentgenograms of the lumbar spine and the sacro-iliac
articulations were normal.

After he had received two prostatic massages he volunteered
that his back felt much better. He was referred to his physi-
cian for further treatment. In three weeks he returned to
work.

Case 16. J. N., aged 38, a steamfitter, was injured July 5,
1932. He fell from the top of a coach striking his left
buttock on his partner’s knee. He fell a distance of five or
six feet. He had pain in the left side of the lower part of the
bark immediately. He continued to work. The pain grad-
ually became worse and he went to a physician on September

19, 1932. On examination the back was found to be normal.
There were tender areas over the fifth lumbar vertebral spine
and over the left sacro-iliac regions. Roentgenographic studies
of the lumbar spine and sacro-iliac articulations were normal.
This man was treated with heat and massage treatments to his
back. A low back brace was applied. Five injections of strep-
tococcus vaccine were given. He had had hospitalization for
eleven days in November and leg traction had been applied.

He presented himself on November 21, 1932 complaining of
a constant pain in the left side of the lower part of the back.
The pain was present day and night and was aggravated by
standing. He had a catch in the lower part of the back when
he bent forward and when he straightened up he had sharp
pains.

The past history was non-essential.

On examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. There
were no tender areas. The prostate gland was swollen, boggy
and tender. The smear of the secretion contained ten to fifteen
leucocytes per low power field.

This man returned to his physician, treatment was carried
on for chronic prostatitis. He was free from back pains and
returned to work four weeks later.

Case 17. C. M., aged 48, a switch foreman, was injured
March 28, 1934, by being caught between a moving box car
and a platform. He sustained a compound fracture of the in-
ternal condyle of the left femur involving the knee joint and
a fracture of the right fibula.

Three months after the accident he began to have soreness
and stiffness in the lower part of the back when he stooped
over. It was hard for him to straighten the back. The lower
part of the back became sore when he sat and drove his car.
The soreness in the back gradually became worse so that he
had constant aching. The aching was relieved by lying down.
The pain did not radiate.

The past history was non-essential. He had not had any
venereal disease.

On examination the back was found to be of normal con-
tour. There was no muscle spasm or rigidity of the back
muscles. There were no tender areas. The prostate gland was
flat, soft and tender. No secretion was obtained at the trethral
meatus on the first examination. On the second examination
the smear contained one hundred to one hundred twenty leuco-
cytes per high power field.

After receiving treatment for six weeks the patient stated,
"My back does not feel stiff and I have no soreness.” He re-
turned to work September 21, 1934.

Case 18. G. M., aged 50, a section foreman, was injured
June 14, 1935. He fell backwards, eight feet, off a ladder. He
landed on the ground on his back. He had pain across the
lower part of the back immediately. He was taken to a physi-
cian. The back was X-rayed and adhesive tape was applied.
He received heat treatments to the back.

He presented himself on July 20, 1935 complaining of hav-
ing a pain in the center and the right side of the lower part
of the back. The pain was relieved by lying down. Walking
and bending forward aggravated the pain.

The past history was non-essential.

On examination the back was found to be of normal contour.
There was no muscle spasm or rigidity of the back muscles.
There were no tender areas. He localized the pain in the re-
gion of the fifth lumbar vertebra. The prostate gland was en-
larged, firm and tender. The smear of the secretion contained
twenty to thirty leucocytes per low power field.

The roentgenograms of the lumbar spine and sacro-iliac ar-
ticulations were normal.

After the second prostatic massage the back was better. He
was referred to his physician for the continuation of the treat-
ment. He returned to work at the end of two weeks, free
from back pains.

Case 19. A. K., aged 25, laborer at the time of injury, was
injured June 25, 1934. He was helping lift a slab of marble
when he felt a snap in the middle of the lower part of the
back. He continued to work. That evening, after sitting still,

374

THE JOURNAL-LANCET

his back became stiff. When he straightened up he felt a pain
in the back. He continued to work for one week at which time
the job was finished. The day following the injury he went
to a physician who taped his back and applied heat treatments
for seven weeks.

Because the pain continued, he went to an osteopath who first
had his back X-rayed by a competent roentgenologist. It was
found to be normal. He received treatments to his back during
July and August without obtaining relief.

In the last part of August he returned to the original physi-
cian and received heat treatments regularly up to October. A
canvas belt was applied to his back in September. He began
teaching school in September but could not perform his duties
as an assistant athletic coach because of the back pains.

He presented himself on December 28, 1934 complaining of
pain across the lower part of the back and in both buttocks.
The pain was felt at times down the back of both thighs. It
was aggravated by walking, especially on irregular surfaces.
The pain was worse when lying in bed and he was unable to
roll from one side to the other because of the pain in the lower
back and buttocks. There was no pain present when he stood
or sat still. He was unable to play golf, volley ball or referee
basket ball games because of the pain in the lower part of the
back and buttocks.

The past history was non-essential. He had never had any
venereal disease.

Upon examination the back was found to be normal. There
was no muscle spasm or rigidity of the back muscles. The
prostate gland was enlarged, soft and tender. The smear of
the secretion showed fifty to sixty leucocytes per high power
field.

After the second treatment his back felt better. In three
weeks he stated that his back was cured and that he had
played seven games of volley ball and refereed an overtime
basketball game.

Case 20. W. B., aged 39, a railway conductor, was injured
in February 1931. He fell five or six feet from the side of a
box car landing first on his feet and then falling to the ground.
The left knee was injured. He returned to work two days
later and in three weeks the knee was well. About six weeks
after the accident he began to have soreness and lameness in
the lower part of the back on the left side. He continued to
work. The pain remained in his back and gradually became
more severe. On April 15, 1932 he had to quit working be-
cause of the pain, and consulted a physician. He continued
to be disabled and during the first part of June went to an
orthopedic surgeon near his home town. The back and pelvis
were taped and later he was supplied with two different ortho-
pedic belts without obtaining relief. At the end of four weeks
a sacro iliac fusion operation was advised.

He presented himself on June 24, 1932 complaining of a
constant pain in the lower part of the back on the left side.
The pain felt like as if it were "deep in.” He also complained
of pain in the back of the left thigh. Walking aggravated the
pain to such an extent that he could only walk a distance of
two blocks before he had to stop. He was most comfortable
sitting down and at night got up and sat in a chair to get
relief from the pain.

The past history was non-essential. He had not had any
venereal disease.

On examination the back was found to tilt to the left when
the patient stood. When lying down there was no muscle
spasm or rigidity of the back muscles. There was a tender
area over the left sacro-iliac region and around the left posterior
iliac spine. Motions of the back when he stood were limited
because of producing pain. The back motions were free when
he sat on a stool. The prostate gland was diffusely enlarged,
tender and felt boggy. The first two examinations of the secre-
tion did not contain leucocytes. On the third examination the
smear of the prostatic secretion contained fifteen to twenty
leucocytes per high power field.

The roentgenograms of the lumbar spine and the sacro-iliac
articulations were normal.

This man returned home and his physician carried out the
treatment for the chronic prostatitis. He returned in eight
weeks for observation and at that time he was free from back
pains and was planning to return to work.

Case 21. L. S., aged 30, laborer, was injured January 20, 1
1931. He was knocked off a fifteen foot scaffold striking his
back and head on the frozen ground. He was unconscious
and was taken to the hospital in an ambulance. On regaining
consciousness he had headaches and pain in the small of the 'n
back. The head and back were X-rayed and found to be nor-
mal. At the end of twenty-four days he left the hospital wear-
ing a wide canvas belt.

Four weeks after the accident he was examined by a con-
sulting physician who reported the spinal column normal, no
muscle spasm or rigidity in the back and the motions of the
back normal. A rectal examination was not made. A diag-
nosis of functional neurosis was made and it was estimated
that he would be back to work in three months.

This man was examined in July 1931 by the third physician
who reported that the physical examination, including a rectal,
was normal. The pain in the back was considered the result
of the contusion to the back.

On September 4, 1931 he first presented himself. His com-
plaints were: first, a constant aching in the lower part of the
back and in the back of the left hip, the pain being sharp
when a quick step was made or when stepping on an irregular
surface; second, he was unable to walk without crutches because
of the pain; third, he had headaches; fourth, he had an aggra-
vation in his diabetic condition, necessitating him to take more
insulin.

Past History: The diabetes mellitus had been present for
four years. He had gonorrhea when fifteen years of age.

Upon examination the back was found to be normal except
for tenderness over the left sacro-iliac articulation and medial
to the left greater trochanter. The prostate gland was enlarged,
smooth and tender. The left seminal vesicle was enlarged and
tender. The smear of the secretion contained five to ten leuco-
cytes per high power field. The blood Wassermann was posi-
tive. The urine gave a positive reaction for sugar.

This man was hospitalized and Dr. Donald McCarthy was
called as consultant. The diabetes was studied and controlled.
The chronic prostatitis and seminal vesiculitis were treated by
massage and hot Sitz baths. He developed acute thyroiditis
which subsided with the use of hot packs and the discontinu-
ation of the prostatic massage. He left the hospital October 3,
1931 walking on crutches with the back and hip pains un-
changed. The prostate gland became markedly enlarged, near-
ly touching the sacrum. It was very tender and the secretion
was loaded with leucocytes.

On October 13, 1931 the prostate gland was drained by
Dr. R. C. Webb through a perineal incision. The tissue of the
gland was edematous and no abscess cavity was found. As
soon as the soreness from the operation subsided he was free
from back and hip pains. He left the hospital on October 31
walking without crutches and without pain. The prostate
gland has been examined on several occasions since and found
to be of normal size, firm and not tender. The smears of the
secretion contained no leucocytes. Anti-luetic treatment was
begun at Ancker Hospital the last part of November 1931. He
returned to work January 15, 1932.

In some cases chronic prostatitis and seminal vesiculitis will
cause referred pains in the lower back thereby producing a
clinical picture that may be confused with conditions brought
on by injury. The prostate gland and seminal vesicles should
be examined in all cases of low back pain. Where they are
suspected of being the cause of the pain it may be necessary
to make repeated examinations to determine the presence of
the infection.

Disability will be reduced if the chronic prostatitis and semi-
nal vesiculitis are recognized and eradicated at the onset.

References

1. Boies, L. R.: Prostatic backache as a cause of prolonged dis-
ability following injury, Minnesota Med. 11:576-579, Sept., 1928.

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375

2. Duncan, W. L.: The relation of the prostate gland to ortho-
pedic problems, J. of Bone and Joint Surg., 18:101-104, Jan.,
1936.

3. Young, H. H., Geraghty, J. T. and Stevens, A. R.: Chronic
prostatitis. An experimental and clinical study with an analysis of
358 cases, Johns Hopkins Hosp. Rep. 1 3:271-384, 1906.

4. Webb, R. C. : Chronic prostatitis and back injuries, Proceed-
ings of the Medical and Surgical Section of the American Railway
Assoc. 82-85, 1928.

5. Wesson, M. B. : Backache due to seminal vesiculitis and

prostatitis, California and West. Med. 27:346-352, Sept., 1927.

Discussion

Dr. H. B. Dornblaser: I have had only one case of pros-

tatitis in my gynecological practice and that cleared up very
nicely with Elliott treatments. A rubber prostatic applicator
was introduced into the rectum with a great deal of pain to the
patient the first few times it was used. It was surprising, how-
ever, how quickly the prostatitis cleared up.

Dr. M. O. Henry: I think the paper is most interesting, and
it reminds me of what we were taught in school days about
syphilis. We were taught that syphilis may simulate almost
any condition in medicine and surgery. This seems to be true
of back pain — almost anything may produce it. I suppose that
every adult male has had a prostatic back-ache at some time or
another, but I do not think it is attended by muscle spasm.
Prostatic disease may cause back-ache, but it is unlike the acute
traumatic back pain and is not attended by muscle spasm.

Dr. J. M. Hayes: I was with the Mayo Clinic when Von
Lackum first called attention to the fact that many of these pains
were due to prostatic infection. He was about the most en-
thusiastic adherent to this theory I have seen. Dr. Herbst, who
trained in that department and later came to Minneapolis, was
also a very ardent supporter of this belief. In many of these
indefinite back pains, I am sure he did get some good results
by massaging the prostate. The great difficulty is to determine
which patients should be subjected to this treatment. I have
seen several patients receiving this treatment over long periods
of time in whom I could see no definite indication for the treat-
ment, neither did I see any improvement in the condition of
the patients. No doubt, it requires good judgment and a
proper knowledge of the technique to get the desired results.
These cases of Dr. Anderson’s are interesting. After all, the
clinical result is what counts.

Dr. C. J. Ehrenberg: I would like to ask if there is any
relationship between this type of infection and allergy. Can
allergy cause back pain and if so, just what is the mechanism
of the thing? From the standpoint of infection in gynecology
one must recognize that infection does give rise to low back
pain. There are too many women in whom a cervicitis is
cleared up and the back pain relieved, to discount it. But what
is the mechanism of that infection causing the back pain, if that
can be answered.

Dr. Donald McCarthy: Do you think you are justified in
calling or diagnosing a case of chronic prostatitis purely on the
presence of 5-10 leukocytes per HPF in the third attempt? Do
you think this necessarily means that this patient has a chronic
prostatitis? I grant you that where the patient has a lot of
pus cells that is another matter; but if you were to take a fair
number of prostates and massage them a few times don’t you
think you would get a few leukocytes in a rather high per-
centage of them?

Dr. C. D. Creevy: There are three things I would like to
say about prostatitis. 1. Usually the infected prostate feels
perfectly normal on rectal examination. 2. One can hardly
talk about curing prostatitis. I will wager that if you got
those patients back you would find pus in the prostatic secre-
tion of all of them. Relief is usually due to improvement in
drainage because the prostate was not designed to be cured of
an infection. 3. I do not think you designate any fixed num-
ber of pus cells per H. P. F. as constituting prostatitis. I think
the best test is whether the patient gets relief from treatment.

Dr. C. J. Ehrenberg: How can you say there is no muscle
spasm simply because you do not feel it? These men admit
that when they walk along they can only walk two blocks before
they have to stop, or they cannot walk on uneven ground. Is
that muscle spasm? Many of these people say they get up in

the morning and cannot stoop over, but as they go along
through the day they find a little more freedom in bending.
Is that muscle spasm? Personally, I think it is muscle spasm
in the deep vertebral muscles, and not reflex visceral pain mani-
fested peripherally. Nobody, as far as I know, has ever ex-
plained satisfactorily the mechanism of this low back pain —
even though chronic infection is the cause.

Dr. E. T. Evans: How can a man have a tilt which is an
assumption of a position for protection unless he assumes that
position voluntarily as a malingerer or unless he assumes it be-
cause there is a stimulation requiring him to assume that posi-
tion for protection, and when he assumes that position for true
protection there is a muscle spasm. When you lay a man
down he may relieve himself. The absence of spasm on a par-
ticular test does not mean he does not have that spasm on
another test. I have never seen a patient with a scoliotic tilt
who did not have a muscle spasm for a basis unless he was
assuming that postion as a voluntary malingerer.

Dr. E. R. Anderson: This discussion dealt only with cases
of back pain, following injury, which unquestionably was caused
by chronic prostatitis. As brought by the discussers there are
other conditions which cause back pain. In selecting the cases
for the basis of this paper, those that revealed any abnormal
conditions of the spine or sacro-iliac articulations by X-ray
study were excluded. The chronic prostatitis may be the focus
of infection from which a metastatic infection can orginate and
cause arthritis in the spine.

Involuntary muscle spasm was not present in any of the
cases selected for the basis of this study. In some of the cases
there was an apparent muscle spasm present when the patient
was examined in a standing position. When the patient was
placed on the abdomen and the back examined, no muscle
spasm was found. Muscle spasm is not produced by chronic
prostatitis.

The pain that is present is a referred pain. The stimulus
is set up in the infected prostate gland and pain is interpreted
by the patient in the area of distribution of the peripheral
nerve that originates from the same spinal segment as the
visceral nerve.

The prostate gland to be normal should not contain any
leucocytes in the secretion. The degree of infection can not
be determined by the number of leucocytes present.

The diagnosis of chronic prostatitis is based upon the find-
ings of palpation and on the microscopic examination of the
secretion. In some cases of chronic infection leucocytes will
not be found on a single examination. It may be necessary to
make repeated examination of the secretion. The number of
leucocytes in a smear vary greatly. One examination may
show a large number and the next one may contain only a few.
There is no relationship between the number of leucocytes
present and the size of the prostate gland or the amount of
tenderness present. The gland can be very large and the
secretion contain just a few cells or the gland may feel normal
and the secretion contain a large number of leucocytes.

The chronic prostatitis usually does not stay cured. Treat-
ment to the gland improves it and the patient gets relief from
his symptoms. When relieved of the back pains which had
been attributed to the accident but which were actually due to
the chronically infected prostate gland the disability ceases.

THE STATUS OF TRANSURETHRAL RESECTION
OF THE PROSTATE
Inaugural Thesis
Dr. C. D. Creevy

In the past ten years the treatment of obstructive lesions at
the vesical neck has undergone a substantial change which has
been accompanied by a good deal of acrimonious debate. The
extent of this change may be judged by the titles under "Pros-
tate Gland” in the Quarterly Cumulative Index. In 1927 there
were five references to transurethral operations and fifty-three
to prostatectomy. In the last half of 1935 and the first half
of 1936 there were eighty-five relating to transurethral pro-
cedures and fifteen to prostatectomy.

376

THE JOURNAL-LANCET

The references in the 1927 volume all came from the United
States, where the modern operation of transurethral resection
originated, while those of the past year came from nearly every
civilized country in the world. The rapidity and extent of the
spread of interest in this subject are valuable indices of the
need for improvement in the surgical treatment of the obstruct-
ing prostate.

It is interesting to speculate as to the cause of the change
from prostatectomy to resection, particularly when one recalls
the smug references to the virtues of prostatectomy which were
current when the transurethral operation appeared.

One reason for the widespread interest in closed operations
upon the prostate is to be found in the recent substantial in-
crease in longevity, so that far more men live into the prostatic
age than was formerly the case. In the time of Shakespeare,
few reached the age of prostatism; today most men face this
possibility. Moreover, the fact that most physicians expect to
and do reach this age has certainly contributed to the rapid
development and spread of the method.

Additional factors are readily found. The average patient
who undergoes prostatectomy must expect to face the following
possibilities: (1) A hospital stay of 7 to 14 or more days in

preparation for operation. (2) A mortality rate ranging from
2.3 per cent1 in the hands of a very few experts to 25 per cent-
in the hands of less experienced surgeons, and averaging at least
6 per cent in good hands under average conditions'*. (3) A
period following operation during which he will be wet, emit
unpleasant odors, and possess uncertain control over the escape
of urine. (4) A postoperative stay in the hospital averaging
thirty days4.

Such a patient could, if he were a physician, balance the
greater risk of death and the very slight risk of incontinence
after the supra pubic operation against the lower mortality and
greater risk of incontinence after the perineal method. He
might be influenced by the possibility that there are, among
those surviving the perineal operation many whose uncertain
or absent control of micturition is a source of very severe dis-
comfort and embarrassment to them.

Anyone weighing these facts and contemplating the possi-
bility of developing prostatism himself was certain to search
for safer, pleasanter methods. The search began early in the
modern surgical era and suffered many vicissitudes before at-
taining any measure of success. The attempts of Guthrie
(1834), of Mercier, and of Bottini (1874) failed because their
instruments were blind and because the danger of operating
upon the prostate in the presence of impaired renal function
was not recognized. Before the beginning of the current cen-
tury both Wossidlo and Wishard had developed cystoscopic
cauteries that might well have become widely used, had not
Freyer at this time demonstrated the ease and effectiveness of
suprapubic prostatectomy which then had a lower mortality
than the unperfected transurethral procedures.

The modern operations date from the prostatic punch of
Hugh Young in 1911. This was the first instrument to permit
the actual removal of tissue under direct vision. It was devised
by Young and used by him only for the fibrous, contracted
prostate which could not be enucleated; the operation might
have remained thus limited in scope had not Caulk**, in 1920,
begun attacking the hypertrophied gland with a similar instru-
ment. To him goes the credit for awakening interest in the
possibilities of the method.

Once he had broken down the resistance of the profession,
which took almost ten years, development was rapid. The work
of T. M. Davis7 gave a great impetus to the wide application
of these methods, as did the reports of Bumpus8, Alcock9, and
Thompson10, all of whom reported large series of cases with,
in many instances, almost incredibly low mortality (0.9 to
2.5%).

At the present time the instruments used in this country are
fairly well standardized in two forms, the punch and the re-
sectoscope. The former employs either a knife (Braasch-
Bumpus, Thompson) or a cautery (Caulk) and all resemble in
principle the original instrument of Young. The latter are
derived from the instrument of Stern, the modification of Mc-

Carthy being more generally used than all other instruments
combined. These instruments excise tissue with a wire loop
charged with high frequency (diathermy) current.

With either instrument, the object is the removal of a suffi-
cient number of small pieces of prostatic tissue to convert the
prostatic urethra into a funnel shaped opening which is free
from encroachments either in its lumen or at its junction with
the bladder. The original notion of some early writers that
one could cut a channel through a large gland by removing a
few bits of tissue is wholly incorrect because the hypertrophied
gland is flexible and movable. If a few pieces are removed, the
remaining mass moves over and continues to occlude the
urethra; it is quite possible to convert a partial retention of
urine into a complete one by removing a small median lobe
and allowing the lateral lobes to move together.

In any case, bleeding is controlled by electro-coagulation of
individual bleeding points, and postoperative drainage is pro-
vided by a large inlying catheter.

The general application of these methods has met with
bitter resistance, particularly from the older urologists, and the
literature is filled with unsound statements both condemning
and praising transurethral operations. For example, one of its
early proponents did serious harm by stating that he per-
formed the operation in his office under caudal anesthesia and
had the patient walk to the hospital. While he did this suc-
cessfully, any attempt by inexperienced operators to emulate
this rash plan must have caused serious mishaps and have
thrown the method into disrepute in many quarters.

At the other extreme is the prominent urologist who said in
1933, "This is as serious an operation as exists in surgery.” The
absurdity of making such a statement about an operation which
has a mortality as low as one to two per cent in expert hands
is too manifest to require comment. His statement that resec-
tion bottles up infection by sealing the prostatic ducts is also
incorrect, as one may readily obtain prostatic secretion by mas-
saging the gland which has healed after a resection.

The chief differences of opinion in discussions of trans-
urethral resection have involved:

(1) The true mortality of the operation;

(2) The indications for its use;

(3) The incidence of postoperative hemorrhage;

(4) The risk of incontinence;

(5) The danger of "missing a cancer which might have
been cured by prostatectomy”; and

(6) The danger of early recurrence of obstruction to urina-
tion.

The arguments on behalf of the operation are easily sum-
marized. They are:

(1) The mortality in general is much below that of pros-
tatectomy;

(2) It may be used by the experienced operator for all but
the largest glands; which means more than 90% of all
obstructing prostates, irrespective of their configuration;

(3) The incidence of postoperative hemorrhage is very low
in experienced hands. (The proponents of prostatectomy
have entirely forgotten that it is also followed at times
by secondary hemorrhage) ;

(4) The risk of incontinence in experienced hands is slight;

(5) The possibility of curing cancer of the prostate by anv
method now available is extremely small, but opponents
of resection have raised the objection that with it, early
cancers which might be cured by prostatectomy will be
overlooked.

That this objection is not a serious one is shown by the
report of Bumpus11, who found that only 7.3 per cent of car-
cinomas, most of them early, were cured by prostatectomy.
Young1” had 60% of five year survivals in operable cases after
radical perineal prostatectomy, but only 24 of 258 cases were
operable; 8 of these lived five years, a percentage of cure in
the whole series of 3.1%.

Thus, an opportunity to cure cancer will be missed in but
3% of carcinomas; since carcinoma accounts for not more than
20% of obstructions at the vesical neck, the use of trans-
urethral resection instead of any form of prostatectomy in all

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377

cases of obstruction will result in missing a theoretical oppor-
tunity for cure in 0.6% of the cases.

The substantially lower mortality of the resection compen-
sates many times over for the above-cited theoretical advantage
of prostatectomy. Moreover, Hunt13 has pointed out that
ptostatectomy for benign hypertrophy does not guarantee
against the subsequent development of carcinoma in the pos-
terior lobe which remains as a part of the surgical capsule.

(6) Recurrence has not yet proved a serious problem, and

(7) The period of hospitalization, both preoperative and
postoperative, is much shortened (14 days in my ex-
perience), and the wet period is eliminated. This is an
economic advantage to the patient, and effects a con-
siderable saving to the hospital in linens, dressings, and
nursing care.

Nevertheless, there are two disadvantages inherent in trans-
urethral resection. The first of these is the difficulty of mas-
tering the technique of operation. No conscientious surgeon
will attempt it until he has first become an expert cystoscopist,
and then had competent instruction in the technical aspects of
the operation. Alcock has suggested that no one may attain
reasonable proficiency until he has performed fifty resections,
but my own opinion is that a hundred is more nearly correct.
v There are very few places in this country where one may attain
such an experience, and these are closed except to those few
who are bent on securing general training in urology. There-
fore, relatively few men may attain proficiency in the method,
but to use this as an objection to the operation is like condemn-
ing all surgery of the brain because relatively few surgeons are
able to secure the requisite training. Transurethral resection will
always remain an operation for specialists.

The one genuine objection to the method is the possibility of
early recurrence of the obstruction. It is manifestly impossible
to remove all of the abnormal prostatic tissue in a given case
by transurethral resection, since one cannot tell at operation
when normal tissue has been reached. It is therefore necessary
to remove only that: portion which is causing the obstruction.
While Caulk claims that the regaining abnormal tissue will
atrophy if the obstruction has been completely relieved, this
is open to doubt, and the fact is that there is a very definite
possibility that recurrence will be relatively frequent after re-
section for benign hypertrophy.

Several factors mitigate the seriousness of this possibility.
First, the average age of the patient coming to operation at my
hands has been 66 years in 561 cases, so that his normal life
expectancy is but a few years.

Second, the duration of symptoms before operation averages
about five years; it is well known that symptoms do not appear
until the hypertrophy has become large enough to produce ob-
struction, probably a matter of several years after the actual
onset of the disease.

It is thus apparent that, if an adequate amount of tissue is
amoved, the chances of recurrent obstruction are small. The
determination of what constitutes an adequate amount of tissue
in a given case must be determined by the individual surgeon.
In my own cases, it has averaged 26.6 grams in the past year,
although it was but 3 grams during the first two years — sug-
gesting that the first cases done will probably develop recurrent
obstruction, while the last ones probably will not.

Unfortunately, no one has yet been able to report the late
results of resection done for relatively large glands sufficiently
long ago to permit the drawing of conclusions as to the in-
cidence of recurrence, but these data will be available before
long.

There is no doubt that the immediate results are satisfac-
tory, and that symptoms can be relieved in all but the largest
glands, which constitute 5% or less of all obstructing prostates.

The indications for the employment of resection instead of
prostatectomy depends upon the individual surgeon. If he is
relatively inexperienced or if he is prejudiced against the method,
he will probably limit his efforts to the contracted, fibrous
glands, small carcinomas, and to small hypertrophies of the
median lobe, while the operator of greater experience may
readily and safely remove more than a hundred grams of pros-

tatic tissue uninfluenced by the anatomic type of hypertrophy
ptesent and will perform prostatectomy in but two to five per
cent of the cases. I am certain that this will continue to be
true unless an unexpected number of recurrences takes place
in the future. The general surgeon will probably continue to
confine himself to prostatectomy. Indeed, in the hands of the
man who performs cystoscopy and operates upon the prostate
only occasionally, two-stage supra-pubic prostatectomy will re-
main the treatment of choice unless we, experience unforeseen
developments in therapy with the X-ray or with endocrine prep-
arations both of which, at present, appear to promise but little.
Summary of Results

Between April 1930 and February 1937, I have done 707
resections on 574 patients. In 1930, 18 patients underwent
resection while 25 were submitted to prostatectomy. In 1936,
160 (98.2%) underwent resection and three prostatectomy

(1.8%).

The patients averaged 66 years of age, 30% being past 70,
and 4% past 80, while one was 5 and one 16 years old. 52%
had complete retention of the urine, and the residual averaged
460 cc. before operation. Preliminary cystostomy was done in
11% (6% in 1936) either for impaired renal function, acute
infection or the removal of large stones.

83 patients (15%) had cancer, 20 of which were treated by
litholapaxy, 43 (7%) had stones, 20 (3.8%) had neurogenic
vesical dysfunction, and 12 (2%) had diverticula large enough
to require removal; in other words, there was complicating local
pathology in 27%, nearly all had pus in the urine; the two-
hour phthalein excretion averaged 50%.

20% of the patients had two resections before leaving the
hospital, and a very few had three. The amount of tissue
removed averaged 3 grams per patient in 1930 and 26.6 grams
in 1936. Only one patient has been refused operation, and
this because of far advanced pulmonary tuberculosis.

There have been 21 deaths or 3.6%. By a process of calcu-
lation well-known to the profession, this can be reduced to
2.8%, but I cannot justify it.

In general, the results have been good, the postoperative
residual having averaged less than 30 cc. Deaths have been due
to infection, and this has been responsible for more of the
postoperative complications such as epididymitis, periurethritis,
pyelonephritis, etc. There have been 12 (2%) postoperative
hemorrhages, 4 of which (0.66%) have required cystostomy.
Partial incontinence for 24 hours is not uncommon, and a few
patients have left the hospital incontinent but only one of the
whole group has remained so.

Pyuria occurs postoperatively in all the patients, but usually
is not associated with symptoms and disappears after 6 to 12
weeks. Hence it is not treated unless it persists beyond that
time.

Bibliography

1. Davis, Edwin, Analyses of results of 378 consecutive perineal
prostatectomies, Tr. Am. Assn. G. U. Surgeons, 387-399, 1931.

2 Keyes, E. L. 6c Ferguson, R. S., Urology, Appleton-Century
Co., N. Y., 1935, p. 236.

3. Klika, M., Indikationen, Operationstechnik, und Resultate
der Suprapubische Prostatektomie, Wien. Med. Wochenschr, 82:
110-1 12, 1932.

4. Swan, C. S., 6C Mintz, E. R., A review of the prostatec-
tomies for benign hypertrophy at the Massachusetts General Hos-
pital, J. Urol. 26:67-90, 1931.

5. Young, H. H., Practice of Urology, W. B. Saunders 6 i Co.,
Phila., 1926, p. 481.

6. Caulk, J. R., Transurethral surgery, S. G. 61 O., 58:341,
1934.

7. Davis, T. M., Transurethral resection, Urol, and Cutan. Nev.,
39:372-377, 1935.

8. Bumpus, H. C., Transurethral resection, Minn. Med., 12:22,
1929.

9. Alcock, N. G., Prostatic resection and surgical prostatectomy,
J. A. M. A., 101:1 355-1 358, 1933.

10. Thompson, G. J., Transurethral resection, J. Urol., 34:
405, 1935.

11. Bumpus, H. C.. Carcinoma of the prostate; A review of
1000 cases; S. G. 6C O., 43:150-155, 1926.

12. Young, H. H.. Loc. Cit., pp 653-654.

13. Hunt, V. C., Carcinoma of prostate gland and capsule de-
veloping subsequent to prostatectomy for benign hypertrophy, J.
Urol., 22:351-362, 1929.

378

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Discussion

Dr. J M. Hayes: I would like to ask Dr. Crcevy if he
thinks now that he might have prevented some of these post-
operative complications by more careful preoperative prepara-
tion if he could have foreseen these untoward results.

Dr. C. D. Creevy: Pyelonephritis as a postoperative com-
plication is often attributable to the operator’s bad judgment
in operating with insufficient preparation. Patients without
fever and with normal renal function require no preparation;
those with functional impairment require preliminary drainage,
with the catheter in mild impairment and by cystostomy if the
renal damage is severe.

I do not believe that postoperative pyuria can be avoided in
most cases.

Dr. Donald McCarthy: I wonder if it would be within

the realm of this paper to discuss what you really believe the
criteria for proper preparation. Do you consider phthalein and
urea alone, or do you consider evidence of infection, or both?

Dr. C. D. Creevy: The principles I have tried to follow are
briefly these: if the patient’s phthalein is good, (50% or more
in two hours) , and the temperature is normal, I do not care
whether he has pus in the urine or not. If he is afebrile he is
taking care of the infection and is ready for operation. If the
phthalein is reduced I use an inlying catheter until it has come
back to a normal level or until I am convinced that it won’t
when I use a cystostomy. If the patient has a very severe im-
pairment when he comes to the hospital I prefer to make a
cystostomy first.

The tone of the bladder must also be considered. If the
bladder is very flabby the patient needs preparation even though
his phthalein is normal and he is afebrile. Such a patient may
even require a cystostomy.

There are other conditions which must be considered such as
cardiovascular lesions, anemia, etc. A considerable number of
our cases are transfused preoperatively, or have a period of ther-
apy for cardiac disorders before operation.

Dr. Donald McCarthy: Has the question of gradual de-
compression gone by the boards?

Dr. C. D. Creevy: I am a bad one to ask about that be-
cause I have never employed it. I once spent two or three
years going over the literature but I could not find any evidence
that there was a lesion that could be attributed to the rate of
emptying the bladder. I think it is a question of infecting the
patient. They have adopted this view at the Mayo Clinic, but
the textbooks still speak of gradual decompression.

I once went over the cases for two comparable periods of
years at the Mayo Clinic with this in mind. In 1917-1918
they simply put in a catheter and emptied the bladder. In
1921-22 they employed gradual decompression. I found no
difference in the mortality from catheterization between those
two periods.

Every urologist knows about some patient who died as a
result of a sudden emptying of the bladder but no one can
furnish the details. The idea is very firmly fixed in all the
textbooks, but I can find no proof of it. I have never had any
ill effects that I can attribute to the rate of emptying of the
bladder. If patients die after emptying of the bladder they
die of infection. I could not find in the literature any record
of a complete autopsy on one of those patients.

Dr. Robert P. Caron: I would like to ask Dr. Creevy the
clinical indications for prostatectomy.

Dr. C. D. Creevy: I do not think that one can make any
hard and fast rules as to the amount of residual urine which
constitutes an indication for transurethral resection. If the pa-
tient is comfortable, he may do well indefinitely with 100 cc. of
residual. A very definite indication occasionally exists in the
absence of residual urine in patients who have the most extreme
difficulty in voiding and who get no benefit from prostatic
massage and dilation. Such people may get the most gratifying
results from prostatic resection. I have recently had a patient
who never had more than 45 cc. of urine but who had a great
deal of difficulty in emptying his bladder and resection relieved
him completely. The result is just as gratifying to him as if he
had had a large retention. If the patient is comfortable, has

good renal function and isn’t losing a lot of rest, I do not see
any reason for operating on him.

Dr. Robert P. Caron: Is prostatic massage very beneficial
in these older persons?

Dr. C. D. Creevy: Some patients will get relief from mas-
sage if part of the enlargement is due to prostatitis, but if it
is all due to true hypertrophy they won’t. The only practical
way of discovering these patients is to try massage and see if
it relieves them, (I always explain it may or may not).

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of April 14, 1937

The regular monthly meeting of the Minnesota Academy of
Medicine was held at the Town & Country Club on Wednes-
day evening, April 14th, 1937. The meeting was called to
order at 8 o’clock by the President, Dr. E. M. Jones.

There were 50 members and 1 guest present.

Minutes of the March meeting were read and approved.

The scientific program followed.

NOTES ON A COMMON TYPE OF EMOTIONAL
PROBLEM ENCOUNTERED AMONG
COLLEGE STUDENTS
E. M. deBerry, M.D.

Dr. deBerry, University of Minnesota, read his Inaugural
Thesis on the above subject.

Summary

1. It is possible to describe a psychiatric syndrome character-
ized by self-consciousness, shyness, feelings of unworthiness
and insecurity.

2. Cases falling into this group have, because of circum-
stances, misinformation, ignorance, etc., been led to interpret
certain experiences as evidence of inferiority in themselves.

3. Their reaction to this is the natural one of self-conscious-
ness, withdrawal from group and personal contacts, with the
development of pathological compensatory day-dreaming closely
resembling the production of schizophrenia.

4. Because of the accessibility, as contrasted to the inaccessi-
bility of the schizophrenic, the physician is able to observe the
causal relation existing between the patient’s behavior, his emo-
tional disturbance, and his previous experiences. He is able
adequately to explain the syndrome in terms of experience with-
out resort either to physical factors on the one hand, or to deep
psychological analysis on the other.

5. Since the etiology of the self-conscious syndrome may be
adequately explained in this manner, and since this condition
closely resembles schizophrenia, it is suggested that investigation
in this pre-psychotic field should throw considerable light on the
etiology of the more serious disease.

Discussion

Dr. W. H. Hengstler, St. Paul: This splendid presenta-
tion of Dr. deBerry touches a field in psychiatry which has
grown tremendously in the last ten years. Those of us prac-
ticing psychiatry are thought by many to deal only with the
insane, but the greater part of our practice today is with these
emotional disorders. Dr. deBerry is fortunate in seeing a wealth
of material in the adolescent period and to be able to see these
conditions in their incipiency, that we see in the adult and
their struggle in competition with the world. I was very glad
to have him say what he did about masturbation. In these
emotional cases, the problem of masturbation is invariably pres-
ent. It even pops up in the involutional period of life and
offers the basis for the type of depression which leads to suicide.
The tendency of all these people who have these emotional
disorders is to go to the public libraries and get some book
and read all about what some layman has said about it. The
most common question asked of the psychiatrist is "what books
can you recommend for me to read to help solve my problem?’’
Of course there is nothing worse than a book written by a lay-
man describing all the signs and symptoms of his own exper-
ience and trying to tell the rest of the world what to do about
it. The best advice would be that the patient go to a good
psychiatrist and have him get his information from that one

THE JOURNAL-LANCET

379

source. I recall one case which shows very well this sudden
feeling of inadequacy in these patients. This young man was
a perfectly normal young man, employed by a large corporation,
and a graduate of a mining engineering school. He was per-
fectly normal until he became involved in an affair with a girl
whom he later married because he had to. After the wedding
he continued normal until the birth of a baby which was about
one month prior to the necessary gestation period. After that,
when he reported for work, he got the idea that everyone in
his office knew about this and he began to blush; and ever since
then he has been unable to approach friends or any one in the
office without this sensation of blushing and intense perspira-
tion. It has so interfered with Lis work that he is completely
demoralized.

I want to express my appreciation of Dr. deBerry’s contri-
bution. I think there is nothing more important than these
disorders of personality; it is a subject worthy of the considera-
tion of every doctor practicing medicine.

Dr. deBerry, in closing: There is nothing much to add ex-
cept possibly in response to Dr. Hengstler's remark about read-
ing of books written by laymen. The reading of books written
by psychiatrists is even worse. The layman may invent terms,
but the psychiatrist has it all over the layman in inventing
terms. Physicians are particularly careless in what they say, per-
haps because these books are supposed to be read only by phy-
sicians. They are read by laymen, however, on whom they have
quite a different effect. It seems to me this problem (certainly
my problems at the University) would be lightened if medical
books were not available to students and the general public.

OSTEOCHONDROMATOSIS OF THE
KNEE JOINT

Arthur W. Ide, M.D.

ST. PAUL

This patient, J. C. C., has been for many years employed
as a railroad freight conductor. He is 52 years old, and has
been under observation and treatment for the last year on
account of trouble with his right knee.

He gives a history of first injuring this knee when he was
14 years old. At that time he was shot with a 22 caliber
bullet. The bullet penetrated the skin just below the patella
and emerged in front of the patella. It probably did not enter
the joint. The wound healed in about three weeks and gave him
no serious difficulty at that time or later. About three weeks
after this injury, the patient fell over a stump and injured his
knee again. The knee was injured by some splinters from this
stump and the resulting wound was slow in healing. He says
it "festered". It took him five or six weeks to recover from this
injury, but, once healed, it gave him no further trouble.

About six weeks later, he struck this knee again. At that time
he was working as a brakeman on the railroad and injured the
knee while handling freight. He was struck above the knee by
a heavy fly-wheel which he was handling. He was unable to
work for only two weeks at that time, but he thinks that this
accident damaged the knee considerably. After that, he worked
for about 25 years without serious trouble. He does not think
he had any disability whatever in this knee during those years.

The next time he experienced any difficulty was in 1934. At
that time he noticed some little trouble with this knee, but
there was no serious inconvenience. In May 1935, he was taken
seriously ill with pneumonia and did not regain his health
until October 1935. When he recovered from this pneumonia,
the knee began to give him some trouble. Prior to that time
he had felt a small lump above the patella but he had not
given the matter any serious consideration.

As a young man he had worked as a brakeman on freight
trains and during the later years he had been a conductor on
a freight train. He was able to get about very well even in these
occupations.

Following his sickness in 1935, he went back to work in
December. At that time he began to have stiffness and pain
in his right knee. The knee gradually became worse. In spite
of this trouble, he worked for six months before reporting for
X-ray examination. He was still able to work at his job as

conductor on a freight! train, but, on account of this trouble,
his occupation was changed in August 1936 and he went to
work as conductor on a passenger train. He was able to handle
this job until December 1936. At that time his knee became so
bad that he was not able to work at all and he was pensioned
on a basis of total disability.

Since that time he has not been able to get about except on
crutches and even with his crutches he has considerable diffi-
culty. The knee is painful when he puts his weight on it and
it is also painful when he bends the joint.

X-ray pictures, taken in July 1936, showed many irregulat
bodies in the joint and in the connecting bursa. These bodies
are found in all parts of the knee joint and in the bursa. They
are particularly noticeable posteriorly. There is also a very no-
ticeable roughening of the articular surface of the joint and
there is other evidence of arthritis.

X-ray pictures, taken in February 1937, show evidence of
progress in the arthritic condition in this joint. The diagnosis
in this case is one of osteochondromatosis with an accompanying
arthritis.

Osteochondromatosis is a rare condition characterized by the
formation of bodies in the joint. These bodies are pedunculated
and may become detached and form loose bodies in the joints.
They occupy the joint spaces and connecting bursa. This disease
is usually non-articular. Various joints may be affected, but the
knee is the joint most commonly affected. Osteochondroma-
tosis is a clinical entity and should not be confused with other
conditions where loose bodies are found in the joints.

Rixford, in 1930, referred to 80 cases which were reported
up to 1929 and he added 5 cases, bringing the total number of
cases reported to that date up to 85. These figures indicate a
rarity of this condition which is probably not borne out by the
actual facts. Undoubtedly this condition is far more frequent
than these figures would indicate.

Etiology. There are four factors that are considered impor-
tant in the etiology of this condition, namely, infection, trauma,
embryonic rests, and neoplasm. Infection has not been given
a very prominent place in the consideration of this condition.
In the case here reported, infection is undoubtedly a compli-
cating factor, but not an etiological factor. Undoubtedly this
patient has had an osteochondromatosis for many years but
has had no disability from it until recently. The disability has
been due to the complicating arthritis. He had a severe respira-
tory infection with a resulting arthritis in this diseased knee
joint.

It is surprising that these patients do not have more disability
in these joints that contain so many loose bodies. Undoubtedly
this patient worked in railway train service for many years with
this knee when it contained a great many of these bodies. He
did not know there was anything particularly wrong with the
knee during most of this time. The real disability began when
the arthritis developed.

Disability in these uncomplicated cases comes from locking
of the knee joint, the same factor that produces disability in
ordinary cases of foreign bodies in the joints. Trauma is un-
doubtedly a factor in the consideration of this condition. How-
ever, it is not thought to be a cause of the condition. These
bodies may be broken from their pedicle by trauma and un-
doubtedly trauma is, in many instances, a complicating factor
in causing disability in these joints. Most of these cases give
a history of trauma, as does this case. Just how much effect
the trauma has had is problematical.

It is quite likely that embryonic rests are important etiological
factors. These bodies apparently grow from the synovial mem-
brane, particularly near the attachment of this membrane to
the articular cartilage. These bodies grow out and are con-
nected with the synovial membrane by means of stalks. These
stalks may be broken off and in this way the bodies may be-
come loose in the joint. It has been suggested that these
bodies may continue to grow after they do become loose in
the joint. If this is the case, it is perhaps one of the best
examples of a body growing in vivo without definite connection
with other structures. It is possible that the joint fluid may
nourish these bodies and cause them to grow. It would seem

380

THE JOURNAL-LANCET

reasonable that this may occur, but this has never been dem-
onstrated.

Ewing describes the microscopic appearance of one of these
bodies as follows: "It appears to be an ossifying, papillomatous
synovitis that has taken on the aspects of a benign neoplasm.
Microscopically, these bodies show a cartilaginous formation
with a tendency toward calcification."

It is argued that this is a neoplasm; however, it is never a
malignant growth.

Henderson has reported one case of osteochondromatosis
with chondro-sarcoma of the femur. This is, so far as I know,
the only case reported of this condition with a malignant con-
dition coexisting.

Diagnosis. Diagnosis is made by X-ray. Undoubtedly these
bodies exist before they can be demonstrated by X-ray. This
can be shown only when the calcifying process is developed to
such an extent that the X-ray will show the shadow.

Treatment. The treatment is surgical. In uncomplicated
cases the joint is exposed by an appropriate incision and the
bodies are removed as completely as possible. It has been sug-
gested that a thorough flushing of the joint with saline solution
under pressure may dislodge bodies that otherwise might be
overlooked. A complete Synovectomy may be advisable.

In the case here reported, surgical treatment has been delayed
because of the coexisting arthritis. The knee has been im-
mobilized and when the arthritis has subsided surgical treat-
ment will be instituted.

Discussion

Dr. Arnold Schwyzer, St. Paul: My experience with this

condition has been in just one case. It involved the elbow.
There were very large bulky masses. The parts removed, com-
pletely filled a 2-ounce vaseline bottle. What Dr. Ide said
about not being hesitant at removing large parts of the affected
synovalis is important. I had to cut out the major part of it
and the result was very good. I think this is quite a promis-
ing case, but unless one opens the joint very widely, frees the
tendon of the quadriceps, and gets at the posterior recesses of
the joint, one could not expect very much of a result in such
a case.

Dr. Kenneth Bulkley, Minneapolis: I would like to ask
Dr. Ide how he plans to expose the joint when he does do some
surgery on it.

Dr. Ide, in closing: I am inclined to think that I will use
the "U” shaped incision and saw the patella transversely. This
undoubtedly gives the best exposure. This is desirable in this
case. A radical operation should be done. I believe we will
eventually get a satisfactory result.

SOLITARY CYST OF THE KIDNEY
Report of Two Cases
Arnold Schwyzer, M.D.

ST. PAUL

The first case was in a woman 55 years of age who had
had seven children. For about a year she had suffered from
some substernal pain and from nausea. The nausea had, how-
ever, disappeared during the last months. In the left side of
the abdomen one could readily feel a large rounded mass reach-
ing down from under the left ribs to the level of the iliac spine
and within an inch of the midline at the level of the navel.
Palpation was sensitive. A retrograde pyelogram demonstrated
a normal right side, while the left kidney shadow reached to
the iliac spine and a fainter contour to the lower end of the
sacro-iliac synchondrosis. The renal pelvis was rather stretched
inward and the lower calyx appeared widened and elongated.
The loss of its terminal endings and the rounded bulky contour,
instead of a bulging inward as seen in tumors invading the
calyx lumen, made the roentgenologist correctly suspect a large
cyst. The examination of the patient had allowed us to make
this diagnosis beforehand as the tumor was ideally round and
smooth and there was no cachexia or serious constitutional
change. The ureter as you can see (X-ray film shown) was
forced mesially onto the shadow of the spine. The solitary cyst
had the dimensions of a large-sized grapefruit.

At operation the upper pole of the kidney did not have to

be meddled with. A catheter was simply thrown around the
narrows between lower pole and cyst. This gave a good hold.
The lower pole was resected while step by step the kidney was
sutured as the division through the parenchyma progressed.
Recovery was uneventful.

The second case was a woman, 35 years old, who had had
three children. She gave a history that four days previous to
her first visit at the office she felt a pain in the right iliac. She
appeared rather debilitated, pale and pasty, had no appetite and
eating gave her cramps. Her hemoglobin was 70 per cent. The
right kidney was markedly ptotic and flopped around in the
abdomen very freely. It could readily be rotated, as it seemed,
in any direction and could easily be brought over the spine into
the midline and with its lower half into the greater pelvis.
However, this was not the area of the pain. The cecum was
bulky and was the seat of the pain. On the kidney was felt
a rounded protuberance the size of a tangerine.

In a pyelogram the left kidney appeared normal in size,
shape and position. The right one was described as markedly
ptotic when the patient was standing and as rotated around its ,
horizontal transverse axis. The upper and lower calyces were
foreshortened and superimposed upon each other.

At operation we removed the appendix through a small grid-
iron incision. It was moderately irritated and on microscopic
examination showed recent irritation by groups of round cell
infiltration. The kidney was readily brought to this appendec-
tomy wound and through the posterior peritoneum one could
see the bluish cyst very clearly. After closing the wound, a
lumbar incision was made, almost half of it over the erector
spinae. Anteriorly from this muscle, the muscles were pulled
apart widening the triangle of Petit and hardly cutting anv
muscles. The kidney was brought into the wound, but not
outside, and the cyst removed by resection of the adjoining
kidney parenchyma. The cyst was located in the middle of the
posterior surface of the kidney and was the size of a lemon.
The kidney wound was sutured and there was no leakage of
urine later on, though the pelvis had been opened. However,
the wound in the retroperitoneal space was unusually large and
required good draining with rubber tissue. The last of the
rubber drains were removed on the 12th postoperative day. The
fat was thoroughly removed from the quadratus and posterior
muscles and from the posterior surface of the kidney to guard
against a recurrence of the kidney floating about. After the
operation she was given 550 cc. of blood. Since the patient left
the hospital I have not seen her as yet. I fee! quite sure that
this kidney will not become troublesome any more on account
of an abnormal mobility.

A third case may be seen here. (X-ray film shown.) The
pyelogram was kindly loaned to me by Dr. Meddleman. The
outlines of the cyst are unusually clearly seen. They measure
six inches in the transverse diameter. Downward the shadow
reaches the upper level of the iliac crest.

These solitary cysts of the kidney are usually at one of the
poles and most frequently at the lower. Their relation to poly-
cystic kidneys is problematical, and surely in their clinical course
they differ greatly from polycystic kidneys. Their origin lies
probably in some congenital malformation, possibly in an early
inflammatory process, but this latter is pure conjecture based
more or less on the frequently seen multiple small cysts in
chronic interstitial nephritis.

The meeting adjourned.

'A. G. Schulze, M.D.

Secretary.

MINNESOTA STATE BOARD OF
MEDICAL EXAMINERS
Julian F. DuBois, M.D., Secretary
St. Paul, Minnesota
DOCKET OF CASES

STATE OF MINNESOTA versus CHESTER E. PAUL
( two cases) .

On April 2, 1937, one Chester E. Paul, 36, a chiropractor,
performed an abortion on a 24-year old St. Paul girl who died

THE JOURNAL-LANCET

381

on May 19, 1937, in Ancker Hospital, St. Paul. On June 8,
Paul pleaded guilty to the crime of abortion, an indictment
having been returned on May 21 by a grand jury. When he
surrendered his basic science certificate and his chiropractic
license in open court, he was allowed to plead guilty, and Judge
Richard D. O'Brien sentenced him to a term of not more than
4 years in a state penal institution; then placed him on probation
in the custody of the Ramsey County probation officer. His
basic science certificate and his chiropractic license have been
cancelled.

NEWS ITEMS

Dr. John Francis Quinn, Elkton, S. D., has removed
to Waubay, S. D.

Dr. Francis Kenneth Waniata, formerly of the Miles
City General Hospital in Montana, has taken up prac-
tice at Great Falls, with offices in the Strain Building.

Dr. Murdock MacGregor, Fargo, is chairman of the
state executive committee (for North Dakota) of the
American College of Surgeons.

Dr. Hans C. Ericksen, formerly of Wyndmere, N.
D., has taken the place of Dr. Ernest L. Grinnell, of
Aneta, in Nelson County.

Dr. Neil T. Norris, St. Mary’s Hospital in Minne-
apolis, will associate with Dr. Garnett B. Belote, at
Caledonia, Minn.

Dr. John R. Westaby, Madison, motored to Atlantic
City, where he was South Dakota’s delegate to the
meeting of the American Medical Association in June.

Dr. Lloyd Arthur Smith, Watford City, N. D., a
graduate of the University of Minnesota Medical School
in 1934, will inaugurate practice in Balaton, Minn.

Dr. Archie Merle Smith, formerly of the Bratrud
Clinic at Thief River Falls, has opened new offices in
Hopkins, Minn.

Dr. John Dickinson Carr, for several years superin-
tendent of the North Dakota State Hospital for the
Insane at Jamestown, has resigned.

Dr. J. H. Garberson, Miles City, Mont., spoke on
"Recent Advances in Medicine” on June 29 before the
Miles City Rotary Club.

Dr. John A. Kittelson, Sioux Falls, S. D., has been
appointed Minnehaha County physician. He took office
cn July 1st.

Dr. Emil Ericksen, Sioux Falls, South Dakota, has
been re appointed city health officer of Sioux Falls for
one year.

A fund is being collected by the Minnesota State
Medical Association for the purpose of establishing a
memorial to the late Dr. Herman M. Johnson, who
lived at Dawson.

At the annual meeting of the Montana State Medical
Association held at Great Falls July 13-14, Dr. J. C.
McGregor, Great Falls, was elected president-elect.
Other officers are Dr. E. D. Hitchcock, Great Falls,
vice-president, and Dr. Thomas L. Hawkins of Helena,
secretary. Dr. William P. Smith, Columbus, is the pres-
ident for this year.

Mrs. Stephen H. Baxter, wife of Dr. S. H. Baxter,
Minneapolis, died on July 29 at the home of her daugh-
ter, Mrs. Benjamin E. Thurston, at West Point, N. Y.

Dr. C. W. Froats, formerly of Thief River Falls,
Minnesota, is now associated with Dr. E. C. Hartley
in the practice of obstetrics and gynecology, at Saint
Paul.

Dr. Amos Leuty, 69, Morris, Minn., died at Morris
on June 24. He was a graduate of the old Drake Uni-
versity College of Medicine (Des Moines, la.) in 1898;
and came to Morris in 1903.

Seventy-five pre-school children were examined at a
child health clinic in Cavalier, North Dakota, by Dr.
August Costello Orr, of the division of child hygiene,
North Dakota State Board of Health.

Dr. David W. Mackenzie, chief of the urological
service in the Royal Victoria Hospital at Montreal,
Canada, was elected president of the American Uro-
logical Association at its recent meeting in Minneapolis.

Dr. Robert Catey, of Mobridge, S. D., first lieutenant
in the United States Army Medical Reserve Corps, is
now in Chicago, where he is completing his internship
at the Norwegian-American Hospital.

Dr. Galen Krauth Sellers, Motley, a graduate of
the University of Illinois College of Medicine in 1929,
has removed to Dassel, Minn., where he will practice
henceforth.

Dr. Arthur Thompson, of Cokato, Minnesota, who
maintains an office in the Cokato Hospital, where he is
medical director, has opened another office in the Cokato
State Bank Building.

Lewis & Clark County in Montana is expecting to
build an $80,000 hospital at Helena to be financed in
part through the Works Progress Administration. It is
to be earthquake-resistant and acoustically treated.

Dr. Frank Ward Bilger, Hot Springs, South Dakota,
has been named a member of the medical staff of the
American Boy Scout jamboree at Vogelenzang, Holland.
He will leave this summer, and return to Hot Springs
in September.

Dr. Myron O. Henry, of Minneapolis, instructor in
orthopedic surgery in the University of Minnesota Med-
ical School, gave an orthopedic clinic on "Fractures of
the Neck of the Femur” before the South Dakota State
Medical Association at Rapid City on May 25.

Dr. Leonard Jerome Monson, of Hendricks, Minne-
sota, a graduate of the University of Minnesota Medical
School in 1934, will locate at Canby, Minnesota. Dr.
Robert T. Potter, of Minneapolis, will take Dr. Mon-
son’s place in the office of Dr. Peter E. Hermanson, of
Hendricks.

Dr. William A. O’Brien, associate professor of path-
ology and preventive medicine at the University of
Minnesota, will talk on these dates for the broadcasting
schedule of the Minnesota State Medical Association:
August 7, "Pre-school Examinations”; August 14, "Cor-
onary Occlusion”; August 21, "Sore Throat”; and
August 28, "Dental Anesthesia.” Station WCCO (810
kilocycles or 370.2 meters), 9:45 A. M., each date.

382

THE JOURNAL-LANCET

Of 1,264 students enrolled in the 6 Lewis and Clark
County schools in Montana, 790 have been given Man-
toux tests, according to the Montana Tuberculosis Asso-
ciation; and 201 students were reactors.

A $170,000 woman’s ward building will be erected at
the South Dakota State Hospital for the Insane at
Yankton. The legislature has appropriated $93,500 and
the Public Works Administration has allocated $76,500
toward it.

Dr. Louis B. Wilson, professor of pathology and di-
rector of the Mayo Foundation at Rochester, retired on
June 30. The board of regents of the University of
Minnesota appointed Dr. Donald C. Balfour as Dr.
Wilson’s successor.

Dr. Leo G. Rigler, professor of radiology and director
of the Cancer Institute of the University of Minnesota,
spoke on "The History of the American Registry of
Technicians” at the American Society of X-Ray Tech-
nicians meeting in Denver, Colorado, on July 6.

Dr. John James Gelz, 54, of St. Cloud, Minn., a
graduate of the Minneapolis College of Physicians and
Surgeons in 1909, and a fellow of the American College
of Surgeons, died in that city on June 26. He was
a past president of the Stearns-Benton County Medical
Society.

Dr. Jacob Fowler Avery, 62, who practiced in Minne-
apolis, died at Lajolla (San Diego), Calif., in June.
Dr. Avery was a graduate of the University of Minne-
sota Medical School, a member of the American College
of Physicians, and a major in the Medical Corps during
the World War.

Dr. Arthur A. Zierold, professor of surgery in the
University of Minnesota Medical School, has become a
member of the American Surgical Association. This
group has only 150 members in the United States, and
Professor Owen Wangensteen, chief of the department
of surgery, is the only other member in Minneapolis.

Dr. Charles A. Donaldson, 74, of Mesa, Arizona, died
on May 3, 1937, it has been learned. He was once presi-
dent of the Hennepin County Medical Society, was a
member of the American College of Radiology, and
came to Minneapolis in 1888. He went to Arizona in
1925.

Dr. Elmer Harry Hansen, of Menno, South Dakota,
formerly of Princeton, Minnesota, was sentenced in
Minneapolis on June 14. Dr. Hansen pleaded guilty to
a charge of selling narcotics in Princeton in September
and October, 1936. He is a graduate of the Tulane
LIniversity Medical School at New Orleans, in 1914.

Fifteen physicians have been licensed to practice medi-
cine in North Dakota. They are: Drs. Edith E. Nor-
man, Fargo; Ralph E. Mahowald, Grand Forks; Amos
R. Golsdorf, Dickinson; Joseph D. Craven, Williston;
Robert R. Saint Clair, Leslie R. Grams, Willard W.
Hall, and Herbert Brunner, of Minot; Bernard L. Sin-
ner, Fargo; Paul Reed, Langdon; Jesse H. Roth, James-
town; Irving W. Kellogg, Fairmount; Robert F. Nuessle,
Bismarck; and Woodrow Nelson and William E. Olson,
of Larimore.

Dr. W. A. Gerrish, Jamestown, North Dakota; Dr.
Jesse W. Bowen, Dickinson; and Dr. William C. Faw-
cett, Starkweather, were named to the North Dakota
State Board of Medical Examiners by Governor William
Langer.

Dr. Sidney Alexander Cooney, of Helena, Montana,
secretary of the Montana State Board of Medical Ex-
aminers, is the new president of the Lewis & Clark
County Medical Society. Dr. Everett Harry Lindstrom
was elected vice president; and Dr. William Francis
Cashmore, Jr., Helena, secretary-treasurer.

The University of South Dakota School of Medicine,
which offers a 2-year course in medicine, has been grant-
ed provisional rating by the Council on Medical Educa-
tion and Hospitals of the American Medical Associa-
tion, according to Dean Joseph C. Ohlmacher, M.D.,
of Vermillion, South Dakota. The school will be in-
spected in 1939 for final rating.

Dr. Irvine McQuarrie, professor of pediatrics and
chief of the department, and Dr. Chester A. Stewart,
clinical professor of pediatrics and a member of the
Board of Editors of The Journal-Lancet, both of the
University of Minnesota Medical School, will address
the International Pediatric Congress at Rome, Italy, on
September 27-30.

Three professors in the University of Minnesota
Graduate School of Medicine at Rochester shared the
gold medal awarded by the Committee on Scientific
Exhibits of the American Medical Association at At-
lantic City in June. They are: Drs. Melvin S. Hender-
son, professor of orthopedic surgery; Henry W. Meyer-
ding, associate professor of orthopedic surgery; Ralph
K. Ghormley, associate professor of orthopedic surgery;
and H. B. Macey, of the Mayo Clinic.

The International Assembly of the Inter-State Post-
graduate Medical Association of North America, under
the presidency of Dr. John F. Erdmann of New York,
will be held in the beautiful new public auditorium of
St. Louis, Missouri, October 18, 19, 20, 21 and 22, with
pre-assembly clinics on Saturday, October 16 and post-
assembly clinics, Saturday, October 23, in the hospitals
of St. Louis.

The aim of the program committee, with Dr. George
Crile as chairman, is to provide for the medical profes-
sion of North America an intensive post-graduate course
covering the various branches of medical science. The
program has been carefully arranged to meet the de-
mands of the general practitioner, as well as the spe-
cialist.

A complete list of the distinguished teachers and
clinicians who will take part on the program will be
found in the September issue of this journal.

A most hearty invitation is extended to all members
of the profession who are in good standing in their
State or Provincial Societies to be present. A registra-
tion fee of $5.00 will admit each member to all the
scientific and clinical sessions.

For further information, write Dr. W. B. Peck, Man-
aging-Director, Freeport, Illinois.

Minneapolis, Minnesota
September, 1937

Transactions of the South Dakota State
Medical Association

Fifty-Sixth Annual Session — 1937
Rapid City, South Dakota
May 24, 25, 26, 1937

OFFICERS, 1937-38

PRESIDENT

E. A. PITTENGER, M.D. Aberdeen

PRESIDENT-ELECT

J. F. D. COOK, M.D Langford

VICE-PRESIDENT

J. C. SHIRLEY, M.D Huron

SECRETARY-TREASURER

C. E. SHERWOOD, M.D Madison

EXECUTIVE SECRETARY

B. A. DYAR, M.D _ Pierre

DELEGATE AMERICAN MEDICAL ASSOCIATION

J. R. WESTABY, M.D., 1937-1938 Madison

ALTERNATE A. M. A.

J. F. D. COOK, M.D Langford

COUNCILORS

FIRST DISTRICT

J. D. WHITESIDE, M.D., 1938 Aberdeen

SECOND DISTRICT

M. J. HAMMOND, M.D., 1938 Watertown

THIRD DISTRICT

D. S. BAUGHMAN, M.D., 1938 Madison

FOURTH DISTRICT

B. M. HART, M.D., 1938 Onida

FIFTH DISTRICT

G. E. BURMAN, M.D., 1939 Carthage

SIXTH DISTRICT

O. J. MABEE, M.D., 1939 Mitchell

SEVENTH DISTRICT

W. E. DONAHOE, M.D., 1939 Sioux Falls

EIGHTH DISTRICT

S. M. HOHF, M.D., 1938 .Yankton

NINTH DISTRICT

R. B. FLEEGER, M.D., 1938 Lead

TENTH DISTRICT

H. R. KENASTON, M.D., 1940 Bonesteel

ELEVENTH DISTRICT

Charter surrendered to join the Third District.

TWELFTH DISTRICT

WM. DUNCAN, M.D., 1940 Webster

COUNCILOR AT LARGE

J. L. STEWART, M.D Nemo

STANDING COMMITTEES
1937-1938

COMMITTEE ON SCIENTIFIC WORK

E. A. PITTENGER, M.D Aberdeen

J. C. SHIRLEY, M.D Huron

C. E. SHERWOOD, M.D Madison

COMMITTEE ON PUBLIC POLICY AND LEGISLATION

E. A. PITTENGER, M. D Aberdeen

J. F. D. COOK, M.D. Langford

THE COUNCIL.

384

THE JOURNAL-LANCET

COMMITTEE ON PUBLICATIONS

C. E. SHERWOOD, M.D Madison

A. S. RIDER, M.D Flandreau

R. E. JERNSTROM, M.D Rapid City

COMMITTEE ON MEDICAL DEFENSE

T. F. RIGGS, M.D. (1938) Vermillion

L. N. GROSVENOR, M.D. (1939) .... Huron

L. J. PANKOW, M.D. (1940) Sioux Falls

COMMITTEE ON MEDICAL EDUCATION AND HOSPITALS

J. C. OHLMACHER, M.D. (1938) Vermillion

W. A. DELANEY, M.D. (1939) Mitchell

W. A. DAWLEY, M.D. (1940) Rapid City

COMMITTEE ON MEDICAL ECONOMICS

W. E. DONAHOE, M.D. (1938) Sioux Falls

W. F. BUSHNELL, M.D. (1939) Elk Point

P. R. BILLINGSLEY, M.D. (1940) Sioux Falls

COMMITTEE ON PUBLIC HEALTH

D. S. BAUGHMAN, M.D. (1938) Madison

P. D. PEABODY, M.D. (1938) Webster

F. S. HOWE, M.D. (1938) Deadwood

W. R. BALL, M.D. (1939) .... Mitchell

H. R. HUMMER, M.D. (1939)) Sioux Falls

J. V. SHERWOOD, M.D. (1939) ... Sanator

K. W. NAVIN, M.D. (1940) Philip

W. E. MORSE, M.D. (1940) ... Rapid City

EMIL ERICKSEN, M.D. (1940) Sioux Falls

COMMITTEE ON NECROLOGY

J. B. VAUGHN, M.D. (1938) Castlewood

W. H. SAXTON, M.D. (1939) _ Huron

R. J. QUINN, M.D. (1940)) Burke

SPECIAL COMMITTEES

COMMITTEE ON RADIO BROADCAST

S. M. HOHF, M.D Yankton

E. W. JONES, M.D Mitchell

E. L. PERKINS, M.D. .. ... Sioux Falls

EDITORIAL COMMITTEE

E. A. PITTENGER, M.D Aberdeen

J. F. D. COOK, M.D Langford

J. C. SHIRLEY, M.D Huron

A. S. RIDER, M.D Flandreau

S. M. HOHF, M.D Yankton

J. C. OHLMACHER, M.D. Vermillion

J. L. STEWART, M.D. Nemo

C. E. SHERWOOD, M.D Madison

COMMITTEE ON SYPHILIS CONTROL PROGRAM
U S P H SFRVICF

D. S. BAUGHMAN, M.D. (1938) Madison

R. G. MAYER, M.D. (1939) Aberdeen

ANTON HYDEN, M.D. (1940) Sioux Falls

COMMITTEE ON BASIC SCIENCE

J. D. ALWAY, M.D. (1939) Aberdeen

S. M. HOHF, M.D. (1939) Yankton

O. J. MABEE, M.D. (1939) Mitchell

COMMITTEE ON MILITARY AFFAIRS

H. T. KENNEY, M.D. (1938) Watertown

P. V. McCarthy, M.D. (1939)... Aberdeen

E. W. JONES, M.D. (1940) Mitchell

COMMITTEE COOPERATING WITH STATE BOARD OF
MEDICAL LICENSURES

S. M. HOHF, M.D. (1938) Yankton

F. S. HOWE, M.D. (1939) Deadwood

J. D. WHITESIDE, M.D. (1940) _ Aberdeen

ADVISORY COMMITTEE ON WOMAN’S AUXILIARY

J. C. SHIRLEY, M.D Huron

E. A. PITTENGER, M.D Aberdeen

J. F. D. COOK, M.D..... Langford

C. E. SHERWOOD, M.D Madison

ALLIED GROUP COMMITTEE

N. K. HOPKINS, M.D Arlington

E. A. PITTENGER, M.D Aberdeen

B. A. DYAR, M.D., Secretary Pierre

South Dakota State Medical Association Fifty-Sixth
Annual Session, Rapid City, South Dakota
Monday, May 24th, 1937, 4:00 P. M.

Alex Johnson Hotel

FIRST SESSION COUNCIL

The Council was called to order by H. R. Kenaston, chair- <
man, at 4:00 p. m. in the ballroom of the Alex Johnson Hotel.

Roll call; the following were present: J. L. Stewart; E. A.
Pittenger; J. F. D. Cook; J. R. Westaby; J. D. Whiteside;

C. E. Sherwood; B. M. Hart; J. C. Shirley; O. J. Mabee;

S. M. Hohf; H. R. Kenaston; N. K. Hopkins. A quorum
present.

In the absence of Dr. W. E. Donahoe, Motion by E. A.
Pittenger supported by S. M. Hohf that Dr. N. J. Nessa be
seated as councilor for the Sioux Falls District. Motion car -
ried.

Motion by S. M. Hohf supported by J. R. Westaby that <
Dr. P. D. Peabody be seated as councilor, as requested by his
councilor and secretary of his district for Whetstone Valley
District. Motion carried.

Secretary presented for approval the minutes of the 1936
annual session as printed in the July issue of The Journal- j
Lancet 1936.

Motion by O. J. Mabee supported by C. E. Sherwood that
the minutes of the annual meeting of 1936 be approved as
printed in Journal-Lancet without being read. Motion car-
ried.

Secretary Cook read the minutes of the quarterly meetings.
Motion by C. E. Sherwood supported by E. A. Pittenger that
the minutes be approved as read. Motion carried.

Minutes of Meeting of Council

Huron, S. D., July 2, 1936.

Council met at the Marvin Hughitt Hotel; noon.

On roll call the following were present; Drs. J. D. White-
side; C. E. Sherwood; B. M. Hart; J. C. Shirley; S. M. Hohf;

H. R. Kenaston; N. K. Hopkins; A. S. Rider; B. A. Dyar;

E. A. Pittenger and Secretary Cook. A quorum being present,
Chairman Kenaston called the meeting to order. The secretary i
announced telegrams from Drs. Flett and J. L. Stewart, who
were unable to be present on account of illness.

Communications were received regarding a vacancy occurring
on the State Board of Health and Medical Examiners, with
suggestions that the council submit a list of candidates to Gov-
ernor Thomas Berry, for his consideration in making an ap-
pointment.

Dr. S. M. Hohf said that Governor Berry indicated that he
would gladly receive a list of names so submitted.

Dr. Pittenger: How many names should we submit?

After a general discussion, it was decided to submit three
names. On motion of Dr. Pittenger; that three names be sub-
mitted by the secretary of the council to the Governor for his
consideration. Motion carried.

Dr. J. D. Whiteside moved that the name of Dr. J. B.
Vaughn of Castlewood be submitted. Seconded by Dr. Pit-
tenger, on vote carried. Dr. Shirley, Moved that the name of
Dr. A. S. Rider, of Flandreau be submitted, Seconded by Dr.

C. E. Sherwood; on vote carried. Dr. S. M. Hohf, Moved the
name of Dr. W. A. Bates of Aberdeen be submitted. Seconded
by Dr. Pittenger. On vote carried.

The Resettlement program of Medical, Dental, Hospital, and
nursing care to Resettlement clients was considered.

Dr. B. A. Dyar, of the State Board of Health was asked
to present the program. Dr. Dyar stated that he had conferred
recently with the State Welfare Committee and also with Re-
settlement officials from Washington and Lincoln and that they
desired a plan to be presented by the Medical Association.

The situation and a plan was discussed. Questions.

Dr. Rider: Could they allot a certain amount to the coun-
ties?

Dr. Dyar: A certain amount is already given to the coun-
ties each month.

THE JOURNAL-LANCET

385

Dr. Sherwood: Would this plan apply to WPA and PWA?

Dr. Dyar: Yes, it would take care of all people that the

government is helping. However, this plan would not set so
good with the Pharmacists because Mr. Ward intimated that
under this plan the doctors should dispense drugs and then put
it on their bills.

Dr. Hart: Wouldn’t it be better to have this plan come

through the Inter-Allied Council?

Dr. Dyar: Yes.

Dr. Pittenger: I think it would be a good idea to have a

committee appointed to bring this plan to the Allied Council
and then bring it to the Allied groups.

Dr. Dyar: Yes, get the plan formulated and then hold

meetings of the Inter-Allied Council.

Dr. Rider: I think we should find out what other states are

doing.

Dr. Hohf: I move that Drs. Hopkins, Pittenger, in co-

operation with Dr. Dyar act as a committee of the State Med-
ical Association in formulating a set-up of Medical Relief as
has been presented by Dr. Dyar. Motion supported by C. E.
Sherwood. Carried.

Dr. Hopkins: I am sure we can get cooperation in the

Inter-Allied Council. We are going to back the Dentist’s bill
in the coming legislature.

Dr. Shirley: I think we should be careful about the fee

schedule in formulating this plan.

Dr. Pittenger: If we find that we need some help on this

committee, would it be possible to have some more members
appointed on this committee?

Dr. Dyar: Yes. Discussion of medical relief concluded.

Dr. Sherwood: I think that these medical lectures have

been very much worthwhile and I would like to offer for this
council a resolution commending the State Board of Health for
its work in this matter and our desire in the future to repeat
it along this same line with other subjects offered, if possible.

Dr. Hohf: I second the motion. Carried.

Dr. Hohf: If it is to continue, I think that careful analysis

of dates should be considered. Two of the three meetings in
Yankton occurred on dates when other events in Yankton were
being held. Now, on this matter of Broadcasting, we are now
at the bottom of the well. I have one more paper to be sub-
mitted.

Dr. Cook: I have given ample notice asking for papers to

complete this program. No response so far, from the districts.
Dr. Pittenger suggested that this committee use papers that
the Aberdeen District used in their local broadcasting station.

Dr. Hohf: Is there anything that can be improved or any

suggestions that can be made?

Dr. Cook: We have received a very good and worthwhile

service over WNAX. I do not believe that there are any rec-
ommendations as to the service rendered.

Dr. Dyar: Read the financial report of the Inter-Allied

Meeting in Sioux Falls. SEE REPORT.

Meeting adjourned.

J. F. D. Cook,

Secretary.

COUNCIL MEETING
Pierre, S. D., September 22, 1936
This meeting was called at the request of councilors and a
phone conference with Drs. Stewart and Pittenger. To con-
sider a program to be presented by Dr. R. C. Williams, Wash-
ington, D. C., of the Resettlement Administration, to provide
medical, dental, hospital, and nursing care to relief clients on
resettlement.

On roll call; H. R. Kenaston presiding; the following officers
were present: Drs. J. L. Stewart; E. A. Pittenger; J. D. White-
side; M. J. Hammond; C. E. Sherwood; J. C. Shirley; B. M.
Hart; O. J. Mabee; N. K. Hopkins; Chas. Flett; A. S. Rider;
B. A. Dyar, Sec’y Inter-Allied Council; J. F. D. Cook, Sec’y.
Letters and messages were received from W. E. Donahoe, S.
M. Hohf and R. B. Fleeger, expressing their vote on resettle-
ment program.

Dr. Pittenger of the Public Health Committee of the South
Dakota Planning Board. Presented recommendation of the
planning board, relative to the advisability of a separate board
of Medical Examiners, to be divorced from the State Board
of Health.

That the State Medical Association prepare such a bill to be
presented to the 1937 legislature.

Dr. Rider moves, supported by Dr. Pittenger; That the
Council approve the recommendations of the South Dakota
Planning Board relative to the board of medical examiners and
appoint a committee of three to assist in preparing such a mea-
sure and present same to the legislature. On vote carried.

Chairman Kenaston appointed as follows: T. F. Riggs;

B. A. Dyar; J. C. Shirley, as the "Committee on Medical Li-
censure.”

The subject of annual registration was considered; after a
full discussion, it was decided to place this matter in the hands
of the committee on medical licensure legislation as appointed
by Chairman Kenaston.

At this time the committee report of N. K. Hopkins, Presi-
dent; E. A. Pittenger; and B. A. Dyar, Sec. of the Inter-
Allied Council, was presented. This committee report having
contacted the Resettlement administration at Lincoln, Neb., rel-
ative to a program of medical, dental, hospital and nursing care
to resettlement clients.

It was anticipated when this meeting was called that Dr.

R. C. Williams, Washington, D. C., of the Resettlement Ad-
ministration would be present. Dr. Dyar was called upon for
a report and he informed the council that Dr. Williams was
unable to be present to present the Resettlement program for
medical care.

Dr. Dyar gave a verbal report of the proposed plan, out-
lining the articles of incorporation of the SOUTH DAKOTA
FARMERS AID CORPORATION. He stated that the com-
mittee felt that they had gone as far as they could without the
cooperation of the council. A prolonged discussion of the plan
was had.

Dr. A. S. Rider moved, That it be the sense of the South
Dakota State Medical Association to approve the Emergency
Relief set-up as presented by the committee, with the provision,
as amended by the motion of Dr. O. J. Mabee, supported by
Dr. Chas. Flett, "That after the councilor presented this plan
to his District Medical Society, he may vote as directed by his
society.” Supported by Dr. J. L. Stewart. Motion carried.

A roll call vote was then taken on the adoption of the plan
as presented for medical relief; FOR: J. L. Stewart; E. A.
Pittenger; C. E. Sherwood; J. C. Shirley; N. K. Hopkins; A.

S. Rider; *W. E. Donahoe; Chairman H. R. Kenaston.
AGAINST: J. D. Whiteside; M. J. Hammond; B. M. Hart;
O. J. Mabee; *S. M. Hohf; *R. B. Fleeger; Chas. Flett; J.
F. D. Cook. *V oted by letter. Tie vote.

Dr. Rider, moved that it was the concensus of opinion of
the council that if this plan is put through, Dr. B. A. Dyar
will act as Secretary to the South Dakota Farmers Aid Cor-
poration. Duly seconded and carried.

A meeting of the council to be held as soon as the District
Societies make their reports. Dr. Dyar promised to contact Dr.
R. C. Williams of the Resettlement Administration and have
him present at the meeting of the council when next convened,
to further present the plan for medical relief to Resettlement
clients.

Motion to adjourn was had; adjourned.

J. F. D. Cook,

Secretary.

Huron, S. D., October 20, 1936
Meeting called for 2:00 P. M. Marvin Hughitt Hotel. By
Dr. B. A. Dyar, Secy. Inter-Allied council to meet with the
Inter-Allied Council at which time Dr. R. C. Williams of the
Resettlement Administration would present the program for
medical relief to Resettlement clients.

Roll call; Drs. H. R. Kenaston; E. A. Pittenger; A. S. Rider;
C. E. Sherwood; J. C. Shirley; N. K. Hopkins; S. M. Hohf;
O. J. Mabee; J. D. Whiteside; B. M. Hart; (W. E. Donahoe,

386

THE JOURNAL-LANCET

by letter) W. H. Karlins; (Proxy Chas. Flett,) J. L. Calene,
President; and J. D. Alway, Secy. Aberdeen District Medical
Society. Quorum present.

After the Inter-Allied Council presented Dr. Williams and
he presented the South Dakota Farmers Aid Corporation, pro-
gram for medical aid to Resettlement clients and By-Laws
covering same, which was presented for the first time.

The Council retired for the consideration of the plans of
Dr. Williams. After a full discussion it was deemed advisable
to defer action to study the By-Laws, which were presented the
Council at this meeting, also to procure legal opinion.

Dr. S. M. Hohf; Moved, That the program proposed by
Dr. R. C. Williams for medical aid to resettlement clients, be
laid on the table for study and legal opinion, and to be
considered at the next meeeting of the council. Supported by
B. M. Hart.

A. S. Rider, moved to amend; by "stipulating that the time
of postponement be sufficient to send an abstract of the By-
Laws and a card to vote, for oi* against, to each doctor in the
State. Supported by J. D. Whiteside.” The amendment was
duly considered and on vote was duly carried.

The original motion as amended was duly considered.
Carried.

The secretary was directed to prepare such material as above,
for the vote of the doctors in the state. Motion to adjourn,
Adjourned at 5:00 P. M.

J. F. D. Cook, Secretary.

Huron, S. D., December 10, 1936.

Council meeting.

Roll call: Drs. J. L. Stewart; E. A. Pittenger; J. D. White-
side; M. J. Hammond; C. E. Sherwood; B. M. Hart; J. C.
Shirley; O. J. Mabee; W. E. Donahoe; S. M. Hohf; H. R.
Kenaston; N. K. Hopkins; A. S. Rider; B. A. Dyar; J. F. D.
Cook. Quorum present.

H. R. Kenaston presiding. Communication from Dr. Thomas
Parran, Surgeon General U. S. Public Health Service, re-
questing the State Medical Association to appoint a committee,
to act in an advisory capacity cooperating with the State Board
of Health.

E. A. Pittenger moved, That a committee be appointed to
act in an advisory capacity with the State Board of Health in
the Public Health program for the control of syphilis. Sup-
ported by S. M. Hohf. On vote motion carried.

The following were appointed by the chairman;

Drs. C. E. Sherwood; R. G. Mayer; Anton Hyden.

Motion by C. E. Sherwood, supported by B. M. Hart, That
the secretary write Dr. Thomas Parran, asking if transportation
would be available for a representative from S. D. Medical
Association to the National Conference on Venereal Disease
control. Carried.

("The answer to this communication is to the effect that no
provision for such funds.”)

COUNCIL MEETING
December 10, 1936

Post card vote of the medical men of state, on the Resettle-
ment program of medical aid. 478 cards were mailed. Cards
returned 296. Voting yes 174. Voting no 122.

Dr. W. E. Donahoe presented certification of a change of
vote of ten members of the Sioux Falls District from No to
Yes. Which made the vote Yes 184, No 112.

Dean Searles, of Brookings was presented and gave a plea
for cooperation in the Resettlement program.

Motion by C. E. Sherwood, Supported by M. J. Hammond;
That the council endorse the Resettlement for one year, as a
result of the poll. Motion carried.

At this time the members of the Allied-Council were in-
vited in to participate in the report to be given by Dean J. C.
Ohlmacher, of the University Medical School.

In support of the University Medical School the following
resolution was presented and duly adopted on motion of Dr.
E. A. Pittenger, supported by C. E. Sherwood. A copy of the
resolution to be mailed to the Council on Medical Education,
American Medical Association, Wm. D. Cutter, Chicago, 111,

Whereas, we have followed interest and understanding the
activities of the School of Medicine of the University of South
Dakota; have come to believe that it holds a very important
place among the schools of higher education in the state, and
Whereas, the records of its students throughout the years
of its existence have been a source of pride and gratification to
us, and

Whereas, we feel that its continuance is essential to the best
interests of the University of which it forms a part, and to
the citizens of South Dakota, and

Whereas, we are firm in the conviction that it can be de-
veloped to meet the exacting requirements of modern day
medical education,

Be it resolved that we, the representatives of organized
medicine and allied professions of South Dakota, do hereby
pledge ourselves to do all in our power to give such support
for the school of Medicine as will enable it to meet the re-
quirements of a Class A two year medical school.

Dated this 10th day of December, 1936, at Huron, S. D.
Representing the State Medical Association
Signed:

J. L. Stewart, President
J. F. D. Cook, Secretary
Representing Inter-Allied Council

N. K. Hopkins, President, B. A. Dyar, Secretary
Medical Board of Licensure
B. A. Dyar, Secretary
State Board of Health

P. B. Jenkins, Superintendent
Motion that Dr. B. A. Dyar appoint the County Medical
Committee as required in the Resettlement understanding, to
audit the medical bill, if and when required. Carried.

Motion by W. E. Donahoe, supported by B. M. Hart That
a notice of the resolution pertaining to the University Medical
School be given to the Associated Press. Motion carried.

Motion by S. M. Hohf, That the secretary request Mr.
George Kienholtz, to represent the State Association at the
coming session and inform the officers of any and all bills in-
troduced that may affect public welfare. Supported by C. E.
Sherwood. Motion carried. Adjourned at 3:30 P. M.

J. F. D. Cook, Secretary

Financial Report of Secretary-Treasurer
1936

May 2, 1936. Cash balance in Aberdeen National

Bank and Trust Co., Aberdeen, S. D. $ 790.74

Back dues received for 1936 201.00

1937 dues 248 members at $8.00 1,984.00

12 dues at $5.00 60.00

Sioux Falls District cash from exhibitors 50.00

Cash Bond and interest 555.00

Yankton district over paid dues 15.00

Sioux Falls District over paid dues 10.00

Total cash $3,665.74

Disbursements , $2,602.20

May 19, 1937 Cash balance in Aberdeen Bank $1,063.54

Trust certificate Langford State Bank No. 375 735.92

Membership by Districts

Aberdeen District No. 1 34

Watertown District No. 2 24

Madison District No. 3 — 14

Pierre District No. 4 16

Huron District No. 5 15

Mitchell District No. 6 22

Sioux Falls District No. 7 32

Yankton District No. 8 33

Black Hills District No. 9 - 49

Rosebud District No. 10 - 8

Kingsbury District No. 11 7

Whetstone Valley District No. 12 11

THE JOURNAL-LANCET

387

Members 265

Honorary 5

Total ... 260

Total Doctors in State 562

Deceased _ 23

Retired 22

State Institutions and other facilities 49

Left state 10

104 104

Total in practice 458

Motion by S. M. Hohf supported by C. E. Sherwood that
the financial report of Secretary-Treasurer be accepted and
referred to an auditing committee, such committee to be ap-
pointed by Chairman H. R. Kenaston. Motion carried. H.
R. Kenaston appoints the following as auditing committee:

C. E. Sherwood; B. M. Hart; S. M. Hohf.

Mr. L. M. Cohen, of Minneapolis, Minn., representative of
The Journal-Lancet, was introduced by Secretary Cook.

Mr. Cohen expressed appreciation of being permitted to meet
the council. He asked for expression of the councilors regard-
ing the publication of The Journal-Lancet; any suggestions
would be gladly received. Mr. Cohen stated that due to the
financial conditions of the country, the price of The Journal-
Lancet would be continued for another year at the price of
one dollar and fifty cents per member ($1.50).

Motion by C. E. Sherwood supported by E. A. Pittenger
that the Council express to the editors of The Journal-
Lancet their appreciation of the continued price of The
Journal-Lancet as expressed by Mr. Cohen. Motion carried.

Secretary Cook presented a communication from Mr. J. H.
Kean, Chairman of the Legislative Committee of the State
Hospital Association, relative to a claim of that association
against the State Medical Association for lobbying at Pierre
relative to H. B. No. 39 and No. 40. The expense account
was for $300.00. After a discussion of their claim, motion by
B. M. Hart supported by P. D. Peabody that this claim be
laid on the table until further investigation of the account
could be made, to be considered at the next quarterly meeting
of the council. Motion carried.

No further business a motion to adjourn was had.

Adjourned at 5:30 p. m.

J. F. D. Cook,

Secretary-T reasurer.

SECOND MEETING OF THE COUNCIL
May 26, 1937

Meeting called to order by Chairman, H. R. Kenaston; Roll
call, J. L. Stewart; E. A. Pittenger; J. F. D. Cook; J. D.
Whiteside; C. E. Sherwood; B. M. Hart; J. C. Shirley; N. J.
Nessa; S. M. Hohf; H. R. Kenaston; P. D. Peabody; N. K.
Hopkins; A. S. Rider; J. H. Lockwood. Quorum present.

The minutes of the Council meeting of May 24 were read
and approved. Discussion of the claim of the State Flospital
Association, as presented by Mr. J. H. Kean, Chairman Legis-
lative Committee State Hospital Association was next in order.
N. J. Nessa was asked to contact Mr. Kean and Rev. C. M.
Austin of the Hospital Association relative to the claim. J. F.

D. Cook to contact Geo. Kienholz of Pierre relative to this
claim.

Secretary Cook, Moved that a vote of thanks be tendered
to Black Hills District Medical Society, the Woman’s Aux-
iliary and local committees for their splendid assistance, well
planned program and entertainment extended this Association
during this convention. To the Commercial Club and Alex
Johnson Hotel for their cooperation and hospitality. Duly
adopted on vote.

E. A. Pittenger, moved that there be a committee appointed
to give attention to the basic science bill, such committee to

serve until the next session of the Legislature. Supported by
J. C. Shirley. Motion carried.

Secretary Cook, presented the necessity of consideration of
the annual dues. It was moved by A. S. Rider supported by
E. A. Pittenger that the dues be ten dollars for the coming
year. Motion carried.

Election of Secretary-Treasurer was next in order as the
present secretary’s term expires. Motion by B. M. Hart that
C. E. Sherwood be elected Secretary -Treasurer. Motion
carried.

Motion by C. E. Sherwood, that D. S. Baughman be elected
councilor for Madison District, C. E. Sherwood vacating the
office of councilor to accept that of Secretary-Treasurer. Mo-
tion carried.

Motion by N. K. Hopkins, to elect B. A. Dyar Executive
Secretary to the Allied-Council. Motion carried.

Motion by S. M. Hohf, that the Council at this time give
a rising vote of thanks to J. F. D. Cook, our retiring Secretary-
Treasurer, for his many years of efficient and beneficial service
to the Medical Association.

There being no further business, it was moved by J. C.
Shirley that we adjourn. Carried.

J. F. D. Cook,

Secretary-T reasurer.

First Meeting of the House of Delegates, South Dakota
State Medical Association
May 24, 1937, Rapid City, S. D.

President J. L. Stewart, M.D., presiding. J. F. D. Cook,
M.D., Secretary. Meeting called to order at 7:00 p. m.
Monday, May 24, 1937, in the ballroom of the Alex Johnson
Hotel, Rapid City, South Dakota. Roll call by the secretary;
Drs. J. L. Stewart; E. A. Pittenger; J. F. D. Cook; J. R.
Westaby; John Calene; J. B. Vaughn; W. D. Farrell; C. E.
Sherwood; B. M. Hart; O. A. Kimble; J. C. Shirley; G. E.
Burman; E. W. Jones; Wm. R. Ball; R. G. Stevens; L. J.
Pankow; S. M. Hohf; H. F. Hansen; F. E. Williams; F. S.
Howe; H. R. Kenaston; N. K. Hopkins; P. H. Rozendal;
E H. Grove; P. D. Peabody; F. Pfister; J. D. Whiteside; O.
J. Mabee. Quorum present.

J. L. Stewart appointed the following reference committees:
Reports of Officers — C. E. Sherwood, J. C. Shirley, W. R. Ball.
Resolutions and Memorials — J. B. Vaughn, E. W. Jones, S. M.
Hohf. Amendments to Constitution — J. D. Whiteside, B. M.
Hart, A. S. Rider. Nominations and Place of Meeting for
1938 — J. L. Calene, J. B. Vaughn, C. E. Sherwood, B. M.
Hart, G. E. Burman, O. J. Mabee, R. G. Stevens, F. E. Wil-
liams, F. S. Howe, H. R. Kenaston, N. K. Hopkins, F. Pfister.

Secretary presented the minutes of the 1936 sessions as print-
ed in the July 1936 issue of The Journal-Lancet.

Motion by L. J. Pankow and supported by E. W. Jones,
that the minutes of the House of Delegates as published in the
July 1936 issue of The Journal-Lancet be approved. Motion
carried.

Report of membership last report 288, delinquent members
paid up 40 making a total membership for 1936 of 328.

For 1937 members paid dues 260. Of this membership 21
new members, majority of new members are recent graduates.

J. R. Westaby presented his report as Delegate to A. M. A.
Referred to reference committee on Reports of Officers. (See
Report) .

Committee on scientific work presented the official program
for this meeting as their report.

Committee on public policy. J. L. Stewart presented a verbal
report stressing medical influence in the legislature, pointing
out the necessity of having representation in the House and
Senate of medical men.

Committee on Publication. H. R. Kenaston reported that
The Journal-Lancet was the official publication for this As-
sociation.

Committee of Medical Education and Hospitals. No report,

388

THE JOURNAL-LANCET

Committee on Medical Defense. No report. (Secretary has
material emanating from the Bureau of Legal Medicine A. M.
A. May 18th relative to the action of the Committee on Un-
authorized Practice of Law of the Committee on Professional
Ethics and Grievances, of the American Bar Association, in
which it was held that the operation of the medical defense plan
of the Ohio State Medical Association constituted the un-
authorized practice of law in that State.

This material came to my hands May 21st, is placed in the
hands of T. F. Riggs, chairman of Medical Defense Com-
mittee.)

Committee on Medical Economics. W. F. Bushnell presented
the committee report. Discussion by E. W. Jones, L. J.
Pankow.

Motion that the report be referred to the reference committee.
Motion carried. (See report reference committee.)

Committee on Public Health. C. E. Sherwood, chairman,
presented the report. L. J. Pankow reported on the Minne-
haha County plan of venereal disease control which was giving
satisfactory results.

Moved by L. J. Pankow supported by P. D. Peabody that
the report of C. E. Sherwood be referred to the reference com-
mittee. Carried. (See report.)

Committee on Necrology. In the absence of the report the
secretary read the names of deceased medical men of the state
during the past year, a total of twenty-three (23). Eleven of
these were members of the State Medical Association as indi-
cated in the list. (See report.)

Committee on Medical Licensure: The report of T. F. Riggs
was presented by the secretary, and on motion was referred to
the reference committee. (See Report.)

Committee on Radio Broadcast. S. M. Hohf reported no
change in the status of this committee. However, he added,
"I think the medical profession are lax in missing out in not
using that which is available to spread the gospel of clean med-
ical practice.” He further urged "a re-establishment of that
which we carried out previously through radio-broadcast, and I
assure you that I would be glad to serve again as your mouth-
piece.” The subject of radio-broadcast was further commented
on by E„ W. Jones.

Committee on Allied Group. N. K. Hopkins, President of
the Allied-Council, read his report. On motion report was re-
ferred to Committee. (See report.)

Secretary read a communication from the Massachusetts
Medical Society inviting our association to send a repre-
sentative to attend a meeting, during the session of A. M. A.
at Atlantic City, New Jersey, to study courses of post-graduate
instruction as carried out by the State Medical Associations.
Motion by L. J. Pankow, supported by S. M. Hohf, that J. R.
Westaby, our Delegate to A. M. A. asked to attend this meet-
ing, that E. A. Pittenger give his co-operation to our delegate.
Carried.

A communication from G. H. Twining of Mobridge citing
the opinion of the Attorney General regarding the use of Dr.
Doctor, etc., by Optometrists and Chiropodists. The Attorney
General in his community has succeeded in compelling them to
delete this from their advertising. N. T. Owen, of the State
Board of Health, cited a case of an osteopathic physician using
the title "Doctor”. Legal advice should be had in such cases.

Secretary Cook introduced R. G. Leland, of the Bureau of
Economics of the American Medical Association requesting
that hei explain the recent communication of Wm. C. Wood-
ward, of the Bureau of Legal Medicine, relating to the attitude
and findings of the Committee on Professional Ethics and
Grievances and on Unauthorized Practice of Law of the Amer-
ican Bar Association. The Medical Defense Plan of the Ohio
State Medical Association being the basis for this report. Dr.
Woodward states that:

"It is well to bear irt mind that if the analysis of the Ohio
plan is correct, then to the extent that the medical association
provided and controlled, or assisted in providing and control-
ling, legal service for a member charged with malpractice, it
engaged in practice in the field of law in a way similar to cor-

porate and group practice in the field of medicine, a form of
practice condemned by the American Medical Association.
(This material is placed in the hands of the Medical Defense
Committee for study and report.)

Dr. Leland next discussed the medical economic situation
under the present day emergencies. Calling attention to the
requirement of listing the diagnosis in reports to the Resettle-
ment Administration, stating that in his opinion this would be
contrary to law divulging a privileged communication, that the
doctor in making such a report should require the patient to
sign a waiver in every case.

He maintained that if "there could be secured a uniform
method of medical care of these people who are government
wards, I have every confidence in the medical profession that it
would respond to the care of these people needing medical
assistance in the same way they have always responded — not
because they are federal wards, but because they are sick
people.”

Mew Business —

C. E. Sherwood presented the matter of a Veterans Hospital
for Eastern South Dakota, as sponsored by Rep. Fred Hildebrand
who is endeavouring to secure appropriations from the federal
government for this purpose. After a discussion of the actual
needs of such a hospital, a motion by L. J. Pankow, supported
by E. W. Jones, That the question be referred to the Resolu-
tions Committee to prepare a resolution against such appropria-
tion, for a Veterans Hospital. A copy of the resolution to be
sent to Rep. Fred Hildebrand. Motion carried.

S. M. Hohf presented a resolution relative to the status of
the Medical School of the University of South Dakota. On
motion of S. M. Hohf, supported by L. J. Pankow, to refer
the resolution to the committee on resolutions. Motion carried.
(See reference Committee report.)

Secretary Cook reported on the Spafford Memorial Scholar-
ship; 1935. Not awarded. 1936, Louise Breckerbaumer,
Sioux City, Iowa. As reported from President I. D. Weeks.

S. M. Hohf proposed the name of C. M. Keeling, M.D.,
of Springfield as honorary member of Yankton District Med-
ical Society.

Secretary Cook, All honorary members of the district med-
ical societies, according to the By-Laws are to be elected by
the district Society and presented to the House of Delegates
for approval.

E. A. Pittenger, suggested that the next meeting be held on
Sunday, so that a day would not be lost from members' prac-
tice. This suggestion to be acted upon later. Motion by W. R.
Ball to adjourn. Motion carried.

J. F. D. Cook, Secretary

HOUSE OF DELEGATES SOUTH DAKOTA
STATE MEDICAL ASSOCIATION
Socond Meeting

Rapid City, S. D., May 25, 1937

President J. L. Stewart, Presiding.

Meeting called to order by the chair.

Roll call as follows: J. L. Stewart; E. A. Pittenger; J. F. D.
Cook; J. D. Whiteside; J. B. Vaughn; B. M. Hart; G. E.
Burman; O. J. Mabee; E. W. Jones; Wm. R. Ball; N. J.
Nessa; R. G. Stevens; C. E. Sherwood; L. J. Pankow; S. M.
Hohf; H. F. Hansen; F. E. Williams; F. S. Howe; H. R.
Kenaston; N. K. Hopkins; P. H. Rozendal; E. H. Grove;
P. D. Peabody; F. Pfister. Quorum present.

Reading minutes of the meeting held Monday evening May
24th, was in order. Motion by L. J. Pankow and duly sup-
ported that the reading of the minutes be dispensed with.
Motion carried.

REFERENCE COMMITTEE REPORTS
C. E. Sherwood, Chairman submits the following report of
his committee; That the report of J. R. Westaby, Delegate
to the American Medical Association 1936 Sessions, is hereby
approved.

That the report of Sub-Committee on Medical Licensure,
as presented by T. F. Riggs, chairman, is hereby approved.

THE JOURNAL-LANCET

389

That the report of the Public Health Committee as pre-
sented by C. E. Sherwood, Chairman is hereby approved.

That the report of J. F. D. Cook, Secretary-Treasurer, is
hereby approved.

That the report of the Council as given verbally by J. L.
Stewart, be approved.

That the report of Committee on Scientific program, Secre-
tary reports the printed program as our report. Is hereby
approved.

That the report of the Committee on Medical Economics.
The Committee begs to report as follows: "We are of the

opinion that the report indicates much thought and work on
the part of the Committee, and much merit is contained there-
in. We refer the same to the House of Delegates for your
consideration.”

Motion by Wm. R. Ball that the report of the reference
committee be approved as presented. Motion carried.

(See reports.)

REPORT OF REFERENCE COMMITTEE ON
RESOLUTIONS AND MEMORIALS

The matter of building a Veterans Hospital for eastern
South Dakota as sponsored by Representative Fred Hildebrand
of Watertown, S. D., Your Committee begs to report as
follows;

Whereas: Representative Fred Hildebrand of Watertown,

S. D. is sponsoring and working for the establishment of a
$450,000.00 hospital for Eastern South Dakota:

We, the South Dakota Medical Association, in convention
assembled do protest the establishment of this Hospital and
and the further building of Hospital facilities by the Veterans
Administration for the following reasons:

"FIRST: We believe that there are ample Hospital facilities
for the care of all service-connected disabilities.

"SECOND: There are ample fully accredited hospital beds
and facilities for care of all non-service connected disabilities
in the private and public1 hospitals of the State.

"THIRD: These non-service connected disabilities can be
taken care of more satisfactorily to the Veteran at home.

"FOURTH: These non-service connected disabilities can be
taken care of in existing private and public hospitals with less
expense to the Administration.

"FIFTH: The building of further hospitals for the care of
non-service connected disabilities at public expense constitutes
direct governmental competition and unnecessarily adds to the
tax-payer’s load.

"THEREFORE: We, the South Dakota State Medical Asso-
ciation respectfully protest the appropriation of monies for the
further building of Veterans Hospitals.”

Motion by C. E. Sherwood that the above committee report
on Hospitals be approved. That the Secretary send copies of
the resolution to members of Congress from South Dakota.
Motion carried.

S. M. Hohf presented the following resolution to the
Council on Medical Education and Hospitals of the American
Medical Association:

Whereas: The State of South Dakota, through its legislative
body, has recently manifested an earnest desire to adequately
support and perpetuate the School of Medicine of the Univer-
sity of South Dakota, and

Whereas: the sum appropriated by the legislature is sufficient
to meet the immediate needs of the School through the addition
of teaching personnel, increased library facilities and needed
equipment, and

Whereas: the organized medical profession of the State,
as no other group, realizing the need of such a school in South
Dakota, has always taken great interest in its welfare and has
felt pride in its accomplishments as manifested by the records
of its students, and

Whereas: it has been brought to our attention that the
School’s authorities sense difficulty in procuring the right kind
of instructors for the School and enrolling students for the
school years of 1937-38 and 1938-39 if the present status of

the School is not bettered by immediate action by the Council
on Medical Education and Hospitals,

BE IT RESOLVED THEREFORE: That the House of
Delegates of the South Dakota State Medical Association, in
annual meeting assembled, does hereby respectfully urge the
Council on Medical Education and Hospitals of the American
Medical Association to take immediate steps which will permit
provisional enrollment of students and to take such other
action as will not unduly handicap the School of Medicine of
the University of South Dakota in its earnest endeavor to
meet the requirements imposed by your Council and allied
agencies.

Signed, Committee
S. M. Hohf, M.D., Yankton, S. D.

E W. Jones, M. D., Mitchell, S. D.

J. B. Vaughn, M.D., Castlewood, S. D.
Dated Rapid City, S. D., May 24th, 1937.

On motion of S. M. Hohf, supported by E. A. Pittenger,
That the above resolution be approved. Motion carried.

COMMITTEE ON NECROLOGY
"In submitting a list of members of our Association who
have passed on during the year, your committee feels that it is
befitting to pause a moment in the deliberations of this meet-
ing in memory of those who have been with us in the past,
some of whom have served in an official capacity. Roll Call
follows.

J. B. Vaughn, for the Committee
DECEASED— 1936-37
MICHAEL E. EGAN, M.D., Sioux Falls.

Died April, 1936. Aged 74.

Hamline University Medical School, St. Paul, Minn.
JOHN SUTHERLAND, M.D., Britton.

Died May 28, 1936. Aged 79.

Rush Medical College, Chicago, 111.

WILLIAM MOODY HUNT, M.D., Murdo.

Died June 18, 1936. Aged 71.

Cleveland Medical College, Cleveland, Ohio.

*CARL GILBERT LUNDQUIST, M.D., Leola
Died June 26, 1936. Aged 53.

Rush Medical College, Chicago, 111.

ALBERT LUKE STUBBS, M.D., Hot Springs.

Died June, 1936. Aged 71.

Keokuk College of Physicians & Surgeons, Keokuk, Iowa.
'OTTO HENRY GERDES, M.D., Eureka.

Died June 29, 1936. Aged 68.

Rush Medical College, Chicago, 111.

H. P. HANSON, M.D., Beresford.

Died June, 1936. Aged 90.

Creighton University School of Medicine, Omaha, Neb.
*E. W. GOLDMAN, M.D., Madison
Died August 8, 1936. Aged 56.

Creighton University School of Medicine, Omaha, Neb.
*BENJAMIN THOMAS, M.D., Huron.

Died August 19, 1936. Aged 70.

University of Illinois College of Medicine, Chicago, III.

* ANDREW PAULSON, M.D., Watertown
Died September 16, 1936. Aged 63.

Jefferson Medical College of Philadelphia, Pa.

*PHILIP R. BURKLAND, M.D., Vermillion.

Died September 30, 1936. Aged 61.

Northwestern University Medical School, Chicago, III.
SARKIS K. MERDANIAN, M.D., Oelrichs.

Died November 7, 1936. Aged 72.

Missouri Medical College, St. Louis, Mo.

*MONTE A. STERN, M.D., Sioux Falls.

Died November 7, 1936. Aged 51.

Creighton University School of Medicine, Omaha, Neb.
E. O. CHURCH, M.D., Menno.

Died December 3, 1936. Aged 64.

University of Illinois College of Medicine, Chicago, 111.
LARS J. HAUGE, M.D., Howard.

Died November 20, 1936. Aged 76.

Sioux City College of Medicine, Sioux City, Iowa.

390

THE JOURNAL-LANCET

DECEASED— 1937
*E. C. SMITH, M.D., Mission, S. D.

Died January 20, 1937. Aged 77.

Not listed in directory.

J. L. MILLER, M.D., Spencer.

Died January 6, 1937. Aged 62.

Drake University College of Medicine, Des Moines, Iowa.
*CARL A. FEIGE, M.D., Canova.

Died January 26, 1937. Aged 59.

Hahnemann Medical College, Chicago, 111.

*C. WM. FORSBERG, M.D., Minneapolis, Minn.

Sioux Falls Dist. Med. Soc.

Died February 21, 1937. Aged 40.

University of Minnesota Medical School.

*RAMEY M. BAKER, M.D., Sturgis.

Died March 1, 1937. Aged 30.

University of Nebraska College of Medicine, Omaha, Neb.
L. M. HARDIN, M.D., Flandreau.

Died March 19, 1937. Aged 68.

Marion Sims College of Medicine, St. Louis, Mo.

FRIEDE VAN DALSEM, Huron.

Died 1937. Aged 92.

(Non-graduate; licensed in 1887.)

J. D. FREED, Goodwin.

Died March 27, 1937. Aged 85.

New York Homeopathic Medical College.

♦Deceased member of State Medical Association.

COMMITTEE ON NECROLOGY

To The South Dakota State Medical Association:

Rapid City, S. Dak.

The committee on necrology wishes to make the following
report of the doctors that passed away in the state during the
last twelve months.

Dr. Michael E. Egan, aged 74 years, of Sioux Falls, S. D.,
died at a Chicago hospital recently after a short illness. Dr.
Egan was a graduate of Hamline University.

Dr. John Sutherland, aged 79 years, who has been in active
practice for many years at Britton, S. D., passed away on May
28. Dr. Sutherland held degrees from several European
universities, and has contributed many valuable papers that
have been published in The Journal-Lancet.

Dr. William Moody Hunt, of Murdo, S. D., a graduate of
Cleveland Medical College, Cleveland, Ohio, died June 18.
1936, at the age of 71 years.

♦Physicians of South Dakota and the Northwest were
bitterly grieved to learn of the death of C. Gilbert Lundquist
of Leola, South Dakota, who died at Saint Luke’s Hospital in
Aberdeen at 7:30 A. M. on June 26, 1936, as the result of
an automobile accident on June 26, suffered in the course of
his practice. Dr. Lundquist was born on October 14, 1883, in
Pembrook Township, Edmunds County, in what was then
Dakota Territory. He was the second white child born in the
Territory.

Dr. Jessie E. Stubbs, one of the well known physicians of
Hot Springs, S. D., passed away last month after an illness of
several months. Sh$ was always very active in religious, social
and civic matters, and will be sadly missed in that city.

*Dr. O. H. Gerdes, who has been in active practice at
Eureka, S. D., for over 43 years, died at his home on July 29,
aq the age of 68 years, after an illness of many months. Dr.
Gerdes was a graduate of Rush Medical College in the class of
1892.

Dr. H. P. Hanson, Beresford, one of the pioneer physicians
of South Dakota, passed away last month at the advanced age
of 90 years. Dr. Hanson had always taken an active part in
church and all community activities.

*E. W. Goldman, M. D., Madison, S. D., graduate of
Creighton University School of Medicine, Omaha, Nebr., died
August 8, 1936, at the age of 56.

*Dr. Benjamin Thomas, Huron, S. D. was suddenly called
by death on August 19th. The doctor had been in practice in
Huron for over 30 years.

*Dr. Andrew Paulson of Watertown, S. Dak. died Septem-

ber 16, 1937, after a long illness, the result of an automobile
accident some years past.

*Dr. Philip R. Burkland, one of the pioneer physicians of
Vermillion, S. D., died suddenly at his home in that city
September 30, 1936.

Sarkis K. Merdanian, M. D., Oelrichs, graduate of Missouri
Medical College of St. Louis, Mo., died November 7, 1936,
aged 72.

*A sudden heart attack while he was attending to profes-
sional duties at his office caused the death of Dr. Monte A.
Stern, 51 years old, prominent Sioux Falls physician and sur-
geon. Dr. Stern had lived since childhood, and practiced
medicine in Sioux Falls for nearly a quarter-century. He was
at his office attending to a patient when the fatal attack
occurred. His death came as a distinct shock.

Dr. E. O. Church, Menno, South Dakota, died suddenly on
December 3, 1936, of a heart attack. He was a graduate of
the University of Illinois College of Medicine in 1900. Dr.
Church had practiced medicine in Revillo, South Dakota, for
24 years, and in Menno for 4 years.

Dr. Lars J. Hauge, for the past 32 years a physician of
Howard, S. D., died at the age of 76 in Howard, November
20, 1936. Dr. Hauge was a graduate of the old Sioux City
(Iowa) College of Medicine; but prior to that had been a
minister in the Norwegian Lutheran Church.

*Dr. E. C. Smith, 77, passed away on January 20, 1937, at
Winner, South Dakota. Doctor Smith, a pioneer physician of
South Dakota, was president of the Rosebud District Medical
Society, and health officer for Todd County at the time of his
death. He was a member of the South Dakota State Medical
Association and of the Sioux Valley Medical Association.
He was in practice at Mission, S. Dak.

J. L. Miller, M.D., Spencer, graduate of Drake University
College of Medicine, Des Moines, Iowa, died January 6, 1937.

*Dr. Carl A. Feige, 58, died January 26 after an illness of
two months. Spending the early days of his practice in Kansas
City, Dr. Feige came to South Dakota in 1924. After being
in Iroquois and Huron, he settled in Canova in 1928. Dr.
Feige was appointed a member of the State Board of Medical
Examiners by Governor Green, and was re-appointed to the
post by Governor Berry. Of a very public-spirited nature, Dr.
Feige took great interest in the community affairs. As a mem-
ber of the town council and mayor for several years, he helped
in the building of the town park. He was a Master Mason,
a member of the Consistory, and a Shriner.

♦Carl William Forsberg, M.D., Ph D., instructor in path-
ology at the University of Minnesota Medical School, died on
Feb. 21, 1937 in University Hospital. His degree was ob-
tained from the University in 1922; but he was a member of
the South Dakota State Medical Association. He practiced in
Sioux Falls from 1927 to 1933.

*Dr. Ramey M. Baker, 30, of Sturgis, South Dakota, died
at St. John’s Hospital in Rapid City on March 2, 1937. Dr.
Baker was graduated from the University of Nebraska College
of Medicine in 1931, coming to Sturgis in 1933.

Dr. L. M. Hardin, Flandreau, S. D., a graduate of Marion-
Sims College of Medicine, St. Louis, Mo., died March 19,
1937 at the age of 68.

Dr. Friede Van Dalsem, 92, pioneer physician of Beadle
County, South Dakota, died in Huron during March. She is
survived by four children and one sister.

Dr. J. D. Freed of Goodwin, S. Dak., died in the Luther
Hospital, Watertown, S. Dak., March 27, 1937, at the age
of 85 years, 5 months. Dr. Freed had been in poor health
for some time previous to his death. He had been in active
practice for about 55 years, most of the time in Goodwin,
S. Dak. Dr. Freed will be missed very much by his friends in
and around Goodwin. Mrs. Freed preceded the doctor in
death three years ago. They had no children.

♦Deceased member State Medical Association.

Respectfully submitted,

Dr. M. J. Hammond,

Dr. J. B. Vaughn,

Dr. W. H. Saxton.

THE JOURNAL-LANCET

391

Report of Committee on Nominations and Place of
Meeting for 1938

Chairman, J. L. Calene to make the following report; nomi-
nations for President Elect; J. F. D. Cook; T. F. Riggs; Vice
President; J. C. Shirley; J. C. Ohlmacher. Councilors: No. 9,
R. B. Fleeger; No. 10, H. R. Kenaston; No. 11, N. K.
Hopkins; No. 12, Wm, Duncan.

Place of meeting for 1938 Huron, S. D. We recommend
that no group meeting be held with other societies next year.

The committee report accepted and proceeded to vote by
ballot. Chair appointed B. M. Hart, P. D. Peabody and
J. R. Westaby as tellers. Vote for President Elect was had.
tellers report a unanimous vote cast for J. F. D. Cook, who
was declared elected as President-Elect.

Election of Vice-President. A vote was prepared and the
tellers report as follows; J. C. Shirley 15. J. C. Ohlmacher 7.
Motion by E. W. Jones supported by L. J. Pankow that J. C.
Shirley be declared unanimously elected Vice-President. Motion
carried. J. C. Shirley declared elected.

Motion by C. E. Sherwood stated in view of the fact that
the nominees were not opposed in their respective districts,
the rules be suspended and the nominees be declared elected.
As a motion this was supported by J. F. D. Cook. Motion
carried. The Secretary cast the unanimous vote of the House
for the nominees who were declared elected.

The Committee report on place of meeting and the in-
vitation of the Huron Commercial Club be accepted, and the
Association meet in Huron, S. D. in 1938.

That no group meeting be held with other societies next year.

This motion by C. E. Sherwood, supported by L. J. Pankow.
Motion carried.

President, J. L. Stewart reported that an oral request from
a dentist asking support of the House of Delegates in placing
a dentist on the State Board of Health. No action was taken
and further details of the proposition asked for.

Communication from Elvira Nelson, secretary of the South
Dakota Nurses Association regarding the support of the State
Medical Association in an effort to procure legislation to require
registration of all available nursing service — registered nurses,
undergraduates and practical. Motion by E. A. Pittenger,
supported by E. W. Jones that this be referred to the com-
mittee on legislation at their next meeting. Motion carried.

Motion by N. K. Hopkins, that G. E. Burman be elected as
councilor for District No. 5 from which office J. C. Shirley
automatically vacates by his election as Vice-President. Motion
carried.

Motion by E. A. Pittenger that the House of Delegates begin
their meeting on Sunday next year. A standing vote was
called for by the chair. Motion lost. N. K. Hopkins called
attention to the condition of his district because of removals, it
was decided by the district to surrender its charter and the
members join with the Madison District. Secretary asked for
a resolution from the officers of the Kingsbury District Society
for a matter of record.

District boundaries should be a matter of consideration by the
council. Motion by B. M. Hart to adjourn. Motion carried.

J. F. D. Cook, M.D., Secretary-Treas.

The Committee on Public Health Submits the Following
Report

The Committee on Public Health has been fairly active dur-
ing the past year. We pursued the policy adopted two years
ago that all matters pertaining to Public Health be consolidated
and referred to this committee.

In September of last year the American Society for the
Control of Cancer started organization of this state for the en-
listment of the Women’s Field Army. Your committee was
contacted by Dr. Flude, the field representative, when he was
here in the fall. Mrs. Howard E. Trask, of Pierre, was
appointed as State Commander with our approval in October.
The executive committee is made up of Doctors C. E. Sher-
wood (chairman) , D. S. Baughman, W. R. Ball and B. A.
Dyar. While the organization went slowly the enlistment met

with fair success and we are sure more progress will be made
next year. The executive committee was also instrumental in
securing the services of Mr. John Barton, of Sioux Falls, as
state treasurer.

In the fall, Surgeon General Parran, of the United States
Public Health Service, requested that a special committee on
control of Syphilis be appointed from the State Medical
Society. In accordance with our policy this matter was referred
to your committee on Public Health. A special sub-committee,
to act in this matter, was appointed with the chairman of your
committee as chairman and Doctors R. G. Mayer and Anton
Hyden members. The following is a copy of their recom-
mendations to Surgeon General Parran.

"In reply to your letter of March 20th, relative to recom-
mendations of our committee for control of Syphilis which
will be practical of application within our state we offer the
following.

First, due to the largely rural character of our population
we feel that the establishment of special venereal disease clinics
would not be practical in South Dakota except in two or three
instances. It is probable that Sioux Falls and Aberdeen are
large enough centers so that the establishment of clinics might
be an important factor in control. Rapid City might possibly be
included also.

Second, through our State Board of Health we are already
furnishing medicine for the treatment of Syphilis, which can
be had upon application, to the Health Officer, by any physi-
cian treating such cases. Our state Health Laboratory furnishes
to all physicians mailing outfits for the collection of blood for
sero-diagnosis, which is done free of charge to the physician.

Third, dark field diagnosis should be made more readily
available, at least in every hospital in the state.

Fourth, funds should be made available to partially recom-
pense physicians for the treatment of indigent syphilitics.

Fifth, for the present, at least, we feel that the program of
Syphilis eradication should be largely educational on two fronts,
(a) to the physicians, through talks at Medical Society and
special meetings and possibly into the office of the individual
physician stressing the points of diagnosis and treatment, (b)
education of the public through newspaper articles, radio talks,
and public speakers much on the order of the popular propa-
ganda put out by the Tuberculosis and Cancer Organizations
leading to the education of the public in early consultation of
their family physician for diagnosis and treatment.”

Several members of your committee have been appointed to
the advisory council of the South Dakota Public Health As-
sociation and have met and advised this association on their
policies. It is our opinion that this association is doing a good
piece of work in Tuberculosis control and that it should have
the whole hearted cooperation and support of the physicians of
the state.

Federal funds are still being made available for child and
maternal welfare work as well as for assisting crippled children.

Health conditions generally throughout the state are about
average. An epidemic of Cerebrospinal Meningitis in the
Hills area being promptly brought under control.

Influenza reached epidemic proportions during the early
months of the year.

Dr. J. V. Sherwood, Superintendent at Sanator, called atten-
tion to the fact that recent legislation gives the Sanatorium
the right to discharge patients not being benefited by sanator-
ium treatment after six months of residency. This law, of
course, was passed to facilitate taking care of incipient and
moderately advanced cases of Tuberculosis who have some
chance to get well. This then will discharge from the Sana-
torium old chronic cases which have not been benefited by
sanatorium treatment. Perhaps for a time this will increase
the public health problem in taking care of these open cases
that are not in the Sanatorium. He is of the opinion that
steps should be taken for the establishment of a farm or some
such place for the care of these chronic open cases. He further
advises the establishment of a contact program, that is, a follow-
up program in an effort to run down contacts both in re-

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actors as discovered by tuberculin tests of school children and
in active cases discovered.

Your committee wishes to report the whole hearted coopera-
tion of the State Board of Health with the Society in all mat-
ters dealing with the Public Health.

Respectfully submitted,

Clarence E. Sherwood, M.D., Chairman

REPORT OF ECONOMICS COMMITTEE

It is with marked sadness we here are reminded of the loss
of a fellow member of this committee.

The sudden death of Dr. M. A. Stern, in November, re-
moved from our gatherings one keenly interested in the prob-
lems concerning this particular committee, and one generally
respected for his devotion to the highest ideals and traditions
of the medical profession.

Paradoxical as it is — with the economics of the profession
so upset in readjustment — this report shall be brief.

To go back to the 1934 meeting in Mitchell, be reminded
that the personnel of this committee was purposely chosen be-
cause of criticism and debate in the meeting of the Delegates,
and concerned or opposed principally:

1 . The stereotyped committee reports which were customarily
read year after year, with no real committee work ever being
done.

2. The lack of cooperation and coordination between the
State Medical Association and the State Board of Health, as
well as the other Allied Groups.

3. The lack of executive authority on the part of the officers
of the Association.

These committee members, fully cognizant of these reasons
for their appointment, therefore had naught to do but to accept
and serve with a determination to prove their justification.
This took considerable time and effort in study and travel, to
bring in the report for the 1935 meeting in Pierre; which re-
port was unanimously adopted and approved and which in the
main:

1. Announced an established relationship with the State
Board of Health.

2. Provided for a full time Executive-secretary to work
along with the Elective-secretary of the state Association, which
was made possible solely because of the relationship established
with the State Board of Health.

3. Promoted direct cooperation and coordination of all
Health Agencies and Health Programs in the state.

4. Instituted a Speaker’s Bureau.

5. Established an Educational Bureau.

6. Advocated complete divorcement of politics in all health
matters, requiring instead, qualifications and society endorse-
ment.

7. Urged an immediate increase in membership in the State
Medical Association.

8. Suggested the formation of a working unit with the
Allied Medical Groups of the state, i. e., Dentists, Nurses,
Druggists, Hospitals and Veterinarians.

For the 1936 meeting, the committee devoted most of its
effort to the development of a mutual understanding and con-
duct between the Allied Medical Groups in things professional
and politic; and succeeded in affecting a combined meeting in
Sioux Falls in 1936, for the purpose of demonstrating poten-
tial strength and the formation of a positive organization. This
was accomplished to the complete satisfaction of this committee,
which left little more to report except to present a review of
what had already been recommended and accepted.

NOW IS 1937 — and the final report of this committee. As
stated in the opening paragraph, it shall be brief in order to be
true to our convictions that are even more pronounced now than
in 1934, regarding professional unity and Association conduct.
A detailed report and recommendations would be easy to pre-
pare, but it is fulfillment of those already accepted, that shall
advance our Association. We shall therefore, at this time, res-
pectfully request enforcement of previous approved recom-

mendations of this committee in the firm belief that if this be
done with this, and all committee reports, the South Dakota
State Medical Association shall progress, the profession shall t
maintain its right and dignity in its social and economic re-
lationship to the betterment of the individual physician and
the greater satisfaction of the public.

At this time, this committee would like to restate and speci-
fically emphasize:

I. COMMITTEE RECOGNITION AND FUNCTION.
Each committee should be responsible throughout the year,
and receive all respective material for study and recommenda-
tion back to the Council or Executives. To illustrate — this
Committee, during its tenure, has never had referred to it
matters affecting the economics of the Association. Maybe we
are wrong, but we feel that if the Rehabilitation Medical Re-
lief had been thus opinionated, it might have been more easily
and satisfactorily handled. Not in any way as a criticism, but
simply as a fact, this Rehabilitation Relief problem not only j
deprived the membership of all the Medical Groups any pecun-
iary aid, but went a long way in breaking down trust and con-
fidence in our own Association and in the Inter-Allied Council. 1
It is to be regretted that it proved so unpleasant for all con- I
cerned, particularly the Council and Executive Officers. In this 1
connection, our Council is unwieldy and more or less unin-
formed. The personnel is scattered — meetings require personal
sacrifice and are hurried. Instead, some State Associations are
setting up Executive Boards of five or seven members which
this Committee believes practical and efficient and worthy of
consideration.

II. It is recommended that more real authority be delegated
to the Association executives and that they be upheld by the
membership.

III. It is urged that the State Medical Association formulate,
without delay, a Basic Science Law, and through the Inter-
Allied Council, prepare at once for its enactment.

IV. Our urgent plea is that this Association bend all effort
to the fulfillment of the opportunities of the Inter-Allied
Council. This, we regard as our prime accomplishment. The
Executive-secretary of the State Medical Association serves also '
as Secretary of the Inter-Allied Council — which is an ideal
arrangement because of his association with, and the attitude

of the State Board of Health. Compensation should be
afforded him by the Inter-Allied Council that he could have a
full-time girl, and the State Medical Association should see to
this provision.

V. It is a foregone conclusion that finances must be had if
we are to progress. We recommend the establishment of an
Educational Fund, to be built up to an appreciable amount
before being used not only for the education of the member-
ship, but for the enlightenment of the public and the protection
and improvement of our economic and professional welfare.
The ways and means of this fund should receive immediate
attention and a few suggestions might be through dues, assess-
ments, an individual percentage of fees from Resettlement
work, bequests, etc.

VI. We urge again that the Association take steps to stop
the nefarious practice of all groups, private and civic, when
soliciting charity funds, of stressing first that the money is
needed for medical services. It never is as the people are so
led to believe. State-wide action should be directed against
this, and the public not further misinformed. It might also
be advocated that physicians’ services in all instances be credited
as donations, and in lieu thereof.

VII. This Committee wishes to express a word of commenda-
tion to the Radio Committee for its untiring effort. If it
be re-established, might we suggest the consideration of a circus
or entertainment feature, only just touching on medical topics
in the announcements.

In closing, we wish the membership to know that we have
been afforded a most enjoyable and profitable three years and
are grateful for our many pleasant contacts and associations.

We are grateful to our fellow officers for their many courtesies,
and we would be remiss if we did not mention our personal
appreciation for the trust and confidence and many kind favors,

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393

extended to us from the beginning by Dr. Jenkins and his
associates in the State Board of Health. Out of this came the
office created for Dr. Dyar, who has endeavored at all times to
fulfill his trust, and has been of immeasurable assistance in
the lightening of what would have been an impossible task for
our long-time secretary, Dr. J. F. D. Cook.

WE ARE MORE CONVINCED THAN EVER THAT,
"THE ETHICS AND IDEALS OF THE MEDICAL
PROFESSION” MEAN MORE TO "THE BROTHER-
HOOD OF MAN” AND "THE GLORY OF OUR
CREATOR,” THAN THOSE OF ANY GROUP ON
EARTH, AND WHAT A PITY WHEN THEY BE
DESECRATED!

Will E. Donahoe, M.D., Chairman
Wm. F. Bushnell, M.D.

May, 1937

REPORT OF DR. J. R. WESTABY
DELEGATE
A. M. A.

SOUTH DAKOTA STATE MEDICAL
ASSOCIATION
HOUSE OF DELEGATES

Gentlemen:

It is my pleasure at this time to report to you some of the
proceedings of the American Medical Association whose House
of Delegates convened on May 11th in Kansas City in the
Ballroom of the Muehlebach Hotel at 10 A. M.

The Speaker of the House, Dr. N. B. Van Etten called the
meeting to order and the Reference Committee on credentials
reported that 153 delegates were properly registered and
vouched for.

Dr. Van Etten charged all delegates with the seriousness
of the work before them, and asked for courageous and diligent
consideration of all work presented in the interest of whatever
is best for American Medicine and the American People.

Tribute was paid as usual to the past members of the
House of Delegates answering the final call since the Atlantic
City Meeting and the Speaker summed up the Memorial
Address with these words: These our friends, have passed
beyond our vision, but they will continue to live in our memory.
Time like an ever rolling stream
Bears all its sons away
They fly forgotten, as a dream
Dies at the opening day.

Our God our help in ages past.

Our hope for years to come

Be thou our guard while life shall last,

And our Eternal home.

President James S. McLester was next introduced and spoke
at quite some length regarding the conditions affecting the
American Physician during these times of depression and ex-
pressed satisfaction in the loyalty of the profession in general
for maintaining high ideals, scientific attainments and pro-
fessional usefulness.

Dr. McLester pled earnestly for the profession to. avoid
State Medicine and Socialized Medicine under whatever dis-
guise they attempted to appear, and called attention to the pro-
vision of the Social Security Act, recently enacted by Congress
by which politicians in the near future will carry governmental
subsidies to include medical care in an attempt to ensnare the
public and physician into adopting unsound principles in the
care of the sick. The attitude of the American Medical Asso-
ciation as in the past should be one of close attention to the
medical needs of the American people and of alert preparedness
to meet those needs.

President McLester spoke the thoughts in the minds of all
those present when he called attention to our great regret over
the illness of our friend and President Elect, Tate Mason.

Dr. B. T. King of Washington read Dr. Mason’s message

in which he analyzed his visiting tour about the United States
before being compelled to give up with an attack of influenza.

Dr. Mason said he found the physicians of the United States
divided into three groups.

1. Those who felt that the A. M. A. should have and needed
more leadership; that the House of Delegates should meet
twice a year; that the A. M. A. should spend much more to
educate the public, by radio, newspaper, and platform so that
misconception and false impressions might not gain a foothold
regarding the practice of medicine.

2. In this group were physicians who wished a change in the
delivery of medical care to the public. They approved the
small Health Units of Service similar to those now established
over limited geographical areas such as have appeared in South
Dakota.

3. A third and by far the largest group of physicians felt
that the House of Delegates should recognize the medical sit-
uation existing at this time and give special attention to the
financial aspects of the practice of medicine.

It is not surprising that the stringency, in its acute phase,
made medical economics a matter of primary concern among
physicians and the public itself. Some of the plans being pro-
posed to remedy this situation have originated within and some
without the medical profession. Some of the propositions show
careful thought and have received great support in the hope
that their application might improve the economic situation for
both the public and the physician. Many other schemes show
very little constructive thinking and consequently are offered
as a cure-all for all the economic ills of all concerned.

The House of Delegates feel that no plan should be en-
couraged unless its aim is to preserve the individual practice
of medicine, with unhampered and open competition among
physicians and the continuance of personal relationship of doctor
and patient. It is the opinion of leaders of medical thought
today that once the above principle is compromised, the med-
ical profession of our country is headed toward political corrup-
tion and serfdom.

We of course knew the hopeless condition of our president-
elect, confined in his own hospital in Seattle, and his death
a short time after the convention was expected, although every-
one hoped that he might be the exception to the rule and that
he might recover. The majority of the Delegates felt that he
should have the honor of being installed, and so at the gen-
eral scientific assembly meeting he was made President of the
A. M. A. with Dr. B. T. King acting as his proxy, while Dr.
Mason listened to the ceremony by radio.

At the business session on Tuesday the Committee on Med-
ical Education recommended the adoption of a resolution mak-
ing the requirements for entrance into all ranking medical
colleges uniform and prescribing the courses of those require-
ments.

The Committee on Legislation and Public Relations urged
the medical profession to co-operate in good faith in carrying
out the provisions of the "Social Security Act” since it is now
a Federal Statute. This Committee also pointed out that the
creation of multiple non-medical agencies is not desirable or
acceptable to the medical profession. We should insist that
these studies be made by medical men under medical super-
vision. The Committee also rcommends that since medical men
must now report to the local police the care of all gunshot
wounds, the same requirement be imposed on everyone having
knowledge of the wound and the possible condition under which
it was inflicted. The Committee also condemned the practice
of performing operations designed to alter the appearance so
as to conceal the identity of an individual.

A large number of the resolutions and recommendations of
committees were very lengthy and required several pages of ex-
planation and required much discussion and I feel that it is
not necessary to burden you with a prolonged report at this
time.

The Secretary reported that the increase in membership had
exceeded that of all previous records by 2,000 and that the

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tendency was showing greater interest in the affairs of the As-
sociation. Dr. Olin West also commended the State Secretaries
for the good work they were doing and praised the Annual
Conference of Secretaries and the field work of the Association.

On Thursday afternoon the following officers of the Asso-
ciation were elected for the coming year:

President-Elect for 1938-39 — Dr. J. H. J. Upham of
Columbus, Ohio.

Vice-President — Dr. Chas. Gordon Heyd of New York
(became president, 1936-1937 on death of President Mason).

Secretary — Dr. Olin West of Chicago, Illinois.

Treasurer — Dr. Herman L. Kretschmer of Chicago, Illinois.

Speaker of the House of Delegates — Dr. N. B. Van Etten
of New York.

Vice Speaker of the House of Delegates — Dr. H. H. Shoul-
ders of Tennessee.

The place of meeting for 1937 was discussed and invitations
were formally extended from Philadelphia, Pa., and Atlantic
City, N. J. The vote stood Philadelphia 69, Atlantic City 70.

Report of Subcommittee on Medical Licensure to the
Officers of the South Dakota State Medical Association

Gentlemen:

In accordance with communication under date of March 31st,
1937, coming from the Secretary of The South Dakota State
Medical Association, we beg leave to make the following report:

1. In accordance with instructions received from the Coun-
cilors and Officers of the Association, we prepared a bill pro-
viding for a special Board of Medical Examiners separate from
the Board of Health, one idea being, as we understood it, that
by this means the fees of the applicants to practice could be
turned over to the treasurer of the State Medical Association.
Following the preparation of the bill we were made aware that
licenses to practitioners in medicine are granted by the State of
South Dakota and not by the State Medical Association, con-
sequently, the fees obtained from the applicants would of
necessity revert to the Treasurer of the State of South Dakota.
This made the inadvisability of such a bill self-evident.

2. In accordance with instructions, we prepared a bill requir-
ing the annual registration of all practitioners of the healing
arts. We were informed and had reason to believe that the
groups known as osteopaths and chiropractors would join us
in attempting to pass this bill providing the fees obtained from
each of these groups should go to its respective treasurer. This
bill was submitted to the Council and so many criticisms and
additions were received that it was evident there would be no
possibility of getting the bill through. Details can be furnished
on request.

3. The matter of Senate Bill 205, while not coming directly
under the field of activity of the special committee, yet related
in a way to licensure. This bill related to the qualifications of
applicants for examination before any state board for a license
to practice the healing arts and carried with it the appointment
of an examining board consisting of the Superintendent of
Public Instruction, the President of the State University, and
the President of the South Dakota State College. In reality it
was a Basic Science Law and would have worked out well
could it have been put across. It was introduced through the
State Affairs Committee but was not reported out of the Com-
mittee owing to the fact that no details were carried in the bill
relative to the types of examinaions which the examining board
was to carry out.

Respectfully submitted,

T. F. Riggs, M.D.

B. A. Dyar, M.D.

John C. Shirley, M.D.

PRESIDENT’S ADDRESS
J. L. Stewart, M.D.

Nemo, South Dakota
Delivered at Rapid City, South Dakota
May 25, 1937

AS PRESIDENT of this Association it becomes my
privilege to deliver the Annual Address, and I
Lwill begin by thanking the members for electing
me to this office. It is the greatest honor within the gift
of the greatest and most beneficent organization in the
State.

Tonight as I stand on the high hill of advancing
years and look back over the days that are gone, and
over the tremendous advances that medicine has made
during the last fifty years, I wonder how many of the
younger doctors present realize what an honor it is to
belong to the noblest profession under the sun, and to
the association that is representative of that profession.

You know, of course, that in recent years we have
nearly stamped out several preventable diseases, but do
you realize (as do the older men) what these diseases
really meant?

The death-dealing epidemics of typhoid fever, scarlet
fever, diphtheria, and summer complaint in babies were
real tragedies to the doctors of former years.

You can all recall the typhoid epidemic at Chamberlain
a few years ago, and what excitement it caused. Now,
think that forty or fifty years ago most any doctor in
the State had that many cases every year. During that
period Sioux Falls had over 300 cases in one year.
Imagine a country doctor hitching up his team and
driving out to see four, six, eight, or even ten cases of
typhoid fever in one day and you will have a picture of
early day conditions. Typhoid fever was almost con-
stantly with us in those days.

Those of us who represent a fast vanishing generation,
and have lived through this period of advancement,
probably realize more fully than others the great change.
Not only do people live longer, but I am sure that there
is less pain and suffering today than there was years ago.

Why all this advance in iife saving and in pain re-
lieving? The answer can be given in two words; or-
ganization and co-operation. The doctor of years ago
worked independently. True, he consulted the ethical
men in his neighborhood and took post graduate work,
but in the main he worked as an individual.

A little over fifty years ago the profession began to
organize. Gradually the spirit of organization spread
until to-day we have the American Medical Association,
the State and District Societies, and they are all work-
ing together harmoniously trying to relieve suffering and
save life.

About this time we began to have specialists to whom
doctors could send their most difficult cases. This further
helped in saving life. Not that the specialist was any
better doctor than the general practitioner, but because
he limited his work to one line of practice, he became
more proficient in that line.

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395

Then came the clinic or group of specialists, that still
further added to our ability to save life. The Mayo
Clinic at Rochester pioneered in this kind of service and
the good that they have done would be hard to estimate.

As our profession became more and more organized,
doctors realized that they must have the authority of law
back of them if they were going to accomplish very
much in their life-saving program.

Then began the struggle to establish State and County
Boards of Health. These Boards had little authority at
first but it was a beginning.

Then came the greater struggle to pass a law estab-
lishing a Board of Medical Examiners. That law was
opposed by all patent medicine companies and all irreg-
ular practitioners, but after several sessions of the legis-
lature it was passed.

Later came the laboratory that has aided so much in
diagnosis, and we must not forget the trained nurse, the
dentist, the druggist, the veterinarian and the hospital.
To-day all these agencies are working with us to help
us to heal the sick.

We have in this State an organization that takes in
all of these allied professions, and, if I have been cor-
rectly informed, it is the only such organization in the
United States. We expect great things from this asso-
ciation.

Through our State Board of Health and Board of
Medical Examiners we have put our own house in order
to such a degree that today we are safe in saying that
there is no doctor in the State having the degree of
M.D. who has not had schooling enough to be a good
doctor. This being the case, if only regular doctors were
allowed to practice the healing art, good diagnosis and
treatment would be the rule in our State.

But unfortunately this is not the case. Our work is
interfered with by practitioners who are not M.D.’s.
These false doctors not only oppose and obstruct every
advance in science, but carry on an active campaign in
which they teach the public to fear and hate the regular
doctor.

We have accomplished great things in the past, but
how much more we could have accomplished had we
not been opposed, will never be known.

Let us consider this false doctor or cultist. VHio is
he? Why does he exist? How does he exist?

A quack desires to practise medicine, without properly
preparing himself for such practice, and actually pre-
tends that he has the necessary knowledge. The reason
that he does this is not that he desires to relieve suffer-
ing humanity. If he had any such wish he would want
to gain the necessary knowledge.

Every cultist is a quack, but every quack is not a
cultist. The ordinary layman is not far removed from
quackery. Dr. Howard W. Haggard says that nearly
everyone is a potential quack and tells the following
story to prove it.

A famous nobleman of the sixteenth century one day
fell to speculating as to what trade or profession was
most common. His jester said that medicine had the

largest number of professors and offered to prove his
assertion. The story runs something like this.

The next morning the jester left his quarters with his
head swathed in a bandage. The first man that he met
asked him what was wrong. On being told, he said that
he knew what would cure his trouble. Every one he met,
asked what was wrong, and on being told, offered some
kind of treatment. Each treatment was different from
every other, but was declared to be a sure cure for such
a case. When he reached the courtyard of the palace,
the attendants surrounded him, each one eager to offer
advice.

Finally he reached the duke, who called out at once,
"What is the trouble?” On being told, he at once
offered a treatment that he knew would cure the trouble.
The jester then threw off his bandage and said, "You,
too, My Lord, are a doctor. I have on my way hither,
although I passed only one street, found more than two
hundred others. Everyone in town thinks he is a physi-
cian. Can you find more people practising any other
profession?”

The friends of the jester were not quacks. They were
only potential quacks, but if one of them had attempted
to commercialize his useless advice, he would then have
become a real quack.

A real quack becomes a cultist whenever he is able
to attract to himself a sufficient number of followers to
form an organization for the purpose of teaching the
propaganda that he wishes to spread abroad.

The potential quack does some harm by giving useless
and often wrong advice. The real quack does much
more harm, because he takes people’s money, and be-
cause by advertising himself as a doctor, he often treats
large numbers of patients. The cultist does the greatest
harm, because he has an organization to help spread
false propaganda. This false propaganda is spread not
only by the practitioners of the cult, but by laymen who
are often influenced by the sales talk of the followers
of the cultist.

It is hard for professional people to understand why
nearly every layman believes, that without any special
study of the subject he is qualified to advise people in
medical matters, where even a doctor would hesitate to
make a positive statement.

Many cultists never get beyond the quack stage. As
an illustration, I will' tell a story of my student days.

A, lot of hand-bills had been scattered in and about
the medical schools that cluster about Cook County Hos-
pital in Chicago, inviting the students to attend a lecture
to be given by a doctor in a certain hall.

Some of us attended the lecture and discovered that
the so-called doctor was a real quack.

He began his lecture by telling us how he could cure
cases where regular doctors had failed. He said that he,
himself, had had a cancer that had been so diagnosed by
leading surgeons in both Minneapolis and Chicago, and
that they had all wanted to operate and remove it. Then
he had cured himself by a very simple method of his
own discovery.

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He told us that we were foolish to spend so many
years in a medical school, that taught only a lot of non-
sense that would be useless in treating disease; that
surgery was never justifiable. That, in the main, there
was only one cause for disease and consequently only
one line of treatment.

He said that a doctor could learn all that was neces-
sary to learn in two weeks; that he was going to organ-
ize a school and invited us to join his class. He told us
that if we would come to his school, he could, in two
weeks’ time, make better doctors out of us than a reg-
ular medical school could in several years, and he want-
ed only $125 for the two weeks course.

None of the medical students joined his class, but
I know of a teamster who did. I never heard of the
quack again, so have reason to believe that he never
gathered together a sufficient number of followers to
form a cult.

The public, it seems, likes to think that the practice
of medicine is a simple thing. That there is a simple
and universal cure for all diseases. The quack says that
this is true. One cause for all diseases and therefore
only one line of treatment. How simple! How wonder-
ful! Doctors would like to think so too, but they know
better.

Quacks have always existed and, of course, are more
numerous than cultists, but many cults have come into
being since the days of Hippocrates, flourished for a
time and then died out.

Once in a great while a cult takes on some of the
education of the regular profession, and if they take on
enough of it, they are absorbed. In the last fifty years
two cults have been so absorbed by our profession.

All that the regular profession demands of the cultist
is that he become educated and ethical.

Is it too much to ask of one, in any profession, that
he become educated and ethical? Should these qualifi-
cations not be more necessary in medicine than in other
professions?

Most of the cultists refuse to comply with these two
simple demands and continue their propaganda that con-
sists of telling the public:

That they have discovered something new and won-
derful,

That they cure cases where regular doctors fail,

That they are persecuted by a regular medical trust,

That the regular profession is afraid of them and
their skill,

That vaccination is a crime,

That surgery is unnecessary, and therefore wrong,

That medicine has had its day and will be super-
seded by the cult.

These are only a few of the false statements that enter
into the sales talk of the cultist. As long as these state-
ments appeal to the public, quacks will use them, but
they are every one false.

In the meantime we will go on doing our best to heal
the sick, and we will never be satisfied until we reach a

point where everyone lives long enough to die of old
age.

We wonder sometimes just what is the attitude of the
public towards the regular profession. It can best be
illustrated by a story.

A young woman, who had taken an excursion into
quackland, returned to her regular physician. He asked
her, "What if I should refuse to take you back?” She
answered, "Oh, but I know that you won’t.” He asked,
"How do you know that I won’t?” She answered, "You
will take me back for the same reason that parents take
their children back, when they have gone astray. Chil-
dren often disobey their parents, say mean and some-
times untrue things about them, and even run away from
home; all the time knowing that if they get into trouble
they can return to the old home, and receive a welcome
and forgiveness.”

That is the way most people feel towards the medical
profession. There is a group, however, about 7 or 8%
of our population, whose minds have been so poisoned
by quack propaganda that they will never again look
upon us with anything but suspicion.

We are greatly annoyed, at times, a: the number of
unqualified people, who are trying to pose as doctors,
when in fact, we should feel complimented. Everything
good is counterfeited. If we were not good we would
not be counterfeited.

Because we are recognized as being good, the public
does not wish to destroy us; neither does the cultist.
Both realize that they will need us some day. What
doctor present in this room, has not had a cultist appeal
to him for aid? The cultists would all be panic-stricken
if they thought that the regular medical profession was
going out of existence.

The action of the Soviet Russian Government proves
that the public does not wish to destroy the medical
profession. In their formation of the new order of things,
they outlawed and destroyed practically all the other
learned professions, but they left the medical profession
intact. They were regimented but not destroyed.

The cultist, however, is with us. He has received legal
recognition, and in spite of our science, our high stan-
dards, and our good work, he goes on his way rejoicing.

What are we going to do about it?

The chances are that we will do little or nothing, the
same as we have done in the past, but there are some
things that we might do.

We might make a general appeal to the public (just
as the cultist does) but that would cause us to do a lot
of unethical things. We would have to do a lot of un-
justifiable bragging and advertising. We would have
to indulge in sales talks and do other things that would
be beneath the dignity of our profession.

We could call the attention of the public to what we
have done in the past; how we have raised the span of
life from 30 years to over 60 years in the last half cen-
tury, but the public already knows that, and it seems
to be unimpressed.

There is one weapon that we could use that would
have a real effect. We could refuse to help the cultist

THE JOURNAL-LANCET

397

or his patient out. When the cultist is in trouble he
comes to the regular doctor for help, and many a cultist
would retire from practice if he could not run to us
for help. Many patients would not go to quacks, if they
knew that they could not return to the regular doctor,
when in danger. In the interest of humanity we will
not make general use of this weapon.

The only thing left for us it seems is to work through
politics, and we are not politicians; neither are we busi-
ness men.

The cultist, usually, is both a business man and a
politician. If he were not; he could not succeed as a
cultist.

The average legislator understands the language of
the business man and the politician, but he docs not un-
derstand the language of the medical man.

It behooves the medical man, then, to learn another
language.

I say this in all seriousness.

Few, if any of us, want to do this, but if we are to
accomplish what should be accomplished, it will have
to be done.

Who is going to sacrifice himself for the common
good? That is a question that each one must answer
for himself. In some counties the political set-up is such
that certain doctors can do nothing, but wherever it is
feasible each doctor should interest himself in legisla-
tion, and perhaps gain a seat in our legislative body.

There is no question but that we could make ourselves
felt in politics if we would set ourselves to the task.

In the first place, we must agree a3 to what we want
and then work with the political organization with which
we are affiliated.

We should be able to place at least 10 or 15 members
in our legislature at each session. If we did this our
life-saving program would proceed much faster. The
Surgeon General of the United States Public Health
Service recently declared that 10 years might be added
to our life expectancy, if present medical knowledge were
applied fully. The present legislative trends are favor-
able to our enemies, who are, of course, enemies to
public health.

With this situation confronting us, shall we do as we
have always done, or shall we take sufficient interest in
politics to give the public the full benefit of present med-
ical knowledge? What a great achievement it would be
to raise the span of life to over 70 years!

Summary

1. For centuries regular medicine has labored to re-
lieve human suffering and save life.

2. Our profession will never have reached the hill
crest of its ambition until everyone dies of old age, in-
stead of disease.

3. Organization has done much to bring about the
great advance of the last 50 years.

4. Every M.D. in our State today has had schooling
enough to make him a good doctor.

5. With the accumulated knowledge of past centuries
at our command we still know little enough, and anyone

knowing less than we do should not be allowed to prac-
tice the healing art.

6. Our progress has always been obstructed by cults.

7. We could do more good for humanity if there were
no cults.

8. The cultist has influence with legislators because
he is not a professional man, and talks from the stand-
point of a business man and politician.

9. We are not politicians, and do not speak the
language of the politician or the business man.

10. It may be that we should learn what would be
to us a new language.

11. The cultist does not want to utterly destroy us,
neither do the people. They are afraid that they will
need us some day. They will continue to revile us, and
persecute us, and say all manner of evil against us, false-
ly; but they will call upon us in time of trouble.

ADDRESS OF THE PRESIDENT-ELECT OF
THE SOUTH DAKOTA STATE
MEDICAL ASSOCIATION

E. A. Pittenger, M.D.

Aberdeen, South Dakota

The medical profession during the last few years has
been visited by certain groups of uninvited and unwel-
come satellites. We have been beset by groups of profit
seekers, paid reformers, unscrupulous politicians and
the paid agents of certain philanthropists. The profit
seekers are a group that would gain from the by-prod-
ucts of a system of socialized medicine. They are the
third party, intervening between patient and physician,
such as the insurance carriers, the lodge, "the friendly
society”; all these would immediately take on new activ-
ities and more tax-supported employees. There are cer-
tain business firms which would stand to profit from
large orders for supplies and building materials resulting
from a governmental system of medical care. We also
have a very small minority group of physicians whose
friendship with unscrupulous politicians would result in
their sharing in the spoils.

But the most important in the class of seekers after
personal profit are the social workers, a new profession
which has been created by professional philanthropy and
social welfare. These social workers see in socialization
of medicine a multiplication of their work in providing
medical relief and also the creation of a fertile field for
their fast-growing profession and for the employment
of a large number of such social workers. More work —
more social workers!

All these profit-seekers know that the complicated ad-
ministrative work and governmental red tape of a social-
ized medical program would require thousands of em-
ployees, with the high salaried positions picked off by
those in power. They also know that the expenses for
administration in England have amounted to over half
of the total paid to physicians and that the number of
non-medical workers in Germany is greater than the
total of physicians doing the medical work. And to

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pay for this medical care, the workers in Germany must
turn over to the Government 6.5% of their monthly
earnings.

The paid reformer is ever seeking a panacea for pov-
erty. He would completely change the present facilities
for medical service because of a negligible percentage of
the people who are said to find illness costs heavy in a
given year. The paid reformer has been told, but for-
gets, that the Committee on the Cost of Medical Care
surveyed from month to month for an entire year the
health needs of some 39,000 people in this country. Of
the total, some 47.9% needed medical care and received
it; 47.1% of the people had no need for medical care
during the year despite monthly visits of a nurse who
was endeavoring to check their needs. This leaves but
5% of the people to be accounted for and, having in
mind those who choose to go to cult practitioners, it
would appear that there is a negligible, if any, percent-
age of the people who ask for medical service and do
not receive it. The paid reformer has failed to show
that the scientific benefits of our present system of qual-
ity service should be sacrificed to protect against sick-
ness costs for a negligible percentage of the population.

The unscrupulous politician sees in socialization of
medicine the control of a vast new patronage army.
Hundreds of choice jobs will be his to pass out. He
knows that this system will shunt large sums of money —
millions of dollars — into his hands, to be administered
by himself and his aides. This form of control will re-
sult in less skilled men in the profession, since young
men of ability will not be attracted to the conditions of
socialized practice. We would have a mechanical system
wherein there would be no incentive for research or
progress. There would be a loss of independence and an
inability to provide treatment thought necessary for the
patient, with resulting overwork by the physician and
loss of respect by the patient. Changes of administra-
tion and the spoils system would cause the practice of
medicine to become a political lottery, with political
skill, instead of professional skill, rewarded. We dif-
ferentiate between the unscrupulous politician and the
statesman.

The paid agents of certain philanthropists and social
workers are interested in the relief of poverty and in
securing the resources for such relief. Such social work-
ers distribute cash benefits, not their own money, accord-
ing to their standards and opinions of what is good for
the recipient. They naturally seek to do the same with
the services of the physician (also not their property),
and resent any implication that they are not equally
competent to determine how, and to whom, and in what
amounts these services shall be distributed. A number
of so-called philanthropic foundations have spent mil-
lions of dollars in the past ten years on surveys of med-
ical care. This money might better have been spent for
the care of the sick as it was originally intended to be
used. These foundations represent no truly public or-
ganization, or the people, but extremely limited groups
which dominate. These representatives of certain large
corporations are interested because of savings in wages

their corporations could effect under a socialized system
oI medical care. These foundations have never studied
or proposed any legislation to increase the money wage
of labor so that the individual could select his own phy- j
sician and be financially able to pay for his care.

We should give careful study to these critics of our
profession, but must not be too ready to accept their ,
many untried and illogical suggestions and plans. There
are several fundamental facts which the profession must
remember and adhere to when any new plan is consid-
ered. All features of medical service in any method of
medical practice should be under the control of the
medical profession. No other body or individual is
legally or educationally equipped to exercise such con- I
ttol. No third party must be permitted to come between
the patient and his physician in any medical relation.
All responsibility for the character of medical service
must be borne by the profession. Patients must have
absolute freedom to choose a legally qualified doctor of
medicine who will serve them from among those quali-
fied to practice and who' are willing to give service. The
relation between patient and family physician must un-
der all conditions be maintained. Any form of medical
service should include, within its scope, all qualified phy-
sicians of the locality covered by its operation who wish
to give service under the conditions established. Also
there should be no restriction on treatment or prescribing
not formulated and enforced by the organized medical
profession. In formulating any new plan these facts
should be rigidly adhered to and we should also remem-
ber that the public, in general, finds no real dissatisfac-
tion with the kind of medical service it is receiving. It
finds that under the present medical system, American
preventive medicine is not equalled anywhere in the world
and that American sickness and death rates are lower
than in any other country. Also the medical profession
has always provided and furnished good medical care.
No other class of men is so generous of its service and
do so much charity cheerfully. Our critics have failed
to show us why we should change this picture.

Now let us study the situation at the present time in
our own state medical society and see how we are
going to be situated* when it becomes necessary for us,
as a society, and as individuals, to influence the laws and
regulations which are going to govern our practice of
medicine. We have just passed through a session of the
State legislature in which we encountered a great
amount of anti-medical sentiment. It seems that the
osteopaths have set out to secure recognition so that they
can be eligible to receive payments for their work under
the various forms of the Social Security Act. They had a
very active and well organized lobby at Pierre through-
out the entire session, and seemed to have ample funds
to carry on their work. The osteopaths were represented
either by friends or relatives on the Public Health Com-
mittee in both the House and the Senate and were able
to place one of their members on our State Board of
Health.

If the medical profession is to receive the proper con-
sideration from the politicians we must take an active

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399

part in our respective parties, and educate the general
public on the superiority of medical care over the various
cults. The osteopaths are attempting to secure, by legis-
lation, the right to do medical work which is denied them
because of insufficient skill and education. They wish
to lower the standards of the care of the sick so that
they can be allowed to do government work.

It has been suggested by several of our past presidents
and I call it to your attention, again, that it is absolutely
necessary for several of the doctors in the State to stand
for election to the legislature in their respective parties.
This has always been important, but at the present time,
with all these new medical suggestions before our legis-
lature it is doubly important that we be represented in
both houses. By having competent medical men on the
Health Committee of both Houses is the only way we
can get proper consideration from the political parties
in power when these important health matters come up
for their consideration.

I also feel that some move should be made to include
all practitioners of medicine, in the State, in the society.
A committee was appointed last year to give this study
but were unable to work out any satisfactory plan. I am
requesting this committee to give the matter further
study so that they may have some law formulated to pre-
sent to our legislature in 1938. It has been suggested
that an annual registration fee of 05 should be paid to
the office of the secretary of the state medical society.
The payment of this fee would entitle the practitioner of
medicine to a certificate to practice for the ensuing year
and would pay his dues in the state medical society.
Whatever this society does to improve the practice of
medicine in the State is going, to benefit all so engaged
in the practice of medicine, and it is no more than fair
that all doctors should contribute to the expenses of the
society rather than the minority who are doing so now.
Within the last two years North Dakota has required
such a registration fee of 05 from all doctors engaged in
the active practice of medicine in the State.

There has been a great influx of all forms of cult prac-
titioners into South Dakota in the last few years, since
our neighboring States have passed basic science laws.
These irregular practitioners have gone into the smaller
communities, called themselves "doctors,” and most of
the people really think they are M. D.’s. To remedy
this, during the last session of the legislature a modified
basic science law was introduced into the Senate but
never got out of the committee. All agree that the time
has arrived when we must have a basic science law in
South Dakota; and to pass such a law we must start

our program this year and not wait until just before the
legislature convenes. With this in mind, I am asking
for a committee to be appointed within the next few
days to serve for two years or until after the next session
of the legislature. The committee is to have the law
written, then explain it to the medical profession so that
they in turn can start to educate the general public on
the fundamental values of such a law. I feel that it
can be passed if it is properly explained to the public
and we can get the whole hearted cooperation of the
entire medical profession.

There has been much discussion regarding the resettle-
ment relief. Your committee of the state medical soci-
ety asked for some form of relief such as we had in 1934
but the Resettlement officials in Lincoln, Nebraska, and
Washington, D. C., insisted that the medical care should
be handled by county cooperative associations such as
they have in the South. The present plan now in force
was not worked out by your committee, but we were
told that if we were to secure the relief necessary in
many parts of the State, we would have to use their
plan. Their attitude was, it was their money and they
were going to keep control of it. There is no question
that some form of relief is vitally necessary in many
parts of the State and for that reason I feel that we
should go along with their plan. The referendum vote
on the Resettlement relief carried by a good majority
and so we should give it our support as long as drought
conditions continue to exist, but as soon as conditions
return to normal we, of the medical society, should see
that it dies a natural death.

It is one of the ironies of fate that our profession,
which above all others has taught the world the value
of scientific research, should, at a time when the discov-
eries of medical science have so miraculously relieved
mankind of so many ills, be made the victim of er-
roneous conclusions drawn from research of another sort.
We have been put through the wringer of statistical
analysis and socialogical research, and have come out
drenched with printer’s ink, confused and harassed by
discordant voices contending in continuous debate over
socialized medicine. After such an experience, what we
of the medical profession need most is rest and a little
quiet thought. As your President for the coming year,
I realize that I have a great responsibility to fulfill and
I assure you that I will give you my best. It is your
society and I ask for your aid and cooperation that it
may become a better society and if we must have crit-
icism, let it be of the constructive type.

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THE JOURNAL-LANCET

ROSTER SOUTH DAKOTA MEDICAL ASSOCIATION-1937

Membership by Districts

PRESIDENT

King, Owen Aberdeen

SECRETARY

Alway, J. D. Aberdeen

Ahlfs, J. J. Conde

Alway, J. D. Aberdeen

Bates, W. A. Aberdeen

Brinkman, W. C. Veblin

Bruner, J. E. Aberdeen

Bunker, P. G. Aberdeen

Bloemendaal, G. J. Ipswich

Cook, J. F. D. Langford

PRESIDENT

Richards, G. H. Watertown

SECRETARY

Johnson, A. E. Watertown

Ash, J. C. Garden City

Adams, M. E. Clark

Bartron, H. J. Watertown

Bates, J. S. Clear Lake

PRESIDENT

Mokler, V. A. Wentworth

SECRETARY

Sherwood, C. E.. — Madison

Baughman, D. S. Madison

Davidson, Magni Brookings

PRESIDENT

*Murphy, Joseph Murdo

SECRETARY

Robbins, C. E Pierre

Burgess, R. E. White River

Collins, Howard Gettysburg

PRESIDENT

Griffith, W. H Huron

SECRETARY

Buchanan, R. A. Huron

Burman, G. E Carthage

ABERDEEN DISTRICT No. 1

Driessen, E. M. Britton

Eckrich, J. A. Aberdeen

Elward, L. R. Ashton

Farrell, W. D. Aberdeen

Gelber, M. R. Aberdeen

Graff, L. W. Britton

Hill, Robert Ipswich

Keller, Ted Chisholm, Minn.

Jones, T. D. Bowdle

Lien, H. D. Mobridge

Keegan, Agnes Aberdeen

Kraushaar, F. J. O Aberdeen

King, H. I. Aberdeen

King, Owen Aberdeen

WATERTOWN DISTRICT No 2

Brown, R. H. Watertown

Christensen, A. H. Clark

Freeburg, H. M. Watertown

Hammond, M. J Watertown

Hershkowitz, S. T. Clear Lake

Johnson, A. E. Watertown

Jorgenson, M. C. ... Watertown

Kenney, H. T. Watertown

Kilgard, R. M. Watertown

Koren, F. Watertown

MADISON DISTRICT No. 3

Engelson, C. J. Brookings

Gulbrandsen, G. H. Brookings

Jordan, L. E. Chester

Miller, H. A. Brookings

Mokler, V. A. Wentworth

Sherwood, C. E Madison

PIERRE DISTRICT No. 4

Hart, B. M. Onida

Jenkins, P. B. Pierre

Jordan, A. A. Highmore

Kimble, O. A Murdo

Morrissey, M. M Pierre

Martin, H. B. Harrold

McLaurin, A. A. Pierre

HURON DISTRICT No. 5

Dyar, Robert Baltimore

Griffith, W. H. Huron

Grosvenor, L. N. Huron

Hagin, J. C. Miller

Saxton, W. H. Huron

Shirley, J. C. Huron

Sewell, H. D Huron

McCarthy, P. V. Aberdeen

Murdy, R. B. C. Aberdeen

Murphy, T. W. Bristol

Olson, C. O. Groton

(1221 Browning Blvd.,

Los Angeles, Cal.)
Pittenger, E. A. ... . Aberdeen

Potter, G. W. Redfield

Ranney, T. P. Aberdeen

Rice, D. B Britton

Stephens, E. E. Eureka

Spiry, A. W. Pierre

Twining, G. H. Mobridge

Whiteside, J. D. Aberdeen

Lockwood, J. H Henry

Magee, W. G. . Watertown

McIntyre, P. S. Bradley

Schmidt, Hilmer . Estelline

Sherwood, H. W. ... Doland

Richards, G. H. Watertown

Vaughn, J. B .. Castlewood

Watson, E. S. Estelline

Wilkinson, E. A Hayti

Randall, O. S. ....Watertown

Tillisch, Henrik Brookings

Torwick, E. T. Volga

Tank, Myron C. Brookings

Westaby, J. R. Madison

Westaby, R. S. Madison

Whitson, Geo. E. . Madison

Northrup, F. A. Pierre

Ramsey, Guy Philip

Riggs, T. F Pierre

Robbins, C. E. Pierre

Salladay, I. R. Pierre

Van Heuvelen, G. J. ... Pierre
Zeiss, Fred Chicago, 111.

Saylor, H. L Huron

Tschetter, J. S. Huron

Lenz, B. T. Huron

Rice, Wayland R. Wessington

Wright, O. R Huron

Pangburn, M. W. ..Miller

Foxton, J. L. (Honorary) Iroquois

THE JOURNAL-LANCET

PRESIDENT

Weber, R. A. Mitchell

SECRETARY

Boyd, Frank „ Mitchell

Ball, W. R. .. Mitchell

Boyd, Frank Mitchell

Bobb, B. A. Mitchell

Bobb, C. S. Mitchell

Beukelman, W. H Stickney

MITCHELL DISTRICT No. 6

Cochran, F. B. Plankinton

Dick, L. C. Spencer

Gillis, F. D..__. ... Mitchell

Hoyne, A. H. _i Salem

Jones, E. W. Mitchell

Kelly, R. A. Mitchell

Lloyd, J. H. Mitchell

Mabee, D. R. Mitchell

Mabee, O. J. Mitchell

401

Maytum, W. J. Alexandria

Malloy, J. F

Thief River Falls, Minn.

Privet, L. B McCall, Idaho

Rieb, Wm. G. Parkston

Tobin, F. J. Mitchell

Waldner, J. L. Parkston

Weber, R. A. Mitchell

Volmer, F. J. Howard

PRESIDENT

De Vail, Frederick C. ... Garretson
SECRETARY

Hummer, Harry R. .. . Sioux Falls

Billingsley, P. R. Sioux Falls

Billion, Thomas J. Sioux Falls

Dehli, H. M. Colton

De Vail, Frederick C. Garretson
Ericksen, Emil G. Sioux Falls

Gage, E. E. _. Sioux Falls

Gregg, John B. Sioux Falls

Groebner, Otto A. Sioux Falls

SIOUX FALLS DISTRICT No. 7

Hannon, Leo J. Brea, Calif.

Hanson, Otto L. Valley Springs
Hummer, Harry R. Sioux Falls

Hyden, Anton Sioux Falls

Keller, S. A. Sioux Falls

Kittelson, John A. . Sioux Falls
Lamb-Barger, Hazel Sioux Falls

Lewison, Eli Canton

McDonald, C. J. ... Sioux Falls
Moe, Anton J. Sioux Falls

Mueller, Julius D. Flandreau

Mullen,. R W. Sioux Falls

Nessa, Nelius Julian Sioux Falls

Nilsson, F. C. Sioux Falls

Opheim, Odd V. Sioux Falls

Pankow, Louis J. Sioux Falls

Reagan, Rezin Sioux Falls

Rider, A. S. Flandreau

Sackett, R. F Parker

Stenberg, Edwin S. Sioux Falls

Stevens, George A. Sioux Falls

Stevens, Roy G. Sioux Falls

Van Demark, Guy E. Sioux Falls
Zimmerman, Goldie E. Sioux Falls

HONORARY MEMBERS

Craig, D. W. Sioux Falls

Perkins, E. L. Sioux Falls

Posthuma, Anne Sioux Falls

Roberts, William P Sioux Falls

YANKTON DISTRICT No. 8

PRESIDENT

Hansen, H. F. Vermillion

SECRETARY

Hohf, J. A. Yankton

Abts, F. J. Yankton

Beall, L. F. Irene

Benesh, L. C. Freeman

Blezek, F. M. Tabor

Bury, C. L. Geddes

Bushnell, J. W. Elk Point

Bushnell, Wm. F. Elk Point

Fairbanks, Warren H. Vermillion

Freshour, Ina Moore Yankton

Greenfield, J. C. -Avon

Hansen, H. F. Vermillion

Haas, F. W. .. Yankton

Hill, John F. Yankton

Hohf, J. A ,. Yankton

Hohf, S. M. Yankton

Johnson, Geo. E. Yankton

Joyce, E. ..Hurley

Kalayjian, D. S. Parker

Kauffman, E. J. Marion

Keeling, C. M. Springfield

Landmann, G. A. Scotland

Leonard, B. B. Yankton

Meyer, W. L Centerville

Moore-Freshour, Ina L Yankton

Neisius, F. A Platte

Morehouse, E. M. Yankton

Reding, A. P. Marion

Murphy, Jennie C. Yankton

Stansbury, E. M. Vermillion

Smith, A. J. Yankton

Trierweiler, J. E. Yankton

Willhite, F. V. ._. Redfield

Wynegar, David E Yankton

BLACK HILLS DISTRICT No. 9

PRESIDENT

Ewald, P. P. Lead

SECRETARY

Jernstrom, R. E Rapid City

Bilger, F. W. Hot Springs

Bailey, J. D Rapid City

Butler, John M Hot Springs

Chassell, J. L. Belle Fourche

Clark, O. H Newell

Clark, B. S Lead

Crane, H. L Oroya, Peru, S. A.

Davis, J. H. Belle Fourche

Durkee, H. C Faith

Dawley, W. A. - Rapid City

Davidson, H. E Lead

Ewald, P. P Lead

Fleeger, R. B Lead

Hare, Carlyle Spearfish

Hargens, C. W. Hot Springs

H owe, F. S. Deadwood

Heinemann, A. A. , Wasta

Hummer, F. L. Lead

Hultz, E. B. ..Hill City

Ince, H. J. T. Rapid City

Jackson, R. J. ..Rapid City

Jackson, A. S. Lead

Jernstrom, R. E..__ Rapid City

Kegaries, D. L Rapid City

Lemley, Ray E. Rapid City

Mattox, N. E. Lead

Minty, F. W. Rapid City

Manning, F. E. Custet

Minty, E. W. Rapid City

Mills, G. W Wall

Morse, W. E. Rapid City

Morsman, C. F. Hot Springs

Newby, FI. D Rapid City

O’Toole, T. F. __ New Underwood

Owen, N. T. Rapid City

Pemberton, M. O. Deadwood

Richardson, W. E. Philip

Radusch, Frieda J Rapid City

Sherwood, J. V. Sanator

Sherrill, S. F. Belle Fourche

Soe, Carl A. Lead

Smiley, J. C. — Deadwood

Spain, M. L. Hot Springs

Stewart, N. W. Lead

Stewart, J. L Nemo

Threadgold, J. O. Belle Fourche

Triolo, Anthony Buffalo

Walters, C. A. Belle Fourche

Zarbaugh, G. F Deadwood

402

PRESIDENT

Carmack, A. O.

. . Colome

THE JOURNAL-LANCET

ROSEBUD DISTRICT No. 10

Carmack, A. O. Colome

**Jones, A. L. Gregory

Quinn, R. J.
Wilson, F. D. ......

Burke

Winner

SECRETARY

Overton, R. V.

Winner

Kenaston, H. R.
Overton, R. V.

Bonesteel

Winner

Walters, S. J.

Malster, R. H. ....

Winner

Carter

PRESIDENT

KINGSBURY
Bostrom, A. E.

DISTRICT No. 11
Portland, Ore.

Peeke, A. P.

Volga

Bostrom, A.

b. Portland, Ore.

Dyar, B. A.

...Pierre

Rozendal, P.

Lake Preston

SECRETARY

Grove, E. H

Arlington

Scanlon, D.

Volga

Peeke, A. P.

Volga

Hopkins, N. K

Arlington

WHETSTONE VALLEY

DISTRICT No.

PRESIDENT

Brown, A. E.

Webster

Jacotel, J. A.

Milbank

*Pearson, A. W

Sisseton

Cliff, F. N. ..

Milbank

Karlins, W. H.

Webster

Duncan, Wm.

... . Webster

Pfister, F. F.

Webster

SECRETARY

Gregory, D. A

* Not member — failed to pay

Milbank
1937 dues.

Flett, Chas

Gregory, D. A.
Hawkins, A. P.

** Died, August, 193 7.

Milbank

Waubav

Porter, Oliver M. ....
Peabody, Percy D.

Sisseton

Webster

Roster South Dakota State Medical Associatiori"1937

Abts, F. J.

Yankton

Gillis F D

Adams, M. E.

Clark

Chassell, J. L.

Belle Fourche

Graff, L. W

Britton

Ahlfs, J. J.

— Conde

Alway, J. D.

Aberdeen

Clark, B. S. .....

Spokane, Wy.

Gregg, J. B.

Sioux Falls

Ash, J. C. ...

Garden City

Clark, O H

Ball, W. R.

Mitchell

Cliff, F N

Griffith W H

Bailey, J. D. .

Rapid City

Cochran, F B.

Plankinton

Groebner, O. A. ..

Sioux Falls

Bartron, H. J.

... Watertown

Collins, Howard

Gettysburg

Grosvenor, L. N.

Huron

Bates, J. S. ._

...Clear Lake

Cook, J. F. D. .

Langford

Grove, E. H.

Arlington

Bates, W. A. .

Aberdeen

Crane, H. L L'Orya, Peru, S. A.

Gulbrandsen, C. M.

Brookings

Baughman, D. S.

Madison

Creamer, Frank

Dupree

Haas, F. W.

Y ankton

Beall, L. F.

. .... Miller

Benesh, L. C. .

Freeman

Davidson, Magni

Brookings

Hammond, M. J.

Watertown

Billingsley, P. R.

Sioux Falls

Davis, J. H.

Belle Fourche

Hannon, L. J.

Brea, Calif.

Billion, T. J.

Sioux Falls

Dawley, W. A.

Rapid City

Hansen, H. F.

Vermillian

Blezek, F. M.

.. Tabor

Dehli, H. M.

Colton

Hare, Carlyle

Spearfish

Bloemendaal, G. J.

Ipswich

Delaney, W. A.

Mitchell

' Hargens, C. W.

Hot Springs

Bobb, B. A. .

Mitchell

De Vail, F. C.

Hart, B. M.

Onida

Bobb, C. S. ...

Waubay

Boyd, Frank ._

Mitchell

Duncan, William

Webster

Heinemann, A. A.

Wasta

Bostrom, A. E. Portland, Oregon

Durkee, H. C.

Faith

Hershkowitz, S. T.

Clear Lake

Brinkman, W. C.

Ipswich

Brown, A. E. ....

Webster

Dyar, Robert

Baltimore

Hohf, J. A.

Y ankton

Brown, R. H.

. _ Watertown

Hohf, S. M.

Y ankton

Bruner, J. E.

Arlington

Buchanan, R. A.

Huron

Engelson, C. J.

Brookings

Howe, F. S.

Deadwood

Buekelman, W. H.

Stickney

Ewald, Paul P. ....

Lead

Hoyne, A. H. ...

Salem

Bunker, P. G.

Aberdeen

Fairbanks, Warren

H. Vermillion

Hummer, F. L.

Lead

Burgess, R. E.

White River

Farrell, W. D

Aberdeen

Hummer, H. R.

Sioux Falls

Burman, G. E.

Hultz, Eugene B.

Hill City

Bury, Chas. L.

Hyden, Anton

Sioux Falls

Bushnell, J. W.

Ince, H. J. T.

Rapid City

Bushnell, W. F.

Elk Point

Gage, E. E.

.... Sioux Falls

Jackson, R. J.

Rapid City

Butler, J. M. ...

Hot Springs

Gelber, R. M.

Aberdeen

Jackson, A. S.

Lead

Jacotel, J. A. Milbank

Jenkins, P. B. Pierre

Jernstrom, R. E. Rapid City

Johnson, A. E. Watertown

Johnson, G. E. Yankton

**Jones, A. L. Gregory

Jones, T. D. Bowdle

Jones, E. W. Mitchell

Jordan, L. E. Chester

Jordan, A. A. Highmore

Jorgenson, M. C. Watertown

Joyce, E. — Hurley

Kalayjian, D. S. Parker

Karlins, W. H. Webster

Kauffman, E. J. Marion

Keegan, Agnes Aberdeen

Keeling, C. M. Springfield

Kegaries, D. L. Rapid City

Keller, S. A. Sioux Falls

Keller, Ted Chisholm, Minn.

Kelly, R. A Mitchell

Kenaston, H. R Bonesteel

Kenney, H. T. Watertown

Kilgard, R. M. Watertown

Kimble, O. A. Murdo

King, Owen Aberdeen

King, H. I Aberdeen

Kittelson, John A. Sioux Falls

Koren, F. — Watertown

Kraushaar, F. J. O. Aberdeen

Lamb-Barger, Hazel Sioux Falls

Landmann, G. A. Scotland

Lemley, R. E Rapid City

Lenz, Bernard T. Huron

Leonard, B. B. Yankton

Lewison, Eli Canton

Lien, H. D. Mobridge

Lloyd, J. H. Mitchell

Lockwood, J. H. Henry

Mabee, D. R. Mitchell

Mabee, O. J Mitchell

Magee, W. G Watertown

Malster, R. M. Carter

Malloy, J. F

Thief River Falls, Minn.

Martin, H. B Harrold

Manning, F. E. Custer

Mattox, N. E. Lead

Maytum, W. J. Alexandria

McCarthy, P. V. Aberdeen

McDonald, C. J. Sioux Falls

McIntyre, P. S. Bradley

McLaurin, A. A. Pierre

Meyer, W. L Centerville

** Died, August, 1937.

THE JOURNAL-LANCET

403

Miller, H. A.

Brookings

Sackett, R. F.

Parker

Mills, G. W.

Wall

Salladay, I. R.

Pierre

Moe, A. J.

Sioux Falls

Saylor, H. L.

Huron

Mokler, V. A.

_ Wentworth

Saxton, W. H.

Huron

Moore. F. A.

Vankton

Scanlon, D. L.

Volga

Moore-Freshour, Ina L. Yankton

Schmidt, Hilmer

-Estelline

Sewell, H. D :

Huron

Morrissey, M. M.

Pierre

Sherrill, S. F

Belle Fourche

Mueller, Julius D.

Flandreau

Sherwood, C. E.

Madison

Mullen, R. W.

Sioux Falls

Sherwood, H. W.

Doland

Murdy, R. B. C.

Aberdeen

Sherwood, J. V.

Shirley, J. C.

Smiley, J. C.

Deadwood

Minty, F. W.

Rapid City

Smith, A. J. .

Yankton

Minty, E W

Soe, Carl F.

Morsman, C. F.

Hot Springs

Spain, M. L.

Hot Springs

Neisius, F. A

Platte

Stansbury, E. M.

Vermillion

Nessa, N. J.

Sioux Falls

Stenberg, E. S.

Sioux Falls

Stephens, E. E.

Nilsson, F. C. ... ...

Sioux Falls

Stevens, George A.

Sioux Falls

Northrup, F. A.

Pierre

Stevens, Roy G.

Sioux Falls

Olson, C. O.

Groton

Stewart, N. W.

I ead

(1221 Browning Blvd.,

Stewart, J. L.

Nemo

Los Angeles, Cal.)

Spiry, A. W

Mobridge

Opheim, Odd V. ...

.... Sioux Falls

Tank, Myron C.

Brookings

Overton, R. V.

Winner

Tarbell, H. A.

Watertown

Owen, N. T.

Rapid City

Threadgold, J. O.

Belle Fourche

O'Toole, T. F. New Underwood

Tillisch, Henrik .

Brookings

Miller

Tobin, F. J.

Mitchell

Pankow, L. J.

Sioux Falls

Torwick, E. T

Volga

Peabody, Percy D.

— Webster

Trierweiler, J. E.

Yankton

Peeke, A. P.

Volga

Triolo, Anthony

Buffalo

Pfister, F. F.

Webster

Tschetter, J. S. ...

Huron

Twining. G. FI.

Mobridee

Porter, Oliver M.

... _ Sisseton

Van Demark, Guy E. Sioux Falls

Potter, George -

Redfield

Van Heuvelen, G.

J. Elk Point

Privet, L. B.

McCall, Idaho

Vaughn, J. B.

Castlewood

Vollmer, F. J.

Howard

Radusch, Frieda J.

Rapid City

Waldner, J. L.

Parkston

Ramsey, Guy

Philip

Walters, C. A.

_ Belle Fourche

Winner

Ranney, T. P.

Estelline

Weber, R. A.

Mitchell

Reding, A. P.

Madison

Rice, Wayland R.

Wessington

Whiteside, J. D. ..

Aberdeen

Richards, George H

Watertown

Whitson, G. E. — .

Madison

Richardson, Walter

E. Philip

... Redfield

Rider, A. S.

Flandreau

Wilson, F. D.

Winner

Rieb, Wm. G.

Parkston

Wright, O. R.

Huron

Riggs, T. F. j

Pierre

Wynegar, David E.

Yankton

.. Deadwood

Rozendal, P. H .

. Lake Preston

Zeiss, Fred

.... Chicago, 111.

Rudolph, E. A.

Aberdeen

Zimmerman, Goldie E. Sioux Falls

404

THE JOURNAL-LANCET

Methods and Motives in Medicine *

W. G. Richards, M.D., F.A.C.P.

Billings, Montana

WHEN a physician essays to diagnose a pa-
tient’s disease and to treat it, he first sets out
to acquire certain sensory stimuli coming from
the patient’s body. Some of these he receives simply by
listening to the patient’s complaints; others by his own
physical activities, as by the time-honored sequence of
inspection, palpation, percussion, and ausculation; others
through the medium of more or less complicated de-
vices designed to increase the range of receptivity of
his own sensory organs. The microscope and X-ray
machine are examples. All these are transmitted to his
central nervous system, where they are co-ordinated and
correlated, and their relationship determined with mem-
ories of past experiences, while at the same time they un-
avoidably receive an emotional affect. The result of all
this is that response on his part which we call his diag-
nosis, and his recommendations for treatment, are his
further response to the mental state induced within him
by that diagnosis.

The accuracy and effectiveness of these will depend
upon the correctness of each step in the process. The
whole result may be invalidated by an initial false sen-
sory impression or by an omission of some vital fact.
Such errors we cannot, unfortunately, always avoid.
That is not possible in this imperfect scheme of things.
But we can avoid some of them. Points are often missed
by haste. Adequate time needs to be given each patient,
for medicine can never be made into a wholesale busi-
ness. Fatigue, also, will make one careless and over-
look some slight but important sign. No less than in
industry, a doctor’s working hours need reasonable
limitation, and the ambitious individual who tries to
give the impression of great popularity and success, with
many demands and a crowded waiting room, is likely to
be more of a menace than a benefit to his patients.

In recent years, there has been a great multiplication
of mechanical devices and chemical tests. Theoreti-
cally, this is all to the good, but inaccurate technique or
false deductions from them can vitiate their usefulness.
Even such a simple device as the stethoscope can do
harm by its revelation of a murmur, upon which an un-
due emphasis is laid rather than upon a broad analysis
of all the factors indicating the condition of the heart
and the manner in which it is doing its work.

The X-rays are so valuable as an aid to diagnosis
that it would be impossible to over-rate them, but the
machines require a meticulous technique in their opera-
tion, and much skill and knowledge are needed in the
interpretation of their showings. Good salesmanship
on the part of manufacturers has scattered X-ray out-
fits widely, both among regular and irregular practi-
tioners, and consequently entirely unjustifiable diag-

*Read at the Midland Empire Medical Conference, Billings,
Mont., May 3, 1937.

noses are often made from them, while films are not in-
frequently seen so poorly made that no conclusions are
justified from them at all. Those of us interested in
chest work will remember how much confusion existed in
their early use for this purpose from a sheer inability to
distinguish between the normal and the abnormal. Un-
conscious mental factors enter here too. Like all
specialists the X-ray man has to guard against the ten-
dency to over-value his particular contribution. I remem-
ber a caustic but suggestive comment I once heard at a
famous tuberculosis sanitarium, where, exhibiting a cer-
tain film, the lecturer remarked that "even an X-ray man
could not find evidence of tuberculosis on that.” This, i
however, was some time ago, and since then, he, too,
has become more critical. On the other hand, the
clinician may fall into the opposite error and pay too
little attention to the suggestions of his confrere. Again, r
in a difficult case too much is sometimes asked of the j
roentgenologist. In army parlance one tries to pass the
buck to him, disregarding the obvious fact that the
X-rays will not tell the whole story. I recall a woman’s
life which was endangered by the waiting for an X-ray
diagnosis in a case of intestinal obstruction, an error in
which I am sorry to say I participated, and for which
I accept my full share of responsibility, though the les-
son was a salutary one.

The advent of the technician has brought a fresh
crop of possibilities for error. Basal metabolism deter-
minations are a good example. There is a deceptive sim-
plicity about the machines now in use which make it
appear that almost anyone can run one, and all the
physician has to do is to accept the final figures given
him. But the simplicity is only apparent. Besides the 1
multitude of small attentions which must be given to the
machine itself for its proper operation, great care is
needed to secure 'the proper conditions in the patient
himself. The significance of the term "basal” is not
always remembered. With nervous or stupid people it
is sometimes impossible to secure these conditions, a fail-
ure which the mere figures returned by the technician
will not show, for only by careful observation of the
patient himself can one appreciate his mental condition.
Often, indeed, he appears outwardly calm while inward-
ly a mental hurricane is passing over him.

The electrocardiograph is a very useful instrument,
but it requires most critical interpretation as to both
diagnosis and prognosis. With its more general use,

Sir Thomas Lewis’ warning as to the danger of drawing
too fine conclusions will need repeated emphasis.

Laboratory reports need a considerable infusion of the
Missouri spirit. A recent instance of a suggested diag-
nosis of renal glycosuria when the low blood sugar fig-
ures were really due to inaccurate reagents is a case in

THE JOURNAL-LANCET

405

point. The skeptical attitude which saved the physician
concerned, whatever it may be in religion, is a com-
mendable virtue in medicine.

In this connection Thomas Addis’ remarks in his ad-
mirable work on Bright’s disease might well be taken
to heart in all fields of medicine. "At the present time,”
he says, "routine work means work done by someone
else than the clinician, someone who has no knowledge
of the patient or of the purposes for which the work is
done. The necessary degree of accuracy in the timing
of urine and blood collections and the constant watchful
care in the manipulations of the chemical work can come
only from someone who has an immediate personal in
terest in the results. . . Without such special experience
and without a personal interest in the patient it is
scarcely to be expected that reliable results will be ob-
tained. . . There is more in these examinations than can
be expressed in figures. It is the picture as a whole
which is suggestive, not the separate items, but the sug-
gestion comes only to the man who knows the patient.”1

The guarding against these inaccuracies in the sen-
sory impressions received is, of course, a function of the
mind, but above and beyond this the workings of the
mind in the use it makes of these impressions need
critical watching.

Of course, both diagnosis and treatment are limited
by the mental content of the person responsible for
them. One cannot diagnose a disease of which one is
ignorant, or utilize a method of treatment one knows
nothing about. What we call a disease is simply a men-
tal concept. We find patients presenting a certain ag-
gregation of signs and symptoms, and we call that by a
certain name, as, for instance, typhoid fever, with the
result that when we again hear this word we recall a
mental image of a patient with these characteristics.
Later, some one notices that all the individuals of this
group are not exactly alike. The symptoms they pre-
sent tend rather to group into two or more sub-groups.
So we revise our original concept and now have two or
more diseases instead of the original one. Typhoid
fever, you will remember, was originally confused with
typhus.

This multiplication of concepts makes progress in
medicine, but the price of it is continued vigilance and
constant study. Unfortunately, the need of making a
living, or, as John Hunter once said, the necessity of
"chasing the damn guinea,” takes up so much time that
often, if one is fortunate enough to build up a practice,
little remains for study. Sooner or later, if one is not
careful, one’s mental content will congeal as of a cer-
tain time, and one will get farther and farther from
contemporary medicine. As recently said, "It is almost
possible to date a man by his methods. There will be
the vaccine fan turned out in the opsonin days, the sur-
geon of a little later date who fixes the abdominal vis-
cera, the man who circumcises all the babies, or blocks
i p sinuses with gauze, or the one who has one or another
special drug for pneumonia.”2 Nor will the occasional
attendance at medical meetings and clinics, nor even a

jaunt to Europe in pleasant society with much sightsee-
ing and a little sitting at the feet of famous teachers,
entirely help, valuable though these may be. Constant
study and reflection are the only means, for, after all,
no one can really be taught anything. One must learn,
and that implies the primeval curse, work, and work by
the sweat of one’s brow. Then, too, one may become
too much preoccupied with other matters. A certain
diffusion of interest is good, for it broadens the mind,
and the doctor who has no intellectual interests other
than medicine can hardly claim to be more than a mere
craftsman. But medicine is a jealous god, and brooks
not the worship of other gods.

A fruitful source of error is a failure properly to
evaluate psychological factors. Unfortunately, a merely
materialistic or physical conception of disease is too
widely held, though this is often to ignore completely
the significance of the patient’s complaints. What we
call symptoms or signs are physical reactions produced
by various stimuli. These reactions may occur in the
organ which received the stimulus, as vomiting from un-
pleasant food introduced into the stomach, or in some
part of the body distant from that receiving the stimu-
lus, as vomiting from a bad smell or an unpleasant sight,
where the stimulus is upon the endings of the olfactory
or ophthalmic nerve, and the response an indirect one
through the mediation of the central nervous system.
The central nervous system can cause reactions in distant
organs through the operation of many factors. Cannon
showed how, in a cat, the emotion produced by the
proximity of a dog inhibited the movements of the
stomach. Emotions are continually producing physical
reactions, though there is a great difference in the char-
acter of the responses in individuals. A mere unkind
remark will cause in one a violent fit of weeping, but, in
another, merely a smile or a shrug of the shoulders. The
difference comes frorri the state of the nervous system.
The emotional center in one is highly sensitive, and a
profound effect results, while in the other it is relatively
insensitive, and little effect is produced. Where the
emotional center is easily affected it: is constantly stimu-
lating and causing responses on the part of various or-
gans of the body, for our emotions are continually being
excited. Life at its best is not a smooth proposition. We
are continually having unpleasant experiences, and few
of us get what we would like. We are all more or less
frustrated. As Beatrice Harridan said, "We start in
life intending to build a grand cathedral, a crowning
glory to architecture, and we end by contriving a mud
hut.” With most people it is a struggle to get even the
necessities of life. In an ecstatic moment men and
women marry, only to discover later the personal incom-
patibilities which make living together one long drawn
out agony. Anxieties and fears haunt all of us, and
emotional crises sooner or later overtake every one. And
yet, as physicians, because these emotional experiences
produce physical reactions, we often attack the respond-
ing organ, and remove a gall bladder or a fanciful
chronic appendix, or give histidine injections for a gastric
ulcer which does not exist. Alvarez, you will remember,

406

THE JOURNAL-LANCET

estimates that half the people who consult a doctor for
digestive troubles are really suffering from so-called
functional conditions.

Notwithstanding this, it is rare in case reports to find
mention made of the psychological aspect of the patient.
No attention is generally paid to his emotional state,
nor the conditions of his environment as affecting this,
though these may be having a profound influence on the
production of his symptoms, and may also have a very
great bearing upon the causal relationship between the
measures employed for his treatment and his recovery or
otherwise. I know of nothing which will produce a more
wholesome skepticism as to the therapeutic effects of
drugs administered than to carry around a few tablets
of plain milk sugar. I have secured the most varied
and wonderful results from them. In evaluating the
immediate results even of surgery one should remember
the profound emotional effects of an operation and the
change in environmental conditions from an often un-
sympathetic family to the constant attentions of trained
nurses and the visitations of relatives and friends bring-
ing flowers and other evidences of solicitous interest.

But if the patient’s reactions must be scrutinized for
other causes than those which seem apparent, no less
must the physician’s conduct be subjected to similar
scrutiny. Bertrand Russell, under the title of "Phil-
osophy’s Ulterior Motives,” points out the influence of
unappreciated factors in the reasonings and conclusions
of philosophers, and no less than philosophers do physi-
cians have ulterior and unrecognized motives.

This may be denied, for we prefer the more flattering
belief that the single purpose in the mind of every
physician is to recognize and cure the disease from
which his patient is suffering. Secular writers, on the
other hand, have more than suspected the existence of
ulterior motives, and some, such as Moliere and Bernard
Shaw, have even held such pretensions up to ridicule.
These, for the most part, have been treated by the medi-
cal profession either with a lofty indifference or an air
of injured innocence, and the wholesome lessons which
might have been derived from them entirely lost. We
would rather remember such eulogies as that of Robert
Louis Stevenson, or such flattering characterizations as
that of Ian Maclaren, and, though we readily admit
questionable practices on the part of unorthodox prac-
titioners, we, too often, like the Pharisee of old, fold
cur virtuous cloaks around us, and with unctuous recti-
tude thank God that we are not like other men, or even
as this chiropractor.

That we may have misgivings in the matter is, how-
ever, sometimes evident, for I remember the applause
which greeted a clergyman at a medical society banquet,
when he said that "the medical and clerical professions
had many things in common, one of which was that
there was a good deal of humbug about both of them.”

Human behavior is a complex matter, and many fac-
tors enter into it, not all being within the individual’s
consciousness. The physician, being human, is similarly
influenced. He, too, has his inherited weaknesses and

acquired prejudices. He, too, suffers from the effects
of faulty training and the defects of the environment
in which he was brought up. He, too, is influenced by
the conventional standards of thought and conduct of
the society of which he is a part. And he, too, is all
the time being affected by his emotions. All these fac-
tors may and do enter into everything which he does, and
even into what appears such impersonal matters as diag-
nosis and treatment, for no more than philosophers or
even judges is he a purely logical machine.

In fact, none of us are pure reason nor pure will, for
unconscious motivation enters largely into all we do,
and what appear at first sight to be altruistic motives
will often on analysis prove to be purely selfish. Whether
we admit it or not, we are all at bottom largely hedonists,
and we camouflage this hedonism by ethical or religious
professions.

We are all affected by the money motive, for we live
in a social system which is based upon competitive prin-
ciples, and success in life is gauged by acquisitive results.
To live in pretentious houses, to own impressive motor
cars, to be social leaders ourselves or to have our wives
fulfill the same functions as our proxies, are ambitions
we all share to a greater or less extent.

To achieve these ambitions requires money, and con-
sciously or unconsciously one’s mind will be bent in the
direction from which the money may come. Some will
turn to surgery, as being the most profitable part of
medicine, but the same object may be achieved by elab-
orate and expensive methods of diagnosis and treatment.
Of course there are few so crude as to recommend these
when they know there is absolutely no need for them,
but I am speaking of unconscious motivation, which
plays a far greater part in our lives than most people
appreciate. The reasons we give, and give honestly, for
our conduct are not always, probably not even generally,
the real ones. They may be a factor, but are not all
the factors, for we utilize the process of rationalization,
by which we find reasons for doing those things which
we would like to do. Much, indeed, of what passes as
reasoning is pure rationalization, and if you will only
watch your own conduct in ordinary and unprofessional
matters you will soon see how often, when you are
arguing in favor of some course of action, you had pri-
marily determined that the action was desirable, and are
simply finding reasons for justifying your doing it. You
will see the same process at work in legal decisions,
where a judge in a lengthy opinion elaborates reasons
for some position he is taking, when it is very plain that
any other position would be distasteful to him, or run
contrary to all his previous training and habits of
thought. In our own profession it is noteworthy how
very soon methods which bring in the money become
popular, and are even justified with an elaborate litera-
ture, especially the literature so generously furnished by
the makers of drugs and instruments.

Understand I am not contending that we should have
no regard for financial rewards. We have to, for, under
a money economy, money is the only medium by which

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407

we can exchange our services for life’s necessities. But
we might as well admit it, and cut out the buncombe by
which we try to appear as a lot of altruistic gentlemen
practicing medicine for sheer love of humanity or as a
Christian virtue. Recognizing it, we will be far more
likely to be on our guard against this need of money’s in-
fluencing our judgment, if only by unconscious mental
processes. When the rent is coming due and the secre-
tary asking for back salary, when the wife and the girls
are clamoring for new clothes and the boys are reflecting
on the antiquity of the automobile, the while the bank
account is mildly positive or even negative, one would be
either more or less than human not to veer a little in
one’s judgment in a doubtful case towards a diagnosis
which would suggest an operation or some specially re-
munerative treatment.

I once heard a worldly-wise old cynic remark that no
doctor could run a private hospital and remain honest.
But the suggestion in this is not only applicable to doc-
tors. It is equally true of all hospitals which depend
upon patients’ fees, and simply means that unconscious
mental processes may influence anyone upon whose
shoulders lies the responsibility of finding the where-
withal to keep a hospital running. I think the custom
of charging a patient for routine laboratory work is an
illustration. The need for laboratory tests should be
determined by the responsible physician in each individ-
ual case, for, if there is no probability of their furnishing
useful information, to charge a patient for them is, to
say the least, unfair. Similarly with pathological reports.
Recently, I was interviewed by an irate parent, indig-
nant at a charge for such an examination of a removed
appendix. He could not see, nor could I either, how,
after the appendix had been removed, it could do either
him or his daughter the slightest good to have it sub-
jected to an elaborate and expensive examination. One
might protest, too, against the attempt to exalt the lab-
oratory into an infallible court of appeal. Pathologists,
even the best, not seldom differ, and frequently make
mistakes, and very often a gross examination is all that
is needed. But again we have the rationalization of the
patient’s interests.

One can see in oneself this subtle influence of financial
interest in law suits. When appearing as a medical wit-
ness one unconsciously veers toward the side on which
one is, and which presumably is to pay one. Also, when
examining a claimant for an insurance company one un-
consciously assumes the company’s cautious and sus-
picious attitude.

But besides the money motive there is the love of
power. We all want to be exalted above our fellows
and to reign superior. This is what engenders profes-
sional jealousy, and is very evident in those commercial
clinics in which one man reigns supreme. It is rational-
ized here by the plea that group practice or team work
makes for the best interests of the patient. There is, of
course, some truth in this. There is in all rationaliza-
tions. When a patient can conveniently secure the ser-
vices of men specially competent in the various branches

of medicine he is most likely to get the best advice, and
the ultimate organization of medicine will probably be
along these lines. The advantages are evident in the
nonprofit clinics connected with all medical schools. But
the grouping must be on a purely cooperative basis,
free from all megalomaniac tendencies, representing
real specialized information, n6t capitalizing religious
affiliations, and always conducted so as to give a square
deal to fellow practitioners outside it. Such associations
could be of immense service to medicine. It is, however,
a little hard to see these conditions in some of the com-
mercial associations, and too often, the megalomania or
the money motive shines clearly through all the cam-
ouflage.

This power motive, however, is not confined to our
own profession. It can be seen not seldom in the clergy,
where one man, though preaching humility as a Christ-
ian grace, is always finding opportunities to get into the
public limelight. Thackeray has given us one such
character in the Reverend Charles Honeyman. It is
very evident in many politicians, who, while plainly
grasping for place and power, talk eloquently of the
dear people and their rights.

Another unconscious motivation is sadism. This, as
you know, is the love of inflicting pain. We are all
guilty of it more or less. As children we pull the legs off
insects, or tie cans to dogs’ tails. As parents we spank
the children. Dickens’ Mr. Squeers illustrates it in the
schoolmaster, and where I went to school the type was
quite common. One I had was a particularly good
specimen, as many sore posteriors could testify. It has
played a large part in religious persecutions, where it
was rationalized by the plea that it was a virtuous action
to destroy or torture the body if thereby the soul might
be saved. Like all other bad tendencies, it may be turned
to good account and is then said to be sublimated. Sur-
gery is said to be one of its sublimations, but sometimes
the sublimation seems rather thin. I remember a sur-
geon in whom for long I suspected it, but felt absolutely
certain when I learned the manner in which he punished
his children. You can see the same thing in the legal
profession, in the pleasure of some prosecuting attorneys
in securing convictions, and in the excessive sentences of
some judges. In war time, all the mask is thrown off
and ruthlessness prevails, often rationalized, of course,
by "military necessity.” Sherman’s march through
Georgia is a typical illustration, as well-shown recently
in Gone With the Wind, and the World War fur-
nished many examples.

When one has made a diagnosis, like a literary pro-
duction, it becomes the child of one’s brain, to be de-
fended against all who would take it from one. When
it is based upon deductions from facts about which
there is no dispute one resorts to arguments and rational-
izations to support it, and it requires a very great pre-
ponderance of evidence to overcome the opinion formed.
When, however, the diagnosis depends upon sensory im-
pressions, as, for instance, the presence or character of
heart murmers, no amount of argument is likely to con-

408

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vince, for sensory impressions cannot be shared or com-
pared. What one hears as a heart murmur, another
either does not hear at all or interprets differently. The
differences of opinion are particularly evident when it
comes to timing the murmur. Lewis says, "Most people
cannot, and never will, time murmurs reliably.” It is of
no use to argue on such a matter. The same rule ap-
plies as in matters of taste. De gustibus non est dis-
putandum.

Unconscious and emotional factors are very likely to
creep into consultations. The mere fact of being called
in to advise implies either that the attending physician
is in doubt or that the patient or his relatives are not
exactly satisfied, and that the man called in is suspected
of being able to supply what is lacking. This in a
measure implies superiority, and carries with it a tempta-
tion unconsciously to assume a superior attitude, to sup-
port which one may take a different view of the case or
unnecessarily modify the treatment. Did you ever
notice, too, how you are liable to disagree with the man
you dislike or the one you consider your most formid-
able competitor?

However, the fault is not always on the side of the
consultant. Sometimes the attending physician has an
inflated ego, or it may be an overcompensated inferiority
complex, and shows his resentment at what he considers
a reflection upon his ability. This makes a most em-
barrassing situation. Consultations, indeed, are not al-
ways conductive to the patient’s interests. Differences
of opinion may lead to a paralysis of action, and while
the doctors are arguing the patient dies.

The position of a doctor in relation to his patient, and
the attribution to him of almost miraculous powers as to
life and death, can very easily inflate his ego. Fortunate-
ly we have shed most of the pomposity of an earlier
generation. We no longer carry a gold-headed cane and
a bejewelled snuffbox, nor even garb ourselves in the
silk hat and frock coat of more recent times. But 1
think we still like to play the part of a god in the
machine. In fact, in some it is easy to see a very dis-
tinct indentification with God. This is why we so often
ignore the patient’s point of view entirely, expecting
him to submit quietly to the means we devise for his
benefit and resenting any objections on his part. I
sometimes wonder, though, if patients only realized the
changing fads and fancies in treatment whether they
would trust themselves to our hands at all. Previously,
we took the blood out of them, but now we put it in.
Once we deprived them of fluids, but now we drown them
in them. There are fads and fancies in electric modali-
ties and lights. We look with scorn on the promiscuous
drugging of our predecessors, and prescribe the pro-
prietary mixtures left with us by a horde of travelling

salesmen. At one time we starve our patients and at
another time we feed them. I remember the living
skeletons who were fortunate enough some years ago to
survive a siege of typhoid fever, and the cynicism of the
wit who remarked that it took six weeks to recover from
the disease and six months to recover from the treat-
ment. Each generation of doctors commences its prac-
tice with a positiveness as to the accuracy of the theories
it has been taught and the efficacy of its remedies, only
to find in a few years most of them demonstrated to be
wrong or useless. When a patient rebels we write him
down as uncooperative, as was done of one recently who,
hot and copiously sweating from a fever, objected to the
mountain of bedclothes piled upon him for fear that he
might "catch cold.”

Neither are hospitals entirely guiltless. Founded pri-
marily for the sick poor who could be thankful even
for a roof over their heads, to say nothing of the pittance
of food with which they were supplied and the scant
care given them, the tradition of charity still lingers,
and even when a patient is paying a good price for his
accommodation the attitude towards him seems often that
he should take what he gets and be grateful. Compare
the alacrity with which a bellboy answers a call in a
hotel with the difficulty of getting a floor nurse to ans-
wer the number board. I sometimes think that a hard
boiled profane efficiency expert let loose in hospitals,
both religious and otherwise, might do a world of good.
There are ulterior motivations behind them too.

For the same reason, the various inquiries into the
methods of medical practice now going on cannot but
have beneficial results, even though their specific recom-
mendations may not be adopted. Outsiders often see
things to which long use has so accustomed the insider
that he fails to notice their defects, and there are evils
of which the influence of vested interests prevents re-
form. Certainly the profession cannot afford to ignore
these inquiries, or to dismiss them as the impertinent
efforts of officious trouble makers. Our ultimate in-
terests will be best served by a sympathetic cooperation,
for if, as the parson said, like the clerical profession
there is a good deal of humbug about our own, to recog-
nize and admit this humbug, or even to appreciate the
possibilities of it, is the first step towards its prophylaxis.
Indeed, in all our goings in and comings out we would
do well constantly to bear in mind the wise saying of
Jeremiah that "the heart is deceitful above all things;
who can know it?” And no one is it more liable to de-
ceive than its possessor.

References

1. Addis, T. and Oliver, J.: The Renal Lesion in Bright’s Dis-

ease, pp. 36, 37, 1931, Paul B. Hoeber, Inc., N. Y.

2. Grains and Scruples, Lancet, London, 1:56 (Jan. 1) 1937.

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409

History of Medical Education in Minnesota

Franklin R. Wright, M.D.t
Minneapolis, Minnesota

IN TERRITORIAL DAYS, about 1856, when the
University was organized, provision was made in
its charter for a Medical School. This school did
not come into existence until 1888 when under the direc-
tion of Dr. Perry H. Millard of St. Paul, the St. Paul
Medical School and the Minnesota Hospital College in
Minneapolis gave up their charters and joined to form
the University Medical School. The history of these
early schools is interesting.

The St. Paul Medical School was organized in 1871.
It occupied a building in the neighborhood of Seven
Corners. This building was two stories high, had a broad
awning in front, and on the side of the awning was
labeled saloon. On the side of the building a second
floor sign read St. Paul Medical College. A picture of
this building was published recently in the magazine
section of The Minneapolis Journal.'

Some of the men who brought about this organization
and inspired the teaching were Dr. Charles Wheaton;
Dr. Alex Stone; Dr. John F. Fulton; Dr. C. E. Riggs;
Dr. James Quinn and Dr. Talbot Jones.

In 1881 under the guidance of Dr. Frederick A.
Dunsmoor the Minnesota College Hospital was organ-
ized in Minneapolis. The Board of Trustees, five in
number, consisted of Mr. Thomas Lowry, president;
Dr. F. A. Dunsmoor, vice-president, and dean of the
School; Dr. George F. French, secretary; Dr. Amos W.
Abbott, treasurer, and Mr. Charles Vanderburg, who
later was justice on the State Supreme Bench. It is in-
teresting to know the amount of money in those days
that was necessary to establish a medical school. Funds
to establish this college were provided by the Board of
Trustees, Mr. Lowry and Dr. French $5,000 each, Dr.
Dunsmoor $10,000 and the other two $2,000 each.

In the early days, about 1854-55, during the rivalry
for supremacy between St. Anthony on the east side of
the river, and Minneapolis on the west side, there was
built in St. Anthony, approximately where the Savage
Building or the old Exposition Building now stands, a
hotel of about two hundred beds. This hotel was known
as the Winslow House. When Minneapolis out-stripped
St. Anthony this building fell into disuse. The Board
of Trustees of the new College acquired this disused
hotel building. It was remodeled to furnish lecture
rooms, laboratories, and a thirty-bed hospital was estab-
lished. The remaining rooms were used as a dormitory
for the students, establishing what was probably the first
student dormitory in the State of Minnesota.

The feeling between these two rival schools was very
friendly, and three members of the faculty in St. Paul,
Dr. Riggs, Dr. Wheaton and Dr. Talbot Jones, lectured

1. May, 1936.

* Presented at the testimonial dinner to retiring members of the
University of Minnesota Medical School Staff, June 10, 1936.

t Associate professor of urology, University of Minnesota
Medical School.

in the Minnesota College Hospital while Dr. Dunsmoor
lectured on surgery and Dr. Thomas C. Quinby on
materia medica and therapeutics in the St. Paul School.

Dr. Thomas Quinby has his office in the Donaldson
Building in Minneapolis and is the last surviving mem-
ber of the original faculty of either of these schools.

In 1885 the Minnesota College Hospital was re-
organized and became the Minnesota Hospital College.
A new building was built on the corner of Sixth Street
and Ninth Avenue South. The faculty was enlarged
and a Dental School added.

These pioneer teachers of dentistry believed that
dentistry was a specialty in medicine; therefore they re-
quired the dental students to take the science branches of
medicine with the medical students and to pass the same
examinations that were given them.

I registered in the Dental School on the 16th day of
September 1887, and by so doing became a student in
the Minnesota Hospital College Medical School. Later
I came to have a personal acquaintance with every man
on the medical faculty which at that time consisted of:

Dr. F. A. Dunsmoor, Dean of the Faculty, professor
of surgery.

Dr. J. H. Dunn, professor of clinical surgery.

Dr. J. E. Moore, professor of orthopedic surgery.

Dr. Frank Burton, professor of anatomy.

Dr. J. Clark Stewart, demonstrator of anatomy who
had charge of dissecting room.

Dr. R. O. Beard, professor of physiology.

Dr. H. M. Bracken, professor of materia medica.

Dr. C. M. Drew, professor of chemistry and tox-
icology.

Dr. C. H. Hunter, professor of medicine.

Dr. J. W. Bell, professor of physical diagnosis.

Dr. A. B. Cates, professor of obstetrics.

Dr. A. W. Abbott, professor of gynecology.

Dr. Frank Alport, professor of eye and ear.

Dr. W. S. Layton, professor of nose and throat.

Dr. W. A. Jones, professor of nervous and mental
diseases.

Dr. C. L. Wells, professor of children’s diseases.

Dr. Max P. Van Der Horck, professor of dermat-
ology.

Of this re-organized faculty Dr. H. M. Bracken,
Claremont, Calif., is the only surviving member.

The spirit of the teaching in this old Minnesota
school is shown by the fact that the Minnesota Hospital
College was one of the first schools in America to require
any microscopic laboratory work. Courses in this kind
of work had been given in various colleges as elective
work but in 1887-88 the University of Michigan at
Ann Arbor, and the Minnesota Hospital College of
Minneapolis required a course in microscopic histology.
This work was under the direction and personal charge

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of Dr. J. Clark Stewart. The primitiveness of this
course can be understood when I say that there were not
microscopes enough to supply the class of fifty so that
three or four students used one microscope. When the
study of blood was taken up the blood which was used
for material for the fifty men was taken from the tip
of my finger. This was advance study compared with
the curricula of other schools. When I graduated in
medicine in 1894, I took an internship at Asbury
Hospital. My colleague, who was a graduate of Rush
Medical College, Chicago, of that same year, had never
looked through a microscope when he arrived at the
hospital to take up his internship.

In 1883 the University appointed a board to give the
degree of Bachelor of Medicine by examination.
Willard B. Pineo was given this degree. The diploma
given him is now in the possession of the Hennepin
County Medical Society as part of the material gathered
for history of early medical teaching in Minnesota.

In 1888 the Medical School of the University of
Minnesota became a teaching institution. Under the
guidance of the dean, Dr. Perry H. Millard of St.

Paul, a curriculum was arranged which was on a par
with that of the high grade medical schools of the East.

The character of Dr. Millard is well shown by an
instance which occurred in the first session of the
University School. It was announced that lectures
would be continued Friday and Saturday following
Thanksgiving Day. The students promptly petitioned
the faculty that they might have Friday and Saturday
as holidays. On Wednesday morning Dr. Millard met
his class with the remark that he had received their
petition and in reply he could only say that doctors and
medical students had no holidays and that the work
would go on as usual Friday and Saturday.

What the future holds for the University Medical
School I do not know, but judging the future by the
past I am sure that the course of study at the Univer-
sity will be on a par with the advancement of medical
science and education, and that the University will con-
tinue each year to give the public a class of young men
and women who are equal in ability and training to the
graduates of the best schools and universities in America.

A Clinical Evaluation of a New Feeding"

For Premature Infants

Albert V. Stoesser, M.D.)- and Evelyn Johnson, M.D.ff
Minneapolis, Minn.

THE feeding of the premature infant has always
been considered a special problem. Experiences
over many years have shown that breast (human)
milk is most easily assimilated by the premature baby.
In some instances, however, close observers have felt
that the response in the growth of the infant has not
been entirely satisfactory. The result of these observa-
tions has been the preparation of several modifications
of the breast milk feeding. Various types of carbo-
hydrate have been added to the milk. Protein in the
form of calcium caseinate has been employed to give
the breast milk additional value. Small amounts of
dry or powdered cow’s milk have been mixed with
human milk in order to obtain the desired results.

The addition of two per cent calcium caseinate
to breast milk has yielded a, mixture which is
simple to prepare, and which has given a most satis-
factory and consistent daily gain in weight. The formula
is made by adding 2 grams (one tablespoon) of calcium
caseinate to 100 cc. (3x/3 ounces) of previously-boiled
breast milk. The human milk is at times difficult to
obtain, as the infant’s own mother generally leaves the
hospital after ten days and milk from other mothers
may not be available. Economic or physical conditions

* From the Pediatric Division of the Department of Pediatrics
of the University of Minnesota, at the Minneapolis General
Hospital.

t Assistant professor of pediatrics, University of Minnesota,
ft Resident physician, Minneapolis General Hospital.

may offer sufficient reason for the inability to obtain
breast milk from the mother after she leaves the hos-
pital. Mother’s milk may be purchased occasionally but
it is expensive and such an expense is often a burden to
the family.

In the absence of human milk, many formulae of
cow’s milk have been used. Years ago these feedings
were not considered to be as good as breast milk. Lately,
however, preparations have been formulated which come
very close to being adequate substitutes. Some of the
most recent formulae are based on scientific investiga-
tions. Following the observations of Utheim1 that pre-
mature infants have low values for serum protein during
the first three months of life, some physicians increased
the protein content of the milk mixtures employed for
the feeding of the premature infant by adding one-third
buttermilk or one-third skimmed lactic acid milk. Lact-
albumin was also tried. Finally cow’s milk was fortified
by the simple addition of one to three per cent calcium
caseinate. Tow2 reports excellent results in feeding pre-
mature babies with this preparation.

Fat absorption interested investigators next, and Holt3
and his colleagues made extensive studies in the fat
metabolism of normal, premature, and twin infants.
They found that the premature babies did have marked
difficulty in fat absorption. There was also a striking
difference in the ease with which the different fats were

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411

absorbed. Olive oil was more completely absorbed than
butter fat, and thus when olive oil was substituted for
butter-fat, there was a more rapid gain in weight. One
of the authors (A. V. S.) had also made similar ob-
servations in connection with the use of olive oil in new-
born babies born of mothers with chronic skin dis-
orders, such as eczema. In view of the work of Hansen4,
these babies received fats more unsaturated than that of
cow’s milk as a prophylactic measure for infantile ec-
zema. At first, corn oil was used in place of butter fat
and then a change was made to olive oil chiefly because
of the remarks of Ladd'1 concerning the superior value
of olive oil in the feeding of infants. Although no skin
disorders developed, the most striking observation was
the sharp upward turn in the weight curves of the pre-
mature infants following the use of the olive oil.

As a result of this observation, it was thought to be
worth while to prepare a feeding formula for premature
infants containing both calcium caseinate and olive oil.
This was considered even in spite of the fact that fairly
satisfactory results were being obtained with an evap-
orated milk feeding0. The new mixture was to be com-
posed of skimmed cow’s milk, calcium caseinate, olive
oil and dextri-maltose, the latter being added to furnish
maltose and dextrin which is in line with recommenda-
tions of Powers’. Three distinct forms of carbohydrate
(lactose, maltose and dextrin) are considered by some
physicians to be of advantage, in that fermenta-
tion is less likely to develop, and the absorption of car-
bohydrate is more uniform.

Unfortunately, it was soon observed that the formula
proposed above was too expensive to prepare in the
hospital as a homogeneous mixture. However, it was
learned that a very similar product could be obtained
as a spray dried powder*.

The preparation was intended especially for premature
and newborn infants and consisted of 40.6 per cent
skimmed milk solids, 10.1 per cent calcium caseinate,
17.5 per cent olive oil and 31.7 per cent dextri-maltose.
In view of the fact that vitamin A was removed when
the cow’s milk was skimmed, halibut liver oil (0.1 per
cent) was added.

The powdered milk preparation was accepted
as a satisfactory substitute for the special product
originally formulated, and it was employed in a dilution
of one ounce of powder to 5 ounces of previously-boiled,
cooled water. This yielded a palatable preparation with
a composition consisting of protein 4 per cent, fat 3.2
per cent, carbohydrate 9.1 per cent, mineral 0.6 per cent
and moisture 83.1 per cent. The caloric value was found
to be 23 calories per ounce or approximately 77 calories
per 100 cc. of fluid mixture. In this simple dilution, the
skimmed milk-olive oil formula was considered
to be a feeding for the premature infant which could be
easily substituted for the boiled breast-milk with 2 per
cent calcium caseinate or the cow’s milk mixture con-
sisting of equal parts of unsweetened evaporated milk
with 3 per cent dextri-maltose.

A very carefully-controlled clinical study was insti-
tuted in which the premature babies of the pediatric di-

vision of the Minneapolis General Hospital were con-
sidered. During the period of observation very close at-
tention was given to the cardinal points in the manage-
ment and feeding of the premature infants*. The babies
received special nursing care. A proper environment was
maintained from the moment of birth. Strict isolation
technique was followed in order to reduce to a minimum
upper respiratory infections and skin disorders. The
establishment and maintenance of an adequate fluid in-
take and feeding was rigidly kept uniform by following
a routine method of feeding. Vitamin and iron require-
ments were supplied in a satisfactory manner.

Two hundred and two premature infants were ob-
served from birth until the time they were discharged
from premature care. These babies represented 73 per
cent of the premature infants born during the period
of observation. The remaining 27 per cent died and
were not considered in this study. The infants were
divided into two groups according to weight at birth:

1. Premature infants weighing 2000 grams or less
(56 babies, 27.7 per cent of the cases).

2. Premature infants weighing 2001 to 2500 grams
(146 babies, 72.3 per cent of the cases).

In a more or less alternate fashion, the premature
babies of the two groups received the various formulae
which were to be compared. Some infants of each group
were given boiled breast-milk with 2 per cent calcium ca-
seinate, others received the unsweetened evaporated milk
mixture with, 3 per cent dextri-maltose, and a third or
remaining portion obtained the new preparation of
skimmed-milk and olive oil. An attempt was made to
give each baby the maximum amount of food required
to yield a consistent gain in weight without causing any
serious gastro-intestinal disturbances. Complete records
were kept and information as to the total initial weight
loss was obtained, together with the day of life on which
the minimum weight was reached. In addition the day
on which the birth weight was regained was noted and
the caloric intake per kilogram of body weight on that
day was determined. For the sake of simplicity and
clearness this data is all summarized in Table I.

There were 12 infants in the lower weight group
which were fed the breast-milk formula. The majority
of the cases lost 90 to 160 grams (3 to 5.3 ounces) with
the minimum weight being reached as early as the third
day, and as late as the ninth day of life. About two-
thirds of the babies regained their birth weight between
the eighth and nineteenth day with an average of four-
teen days. Caloric values at this time ranged in most
cases from 104 to 145 per kilogram or 47 to 65 per
pound of body weight.

Seventeen infants of the lower weight group received
the evaporated milk mixture. Except for the difference
in the type of feeding they were cared for in exactly the
same way as the infants of the breast milk group. The
initial total weight loss was 60 to 175 grams (2 to 5.8
ounces) in the majority of the cases. The babies reached
their lowest weights as early as the third day, and as late
as the twelfth day of life. The birth weight was regained

412

THE JOURNAL -LANCET

TABLE I.

Analysis of the Various Groups of Infants With Respect to Total Initial Weight Loss, Day of Minimum Weight, Day
on Which Birth Weight Regained, and Caloric Intake per Kilogram of Body Weight on That Day.

No.

See

Birth

Minimum

Total

Day of

Day

Caloric Intake

Premature

Foot-

Weight in

Initial Weight

Minimum

Birth Weight

per Kilogram

Feeding

Cases

note

Grams

Loss

Weight

Regained

on That Day

Premature Infants Weighing 2000 Grams or Less

Boiled Breast
Milk with

1350-2000

1190-1905

40-260

2-14

5-23

91-153

2 per cent
Calcium

1690-1995

1580-1865

90-160

3- 9

8-19

104-145

Caseinate

1812

1685

125

124

Evaporated
Milk Mixture,

1365-2000

1200-1945

5-205

2-18

6-22

83-188

with 3 per cent

1550-2000

1490-1890

60-175

3-12

11-20

102-167

dextri-maltose

1798

1679

114

134

Skimmed milk,
Olive oil. Cal-

1405-2000

1325-1980

20-170

2- 5

3-14

57-179

cium Caseinate,

1 500-1950

1410-1850

85-140

2- 4

6-1 1

84-126

and dextri-
maltose

1741

1639

100 .

108

Premature In

fants Weighing

2001-2500 Grams

Boiled Breast
Milk with

2150-2490

1980-2420

20-260

2- 9

3-21

50-150

2 per cent
Calcium

2260-2460

2 1 35-2350

70-170

2- 6

5-12

82-132

Caseinate

2370

2249

121

108

Evaporated
Milk Mixture,

2030-2500

1900-2465

25-330

2-15

2-26

37-163

with 3 per cent

2225-2480

2010-2350

55-220

2- 7

5-17

89-139

dextri-maltose

2347

2207

140

114

Skimmed milk,
Olive oil. Cal-

2005-2470

1855-2430

20-310

2-10

2-21

40-250

cium Caseinate,
and dextri-

2095-2410

1960-2300

70-190

2- 6

6-15

90-139

maltose

2247

2120

127

117

A — Complete range. B — Range of two-thirds of the cases. C — Total average.

in two-thirds of the cases between the eleventh and
twentieth day which differs very little from the observa-
tions made in connection with the infants fed with
breast milk. However, to obtain this same result, the
evaporated milk fed babies received slightly higher food
intakes, the caloric values being 102 to 167 per kilogram
or 45 to 75 per pound of body weight.

The new skimmed milk-olive oil preparation was of-
fered to twenty-seven infants of the lower weight group.
Weight losses in two-thirds of the cases ranged from 85
to 140 grams (2.8 to 4.6 ounces) and this loss reached
its maximum no later than the fifth day of life. It was
rather rapidly regained in the majority of the cases be-
tween the sixth and eleventh days of life with an average
of eight days. This is a most interesting observation and
may indicate that the smaller premature babies quickly
adapt themselves to the skimmed milk-olive oil feeding.
Furthermore to attain this response only 84 to 126 cal-
ories per kilogram or 36 to 57 calories per pound were
necessary. In fact, the average caloric intake per kilo-
gram, 108 calories, on the day the birth weight was re-
gained was the lowest in this group.

The infants of the higher weight group were also
divided into three sub-groups. Thirty-nine received the
breast milk formula, fifty-four received the evaporated
milk mixture and fifty-three received the skimmed milk-
olive oil preparation. The response to all the feedings
as indicated by the length of time necessary to regain
the birth weight after the initial loss was practically the
same in each instance. The babies fed the breast milk

formula appeared to progress a little better than those
of the other two sub-groups. However, all the infants
of the higher weight group did very well including those
receiving the skimmed milk-olive oil feeding.

Observations were next made as to the length of time
the infants remained in the hospital and the caloric in-
take per kilogram of body weight necessary to attain a
weight large enough to permit graduation from pre-
mature care. The average weight gain in grams per day
of residence in the hospital was also determined. All
this data has been summarized in Table II.

The average discharge weights for the infants of each
sub-group of the lower weight group were quite close
together. The babies of the group receiving the evap-
orated milk mixture remained the longest in the hospital
under the permature care. About two-thirds of the
babies in this group were discharged between the ages
of thirty-seven and sixty-three days (5 and 9 weeks)
with an average of forty-nine days (7 weeks) while the
majority of those of the group receiving the breast milk
formula left the hospital between the twenty-ninth and
forty-sixth day (4 and 6/4 weeks) of life with an av-
erage residence of thirty-seven days (5 weeks). Prac-
tically the same results were obtained with the skimmed
milk-olive oil feeding.

Caloric values as high as 200 calories per kilogram of
body weight have been reported as necessary to obtain
a satisfactory consistent weight gain in the premature
infant during the first 4 to 6 weeks of life. This has
not been necessary in this study. The majority of the in-

THE JOURNAL-LANCET

413

TABLE II.

Analysis of the Various Groups of Infants With Respect to the Day of Discharge From Premature Care, Caloric Intake
per Kilogram on That Day and Average Weight Gain in Grams per Day

No.

See

Discharge Weight

Day of Dis-

Caloric Intake

Average Weight

PREMATURE FEEDING

Foot-

charge from

per Kilogram

Gain in Grams

Cases

note

Grams

Premature Care

on That Day

per Day

Prema'ure Infants Weighing 2000 Grams or Less

BOILED BREAST MILK

2480-2745

27-52

115-179

27-41

with 2 per cent

2590-2710

29-46

136-160

29-39

Calcium Caseinate

2633

143

EVAPORATED MILK MIXTURE,

2505-2870

29-69

138-176

20-33

with 3 per cent

2610-2790

37-63

140-170

21-33

dextri-maltose

2680

156

SKIMMED MILK, OLIVE OIL,

2570-3400

26-50

104-179

26-44

Calcium Caseinate, and

2610-2780

30-44

132-166

31-40

dextri-maltose

2710

147

Premature ]

nfants Weighing 2001-2500 Grams

BOILED BREAST MILK

2525-301 5

9-45

104-203

17-40

with 2 per cent

2605-2895

13-29

1 17-150

26-34

Calcium Caseinate

2732

137

EVAPORATED MILK MIXTURE,

2550-3300

1 1-55

94-233

1 3-39

with 3 per cent

2625-2790

16-33

117-166

19-33

dextri-maltose

2721

1 38

SKIMMED MILK, OLIVE OIL,

2525-3 190

10-35

104-198

24-46

Calcium Caseinate, and

2620-2760

16-28

137-167

28-42

dextri-maltose

2696

146

A — Complete range B — Range of two-thirds of the cases. C — Total average.

fants of the breast milk fed group required only 136
to 160 calories per kilogram of body weight or 60 to 70
per pound of body weight to give a daily weight gain
ranging from 29 to 39 grams with an average of 35
grams per day. The group receiving the evaporated milk
formula did not do as well in that the caloric intake
although as high as 140 to 170 calories per kilogram or
60 to 80 per pound did not yield more than a daily
weight gain of 21 to 33 grams in the majority of the
babies. The average figure was as low as 25 grams. On
the other hand, the skimmed milk-olive oil preparation
produced the same daily weight gain as the breast milk
feeding, although it did include a few more calories per
kilogram to accomplish this result.

The infants of the larger weight group were dis-
charged at an average age of three weeks. There was
only a small difference in the various sub-groups, the
babies receiving the breast milk remaining in the hos-
pital the shortest time and those obtaining the evap-
orated milk mixture remaining the longest time. The
infants which were fed the skimmed milk-olive oil feed-
ing did not leave the hospital as early as the breast milk
group nor as late as the evaporated milk group. They
were able to take fairly large amounts of the prepara-
tion without the development of regurgitation, or vom-
iting and frequency of bowel movements, or diarrhea.
The caloric intake therefore averaged 146 per kilogram
or 66 per pound of body weight which yielded an av-
erage daily weight gain of 34 grams, the highest for
the babies of the larger weight group. The infants fed
the evaporated milk mixture made the poorest showing
in that their average daily gain was only 26 grams.

It is interesting to note that the infants in each of
the two weight groups responded quite uniformly to the
various feedings except in the case of the babies receiv-
ing breast milk. With this feeding, the smaller infants
gained more rapidly than the larger. Their daily weight

gain was 35 grams per day in comparison with a 30
gram gain per day shown by the larger infants. On the
other hand, the babies of both weight groups maintained
on the skimmed milk-olive oil feeding made practically
the same daily average gains in weight, and this gain
was equal to that of the smaller infants receiving the
breast milk formula. The variation in the response to
the breast milk and the uniformity in the gain from the
new preparation revealed the skimmed milk-olive oil
preparation as being equal to breast milk for the smaller
babies and superior to breast milk for the babies of the
larger weight group. This is even more significant in
view of the fact that the breast milk was being re-
inforced with protein in the form of calcium caseinate.
During the study the complications of prematurity which
developed were fairly evenly divided between the various
groups of infants. Occasionally short periods of regur-
gitation or/ and frequent bowel movements with liquid
stools would appear. These were a little more common
in the groups receiving the breast milk formula. As a
whole, however, very few gastro-intestinal disturbances
were encountered.

Comment

From the foregoing results it is evident that the new
preparation is of value in satisfactorily promoting growth
and development in premature infants. By comparison
with other types of premature feedings, namely breast
milk and evaporated milk, it is found to be equal to or
even better than these feedings, especially during the
period from the third to the tenth day of life. This
period has been considered the phase of a baby’s life
during which a most careful adjustment of the feeding
is made by the infant. If too little or too much food
or an improper mixture is offered at this time the pre-
mature may not readily respond in a satisfactory way
and the result can tend toward a rapidly fatal outcome.

414

THE JOURNAL-LANCET

The most essential requirements for the clinical eval-
uation of infant feeding formulae include an approved
method of selection of the cases, strict attention to the
possible influence of seasonal variations, and proper pre-
mature management. The latter constitutes uniform
nursing care, maintenance of satisfactory environment
throughout the period of observation, prevention of
upper respiratory infections and skin disorders and early
establishment and maintenance of an adequate intake of
fluid and feeding. When cases are selected in an alter-
nate fashion through all seasons of the year and the
method of handling the infants is very carefully kept
constant, then the results which are obtained in evaluat-
ing any set of infant feedings or formulae should have
some clinical value and be worthy of record.

The skimmed milk-olive oil preparation responds well
to the clinical tests. It represents a mixture of skimmed-
milk solids, calcium caseinate, olive oil and dextri-
maltose in proportions found to date by scientific inves-
tigations to be most ideal for the promotion of proper
growth and development in the newborn and premature
infants. The small as well as large infants assimilate it
very easily, with very little digestive disturbance and
accordingly gain rapidly in weight. The physiological
weight loss is cut to a minimum and the baby gains so
rapidly that in a short period of time its weight is great
enough to warrant discharge from premature care. The
total number of days of residence in the hospital is cut
to a low figure.

Summary

1. The skimmed milk-olive oil formula pre-
pared for the feeding of premature infants when breast
milk is not available has been given a clinical trial.

2. Eighty premature babies received the new prepara-
tion and at the same time fifty-one premature infants
were fed a breast milk formula and seventy-one were
offered an evaporated milk mixture. The latter two
groups acted as controls.

3. The clinical evaluation of the feeding was as care-
fully controlled as the facilities of the hospital would
permit. A satisfactory schedule of premature manage-
ment and feeding was constantly followed. Complete
records were kept during the entire period of observa-
tion.

4. No attempt has been made to present at this time
an elaborate statistical analysis of the data obtained. A
simple study of the results revealed that the skimmed
milk-olive oil formula was easily assimilated by the in-
fants with a birth weight below 2000 grams, and in this
respect it equaled the breast milk formula and surpassed
the evaporated milk mixture. The larger infants with a
birth weight over 2000 grams which received the new
preparation made a better showing than the other two
units of larger weight group which were fed the breast
milk and the evaporated milk.

5. The preparation may prove to be a valuable ad-
dition to our knowledge of premature feeding and at
the same time lend itself to further modification. Fur-
ther studies are indicated.

Bibliography

1. Utheim, K., Am. J. Dis. Child. 20:366, 1920.

2. Tow, Abraham, N. Y. State J. of Med. 36:1, 1936.

3. Holt, L. Emmett Jr., Tidwell, Herbert C., Kirk, Claude M..
Cross, Dorothea M., Neale, Sarah, and Farrow, Howard L., J.
Pediat. 6:427, 1935.

4. Hansen, Arild E., Proc. Soc. Exper. Biol. Qc Med. 31:160,

1933.

5. Ladd, M., Arch. Ped. 32:409, 1915 and 33:501, 1916.

6. Stoesser, A. V. and Perlman, E. C., Minn. Med. 17:70,

1934.

7. Powers. G. F.. J. A. M. A. 105:753, 1935.

8. Stoesser, A. V., J. Lancet, 57:190, 1937.

Silicosis

C. S. Raadquist, M. D.
Hibbing, Minn.

THE Committee on Pneumoconiosis of the Indus-
trial Hygiene Section of the American Public
Health Association defines silicosis as follows:
"Silicosis is a disease due to breathing air containing
silica, characterized anatomically by generalized fibrotic
changes and the development of miliary nodulation in
both lungs, and clinically by shortness of breath, de-
creased chest expansion, lessened capacity for work,
absence of fever, increased susceptibility to tuberculosis,
and by characteristic X-ray findings.”

Silicosis is caused by the inhalation of air in which
dust containing free silica is suspended. The particles
of silica must be small enough to enter the finer air
spaces of the lungs. These conditions are present in
such occupations as driving of tunnels, development of

*Read before the Annual Session of the Northern Minnesota
Medical Association, held at Fergus Falls, Minnesota, August 31-
September 1, 1936.

highways, in the mining industry, smeltering and refin-
ing of ores, quarrying and carving of stone, particularly
granite, and the processing of various forms of free
silica.

The pathology resulting from breathing air containing
silica is fibrosis. This condition has until quite recently
been spoken of under the general term, pneumoconiosis.
Other dusts, when inhaled long enough and in sufficient
concentration, will cause a definite pulmonary fibrosis,
but it has been shown clinically and experimentally that
the nodular fibrosis characteristic of this disease is
caused only by inhalation of silica. It was at first be-
lieved that the injury caused by the silica particles was
due to mechanical irritation caused by its hard cutting
edges bist it has been shown by Gardner experimentally
that carborundum dust of greater hardness than silica
does not produce the miliary nodulation characteristic of

THE JOURNAL-LANCET

415

FIRST STAGE SILICOSIS
Note increase in hilus shadows.

FIRST STAGE SILICOSIS
Note marked increase in hilus shadows.

silicosis. It has been shown by Gye and Kettle that
silica in solution or non-crystalline form exerts a toxic
action upon the tissues causing proliferation of fibro-
blastic cells. Miller and Sayers have shown by experi-
mental studies on animals that only dust containing
silica has uniformly produced proliferative reaction.
Other dusts have been either completely absorbed, leav-
ing no scar tissue, or have remained unchanged in the
form in which they were injected. They determined
three types of reactions by injecting intraperitoneally in
animals a ten per cent suspension of various dusts in
physiological sodium chloride. Type 1: Absorption or
dissolution of the dust. The dust particles as well as
the lesions gradually disappeared. Type 2: Inert re-

action. There was no absorption or any tissue reaction.
All the dusts injected that contained no silica produced
one of these reactions. Type 3: Proliferative reaction.
The silica dust alone produced this reaction.

From these experimental studies it appears that the
pathology of silicosis is brought about in the following
manner: The silica dust suspended in the air enters the
finer divisions of the lungs, the terminal bronchioles and
air sacs, where, attacked by the phagocytic cells, a solu-
tion of silica is formed. The silica in solution exerts a
chemically toxic action upon the tissues leading to pro-
liferation of fibroblastic cells. Then are formed the
characteristic nodules of hyaline fibrous tissue character-
istic of silicosis. The nodules increase in size by exten-
sion at their periphery. Adjacent areas may coalesce
and bring about further involvement.

It appears from the literature on the condition that
no nationality is exempt, and that all races are suscepti-
ble. It is possible that previous occupations may be a
predisposing factor if the individual has been exposed
to dust or other respiratory irritants. Respiratory infec-
tions have been shown to be the greatest predisposing
and complicating factor in the development of silicosis.
In regard to individual susceptibility, if there is any
difference, it must be considered an acquired and not a
congenital condition. Perfectly functioning nasal pass-
ages may retard the development. Lehman in his experi-
ment using dust with a high silica percentage, found
that the average retention by the nose in the cases of
non-silicotics was about 50 per cent, while in the case
of miners with silicosis the average retention was only
about 22 per cent. The robust type of individual with
less respiratory reserve appears to be somewhat more
susceptible than slender individuals. Men who have
had respiratory disease, especially tuberculosis, are ap-
parently more readily affected by silica dust. Besides
tuberculosis must be mentioned bronchial asthma, chronic
bronchitis, bronchiectasis, emphysema, and pleurisy as
favoring the development of the condition by lessening
the ability of the lung to rid itself of foreign materials.
Sinus infection may act by decreasing the efficiency of
the upper respiratory tract in removal of dust from the
air passages to the lungs.

The silicotic individual is much more susceptible to
tuberculosis than the normal man. Due to the perma-
nent lung damage by the silica dust, such persons stand

416

THE JOURNAL-LANCET

SECOND STAGE SILICOSIS
Note mottling through both lung fields.

a much lesser chance of overcoming the disease even
with proper care. An analysis of the mortality statistics
of 12 insurance companies for 1915-1916 by Lang and
Vane, shows that the actual mortality rate from tuber-
culosis among persons exposed to silica dust was about
three times that of a group not so exposed. If this
comparison is limited to the occupations with a very
great silica exposure such as metal mining, sandstone
and granite quarries, the death rate is about ten times
that of the non-silicotic group. Gardner has stated that
at least 75 per cent of those who develop silicosis die
of tuberculosis. This may be so if all the industries
having a silica hazard are considered as a whole. How-
ever, it is my impression from my studies of iron miners,
that the mortality rate from tuberculosis as a complica-
tion of silicosis among them is low, probably not much
greater than among those not affected with silicosis. It
has been shown by Kettle, Price, and others, that the
tubercle bacillus grows more rapidly upon culture media
to which a small amount of silica has been added.
Gardner has shown that animals exposed to silica when
inoculated with a strain of tuberculosis of low virulence
will develop tuberculosis and die, while animals not ex-
posed to silica are not seriously affected.

The stages of silicosis are, in the United States, called
first, second, and third. The symptoms of the uncom-
plicated first stage are few and indefinite, and in most
instances, entirely lacking. The man’s working capacity
is not noticeably impaired and he appears as well as
usual. It has been stated that recurrent colds, slight
cough, slight shortness of breath on exertion, are the

SECOND STAGE SILICOSIS
Shows mottling throughout both lung fields.

most common symptoms. However, the number showing
even these symptoms is small and it is questionable if
men in this group show them any more than those hav-
ing no silicotic condition. Chest expansion may be
slightly less than normal. From symptoms alone it is
impossible even to suspect the condition when it is in
the first stage. The radiograph gives the earliest specific
indication of its presence. Therefore, all miners should
be subjected to both pre-employment and periodic X-ray
examinations. The radiographic appearance consists of
small discrete mottling. This characteristic mottling is
due to shadows cast by nodules of fibrous tissue and is
essential to the diagnosis of silicosis. Then, there is
bronchial accentuation. The entire bronchial tree in-
creases in density and can often be traced to the outer
margins of the lungs. Near the hilum along the thick-
ened bronchial tree are small spots. When these spots
appear throughout the lower section of the lungs, the
case is classified as beginning, first stage silicosis. As
the disease advances, the spots increase in number, dens-
ity, and size. Now remember, in order to diagnose sili-
cosis, the spots must be present. As stated there always
is, or almost always is, an increase in the density of the
bronchial tree, but this, also, is the case in many other
conditions. Large calcified spots in the hilus shadows
may be significant, especially if there are many of them.
Pitcher claims cases where such calcifications involved
the entire hilum. It is claimed that these calcifications
are larger than those resulting from childhood tubercu-
losis.

THE JOURNAL-LANCET

417

Second Stage: The symptoms as a rule are more pro-
nounced. There often is definite shortness of breath on
exertion. Often there is pain in the chest, recurrent
colds are more frequent, and usually there is a dry
morning cough. The man’s appearance may still be
healthy, but he is easily fatigued. There is noticeable
decrease in chest expansion. However, even in this
stage, there is a surprising number who show very few
symptoms. Their working capacity is not impaired. If
such individuals could change their occupation so that
any further exposure is stopped, it is quite possible that
they might lead a useful life for their expected number
of years. There is further accentuation in the radio-
graphic findings. Throughout both lung fields there is
medium-sized mottling. The spots are larger, more nu-
merous, denser, and clearer, in outline. The mottling
is usually about equal on both sides. This would indicate
that the condition started on both sides about the same
time.

Third Stage: There is further accentuation of all

the symptoms. Even on slight exertion the dyspnea is
distressing. The cough is more distressing; it may be
productive or dry. Expansion is greatly decreased. Due
to the respiratory difficulty, a great load is placed upon
the heart. Its rate is increased and it may become
dilated. There is usually some loss of weight. The
radiographic appearance is more striking. The mottling
is more marked. There is a tendency to coalescence of
the spots so that we see large fibrotic areas of marked
density. These areas may be very similar to tuberculous
consolidation.

As stated, tuberculosis may complicate any stage of
silicosis. In diagnosing this complication both the clin-
ical findings and X-ray appearance must be taken into
account. The X-ray findings may be very confusing,
especially in the third stage when large areas of fibrosis
have formed. In the first, and early second stages, when
the silicosis is still confined to small spots, the differen-
tiation is, of course, less complicated. It was noted in
the Pitcher cases that, in beginning tuberculosis, areas
of density were observed in one or both apices. These
areas were not as dense as the fibrotic areas of silicosis.

Simpson, of Trudeau, states that the sputum in sili-
cotic patients becomes positive very late; that it is pos-
sible to diagnose tuberculosis in these patients very much
earlier by the X-ray. Lately, experimental studies done
at Saranac Lake, appear to show that the silicosis on the
Iron Ranges in Minnesota is not as serious as that
caused by silica in combination with other ores and
material. The iron appears to have an inhibiting effect
upon the action of the silica. Gardner claims that tuber-
culosis in iron miners is much slower than in workers in
other mines such as lead and zinc. He claims that sili-
cosis is not progressive after exposure is stopped.

Prevention of silicosis comes under two main divi-
sions, mechanical and medical. It is up to the engineers
to find means for preventing or decreasing the amount
of silica dust in the air, or, when it gets into the air, to
prevent it from being inhaled. Wet methods have been

used in the mining industry to prevent the dust from
getting into the air. In other occupations, air filtering
arrangements which will secure clean air for dusty air
have proved successful. In mining and the driving of
tunnels, blasting is the source of much of the dust in
the air. Doing the blasting after regular working hours
or between shifts will greatly lessen exposure. In occu-
pations where there must always be a fairly high con-
centration of silica dust in the air, the workmen should
be frequently changed. If the total exposure in such
occupations can be limited to one year it is believed
serious trouble can be prevented.

Pre-employment and periodic physical and X-ray ex-
aminations should be made of all employees in occupa-
tions where they are at all exposed to silica dust. If in
fections can be lessened or prevented it will aid the
silicosis problem greatly, because the rate of progress
of silicosis in the absence of infection is so slow that the
individual affected may never be disabled.

It is essential that there be close co-operation between
the engineering and the medical personnel. If the most
practical methods that have been discovered and that
will be discovered are put into operation under capable
direction, the silicosis problem will be largely solved.

Some of my personal observations among the iron
miners of the Hibbing district follow. This work has
been done at the Adams Hospital in co-operation with
the other physicians on the staff. Since August, 1933,
chest X-ray examinations have been made on 501 miners.
Of this number, 392 or 78.24 per cent were entirely
negative. Seventy-eight, or 15.56 per cent, had defects
such as broncho-vascular accentuation without silicosis,
pleurisy, or cardiac hypertrophy. Twenty-eight, or 5.58
per cent, showed first stage silicosis; 3, or 0.59 per cent,
showed second stage silicosis. There was none in the
third stage.

Of the 501 men examined, 195 were surface miners,
and 306 underground miners. Of the 195 surface miners,
177 were entirely negative, 17 showed other defects
such as broncho-vascular accentuation, pleurisy, and car-
diac hypertrophy. There was some question if one had
a beginning silicotic condition. Of the 306 underground
miners, 205, or 66.99 per cent, were entirely negative.
Seventy, or 22.87 per cent, had defects, such as broncho-
vascular accentuation, pleurisy, and cardiac hypertrophy.
Twenty-eight, or 9.15 per cent, showed first stage sili-
cosis; 3, or 0.98 per cent, showed second stage silicosis.
There was none in the third stage. All the men showing
any silicotic condition with the possible exception of one,
were underground miners. Of the three showing second
stage silicosis, one was 46 years old and had worked
underground 23 years. No chance to check this man
up in the usual periodic check-up examinations occurred,
as he left his job. The second man showing this stage
is 60 years old, has worked underground 25 years, and
has a chest expansion of one inch. Physical and X-ray
examinations after one year showed no accentuation of
findings. He has been working underground at his
usual work. The third man was 43 years old, has

418

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worked underground 23 years, and had a chest expan-
sion of two inches. During the past year he has been
working underground at his usual work. Physical and
X-ray examinations after one year showed no progress
of the condition.

The ages of the men showing first stage silicosis
ranged from 28 to 59 years with an average age of 44
years. They had been working underground for from
one to 27 years with an average of 14 years under-
ground. They had an average chest expansion of 2.84
inches. Physical and X-ray examinations after one year
showed no increase of findings. They have all been
working underground at their usual work.

The 205 underground miners with negative findings
had an average of 14 years underground. This shows
that the condition is slow to develop in iron miners.

The absence of any aggravation of symptoms or any
accentuation of the X-ray findings in the periodic exam-

inations after one year, during which the first and sec-
ond stage groups had been working underground at
their usual work, indicates that the condition, even when
started, is very slowly progressive in iron ore miners.

In regard to tuberculosis: Considering the data ob-
tained from examining this number of men, the impres-
sion prevails that the tuberculosis problem among the
iron miners is not so serious. The findings enumerated
at least indicate that silicosis is slow to develop in iron
miners; also that tuberculosis is slow to develop as a com-
plication after a silicotic condition has started. Of the
501 miners examined, there was not a single case of
definite tuberculosis. There were two or three with
slightly suspicious X-ray findings but in the periodic
re-check after one year there was no accentuation in
these findings. Several of these cases showed healed
childhood tuberculosis.

A Method of Roentgen Pelvimetry*

A Preliminary Report
Owen F. Robbins, M.D.f
Minneapolis, Minn.

THE VALUE of roentgen pelvimetry has been
proven repeatedly by various investigators.
Thoms1 states that he is convinced that only by
roentgenometric means can the true proportions of the
superior strait be determined, and, furthermore, that the
ordinary external methods of pelvimetry are often mis-
leading. From his work, Thoms has concluded that every
primipara and every multipara with a history of previous
difficult labors should be measured by means of the
X-ray. For this reason it is essential that every well
equipped hospital, which has a maternity service, should
have facilities for the study of pelves radiographically.

There is a tendency for men doing obstetrics to look
upon roentgren measurement of the pelvis as a procedure
which entails the use of costly equipment. This, on the
contrary, is not true, for there are very accurate meth-
ods, which use for their apparatus materials which can
be purchased reasonably or can be made by a good car-
penter. This equipment can be added to the standard
X-ray found in most hospitals.

Roentgen rays were first used in 1897 for the study
of the pelvis. This early work was done by Budin" who
emphasized the fact that the shape of the circumference
of the superior strait was more important than the an-
tero-posterior diameter. Pinard and Varnier3 tried to
make radiographic measurements by comparing the ex-
posure of the pelvis in the living with a normal dried
pelvis taken under identical conditions. Albert4 in 1899

♦Read before the Minnesota Association of Obstetricians ft:
Gynecologists by invitation, Minneapolis, Minnesota, January 16,
1937.

t Instructor in the Department of Obstetrics and Gynecology,
University of Minnesota, Minneapolis.

advocated the use of the semi-recumbent position in
order to get the plane of the superior strait parallel to
the film. Because of technical difficulties his films were
too blurred to be of any value. However, his position is
still used in many of the methods of the present day.
Fabre'J the next year described his frame method. A
metal frame with notches at every centimeter was placed
around the pelvis in the plane of the superior strait.
From the film the outline of the inlet was drawn on
graph paper in its exact dimension and the diameters
measured. The work of these men done only a few (
years after the discovery of the X-ray established roent-
gen pelvimetry as a definite procedure.

Moore6 divides the existing methods into five types:

Comparative: Radiograms are taken of a dried pelvis.
These are compared with radiograms of pelves in living
individuals under similar conditions. A matching of the
radiograms, so to speak, and referring back to the
original dried pelvis for measurements.

Teleoroentographic : By establishing a long focal dis-
tance with the superior strait of the pelvis parallel to the
film. Distortion is at a minimum.

Frame: By this method a scale is superimposed at
the sam.7 level at which the measurements are to be taken
and when the exposure is made, the super-imposed scale
on the film is distorted in the same proportion as the
region to be measured. Measurements are then read di-
rectly on the film from the distorted scale.

Triangulation: A study of triangles with known quan-
tities. The procedure involves the same principles of

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419

Fig. 1. The patient is resting against the backrest. The
symphyseometer is in place to measure the distance of the up-
per border of the symphysis from the table top. The plumb
bob centers the tube four centimeters behind the symphysis.

mathematics and radiology as used in the localization of
foreign bodies.

Stereoroentgenographic : The patient is firs-, placed in
such a position that the obstetrical landmarks will be
clearly seen. Stereoscopic films are taken with a known
tube shift and a known focal distance. Computations
must be made by the use of precalculated tables and
formulas or by means of mechanical devices used to re-
construct the problem involved.

The method which I wish to present at this time is a
modification of the Thoms' method, which was in-
troduced in 1929. This is a frame method and can be
used only for measuring the inlet. In making a study
of a pelvis by this means, the outlet must be measured by
the ordinary methods of outlet pelvimetry. Thoms’
method is as follows: First the patient is placed in a
semi-recumbent position such that the plane of the su-
perior strait is parallel to the film. The height of the
symphysis above the film is measured. The tube target
is centered five centimeters posterior to the symphysis at
32 inches from the film. The picture is taken. The pa-
tient is removed from the table, the tube target and film
remaining in situ. The lead grid is substituted for the
patient at the height determined and a second flash ex-
posure is made on the same film.

Thoms states that his method is accurate to two milli-
meters from a study of dried pelves. He states that the
height of the grid may vary as much as four centimeters
from the height of the plane of the superior strait with
no more than 0.6 centimeter error in the final calcula-
tion.

The method to be described was devised while working
on a study of the fetal head-bladder relationships in
which accurate methods were desirable. In this problem
it was necessary to place the patient in a semi-recumbent
position with the backrest at about a 40-degree angle
with the horizontal. In studying the plates obtained, we

were impressed with the large percentage which showed
clearly defined pelvic inlets. This was true in those pa-
tients at term as well as those in the earlier months of
gestation. From these findings it was concluded that it
was not necessary to have the patient sitting up as
acutely as in the Thoms method and thereby a clearer
definition of the superior strait could be obtained in
pregnancies at term. To add to the accuracy of the pro-
cedure, instruments were devised whereby the grid could
be placed in the exact angle that the plane of the su-
perior strait had borne to the horizontal. The grid could
be angled as much as 30 degrees without the occurrence
of foreshortening. In the entire series of over 200 pa-
tients, it was only rarely necessary to tilt the grid more
than 30 degrees. In those patients who did require more
angling of the grid, it was necessary only to raise the
backrest several notches to compensate.

These instruments, as well as the grid, were made in
the carpenter shop of the Minneapolis General Hospital
at a very small cost.

Apparatus

The backrest is of the ordinary hospital type being
narrowed somewhat in order that it might fit on the
Bucky diaphragm. In the region of the spinous pro-
cess of the fifth lumbar vertebra a slit is made in the
canvas so that the height of the posterior point (to be
described later) could be determined.

The symphyseometer (Fig. 1) which is used to measure
the distance from the table top to the upper border of
the symphysis, is a steel upright on which slides a sleeve
to which is attached an old pelvimeter arm. The height
is read off on the upright.

The calculator (Fig. 2) is designed to make calcula-
tion of height and angle of the grid a simple procedure.
It consists of three upright bars with bases. On the
central upright is a centimeter scale. A wire is placed
in such a way that the angle may be read off on a pro-
tractor placed on a horizontal bar. The horizontal bar is

420

THE JOURNAL-LANCET

Fig. 3. The grid (Modified Thoms).

perforated in such a way that a set-screw may he ad-
justed at any distance from the center and at any height
on each of the lateral bars which have threaded holes a
centimeter apart.

The grid (Fig. 3) is an ordinary Thoms grid which
has an added feature in the protractor and the centi-
meter scale on each of the supporting uprights. The
grid may be set at the desired angle and the desired
height. For purposes of centering, the central hole is
circled and the other holes numbered as shown.

Technique

The external conjugate of the patient is determined
by external measurement. An adhesive tape marker is
placed between the spinous processes of the fourth and
fifth lumbar vertebrae. This represents the location of
the promontory of the sacrum.

The patient is placed on the backrest (Fig. 1) which is
set at approximately a 40 degree angle. The distance
from the table top to the adhesive marker is determined.
The slit in the backrest facilitates this measurement.
The distance from the upper border of the symphysis to
the table top is measured with the symphyseometer.

The tube target is placed at 30 inches. The plumb
bob centers the tube over a point four centimeters behind
the symphysis. The rays will then pass approximately
through the middle of the pelvic inlet. The picture is
taken, the tube and film are left as they are.

Knowing the length of the external conjugate and the
height of the adhesive marker and symphysis, the angle
and height of the grid can be determined by the calcu-
lator. This is done (Fig. 2) by placing a set-screw in a
hole on the horizontal bar which represents one-half the
external conjugate. On one side the set-screw is
screwed into the hole which corresponds to the height
of the symphysis and on the other the hole which repre-
sents the height of the adhesive marker. The angle is
read on the protractor. The height will show on the
central upright.

Fig. 4. Method of placing grid so that it has the same re-
lationship to the film and tube that the superior strait had had.

Fig. 5. Typical plate.

The grid is now set at the desired angle and height
and is set on the Bucky table. With the plumb bob as
a guide, the grid is placed in such a way that it has the

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421

same relationship to the film that the plane of the super-
ior strait once had had. This is done by moving the grid
(Fig. 4) so that the plumb bob centers over the hole on
the grid which is four minus one-half the external con-
jugate.

A second exposure is made on the same film.

Figure 5 shows a typical picture. Unfortunately it
did not reproduce well in the photograph. From this
film the conjugata vera and greater transverse diameter
can be read off directly.

If in the film there appears to be too much of the
sacrum showing, it is in that group of patients who must
be set up more acutely. This group represents about
20 per cent of the 207 patients studied.

Conclusions

A modification of Thoms’ method of roentgen pelvi-
metry is described. It presents the advantages of the
original method and overcomes the disadvantage of the
lack of a clear picture of the inlet in term pregnancies
by a different positioning of the patient. The change
of position is compensated for by the use of instruments
which make it possible to place the grid in the exact

angle which the plane of the superior strait makes with
the horizontal.

I wish to thank Dr. J. C. Litzenberg, professor of
obstetrics and gynecology and Dr. John A. Urner,
associate professor of obstetrics and gynecology at
the University of Minnesota, for their help in the
preparation of this paper. I also wish to thank the
Roentgenological Department of the Minneapolis
General Hospital for their assistance in this work.

References

1. Thoms, H.: The Inadequacy of External Pelvimetry,

Am. J. Obst. 6C Gynec., 27:270 (1934).

2. Budin: Photographic par les rayons X d’un bassin de

Naegle, Obstetrique, 2:499 ( 1897).

3. Varnier: Note preliminaire sur, une methode nouvelle de

radio pelvigraphie, Compt. rend, d’obst. de gynec. et de paediat.,
2:224 (1900).

4. Albert: Ueber die Verwertung der Roentgenstrahlen in

der Geburtshilfe, Zentralbl. f. Gynaek., 13:418 (1899).

5. Fabre: De la radiographie metrique appliquee a la men-

suration des diameters due detroit super, Cong, internat. de.
med. c.-r. sect, d’obst.. Par., 403 ( 1900).

6. Moore, G. E.: Roentgen measurements in pregnancy,

Surg. Gynec. 6c Obst., 56:101 ( 1933).

7. Thoms, H.: Roentgen Pelvimetry: A Description of the

Grid Method and a Modification, Radiology, 21:125 (1933).

CASE REPORT

SENSITIVITY TO SCARLET FEVER STREPTO-
COCCUS TOXIN IMMUNIZING DOSE

Llewellyn R. Cole, M.D.

Director, Department of Student Health
University of Wisconsin

This brief report of the reaction in an individual following
one of a series of immunizing doses of scarlet fever strepto-
coccus toxin is intended to remind physicians that such pro-
cedures are not without danger, and that the time element
becomes of greater importance as it increases.

This case (A.A.S. — 52190) was seen in the Student Infirm-
ary at the University of Wisconsin a short time ago, and im-
pressed upon those of us who observed it the gravity of such
generally used measures as scarlet fever immunization where
there is, apparently, some sensitizing of the individual by the
streptococcus antigen. It points out the necessity for extreme
caution in these cases, as well as the care necessary in observing
that the time limit between doses must be kept to a low max-
imum and not be exceeded without danger of severe reaction.

The patient was a fourth year medical student preparing
for his service in the Isolation Hospital, and he was taking the
series of scarlet fever immunizing doses prescribed for those
students who had positive Dick tests. An interval of four
weeks had elapsed between the third and fourth doses. He ap-
peared and was given his fourth dose with no particular ques-
tioning in regard to the date of the preceding dose. This dose
was given at 10:50 A. M. with no immediate ill effects. At
noon he had a sudden chill with profuse diaphoresis followed
by nausea, vomiting and diarrhea which occurred almost simul-
taneously. The vomitus was watery and bloody as well as the
stool. There was intense abdominal pain, frequent watery
stools which showed much bright red blood, and frequent
hematemesis with bright blood. The prostration increased and
a physician was summoned who sent the patient to the In-
firmary. When seen at the Infirmary the patient was much
prostrated, the skin was cold and "leaky,” the respirations were
sighing, the voice was very weak, the temperature was 94.8 F.;

the blood pressure on admission was 106/74, but quickly fell
to 70/60. The pulse was of fair quality and 84 per minute,
but soon rose to 116. There was marked epigastric tenderness.
Examination of the lungs revealed no pathology. The patient
began to complain of numbness in his fingers and hands, and
the blood pressure dropped to 60/48 in spite of supportive
therapy, which consisted of local heat, caffeine sodium ben-
zoate, adrenalin, fluids, etc. During the course of the first ten
hours the blood pressure rose to 80/54 but fluctuated between
60/48 and 80/54. The temperature rose to 101.8 F. During
the course of the first twenty-four hours the entire urinary
output was 10 cc. On the following day there was a bright

red flush over the entire body which gradually faded in the

course of twenty-four hours.

The past medical history revealed acute neohritis in child-
hood and we feared a recurrence of this difficulty with the

present insult. The blood picture at the time of admission

showed 90% hemoglobin; 6,060,000 red blood cells; 23,100
white blood cells; 61% neutrophiles; 33% stab cells;
4% small lymphocytes; 1% monocytes; and 1% metamyelo-
cytes. On the following day the white blood count rose to
36,100 with 73% neutrophiles; and 23% stab cells, 2% small
lymphocytes, and 2% eosinophiles. The blood count grad
ually returned to normal so that on the day of discharge, eight
days later, it was completely normal again. The urine revealed
a few casts and a trace of albumin but nothing more. The
Wassermann was negative, the blood N.P.N. 33 mg. and the
blood sugar 86 mg. per 100 cc. The only complaint after the
acute part of the episode had passed was generalized body and
muscle soreness. The patient recovered and was discharged
after eight days.

This case should point out the importance of carefully
checking time intervals when giving therapy of this type, and
if more than a week has passed to be very cautious, and not
to administer in such cases as the one reported. The symp-
toms of an anaphylactic reaction with an associated increase in
the permeability of the capillary bed were present in this patient,
as indicated by the bleeding into the gastro-intestinal tract with
the symptoms of shock and prostration. A dilatation of the
superficial vascular bed was apparent from the bright red flush
that appeared.

The Official Journal of the

North Dakota State Medical Association The Minnesota Academy of Medicine Great Northern Railway Surgeons Assn.

South Dakota State Medical Association The Sioux Valley Medical Association American Student Health Association

Montana State Medical Association Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. A. W. Skelsey, Dr. C. E. Sherwood, Dr. Thomas L. Hawkins - Associate Editors

Dr. J . O. Arnson

Dr. W. A. Fansler

BOARD OF EDITORS
Dr. A. Karsted

Dr. A. S. Rider

Dr. C. A. Stewart

Dr. Ruth E. Boynton

Dr. H. E. French

Dr. H. D. Lees

Dr. T. F. Riggs

Dr. J. L. Stewart

Dr. J . F. D. Cook

Dr. W. A. Gerrish

Dr. J. C. McGregor

Dr. J. C. Shirley

Dr. E. L. Tuohy

Dr. Frank I Darrow

Dr. James M. Hayes

Dr. Martin Nordland

Dr. E. I . Simons

Dr. O. H. Wangensteen

Dr. H. S. Diehl

Dr. A. E. Hedback

Dr. 1 C. Ohlmacher

Dr. J . H. Simons

Dr. S. Marx White

Dr. L. G. Dunlap

Dr. E D. Hitchcock

Dr. K. A. Phelps

Dr. S. A. Slater

Dr. H M. N. Wynne

Dr. Ralph V. Ellis

Dr. S M. Hohf

Dr. E. A Pittenger

Dr. D. F. Smiley

Dr. Thomas Ziskin

W. A. Jones, M.D.,

LANCET PUBLISHING CO., Publishers

1859-1931

84 South Tenth Street, Minneapolis, Minnesota

Secretary

W. L. Klein, 1851-193

Minneapolis, Minn., September, 1937

DECREASING INCIDENCE OF
PULMONARY ABSCESS

Hedblom collected a series of 2,458 cases of pul-
monary abscess from the world’s literature and found
that 26.7 per cent followed surgery. He was of the
opinion that in this country from one-third to two-
thirds of the total number of abscesses are post-operative.
King and Lord reported 210 cases, 55.7 per cent of
whom recently had operations on the upper respiratory
tract and 9 per cent followed other operations under
general anesthesia.

Such workers as Smith have established a close rela-
tionship between the bacterial flora of the mouth and
nose and that of pulmonary abscess, and Lemon has
shown that material introduced into the mouths of
anesthetized animals frequently finds its way into the
bronchial tree. Since the close relationship between oral
hygiene and pulmonary abscesses has been understood,
most cautious surgeons insist upon having the mouths of
their patients rendered as free from micro-organisms as
possible before performing operations. Moreover, they
prefer to do surgery about the mouth and throat under
local anesthesia so the cough reflex is not abolished.
Great care is also being exercised by surgeons with ref-
erence to position of patient, anesthesia, etc., to prevent
material from the mouth and nose reaching the bron-
chial tree of the patient. Moreover, the use of carbon-
dioxide inhalations following surgery and encouraging
the patient to cough and expectorate any secretions

which may have reached the lower respiratory tract, is
an attempt to prevent abscess formation. Where such
precautions are practiced by surgeons, a definitely de-
creased incidence of post-operative pulmonary abscesses
has occurred.

By no means are all pulmonary abscesses post-
operative. Indeed, in forty-eight of the 210 cases
reported by King and Lord, the onset was insidious and
the cause was not determined. In a small group, pneu-
monia immediately preceded the abscess. In cases of
pneumonia which do not resolve at the usual time the
bronchoscopist is often able to remove mucous plugs
which results in free drainage and disappearance of
atelectasis, and, thus, abscess may be prevented. Today
numerous foreign bodies are also being removed by the
bronchoscopist before abscess formation has occurred.
Persons who are unconscious from any cause, such as
accident, alcohol, narcotic, or epilepsy, should be placed
in such position that material from the mouth and nose
cannot gravitate to the bronchial tree.

It has long been observed that abscesses and gangrene
of the lung are seen much less frequently in children
than adults. This probably is due to the fact that the
mouth of the child has not become so contaminated
with the organisms capable of producing pulmonary
abscesses. In fact, one rarely finds pyorrhea in children.
Observation has also shown that fewer pulmonary
abscesses develop in women than in men. It seems more
than likely that the better oral hygiene which women

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423

employ, generally speaking, accounts in no small part
for their lower incidence of abscesses.

In addition to the great care exercised by surgeons,
much credit must also go to the campaign for better
oral hygiene as taught in the schools through tooth-
brush drills, awarding gold stars to children who meet
the necessary requirements with regard to their teeth,
and to the fine educational program in this field by the
practicing dentists of the nation.

Such preventive measures apparently have had a
definite influence on the incidence of pulmonary abscess.
Within a period of approximately ten years in some
parts of the country, the incidence has been reduced
more than one-half.

J. A. M.

References

Hedblom, C. A.: The Treatment of Pulmonary Abscess, Soc.

Proc., Jour. Amer. Med. Assn., 100:368, February 4, 1933.

King, Donald S. and Lord, Frederick T. : Certain Aspects of

Pulmonary Abscess from an Analysis of 2 1 0 Cases, Ann. Int. Med.,
8:468, October, 1 934.

Smith, David T.: Oral Soirochetes and Related Organisms in

Fuso-Spirochotal Disease, Williams and Wilkins Co., Baltimore,
1932.

Lemon, Willis: Aspiration: Experimental Study, Arch. Surg.,

Part II, 12:187, 1926.

REGIONAL ILEITIS

Hagen has told us that since Crohn, Ginzburg and
Oppenheimer first, in 1932, described the entity known
as regional ileitis, 50 cases have been reported in the
literature. It is most frequently confused with some
form of colitis, and approximately 50 per cent of the
cases reported have previously been operated upon for
appendicitis. In any widespread effort, then, to reduce
mortality from appendicitis, such pathology should be
borne in mind.

Clinically, this disease is suggested by recurrent at-
tacks of diarrhea, pain in the right lower quadrant,
nausea, vomiting, a low fever and leucocyte count.
Often a mass is palpable in the appendiceal region. In
advanced cases, the involved intestinal loops roentgen-
ologically resemble a cotton string, a finding designated
by Kantor as the "string sign.”

Pathologically, there is a thickening and tubular con-
striction of the lumen of the terminal eight to 12 in-
ches of the ileum. This induration and inflammation
often involves the mesentery. Ulceration of the mucosa
develops, obstruction often ensues, and fistulae form.
No specific microorganisms have been awarded the
etiological role.

The significance of recognizing the process clinically
lies in preparedness to treat properly the lesion at opera-
tion. Opinion is now beginning to crystallize regarding
correct treatment. Meyer and Rosi believe that acute
regional enteritis limited to the bowel, and not associated
with mesenteric thickening, may resolve spontaneously.

Chronic regional enteritis with stenosis is best treated by
resection or a short-circuiting operation. When compli-
cated by an external intestinal fistula, resection of the
involved bowel with the fistulous tract is necessary to
close the fistula.

Significant is the fact that reports of cases are already
filtering into the literature from the rural and less popu-
lous districts. Outposts have already been established,
and the frontier is pressing onward in the conquest of
a new disease.

J. E. S.

SOUP THERMOMETERS

There should be a law regulating the temperature of
liquids served in public eating places. Often consisting
of soups or beverages on the assumption that these can
be swallowed without the annoying delay imposed by
time-consuming mastication, if too hot they are not only
unpleasant but actually harmful. Chicken broth, as
everyone knows, has pretty much the same surface ap-
pearance whether scalding hot or merely warm; and so
has a cup of hot chocolate; and this is true whether
served at a lunch counter or in the home. As it is now,
we have no warning. Good manners compel us to
swallow the fiery potion, when by right we should spew
it out.

It has been suggested that the greater prevalence of
cancer of the throat among Chinese men than women
might be due to the fact that the men eat at the first
table while the rice served is exceedingly hot. The
women, who eat after the men, are not subjected to this
thermal infliction.

So far as we know, no study has been made of the
comparative incidence of cancer of the stomach in per-
sons who eat and hastily swallow very hot foods and
those who avoid this possible danger. In this day of
haste in eating going hand in hand with the increase of
gastric ulcer and cancer, such statistical study might
yield information of an illuminating nature. Certain
it is that the temperature of foodstuffs, especially soups
and beverages, varies tremendously. With the modern
gadgets that have already entered the culinary art, it
should be simple enough in like manner as we now
order a "three or four-minute egg” to be able to ask for
soups and beverages of certain temperatures with the
assurance that they be obtained as ordered.

Until this matter can be arranged, we propose that
hurried mortals carry soup thermometers in self defense.
The consternation stricken hostess might never forgive
the rudeness but neither could she ever forget the im-
pressive lesson entirely justifiable in the light of cancer
provoking possibilities.

A. E. H.

424

THE JOURNAL-LANCET

Societies

PROCEEDINGS OF THE
SECOND NATIONAL CONFERENCE ON
COLLEGE HYGIENE*

The First National Conference on College Hygiene was held
in 1931 at Syracuse University under the sponsorship of the
President’s Committee of Fifty on College Hygiene, the
American Student Health Association and the National
Health Council. Its purpose was "to focus the attention of
our most competent authorities upon the identification of the
basic problems of college hygiene; secure their expert analysis
of those problems; and then have them formulate a consequent
statement of their conclusions.”

The Second National Conference on College Hygiene was
held under the same auspices and with a similar purpose in
Washington, D. C., December 28-31, 1936. Under the leader-
ship of President Livingston Farrand and according to plans
developed by Dr. William F. Snow, Miss Louise Strachan and
an Organizing Committee each of the 347 registered delegates
joined or was assigned a place in one of the five Sections on
one of the 25 working committees of the Conference. The
results of the deliberations of the working committees were
summarized in each Section and are briefly set forth by Dr.
Kendall Emerson and his Continuation Committee in the 112-
page report herewith reviewed.

The Section on Organization and Correlation under the
leadership of Dr. Thomas Storey included the following among
its conclusions:

(1) "College authorities have a definite responsibility to
organize and maintain a college hygiene program that will
effectively assist students in preparing themselves physically,
mentally and socially for healthful living, for wholesome home
building and parenthood, and for wise leadership in the forma-
tion and maintenance of high standards of individual, group,
and community health.”

(2) "It should be the policy of the college to give the
student the best possible practical opportunities for securing
experience in the wise management of his affairs while sick.”
"Whether or not a college shall become in loco parentis for its
students when ill, can be decided only by its trustees.”

(3) College authorities should make a planned effort to
"build up a teaching relationship between the physician in the
student health service staff and the individual student who
comes to him for health examination, conference, consultation
or other help.”

(4) "The responsibility rests on college authorities to have
its department of physical education activities so organized
that it will consider leadership in the formation of health
habits and health ideals as one of the determining objectives
of the department.”

(5) "Appointment to the college staff should be contingent
on the candidate’s passing satisfactorily a health examination.”

(6) "There should be no competition in the practice of
medicine and dentistry between the full-time college staff and
local private practitioners.”

(7) "It is urged that college authorities organize their
hygiene program as a unit made up of effectively cooperating
officers, committees, departments, division and schools.”

The Section on Student Health Service under the leadership
of Dr. Ralph I. Canuteson included among other conclusions
the following:

(1) "It is recommended that there be one full-time physician

for aDproximately each 500 resident students. There

should be thirty beds for every thousand resident students.

There should be one nurse for every eight beds.”

(2) "Surgical operations and other strictly clinical treat-
ment of an extensive nature are not a primary function of the

* Health in Colleges. Proceedings of the Second National Con-
ference on College Hytriene. ComDiled by the National Tubercu-
losis Association. Cloth. Pp. 112. New York City: National

Tuberculosis Association, 1937.

college, but should be undertaken only because of conditions
which may practically demand such activity of the college.

(3) "College matriculation for all new students, either grad-

uate or undergraduate, should not be considered complete until
a health examination has been given by a physician and his
recommendation for the admission of the student has been
made. . Where possible annual health examinations for

all students are recommended.”

(4) "The health service should bring all reasonable pressure
to bear in order that students secure corrections of remediable
conditions.”

(5) "The Standard Classified Nomenclature of Diseases is
advised.”

The Section on Health Teaching led by Mrs. Kathleen W.
Wooten included the following in their conclusions:

( 1 ) "There should be a required course in hygiene of not

less than two semester hours in all institutions of the collegiate
grade . . Credit should be given for such a course.”

(2) "Health teaching in college must be recognized as one

of the most difficult teaching assignments in the college curric-
ulum. The qualifications of the teachers as to per-

sonality as well as to sound professional training become par-
ticularly important.”

(3) "The subject matter presented should be developed with
reference to the student’s own problems.”

(4) "Most effective consideration of student health problems
can be obtained in classes small enough to allow for individual
participation in the discussions.”

The Section on Special Problems under the chairmanship of
Dr. Jesse Williams summarized its conclusions under its sub-
committee headings. Among those conclusions we find the
following:

(la) "It should be realized that mental ill health or mal-
adjustment ... is essentially a clinical manifestation . . .

it is fundamentally a medical concern it is therefore

urged that the approach to this category of problems be under
the direction of a physician qualified in psychiatry.”

(b) The maximum load per full-time psychiatrist should be
150 treatment cases per academic year.

(c) "After the psychiatric unit has become established, about
10% annually of the student body may be expected to use it.

(d) "It is just as important a function to discourage negative
material as to encourage the positive.”

(2a) "The food needs of college students are characteristically
those of the period of growth — higher proportions of growth —
promoting materials and larger allowances of energy-bearing
foods.”

(b) "It is optimum in contrast to passable health that the
college nutrition program should have as its objective.

"In fraternity and sorority houses the advisory assistance of
a trained dietitian should be made available by the college
administration.

(d) "To reach all students the fundamentals (of nutrition)
should be taught as an important unit in the course in fresh-
man hygiene.

(3a) "There should be a proper distribution of required and
elective class work and provision for all students (including
athletes) to acquire skill in a variety of activities including those
of recreative, continuing types, and minimum achievement stan-
dards for all students (including athletes) should be set.”

(b) "An individual physical education program should be
provided for all students who are unfit for participation in
normal activities.’ ’

(4a) "College hygiene should deal at least with four major
aspects of social hygiene: ( 1 ) educational; (2) social-protective;

(3) legal; (4) medical.”

(b) "There should be in each college an effective committee
representing the several departments concerned with social
hygiene instruction and problems ...”

(5a) "Colleges and universities must accept the responsibility
for seeing that all places in which students are housed . . .

THE JOURNAL-LANCET

425

are safe, sanitary and properly managed from the standpoint of
health.”

(b) "It is recommended that special care be taken to insure
an effective spread of opportunity for sharing in recreation and
all forms of social activity among students ...”

(6a) "A complete history of all new students should be
taken to discover (tuberculosis) contact cases and the nature of
previous lung infection in the student or his family ...”

(b) "A physical examination should be made of all students
on admission and annually thereafter.”

(d) "Routine flat X-ray films of the chest are recommended
on all new students showing a positive tuberculin reaction and
should be repeated on such cases yearly.”

(e) "Routine flat X-ray films of the chest are recommended
as a matter of record on all new students, regardless of the
tuberculin reaction, when sufficient funds are available.”

The Section on the Relation of College Hygiene to Teacher
Training and Secondary Schools under the chairmanship of Dr.
John Sundwall attempted with considerable success to answer
the three following questions:

( 1 ) "In view of the fact that many preventable and correct-
able physical defects are found through the medical entrance
examinations of college freshmen, what may be expected of
secondary schools in the prevention and correction of such
defects and what can the colleges do to assist them?”

(2) "In view of the fact that recent health knowledge tests
of college freshmen indicate that hygiene instruction in sec-
ondary schools is uncertain and variable, what may be expected
of secondary education to improve quantity and quality of its
health instruction and how can colleges cooperate to bring this
about?”

(3) "What relationship should exist between regular college
hygiene instruction and hygiene training courses designed for
teachers in the secondary schools?”

In the 112 pages are assembled the conclusions of our most
competent college health authorities. Between the reports of
different committees some slight discrepancies are discoverable.
Throughout the entire report there is discernable, however, the
very definite conclusion that college health programs have very
important functions to perform but that these functions are
primarily preventive and educational rather than therapeutic.

Let us hope that every college administrator and student
health worker will have the opportunity to review this little
volume since it so obviously presents a true consensus of
opinion in this important field.

D. F. Smiley, M.D.

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB

Meeting of March 11, 1937.

Dr. Donald McCarthy, Presiding.

ARTIFICIAL FEVER AND PRONTYLIN AS
ADJUNCTS IN THE TREATMENT OF MENINGO-
COCCIC INFECTIONS
Dr. E. S. Platou, and Dr. M. Cook, (by invitation) .

Doctors Platou and Cook presented a preliminary report on
experiments carried out with meningococci. These indicate:

1. That most strains of the meningococcus have a relatively
short thermal death time in vitro.

2. That the course of meningococcal infection in Macaccus
Rhesus monkeys is influenced favorably by fever therapy.
(Five strains employed) .

3. That certain types of human meningococcus infections re-
cover following the use of hyperthermia. (The authors
reported two from their own and two from Dr. Bennett’s
service) .

4. That prontylin (sulfanilamide) will protect mice against
large doses of meningococci and may serve as a valuable
adjunct to serum therapy in human meningococcic infec-
tion.

The details of the authors’ work on meningococcic infection
will be published more fully in another communication.

Case Report:

Streptococcic Meningitis Treated With Prontosil —

Recovery

Dr. E. D. Anderson

Abstract

A case of hemolytic streptococcic meningitis of otitic origin
was reported. The child was treated with prontosil and pron-
tylin, and made a rapid and complete recovery.

Discussion

Dr. E. S. Platou: From the evidence available it would

seem that prontosil and prontylin may offer us something quite
promising in the treatment of virulent hemolytic streptococcus
and meningococcic infections. We have had experience with
the drug in several different types of infection during the past
few months at the Minneapolis General Hospital. Although
the results seem encouraging our series with controls are still
too small to warrant any conclusions. I think, however, that we
must not lose sight of accepted principles of treatment that are
well established when we use this or any other new method of
treatment. Sixty per cent of 102 cases of purulent meningitis
observed at the hospital had otitic and sinus foci that were sup-
purative. It should be borne in mind that in all the recovered
cases of purulent meningitis reported in the literature to date,
two things have uniformly been done, namely, eradication of
the focus and spinal drainage.

Dr. Willard D. White: This case report is very interest-
ing. Dr. Anderson is to be congratulated on the splendid out-
come. He has brought out a point which bears emphasis. When
a new substance is used in the treatment of a serious condition
and a favorable outcome is the result it is natural to ascribe the
success to the new substance. However, as Dr. Anderson has
related there are something like 76 cases where streptococcus has
been found in the cerebrospinal fluid and the patient has gotten
well. These have all occurred previous to the advent of pron-
tosil. I remember one such case that I saw during my interne-
ship at Cook County Hospital. A nurse had had scarlet fever,
otitis media, mastoiditis and finally, streptococcus meningitis.
She was on the service of Dr. Frederic Tice and I was interne
on this service. We naturally thought when we found the
streptococcus that a fatal outcome would be almost certain. She
was treated in the ordinary way, the mastoid operated upon, re-
peated spinal punctures done and she got well. I happened to
see her on the street a year or so later in Chicago and she was
entirely well.

In my opinion Dr. Anderson sounds the right note when he
states that there is some possibility that the recovery of such
patients might be due to other factors in the treatment besides
the use of prontosil. The use of this substance may be and
probably is of great aid.

Dr. H. B. Sweetser, Jr.: I had two cases at St. Mary’s who
had acute hemolytic streptococci in their sinuses, one in the
maxillary and one in the frontal. They did not have menin-
gitis but they did have a streptococcus infection. We used
prontolyn and prontosil. In neither of them was there any
particular effect to be observed from the drug. I think, as Dr.
White says, we are going to be very enthusiastic about this new
dye, but after a while we may find certain limitations as Dr.
Platou did in his work. I did not mean to criticize Dr. An-
derson. I think he is to be congratulated on the way this patient
has been handled.

There is one thing I want to say, — that as I grow older it
seems I become more confused instead of less confused. That
might be an obvious statement, I don’t know; but it has been
taken as an axiom that any focus of infection should be
drained. We all recognize that if we have an acute frontal
sinus or an acute ethmoid sinus, opening it might produce a
brain abscess or meningitis, so usually such an infection is left
alone. It seems to me that is true of abscessed teeth sometimes.
Apparently that is different from other situations as seen by an
ordinary internist because you always drain every hemolytic
streptococcus focus and perhaps my experience has been dif-
ferent from the experience of nose and throat men.

Dr. E. D. Anderson: I would gather that if a man reports
a case of recovery from some particular form of treatment, it

426

THE JOURNAL-LANCET

is immediately assumed that he is going around stating that
this treatment is a cure for all ills. This is far from the fact
in this case. I do feel that when we have a drug which is
shown to have an effect on hemolytic streptococci, and when
we get a result such as was obtained in this case, we are justi-
fied in reporting it. I would be the last one to say that every
case of hemolytic streptococci would be cured by prontosil, as
no one knows. All I do say is that this boy made a complete
recovery following the use of prontosil and I must admit that
I got quite a kick out of seeing him do it. As to the question
of cleaning up the focus of infection in streptococcic menin-
gitis, to me this case is interesting from this standpoint. I am
very sure some might criticize me for not having a mastoid-
ectomy done on this boy. There is no question that he had an
ear condition but X-ray showed comparatively little destruction
of cells on that side. It seemed to me, inasmuch as meningiti?
and not his ear was the primary condition, that we were justi
fied in letting the mastoid ride. We did so and the child re
covered and under the same circumstances we would do th»
same again.

TRACHEOTOMY: A STUDY OF 65 CONSECUTIVE
CASES

Lawrence R. Boies, M.D.

The operation of tracheotomy is done for one of two pul
poses — to relieve impending suffocation when there is obstruc-
tion at the glottis, or to provide an added factor of safety pre-
liminary to surgical treatment or radiation in certain cases of
tumor in or adjacent to the larynx. In the latter condition, tie
selection of tracheotomy is the unquestioned procedure. When
an obstructive laryngitis due to a recent acute inflammation, or
edema of the glottis from some other cause exists, the merits of
intubation are usually first considered.

It is not my purpose in this brief discussion to consider in
detail the factors in a choice between intubation or tracheotomy.
The following considerations express the attitude of the ma-
jority of contributors to the current literature on this subject:

1. Intubation may be suitable in the relief of laryngeal ob-
struction when the need for this relief is for a relatively short
duration.

2. It is unsuitable when there is a membrane formation below
the level of the larynx or there is much secretion which should
be afforded removal.

3. An infant tends to take food or fluids poorly by mouth
with an intubation tube in place.

4. Intubation requires that an experienced intubator be avail-
able to put the tube back once it is coughed out.

5. Repeated intubations or prolonged use of an intubation
tube may produce an irritation in the subglottic area which may
cause stenosis. Tucker has emphasized the fact that tracheoto-
my conserves the laryngeal structure better than intubation in
infants.

6. The factor of drainage provided by tracheotomy in the
acute fulminating infections has probably been overlooked.

7. The fact that a tracheotomy opening does not admit air
warmed and moistened in the upper respiratory tract has been
shown from clinical experience to be an unimportant considera-
tion. The use of a warm steam room is a satisfactory substi-
tute.

There seem to be misconceptions regarding the mortality and
ill effects from tracheotomy. This review was suggested by that
fact.

In the five year period preceding January 1st, 1937, I have
had the opportunity to observe 65 consecutive cases of trache-
otomy on the laryngologic service at the University, and in my
private practice. In the same period, 10 additional tracheoto-
mies were performed at the University Hospital by the gen-
eral surgical staff. In this same period but one intubation was
done. This is accounted for by the fact that there is no con-
tagious service at the University Hospital and cases of obstruc-
tive laryngitis due to diphtheria are not encountered. A num-
ber of cases of mild obstructive laryngitis were encountered in
which adequate nursing care and the removal of secretions
through the direct laryngoscopic exposure effected a cure.

Tracheotomy was performed in the 65 cases for the follow-

ing conditions:

1. Tumors
Larynx —

Carcinoma 32

Multiple papillomata 2

Chondroma 1

Adjacent to the glottis (upper end of esophagus,
pharynx, epiglottis, piriform sinus, etc.) 11

2. Infections
Acute —

Originating in pharynx or larynx 8

Laryngotracheo-bronchitis .. 2

Chronic

Syphilis or tuberculosis (1 each). 2

3. Paralysis

Bilateral recurrent paralysis following thyroid

surgery 2

4. Trauma

Stenosis from fracture of larynx 1

Edema from a blow on the larynx 1

Edema from bronchoscopic removal of foreign body 2
For removal of a foreign body 1

There were four deaths following tracheotomy. One was in
a case of an inoperable carcinoma of the larynx in which a
fatal hemorrhage occurred from the tumor and death four days
after the operation. Another death occurred from pneumonia
following a lateral pharyngotomy for cancer of the post-cricoid
area. The tracheotomy had been done 10 days previously. The
third case was in a 3 year old child invalided by Little’s disease
who developed an acute throat infection with laryngeal obstruc-
tion. Death occurred apparently from sepsis a few hours after
the operation. The fourth case was one of acute laryngotracheo-
bronchitis relieved temporarily by tracheotomy but requiring
repeated bronchoscopic removal of the glue-like membrane from
the trachea and bronchi. Death occurred several days after the
tracheotomy.

It would seem incorrect to designate these as surgical mor-
talities due to tracheotomy.

In the other 61 cases, the performance of tracheotomy was
not followed by an increase in morbidity. In the cases of
marked laryngeal obstruction, tracheotomy brought dramatic
relief of this terrifying symptom.

A variable amount of tracheitis and bronchitis usually fol-
lows. There is a moderate temporary elevation of temperature
and cough. With adequate nursing care, which is highly im-
portant, the reaction promptly subsides.

Tracheotomies have been classified as "Emergency” and
"Orderly.” The emergency type is fortunately much the less
common and denotes a circumstance in which there is the sud-
den need to open the trachea below the cricoid cartilage. The
trying conditions under which this is done are in sharp contrast
to the ease with which most orderly tracheotomies are done
except in the cases with short fat necks. Emergency tracheoto-
mies can be converted to the orderly type by the insertion of a
bronchoscope through the glottis into the trachea. This pro-
vision, however, is usually not available to the average case
requiring the operation unless it be done within access to the
physician equipped to do bronchoscopy. There is a very satis-
factory substitute, however, in the form of this instrument
known as the Mosher life saving tube. This slide illustrates
its use. It can be introduced with the same maneuvers used to
introduce intubation tubes, but more easily.

The technic of tracheotomy is well standardized among lar-
yngologists. The old descriptive terms of high, low, or median
tracheotomy have been discarded. All tracheotomies should be
low except those preliminary to laryngectomy when conserva-
tion of as much of the trachea as is possible is important.

We prefer the removal of a disc of cartilage slightly larger
than the tube to be inserted. The incision, unless unusually
long, is not sutured. Drainage around the tube is important.
Suturing causes more reaction and a tendency to emphysema.
Experimental work (Richards & Glenn) has shown that this

THE JOURNAL-LANCET

427

type of opening does not interfere with the patency of the
tracheal lumen after the tube is removed and healing has taken
place. It seems illogical to insert a tube through a narrow

transverse or longitudinal slit with the resultant tension on the

margins of this slit. An adequate opening facilitates exchange
of tubes with the least amount of irritation.

There seems to be a tendency to use too small a tube. Clin-
ical observation indicates that the size of the lumen is not a
factor in producing irritation in the trachea. In this respect
only the length of the tube is important. The larger the lumen
of the tube the less the tendency for it to clog with mucus

to an extent to interfere with an adequate airway. A larger

lumen is also easier to keep clean. ,

Nursing care by those experienced in the management of
this type of care is extremely important.

Patients are surprisingly comfortable in permanent trache-
otomy. Tracheitis and bronchitis are uncommon after the var-
iable amount of this reaction present in the first few days after
the operation. There seems to be no increased susceptibility to
pneumonia. Thomson and Wood have each reported a case of
tracheotomy tube worn over 70 years. Wood remarked that
his patient claimed that she had never had bronchitis.

PROGRAM

INTERNATIONAL MEDICAL ASSEMBLY
INTER-STATE POSTGRADUATE MEDICAL
ASSOCIATION OF NORTH AMERICA

October 18, 19, 20, 21, 22, 1937

ST. LOUIS, MISSOURI

MONDAY A. M.

Diagnostic Clinic: "Cosmetic Results in the Treatment of
Cancerous Skin Lesions”— Dr. Joseph Eller, Professor of Clin-
ical Dermatology and Syphilology, New York Postgraduate
Medical School, Columbia University, New York, N. Y.

Diagnostic Clinic: "Hypertensive Heart Disease, Manifesta-

tions, Diagnosis, Treatment” — Dr. Fred M. Smith, Professor of
Theory and Practice of Medicine, State University of Iowa
College of Medicine, Iowa City, Iowa.

Diagnostic Clinic: "Deficiency Diseases” — Dr. Russell L.

Haden, Chief of Medical Division, Cleveland Clinic, Cleveland,
Ohio.

Intermission to Review Exhibits

Diagnostic Clinic: "The Symptoms and Treatment of In-

juries of the Spinal Cord” — Dr. Loyal Davis, Professor of Sur-
gery, Northwestern University School of Medicine, Chicago,
Illinois.

Diagnostic Clinic: "Types of Obesity and Their Treat-

ment”— Dr. Reginald Fitz, Associate Professor of Medicine,
Boston University Medical School, Boston, Mass.

Noon Intermission

Diagnostic Clinic: "Surgical Treatment of Peptic Ulcer” —

Dr. Donald C. Balfour, Professor of Surgery, University of
Minnesota Graduate School of Medicine, Mayo Clinic, Roches-
ter, Minn.

Address: "Ulcerative Colitis and Its Surgical Management”
— Dr. Richard B. Cattell, Lahey Clinic, Boston, Massachusetts.

Address: "The Roentgen Treatment of Infections” — Dr.

Frederick M. Hodges, Professor of Clinical Radiology, Medical
College of Virginia, Richmond, Virginia.

Intermission to Review Exhibits

Address: "Meningitis Secondary to Disease of the Bones of
the Skull” — Dr. Wells P. Eagleton, Newark, New Jersey.

Address: "The Treatment of Urinary Infections in Infants
and Children” — Dr. John R. Caulk, Professor of Clinical
Genito-Urinary Surgery, Washington University School of
Medicine, St. Louis, Missouri.

Address: "Prenatal Care”— Dr. Otto H. Schwarz, Professor
of Obstetrics and Gynecology, Washington University School
of Medicine, St. Louis, Missouri.

Address: "Granulomatous Lesions of the Intestines” — Dr.

Claude F. Dixon, Assistant Professor of Surgery, University

of Minnesota Graduate School of Medicine, Mayo Clinic,
Rochester, Minn.

Dinner Intermission

Address: "Recent Advances in the Field of Abdominal Sur-
gery”— Mr. W. Hugh Cowie Romanis, F.R.C.S., Surgeon to
St. Thomas Hospital, London, England.

Address: "The Influence of Drugs Upon the Physiology of
the Failing Heart” — Dr. Maurice B. Visscher, Professor of
Physiology and Head of the Department, University of Min-
nesota Medical School, Minneapolis, Minnesota.

Address: "The Mechanism and Treatment of Congestive

Heart Failure” — Dr. Tinsley R. Harrison, Associate Professor
of Medicine, Vanderbilt University School of Medicine, Nash
ville, Tennessee.

Address: "The Diagnostic Significance of Abdominal Pain”
— Dr. Frederick J. Kalteyer, Clinical Professor of Medicine,
Jefferson Medical College, Philadelphia, Pennsylvania.

Address: "Carcinoma of the Stomach” — Dr. Waltman Wal-
ters, Professor of Surgery, University of Minnesota Graduate
School of Medicine, Mayo Clinic, Rochester, Minnesota.

Address: "Chronic Prostatitis” — Dr. Cyrus E. Burford,

Professor of Urology, St. Louis University School of Medicine,
St. Louis, Missouri.

TUESDAY A. M.

Diagnostic Clinic: "The Effects of General Infection on the
Nervous System of Children” — Dr. Bronson Crothers, Assist-
ant Professor of Pediatrics, Harvard University Medical School,
Boston, Mass.

Diagnostic Clinic: "Spastic Paralyses” — Dr. Alan deForest

Smith, Clinical Professor of Orthopedic Surgery, Columbia
University College of Physicians and Surgeons, New York,
N. Y.

Diagnostic Clinic: "The Relation of Chronic Cystic Mastitis
to Cancer of the Breast” — Dr. Dean Lewis, Professor of Sur-
gery, Johns Hopkins University School of Medicine, Baltimore.
Maryland.

Intermission to Review Exhibits

Diagnostic Clinic: "Pitfalls in the Diagnosis of Acute Ab-
dominal Conditions” — Dr. Anton Ochsner, Professor of Sur-
gery, Tulane University of Louisiana School of Medicine, New
Orleans, La.

Diagnostic Clinic: "Various Types of Edema and Their
Treatment” — Dr. David P. Barr, Busch Professor of Medicine,
Washington University School of Medicine, St. Louis,
Missouri.

Noon Intermission

Diagnostic Clinic: "The Management of Compound Frac-

tures of the Extremities” — Dr John J. Moorhead, Professor of
Clinical Surgery, New York Postgraduate Medical School,
Columbia University, New York, N. Y.

Address: "Migraine” — Dr. Thomas Cecil Hunt, St. Mary’s
Hospital, London, England.

Address: "Cicatrizing Enteritis — A Neglected Clinical

Entity” — Dr. Elliott C. Cutler, Moseley Professor of Surgery,
Harvard University Medical School, Boston, Mass.

Intermission to Review Exhibits

Address: "The Problem of Ocular Tuberculosis” — The

Joseph Schneider Foundation Presentation — Dr. Alan C. Woods,
Acting Professor of Ophthalmology, Johns Hopkins University
School of Medicine, Baltimore, Md.

Address: "Combined Abdomino-Perineal Resection for Car-
cinoma of the Rectum” — Dr. Thomas E. Jones, Cleveland
Clinic, Cleveland, Ohio.

Address: "Early Diagnosis and Treatment of Cancer of the
Cervix” — Dr. John R. Fraser, Professor of Obstetrics and
Gynecology, McGill University Faculty of Medicine, Montreal,
Canada.

Address: "General Consideration of Fractures of the Femur”
— Dr. Marion L. Klinefelter, St. Louis, Missouri.

Dinner Intermission

Address: "Growth Disturbances of the Pelvis and Femur
Resulting From Diseases of the Hip Joint” — Dr. Dallas B.
Phemister, Professor of Surgery, University of Illinois College
of Medicine, Chicago, Illinois.

428

THE JOURNAL-LANCET

Address: "The Post Hoc Ergo Propter Hoc Fallacy in Medi-
cine”— Dr. Robert D. Rudolf, Professor Emeritus of Thera-
peutics, University of Toronto Faculty of Medicine, Toronto,
Canada.

Address: "Allergy as Related to the Otolaryngologist” — Dr.
Harold G. Tobey, Boston, Massachusetts.

Address: "Newer Methods in the Medical Treatment of

Peptic Ulcer” — Dr. Horace M. Soper, St. Louis, Missouri.

Address: "Subdural Hematoma”-— Dr. Eric Oldberg, Pro-

fessor of Neurology and Neurological Surgery, University of
Illinois College of Medicine, Chicago, Illinois.

Address: "Toxemias of Pregnancy”- — Dr. Nicholson J. East-
man, Professor of Obstetrics, Johns Hopkins University School
of Medicine, Baltimore, Maryland.

WEDNESDAY A. M.

Diagnostic Clinic: "Hay Fever” — Dr. J. Harvey Black, Pro-
fessor of Preventive Medicine, Baylor University College of
Medicine, Dallas, Texas.

Diagnostic Clinic: "Newer Methods of Vascular Surgery” —
Dr. Wayne Babcock, Professor of Surgery and Clinical Sur-
gery, Temple University School of Medicine, Philadelphia,
Pennsylvania.

Diagnostic Clinic: "Bronchiectasis and Certain Phases of

Tuberculosis” — Dr. Charles R. Austrian, Associate Professor
of Medicine, Johns Hopkins University School of Medicine,
Baltimore, Maryland.

Intermission to Review Exhibits

Diagnostic Clinic: "Dyspepsia, Organic Reflex and Func-

tional”-— Dr. Walter C. Alvarez, Professor of Medicine, Uni-
versity of Minnesota, The Mayo Foundation, Rochester, Minn.

Diagnostic Clinic: "Syphilis of the Central Nervous Sys-

tem”— Dr. Leon H. Cornwall, Associate Professor of Neurol-
ogy, Columbia University College of Physicians and Surgeons,
New York, N. Y.

Noon Intermission

Diagnostic Clinic: "Abdominal Pain” — Dr. Irvin Abell,

Clinical Professor of Surgery, University of Louisville School
of Medicine, Louisville, Kentucky.

Address: "Drugs in the Treatment of Heart Disease” —

Dr. Robert L. Levy, Professor of Clinical Medicine, Columbia
University College of Physicians and Surgeons, New York,
N. Y.

Address: "Diagnosis and Treatment of Brain Abscess” —

Dr. Walter E. Dandy, Adjunct Professor of Neurological Sur-
gery, Johns Hopkins University School of Medicine, Baltimore.
Maryland.

Address: (Subject to be supplied) — Dr. Charles H. Mayo,

Mayo Clinic, Rochester, Minn.

Intermission to Review Exhibits

Address: "X-Ray Treatment of the Pituitary Gland” — Dr.
Merrill C. Sosman, Assistant Professor of Roentgenology, Har-
vard University Medical School, Boston, Mass.

Address: "Water Balance in Surgical Patients With Special
Reference to Pre- and Postoperative Management” — Dr. Fred-
erick P. Coller, Professor of Surgery, University of Michigan
Medical School, Ann Arbor, Michigan.

Address: "Anxiety States in General Practice” — Dr. William
J. Kerr, Professor of Medicine, University of California Med-
ical School, San Francisco, California.

Assembly Dinner

For Members of the Profession, Their Ladies and Friends
7:00 P. M.

Informal

Dr. John F. Erdmann, Master of Ceremonies.

Presentation of Token of Appreciation to Dr. George W.
Crile, Cleveland, Ohio.

Addresses by eminent members of the profession and other
distinguished citizens of the world.

THURSDAY A. M.

Diagnostic Clinic: "Cirrhosis of the Liver” — Dr. Charles A.

Elliott, Professor of Medicine, Northwestern University School
of Medicine, Chicago, Illinois.

Diagnostic Clinic: "Factors to be Considered in the Diag-

nosis of Diseases of the Genito-Urinary Tract” — Dr. William
E. Lower, Cleveland Clinic, Cleveland, Ohio.

Diagnostic Clinic: "Nephritis” — Dr. Jonathan C. Meakins,
Professor of Medicine, McGill University Faculty of Medicine,
Montreal, Canada.

Intermission for Review of Exhibits

Diagnostic Clinic: "Post-Operative Fistulae With Special

Reference to the Gall-Bladder” — Dr. John F. Erdmann, At-
tending Surgeon, New York Postgraduate Hospital and Med-
ical School, Columbia University, New York, N. Y.

Diagnostic Clinic: "The Relation of Diabetes to Arterio-

sclerosis”— Dr. Elliott P. Joslin, Clinical Professor of Medicine,
Harvard University Medical School, Boston, Mass.

Noon Intermission

Address: "A New Approach to the Treatment of Peptic

Ulcer” — Mr. Wilson Hey, F.R.C.S., Surgeon, Manchester
Royal Infirmary, Manchester, England.

Address: (Subject to be supplied) — Dr. William J. Mayo,

Mayo Clinic, Rochester, Minn.

Address: "The Adherent Posterior Duodenal Ulcer” — Dr.

J. William Hinton, Associate Professor of Clinical Surgery,
New York Postgraduate Medical School, Columbia University,
New York, N. Y.

Address: "The Prevention and Treatment of the Exan-

themata”— Dr. John A. Toomey, Associate Professor of Ped-
iatrics, Western Reserve University School of Medicine, Cleve
land, Ohio.

Intermission to Review Exhibits

Address: "High Saphenous Ligations Plus Injection for

Varicose Veins of the Leg” — Dr. William D. Haggard, Pro-
fessor of Surgery, Vanderbilt University School of Medicine,
Nashville, Tennessee.

Address: "Endocarditis” — Dr. Ralph A. Kinsella, Professor
of Internal Medicine, St. Louis University School of Medicine,
St. Louis, Missouri.

Address: "Recent Advances in Hormone Therapy as Applied
to Gynecological Problems” — Dr. Emil Novak, Associate in
Gynecology, Johns Hopkins University School of Medicine;
Associate Professor of Obstetrics, University of Maryland
School of Medicine, Baltimore, Maryland.

Dinner Intermission

Address: "The Surgical Treatment of Diverticulitis” — Dr.

Fred W. Rankin, Lexington, Kentucky.

Address: "Diagnosis and Treatment of Displacements of

the Uterus” — Dr. William H. Vogt, Director of the Depart-
ment of Gynecology and Obstetrics, St. Louis University School
of Medicine, St. Louis, Missouri.

Address: "The Relation of the Development of the Child

to the Endocrine System” — Dr. Charles R. Stockard, Professor
of Anatomy, Cornell University Medical College, New York,
N. Y.

Address: "Indications for Exploratory Laparotomy” — Dr.

William T. Coughlin, Professor of Surgery, St. Louis Univer-
sity School of Medicine, St. Louis, Mo.

Address: "Tumors of the Kidney” — Dr. Herman L.

Kretschmer, Clinical Professor of Surgery, Rush Medical Col-
lege, University of Chicago, Chicago, Illinois.

FRIDAY A. M.

Diagnostic Clinic: "Surgical Lesions of the Common and
Hepatic Ducts” — Dr. Frank H. Lahey, Director of Surgery,
Lahey Clinic; Surgeon to the New England Baptist Hospital
and the New England Deaconess Hospital, Boston, Mass.

Diagnostic Clinic: "The Diagnosis and Management of Car-
diac Arrhythmias” — Dr. Roy W. Scott, Professor of Clinical
Medicine, Western Reserve University School of Medicine,
Cleveland, Ohio.

Diagnostic Clinic: "Chest Surgery” — Dr. Evarts A. Graham,
Bixby Professor of Surgery, Washington University School of
Medicine, St. Louis, Missouri.

Intermission to Review Exhibits

Diagnostic Clinic: "The Medical Treatment of Arthritis” —
Dr. Cyrus C. Sturgis, Professor of Internal Medicine, Univer-
sity of Michigan Medical School, Ann Arbor, Michigan.

Diagnostic Clinic: "Diagnosis and Management of Diseases
of the Thyroid Gland” — Dr. George Crile, Cleveland Clinic,
Cleveland, Ohio.

THE JOURNAL-LANCET

429

Noon Intermission

Address: "The Surgical Treatment of Arthritis” — Dr.

Philip D. Wilson, Clinical Professor of Orthopedic Surgery,
Columbia University College of Physicians and Surgeons, New
York, N. Y.

Address: "Diet of Infants” — Dr. Charles Hendee Smith,

Professor of Pediatrics, University and Bellevue Hospital Med-
ical College, New York, N. Y.

Address: "The Relation of the Pituitary, Thyroid, Adrenals,
Liver, and Pancreas to Hyperinsulinism and Spontaneous Hypo-
glycemia”— Dr. Seale Harris, Professor Emeritus of Medicine,
University of Alabama School of Medicine, Birmingham, Ala-
bama.

Address: "Relief of Intractable Pains by Subarachnoid Al-
cohol Injections, Nerve Blocks, Root Sections, and Choro-
dotomy” — Dr. W. McK. Craig, Professor of Neurosurgery,
University of Minnesota Graduate School of Medicine, Mayo
Foundation, Rochester, Minnesota, and Dr. Alfred W. Adson,
Professor of Neurosurgery, University of Minnesota Graduate
School of Medicine; Senior Neurosurgeon of Mayo Clinic,
Rochester, Minnesota.

Intermission to Review Exhibits

Addresss: "Diagnosis and Treatment of Pneumonia” — Dr.
Russell L. Cecil, Professor of Internal Medicine, New York
Polyclinic Medical School and Hospital, New York, N. Y.

Address: "The Significance of Hoarseness and Local Dis-

comfort in Laryngeal Disease” — Dr. Gabriel Tucker, Professor
of Clinical Bronchoscopy and Esophagoscopy, University of
Pennsylvania School of Medicine and Professor of Bronchoscopy
and Laryngeal Surgery, Graduate School of Medicine, Uni-
versity of Pennsylvania, Philadelphia, Pa.

Address: "The Surgery of Hermaphroditism and Associated
Adrenal Diseases” — Dr. Hugh H. Young, Professor of Urol-
ogy, Johns Hopkins University School of Medicine, Baltimore,
Maryland.

Address: "The Menace of Post-Operative Adhesions”— Dr.
Fred W. Bailey, St. Louis, Missouri.

MINNESOTA STATE BOARD OF
MEDICAL EXAMINERS
Julian F. DuBois, M.D., Secretary
St. Paul, Minnesota
DOCKET OF CASES

STATE OF MINNESOTA versus VIVI ANN WYN-
TOR, also known as VIVI ANN MIELKE.

On July 12, 1937, Judge Richard D. O’Brien of District
Court made an order overruling the demurrer interposed by the
defendant in the above case. Judge O’Brien has certified the
legal question involved to the State Supreme Court for final
decision. By demurrer, the defendant has admitted the facts
of the charge, but holds that they do not violate the laws of
Minnesota. Mrs. Wyntor, 24, claims she is a staff lecturer for
an osteopath, R. A. Richardson, of Kansas City, Missouri; and
she was arrested on April 23, 1937, charged with practicing
healing without a basic science certificate. On the last day of
her so-called "health lectures” at the Lowry Hotel in St. Paul,
she offered certain products for sale. She was also recommend-
ing rectal dilators and colonic irrigation apparatus. On being
arraigned in court, she posted a bond of $500.00. She is
represented by State Senator George H. Lommen, of Eveleth,
Minnesota.

Julian F. DuBois, M.D., secretary of the Minnesota State
Board of Examiners, asks every physician to watch for one
Ramon L. de Silvio, a Negro, who has been representing him-
self as a physician in the northern part of Minnesota. De Silvio
has served six months of a sentence of one year in the St.
Louis County Work Farm at Duluth; and was arrested in San
Jose, California, in 1932, for violating the medical practice act.
If De Silvio is found, the Minnesota State Board of Medical
Examiners, 524 Lowry Medical Arts Building, St. Paul, Minne-
sota, should be notified. Telephone: CEdar 2064.

The license of Dr. David Hamilton Nusbaum, 81, Jackson,
Minnesota, has been revoked by the Minnesota State Board of
Medical Examiners, for conviction by the District Court (4th
division) on March 19, 1937, of violating the Harrison Nar-
cotic Act. He was graduated from Western Reserve Univer-
sity in 1885, and licensed in Minnesota in 1910. The Board
has also revoked the license of Dr. Walter Bertram Clement,
30, of Shakopee, Minnesota, for "immoral, dishonorable, and
unprofessional” conduct following the death of a 24-year-old
St. Paul girl on May 19, 1937. Dr. Clement was graduated
from the University of Colorado in 1934, licensed in Minne-
sota in 1935.

STATE OF MINNESOTA versus A. C. MARTIN :

On July 27, 1937, one A. C. Martin, 54, pleaded guilty
to information charging him with practicing healing with no
basic science certificate. He was thereupon sentenced by Judge
Joseph J. Moriarty, of Shakopee, to pay a fine of $200.00
and costs of $9.85 or serve one year in the McLeod County
jail at Glencoe. He stated he would pay the fine and costs.
Martin had been making trips to Brownton, where he had a
room at a hotel, for the purposes of receiving patients. He
tried to treat goiter and glandular conditions, and also did
some massage. He claimed to have lived for many years in
Martin County, and for two years in Mankato. The Minne-
sota State Board of Medical Examiners received first-class
cooperation from Mr. Joseph P. O’Hara, of McLeod County,
and from Mr. Alfred Beihoffer, sheriff of McLeod County.

RESOLUTION

By the North Dakota State Medical Association
Concerning U. S. Senator Lewis’s Plan for Federalized
Medical Aid

At a meeting of the Executive Committee of the North
Dakota State Medical Association, August 1937, there was
considered the speech of United States Senator J. Hamilton
Lewis of Illinois delivered before the House of Delegates of
the American Medical association at the sessions held in At
lantic City June 10th, 1937; and also there was discussed Senate
Joint Resolution 188 introduced by Senator Lewis apparently
with the definite object of compelling all physicians and sur-
geons to become civil officers of the federal government, and
imposing a heavy fine upon and imprisonment of any doctor
refusing to render professional aid to any indigent person.

The consensus of medical opinion in this State definitely

opposes any such compulsory regimentation of any body of its
citizens except in direct national emergency.

This proposal violates all of the precepts that the medical
profession holds essential for the best care of the sick. It
would burden the competent physicians beyond physical endur-
ance, and because of the excessive burden of the indigents,
forced upon the more competent practitioners, the honest, thrifty
taxpaying middle class would necessarily suffer. The demands
of the indigent, and especially of a certain type, are so no-
toriously known to exceed reason that this feature would require
of itself an army of social workers to keep their demands

within bounds. This would be only another step towards

building up an enormous bureaucracy controlled by the dom-
inant political party.

The medical profession of this State has shown its willing-
ness to cooperate with the governmental agencies, both local
and federal, in supplying emergency medical care to its in-
digents on a fee scale far lower than the actual costs of such

care, during the past years of droughts and depressions. And
over and above all of these cases, in all past years the majority
of physicians and surgeons have given freely and gratis their
professional services to very many persons not coming within
the scope of governmental relief. It stands ready again to
continue such services, but it feels that the plan proposed by
Mr. Lewis denies the right of individual prerogative to such
an extent that the individual is reduced to practical serfdom.

430

THE JOURNAL-LANCET

VUws ltc*n6

Dr. Frederick C. Drenning, 69, of Duluth, Minne-
sota, died at Duluth on July 25, 1937, of a heart attack.

A two-story stucco hospital costing $14,000 will be
erected at Watford City, North Dakota.

Dr. Thomas Horatius Baer, Timber Lake, South Da-
kota, has been appointed Dewey County physician.

Dr. Theodore Robert Schweiger, of the Morsman
Clinic in Hibbing, Minnesota, has located with the
Morsman Clinic in Grand Rapids.

Dr. Charles W. Bray, 69, of Biwabik, Minnesota, a
past president of the Northern Minnesota Medical
Association, died on July 7, 1937, of heart failure.

Ernest LeRoy Grinnell, M.D., former mayor of
Aneta, North Dakota, has joined the Healy, Law &
Moore Clinic in Grand Forks.

Dr. Albert S. Rider, Flandreau, South Dakota, is the
new member of the South Dakota State Planning
Board, succeeding Dr. Park B. Jenkins, of Pierre.

Dr. Paul E. Kenyon, of Wadena, Minnesota, a grad-
uate of the Northwestern University Medical School in
1896, has retired, and will go South with Mrs. Kenyon.

Dr. Walter Clinton Jump, of Madison Lake, Minne-
sota, has taken over the practice of Dr. Frank D. Smith,
Kasson, Minnesota. Dr. Smith has moved to Rochester.

Dr. Roy G. Swenson, Harris, Minnesota, has pur-
chased the practice of Dr. Gregor Elmer Schoofs, of
North Branch, and will locate there.

Dr. J. L. Conrad, of Jamestown, North Dakota, is the
new president of the Stutsman County Medical Society.
He was formerly its secretary.

The new Hodgkin Medical Clinic at Kalispell, Mon-
tana, owned by Dr. W. E. Hodgkin and costing $10,000,
will open about December 1, 1937.

Dr. Robert Joseph Quinn, of Burke, South Dakota,
has been appointed to the South Dakota State Board of
Health, to serve until July, 1942.

Dr. Edwin Marius Howg, of Lennox and Humboldt,
South Dakota, has located at Canova. His office will be
in the Canova Hospital.

The 15th annual meeting of the American Academy
of Physical Medicine will be held in Philadelphia on
October 19, 20, and 21, 1937.

Dr. Oswald W. Katz, who formerly practiced at
Hartford, South Dakota, has returned to Faulkton to
open offices in the First National Bank Building.

Dr. Charles Milton Clark, 47, who was associated
with the Mayo Clinic from 1915 to 1920, died at Akron,
Ohio, on July 21, 1937.

Dr. Clyde H. Frederickson, of the Great Falls Clinic
in Great Falls, Montana, is now associated with the
Western Montana Clinic in Missoula.

Dr. Donald Kay Bacon, St. Paul, Minnesota, has
been invited to address the International Congress on
Blood Transfusion at Paris, France, September 29 to
October 3, 1937.

Dr. Wilbert William Yaeger, Ivanhoe, Minnesota,
has sold his practice to Dr. Alvin Erickson, of Sanborn,
Minnesota. Dr. Erickson has moved to Ivanhoe.

Dr. Walter Henry Valentine, of Tracy, Minnesota,
will offer bonds to the amount of $75,000 to build a
modern 30-bed hospital in Tracy.

Dr. William Gustav Rogne, formerly of McClusky,
North Dakota, has associated with Doctors Gustav M.
and John William Helland at Spring Grove, Minnesota.

Dr. John A. Paulson, a recent graduate of the Uni-
versity of Minnesota Medical School, has located at
3 Vi South Broadway in Rochester, Minnesota.

Dr. Harry A. Palmer, who has completed his intern-
ship at Saint Luke’s Hospital in Duluth, Minnesota,
has located at Virginia in the City Drug Store building.

The Upper Mississippi Valley Medical Society met
at Cass Lake, Minnesota, on July 31. About 100 physi-
cians and their wives were present.

Dr. Johan Martin Arnson, of Benson, Minnesota, has
been designated school physician by the Benson Board
of Education.

The Bowbells Civic Club, of Bowbells, North Dakota,
arranged to have Dr. Robert T. St. Clair, of Minot,
open an office in the Bowbells City Hospital on July 15.

Dr. A. W. Pearson, formerly of Minneapolis, and a
former student in the University of Minnesota Medical
School, is now located at 307 East Manchester Boule-
vard in Inglewood, California.

Dr. Ralph K. Ghormley, Rochester, Minnesota, asso-
ciate professor of orthopedic surgery in the University
of Minnesota Graduate School of Medicine, is the new
secretary of the American Orthopedic Association.

Dr. Edward John Zeiss, of Wildrose, North Dakota,
has received an appointment as resident physician in the
Cook County Hospital in Chicago, to commence on
January 1, 1938.

Dr. Carl Abraham Fjelstad, Minneapolis, who was
graduated from the University of Minnesota Medical
School in 1892, is the new house physician at Mudbaden
Sanitarium, near Jordan, Minnesota.

Dr. Joseph Francis Malloy, a graduate of the Creigh-
ton University Medical School in 1921, has left Mitchell,
South Dakota, to become a member of the staff of the
Bratrud Clinic in Thief River Falls, Minnesota.

Dr. Grant F. Hartnagel, who recently completed his
internship at the Milwaukee County General Hospital
in Wauwatosa, Wisconsin, has located in Red Wing,
Minnesota, in the office of Dr. Edward Henry Juers.

Dr. Henry E. Rokala, who recently completed his
internship at St. Luke’s Hospital in Duluth, Minnesota,
has become a member of the staff of Biwabik Hospital,
Biwabik.

Dr. Charles Gordon Uhley, a graduate of the Uni-
versity of Minnesota Medical School in 1933, has been
added to the surgical staff of the Northwestern Clinic
in Crookston, Minnesota.

Dr. Rush Leslie Burns, for 22 years a surgeon in Two
Harbors, Minnesota, has sold his interest in the Burns-
Christensen Hospital to Dr. Edward E. Webber, of
Duluth. Dr. Burns has gone to California.

THE JOURNAL-LANCET

431

Dr. Carl Blotner, Charlottesville, Virginia, a graduate
of the St. Louis University School of Medicine in 1933,
is the new associate medical officer of the Cheyenne River
Indian Agency in South Dakota.

Dr. Bension Scodel, a graduate of Tufts University
School of Medicine, Boston, Massachusetts, in 1921, has
located at Maynard, Minnesota, in the telephone
building.

The new $2,500,000 asylum for the insane at Moose
Lake, Minnesota, is expected to open shortly after Jan-
uary 1, 1938, according to John Foley, chairman of
the Minnesota State Board of Control.

Dr. George Alfred Dodds has been appointed super-
intendent of the North Dakota State Tuberculosis Sana-
atorium at San Haven by the State Board of Adminis-
tration, for a 2-year term.

The Association of Military Surgeons of the United
States will hold its 45th annual convention at Los An-
geles on October 14, 15, and 16, 1937. Rear Admiral
P. S. Rossiter, M.D., U. S. Navy, is president.

The annual meeting of the Mississippi Valley Med-
ical Society will be held on September 29 and 30 and
October 1, 1937, at Lincoln-Douglas Hotel, Quincy,
Illinois, with 60 lectures and 48 teachers and clinicians.

Dr. Clarence George Owens, a graduate of the
University of Minnesota Medical School in 1930, has
associated with Dr. John Douglas Graham, in the
World Building at Devil’s Lake, North Dakota.

Dr. William Cyril Ferguson, formerly of the North-
ern Pacific Hospital in Fargo, North Dakota, has pur-
chased the practice of the late Dr. Earl Jamieson of
Walnut Grove, Minnesota.

Dr. Irving W. Kellogg, of Perris, California, a grad-
uate of the College of Medical Evangelists at Los An-
geles in 1931, has taken over the practice of Dr. Albert
H. Reiswig, of Fairmount, North Dakota.

Dr. Kasper P. Caveny, a recent graduate of the Uni-
versity of Minnesota Medical School, has completed his
internship at Bethesda Hospital in Saint Paul, and has
located in Elkton, South Dakota.

Dr. David J. Almas, a graduate of the University of
Minnesota Medical School, finished his internship at
Ancker Hospital in Saint Paul, and has located at
Havre, Montana, above the Owl Drug Company’s store.

Dr. Ivar Sivertsen, of Minneapolis, a member of the
Minnesota State Board of Medical Examiners, has been
given the Order of Saint Olaf by King Haakon of
Norway.

Dr. Hazel Reed, a graduate of the University of
Colorado School of Medicine in 1917, will leave Grass
Range, Montana, to practice medicine at Stanford in
Judith Basin County.

Dr. Arthur LeRoy Jones, 42, of Gregory, South
Dakota, died in August of a heart attack. He was a
graduate of the University of Iowa College of Medicine
in 1922.

Dr. August C. Orr, of the State Public Health De-
partment, conducted a pre-school clinic in the basement
of the Mandan Memorial Building at .Mandan, North
Dakota, during the week of August 16, 1937.

Silver Bow County in Montana now has a well-
equipped laboratory for public health work, as a result
of the work of the Butte Junior Service League, which
donated the equipment.

Dr. Fred Lowe has obtained the practice of the late
Dr. D. Euclide Rainville in Boulder, Montana, and will
occupy offices in the bank building where Dr. Rainville
practiced.

Dr. Thomas Cruickshank, instructor in medicine in
the University of South Dakota at Vermillion, and a
graduate of the old Barnes Medical College in St. Louis
in 1899, has retired after 38 years of practice.

Dr. William Frank Sercl, a graduate of the Univer-
sity of Nebraska College of Medicine in 1932, has
located in the Sioux Falls Clinic Building in that South
Dakota city, to specialize in obstetrics and gynecology.

Dr. Martin Joseph Fiala, 34, of Duluth, Minnesota,
died on August 9, 1937, at Rochester, Minnesota, of a
brain tumor. He was a member of the Minnesota
Urological Association.

Dr. Emil Theodore Keller, of Leola, South Dakota,
a graduate of the University of Minnesota Medical
School in 1936, has joined the staff of the new Rood
Hospital in Chisholm, Minnesota.

Dr. William Gerard Paradis, since 1929 medical di-
rector of Sunnyrest Sanatorium at Crookston, Minne-
sota, has resigned to enter private practice at Canton,
Ohio.

Dr. Pearl V. Matthaei, formerly of the staff of the
State Hospital for the Insane at Jamestown, North
Dakota, has resigned to go to her home at Great Bend,
Kansas.

Ralph Edward Mahowald, A.B., S.B., M.D., a grad-
uate of Rush Medical College of the University of
Chicago in 1936, will take over the practice of the late
Thomas Mulligan at Grand Forks, North Dakota.

Dr. John Joseph Mertens, Gettysburg, South Dakota,
a graduate of the old College of Physicians & Surgeons
in Minneapolis in 1903, has been elected a life member
of the Potter County Historical Association.

Dr. Edward W. Fahey, St. Paul, was elected supreme
physician of the Knights of Columbus at the 55th in-
ternational convention held recently at San Antonio,
Texas.

Dr. John R. Thompson, 79, pioneer South Dakota
physician and a past president of the South Dakota
State Medical Association, died at his home in North-
ville on August 24, 1937.

Dr. John Walter Williams, 52, Minneapolis, a grad-
uate of the old Minneapolis College of Physicians &
Surgeons in 1907, died near Brainerd, Minnesota, on
August 22, of a heart attack. Captain Williams was
flight surgeon of the 109th aero squadron, Minnesota
National Guard.

Dr. Frank Benjamin Hicks, 76, a graduate of the
Rush Medical College of the University of Chicago in
1899, died at University Hospital in Minneapolis on
August 21, 1937. He founded the First Congregational
Church in Grand Marais, Minnesota, and was the first
physician to open an office in Cook County, Minnesota.

432

THE JOURNAL-LANCET

Dr. Harry A. Palmer, a recent graduate of the Uni-
versity of Minnesota School of Medicine, has opened
offices above the City Drug Store in Eveleth, Minnesota.

Dr. George H. Purves, of Russell, Minnesota, has
purchased the practice of Dr. Peder J. Bursheim, Lake
Benton. Dr. Bursheim will go to Atlantic, Iowa, to
enter the drug business of his son.

Dr. Samuel Leonard, a graduate of the University
of Minnesota Medical School in 1930, is leaving Minne-
apolis to do post-graduate surgical study at Cook County
Hospital in Chicago.

Dr. Stuart W. Harrington, Rochester, Minnesota,
professor of surgery in the University of Minnesota
Graduate School of Medicine, is the new president of
the American Society for Thoracic Surgery.

Orthopedic surgeons in North Dakota have examined
no less than 831 crippled children under the auspices of
Elks Clubs and state child service agencies, according to
Mr. E. A. Willson, executive director of the State Public
Welfare Board.

Dr. John C. Wilkinson, 65, a graduate of the Uni-
versity of Iowa College of Medicine in 1896, who left
Red Lake Falls, Minnesota, in 1922, died recently at
Gatun, Canal Zone, where he had been in government
service.

Dr. Karl Eugene Sandt, a graduate of the University
of Minnesota Medical School in 1935, has completed his
internship at the Manhattan Eye, Ear & Throat Hos-
pital in New York City, and has located at Osseo,
Minnesota, with Dr. Kenneth J. St. Cyr.

Dr. Louis H. Fligman, Helena, Montana, four times
president of the Montana State Board of Health, and a
board member since 1919, has been reappointed by Gov-
ernor Roy E. Ayers. Dr. Fligman was president of the
Medical Association of Montana in 1936.

Dr. John Luverne Mulder, a graduate of the Uni-
versity of Minnesota Medical School in 1919, has sold
his practice and equipment at Cavalier, North Dakota,
to Dr. Henry Mitchell Waldren, Dr. Henry Mowat
Waldren, and Dr. George Richard Waldren.

Dr. Jay M. Cook, Staples, Minnesota, a graduate of
the Creighton University School of Medicine in 1922,
is the president of the staff of the new Staples Municipal
Hospital. Dr. Werner J. Lund is vice-president; and
Dr. Charles F. Reichelderfer is secretary.

Dr. Gerald John van Heuvelen, of the South Dakota
State Board of Health, addressed the final spring-
summer meeting of the Seventh District Medical Socie-
ty (South Dakota) at Sioux Falls on "The Control of
Venereal Diseases.”

Dr. John Lucian Calene, F.A.C.S., of Aberdeen,
South Dakota, a graduate of Rush Medical College
of the University of Chicago in 1921, has been elected
to the board of governors of the American College of
Physicians, to represent South Dakota.

Dr. Hans M. Lichtenstein, 70, a graduate of the
University of Tubingen (Germany) in 1888, and a
member of the Winona County Medical Society in
Minnesota since 1894, died on August 6 at Colonial
Hospital in Rochester.

Dr. B. L. Pampel, Livingston, Montana, was elected
president of the Montana State Board of Health on
August 12, at Helena. Dr. Enoch M. Porter, Great
Falls, was elected vice president. Dr. L. H. Fligman, of
Helena, is the retiring president.

Dr. James Harold Drake, of International Falls,
Minnesota, a graduate of the Chicago Homeopathic
Medical College in 1902, was elected surgeon of the
Minnesota department of Veterans of Foreign Wars at
the annual encampment at Chisholm.

Dr. Albert Eric Olson, of West Duluth, Minnesota,
and a member of the Board of Regents of the Univer-
sity of Minnesota, was elected to the Saint Louis County
Sanatorium Commission to succeed Dr. E. L. Tuohy,
Duluth, who had held the post for 30 years.

Dr. Eugene B. Hultz, Hill City; Dr. Albert A.
Heinemann, Wasta; Dr. Norris Tillman Owen and Dr.
Stanley Owen, both of Rapid City; have been hired by
Pennington County in South Dakota to give medical
care to indigent patients.

Dr. Frank James Bickford, 67, of Centralia, Wash-
ington, died in that city on July 22. Dr. Bickford was
graduated from the University of Minnesota Medical
School in 1902, and for a time practiced in Pine River,
Minnesota. He went to Centralia in 1910.

Dr. Earl Jamieson, 60, of Walnut Grove, Minnesota,
died on July 17, 1937, of meningitis following a nasal
operation. He was graduated from the University of
Illinois College of Medicine in 1908. He was buried at
Mankato.

Dr. Joseph Lorin Mondloch, Butte, Montana, county
physician for Silver Bow County, conferred with the
State Board of Health at Helena on August 12, rela-
tive to the vaccination of school children for smallpox
in Butte and Anaconda.

Dr. Thomas Parran, Jr., surgeon-general of the
United States Public Health Service at Washington,
visited the Rocky Mountain Public Health Service Lab-
oratory at Hamilton, Montana, on August 10. He was
the guest of the Hamilton Lions Club that evening.

Dr. Carl M. Anderson, 55, assistant professor of oto-
laryngology in the University of Minnesota Graduate
School of Medicine, and a member of the section on
otolaryngology and rhinology of the Mayo Clinic, died
at Rochester on August 10, 1937, of coronary throm-
bosis.

Dr. G. Harmon Brunner, a graduate of the Univer-
sity of Colorado School of Medicine in 1928, and for-
merly resident physician at the Illinois Eye & Ear In-
firmary in Chicago, has joined the staff of Dr. Archie
D. McCannel and Dr. C. R. Kempthorne, in Minot,
North Dakota.

The broadcast of the Minnesota State Medical Asso-
ciation for September is as follows: 4th, "Diphtheria &
Smallpox”; 11th, "Duodenal Ulcer”; 18th, "Insomnia”;
25th, "Cancer of the Mouth.” Dr. Frederick A. O’Brien,
associate professor of pathology and preventive medicine
in the University of Minnesota, will speak. Station
WCCO (810 kilocycles, 370.2 meters); 9:45 a. m. each
Saturday.

THE JOURNAL-LANCET

433

The North Dakota Department of Public Health is
cooperating with Surgeon-General Thomas Parran, Jr.,
in trying to stamp out syphilis and gonorrhea, reports
Dr. Maysil M. Williams, director. Dr. John A. Cowan,
state epidemiologist, has been lecturing throughout the
state on the subject.

Dr. Frank C. Rodda, clinical professor of pediatrics,
and Dr. Vernon L. Hart, instructor in orthopedic sur-
gery, both of the University of Minnesota Medical
School, spoke before the Upper Peninsula Medical So-
ciety at Houghton, Michigan, on August 19 and 20,
1937.

Dr. Harry B. Fralic, 56, who was medical director of
the Veterans’ Administration Facility at Fort Snelling,
Minnesota, from 1927 until August 1932, died at St.
Petersburg, Florida, on August 12, 1937. From 1922
until 1926 he was medical director of the old Aberdeen
Hospital for veterans in St. Paul. He was graduated
from the Medico-Chirurgical College of Philadelphia in
1905.

The bid of $159,175.00 of Henry H. Hackett, of
Rapid City, South Dakota, for construction of an ad-
dition to the Hospital No. 12 of the Veterans’ Facility
at Hot Springs, South Dakota, has been accepted by the
Veterans’ Administration. The bid of H. B. Kilstofte,
of Winona, Minnesota, of $30,000.00 for the alteration
and addition to a hospital at Fort Snelling, Minnesota,
has been accepted by the War Department.

Dr. Albert E. Meinert, Winona, Minnesota, was
elected president of the Southern Minnesota Medical
Association at the annual meeting on board the steam-
boat Capitol on August 11, 1937. Dr. W. A. Fansler,
Minneapolis, assistant professor of surgery (proctology)
in the University of Minnesota Medical School, was
elected 1st vice president; Dr. Albert Fritsche, New
Ulm, was selected 2nd vice president; and Dr. Nelson
W. Barker, Rochester, assistant professor of medicine
in the University of Minnesota Graduate School of
Medicine, was elected secretary-treasurer.

LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS

ON JUNE 29, 1937
(BY EXAMINATION)

Name School Address

Aides, John Henry U. of Minn., M.B., 1937 St. Joseph’s Hospital, St. Paul, Minn.

Beckjord, Philip Rains U. of Minn., M.B., 1937 317 S. E. Union St., Minneapolis, Minn.

Boraas, John Albert '. U. of Minn., M.B., 1936 Ada, Minn.

Butler, John Kenneth U. of Minn., M.B., 1936 Belle Plaine, Minn.

Cherry, James Henderson Duke U., M.D., 1933 Co. 2703, C.C.C., Park Rapids, Minn.

Crago, Felix Hughes Duke U., M.D., 1935 University Hospital, Minneapolis, Minn.

Donath, Douglas Harry U. of S. Cal., M.D., 1936 ..Mayo Clinic, Rochester, Minn.

Erickson, Ralph Edward U. of Minn., M.B., 1936 5128 31st Ave. S., Minneapolis, Minn.

Evans, Charles Albert U. of Minn., M.B., 1936 427 8th Ave. S. E., Minneapolis, Minn.

Grant, Russel U. of Minn., M B., 1937 Hackensack Hospital, Hackensack, N. J.

Hanson, Harry Albert U. of Minn., M B., 1937 Rochester Gen. Hospital, Rochester, N. Y.

Haury, Victor Givens ___.U. of Minn., M.B., M.D., 1935 3430 Warden Drive, Philadelphia, Pa.

Heilman, Dorothy Marg’t Henderson Northwestern, M B., 1931, M.D., 1932 Mayo Clinic, Rochester, Minn.

Hilger, Jerome Andrew U. of Minn., M B., 1936 1941 Selby Ave., St. Paul, Minn.

Hilger, Laurence David U. of Minn., M B., 1936 . 1941 Selby Ave., St. Paul, Minn.

Jaeck, James Lyman U. of Minn., M.B., 1936 401 Cedar Ave., Minneapolis, Minn.

Koch, Ferdinand Leonard Philip Johns Hopkins, M.D., 1933 _Mayo Clinic, Rochester, Minn.

Lindblom, Alton Edwin U. of Minn., M B., 1936.._.J 4344 Lyndale Ave. S., Minneapolis, Minn.

Maun, Mark Emmett Northwestern, M B., 1936, M.D., 1937 Ancker Hospital, St. Paul, Minn.

Maves, Robert Arthur U. of Minn., M.B., 1937 Mpls. General Hospital, Minneapolis, Minn.

Moos, Daniel James U. of Minn., M.B., 1937.. 1021 E. River Road, Minneapolis, Minn.

Nelson, Kenneth L U. of Minn., M.B., 1936 Willmar Clinic, Willmar, Minn.

Nelson, Lloyd Joseph U. of Minn., M.B., 1936 Mpls. General Hospital, Minneapolis, Minn.

Nessa, Curtis Blaine U. of Minn., M.B., 1936 801 E. River Road, Minneapolis, Minn.

Olson, Duane Oliver Chas ___U. of Minn., M B., 1937 Mpls. General Hospital, Minneapolis, Minn.

Potter, Robert B U. of Minn., M.B., 1936 Hendricks, Minn.

Pumphrey, Robert Earl Ohio State U., M.D., 1930 Mayo Clinic, Rochester, Minn.

Rademaker, William U. of Minn., M.B., 1935, M.D., 1936 Evansville, Minn.

Schuele, David Thaddeus U. of Wis., M.D., 1936.. Ancker Hospital, St. Paul, Minn.

Sinclair, James William U. of Toronto, M.D, 1933 74 Bingeman St., Kitchener, Ont., Canada

Sprafka, Ambrose Edward U. of Minn., M.B., 1936 St Anthony de Padua Hosp., Chicago, 111.

Walsh, Francis Mark U. of Minn., M.B., 1937 4037 Garfield Ave. S., Minneapolis, Minn.

Welton, Philip Charles Marquette U., M.D., 1937 Nopeming, Minn.

Yaffe, Henry Irvin U of Minn., M.B., 1934, M.D., 1936 610 Logan Ave. N., Minneapolis, Minn.

BY RECIPROCITY

Beech, Raymond Henry Northwestern, M.D., 1933 .. E. 7th and Minnehaha Sts., St. Paul, Minn.

Dworak, Arthur Francis Creighton U., M.D., 1930 Walker, Minn.

Northrop, Cedric U. of Ore., M.D., 1936 Glen Lake San., Oak Terrace, Minn.

Sheedy, Leo Patrick — Geo. Wash. U., M.D., 1933 Mayo Clinic, Rochester, Minn.

BY NATIONAL BOARD CREDENTIALS

Adams, John Milton Columbia, M.D., 1933 1009 Nicollet Ave., Minneapolis, Minn.

Miller, Donald Frank Northwestern, M.D., 1933 Williamsburg, Iowa

Patton, George DuBarry Temple University, M.D., 1935 Mayo Clinic, Rochester, Minn.

Uhley, Charles Gordon U. of Minn., M.D., 1933 Crookston, Minn.

434

THE JOURNAL-LANCET

Boole Holices

CHILD PSYCHIATRY

Our Children in a Changing World, by Erwin Wexberg.

M.D., and Henry E. Fritsch; 1st edition, cloth, 232 pages;

The Macmillan Company, New York: 1937. Price, $2 00.

When one is confronted with the task of reviewing another
one of those books on child psychology, one wonders whether
anything new or useful can be learned. But after wading
through the pages of Our Children in a Changing World, the
reviewer feels well-paid for his time. For the authors have em-
phasized and consistently developed the point of view of indi-
vidual psychology, which is still too often neglected by physi-
cians as well as parents. They stress the point that there are
no "bad” children — that the final pattern of personality is the
result of the welding of the inherent instincts and abilities with
the educational influences to which the child is exposed. In
other words, a child becomes what he is in accordance with
the things that happen to him after he is born, and before he
becomes an adult. This point of view offers the best practical
means of preventing and treating the common behaviour dis-
orders in childhood.

The material first includes the environmental factors that
are responsible for maladjustment in children. (1) The phys-
ical condition of the child, (2) the social and economic in-
fluences, (3) sex, (4) the family and (5) education. Next he
presents much varied clinical material in behalf of the crim-
inal, lying, fearful, and lazy child. The last chapter on educa-
tion and corrective measures sums up the educational task for
the parent in a concise, practical way.

There are only two criticisms which the reviewer believes
should be made, both of minor importance (1) the word in-
feriority appears too frequently and (2) a book that presents
the biological point of view should give more consideration to
the physiology of behaviour.

The author is professor of neuro-psychiatry in the Louisiana
State University.

COUNTRY DOCTOR S SAGA

Dr. Betterman's Diary, by Amos Betterman, M.D., edited
by Charles Elton Blanchard, M.D.; 2nd edition, black
fabrikoid, 278 pages, illustrated; Youngstown, Ohio: The
Medical Success Press: 1937. Price, $3.00.

This is the second edition of a work first published in 1933.
It concerns the years shortly after the Civil War, and extends
well up to what we consider the modern age. The author
wrote with a saltiness and a pith that is at once apparent in
every page. He was born in 1825 and died in 1910.

REGIONAL ANATOMY TEXT
Regional Anatomy, by J. C. Hayner, B.S., M.D.; 1st edition,
dark blue cloth, 634 pages plus index, no illustrations, gold-
stamped; Baltimore, Maryland: William Wood & Company:
1935. Price, $6.00.

Dr. Hayner, who is associate professor of anatomy and
assistant surgeon of the Flower Hospital in New York City,
has written a text essentially for students in anatomy. This
volume does not attempt to displace the customary surgical
anatomy; but it does recognize that many so-called "regional
anatomies” have actually been surgical anatomy texts. Professor
Hayner takes the position that the purely descriptive anatomy
must be thoroughly mastered before pathological anatomy can
be attempted; and with this viewpoint The Journal-Lancet
is in accord.

The book is well-printed and handsomely bound. While it
is "a hand-maiden to other books on anatomy,” its concision
and accuracy recommend it highly.

NORTH DAKOTA MEDICINE
North Dakota Medicine: Sketches 8C Abstracts, by James
Grassick, M.D.; 1st edition, brown fabrikoid, gold-stamped,
365 pages plus index, illustrated; Fargo: The North Dakota
State Medical Association: 1926. Price, $2.25, postpaid

from Albert W. Skelsey, M.D.

This volume was presented to the library of The Journal-
Lancet by the North Dakota State Medical Association, and
is greatly appreciated. A vast amount of personal labor has
gone into it. Dr. Grassick’s work is evident on every page, par-
ticularly in the very valuable roster of physicians in Dakota
territory from 1885 to 1890. The sketches are excellently done
and are, withal, highly interesting, even to one who knows
nothing of North Dakota history. This is a venture which
should have been undertaken by every state medical association,
but which actually has been done, to our knowledge, by very
few. The North Dakota State Medical Association is to be
congratulated, and the work of Dr. Grassick should be in
the possession of every North Dakota physician. It is said that
only a few copies remain with Dr. Skelsey.

FOR THE PHYSICIAN-PRESCRIBER

Remington’s Practice of Pharmacy, by E. Fullerton
Cook, P.D., Ph.M., Charles H. LaWall, Ph.M., Pharm.
D., Sc.D., and others; 8th edition, heavy cloth, 2,162 pages,
702 illustrations; Philadelphia: The J. B. Lippincott Com-
pany: 1936. Price, $10.00.

It is a surety that no men other than the authors could have
been chosen with such felicity for the task of revising Rem-
ington’s standard text on pharmaceutical practice. Doctor
Cook is chairman of the Committee of Revision of the Phar-
macopoeia of the United States, and Doctor LaWall is dean
of pharmacy in the Philadelphia College of Pharmacy and
Science.

This particular revision was imperative, since the Eleventh
Edition of the U. S. Pharmacopoeia appeared in June 1936,
and the National Formulary, 6th edition, and the American
Medical Association’s New and Non-Official Remedies both
came out during 1936. This edition of Remington is there-
fore revised to include revisions in the texts named above.

This is a very good volume for those physicians who still
prescribe and fill their own prescriptions. Not many are left;
yet those who do remain have a definite need for such a work.
There is a good chapter on glandular products, and a new sec-
tion on hospital pharmacy. In spite of the frequent typo-
graphical errors, The Journal-Lancet recommends this work
as an invaluable addition to pharmaceutical literature.

PHYSICIAN’S LABORATORY SYPHILIS
MANUAL

The Laboratory Diagnosis of Syphilis, by Harry Eagle,
M.D., with an introduction by Joseph Earle Moore, M.D.;
1st edition, blue cloth, dark blue cloth, gold-stamped. 377
pages plus appendices, references and index, 27 illustrations;
St. Louis: The C. V. Mosby Company: 1937. Price $5.00.

This book is quite opportune at the present time, when so
much work and thought are centered on the diagnosis and
control of syphilis. The author has dealt in detail with the
various serologic tests, their variations and their interrelation-
ship with each other as well as their relationship to the clinical
manifestations.

The chronological classification of tests with the various
modifications of the original serologic tests from Bordet and
Wassermann up to the present time are listed, and their
various techniques dealt in detail.

The bibliography is voluminous, and the author has done a
great piece of work in arranging his material so smoothly.
Because of its subject matter, if for no other reason, the book
is a valuable contribution. Every serologic laboratory worker
should have access to this book. The general practitioner would
also benefit by reading chapters I, IV, VI, VII, IX, and XVI
to XXII, inclusive.

A Discussion of Protamine Insulin*

R. O. Goehl, M.D.

Grand Forks, North Dakota

ANEW ERA in diabetic therapy has begun,
which may very well be named the "Hagedorn
Era.” Since the introduction of insulin 14 years
ago, there had been very little modification of this
product until Hagedorn1 and others of Denmark showed
that the blood-sugar-lowering action of insulin was pro-
longed when it was combined with protamine. This
product, which was first called protamine insulinate, con-
sists of insulin hydrochloride combined with a protamine
prepared from the sperm of a species of trout. The ad-
vantage of protamine insulin is its slow blood-sugar-
lowering action, which results from its retarded absorp-
tion, thus allowing for a more even and prolonged effect
upon the blood sugar. Scott and Fisher9 working at
the University of Toronto, found that the addition of
certain metals to protamine insulin further enhanced its
absorption, and that zinc seemed most ideal of these
metals. This product is the one which is now commer-
cially available under the name "Protamine Zinc In-
sulin,” and is a turbid solution marketed by several com-
panies in the one concentration, U-40.

Since the announcing of protamine insulin, a num-
ber of clinicians1,2'*’4’5’10'11 have given it careful trial,
and almost without exception they have spoken favorably
of it and have given suggestions, all of which has led
to its present stage of development and usefulness.
Joslin6, in a recent discussion, suggested that most of
the mild and moderately severe cases of diabetes could
keep their disease well-controlled by diet and only a
single daily dose of this new insulin. If this is true, and

• Presented before the annual meeting of the North Dakota
State Medical Association held at Grand Forks May 16-18, 1937.

it certainly seems already established, we can readily
see the advantage of acquainting ourselves with the use
of this new product.

Dosage and Administration

In deciding upon the amount of protamine zinc in-
sulin to be given to a patient, we are able to follow some
general rules; but it must be remembered that each
case is an individual problem. If the diabetic is already
receiving the old type of insulin, then the new product
may be started in the dose of two-thirds to the equal of
the total amount formerly taken in a 24-hour period.
After being on the protamine zinc insulin for a short
time, the total amount used becomes less, because the
new product is thought to utilize about 20 per cent more
dextrose per unit than the regular insulin. A small, sup-
plementary dose of regular insulin may be employed if
conditions are such as to make a rapid blood-sugar-
lowering effect desirable. Care must be exercised that
the peak effect of both insulins does not come at the
same time, keeping in mind the facts that regular in-
sulin acts almost immediately and lasts only from three
to four hours, while protamine zinc insulin does not
begin its effect for from three to four hours and lasts
for 12 to 24 hours. In most instances, when both are
required, they may be administered at one time, in the
morning, but at separate sites, and the regular insulin
should be given first if the same syringe is to be used
for both. Protamine zinc insulin should be given sub-
cutaneously and not intravenously; and, on account of
its slow, prolonged action, it is not recommended for

436

THE JOURNAL-LANCET

the treatment of diabetic coma unless accompanied by
the unmodified insulin.

Diet

Protamine zinc insulin has not made any essential
change in the dietary regulation of diabetes; and it is
just as important now to obtain the intelligent coopera-
tion of the patient in this respect as formerly, when we
had only the unmodified insulin. Sometimes, a reappor-
tionment of the carbohydrate given in different meals
will assist greatly in maintaining the proper balance.
Since protamine zinc insulin exerts its maximum effect
later than does unmodified insulin, the carbohydrate of
the meal following the injection must in many cases
be reduced in order to prevent hyperglycemia, and the
amount withheld is then included in the other meals.
In this manner, the carbohydrate load may be lessened
at one time of the day when it is not utilized well, and
transferred to other periods when it is more readily
controlled. Each case is an individual problem, and
success in many instances will depend more upon the
proper apportioning of the diet than upon the altera-
tion of the protamine zinc insulin dosage.

One further thought that seems evident from using
the new insulin is the possibility of a more liberal dietary
allowance. This is further illustrated by a case men-
tioned by Sprague, et al'A, where a severe diabetic was
given a large morning dose of protamine zinc insulin
and allowed to eat three regular meals per day from
the general kitchen, the only restricted foods being candy
and raw sugar. On this regime, this patient remained in
excellent control. With this suggestion of a more liberal
dietary regulation a word of caution is also in line, so
that a laxity will not result from the added benefits of
this new product.

Reactions

Insulin reactions under protamine insulin have been
characterized by their rarity and usually mild symp-
tomatology; but there is a definite tendency for them
to be very insidious in their onset. Owing to the slow-
ness with which protamine insulin lowers the blood-
sugar level, marked hypoglycemia may result without
apparent discomfort to the patient. Such reactions
should be avoided, and the occurrence of fatigue,
drowsiness, nervousness, headache, nausea, or tingling
sensations in the extremities, as well as weakness and
sweating, should suggest hypoglycemia, and should be
checked up by laboratory tests. If disregarded, these
symptoms may be followed by stupor, unconsciousness
and perhaps even more serious results. As is the case
with any hypoglycemia, these symptoms should be treat-
ed by the administration of some form of available car-
bohydrate. However, a slowly absorbable carbohydrate
as well as a rapidly utilizable one should be given. In
this way, orange juice or sugar will immediately relieve
symptoms, while a glass of milk with crackers will con-
tinue a balance of the slowly-acting protamine insulin.

Transfer to Protamine Insulin

For the procedure of changing a diabetic patient who
is taking the regular insulin to a schedule of protamine
insulin, it was first suggested12’13’15 that hospitalization
was necessary. Time and experience have changed this
feeling, so that now many patients are being transferred
without hospitalization; but we should not dispense with
close observation when the change is being made. None
of the cases that I have observed was in control when
I first saw them, yet it was possible to switch them to
the new insulin by observing them from the clinic.
When protamine insulin is used alone and is given in
a single dose before breakfast, the meals usually pro-
duce a glycosuria the first few days. However, the blood-
sugar level on successive mornings usually decreases pro-
gressively, so that there is no glycosuria by the fifth or
sixth day. By supplementing the protamine insulin with
a small dose of regular insulin, the period of transition
can be shortened.

Comment

According to clinical investigation to date1,3’11’12,
several methods of using protamine insulin have been
suggested which may vary somewhat with the severity
of the diabetes. First was the original procedure adopted
in Copenhagen, where the insulin protamine compound
usually had been given in the evening. Due to the lack
of any immediate effect and the prolongation of its
action, Wilder12 was led to give it in the morning with
or without a supplementary dose of the old insulin.
Campbell and his co-workers11 have suggested that a
large dose of protamine insulin before breakfast, and a
small dose of the same insulin given at bedtime may be
beneficial when a single injection fails to control the
glycosuria and hyperglycemia. Still another combination
is that of giving old insulin before breakfast and pro-
tamine insulin before supper, which carries with it a
word of warning14, since the patient will awaken in the
morning with a lower blood sugar than on the old
regime, and the action of the old insulin taken before
breakfast may be more effective than is expected. Quite
recently, Sindoni10 has suggested that protamine insulin
be used only to supplement the usual method of giving
ordinary insulin, particularly in the more severe diabetics.

I believe that the procedure of giving a single morn-
ing dose of protamine insulin with or without a supple-
mentary dose of old insulin is the most applicable in the
great majority of cases. By this method, patients can
be watched quite satisfactorily by the use of fasting
blood-sugar determinations or simple urinalysis, and
definite instructions can be given to patients as to their
home care. If glycosuria is present in the late forenoon,
then a supplementary dose of old insulin may be neces-
sary before breakfast; but if the urine is sugar-free
before breakfast, the old insulin may be omitted or re-
duced. If sugar shows during the latter part of the day,
and particularly on rising, the protamine insulin may
need an increase. Protamine insulin should not be
altered too frequently, since its prolonged effect makes it
necessary to observe its influence for several days at a

THE JOURNAL-LANCET

437

time before changing the dosage. Sometimes, sugar
will show on retiring because of too great a carbohydrate
load; and because of the slow action of the protamine
insulin the urine will be sugar-free by morning. There-
fore, caution should be used in giving old insulin in the
morning; and if used, it should be given just before
breakfast, while the protamine insulin may be given as
much as one hour before eating. Also, the effect of the
slow action of protamine insulin must be considered in
the arrangement of the diet. For example, it may be
well to give 20 per cent of the carbohydrate allowance
at breakfast and 40 per cent at each of the other two
meals.

Mention of Cases

In order to emphasize further a few points concern-
ing the value of protamine insulin in diabetes, I wish to
cite briefly a few case histories.

The first case is that of a male, age 83, who has had
diabetes for several years. Until January, 1937, he
had been taking from eight to ten units of regular in-
sulin twice daily (morning and evening) , and he would
occasionally omit the evening dose because he greatly
disliked "fussing with insulin.” On this regime, he fre-
quently showed three to four plus glycosuria and at
times "did not feel well.”

On January 18, 1937, protamine insulin in the dose
of 15 units was begun in the morning, as well as a
supplementary dose of five units of regular insulin. After
the first five days the regular insulin was discontinued,
and he has been feeling much better on the new regime
with much less frequent glycosuria. Furthermore, he is
not as strict with his diet as formerly; yet he seems to
get along better. This case is illustrative of a number
of diabetics who dislike very much the taking of insulin,
and who are lax in adhering to a strict diet. This pa-
tient has not only benefited by an increased sense of well-
being and the relief of muscular pains since he has been
on protamine insulin, but he also can be more liberal
with his diet, and gets along on less insulin than would
otherwise be necessary. Like many others, he delights
in the fact that he can take his insulin in the morning,
and then be through with it for the day.

The second case is that of a female, age 46, who was
in a serious condition when first seen in February, 1937.
She had a severe hyperthyroidism, marked polyuria,
polydipsia, and hypertension, and had lost about 40 to
50 pounds in weight. She had never had medical atten-
tion, and when first seen, her blood sugar was 425 mgms.
She had a moderate acidosis. For the first few days, I
attempted to control her diabetes with regular insulin,
with some success. However, she was unable to take
much nourishment at any one time, and had much dif-
ficulty in eating. Because of this situation, I began a
morning dose of 30 units of protamine insulin with
frequent small feedings during the day and night, and
then gave supplementary doses of regular insulin two
or three times daily, according to the amount of food
she was able to take. On this schedule the patient began

to improve and gain weight so that she could soon take
three regular meals daily. This case exemplifies the
beneficial effect of the gradual and prolonged action of
protamine insulin. As has been shown in recent inves-
tigations1,2’3, a more even blood-sugar curve can be
sustained by its use. By giving this patient protamine
insulin and frequent feedings it was possible more nearly
to meet the demands of her hyperthyroidism, namely,
a high caloric intake.

The third case is that of a male, age 58, whose dia-
betes has been present for four or five years. By watch-
ing his diet strictly, he had usually been able to get
along without insulin until September, 1936, when he
began taking ten units of regular insulin before each
meal. In February, 1937, he began to have considerable
glycosuria. I then transferred him to 30 units of pro-
tamine insulin taken each morning. This regime has
not only controlled his glycosuria, but has allowed him
to be more liberal with his diet. This case, as well as
the first one, illustrates how well diabetes may be con-
trolled with less protamine insulin than would be re-
quired of the regular insulin; also, that these people are
much happier on one instead of three doses of insulin
per day, as well as being more liberal with their diet.

In conclusion I wish to quote Joslin in saying that
"with protamine insulin, the fundamentals of the treat-
ment of diabetes are not changed; but the ideals of treat-
ment are more nearly achieved. Diabetes today is a dis-
ease to be respected, and neglect to do so spells disaster.
Diet and exercise are as essential as ever14.”

Bibliography

1. Hagedorn, C. H., Jenson, B. N., Krarup, N. B., and Wod-
strup, I.: Protamine Insulinate, J. A. M. A. 106:177 (Jan. 18),

1936.

2. Root, H. F., White, P., Marble, A., Stotz, E. H.: Clinical
Experience with Protamine Insulinate, J. A. M. A. 106:180
(Jan. 18), 1936.

3. Sprague, R. G., Blum, R. B., Osterberg, A. E., Kepler, E. J.

and Wilder, R. M.: Clinical Observations with Insulin Protamine

Compound, J. A. M. A. 106:1701 (May 16), 1936.

4. Freund, H. A., and Adler, S.: Effects of Standard, Pro-

tamine and Crystalline Insulin on Blood Sugar Levels, J. A. M.
A. 107:573 (Aug. 22), 1936.

5. Wilder, R. M.: The New Insulin, Minn. Med. 20:6 (Jan.),

1937.

6. Joslin, E. P.: Protamine Insulin — The Insulin for Use by

the General Practitioner for the Majority of Diabetics, Med. Clin,
of North America 21:417 (March), 1937.

7. Allen, F. M.: Some Difficulties Arising in the Use of Pro-

tamine Insulinate, J. A. M. A. 107:430 (Aug. 8), 1936.

8. Protamine and Insulin; Current Comment, J. A. M. A.
108:644 and Council on Pharm. 6c Chem. 108:640 (Feb. 20),
1937.

9. Scott, D. A., and Fischer, A. M.: Studies on Insulin with

Protamine, J. Pharm. and Exper. Ther. 58:78 (Sept.), 1936.

10. Drysdale, H. R.: Protamine Insulin in Juvenile Diabetes,

J. A. M. A. 108:1250 (April 10), 1937.

11. Campbell, W. R., Fletcher, A. A., and Kerr, R. B.: Pro-

tamine Insulin in the Treatment of Diabetes Mellitus, Am. J. M.
Sc. 192:589 (Nov.), 1936.

12. Wilder, R. M.: Clinical Investigations with Insulin Pro-

tamine Compound, Proc. Staff Meet. Mayo Clin. 11:257 (April 22),
1936.

13. Richardson, R., and Bowie, M. A.: Observations on the

Effectiveness of Protamine Insulin, Am. J. M. Sc. 192:764 (Dec.),
1936.

14. Joslin, E. P., Root, H. F., Marble, A., White, P., Joslin, A.

P., Lynch, G. W.: Protamine Insulin, New England J. Med.

214:1079 (May 28), 1936.

15. Sindoni, A. Jr.: Protamine Insulin versus Ordinary In-

sulin, J. A. M. A. 108:1320 (April 17), 1937.

438

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Anesthesia and the Relief of Pain*

By the General Practitioner

John S. Lundy, M.D.f
and

Edward B. Tuohy, M.D., M.S. (anes.)f
Rochester, Minnesota

THIS Fiftieth Anniversary meeting of the North
Dakota State Medical Association marks a period
of special significance in the field of anesthesia.
The developments that are taking place now and those
which have taken place during the last twenty-five years,
if continued for another twenty-five years, should es-
tablish those who are engaged in this type of medical
practice as specialists in this relatively new specialty. At
one time the anesthetist had no special standing with
other specialists, except that he narrowed his practice to
the administration of ether by the open drop method.
A few enterprising physicians modified the methods,
but the progress was slow. Then came the great group
of anesthetic agents and methods, most of which are
available in some large hospitals and institutions, but in
general, many of the most useful ones are still not avail-
able in general practice. There are some, however, that
seem to serve a useful purpose in selected cases in the
hands of a man in general practice, and in general prac-
tice there are certain agents and methods that may be
used to advantage in certain cases. Some of them will
be mentioned briefly.

In addition to anesthetic procedures, the anesthetist
of today and tomorrow will be engaged in other related
activities, such as the transfusion of blood, resuscitation,
and the support of patients through the use of intra-
venous solutions of dextrose and sodium chloride. We
also shall refer to some of these activities.

The local anesthetics, procaine and metycaine', are not
used enough in general practice. Most operations, un-
less major in character, have been done and could be
done under infiltration anesthesia. For example, the in-
jection of 10 to 20 cc. of a 2 per cent solution of pro-
caine or metycaine into the hematoma of a recent frac-
ture provides an almost ideal anesthetic for the re-
duction of a fracture. The resulting anesthesia will
last sometimes as long as an hour so that a cast may be
applied after the reduction has been accomplished.

For abdominal operations it is advantageous to in-
ject a 0.5 per cent solution of procaine or metycaine
with epinephrine into the line of incision in the ab-
dominal wall. Six minims (0.37 cc.) of epinephrine
in 1:1000 concentration is added to each 200 cc. of a
0.5 per cent solution of the anesthetic agent. This tends
to make the incision dry and reduces the amount of
general anesthetic that would otherwise be necessary.

Certain methods of block anesthesia also are of value.
If the physician would make the effort to use caudal

* Presented before the annual meeting of the North Dakota
State Medical Association, Grand Forks, North Dakota, May
16 — 18, 1937.

f Section on Anesthesia, the Mayo Clinic, Rochester, Minnesota.

anesthesia occasionally, he would find many cases in
which it could be used to advantage. It produces a
"saddle type” of anesthesia so that any operation on
the rectum, vagina, perineum, or urethra may be carried
out. It may be used in operative obstetrics, although a
simpler injection will usually suffice. When the patient
is in the lithotomy position, the injection of 10 to 15
cc. of a 1 per cent solution of procaine or metycaine
just mesial to the tuberosities of the ischii will produce
anesthesia of the anterior half of the perineum that will
last for more than half an hour. This injection may be
repeated from time to time if necessary. This produces
anesthesia of the labia and urethra but not of the anus.
However, this block may be supplemented by the in-
jection of very small amounts of a 0.5 per cent solution
of procaine or metycaine at the points at which tender-
ness occurs, if necessary.

Other blocks that are easily done are block of the
ulnar nerve at the elbow, or the hand or foot may be
anesthetized by intradermal or subcutaneous injection
and injection through the balance of the tissue to the
bone. This bracelet can be accomplished easily, and it
is usually done with a 0.5 per cent solution. If the
needle actually touches a nerve trunk, it should be im-
mobilized there and 5 or 10 cc. of a 1 per cent solution
should be injected.

For operations on the neck, one may use deep and
superficial cervical block or just a superficial block plus
infiltration. These serve admirably in most cases, pro-
vided that with this block, or with any other form of
local anesthesia, the patients, especially nervous ones,
are given preliminary medication the night before and
the morning of operation. Pentobarbital sodium (nem-
butal) is given in a dose of V/2 grain (0.097 gm.) by
mouth the night before; this dose is repeated the next
morning when the patient awakes. For adults, 1/6
grain (0.01 gm.) of morphine sulphate and 1/150 grain
(0.0004 gm.) of atropine sulphate should be administered
by hypodermic injection at least thirty or forty minutes
before anesthesia is to be induced. In some cases an
additional l/2 grain (0.097 gm.), or even 3 grains
(0.2 gm.) , of pentobarbital sodium (nembutal) may be
necessary, especially if the patients are suffering from
pain; if the pain is intense, more than 1/6 grain (0.01
gm.) of morphine will be required to bring the patient
to a condition in which he will cooperate and permit the
use of a local anesthetic. For children about ten years of
age or less, the use of pentobarbital sodium (nembutal)
is a very worthwhile measure, and the amount necessary
to eliminate apprehension on the part of a child may be

THE JOURNAL-LANCE'

439

a dose which will also put him in a condition called basal
narcosis, from which one can barely arouse him. When
he is in this condition, one may proceed with the ad-
ministration of the local anesthetic and do most oper-
ations that might be carried out on adults under local
anesthesia. Such medication is also of value in bringing
children to a condition in which blood transfusion may
^easily be carried out. They do not struggle and pull
away when one is attempting to carry out venipuncture,
and they will lie quietly during the administration of
blood or other intravenous solutions that may be neces-
sary. The venipuncture is also facilitated by the fact
that barbiturates tend to increase the circulation of
blood in the extremities and definitely increase the tem-
perature of the extremities; the veins will be better filled
with blood and for that reason will more easily be en-
tered with the needle.

While preliminary medication in doses sufficient to
produce marked effect is important in connection with
local anesthesia, it is not, as a rule, a good measure in
connection with inhalation anesthesia, for in most in-
stances it is better to employ only moderate doses of
preliminary medication. It is better not to give a hypo-
dermic injection of morphine when ether is to be used
by the open drop method, for the reason that ether and
morphine each depress respiration and the two together
often depress respiration before the patient receives
enough ether to produce relaxation. A situation may
be brought about in which operation cannot proceed
without relaxation and when one is without sufficient
assistance nothing further can be done, except to in-
filtrate the abdominal wall and attempt to proceed by
using a form of balanced anesthesia in which the pre-
liminary medication, local anesthesia, and light ether
anesthesia may suffice.

If one wishes to use nitrous oxide in the home, it will
be necessary to obtain a gas machine of the portable
type and have someone to operate it. The same is true
of ethylene and cyclopropane but additional precautions
are necessary with the latter agents because of their in-
flammable and explosive qualities. If a case calls for
this type of anesthesia and it can be provided, one should
obtain a canister of soda lime and use it so that the ex-
pense of the gas is reduced to a point which is not pro-
hibitive, even in the charity case.

Cyclopropane has been a recent development and is of
value when a general inhalation anesthetic is to be used,
when ether must be avoided, and when fireproof con-
ditions are not necessary. Most people tolerate cyclo-
propane very well, but a few do not tolerate it in doses
sufficient to produce deep surgical anesthesia. It is ad-
visable, therefore, to palpate the pulse throughout the
period of induction, and if it becomes markedly altered
in character and volume, the patient may be considered
unsuitable for deep anesthesia with this gas, and ether
will have to be added rather than more cyclopropane.
In obstetric cases it is being employed by several men1,3
with satisfaction. This might be expected from the fact
that anesthesia is induced more quickly with it than
with the other gases or ether, and a high percentage of

oxygen may be administered with cyclopropane without
reducing its efficiency as an anesthetic.

In the use of inhalation anesthetic agents, there is one
aid which should be generally used and that is the
Magill large-bore, soft-rubber intratracheal tube, which,
when greased, may be passed through the nose and into
the throat and, in more than half the cases, will find
its way into the larynx and then into the trachea. With
this tube acting as an airway, the administration of a
general anesthetic is made easy. Respirations are quiet
and effortless and ventilation is adequate. It is im-
portant that the use of this method be mastered by those
who are either to administer the anesthetic or are to be
responsible for its administration. When the tube will
not enter the larynx easily after being introduced through
the nose, it may be necessary to use a tongue depressor
and raise the tongue and epiglottis and introduce the
tube under direct vision, either through the nose or
through the mouth. A lighted instrument such as a
laryngoscope greatly facilitates such a maneuver, but if
an assistant is at hand, another light may be used to
illuminate the throat. This method is one that will be-
come widely used, and I wish to call your attention to
the advisability of acquainting yourselves with it, for
not only is it of great value in the administration of an
inhalation anesthetic, but it also may be used for the
resuscitation of individuals who have for any reason be-
come asphyxiated. The great ease with which artificial
respiration can be carried out either manually or me-
chanically needs to be sufficiently emphasized so that
the Magill tube will shortly be available whenever a
physician is available.

A modification of this technic is carried out to ad-
vantage in the resuscitation of the newborn, when a
catheter and glass tip may be used to aspirate mucus
from the baby’s throat and trachea. The tube may be
also slipped into the larynx and artificial respiration may
be carried on by direct inflation by blowing through the
tube.

Rectal anesthesia with oil in ether is often used to ad-
vantage in obstetric cases, but it is seldom used in other
cases; however, there are times when it might well be
used provided the dose is that which is only sufficient to
bring about basal analgesia. One of the disadvantages
is, of course, that patients exhale the ether very shortly
after they begin to absorb it into their blood stream
from the rectum, and so morphine is necessary, especially
in adults, in order to depress respiration a little and
thus minimize the rate of escape of the ether in surgical
cases. In obstetric cases one must be guided by the con-
ditions as they present themselves and be governed ac-
cordingly in the use of this method.

For surgical operations the drug tribrom-ethanol
(avertin) , when given in a dose small enough to produce
basal analgesia, is useful as it breaks down in the body
and is not exhaled. Its effect is more certain than oil
and ether by rectum, it lasts longer, and, for children
who safely tolerate this agent in larger doses than do
adults, this drug brings a patient to a condition in which
many procedures may be carried out by merely supple-

440

THE JOURNAL-LANCET

meriting this form of anesthesia with local anesthesia
or a very light ether anesthesia by the open drop method.

Barbiturates may be administered by rectum to bring
about a somewhat similar effect, and from a standpoint
of convenience, this may be more useful in general
practice than ether in olive oil, or avertin. This is es-
pecially true when one is faced with the problem of
transporting a patient who has been severely wounded
or burned, or who has convulsions or a psychosis. The
safest way to use such barbiturates is to introduce a cap-
sule of the barbiturate into the rectum just as one would
administer a suppository. The original dose should be
administered and followed at intervals of twenty to
thirty minutes with smaller amounts until the patient
is brought under control. One of us (Lundy) used
this scheme on an insane adult until he was thoroughly
quieted. The patient then was placed on his side in the
back seat of an automobile and transported as far as
100 miles without untoward result.

The intravenous anesthetics5, evipal soluble and pen-
tothal sodium, are helpful if one is cautious in their use.
They should not be administered to individuals who
have symptoms of dyspnea, whether because of pulmo-
nary or cardiac disease, nor to a patient who has any de-
gree of respiratory obstruction or is likely to have res-
piratory obstruction during or after anesthesia. They
should not be administered to children who are ten
years of age or less, because respiratory depression is
associated with the surgical stage of anesthesia, and in
children who have small respiratory passages this tends
to cause an unsafe degree of pulmonary hypoventilation.
These agents are not especially potent anesthetics and
are very useful for short procedures, which last five or
ten minutes, such as the extraction of a large splinter or
removal of painful packs, and for many short minor
operations in which the patient’s jaw can be well sus-
tained by some individual. A cotton or paper "butter-
fly”4 should be used to indicate that the respiratory pas-
sages are patent and being used. Anesthesia is quickly
induced and can be maintained by keeping the needle
in the vein and administering small quantities of the
drug in a 5 per cent solution from time to time, much
as one would administer ether intermittently by the
open drop method. In general practice, the use of
these drugs for procedures which last longer than five
or ten minutes requires an additional person to adminis-
ter the anesthetic. For short operations, it is possible
to induce anesthesia and withdraw the needle and then
carry out the contemplated procedure. If this is to be
done, anesthesia should be slowly induced, as the patient
counts, so that the voice may be audible, or the patient
may raise the other arm and the anesthetic may be in-
jected until the arm falls. Then, after a minute has
elapsed, 1 or 2 cc. more of the solution may be in-
jected slowly by using the character of the respiration
as a guide. Respiration should not stop entirely at any
time. It is the administration of the drug in divided
doses that permits the induction of anesthesia slowly and
with relative safety. When one is without an assistant,
one may have to resort to the less desirable method of

administration, which is not as safe as the intermittent
method. The concentration of the drug in the solution
should not be more than 5 per cent, and if the patient
stops breathing and shows signs of asphyxia, a clear
airway should be maintained by sustaining the jaw,
and manual artificial respiration should be carried out,
or oxygen and carbon dioxide should be administered
if they are available. The patient should survive if the*
period of asphyxia has not been too long and if he is
ventilated by artificial respiration until automatic breath-
ing returns. Delay in maintaining a clear airway by
sustaining the jaw might be fatal.

Since these drugs are barbiturates and in general are
anti-spasmodics, they may be used in the control of con-
vulsions, but because of their transient effect they may
not be as satisfactory as is sodium amytal or pentobar-
bital sodium (nembutal), which are used in conditions
associated with eclampsia, tetanus, and poisoning by con-
vulsants such as strychnine, or in those rare cases in
which convulsions are associated with general anes-
thesia. In the latter cases the patients are often children
who have an acute infection, such as acute appendicitis,
and on being anesthetized with an inhalation anesthetic
begin to twitch and convulse and may die unless the con-
vulsions can be controlled until the anesthetic has been
entirely eliminated and until the toxemia of the infec-
tion subsides. Avertin may be used instead of the bar-
biturates in many cases; it is especially useful in tetanus,
where it may be alternated with the barbiturates with
the hope that less pulmonary edema will take place if
the patient is not given huge doses of the same drug one
or more times daily.

The use of intravenous therapy is really about as val-
uable in general practice and in the home as it is in insti-
tutions. By the use of a little foresight, a physician in a
community can readily2 group the blood of a few persons,
and if one needs blood for a transfusion, the physician
may send for an individual to come to the place where
he is needed, or the donor may come to the office where
the physician may draw the blood, add a citrate, put it
in a sterile bottle, and carry it to the place at which it
is to be used. If it is not all needed, the remainder can be
put in a refrigerator at 40° F. and can be kept for a
week or ten days and still be used. We do not like to
use blood after it has been kept in a refrigerator for
longer than twelve days. At the present time we know
of no reason why citrated blood is not as beneficial as
unmodified blood, and we believe the method of indirect
transfusion is much simpler for the general practitioner,
as well as for use in the hospital.

Our custom is to add 18 grains (1.16 gm.) of sodium
citrate and 50 cc. of physiologic saline solution or sterile
distilled water to 500 cc. of blood. The blood is collect-
ed in this solution which is stirred all the while so that
the blood will become citrated immediately and as fast
as it is drawn.

The administration of blood should be not faster than
15 cc. a minute, and many physicians prefer to use a
Murphy drip arrangement in the tubing between the
bottle and the needle. In most instances an 18-gauge

THE JOURNAL-LANCET

441

needle is the best size for the administration of blood
and intravenous solutions. A 19-gauge or 20-gauge
needle may, however, be used.

When blood is not available, a 6 per cent solution of
acacia in physiologic saline solution is a temporary sub-
stitute, and in some cases this will support the patient
sufficiently; therefore, many physicians consider it a good
substitute for blood. Sometimes it may be given before
or after some blood has been given; it also may be used
when blood is needed in a large quantity but not much
of it is available. One should, however, guard against
mixing the solution of acacia and the blood in the buret,
tube, or needle, for the acacia changes the sodium citrat-
ed and allows the blood to coagulate. This does not
occur in the vein, as the solution of acacia is very quickly
and markedly diluted.

A 5 to 10 per cent solution of dextrose is very useful
for many purposes when patients need fluid or food and
cannot take them by mouth. Physiologic saline solution
is of marked usefulness in many conditions of dehydra-
tion, such as starvation or excessive or prolonged vom-
iting. It is, of course, of great value in replacing the

large amount of salt lost in the exudate in cases in which
patients have been severely burned.

Venipuncture may be accomplished readily if heat
has been applied to the whole of the extremity for
twenty to thirty minutes, as has been described else-
where6.

The rate of intravenous injection of solutions should
be about the same as that recommended for the admin-
istration of blood.

References

1. Bourne, Wesley: Cyclopropane anaesthesia in obstetrics.

Lancet. 2:20-21 (July 7) 1934.

2. Correspondence: Syphilis in blood donors. Jour. Am. Med.

Assn. 108:224 (Jan. 16) 1937.

3. Knight, R. T. and Urner, J. A.: Obstetrical analgesia, with

particular consideration of the use of cyclopropane in a specially
constructed apparatus for controllable analgesia. Journal-Lancet.
56:608-612 (Dec.) 1936.

4. Lundy, J . S. : A method of minimizing respiratory depres-

sion when using soluble barbiturates intravenously. Proc. Staff
Meet. Mayo Clinic. 10:791-792 (Dec. 1 1 ) 1935.

5. Lundy, J. S.: Intravenous anesthesia. Am. Jour. Surg.

34:559-570 (Dec.) 1936.

6. Lundy, J. S.: Suggestions to facilitate venipuncture in blood
transfusion, intravenous therapy, and intravenous anesthesia. Proc.
Staff Meet. Mayo Clinic. 12:122-125 (Feb. 24) 1937.

7. Tuohy, E. B. : The use of metycaine in spinal anesthesia.

Surgery. (In press).

The General Symptomatology "

Of Common Rectal and Anal Diseases
James Kerr Anderson, M.D., F.A.C.S.f
Minneapolis, Minnesota

PATHOLOGICAL changes are present in and
about the anus and lower end of the rectum in
approximately 15 per cent of people. The relief
of these difficulties will be accomplished by treatment of
the findings discovered by examination of the rectum
and anal canal. This examination should consist of
inspection, palpation, and vision through an anoscope
and proctoscope. Most of these patients present symp-
toms referable only to the area in question; but a few
complaints are more general in nature, which, when in-
vestigated, are found to be due to rectal or anal path-
ology. Correct diagnosis, of course, is necessary for suc-
cessful treatment, and while subjective symptoms are im-
portant, they are not to be relied upon to establish the
diagnosis, and should always be supplemented by a care-
ful local examination. To the laity, and unfortunately,
many physicians, "rectal trouble” means "piles,” and
too often a suppository or ointment is prescribed without
examination, or used upon the advice of a friend.

We cannot control a patient or his friends, but no
physician should prescribe treatment without a definite
evaluation of symptoms, adequate examination, and rea-
sonable assurance of the pathology actually present.
Failure to diagnose correctly may be excused, but NOT
failure to examine adequately. There is nothing partic-
ularly difficult or obscure about the diagnosis of the ma-

* Presented at the Meeting of the Chippewa County Medical
Society, Chippewa Falls, Wisconsin, February 9, 1937.
t Instructor in Surgery, University of Minnesota.

jority of rectal and anal diseases, yet I am sure that
rectal examination is the most commonly neglected pro-
cedure in medical practice, even when the patient’s com-
plaints are suggestive. It is common observation that
an appreciable percentage of patients suffering from
rectal malignancies have had a hemorrhoidectomy, or
some anal treatment, shortly before the discovery of the
more serious lesion. Most of these omissions in diagnosis
could have been avoided had an adequate examination
been carried out when the patient first presented himself.
The eventual discovery of the existing malignancy occurs
only because the patient’s symptoms continued to in-
crease in severity, rather than diminish, following the
operation.

Before taking up various local symptoms and the at-
tendant pathology, a brief discussion of the anatomy
of the region is essential.

The rectum is derived from the posterior division of
the hind-gut and the anal canal from the proctodeum;
different germ layers. Where these tubes or blind
pouches approximate in intrauterine life is evidenced
throughout life by a line or ridge, seen encircling the
bowel. Usually this line or ridge, called the anorectal
line or junction, the pectinate or dentate line, and by
some, the white line of Hilton, is well within the anal
opening (/2 to % of an inch), but occasionally is seen
upon spreading the nates and anus. The length of the

442

THE JOURNAL-LANCET

anal canal is subject to some variation. This anorectal
line or junction serves as a means of classifying lesions —
those distal being anal, and those proximal, rectal. It
also indicates the change in blood supply and drainage,
the lymphatic drainage and the nerve supply. This
anatomical landmark should always be identified in the
anoscopic examination, particularly if any injection
treatment is anticipated.

The lymphatic drainage is particularly important in
reference to lymphopathiavenerum (lymphogranuloma
inguinale) , distal to the anorectal line to the inguinale
glands, and proximal to the glands about the rectum.
There are also distinct differences in the male and
female, accounting for the preponderance of strictures
seen in women. The difference in the nerve supply
above and below this anorectal junction is most impor-
tant. Above the line, that is, in the rectum, the nerve
supply is primarily from the sympathetic nerves, thus
here a poorly-developed pain sense. Below the line in
the anal canal, the nerve supply is from the spinal
nerves, which renders this area most sensitive. Non-
surgical or injection methods may be used above the
line, but never below, for this reason alone.

Pain is the most frequent symptom which brings the
patient to the physician. It very often indicates an in-
flammatory lesion, or the result of a vascular accident in
the anal canal distal to the anorectal line, although in-
flammatory lesions in the rectum causing much disten-
tion also produce acute pain. The location of the pain
is important and helpful; it may be low and close about
the anus, in the anal canal, rectum, or buttocks. It may
be generalized about the anus, or definitely localized in
a small spot or area. The character may be dull, sharp,
sudden, spasmodic, constant, throbbing, or limited to a
mild tenderness. The time of the pain relative to the
bowel movements is very helpful. Sharp pain coming
on during or immediately after the movement is usually
diagnostic of a lesion in the anal canal, such as an ulcer,
fissure, or thrombosis. A throbbing, constant pain,
usually means an acute inflammatory process which may
be under the peri-anal skin, about the canal, or in the
rectum. Early in its development, this may be only
tenderness, but as pus accumulates and the tension is
increased, acute pain develops. Lesions in the rectum,
inflammatory or neoplastic, may progress to a marked
degree without causing pronounced symptoms, this again
being due to the lack of sensory nerve supply. This is
in marked contradistinction to the same type of lesions
in the anal canal, where the sensory nerve supply is
profuse and pain is acute. Pain may be referred to
other structures, as the bladder, coccyx, uterus, prostate,
etc. It is very common for pain to be referred in rectal
lesions, and backache, sciatica and dysuria often dis-
appear following the treatment or removal of hemorr-
hoids, or other anal pathology. The question of referred
pain is complicated, and many times difficult to explain.
Spasmodic pain is commonly seen in ulcerative lesions in
the anal canal — fissure and ulcer being the most com-
mon. Anything causing an irritation of the sphincter
muscle causes pain, such as an anal thrombosis, foreign

body, prolapsed papilla, or internal hemorrhoid. Types
of pain with non-thrombosed hemorrhoids are dull, bear-
ing-down, and spasmodic when protruded. If prolapsed
and strangulated, a throbbing constant pain is present.
If thrombosed, a constant burning, distension type is
present, which is aggravated by movements. With a
fissure or ulcer, the spasmodic pain is definitely aggra-
vated by the movement and may last several hours. With
abscess, the pain is constant and gradually increasing —
the amount depending upon its location and extent.

Bleeding is one of the most common and important
symptoms presented, and should always demand a com-
prehensive anal, rectal, and sigmoidoscopic examination.
Bleeding is more common in adults; but is seen fairly
frequently in children, and with them, it is usually due
to polypi, prolapse, adenoma, diverticula, intussuscep-
tion, or trauma from a constipated stool. The origin of
the blood in adults may be any of the following: hem-
orrhoids, prolapse, fissure, ulcer, stricture with ulcera-
tion, malignancy, proctitis, colitis, polypi, adenoma,
diverticula and intussusception. While the type of
blood, its amount and time of passage are important
and suggestive, they give no definite indication as to
the type or location of the lesion. Bleeding in rectal
disease may be profuse or scanty, bright red or dark
and clotted, accompanied or not by pain. These symp-
toms can be brought out easily in the history. Profuse
bright red blood following the stool and without pain,
usually indicates internal hemorrhoids or a sloughing
area from a previous injection treatment. A small
amount, or streaks on the toilet paper, accompanied by
some pain or discomfort, suggests a fissure, ulcer, or tear
in the anal canal. Fresh bright red blood, of course,
suggests a lesion low in the rectum or anal canal, while
dark or clotted blood indicates a higher origin. It
must be remembered, however, that blood from internal
hemorrhoids may not be expelled immediately, and hence
becomes dark and clotted and may thus be quite mis-
leading. On the other hand, a malignant ulcerative neo-
plasm may bleed profusely and the blood may be ex-
pelled before becoming clotted and dark. A search for
the bleeding-point should, of course, be made, first
using an anoscope and if not found, a proctoscope. It
is very difficult at times to locate the bleeding point,
even though the bleeding has been recent, and there is
even fresh blood in the rectum. If a bleeding-point is
discovered, a suture or touching with the actual cautery
may be necessary. Bleeding usually frightens the patient,
and brings him to the physician. If all cases presenting
this symptom would present themselves, I am sure many
malignancies would be discovered earlier, and in a more
favorable stage to operate.

Protrusion about the anus or from the anus is quite
common. Whether the protrusion is present at all
•imes, or only following the movements, should be
elicited. The relation of the protrusion to the passage
of the stool gives some index as to the extent of the
pathology, as well as to the type. The common types
of protrusion following the passage of stool, gas, strain-
ing, or excessive exertion, are hemorrhoids, hyper-

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443

trophied papillae, prolapse, or pedunculated polypi. The
common, constantly present protrusions are skin tags,
external thromboses, old atrophied external hemorrhoids,
and condyloma accuminata. Internal hemorrhoids are
arbitrarily classified as to their replaceability into four
degrees. Those of the first degree do not prolapse at
any time; those of second degree prolapse with strain-
ing, but replace themselves on cessation of straining or
upon lying down; those of the third degree prolapse
and have to be replaced, usually following each move-
ment; those of the fourth degree are constantly pro-
lapsed. Bleeding at the time of protrusion is common,
and assists in the diagnosis. The same may be said of
pain with protrusion, which is relieved after the pro-
trusion is replaced. It is commonly observed that pa-
tients will complain of a protrusion when they are re-
ferring to a protrusion which is always present and
cannot be replaced; or to a bulging, which occurs on
straining. These, of course, are not protrusions in the
sense that they descend through the anal canal.

Itching is a very frequent and troublesome complaint,
and is often due to lesions or pathology in the anal canal
or lower rectum. Hemorrhoids, cryptitis, papillitis,
parasites, prolapse, fissure, and fistula are the notable
contributors. In those cases in which there are these
contributing factors, other symptoms are usually pre-
sent. Local itching usually has its origin locally, except
in those persons with certain constitutional diseases, and
with these, other areas are pruritic. Fortunate is the pa-
tient with pruritus who has local pathology about the
anus, because it is these cases which can be aided most.
Pruritus ani without any local pathology or any detect-
able contributing factors is one of the most discourag-
ing ailments encountered, for both the physician and the
patient. It is the consideration of the treatment and
etiology of pruritus ani which offers such controversy,
because the symptoms are well-defined.

Discharges other than blood — Excess of mucus usually
means an acute or chronic inflammatory, or neoplastic,
process in the rectum. The exception to this is mucous
colitis, where large quantities of mucus are expelled, and
yet the bowel mucosa appears quite normal. Pus, in any
amount, indicates an internal fistula, sinus, or ulcerated
mucosa. Smaller amounts may come from smaller
sinuses, single ulcers, or chronic colitis. With malignant
lesions, the mucus is usually mixed with the blood, and
there is a characteristic musty odor present. Moisture
about the anus means some low pathology in the anal or
local skin from which serum escapes, the patient often
considering this as a rectal discharge.

Constipation — The usual type seen is of the habit
variety but examination should be carried out to elim-
inate stricture or some mechanical narrowing within the

length of the proctoscope. If this is negative, an X-ray
study with a barium enema is indicated.

Diarrhea — Proctoscopic examination will many times
reveal the underlying pathology, as in different types of
colitis and malignant disease. Diarrhea, to a patient,
may mean the passage of any liquid; mucus, pus, blood
or liquid stool. Internal rectal abscesses which rupture
into the bowel may simulate diarrhea. A heavy feeling
in the rectum should always be investigated, as many
times malignancy may be the cause. Fecal impaction
also gives this symptom, but this seldom occurs in an
ambulant patient. Tenesmus suggests irritation or in-
flammation of the rectal mucosa, and is caused by various
lesions, such as colitis, malignancy, impaction, or pres-
sure from extra rectal tumors.

Referred symptoms are often caused by rectal and
anal lesions. Back-aches are a common accompaniment
of hemorrhoids, fissure, malignancy, prolapse, and im-
paction. Pains down the legs or sciatica-like pains are
often seen with fissures, hemorrhoids, abscess and cryp-
titis. Local symptoms, however, are usually present.
Scanty or absent menses are often seen with fissure
and hemorrhoids. Urinary difficulties are possibly most
frequently observed in anal fissure. Slowly protracted,
hemorrhoidal bleeding is often overlooked as a cause
for an unexplained secondary anemia (the pale appear-
ance of the bowel noted on anoscopic and proctoscopic
examination may give the first clue) . We have seen cases
in which the hemoglobin fell to 18 per cent from bleed-
ing hemorrhoids. Rectal symptoms with emaciation is
always an index of gravity, and should demand procto-
scopic examination as well as a barium ray. Nervous-
ness and irritability are many times due to anal and
rectal lesions, particularly hemorrhoids, fissure, ulcer and
cryptitis. The effect of these lesions is many times not
recognized until the pathology has been removed.

Conclusions

Non-mahgnant, rectal, and anal diseases are quite
common, and malignant ones, too common.

The diagnosis of these diseases is not particularly
difficult when a careful history is taken, proper evalua-
tion made of the symptoms presented, followed by a
careful painstaking digital, and an anoscopic and proc-
toscopic examination.

Cases presenting rectal or anal symptoms are entitled
to a digital and visual examination of the anus and
rectum, at least to eliminate the possibility of a ma-
lignant lesion.

Early and operable malignancies are most often first
seen by those doing general medicine, and in order to
increase the percentage of early diagnosis, it behooves
us all to be on the alert.

444

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Feeding Problems in Infancy*

George E. Robertson, B.Sc., M.D. f
Omaha, Nebraska

ONE OF THE advantages of breast feeding over
artificial feeding lies in the fact that feeding
disturbances are met with much less frequently
in the breast-fed child than in the artificially-fed one.
This applies to all the ordinary symptoms interpreted as
feeding disturbances, except those due to organic disease
in the infant. For this reason, this discussion will deal
largely with feeding problems as they occur in the arti-
ficially-fed infant, with occasional reference to situa-
tions that arise in the breast-fed infant.

Feeding difficulties met with by the pediatrician may
be classified according to their causes in the following
ways:

Causes of Feeding Difficulties

1. Errors in formula prescription.

2. Errors in formula preparation.

Milk and top cream not mixed, spoiled milk,
faulty refrigeration, milk not boiled, incorrect
measuring.

3. Errors in feeding technic.

Poor schedule, improper or plugged nipples, air-
swallowing, milk not at proper temperature,
over-handling and over-stimulation.

4. Organic disease in the infant.

5. Low tolerance for carbohydrate.

6. Low tolerance for cows’ milk.

Allergy.

7. Intolerance for cod liver oil or orange juice.

Errors in formula prescription usually result from the
physician’s failure to observe the familiar rules cov-
ering the infant’s feeding requirements, or his neglect
to apply the familiar devices used to individualize a
formula to a particular infant’s symptomatic response.

Errors in formula preparation usually result from
lack of detail in the explanation made to the mother in
connection with the formula prescription. They can
usually be avoided if a demonstration of formula prep-
aration technic is provided for each mother. Familiar
errors in formula preparation are: the failure thoroughly
to mix the cream with the milk before the milk is
measured; use of milk which is slightly spoiled; faulty
refrigeration of the formula; failure to boil the milk,
or failure to remove the thin film, which forms during
the boiling process; the use of incorrect measures, or
carelessness in measuring out the quantities prescribed.

Errors in the feeding technic are usually the result
of oversight on the part of the mother. They include
carelessness in following the schedule specified by either
feeding irregularly, too frequently or at intervals which
are too long; the use of improper nipples, with Holes
either too large or too small, or the use of nipples which

* Presented before the annual meeting of the South Dakota
State Medical Association, Rapid City, South Dakota, May 24-26,
1937.

t Instructor in pediatrics, University of Nebraska College of
Medicine, Omaha.

have become plugged by a precipitated milk; failure to
remove the air from the stomach, after the nursing;
and the very common error of over-handling and over-
stimulation of the child by active play near the feeding
time.

The role of organic disease in producing symptoms in
infants must always be borne in mind. Any disease
affecting the child, or any one of the child’s systems, may
produce gastro-intestinal symptoms.

The three last causes are those in which the baby’s
formula actually does not agree with the child, due to
conditions inherent in the child, which bring about a
decreased tolerance for one or more of the elements of
the formula.

This group, alone, represents what might be termed
true feeding problems, i. e., the disturbances due pri-
marily to the elements of the feeding. It is in the man-
agement of the infants falling into this group that the
ordinary rules for infant feeding fail. In this group are
included those cases, which incidentally are rare, in
which allergy is the underlying cause of the disturbance.

Requirements for Adequate Diet

1. Sufficient protein, carbohydrate, fat, water, min-
eral salt, vitamins A, B, C, and D.

2. Sufficient calories.

3. Food must be clean and digestible.

Formula must supply:

Protein — \/2 to 2 oz. cows’ milk per pound in
24 hrs. (Limit — 32 oz.)

Fat — Supplied by above milk.

Carbohydrate — 1 oz. added for each 10 to 20
oz. of cows’ milk (5-10%).

Calories — 50 per pound in 24 hrs.

Water — 1/2 oz. per pound in 24 hrs.

The requirements for an adequate diet for a child are
familiar. There are certain reciprocal relationships which
exist in these requirements. The first is the relationship
between the caloric value per ounce, and the fluid re-
quirements of the child. A formula providing 20 cal-
ories per ounce, a value equal to that of breast milk,
exactly satisfies the fluid requirements of the child. A
formula low in protein must necessarily be high in car-
bohydrates, and vice versa, a formula high in protein
must necessarily be low in carbohydrates. Consideration
of these factors is of importance in altering the formula
to suit the symptomatic response of the individual
infant.

Familiar Devices in Infant Feeding

For Vomiting —

Diminish quantity of food.

Lengthen feeding interval.

Reduce fat content.

For Diarrhea —

Reduce carbohydrates.

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445

Reduce fat.

For Constipation —

Increase carbohydrates.

Decrease fats.

For Anorexia —

Lengthen feeding interval.

Decrease concentration.

For Failure to Gain —

Strengthen formula.

The devices employed in altering the formula to meet
the symptomatic response of the infant recognize the
necessity for considering the infant’s stomach capacity,
its emptying time, his reaction to cows’ milk, his re-
sponse to cows’ milk fat, and his ability to handle var-
ious types of sugar. The size of the individual feedings
must be determined by the infant’s stomach capacity.
The length of the interval between feedings must de-
pend upon how rapidly the stomach empties. The fat
content of the formula may delay the emptying time.
Formulas high in carbohydrates tend to produce loose
stools. Those low in carbohydrates tend to produce con-
stipation. A high fat content in the formula may pro-
duce either diarrhea or constipation. The application
of these few facts makes possible successful feeding of
the larger majority of all normal infants on simple milk
dilutions with varying percentages of carbohydrate
added, and the solving of many of the minor digestive
disturbances that arise.

In the cases that show persistent symptoms in spite
of management of this type it is necessary to go into
rather complete detail in the study of the individual
case.

Management of Feeding Problems

1. Rule out all other factors before attributing

symptoms to formula.

A. Pre-natal and birth history.

B. Detailed feeding history.

C. Complete physical examination.

D. Laboratory work as indicated.

a. Stool examinations.

b. Gastric lavage to determine emptying
time.

c. Blood count — hemoglobin.

d. Urinalysis.

e. Roentgenologic examination.

f. Blood pressure.

g. Tuberculin test.

h. Blood Wassermann.

2. Change formula only when indications are

clear-cut.

A. Frequent changes of formula are not de-
sirable.

B. Infant requires 3 or 4 days to adjust to

change in formula.

3. Temporary underfeeding may be necessary in

some cases.

A. Fluid intake must be maintained.

B. Return to full diet must be gradual.

4. Dangers in rapid weight gain are slight if due
attention is paid to vitamins and minerals.

In the management of feeding problems of this type
it must be the first principle in the investigation of each
case to rule out all other factors before attributing the
symptoms exhibited to the formula alone. A careful
and complete history must be taken of the child, in-
cluding pre-natal factors, such as maternal health and
diet, and length of term, birth history, with particular
reference to injury, and all the minute details relating
to feeding. A careful physical examination should be
done, supplemented by such laboratory work as may be
indicated. Stool examinations are not done as fre-
quently as they were at one time, or as frequently as
they should be done. Considerable information can be
obtained from an examination of the stools as to the
digestive efficiency of the child’s gastro-intestinal tract.
Gastric lavage is of value in cases of vomiting in de-
termining the emptying time of the stomach. It may
also serve to reveal the presence of undue amounts of
mucus in the stomach, which may be concerned in the
production of the symptom, vomiting. In connection,
especially, with those infants who show nutritional fail-
ure, examination of the blood may be of great value.
The presence of iron deficiency anemia, or the presence
of some other type of anemia often explains certain
cases of failure to gain. A urinalysis may likewise ex-
plain some of these cases. X-ray examination should be
done in every case of persistent vomiting, in order to
rule out the possibility of organic obstruction. Among
the laboratory procedures, almost universally overlooked
in the care of the infant, is the determination of the
blood pressure. This may be of value in the recognition
of early cases of acrodynia. In all cases showing nu-
tritional failure, the tuberculin test and blood Wasser-
mann should not be overlooked.

The principles underlying the management of the
feeding problems are as follows:

It is not necessary to change an adequate formula
unless clear-cut indications for such change can be
made out. Frequent changes in the formula are not only
not desirable, but may be actually harmful to the child.
The average infant requires three or four days to adjust
to a change in his formula, and it is impossible to eval-
uate the results of the change in a period less than this.
In cases of vomiting, diarrhea, anorexia, and failure to
gain, temporary underfeeding may be necessary. While
this is being carried out, it is necessary to watch very
carefully the fluid intake of the child. When symp-
tomatic relief is apparent, the return to full diet must
be accomplished in a gradual manner. After symp-
tomatic relief, weight-gain is often very rapid. The
danger in rapid weight-gain is very slight, if due atten-
tion is paid to vitamin and mineral content of the diet.
This is mentioned in order to call attention to the inad-
visability of restricting too greatly, the diet of the child
who is showing a rapid weight-gain. It is much wiser
to increase the vitamin and mineral content of the child’s
diet, and continue to provide sufficient food for his re-
quirements.

446

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The older articles on feeding problems are difficult
to interpret because of the use of classifications em-
ploying such terms as dyspepsia, milk injury, dystrophy,
atrophy, weight disturbance, decomposition, etc. A
clearer and more workable classification of the common
feeding problems is reached by considering them accord-
ing to the symptoms presented. This method of classifi-
cation is used without any disparagement of the older
classifications or the theories on which they are based.

Possible Causes of Colic

1. Hunger?

2. Overfeeding?

3. Gastro-enterospasm?

4. Carbohydrate fermentation?

5. Protein indigestion?

6. Tough curd formation?

7. Fat intolerance?

8. Air-swallowing?

9. Immaturity of gastro-intestinal tract?

10. Calcium deficiency?

11. Fatigue toxin?

12. Allergy?

13. Abuse of laxatives, enemas and suppositories?

Consider first, the familiar symptom, colic. It is well

to call attention to the fact that some observers consider
colic to be such a common occurrence that they would
rather interpret it as a characteristic of the infant, rather
than as an abnormal symptom. These observers call
attention to the fact that all infants are more or less
colicky. No one can deny that the more colicky infant
is often a very troublesome problem. In the literature
on infant feeding there have been a vast number of
causes for colic advanced by different authors. Marriott
has said that colic is hunger, nothing more. Other ob-
servers say that all colic is due to overfeeding. In the
same way, the rest of the causes stipulated have been
indicted by different authors in papers dealing with the
subject of colic. It is often very difficult to determine
just what factors may be active in a particular situation.

Management of Colic

During attack — hot water bottle to abdomen, car-
minative, enema.

Prophylactic :

1. Check formula — actual amounts taken against
requirements.

2. Check feeding schedule — too frequent feed-
ings common — 4-hour schedule is desirable.

3. Check associated symptoms — may suggest de-
sirable changes in formula or management.

4. Restrict enemas or suppositories to once daily.

5. Discontinue laxatives.

6. Sedative — elixir phenobarbital gtt. X to XXV
before feeding.

In the management of colic, there are two phases
of the situation to be considered: First is the manage-
ment during the attack, when the infant is screaming
with pain, drawing his legs upon his abdomen, and in
very evident distress. The attack can generally be re-
lieved by applying a hot water bottle to the abdomen,

the use of a carminative, such as elixir catnip, and
fennel; or a small portion of a soda mint tablet in
water, and the use of an enema to empty the bowel
of gas.

Second, the prophylactic management is of much more
importance. The details of this are enumerated above.
In a check of the formula it is not only neces-
sary to determine whether the total formula is adequate,
but also to determine whether the amounts taken are
sufficient. On dilute formulas, the amount taken may
often be too little to provide an adequate food intake.
The feeding schedule usually reveals that the infant is
being fed much more often than the formula prescription
specifies. A four hour schedule is usually advisable in
these cases. It can be instituted most readily when sed-
atives are employed. Associated symptoms, intelligently
interpreted, furnish valuable indications in manage-
ment. The presence of vomiting and regurgitation sug-
gests too frequent feedings which never permit the
stomach to be emptied. The loose, acid and frothy stools
of carbohydrate fermentation suggest the use of too
high sugar content. Constipation suggests too high fat
content in the formula or underfeeding. If the formula
is found to be satisfactory and does not contain more
than approximately seven per cent added carbohydrate,
and if the feeding schedule is being followed conscien-
tiously, the probability is that either the use of too much
rectal stimulation, by enemas or suppositories, or the
abuse of laxatives, plays a part in the production of
the symptom. The use of an evaporated milk formula
containing about seven per cent added carbohydrate,
such as dextri-maltose, diluted to provide 20 calories per
ounce, plus the administration of elixir phenobarbital,
in doses from 10 to 25 drops, before each feeding, is
generally found to be helpful in these cases. The use
of cereal waters as the diluent in the formula may be
necessary in certain instances.

Vomiting

Carefully exclude all other factors before attrib-
uting vomiting to the milk formula alone.

Air swallowing.

Excitement — too much handling.

Infection — chiefly parenteral.

Mechanical obstruction.

Seldom due to intracranial pressure alone.

May rarely be a constitutional characteristic.

Normal weight gain in face of persistent
vomiting.

The symptom, vomiting, is one of the most frequent
of the digestive complaints exhibited by both breast-fed
and artificially-fed infants. It is necessary carefully to
exclude all other possible factors before attributing vom-
iting to the milk formula alone. Air-swallowing is a
very frequent and simple explanation for much of the
vomiting which occurs. Too much excitement at time
of feeding, with too much handling of the infant may
be another simple explanation. Vomiting occurs with
many of the infections in infancy, particularly those
outside the gastro-intestinal tract. In any case of vom-

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447

iting which does not respond to simple measures, it is
necessary seriously to consider the possibility of mechan-
ical obtruction. In infancy, vomiting is seldom due to
intracranial pressure alone. Very frequently, cases of
persistent vomiting are met, in which there is a normal
weight gain, and no evidence of nutritional disturbances
despite the persistent vomiting. In these cases, the symp-
tom seems to be a constitutional characteristic, and as
such may have to be overlooked as much as possible.

Constipation

A common complaint when boiled whole milk
formulas are used. Infrequent with evaporated
milk formulas.

Underfeeding.

Tight rectal sphincter.

In combination with vomiting suggests ob-
struction.

Megacolon.

The symptom, constipation, is of common occurrence
when boiled whole milk formulas are used. In evaluat-
ing the symptom, constipation, it is necessary to con-
sider not only the number of stools, but more especially,
the consistency and amount of moisture of the individual
bowel movement. Often the so-called constipated baby
is having normal stools, but not as frequent stools as the
mother feels is necessary. Constipation is not frequently
met with, when evaporated milk formulas are used.
Underfeeding is a frequent cause of constipation, par-
ticularly in the breast-fed baby. In every persistent case
of constipation, a tight rectal sphincter may be the un-
derlying cause. In association with vomiting, constipation
should suggest the possibility of obstruction. A gastro-
intestinal X-ray series is indicated to rule out this possi-
bility. In connection with persistent constipation, mega-
colon should not be overlooked as a possibility.

Diarrhea

With clean, boiled milk and proper refrigeration,
diarrhea is rarely due to milk formula alone.

Starvation diarrhea.

Infections — G. I. or parenteral.

External heat — hot weather or excessive
clothing.

Diarrhea due to milk formulas is much less frequent
than it was in the past. The use of clean milk, boiled
in the preparation of the formula, and kept properly
refrigerated until the formula is fed, has greatly de-
creased the incidence of diarrhea. One of the forms of
diarrhea which may not be recognized is starvation
diarrhea. The characteristic of this form of diarrhea
is the passage of frequent, small, greenish stools, con-
sisting mainly of mucus and bile. The possibility of this
condition should always be borne in mind in the treat-
ment of diarrhea, since it is quite possible by improper
management to convert a mild diarrhea into a starvation
diarrhea by prolonging the underfeeding period too long.
The most severe diarrheas are those associated with in-
fections, more frequently outside of the gastro-intestinal
tract than of enteric nature. Careful search for par-
enteral infection should be made in every case of di-
arrhea. The occurrence of diarrhea during the hot sum-

mer months has markedly decreased. The dreaded chol-
era infantum of past years is met with frequently in
large cities; but is a rare occurrence in smaller com-
munities. This type of diarrhea is the one in which the
dangers from dehydration and acidosis constitute the
chief threat to the child’s system.

Failure to Gain

Individual growth potentialities are determined by
heredity.

Underfeeding — frequent cause.

Search for organic basis.

Congenital defects of heart, kidney, liver,
endocrines, C. N. S.

Repeated infections.

Chronic infection.

Deficiency diseases.

Lipoid pneumonia.

Poor hygiene.

Often associated with
Anorexia

Any of above causes may be operative.

Psychic effects of forcing food.

The symptom, failure to gain, is troublesome to any
one handling infant feeding cases. It is important to
remember in connection with this complaint that the
individual growth potentialities of an infant are de-
termined by heredity. The most frequent cause of failure
to gain is underfeeding. Underfeeding at the breast
is probably more frequent than underfeeding by arti-
ficial means. If an adequate diet is being offered the
child, and normal weight-gain does not occur, and, if
there are no digestive symptoms to explain the slow gain,
a very careful search must be made for an organic basis
for the difficulty. This may be found to be in congenital
defects involving the heart, kidney, liver, endocrines or
central nervous system. The organic basis may lie in
repeated infections, particularly of the upper respiratory
tract, especially the nose and ears. Repeated infection
usually plays a larger part in retarding weight-gain
than do the chronic infections, such as tuberculosis and
syphilis. These two conditions must always be ruled out,
however. Deficiency disease, involving particularly min-
eral disturbances, may be the underlying cause, and a
careful history of the maternal diet, the maturity of the
child, and the mineral content of the diet may give
leads, making possible a suitable management for the
condition. One of the conditions which may very easily
be overlooked, and which may be responsible for this
symptom is lipoid pneumonia. This condition probably
occurs much more frequently than is recognized. It is
usually the result of injudicious use of oily nose drops,
or the attempt to choke cod liver oil down a resistant
child’s throat. A last factor, which is almost always
associated with failure to gain, is poor hygienic sur-
roundings. This factor explains the greater incidence of
failure to gain in clinic practice than in private practice.
Failure to gain is usually associated with anorexia. Any
of the causes enumerated above may be operative in
producing this symptom. In addition to these causes
is the matter of psychic insults which result from forcing

448

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food upon a child who has no physiologic desire for
food.

Symptomatic Treatment

For Vomiting — elevate head of crib, gastric lavage,
atropine, thick cereal feedings.

For Diarrhea — initial period of starvation, skim-
med milk plus casec, or powdered protein milk;
paregoric indicated only for pain; raw apple diet
seldom necessary in infancy.

For Constipation — addition of malt soup, rectal
examination, prune juice; laxatives seldom
needed.

For Anorexia and Failure to Gain — Lactic acid
formula, Vitamin B preparations, minerals (iron,
calcium, phosphate) , insulin.

In the management of the symptoms which we have
discussed, it is necessary always to bear in mind the
general principles previously enumerated.

Treatment of the more persistent feeding disturb-
ances resolves itself into two considerations: symp-
tomatic treatment designed to relieve the condition, and
systematic investigation to determine the underlying
cause. In connection with vomiting, the usual symp-
tomatic treatment is to elevate the head of the infant’s
crib, in order that the position may favor easy relief of
gastric distention and prevent the ready expulsion of the
stomach content; gastric lavage for the purpose of de-
termining the emptying time and removing any mucus
which may be in the stomach; the use of atropine
pushed to produce a physiological response, bearing in
mind the possibility of toxic effects characterized by
flushing of the skin and hyperpyrexia; or the use of
elixir phenyl barbital as a sedative to produce relaxation
through general effect; and lastly, the use of thick cereal
feedings. The investigation of the case which must be
carried on before the symptom has progressed to the
extent that dehydration has occurred consists largely in
fluoroscopic and roentgenographic examination of the
stomach to determine the rapidity of emptying in order
to rule out the possibility of congenital defect or ob-
struction.

The symptomatic treatment of diarrhea involves the
use of an initial period of starvation of from 12 to 24
hours, followed by a diet of high protein content; the
use of either boiled skimmed milk to which casec has
been added or the use of powdered protein milk after
the initial starvation with a gradual return to an adequate
diet for the individual child. Paregoric should be used
only to relieve pain, and should not be employed in
doses sufficient to stop peristalsis. The raw apple diet
which has been so much in evidence in recent literature
is seldom necessary in infancy. In fact, it is a treatment
which is viewed with tremendous suspicion by mothers.
For this reason alone it is not practical. In addition, it
must be said that the raw apple diet has not become
well-established in general pediatric practice. The in-
vestigation of the case to determine the factor under-
lying the diarrhea consists largely in a thorough search
for any source of infection, and adequate treatment for
the source, when determined. The necessity for main-

taining the child’s fluid and mineral balance is of ut-
most importance. On the use of subcutaneous injec-
tions of normal salt solution, intravenous glucose plus
transfusions, whenever indicated, may depend the ulti-
mate outcome of the particular case.

The symptomatic management of constipation de-
pends upon the administration of a more laxative type
of formula. The change from whole milk to evaporated
milk may bring decided improvement. The use of car-
bohydrates containing higher percentages of maltose is
advisable or a similar effect may be obtained by the
addition of malt soup to the formula. The use of
prune juice may be of some value. Laxatives are seldom
needed in the management of constipation in infancy,
though in certain instances, it may be necessary to
employ mixtures of mineral oil and agar-agar. The in-
vestigation of the case should include a rectal examina-
tion for the presence of a tight rectal sphincter, and in
persistent cases the use of barium enemas to rule out
the presence of megacolon or minor obstruction in the
large intestine.

The management of anorexia and failure to gain is
usually the most difficult problem in infant feeding.
Those cases in which underfeeding has been the pri-
mary cause will usually respond quickly to an increase
in the diet. The use of measures designed to increase
the digestibility of the milk formula, particularly the
use of lactic acid are well accepted procedures for these
cases. The addition of vitamin B to the diet may be
of help in some cases. In every case emphasis should
be laid upon the mineral content of the diet, partic-
ularly the content of iron, calcium, and phosphorus.

The use of insulin to stimulate appetite may occa-
sionally produce good effects, but procedures of this
kind are best carried out in hospital practice. Hos-
pitalization for these infants is usually not recommended,
although a change of environment may be helpful. The
most important point in the management of these cases
is to rule out all organic disease. If none can be found,
the factor of hereditary type of body build may be
acceptable as the explanation for the symptom, and a
slow gain may be entirely compatible with health. In
the recognition of the types of body build associated
with slow gain, the tables of Lucas and Pryor, in which
the intercristal diameter is coordinated with height, may
be of value in determining the infant’s growth poten-
tialities.

To summarize a discussion of this kind would scarcely
be feasible. It would be more practical to stress again
the more important considerations. It is to be empha-
sized: first, that most feeding difficulties are not ac-

tually problems in devising an acceptable formula but
partake more of the nature of correcting defects in
the formula or feeding technic. Second, that frequent
changes in the formula accomplish very little. Third,
that simple measures based on physiologic concepts will
solve many minor feeding problems. Fourth, that or-
ganic disease or abnormality must be sought in any
case which fails to respond to these simple physiologic
measures.

THE JOURNAL-LANCET

449

The Treatment of Burns

W. A. Wright, M.D.

Williston, North Dakota

BURNS are accidents, therefore, emergencies,
and require prompt emergency treatment. It
sometimes happens that in emergencies the early
treatment tends to be hurried and not carefully consid-
ered. Again, in burns, there is the urgent desire of the
patient and friends to get something on the burned area
at once. So it is desirable to have fixed in one’s mind
a more or less routine method of procedure which is set
in motion immediately a case is seen. Naturally, as
burns vary in extent and depth, treatment must also be
adapted to suit each case. In this outline of treatment
I do not intend to suggest that each procedure is always
necessary.

Burns, being accidents, can occur at any time or place,
and frequently some time elapses before medical aid
can be given. The individual suffering severe pain seeks
and requires some immediate help. Usually, relief is
sought from the intolerable smarting pain by some form
of local application, generally an ointment. Because a
simple ointment such as petrolatum eases the smarting
of a superficial burn, it by no means follows that it is
a suitable substance to apply to a deeper one. Rose1
in a recent article offers what has seemed to me to be
a very satisfactory immediate treatment. He points out
that immediate application of cool tap water will give
a large measure of relief. In local burns covering a
small area, he uses cool wet applications; and in severe
burns he puts the patient, clothes and all, into a tub
of water. This simple first aid treatment might well be
utilized prior to the arrival of the doctor or of the pa-
tient at hospital or office.

Usually, when first seen, a burned patient will be
suffering severe pain and will be in a state of from mild
to severe shock. While it is desirable to inspect promptly
the burned area, actual treatment of it may be delayed
for a few minutes until measures for relief of pain have
been instituted. Morphine should be injected at once
and may, on occasion, be given intravenously, when
relief will be very prompt. The burn is protected with
sterile dressings or towels and the patient is covered with
blankets. Additional warmth may be secured by hot
water bottles or heat from electric lamps, and the head
may be lowered by raising the foot of the bed. Warmed
fluids should be given by mouth, subcutaneously or in-
travenously. In giving fluids one must remember that
frequently kidney function is depressed and care must
be taken not to overload the body with excess fluid.
Tissue edema may easily be produced. Intravenously
one may give saline, dextrose, six per cent acacia or
blood transfusion. Blood transfusion is probably of more
value in the secondary shock, arising a day or so later
supposedly from absorption of tissue products, than in
primary shock caused by the initial injury.

* Presented before the annual meeting of the North Dakota
State Medical Association, held at Grand Forks, May 16-18, 193 7.

In the care of the burned area, every effort is to be
made to avoid infection. The burn and surrounding
skin should be cleaned thoroughly with soap and water.
Ether or benzene may be used to remove grease. If
necessary, a general anesthesia should be induced. Fol-
lowing cleansing, blisters are opened and all loose epi-
thelium carefully removed. This will leave a raw sur-
face ready for a protective covering. Care of this raw
surface has always been the main problem, and has been
met in many ways. Prior to 1925, it was usually cov-
ered with some sort of oil, ointment, moist application,
or occasionally it was left uncovered and exposed to
heat. In Europe at the present time, cod liver oil dress-
ings are greatly favored, Loehr2 and Steele3 considering
them far superior to all others. In this country since
the introduction of the tannic acid spray by Davidson4,
some form of coagulation or crust formation has been
generally used. The aim has been to secure a thin dry
crust by coagulation of the overlying dead tissue, form-
ing a firm protective coating. Originally Davidson ap-
plied tannic acid solution by means of frequent sprays.
Later, Coan5 used ferric chloride, Aldrich6 gentian violet,
and Narat7 brilliant green. A plan of tanning has been
developed by Bettman8, which is, I believe, the most
satisfactory at present. Using his method, a fresh five
per cent solution of tannic acid is applied with ordinary
cotton applicators. The entire raw surface receives a
liberal amount of tannic acid solution resulting in a
greyish-white layer of coagulum. After removal of any
excess tannic acid solution, application of ten per cent
silver nitrate completes the process. It is well to remem-
ber that a silver nitrate swab should only be used once,
because getting tannic acid mixed with the silver nitrate
will cause precipitation. Inside of 30 minutes, or less if
dry heat is used, a fairly pliable coagulum forms. The
part may then be protected from the bedding by a
cradle, and it is well to have one or two electric lights
under the cradle. The advantages of this method over
the use of the spray are readily apparent. Bettman8
has an article in the May first issue of the Journal of
the American Medical Association in which he points
them out at some considerable length. He considers that
most of the general body reaction to burns occurs as a
result of loss of circulating fluid. Immediate tanning
unquestionably reduces or entirely prevents this loss, de-
pending on the amount of time elapsing between the
time of the burn and its application. Infection rarely
occurs because of the early drying and the antiseptic
action of silver in the coagulum. As there is only the
one application, there is very much less chance of de-
stroying viable epithelium.

It is important that the tannic acid solution be freshly
prepared. This may be conveniently cared for by having
the correct amount of powder weighed-out and left in

450

THE JOURNAL-LANCET

a stoppered bottle. Then when required, a solution can
be quickly prepared by adding the proper amount of
distilled water. The silver nitrate crystals may be
weighed out and kept in a similar manner. If one has
to prepare a solution in a hurry, adding one tablespoon-
ful of tannic acid to one ounce of water will give ap-
proximately a five per cent solution. A half teaspoonful
of silver nitrate to an ounce of water makes a ten per
cent solution. As a matter of fact, the percentage of
the solutions may vary within wide limits and still be
effective. Wilson9 uses tannic acid in 20 per cent solu-
tion; Davidson originally recommended 2% per cent
solution. I have used silver nitrate in a one per cent
solution and found it satisfactory.

While this is generally considered to be a safe and
rational form of treatment, satisfactorily used and rec-
ommended by most writers, it should be pointed out that
not everyone agrees. Taylor10 in an article entitled "The
Misuse of Tannic Acid” disagrees with the original con-
tention that tannic acid coagulates only dead tissue. He
makes the pertinent observation that the fact that tannic
acid has no effect on the epidermis does not prove that
cells of the deeper layer may not be destroyed. He con-
tends that tannic acid or other coagulation applications
result in destruction of many cells of the germinal
layer and of the hair follicles, which otherwise are
viable, so that healing may be actually delayed. While
this may be true, the many practical advantages of
coagulation make it the accepted treatment at the
present time.

If infection develops under the crust or spreads to
adjacent tissues, hot wet dressings should be used and
continued until the infection subsides. The coagulum
will have been removed by wet dressings, or sufficiently
loosened to remove by forceps, leaving a raw area per-
haps bathed in purulent secretion. Further moist applica-
tions of boric acid or Dakin’s solution may be used. If
the latter is used, the skin should be protected by vas-
elined gauze. Then the raw surface may conveniently
be covered by repeated coatings of one per cent gentian
violet solution which will form a new thin coagulum.
This may be applied as often as necessary, and will
form an efficient covering and aid in clearing up the
infection. I believe gentian violet is a particularly use-
ful covering where there is low grade infection, and will
tend to reduce the amount of scarring when final heal-
ing occurs.

If there is no infection, the coagulum tends to loosen
in six to 12 days leaving either a healed skin surface or
clean granulating areas depending on the depth of the
burn. Small granulating areas may be left to heal from

the edges, being covered by a gentian violet crust or
simple vaseline gauze. Large granulating surfaces should
receive skin grafts, and are usually ready for grafting
within three weeks. The exact type of graft will depend
on the location, size and relative sterility. Thus small,
so-called pinch grafts may be successfully used over
large areas where there is some low grade infection,
whereas a full-thickness graft requires practically a
sterile bed. The important consideration is that every
effort should be made to secure early epithelial covering
of all raw surfaces. It is in those wounds which have
escaped infection that most rapid healing, with or with-
out skin graft, will occur. So, from the very beginning
of treatment until the burn is entirely healed, every
reasonable effort must be made to prevent infection. One
should also be on the alert to recognize infection in early
stages, and to institute prompt treatment.

Burns of special regions such as the face, neck,
axillae, groins, and other flexures require more careful
attention than burns in other areas. I believe the tannic
acid-silver nitrate treatment can be used satisfactorily in
most of these special situations. However, in certain
folds such as about the perineal and anal region, some-
times in the axillae and about the neck in obese individ-
uals, there is an excess of moisture, and one has diffi-
culty maintaining a satisfactory dry crust. Use of dry
hot air may help, but this cannot be continued indefi-
nitely and it may be necessary to use in these areas
a vaseline gauze dressing. Burns of the face should be
treated by a tannic acid jelly. Silver nitrate should not
be used because of the possibility of residual pigmenta-
tion. Where joint regions are involved, splinting may be
required, but when possible, early active motion is to be
preferred.

References

1. Rose, H. W.: Initial Cold Water Treatment for Burns,

Northwest Med. 35:264 (July) 1936.

2. Loehr, W.: Chirurg. 6:265, 1934.

3. Steel, J. P.: The Cod Liver Oil Treatment of Wounds, The
Lancet (London) 229:290 (August 10) 1935.

4. Davidson, E. C. : The Use of Tannic Acid in the Treatment
of Burns, Surg., Gynec. and Obst. 41:202, 1925.

5. Coan, G. L.: Ferric Chloride Coagulation in Treatment of

Burns, Surg., Gynec. and Obst. 61:687 (November) 1935.

6. Aldrich, R. A.: The Role of Infection in Burns, Special Ref-
erence to Gentian Violet, New England J. M., 208:299-309 (Feb-
ruary 9) 1933.

7. Narat, J. K.: Treatment of Burns With Brilliant Green,

Am. J. Surg. 36:1 (April) 1937.

8. Bettman, A. G.: The Tannic Acid-Silver Nitrate Treatment

of Burns, Northwest Med. 34:36-51 (February) 1935. The
Rationale of the Tannic Acid-Silver Nitrate Treatment of Burns,
J. A. M. A. 108:18 (May 1) 1937.

9. Wilson, W. C.: Modern Methods in the Treatment of

Burns, The Practitioner 136:394 (April) 1936.

10. Taylor, F.: The Misuse of Tannic Acid, J. A. M. A.

106:14 (April) 1936.

THE JOURNAL-LANCET

451

The Results of Routine Examination*

Of Candidates for the Teachers Certificate at the University of Wisconsin

Llewellyn R. Cole, M.D.f
Madison, Wisconsin

THE PROGRAM of examining each candidate
for the University Teacher’s Certificate here at
the University of Wisconsin has been in progress
for only the past two years; but has clearly demonstrated
its value in a multitude of ways. The discovery of
remediable defects and suggestions for their correction
should be primary functions of a student health service,
which in itself implies a patient constituency of a very
excellent age-selection, where the morbidity is excep-
tionally low. However, some of the group are on the
lower fringe of middle age, and the wear and tear of
time and physiological changes need checking in order
that the individual does not allow some process to pass
out of the controllable stage. This has been the ob-
jective in this group of examinations.

Under the stress and strain of college life — possibly
the necessity for partial or total self-support in addition
to the duties and obligations of a student in his aca-
demic pursuits — the health of the individual may suffer,
sometimes to a marked degree, and decidedly to his phys-
ical disadvantage. There may develop an incapacity of
serious consequence which, if allowed to proceed, may be
the physical or mental undoing of the individual and
seriously impair his capabilities as a wage-earner. Per-
sons who plan to follow educational pursuits for any
length of time, and as a consequence intimately associate
with groups of younger people, should of necessity be
in relatively good health, both mental and physical, as
an implied obligation to the community in which they
are employed. Communities are gradually requiring
more substantial evidence of good health than the mere
statement of the individual, and the obligation is re-
flecting itself upon our colleges and universities. Ex-
amples of the type of physical problems which present
themselves are tuberculosis, nervous disorders, thyroid
dysfunction, heart disease, and to a lesser degree, changes
in vision and hearing. If recognized at a sufficiently
early date, these are usually correctible or amenable to
proper therapy; or at least the course of the affliction
may be so altered as to render the individual eligible for
more normal living, as in the case of diabetes mellitus.

In a survey of 261 individual senior students made
during the school year of 1936-37, many interesting ob-
servations were made. The examinations were performed
on all of the seniors in the School of Education in the
University of Wisconsin, with the idea of giving to each
individual a thorough physical inventory before granting
him a clean bill-of-health, and sending him forth into

* Examinations performed by Dr. Chalmer Davee, of the
Department of Student Health, University of Wisconsin.

t Director, Department of Student Health, University of Wis-
consin, Madison.

the communities of the state and the nation to instruct
the next generation in the many pursuits required in the
present day educational system. In this group of 261
students, there were 181 females and 80 males. The
males were largely classified as physical education stu-
dents who were qualifying for coaching positions and
similar situations in the teaching profession. All these
persons had been previously examined and given a
physical grade representing our estimation of their phys-
ical qualifications and limitations. In addition, all who
had not previously had the advantage of the Mantoux
test, or those who had previously shown negative reac-
tions, were tested or retested with a weak and a strong
dose of Old Tuberculin (in the event of a negative re-
action to the weak dose) . The positive reactors, num-
bering 114, were all studied with the X-ray and fluoro-
scope1. It is interesting to note that the percentage of
positive reactors among the newly entering students at
the university is approximately 28%f, but that the per-
centage has jumped to about 44% in this group of
seniors, indicating that there had been exposure to the
tubercle bacillus in many of these people during the
interval between freshman and senior years. There were
doubtful reactions to the large dose of Old Tuberculin
(1.0 mg.) in three cases, and in one case the candidate
refused the Mantoux test. The X-ray studies were
essentially negative in 87 cases, but 27 individuals showed
roentgenologic evidence of pulmonary pathology to a
greater or lesser degree. These changes included such
pathology as primary complexes or Ghon tubercles, calci-
fied glands in the hilum or elsewhere in the chest, apical
"caps,” pleural reactions and healed lesions in the lung
parenchyma. The pleural changes consisted of thick-
ening, or adhesions, in some cases with involvement of
the diaphragm. One case showed gross and definite
evidence of an early but active tuberculosis. The Man-
toux test had been negative in both the weak and strong
doses of tuberculin in September, 1935; but in Decem-
ber, 1936, showed a positive reaction to a dose of 0.1
mg. O.T. The X-ray studies revealed a tuberculous
pleurisy with a minimal subpleural parenchymal infiltra-
tion at one apex. This patient withdrew from the uni-
versity for an extended period of rest at home (90037) .
If this patient had been allowed to continue in the uni-
versity, no one can determine how many other persons
would have been unwittingly exposed; and had the pa-
tient been sent out to teach there can be no prediction
as to the number of pupils who would have been exposed

1. Personal communication from Dr. R. H. Stiehm regarding
figures on positive reactors in 1936-3 7. Also see: Stiehm, R. H.,
Tuberculosis Among University of Wisconsin Students. The Amer-
ican Review of Tuberculosis, Vol. XXXII, No. 2, August, 193 5,
pp. 175-176.

452

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to this case of minimal tuberculosis which might well
have become active, with widespread dissemination of the
tubercle bacilli. The economic and social consequences
of such an unfortunate situation can only be contem-
plated. The entire program is justified by the discovery
of this one single case of tuberculosis, if for no other
reason.

We, of the Department of Student Health, are
strongly of the opinion that protection against small-
pox is still an extremely important phase of preventive
medicine, and that the disease should continually be
guarded against. This is particularly true in those cases
where individuals are going out into widely scattered
communities to be exposed to all types of diseases. This
applies to school teachers as well as others, and we urge
vaccination for all individuals in the university. Each
candidate for a teacher’s certificate is vaccinated against
smallpox unless some religious objection or equally valid
scruple exists. Most of the members of the group had
been previously vaccinated, and 167 had "immune”
reactions. Eighty-nine persons showed reactions in the
form of "takes.” Five persons were not vaccinated.

Routine urine examinations were done in each case,
and one diabetic was discovered and put under treat-
ment. In the event that sugar, albumin, blood cells or
casts were discovered, further studies were made. The
value of such a procedure is self-evident.

Ten cases of heart disease were noted, of which seven
were definitely of rheumatic origin, one was a congenital
heart lesion, and two others were cases of hypertension
of doubtful origin. Eleven functional murmurs were
noted in addition to the above. Where there was any
question as to the condition of the cardiovascular system,
an orthodiagram and an electrocardiogram were obtained
through the courtesy of the Department of Cardiology
of the Wisconsin General Hospital, along with the
opinion of the cardiologist as to the cardiac situation.
Several cases were reported as having cardiac enlarge-
ment as evidenced by the chest X-ray, and each of these
was carefully checked by orthodiascopic study.

One hundred cases of enlarged and palpable thyroids
were noted, and where indicated a basal metabolic rate
determination was done. One case of adenomatous thy-
roid was found, and in all cases the patient was advised
as to the future course of procedure.

In the matter of vision I am indebted to the National
Society for the Prevention of Blindness and to Annette
M. Phelan for suggestions as to procedure and the edu-
cation of the future teacher in matters relating to vision
and eyesight, and their preservation. Many teachers
must perform vision tests upon children, and so must
know the methods of testing. We use a testing char-
made up of the letter "E” placed in one of four posi-
tions. The opening of the letter may be to the right
or left, up or down, and the individual tested must re-
spond with an answer indicating the direction of the
opening of the letter. The ordinary type of vision chart
is also used. Sixty cases of myopia were noted, six of

which were not corrected, and eleven cases of hyperopia
were found, of which two had not been corrected. (It
is to be noted that the vision testing was done on less
than one-half of the group, as it was a later addition to
the examination.) Education in matters of vision is
essential to the future school teacher. We can advise
as to whether further changes in lenses are indicated,
but we do none of the refractions, feeling that this is a
function of the private physician trained in the correc-
tion of pathology of the visual apparatus.

One individual was passing through her menopause
and had had an amputation of a breast (84932).

It is to be hoped that another year will see the intro-
duction of simple tests for auditory acuity into this
rather comprehensive physical inventory of the individ-
ual, inasmuch as this is such an important member of
the group of senses. I sincerely hope that more can be
done in the evaluation of the psychic endowment of
the student who is going out to instruct by precept and
pedagogy the youth of the next generation of the coun-
try, at a not too far distant date. Some individuals are
psychologically unfit to teach, and the time to tell them
is before they begin.

In summary, attention should be called to the several
facts brought out by this survey.

1. All seniors in the School of Education at the Uni-
versity of Wisconsin are given a thorough physical check-
up before graduating, including Mantoux testing, X-ray
study where indicated, and routine smallpox vaccination.

2. One case of tuberculosis and one case of diabetes
were discovered in these examinations, numbering 261.

3. Vision testing is calling attention to defects in the
individual’s vision and at the same time instructing in
the nature of simple vision tests.

4. It is to be noted that the number of positive re-
actors to the Mantoux test has increased from 28%
to 44%.

5. Heart disease can be discovered or re-evaluated in
such a procedure and advice given to the mature indi-
vidual as to the future course and conduct of his or her
life. This can be done with much greater success to the
group of seniors than to the same group of freshmen.

6. The females outnumber the males in the group
by more than two to one.

7. A routine psychiatric inventory and evaluation
would make a valuable addition to this type of exam-
ination of future school teachers and result in a reduc-
tion in the number of misfits. This was clearly dem-
onstrated by the results last year when such service was
given.

8. This procedure has a fixed and definite place in
the practice of preventive and prophylactic medicine as
contrasted to remedial.

9. Simple tests for hearing are indicated in this type
of examination.

THE JOURNAL-LANCET

453

Brucellosis4

N. M. Levine, M.S., and J. Arthur Myers, M.D., Ph.D.,ff

Minneapolis, Minnesota
and

Elizabeth A. Leggett, M.D.,fff
Kent, Ohio

BRUCELLOSIS (undulant fever) can be defined
as a mild septicemia caused by Brucella organ-
isms and characterized by a reaction of the
reticulo-endothelial system. It would seem somewhat
odd to talk about this disease in the presence of men
interested in lung diseases. But as a mild septicemia,
there is involvement of the lungs and pleura which may
be so mild and indistinct in character that it may be
missed entirely or misdiagnosed. In fact, brucellosis
comes to the attention of every specialist. Its striking
feature is the presence of an afternoon fever. Its strik-
ingly ignored symptom is weakness. In the late Nth
century before the actual significance was known, the
fever was named after the locality in which it was found,
such as Malta fever, because there was an epidemic in
Malta; likewise Mediterranean fever, and Cyprus fever.
The clinical picture was first described by Marston in
18611, but the bacterium was not found until 1887, when
Bruce2 cultured the spleen of his patients and found an
organism which reproduced the disease. How this or-
ganism reached the human body was not discovered until
1904, when the Mediterranean Fever Commission traced
the source to raw infected milk of goats. Elimination
of raw goat’s milk stopped the spread of the disease.
In 1918, while classifying bacilli, Evans3 found that
Bruce’s organism was almost indistinguishable from an-
other organism discovered by Bang in 1897 to be the
cause of abortions in cattle. And these two organisms
were similar to one found by Traum in 1914, and Good
and Smith in 1914 in hogs. These three organisms not
only are closely related in form, cultural growth and
ordinary agglutination tests, but they cause practically
the same disease in man. Therefore, at the present time
all three organisms are called Brucella, i. e., Brucella
melitensis from goats; Brucella abortus from cattle, and
Brucella suis from hogs. These organisms are found in
the organs of the animals, including fetus and placenta7;
in the secretions as milk, on the surface of the udders,
and in their excreta7. At present Malta fever is not
named after the locality in which it is found, but is
named after the chief clinical finding, "undulant fever.”
The most recent authors, however, tend to name the
fever after the cause, "brucellosis.”

The only two proven ways by which man may become
infected with these organisms is by contact or through
ingestion of raw infected milk and its products9, 10,1 l»
12,13. Many cases have been reported in which the
source of infection was traced to raw milk from infected

•Presented before the Lymanhurst Medical Staff November 24,
1936.

t Assistant in medicine, University of Minnesota,
tt Professor of medicine, University of Minnesota,
ttt Kent State University, Kent, Ohio.

herds. School children drinking milk from abortus-free
herds were negative to agglutination tests, while a high
percent of those fed on market milk were positive re-
actors22. Contact is proven by the presence of rashes on
the hands, undulant fever and positive agglutination
tests in veterinarians, slaughter-house workers, and farm-
ers. Twenty per cent of the cattle in the United States
are infected73. The percentage of infected cattle varies
with epidemics as is shown by testing certified herds in
Los Angeles County0. In 1927 there were 33.7 per cent
positive agglutination tests for undulant fever. Repeat-
ing the test in 1932 only 0.34 per cent were positive. The
per cent of infected raw milk roughly corresponds to the
per cent of infected cattle. In Edinborough Beatty6
showed Brucella abortus in 34.9 per cent.

When brucellosis was first recognized in the United
States it was found in the goats of Texas in 1905. Since
that time there has been a definite spread of the disease
northward and eastward, with a marked increase in the
number of reported cases. Millett23 gives the following
summary: from 1905 to 1925 one hundred and twenty-
eight cases were reported; in 1925 twenty-four cases; in
1926 forty-five cases; in 1927 two hundred and seven-
teen cases; in 1928 six hundred and forty-seven cases;
in 1929 nine hundred and fifty-two cases; and in 1930
one thousand three hundred and eighty-five cases. In
Minnesota forty-five cases were reported in 1929; sixty-
four cases in 1930; seventy-two cases in 1931; sixty-seven
with three deaths in 1932; and seventy-one with no
deaths in 1933. The apparent peak of infection occurs
during the summer months24.

Brucellosis is more apt to follow contact with infected
animals than after ingestion of infected milk, as shown
by the following facts:

(a) 13 per cent66 to 17 per cent 21,22 of children
drinking market milk are positive to agglutination com-
plement fixation tests. Only 1 per cent of children de-
veloped actual disease from drinking infected milk66.

(b) Hasley4 found that Brucella abortus organisms
could not be found in the milk of cows whose agglu-
tinations were positive in the blood serums in less than
1-100 dilution. Assuming that the agglutination signifies
presence of active infection, this would mean that not
all infected animals excrete the bacteria in their milk.
Only 40 per cent of infected cows excrete Brucella in
their milk73.

(d) The age curve in undulant fever shows the dis-
ease to prevail most commonly between the ages of 20-44
years. In 442 cases listed by Hasseltine13 only 3 per

454

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cent occurred in children under ten years of age. In
smaller groups the percentage rose to 13 per cent66.

(e) Agglutination tests made on routine Wasser-
manns show that there were eight times as many posi-
tives in veterinarians, farmers and slaughter-house work-
ers as in those of other occupations. In veterinarians,
farmers and slaughter-house workers 54.7 per cent are
positive to skin test6u.

When the bacteria attack the human either by con-
tact as indicated by the maculo-papulary rash on the
bands of veterinarians, or through the drinking of raw
milk there begins a period of incubation which lasts
between five days and three weeks, after which time
appear the septicemia and the resulting reticulo-endo-
thelial reaction which characterize undulant fever.

The reaction of the reticulo-endothelial system is
either nodular or generalized. In animals and in the few
postmortems55 of humans in undulant fever, one may
find greyish uniform millet-seed size nodules which
may resemble the tuberculous tubercle. On microscopic
examination these nodules consist of granular and fatty
epithelial cells and giant cells. In larger nodules PMNs
and capillaries can be seen in the center. Although
necrosis may occur, especially in the nodules of the liver,
caseation never appears as in tuberculosis. More rarely
in these nodules, one finds plasma cells, fibroblasts and
lymphocytes. The general reaction of the reticulo-
endothelial system consists grossly of a congestion of
all the internal organs which is intense in the acute
cases (for example soft spleen), and is less intense in
chronic cases (a chronic passive congestion — hard spleen
or a nutmeg liver) . The blood shows usually a relative
or absolute lymphocytosis and a mononucleosis, while
the PMNs and platelets decrease. Also, there is de-
velopment of sensitivity and immunity. The skin is
allergic to the injection of dead bacteria. The allergy
increases with the duration of contact with Brucella5,5.
The blood shows agglutinins which may appear after
ten days, but usually after fifteen to twenty-one days.
They disappear with the infection either immediately
or after three to four months. Immunity is indicated
also by the flocculation test of Julian and Laurent; by
the opsonocytophagocytic index; precipitans, etc.

Brucellosis may persist three to four months. In rare
cases the Brucella organisms have been recovered from
the body after from five to six years (in ovarian cyst-
Wainright, 1929) . The disease is usually mild. Up to
1929 no deaths were reported in Switzerland. In ex-
ceptional epidemics, one of which is reported by Aubert,
Canteloupe and Thebaux, the mortality rose to 40 per
cent. In the endemic stage, however, the actual number
of deaths do not exceed approximately 3 per cent. De-
pending on the severity of the attack, undulant fever
is subdivided into five types: (a) subclinical, in which
agglutination tests are positive but no clinical findings are
present; (b) intermittent 55 per cent; (c) ambulatory
type 25 per cent; (d) relapsing type 15 per cent; (e)
fatal cases. The majority of cases remain unrecog-
nized10. Symptoms in the acute stage of the septicemia
and reticulo-endothelial reaction are fever, weakness,

chills (90 per cent) , sweats, generalized aching, back-
ache, joint pain, rigor, dizziness, abdominal pain, nausea,
vomiting, cardiovascular disturbances and joint swellings.
The physical findings vary with the locality where the
infection predominates, and the severity of the reaction.
The physical findings may be listed in summary as
follows:

1. Heart: ulcerating endocarditis and findings of

valvular lesions.

2. Spleen: enlarged; soft at first, hard later.

3. Liver: may be enlarged, soft at first, hard later,
resulting in ascites, jaundice and varicose hem-
orrhages. Very large necrosis may lead to sub-
diaphragmatic abscess.

4. G. I. tract: hemorrhage from ulcerating Peyer’s
patches. Peritoneal abscesses.

5. Joints: swelling.

6. Bones: destruction, osteoarthritis, mediastinal ab-
scess.

7. Uterus: abortion.

8. Ovary: cysts.

9. Testis: orchitis.

10. Kidney: nephritis; uremia.

11. Lung: pleurisy, dry or with effusion; broncho-

pneumonia.

12. Brain: psychosis; neurasthenia.

13. Meninges: hemorrhage, and pus70.

14. Skin: maculo-papulary rash 5 per cent; petechiae.

When brucellosis becomes chronic, the one constant

symptom is weakness; fever may not be present at all.
The symptoms are confused with neurasthenia'- because
there is exhaustion, insomnia, irritability and complaints
of aches and pains for which no objective signs can be
found.

Considering the organs involved, one realizes the
number of similar diseases that arise in the differentia-
tion. The diagnosis is made on the history, the symp-
toms and findings, and the laboratory tests. Since un-
dulant fever is a septicemia, the Brucella organisms can
be and are found in blood, urine, feces29 and spinal
fluid30,52,70 by cultures or by animal inoculation. Since
the organisms elicit a reticulo-endothelial reaction, evi-
dence of immunity appears. A positive agglutination
test in a dilution of 1-8010 or 1-10027 is sufficient for
diagnosis of active infection. An agglutination of 1-50
would be considered suspicious (Maxey). Agglutina-
tion is absent entirely in 16.6 per cent (Burnet). Since
the reticulo-endothelial system reaction leads not only to
immunity but to allergy, skin sensitivity tests are also
useful in diagnosis31. An injection of heat-killed sus-
pension of bacteria is used. The intradermal test is
not valuable in diagnosing active disease63,66, thereby
resembling the tuberculin test. Huddleson’s opsonocyto-
phagic test is an indication of the degree of human
resistance.

In 1936 Bogart reported four cases of undulant fever
with pulmonary changes. The X-ray findings showed a
marked widening or infiltration of the hilum and a
marked peribronchial infiltration especially in the bases.
One fatal case had bronchopneumonic consolidation at

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455

the bases. An autopsy showed slight ascites, subacute
gastritis, chronic splenitis, chronic hepatitis, and local-
ized pneumonic consolidation in the right lung. Micro-
scopic examination revealed bronchopneumonia and mul-
tiple granulomas of the spleen and liver. Culture of the
lung, spleen and bile revealed the bacillae abortus.
Richard Johnson68 reports three cases of pneumonia in
undulant fever at the University of Minnesota. All
three cases had positive agglutination reactions. Two
were in contact with infected animals. X-ray of each
showed a chronic nontuberculous shadow suggesting un-
resolved pneumonia. In no case were Brucellae isolated
from the sputum.

It is very common to confuse cases of undulant fever
with tuberculosis and cases have been referred to the
sanitoriums for treatment (Frik and Briskman) . This is
due to the similarity of symptoms and the course. We
also wish to present four cases that were brought to our
attention because tuberculosis was suspected.

The first patient, L. H., was diagnosed by Dr. F.
Callahan. He was a farmer boy 16 years of age. He
had not been exposed to tuberculosis as far as he knew.
The family was drinking raw milk from cows, two of
which had positive reactions to tuberculin six months
previously, and in one of which there had been one
spontaneous abortion. Illness began March, 1930, and
on April 27th examination revealed a temperature of
101.2 degrees; a palpable spleen and slight enlargement
of the epitrochlear inguinal and axillary lymph nodes.
Laboratory examination revealed 3,390,000 RBCs and
6,700 WBCs of which 44 per cent were PMNs and 46
per cent lymphocytes. The RBCs presented central
pallor; some nucleated RBCs were found and there was
slight anisocytosis. Occasional eosinophiles and baso-
philes were found. Agglutination was present in 1-1280
dilution when tested with Brucella abortus antigen. The
tuberculin test was negative. Physical examination and
stereoscopic X-rays of the chest showed no definite evi-
dence of pathology. He was treated symptomatically.

The second patient, L. S., was a salesman 27 years old
with no known exposure to tuberculosis. On August 24,
1931, he complained of severe pain in the left side of
his chest, dull pain in the lower back, loss of nine
pounds in weight, weakness and fever. A chiropractor
had made a diagnosis of cystic fluid on the chest. These
symptoms had been present for two months. The lab-
oratory examination revealed a hemoglobin of 90 per
cent, 4,600,000 RBCs, 7,200 WBCs, and a negative
Wassermann. The patient failed to react to 0.1 mgm. of
tuberculin but had a three plus reaction to 1.0 mgm.
Physical examination and a single X-ray of the chest
revealed no evidence of pulmonary pathology. On
August 26, 1931, agglutination for Brucella abortus
antigen was present in a dilution of 1-1280. Feces and
urine culture for Brucella organisms showed no growths.

Treatment was started using methyl violet in 10 mgm.
doses in keratin-coated capsules five times a day. A re-
tention enema of 300 cubic centimeters of 1-50,000 so-
lution of methyl violet was given daily. He was uncom-
fortable after the first capsule, nauseated after the sec-

Date

Thionine Orally in
Salol-Coated Pills

Thionine by Retention
Enema

9-25 to 9-27

25 mgm. daily

250 cc. of 1-100,000
solution daily.

9-28 to 9-29

Rest

9-30 to 10- 3

50 mgm. daily

300 cc. of 1-100,000
solution daily.

10- 3 to 10- 4

Rest

10- 5 to 10- 8

50 mgm. daily

300 cc. of 1-50,000

ond, and vomited violently after the third. The capsules
were discontinued. On September 24, 1931, the course
of treatment described by Leavell, Poston and Amoss48
was recommended.

By October 13, 1931, his temperature became normal
and he had gained three and one-half pounds in weight.
On June 4, 1932, there was no agglutination to Brucella
abortus antigen in a dilution of 1-40.

The patient W. O., 44 years of age, was a dairy
farmer and owned an accredited herd. He had no
known exposure to tuberculosis. In December, 1931, one
of his cows aborted spontaneously. He removed the
placenta with his bare hands. In January, 1932, a second
cow aborted spontaneously. On February 5, 1932, he
complained of loss of strength during the past year,
chills and fever; had night sweats of two months dura-
tion; loss of seven pounds in weight in five weeks. For
two or three nights his temperature had reached 103
degrees. He stated his illness began one month after the
first abortion. Physical examination revealed a tempera-
ture of 101, easily palpable spleen and nothing abnormal
in the chest. The tuberculin test was negative. The
hemoglobin was 85 per cent, Wassermann was negative.
The blood, urine and stool tests were negative for Bru-
cella organisms. X-ray examination revealed nothing ab-
normal in the heart or lungs. His blood agglutinated
Brucella abortus antigen in a dilution of 1-1280. Up to
February 17, 1932, he had been having severe chills fol-
lowed by a high fever and a feeling of malaise. The
same course of treatment was given with thionine as
outlined for patient number two. His temperature be-
came normal, although he had lost five pounds in weight.

The fourth patient, W. F., was a 19-year-old farm
boy. He had no known exposure to tuberculosis. The
cows were negative to the tuberculin test and none of
the cows or hogs had had any spontaneous abortions.
On entrance to the sanatorium he complained of having
had an afternoon fever of 100 degrees since March
1932; of generalized aching; several moderately severe
nights sweats and loss of fifteen pounds in weight. This
patient had been told that he had moderately advanced
pulmonary tuberculosis, although no tuberculin tests or
X-ray study had been made. Examination on May 16,
1932, revealed no pulmonary pathology on physical or
X-ray examination. Tuberculin test was slightly posi-
tive. The blood showed a hemoglobin of 85 per cent,
4,200,000 RBCs and a differential of 52 per cent lympho-
cytes, 38 per cent PMNs, 7 per cent monocytes, 2 per
cent eosinophiles and 1 per cent myeloblasts; negative

456

THE JOURNAL-LANCET

Wassermann reaction, and agglutination of Brucella
abortus antigen in dilution of 1-1280. The patient was
referred back to his family physician, who later reported
that after a course of treatment he had examined the
patient and found him free from symptoms.

As in the case of all diseases where the cause is found,
attempts should be made to eliminate the disease by pre-
vention, and specific methods should be used if the dis-
ease is already present. Prevention of undulant fever
would consist of pasteurization of raw infected milk or
by the removal of infected animals (experimental im-
munization of infected cattle has failed ’ ’) . The treat-
ment at the start was naturally symptomatic because
the disease usually ran rather a short and mild course.
Later on, foreign protein44>4a was used, neoarsphen-
amine2u, quinine, dyes like mercurochrome49, theo-
nine and methyl violet48. These were aimed at the
septicemia and were not specific. The best treatment, of
course, would be specific treatment: either vaccine ther-
apy40,41,42 or use of immune serum obtained from ani-
mals07 or humans02. Both the latter methods have been
found successful, although clinical trial has not been
sufficiently controlled. Of two cases of meningitis, one
treated specifically recovered'0. Hannock and McGath
report two cases in which they used a detoxified serum
obtained from horses and goats in which there was a
sudden fall of temperature and relief of toxicity.
However, the temperature did recur without any tox-
icity. Cresswell and Wallace02 report the use of immuno-
transfusion in two cases with sudden relief of symptoms
and temperature. They took the donors who had un-
dulant fever and whose opsonophagocytic index was
high. Even with specific vaccines and serum, recurrence
of disease takes place in 11 per cent 09 to 20 per cent07
of cases.

Conclusions

1. Brucellosis is a mild septicemia caused by Brucella
organisms and characterized by a reticulo-endothelial
system reaction.

2. Cases with persistent fever, weakness, relative
lymphocytosis should suggest brucellosis.

3. Pulmonary changes may suggest atypical, slowly
resolving pneumonias.

4. The history and symptoms may suggest a diagnosis
of tuberculosis.

5. Diagnosis of undulant fever can be confirmed or
ruled out by laboratory tests.

6. Although our series of cases was too small, and
period of observation too short to justify drawing final
conclusions as to the success of treatment, thionine was
found to give prompt symptomatic relief.

7. In two cases improvement in symptoms was paral-
leled by a diminished agglutination with Brucella meli-
tensis (abortus) antigen.

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Some Allergic Problems Puzzling to the
General Physician*

J. A. Rudolph, M.D.f
Cleveland, Ohio

BRONCHIAL ASTHMA, hay fever, urticaria
and angioneurotic edema are generally accepted
as the commonest clinical forms of allergy, and
usually are recognized without especial difficulty. With
these obvious varieties this paper is not concerned; but
rather with those conditions which are definitely allergic,
but are not readily apparent, often being quite difficult
to identify.

These vague allergic conditions can be classified into
two main groups: (1) atypical allergic complaints, (2)
identical complaints shared by the non-hypersensitive
patients.

The first really comprises the atypical forms of the
usually-evident allergic complaints mentioned above, the
identifying signs being so faint, so indefinite, or so inter-
mingled with the symptoms of complicating conditions
as to render the allergic features difficult of recognition.

•Read before the Medical Section of the Cleveland Academy
of Medicine, March 10, 1937.

t Associate clinician, Department of Allergy, Mount Sinai Hos-
pital, Cleveland, Ohio.

The second group contains the allergic varieties of
such conditions as eczema, headache, and gastrointes-
tinal disturbances. Here the identification of the allergic
status is puzzling, since the symptoms are usually in-
definite and non-specific, being very often shared by
other non-hypersensitive complaints.

Frequently these vague hypersensitive complaints are
linked with the more definite allergic conditions; the
history past or present, of an associated bronchial asthma,
hay fever or urticaria, may be the clue which establishes
the allergic nature of the more obscure complaint. Again,
the presence in the family history, collateral or ante-
cedent, of clinical hypersensitiveness is of significance,
since it is a fact that the tendency to hypersensitiveness
is an inherited, familial trait. The skin tests, cutaneous
scratch or intracutaneous, or in dermatitis venenata cases,
the contact or patch tests, very often afford conclusive
evidence; but in those individuals where the skin reac-
tions prove negative, the allergic basis may be established
by studying the clinical symptoms resulting from the test

458

THE JOURNAL-LANCET

of placing the patient in contact with the suspected
cause. In food allergies, especially, "trial and error” or
limited diets are employed.

For convenience, these puzzling allergic complaints
may be divided arbitrarily into the following three
groups: (1) respiratory, (2) gastrointestinal, and (3)

cutaneous.

These groups will be considered separately although
often a single patient may possess a variety of these
manifestations from a single cause; for example, coryza,
gastro-intestinal distress, dermatitis may result from
foods such as egg, or chocolate, or nuts.

Respiratory Group

Under the designation "acute colds” are hidden mild
allergic reactions, many of which are atypical cases of
hay fever, or pollinosis; this is especially true where the
significant signs and symptoms (itching and congestion
of the eyes, lacrimation, nasal congestion and discharge,
and sneezing) are lacking except for one or two of their
members. For instance, hay fever with the one symptom
of nasal congestion or of headache, or of irritation of
the eyes, alone may present some difficulty in diagnosis,
particularly where the seasonal limits are indefinite. A
young man of twenty-five suffering each spring with a
persistent nasal obstruction, without sneezing, lacrima-
tion or irritation of the eyes, was considered as having
a case of "spring colds” due to the changeable weather,
until the periodicity furnished the clue that led to the
diagnosis of tree hay fever proven by a positive intra-
dermal test, and the resultant treatment with an extract
of sycamore tree pollen. A young boy of nine years was
seen with a conjunctivitis and an episcleritis which oc-
curred late each summer soon after the beginning of
the school term and lasted several weeks, being attrib-
uted to the increased eye strain after the summer vaca-
tion. It had not responded to the usual therapy. There
were no nasal symptoms. Since the seasonal limits were
similar each year, and corresponded to the autumnal hay
fever season, the case was suspected of being atypical hay
fever, which was verified by a positive cutaneous test, and
the resultant treatment was with ragweed pollen extract.

Attacks of too frequent "acute winter colds” are sim-
ilarly found to be due to the allergic reaction of the
respiratory mucosa to air-borne excitants of environ-
mental origin. These appear in the fall, soon after the
individual (usually a child, with added hours indoors
after a summer in the open) is often subjected to the
heated and often dry air of the home, with its accumu-
lation of dusts, feathers, toilet powders, animal epider-
mals, etc. Such attacks should be easily identified as
allergic, due to the suddenness of their appearance and
disappearance, the lack of fever, malaise, and contagious-
ness, the absence of any mucopurulent or purulent nasal
discharge, and the immediate improvement upon correc-
tion or change of environment. The cause can usually be
determined by skin tests, and perhaps by careful ques-
tioning.

These frequently recurring paroxysmal allergic re-
sponses readily develop into a persistent form frequently

mistaken for a "chronic cold” or "chronic sinusitis.” A
young woman of twenty-eight years had suffered for
three years with a persistent watery nasal discharge,
stubborn nasal obstruction, sneezing, lacrimation and
frequent headaches. Several X-ray films had shown
light to be poorly transmitted through all the sinuses.
Several nasal operations had aggravated rather than
lessened the symptoms. The patient was identified as
being an allergic case by the following clue given by
herself: that a "henna wash” given at a beauty shop
always made the sclera and conjunctiva intensely irri-
tated and congested.

By skin test she was found sensitive to henna powder,
and improved greatly under the allergic treatment in-
dicated. In all individuals with periodically recurring
"colds” it is well to consider the possibility of an allergic
background before employing catarrhal vaccines, sinus
treatments, or other general non-specific measures. In
children particularly, any chronic "cold” or "sinus con-
dition” should be strongly suspected of being basically
allergic.

When not treated with specific measures, such purely
allergic "colds” by their continued presence, frequently
lower the local resistance of the individual, and allow
the increase of the bacterial flora of the nasopharynx,
thus rendering him susceptible to secondary infection
and subsequent complications of the respiratory tract.
Thus the exciting principle, the allergic factor, though
still present, may be difficult to identify, being over-
grown by the secondary bacterial invasion with its at-
tended symptoms. In such cases of long standing respir-
atory infection, the results of therapy are often most
discouraging, even when the allergic agent is recognized
and taken into consideration in treatment. This type
of case is often associated with chronic bronchial
asthma.

In children especially, foods are frequently responsible
for nasal and bronchial symptoms which are difficult to
classify as allergic. A child of twelve with a history of
continuous non-seasonal colds, refractory to all treat-
ments, was otherwise healthy, there being no asthma,
bronchitis, eczema or cutaneous symptoms. The one
point of significance in the history was that on one occa-
sion, when egg was purposely smeared on an accidental
arm burn, it caused violent itching and edema of the
entire arm. Eggs were eaten daily, being well-tolerated,
with no evident discomfort resulting. Upon removal of
egg from the diet, the nasal symptoms promptly and
completely disappeared. A mild persistent cough, with-
out nasal, gastric or cutaneous symptoms, may be due
to a food, particularly chocolate, fish or nuts. In other
instances, concomitant with the nasal discomfort may be
pallor, listlessness, fatigue, malnutrition, abdominal dis-
comfort and diarrhea, symptoms of a more profound,
gastro-intestinal type of food allergy.

Gastro-intestinal Group

The allergic gastro-intestinal conditions may be
divided according to the reaction time into the im-
mediate type, where the interval between the ingestion

THE JOURNAL-LANCET

459

of food varies between a few seconds and two to three
hours, and the delayed type when the interval varies
between three hours and several days. In the first,
immediate type, the symptoms could never be considered
as vague. In fact, they are so prompt and usually so
marked that cause and effect are easily noted by the
patient. An instance of this reaction of acute gastro-
intestinal allergy, is the individual who is so sensitive to
clams that faintness, nausea, vomiting and diarrhea reg-
ularly develop within a few minutes of ingestion. The
skin tests with extracts of the offending foods are usually
positive. In this rapid type of reaction there may also
occur symptoms referable to other systems of the body,
such as asthma, urticaria and angioneurotic edema.

This immediate type, with its usually obvious causes,
is mentioned to contrast it with the delayed type less
frequently recognized, since it is more obscure. Here
the interval between ingestion and reaction is greater;
often two to three days, the symptoms usually being
more prolonged and stubborn. Frequently the symptoms
presented are not specific for allergic conditions, as is
true in a large group where the major complaint is
"indigestion.” Anorexia, coated tongue, bad taste in the
mouth, bad breath, abdominal distress, feeling of full-
ness or pain in the epigastrium soon after eating, some-
times nausea, eructations of gas and at times of bitter
fluids, vomiting, either spontaneous or induced for relief,
from a few minutes to two hours after eating — all these
are symptoms which point to organic lesions of the
stomach, gall-bladder or appendix. They are, however,
at times purely functional, and are due to existing food
hypersensitiveness. Seldom does the patient determine
the cause in this condition, since the longer reaction-
time so confuses the picture that he does not know the
food excitant, and is very often unaware that a food is
responsible. The cutaneous tests should be done, but are
usually of little value in this delayed type. A clue may
frequently be obtained, however, by a searching clinical
history, by determining for instance if there are any ab-
normalities in the diet; what foods, if any, are eaten to
excess, or what foods are eaten though disliked. Elim-
ination, or "trial and error” diets, are often used to
advantage here. A man of 42, suffering for ten years
from bad breath, coated tongue, nausea, eructations and
constipation, had been examined, X-rayed, and had had
an appendectomy. His symptoms disappeared and his
weight increased upon total abstinence from eggs. A
young woman with similar symptoms, in order to econ-
omize, made her lunch continually a glass of milk. All
symptoms disappeared upon avoidance of milk. In
neither case were skin tests of any assistance, being en-
tirely negative. Often in both the immediate and de-
layed types of gastro-intestinal allergy, cutaneous symp-
toms are present and are caused by the same food
allergens, by ingestion.

Cutaneous Group

Less well-known is the fact that in many instances a
food, not by ingestion, but by contact alone with the
unbroken skin, causes skin symptoms. An example of

this is the cook who develops a rash soon after handling
a raw vegetable, such as white potato. Any variety of
food may act in this way. Known especially as excitants
of this type are egg, beef, fish, berries, pineapple, apple,
carrots, celery, string beans and asparagus. The symp-
toms are usually mild, and evanescent, with itching and
redness of the face, neck and hands, congestion of the
eyes, and sometimes coryza and sneezing. The interval
between cause and effect here is usually so brief that the
disturbing food is well-known to the patient. The symp-
toms rarely become chronic or severe.

Not only foods but air-borne excitants, best known as
causes of respiratory allergy, by contact, occasionally
produce a dermatitis or eczema. Such cases are usually
chronic and so masked that they would be difficult to
recognize were it not for the respiratory allergy, asthma,
hay fever, with which they are usually associated. Fre-
quently the skin tests are of value. In some excitants of
this air-borne type, the exciting principle is an oil, as in
the case of ragweed dermatitis, which is seasonal. Con-
tact or patch tests with the oil, obtained, from ragweed
pollen gives a positive reaction in these cases.

Dyes, drugs and chemicals, by contact produce allergic
dermatoses. Paraphenylendiamine, an ingredient of many
dyes, inks, and stains, is especially irritating. In a young
woman of twenty-eight years, a dermatitis of the eyelids
of over a year’s duration was found by patch test to be
due to black dye and sodium bichromate, both present in
her leather shoes, purse and gloves. Avoidance of black
leather contacts cleared the condition. Dyes for furs,
shoes, and fabrics must be borne in mind as possible
causes of dermatoses, ranging from a mild acute itching
and erythema to a chronic stubborn involvement. Lac-
quers, wood stains, dry cleaning fluids, and petroleum
products also must be considered here. The clinical his-
tory and the anatomical distribution of the lesions often
aid in determining the cause in these cases. Patch tests
with a small quantity of the suspected material should
be made, but with caution. Hair tonics and lotions,
wave-set preparations of flax seed or quince seed, and
other cosmetics, often containing bichloride of mercury,
quinine or other chemicals, are known to have been con-
tact irritants in many cases.

Drugs, by ingestion, are of course frequently respons-
ible for acute and chronic rashes. Acetylsalicylic acid,
phenacetin, the salicylates, quinine, antipyrine, pyrami-
don, mercury, arsenic, and the essential oils must be
considered as causes. The specific allergic reaction pro-
duced in hypersensitive individuals by these drugs must
not be confused with the effect of ordinary overdosage,
from which it is quite different.

There are a variety of other unusual allergic reactions
which do not fall into the three groups just discussed,
such as the occasional cases, proven to be allergies, of
acute urinary bladder distress, epileptiform seizures,
allergic arthritis, allergic labyrinthitis (with resemblances
to Meniere’s disease) . The majority of such hyper-
sensitive problems doubtless go unsuspected, indeed
without a definite history, or the presence of known
allergy, past or present, in the patient or his family, the

460

THE JOURNAL-LANCET

probability of proper etiologic classification is very
slight. Rendering the situation more complex is the fact
that the cutaneous test is of little aid in the majority of
cases. With such a paucity of concrete evidence, it is
little wonder that the border lines of clinical allergy
become hazy and befogged, and that continually the
temptation exists to make the diagnoses in these obscure
conditions upon mere surmise.

In conclusion, it should be emphasized that these
puzzling allergic forms of hay fever, bronchial asthma,
urticaria and food disturbances differ from the more
obvious chiefly in the difficulties they offer in identifica-
tion, rather than in the problems connected with treat-
ment. Certainly once their allergic nature has been rec-
ognized, it becomes apparent that the therapeutic meth-
ods applied to the typical cases, are equally applicable
to these obscure allergic forms.

Vitamins and Infections of the Eye, Nose,
Throat and Sinuses

G. M. Koepcke, M.D.

Minneapolis, Minnesota

VITAMIN therapy and a general knowledge of it
has been advancing rapidly in the past Hw years.
Heretofore, this therapy due to its newness, its
derivation from food products, its wide scope and ease
of applicability, has been dominated by the irregulars,
most of whom were not careful clinical observers. This
served to bring the entire therapy into a state of dis-
repute with the conscientious and conservative medical
practioner. To clarify conditions, laboratory investiga-
tors undertook to weigh its real value in closely guarded,
highly technical, biological tests. However, their reports
were of such nature that it was usually perplexing or
impracticable to make any clinical application of the
data they published.

That phase is now finished. Contributions are reg-
ularly being published by investigators versed in sound
clinical medicine as well as experimental physiology.
The development of the visual photometer test for vit-
amin A deficiency, the urine analysis and capillary fragi-
lity test for vitamin C, and to a more limited degree the
heart-rate test for vitamin B, enable us to proceed with
a much better perspective. Bacterial examination and
other clinical observations carried out at the beginning
and during the treatment, provide a double check on the
progress of the patient. The result is a confirmation of
many of the early ideas advanced as to its therapeutic
merit.

In the past, the use of the combined or multiple vit-
amin concentrate preparations has been questioned some-
times as being unscientific and hence unjustifiable, but
the findings reported by the investigating experimental-
ists and clinicians indicate that almost every deficiency
syndrome is likely to present symptoms of a multiple
vitamin deficiency nature by the time the physician first
gets to see the patient. Next, once deficiency syndromes
become apparent, the individual seems either unable to
utilize the minute quantities of these vital food sub-
stances in their regular dietary, or consume greater
quantities because of the disease and temporary vitamin
imbalance, thereby setting up a vicious circle that only
the administration of a sufficient quantity of all the

vitamins, fortified by specific vitamins where necessary,
can alter. And, finally, due to lack of knowledge of the
complex molecular structure of vitamins, the natural
products or those concentrated from the natural source
without too great a loss or alteration of the vitamins,
are found to be superior to the chemically synthesized
pro-vitamin or minutely fractionated concentrate. Thus,
it may be seen that the extreme opposition to the part
vitamins play in physiological chemistry is gradually
giving way to a more rational outlook and better under-
standing. Furthermore, we may confidently look for-
ward to a sound development and wide use of this
therapy.

Vitamin deficiencies are now generally becoming recog-
nized as a causative factor in the infections of the re-
spiratory tract. Deficiencies of certain or all of the
vitamins must be considered in the infections of the
nose, throat and sinuses. However, it must be under-
stood that vitamins are not a cure-all for diseases, but
must be looked upon as a useful and necessary adjunct
in the treatment and the prevention of disease. Bircher-
Benner1 states that neither prophylaxis nor therapeutics
can be completely effective unless sufficient quantity of
the vitamins are available to the human economy.

Of all the vitamins, A and C seem to be especially
concerned with the lowered body resistance, thus per-
mitting the infective processes to take place. Mendel2,
discussing vitamin A, states that bacterial invasion occurs
in test animals when the A factor is eliminated from
the food, and can be readily cured if the disease pro-
cesses have not advanced too far, by the administration
of the vitamins. The outstanding change in vitamin A
deficiency is substitution of stratified keratinizing epi-
thelium for normal epithelium in various parts of the
respiratory tract. Mackie3 in his work on deficiency
states, has confirmed the fact that infections of the
eyes, tonsils, sinuses, buccal and lingual mucosa and the
skin are conditions of avitaminosis A in the human
subject. P^rk4, also Jeghers5, in recent papers call at-
tention to the use of the visual photometer according to
the technique of Jeans and Zentmire, as a simple method

THE JOURNAL-LANCET

461

for the detection of vitamin A deficiency and for
measuring response to vitamin A therapy. Vitamin A
evidently acts as a barrier against infection, by stimu-
lating healthy epithelial tissue. It has a definite con-
nection with the normal regeneration of visual purple
and the prevention or cure of night blindness.

Deficiency of vitamin A reduces the resistance to in-
fecting organism with resulting infection of sinuses,
tonsils and ears. Glands of internal secretion seem de-
pendent on the amount of vitamin ingested in food.

Sajous'1 has shown that the opsonin of bacteriology is
a secretion of the thyroparathyroid glands and the
spleen. The pancreas produces Ehrlich’s complement while
the amboceptor of Ehrlich is secreted by the adrenals.
Ehrlich’s amboceptor and vitamin C were thought by
Sajous to be identical. Vitamins A, B, C and D are
considered necessary for the thyro-adrena-pituitary
group. Szent-Gyorgi' states that vitamins B and C are
necessary for the proper functioning of the adrenals.
TakahashL noted a pronounced lowering of resistance
to bacterial infection in his animal experiments in B and
C deficiencies.

Tislowitz" cites the successful treatment of diphtheria
circulatory weakness with adrenal-cortical extract and vit-
amin C, and suggests that extracts of adrenal cortex
together with vitamin C may prove helpful in the treat-
ment of circulatory disturbances that develop on an
infective or toxic basis.

While vitamins A and C tend to be pointed out as
very important, vitamin Bi, D, G and possibly E and F
should also be considered. When the first clinical symp-
toms of disease present themselves, it is important to
start the vitamin medication at once. Multiple vitamin
therapy often is indicated, not with the idea of instituting
a hit or miss treatment, but for the purpose of establish-
ing a prophylactic immunity toward any contributory in-
fections while at the same time therapeutic immunization
is enhanced toward the particular organism predomin-
ating in the infection. It is imperative that treatment
should be started early, before the infection has become
extensive, to obtain the best results. The rarity of con-
tra-indications and the ease of instituting the multiple
vitamin therapy, makes this treatment highly desirable.

Vitamin therapy is of great value in acute conditions
which are slow in healing and tend to become chronic.
It should be routine treatment in all chronic conditions
which show a tendency to be latent. It is useful both
in pre-operative and post-operative cases.

A few of the manifold conditions in eye, nose and
throat in which vitamins are useful, are as follows:

Corneal Ulcers

Corneal ulcers, especially of the nutritional type, re-
spond very readily to vitamin therapy. The patient com-
plains of pain, scratching and soreness of the eye. On
examination, small punctuate areas of ulcerations are
found usually near the limbus. After a few days the
areas have a tendency to coalesce, and further corneal
destruction progresses very rapidly.

With a balanced combination of vitamins, reinforced
by additional amounts of vitamins A and B, the process
of healing is readily stimulated. The ulcer process stops
and begins to heal. Vitamins are imperative in this
type of ulceration.

Congenital Cataract

Congenital cataract responds favorably to vitamin
administration. A case now under observation, has been
treated solely with vitamin concentrates. Owing to the
fact that the patient was a great distance from the
Cities, a rude, yet standard testing equipment was
arranged in the home. The test type could be seen at a
distance of 10 feet and reading at 6 inches in January,
1936. Today, the distant vision is 18 feet and the read-
ing vision distance is 21 inches. The lens opacity could
be visualized easily in January, 1936. Today, the opacity
can hardly be made out except by the use of reflected
light.

The changes in photophobia, and general physical
condition are so utterly changed that one would hardly
recognize the patient as the same individual.

The vitamins, fortified particularly with A and C
have a definite place in the treatment of this type of
cataract.

Acute Inflammations

A noticeable observation in the treatment of acute
inflammation with vitamin medication is that the con-
valescent period is shortened. The "all in” feeling so
often mentioned by the patient following severe acute
inflammation disappears.

Herpes Zoster Ophthalmia

Vitamin therapy in our hands, as an adjunct in the
treatment of herpes zoster, has given very good results,
and we feel that vitamin Bi has a very definite place in
the therapy for herpes zoster.

Sensitivity to Light

Patients examined for glasses complaining of sensitiv-
ity to light, and especially those having difficulty in
driving at night, may have a hypo-vitaminosis A. Vi-
tamin A given over a period of several weeks usually
relieves the symptoms. Our experience over a period of
eight months using the visual photometer to measure
light sensitivity, visual purple regeneration, or night
blindness, has shown us that within a reasonable per-
centage of error, we can ’estimate the need for the vi-
tamin from our clinical observation alone. A careful
recording of the symptoms and examination often reveals
this in a much shorter time than the twenty-five minutes
necessary to check each patient on the photometer.*

Sphenopalatine Neurosis

The severe pain and extreme discomfort can be
quickly benefited by the addition of Bi therapy.

*Frober-Faybor Biophotometer, loaned us through the courtesy
of the Vitamin Products Company, Milwaukee, Wise.

462

THE JOURNAL-LANCET

Acute Nasal Infections

Acute sinusitis responds nicely to vitamin A plus com-
bined concentrates. It must be understood again, that
vitamins do not replace any treatment for acute sinusitis,
but enhances the routine in hand. The period to estab-
lish immunity to the predominating organism in the in-
fection is materially shortened, thereby allowing quicker
surgical interference with less danger of extension of
the infection in adjacent structures. The healing period
is surprisingly short. Vitamin A and multiple concen-
trate must be given in large doses. So far, no patient
has experienced or shown any toxic effect or a hyper-
vitaminosis in an acute infection. We feel that vitamin
substance is the food for the endocrine glands. During
an acute infection, the endocrine system, especially the
suprarenal gland, is under tremendous strain. The
patient is easily fatigued, feels tired and is slow in tissue
healing. Vitamin therapy during the acute period and
post infectious period gives the endocrine system the
needed food for balanced function.

This may be shown by the fact that when a patient
does not respond to glandular therapy, a response can
be produced by adding vitamin concentrate medication.

Careful examinations of the nose and throat are im-.
perative to determine the presence of abnormalities or
a possible pent up pus in the paranasal sinuses. Where
deformities exist, drainage of pus accumulations and
needed surgical corrections should be made. It is good
practice to give the vitamins before operative measures
are instituted to build up the general systemic resistance,

and in this way hasten the healing process, and possibly
help avoid the post-operative extension or the infections.

Summary

(a) Vitamin deficiencies are generally becoming
recognized as an important causative factor in the in-
fections of the respiratory tract.

(b) When the first clinical symptoms of disease pre-
sent themselves, it is important to start vitamin therapy
at once.

(d) Vitamin therapy hastens the healing period.

(e) So far, no patient has experienced or shown any
toxic effects of vitamin therapy in acute inflammations.

(f) Vitamin therapy gives the endocrine system the
needed food for balanced function.

Bibliography

1. Bircher-Benner, von, "The Bread Question,” Schweizerische
medizinische Wochenschrift 67:p. 396 (May 1 ), 1937.

2. Mendel, L. B„ ''Vitamin A,” J. A. M. A. 98:1981-1987
(June 4) 1932.

3. Mackie, T. T., "Ulcerative Colitis: II. Deficiency States,"
Journ. A. M. A. 104:175-178 (Jan. 19) 1935.

4. Park, I. O., "Observations on Vitamin A Deficiency as
Shown by Studies With the Visual Photometer,” J. Oklahoma M.
A. 28:357-357 (Oct.) 1935.

5. Jeghers, H., "Night Blindness as a Criterion of Vitamin A
Deficiency," Ann. Int. Med. 10:1304 (March) 1937; and Jeghers,
H., "The Degree and Prevalence of Vitamin A Deficiency in
Adults,” Journ. A. M. A. 109:756-762 (Sept. 4) 1937.

6. Sajous, E. de M., "Internal Secretions," 4th ed., 696-699 and
713-715, Volume I; Philadelphia: F. A. Davis Co.: 1911.

7. Szent-Gyorgi, A., Biochem. Journ. 22:1 387, 1928; and Szent-
Gyorgi, A., "Identification of Vitamin C,” Nature (London) 131:
225-226 (Feb. 18) 1937.

8. Takahashi, R., "Infection Due to Vitamin Deficiency, Espe-
cially in Acute Infectious Osteomyelitis," Archiv f. klinische
Chirurgie, Berlin 181:103 (Oct. 4) 1934.

9. Tislowitz, R., "Cevitamic Acid and Function of Adrenal Cor-
tex," Klin. Wochen. (Berlin) 14:1641 (Nov. 16) 1935.

BmIi ftotices

A GREAT SURGICAL WORK

Surgical Treatment, by James Peter Warbasse, M.D., and
Calvin Mason Smyth, Jr., B.S., M.D.; 2nd edition, thor-
oughly revised and re-set, 3 volumes with separate index,
bound in maroon cloth, stamped in black and gold, 2,617
pages, 2,486 illustrations on 2,237 figures, some in colors;
Philadelphia: The W. B. Saunders Company: 1937. Price,
#35.00 for the set.

This imposing work first appeared in 1918; this is its 2nd
edition. The publishers have wisely allowed it to be completely
re-set and thoroughly revised, and the result is an invaluable
mass of surgical literature from a plenitude of sources. Every
section of the work has been altered; some have been entirely
re-written. Steps forward have been made in internal medicine,
in radiology and roentgenology, in physical methodology, in
anesthesia, in cranial operative surgery, in fracture treatment,
etc., since 1918, the year this set first appeared. Thus, it has
been imperative to present modern approaches and discussions
of these great advances, and Warbasse and Smyth have done
it honestly and competently. New drawings have been made
by Mr. William Brown McNett, and Mr. Albert Comroe.
Some of the photographic illustrations were made by James
F. Schell, M.D.

Every general practitioner ought to have this great work;
and many surgeons no doubt already have had the 1918 edition
these many years. This Warbasse-Smyth set cannot be rec-
ommended too highly.

A VALUABLE EDITORIAL HANDBOOK
The Preparation of Scientific and Technical Papers, by

Sam F. Trelease and Emma Sarepta Yule; 3rd edition,
blue cloth, stamped in black, 116 pages plus bibliography
and index; Baltimore, Maryland: The Williams & Wilkins
Company: 1936. Price, #1.50.

This is a model handbook for all who wish exactitude in the
preparation of scientific papers. It should be valuable to physi-
cians in the preparation of their papers, although the work
does not approximate in every respect the style used by The
Journal of the American Medical Association, usually consid-
ered final authority by most physicians.

This book is rather a compendium of styles used by several
authorities or societies in the preparation of printed material.
Alternative styles are freely given. On the whole, The
Journal-Lancet recommends this little volume.

POCKET PATHOLOGY TEXT
Pathology, by Edward B. Krumbhaar. M.D., Ph.D.; 1st
edition, red cloth, stamped in black, 185 pages plus bibliog-
raphy and indices, 18 illustrations; New York: Paul B.
Hoeber, Inc. (Harper Medical Books) : 1937. Price, #2.00.

This is the 19th in the series of primers addressed to "The
Medical Muse,” and edited by Edward B. Krumbhaar. M.D.,
Ph.D., professor of pathology in the University of Pennsylvania
School of Medicine. It so happens that Professor Krumbhaar
also wrote this one. The volume might be called a literary
approach to pathology. It is very interesting, excellently
printed and bound, and constitutes a most pleasant history of
pathology from the earliest to modern times. It is well worth
owning.

JOURNAL

LANCET

Represents the
MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

The Official Journal of the

North Dakota State Medical Association The Minnesota Academy of Medicine Great Northern Railway Surgeons’ Assn.

South Dakota State Medical Association The Sioux Valley Medical Association American Student Health Association

Montana State Medical Association Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. A. W. Skelsey, Dr. C. E. Sherwood, Dr. Thomas L. Hawkins - Associate Editors

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. J . F. D. Cook
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

BOARD OF EDITORS

Dr. W. A. Fansier
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. S. M. Hohf

Dr. A. Karsted
Dr. H. D. Lees
Dr. J. C. McGregor
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. J. C. Shirley
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley

W. A. Jones, M.D., 1859-1931

LANCET PUBLISHING CO., Publishers

84 South Tenth Street, Minneapolis, Minnesota

Dr. C. A. Stewart
Dr. J . L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

W. L. Klein, 1851-1931

Minneapolis, Minn., October, 1937

THE CITADEL

The Cttadel, as nearly as we can make out, unfairly
attacks the medical profession, more particularly that of
London. How anyone could speak of the author as
a "distinguished physician,” we cannot understand. He
attained the honorable degree of doctor but practiced
medicine only five brief years, during which time he
popped in and out of several positions of little im-
portance. It is unfortunate, of course, that any man
after graduation should fall in with such associates as
he must have done, but in a land of free choice where
birds of a feather may flock together, he lays himself
open to a very natural implication in this connection.

Whether he had some guilty knowledge or merely
dreamed about the possibilities of making "easy money”
by criminal depravity in a profession that had enjoyed
the confidence of humanity in all times, we do not know.
At any rate, he deserted the practice of medicine for
fiction, and this, his latest work, has created a furore
on both sides of the Atlantic.

A. E. H.

THE BRONCHOSCOPIST MAKES
ANOTHER CONTRIBUTION

Since the advent of collapse therapy in the treatment
of pulmonary tuberculosis, it has been observed that
some patients with satisfactory collapse of the lung con-
tinue to cough and to have numerous tubercle bacilli in
the sputum. It has also been observed that the occa-

sional person has cough and positive sputum when no
phase of the examination, including X-ray films made
in various diameters of the chest, reveals any evidence
of pulmonary lesions. Some of these cases have been
thought to be due to the ulceration of tracheo-bronchia!
lymph nodes into the air passages. However, within
less than ten years the bronchoscopists have made con-
tributions which adequately explain this previously ob-
scure condition. Such physicians as Schonwald, Clerf,
McConkey, Myerson, Tucker, Eloesser, Coryllos, and
Barnwell, have made important observations on tubercu-
losis of the trachea and bronchi.

Examinations for involvement of these parts of the
air passage are being conducted in a very extensive man-
ner in several parts of the country, and enough cases
have already been reported to lead one to believe that
the condition is by no means rare. The finding of tu-
berculous tracheo-bronchitis, which usually has a back-
ground of pulmonary tuberculosis, definitely complicates
not only the treatment but also the ultimate prognosis.
Indeed, when severe ulcerative tuberculous lesions are
found in the trachea and bronchi, the advantages to be
gained by collapsing the diseased lung are slight, since
following collapse the sputum will continue to contain
tubercle bacilli, and the prognosis of the tracheo-bron-
chial condition remains bad.

Bronchoscopic examination may soon be considered
important in every case of pulmonary tuberculosis, in
order to detect slight involvement of the trachea or

464

THE JOURNAL-LANCET

bronchi, when treatment may be of some avail. More-
over, periodic examinations by means of the broncho-
scope should be made on all patients who continue to
have such symptoms as cough and sputum containing
tubercle bacilli after the lung has been adequately col-
lapsed. The skill and care with which the bronchoscopist
now makes his examination has so reduced the discom-
fort and harm to the patient that pulmonary tubercu-
losis is no longer considered a contraindication.

Schonwald, P.: Tuberculous granuloma of the bronchus, Amer.

Rev. Tuberc., 1928, 18:425.

Clerf, L. F.: Is bronchoscopy indicated in tuberculosis? Jour.

Amer. Med. Assn., 1931, 97:87.

McConkey, M.: Occlusion of the trachea and bronchi by a

tuberculous process complicating pulmonary tuberculosis, Amer.
Rev. Tuberc., 1 934, 30:307.

Myerson. M. C.: Bronchoscopy in tuberculosis, Ann. Otol.,

Rhin. and Laryng., 1934, 43:1 139.

Tucker, G.: Bronchoscopy in pulmonary disease, Ann. Int.

Med., 1934, 8:444.

Elcesser, L.: Bronchial stenosis in pulmonary tuberculosis,

Amer. Rev. Tuberc., 1934, 30:123.

Coryllos, P. N.: The importance of atelectasis in pulmonary

tuberculosis, Amer. Rev. Tuberc., 1933. 28:1.

Barnwell. John B., Littig, John and Culp. John E.: Ulcerative

tuberculous tracheobronchitis, Amer. Rev. Tuberc., 1937, 36:8.

J. A. M.

OLD AGE ASSISTANCE— ITS MEDICAL
DANGER

Already there is to be envisioned on the horizon of
medical economics a many-headed ^monster. Viewed
hastily, it is innocuous enough, but, on closer examina-
tion, it is potentially the beast which has throttled the
art and science of medicine in some foreign lands. The
ogre under consideration is Old Age Assistance.

Administration of this governmental pension is not
uniform in all counties. In one county of Minnesota,
when the eligible recipient desires an increase of pension,
he is referred by his county commissioner to his family
physician. The pensioner is told that the doctor will,
if he is willing, take up the matter with the proper
officials and thus secure the additional income. There-
upon, the doctor becomes the pensioner’s benefactor or
persecutor.

In another county, the pensioner is referred to the in-
vestigator of the Old Age Assistance Division by the
commissioner. Then, after the case is adequately in-
vestigated, the family physician receives a blank request-
ing the diagnosis, prognosis and estimated monthly cost
of drugs and medical care. In one instance, at least,
the blank has a postscript stating that 40 per cent reduc-
tion of medical fees in such cases is expected.

In both of these administrative methods the advisa-
bility, to say nothing of the legality of transmitting the
diagnosis and prognosis to lay social workers, is subject
to question. Endless controversy and unpleasantness may
result. Law suits for malpractice may develop. In
Minnesota it is illegal to inform a third person of the
diagnosis of syphilis or gonorrhea in any case. And,
finally, is it not conceivable that the accumulation of
such statistics by social service workers can or will be
used to the disadvantage of the medical profession in
years to come.

During the depression years the medical profession
pf Minnesota, even though its income as well as that of

others was markedly curtailed, accepted a fee schedule
40 per cent lower than current medical fees for care of
the indigent under both S. E. R. A. and F. E. R. A.
This, it might be pointed out, is far more magnanimous
than the action of the dispensers of the other necessities
of life — food, clothing and shelter. And now, when
boom times are apparent and the depression exists only
as history, the profession is being coerced to continue
its precedent of 40 per cent reductions of medical fees
for the care of a group which the government has vol-
untarily decided to safeguard.

Superficially considered, these are minor matters. Yet,
are they not the very essence of the practices which have
led to so many evils, or even the downfall of medicine
in Europe? Is it not the practice of certifying disability
in both Germany and England that has increased the
practices of the insurance physicians in those countries?
But, is it not indirectly the result of such effort toward
either self-aggrandizement or possibly self-preservation
that has increased the number of sick days per year per
employee in Germany from 5 Zz to 28, and in England
from 9 to 12’/2? And, are not such practices responsible
equally for the failure of the system and the lowering
of medical standards in these countries?

What is the answer? First should be considered the
safeguarding of the ideals and principles of the Amer-
ican system of medicine. This in turn demands that
absolute honesty and fairness be the keynote in the
evaluation of any case coming under the jurisdiction of
the Old Age Assistance Division. Beyond this, a unified
attempt should be made to eliminate those features
which tend ultimately to undermine American medicine.

J. E. S.

Societies

SCIENTIFIC PROGRAM OF THE
MINNEAPOLIS CLINICAL CLUB

Meeting of April 8, 1937.

Dr. Donald McCarthy, Presiding.

THE FOUR LEAD ELECTROCARDIOGRAM IN
CHILDREN*

(Inaugural Thesis)

Paul F. Dwan, M.D.f
(Abstract)

Recent years have brought increasing interest in the use of
the electrocardiograph as a means of understanding the damage
to the heart muscle wrought by disease. The conventional
three lead electrocardiogram has been of great help but in many
cases seemed to fail us. Wolferth and Wood in 1932 reintro-
duced and made popular a fourth or so-called chest lead. This
modification of technique was thought to elicit damage in parts
of the myocardium which were "silent” to the conventional
leads.

The technique of the chest lead is discussed and tables
showing the normal and abnormal findings in adults and chil-
dren are presented. We studied seventy-two convalescent cases
of rheumatic fever by means of the conventional electrocardo-
grams and the chest lead. Our findings were presented in
tabular form. From our study we feel that use of the four

* Am. J. D. Ch. — In Press.

t Frcm the Department of Pediatrics, University of Minnesota,
and Convalescent Home for Rheumatic Children, Lymanhurst
Health Center.

THE JOURNAL-LANCET

465

lead electrocardiogram is indicated in all cases of suspected
myocardial damage.

Discussion

Dr. H. L. Ulrich: I do not see children; — we have been

carrying on fourth leads in adults recently. I was at first averse
to doing this because of the variety of fourth leads that had
been established. Like all new methods, the variety was so
marked that you got disgusted and thought it a matter of extra
work. But they are coming around to a standard system of
the fourth leads in adults. The right arm electrode on the
chest with left leg electrode in its usual position has been
adopted by the Deutch and by Wilson of Ann Arbor. What-
ever method is used, it should be stated so that fourth leads
could be interpreted by any reader of graphs. Even in the
fourth leads we experience normal configurations in the pres-
ence of coronary disease. A case came in on April 2nd, the
four leads were normal, yet on April 4th that man had died
of a coronary closure. From the history he was closing at the
time we took his tracing. I think the taking of the fourth
lead should be encouraged. I would like to see more work
on the method I mentioned above because it is much easier
for the technician and sometimes for the patient.

Dr. Jay C. Davis: For the last two years I have been using

the fourth lead. It has been a valuable addition to electro-
cardiography in my opinion. We are all looking for aid in
diagnosing coronary occlusion in the posterior or diaphragmatic
portion of the heart and we all hoped the fourth lead would
give us valuable information. It has helped some but not as
much as we might wish. My experience has been that the
fourth lead more often helps in anterior closure than it does
in posterior closure. Not infrequently evidence of a closure
is discovered in the fourth lead 18 to 24 hours before it shows
up in the conventional leads.

Dr. Levine, of Boston, in his book on heart disease, stated
that an absent Q4 together with positive T4 is almost pathog-
nomonic of coronary occlusion. However, since that time it
has been recognized that other conditions may give an absent
Q4, an example of which was the patient I saw in consultation
with subacute bacterial endocarditis whose heart was very care-
fully examined microscopically after death and no evidence of
involvement of the coronary arteries could be found. This
particular patient, however, had fluid in both sides of the chest,
a small amount on the right and over 600 cc. on the left.
Fluid in the chest may be one of the factors which can in-
fluence Q4.

The use of the left leg for one electrode with the right arm
electrode used as the exploring electrode on the chest is more
convenient for the technician and is also much better in the
case of a very ill patient because it is not necessary to disturb
him as it is when applying the electrode to the back. Another
thing to bear in mind about the exploring electrode is that,
as a rule, the nearer to the apex it is the more valuable is your
information. The difficulty is that often the technician does
not know where the apex is located. It might be well to set
a standard and have the technician always place the exploring
electrode at a specified distance from the left border of the
sternum in a specified interspace.

Dr. Paul Dwan: As to using the left leg instead of the
back, there is no objection at all to anybody’s using this means
of recording. If we had all of the reports that have been
done on the multitudinous varieties of chest leads under
one standard, we would then have something to go on. It
makes no difference which one we use so long as we stick to
one procedure and establish our standards.

GENERAL SARCOIDOSIS

Jay C. Davis, M.D.

MINNEAPOLIS

The pathology of sarcoid was first described by Caeser Boeck
in 1899. The histology of a section from a skin lesion was
described by him as follows: First, foci of the epitheloid con-
nective tissue cells, second degeneration in the central cells evi-
denced by the appearance of granules, and third where the
destroyed cells had been removed, a. ratification of the new

growth had occurred leaving a net work of reticulum. Further-
more, occasionally large foci were divided by connective tissue
septa and a few giant cells of a sarcomatous type were seen.
Mitosis was scarcely anywhere to be detected.

Since Boeck’s description of the disease in the skin, the same
ailment has been found to involve many organs of the body
with or without skin manifestations. Many papers have ap-
peared describing the condition under a variety of names such
as Boeck’s disease, Besnier’s disease, Besnier-Tenneson’s dis-
ease, Besnier-Boeck’s disease, benign lymphogranulomatosis,
sarcoid, multiple benign sarcoid of the skin, osteitis tuberculosa
multiplex cystica, miliary or disseminated lupoid, lupus pernio
and recently Hutchinson-Boeck’s sarcoid.

The disease may manifest itself in many ways. It has been
reported to occur in the skin, lymphatic glands, bones, lungs,
heart, liver, spleen, intestine, brain, pituitary, testis; also, as
was found in the patient to be reported herein, an interesting
morphological picture of the blood revealed evidence of in-
volvement of the reticulo endothelial system.

The etiology of sarcoid is still obscure. Some of the der-
matologists claim the condition is due to tuberculosis even
though the majority of cases have negative tuberculin tests and
the inoculation of the sarcoid tissues into animals has usually
given negative results. Those who believe tuberculosis to be a
cause of the condition explain the negative tests on the assump-
tion that the microscopic changes are a result of anergy to
chemical products of the tubercle bacillus. Because similar
microscopic findings are seen in lues and leprosy, some French
writers speak of "Terrain Sarcoidique.” In more recent years
most authors have come to regard sarcoid as an unknown en-
tity although some believe it may be due to an unknown virus.
Williams and Nickerson studied four cases in which there were
biopsies. These studies were made of the skin in one case,
of the spleen, liver and mesenteric nodes in the second, of the
intestine in the region of the ileocecal valve in the third, and
in the fourth the biopsy was taken from a case of regional
ileitis. All gave the microscopic picture of sarcoid. In these
four cases a skin reaction following the intradermal injection
of an antigen made from a sarcoid lesion of the skin was
positive, whereas four normal persons gave no such reaction.
These results suggest sarcoid to be a virus disease. Some be-
lieve that sarcoid disease may be related to leprosy, or that
there may be various types such as a leprosy type, a tuberculosis
type, and an undetermined type.

The following is a case report of a patient with sarcoid dis-
ease who did not present skin manifestations.

In the treatment of these cases there is no single remedy.
Drugs have been used such as arsenic, cod liver oil, and col-
loidal gold, and other measures such as milk and varying doses
of roentgen therapy and sunlight have been recommended.
However, none of these are specific, and since so many cases
seem to recover spontaneously it is doubtful if any drug therapy
is actually of value.

The patient is a married woman, age 24 years, 66 Vi inches
tall, weighing 125 Vi pounds. She was first examined March
13, 1936, at which time she stated that she had been in good
health until four years ago when she developed urticaria which
was present off and on for one year and was followed by
leukoderma of the face and neck. Three years ago she noticed
that she began to be upset by matters of little importance and
cried frequently. This continued to the present time. During
the last two years she has had frequent head colds.

At the present time her complaints are a burning sensation
in the epigastrium for the past two weeks coming on im-
mediately after eating and lasting one to one and a half hours.
Meats, fried foods and boiled cabbage seem to cause the
distress. Milk or soda give her relief from these symptoms.
Eight weeks ago she developed a head cold which is still pres-
ent, and with the onset of this infection she noticed a swelling
over both parotid glands, which gradually increased for three
weeks but has remained stationary for the last five weeks. She
has not had fever as far as she knows and has not lost any
weight. She had an eccentric pear-shaped right pupil which,
her mother states, was present as a baby and which the patient

466

THE JOURNAL-LANCET

remembers distinctly being present eight years ago when she
entered high school.

She had smallpox, measles and whooping cough in child-
hood. Two days ago biopsy of the left parotid gland was
done by Dr. Lawrence Larson.

Family History. Her maternal grandmother died of cancer
of the breast, at the age of 58. Her maternal grandfather
died of an undiagnosed stomach ailment, at the age of 60.
Her father was killed in an accident at the age of 37. Her
mother is 52 years of age and is living and well. Three sisters
are living and well. The patient has spent several days visit-
ing two sisters-in-law who have pulmonary tuberculosis.

Physical Examination: She has a patch of eczema on the

occipital region of the scalp. The right pupil is of an eccentric
pear shape and is drawn nasally where it is bound down to the
lens by an adhesion. There is a mass the size of a small
walnut in the region of the isthmus of the thyroid. There is
marked hard swelling in the region of both parotid glands.
In the posterior portion of the left parotid there is an incision
1-0 cm. long resulting from a biopsy. It is healing by primary
intention. Over the face and neck there are many irregular
shaped areas of leukoderma 1 to 5.0 cm. in diameter. The
remainder of the examination was negative except for a slight
cervicitis. The blood pressure was 104/72, pulse 90, and
temperature 97.8°.

Laboratory: The value for the hemoglobin was 88%, the

red cells numbered 4,400,000, and the white cells 6,200 per
cubic millimeter of blood. Examination of a smear of the
blood stained by the Giemsa stain showed many monocytes,
some with vacuolated cystoplasm. The smear was examined
by Dr. Hal Downey whose report follows: "The most impor-
tant feature of the blood is the presence of many monocytoid
reticulo-endothelial cells. Some of these have vacuolated cysto-
plasm and so appear quite histiocytic. The majority of them
are intermediate between reticulo-endothelial cells and mono-
cytes and do not show the histiocytic features.” Urinalysis
gave essentially negative results. The fasting blood sugar was
87 mgm. The fasting blood urea nitrogen was 13 mgm. An
intradermal Mantoux test using 1-1000 and 1-500 dilution
of tuberculin was negative. Intradermal skin tests for food
sensitivity were negative. Likewise, pollen scratch tests gave
negative results.

Urine examined for tubercle bacilli by smear as well as by
intraperitoneal inoculation of a guinea pig gave negative
results.

The Kolmer and Wassermann tests of the blood were
negative. The Kline test of the blood was negative. Agglu-
tination tests of the blood for typhoid, paratyphoid, and Malta
fever were likewise negative.

The electrocardiographic findings showed a low potential of
QRS, 2 mm. with notching. T3 = +0.3 mm. and P3 +0.4 mm.
Q3 — 3 to 4 mm. and R4, 1 to 2 mm. In lead IV the ex-
ploring electrode was at the apex and the other electrode on
the left leg.

X-ray studies were made by Dr. Russell Morse. Those of
the gastro-intestinal tract including a barium enema, and those
of the bones of the hands and feet, long bones, and pelvis
were negative for any pathological changes with the exception
of a small cyst-like area at the base of the medial portion of
the spine of the right tibia. X-rays of the chest revealed
marked swelling of the glands at the hilum of the lungs and
these were apparently disseminated throughout both lungs with
a slight increase apparent in the lower part. In the upper there
was a very fine discreet mottling. Expression of the gastric
contents was done and analysis of the contents gave negative
findings. Sections made from the biopsy of the parotid gland
showed the histology of sarcoid.

Progress: Her condition remained stationary until May,

1936, when the swelling of the parotid glands became some-
what less but about this time swelling of the submaxillary
glands appeared. By the latter part of June the swelling of
the parotid glands and the submaxillary glands was less marked
and the blood picture showed no monocytoid cells having
reticulo-endothelial characteristics noted in earlier smears. The

course of the disease as followed by blood smears showed
the monocytes becoming progressively more mature as the
patient improved although numerous toxic p.m.n.’s persisted
for a long time. The assumption is that the monocytoid cells
of the earliest smears were not reticulo-endothelial cells but
immature monocytes showing some reticulo-endothelial char-
acters and that they were derived from the reticulum which
was active at that time.

Summary

Hutchinson-Besnier’s disease, or generalized sarcoidosis, is
frequently a generalized systemic disease that may involve the
skin, bones, lymph glands, spleen, liver, lungs, heart, mucous
membranes, conjunctiva, parotid, submaxillary and sub-lingual
glands, intestines, testis, pituitary, brain. As Hunter states,
Hutchinson was presumably the first to mention the condition,
although Boeck was undoubtedly the first to describe the micro-
scopic appearance of the lesion.

A case is reported with involvement of the parotid, submax-
illary and sublingual glands, lungs and bones, as well as a
long-standing iridocyclitis. In addition, a very interesting blood
picture is reported showing numerous very early monocytes
apparently derived from the reticulo-endothelial system. These
monocytes varied with the course of the disease, being most
numerous and showing the greatest immaturity at the height
of the disease and becoming progressively more mature as the
patient recovered. Also this type of monocyte indicates that
at the height of the disease there was an increased activity of
the reticulo-endotheliaj system.

This patient was seen last July 12, 1937, at which time she
appeared to have completely recovered.

Discussion

Dr. Russell W. Morse: Roentgenograms made of the

chest of this patient showed a slight thickening of the hilus
shadows and an unusual slight thickening of the interstitial
tissues, particularly in the middle and lower parts of the lung.
We were unable to classify this pathologic change and felt
that it might be due to any one of several pathological con-
ditions.

When Dr. Davis told us that tissue sections of the parotid
were tuberculous, we were still unwilling to consider these
pulmonary changes as a tuberculous lesion. The findings
which we observed were similar to changes described as occur-
ring in sarcoid disease.

Dr. Jay Davis: This girl did not have skin lesions of sar-

coid. The first diagnosis was parotitis; the second diagnosis
was uveal parotitis, which I changed to generalized sarcoid after
finding the pathology in the chest, the bone cyst, and the in-
teresting morphological picture in the blood. She was treated
first with X-ray by Dr. Morse, and later Dr. H. Michelson
gave her colloidal gold.

Lawrence R. Boies. M.D.,

Secretary.

PROCEEDINGS

MINNESOTA ACADEMY OF MEDICINE
Meeting of May 12, 1937.

The regular monthly meeting of the Minnesota Academy
of Medicine was held at the Town & Country Club on
Wednesday evening, May 12th, 1937. The meeting was
called to order at 8:00 P. M. by the president, Dr. E. M.
Jones. There were fifty-one members and one guest present.

The scientific program followed.

TUMORS OF THE JEJUNUM
Dr. James A. Johnson

MINNEAPOLIS

Abstract

Tumors of the jejunum, both malignant and benign, are
comparatively rare. Carter states that malignant tumors of
the jejunum comprise approximately one per cent of all of
those occurring in the gastro-intestinal tract. Benign growths
are likewise rare and consist chiefly of adenomas, myomas and
angiomas. Textbooks on surgery contain very little, if anything
at all, on this subject except to mention that they are very
rare. In 1927 Hellstrom reported 73 cases of cancer of the

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467

small bowel but did not mention their location. In 1936
Nettrour, Webber and C. W. Mayo found only 31 cases of
carcinoma of the jejunum in the files of the Mayo Clinic.
Geschickter, from the Surgical Pathologic Laboratory of Johns
Hopkins, reported 39 cases of benign tumors of the small
bowel with 16 cases of carcinoma, four of which were in the
jejunum. In the University of Minnesota Pathologic Laboratory
files were found only two cases of cancer of the jejunum in
a total of 20,000 complete autopsies in adults. In reviewing
case reports, it is evident that many of these growths occur
very near the ligament of Treitz and become a difficult sur-
gical problem. It is my purpose, therefore, to discuss in par-
ticular the surgical treatment and to report four operated cases
with successful termination.

There are three types of carcinomata of the jejunum: (1)
the constricting or stenosing type, (2) the flat ulcerating type,
and (3) the polypoid type. Sarcoma may arise from the sub-
mucous, muscular or subserous coats and tends to assume an
external growth, either solid, but more often cystic, with areas
of degeneration. Benign tumors consist chiefly of adenomas,
single or multiple, which are not infrequently responsible for
intussusception. The symptoms are of an indefinite nature,
often consisting of vague gastric distress with weakness, loss
of weight and fatigue. If the growth progresses to stenosis,
there is of course evidence of high intestinal obstruction. Diag-
nosis is difficult and depends upon the amount of obstruction
present. Obstruction in this locality, if marked, may produce
some dilatation of the proximal loop of the duodenum or
jejunum and this dilatation may become an important X-ray
finding. If there is a stenosing growth, it can be recognized
as well here as in any other portion of the bowel. Very few
cases, however, are diagnosed before operation.

If complete obstruction has been present for some time, it is
important to prepare the patient before operation is under-
taken. This can best be done by emptying the stomach with
nasal suction and administering glucose and saline intravenously.
If anemia is pronounced, a blood transfusion should be given.
The operation consists of thorough removal of the growth, to-
gether with proper restoration of function by an end-to-end or
side-to-side anastomosis. This is not especially difficult when
the tumor is located far enough down so that a side-to-side
anastomosis can be done. When it is located at or so near
the ligament of Treitz that this becomes impossible, the restora-
tion of the lumen often becomes a difficult problem, because
the proximal loop is usually very dilated and so edematous that
an end-to-end anastomosis cannot be done. R. Franklin Carter,
in the Annals of Surgery for December, 1935, recommends a
side-to-side anastomosis of the distal end of the jejunum to
the third portion of the duodenum. This appeals to me as
a splendid procedure but it may be difficult in some instances,
particularly where the duodenum is not much dilated.

I wish to present here another method. Recently I encoun-
tered an annular carcinoma of the jejunum, located so near
the ligament of Treitz that only a small stump of the proximal
loop remained when the growth was adequately removed. The
proximal loop was so dilated and hypertrophied that an end-
to-end anastomosis could not be done. I decided to employ
a large, round Murphy button. This was easily inserted and
was reinforced by two layers of catgut in the serosa and
muscularis, thus producing a tight, secure, end-to-end enclosure.
The postoperative convalescence was uneventful. The patient
has no symptoms and shows no evidence of obstruction by
X-ray at present, and has regained his normal weight. I rec-
ommend this method in cases where the tumor is located so near
the ligament of Treitz that a side-to-side anastomosis is im-
possible or when the proximal loop is so dilated and edematous
that an end-to-end union becomes unsafe.

The immediate operative mortality in removing tumors from
the jejunum is high. Hellstrom in 1927 reported a primary
mortality in resected cases of 36.2 per cent. R. Franklin Carter
in 1935 reviewed 30 cases, 24 of which had resections with a
primary mortality of 43.4 per cent. The mortality was highest
in those in which an end-to-end anastomosis was done.

Case 1. On February 27, 1935, I was called in consultation
by Dr. H. W. Quist, to see Mrs. G. H., age 35, who had

been admitted to the hospital February 23rd with a severe
attack of upper abdominal pain which was thought to be gall-
stones. She had had previous attacks. She continued to vomit,
however, and a couple of days later she passed a bloody stool.
On the same day a mass was felt in the left upper abdomen.
A small amount of barium was given and showed a dilatation
of the duodenum and jejunum. An obstruction in the jejunum
was diagnosed and operation was advised. At operation, about
four inches below the ligament of Treitz there was an intus-
susception of gangrenous bowel. A resection was done with
side-to-side anastomosis. On opening the bowel a papillary
growth with a necrotic polyp was located on the bowel wall.
Pathological report showed that this was an adenomatous non-
malignant growth. She was given a blood transfusion and had
an uneventful recovery and has been well to date.

Case 2. Mr. G. F., age 63, gave a negative past history.
His present trouble dates back about one and a half years, dur-
ing which time he had had indefinite symptoms of indigestion
with epigastric distress. He had lost 40 pounds in weight. He
had previously had two X-ray studies of his stomach elsewhere
and a diagnosis of duodenal ulcer had been made. Treatment
had been given without any relief. He was admitted to the
Eitel Hospital on September 13, 1936. X-rays of the gastro-
intestinal tract revealed considerable dilatation of the duo-
denum, which extended to about three inches beyond the liga-
ment of Treitz, at which point an annular constricting growth
was located and Dr. Ude made a diagnosis of carcinoma of
the jejunum with partial obstruction. Operation on September
18, 1936, revealed a large, annular carcinoma of the jejunum
three and one-half inches from the ligament of Treitz. The
growth was almost completely obstructing the bowel. The
proximal loop was much dilated and edematous. The mesen-
teric glands were involved. The growth was widely resected
and an end-to-end anastomosis was made with a large round
Murphy button. His convalescence was uneventful. He has
regained his normal weight and has no symptoms. Pathologic
report by Dr. O’Brien revealed adenocarcinoma of the jejunum
with metastasis of the regional lymph nodes.

Case 3. Mrs. L. B., age 57, had been treated for secondary
anemia for the past 18 months. She had had during the past
vear two attacks of abdominal distension with cramps lasting
for two davs. After the first attack in April, 1936, she felt
a mass in the left lower abdomen. The last attack in Septem-
ber was severe. She consulted her family physician, Dr. Oliver
Porter, who immediately sent her in for examination. There
was a movable mass in the left abdomen which, when the
patient was lying down, could be felt in the upper abdomen
and when the patient was standing could be felt below the
navel. A barium enema was given. There was no evidenec of
any tumor in the colon. Operation October 15, 1936, at which
time a large partly cystic tumor was found in the jejunum
about seven inches below the ligament of Treitz. There were
metastases in the liver around the gallbladder. There were
numerous glands in the mesentery involved. The growth was
widely resected and a side-to-side anastomosis was done. Path-
ological report by Dr. O'Brien showed that the tumor was
a sarcoma, presumablv a neurosarcoma. Postoperative conva-
lescence was uneventful. She has been in fair health and
relieved of her previous symptoms.

Case 4. Mrs. L. B., age 36, admitted to Eitel Hospital on
January 8. 1937. There was a history of attacks since June.
1936, which consisted of dull pain in the region of the navel
with epigastric distress. Attacks had gradually increased in
severity and lasted about three hours. At various times she
vomited. Between attacks she had much epigastric distress and
feared to eat, losing 20 pounds in weight. X-rays of the gall-
bladder showed impaired function with a single stone. Gastro-
intestinal X-ray showed a normal stomach and duodenum. There
was also an irregular distribution of barium in the small bowel
with some areas of dilatation and stasis. X-ray of the colon
was normal. Operation January 22, 1937, revealed a thick-
walled gallbladder, containing a solitary stone. Cholecystectomy
was done. The entire bowel was then carefully examined. At
a point about four feet from the ligament of Treitz there was

468

THE JOURNAL-LANCET

a movable mass in the bowel. The bowel was opened and an
ulcerating adenoma was exposed, which looked malignant. The
growth was resected and a side-to-side anastomosis was done.
Pathologic report by Dr. O’Brien showed no evidence of
malignant changes but revealed a large polyp with ulceration.
Convalescence was uneventful. She has been relieved of all her
previous symptoms and regained her normal weight.

Summary

1. Tumors of the jejunum probably comprise about one
per cent of all those occurring in the gastro intestinal tract.

2. When an unexplained high obstruction is evident and no
cause can be found in the pylorus or duodenum, it should be
remembered that tumors may be present in the jejunum.

3. A simple, safe method of end-to-end anastomosis is here
recommended in cases that are located so near the ligament of
Treitz that the usual operative procedures are either too dan-
gerous or impossible.

Discussion

Dr. A. R. Colvin, St. Paul: I just want to emphasize one

point made by Dr. Johnson and which he has emphasized,

i. e., in case of gastro-intestinal hemorrhage, if, at operation,
the cause which has been suspected is not evident, to make a
thorough search for causes which maybe have not been
suspected.

I recently saw a patient who had an inoperable carcinoma of
the jejunum. He had had several transfusions and finally a
gastro enterostomy, under the belief, evidently, that the hem-
orrhage was due to peptic ulcer. The autopsy revealed a car-
cinoma which had become spontaneously anastomosed with
another coil and was clearly inoperable. The story of bleeding
had extended over several years.

Dr. Arnold Schwyzer, St. Paul: I want to congratulate
Dr. Johnson for this group of interesting cases. These cases
are rare and that he should have had four of them in a short
time is quite an experience. I have seen only one and detected
that one by accident. In the course of a gallstone operation
we noticed a thickening which was rather circular in the lower
duodenum or upper ileum. I resected and the patient recovered
from the operation but gradually lost ground and later died
from carcinoma.

This presentation was very good and the microscopic slides
excellent. I am glad the Murphy button has come into its
own again. I have used the Murphy button every now and
then right along and feel just as Dr. Johnson does, that where
there is difficulty in suturing, the Murphy button will get you
out of some tight places. However, when there is a large
upper gut end and a smaller lower one, there is great danger
of the Murphy button staying there for a long time. For
such a case I have a Murphy button on which the two halves
are a little different in size. The half with the smaller diameter
is put in the upper gut and the larger one into the lower gut.
If I do not feel quite safe as to the union on account of tension,
I make an invagination stretching the lower narrower part of
gut over the button for half an inch or one inch above and
secure it there with a couple of continuous or interrupted
sutures. Then I know the button must go down. I think that
is a worth-while point.

Dr. John Noble, St. Paul: I am rather hesitant to discuss

the question of malignancy of the small intestine because of
my meager first-hand experience. I feel that statistics on the
matter of frequency have perhaps been distorted and I am
perfectly in agreement with Dr. Johnson as far as these fig-
ures are concerned. Yet, in my experience, I have seen only
three cases of malignancy of the small intestine. The first case
was a gelatinous carcinoma of the duodenum; the second case
was a liomyoma-sarcoma of the jejunum and the third case
was mentioned by Dr. Colvin. I think the discrepancy in sta-
tistics may be due to the fact that the case reports of ma-
lignancy of the small intestine are more likely to be published
than are reports of carcinoma of the stomach, for instance.
In the first case mentioned, the patient’s condition warranted
no surgical interference. The second case presented a picture
of low-grade chronic partial intestinal obstruction. Efforts were

made to localize the point of obstruction but these were un-
successful and the patient died before any surgical exploration
could be done. This tumor proved to be a liomyoma-sarcoma
situated in the jejunum. I know this type of tumor is usually
benign and that it is the most common tumor found in the
stomach. It also occurs in the small intestine, however, and in
this instance the lesion was malignant. Here there was defi-
nite evidence of local invasion but no distant metastases were
found. The third case was the one Dr. Colvin mentioned.
The picture was that of a high intestinal obstruction and the
patient had had previous gastric surgery. The tumor at
autopsy was found to be adenocarcinoma of the jejunum, in
which, due to adhesions and infiltration of the several loops
of the small intestine, anastomoses had occurred. The lesion
was grossly mistaken for an inflammatory mass and not until
microscopic sections were studied was it discovered that the
lesion was adenocarcinoma. In none of the three cases was
clinical diagnosis made. These are the only three cases I have
seen first-hand. Recently I have been impressed with the
newer methods in the X-ray diagnosis of tumors of the small
intestine and I feel that as this technic is developed we will
be able to diagnose these lesions more frequently and that our
accuracy will be somewhat comparable to the diagnosis of the
lesions in the stomach and colon.

Dr. R. G. Allison, Minneapolis: X-ray diagnosis of tumors
of the small intestine can readily be made, with even a mild
degree of obstruction, by a barium meal. In cases which pre-
sent themselves with symptoms of obstruction, a flat film of
the abdomen should always be made as a preliminary measure.
If dilated loops of small bowel are found, barium should not
be administered. If, however, no dilated loops are found, it
is perfectly safe to administer a barium and water mixture.

Dr. Johnson, in closing: I want to thank the gentlemen
for their interesting discussions. I would like to see the button
Dr. Schwyzer has been using. I have used the Murphy button
for many years and have never seen one that failed to pass.
If such cases have been reported, it is quite probable that the
button has been defective or inserted wrong; the male portion
of the button should always be inserted in the proximal loop.
During the four years I was with Dr. Murphy, I never saw
him use anything but a button for gastro-enterostomy except in
a case of a small child. They all passed without any difficulty.
The button usually comes loose in about ten days and then
passes so silently that the stool has to be watched carefully to
recover it. The button used in this case was so large that it
became lodged in the rectal pouch. I have never before had
to remove one.

Tumors of the jejunum of course are a rare condition, but
I want to leave with you two thoughts concerning them. First,
if a case is being operated for a lesion in the pylorus or
duodenum, especially of an obstructing type, and none is found,
it would be well to remember that it might be in the jejunum
and, accordingly, do not forget to explore it. Second, if one
is confronted with a difficult anastomosis in the small bowel,
such as occurs at or very near the ligament of Treitz, it is well
to remember that a Murphy button can often be used to
advantage.

ADAMANTINOMA WITH CYST OF LOWER JAW

Dr. A. R. Colvin

ST. PAUL

An enumeration of the various names given to adamantinoma
is an indication of the direction in which a knowledge of these
tumors has developed, i. e.\

1. Epithelioma adamantinoma.

2. Central epithelioma.

3. Cystoma.

4. Multilocular cystoma.

5. Proliferating cysts of the jaw.

6. Embryo-plastic adantome.

7. Central paradental cyst.

8. Central cystadenoma.

9. Central papilloma of the jaw.

10. Adamantine adenoma.

THE JOURNAL-LANCET

469

At the present time they are designated "Solid Adamanti-
noma” and "Cystic Adamantinoma.” In the early stages of
their development they may be confused with root cysts or
follicular cysts; in other words, they may present as small
cysts.

These cysts have frequently been operated on under the
belief that they were root cysts. This was my experience in
the case I am reporting, except that I operated on a cyst twice
before recognizing the real nature of the trouble. Because of
the, at times uncertain, nature of the behavior of these tumors,
I am reporting a case demonstrating the long-drawn-out his-
tory and apparently benign course. They are almost always
found in the lower jaw and have their origin from the germ
cells of the enamel epithelium or from the epithelial remnants
of this structure. They grow slowly and distend the jaw more
than they destroy it. They may involve the entire half of the
jaw, and, while usually possessing all the characteristics of a
benign tumor, they must often be treated as malignant because
of the continuous growth of tumor cells remaining after in-
complete removal. Heath reported a case recurring after 35
years, and one case has been reported as recurring after 45
years. They may appear at any time of life. Perthes says they
never metastasize. Ludek reports a case with undoubted
metastases in the lung. Adamantinoma may vary greatly in
size, at times growing as large as a child’s head.

Histologically, there is seen a large amount of connective
tissue stroma in which are found epithelial cords and islands
resembling the structures found in the germ cells of the enamel
of the tooth follicle. This arrangement is found in the walls of
the cysts as well as in the solid tumors.

Differential diagnosis is uncertain not only in the early stages
of root cysts and follicular cysts, but also in later stages. The
central fibroma presents difficulties not only clinically but also
radiographically. The X-ray is important not only for diag-
nosis but to establish as accurate a plan of operative procedure
as possible, so that, because of the great tendency to recur-
rence, it can be determined whether it may not be possible
to operate radically and still leave a sufficient ridge of the lower
border to maintain the form and support of the jaw. Recur-
rences may, however, be a long time delayed (45 years) and
so it may be advisable to remove all suspicious tissue before
resorting to exarticulation, and observe the case frequently for
recurrences, hoping that they may be long delayed.

I wish to report the following case of adamantinoma:

The patient, a female age 42, was first seen in 1921 with a
history of a painless lump in her lower jaw. Believing this to
be either a root or follicular cyst, it was operated by removing
the outer wall and curetting out the lining membrane. For a
recurrence in 1923 the same procedure was carried out. In
1926, at operation for another recurrence in which the cyst was
clinically about the size of an almond nut, on removing the
outer wall there were now found several smaller cysts. These
were opened in such a manner than an open cavity was made.
This healed over, but recurrence took place about one year
later (January 12, 1928). At this time an incision was made
in the submaxillary region and the cyst exposed extra-orally.
The outer wall was removed, revealing a multilocular cyst.
Cavities extending from the lower end of the ascending ramus
forward to the lateral incisor were found, and these cyst walls
were removed with burr and curette.

In November, 1929, another recurrence was evident and
again the bone was approached in the same manner; the lateral
incisor, canine and bicuspids were removed, and, with rongeur
forceps and burr, the bone was removed leaving only a ridge
of the lower margin of the jaw about half an inch thick.

It is now seven years since this was done and there is no
evidence of recurrence at this time.

Osteitis fibrosa, and bone granuloma or osteodystrophia
fibrosa beginning in the central part of the jaw, or doubtful origin,
and consisting of at first loose and later much firmer fibrous
tissue, presents difficulties in diagnosis also; and histological
examination must in all of these conditions furnish the deciding
evidence in the differentiation from adamantinoma and, indeed,
from all tumors of the jaw. In this connection, to illustrate

the difficulties of diagnosis and the necessity for making use of
every form of information to be gained from clinical, radio-
graphic, histological and the findings of gross pathology as

exposed as operation, I would like to refer to the following
case:

The patient, a female age 18, first noticed a swelling of the
gums over the upper jaw two years ago. This increased grad-
ually for over a year. Two months ago she was hit over the
left side of the face by a horse suddenly jerking its head in
her direction. She says the swelling increased more rapidly

since then. She had not at any time suffered any pain. There
was marked fullness of the cheek on the left side; just above
the lateral incisor was a firm elastic mass about the size of a

walnut. There was a fullness of the left side of the hard

palate.

At operation an incision was made over the prominent mass.
After reflecting the mucous membrane, the mass was exposed
and found to have destroyed the outer wall of the antrum.
The tissue comprising the mass was of a very tough fibrous
consistency and filled the entire antrum, so that, in removing
it, it was found that the walls of the antrum in various places
were destroyed; and on attempting to remove all of the tissue
comprising the mass, one felt that this tissue became part of
the wall very much like the insertion of the larger tendons.
It soon became apparent that if the tissue was malignant (which
it did not seem to be) , and, having perforated the walls of
the antrum in various places so that its complete removal was
impossible, radical resection of the upper jaw would still fail
to remove all diseased tissue; and if it were not malignant
further damage to the adjacent structures (the contents of the
orbit, for instance) was inadvisable. Recovery from the op-
erative attack was uneventful and she was given X-ray treat-
ment. When seen a few weeks ago there were no clinical evi-
dences of recurrence. A radiograph still shows a dense shadow
in the antral region.

Pathological Report by Dr. John Noble: The specimen con-
sists of a large mass of small, irregular fragments of tissue of
varying size all of which have about the same gross appearance
and structure. There appears to be an outer, quite friable,
papillary surface and central portion which is quite fibrous and
tough in consistency. It cuts with increased resistance. All of
the tissues present the same gross appearance.

Microscopic : Sections of the tumor of the antrum and

maxilla show it to be composed of masses of dense hyaline
connective tissue showing large amounts of collagen fibril. The
bulk of the tumor is composed of this tissue but there are
some small areas of connective tissue which are somewhat more
cellular. Throughout the stroma small spicules of bone and
osteoid tissue are scattered at irregular intervals. There is no
evidence of epithelial tissue and no evidence of malignancy is
seen. From the gross picture and from previous experience with
similar lesions in other bones, a very guarded prognosis should
be given, however. The histologic picture is that of an osteitis
fibrosa of the solid type.

Diagnosis: Osteitis fibrosa.

The conditions described above conform more nearly to the
condition defined as "bone granuloma” and, while isolated
cases have been reported, it is still unsettled as to whether it is
of inflammatory or neoplastic nature. Perthes comments on the
fact that it has not previously been described in systematic
treatises of the jaw and that in the former edition of his own
work it was not referred to; but now, in his newest work, he
is evidently endeavoring to arrange some of these conditions
under the heading of "Granuloma” or "Osteodystrophia Fi-
brosa.” With all of these facts in mind, one would scarcely
have been justified in doing more than was done in this case.

Discussion

Dr. John Noble, St. Paul: These two cases reported by
Dr. Colvin have been interesting to me, particularly the second
one. In the first case I studied only the sections and, as
shown on the lantern slides, the tumor was adamantinoma.
These tumors arise from the peridental epithelium and they
take on various forms. The tumor can present a picture simi-
lar to the one shown forming numerous cysts, or it can be a

470

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solid adenocarcinoma. Squamous cell tumors are also seen
and one form is indistinguishable from a sarcoma, being com-
posed of spindle cells. These tumors are characteristically
slow growing and the difficulty from the standpoint of surgical
treatment is the matter of complete removal. They frequently
recur but seldom metastasize. Distant metastases have, howev-
er, been reported in lung and cervical lymph nodes. The sec-
ond case I saw clinically with Dr. Colvin. She was a young
girl and the tumor from an X-ray standpoint was malignant.
As far as could be determined, the tumor arose from the
antrum or the maxilla. It invaded the walls of the antrum
and the orbit. We came to the conclusion, after microscopic
study of the tumor, that it was an osteitis fibrosa of the solid
type. In long bones we know that this lesion occurs in two
forms the cystic and the solid type. This lesion resembled
more closely the solid type but had none of the giant cells
so frequently seen. We know that osteitis fibrosa may take
one of three courses. It has been known to subside without
any therapy. It can be eradicated by curetting the cysts. The
lesion is closely related to giant cell tumors of the bone and
malignant changes have been reported following this type of
lesion. The thing that interested me particularly in this case
was the matter of the fundamental etiology of the disease.
Did it represent a true neoplasm or was the lesion simply a
proliferative inflammation? We know that chronic inflam-
matory processes in the antrum are extremely frequent. This
type of reaction to inflammation must be very rare. The fact
that bone destruction occurred need not be evidence against
the inflammatory nature of the lesion. We know that certain
proliferative inflammatory processes of the bone can be de-
structive. It will be interesting to follow the eventual outcome
in this instance.

Dr. R. G. Allison, Minneapolis: The case Dr. Colvin ex-

hibits, with involvement of the antrum, gives the characteristic
X-ray appearance of a malignant lesion. I think it extremely
rare to see chronic involvement of the antrum progress either
to destruction of bone or to a wide-spread osteomyelitis. These
tumors are much more common in the lower jaw.

Dr. Kenneth Bulkley, Minneapolis: In connection with

this case of Dr. Colvin’s, I would like to report a case of
adamantinoma of the lower jaw which went on eventually to
death. The man was a first cousin of Dr. Janeway and a
brother-in-law of mine. Shortly after graduation from medical
school he developed a mass in the lower jaw. ITe was operated
three times, each time with recurrence, and perhaps two or
three years between each recurrence. Finally he went to Balti-
more and saw Dr. Bloodgood who did a resection of the lower
jaw. The laboratory diagnosis was made in this case by Dr.
Ewing. This man lived to be about 54. He eventually de-
veloped local extension into the nasopharynx and a trifacial
neuralgia for the relief of which Dr. Harvey Cushing operated
on the gasserian ganglion. The process finally extended through
the base of the skull with secondary infection and meningitis.
This was a typical case of adamantinoma which continued
over a period of 25 years after the first local incision in the
lower jaw.

The meeting adjourned.

A. G. Schulze, M.D.,

Secretary.

Hews Items

Dr. Warren Fetterly, Minneapolis surgeon, has asso-
ciated with the Malmstrom-Sarff Clinic in the First
National Bank Building in Virginia, Minnesota.

Dr. Peter Douglas Ward, superintendent of Miller
Hospital in St. Paul, Minnesota, has been named a
member of the board of directors of the American
Hospital Association.

Dr. Ray Kenneth Proeschel, of Kimball, Minnesota,
has located at Willmar, Minnesota.

Dr. William E. Morse, Rapid City, South Dakota,
spoke on "Syphilis” before the Rapid City Lions Club
on August 31, 1937.

Dr. J. Emery Frank, Springfield, Minnesota, has sold
his practice to Dr. Engward Lewis Penk, of Stewart, and
will move to Marshall, Minnesota.

Dr. Nils Orville Agneberg, a graduate of the North-
wesrern University Medical School, is a member of the
staff of the North Dakota State School at Grafton.

Dr. Hubert Waldemar Lee, formerly of Northfield,
Minnesota, has located with Dr. Nesmith Perry Nelson,
Brainerd, Minnesota.

Dr. Joseph Ewing Cowperthwaite, 65, of Butte, Mon-
tana, died September 15, 1937. He was graduated from
the Chicago Homeopathic Medical College in 1896.

Dr. Amos R. Gilsdorf, a graduate of the University
of Minnesota Medical School, is now an associate fellow
of the Dickinson Clinic, Dickinson, North Dakota.

Dr. Zachariah Eugene House, for 30 years in the
U. S. Indian Service, and at present serving the Cass
Lake (Minnesota) district, will retire.

Dr. Roscoe C. Hunt, of Fairmont, Minnesota, will
build a two-story air-conditioned hospital with capacity
of fifteen beds on the site of Fairmont’s old hospital.

Dr. Edwin John French will be on the staff of the
Ronan Hospital in Ronan, Montana. The hospital is
now managed by Mrs. Margaret Ross, R.N.

Dr. William J. Mayo, of Rochester, Minnesota, has
been named a trustee of the Mount Rushmore National
Memorial Society, according to press dispatches.

A $7,864 addition to Hospital Building No. 12 at the
Veterans’ Facility at Hot Springs, South Dakota, will
be erected as soon as bids have been accepted.

The Minnesota State Board of Health will have a
new $225,000 brick and tile building on the University
of Minnesota campus, according to news dispatches.

Dr. Elmer W. Wahlberg, Isle, Minnesota, has moved
to Morgan, Minnesota, to assume partnership with Dr.
William E. Johnson, of that town.

Dr. Otmar Thurlimann, 37, of Harvey, Illinois (Chi-
cago), died in Duluth, Minnesota, on September 14,
1937.

Dr. Arthur Neumaier, a graduate of Duke University
School of Medicine (Durham, North Carolina) in 1935,
has joined the staff of Raiters Hospital in Cloquet,
Minnesota.

Dr. Joseph Anthony Muggly, Norway, Iowa, a grad-
uate of the Creighton University School of Medicine
in 1934, has associated with Dr. Daniel S. Baughman,
at Madison, South Dakota.

Major William S. Bentley, M.D., formerly resident
physician of the old Asbury Hospital in Minneapolis
when it was used as a veterans’ hospital, died in Sioux
Falls, South Dakota, during August. He was grad-
uated from the Hahnemann Medical College & Hos-
pital, Chicago, in 1893.

THE JOURNAL-LANCET

471

Dr. Gilbert Seashore, coroner of Hennepin County,
Minnesota, was named a member of the board of di-
rectors of the National Association of Coroners at the
recent meeting in Cleveland, Ohio.

Dr. Robert Bray, a graduate of the University of
Minnesota Medical School, came from Fargo, North
Dakota, on September 2, to begin as a staff member
of Biwabik Hospital, Biwabik, Minnesota.

Dr. Donald Leo Gillespie, a graduate of the Uni-
versity of Minnesota Medical School in 1934, has joined
the pediatrics staff of Murray Hospital in Butte, Mon-
tana.

More than 1,100 cases were treated at the University
of South Dakota Students’ Health Service during the
1936-1937 school year, reports Dr. Hugo C. Andre,
director.

Dr. Ralph Phillip Jones, 46, a graduate of the Hahne-
mann Medical College & Hospital of Chicago in 1915,
died at Veterans’ Facility, St. Cloud, Minnesota, on
August 22, 1937. He was buried at Azalea, Michigan.

Dr. Peter T. Spurck, chief of the X-ray department
of St. James’s Hospital in Butte, Montana, was a vis-
itor to the Fifth International Congress of Radiology
held recently in Chicago.

The $40,000 hospital scheduled to be erected in Wolf
Point, Montana, will not be built until 1938, because of
crop failure. It was to have been operated by the Trin-
ity Hospital Association, Inc.

Dr. Herman H. Jensen, of Atwater, Minnesota, has
moved his family to Minneapolis, where he will do post-
graduate work at the University of Minnesota. He will
retain his Atwater practice, however.

Dr. Charles Nutzman, a graduate of the University
of Nebraska College of Medicine, will be a member
of the Health Service of the University of Montana
for the coming school year, according to dispatches.

Dr. Andrew John Heimark, 57, of Fargo, North
Dakota, died in a Fargo hospital on September 17, 1937.
He was graduated from the University of Illinois Col-
lege of Medicine in 1904.

Dr. Milton Charles Rosekrans, Neillsville, Wisconsin,
a graduate of the University of Minnesota Medical
School in 1929, has located in Wahpeton, No. Dak.,
to assume the practice of the late Dr. Benjamin Thane.

Dr. John Edward Mannion, formerly of Platte and
Wagner, South Dakota, and a graduate of Creighton
University School of Medicine in 1920, has located at
Gregory, South Dakota.

The Silver Bow County Hospital in Montana is buy-
ing a new portable X-ray unit and other X-ray equip-
ment, according to Mr. Emmett P. O’Brien, chairman
of the board of commissioners of Silver Bow County.

Dr. Wilbert W. Yaeger, Ivanhoe, Minnesota, a grad-
uate of the University of Minnesota Medical School in
1927, has moved to Marshall, where he succeeds Dr.
Lawrence John Happe.

Dr. Cecil A. Wilmot, a graduate of the University
of Minnesota Medical School, has joined his brother,
Dr. Harold Eugene Wilmot, Litchfield, Minnesota, in
the practice of medicine.

A Federal grant of $25,364 has been received by Dr.
George Sheldon Adams, superintendent of the Yankton
State Hospital of South Dakota, for the construction of
a new watering system.

Dr. Agnes Dunnigan Gray Stucke, Garrison, North
Dakota, has been named a member of the Public
Health Advisory Council of the state for a 6-year term,
by Governor William Langer.

Dr. Warren Wilson, Sr., of Northfield, Minnesota,
died on September 4 at his home. He was graduated
from Northwestern University School of Medicine in
1889.

Dr. Moses Barron, professor of medicine in the Uni-
versity of Minnesota Medical School, spoke before the
Blue Earth County Medical Society on September 13,
1937.

Dr. Myron O. Henry, Minneapolis, spoke on "The
Surgical Treatment of Fractures of the Hip” and
"Spinal Fusion: The Chip Graft Method,” before the
British Columbia Medical Association at Vancouver on
September 14 and 15, 1937.

Dr. Frank L. Bryant, instructor in otolaryngology in
the University of Minnesota Medical School, spoke on
"The Fever Therapy Treatment of Acute Sinusitis”
at the annual meeting of the American Congress of
Physical Therapy in Cincinnati, Ohio.

Dr. William George Durnin, a graduate of the Uni-
versity of Colorado School of Medicine in 1932, and
formerly of the department of orthopedics in Los An-
geles County Hospital, California, has located in Bot-
tineau, North Dakota.

Dr. James Moorhead Murdoch, for 10 years superin-
tendent of the Minnesota School & Colony for the
Feebleminded at Faribault, was presented with a gold
watch by the Minnesota State Board of Control and
other medical superintendents recently. He has retired.

Dr. Robert Warren Diver, a graduate of the Uni-
versity of Kansas School of Medicine in 1924, left Clay
Center, Kansas, recently to establish ophthalmological
and otorhinolaryngologic practice in Livingston, Mon-
tana.

Dr. Edmund S. Donohue, formerly of the Marine
Hospital in Baltimore, Maryland, and a graduate of
the Creighton University School of Medicine in 1933,
has purchased the practice of the late Dr. A. L. Jones,
Gregory, South Dakota.

The Grand Forks District Medical Society met at
Grafton, North Dakota, on September 15. Dr. Oliver
Sayles Waugh, associate professor of clinical surgery on
the University of Manitoba Faculty of Medicine at
Winnipeg, spoke on "Head Injuries.” About 25 physi-
cians attended.

Dr. Peter Potter, of Butte, Montana, was honored by
a banquet in his honor given by the Silver Bow County
Medical Society on September 23, 1937, on the occa-
sion of his retirement. Dr. Potter came to Butte on
October 1, 1907. He has been president of the Murray
Hospital in Butte for many years; and has been presi-
dent of the Butte Chamber of Commerce since 1929.
He retires on November 1.

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Dr. John Earl Schroeppel, New Ulm, Minnesota, has
purchased the practice of Dr. W. B. Kaufman, of Win-
throp, and will practice there. Dr. Kaufman will go to
the Baltimore Eye & Ear Hospital for training before
re-locating at New Ulm.

Dr. Thomas B. Magath, Rochester, Minnesota, pro-
fessor of parasitology in the University of Minnesota
Graduate School of Medicine, has been elected presi-
dent of the American Society of Clinical Pathology. He
is city health officer of Rochester.

Dr. Gaylord W. Anderson, chief of the department
of preventive medicine and public health at the Univer-
sity of Minnesota, assumed his duties on September 8,
1937. He succeeded Dr. Kenneth Maxcy, who went
to Johns Hopkins University.

Dr. Carl Sandstrom, chief of the radiological depart-
ment of Saint Eric’s Hospital in Stockholm, Sweden,
visited the Quain-Ramstad Clinic in Bismarck, North
Dakota, on September 24, 1937. He also made a tour
of the North Dakota bad lands.

On September 27, 1937, the Woman’s Club of Crystal
Bay, Lake Minnetonka (Minnesota), unveiled a plaque
in the Orono Town Hall at the lake in honor of Dr.
William Newhall, who practiced medicine at Crystal
Bay for 33 years. Dr. Newhall died nine years ago.

Students in the University of South Dakota School
of Medicine at Vermillion ranked highest in scholar-
ship of any group in the university during 1936-1937,
according to Mr. H. W. Frankenfeld, registrar. The
general average was 85.12.

Dr. Roger L. J. Kennedy, assistant professor of
pediatrics in the University of Minnesota Graduate
School of Medicine, Rochester, was elected president of
the Northwestern Pediatric Society at Duluth, Minne-
sota. He was formerly secretary-treasurer of the group.

Dr. Milo Raymond Snodgrass, Miles City, Montana,
described his observations and study at the University
of Michigan Hospital while he was there last summer,
before the Miles City Kiwanis Club on August 30, 1937.
Dr. Snodgrass was graduated from the University of
Michigan in 1928.

Bids will be accepted on October 12 for construction
of the new $130,000 hospital to be built by Lewis &
Clark County in Montana, according to Mr. Thomas
J. Cooney, chairman of the county commissioners. The
PWA has allotted $60,144.00 toward this project. It
will be T-shaped, three stories.

Dr. William Francis Cashmore, Jr., who was grad-
uated from Rush Medical College of the University of
Chicago in 1933, and took his internship at St. Luke’s
Hospital in Chicago, became a member of the staff of
the Thompson-Klein Clinic in Helena, Montana, on
September 1.

Dr. Walter J. Marcley, for 10 years chief of the
tuberculosis service of the Veterans’ Administration Fa-
cility at Fort Snelling, Minnesota, was guest of honor
at a dinner held for him at the Curtis Hotel in Minne-
apolis on September 28, 1937. He was a founder of the
National Tuberculosis Association, and a president of
the Minnesota Public Health Association.

Dr. Marcus Claude Terry, a graduate of the Keokuk
Medical College in Iowa in 1897, has been transferred
from Palo Alto, California, to the Veterans Adminis-
tration Facility at Saint Cloud, Minnesota.

Dr. Frances Ralston Vanzant, of Houston, Texas,
who was an instructor in medicine in the University of
Minnesota Medical School in 1934, and assistant director
of the University Hospital, has gone to Spain as a
physician sent there by the Medical Bureau to Aid
Spanish Democracy.

Although South Dakota has no respirator for the
treatment of poliomyelitis, the 40 et 8 group of the
American Legion proposes to purchase one, according
to Harry Darling, D.D.S., of Aberdeen, grand chef de
gare of the organization. It will cost about $2,000.00,
and will be kept at either Huron or Mitchell.

Dr. Herbert H. James, chief of the surgical depart-
ment of Murray Hospital in Butte, Montana, has been
made a member of the American Radium Society. One
of his articles, "Treatment of Uterine Hemorrhage of
Benign Origin With Radium,” was published in the
January 1936 issue of The Journal-Lancet.

More than one year ago. Dr. Marion Mercer Hursh,
of Grand Rapids, Minnesota, published an advertisement
saying that he was writing off a large number of ac-
counts. During September a man from Arkansas who
had owed him a bill for 24 years walked in to pay it.
The man had read Dr. Hursh’s advertisement.

Dr. Harry Eagle, Baltimore, Maryland, whose new
book, The Laboratory Diagnosis of Syphilis, was re-
viewed in the September issue of The Journal-Lancet,
spoke before the Interurban Academy of Medicine in
Duluth, Minnesota, on September 15. Dr. L. F. Hawk-
inson, Brainerd, was another speaker.

Dr. Milo M. Loucks, a graduate of the University
of Minnesota Medical School in 1930, who spent some
time at Fort Crook, Nebraska, as assistant district sur-
geon for the Army as a reserve officer, has entered prac-
tice with Dr. Alfred G. Chadbourn, at Heron Lake,
Minnesota.

Dr. Frank H. Krusen, associate professor of physical
medicine in the University of Minnesota Graduate
School of Medicine, Rochester, was elected president of
the American Congress of Physical Therapy at Cincin-
nati, Ohio, on September 24; and Dr. M. E. Knapp,
Minneapolis, was elected a vice-president.

Dr. E. A. Meyerding, St. Paul, Minnesota, secretary
of the Minnesota State Medical Association, and for
thirteen years executive secretary of the Minnesota Pub-
lic Health Association, was elected president of the Mis-
sissippi Valley Conference on Tuberculosis at a meeting
in Dayton, Ohio, on September 25, 1937.

Dr. Wallace Lynnville Matlock, formerly of Huron
and Rapid City, South Dakota, has established offices
at 653 Main Street in Deadwood. Dr. Matlock was
graduated from the medical department of the National
University of Arts & Sciences, St. Louis, in 1918. He
served in the World War as an army physician, and
returned to the army in 1933. He returned to private
practice on September 1, 1937.

THE JOURNAL-LANCET

473

Woodrow Nelson, B.S., M.D., who was graduated
from the University of Minnesota Medical School, has
completed a two-year internship at the Gallinger Mu-
nicipal Hospital in Washington, D. C., and will associate
himself with Dr. John Leo Devine, of Minot, North
Dakota.

Dr. Edward J. Engberg, of St. Paul, Minnesota, who
specializes in neurology and psychiatry, and who is a
member of the Minnesota State Board of Health, has
been appointed superintendent of the School for Feeble-
Minded at Faribault, Minnesota, by the State Board
of Control.

Dr. Irwin Henry Schmidt, 46, of Faulkton, South
Dakota, died at his home and was buried on September
5 in the Faulkton cemetery. He was graduated from
the St. Louis University School of Medicine in St. Louis
in 1916, and was health officer for Faulk County.

Dr. George Goble Sale, a graduate of the Cornell
University School of Medicine, New York City, in
1935, and recently of the George F. Geisinger Memorial
Hospital in Danville, Pennsylvania, has been appointed
assistant to Dr. Meredith B. Hesdorfer, chief of the
students’ health service of the Montana State Univer-
sity at Missoula.

A new hospital whose cost is estimated at from $5,000
to $7,500 will be constructed at Shelby, Montana, by
remodeling the old East Side grade school in that city.
The new hospital will be 44 feet by 58 feet, and will
contain four private wards, three 3-bed wards, a kitchen,
surgery, nursery, reception room, dark room, X-ray
room, etc. It will be owned by Toole County.

Brigadier-General Frank T. Hines, chief of the Vet-
erans’ Bureau in Washington, D. C., reports that 6
cancer clinics will be established to treat 400,000 Amer-
ican veterans expected to develop the disease. They will
be at Hines, Illinois; Washington, D. C.; Portland,
Oregon; Los Angeles, California; New York City
(Bronx); and Atlanta, Georgia.

Dr. Carl John Potthoff, Sherburn, Minnesota, has
accepted the post of assistant professor of biological
studies in General College of the University of Minne-
sota. Dr. Potthoff was graduated from Johns Hopkins
University School of Medicine, and went to Sherburn
to take over the practice of Dr. Walter Bret Wells, who
had gone to Jackson.

The first west coast meeting of the American Acad-
emy of Orthopedic Surgeons will be held January 16 to
20, 1938, at the Hotel Biltmore, Los Angeles. Special
trains will be run with stop-overs at Santa Fe, the Grand
Canyon, San Francisco, and other points. Physicians may
write to Mr. Robert L. Lewin at the Hotel Biltmore in
Los Angeles for further details.

The Wabasha County Medical Society of Minnesota
will hold its 69th annual meeting at Kellogg, Minnesota,
on October 7, under the presidency of Dr. B. A. Flesche,
Lake City. Drs. E. G. Bannick and J. F. Weir, Roches-
ter, will speak. Others are: Dr. R. H. Frost, Wabasha;
and Dr. George E. Hudson, assistant professor of
obstetrics and gynecology in the University of
Minnesota.

A three-months’ report was submitted to the Butte
(Montana) Anti-Tuberculosis Society on September 21
by Dr. Joseph Lorin Mondloch. Dr. Alfred Karsted is
vice-president of the society’s board.

Dr. Byrl R. Kirklin, of the Mayo Clinic, Rochester,
was elected president of the American Roentgen Ray
Society in Chicago on September 16; and Dr. Charles
Sutherland, also of Rochester, was elected librarian of
the Radiological Society of North America.

Dr. Magnus Bjornson Halldorson, of Winnipeg,
Manitoba, Canada, a graduate of the University of
Manitoba Faculty of Medicine in 1898, has taken over
the practice of Dr. George Richard Waldren, of Pem-
bina, North Dakota. Dr. Halldorson is a member of
the North Dakota State Medical Association.

Dr. Arthur David Haverstock, 53, who was born in
Minneapolis and was graduated from the Minneapolis
College of Physicians & Surgeons in 1909, died in Mon-
rovia, California, on September 9, 1937. He had prac-
ticed at Seward, Alaska, and in 1935 was president of
the Alaska Territorial Medical Association.

Dr. Byrl R. Kirklin, professor of radiology in the
University of Minnesota Graduate School of Medicine
at Rochester, and Dr. Harry M. Weber, instructor in
radiology, won the first award for their exhibit at the
International Congress of Radiologists at Chicago on
September 17, 1937.

Dr. G. Alfred Dodds, superintendent of the North
Dakota State Tuberculosis Sanatorium at San Haven,
announces that beds are now available at the sanatorium
for both male and female tuberculosis patients. Any
North Dakota physician may now secure immediate
sanatorium care for his patients. Application forms may
be secured by writing to Dr. Dodds at the sanatorium.

Dr. Howard William Karl Zellhoefer, a graduate of
the Harvard Medical School in 1931, former fellow
at the Mayo Clinic, and ship surgeon on the Grace Line’s
Santa Paula, has established practice (surgery) at Sioux
Falls, South Dakota, in the Medical & Surgical Building.

The customary Saturday morning broadcasts (9:45
A. M., WCCO, 810 kilocycles, 370.2 meters) of the
Minnesota State Medical Association, with Dr. William
A. O’Brien, professor of pathology and preventive medi-
cine in the University of Minnesota, as speaker, will pre-
sent these subjects: October 2, "Heart Disease”; Octo-
ber 9, "Hand Infections”; October 16, "Dietary Dan-
gers”; October 23, "Hemorrhage”; October 30, "Dental
Health Education.”

The Eastern Montana Medical Association and the
Northeastern Montana Medical Association met jointly
at Sidney, Montana, on September 23. Dr. J. H. Gar-
berson, of Miles City, spoke on "The Diagnosis and
Treatment of Head Injuries”; and there was a motion
picture film lent by Dr. Jesse G. M. Bullowa, clinical
professor of medicine in the New York University
College of Medicine, New York City. A committee
was appointed to investigate the formation of a women’s
medical auxiliary. The next meeting of the Eastern
Montana Medical Association will be held in January
1938 at Terry, Montana.

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THE JOURNAL-LANCET

Dr. and Mrs. Roy F. Raiter, Cloquet, Minnesota,
sailed on the steamship Aquitania on August 18 for
Europe, where Dr. Raiter will spend two months at
various surgical clinics.

Health officers of every political district of Minnesota
met at the University of Minnesota on September 24 for
the annual Minnesota Sanitary Conference. Dr. Royd
R. Sayers and Dr. George W. McCoy, of the United
States Public Health Service, Washington, D. C., were
among the speakers. Dr. John A. Ferrell, associate
director of the international health division of the
Rockefeller Foundation, New York City, was also a
speaker.

Applications for the post of associate medical officer
for the U. S. Government (various branches) at $3,200
a year must be filed with the United States Civil Service
Commission at Washington, D. C., by October 18, 1937;
or in the case of physicians living in Montana, by Oc-
tober 21, 1937. Applicants must be citizens, have a
Class A medical diploma granted not more than 7 years
prior to May 1, 1937, must have had one year of in-
ternship, must not be 35 when application is tendered,
and must be in good health.

Dr. Frank J. Heck, chairman of the Committee on
Medical Education & Research of the Mayo Clinic,
Rochester, Minnesota, announces that a special program
of lectures and demonstrations in surgery and medicine
will be held at the Mayo Clinic from November 8 to 12,
inclusive. Mornings will be devoted to surgical and med-
ical clinics. Afternoons and evenings will be given to
clinics, pathological conferences, symposia, etc., on gas-
troenterology, sulfanilamide therapy, hematology, neurol-
ogy, allergy, diseases of the chest, and cardio-vascular
diseases. Visiting physicians are urged to attend.

On August 30, 1937, Dr. J. Arthur Myers, Minne-
apolis, professor of medicine in the University of Minne-
sota Medical School, spoke before the Idaho Tubercu-
losis Association at Boise; on September 15, before the
96th anniversary meeting of the Wisconsin State Med-
ical Society at Milwaukee; on September 22, before the
joint meeting of the Medical Society of the County of
Queens and the Queensboro Tuberculosis and Health
Association at Brooklyn, New York; and on September
25, before the health education session of the Missis-
sippi Valley Conference on Tuberculosis at Dayton,
Ohio. On September 30, Dr. Myers addressed the
Southern Tuberculosis Conference and the Southern
Sanatorium Association at Richmond, Virginia.

Dr. John Francis Norman, of the Crookston Clinic,
Crookston, Minnesota, was elected president of the
Northern Minnesota Medical Association at the close
of the 17th annual session at Hibbing, Minnesota, on
August 27 and 28, 1937. Dr. Owen W. Parker, Ely,
was elected vice-president; and Dr. Clarence Jacobson,
Chisholm, was chosen secretary-treasurer. Professor J.
A. Merrill, formerly president of the Superior State
Teachers College, spoke on "The Wonderland of Lake
Superior”; and Dr. R. G. Leland, of the Bureau of
Economics, American Medical Association, Chicago,
spoke on "The Business Side of Medicine.” Dr. A. W.

Adson, president of the Minnesota State Medical Asso-
ciation, and professor of neurosurgery in the University
of Minnesota Graduate School of Medicine, also spoke.
Dr. Oscar O. Larsen, Detroit Lakes, the retiring presi-
dent, asked physicians to participate in the national cru-
sade against venereal diseases.

The Center for Continuation Study of the University
of Minnesota announces the program of medical sem-
inars for 1937-1938. The faculty will be selected from
the medical school, graduate school, Mayo Foundation,
and general extension division, and will also include
distinguished teachers from other medical centers. Lec-
tures will be given in the classrooms of the Center, and
clinics and demonstrations in the medical school, Uni-
versity of Minnesota Hospitals, and affiliated institutions.

Each seminar will occupy the full time of the grad-
uates from Monday to Saturday, inclusive. There will
be no evening classes. Special library facilities for each
seminar will be provided at the center. If the interest
warrants, lecture, clinic and demonstration mimeo-
graphed outlines will be sold for a nominal fee after
each week’s program. A special feature will be round
table conferences at the close of the daily program to
give the graduates an opportunity to ask questions.

Any licensed physician who is a member of his local or
state medical association or of the American Medical
Association may register for the seminars. Physicians
residing outside the state are accepted on the same basis
as Minnesota physicians. All physicians should register
as far in advance as possible. This will give the chair-
men of the seminar committees an opportunity to plan
for the special needs of those who will attend. This
planning has been an important factor in the success of
the programs presented previously.

Subjects will include: from November 1 to 6, "Sur-
gical Diagnosis and Treatment”; December 6 to 11,
"Dermatology & Syphilology”; January 16 to 21, "Oph-
thalmology & Otolaryngology”; Februarv 7 to 12, "Med-
ical Diagnosis &t Treatment”; March 7 to 12, "Trau-
matic Surgery”; April 4 to 9, "Endocrinology”; and
dates not yet announced, "Diagnostic Radiology,” "Clin-
ical Pathology,” and "Proctology.” Address all inquiries
to: Director, Center for Continuation Study, or to Dr.
William A. O’Brien (same address) , University of
Minnesota, Minneapolis.

Four new teachers have been added to the staff of the
University of South Dakota Medical School at Ver-
million, according to J. C. Ohlmacher, M.D., dean.
They are: Russell William Heady Gillespie, Ph.D., of
Yale University; John T. Manter, Ph.D., Columbia
University; Henry Morrow Sweeney, B.S., M.S., Ph.D.,
formerly instructor in physiology in Tulane University,
New Orleans; and Harold Douglas McEwen, B.A.,
M.A., Ph.D., formerly instructor in biochemistry in the
University of Rochester, Rochester, New York. Einar
Leifson, Ph.D., formerly instructor in bacteriology in
Johns Hopkins University, replaces Professor Charles
Hunter (bacteriology) ; and William H. Waller, Ph.D.,
replaces Professor C. M. Macfall (anatomy) .

The Sanatorium Care of Tuberculosis*

In South Dakota

J. Vincent Sherwood, M.D.

Sanator, South Dakota

IN SAYING a few words about the sanatorium
care of tuberculous patients in South Dakota, I
will not advance any theories, or make any recom-
mendations about how tuberculosis should be cared for.
This is obvious for two reasons: (1) You could learn
that from someone perhaps far more able to teach it
than myself; (2) Although tuberculosis care is a vital
subject, still much attention has been called to the gen-
eral care of tuberculosis, and it need not be repeated
at this time.

A brief history of the sanatorium is as follows: In
1909 the legislature of South Dakota passed an act
establishing the South Dakota State Sanatorium for
Tuberculosis, and directed the Board of Charities and
Corrections to select a site. The present site was selected,
and a few years later a building was erected. In the fall
of 1911, the place was opened with six patients as resi-
dents. A few years later the present structure was built,
enabling the institution to care for something less than
200 patients. The reason for the selection of this site,
I do not know. The story is that a certain doctor in
the Black Hills who was active in the legislature was
approached by those interested, and, asked about a site
in the Black Hills, he made the remark that it would
be fine so long as a site was chosen as far from him
as possible — it was.

The original statutes for this institution called for
treatment of incipient cases, and we have no legal

* Presented before the annual meeting of the South Dakota
State Medical Association held at Rapid City, May 24-26, 1937.

right to admit any other cases to this sanatorium. The
charter also called for keeping these patients until cured.
The thought back of this, of course, was evident. If
only incipient cases were admitted, the incidence of
apparently cured would be quite high, and our dismissal
rate would be steady and fairly rapid. As a matter of
fact, in going over our records for the past 20 years,
I find that out of 3,451 admissions, only 427 were classi-
fied here as incipient. These were mostly dismissed
within a few months as arrested cases; but the others
stayed on for an indefinite length of time. This has
crowded the sanatorium with chronic incurables or prob-
able incurables, and has decreased the actual benefit to
the state that this institution should have produced. Of
course, we could not discharge these cases, once en-
tered, for they were never cured. We could very nicely
take care of 30 or 40 incipient cases, keep them, arrest
their infection, and return them as useful citizens to the
state if we had vacant one bed now being occupied by
an old patient who has been here for 14 years or more.
We have now overcome this, as I will mention later.

We classify as incipient, a case with slight infiltration
in one or both apices, or a small part of one lobe, with
or without positive sputum but with no constitutional
symptoms or very slight, slight or no elevation of tem-
perature and pulse rate, and no gastro-intestinal, throat
or other complications. This is essentially the definition
given by the National Tuberculosis Association.

Moderately-advanced cases are those with no marked
impairment of functions, either local or constitutional,

476

THE JOURNAL-LANCET

localized consolidation moderate m extent with little or
no evidence of cavity formation, or infiltration more ex-
tensive than incipient, and no serious complications.

Far-advanced cases are those with marked impair-
ment of functions, local and constitutional, marked con-
solidation of either lobe, or disseminated areas of be-
ginning cavity formation and serious complications.

As long as far-advanced cases are sent out here, I
suppose that long will they be admitted to the sana-
torium. It is true these cases should be segregated, but
the question is should they be here, thus keeping a
curable case from obtaining benefit?

Our routine for entrance provides that when you, as
physicians, have a case that you think should have spe-
cialized care, you must examine him, have the county
judge question him, and issue an order for his admit-
tance. The judge then sends us a copy of the order,
which we keep on file. Then, when there is room, we
send a notice to the patient to come, and give the judge
a copy of this letter. This, then, makes the entry legal.
We cannot admit anyone without this procedure. We
have found that patients do much better if no relatives
are around. The average person does not realize that
time is essential in treatment. Any relative keeps the
patient constantly wrought up about his condition, be-
sides constantly stopping us to answer questions. Even
eight-year-olds get along better alone.

After a patient is entered, he is put to bed on strict
rest for a period of a month or more, during which time
he is observed and classified for continued rest or he is
allowed some privileges. By privileges, I mean that he
is allowed to go to the bath room once or twice a day,
and this is increased gradually to four times a day, or
full bathroom privileges. We observe the patient’s pulse
and temperature, as well as his chest lesion, and use
these criteria as guides in allowing more privileges. Each
individual reacts differently to exercise, both physically
and mentally, and we allow considerable flexibility in this
arrangement.

When a patient is able to be up and about for some-
■-ttine, we let him take his meals at the dining room and
go- for- short walks. Some do a small amount of work
ih the occupational therapy shop, or carry on a craft
in their own room. Specimens of these patients’ work
ate Seen in the lobby of the building.

As far as special treatment directed toward the chest
tuberculosis is concerned, pneumothorax and phrenic
nerve sections are done here, and further surgical col-
lapse is done by surgeons throughout the state. It has
always been the policy here to be rather conservative in
collapse. We have had a tendency to watch the tuber-
culosis, and not to do pneumothorax if the disease is not
spreading. Some others disagree with this policy, and
we are changing our idea on that, also. Some go so
far as to say that if thoracoplasty is needed, it is be-
cause of neglect or if pneumothorax was started in time,
it would have made further surgery unnecessary. We
will not go into that, as this paper is to outline our care
here at Sanator. We feel, however, that where pneu-
mothorax has been instituted, and good collapse is not

obtained, and the disease extends or does not improve,
we should send these cases to a surgeon who does tho-
racoplasty, and have his opinion as to whether or not
he feels surgery would benefit the patient. In 1936, we
had about 60 patients to whom we gave pneumothorax
and a few more than 20 each, on whom phrenic and
thoracoplasty operations were performed. The distribu-
tion over the state you can see by the map before you.

Some cases of glandular, intestinal and bone tubercu-
losis, we feel are helped by ultra-violet irradiation. Ex-
cept for the above and throat infections, we do not use
irradiation. Irradiation of the throat and direct applica-
tion of the sun on the vocal cords, we feel in some cases,
does hasten healing. These throat cases give themselves
sun applications direct to the larynx by means of metallic
mirrors. Patients can do this by themselves with less gag-
ging than with help. When the infection causes much
pain, it may be necessary to alleviate it with an anes-
thetizing spray and by actual cautery. We will add
equipment for the latter as soon as we can.

We are about ready to open an additional ward
just back of the auditorium, which we hope eventually
to make into a surgical ward. Then, we can keep our
thoracoplasties here. We will, of course, still have sur-
geons come in to do this work. A tuberculous patient
is best watched at a sanatorium. We hope also to add
the necessary instruments with which to do this work
and also the work of freeing adhesions, which keep
some of the pneumothoracies from becoming effective.
For the time being, we will use the above-mentioned
ward for an admittance ward; and concentrate the ad-
vanced patients there, also. A few cases come in for
observation, and it is advisable to keep them away from
contact with active open cases. We can do that in this
new ward. The sick patients, of course, will be in their
own rooms, and the observation cases will be in their
beds for a period, although they may have use of the
parlor.

It is not the far-advanced cases which should be ad-
vised to receive sanatorium treatment, for they are the
cases least benefited. We do at times have moribund
patients sent out here. An emaciated, far-advanced case
usually does become physically improved at the sana-
torium, that is true; but that is because he remains in
bed. He usually is not cured of his tuberculosis, howev-
er, and more frequently than not his tuberculosis im-
proves very little. After destruction of the lung begins,
there are usually such massive adhesions to the chest
wall that collapse of the lung by pneumothorax is im-
possible, and the patient is a poor risk for surgery. The
only hope for control of tuberculosis is, of course, by
early diagnosis and early collapse where improvement
is not satisfactory. It is, therefore, the early case, in
which there is hope of cure, that should be sent to the
sanatorium — legally the only case admitted to Sanator.

I am pleased to see, more and more, earlier cases being
admitted here. Recently, we have had questionable
cases sent out here for observation and it should be so.
These can be observed better where one can follow their

THE JOURNAL-LANCET

477

condition, and after a few weeks, can put their minds
at ease.

The control of tuberculosis will become more of a
public health problem if the chronic cases are not ad-
mitted to the sanatorium. Of course, there should be
a place for segregation of these chronic cases. Either an
enlargement of the present institution in the form of a
new wing, or establishment throughout the state of
farms or colonies for this purpose would serve the pur-
pose best. Many of the older patients are able to take
care of themselves and others, too. If two or three
colonies were established throughout the state, these un-
fortunate cases could be segregated nearer home, where
they would be more content, but still be separated from
the public, where heretofore they have been wont to
stray. It has always been my thought that public health
laws have been a little too lenient with this disease.

Perhaps the past few remarks might be considered
outside the subject announced; but I do hope that some
day we will have other institutions in the state for the
care of chronic cases.

You know that this sanatorium has a laboratory in
which the usual routine tests are made and an X-ray
and light room from which some commendable work
is turned out. Not only chest work but as occasion
demands, bone and gastro-intestinal X-rays are taken.
In other words, we attempt to treat the patient as well
as the disease.

We, of course, have our own dairy which supplies us
with an abundance of excellent milk. Weekly counts
show that we keep the bacterial content of the milk
from 50 per cent to 75 per cent below the permissible
count for certified milk.

We buy and serve only first-grade food to the pa-
tients, and we maintain an excellent cooking staff and
dietitian. Special diets are frequently called for.

We have a motion picture show for those who may
be up; and have weekly church services in charge of
various ministers from the Hills region. Occasionally
other diversions help keep the patients content.

Legal Problems

I mentioned previously of being able now to cope with
the prolonged residence of chronic cases in the institu-
tion. At the last legislature, a bill was introduced and
passed which called for a probation period of six months
for new entrants to the sanatorium, and also called for
a maximum residence time of 18 months. Occasionally,
we receive patients who we feel, after due observation,
do not have active tuberculosis and should not be here.
Any time before six months, then, these patients may be
dismissed from observation. Likewise, some cases re-
ceived are far-advanced and receive no special benefit
from residence here; and these may be dismissed. Then
again, some patients refuse to submit to sanatorium
routine and demoralize the other patients. If patients
pass through the probationary period, and after 18
months seem to be unimproved, they may be legally
dismissed. However, if we feel further care will be
beneficial, any patient may be kept longer upon our

recommendation. We do not mean ruthlessly to dis-
charge every patient after 18 months, but we do want
the authority to do so when we deem it advisable* I
believe that with the aid of this law, this sanatorium can
be made more useful to the stata, and be kept from
being an old folks’ home.

While I am speaking of laws, I would like to men-
tion House Bill 126. This law provides that the counties
shall place a lien against any property a recipient of
county aid might have, or against the property of those
responsible for the recipient’s support. The purpose of
the law is evident. However, instead of specifically
mentioning the patients at the State Sanatorium who
have county aid, I believe it should have exempted them.
I feel this way not because I am here, but because it has
created a very unhealthy mental attitude in a large
number of the patients here. Mental equanimity k a
very important part of the treatment for tuberculosis.
A large debt accumulating month after month is dis-
turbing to a well man; but to a man with tuberculosis
who must necessarily look to a life of limited activity,
this debt of hundreds of dollars and sometimes thousands
of dollars, is appalling. Proper rest cannot be obtained.
It has so disturbed many here that they have refused
to remain any longer and have gone home. To be sure,
their health should be more important to them than
the property they have, yet some of this property does
not belong to them, but to parents or relatives who had
resumed the responsibility of the patient’s support before
he came out here. I cannot believe the law was passed
with due deliberation; but until some different arrange-
ment is made, many tuberculous patients wifi stay at
home with disastrous results to themselves and to those
with whom they come in contact.

Occupational Therapy

We have had a full time occupational therapy in-
structor at the institution in times past. At the present
time, our occupational therapy department is being
supervised by patients. Those interested, then, wander
down and try their hand. I believe that this is an im-
portant part of treatment and should be developed.
Many of the patients are well enough to be up and
about, and they need something to keep them from
becoming mentally inert. It will be necessary for most
patients to change their vocation after being dismissed,
if they wish to support themselves without loss of health.
I believe that a capable staff of teachers is essential for
rehabilitation of these patients. Whether this staff is
one or more, it can be worth many times its cost by mak-
ing discharged patients wholly or partly self-supporting,
and by creating in them a desire to do something useful.
It is not only a pitiable thing to see some of these better
patients spending three or four hours a day doing noth-
ing more than playing cards, but it is a terrific waste
of human energy as well. A few of these patients will
need to have encouragement to direct their energies along
some useful line, if it be only education in English or
history. Recovery is complete only when physical and
mental conditions have become normal. Many corres-

478

THE JOURNAL-LANCET

pondence courses could be obtained without cost to the
patient and used by several patients at a time and saved
■for future ones as well. I expect within the near future
to start a movement which I hope eventually to convert
into a rehabilitation program. If tentative plans work
out, we will have help through the Federal recreational
program. We may have one or two workers trained
in the "hobby” arts to organize and conduct such a pro-
gram. This will be a start, and from that, eventually
this necessary department may be permanently a part
of the regular sanatorium treatment.

More education on tuberculosis is needed in this state.
We have one county judge who is very uncooperative;
in fact, he has suggested to applicants for entry that
when we get a patient we keep him forever so that we
will have a job. Of course, that is complete ignorance
of tuberculosis and its treatment.

These few words on the institutional care of the tu-
berculous in South Dakota, I hope, will have given some
insight to the work we do, how we do it, and what we
hope to do in the future.

Vital Capacity Determinations in Health Examinations

Robert G. Hinckley, M.D.|

Minneapolis, Minnesota

HUTCHINSON, in 1848, advanced the concep-
tion that the vital capacity of man is a constant
quantity directly disturbed or modified by four
circumstances: height, weight, age, and disease. This
stimulated an interest in the subject, so that over a
period of years numerous studies of vital capacity were
made. From the data thus accumulated, standards of
normal were developed; and the relation of vital capacity
to such factors as physical training, occupation, body
position, posture, race, nationality, and sex was shown1.
Because of this interest and the simplicity of the test, the
measurement of vital capacity came to be included as a
regular procedure in the routine examination of prac-
tically all college students. There have been surprisingly
few attempts, however, to evaluate its diagnostic use-
fulness.

At the University of Minnesota several thousand
physical examinations of students are done routinely
each year. For the past fifteen years such examinations
have included the routine examination of vital capacity.
It seemed evident, however, that little actual diagnostic
use was made of these readings. The question was raised
.as to what immediate diagnostic value such vital capacity
determinations are in examinations of relatively healthy
young men and women. It was in an attempt to answer
this question that the present resume was undertaken.

Records of vital capacity used in this study were in
terms of per cent of normal according to accepted stand-
ards rather than in actual cubic centimeters of expired
air. This normal was the hypothetical value determined
by West’s2 formula which is based upon surface area.
Per cent of normal for each person was arrived at by
comparing the actual vital capacity readings, measured
with a water spirometer, with the normal determined by
West’s formula.

These vital capacity values were analyzed in relation
to other health data on some 2,500 college entrance
examinations. Analysis of the records for the two sexes
was kept separately. First, the records were divided into

t From the Students’ Health Service and the Department of
Preventive Medicine and Public Health, University of Minnesota.

five groups according to the relative per cent of normal
vital capacity. These percentage groups were as follows:
less than 80%, 80 to 89%, 90 to 109%, 110 to 119%,
and 120% or more. With certain exceptions two hun-
dred records were included in each of these groups.
The exceptions were as follows: There were 129 in the
group of men with vital capacity values of 110 to 119%;
182 women for the group of 110 to 119%, and only 43
women with values of 120% or more of normal.

The means of various measurements — age, height,
weight, height-weight per cent, systolic and diastolic
blood pressure, and pulse — were computed for each vital
capacity group. The percentage incidence of deviations
of pulse exercise-response, posture ratings, and Mantoux
readings were also computed for the group in each vital
capacity range.

Tables 1 and 2 present the data for these findings in
both sexes. In both cases the lowest mean height-weight
per cent is in the lowest vital capacity range. There is
a consistent increase of this mean through the groups so
that the highest mean height-weight per cent is found
in the group of greatest vital capacity. This one would ex-
pect, as various workers have demonstrated a correlation
of vital capacity to height, weight, age, and sex. Howev-
er, since the total fluctuation of height-weight percent-
age in women was 8.92 or less than 5% above or below
normal, and for men a total of 11 or less than 5%
below and not 7% above the normal, it would seem
apparent that these factors, although related to vital
capacity, were not the primary ones in producing the
fluctuations of more than 20% above or below normal
vital capacity. Also the mean age for both sexes can be
discounted as a primary factor in these vital capacity
groups as the greatest variation in mean age was roughly
three-fourths of a year for the men and four-fifths year
for the women. The data reveal no consistent or signifi-
cant relationships between vital capacity in either sex
with blood pressure, pulse rates, deviations of posture,
or Mantoux readings.

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479

TABLE I.

VITAL CAPACITY OF

WOMEN AND CERTAIN PHYSICAL

DATA.

% Stand. V. C.

Less Than 80%

80-89 %

90-109%

110-119%

120% or More

Mean Age

20.10± .08

20.11± .07

19.28± .07

19.67± .08

19.58± .15

Mean Height

63.24± .11

63.80± .12

63.72± .11

64.63± .11

64.24± .26

Mean Weight

117. 21± .82

121. 47± .77

123. 86± .83

130. 46± .90

1 32.14rt2.20

Mean Ht. Wt. %

95.84± .59

97.98± .58

100. 25± .57

103. 45± .63

104.76±1.12

Mean Systolic Blood

Pressure 114.57± .51

113. 43± .50

118. 00± .60

115. 88± .56

116.28±1.52

Mean Diastolic Blood Pressure 72.6 lit .48

71.46± .46

73.07± .41

71.63± .51

70.00±1.20

Mean Pulse, Sitting

86.35± .56

86.35± .70

89.45± .61

85.61± .68

88.02±1.34

Pulse 2 minutes after

exercise (Following figures indicate percentage of group)

Sitting rate or less

67.17±2.3

59.30±2.4

38.95±2.6

42.70±2.5

50.00±5.2

1—5 more

1 6.67—1.8

20.60±1.9

17.44±2.0

28.09±2.3

4.76±2.3

6—10 more

12.63±1.6

10.55±1.4

12.21±1.7

15.73±1.9

19.05±4.1

Posture A

5.20 — 1 .1

3.31±0.9

3.01±0.9

6.1 3 rt 1.3

6.06±2.8

Rating B

68.21±2.4

67.40±2.4

34.34±2.5

49.08±2.6

51.52±5.9

Rating C

25.43±2.2

28.18±2.2

55.42±2.6

40.49±2.6

36.36±5.5

Rating D

1.16±0.5

1.10±0.5

7.22±1.4

4.29±1.1

6.06±2.8

Positive Mantoux

38.79±2.3

39.29±3.2

33.58±2.2

30.33±2.3

36.36±4.9

Negative Mantoux

61.21±2.3

60.71±3.1

66.42±2.2

69.67±2.3

63.64±4.9

Number of Cases

200

182

43.

TABLE II.

VITAL CAPACITY OF MEN AND CERTAIN PHYSICAL DATA.

% Stand. V. C.

Less Than 80%

80-89 %

90-109%

110-119%

120% or More

Mean Age

20.21± .10

20.62± .10

20.61± .09

20.69± .10

19.91± .08

Mean Height

67.47— .14

67.8 1 rt .12

68.36± .12

69.42± .11

70.1 5± .11

Mean Weight

131. 28± .89

136. 22± .81

140. 34± .76

152. 27± .75

156. 93± .90

Mean Ht. Wt. %

95.41± .63

98.97± .46

99.62± .55

104. 44± .44

106. 41± .58

Mean Systolic Blood Pressure

122. 54± .75

122. 30± .53

122. 98± .56

121. 21± .55

124. 40± .58

Mean Diastolic Blood Pressure

76.59± .49

77.30± .41

78.34± .42

76.23± .38

77.53± .58

Mean Pulse, Sitting

85.47± .63

81.65± .58

85.80± .63

80.45± .54

82.75± .58

Pulse 2 minutes after exercise —

(Following figures indicate percentage of group)

Sitting rate or less

51.66±2.8

49.75±2.4

42.93 — 2.4

44.27±2.4

43.65±2.4

1—5 more

24.50±2.4

28.93 — 2.2

27.27±2.2

30.21±2.2

26.40±2.2

6—10 more

1 1.92±1.9

13.71±1.7

21.72±2.0

1 3.54±1 .7

17.26±1.8

Posture A

7.55±1.5

7.69±1.3

5.12±1.1

8.33±1.3

3.05±0.8

Posture B

56.60±2.6

50.26±2.4

50.51±2.4

59.44±2.5

49.75±2.4

Posture C

32.70±2.6

38.97±2.4

42.47±2.4

31.11±2.3

46.19±2.4

Posture D

3.14±0.9

3.08±0.9

2.06±0.7

1.1 1±0.7

1.02±0.5

Positive Mantoux

35.58±3.2

37.12±2.8

31.39±2.7

31.85±2.2

31.91±2.7

Negative Mantoux

64.42±3.2

62.88±2.8

68.61±2.7

68.14±2.2

68.08±2.7

Number of Cases

169

200

Second, the percentage incidence of a history of rheu-
matic fever, St. Vitus dance, pneumonia, influenza, tu-
berculosis, and pleurisy was determined from the stu-
dents’ past medical histories. The same was done for
family histories of tuberculosis, apoplexy, kidney trouble,
high blood pressure, and heart disease.

Table 3 shows the frequency with which these disease
conditions were reported by the students, both for them-
selves and for their families. The absence of any con-
sistent relationship between these conditions and vital

capacity is apparent. It is perhaps interesting to note
that pneumonia, influenza, and pleurisy were reported
most frequently by the lowest vital capacity group of
both sexes, but even here the differences in incidence
throughout the vital capacity groups is not consistent.
Also, for these data, the number reporting family or past
medical history of each disease in most cases is very
small.

A third approach was to determine the mean vital
capacity of individuals with certain known physical con-

480

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TABLE III.

INCIDENCE OF VARIOUS DISEASES IN PERSONAL AND FAMILY HISTORIES *

Per Cent of Normal Vital Capacity

STUDENTS’ HISTORIES

Below 80%

80-89 %

90-109%

110-119%

120% or More

Rheumatic Fever

Male

1.8%

3.0%

2.5%

3.0%

Female

5.5%

1.0%

3.5%

1.7%

2.3%

St. Vitus Dance

Male

1.2%

.0%

.5%

Female

1.0%

1.5%

.0%

Pneumonia

Male

21.7%

15.5%

12.0%

18.0%

10.0%

Female

16.5%

14.0%

14.5%

15.4%

11.6%

Influenza

Male

72.3%

40.0%

45.0%

47.0%

59.5%

Female

51.0%

52.0%

54.0%

52.8%

62.8%

Tuberculosis

Male

1.8%

1.0%

.0%

1.5%

Female

.0%

.5%

.6%

.0%

Pleurisy

Male

8.3%

5.5%

7.0%

5.5%

Female

6.0%

2.5%

3.5%

- ■ 2.3%

FAMILY HISTORIES

Tuberculosis

Male

10.1%

14.1%

13.5%

12.1%

13.5%

Female

13.5%

18.0%

17.5%

18.1%

25.6%

Apoplexy

Male

9.5%

14.1%

19.0%

20.1%

18.1%

Female

18.0%

23.5%

16.5%

17.6%

13.9%

Kidney Trouble

Male

6.5%

18.7%

9.5%

12.6%

14.5%

Female

17.5%

18.5%

14.0%

14.8%

18.6%

High Blood Pressure

Male

18.9%

21.6%

20.0%

24.5%

18.1%

Female

25.5%

28.5%

24.5%

22.0%

16.3%

Heart Disease

Male

21.9%

17.6%

19.0%

20.5%

21.6%

Female

26.0%

20.5%

21.5%

24.7%

11.6%

Total Number Records in Division

Male

169

200

Female

200

182

* In a few cases the histories were

not com

plete. Such cases

were excluded

from the computations.

editions which presumably might affect the vital capacity.
Groups with tuberculosis, suspicious lung findings, elevat-
ed blood-pressure, heart defects, asthma, and dia-
phragmatic pleurisy were selected for this purpose. The
individuals under each condition were limited to white
males within ten per cent of their standard height-
weight and between 18 and 24 years of age. This
method stabilized more or less such factors as race, sex,
height, weight, and age. All tests were made while pa-
tients were standing and therefore the factor of position
was the same. A similarly limited group of one hundred
individuals with no noted abnormalities was included for
comparison. As may be seen by Table 4, the only con-
dition studied in which there Was a significant decrease
in the per cent of normal vital capacity was dia-
phragmatic pleurisy. However, the groups with active
and arrested tuberculosis, suspicious chest findings, or-
ganic heart defects, and asthma had a mean vital ca-
pacity percentage lower than the normal group. The
groups with elevated blood-pressure and functional heart
defects had mean vital capacity percentages above the
normal group. These fluctuations, however, were not
marked.

Summary

1. Vital capacity deviations from the normal in rela-
tively healthy individuals are apparently much more
closely related to age, sex, stature, and weight than to
any of the health data studied. These data included
blood-pressure, pulse, pulse exercise response, deviations
of posture, Mantoux readings, and past medical and

TABLE IV.

VITAL CAPACITIES IN CERTAIN DISEASES

No.

Mean V. C.

Diagnosis

Cases

% Normal

Active Pulmonary Tuberculosis

90.00

Healed or Arrested Tuberculosis

90.88

±2.29

Suspicious Chest Findings ...

116

98.36

.79

Blood Pressure (Systolic "1 40 -f-V -

100

102.00

.63

Blood Pressure (Diastolic 90-f)

100

100.10

.75

Heart Defects-'— Functional

105

99.86

.67

Heart Defects — Organic

' 69

94.57

.83

Asthma -

95.42

±1.79

Pleurisy, diaphragmatic . -

88.33

±1

.83

No Defects or Abnormal Findings

100

98.70

.64

family histories of rheumatic fever, St. Vitus dance,
pneumonia, influenza, tuberculosis, pleurisy, apoplexy,
kidney trouble, high blood-pressure, and heart disease.
Age, sex, stature, and weight, which might be considered
normal variables in vital capacity measurement, are de-
termined separately in each examination and are not
interpreted from vital capacity, so that their relationship
to it is of little value.

2. Certain functional and organic conditions noted on
these health examinations show some relationship to
variation in vital capacity. The conditions included were
active and healed tuberculosis, elevations of blood-
pressure, functional and organic heart defects, asthma,
and chronic diaphragmatic pleurisy. Also the variations
of vital capacity in these relationships, except possibly
for diaphragmatic pleurisy, are hardly great enough to
be outside the variability of the test itself when applied
to any one individual. The diagnostic value of these

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481

relationships is negligible because there are so many other
variables that one cannot be certain that the condition
studied produced the vital capacity change.

3. In the groups of individuals with more serious
grades of pathological conditions, the test might have a
greater diagnostic value; but it appears to be of little

value for this purpose in the routine examination of
relatively healthy young men and women.

References

1. Myers, J. A.: Vital Capacity of the Lungs. Williams and

Wilkins Company, Baltimore, Maryland. 1925.

2. West, H. F.: Clinical Studies on Respiration: a comparison

of the various standards for the normal capacity of the lungs.
Arch. Int. Med. 25:306. 1920.

The Management of Nephritis*

W. H. Long, M.D.

Fargo, North Dakota

A CONSIDERATION of the management of
nephritis is necessarily divided according to the
separate types of the disease encountered. There
have been many classifications of nephritis based on the
various authors’ conceptions of the correlation of patho-
logical, clinical and functional features of the disease.
To me, there is none so understandable and yet so ample
as that of Christian. His article in the Journal of the
American Medical Association for January 20, 1934,
should be kept in every practitioner’s files, and reference
to it will clarify many doubts when these cases present
themselves.

His classification is as follows: (1) acute nephritis
and subacute nephritis with two sub-groups (a) with
edema (nephrotic syndrome) and (b) hemorrhagic
nephritis, (2) chronic nephritis (a) with renal edema,
(b) without renal edema, (3) essential hypertension
progressing to chronic nephritis, and renal arterio-
sclerosis progressing into chronic nephritis. This re-
solves itself into essential factors as to the origin of the
disease; first, the acute nephritis associated with an in-
fectious process, which may progress into chronic neph-
ritis, and second, the degenerative changes of vascular
disease which lead to the same type of kidney lesion.

The acute type, then, is always a complication «r
sequela of infection. The infection is most likely to be
of streptococcal origin, scarlet fever, a common cold or
sinus infection, a tonsillitis, or a surgical infection. The
prevention of acute nephritis resolves itself into the
careful and adequate management of these diseases.
But in spite of all care, many such infections will ini-
tiate an acute damage to the glomeruli, and frequent
and complete urinalysis in such cases will reveal many
mild cases of nephritis. It should be emphasized that
it is the mild cases which are likely to escape diagnosis
and adequate care, and that they are as likely to end in
typical chronic nephritis as the more severe ones. This
is very obvious in obtaining histories from individuals in
the chronic stage. So often, only the fact that there was
an infectious disease and that there was albumin found,
is obtained; and too often it is seen that no adequate
treatment was given.

The reason that more consideration of these mild
forms is not given is the frequency of benign albuminuria

* Presented before the annual meeting of the North Dakota
State Medical Association, held at Grand Forks, May 16-18, 1937.

in febrile states, the so-called "febrile albuminuria.”
Therefore, it is essential to make complete urinalyses,
for surely the finding of red blood cells and granular
casts and albumin is sufficient to label such cases true
nephritis. Also, if albumin is once found, subsequent
urinalyses must be made, and if it persists for an ap-
preciable time after the infection has subsided, then
there can be no doubt. Blood pressure readings at this
time, while not necessarily extreme, will often be elevat-
ed. Especially significant are diastolic pressures above
90.

The frank cases with marked nephritic edema or
those with hemorrhagic urine need no special word.
The management of both should be equally strict, if we
are to succeed in preventing the progression to the
chronic stage. And it is surprising how completely the
most severe case may recover. The management of these
acute cases, of whatever severity, consists of complete
bed rest until the signs of active infection have disap-
peared. This will usually require six to 12 weeks. The
best indication of healing will be diminution or disap-
pearance of albumin, red blood cells and granular casts
in the urine. If, after three months, there is still a
little albumin and a very few red blood cells, it is likely
that this stage will continue indefinitely, and such
patients may be allowed to be about cautiously.

The diet in the acute stage must be adequate. There
is no need for avoidance of any type of food. The
caloric intake must be sufficient to avoid wasting. Strict
protein restriction is not necessary. Milk and fruit
juices are adequate for the first week or two, while
gastro-intestinal symptoms are prominent. Then the diet
should be increased to include vegetables, cereals, and
a small amount of meat and eggs, so that protein loss
may be replaced.

Special symptoms that may require consideration in
the acute stage are anuria, convulsions, and edema.

Anuria will usually respond to adequate fluid intake
by mouth. If it does not, then glucose in 20 to 50 per
cent solution by vein in amounts from 50 to 200 cc.
is given. Cupping over the kidney, and the use of
diathermy through the kidney region, have occasionally
started the flow. If these measures fail after three or
four days and the urea is rising, decapsulation of the
kidney should be considered.

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Edema is usually transient, but if it persists unduly,
digitalis should be given. Salt restriction should be
enforced, and mild diuretics such as potassium nitrate
may be tried. Salyrgan has been recommended in this
stage, but I do not consider it advisable. Sweating is
of very little value, and catharsis is likely to do more
harm than good.

Convulsions and uremic manifestations are rare in
the acute stage. When threatening, venesection and the
use of sedatives such as chloral hydrate are in order.
Injectable barbiturates (as allurate injectable) are val-
uable here in allaying the nausea and controlling the
seizures. Hypertonic glucose by vein and spinal tap
are frequently necessary.

The subacute stage requires, largely, enforcement
procedures. See that the patient is kept in bed until the
urinary findings are normal. See that the protein intake
is adequate to prevent the development of edema from
protein insufficiency. It has been shown that plasma
proteins are normally seven per cent, and that if they
fall below five per cent, this in itself causes edema of
the "hydremic type.” The caloric requirements must be
met. This state may continue for three to six months.
The prevention of upper respiratory infections is most
important, as these are very likely to result in exacerba-
tions of the disease. Foci of infection, especially diseased
tonsils and sinuses, should be treated. Iron is often
needed for the anemia.

When edema is the principal problem in this stage,
it may be of the so-called nephrotic type. Some stu-
dents prefer to consider nephrosis a separate disease
entity. The criteria for such a diagnosis being prom-
inent edema, large amounts of albumin and no red
blood cells in the urine, and a virtually normal blood
pressure. Long observation of such cases, however, re-
veals that most of them terminate as chronic glomerular
nephritis. There are certain special features of value in
their treatment, however; that is high protein feeding
which often results in marked diuresis. Thyroid feeding
is also recommended. Salyrgan can safely be used in
these cases.

The chronic stage of nephritis leads to a considera-
tion of terminal events. The hypertension with attend-
ant headaches can be modified only symptomatically. The
gastric irritability of mild uremia is trying, and seda-
tives such as codein, bromides and barbiturates are in-
dicated. The food the patient wants had better be
allowed. Active bowel elimination must be had, best
by the milder laxatives; strong purgation depletes the
patient unduly. Spinal puncture has been very helpful
for the intractable headaches.

Edema in the chronic stage is frequently troublesome.
It is often due to cardiac failure from the long stand-
ing hypertension. Such edema yields promptly to ade-
quate digitalis therapy. The presence of hypertension
is not a contraindication for digitalis administration.
Fluid restriction and salt restriction are enforced. Di-
uretics in this stage are less harmful and more likely
to be efficacious than in the acute stage. Potassium nitrate

is the one of choice, and is used in doses of 3 to 6
grams daily. It is less toxic than the ammonium salts
and does not produce an acidosis. When there are no
red cells in the urine, and other measures have failed,
salyrgan may be used. At times all these measures fail
and paracentesis is necessary.

Uremia is treated as in the acute stage by venesection.
Ii the hemoglobin is low, transfusion should follow.
Injectable barbiturates are of the greatest value to pre-
vent and control convulsions. If an acidosis exists,
sodium bicarbonate by vein is indicated when vomiting
is present. If no acidosis exists, then ten per cent glu-
cose in Ringer’s solution is given by vein.

A word should be said about the nephritis of preg-
nancy. It is necessary to differentiate between the frank
toxemia of pregnancy in a previously normal kidney,
and the exacerbations due to the pregnancy in previously
existing latent or mild nephritis. This problem resolves
itself into careful history taking. Such a differentiation
is not always possible. But it is always possible to follow
these cases over a sufficient time following delivery to
be sure that no permanent kidney damage is present.
These patients in whom the blood pressure remains
elevated and even mild albuminuria and casts continue
for a period of months, had best be protected from
further pregnancies, because each ensuing pregnancy is
likely to damage further the renal function.

Our own experience with these cases is that there are
a large number with permanently damaged kidneys,
progressing as other chronic nephritides. The actual
percentage one can expect to be so damaged is pretty well
predicted by Herrick and Tillman’s study of 594 such
cases followed from one to 22 years. In this large group,
more than one-half were found to present evidence of
either glomerular nephritis or hypertensive cardiovas-
cular disease within three years.

This paper has so often emphasized the importance
of adequate protein intake that it might be well to
discuss the reasons for such a positive opinion. The
question of protein in nephritis has been seriously con-
sidered by a number of the best students of the disease.

Christian says "only with a rising value of blood
nitrogen is there any reason for marked dietary restric-
tion.”

McCann, from an analysis of experimental and clin-
ical data, says, "These experiments have convinced us
that liberal protein allowances in the diet do not of
themselves injure the kidneys. . . . Full advantage

should be taken of the tendency to deposit protein by all
individuals who have lost it, either by inanition or by
toxic destruction or through albuminuria.”

Meakins states, "Do not reduce proteins to an ab-
surdly low level when the patient is constantly losing
proteins. In the final stage you can reduce the protein
to some extent, if only to help the patient from over-
eating.”

In closing I would emphasize the following points:

(1) Take care to detect the milder cases which may
arise from any acute infection, especially the strepto-
coccal infections.

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483

(2) Do not starve these patients in the acute stage.
Feed diets to maintain the patient’s strength, and give
adequate protein for replacement of that lost through
albuminuria.

(3) Enforce prolonged bed rest until the disease
becomes quiescent, the edema gone, and the urine vir-
tually clear.

(4) Remove active foci of infection and protect
against upper respiratory infections.

(5) In the subacute and chronic stages enforce mod-
eration in food and activity, and give an adequate diet
with an average protein intake.

Bibliography

McCann, W. S., The Many-Sided Question of Protein in
Nephritis, Ann. Int. Med. 5:579 (Nov.), 1931.

Herrick, W. W., and Tillman, A. J. B., Toxemia of Pregnancy;
Its Relation to Cardiovascular and Renal Disease, Arch. Int. Med.
55:643 (April), 1935.

Christian, H. A.: Types of Nephritis and Their Management,
J. A. M. A. 102:169 (Jan. 20), 1934.

Meakins, J. C. : Nephritis, Med. Clin. North America 16:681
(Nov.), 1932.

Acute Abdominal Disease*

Claude F. Dixon, M.D.f
Rochester, Minnesota

MANY in this audience have very definite ideas
regarding the management of most acute ab-
dominal conditions; at least, it would be diffi-
cult to find a surgeon who would not willingly confess
this, and I am here, I suppose, to make my confession
along with the others. I propose to consider briefly
acute appendicitis, acute intestinal obstruction, perforat-
ed peptic ulcer, acute disease of the gallbladder and
acute pancreatitis.

Acute Appendicitis

Unruptured gangrenous appendix: — Not infrequently
older contemporary surgeons have stated that an ap-
pendicectomy may be one of the most difficult of ab-
dominal operations. I heartily subscribe to the state-
ment, as I have encountered many retrocecal, unruptured,
gangrenous appendices that required a considerable
amount of something — call it skill if you like — in order
to perform an appendicectomy without bringing about
perforation. How often one hears the remark, "Just
an appendix,” when inquiry is made regarding an op-
eration! But, if one actually collects the statistics
throughout the United States, it is obvious that deaths
occur following removal of unruptured acute appendices,
and that the death rate is entirely too high. It is evi-
dent that the facts concerning this situation have not
been stressed as they should be.

Let us examine some of the factors which contribute
to the high mortality from appendicitis. Within the
past month, a young physician came to me and said that
he was about to take the practice of a rural physician,
and that it was for this reason he had come to spend
a few days making observations in the Clinic in order
that he might learn to do some of the simpler types of
operations, for example, appendicectomy. Frankly, I
think that full experience with the operation would
have a favorable effect on the mortality from appendi-
cectomy, and that the factor next in importance is that
the operation is often performed after a snap diagnosis

* Presented before the annual meeting of the South Dakota
State Medical Association, Rapid City, South Dakota, May 24*26,
1937.

t Division of Surgery, the Mayo Clinic, Rochester, Minnesota.
Associate professor of surgery, University of Minnesota Graduate
School of Medicine.

and without proper indications. Generalized abdominal
pain, diarrhea, and possibly vomiting, may occur without
being attributable to a diseased appendix. These symp-
toms may be referable to a type of enteritis, manifested
by reddening and congestion of the parietal peritoneum,
small intestine and colon, and even gentle manipulation
of the bowel would be attended with considerable risk.
In some of these cases, if only the appendix were re-
moved, the patient might make a fairly satisfactory con-
valescence, but, since the surgeon is somewhat chagrined
at finding only a shriveled appendix, an extensive ab-
dominal exploration may be carried out which will pro-
duce sufficient trauma to cause the acute infectious
process in a portion of the intestinal tract to become gen-
eralized, and peritonitis may be precipitated. I cannot
urge too strongly against carrying out an exploratory
operation in this type of case. It would be far better
to admit error or confine the procedure to removal of a
so-called chronic appendix. Furthermore it behooves all
of us to cease minimizing the dangers incident to the
removal of a diseased appendix. Even though there
may be little risk if the surgeon is well-trained, there
will be some experiences that are far from pleasing, due
to the extremely poor condition of the patient at the
time he presents himself for attention. However, the
risk should be so small that every fatality would be
looked on as an unusual tragedy. Facing matters square-
ly, the situation may be considered from still a different
angle. The mortality may be only a few per cent if each
surgeon reviews only his own experiences, but to the
family in which a death occurs, the mortality is 100
per cent. My opinion regarding treatment of acute
appendicitis, complicated and uncomplicated, will most
likely not meet with the approval of all of you, but I
shall tell you about my experiences in the hope that I
may say something helpful.

Rupture of the appendix : — In cases in which, ac-
cording to the history, it is reasonable to assume that
the appendix ruptured only a few hours previous to
consultation, an examination will reveal generalized
rigidity of the abdominal muscles which is so marked

484

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that- one might be justified in suspecting the presence
of a perforated peptic ulcer. Let us assume, however,
that the diagnosis of perforated appendix is correct. In
such cases, I feel that the best plan is to institute drain-
age through a right rectus or a McBurney incision. Two
Penrose cigarette drains are inserted, one of which points
upward toward Morrison’s pouch and the other is di-
rected downward into the pelvis. No attempt is made
to visualize the appendix, and there is no exploring
whatever. Usually, if there has been severe pain before
the operation, this ceases soon after drainage is estab-
lished. Some surgeon has said that it is impossible to
establish adequate drainage of the abdominal cavity in
this manner; this may be true, but in a case in which the
appendix has ruptured, scattering pus throughout the
abdomen, and there is no attempt at localization of the
process, drains properly placed will permit the pus to
be discharged freely. About the seventh postoperative
day it is justifiable to begin loosening and shortening
the drains preliminary to removing them on about the
twelfth postoperative day.

Let us consider another type of perforated appendix.
A typical attack occurs, and the pain becomes localized
in the right lower abdominal quadrant; then, six to
eight hours before the patient’s admission to the hospital,
the rather severe pain ceases suddenly, indicating that
perforation has taken place. Physical examination re-
veals muscular spasm confined almost entirely to the
right lower abdominal quadrant. From my observations
and from the review of many hundreds of histories of
similar cases, an operation at this stage of the disease
is most likely to thwart nature’s efforts to make the
process a local one. If surgical intervention is under-
taken at once, complications such as diffuse peritonitis,
pelvic abscess and subphrenic abscess ensue. Although it
is possible to remove the appendix in some such cases
and have recovery ensue, the risk is much less if a
medical regimen is employed. Drainage of a well-
localized appendiceal abscess should be established after
the body temperature has reached normal or nearly
normal. The appendix is not removed, even though it
is easily accessible. Does it not seem reasonable that
removal of the ruptured appendix would encourage
spread of the infectious process? Study of a large
series of such cases appeared to bear out that conten-
tion for the death rate was not only appallingly high,
but in many instances death was attributed to subphrenic
or subdiaphragmatic abscess and empyema. Needless
to say, an appendix which has perforated ultimately
should be removed; usually this can and should be done
in a period of two or three months.

I have compiled a table showing the results in 523
cases of all types of acute appendicitis which were man-
aged according to the methods described. (Table 1.)
Fortunately the mortality rate is somewhat lower at
present, and I attribute this to the measures employed
for the control of peritonitis. Priestley and I have been
using an anaerobic serum which was originally suggested
by Weinberg of the Pasteur Institute as a result of the

feeling that many anaerobic bacteria are perhaps more
pathogenic than they were formerly supposed to be.
Before giving the serum, the patient is desensitized; then
20 cc. of the serum in 200 to 300 cc. of physiologic
saline solution are administered intravenously. The pro-
cedure may be repeated two or three times in 24 hours.

As stated in the beginning, the plans I have so briefly
outlined may not meet with your approval, but I have
found them helpful and submit them to you, because
they represent my best judgment in the matter.

Acute Intestinal Obstruction

During the past decade, definite progress has been
made in the treatment of acute intestinal obstruction.
There was marked change in our concept of the entire
situation following recognition of the fact that the
most marked change in the chemical composition of
the blood is an alkalosis, and not acidosis, as was formerly
believed. Pre-operative decompression by nasal siphon-
age, as suggested by Wangensteen, is a comparatively
recent maneuver which has proved of great advantage;
at times it saves the life of the patient. If difficulty is
experienced in passing the tube into the duodenum, the
maneuver will be accomplished rather easily by placing
the patient on his right side, and allowing him to have
frequent sips of water while the tube is being inserted.
Roentgenologic examination of the abdomen with the
patient in a sitting position will show whether or not
the tube has entered the duodenum. It must be re-
membered that patients lose an enormous amount of
fluid by use of a suction apparatus and therefore the
fluid balance must be maintained by the administration
of fluids intravenously and subcutaneously; usually 3000
to 4000 cc. of fluid should be given in 24 hours. The
solution I prefer if the blood chlorides are normal is
five per cent glucose. This solution is nearly isotonic,
and furnishes the patient with both food and water.
Physiologic saline solution combats the toxicity of in-
testinal obstruction to a considerable extent, but one
must remember that it is possible to administer an over-
supply of salt and thereby defeat the purpose because,
if the chloride content of the blood plasma is raised
high above normal, fluid from the tissues is drawn into
the circulation and dehydration is increased. Intranasal
suction performs two important tasks: first, after com-
plete decompression has been brought about, the ob-
structed segment may be freed so that operation is un-
necessary; second, it is an aid in preparing the patient
for the operation if one is required.

Finally, the possibility of closed-loop intestinal ob-
struction must be kept in mind. A small segment of
bowel may be caught in a mat of adhesions in such a
manner as to occlude it proximally and distally. I have
seen three or four cases in which there was no clinical
evidence of intestinal obstruction, but necropsy disclosed
that a segment of intestine eight to ten inches (20.3 to
25.4 cm.) had been occluded in this way. The blood
supply was not impaired. An enterostomy or an entero-
anastomosis had been made proximally, so that the in-
testine was functioning normally and yet the patients

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485

TABLE I.

SUMMARY OF CASES OF APPENDICITIS

Mortality

Type of Appendicitis

Cases

Operation

Cases

Per Cent

Acute, diffuse, purulent and gangrenous

437

Appendicectomy without drainage

o.p

Ruptured, localized abscess

Extraperitoneal drainage

7.7

Ruptured with diffuse and spreading peritonitis

Abdominal drainage

10.4

Total

523

1.52

* One patient died 12 days after operation from exacerbation of a cerebral condition of long standing. The abdomen was clean.

succumbed; apparently the cause of death was an un-
controllable imbalance in the composition of the blood
which was characterized by alkalosis. Therefore, if the
blood does not return to normal in a case in which
occlusion has been relieved, exploratory laparotomy is
indicated, as a closed loop may be found to be the cause
of the trouble.

Acute intestinal obstruction which has been present
only a few hours may be rectified without great risk
in most cases. When the obstruction is of longer dura-
tion, duodenal siphonage should be instituted and intra-
venous therapy begun. If the patient’s condition im-
proves, the tube may be clamped off to determine
whether or not the obstruction has been released. If it
has not, surgical intervention should be carried out.
Roentgenologic examination of the abdomen always
should be made to determine the situation of the oc-
cluded segment of intestine.

Perforated Peptic Ulcer

The management of perforated peptic ulcer is a
surgical problem. The length of time that has elapsed
since the perforation should be taken into consideration
in determining the type of surgical procedure to be
employed. If the exploratory operation can be carried
out within an hour or two following perforation, ex-
cision of the ulcerated intestine and gastroduodenostomy,
or closure of the perforation and gastro-enterostomy,
might be employed with a comparatively low mortality.
However, one rarely has an opportunity to care for a
patient so soon after perforation of an ulcer, and it is
my plan in almost 100 per cent of such cases to close
the perforation and do nothing more. Over the area
I usually suture omentum, and when this is not easily
available, I divide the suspensory ligament of the liver
and use one end of it as a patch over the anterior sur-
face of the duodenum. One patient was admitted 60
hours after perforation of the duodenal ulcer and re-
covered following closure of the perforation, which was
carried out under local anesthesia. About 30 per cent
of the patients with perforated peptic ulcer who have
come under my observation have given no history of
previous digestive disturbance whatsoever. More than
half of those on whom I have operated for this condi-
tion have been imbibing freely of alcoholic beverages.
Possibly the reason that more fatalities have not oc-
curred is that the alcohol that is ingested aids in ren-
dering the gastric contents sterile. If there is an appre-
ciable quantity of gastric contents (particles of food)
in the peritoneal cavity, drainage seems a most reason-
able procedure. To institute drainage, I make a small
stab wound in the lower middle portion of the abdomen

midway between the symphysis pubis and the umbilicus,
and a soft tissue rubber drain is then placed, with the
proximal end so situated as to afford pelvic drainage;
abscesses in the pelvis are more frequent following this
catastrophe than is generally supposed. The drains are
not disturbed for seven to ten days, after which they
are removed gradually.

Acute Disease of the Gallbladder

Those who believe that an acutely diseased gallbladder
should be removed argue that the condition deserves the
same type of surgical management as does an acutely
inflamed appendix. In other words, there is still con-
siderable discussion as to whether cholecystectomy or a
cholecystostomy should be carried out or whether op-
eration should be postponed. In a recent symposium,
a mortality of ten per cent was reported for a series
of 100 cases in which cholecystectomy was performed
for acute cholecystitis. It seems to me that the mor-
tality might have been lower had the attack been allowed
to subside before subjecting the patients to operation.
It is my opinion that cholecystectomy should be deferred
for two or three weeks following an acute attack. Oc-
casionally, localized tenderness persists following such
an attack, and the body temperature remains elevated
to 103° or 104° F. In this type of case, I prefer to
perform cholecystostomy and remove any stones that
may be present, for this operation can be carried out
by the use of local anesthesia and with comparatively
little risk. Furthermore, the edema present during the
acute stage enhances the danger of injuring the com-
mon bile duct while performing cholecystectomy.

Pre-operative and post-operative pain : — McGowan has
shown recently that the pain occurring with disease in
the biliary system is attributable, in a large majority of
cases, to distention of the common bile duct resulting
from spasm of the sphincter of Oddi. By injecting an
opaque substance into the common bile duct through a
T-tube, he found that the material would be retained
in the duct if morphine recently had been administered.
It therefore seems illogical that morphine should be
employed during the acute phase of gallbladder colic.
Relief of pain is obtained if the dose of morphine is
sufficiently large to impair the higher centers; in small
doses it will actually increase the patient’s discomfort.
But, if glyceryl trinitrate is administered or amyl nitrite
inhaled, the sphincter of Oddi usually relaxes almost
immediately, allowing the opaque material to pass rap-
idly into the duodenum. This observation constitutes a
distinct advance in the understanding and management
of cholecystic disease.

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It should also be kept in mind that at times the
etiologic process is a definite cholangeitis which even-
tually will require prolonged external drainage of the
biliary system by means of a T-tube placed in the com-
mon bile duct.

Acute Pancreatitis

About 70 per cent of the patients who have acute
pancreatitis give a history of disease of the gallbladder
and until recently the consensus seemed to be that drain-
age of the gallbladder and lesser peritoneal cavity was
the procedure of choice in the management of acute
processes in the pancreas. In Dragstedt’s experimental
studies on animals, he found that the predominating or-
ganism associated with pancreatitis is Clostridium welchii,
and reasoned that the necrosis which occurs during the
acute phase of pancreatitis is caused by bile salts, and
that the hemorrhages which so frequently accompany
this condition are most likely protective phenomena
against toxicity of the bile salts. The mortality from
cholecystostomy is extremely high because the patient
is usually in rather marked shock as a result of the
disease before the operation is begun, and because sur-
gical interference tends to disseminate the infection
which nature attempts to localize in the lesser peritoneal
cavity. I know of no work that has thrown more light
on the cause and treatment of acute pancreatitis than
that of Dragstedt. The clinical application of his find-
ings is that acute pancreatitis is an infectious process,
and surgical interference is positively contraindicated.

My experience teaches that the best type of manage-
ment of this condition is absolute quiet, transfusion of
blood, and administration of physiologic saline and glu-
cose solutions intravenously. The majority of patients
will recover if treated in this manner, and at a later
date attention can be given to the disease of the gall-
bladder, which so frequently coexists.

Enemas

I mention the subject of enemas last because what
I have to say pertains to the treatment of all of the
processes I have discussed, and, furthermore, because I
wish to emphasize strongly the dangers attending the
employment of the procedure. An enema given on the
third or fourth day after operation is comparable to
the administration of a cathartic in the course of an
attack of appendicitis. A study of postoperative hospital
records shows clearly that serious difficulty not infre-
quently succeeds a series of enemas ranging from in-
jections of soapsuds to mixtures of milk and molasses.
Some patients are able to stand the treatment, but
more often than is realized, complaints follow which are
thought to be of little consequence, but which finally
culminate in definite signs of shock. For two or three
days the patient may be nauseated and may vomit
occasionally; meanwhile, the temperature becomes ele-
vated and the pulse is rapid. There seems little doubt
that peritonitis can be precipitated by such a procedure,
especially if an ambitious nurse decides that a high
enema is in order. If abdominal discomfort (gas pain)
occurs and is not relieved by insertion of a rectal tube,
the better plan is to apply hot compresses to the ab-
domen and to instill gently into the rectum two or
three ounces (60 to 90 cc.) of warm mineral oil or
olive oil, which the patient is asked to retain for four
or five hours. The desired results may be obtained by
this treatment, and certainly it does not impose the
dangers attending distention of the bowel by the use
of a large quantity of fluid. The practice of prescrib-
ing enemas within the week following abdominal op-
erations should not only be discouraged but should be
abandoned.

Initial Care and Treatment of Accidental Injuries*

R. H. Waldschmidt, M.D.

Bismarck, North Dakota

HE PROGRAM COMMITTEE requested me
to present a paper on the "Initial Care and
Treatment of Accidental Injuries.” This is a very
broad subject, and it has been difficult to decide just
what special features might be taken up most profitably
in the short time allowed.

If a text were required for a contribution of this sort,
it might appropriately be a quotation from one of the
leading surgeons of the world who said, "The fate of
the wounded rests in the hands of the one who applies
the first dressing. The kind of antiseptic used must re-
main with the man employing it.”

After much experimenting with many kinds of anti-
septics, the surgical consensus seems to be swinging back
to iodine as the safest and best disinfectant, whenever

* Presented before the annual meeting of the North Dakota
State Medical Association held at Grand Forks, May 16*18, 1937.

antiseptic wound treatment is advisable. But more and
more surgeons are now discarding all use of antiseptics
in many situations where formerly they were thought in-
dispensable. It has been shown that all antiseptics do
harm to the body tissues, and by so doing, interfere with
prompt and normal healing. Instead of using iodine or
other antiseptics in open wounds, nothing but soap and
sterile water are used to cleanse the surrounding areas
and the wound. However, soap and water must not
be applied in the same haphazard manner in which we
were in the habit of applying tincture of iodine over
traumatized surfaces. It requires a thorough and meth-
odical washing and rinsing of the wound and its sur-
roundings with the materials mentioned.

The following outline is recommended in the early
treatment of an open wound due to a recent injury. A

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487

sterile gauze sponge or dressing is held firmly against
the wound. The skin surrounding the laceration is then
washed thoroughly with soap and water. Both should, of
course, be sterile and the washing must be continued
for at least eight or ten minutes. The wound itself is
then washed gently but thoroughly with the same ma-
terials. All destroyed and necrotic shreds of tissue are
now removed with knife or scissors, and the wound is
again thoroughly rinsed by pouring a large quantity of
sterile water over it. If this treatment is applied within
the first six hours or so after the injury, it is usually
possible to obtain primary healing. This is true even
when severed muscles, tendons and nerves require sutur-
ing.

In our own experience, we have found that wounds
treated by this method have healed with less irritation,
fewer complications and with much more satisfaction to
both doctor and patient than was the case during a for-
mer era, when antiseptics were the chief and often the
only weapons used against wound infection.

In dealing with superficial injuries, it is necessary to
visualize all the possibilities for damages to deeper struc-
tures. Apparently slight contusions, sprains or abrasions
may be very painful and disconcerting to the patient and
cause him to disregard for the time other signs and
symptoms pointing to injuries in the skeleton or to the
internal viscera. The wise medical man, when meeting
a recent injury, will not be satisfied with a cursory ex-
amination, but will insist on knowing whether or not
there may be other anatomic damage present, which has
not yet had time to become evident. Many permanent
deformities, disfiguring scars, functional defects and
medico-legal problems may be obviated by an early search
for concealed injuries. Here again the patient’s fate
rests in the hands of the first medical consultant.

The primary object of first aid treatment is to save
life. If wounds are present, these should be covered
with sterile dressings, but no attempt should be made to
cleanse the wounds on a patient lying on the street, on
the highway, or in any place where the cleansing process
of necessity must be incomplete. Hemorrhage, if of
serious degree, must be controlled by pressure or tour-
niquet. Morphine should be given freely for pain. If
shock is in evidence, or the distance to the hospital is
great, it is very essential that artificial heat in some form
be maintained until the patient is placed in bed.

Scar formations, which may be either disfiguring or
crippling to the patient, are inevitable after many in-
juries where extensive tissue necrosis has taken place.
Primary or secondary infection with virulent bacteria
may terminate in additional destruction and removal of
important tissues. Much of the damage produced in
this manner is unavoidable. However, it can be limited
to a minimum, if the medical man who first sees the
injured individual renders scentific, careful and purpose-
ful treatment and advice.

The prophylactic use of combined tetanus and gas
gangrene antitoxin may not be as universally important
after injuries on the highway as on the farm. Each case
must be considered by itself in this regard, while remem-

bering that both of these types of anaerobes are very
common throughout our state, and neither is confined
to any location or condition. When in doubt, it is usually
safest to practice prophylaxis.

Burns of different degrees of severity are often brought
to the medical man for treatment. Liberal doses of
opiates should be given at once to relieve pain and to
prevent shock, if not already present. Shock should be
treated by the application of artificial heat and the ad-
ministration of fluids by any and all methods available.
Stimulants are often indicated.

For the local treatment of burns of the second and third
degrees, we have had the most satisfactory results from
the use of ten per cent tannic acid solution sprayed over
the affected area every fifteen minutes until the surface
has become coagulated. The firm eschar formed will
protect the underlying tissues from the air. Thereby,
the pain is relieved, body heat is preserved, fluid loss is
decreased and infection is minimized. A ten per cent
silver nitrate solution may be added to expedite coagula-
tion.

The motorization of our entire population has caused
a tremendous increase in the number and variety of
skeletal fractures. Very nearly a million fractures are
treated annually by the doctors of the United States.
The time limitation precludes more than a mere men-
tion of this most important feature of accidental in-
juries. Through the efforts of the American College
of Surgeons, the treatment of fractures has now become
practically standardized. As a result of this activity, a
very intense interest is being taken in this subject in
the effort to improve the results. This does not refer
merely to the acquisition of more modern splints and
other appliances for the best kind of first aid applica-
tion, but it has a greater reference to a wider and
deeper mental training and equipment for the purpose of
improved handling of recent fractures. Here is a chal-
lenge, therefore, to learn what is expected of us in this
additional training. The primary object for better re-
sults, of course, is the welfare of the patient, but it in-
cludes, also, distinct benefits to the medical attendant.

The American Red Cross has already formulated and
in some places has already put into practice a plan by
which the injured along the highways may receive more
prompt and more scientific attention. It involves the
establishment of first aid stations, training in first aid to
the injured of lay personnel employed near the stations,
organization of transportation services, placing of road
markers showing where the nearest stations are located,
etc. Since the automobile and the highway continue to
be the battleground where most of the wounded are re-
trieved, this Red Cross service may become very useful
and every medical man should cooperate in the move-
ment.

"Splint them where they lie” was an admonition given
by a former generation of surgeons. This is still good
advice. The earliest possible splinting of a fracture
lessens the intensity of pain and shock and prevents
further damage from penetrating bone spicules. Under
such circumstances it is very important that suitable

488

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splints are at hand for the purposes already mentioned.

The ability of the first medical man who is called to
render first aid and to prepare and transport the frac-
ture patient to a hospital may determine the entire course
of the healing process and the functional result of that
patient. We recommend that every physician who is at
all likely to meet fractures in his practice should learn
the art of applying properly the Thomas-Murray and
Kelly-Blake hinge splints. The immediate application of
traction splints was one of the most useful lessons learned
from the World War. It was estimated that this simple
procedure saved many thousands of lives. These splints
are especially useful because they permit traction on the
fimb at the same time that the bone fragments are held
in a state of fixation. This form of handling fresh frac-
tures may now be considered standardized for our use,
and failure to apply both traction and fixation as a pri-
mary treatment might readily become of medico-legal im-
portance. The early application of firm traction before
the bone fragments have become imbedded in blood clots
has often been known to bring about reduction without
further manipulation. The opportunity of moving and
turning the patient about considerably, while taking the
necessary X-ray films, without adding to the pain or
causing further damage to soft parts, is of paramount
importance to the patient.

Injuries to nerves, tendons and blood vessels must be
looked for at the site of every major fracture. If such
lesions are found and noted at once, it will help greatly
in the later management of the abnormal condition.

There is no necessity of sending a patient with a frac-
tured skull to the hospital with a rush tag on the am-
bulance or car. On the contrary, undue hurry and rough
driving are harmful to the patient, and help to produce
a greater shock. If an operation becomes necessary, it
will not, as a rule, be done for several hours, or maybe
even days. The condition of shock must first be combated
and superficial wounds treated. A fractured skull should
be handled slowly, deliberately and without rushing. In
many cases, a few hours’ complete rest may be the best
first aid treatment.

Special attention has been given recently to the proper
handling of patients with injuries to the spine. The
members of the police force in some of our eastern cities
have been given special demonstrations on this partic-
ular subject, together with other first aid instruction.
The spinal column may be fractured in an automobile
wreck, for instance, and the force producing the frac-
ture may have stopped before serious compression or
laceration of the cord has taken place.

The danger of causing a secondary compression of the
cord in such cases through faulty handling of the pa-
tient while lifting him off the ground and transporting
him to the hospital is very real and not at all uncommon.
A number of such injuries have been reported in which
the patient was able to move his legs immediately after
the accident. However, he promptly became completely
paralyzed after he had been lifted off the ground and
sent to the hospital in a semi-sitting posture in the back
seat of an automobile. Any patient in whom a spinal

fracture is suspected, probable, or even possible, from
the nature of the accident, should never have the head
and shoulders raised above the horizontal plane. It is
easy to visualize the danger to the spinal cord from a
"jack-knifing” or bending at the point of fracture and
the wedging in of vertebral bone fragments. Such pa-
tients must have the shoulder and hip of only one side
raised gently and steadily in order to permit a firm
stretcher, wide board, a door, or any solid level support,
to be passed under the injured back. To place such
patients in a half-sitting posture in the back seat of an
automobile, or other carriage, is a reprehensible prac-
tice. If an ambulance is not immediately available, a
truck in which the patient may rest, stretched out hori-
zontally on the improvised back rest, should be the sec-
ond choice.

The treatment of a traumatized abdomen often taxes
all of a surgeon’s knowledge, experience and skill. The
most frequent intra-abdominal injuries are perforations of
viscera. Severe hemorrhages are secondary in importance
and may often be combined with the former. When in
doubt as to the severity of an injury to the abdomen, it
is best to send the patient directly to the hospital where
his developing symptoms may be studied and proper
treatment instituted quickly, if needed. It should be
remembered that a patient with a perforated bowel may
be able to walk about for some time after the accident
without severe pain. Means should be taken to min-
imize shock, whenever possible.

Tissues reduced in vitality from any trauma are more
readily invaded by pyogenic bacteria than are normal
cells. All injured areas, whether the wounds are open
or not, must therefore have special attention in order to
avoid secondary infections. This calls for aseptic treat-
ment of all wounds, the application of splints and ban-
dages to protect injured soft parts and the early and
proper use of massage.

The city administration of Grand Forks should be
congratulated on the passage of Health Regulation No.
525, regulating operators of ambulances and the kind of
equipment they must carry. Such regulations should be
adopted by the larger cities and then, undoubtedly,
would soon be accepted by the smaller communities.
This, I believe, is a step in the right direction for the
care of the injured.

Summary

To summarize, the general principles in first aid care
are as follows:

1. Treatment of shock by keeping the patient at rest
and warm, or by giving simple stimulants.

2. Control of hemorrhage by pressure or tourniquet,
depending on the portion of the body injured.

3. Asepsis in caring for open wounds.

4. Asepsis in the treatment of burns; protection from
air if this can be done with aseptic methods.

5. Relief of pain by adequate use of morphine.

6. Immobilization of dislocations and fractures.

7. Transportation by methods that shall not increase
the extent of injuries.

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489

Acute Suppurative Mediastinitis*

With Report of a Case Also Showing Pulmonary Abscess
Charles Everard Lyght, M.D.f
Northfield, Minnesota

CLASSED among the more rarely encountered
regional inflammations, acute suppurative medias-
tinitis is usually traceable to: (a) one of the

chronic infections such as syphilis, tuberculosis, or osteo-
myelitis; (b) secondary pyogenic involvement of areas
invaded by neoplasms, ulcers, Hodgkin’s disease1, or
aneurysms; or (c) trauma with subsequent mediastinal
contamination through the punctured thoracic wall, frac-
tured sternum10 or perforated trachea or esophagus11’
12’13. In addition to (d) cases traceable to descending
involvement from Ludwig’s angina, retropharyngeal or
peritonsillar abscess, a smaller group (e) has been re-
ported where the inflammatory process seemed to arise
from an acute infection of the respiratory system, such
as tracheobronchitis, influenza, pneumonia, or pulmonary
abscess :i>5’6’11’12.

The lymphatics draining the affected areas convey the
infective agents to the adjacent tracheobronchial lymph
nodes. After a varying period of time, these glands may
undergo necrosis and allow pyogenic invasion of the sur-
rounding mediastinal structures. Occasionally, an ab-
scess, so produced, ruptures into the trachea or bronchus,
into the lung or pleural space, or into the esophagus.
Other instances are reported of rupture into the peri-
cardial sac, or of erosion of the walls of the great ves-
sels. Less frequently, the purulent collection discharges
through one of the intercostal spaces10. In children,
measles and whooping cough seem to have been very
occasionally responsible for mediastinal abscess forma-
tion4.

Acute mediastinitis of the suppurative type seems to
affect males more often than females, if the limited
number of cases in the literature can be accepted as a
reliable criterion. Adults are more frequently affected
than children. In fact, among infants and young chil-
dren, the occurrence of mediastinitis seems predom-
inantly due to erosion of the trachea or esophagus fol-
lowing the lodgement of foreign bodies in these sites.
Even so, the total number of cases in the young is rela-
tively small 2,s.

As regards the portion of the mediastinum invaded,
Lloyd and Hassett7 draw attention to Hare’s study of
36 cases, revealing 30 with involvement of the anterior,
four of the posterior, and two of the whole medias-
tinum. In the cases reported by various observers where
the lesion has arisen from respiratory tract infection, a
significant majority shows involvement of the right su-
perior mediastinum 4’5*6.

* From the department of student health. University of Wis-
consin, Madison, Wisconsin.

t Professor of student health, hygiene, and physical education,
Carleton College, Northfield, Minnesota; formerly director, depart-
ment of student health, University of Wisconsin, Madison, Wis-
consin.

That the occurrence of the condition may be consid-
ered quite rare is borne out by the following statistics,
as well as by the paucity of case reports in the literature.
Since the opening of the State of Wisconsin General
Hospital, Madison, in 1924, only five cases of proved
acute suppurative mediastinitis have been observed
among 91,000 patients, while over the corresponding
12-year period, 24,000 admissions to the University of
Wisconsin Student Infirmary have yielded no cases what-
soever among students. (Case 5, the one here reported,
occurred in a non-student patient.)

Of the five cases mentioned, four prior to the one
here to be reported have been summarized as follows:

1. Male, aged 56, had dysphagia for three months
prior to admission. The diagnosis was cardiospasm. A
barium meal and passage of a bougie was followed by
epigastric pain and signs of probable peritonitis. Lap-
arotomy showed free barium in the abdominal cavity.
Bilateral bronchopneumonia and an acute mediastinitis
developed, and death occurred on the third day after
admission to hospital. Autopsy confirmed the presence
of a perforated esophagus and a mediastinal abscess.

2. Female, aged 64, had dysphagia, nausea and vom-
iting for seven years prior to admission. X-ray revealed
cardiospasm and esophageal dilatation. Attempts to dilate
the constricted portion, first by a metal olive and later
by mild hydrostatic methods, were succeeded by intense
pain, choking, and dyspnea. Death supervened within
50 hours. After her death, the patient’s family volun-
teered the further information that 12 years previously
she had swallowed a quantity of phenol, with some grad-
ually increasing dysphagia thereafter. Autopsy disclosed
an inflamed and edematous posterior mediastinum, with
early abscess present.

3. Female, aged 42, was admitted for surgical removal
of a thyroid adenoma. Three days postoperatively she
developed stridor, dyspnea and cyanosis, making tra-
cheotomy necessary. Bronchopneumonia and medias-
tinitis occurred, with death on the ninth day following
operation. Autopsy verified the presence of a walled-off,
superior mediastinal abscess on the left, displacing the
trachea to the right.

4. Male, aged 17, deaf-mute, was sent to hospital be-
cause of daily afternoon temperature to 101° F. follow-
ing sore-throat of six weeks duration, right sided cervical
lymphadenopathy for four weeks, and pain in right low-
er chest three weeks prior to admission. A dry, non-
productive cough had been present. History further
complicated by the patient’s claim of having swallowed
a toothpick at a recent but indefinite date, without,
however, any immediate discomfort. Roentgenograms

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Dale Symptoms

4.1 3.36 (Adm.)

As above

4.14.36

Severe headache; no nausea;
dry cough continues in par-
oxysms.

4.15.36

Unchanged

4.16.36

Profuse diaphoresis; hyperes-
thesia of right side chest,
neck and scalp; cough con-
tinues; less headache.

4.17.36

More pain in chest and neck,
especially when coughing.

4.18.36

Coughing paroxysms less fre-
quent, still painful.

4.19.36

4.20.36

Most comfortable when flat
on back; lying on side causes
increased pain, slight dyspnea;
there is some dysphagia. (Ox-
ygen therapy begun 4.20.36).

4.21.36 A. M.

Subjectively improved by oxy-
gen therapy.

4.21.36 Noon Foul sputum in considerable
quantities being coughed up.

4.22.36 Had a better night, felt better.
Profuse expectoration of foul,
bad tasting sputum, blood
streaked at times.

4.23.36 More comfortable.

4.24.36 Improvement continues; less

cough and less sputum; pleu-
ral pain on coughing.

4.27.36 A. M.

4.27.36 P. M.

4.30.36

Slow improvement; cough and
production of blood-tinged
foul sputum gradually de-
creasing.

Sicker late in day, until ade-
quate drainage was suddenly
resumed; cough quite dis-
tressing.

Steady improvement

5.5.36 Much improved; cough less
frequent and painful; sputum
greenish, not so foul, very
little blood.

5.7.36 Practically no sputum.

3.9-23.36 Unchanged

5.24.36 Flare-up of fever, cough and
purulent expectoration, with
immediately following im-
provement.

6.4.36 Practically symptomless

CHART I.

Signs

As above.

Right chest findings unchanged; no rales.
Heart less overactive; 3rd sound at apex.
Right pectorals and trapezius sore to
touch; pain substernally on pressure.
Unchanged.

No evidence of consolidation; pneumo-
nia, if present, judged to be centrally
located.

Vague right sided chest signs as before;
no rales.

Percussion note and breath sounds over
right chest both improved. D’Esoine’s
sign positive. Septic type of tempera-
ture.

Harsher breath sounds on right; no
rales. Patient sicker: Temo. 102.2° F.,
pulse 112, respirations 30. Imoression:
rit^ht superior mediastinitis, acute, prob-
ably suppurative.

Temp. 100.6° F. Pulse 84, Rest). 24:
color good; heart action less labored;
P 2 strongly accentuated; no vascular en-
gorgement observed; signs over right
upper chest becoming definite, with more
limited excursion, increased tactile fre-
mitus, vocal resonance, and whispered
voice, prolonged expiratory phase, occa-
sional bronchial squeaks, marked impair-
ment to percussion along right sternal
border.

Bronchoscopic examination showed co-
pious purulent drainage from r»c*ht nv»;n
bronchus, no actual fistula observed, this
being probably well superior to the area
of possible visualization.

Temp. 98° F., Pulse 90. Resp. 24: chest
firdings unchanged; no rales, even after
coughing.

Inconstant pleural friction rub at right
anterior axillary line.

No rales; no rub; breath sounds less
harsh.

No rales; impairment of percussion note
the most noticeable sign.

Temperature 103.4°.

Slow subsidence of increased vibratory
phenomena; no rales.

Practically afebrile; moderate numbei
coarse rales in right interscapular area,
2nd to 5th ribs.

Physical signs steadily less marked.

Cavity located at level of 4th rib pos-
teriorly and 1st rib anteriorly.

Minimal.

Laboratory Findings

As above.

W. B. C. 27,400.

Poly’s. 91%

W. B C. 20,500.

Poly’s. 90%

X-ray: No

pneumonia.

W. B. C. 16,050.

Poly’s. 89 %

W. B. C. 19,800. Poly’s. 87%

Blood cultures: No growth up to 7 days.
Agglutination tests: All negative.

W. B. C. 26,800.

Poly’s. 88%

X-ray: widening of superior mediastinum
to right. Sputum negative pneumococci;
neg. TB.; gram stain showed large gram
pos. pleomorphic bacilli, small gram pos.
bacilli, streptococci, and gram neg. dip-
lococci.

W. B. C. 25,800. Poly’s. 86#

W. B. C. 30,350. Poly’s. 87%

X-ray: Rapidly increasing density in right
superior mediastinum as shown by A-P
and lateral views. Beginning to involve
medial portion of right upper lobe.

W. B. C. 30,900 Poly’s. 86%

Pus — Streptococci predominate, micro,
catarrhalis present.

W. B. C. 29,750. Poly’s. 90%

W. B. C. 27,850. Poly’s. 88%

W. B. C. 17,000. Poly’s. 89%

X-ray: density more sharply demarcated
in right upper lobe, medial half, with
suggestion of cavity formation.

W. B. C. 20,500. Poly’s. 84%

Pus — steadily negative to TB by stain,
culture, and guinea pig inoculation; neg-
ative fungus; flora as before.

Hb. 75%. R. B. C. 4,820,000. W. B.
C. 14,450. Poly’s. 82%. X-ray: dens-
ity about same. Central rarefaction
definite.

W. B. C. 13,200. Poly’s. 84%

W. B. C. 9,750. Poly’s. 66%.

Sputum: Continues neg. to TB. Sedi-
mentation rate: 27 mm. in 1 hr. (Cut-

ler).

X-ray: gradual resorption of inflamma-

tory reaction about abscess cavity; latter
measures about 2x1.5 cm. (flat film). W.
B. C. 7,200 to 9,350; Poly’s. 71% to
61%; Sed. Rate (5.14.36): 15 mm. in
1 hr. (Cutler). X-ray: steadv improve-
ment.

W. B. C. 11,200. Poly’s. 79%

X-ray: cavity measures 3x2.5 cm. (flat
film) .

W. B. C. 8,900. Poly’s. 75%

X-ray: Cavity size of small hen’s egg
(stereoscopic film). Surrounding reaction
has largely disappeared. Sed. rate: 9

mm. in 1 hr. (Cutler).

THE JOURNAL-LANCET

491

6.12.36

6.24.36

6.25.36

6.26.36

6.29.36

7.1.36

Allowed up in chair

To operating room for tem-
porary right phrenic block.
Some pain in upper distribu-
tion of right phrenic nerve.
Comfortable

Comfortable; conscious of
mild restriction of movement
in right chest. Up and about.
Discharged.

Diaphragmatic excursion (to percussion) :
Left is normal. Right lies 2.5 cm. above
left, moves little.

Diaphragmatic excursion (fluoroscopic):
Left, 6:75 cm. Right lies 3.5 cm. higher
than left, moves 2.5 cm.

W. B. C. 7,050. Poly’s. 65%

X-ray; further clearing, but cavity no
smaller.

Hb. 80%. R. B. C. 5,180,000.

X-ray: confirms position of diaphragms;
slight pleural haze over right apex; cav-
ity about same size.

Hb. 82%. R. B. C. 5,510,000. W. B.
C. 7,000. Poly’s. 72%.

^ ^ .

showed a right superior mediastinal density with a defi-
nite fluid level. The impression was that of mediastinal
abscess. Progressive improvement in symptoms, physical
signs, and X-ray findings occurred following a dramatic
drop in temperature within 36 hours after entrance,
though no pus was ever shown to have been vomited or
coughed up. Esophagoscopy showed nothing abnormal,
though the possibility does exist that the pus may have
been evacuated into the esophagus and swallowed.

This last patient, of the four above, stands alone in
bearing etiologically any resemblance to the case now to
be reported. Even in this instance, however, the possi-
bility of a foreign body having caused the initial trauma
cannot be successfully excluded. Incidentally, like the
present case, patient number four made a spontaneous
recovery, whereas the other three cases all terminated
fatally.

Case History

L. R. C., a white, male physician, aged 34, was admit-
ted to the University of Wisconsin Student Infirmary
on April 13, 1936, with the chief complaint of severe
headache and general muscular aching.

History of Present Illness : For almost three months
prior to admission to hospital the patient had been ex-
periencing a dry, hacking cough, worse at night, and
refusing to respond to all ordinary therapy. Repeated
physical examinations of the chest had been negative,
and fluoroscopic examination confirmed by an X-ray film
had shown nothing abnormal in lungs, heart, great ves-
sels, or mediastinum to account for the persistent symp-
toms.

Two days prior to admission to the infirmary there
had developed generalized aching, moderate headache
and some slight eyeball soreness. The patient went to
bed and treated himself as a case of la grippe. He felt
no better the following day, and during that night de-
veloped chills, increased fever, profuse diaphoresis, and
a muchj more intense frontal headache. The cough was
very distressing; there was pain in the right shoulder,
neck and chest increased by respiratory or voluntary
movements; mild abdominal distention, anorexia, nausea
and vomiting.

On the morning of April 13, the patient was exam-
ined at home, where the only positive findings were a
fever of 103.4° F., pulse 108, respirations 26, suppressed
breath sounds in right axilla accompanied by minimal
impairment of percussion note over the upper half of

the slightly lagging right chest. A tentative diagnosis
of early right-sided bronchopneumonia, probably influ-
enzal in type, was made, and the patient admitted to the
infirmary.

Past Medical History: Childhood: measles, mumps,
whooping cough, all mild and uncomplicated. Youth:
scarlet fever, severe, followed by chronic valvular endo-
carditis, as shown by physical examination and repeated
orthodiascopic studies. Adult life: spontaneous sub-
arachnoid hemorrhage, 1932, with full recovery. Sea-
sonal (ragweed) pollinosis, under adequate treatment.

Social History: Irrelevant, except for constant ex-

posure to acute respiratory infections through duties as a
physician in the Student Health Service.

Physical Examination: A thin, rather poorly nour-
ished but well developed white male of 34 years, quite
cooperative and well above the average in intelligence,
lying quietly in bed, but with slightly accelerated respir-
atory rate, and obviously very uncomfortable. Tempera-
ture 103.8° F., pulse 112, respirations 24. The positive
physical findings included: Warm, dry skin; eyeball
tenderness; injection of nasal and nasopharyngeal mem-
branes; anterior cervical glands palpably enlarged but
not tender; slight gaseous abdominal distention. The
chest showed slightly decreased expansion on the right,
accompanied over the right upper lobe by distant and
jerky breath sounds, a mild impairment of percussion
note, and slight accentuation of whispered and spoken
voice sounds. There were no rales. The heart rate was
rapid, 112 or over at all times, pulse of good quality,
blood pressure 124/70. The transverse diameter of the
heart was enlarged, the apex well outside the mid-
clavicular line. A soft, blowing, systolic murmur, audible
at the apex, was transmitted laterally to the mid-axilla.
The pulmonic and aortic second sounds were approxi-
mately equal in intensity.

The impressions at that time were: (1) influenza,

with acute rhinopharyngitis, right-sided bronchopneu-
monia, right-sided diaphragmatic pleurisy; (2) chronic
rheumatic heart disease, with moderate cardiac hyper-
trophy, mitral insufficiency, functionally Grade I.

Although a pneumonic process seemed the most ten-
able diagnosis, yet, because of the pre-existing rheumatic
heart lesion and the relatively recent vascular disaster,
the possibility of a lighting-up of the cardiac pathology
had Po be kept in mind, especially in the presence of
intractable chronic cough, pallor, fatigue, and substernal

492

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GOAPHIC CUNICAL CHADT GPAPHIC CUNICAL CHAOT GRAPHIC CLINICAL CHABT

soreness, succeeded by chills, fever, anorexia, nausea and
vomiting, and profuse diaphoresis.

Laboratory Findings on Admission: Blood culture

showed no growth up to 8 days. Hemoglobin was 82%;
R.B.C. 5,980,000; W.B.C. 19,700. Neutrophiles were
84%, stab cells 9%, metamyelocytes 1%, small lymph-
ocytes 6%. Urinalysis revealed specific gravity 1.015;
acid; albumin 0.005%; glucose 0; acetone positive; a few
W.B.C.; 2 casts in 10 low-power fields. X-ray of chest
showed no evidence of pulmonary consolidation.

In Chart II above will be seen the graphic record of
temperature, pulse and respirations, while Chart I in
chronological order gives the contemporaneous symp-
toms, signs and laboratory findings. The radiographic
studies included are in general comparable, if due allow-
ance be made for the various technics necessary during
the course of the illness. Six films have been selected
from a large series, as representative of the most signifi-
cant phases through which the patient passed. Figs. 1
to 4 are flat bedside films, mostly with the patient re-
cumbent or in semi-recumbency, made with a portable
diagnostic unit, the tube at a distance of three feet from
the chest. Some of these were purposely overexposed in
order that the cavity’s limits might better be appreciated.
Figs. 5 and 6 are from stereoroentgenograms, employing
the six-foot distance. The progress of the lesion is ad-
mirably depicted by these films, showing how it devel-
oped from the right superior mediastinum, invaded and
localized in the right upper lobe, subsequently broke
down, to discharge via the bronchial route.

Summary

The case of a young physician is presented, beginning
with a mild acute respiratory infection, first of the up-
per passages, later of the tracheobronchial system. After

the acute phase had passed, a chronic dry, non-productive
cough developed which lasted for nearly three months,
during which time it defied diagnosis and therapy. Then
occurred either a new acute respiratory infection, or more
probably what represented the toxic manifestations of an
acute pyogenic mediastinitis, originating in all likelihood
in a group of inflamed tracheobronchial lymph nodes,
and extending thence to the right superior mediastinum.
An early diagnosis of right bronchopneumonia accom-
panying a case of influenza was neither supported by
radiologic findings nor by subsequent course. A septic
temperature, high leukocytosis, and evidences of right
phrenic nerve involvement led to a tentative diagnosis of
acute suppurative mediastinitis. At about this stage the
X-ray findings first became recognizable, and a medias-
tinal density developed which gradually spread to the
adjacent upper right lobe. Here, a pulmonary abscess,
with surrounding pneumonitis, localized. Fortunately
this evacuated spontaneously via the eparterial bronchus
serving that area. A moderately stormy course gave way
to a fairly uneventful convalescence, marked by two
recrudescences due to temporarily inadequate drainage.
Necrosis left a central cavitation that for many weeks
showed no tendency to disappear, but the institution of
a phrenic-crushing procedure on the affected side greatly
diminished activity in that lung. The patient left the
hospital in excellent condition, resuming his regular
duties at the beginning of the academic year in Sep-
tember. Therapy had consisted of bed-rest, with purely
symptomatic measures for relief of pain, headache,
cough, and sleeplessness. A high caloric intake, with
frequent general body radiations of ultraviolet light
was supplemented with iron, to correct a mild hypo-
chromic anemia that developed. Oxygen was adminis-
tered for three days, at the height of the patient’s illness,

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493

Figure 3

Figure 2

Figure 4

with excellent result. The laboratory findings, as given,
are those that might be predicted from the clinical pic-
ture. No evidence of active pulmonary tuberculosis was
ever found, by direct sputum examination, cultures, or
guinea pig inoculation. The causal organism was most
likely the predominant streptococcus found in all sputum
specimens, though a very mixed group of micro-
organisms with even a very occasional spirochete was
reported.

Roentgenographic studies made in January, 1937,
finally revealed complete closure of the cavity. The
patient is in excellent health.

Comment

This case rather closely resembles one in a student
nurse reported by Farnum12, and one in a patient con-
valescing from pneumonia, recorded by Lloyd5. All
three proceeded to spontaneous evacuation of their ab-

494

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Figure 5

scesses via the bronchi or trachea. Similar cases are
scarce in the literature, probably because the condition
seems truly infrequent in occurrence. The clinical rec-
ognition of acute suppurative mediastinitis in its early
stages is remarked by most writers as unusual. Occur-
rence of a chronic non-productive cough, substernal pain,
or thoracic visceral pressure effects, especially following
an acute respiratory infection, and accompanied by a
septic temperature, chills, and polymorphonuclear leuko-
cytosis, should arouse suspicion as to its presence, just
as would such symptoms if observed in patients acknowl-
edged to have had more immediate local reason (e. g.,
foreign body) for development of mediastinal inflamma-
tion. While physical signs may be lacking for a consid-
erable period of time, and may never exceed moderate
impairment of percussion note, the roentgenogram
should disclose rather early the increase in the medias-
tinal shadow. It is the prime diagnostic method in these
cases.

The therapy is largely symptomatic and supportive,
though surgery may have to be enlisted where nature
is not as kind as in the case here described. Trephining
of the sternum, or resection of overlying ribs is the
usually recommended procedure in cases of anteriorly
placed abscesses. Malnekoff4 reported a case in an infant
treated successfully by repeated aspirations of pus
through a needle inserted close to the sternum. Salazar
dc Sousa6 added to this procedure the injection of neo-
arsphenamine into the abscess cavity, though his case
eventually came to operation. Butler9 also reported the
employment of neoarsphenamine in local application to

Figure 6

a mediastinal abscess cavity where spirochetes were iden-
tified as the causal organism, with spectacular results.

The prognosis is always grave in cases of acute sup-
puration in the mediastinum, but not hopeless. Early rec-
ognition, followed by judicial selection of the optimum
time and avenue for surgical drainage, would seem to
promise the greatest chance of recovery to those cases
where the abscess is so situated that anatomically the
patient has not been doomed from the beginning.

Bibliography

1. Lemon, W. S., and Doyle, J. B. : Clinical Observations of

Hodgkin’s Disease, with Special Reference to Mediastinal Involve-
ment, Am. J. M. Sc. 162:516, (Oct.) 1921.

2. Cook, O. S.: Acute Mediastinal Abscess, Am. J. Roentgenol.
10:696, (Sept.) 1923.

3. Lerche, W.: Mediastinal Lymph Nodes as Source of Medias-
tinitis, Arch. Surg. 14:285, (Jan.) 1927.

4. Malnekoff, B. J.: Acute Mediastinal Abscess, Am. J. Dis.

Child. 39:591, (March) 1930.

5. Lloyd, M. S.: A Case of Mediastinal Suppuration with Re-

covery after Spontaneous Drainage into the Trachea, New York
State J. Med. 31:471, (Apr.) 1931.

6. Salazar de Sousa, C. : Abces Aigu du Mediastin Posterieur,

Arch, de Med. d. enf. 35:33, (Jan.) 1932.

7. Lloyd, H. J., and Hassett, R. G.: Abscess of the Medias-
tinum, Minn. Med. 16:257, (Apr.) 1933.

8. Moersch, H. J., and Kennedy, F. S.: Mediastinitis, M. Clin.
North Amer. 16:1433, (May) 1933.

9. Butler, E. F.: Putrid Mediastinal Abscess with Spirochetal

Infection: Report of a Case, Ann. Otol. Rhin. and Laryng. 43:

878, (Sept.) 1934.

10. McKinlay, C. A., Kinsella, T. J., and Radi, R. B. : Acute
Essential Hypertension Precipitated by Mediastinal Abscess, Arch.
Int. Med. 54:645, (Oct.) 1934.

11. Whale, H. L. : An Unusual Case of Mediastinal Abscess,

Brit. M. J. 1:154, (Jan. 26) 1935.

12. Farnum, W. B.: Acute Suppuration of the Mediastinum,

New York State J. Med. 95:724, (July) 1935.

13. McLester, J, S., and Christian, H. A.: Oxford Medicine,

New York, Oxford University Press, Vol. II, Part 1:210, 1936.

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495

When Surgery Is Indicated In Pulmonary Tuberculosis '

Thos. J. Kinsella, M.D.f
Minneapolis, Minnesota

THIS TITLE, as originally suggested by Dr.
Coslett, readily lends itself to a consideration of
the subject matter in two distinct divisions, both
of which are of vital importance to the safety of the
tuberculous patient for whom surgery is necessary.
First of all, we may consider, "when is surgery indi-
cated in the patient with pulmonary tuberculosis" for
pulmonary and extrapulmonary foci of either tubercu-
lous or non-tuberculous disease, and secondly, if sur-
gery is indicated and has been decided upon, how shall
we handle the problem so as to afford the patient the
least possible risk to his life or future health? Separate
consideration will be given to both phases of the sub-
ject which, however, must be well correlated if best
results are to be obtained.

When Is Surgery Indicated in Pulmonary
Tuberculosis?

The patient suffering from pulmonary tuberculosis
may require surgical intervention, either to aid him
in controlling his pulmonary lesion, or to relieve him
of some extra-thoracic process which is threatening his
life, interfering with his comfort, or impeding his
efforts to control his pulmonary infection. For the pur-
poses of this consideration, surgical procedures may be
divided into emergency and elective operations. Emer-
gency operations for tuberculous pulmonary disease are
relatively rare, but occasionally, emergencies arise which
demand immediate treatment if the patient is to be
saved. The institution of artificial pneumothorax or the
interruption of a phrenic nerve for the control of pro-
fuse or repeated pulmonary hemorrhage, the aspiration
of air to relieve the pressure of a tension pneumothorax,
or the aspiration of a massive pleural or pericardial
effusion, constitute emergency surgical procedures
which, while relatively simple in themselves, may nev-
ertheless be life-saving in effect. Emergency surgical in-
terference for conditions outside of the chest will prob-
ably be indicated more frequently, and may be equally
as important to the patient. The removal of an acutely
inflamed appendix, the relieving of a strangulated hernia
or an intestinal obstruction, the closure of a perforated
viscus, the drainage of a pelvic or perinephritic abscess,
or the reduction and fixation of a fracture, constitute
emergencies which must be treated in spite of active
pulmonary tuberculosis if the patient is to survive or
avoid more serious complications; yet they should be
handled in such a way as to jeopardize to the least de-
gree the patient’s chances of recovery from his pul-
monary disease. Certain points to be considered in order
thus to safeguard the patient during such procedures

* Presented before the annual meeting of the South Dakota
State Medical Association held at Rapid City, May 24-26, 1937.

t Departments of Surgery of Glen Lake Sanatorium, Minne-
apolis General Hospital, University of Minnesota.

t Assistant professor of surgery. University of Minnesota.

will be considered later. We cannot endorse the feel-
ing, once so common among physicians doing tuber-
culosis work, that tuberculous individuals should not be
subjected to surgery, for this attitude unnecessarily
denies to many a patient his right to live.

An emergency surgical operation properly performed
with due consideration of an active tuberculous lesion
may prove of great benefit to the tuberculous individual,
rather than a detriment to him. We cannot justify the
attitude of some surgeons, who brazenly proceed with
surgical operations which are of a purely elective nature
without any consideration of an active pulmonary tu-
berculosis, and attempt to justify such interference by
the statement that nothing happened during the pa-
tient’s two weeks residence in the hospital, or that they
hoped, by relieving the patient of one focus, to enable
him better to control his pulmonary disease. Pulmonary
tuberculosis is potentially far more dangerous to life
than any other tuberculous focus and should, therefore,
be given prime consideration whenever surgery is in-
dicated. The selection of the proper time for the per-
formance of elective surgery in the patient with pul-
monary tuberculosis is at times a difficult problem, and
one which calls for the exercise of rare judgment in
which the phthisiologist, the internist and surgeon must
carefully weigh all angles before making the decision.
The patient’s whole future may be determined by the
care with which this decision is made, for it avails
nothing to treat successfully an extrapulmonary focus,
and then have the patient succumb to his original pul-
monary disease.

Effective Surgical Procedures for
Pulmonary Disease

Pulmonary tuberculosis is a chronic disease whose
course is frequently marked by exacerbations and re-
missions, but whose general tendency under unfavorable
conditions is toward progression. Under favorable con-
ditions, its progress may not only be stopped, but not
infrequently may be reversed to a degree which permits
recovery. Years of experience in treating tuberculosis
has amply demonstrated that the conditions most fa-
vorable for the healing of a tuberculous lesion are those
which most closely approach absolute physiological rest
for the involved tissue or organ. The disease, however,
is a constitutional one, and any system of treatment
which treats only the local lesion and not the patient
as a whole falls short of giving the individual his best
possible chance of recovery. While it is possible in cer-
tain extra-pulmonary tuberculous foci, such as in knee,
elbow or hip, by proper methods to obtain almost a
complete ablation of all physiological function, this is
impossible in diseases of the respiratory system, for the
patient must continue to breathe if he is to survive. It

496

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is possible, however, to obtain marked reduction, of this
function, and excellent results have been obtained by
the intensive use of such measures, in spite of the fact
that they fall somewhat short of the ideal described
above. The closest approach to ideal conditions by med-
ical management of both the patient and the local lesion
is provided by the prolonged intensive bed-rest available
in the well-equipped modern sanatorium for the intensive
hygienic, dietary and disciplinary control of the patient
suffering from pulmonary tuberculosis. Under such a
regimen, patients suffering from minimal or uncompli-
cated moderately-advanced pulmonary tuberculosis
should have more than a 90 per cent chance of making
a good recovery. The same program may be carried
out in the local hospital or the home, but almost in-
variably at some sacrifice of efficiency of the treatment,
the amount depending upon the conscientiousness of
the patient, and the perseverance with which the re-
quired discipline is maintained.

Complete recovery in individuals with more extensive
disease is impeded or prevented by the massive extent
of the disease itself, by the occurrence of some inter-
current complication such as pulmonary hemorrhage, or
the development of intrapulmonary cavitation, or, more
rarely, by pyothorax or pyopneumothorax. It is in an
attempt to correct or relieve the patient of these com-
plications that our surgical efforts are directed. It must
be understood from the outset that surgical operations
do not cure pulmonary tuberculosis; that they do not
remove one bit of tuberculosis from the patient’s body;
but that they merely act directly in a mechanical way
to control bleeding, to close intrapulmonary cavitation or
obliterate the pleural cavity and indirectly to supplement
our constitutional measures by immobilizing and reduc-
ing the capacity of the lung, and by altering the
respiratory, circulatory and lymphatic systems in such a
way that healing occurs more readily. They are val-
uable adjuncts to our constitutional treatment; but not
the most important part thereof. Their use, without at
the same time treating the patient for his tuberculosis
by constitutional means, demonstrates either a woeful
lack of appreciation of the fundamental principles in-
volved in the treatment of this disease, or a willingness
to gamble on obtaining a good result by half-way mea-
sures with the patient assuming all of the risk. No
patient suffering from pulmonary tuberculosis has any
chances to throw away, and it is folly, with the facilities
available at the present time, to do anything but take
advantage of every possible means to render the patient’s
recovery more certain.

When Is Collapse Therapy Indicated

The patient suffering from active pulmonary tuber-
culosis should be placed in bed, and carefully studied
from head to foot in order to determine the extent of
disease, its complications, what other organs if any
are involved and to what degree — in other words, stud-
ied so that we may know everything possible about the
patient and his disease, and the handicaps which may
confront him. It is only by this method that an in-

telligent program of treatment can be undertaken. We
must treat the patient, and not merely his local disease.
Physical examination of the chest alone is not sufficient,
for it does not give us all of the information needed
concerning even the lungs themselves. Stereoscopic
X-ray films of the lungs, properly made and interpreted,
reveal many things concerning the extent, type of disease
and complications altogether unsuspected from physical
examination alone.

If the disease be minimal or early moderatelv-ad-
vanced, without pulmonary hemorrhage or demonstrable
cavitation, constitutional treatment alone may prove
sufficient. The patient should be placed on an intensive
constitutional regime for a period of six to eight weeks,
at the end of which the situation should again be re-
viewed with the help of additional physical examination
and X-ray films of the chest. If improvement has oc-
curred, and all evidence indicates that everything is pro-
gressing favorably, this program should be continued
until the desired result is obtained and the patient has
cleared up as much tuberculosis as possible. If any ex-
tension of the disease is now demonstrated or cavitation
or other complications have developed, collapse of some
type should be undertaken without delay. Should the
original examinations reveal somewhat more extensive
disease with small cavity or more marked symptoms and
yet disease which is not too advanced, a similar program
may be followed, particularly if the patient, prior to the
time his tuberculosis was discovered, had been under-
going marked strain or exertion, so that the change from
his original program to the sanatorium regime consti-
tutes a marked retrenchment. Constitutional treatment
alone, in some such individuals, may provide an adequate
answer for the whole problem. If, however, at the end
of this observation period, the patient has not dem-
onstrated definite signs of improvement in symptoms,
either toxic or local, or elimination of the cavity, or if
the secondary review of the situation reveals any tend-
ency toward progression or the development of more
cavitation, collapse therapy of some type should be
undertaken without further delay.

If the patient, upon the original examination, pre-
sents more extensive tuberculosis or evidence of extra-
pulmonary tuberculosis, particularly involvement of the
larynx or intestinal tract, or the presence of more than
small cavitation, we feel that collapse therapy by one of
the simpler methods should be attempted without delay
and without the preliminary period of observation. The
general tendency throughout the country in the past
few years has been to establish collapse earlier and on
slighter indications than several years ago, although it
may be said truthfully that at times this has been car-
ried to an absurd extreme by those who have forgotten
or never learned that even fairly extensive tuberculosis
may not infrequently be controlled within a reasonable
time under conservative measures alone. The earlier in-
stitution of collapse therapy, particularly in the presence
of persistently positive sputum, has been followed by a
striking reduction in the incidence of tuberculous com-
plications in the larynx and intestinal tract, and has un-

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497

doubtedly increased the incidence of recovery from ex-
tensive tuberculous disease. It should go without saying
that the simplest type of collapse adequate to meet the
situation should be the one chosen in each particular
instance. We still see considerable lack of judgment
evidenced in the selection of the proper method in some
individuals, varying from the use of extremely radical
methods for relatively simple lesions to the equally ab-
surd extreme of pinning one’s faith upon simple pro-
cedure in the face of very extensive disease capable of
being controlled with difficulty by the most radical form
of collapse.

Types of Collapse Available

Collapse therapy measures available for the treatment
of pulmonary tuberculosis may be roughly divided into
two classes: (1) the group of procedures which are di-
rected against the lung itself, and (2) the series of
procedures in which the lung itself is secondarily affected
through operations directed against the respiratory mech-
anism. The first group includes the procedures of arti-
ficial pneumothorax, intrapleural pneumonolysis (ad-
hesion cutting within a pneumothorax cavity) , and extra-
pleural pneumonolysis with plombe (paraffin pack) . The
second group of procedures directed against the respira-
tory mechanism include: (1) operation upon the phrenic
nerve (phreniphraxis, phrenicectomy, phrenic exeresis) ,
(2) intercostal neurectomy (section of the intercostal
nerves), (3) scalenotomy (section of the scalene muscles),
and (4) extrapleural thoracoplasty. As adequate con-
sideration of even one of these procedures would pro-
vide ample material for a book, we must here be content
with a very brief consideration, and a statement of our
evaluation of them, rather than a detailed discussion
thereof.

Artificial Pneumothorax

Artificial pneumothorax is the simplest and safest, yet
withal the most valuable type of collapse therapy, and
should be given first consideration whenever collapse is
indicated. Its success depends upon the absence of ad-
hesions between the visceral and parietal pleura over the
site of the tuberculosis, particularly the cavity, and our
ability to establish and maintain adequate collapse of
this portion of the lung. Within limits it may be in-
creased and decreased at will by the operator, and is
capable of giving the most complete collapse of the lung
possible by any method or combination of methods. It
may be used as a temporary procedure, and discontinued
when it has served its purpose, allowing the Jung to ex-
pand after the lesion has become healed. Because of
its flexibility and controllability it may, if carefully
handled, be used as a bilateral procedure with a consid-
erable margin of safety. When intelligently used and
properly controlled (fluoroscopic, X-ray, physical exam-
ination frequently) , it is capable of producing miraculous
change in the condition of the patient under treatment.
It will double or treble a given patient’s chances of re-
covery over what he has to expect without it. The oc-
currence of complications, accidental pneumothorax

(frequent, early), spontaneous pneumothorax (occa-
sional) , air embolism (one in 10,000 injections) , pleural
effusion (60 to 80 per cent) and tuberculous pyopneu-
mothorax (eight to ten per cent) , and the necessity for
continuing it for a long period of time detract from its
value but still leave it as the first-ranking type of collapse
therapy.

Intrapleural Pneumonolysis

Complete obliteration of the pleural cavity renders
the establishment of a pneumothorax impossible. Local-
ized obliteration of the pleural cavity, particularly about
the area of tuberculous pulmonary disease, may render
the collapse inadequate or prevent closure of the cavity.
Localized adhesions of the string, cord, thin band or
membranous type, and occasional cone-shaped attach-
ment of the lung to the parietal pleura may be success-
fully sectioned or detached by the operation of intra-
pleural pneumonolysis (adhesion cutting) , performed
either according to the open or closed method. The open
method in which the pleural cavity is opened through
an intercostal incision, and the adhesions ligated and
sectioned under direct vision, is a major procedure en-
tailing more risk but occasionally offering control of
situations which could not be met otherwise. The closed
method in which the adhesions are visualized through a
telescope, and sectioned and detached either by the use
of galvano-cautery or the endotherm is somewhat more
complicated technically, but carries with it less risk and
is entirely adequate for most situations where the pro-
cedure is indicated. Either procedure, if successful, en-
ables the operator to convert an otherwise unsatisfactory
pneumothorax into a satisfactory pneumothorax without
adhesions. The complications of hemorrhage, spon-
taneous pneumothorax, hydro- and pyo-pneumothorax
increase in frequency as the more and more complicated
and consequently more difficult cases are undertaken.
The procedure is a valuable one which has, however, at
times been overemphasized by certain enthusiasts.

Extrapleural Pneumonolysis

When the pleural cavity is completely obliterated by
adhesions, such as follow extensive pleural effusion, and
it has been found impossible to establish pneumothorax,
another type of operation called extrapleural pneumono-
lysis may at times be used to advantage. This pro-
cedure, once used, later abandoned and since revived, con-
sists in the resection of a portion of one rib posteriorly,
the stripping of the parietal pleura from the inside of
the chest wall over the area occupied by the tuberculous
lesion, and the filling of the space thus established by
some type of plastic material (most frequently paraffin
or some combination thereof) in order to maintain per-
manently the collapse obtained. By avoiding those con-
ditions which in the history of the procedure led to
complications, and limiting its use to patients presenting
smaller cavities (under five cm.) not peripherally sit-
uated, and no free pleural space, it has been possible to
avoid such complications as perforation, extrusion, infec-
tion and migration which previously brought the pro-

498

THE JOURNAL-LANCET

cedure into disrepute. When properly used, in care-
fully selected patients, in amounts which were not too
large (200 to 450 grams) it can give us adequate col-
lapse of local lesions in one operation, without deform-
ity save for the scar, and with less reduction of breath-
ing capacity than would accompany a thoracoplasty giv-
ing the same amount of collapse. It has proven partic-
ularly useful in patients with limited vital capacity, in
poor risk patients, and those in whom some type of
bilateral collapse is necessary. To date, in 35 operations
on 32 patients in our experience, there has been no mor-
tality; and the majority have obtained the results de-
sired. In three instances, it has been necessary to per-
form thoracoplasty over the pack because of a recur-
rence of positive sputum, but in none of these has the
pack been removed. Our past experience justifies its
continued use.

Surgery Upon the Phrenic Nerve

Phrenic nerve interruption, temporary or permanent,
has been used widely, if not always too wisely, in the
treatment of this disease since its introduction in 1911.
Because of the apparent simplicity of the procedure,
the publication of numerous over-enthusiastic reports
and the occasional occurrence of almost miraculous re-
sults following its induction, thousands of operations of
this type have been performed on tuberculous individuals
without adequate consideration being given to the mech-
anism of its action, the probability of its producing the
desired results and especially to the possible complica-
tions which might later be encountered as the result of
its indiscriminate use. This, in turn, has brought about
a reaction to the opposite extreme, with some men dis-
carding it completely, and denying any possible benefit
which might follow its use. Neither extreme is justi-
fiable. It has its uses, but likewise its limitations. It
produces a limited reduction in chest capacity (not over
30 per cent at the most) , and a relative immobilization
only, but it does not prevent aspiration of sputum from
apex to base. It may impede rather than facilitate ex-
pectoration. It may not be simple, and it may not be
harmless. The great difficulty has been not so much
in the procedure itself as in the judgment with which
it was used. It is as illogical to expect paralysis of the
diaphragm alone to take adequate care of extensive
tuberculosis with cavitation as it is to treat minimal
pulmonary tuberculosis by thoracoplasty or asymp-
tomatic X-ray shadows by pneumothorax. It may be
of value in certain earlier lesions or in combination with
pneumothorax, where the lung is adherent to the central
portion of the diaphragm, and occasionally as a prelim-
inary preparatory measure for thoracoplasty (exudative
disease or contralateral activity) . Also, it may be of
value as a supplementary procedure to complete thora-
coplasty. As an emergency measure for control of hem-
orrhage, it may also be valuable. Occasionally, miracles
are wrought, but rarely in extensive pulmonary disease
is it satisfactory as a sole therapeutic measure. Perma-
nent interruption (phrenic exeresis or phrenicectomy)
should rarely be performed as a primary procedure, but

may at times be utilized secondarily. Temporary inter-
ruption by crushing (phreniphraxis) should be the meth-
od used as a primary operation, repeated as necessary
subsequently. The wisdom of its use as a bilateral pro-
cedure, in any form but temporary, is open to serious
doubt.

Extrapleural Thoracoplasty

Extrapleural thoracoplasty represents a rather radical
answer to what otherwise might prove a very unfavorable
situation in the life of a patient suffering from pul-
monary tuberculosis. Its use provides collapse and im-
mobilization of the lung in patients in whom the pro-
cedures mentioned above have been either impossible or
inadequate. By this method, the rigid bony frame-
work of the chest is removed to permit the underlying
lung to collapse and retract in an attempt to control
the extensive underlying disease. Originally, thora-
coplasty was used more or less as a last resort in an
attempt to avert what might otherwise be a fatal out-
come. In spite of the unfavorable circumstances under
which many of these operations were undertaken, many
surprisingly good results have been obtained. As a result
of this experience, the attitude of the profession is chang-
ing somewhat, with the result that now the procedure
is being recommended much earlier in the course of the
disease, before the patient’s resources are exhausted and
when the chances of successful rehabilitation following
a satisfactory operation are infinitely better. This change
of policy, together with increased experience in handling
patients of this type, has resulted in a lower mortality
and higher percentage of good results.

The chief indications for which thoracoplasty opera-
tions are performed include pulmonary cavitation, most
frequently, extensive unilateral disease, profuse or re-
peated pulmonary hemorrhage and tuberculous pyo-
pneumothorax or pyothorax with or without secondary
infection. The presence of intrapulmonary cavitation,
either large or small, probably constitutes the chief in-
dication for this type of interference, and the success of
the operative procedure may be pretty well gauged by
our ability to bring about closure of the offending cavity.
If the cavity be small and relatively soft-walled, partial
thoracoplasty even of a limited type may prove adequate.
If the cavity is very large, and there is little or no lung
tissue left in the upper portion of the chest, or if the
overlying pleura or the cavity wall is extremely rigid,
even complete removal of all ribs combined with a num-
ber of accessory procedures may prove insufficient and
the cavity becomes reduced in size but not completely
closed. This constitutes another argument for the ap-
plication of collapse therapy early, if the patient can
be discovered and treated at this time. The use of
partial thoracoplasty in circumstances where it has a
legitimate chance of proving successful is to be com-
mended as the additional breathing space spared in the
lower portion of the chest adds to the patient’s eventual
vital capacity and thereby, if the result is successful,
to his working capacity.

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499

The extent of the thoracoplasty to be performed in
a given individual should be determined in each par-
ticular instance by the extent and character of the dis-
ease, the size of the cavity, as well as the patient’s ability
to withstand surgery rather than by any rule of thumb
or routine procedure. Small lesions at times may re-
quire rather extensive surgery whereas, paradoxically,
large cavities may occasionally disappear following
rather limited rib resection. The amount of surgery
to be performed, like the proper dose of morphine for
the control of pain, should be enough to accomplish the
desired result. If partial thoracoplasties are to be used
frequently, the surgeon may find it advisable, if the
scapula be long, to resect the lower angle in order to
permit the shoulder blade to fall forward and facilitate
subsequent arm motion.

Years of experience have demonstrated the wisdom
and the safety of performing thoracoplasty in stages,
the number and sequence of which should be determined
by the character and extent of the lesion, the patient’s
condition and ability to withstand surgery, his reaction
to trauma while undergoing the operation, the flexibility
of the chest wall and mediastinum, the amount of blood
lost, etc., rather than by any previous plan or technic.
As the surgeon can judge some of these points only as
the operation proceeds, he must be willing to adapt him-
self to changing circumstances as they arise. It is in-
finitely better to have a living patient who will require
further surgery than a dead patient upon whom a
beautiful operation has been performed. The surgeon
should at all times have the patient’s interests rather than
his own inclinations at heart.

The question of local or general anesthesia for tho-
racoplasty, again, must be determined by the patient’s
condition, and to a lesser degree, by the surgeon’s pref-
erence. There can be no question but that in many
patients the choice of anesthetic, if properly given, does
not make a great deal of difference. The sicker the
patient or the poorer his condition, the greater the vol-
ume of his sputum, the lower his respiratory reserve,
whether it be diminished by disease or contralateral col-
lapse, the greater the indication for the use of local
anesthesia, if the surgeon be skilled in its use. Should
the surgeon be technically unskilled or temperamentally
unfitted for the use of local anesthesia, it would be
unwise for him and unfortunate for the poor risk pa-
tient that such an anesthetic should be used. Under
local anesthesia, the time consumed in performing the
operation becomes of less importance. Under any
anesthetic a race to complete the operation in record
time benefits the patient little, if any.

The sequence of operations has varied widely in our
experience. Usually the upper posterior three or four
ribs have been removed first, an anterolateral resection
of the remaining segments of these ribs and cartilages
being performed as a second or third stage if necessary
and the others in whatever sequence seems advisable.
The procedure and sequence has been gauged entirely
by the indications and the patient’s reaction. Zenker’s

fluid, or formaldehyde, applied to the periosteal bed
for four or five centimeters posteriorly in the region of
the angle of the rib, has been used in all stage opera-
tions and apparently has resulted in reduced regenera-
tion of rib in this area. When the costal cartilages have
been removed in front, the perichondrium has always
been carefully-preserved, and no difficulty has Jeen
encountered subsequently in obtaining permanent fixa-
tion of the chest wall in this region. Temporary inter-
ruption of the upper seven intercostal nerves pos‘eriorly
has been used frequently, and we believe contribute? con-
siderably to the patient’s postoperative comfort.

The interval between the operations should be deter-
mined entirely by the patient’s condition and reaction
to surgery, and the changes which occur in the tuber-
culosis under observation. This interval has varied
widely from two weeks to months, with an average of
approximately three weeks. Certain patients who are
poor risks may stand one operation relatively well, but
do badly if subjected to additional procedures within a
short period of time. Occasionally, it is wise to perform
one operation and then wait even several months before
proceeding with others. Even if it is necessary to re-
operate the original ribs at the end of this time, the
patient’s improvement renders the delay valuable in
spite of the reoperation required. Many patients, who
have been subjected to a series of stages at intervals of
three weeks could easily have been operated upon after
only ten to 14 days’ delay, but the additional week of
waiting has enabled the patient to improve to the extent
that he finishes the series in excellent condition, and at
approximately the same weight as when he started. The
blood loss in thoracoplasty varies somewhat, but it need
not be excessive if careful attention is paid to hemostasis.
In our experience, actual determination of losses for
stage operations has been as follows:

Upper stage posterior (3-4 ribs) 450 cc.

Lower posterior (3-4 ribs) 196 cc.

Intermediate posterior (3-4 ribs) 296 cc.

Anterolateral (3-4 ribs and cartilages) 250 cc.

This, we are confident, is considerably lower than
is frequently seen where the whole operation is per-
formed in a pool of blood.

Result of Thoracoplasty

Extrapleural thoracoplasty has been used in the treat-
ment of pulmonary tuberculosis at Glen Lake Sana-
torium for over 15 years, during which time more than
900 operations of this type have been performed on
approximately 360 patients. From this group, 262 or
78.8 per cent are still alive, leaving a total mortality for
all times and from all causes of 21.2 per cent. This is
a surprising figure when one considers the time period,
and the fact that all patients were suffering from pul-
monary tuberculosis of a more or less advanced degree.
One-half of this mortality has occurred in the period
ranging from one to several years following the com-
pletion of the surgery. The operative mortality within
two weeks is 4.74 per cent within the first two weeks,

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6.42 per cent in four weeks, 7.26 per cent in eight
weeks for the whole series as calculated on the basis of
the number of patients. If calculated on the basis of
operations performed, the figures for the same time
period will be approximately 0.4 of those quoted above.
It is of interest to note that 77 per cent of the mortality
occurred in the first 45 per cent of this series, and that
since 1931 the operative mortality within two months
calculated on the patient basis has been 1.7 per cent,
while the mortality on the operation basis for this same
period has been 0.88 per cent.

If we now consider only patients upon whom thoraco-
plasties have been performed more than two years ago,
i. e., from 1922 to 1934 inclusive, we find that 185 of
the 264 patients operated upon, approximately 70.1 per
cent, are still alive, and that of this group 161 or 87
per cent are capable of performing some useful work.
It is extremely difficult to evaluate properly all of the
factors involved or to express in figures all that surgery
may have accomplished for these individuals. A life
saved is a notable accomplishment, but a life prolonged
may likewise be a very praiseworthy attainment. The
elimination of bacilli-laden sputum from a patient who
is returned to his home, while frequently not considered,
may prove of inestimable benefit to the community as
well as to the patient. Without surgical help, the vast
majority of these patients have little to expect save the
life of chronic invalidism. Following successful surgery,
the whole outlook may be changed. Each individual so
rehabilitated contributes his share to encourage the sur-
geon to persevere in the work in the face of many dis-
appointments.

Bilateral Collapse

With increased knowledge of collapse therapy and
chest physiology, surgeons have gained confidence and
experience, which now enables them to cope with bi-
lateral tuberculosis, particularly that involving the upper
portion of the lungs only, with the resultant saving and
rehabilitation of a considerable number of individuals
who previously were considered beyond all help, if they
did not recover under conservative treatment. Bilateral
pneumothorax, if possible and satisfactory, may prove
the most efficacious of the group of procedures available,
but it requires careful handling if consistent successful
results are to be obtained. It may be used either as an
alternating or simultaneous procedure. Intrapleural
pneumonolysis may be done in the presence of bilateral
pneumothorax if indicated, and without undue risk if
judgment and care are used. Various combinations of
pneumothorax with contralateral phrenic nerve surgery,
extrapleural pneumonolysis, and thoracoplasty, have been
successfully carried out at Glen Lake Sanatorium for
years. Likewise, bilateral extrapleural pneumonolysis
and extrapleural paraffin with contralateral thoracoplasty
have been utilized. Bilateral partial thoracoplasty is per-
fectly feasible, but is the least desirable of all of the
bilateral methods, and should be used onlv when noth-
ing else will suffice. The results of many attempts at

bilateral collapse for bilateral pulmonary tuberculosis
will prove disappointing because of the extent of the
disease, and the conditions encountered. The risks in-
crease and the chances of successful rehabilitation dimin-
ish as the amount of reserve breathing-space is reduced,
and the inevitable minimum compatible with life is ap-
proached. Nevertheless, we feel that many such at-
tempts are justifiable, but that the operator and patient
should fully recognize the possibilities and not allow
themselves to be carried away by too much enthusiasm.

When Surgery Is Indicated in Pulmonary
Tuberculosis

When it has once been decided that surgery is neces-
sary in the patient suffering from tuberculosis, every
effort should be made to the end that the patient may
profit, rather than suffer, from the surgical intervention.
This will consist, in the case of emergency surgery, in
performing the minimum amount of surgery which is
consistent with the proper surgical management of the
pathological lesion present, in selecting the proper anes-
thetic or combination of anesthetics which will permit
the proper handling of the situation with the least
possible trauma to the pulmonary lesion, and in the ad-
ministration of adequate postoperative care to return
the patient to the normal conditions of the "cure” as
soon as possible following the operation.

Considering the first point mentioned, it is a well-
recognized fact among men dealing with tuberculosis
that at times even very slight trauma may be followed
by an exacerbation or spread of the tuberculous lesion
in the lung. For this reason, when an emergency arises
and surgical intervention must be undertaken, the sur-
geon should limit himself strictly to caring for the
emergency lesion, and postpone until another time the
surgical handling of other non-emergency conditions
accidentally discovered. To do otherwise may mean to
sacrifice the patient’s chances of recovery from tuber-
culosis for the sake of a simpler lesion which is not
at the moment causing the patient any particular dif-
ficulty.

Anesthesia

The selection of the proper anesthetic is not always
easy. It should provide an anesthesia which is adequate
to permit the surgeon to care for the situation at hand
without embarrassment or handicap, and yet, it should
at the same time be of a type which does not irritate or
favor the dissemination of tuberculous disease. Spinal
anesthesia is a distinct boon for the patient suffering
from pulmonary tuberculosis who must undergo abdom-
inal surgery as an emergency procedure, for it provides
maximum relaxation without in any way traumatizing
the lungs or interfering with the cough reflex. Should
spinal anesthesia prove inadequate for the complete pro-
cedure, it may easily be supplemented by local infiltra-
tion of the abdominal wall, or anterior splanchnic block
if necessary. Local infiltration, field or nerve block with
procaine, may be perfectly adequate for other lesions,
if the surgeon be skilled in their use. The use of gen-

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501

eral anesthesia is to be avoided if possible in the pres-
ence of active pulmonary tuberculosis, because of the
trauma to the lungs from deep breathing as well as for
the increased possibility of aspiration of tuberculous
material into new areas of the lungs, if the anesthesia
reaches the stage where the cough reflex is depressed.
The anesthetic chosen should be picked with due regard
for the pulmonary lesion. Ether, because of its irritat-
ing quality, should be avoided, if possible. If general
anesthesia is necessary, cyclopropane or ethylene may be
used and are especially valuable because of the high
oxygen concentration used with them. Nitrous oxide
of course must be used if cautery is to be utilized, but
for other work, particularly in the face of diminished
vital capacity or collapse of some type, it is not especially
good because of the attendant cyanosis. Where anes-
thesia of short duration is required, the intravenous
administration of barbituric acid derivatives, such as
pentothal sodium and evipal, may be valuable; but it
is well to remember that these agents produce a very
deep anesthesia under which aspiration can easily occur.
It is well to remember that a great many extensions of
pulmonary tuberculosis are the result of bronchogenic
dissemination of tuberculous material into new areas of
the lung. General anesthesia, or intravenous anesthesia,
to the stage where the cough reflex is obliterated, favors
such dissemination, particularly in patients raising spu-
tum and in whom some manipulation is carried out upon
the lung to force sputum from the cavity into the
trachea or bronchi. A stormy anesthetic, or one admin-
istered by an unskilled anesthetist, may intensify all of
these factors and do the patient a great deal of harm.
For similar reasons, the use of doses of opiates suffi-
ciently large to suppress the cough reflex postoperatively
is to be avoided if retention of sputum and aspiration
are to be obviated.

Selection of Time for Elective Surgery

The selection of the proper time for carrying out sur-
gical intervention of an elective type in the patient suf-
fering from pulmonary tuberculosis may be just as im-
portant in the aggregate as the type of surgery per-
formed or the surgical technic itself. Wide experience
in the handling of tuberculous individuals is of untold
value in handling this problem. Close cooperation of the
phthisiologist, internist, roentgenologist and surgeon is
essential if the best results are to be obtained. The first
consideration, when deciding upon surgery of this type,
is the activity of the pulmonary tuberculosis. The pa-
tient suffering from active pulmonary tuberculosis may,
and not infrequently does, react badly to any surgical
intervention. He may not die on the table or within
a week or two following the surgical procedure, but his
pulmonary tuberculosis may be stirred up or spread, and
his chances for recovery jeopardized or destroyed thereby.
Pulmonary lesions are on the average more dangerous
to life, more treacherous, and more easily disseminated
or reactivated than other tuberculous foci. At times,
even very slight trauma or manipulation such as a dental
extraction, a tonsillectomy or a slight fracture, may be

followed by renewed activity of this disease. Such ill
effects may not be manifest at once, but only become
evident some time later. While a number of these ap-
parent ill-effects may be purely coincidental, they occur
frequently enough to engender extreme caution in under-
taking surgical manipulation in the presence of active
or recently active pulmonary tuberculosis. The first
thought then, in selecting the time for the performance
of an elective surgical maneuver in the patient suffering
from pulmonary disease, should be to delay surgical in-
tervention until the pulmonary lesion has become qui-
escent or arrested, if possible.

It has long been recognized among tuberculosis work-
ers that the majority of patients do their coughing and
raising in the morning, and may be relatively free of
symptoms for the rest of the 24-hour period. In order
to take advantage of this, we have for nearly 15 years
performed thoracoplasties and other major surgical pro-
cedures in the afternoon, when cavities are most likely
to be empty.

During certain procedures, such as extrapleural tho-
racoplasty, the position of the patient on the operating
table, and in bed postoperatively, may be important from
the standpoint of possible sputum aspiration. In order
to reduce this danger to a minimum, we have for more
than ten years used the three-quarter prone position for
thoracoplasty, rather than the lateral position so com-
monly utilized. Likewise, we have been extremely care-
ful to avoid turning the patient onto the good side,
either as he is being removed from the operating table
or from the litter to the bed. Postoperatively, the patient
may assume any position except on his unaffected side.
I believe that our low incidence of aspiration spread of
tuberculosis following surgery is definitely related to
this practice.

No patient suffering from tuberculosis should permit
his resistance to become lowered for any reason, if he
can avoid it. No surgeon treating tuberculous individuals
should excessively traumatize a patient and thereby lower
his resistance, if he can possibly prevent it. Excessive
blood loss, unnecessary roughness or trauma, and too
extensive operations, take too much out of the tubercu-
lous patient, and are to be avoided. It is a mistake to
assume that transfusion at the end of an operation rec-
tifies all of the damage which has been done, although,
undoubtedly, following excessive blood loss, it may help
the patient to survive. It is, likewise, unwise to assume
that an extensive procedure performed in 15 or 20 min-
utes is any less brutal than if it were performed in twice
the time. Thoracoplasty, for example, performed in
this way, may, and frequently does, leave the patient in
deep shock from which he rallies only with difficulty;
whereas the same operation performed under local anes-
thesia in a much more gentle manner with more atten-
tion to hemostasis in three or four times as many min-
utes, may leave the patient tired but in good condition
and insisting that more surgery be done. In our entire
major collapse series, approximating a thousand opera-
tions upon some 400 individuals, including extrapleural

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thoracoplasty, extrapleural pneumonolysis, unroofing of
empyema, etc., we have found transfusion necessary but
once, and that several days postoperatively for a hemo-
lytic streptococcic infection. But 25 per cent of patients
in this entire series have required intravenous glucose or
saline postoperatively. Shock and serious blood loss
leave the patient weak and debilitated, and an easy
prey for the lurking tubercle bacillus which, unfor-
tunately, is not similarly affected by the surgical ma-
neuvers. Tuberculous individuals do not have the re-
cuperative powers of normal individuals and in addition
are constantly in danger of undergoing progression or
exacerbation of their original disease, and should there-
fore be protected in every way possible from unnecessary
lowering of resistance if complications are to be avoided.
For the same reasons, extensive surgery should not be
undertaken during very hot weather or epidemics of
respiratory disease.

Postoperatively, these patients require special care. The
maintenance of an adequate fluid balance and proper
nutrition is of course essential. Because of the chronic
disease, they may be somewhat anemic and subsequently
regenerate blood less rapidly than normal individuals.
Great care must be exercised in patients suffering from
tuberculous disease of the lungs to see that the patient
raises his daily quota of sputum each postoperative day
in order to avoid retention, sepsis or extension of the
disease by aspiration. Care must be taken to avoid
allowing the patient to assume positions which will favor
aspiration of infectious material into the sound lung.
Intensive treatment for tuberculosis, to reduce the
chances of exacerbation of the disease or to enable the
patient to control it, if it has occurred, should be in-
sisted upon in all individuals subjected to surgery. It
is extremely unfair to these patients to perform surgical
operations upon them, and then attempt to rehabilitate
them in the same time which would suffice for a healthy
individual. Tuberculous patients should probably spend
at least twice as much time in bed postoperatively as a
non-tuberculous individual, if there is no demonstrable
activity of the disease, and a much longer period if even
a suspicion of activity is found. These patients should,
likewise, be examined and X-rayed repeatedly for months
following the surgical intervention in order to discover
as early as possible any reactivation or extension of tu-
berculous disease. Much of this may seem unnecessarily
complicated to those who are accustomed to dealing
only with non-tuberculous individuals, but those familiar
with tuberculosis know that it is extremely treacherous
and one cannot be too careful in the handling of the
individual suffering from it.

Multiple Tuberculous Foci

Tuberculous individuals not infrequently are con-
fronted with the problem of contending with not one
but even several metastatic foci of disease. The success-
ful treatment of one lesion without the proper handling
of the others will not rehabilitate the individual. The
problem becomes increasingly complex as the number of
foci increase, yet while the problem at times seems hope-

less, it is often surprising how much can be accomplished
in certain individuals so handicapped. The pulmonary
lesion is as a rule the most dangerous to life, and there-
fore requires first attention. Certain other foci, such as
tuberculosis of the larynx or of the intestinal tract, are
secondary to the pulmonary process and tend to retro-
gress as the pulmonary disease is brought under control.
The presence of extrapulmonary foci in general consti-
tutes an added indication for surgical collapse more
frequently than a contraindication to it.

The element of time in the recovery of tuberculous
individuals is all important. Recovery time for these
patients is not measured in days or weeks, but in months
or years. Good results may be obtained in five, six,
seven or eight years, which would be absolutely im-
possible in short periods of time. Patience, perseverance,
encouragement, rest and subsequent surgery and then
ever more rest, may save many lives and rehabilitate
many individuals. The more experienced and careful
the physician, the greater his knowledge of tuberculosis
and his patience in dealing with it; the more he can
accomplish in such complicated situations. The follow-
ing example may seem extreme, but it is only one of a
considerable series of individuals who have been re-
habilitated in this way. V. M., age 21, is a girl who.
in the course of eight years with the help of institu-
tional treatment and surgical aid, has successfully con-
quered the following tuberculous lesions, and is now
rehabilitated and working: (1) tuberculous peritonitis
and salpingitis (salpingectomy and draining abdominal
sinus for two years) ; (2) tuberculosis of the right knee
(spontaneous healing) ; (3) pulmonary tuberculosis

(pulmonary hemorrhage — controlled by artificial pneu-
mothorax) ; (4) tuberculosis of the tarsal bones (treated
surgically by Ollier resection) ; (5) tuberculosis of the
first and second lumbar vertebrae with psoas abscess
(drainage and soinal fusion) . In spite of all of these
lesions, this girl has controlled her tuberculosis, and now
occupies a very responsible position. Without adequate
institutional care and the judicious aoplication of sur-
gical procedures, such a recovery would not have been
possible.

Conclusions

Tuberculosis is a constitutional disease with protean
manifestations. Its successful treatment requires pro-
longed, intensive rest and more prolonged sunervision,
and not infrequently the judicious use of surgical in-
tervention to relieve or treat local complications. It is
not a medical disease, nor is it a surgical disease, but
one in which all specialities may add something to the
individual’s chances for recovery. Institutional manage-
ment intensively applied for a long period of time is
essential to recovery in many instances. Surgical inter-
vention, wisely-selected and properly applied, mav con-
tribute much toward the recovery of the individual, and
frequently proves the deciding factor in making recovery
possible.

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503

College Mental Hygiene*

Henry C. Schumacher, M.D.f
Cleveland, Ohio

SO MUCH has been written in recent years on this
subject that what one now says is to a great extent
a repetition. However, so many colleges are still
doing so little in this held that it is worth while to discuss
the subject from time to time. True, the opinions of
psychiatrists are often under suspicion. The public,
including educators, still believes much maladjustment
is the individual’s own fault and that in a certain sense,
he is paying a justifiable penalty for his offenses. Then,
too, there is the opinion that since college students are
(but not all are) intelligent beings they should be able
through reason to solve their problems. Mentation,
however, implies much more than intelligence. Further-
more, many of the maladjustments of the college student
have their origin in his early years when intelligence and
reason are not highly developed. It should also be
pointed out that far too much of the school and college
time is spent in instilling knowledge, much of which is
of little value in solving or aiding in the solving of life’s
real problems.

One important objective in education is often lost
sight of. I am referring to the need, in addition to the
mastery of subject matter, of the development of the
students into acceptable and efficient social human beings.
Sheer intellect alone does not determine success, for I
am sure all of us know men and women possessed of
good intelligence but unable to use it in a constructive
way. Many of these are blocked because of personality
disorders. Unfortunately, many who finish college and
university with adequate grades in subject matter fail
to make the grade in the world after leaving school.
This fact is clearly and forcibly presented by Anderson
and Kennedy1 who note that of 646 college graduates
selected by able business executives, in cooperation with
personnel experts in colleges, for responsible positions,
over a period of eleven years, 190 were definitely un-
successful. This represents about 30 per cent of the
entire group admitted. And in passing it should be noted
that this 30 per cent represents only those known to have
been unsuccessful and does not include that indetermi-
nate number of young people who quietly resigned for
some, to them, sufficient reason. Nor does it take into
consideration that group who just stuck at the level
where they started, which group comprised about 20
per cent. As a result of this experience, this organization
then decided that all applicants for training should be
seen by psychiatrically-trained people. As a result, now,
around 90 per cent of its placements, according to psy-
chiatric recommendations, have made good. However,
of 344 college men and women who during one year

* Read before the Ohio Student Health Association, April 2,
1 937, at Columbus, Ohio.

t Director, Child Guidance Clinic; associate professor of mental
hygiene, School of Applied Social Sciences; associate in pediatrics.
School of Medicine, Western Reserve University.

(1930) applied for training and were psychiatrically-
examined, two only were sufficiently outstanding to
justify employment on the training unit, while 30 others
were promising. That means that only 9 per cent were
accepted at all, and only a little more than one-half of
one per cent were selected for executive training.

Such facts and figures clearly show the need for
college mental hygiene. Dr. Frankwood Williams'’'
states the aims of mental hygiene in the college to be as
follows:

"I. The conservation of the student body; that in-
tellectually capable students may not be forced
unnecessarily to withdraw, but may be retained.

"2. The forestalling of failure in the form of
nervous and mental diseases, immediate and
remote.

"3. The minimizing of partial failure in later me-
diocrity, inadequacy, inefficiency, and unhappi-
ness.

”4. The making possible of a larger individual use-
fulness by giving to each a fuller use of the
intellectual capacity he possesses, through widen-
ing the sphere of conscious control and thereby
widening the sphere of social control.”

Many studies by college psychiatrists have attempted to
estimate the number of students needing psychiatric aid.
In great part, such estimates are based on relatively
brief contact with the student. However, in order to
bring the subject as forcefully as possible to attention,
let us quote some of these findings.

In a study of 1300 freshman men at the University
of Minnesota, Morrison and Diehl15 found 17.8 per
cent with a history of abnormalities serious enough to
indicate the need for treatment. Blanton0, in a study
of 1000 unselected junior and senior students of Wis-
consin, estimated that 10 per cent of the student body
had maladjustments serious enough to "warp their
lives, and in some cases cause mental breakdowns unless
properly treated.” Cobb11 of Harvard examined all in-
coming freshmen from a psychiatric standpoint, and
found more than 16 °/c in danger of becoming victims
of neurosis if not actual mental disease. And Pressey, ’1
in a study of 100 women undergraduates at Ohio Uni-
versity, found all but 12 with at least one problem which
was considered to be serious. There have been other
such studies. The striking thing is that in all of them
10 to 15 per cent of the student body is found to be
so badly in need of psychiatric attention that without
it they are in danger of developing serious mental diffi-
culties and a much higher percentage show some per-
sonality defect.

In a recent study Raphael04 reports his experiences at
the University of Michigan. Taking as a basis for his

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study the class of 1934, he presents the following facts:
there were a total of 526 students studied, of whom 411
were men and 115 were women, or three and one-half
times as many men as women; 77.8 per cent were rated
physically as excellent or satisfactory. However, as might
well be expected, there was a higher incidence of signifi-
cant somatic handicaps in this group than for the school
as a whole. On psychological test, the general distribu-
tion appeared to approximate quite closely that of the
class as a whole. Of more importance is the actual diag-
nosis of those studied. Of the 526 individuals, only 1 1
cases or 2 per cent were considered as being psychotic.
Nineteen cases or 3.6 per cent showed some form of
organic central nervous system disorder. Fifty-three or
10 per cent were considered reactionary depressions; 196
or 37.2 per cent showed definite psychoneuroses or psy
choneurotic reactions. Eleven cases or 2 per cent were
diagnosed psychopathic personalities, thus leaving 236
or 44.8 per cent of the cases which were adjustment
problems of non-clinical type.

There is probably no single factor that precipitates
the maladjusted state, rather the maladjustment occurs
as a result of the interplay of one or more subjective or
innate factors, and one or more of the environmental
factors under which the individual lives. The conflict,
then, is one between the internal forces of the individual
and the external forces of his environment. Raphael in
his excellent article lists the factors in the problems of
the students under primary and secondary factors, re-
spectively. The reader is particularly referred to this
article. Here I shall list only those factors as found by
Raphael to occur in 14 or more per cent of the cases.

Primary Factors

Perc. of Cases

1. Pronounced tendency to excitability

and tensional response 40.3

2. Worry over school work 40.1

3. Poor orientation to university as part of life

situation 33.4

4. Instability and over-impulsiveness 31.8

5. Actual physical disturbance and

residual states 29.4

6. Over-sensitivity 23.3

7. Immaturity 20.5

8. Stress of transition to university environ-

ment from relatively simpler setting 17.4

9. Poor dependability, lack of regularization,

poor self-discipline 17.0

10. Poor scholastic achievement 16.5

11. Fatigue 15.9

12. Worry regarding possibility of disease 15.2

13. General problem of sex adjustment 14.3

14. Marked feelings of inferiority 14.1

Secondary Factors

1. Immaturity 56.7

2. Inadequacy, over-dependency, and oversug-

gestibility 43.8

3. Over-sensitivity 43.4

4. Instability and over-impulsiveness 39.3

5. Marked feelings of inferiority 37.5

6. Pronounced tendency to excitability and

tensional response 36.4

7. Poor socialization 29.0

8. Poor orientation to university as part of

life situation 22.4

9. Poor general family background 22.2

10. Worry over school work 19.1

11. Poor habits of living, including over-use of

tobacco and alcohol 16.8

12. Inadequate recreational outlets ... 16.8

13. Poor dependability, lack of regularization,

poor self-discipline 16.3

14. General problems of sex adjustment ... ... 16.1

15. Egocentricity; tendency to negative de-

fense reactions 14.8

My own experience over a period of ten years as con-
sultant psychiatrist to several Ohio colleges bears out
Dr. Raphael’s findings.

Probably some highly abstracted case studies will pre-
sent some of these conditions more concretely and realis-
tically.

Case 1. A girl, a sophomore in college, is a short
stockily-built girl of the pyknic type. She gives a history
of periodic swings of mood. However, since entering
college such mood-swings have become more pronounced.
Her mother died a manic-depressive. The girl was
reared in her grandmother’s home and except for a
somewhat rigid religious training her childhood was un-
eventful. However, even in high school her marked
mood-swings were noted. When elated, she rushed head-
long into activities and found the small college town
boring. As a result she comes to the city and goes on
drinking parties. After a while her mood shifts, and
in her depression she is self-accusatory and expresses the
wish that she might do away with herself. During her
free intervals she is an excellent student.

Here we are dealing with a girl of strong manic-
depressive tendencies. Before treatment could be under-
taken, this girl suffered a complete break, and was in-
stitutionalized. Following her recovery from this manic
attack, she did not return to college.

Case 2. A boy age 21, referred by the mental hygiene
department of a large university because of failure in
academic work. He is the fourth of five siblings. The
first born child, a boy, died in early infancy, the second
is a girl, the third a boy (long longed for and given the
name borne by the child that died) , the fourth the
patient, and the youngest a girl.

As long as our patient can remember, he has felt that
he wasn’t given a square deal by his family. He was
convinced that the older sister and brother got more
affection and more of the material things of life than
he. His youngest sister, the baby in the family, was
the pet of all the others. As an elementary school child

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505

he found it increasingly more difficult to get along with
teachers and pupils. He felt he wasn’t getting any
"breaks.” During his high school days he attended three
institutions — a private school, a public high school and
a tutorial school. He can give no definite reason for his
difficulties except that he felt unfairly treated. In com-
paring the three high schools he felt that he was happier
in the tutorial school and this because he was receiving
much more individual attention and so he felt more ap-
preciated. However, on entering college he was again
one among many. His resentment and feeling of unfair
treatment once more cropped out. With the months this
feeling grew. To it he reacted by studying less and less.
He said, "I lost interest in my studies and wanted to
get away.” His first semester’s grades were bad, and he
was duly warned. By the middle of the second semester
his work had fallen down so badly that he was given
permission to resign and had he not done so, he would
have been dismissed. In the early interviews he brought
out his resentment of the family, and told of his desire
to travel, to see the country. He felt himself to be the
black sheep of the family, and didn’t feel he could make
a go of work with his father and brothers, or under
anyone. So, in an attempt to escape, he rationalized,
travel would be the equivalent of an education. Also,
through this means he could force the parents to sup-
port him.

An interpretation of his behavior emphasizing his
ordinal position in the family — the child between the
longed-for boy and the "baby” girl, both of whom be-
cause of parental attitudes had positions of great advan-
tage over him— was given him. This brought up many
memories of his early reactions to older brother and
his feeling of jealousy of baby sister. Bit by bit he began
to see how this gave rise to his feeling of resentment to
parents and parent substitutes. One day he remarked,
"If I told my parents how I have felt all these years,
they would just laugh at me.” Gradually, he began to
see how his reactions had conditioned their outward
behavior to him. On changing his own behavior, he
found that they accepted him in the same way they did
the others. Where at first he felt he never could work
under anyone, he soon discovered, on going to work,
that with his new understanding it was not difficult at
all to take orders. At present he is making good at work
and home adjustment.

Case 5. A girl age 20, referred by the personnel offi-
cer of a college because she was failing in her studies,
and had been told by the dean’s office that she could
not continue in college unless she passed all of the first
semester’s work.

The father died when she was five years old. The
father, a college graduate, was artistic and had done
some creditable work in art. However, this had never
been acceptable to his mother, a domineering woman.
After the father’s death, the paternal grandmother
wished the patient’s mother to make her home with her.
The mother, however, did not wish to be under the
domineering influence of the grandmother, and so made

a bargain with her that the eldest daughter, our patient,
would live with her grandmother, in exchange for which
grandmother would contribute to the support of the
mother and siblings. Our patient grew up with the feel-
ing that she had to respect and obey grandmother in
all things. Grandmother wished her to learn languages.
However, as the girl grew older, she turned more and
more to art, which did not meet with the approval of
grandmother. The grandmother drilled the girl in Eng-
lish and French until our patient states she would have
temper tantrums, and refuse to go on. However, grand-
mother would always come back to it. The patient is
well aware that in this way she built up a strong dislike
for languages, particularly for French.

In her first year at college she was particularly un-
fortunate in her English teacher, an elderly woman who
in every respect reminded her of grandmother. This
teacher spent much time in discussing what girls ought
to do, how they ought to live and why they owed respect
to parents, et cetera. The patient brought out very strik-
ingly her resentment of this teacher on the basis of
identifying her with the grandmother. This, of course,
was the basis of her failure in English.

As long as the girl was in rebellion and trying so
desperately to emancipate herself from the grandmother’s
domination, she had to reject the study of languages.
The whole question of adolescent rebellion and the need
to emancipate herself was gone into very thoroughly.
The reasons for her choice of art as a career — it was
the father’s chief interest and emphasized rebellion
against grandmother — was discussed. Her previous work
in art, however, justified us in agreeing to her plan to
study art in art school. She dropped out of college and
entered art school.

Case 4. A colored boy, age I8V2, referred by a college
physician because of difficulties in his gym work and
because of his physical complaints, such as distention
of abdomen, throbbing headaches, palpitation, twitching
of muscles — all following his gym classes and related by
him to the gymnasium work.

This boy had attended a high school for colored and
came to a Northern college with a certain hesitation. His
relatives and friends had advised him to attend a college
for colored in the South. However, he was ambitious
and felt he could get better training in the North. He
came with a definite determination to make good. In
this he had, on the whole, been quite successful, except
for his gym work. He said gym was a subject he didn’t
have much of in high school. He found, therefore, that
all the others in the class were doing better than he could
do. He wanted to get out of gym, but it was a required
subject. He wrote his folks, telling them he would like
them to aid him in getting out of this work. Instead,
his father and brother wrote, encouraging him to stick
it out, and that it was a mark of failure to give up.
This hurt his pride, but didn’t make gym work more
pleasant.

At Christmas time when he came home on holidays
the first question his mother asked him was, "Son, did
you give up gym?”

506

THE JOURNAL-LANCET

He couldn’t understand why father, mother, and
brother were all against him. He began to feel that
everyone was against him. Seeing no way out of gym,
he converted his mental conflicts over into physical symp-
toms— at first quite consciously. He was excused from
gym for a week, and following his return to gym work
his symptoms became worse. He, at the time of referral,
already had been transferred to a special class section
for gym work. Here he could hold his own better, but
he knew he was not doing as well as many others.

Then, too, he states that early in the school year he
overheard some boys say, "We don’t want that nigger
to play on our side.”

This added to his conflict over gym.

The boy was a bright lad, and in the one interview
was soon discussing his hysterical conversion symptoms,
and the causes that had brought them about, in a very
objective way.

The boy made a good adjustment to his special gym
class. He no longer complained of physical ill effects.

Case 5. A girl age 26, referred because of poor scho-
lastic work and her irritating behavior in class.

The patient is the third child in a family of four,
the oldest and youngest are males. Her father, now
deceased, was a meek, easy-going man who left the
discipline to the mother, a domineering woman. The
patient as a child felt rejected by the mother.
Now she cannot remember ever considering her as a
mother, but looks upon her as a person whom she hated.
The eldest brother was much beloved by mother and in
a definite sense was the man of the house. The patient
admired him very much and resented the mother’s in-
terest in him. She recalls incidents when as a child she
would lie down beside him. He and the patient’s sister
did not get along well. At the time the sister was enter-
ing adolescence he was constantly reprimanding her on
account of her behavior with boy friends. As a result
our patient tried in every way to be different from the
sister and hence the two have been at odds with each
other. This made it impossible for the patient to act
the way her sister did. The sister, a lively vivacious girl,
did excellent school and college work. The patient, in
order to be different from sister, tried hard to act totally
different toward classmates and teachers. Instead of
studying and getting good grades as did the sister, she
did poor work and argued much with her instructors
which not only antagonized them, but also her classmates.
On finishing normal school, she taught — her sister had
also gone into teaching. Her antagonisms to mother and
sister were transferred to women principals under whom
she taught. Because of failure to be promoted, she
sought a way out of teaching. For many years she had
been going with a young man whom her brother had
befriended. Though not overly interested in him, she
married him and thus had to resign her teaching po-
sition. She now re-entered college. She wanted a career,
so that her brother would be proud of her and also to
surpass her sister. However, all her old attitudes again
cropped out. In addition, she now began to complain

of being sick and began to entertain ideas of going
insane. Analysis revealed her strong attachment to
brother and her hate for her mother, based on her re-
sentment of mother’s interest in him. The brother’s in-
terest in her sister’s welfare caused her to resent the
sister and to act totally different from her. Sexually, she
became prudish. She married a brother-substitute, but
could not be happy with him because in his work and
habits he was so different from the brother, and because
of her feelings of guilt. Her complaints and fears of
insanity were motivated as means of escape from her
unhappy marriage. A career signified power and a means
of regaining her brother’s interest in her, since he had
married and now showed no particular attention to her;
in fact, he was rather annoyed by her behavior.

A knowledge of mental hygiene, particularly as it
relates to family relationships, should have made the
teacher’s college instructors and officials aware of this
girl’s difficulties, and thus have avoided failure in school,
in teaching and in marriage, and necessitating a long
analysis.

These cases, I hope, will serve to show that the mental
hygiene problems found among college students are
very similar to those found outside the walls of college
and university. They are problems of people in emo-
tional distress over failure in emancipation from the
home and in the establishment of healthy attitudes
toward social and sexual adjustments.

How then, can this problem in college be met? Well,
first of all, the college must exercise greater discretion
in the admission of students. Those not qualified should
not be admitted. Secondly, the educational program
must cease its exaggerated one-sided emphasis upon the
value of intellectual attainment as a method of prepar-
ing for life. Thirdly, under modern conditions the
college cannot expect as well-adjusted a student body
today as was true years ago, for it must not be for-
gotten that since 1880 there has been a 700 per cent
increase in college enrollment, and that the main impetus
in the increased enrollment has come since 1920. The
student body is much more heterogenous than formerly.
As a result, college adjustment is a difficult problem for
many students. They need help. Freshman week, orien-
tation programs, advisors and counsellors — all of this is
evidence that the college has some recognition of the
need.

Certain colleges offer a series of lectures in mental
hygiene. We favor such a program of lectures, open
to freshmen, provided it is under the direction of a
competent instructor. The course itself should center
around the common problems of the students. Such a
series of lectures might well begin with a full discussion
of the physical development of adolescence. It will be
found that not only are the freshmen not far removed
from the beginning of adolescence but what is more im-
portant many of the problems that confronted them then
still await understanding. Here, of course, a full dis-
cussion of normal sex development with its resulting ten-
sions can be discussed. Even more time can be spent on

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507

the social development of this life period. It might be
well for all students to get some clear appreciation of
the role the public initiation ceremony has played in the
cultural history of the race, for they will meet with some
modern hang-overs and substitutes, such as fraternity
initiations, attitude in general to freshmen, etc. The
social relationship between the sexes is also a problem
worthy of attention.

Since college days are for many students their first
experience away from home, a full and free discussion
of the role of the family and emancipation therefrom
should receive consideration. Many of the problems of
adjustment grow out of this new freedom from home.
Another topic that requires emphasis relates to the moral
and religious attitudes of the student. Religious doubts
are relatively frequent at this age. Such doubts may be
engendered by a desire to break away from a too-strict
and overmoralized early training, or because the student
is in conflict over sex and now questions religious teach-
ing because of the restraints it places upon him. History
and science courses often cause conflicts because of the
narrowness of the previous training of the student, and
last but not least, one should mention the modern vogue
of skepticism. Now morality and religion are intimately
related. Hence, a sound attitude to religion is basic.

Then too, there might well be lectures on tempera-
ment and intelligence. Here such simple facts on tem-
peramental differences in response should be discussed
as well as giving the student a wider interpretation of
what intelligence is. Also, the subject of vocational guid-
ance could be discussed. We could, of course, extend the
list of topics greatly. What I wish to emphasize is
chiefly this, that the topics should center about the com-
monplace problems of the students and avoid an over-
emphasis of the morbid. True, certain types and modes
of responding could well be discussed, but such a course
as I have in mind should not be primarily a course in
abnormal psychology. And just because I feel it should
not be morbid and primarily abnormal in its orientation,
its instructor must be carefully chosen. The course must
be practical and must above all be understandable by the
freshmen.

In addition to such lectures there should be provided
opportunity for personal conferences. In fact, the major
part of the time of the personnel- available for this work
should be so devoted. Here again let me emphasize that
the soundness of those doing this work is all-important.
Not all educators well-qualified in their subject matter
are fitted for student counselling and much mischief is
done students by assuming this. No one is a good coun-
sellor who hasn’t a fair acquaintance with psychology,
sociology and modern psychiatry, as well as a real interest
in human nature.

For a mental hygiene program to succeed, the interest
and cooperation of the faculty is essential. That means
that the members of the faculty will need to be informed
of what the program aims to accomplish and why. Manv
a faculty member has become ‘ so absorbed in his own
field that to a considerable degree he has lost contact

with the problems of every day life and youth’s relation
to them. A program of education is therefore essential.

And now just a few words about the administration
of such a program. Needless to say, the small college
may not find it possible to have full-time personnel.
However, as we have already indicated, personnel now
on the campus may be entrusted with a good share of
the program. This particularly holds true of the lectures
in mental hygiene. Then, too, students are now coming
to deans and counsellors and other members of the fac-
ulty for advice and guidance. Probably it would be well
for the personnel so engaged to have a regular time to
get together and discuss the problems that have come
to their attention. Ideally, of course, the mental hygiene
program should be under the leadership of a competent
psychiatrist, and in a large college there could with ad-
vantage be attached to his staff a well-trained clinical
psychologist, and one or more social workers qualified for
such work. Even in the small college, there should be
opportunity for psychiatric consultation.

Needless to say, there should be the closest working
relationship between the deans of men and women, vo-
cational counsellors, and the psychiatric unit or the psy-
chiatrist. One ought not need to point out that the
therapeutic work should be entrusted only to competent
specialists in psychiatry. The professor of psychology
may have a good understanding of the theory under-
lying mental difficulties, but almost always he is lacking
in clinical experience and in a true appreciation of the
organism-as-a-whole.

I do not mean to imply that all problems in mental
hygiene should come to the psychiatrist — there are many
problems which the deans, the personnel officer, and
the vocational counsellor fortified with a knowledge of
mental hygiene, can and should handle. However, many
of the disciplinary problems are so intimately tied-up
with emotional maladjustment that psychiatric referral
is a wise procedure. Probably, however, the ideal place
for the mental hygiene program to be administratively-
placed is under the direction of a psychiatrist in conjunc-
tion with the student health service, a service organized
to look after the health and hygiene of the student body-
Such placement would insure a complete study of all
incoming students, and through the infirmary and con-
sultation rooms for whatever physical health purpose,
permit contact with the vulnerable students. Further-
more students would feel freer to come to the health
center if the psychiatrist were housed there rather than
elsewhere; the object should, of course, be to have the
student feel just as free to consult the psychiatrist as
he would any other physician.

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COLLEGE MENTAL HYGIENE
Discussion by L. W. Sontag, M.D.f

Mr. President and Members of the Ohio Student Health
Association:

May I express my appreciation for Dr. Schumacher’s excellent
paper? It brings before us very clearly the need for, and most
t Director of research, Antioch College.

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509

desirable set-up for, mental hygiene work in college. I think
Dr. Schumacher’s ideas about the teaching of mental hygiene
to freshmen are excellent.

Since time immemorial, relatively speaking, education has
been concerned primarily with the intelligence quotient or I. Q.
It is only recently that psychiatry has begun adequately to em-
phasize the fact that intelligence and mental achievement alone
are not sufficient for happiness. It is fully time for the edu-
cational institutions of the world to recognize the necessity for
developing emotional, as well as intellectual, maturity. It is time
we evolved an emotional quotient or E. Q. as well as an I. Q.

There are many reasons why a mental hygiene program should
be started not at the college level but at the pre-school level.
It is as early as pre-school that the origin of many emotional
disturbances may be found. When a child takes scarlet fever
germs into his system, he has a relatively short time to wait
before contracting the disease in a form which will rapidly make
itself apparent, and send him to a physician. The disease, in
the case of scarlet fever, is usually acute and is as a rule cured
by the specific resistance developed by the body itself. The
etiology of emotional problems, however, is not so apparent nor
so rapidly productive of manifestations which immediately attract
the attention of untrained assistants. Therefore the effects of
an unhealthy emotional situation may not be apparent until

many years later. Despite the fact that it would be logical to
start the mental hygiene program with pre-school children, such
a plan is as yet impossible.

At the present time, colleges offer us the most plausible and
possible opportunity for the application of mental hygiene super-
vision and care. The college period does have the distinct
advantage of offering first, an opportunity for the observation
and study of emotionally-disturbed individuals, and second, it
offers an environment which is plastic enough to be used con-
siderably to fit individual needs. It is not easy to change a
man’s wife when it seems desirable to do so for his mental
equilibrium, but it is not difficult to change his room-mate.

In most colleges there exist admirable plants for caring for
the body health of students. It seems not too difficult to enlarge
the scope of these institutions to include the mental health of
the student as well. It is futile to argue the relative importance
of physical and mental health since the lack of either is de-
structive of life.

It is fully time that we heed Dr. Schumacher’s warning by
adding to our health service facilities for caring for the emo-
tional fitness of our students and of even greater importance,
that we broaden our vision of health to include emotional health
as well as physical health.

L. W. Sontag, M.D.

Boole Hotices

NEUROLOGY WORK

A Textbook of Nervous Diseases in. Infancy and Child-
hood, by Frank R. Ford, M.D.; 1st American edition,
heavy blue cloth, gold-stamped, 938 pages plus appendix and
index, illustrated; Springfield, Illinois: Charles C. Thomas:
Publisher: 1937. Price, #8.50.

Neurology is the most disputed territory in medicine. It
was first captured by the pathological neurologists, who have
held supreme power for about 100 years. Then along came
the neuro-psychiatrists, who have been rapidly encroaching upon
them for the past 30 years.

Dr. F. R. Ford most successfully defends the stand of the
clinical neurologists. Briefly, his book is concerned with the
essential clinical features of every neurological disease known to
childhood. Precisely and adequately it covers the pathological
anatomy, diagnosis and established methods of treatment. Not
only does it bring together and digest all available information
on this subject, but it includes all conditions which occur in
childhood, and not just merely those conditions peculiar to
childhood. Then too, it gives the neurological complications of
diseases not primarily neurological, together with brief, prac-
tical discussions of the general aspects of each disease.

This book is the last and the best of its kind. No pediatrist,
general practitioner or neurologist should be without it. The
two chapters: "The Examination of the Nervous System,” and
"Clinical Aspects of the Anatomy and Physiology of the
Nervous System,” should be accessible to every medical student
for use at the bedside.

The author is associate professor of neurology in the Johns
Hopkins University School of Medicine.

A DOCTOR-PATIENT SPEAKS
Condition Satisfactory, by Sandor Puder, M.D., translated
by Hildegard Nagel; 1st American edition, light blue cloth,
blue-stamped, 201 pages, no illustrations, no index; New
York: Alfred A. Knopf, Inc.: 1937. Price, #2.00

Dr. Puder is an internist now practicing in Budapest, Hun-
gary. He is chief of the tuberculosis ward of the National
Social Insurance Institute of Hungary, and was graduated from

the University of Pecs in Hungary in 1923. He suffered from
appendicitis for two years, the complicating conditions being
removed only after three operations, each followed by a long
period of illness. The book is well-written, accurate, and ex-
tremely interesting. It recounts each sensation he had, each
spasm of pain, each mental flight of doubt or fear. The
Journal-Lancet endorses this book.

THOMSON ON THE NOSE 8C THROAT

Diseases of the Nose & Throat, by Sir Saint Clair Thomson,
M.D., LL.D., and V. E. Negus, M.S. (London) ; new 4th
edition, heavy pebbled cloth, gold-stamped, 920 pages plus
index, 386 figures, 13 color plates, and 16 radiographic plates;
New York 8c London: The D. Appleton-Century Company,
Inc.: 1937. Price, #14.00.

This book appeared 25 years ago; even in diseases of the
nose and throat it is highly interesting to notice the changes
in treatment and surgical approach. Thomson, for instance,
now omits the Killian operation for frontal sinus disease as
being too dangerous. Diathermy and irradiation had to be
brought fully up-to-date (1937). The section on per-oral en-
doscopy is wholly re-written (by Negus) . Space given to in-
tubation is curtailed; but tracheotomy is given larger attention.
Agranulocytic angina appears for the first time in this edition.

This is a beautiful book, beautifully produced, and mag-
nificently illustrated. There are 386 figures instead of 379, and
16 black 8c white plates instead of 12. One more color plate
has been added. The Journal-Lancet is pleased to recom-
mend this new 4th edition of an old and standard authority
on the nose and throat.

BUSINESS METHODS IN MEDICINE

The Business Side of Medical Practice, by Theodore
Wiprud, with a foreword by MoRRrs FishbeiSc, M.D.; 1st
edition, blue buckram, gold-stamped, 169 pages plus index,
no illustrations; Philadelphia: The W. B. Saunders Com-
pany: 1937. Price, #2.50.

This excellent handbook is the work of the executive secre-
tary of the Medical Society of Milwaukee County (Wisconsin) .
It treats of innumerable economic problems, even to the point
of including investments. The section on office records is very
good; but the rest of the book is by no means inferior. A
book like this should be owned by every private practitioner.

JOURNAL
LANCET

Represents the
MINNESOTA, NORTH DAKOTA,

Medical Profession of

SOUTH DAKOTA and MONTANA

The Official Journal of the

North Dakota State Medical Association The Minnesota Academy of Medicine Great Northern Railway Surgeons’ Assn.

South Dakota State Medical Association The Sioux Valley Medical Association American Student Health Association

Montana State Medical Association Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman , Board of Editors

Dr. A. W. Skelsey, Dr. C. E. Sherwood, Dr. Thomas L. Hawkins - Associate Editors

BOARD OF EDITORS

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. J . F. D. Cook
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

Dr. W. A. Fansler
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. S. M. Hohf

Dr. A. Karsted
Dr. H. D. Lees
Dr. J. C. McGregor
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. J . C. Shirley
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley

Dr. C. A. Stewart
Dr. J. L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

LANCET PUBLISHING CO., Publishers

W. A. Jones, M.D., 1859-1931 W. L. Klein, 1851-1931

84 South Tenth Street, Minneapolis, Minnesota

Minneapolis, Minn., November, 1937

DRUGGISTS’ COUNTER-SALE OF
DANGEROUS DRUGS

Supplemental to the closing paragraph in the Review
of Medicine (Journal-Lancet, August, 1937, p. 357, —
barbiturates, etc., the following items should be of
interest:

I. A letter from a proprietary firm, considering the
subject of dangerous and habit-forming drugs, claimed
that during the previous year four hundred and ninety
million one-grain tablets of phenobarbital were consumed.

II. Druggists admit that such a drug has an over-the-
counter sale much cheaper than other barbiturates carry-
ing a proprietary name; but even at that, the latter prod-
ucts have a very large counter-sale.

III. Concerning other proprietaries sold in this man-
ner, the pharmacists quite frankly admit that due prob-
ably to the great notoriety acquired through newspapers
and magazines like Time, there has been an unusually
great demand for a drug which until a few months ago
was practically unknown to the trade or the public, i. e.,
"Prontylin,” and "sulfanilamide”; in fact, that the brand
bearing the trade-name is called for so freely that the
shops are selling it as cheaply as twelve tablets for
twenty-five cents.

IV. Newspapers to-day are carrying the gruesome
item that in Tulsa, Okla., eight deaths have just been
caused through the use of sulfanilamide; and that one
manufacturing concern is trying to recall shipments to
about three hundred and seventy-five pharmacists.

Even though these recent deaths were not actually due
solely to the drug in question, there yet exists the prob-
lem cited above. Lately the Journal A. M. A. has called
attention to some serious reactions from the use of
sulfanilamide.*

A. W. S.

KEEPING UP

The smell of iodoform and carbolic acid was once a
more certain sign of a doctor’s office than the brass
plate on the door. Antiseptics have been deodorized and
refined. Newer anaesthetics are replacing ether and
chloroform. Calomel and quinine, once so common ev-
erywhere, are now seldom used north of the Mason and
Dixon line, and physics are prescribed with caution.

Osier was frequently accused of being a therapeutic
nihilist and only two prescriptions are recalled from his
Practice of Medicine: one was the acid diarrhea mixture
in typhoid, and the other was Fuller’s lotion for rheu-
matic joints; but who uses them now? Like automobile
designers whose 1938 models are now being exhibited,
the modern physician prides himself on remedies that
are more pleasant to use and that are of greater de-
pendability in performance. It's a break-neck pace to
keep up, but it’s a grand old game and nobody wants
to die on third.

A. E. H.

* Telegram from Chicago seems to indicate that the solvent
in a syrup of sulfanilamide might be the lethal element.

THE JOURNAL-LANCET

511

SUPPLEMENTING PRIVATE PRACTICE

Recently, persons have advocated the extension of
medical service at the expense of the taxpayer so as to
supplant the private practice of medicine; in other words,
provide institutions for cardiacs, arthritics, etc., and em-
ploy physicians to care for them. No matter how far
this idea is extended, even if it includes all phases of
medical care, physicians are the only members of society
qualified to give this service. They become qualified
after many years in school and much practical experience
after graduation. Many of them are already established
and rendering splendid service in private practice. Aside
from the occasional exception, there is no question as
to their ability, skill, honesty, and trustworthiness in
every respect. The critics for the most part center their
attacks around the cost of medical care. Unfortunately,
the proposals the critics offer would be the most costly
method of administering medical care. First, institutions
have to be provided at the expense of the taxpayer;
their maintenance is a large item. The salaries of med-
ical personnel would probably exceed the average income
of private physicians in this country.

When one analyzes the cost of medical care on the
private practice basis much of the expense to the patient
is chargeable to the equipment and materials which the
physician must use, such as salvarsan, anti-pneumococcic
serum, anti-toxins, insulin, X-rays, and operating rocm
charges. Often these materials are purchased by the
physician, and, when added to his bill, they make his
fee seem exorbitant. For example, a working girl re-
ported to a physician’s office because of soreness of her
throat, for which she expected only an office call charge
would be made. She was found to have diphtheria, and
the cost of the anti-toxin which the physician immediately
purchased and administered brought the expense of this
service far beyond what she could conceive as justified,
since it required all of her savings for several weeks.
Another young woman developed Type I lobar pneu-
monia. The physician’s fee for her care seemed exorbi-
tant because approximately one hundred dollars of it
was for anti-pneumccoccic serum. Similar experiences
are frequent among physicians.

It is difficult to see how any advantage whatsoever
could accrue from a system at the expense of the tax-
payer which would supplant the private practice of medi-
cine, resulting in the loss of the patient’s right to select
the physician of his choice. However, state and local
health departments, through funds derived from the
federal government or otherwise, could greatly reduce
the cost of medical care by supplementing the practice
of medicine without interfering in any way with the
freedom and rights of persons requiring such care. In-
deed, a considerable amount of this work has already
been done; for example, many remember the day when
every Wassermann test cost ten dollars or more; when
arsenicals and mercury employed in the treatment of
syphilis added a good deal to the patient’s expense. Now
those unable to pay the fees of their physician plus cost
of tests, arsenicals, etc., are relieved of the additional
expense of tests and drugs by having them provided by

health departments.

Why not extend this service to those who need it
so as to have it include all the special and expensive
phases of the examination, as well as expensive prepara-
tions used in therapy and prevention. This would per-
mit the physician to give the patient the advantage of
all that he has been taught regardless of the patient’s
inadequate financial status; whereas, with the present
system an expensive preparation, such as anti-pneumo-
coccic serum, may be withheld because the family may
not feel able to afford it. Already great strides have
been taken in this direction in some of our states, and,
it appears that it is a logical and important step toward
the solution of the problem of the cost of medical care.

J. A. M.

CORRESPONDENCE

October 12, 1937.

To the Editors:

In the October issue (1937) of your magazine, an editorial
appears entitled Old Age Assistance — Its Medical Danger.
which seems to imply that the "medical economics” of this
salutary provision to the old is a "many-headed monster” and
the beast which has throttled the art and science of medicine
in some foreign lands” and all this because the doctor is asked
to render professional services to these old people at a reduction
in fees amounting to 40 per cent, and to assist them in the
matter of an increase or not of pension because of disability
or want of it.

Another grievance is that "during the depression years, the
medical profession of Minnesota . . . accepted a fee schedule
40 per cent lower than current medical fees for the care of the
indigent under both S.E.R.A. and F.E.R.A.” If he is situated
as we are here in Montana he renders these services now either
for nothing or what little these people can pay. Would he
like that arrangement better? Or does he think these unfor-
tunate people should do without any medical service at all?

The writer implies in his questions that this kind of prac-
tices has led to the "downfall of medicine in Europe,” and
that the "practice of certifying disability . . . has increased

the number of sick days per year per employee in Germany
from 5/ to 28, and in England from 9 to 12/4” and lowered
"medical standards in these countries.”

Did it never occur to this editor that we have enough doctors,
so that under suitable legislation some might do such adminis-
trative work as passing on disabilities altogether, doing no
curative work at all? Is it news to this editor that some persons
in our country remain at work when really unable to do so?
I once attended a young man for a complete transverse frac-
ture of a patella who had remained on the job three days after
the accident, and at pick and shovel work in zero temperature,
at that. How does the editor know that standards of medical
practice has depreciated in those countries he mentions? Why,
of course, on just such flimsy evidence as greater loss of time
among men too ill properly to be at work.

If editors of medical journals persist in a do-nothing attitude
except to growl at governmental interventions while millions
of our people are deprived of proper medical service for want
of purchasing power, we may expect federal and state provisions
not altogether to our liking. It is high time our medical "con-
servatives” get busy and help the profession in figuring out a
sensible arrangement for the distribution of medical service to
all our people under a plan both they and we will accept. Such
a plan would not attempt to pauperize frugal, honest people
attempting to live on too small an income and on the other
hand, would not attempt to pauperize the profession by asking
them to work for nothing.

B. A. Place, M.D.,

Great Falls, Montana.

512

THE JOURNAL-LANCET

Hews Items

Christmas anti-tuberculosis seals will be sent to 10,000
people in or near Butte, Montana, according to reports.

Dr. Roscoe C. Hunt, Fairmont, Minnesota, has opened
bids for a $35,000 two-story, 15-bed hospital which he
will erect.

Dr. Willard A. Wright, president of the Lions’ Club
of Williston, North Dakota, has departed for Edin-
burgh, Scotland, for post-graduate study.

Dr. Theodore F. Riggs, Pierre, South Dakota, spoke
before the Lincoln Parent-Teachers Association at Pierre
on October 12, 1937.

Dr. Paul A. Swedenburg, a graduate of the Univer-
sity of Minnesota Medical School in 1931, has asso-
ciated with Dr. Edwin J. Simons, Swanville, Minnesota.

Dr. Alcibiades Alexander Giroux, a graduate of the
University of Montreal Faculty of Medicine in 1908,
has moved from Duluth, Minnesota, to Red Lake Falls.

Dr. and Mrs. John B. Simons, of Swanville, Minne-
sota, left on October 1 for Whitefish, Montana, where
Dr. Simons will practice medicine.

Granite Falls, Minnesota, will build an addition to
its hospital, and bids are being accepted by Dr. Melvin
S. Nelson, of the Granite Falls Hospital Board.

Dr. Greger Elmer Schoofs, of North Branch, Minne-
sota, has located at 1025 West Broadway in Minne-
apolis, where he will practice.

Dr. Douglas Leonard Johnson, Cambridge, Minne-
sota, has moved to Little Falls, where he will associate
with Dr. Roman V. Fait.

Bids closed on November 2 for the new $39,000
Infirmary Building to be erected at San Haven, North
Dakota, at the tuberculosis sanatorium.

Dr. Bernard Louis Sinner, a graduate of the St. Louis
University School of Medicine in 1933, has located at
402 Black Building in Fargo, North Dakota.

Bids closed on October 20 for the new $170,000
woman’s ward building to be erected at the State Hos-
pital for the Insane at Yankton, South Dakota. Dr.
George Sheldon Adams is the medical superintendent.

Dr. Agnes Dunnington Gray Stucke, of Garrison,
North Dakota, left on October 17 for Bismarck to visit
Dr. Edmund C. Stucke before she sails from New York
City on the S. S. President Pierce on a world tour.

Dr. Raymond Thomas O’Neill, Minot, North Da-
kota, has returned to his practice. He has been critically
ill following an operation at the Mayo Clinic in
Rochester.

Dr. Charles Albert Arneson, Bismarck, North Dakota,
spoke on "Syphilis” before the Bismarck Lions’ Club on
October 4, 1937.

The new $70,000 Service Building of the Lutheran
Deaconess Hospital in Minneapolis is scheduled to open
in November.

The committee on venereal diseases of the North
Dakota State Medical Association has recommended
that every complete physical examination include a Was-
sermann test, according to reports.

Dr. Francis Edgar Manning, Custer, has been elected
president of the South Dakota Health Officers Associa-
tion. Dr. Will Donahoe, Sioux Falls, is vice-president;
and Dr. B. A. Dyar, Pierre, is the secretary-treasurer.

Dr. George Washington Bolkcom, 70, of Minneapolis,
died at his home on October 17, 1937. A graduate of
the University of Minnesota Medical School in 1894,
Dr. Bolkcom was in practice until 1934, when he retired.

A seminar at the Center for Continuation Study at
the University of Minnesota, Minneapolis, will be held
from November 1 to 6, 1937, on surgical diagnosis and
treatment.

The first regular monthly meeting of the Cass County
Medical Society (North Dakota) for the fall season
was held on October 25 at the Fargo Chamber of Com-
merce.

Dr. Francis Weldon Ford, a graduate of the Tufts
College School of Medicine, Boston, in 1935, has asso-
ciated with Dr. Frederick Chase Lorenzen in Elgin,
North Dakota.

Dr. Ralph St. John Perry, 73, a graduate of the
University of Indiana School of Medicine in 1884, died
at the Veterans Administration Facility in Minneapols,
where he had been a surgeon, on October 4, 1937.

Dr. Maurice Martin Heffron, of Dickinson, North
Dakota, was married on September 25 in Chicago to
Miss Maryruth Stephan, of Chicago, and both have
returned to Dickinson.

Dr. Otto W. Yoerg, Minneapolis, was installed on
October 7, 1937, as president of the Minneapolis Sur-
gical Society. Dr. E. A. Regnier is vice-president; and
Dr. Harvey Nelson is the new secretary-treasurer.

Dr. Samuel Saunders Steinberg, of Butte, Montana,
has been awarded a diploma from the American Board
of Radiology. He is the second physician in Montana
to obtain such a certification.

Dr. Clarence E. Sherwood, secretary of the South
Dakota State Medical Association, Madison, South
Dakota, attended the international assembly of the In-
terstate Post-Graduate Medical Association at St. Louis,
Missouri, on October 18 to 22, 1937.

Dr. Edward Aloysius Welch, clinical director of the
Veterans Administration Facility at Hot Springs, South
Dakota, delivered an address recently in that city on
"Syphilis.”

Dr. Carl G. Arvidson, Minneapolis, addressed the
American Prison Conference at Philadelphia on October
9, 1937, on "Experiences and Treatment of Venereal
Diseases in Minnesota Penal Institutions.”

Dr. William P. Ross, for 8 years chief of the South-
western Minnesota Sanatorium in Worthington, has
been named chief of the Otter Tail County Sanatorium
near Fergus Falls.

THE JOURNAL-LANCET

513

Dr. John Cowan, chief of the division of preventable
diseases of the state of North Dakota, spoke on "Com-
municable Diseases” before the Parent-Teachers Asso-
ciation of Jamestown on October 12, 1937.

Dr. Andrew John Heimark, 57, a graduate of the
University of Illinois College of Medicine in 1904, died
at Fargo, North Dakota, on September 17, 1937. Dr.
Heimark came to Finley, North Dakota, in 1904, re-
maining there until 1924, when he removed to Fargo.

Dr. Irvin L. Schuchardt, a graduate of Rush Medical
College of the University of Chicago in 1935, has
located with Doctors M. Robert Gelber and Dr. Gregory
P. Donovan in the Citizens Building in Aberdeen, South
Dakota.

Dr. Amos Roy Gilsdorf, a graduate of the University
of Minnesota Medical School, has completed his intern-
ship at the Minneapolis General Hospital, and has
associated with the Dickinson Clinic in Dickinson, North
Dakota.

Dr. William M. Copenhaver, Jr., a graduate of the
University of Minnesota Medical School in 1932, who
had been studying at the New York Post-Graduate
Medical School & Hospital since 1935, has located in
the Power Block at Helena, Montana.

There are now no less than 115,000 members in the
Minnesota Hospital Service Association, according to
Mr. E. A. van Steenwyk, secretary of the organization.
Liaison arrangements have been established with the
American Hospital Association.

Dr. Arne O. Arneson, McVille, North Dakota, was
tendered a program in honor of his more than 30 years
of service in North Dakota, on October 3, 1937. He
was graduated from George Washington University
School of Medicine, Washington, D. C., in 1911.

Dr. William A. O’Brien, associate professor of path-
ology and preventive medicine in the University of Min-
nesota Medical School, spoke on "Health Hygiene” at
the State Teachers College, St. Cloud, on October 11,
1937.

Dr. Harold William Gregg, of the Murray Hospital
Clinic, spoke on "Lymphatic and Monocytic Leukemia”
at the monthly meeting of the Silver Bow County Med-
ical Society at the Silver Bow Club in Butte, Montana,
on October 5, 1937.

Dr. Guy E. Van Demark, Sioux Falls, South Dakota,
described methods in orthopedic surgery and correction
before a meeting of the Altrusa Club in Sioux Falls on
October 7, 1937. Dr. Goldie Eleonora Zimmerman, an
Altrusa Club member, was also on the program.

Dr. Thomas L. Hawkins, of Helena, secretary of the
Medical Association of Montana, visited the inter-
national medical assembly of the Interstate Post-Grad-
uate Medical Association at St. Louis, Missouri, on
October 18 to 22, 1937. From St. Louis, Secretary
Hawkins went to Chicago, where he attended the meet-
ing of the American College of Surgeons.

Dr. Frank Terrill, superintendent of the Montana
State Tuberculosis Sanatorium at Galen, has departed
for Chicago, where he will enter the American College
of Surgeons, and take post-graduate work at Cook
County Hospital.

Dr. Henry F. Helmhlotz, Rochester, professor of
pediatrics in the University of Minnesota Graduate
School of Medicine, has been named president of the
International Congress of Pediatricians, which met at
Rome, Italy, in September.

Dr. James W. Vidal, 76, a graduate of the Univer-
sity of Michigan Homeopathic Medical School in 1882,
died at Fargo, North Dakota, on October 5, 1937. He
owned a hospital in Fargo, and was a member of the
National Homeopathic Society.

Dr. Clifford Earl Waldorf, a graduate of the North-
western University Medical School in 1918, formerly a
physician at the State School and Home for Feeble-
Minded, at Redfield, South Dakota, has entered practice
on the first floor of the Friedman Apartment Building
in Redfield.

Dr. William Gerard Paradis, superintendent of Sun-
nyrest Sanatorium at Crookston, Minnesota, will not
resign on November 1, as has been announced elsewhere.
Sanatorium commissioners voted to increase his salary
$300 annually, and Dr. Paradis has accepted this
arrangement.

Dr. Joseph Lorin Mondloch, Butte, Montana, con-
ducted a tour of the Butte Anti-Tuberculosis Association
through Silver Bow County Hospital on October 14,
1937. The Association held a business meeting, pre-
sided over by Dr. Curtis L. Wilson, of Butte.

Dr. Charles Otis Wilkins, 65, of Keokuk, Iowa, died
in Winner, South Dakota, on October 12, 1937. A
graduate of the old Keokuk College of Physicians and
Surgeons in 1906, Dr. Wilkins had practiced medicine
at the Rosebud Indian Agency, Hamill, South Dakota,
until 1934, in which year he returned to Keokuk.

Dr. Owen H. Wangensteen, chief of the departments
of surgery in the University of Minnesota and Univer-
sity Hospital, spoke before the Redwood-Brown Counties
Medical Society and the Blue Earth County Medical
Society at a joint meeting on September 26, 1937, on
"The Traumatic Surgical Abdomen.”

Dr. J. C. McKinley, chief of the department of medi-
cine in the University of Minnesota Medical School,
and president of the Minnesota Pathological Society,
delivered his "President’s Address” before the society
in the Institute of Anatomy in Minneapolis on October
19, 1937.

Dr. Patrick Henry Mee, 60, of Osseo, Minnesota,
died on October 2, 1937, at his home. He was grad-
uated from the University of Minnesota Medical School
in 1903, was Sibley County coroner for 8 years, and
moved to Osseo in 1911. He was a member of the Hen-
nepin County Medical Society, and other groups.

514

THE JOURNAL-LANCET

Dr. Cyrus O. Hansen, instructor in medicine in the
University of Minnesota Medical School, was the speak-
er at the dinner meeting of the Seventh District Med-
ical Society at Sioux Falls, South Dakota, on October
12, 1937. He discussed "Recent Advances in X-Ray
Treatment.”

Dr. Raymond F. Peterson, of the Murray Hospital
Clinic, Butte, Montana, spoke on "Cancer” in the Butte
High School auditorium on October 8, 1937, his address
being sponsored by the Silver Bow County Medical
Society and the bureau of safety of the Anaconda
Copper Mining Company.

Dr. Robert D. Mussey, Rochester, professor of ob-
stetrics in the University of Minnesota Graduate School
of Medicine, was chosen president of the Central Asso-
ciation of Obstetricians and Gynecologists at Dallas,
Texas, during October. The 1938 session will be held in
Minneapolis.

Three Minneapolis physicians participated in the 42nd
annual convention of the American Academy of Oph-
thalmology & Otolaryngology held in Chicago during
October. They are: Dr. Horace Newhart, professor and
director of the department of otology, rhinology, and
laryngology in the University of Minnesota Medical
School; Dr. Lawrence R. Boies, instructor in the same
department; and Dr. Erling W. Hansen, who is secre-
tary of the Academy’s public relations committee.

Dr. Gaylord W. Anderson, professor and new chief
of the department of preventive medicine and public
health in the University of Minnesota Medical School,
spoke on "The Present Status of Scarlet Fever Preven-
tion,” before the 66th annual meeting of the American
Public Health Association in New York City in October.
Dr. Max Seham, associate professor of pediatrics, spoke
on "The Screening of Behavior Disorders in School
Children.”

Two junior medical officerships are available to those
physicians who pass the examinations and whose cre-
dentials are in order. The first is a rotating interneship
at $2,000 annually at St. Elizabeth’s Hospital in Wash-
ington, D. C.; the second is a psychiatric residency in
the same hospital at the same salary. Applications must
be on file with the United States Civil Service Commis-
sion in Washington, D. C., not later than November 29.
Information may be had from any 1st or 2nd class post-
office near the applicant.

Western Reserve University School of Medicine in
Cleveland, Ohio, announces a series of graduate courses
in various aspects of venereal disease control, under
authority of the United States Public Health Service
and the Ohio State Department of Health. They are
open without fees to physicians in Minnesota, Wisconsin,
and North and South Dakota. Physicians should address
C. C. Applewhite, M.D., regional consultant of the
U. S. Public Health Service, Room 314, United States
Court House, Chicago, Illinois.

Dr. Henry L. Ulrich, professor of medicine in the
University of Minnesota Medical School, was installed
as president of the Hennepin County Medical School on
October 4, 1937. Dr. Norman P. Johnson, assistant in
medicine at the University, became 1st vice-president;
Frank C. Rodda, clinical professor of pediatrics, is the
2nd vice-president; and Dr. Orwood J. Campbell, assist-
ant professor of surgery, is the new secretary-treasurer.

Dr. James M. Hayes, Minneapolis, assistant professor
of surgery in the University of Minnesota Medical
School, was elected president of the Alumni Association
of the Mayo Foundation at the 19th annual session of
the association at Rochester on October 22, 1937. Dr.
Julius H. P. Gauss, of Indianapolis, assistant professor
of medicine in the University of Indiana Medical
School, was elected vice-president; Dr. George Vincent
Lynch, Oshkosh, Wisconsin, was chosen second vice-
president; Dr. J. Richards Aurelius, St. Paul, instructor
in radiology in the University of Minnesota Medical
School, was chosen secretary; and Dr. Louis E. Prick-
man, Rochester, assistant professor of medicine in the
University of Minnesota Graduate School of Medicine,
was elected treasurer.

MISCELLANEOUS

TO MEMBERS OF THE NORTH DAKOTA
STATE MEDICAL ASSOCIATION

Inquiry has been made to the officials of the State
Medical Association from members in various parts of
the State if any offer had been made to the Board of
Administration by the Association to help them solve
the problem they had at the State Hospital in James-
town.

In order that the profession throughout the State
might know what was done, this brief statement of
facts is made:

September 15th, a telephone request came from Gov-
ernor Langer that the Board of Administration was in
session and requested that the Medical Association name
a Committee on whom they might call when necessary
to assist in solving problems in connection with the State
Hospital, and to send the names of said Committee to
the Chairman of the Board of Administration at once.
The telephone was used to consult Association officials
and the following Committee selected:

Doctors — E. L. Goss, President, Carrington.

J. E. Countryman, Grafton.

R. D. Campbell, Grand Forks.

W. H. Long, Fargo.

N. O. Ramstad, Bismarck.

M. W. Roan, Bismarck.

F. C. Lorenzen, Elgin.

F. W. Fergusson, Kulm.

This list was sent Day Letter September 15th to Mrs.
Jennie Ulsrud, Chairman, State Board of Administra-
tion, and Governor Langer. Acknowledgement of receipt
of this Day Letter has not been received nor has this
Committee been asked to serve in any capacity.

Fifty-Ninth Annual Meeting of the Medical Association
of Montana --Great Falls, July 13 and 14, 1937

OFFICERS, 1937-1938
PRESIDENT

W. P. SMITH, M.D. Columbus

PRESIDENT-ELECT

J. C. MacGREGOR, M.D. Great Falls

VICE-PRESIDENT

E. D. HITCHCOCK, M.D. Great Falls

SECRETARY-TREASURER

T. L. HAWKINS, M.D. .... Helena

DELEGATE TO A.M.A.

J. H. IRWIN, M.D. Great Falls

ALTERNATE

E. M. GANS, M.D. Harlowton

COUNCILORS

Term Expires

J. I. WERNHAM, M.D., Billings 1938

E. D. HITCHCOCK, M.D., Great Falls 1938

E. S. MURPHY, M.D., Missoula 1938

M. SMETTERS, M.D., Butte.. 1938

A. D. BREWER, M.D., Bozeman 1939

J. H. GARBERSON, M.D., Miles City ... 1939

E. A. WELDEN, M.D., Lewistown 1939

L. G. DUNLAP, M.D., Anaconda 1940

E. N. JONES, M.D., Wolf Point ... ...1940

L. T. SUSSEX, M.D., Havre ......1940

ANNUAL MEETING OF THE COUNCIL OF
THE MEDICAL ASSOCIATION
OF MONTANA

July 13, 1937 — Rainbow Hotel
Great Falls, Montana

Those present were: Doctors, President John A. Evert,
E. S. Murphy, E. N. Jones, E. D. Hitchcock, L. P.
Sussex, E. A. Welden, A. D. Brewer and T. L. Hawkins.

Due to the necessary departure of the president,
Doctor E. S. Murphy was selected as chairman of the
meeting.

The finance report of the Association was read, which
included the auditing of the books by H. B. Godfrey
of Billings, Montana, following the death of Doctor
E. G. Balsam, secretary-treasurer. The secretary, Doctor
T. L. Hawkins, asked for advice concerning the invest-
ment of funds. The councilors granted the secretary-
treasurer permission to use his own discretion in the in-
vestment of funds for the Association.

A discussion of the reduction of members of the
Council was held. Doctor A. D. Brewer moved that a
motion for the reduction of the number be tabled, which
was seconded by Doctor E. A. Welden. A motion was
made to that effect and put to a vote and carried.

It was moved by Doctor L. P. Sussex and seconded
by Doctor E. A. Welden that Doctor John A. Evert
and the secretary-treasurer act as a committee to arrange
for an official journal for the Association. The motion
carried.

516

THE JOURNAL-LANCET

A statement of the orthopedic division of the Welfare
Board, as to its policy, was read and adopted with
corrections.

There being no further business the Council ad-
journed.

59th ANNUAL MEETING OF THE HOUSE
OF DELEGATES OF THE MEDICAL
ASSOCIATION OF MONTANA
July 13, 1937

The meeting of the House of Delegates was called
to order by the president, Doctor John A. Evert, on
July 13, 1937, at the Rainbow Hotel, Great Falls,
Montana.

The certificates of the delegates from the various
counties were examined and found to be in order.

It was moved and seconded that the minutes of the
last meeting be dispensed with. The motion carried. The
secretary-treasurer’s report was read.

Doctor S. A. Cooney reported on the Bozeman case,
and cited the significance of the Supreme Court’s
decision.

A communication from the State Welfare Board,
relative to the case of Mae Bell, an indigent, was dis-
cussed. A motion was made, seconded and passed to
communicate with the State Welfare Board and inform
them that the Medical Association did not qualify a
physician over and above the certification to practice in
the State of Montana and since the county physician
is a licensed physician, he is competent to act.

A committee consisting of Doctors H. W. Gregg, A.
D. Brewer and J. H. Graham was appointed to prepare
a memorial to the late Doctor H. A. Bolton and Doctor
Elmer G. Balsam. The resolution as adopted:

"Whereas, during the past year, two very prominent
and much loved members of our Society, namely Doctor
Harris A. Bolton of Warm Springs and Doctor Elmer
G. Balsam of Billings have finished their work, and
have slipped away into the unknown.

"Be it resolved, that the House of Delegates have
assembled, pause to remember their kindliness and
friendship.

"Be it further resolved, that we remember with grati-
tude the fact that the practice of medicine in Montana
is better and our lives are richer because these men
lived and practiced among us.

"Be it further resolved, that there be a permanent
record of the lives and work of these men and such a
record be made a part of the activities of our Society.

"Be it further resolved, that a copy of these resolu-
tions be spread upon the minutes of this meeting, and
that another copy be sent to the families of the men.”

Doctor S. A. Cooney stated that the Medical Exam-
ining Board now requires citizenship as a pre-requisite
in obtaining a license to practice in the State of Mon-
tana.

Doctor H. W. Gregg reported on a nurses’ strike in
Anaconda. Doctor A. J. Willits made further comment
on the Anaconda situation. Doctor H. W. Gregg was

appointed chairman of a committee to report on what
action the Medical Association should take in this
matter.

Doctor J. C. MacGregor reported on the work of
the Medical Defense Committee and stated that the
number of malpractice cases had dropped from over
fifty to fifteen since the committee had functioned.

Mrs. Keck, national representative of the Women’s
Auxiliary, spoke to the delegates and asked permission
to grant the formation of such an auxiliary to the Mon-
tana Medical Association. Doctors J. R. E. Sievers, J.
H. Irwin and F. L. McPhail were appointed on a com-
mittee to investigate this organization, and report back
to the House of Delegates on July 14, 1937.

Doctor J. H. Irwin gave a report as a delegate to the
American Medical Association.

A committee consisting of Doctors E. S. Murphy, F.
R. Schemm and C. H. Peterson was appointed to select
five names for two vacancies on the State Board of
Health. The first vacancy created by the death of
Doctor E. G. Balsam and the second vacancy to occur
shortly at the expiration of the term of Doctor B. E.
Pampel.

Doctor S. A. Cooney, representing the Lewis and
Clark County Medical Society, presented a resolution
from the society, requesting that the annual meeting
of the Association be held in the spring of the year.
Doctors H. W. Gregg, S. A. Cooney and J. H. Irwin
were appointed on a committee to report back and make
recommendations for the change in date of the meeting
for 1938.

A motion was made, seconded and carried that Mr.
E. G. Toomey of Helena be retained as attorney for
the association and that his retaining fee be arranged by
mutual agreement with the secretary-treasurer of the
Association.

Doctor E. S. Murphy spoke on a registration fee for
all who practice the healing art in Montana.

A motion was made, seconded and passed that the
Legislative Committee meet with Mr. Toomey and re-
port at the next meeting.

Doctor W. P. Smith spoke on a formation of an
Inter-Relations Committee on Scientific Papers, and a
motion was made, seconded and passed that such a com-
mittee be appointed.

A motion was made, seconded and passed that the
name of the Committee on Infant Welfare be changed
to the Committee on Maternal and Child Health.

A motion was made, seconded and passed that the
problem of birth control was one of individual judgment
and that it was not a matter to be acted upon by the
Medical Association of Montana.

A motion was made, seconded and passed that a com-
mittee be appointed on tuberculosis.

A motion was made, seconded and passed that a com-
mittee known as the "Fracture Committee” be organized.

A motion was made, seconded and passed that the
Committee on "Periodic Health Examination,” "Vet-
eran’s Affairs,” and "Universities,” be stricken from the
list of committees.

THE JOURNAL-LANCET

517

It was moved and seconded that a committee be ap-
pointed to be known as the "Committee for the Revi-
sion of the Constitution and By-Laws.” This motion was
passed.

A committee on resolutions was appointed consisting
of Doctors L. H. Fligman, F. L. Andrews and C. H.
Nelson.

There being no further business the House of Dele-
gates adjourned.

HOUSE OF DELEGATES
July 14, 1937

A Meeting of the House of Delegates of the Medical
Association of Montana, held July 14, 1937, at the
Heisey Memorial Building, Great Falls, Montana.

After the proper certifying of the delegates, the House
was called to order by President John A. Evert.

The resolution committee made the following report:

"We, the Committee on Resolutions, having met, de-
sire to present the following resolutions:

1. Resolved that we extend to the following organi-
zations our sincere appreciation for their assist-
ance in making this meeting a successful one.

First, to the Cascade Medical Society, for the
efficient manner in which they have contributed
towards making this meeting a pleasant and
profitable one.

Second, to the Great Falls Tribune and
Leader , for their generous space donated in their
press.

Third, to the Rainbow Hotel, for donating
space for exhibits and for its hospitality.”

The Women’s Auxiliary Committee reported that they
recommended that the Association grant authority for
the formation of a Women’s Auxiliary to the Medical
Association of Montana. Such a motion was made, sec-
onded and passed by the House of Delegates.

A committee appointed to select a list of five names
for presentation to the governor for the two vacancies
on the State Board of Health, reported and submitted
the following names: B. E. Pampel, Chas. S. Houtz,
J. I. Wernham, B. E. Smetters, and E. N. Jones.

A motion was made, seconded and carried recom-
mending a permanent record of the lives of the mem-
bers of the Association be kept in the secretary’s office.

Doctor J. H. Bridenbaugh made a report of the
Cancer Committee and the monies spent by such com-
mittee during the past year. A motion was made, sec-
onded and passed accepting the report of Doctor J. H.
Bridenbaugh.

A committee appointed on July 13th reported and rec-
ommended that a letter be written to the National and
State Nurses Association commending them on their
action in disqualifying striking nurses in their organiza-
tion.

A committee appointed to study a change of time of
the state meeting reported as follows:

"Your Committee recommends that beginning in 1938,
our society have two annual meetings, namely as follows:
One business meeting late in April at some central point
of the House of Delegates and the Councilors. This

meeting should require one day.

"The second, a scientific meeting to be held in No-
vember to last two days.

"That a permanent program committee be appointed
by the Chair at this present meeting. That this com-
mittee be composed of three men and the secretary, who
is to be an ex officio member. That one man on the com-
mittee be appointed for three years, one for two years,
and one for one year, thus one new member will be
appointed each year. This would insure continuity in
the work of the committee.

"That the delegate to the American Medical Asso-
ciation be given a place on the scientific program.

"As an alternative, if the men feel that they do not
want two meetings a year, that a meeting comparable to
our present meeting be held in April of each year, but
in that case, there still be appointed the above mentioned
permanent program committee.”

A motion was made, seconded and passed that two
meetings be held each year. The first meeting a business
meeting, consisting of the officers, councilors and House
of Delegates. This meeting to last for one day and to
be purely a business meeting. A second meeting to be
a scientific meeting and to be held in the fall and to
last for two days and at which meeting no business will
be transacted.

Doctor E. A. Welden invited the Association to meet
at Lewistown in 1938. Doctor J. C. Shields moved that
the invitation be accepted. The motion was seconded
and passed.

Doctor H. W. Gregg nominated to the office of
president-elect, Doctor J. C. MacGregor of Great Falls.
Doctor J. J. Kaulbach seconded the nomination and
moved that the nominations be closed and that the sec-
retary be instructed to cast an unanimous ballot for the
election of Doctor J. C. MacGregor. The motion was
carried.

Doctor J. R. E. Sievers nominated Doctor E. D.
Hitchcock for vice-president. Doctor J. I. Wernham
moved that the nominations be closed. The motion was
seconded and passed and the secretary was instructed to
cast an unanimous ballot for Doctor E. D. Hitchcock
for vice-president.

Doctor F. L. Andrews nominated Doctor T. L. Hawk-
ins for secretary-treasurer. Doctor J. C. Shields moved
that the nominations be closed. The motion was sec-
onded and passed and the secretary was instructed to cast
an unanimous ballot for Doctor T. L. Hawkins for sec-
retary-treasurer.

Doctors E. N. Jones, L. T. Sussex and L. P. Dunlap
were elected as councilors for three year term. Doctor
J. I. Wernham was elected councilor to fill out the un-
expired term made by the vacancy of Doctor T. L.
Hawkins.

Doctor J. H. Irwin was elected delegate to the Ameri-
can Medical Association meeting with Doctor E. N.
Gans as alternate.

There being no further business the House of Dele-
gates adjourned. Thomas L. Hawkins, M.D.,

Secretary-T reamrcr.

518

THE JOURNAL-LANCET

Some of the Problems in the Diagnosis
of Intestinal Obstruction*

Kent E. Darrow, M.D.f
Fargo, North Dakota

INTESTINAL OBSTRUCTION, or ileus, is
always a secondary disease caused by some ante-
cedent condition which produces a stoppage of the
bowels. This primary cause may be mechanical, causing
mechanical obstruction, or it may be toxic or nervous,
causing a paralysis of the bowel, which is known as
paralytic ileus. An obstruction can also be caused by a
spasm so severe as to close the lumen of the bowels and
is known as dynamic ileus. Mechanical obstruction
occurs through all grades of partial obstruction up to a
complete one, in which no gas or fecal content can pass
the obstructed point.

Besides obstructing the lumen of the gut, the circula-
tion may also be shut off, either the arterial or the
venous, or both, and we then have strangulation as well
as obstruction. While we generally mean gross obstruc-
tion of the vessels when we speak of strangulation, nev-
ertheless, nearly every case of obstruction, if it persists
long enough, shows marked impairment of the capillary
circulation due to the distention of the bowels; and this
is undoubtedly an important factor in the fatal outcome
of the obstruction. Complete obstruction unrelieved is
a fatal disease; but much more rapidly so if strangula-
tion is added.

It might be mentioned here that strangulation of a
portion of the intestinal tract will occur with thrombosis
or embolism in the mesenteric vessels. The bowel
becomes gangrenous and paralysis follows which in turn
produces obstruction. A partial obstruction may be
present for a long time. When it becomes complete,
we then immediately have an acute obstruction.

A list of the primary causes of obstruction must
always be kept in mind if one is to diagnose this bizarre
condition.

Some of the external mechanical causes are :

Herniation through external or internal openings.
Volvulus.

Peritoneal bands, congenital or acquired, which either
kink or constrict the gut.

Neoplasms constricting the intestinal wall.

Ulcerations with cicatricial constriction. Tuberculosis,
syphilis or colitis.

Internal causes :

Intussusception.

Foreign bodies, gall-stones, enteroliths, swallowed for-
eign bodies.

• Presented before the annual meeting of the North Dakota
State Medical Association, held at Grand Forks, May 16-18, 1937.
t Dakota Clinic, Fargo, North Dakota.

Neoplasms filling the lumen and diverticuli.

Causes which produce paralysis:

Adynamic or paralytic ileus.

Nervous origin, cord lesions, trauma to the abdomen
and psychic trauma.

Infectious or toxic origin — peritonitis, pneumonia,
acute hydronephrosis.

Circulatory origin, thrombosis and embolism.

Dynamic ileus, lead poisoning.

Symptomatology

With all the above different factors as the cause of
obstruction, there can be no single picture to cover this
tragic condition. The textbooks picture a fairly constant
set of symptoms and physical signs quite characteristic
of obstruction. They are directly due to the closure of
the lumen of the gut, but must vary somewhat with the
suddenness of the closure and the site of the closure in
the intestinal tract. As a rule, the nearer the stomach
the obstruction occurs, the more rapid the symptoms will
appear, the more severe they will be, and the more toxic
the patient. The presence of strangulation also makes
the symptoms more severe and the patient more toxic.

The outstanding symptoms are first pain, then nausea,
followed by vomiting, and later, stoppage of the stools
with abdominal distention and generalized toxemia with
rapid feeble pulse, and prostration. The patient is
usually mentally clear with little or no elevation of tem-
perature or increased leukocyte count unless there is
gangrene of the bowel or peritonitis.

The physical signs are anxious facial expression,
doubled-up posture, distended abdomen, tympany, some-
times with fluid and later with visible peristalsis and
borborygmi in mechanical obstruction; but complete
absence of visible peristalsis and borborygmi in the
paralytic type. If the obstruction has lasted some time
there is marked dehydration of the subcutaneous tissues
easily visible to the eye.

Pain is probably the most characteristic symptoms of
obstruction, varying from mild to the most excruciating.
The variation in the pain seems to be due, at least in
part, to the suddenness of the onset and the complete-
ness of the obstruction and the amount of circulatory
disturbance.

The pain may be localized at the point of obstruc-
tion, but more often is generalized, resulting from the
hyperperistalsis. If there is anything characteristic about
the pain, it is that it is apt to be intermittent or paroxys-
mal due to the intermittent contractions of the bowel

THE JOURNAL-LANCET

519

attempting to force the intestinal content beyond the
obstructed point. As the bowel distends and paralysis
approaches the pain becomes less severe, more general-
ized, and more constant. A stage is sometimes reached
when there is little or no pain. This is apt to give a
false sense of security. The pain usually returns and
is even more severe and paroxysmal. In paralytic ileus
without peritonitis pain may be practically absent. This
is due to the lack of peristalsis.

Many abdominal conditions have very similar pain —
acute appendicitis, acute pancreatitis, ruptured ulcer,
ruptured ectopic, acute pelvic peritonitis, acute hydro-
nephrosis or kidney stone and even gall-stones. Any of
these conditions may cause considerable bowel disturb-
ance of an obstructing nature which produces more or
less paralytic ileus.

Nevertheless, the pain in intestinal obstruction with
its varying intensity and site, when considered with
other symptoms and physical findings is an important
link in the chain of evidence leading to the correct
diagnosis.

Nausea and vomiting'. Nausea is nearly always pres-
ent at the very beginning, and usually continues through-
out the course. Often, however, one sees the patient
vomiting nearly continuously without feeling "sick at
the stomach.”

Vomiting also starts early; at first only stomach con-
tents, but later bile and upper intestinal contents, and
still later, the vomitus is fecal in character.

At first, the vomiting is intermittent and in large
amounts; later, it is almost continuous and in small
amounts with occasional violent expulsion of large
amounts of black, foul, fecal-like fluid. Stomach lavage
only gives a little temporary relief. Continuous suction
drainage is much better. It is this great loss of fluids
and the important glandular secretions of the upper
intestinal tract that are the greatest factors in the severe
toxemia.

Constipation : Do not be misled by the return of

colon content with the first enema or two after the onset
of the symptoms. Blood and mucous should make one
think of intussusception in children, and cancer in older
people.

Without a lot of clinical experience, one should not
put too much reliance on the passage or absence of
stools. Several stools may be passed in the presence of
acute obstruction and serious constipation, or even obsti-
pation, may be present in many abdominal and systemic
diseases without obstruction.

Abdominal distention: Abdominal distention is not

characteristic at first. As the disease progresses, the
abdomen is usually uniformly enlarged with some pro-
trusion about the umbilicus and epigastric regions. Some-
times coils of distended bowels or stomach may be seen
together with active peristalsis. The distention is great-
est in paralytic ileus, but is also extreme in many of the
obstructions of the lower colon and sigmoid. The dis-

tention following serious abdominal operations is often
difficult to distinguish from true obstruction.

Physical examination : At first, there are no signs

except the picture of the suffering, pinched face, the
patient usually lying on the back with the knees doubled
up. Then the disrention begins, and visible peristalsis
may be seen.

Palpation: There is a sense of overdistention of the
stomach and intestines. Tenderness is rarely present
and the reflex spasm of peritonitis is usually absent.
Unless a cancer or tumor of long standing is the cause
of the obstruction, usually no masses can be felt. Intus-
susception may be an exception. Hernial openings are
palpated for hernias caught in the rings. Rectal ex-
amination may show a low-lying cancer or the stricture
of an advancing intussusception. Fluid may be sometimes
made out in the abdomen. If perforation has taken
place, an abscess may be localized.

Percussion: As obstruction advances, general tym-

panites can be made out on percussion. Local tympany
might suggest a volvulus. An area of dullness in a child
might suggest intussusception. In advanced life it
would suggest cancer.

Auscultation: Auscultation is most valuable in de-

termining active peristalsis. Gas can be heard gurgling
along the intestinal tract, particularly in mechanical ob-
struction; but it is absent in paralytic types or late in
the mechanical type after the bowel has become para-
lyzed.

Other valuable sign's are a pulse which becomes
faster and faster, but weaker and weaker. The tempera-
ture remains normal without such complications as
peritonitis, strangulation or perforation.

Laboratory findings: The leukocyte count remains

normal in the absence of inflammation or strangulation.
The red blood count may be increased if there is much
dehydration. The non-protein nitrogen in the blood is
increased due to the loss of chlorides from vomiting.
The carbon dioxide combining power is increased.

The X-ray may be used, but does not add a great
deal of information. A flat plate of the abdomen may
show the fairly typical step-ladder appearance, which
some consider quite characteristic of intestinal obstruc-
tion. Barium by mouth is quite dangerous, and should
practically never be given this way in obstruction.
Many object to its being given in pyloric stenosis in
infants. In very high obstructions the barium will be
vomited and can not cause the harm that it would in
obstruction of the large bowel. Barium enemas,
however, are permissible and give valuable information
in obstructions of the large bowel.

Proctoscopic examination will give similar informa-
tion.

The progress of the disease from onset shows a great
variation. An average duration might be placed between
four and five days. High obstructions develop much
more rapidly and are fatal much quicker than obstruc-

520

THE JOURNAL-LANCET

tions lower in the bowels. An obstruction in the sigmoid
without strangulation might last several weeks before
it is fatal. With strangulation present, the constitu-
tional symptoms develop very rapidly and the local
symptoms may be exaggerated.

From the foregoing description of obstruction with
its many causes, one at once realizes the importance of
a most careful and complete history of the patient, his
previous illness, operations, accidents, etc., and a careful
history of the sequence of the present trouble.

Before going into the diagnosis, a few case histories
will be cited to show some of the varieties of obstruc-
tion and the problems to be met.

Case I.

Baby C., female, born June 17, wt. 3350 gm., appar-
ently normal except that the right eye lid is enervated
by same nerve as the superior rectus. The fourth day
she began to vomit all fluids taken, and showed de-
hydration. No fever. On the fifth day, X-ray with bari-
um meal showed an obstruction near the distal end of the
duodenum. The baby was prepared by fluids, and ex-
plored that evening under local block. The duodenum
was found markedly distended, and a 360 degree volvu-
lus of the entire mesentery of the small intestines was
found at the jejunum where it comes from behind the
peritoneum. This was untwisted and a few bands about
the jejunum were cut. The obstruction was thus com-
pletely relieved. She made a good recovery.

Case II.

E. M. C., female, age six months, admitted to hos-
pital 4:30 P. M. She was a normal baby, and had
been perfectly well up to the day before admission. She
began vomiting at 5 A. M. the day of admission. She
had no desire to nurse, and no stool the day before.
An enema the day of admission produced a good stool
and she had two bowel movements since, but only blood
and mucus. She vomited everything taken. T. 101,
P. 130, R. 30.

Physical examination was mostly negative except for
a suggestive mass in the right lower quadrant. No pain
occurred on palpation. A mass was felt by rectal ex-
amination near the left midline. It was not firm or
ballooned out. The barium enema could not be forced
beyond the sigmoid. Urinalysis was negative except for
acetone. White blood count, 16,100. Diagnosis: In-
tussusception. Operation under ethylene at 5:30 P. M.
the same day. Intussusception of about six inches of
ileum into the cecum. This was reduced, and a gan-
grenous appendix was noted after reduction. This was
removed. She made a good recovery.

Case III.

F. M., male, age 22, admitted to the hospital 11:15
P. M. He began 36 hours before to have generalized
abdominal cramps and vomiting. The vomiting con-
tinued, and the pains became colicky and intermittent.
He had no stool for 48 hours; also there was no gas.
He had a history of operation for ruptured appendix

five years before. Since operation he has had three defi-
nite attacks of cramps and vomiting and many minor
spells of gas.

Physical examination was negative except the ab-
domen. T. 98, P. 70, R. 20. General distention was
found but no masses and no especial tenderness. The
abdomen was rigid especially during cramps. Peristalsis
could be seen and gas sounds could be heard all over
the abdomen. Rectal examination was negative, but
fecal matter could be felt in the rectum. Urinalysis was
negative. White blood count, 5,500.

A diagnosis of obstruction was made and immediate
operation at 12:52 A. M. was done under spinal anes-
thesia. At operation a band that might have been a
rudimentary Meckel’s diverticulum was found obstruct-
ing the ileum. This was cut and an ileostomy tube
put in. Recovery was uneventful.

Case IV.

N. J. K., female, age 52, admitted to the hospital
at 10:15 A. M. Pain throughout the abdomen and
vomiting began at 7 P. M. the night before. Pain was
cramp-like and intermittent. She had had two abdom-
inal operations, and gave a history of similar attacks
two years ago and another one a year ago. Lighter
attacks occurred in between.

Physical examination showed generalized distention,
marked tympanites, and gas sounds throughout the
abdomen. Rectal and pelvic examinations were nega-
tive. T. 98, P. 80, R. 20, white blood count, 8,650 on
admission; 7,100 that evening, and 5,800 the next
morning.

A diagnosis of obstruction or partial obstruction was
made. The surgeon’s note was that suction might be
tried, together with enemas and glucose and concen-
trated salt solution by vein. If the pulse increased im-
mediate operation was advised, otherwise observation
seemed best. The medical consultant made the same
notations.

The patient was put on continuous hot stupes, duo-
denal suction, intravenous glucose and salines, and
enemas. Enemas got results that morning and the pa-
tient continued to improve. She left the hospital the
fifth day feeling well. This patient will probably come
to operation some time.

Case V.

Mr. A. P., age 49, was admitted to the hospital on
March 29, 1931. He was well up to that time. He had
severe pain two days before while doing chores. They
were on left side of the abdomen and radiated to the
inguinal ring and up into the left upper abdomen oppo-
site the kidney with occasional pain in the left kidney
region. He had a frequent desire to void, but passed
only a few drops and that with burning. He vomited
a little, and the pain left in about two hours. He had
some burning on urination the next day, but ate a
general diet without distress. Pain began again that
evening in the left side. He had the same dysuria and
desire to void. He had no bowel movements since the

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521

first attack, but passed a little gas at one time. Pain
continued all night and the patient was brought to the
hospital the next day. There was no history of similar
trouble or of operations.

Physical examination was negative except for the
abdomen. Marked general distention and tympanites
was found with marked rigidity throughout the ab-
domen. No localized tenderness was found. Rectal
examination was negative. Tenderness was found in
the left kidney region. T. 99.2, P. 84, R. 22. Urin-
alysis showed a few white blood cells. White blood cell
count, 10,000. 27 mg. urea nitrogen per 100 cc. of

blood. X-ray films of the abdomen were negative ex-
cept for distended intestines.

Diagnosis: Kidney lesion with ileus (?) obstruction?
Cystoscopy was done. Both ureteral orifices secreted
normally, the right more than the left. Catheters could
not be passed on either side, but indigo carmine was
secreted freely on both sides, more on the right than
the left. Exploration was then advised.

Spinal anesthesia was given and when the anesthetic
had reached the nipple line, the bowels commenced to
run off and distention decreased. An enema was given,
and a great deal more was returned than was given
with many particles of fecal matter. He was returned
to bed without exploration. He felt better for a while,
but began to bloat up again, and had considerable dis-
tress. A little gas passed at times with enemas but no
stool. The distention increased and two days later, in
spite of medical opinion that the kidney was undoubt-
edly to blame, he was taken to the surgery and explored.
The spinal anesthesia did not relieve him this time.

No obstruction could be found at exploration, but a
horseshoe kidney was palpated with considerable dis-
tention of the left kidney pelvis. With medical treat-
ment, hot stupes, intravenous glucose and concentrated
salt and continuous duodenal suction, he made a good
recovery in spite of the exploration. He did not return
for further kidney studies.

Case VI.

Mr. E. D. A., age 80, was admitted to the hospital
at 5:00 P. M. Vomiting began at about 10:00 P. M.
the night before and continued. There was no fecal
odor. Four enemas produced no results. No severe
abdominal pain occurred but a continuous diffuse ab-
dominal distress, not paroxysmal, was present. The
abdomen was tender and sore. There was no history
of bowel trouble or operations. Slight diarrhea oc-
curred a week ago.

Physical examination: T. 98.6, P. 100, R. 18, B. P.
150/90. Generalized distention was found with more
tympany in the upper abdomen. Tenderness was mod-
erate in the right upper and left lower abdomen. Rectal
examination was negative. White blood cell count on
admission was 11,500, and the next morning 29,500.

The surgeon’s note that evening stated that the ab-
domen was greatly distended; but not especially tender.
No masses were made out. No hernia was felt. The
abdomen was quiet, with no gurgles heard anywhere.

There must be obstruction without gangrene; he does
not look toxic; can wait until A. M. A medical note
made about the same time stated: "More distention to-
night; stomach washed, small amount of bile-like fluid
obtained, no fecal odor. Explore in A. M.”

He did not vomit during the night, but at 10:00
A. M. he had fecal vomiting, and this was just 36
hours from the first time he vomited. He was taken to
the operating room, but died before he could be ex-
plored. Autopsy showed a volvulus of a piece of small
intestine high up in the jejunum with complete gan-
grene of the bowel. Immediate operation might have
saved this patient in spite of his age.

Case VII.

Miss N. H., age 29, admitted April 13, 1937, and
operated the next day. A large submucous fibroid was
removed without hysterectomy and the wound was closed
without drainage. Moderate fever reaction occurred the
second postoperative day. The pulse was about 100,
but the respiration was unaffected. More pain than
usual occurred. A little vomiting was noted but not
more than in many cases. The enema on the third day
returned with a large amount of flatus and formed stool
with some relief. Considerable nausea and vomiting
and lots of gas pains occurred on the fourth postoper-
ative day. Enemas again brought much gas and some
fecal matter. On the fifth postoperative day there was
still pain and more bloating. Enemas still brought gas and
fecal matter with some relief. Stomach lavage returned
a moderate amount of greenish yellow fluid. More
vomiting occurred. Duodenal suction was started. Tem-
perature was up to 100°, pulse 100 to 110. Sixth post-
operative day found marked distention. Morphine gave
very little relief from pain. Enemas returned with a
large amount of gas and some fecal matter. Rectal
examination was negative, no bulging was found in the
cul-de-sac, but there was some tenderness. The tem-
perature went up to 102° that night; the pulse, 110.
On the morning of the seventh postoperative day, the
patient said she felt better. Her temperature was 100,
pulse 100 to 110, respirations normal. White blood cell
count, 12,500. The X-ray showed marked distention
of the small intestines. No gas had passed since the
preceding night. Complete or nearly complete obstruc-
tion was diagnosed and exploration was advised. Under
spinal anesthesia a loop of ileum was found adherent
to the back of the uterus and was twisted 180 degrees.
This was freed and untwisted and an ileostomy tube was
passed out through a stab wound in the side. A small
abscess with local peritonitis was also found back of the
uterus. Drains were put into the pelvis. The patient
made a very good recovery even though a little stormy.

Diagnosis

First of all comes the history. A general history of
the patient with his previous illnesses, operations, acci-
dents, etc., and a detailed history of his present trouble
with a careful account of the sequence of events are
essential. A thorough examination of the patient with

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special attention to hernial openings is then necessary.
Rectal and vaginal examinations and possibly also a
proctoscopic examination or a barium enema complete
the examination. The laboratory findings are of the
least assistance but should not be overlooked. X-ray
studies come in the same category.

With all the data sifted, one may still have to fall
back on that indefinable, but yet very real sense of
diagnosis only derived from years of observation and ex-
perience with the many perplexing problems of a med-
ical or surgical practice. The diagnosis is a combined
problem for the medical and surgical men working
harmoniously together. That is why, perhaps, the older
men with both a wide medical and surgical experience
make fewer mistakes.

Treatment

Acute intestinal obstruction, once fully established,
is a fatal disease unless the closure of the bowel is
relieved and therefore one can not procrastinate.

As preventive measures, the lesions that might cause
obstruction can be dealt with — hernias repaired, opera-
tions done in such a manner and so gently that adhesions
will not form.

Chronic obstructions can be treated to prevent their
becoming complete. Subacute cases may be at least

partially relieved by duodenal suction. Duodenal suction
is a wonderful aid in treating postoperative paralytic
ileus. I feel, however, that a great deal of harm can
be done by its indiscriminate use in acute intestinal ob-
struction. Put the suction in early if you wish, and
keep it up until a diagnosis is established, keeping it up
only if very definite improvement is noted. No matter
how careful we are, we can never be certain whether
or not strangulation is present and the suction will not
relieve this condition but only give a false sense of
security and valuable time will be lost when operation
should be immediate.

When reasonably certain that you are dealing with
an acute obstruction, do not wait longer than to get
some fluids, Ringer’s, glucose or possibly blood, into
the patient before resorting to immediate operation.
Every hour of delay increases the mortality in almost
geometric proportions.

As this is not a complete paper on the treatment, I
will not go into the important and varied problems the
surgeon must meet, but will merely mention that they
often tax the ingenuity and skill of even the most ex-
perienced surgeons.

Operation and early operation is the treatment for
acute intestinal obstruction.

A Clinic on Disease of the Biliary Tract*

Albert M. Snell, M.D.f
Rochester, Minnesota,
and

Donald L. Kegaries, M.D., and Earl W. Minty, M.D.,

Rapid City, South Dakota

THE TWO SYMPTOMS which most frequently
call attention to the biliary tract are pain and
jaundice. The former may be of the classical
type to which long usage has given the name, "biliary
colic,” and the presence of such a condition is usually
the first definite warning given by gallstones of their
presence in the bile passages. Jaundice likewise occur-
ring either following an episode of pain, or insidiously
without it, points to an obstructive lesion of the biliary
tract. Neither pain nor jaundice necessarily depends on
stones for its production but the association of these
symptoms with stones is so frequently observed that any
patient with these complaints becomes by that fact alone
a subject for surgical consideration. Pain, even of the
classical, colicky type may be dependent on physiologic
as well as pathologic disturbances and jaundice may
ensue from a variety of lesions in the bile passages or in
the liver itself. We propose to discuss certain clinical
problems encountered in dealing with these symptoms
in the cases to follow.

* Read before the meeting of the South Dakota State Medical
Association, Rapid City, South Dakota, May 24-26, 1937.

t Associate professor of medicine. University of Minnesota
Graduate School of Medicine. From the Division of Medicine, the
Mayo Clinic, Rochester, Minnesota,

Report of Cases

Case 1. A white man aged fifty-eight years, was ad-
mitted to hospital April 12, 1937, complaining of jaun-
dice of four weeks’ duration. His illness probably began
four months earlier when slight lumbar pain, general
malaise, and nausea were noted; about two months later
he lost his appetite and complained of vague, dull distress
in the right lower quadrant of the abdomen. Early in
March jaundice made its appearance; there was no severe
pain at that time and none to speak of thereafter. The
jaundice became progressively deeper and the patient
lost about 30 pounds (14 kg.). At the time of his ad-
mission to hospital, deep jaundice was present, the stools
were acholic and the urine was deeply bile-stained. Ex-
amination of the blood gave no evidence of disease other
than slight anemia. On examination of the abdomen a
globular mass, presumably a distended gallbladder, was
felt in the right upper quadrant of the abdomen, beneath
the costal margin. The blood pressure was 110 mm. of
mercury systolic and 64 diastolic; the temperature was
99.4° F. and the coagulation time of the blood was
3.25 minutes.

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523

Inasmuch as the jaundice was obviously of the ob-
structive type and had remained constant over a period
of four weeks, exploration of the biliary tract was ad-
vised. On May 6, under gas and ether anesthesia, the
gallbladder was opened and drained. The organ was
found to be distended to about three or four times its
normal size and on opening it white bile was obtained.
The mucosa of the gallbladder was covered with a mu-
coid coating and blood escaped when this substance was
wiped away. Both hepatic ducts were dilated to the size
of a man’s little finger; the common duct was dilated to
the size of a man’s thumb. Stones were not found in
the gallbladder or ducts but on palpation the head of
the pancreas was found to be enlarged and very firm.
The liver itself was enlarged, congested, and bile-stained.
Cholecystostomy was performed; a tube was secured in
the gallbladder and anchored to the skin of the abdom-
inal wall. Several days following operation, dark green
bile began draining from the tube and the jaundice de-
creased slightly. However, the stools still remained
acholic. The icterus index one week after operation was
101. A week later, the patient’s appetite improved and
the jaundice began to fade. May 21, a choledochogram
was made; the medium used was skiodan, of which 29
cc. was injected through the cholecystostomy tube. As
can be seen in the roentgenogram (Fig. 1), the gall-
bladder had contracted somewhat and the cystic duct
was visible. The common duct was greatly dilated and
the roentgenographic medium was present in the intra-
hepatic bile ducts, extending into the finer biliary radicles
within the liver. Obviously there was an obstruction at
the lower end of the common duct. Nitroglycerin
( 1/ 100 grain, or 0.006 gm.) failed to cause the sphincter
of Oddi to relax; a roentgenogram taken after adminis-
tration of the nitroglycerin was identical with the first.

Discussion: There is, of course, little doubt about

the diagnosis in this case. The patient’s age and sex, the
history of a gradual decline in health, followed by the
appearance of jaundice without pain, the complete ob-
struction to the bile passages, and the palpable and dis-
tended gallbladder, all argue for neoplastic obstruction
of the common bile duct. The lesion which most com-
monly produces such a condition is, of course, carcinoma
of the head of the pancreas and the surgical findings
appeared to confirm the diagnosis of such a lesion in this
case. Confirmatory evidence was offered by the chole-
dochogram, which shows the enormous distention of both
the extrahepatic and intrahepatic bile passages and the
complete obstruction at the ampulla of Vater. This
roentgenogram is almost diagnostic, since there is hardly
any other condition which can produce a similar effect.
Incidentally, it should be emphasized that the practice
of choledochography will give much valuable informa-
tion in cases of external biliary fistula, or in cases in
which the common duct is being drained by T-tube.
The extent to which this method has been used to study
the anatomy and physiology of the bile passages will be
apparent in later paragraphs.

A few words may be said in regard to the prognosis
in the case under consideration. There is no other point

Fig. 1. Choledochogram showing complete obstruction at the
ampulla, with enormous dilatation of the extrahepatic and intra-
hepatic ducts.

in the body where so small a tumor can produce such
marked effects and call attention to its presence so early
in the course of development. Having provided this
patient with an outlet for the dammed-up bile, one can
reasonably expect him to enjoy good health for a con-
siderable period, depending on the rate of growth of the
tumor. It is possible that the lesion in the pancreas itself
may be benign and inflammatory; there are records of
many cases in which cholecystostomy or cholecystgas-
trostomy has been performed for a supposed pancreatic
carcinoma, the patient thereafter surviving and enjoying
good health. It is certain that chronic pancreatitis may
produce complete and long-standing biliary obstruction.
Unfortunately, it is virtually impossible to be certain of
the diagnosis, even at operation, since a specimen for
biopsy can be obtained from the pancreas only with
considerable risk to the patient and usually biopsy is
avoided because of the danger of external pancreatic
fistula. The external drainage of bile in such cases is a
problem in itself.

How long will this patient tolerate the loss of bile
through the external fistula which is now present? In
both clinical and experimental work it has been found
that there is great variation in tolerance to an external
fistula and cases are on record in which such fistulas
have persisted for years without great harm to the
patient. In most cases, however, there is loss of weight,
increasing cachexia, digestive disturbances, and finally a
terminal hemorrhagic state. Hawkins and Brinkhaus
have shown that this hemorrhagic tendency is owing to
a deficiency in prothrombin and that this can be correct-
ed by collecting bile from the fistula and returning it to
the digestive tract. This undoubtedly should be done
in this case. The presence of bile in the intestine will

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favor the absorption of fats, vitamins, minerals, and
other essential substances in the diet; it can be given by
stomach tube, although many individuals have taught
themselves to mix the bile with fruit juice or car-
bonated beverages and to take it by mouth without diffi-
culty. If feedings of bile and a high carbohydrate diet
can be continued for a time it may be possible to re-open
the abdomen and perform cholecystogastrostomy, thus
providing a permanent method of biliary drainage and
leaving the patient in the best possible condition under
the circumstances. Even if the pancreatic lesion proves
to be malignant, such a procedure will insure a year or
more of comfort; if the lesion is benign, the operation
may be curative.

The following three cases illustrate various aspects of
the problem of biliary pain, both from the point of view
of diagnosis and from that of the physiologic mech-
anisms involved.

Case 2. A woman, aged forty-seven years, presented
herself for examination in December, 1935. The past
history was unimportant except that a pelvic operation
had been performed in 1918 and had been followed by
severe vomiting and hematemesis. The patient recovered
spontaneously and was well until about ten years later
when attacks of severe epigastric pain, coming on with-
out relationship to taking of food, were first noted.
These were irregular in time of appearance and did not
seem to bear any relationship to the usual symptoms of
peptic ulcer. About November, 1935, typical attacks of
biliary colic were first noted and were of sufficient
severity to require hypodermic injections of morphine
for relief. These were followed by vomiting and resid-
ual soreness in the right upper quadrant of the ab-
domen. A cholecystogram, made at that time, disclosed
the presence of a poorly functioning gallbladder con-
taining stones. A diagnosis of cholelithiasis was made
and exploration was advised. At operation, December
13, 1935, a large, chronically inflamed gallbladder, con-
taining stones, was found; the cystic duct was tortuous
but contained no stones. The common bile duct was
perfectly normal to palpation and was not dilated.
Cholecystectomy was carried out with some difficulty be-
cause of dense adhesions but the common duct was not
opened. Convalescence was satisfactory and the patient
was dismissed from the hospital after the usual interval.

The woman presented herself for examination again
in November, 1936, stating that she had had occasional
attacks of biliary colic for some months past. These
were less severe than they had been before operation
but they were followed by rather marked digestive dis-
turbances, with nausea and vomiting. Morphine had
been required for relief on several occasions but there
had been no jaundice, chills, or fever. Because of the
persistence and severity of her symptoms it seemed not
unlikely that a residual stone was present in the common
duct and with this in mind a second operation was per-
formed on November 9, 1936. The common duct was
exposed, opened, and explored with scoops; it was not
dilated and stones were not found. A T-tube was placed
in the duct for a prolonged drainage. This was removed

in the course of about two months and the patient there-
after had no further difficulties of any consequence.
There have been one or two minor digestive upsets, pre-
sumably caused by dietary indiscretions.

Discussion. The persistence of biliary colic following
cholecystectomy among patients with normal bile pass-
ages, free from stones and infection, is a problem which
has puzzled students of biliary physiology for many
years. The condition is relatively uncommon and only
a small percentage of patients complain of symptoms of
this type following cholecystectomy. The majority of
sufferers from the condition are women and many have
suffered from supposedly neurogenic visceromotor dis-
turbances in addition to cholecystic disease. The prin-
cipal symptom mentioned by these indn iduals is severe
colicky pain which arises in the region of the gallbladder
and sometimes extends to the right subscapular region.
These attacks usually begin and end suddenly and are
accompanied by nausea and vomiting. Chills, fever,
leukocytosis, jaundice, and residual soreness are absent.
The attacks vary in severity and occur without reference
to the taking of food.

Exploration of the extrahepatic bile passages has been
carried out in many of these cases at varying lengths of
time following cholecystectomy; the surgical findings as
a rule have been essentially negative. In spite of the
paucity of pathologic findings, drainage by T-tube and
decompression of the biliary tract has, in most instances,
produced relief. Repeated clinical and laboratory studies
in such cases have failed to demonstrate any evidence of
other abdominal disease or of any disorders arising in
the central nervous system. In some cases injection of
lipiodol into the biliary tree by way of the T-tube has
shown the presence of tonic contraction of the ampullary
portion of the duct. All available information about
individuals affected with this syndrome, called for want
of a better term "postcholecystectomy colic,” points to
a purely physiologic disturbance, dependent on some
motor dysfunction of the choledochal sphincter and asso-
ciated with temporary increases of pressure in the hepatic
duct system.

The motor functions of the biliary tract require brief
consideration as an introduction to the discussion to
follow. It is now generally agreed that the gallbladder
fills during the digestive cycle, and discharges itself in
response to a hormonal stimulant, cholecystokinin, which
is produced by the passage of certain food substances
through the duodenum. In connection with this cycle
of filling and emptying, the sphincteric mechanism at the
choledochoduodenal junction comes into play.

The existence of such a sphincter has been disputed
by some authors but Boyden, working from the embryo-
logic standpoint, Hendrickson from the anatomic stand-
point, and Mann and Higgins, as well as McMaster and
Elman, from the physiologic standpoint have advanced
proof of its existence. Although anatomically inconspic-
uous, the sphincter is of great physiologic importance,
forming an integral part of the functional unit which
regulates cholecystic filling and evacuation. During the
fasting state, the sphincter is in contraction and can

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525

resist a much greater pressure than the secretory pressure
of the liver. Closure of the sphincter allows the gall-
bladder to fill and, conversely, relaxation of the sphincter
permits the gallbladder to discharge its contents into the
duodenum.

Cholecystectomy alters the mechanism of biliary flow
to a great extent. Following such a procedure the sphinc-
ter becomes temporarily incompetent but subsequently
recovers its normal tone. As Judd and Mann have dem-
onstrated, this physiologic property of the sphincter is
responsible for the dilatation of the extrahepatic ductal
system which invariably follows cholecystectomy; at least,
if the sphincter is sectioned, this dilation does not occur.
Considerable intraductal pressure may be built up by
resistance of the sphincter to the secretory pressure of
the liver. If one assumes that the sphincter may become
spastic, irritable, or hyperkinetic after cholecystectomy,
it is easy to see how intraductal pressure might be ele-
vated to a very significant degree. In other words, there
is a sound physiologic explanation for postcholecyst-
ectomy colic provided one could prove: (1) that a mea-
surable tonic contraction of the choledochoduodenal
sphincter occurs in human subjects, and (2) that in-
creased intraductal pressure causes pain or colic in human
subjects.

Proof of both of these points has been advanced
recently. It has been shown by Zollinger that distention
of the common duct with a small balloon inserted at
operation will produce biliary colic, nausea, and vomit-
ing. McGowan, Butsch, and Walters"'1' have dem-
onstrated by means of studies of pressure in the common
duct and by injection of lipiodol into the biliary tree,
that the biliary colic which occurs following cholecyst-
ectomy is owing to spastic contraction of the sphincter
of Oddi with a sharp rise in intraductal pressure, such
rises in pressure paralleling roughly the severity of the
patient’s distress. In order to study this matter in more
detail it was necessary for them to find some means by
which contraction of the sphincter could be induced. It
was discovered that morphine sulphate and other deriv-
atives of opium had just such an effect on the sphincter
of the common duct and it was possible in the individ-
uals which they studied to precipitate painful contrac-
tions of the sphincter, and rises in intraductal pressure,
by this means. Search for a drug which had the oppo-
site effect proved to be arduous and difficult, but finally
it was found that nitroglycerine and amyl nitrite were
capable of causing prompt relaxation of the sphincter,
a fall in pressure, and complete relief from distress.
This observation has been verified in a great many in-
stances and the therapeutic results obtained in these
cases has justified continued use of nitrites for relief
of pain of this type. Sensitivity to derivatives of mor-
phine is a definite characteristic of some of these indi-
viduals, as is illustrated by case 3.

Case 3. A white man aged sixty-three years, first con-
sulted a physician because of indigestion and a dull pain
in the right upper quadrant of the abdomen, beneath the
costal margin. The attacks of pain and indigestion were
more or less continuous but never very severe. At times

the man could not eat without distress; at other times he
could eat any type of food. Four months before opera-
tion, in 1919, he had been jaundiced for a short time;
at various times he had had periods of vomiting of two
to three days’ duration. A strawberry gallbladder was
removed in 1919. The patient was well from that time
to 1930, at which time a spinal anesthetic was given
before prostatectomy. Thereafter the man complained
of continuous, dull pain in the right upper quadrant of
the abdomen, which lasted for more than a year. This
had not been associated with nausea or vomiting. Since
1930, the patient had had three acute attacks of colicky
pain in the right upper quadrant, beneath the costal
margin. With the first two attacks the pain lasted thirty
minutes. In 1936 an attack of left renal colic occurred
and the patient took J4 grain (.016 gm.) of morphine
by mouth, thus precipitating an acute attack of pain in
the right upper quadrant. In April, 1937, he had another
very severe attack of biliary colic and a physician was
called who administered amyl nitrite; this relieved the
patient’s distress in thirty seconds.

Discussion. Are we justified in assuming that a pa-
tient who has postcholecystectomy biliary colic, who is
sensitive to morphine, and who is relieved by nitrites, is
suffering only from a physiologic disturbance? Consid-
erable further study will be required to answer this ques-
tion, but it seems reasonably clear that not all patients
who have a hypertonic and irritable sphincter are sensi-
tive to morphine; neither are they all relieved of biliary
colic by administration of nitrites. Also, it must be ad-
mitted that a considerable number of persons with stone-
filled gallbladders are promptly relieved of their attacks
of colic by inhalation of amyl nitrite. In other words,
neither sensitivity to morphine nor relief from nitrites
is necessarily diagnostic. Undoubtedly many patients
have residual stones in the common duct and complain
of conditions which are indistinguishable from the
physiologic disturbance mentioned above; in these cases
the diagnostic problem is indeed a difficult one, as is
shown in case 4.

Case 4. A white woman, aged thirty-one years,
sought medical attention because of severe pain in the
right upper quadrant of the abdomen and indigestion,
persisting over a period of nine years. Qualitative dis-
tress from eating fatty and fried foods, radishes, onions,
and cabbage had been noted. The woman was deeply
jaundiced following one attack eight years before. For
a month or two before examination the pain had become
almost continuous and was aggravated by eating. Ex-
amination gave essentially negative results except for
marked tenderness in the right upper quadrant of the
abdomen, just below the ribs. February 19, 1935, at chole-
cystectomy, the gallbladder was found to be filled with
stones and nine stones were taken also from the dilated
common bile duct. A T-tube was inserted for prolonged
drainage of the biliary tract. The postoperative course
was uneventful and the patient was dismissed from the
hospital with the T-tube still in place. She was instructed
to keep this clamped but to release it if she experienced
any pain. On April 13, 1935, approximately two months

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Fig. 2. Choledochogram showing moderate dilatation of the
duct system with spasm at the ampulla.

following the operation, the patient returned to hospital
and a choledochogram was made (Fig. 2). Skiodan
was injected into the common duct by way of the T-tube,
and since there was a free flow of this medium into the
duodenum and since there were no shadows suggestive
of residual stones, the tube was removed. The chole-
dochogram showed some spasm and contraction of the
papillary portion of the common duct; this could be ex-
plained on the basis of hypertonicity and irritability of
the sphincter of Oddi. About twenty-four hours after
removal of the tube the patient had severe colic in the
right upper quadrant and epigastrium. A hypodermic
injection of morphine gave relief. Since then the patient
has gained weight and has been feeling well with the
exception of several attacks of pain in the same situa-
tion. There have been two attacks of acute pain within
the past two weeks, each of which has lasted approxi-
mately an hour. There has been no nausea or jaundice
following these attacks and there has been no extension
of the pain posteriorly.

Discussion. Had this patient consulted a physician
when she had this pain, a trial of amyl nitrite or nitro-
glycerin might have given useful information, since it is
our opinion that these attacks are owing to spasm of the
sphincter of Oddi rather than to stones in the common
duct. The only thing which will settle this point is con-
tinued observation. If jaundice appears it must be ex-
plained on the basis of stone, since so far as we know,
no patient with sphincteric spasm alone has become
icteric. If, on the other hand, symptoms are amenable
to administration of nitrites, the only procedure to be
recommended is continued observation pending the de-
velopment of some more definite symptoms of calculous
obstruction.

Summary

From the evidence presented, it appears that biliary
colic depends, in some instances at least, on a spastic
contraction of the sphincter of Oddi and a subsequent
rise in intraductal pressure. This is certainly true of
patients who have the so-called postcholecystectomy colic,
whose gallbladders have been removed and whose bile
passages are free from stones and infection; it may also
apply to some individuals whose biliary tract has not been
invaded surgically and whose gallbladders present vary-
ing degrees of pathologic change. Since nitrites have a
specific relaxing effect on the sphincter of the chole-
dochus it is logical to use them in an attempt to relieve
biliary colic from whatever cause, although there is no
assurance that pain will be relieved in every case. The
contraction of the sphincter produced by morphine and
its derivatives has been described and a case cited wherein
biliary colic was provoked by its use. This does not
mean that use of morphine is contraindicated in cases
of biliary colic, since its analgesic effect in such circum-
stances has been observed by generations of physicians.
It does indicate, however, that small doses, which contract
the sphincter and do little else, are likely to increase the
pain, and it also points to the necessity of studying the
reaction of the individual patient to morphine and
nitrites. Finally, it is important to recall that neither
sensitivity to morphine nor relief from nitrites is neces-
sarily diagnostic of any particular set of conditions exist-
ing within the gallbladder and bile ducts. The symptoms
produced by stone of the common duct and by physio-
logic hyperactivity of the sphincter are, in many in-
stances, identical and often one cannot be absolutely
certain of the state of affairs within the bile passages
unless careful exploration has been carried out.

The existence of these physiologic disturbances must
be considered in diagnosis of biliary pain; it is probable
that further studies on the physiologic and pharmacol-
ogic aspects of the problem will provide both a better
understanding of the problem and more satisfactory
methods of treatment.

References

1. Boyden, E. A.: The phylogeny of the sphincter choledochus.

Abstr. Anat. Rec. (Suppl.) 64:7 (Mar.) 1936.

2. Butsch, W. L., McGowan, J. M., and Walters, Waltman:
Clinical studies on the influence of certain drugs in relation to
biliary pain and to the variations in intrabiliary pressure. Surg..
Gynec. and Obst. 63:451 (Oct.) 1936.

3. Hawkins, W. B., and Brinhaus, K. M.: Prothrombin de-

ficiency the cause of bleeding in bile fistula dogs. Jour. Exper.
Med. 63:795-801 (June) 1936.

4. Hendrickson, W. F.: A study of the musculature of the

entire extrahepatic biliary system, including that of the duodenal
portion of the common bile-duct and of the sphincter. Bull. Johns
Hopkins Hosp. 8-9:221-232 (Sept. -Oct.) 1898.

5. Judd, E. S. and Mann, F. C. : The effect of removal of the
gall-bladder. Surg., Gynec. and Obst. 24:437-442 (Apr.) 1917.

6. McGowan. J. M., Butsch, W. L., and Walters, Waltman:
Pressure in the common bile duct of man. Its relation to pain
following cholecystectomy. Jour. Am. Med. Assn. 106:2227-2230
(June 27) 1936.

7. McMaster, P. D., and Elman, Robert: On the expulsion oi

bile by the gall bladder; and a reciprocal relationship with the
sphincter activity. Jour. Exper. Med. 44:173-198 (Aug.) 1926.

8. Mann, F. C., and Higgins, G. M.: A physiologic considera-

tion of the sphincter of the ductus choledochus. Proc. Soc. Exper.
Biol, and Med. 24:533-534 (Feb. 23) 1927.

9. Zollinger, Robert: Significance of pain and vomiting in

cholelithiasis. Jour. Am. Med. Assn. 105:1647-1652 (Nov. 23)
1935.

THE JOURNAL-LANCET

527

Ectopic Pregnancy

E. C. Hanson, M.D.

Park Rapids, Minnesota

IN HIS TEXTBOOK of obstetrics, De Lee remarks
that the incidence of ectopic pregnancy is about one
in every 600 pregnancies. Schumann found a rate of
one in 303 pregnancies. A member of the staff of the
Sivertson Clinic estimated an incidence of about one in
every 175 conceptions. During the past 15 years my
personal experience has encompassed 1,050 full term con-
finements, and probably 250 abortions and miscarriages.
In the course of the same years, I have operated upon
21 cases of tubal pregnancy. This high incidence, one
in 70, provides my greatest incentive for this paper.

Historical Notes

Extra-uterine pregnancy was first reported by Albu-
casis in the Eleventh Century. From that time until the
latter part of the Nineteenth Century, only 500 cases
were reported in the literature. In 1878, Veit first sug-
gested the surgical treatment of ectopic pregnancy, but
it was not until 1883 that Tait performed the first op-
eration for extra-uterine pregnancy. Since this original
operative treatment, rapid strides have been made in
its surgical therapy, and probably few other pathological
processes have responded with as much attending success.
Before the work of Veit and Tait, the condition was
considered very rare; so rare, indeed, that one writer
stated that this affection was so uncommon that even the
directors of a large maternity hospital might not see a
case in a lifetime.

Etiology

Of the many possible causes in the literature, prior
infections of the Fallopian tubes head the list. Peri-
toneal adhesions, by constriction of the tube, are an
often mentioned factor. Stricture of the tube from old
inflammatory processes, or extra-tubal pressure as from
pelvic tumors, are cited as causative factors. And finally,
anomalies of the tube, kinking of the tube, loss of cilia
of the tubal lining cells, and many other etiological
factors might be mentioned, even though those men-
tioned form the vast majority of causes.

Symptomatology

Almost invariably, the last menstrual period of these
patients has been at least a week or ten days past due
before anything unusual develops. However, nausea,
vomiting, morning sickness, and the other feelings and
manifestations of pregnancy are described by the patient.
Then a slight amount of irregular vaginal bleeding
occurs. Such blood is usually dark in color, and pain
is present in either side of the lower abdomen. In the
average case, the pain disappears after the unadvised use
of aspirin or hot applications, only to recur several days
later. During this time, even though up and about, the
patient is conscious of discomfort in one side of the

lower abdomen. Frequently, walking aggravates the
pain. Sexual intercourse is nearly always attended with
pain. Previous sterility is often elicited in the history.

This history as outlined may show great variation de-
pending upon the age or size of the fertilized ovum and
the amount or suddenness of the bleeding. A small
amount of bleeding caused by a partial separation of the
decidual membranes from the wall of the tube may
cause few symptoms, except a slight distress and tender-
ness in the lower abdomen. On the other hand, sudden
severe hemorrhage may cause excruciating pain by rapid
stretching of the tube from hemorrhage. Sudden and
extensive hemorrhage may result in all the symptoms of
severe collapse or shock. However, the more common
type of case is the one having repeated attacks of pain,
and the less obvious cases repeatedly consult a physician
until the correct diagnosis can be definitely established.

Physical Findings

Repeated bimanual examination by which pelvic
changes can be observed is often necessary, for little is
to be found by abdominal examination in most cases.
At times, mild rigidity and tenderness over the lower
abdomen constitute the only findings. In those patients
having extensive internal hemorrhage, it is customary to
find rigidity throughout the abdomen accompanied by
marked, generalized tenderness. When bleeding has been
slight, there are varying degrees of tenderness on the
affected side. Not infrequently, the patient states that
there is less pain after the completion of a pelvic exam-
ination than before it was begun. In these instances, the
relief of pain is the result of expulsion of blood from
a tube over-distended by hemorrhage.

Swelling may or may not be palpable. In thin indi-
viduals it may be felt readily, whereas in obese patients
the tube or tumefaction must be fairly hard before it is
palpable. It is doubtful if one ever feels a pregnant tube
until there has been some bleeding into it from a separa-
tion of the decidua from the tubal wall. In cases in
which there has been much bleeding into the abdominal
cavity, one frequently notes a fullness in the cul-de-sac.
Sivertson has mentioned pain on pressure upon the
rectum in these cases, and in some instances it has been
my experience that pain may be elicited by pressure on
the sigmoid. As a rule, the uterus is freely movable,
even though retroverted or retroflexed. The uterus is
always enlarged and may be tilted to one side. The
cervix is softer than usual, and one of the most dependa-
ble signs is pain on movement of the cervix.

These findings are characteristic of those cases seen
between the fourth and tenth week of pregnancy. When
the pregnancy has continued four or five months, the
pelvic findings are far different. In such cases, the tumor

528

THE JOURNAL-LANCET

mass is much larger, even approaching the size of a
cocoanut. If the fetus has survived, the tumor (includ-
ing hematocele) may be even larger. The uterus is
fixed, as is also the cervix, and the usual elasticity of the
vaginal tract is lost. If hemorrhage into the broad liga-
ment has occurred, a round, smooth mass which renders
uterine palpation difficult, is found. The mass is very
tender and fullness of the cul-de-sac is not apparent. If
massive hemorrhage occurs, dullness of the percussion
note in the flanks can be elicited, except in obese patients.
In the presence of massive hemorrhage, one also notes
a rapid and thready pulse, thirst, pallor, air-hunger, cold,
clammy perspiration, and other evidences of shock. Low
blood pressure, low hemoglobin, and an elevated leuco-
cyte count, characterize these cases.

Treatment

The mortality rate has decreased as asepsis and sur-
gical technic have improved. Untreated, the mortality
rate is extremely high. Schauta, in a series of 121 cases
that were treated expectantly, found a mortality rate of
86.9 per cent, whereas in a series of 123 cases treated
surgically, the mortality rate was 5.7 per cent.

There is no expectant treatment for this condition.
Once the diagnosis has been determined, prompt re-
moval of the parts involved is necessary. Adair advo-
cates waiting in cases with severe hemorrhage and col-
lapse. Many gynecologists do not agree with such a
policy, feeling that such cases represent as grave an
emergency as any other internal hemorrhage. Thus, the
operation should be performed in the most rapid manner
consistent with the patient’s safety, which comprehends
the use of supportive measures or transfusion, if indi-
cated.

In the early stage of pathogenesis of the condition, the
operation itself is simple. The abdomen should be
opened in the mid-line, with an incision large enough
to permit rapid work. Large clots should be removed
quickly, but otherwise only sufficient other blood evac-
uated to permit the operative field to be easily visualized.
The Fallopian tube and its contents are then removed,
as in any other salpingectomy. It is wise to remove the
interstitial portion of the tube by excising a V-shaped
piece from the cornu of the uterus. This should then be
closed, and covered with two or three layers of peri-
toneum. In this manner, recurrence in the stump of the
tube is avoided. The abdomen is then closed without
drainage.

In the accompanying tabulation is found a resume
of 21 cases observed during 15 years of practice. Cases
Three and Four, marked with an asterisk, represent two
consecutive extra-uterine pregnancies in the same patient.
Case Six also represents the second ectopic pregnancy
experienced by this patient. In four cases, as can be
seen, the records of previous pregnancies are incomplete.
In eleven cases it was not possible to obtain adequate
history of previous venereal infection. Five cases had
complications, although the pelvic inflammatory disease
of one case preceded the operation and prolonged the
patient’s convalescence.

No.

Age

Para

Grav.

Ven.

History

Normal

Conv.

Complication

—

Phlebitis

—

-f

—

-+■

Pelvic Infl. L)is.

—

1 1

Salpingitis

1 3

—

-f-

—

Pelvic infl. L)is

—

Secondary Anemia

—

In addition to the 21 cases listed in the preceding tab-
ulation, four patients were operated upon for extra-
uterine pregnancy, and this condition was not found in
them. One had a normal miscarriage, but continued
uterine bleeding after dilitation and curettage led to a
laparotomy, during which an ovarian cyst was discovered
and resected. A second case was found to have a normal
pregnancy complicated by an acutely-inflamed appendix.
The third case demonstrated a chronic salpingitis and
an incomplete abortion at operation. In the fourth case,
an ovarian cyst proved to be the cause of irregular uterine
hemorrhage suggestive of an ectopic pregnancy.

Still another case not included in the above tabula-
tion seems worthy of mention. The patient was an In-
dian who first consulted my associate in practice, the
late Dr. C. A. Houston. Her only complaints were
inability to defecate and excruciating pain in the attempt
to defecate. No history which would indicate the exact
nature of her ailment could be obtained. During rectal
examination of the patient a sharp object was found to
obstruct the anal orifice. Upon removal, this object
proved to be the left frontal bone of a full-term fetus.
In view of the fact that this patient was beyond 65
years of age, it must be assumed that this particular
pregnancy occurred at least 20 or more years prior to
the time that the portion of the fetal skull was removed
from the rectum. In his discussion of extra-uterine preg-
nancy, De Lee cites a case of lithopedion carried for 29
years, reported by Wagner, and one carried for 28 years,
reported by Virchow. Also Smith described a case of a
calcified fetus which was removed from a woman 94
years old, 60 years after conception. While the case
reported in this paper is of shorter duration than the
three just mentioned, its duration is long enough to
justify its report.

Conclusion

Ectopic pregnancies are not rare, as the presently re-
ported ratio of one in 70 pregnancies will attest. They
may, and often will, be overlooked unless one keeps the
condition constantly in mind in the presence of men-
strual irregularities. The earlier a diagnosis can be made
and treatment instituted, the lower the mortality ratt
will be.

An extra-uterine or tubal lithopedion of a duration
equal to or exceeding 20 years is reported.

THE JOURNAL-LANCET

529

Tuberculin Tests in State 4*H Club Health

Contestants

M. W. Husband, M.D.t and David T. Loy, M.D.f
Manhattan, Kansas

Jk T THE annual State 4-H Roundups in 1936 and
1937 the health contestants were examined by
-^the Student Health Service, Kansas State Col-
lege. These health contestants were farm boys and girls
of high school age selected through physical examina-
tions in their respective counties to compete in the state
health contest. Each county is limited to one male and
one female health entry.

As a part of the comprehensive physical examination
tuberculin tests were made on each contestant. Before

1936 tuberculin tests were not included as a part of the
state health contest. Through the cooperation of Mr.
M. H. Coe, state 4-H Club leader, Kansas became the
first state, as far as we can ascertain, to introduce routine
tuberculin testing of 4-H state health contestants fol-
lowed by chest X-rays of all positive reactors.

In 1936 the tuberculin tests were made by the intra-
dermal injection of 0.1 milligram of old tuberculin. In

1937 the tests were made by the intradermal injection
of 0.0005 milligram of purified protein derivative. This
amount of purified protein derivative corresponds to the
amount of old tuberculin used in the previous examina-
tion and has been recommended by Hall1 and referred
to by him as the intermediate dilution of purified protein
derivative.

Each year the results of the tests were read 48 hours
after the injections were made. The results were classi-
fied according to the following method: Negative —

absence of redness or swelling at the site of injection.
1 plus — the appearance of an area of swelling between

0.5 and 1.0 centimeter in its greatest diameter. 2 plus —
the appearance of an area of swelling with its greatest
diameter between 1.0 and 2.0 centimeters. 3 plus — the
appearance of an area of swelling with its greatest
diameter more than 2.0 centimeters. 4 plus — the ap-
pearance of an area of swelling with definite necrosis.
This classification is modified from the one given by the
National Tuberculosis Association2.

The results of these tests are given in tabulated form
in Tables 1 and 2. In 1936 there were 141 contestants
with 13 or 9.2% positive reactors. In 1937 there were
117 contestants with 21 or 17.9% positive reactors.
Probably the higher percentage of positive reactors found
in 1937 is due to the use of a better standardized prep-
aration of tuberculoprotein. Each year there was only
one undesirable reaction (4 plus) in the group tested.

The homes of the positive reactors of these groups of
boys and girls are fairly well distributed throughout the
state.

Each year chest X-rays were made of each positive
reactor. We are greatly indebted to Dr. Galen M. Tice,

t From the Student Health Service, Kansas State College.

radiologist at the University of Kansas Medical School,
for the interpretation of the X-ray plates. Of the 13
cases X-rayed in 1936 there were 10 that showed no
roentgenological evidence of tuberculous lung infection,
2 that showed arrested childhood type of tuberculous
lung infection and 1 that showed old pathological lung
changes of non-specific etiology. Of the 21 cases
X-rayed in 1937 there were 9 that showed no roentgen-
ological evidence of tuberculous lung infection, 10 that
showed arrested childhood type of tuberculous lung infec-
tion, and one that showed old pathological lung changes
of non-specific etiology. There were no active cases
of the childhood type of tuberculosis. No cases of the
adult type of tuberculous infection were encountered;
but it should be emphasized that during the next decade
the individuals in this group of tuberculous infections
are much more likely to develop tuberculosis than would
the individuals of a similar non-infected group, as point-
ed out by Myers and Harrington3. For this reason we
made a uniform deduction in the health score of each
positive reactor. In carrying out this procedure we were
aware, of course, that this view is not uniformly held by
workers in this field4.

Each year the X-ray reports of each contestant were
sent to their parents by the 4-H state office. This action
is in accordance with the main purpose of these special
examinations, namely, the dissemination of public health
education in modern methods of diagnosis and control
of tuberculosis to an intelligent and influential section
of the rural population. It is hoped that this tuberculosis
program will be adopted by other state 4-H Clubs.

Summary

1. Tuberculin testing with chest X-rays of all positive
reactors has been introduced to an important group of
the Kansas farm population.

2. Superior general health and absence of physical
defects apparently do not appreciably diminish the in-
cidence of tuberculous infection.

3. The one-test method with the intermediate dilu-
tion of purified protein derivative apparently detects
cases of tuberculous infection with a high degree of
accuracy.

4. In 1936 and 1937, deductions have been made in
the health scores of 4-H Club state health contestants
who had positive tuberculin reactions. It may be found
feasible to extend generally this policy of deduction for
positive tuberculin reactors to health and insurance
examinations.

530

THE JOURNAL-LANCET

TABLE I.

4-H Club Health Contestants Tuberculin Tests

Year

Number

Tested

Material Used
For Testing

Number Positive
Reactors

CHEST X-RAYS OF POSITIVE REACTORS

Negative

Healed

Childhood Type

Active

Childhood Type

Adult

Type

Old Pathological
Changes, of Non-

1936

141

0.1 mgm.

O.T.

specific Etiology

1937

117

0.0005 mgm.
P.P.D.

TABLE II.

Positive Tuberculoprotein Reactors

Year

Sex

County

Old Tuberculin
0.1 mgm. Doses

Purified Protein
Derivative

0.0005 mgm. Doses

CHEST X-RAYS

1936

Male

Barton

1 plus

Normal lung findings.

Pratt

1 plus

Normal lung findings.

”

Sedgwick

1 plus

No tubercular infiltration.

”

Kiowa

1 plus

No pathology is seen.

Mitchell

2 plus

Normal lung findings.

Miami

3 plus

No pathology is seen.

Comanche

3 plus

No pathology is seen.

Leavenworth

4 plus

Gohn complex and hilar calcification

Female

Meade

2 plus

Thickened bilateral apical pleura

Franklin

3 plus

No pathology is seen.

”

Sherman

3 plus

No tubercular infiltration.

”

Sherman

3 plus

No pathology is seen.

Geary

3 plus

Hilar calcification.

1937

Male

Russell

1 plus

Normal lung findings.

”

Chautauqua

1 plus

Normal lung findings.

”

Labette

1 plus

Hilar calcification.

”

Lane

1 plus

Hilar calcification.

Stafford

1 plus

Normal lung findings.

Ford

2 plus

No tubercular infiltration.

Barber

2 plus

Normal lung findings.

Sherman

2 plus

Hilar calcification.

Greenwood

2 plus

Hilar calcification.

Morris

3 plus

Hilar calcification.

Leavenworth

4 plus

Hilar calcification.

Female

Lyon

1 plus

Normal lung findings.

Stafford

1 plus

Hilar calcification.

’*

Clay

1 plus

Normal lung findings.

Ford

1 plus

Hilar calcification.

Cloud

1 plus

Normal lung findings.

Dickinson

2 plus

Pleural adhesions to diaphragm.

J efferson

2 plus

Hilar calcification

Barber

2 plus

Movement (unsatisfactory plate).

Bourbon

2 plus

Hilar calcification.

Cloud

...

2 plus

Normal lung findings.

Bibliography

1. Clifton Hall — A Report of 4,511 Tuberculin Tests Using an
Intermediate Dilution of Tuberculin P.P.D., Journal of the Kansas
Medical Society, 37:230 (June), 1936.

2. Diagnostic Aids, Childhood Type of Tuberculosis, National
Tuberculosis Association, New York, N. Y., 1931.

3. J. A. Myers and F. E. Harrington — The Effect of Initial
Tuberculous Infection on Subsequent Tuberculous Lesions, J. A
M. A. 103:1 530 (Nov.), 1934.

4. B. P. Potter — The Problem of Tuberculosis From the Gen-
eral Practitioner’s Point of View, J. A M A. 108:1 585 (May 8),
1937.

The Present Day Status of the Vitamins"

A Rei’ietc

Marguerite Booth, M.D., and Arild E. Hansen, M.D.f

Minneapolis

Introduction

ALTHOUGH clinical conditions due to avitami-
nosis were apparently known as long ago as 2600
B. C., and in spite of the fact that deficiency
diseases have been of tremendous economic importance
throughout the ages, the tardiness in gaining an under-
standing of these conditions is remarkable. With a
gradual acceleration of knowledge beginning less than a

* From the Department of Pediatrics of the University of Minne-
sota Hospital, University of Minnesota, Minneapolis, Minnesota,
t Assistant professor of pediatrics, University of Minnesota.

Minnesota

half century ago, the whole subject with its vast rami-
fications has been built up by means of chemical, bio-
logical and clinical studies, until at last it has practically
attained the status of an exact science. This has been
brought about by individual and organized efforts of a
multitude of investigators in all parts of the world.
Thus, the fact that we today can actually see the vita-
mins themselves and know or very nearly know the
chemical structure of many of those which are important
in nutrition, is not the result of pure coincidence or

THE JOURNAL-LANCET

531

accident. This is strikingly apparent when one con-
siders that a semi-thorough review during the past sev-
eral years calls for the consideration of some 200 ar-
ticles on a single vitamin, or a rough total of about
2000 for any given year.

Not only is the chemical structure of many vitamins
known exactly, but recent investigators in various chem-
ical laboratories have also developed chemical tests for
determining quantitatively, or approximately so, the
amounts of various vitamins in the different tissues.
Further developments along these lines may prove to be
of far-reaching importance. Many of the ramifications
of vitamin experimentation have proved to be surpris-
ing. One of the most interesting disclosures is that
vitamins have been found to be definitely linked up
with the hormones. By the mere removal of a simple
methyl group or by the change in a double bond, the
vitamin may become hormonal or may take on car-
cinogenic activity.

One of the popular conditions associated with avita-
minosis in the knowledge of the average American is
night blindness, because of the fact that this disability
corresponds with the alleged time incidence of the
greatest number of automobile accidents. The relation-
ship of the vitamins to infections is over-emphasized no
doubt in a popular way. Nevertheless, there are cer-
tain pertinent facts which clearly indicate that such
relationships actually do exist. Not only are we in-
terested in the conditions caused by a lack of vitamins
but also by the possible importance of the administra-
tion of too much of these substances. As regards the
human subject there needs to be little fear of hyper-
vitaminosis.

Judging from a survey of the University of Minne-
sota Hospitals admissions other than rickets there
are relatively few frank cases of avitaminosis in this
section of the country. During the nine-year period
from 1928 to 1937, covering some 63,500 hospital ad-
missions, there has been but one case of keratomalacia.
This infant of 14 weeks had had no cod liver oil but
was given a whole milk formula. Although she im-
proved on cod liver oil therapy, the corneal opacities
persisted.

Evidences of vitamin B deficiency are difficult to
evaluate. Polyneuritis is a major manifestation of vita-
min Bi deficiency, both in experimental animals and in
human beings. A careful search of the records during
this same period reveals thirty cases of polyneuritis. In
none of these did a specific dietary lack appear to be the
prime cause of the condition. In this series, there were
only six which were of unknown etiology, and even here
it was not possible to attribute the complaints to a nutri-
tional deficiency. Recent investigations disclose that
many of the clinical types of polyneuritis are related to
a quantitative deficiency of vitamin B complex. It is
possible that vitamin Bi deficiency may be partially res-
ponsible for the various types of peripheral neuritis
found associated with chronic alcoholism, diabetes, preg-
nancy, and certain toxic states. During this interval,
there have been four cases of polyneuritis in chronic al-

coholism, five in diabetes, three in pregnancy, and five
were believed to be toxic in origin. Of the conditions
which were probably not due to a partial vitamin defi-
ciency, two were due to lead, three to arsenic, while two
were post-diphtheritic.

There were but two instances of definite vitamin B2
deficiency. These were cases of pellagra; one in a male
of 54 years and the other in a female of 30 years. Acro-
dynia is thought by some to have a fundamental re-
lationship to vitamin B complex deficiency. In this
study, five individuals with acrodynia were found. The
age incidence of one of these was unusual: a female of
14 years with symptoms strikingly characteristic of this
condition. Of the five cases, three were placed on a
dietary regimen high in vitamin B complex. In each
instance improvement was noted, but this was gradual.
The other two cases were unable to be followed.

There have been two patients showing slight X-ray
evidence of scurvy but without the typical findings.
These were seen before cevitamic acid determinations
were used. Rickets in a mild degree is very common
and the sequelae are apparent for years afterwards. Only
twenty-seven cases were admitted to the hospitals, in
which rickets formed the major part of the acute clini-
cal picture. There were six of these which had the
symptoms and findings of latent or manifest tetany.

Of even greater importance than the presence of these
infrequent cases of florid avitaminosis is the occurrence
of subclinical states of vitamin deficiency. This is par-
ticularly significant because of the interrelationships be-
tween vitamins and certain clinical disorders. For ex-
ample, Weiss and Wilkins, as well as Sure and Jones,
have demonstrated that the administration of vitamin B
extracts produces favorable clinical response in cardiac
dysfunction. The development of chemical means for
the detection of vitamin deficiencies has already aided
materially in our understanding of certain of these
maladies, and no doubt we can anticipate rapid progress
in this phase of the subject in the near future. The
fact that our knowledge concerning the nature of
these deficiency diseases has advanced so definitely
necessitates a more specific nomenclature regarding
these conditions. At the recent meetings of the Amer-
ican Society of Biological Chemists, a committee was
formed to revise the vitamin terminology. The use of
the letters of the alphabet for designation purposes
appears to be meeting with disfavor. Preliminary ex-
pressions recommended are thiamin for vitamin Bi;
riboflavin for vitamin B2; ascorbic acid, an expression
used by organic chemists, for vitamin C; and calciferol
for at least one of the types of vitamin D. Until more
definite steps are taken to establish the newer termi-
nology, the alphabetical names which we have followed
in this review will be used for some time.

VITAMIN A— History

In 1913, McCollum and Davis, and Osborne and
Mendel simultaneously described experiments which
showed that certain fats were essential for normal
growth. Three years later, McCollum suggested the

532

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term "fat-soluble A” to distinguish it from the "water-
soluble B.” Steenbock, in 1919, noted some correlation
between the vitamin A effect of certain vegetables and
the amount of the yellow pigment carotene present in
these foods. Euler demonstrated that carotene could
replace vitamin A in the diet (1928). In 1930, Moore
showed that carotene is converted into vitamin A in the
liver and is stored there as the vitamin. Karrer (1931)
and Drummond (1932) isolated the almost pure un-
saturated alcohol from fish livers. In 1935, Lasch
showed that liver storage of vitamin A is for the most
part in the Kupffer cells.

Chemistry

Q0H29OH

H2 Vitamin A

An unsaturated alcohol with four double bonds in the
side chain and one in the ring.

Precursors of vitamin A:

1. Alpha carotene

2. Beta carotene

3. Gamma carotene

4. Cryptoxanthin

These precursors of the vitamin are vegetable pig-
ments which are converted by the liver into the com-
pound vitamin A itself. Carotene occurs in nature
usually as a mixture of two or more isomeric forms.
The chemical composition of these isomers differs
slightly, but all have at least one beta-ionone ring, a
grouping which seems necessary for vitamin activity.
Vitamin A has the structure of one-half the carotene
molecule with an alcohol group at the end of the chain.
Since beta carotene is symmetrical and contains two beta-
ionone rings, two molecules of vitamin A could be
formed from it by breaking it down at the middle double
bond with the formation of a primary alcohol at the
terminal carbon atom. Alpha and gamma carotene are
not symmetrical and contain only one beta-ionone ring,
hence forming only one molecule of vitamin A when
broken down. The vitamin activity of beta carotene in
small concentrations is double that of alpha carotene.
Experimental evidence supports this theory.

Carotene is intensely yellow, while vitamin A is color-
less. The vitamin is very soluble in fat and occurs as an
ester in fish liver-oils. It gives a characteristic though
not entirely specific blue color with antimony trichloride
in the presence of chloroform. It has a highly char-
acteristic strong absorption band at 328 mu in ultra-
violet light. Very little vitamin A is lost during pro-
cesses of commercial canning or home-cooking. Vita-
min A has been isolated in nearly pure form, but has
not been synthesized.

Standardization

The U. S. P. XI unit for vitamin A (equivalent to
the International unit) is the amount in milligrams pro-
ducing the growth-promoting and anti-xerophthalmic
activities in vitamin A-depleted rats equal to that of 0.6
gamma of the International standard beta carotene, or
the equivalent amount of U. S. P. Standard Reference
cod-liver oil.

The standard of pure beta carotene adopted by the
International Conference is dissolved in coconut oil to
which hydroquinone has been added. The subsidiary
international standard for vitamin A is the U. S. P.
Reference cod-liver oil which has a potency of 3000 units
per gram.

The U. S. P. XI requires that 1 gram (15 grains) of
cod liver oil shall contain at least 600 U. S. P. units of
vitamin A.

Pathology

The primary effect of vitamin A deficiency is on epi-
thelial structures — a keratinizing metaplasia of the
greater part of the ectodermal covering of the bodv.
There is a substitution of stratified keratinizing epithel-
ium for normal epithelium in various parts of the res-
piratory, alimentary and genito-urinary tract, in the
eyes and in the para-ocular glands. This replacement
epithelium is identical in all locations and comparable
in all its layers with epidermis and is continuously cast-
ing off keratinized cells. The accumulation of these
epithelial cells in many glands and their ducts and in
ether organs is a striking gross pathologic feature of
avitaminosis A. Cysts may be formed in the glandular
organs. In the lungs, these cysts were at first thought
to be abscesses, but there is rarely invasion of the tissues.
The pulmonary keratinization leads also to bronchial
occlusion, bronchiectasis and atelectasis. This metaplasia
in human infants and in a variety of laboratory animals
has been found in the conjunctiva, mucosa of the nares,
accessory sinuses, trachea, bronchi, pancreas, renal pelves,
ureters, salivary glands, uterus, and peri-urethral glands.
It occurs earliest in the trachea and bronchi, then in the
kidney pelvis, and as late involvement in the eye. Meta-
plasia of the epithelium of the cornea and of the con-
junctival sac is followed by vascularization, edema, and
leukocytic infiltration of the cornea. Infection of the
cornea may lead to ulceration and hypopyon.

Secondary effects of vitamin A deficiency are decrease
in weight due to loss of fat in all storage depots, mus-
cular atrophy, anemia, cessation of growth of bones, de-
generative lesions of skeletal muscle, and lymphoid
hypoplasia of the spleen. Degeneration of the myelin
sheath is a late secondary result.

Restoration of the diet rapidly dispels the lesions of
avitaminosis A, unless complicated by destruction of
tissue. The change back to the normal epithelium is an
abrupt one and affords further evidence that the pri-
mary consequence of lack of vitamin A is epithelial,
and not of nervous origin.

Chief Symptoms of Avitaminosis A
A. In Man.

1. Night blindness (nyctalopia or hemeralopia), and

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533

xerophthalmia (keratomalacia) eventually leading to
partial or complete blindness. Bitot’s spots, opaque
whitish deposits in the scleral conjunctiva, are the most
characteristic signs.

2. Keratinization of epithelial cells in various parts of
the body frequently associated with respiratory, gastro-
intestinal and genito-urinary disturbances.

3. Cornification and eruption of the skin with papu-
lar and pustular lesions.

4. Retarded growth, weakness, and loss of weight.

5. Increased susceptibility to infections of mucous
membranes (claimed by some, denied by others). Only
true where supply of vitamin A has been inadequate or
its storage in the body depleted.

B. In Animals (rat).

1. Cessation of growth and loss of weight.

2. Xerophthalmia; impaired regeneration of visual
purple.

3. Keratinization of epithelium in respiratory, gastro-
intestinal and genito-urinary tracts.

4. Formation of urinary calculi.

5. Cutaneous lesions; glandular abscesses.

6. Defective formation of teeth and gums.

7. Impaired reproduction: prolonged gestation, fetal
death and dystocia.

8. Loss of vigor.

Laboratory Diagnosis

Test for subnormal dark adaptation — based on the
ability of the patient to regenerate rhodopsin (visual
purple) after exposure to a calibrated source of light —
elaborated by Jeans and Zentmire (1934). This is par-
ticularly valuable in mild deficiency.

Clinical Applications of Vitamin A

1. Promotion of normal growth in children.

2. Prevention and cure of night blindness and xero-
phthalmia due to lack of vitamin A.

3. Prevention of renal calculi claimed by Higgins —
but discredited by the A. M. A., Council of Pharma-
cology and Chemistry.

4. Maintenance of normal epithelium of the body.

5. Normal tooth formation.

6. Cure of senile vaginitis — by large doses of cod liver
oil or haliver oil (Simpson and Mason).

7. Treatment of epithelial lesions and healing of
wounds by the local application of vitamin A in an
ointment medium. (Proto and Sandor)

Vitamin A can be given in many foods containing the
factors in the form of the vitamin or as its precursor,
carotene. Carotene is not as well absorbed as vitamin
A, hence the vitamin is the more satisfactory preparation
to use by mouth. The absorption of vitamin A or of
carotene may be impaired by infections, pregnancy, ab-
sence of bile, and other pathological processes, such as
damage to the liver which interferes with its ability to
convert carotene to vitamin A. Crystalline carotene is
better than vitamin A for parenteral use. At present,
there are no pure or injectable preparations of vitamin
A available.

Daily Requirements

The quantitative requirement is as yet unknown.
Children require more per kilogram of body weight
because of the demands of growth.

1934 Salter as minimum —.0.3 mg. carotene

1935 Harris as minimum for adults 1,000 U.S.P. I.U.*

1936 A. M. A. for children 6,250 — 10,000 I.U.

League of Nations for pregnancy and lactation 9,000 U.S.P. units

Larger doses may be required in severe avitaminosis.

^International units.

Natural Sources — in order of potency
Vitamin A:

Halibut liver oil is the richest source.

Burbot liver oil ranks next (4 to 10 times as potent as
cod liver oil) .

Cod liver oil.

Liver.

Whole milk supplies more than any other single food.
Large amounts: butter, egg yolk, animal fats (beef
and mutton) .

Provitamins:

Apricots are the richest plant source.

Large amounts — spinach, carrots, chard.

Smaller amounts (1/6 as much as butter) — green
beans, green peas, Brussels sprouts, lettuce, tomato, yel-
low squash, sweet potato, pumpkin.

VITAMIN B COMPLEX
History

In 1884, Takaki of the Japanese Navy demonstrated
that kakke (beriberi) was of dietary origin. Eijkman
believed that it was due to a poison in polished rice
(1887). Funk in 1912 proposed the name "vitamin”
for the substance derived from rice polishings which
cured beri-beri. Mendel suggested that another factor
than certain fats was necessary for normal growth
(1914). McCollum found this substance was water sol-
uble and in 1916 proposed the terms "fat-soluble A” and
"water-soluble B.” The multiple nature of vitamin B
was proved by Smith and Hendrick, and confirmed by
Goldberger, separating the pellagra-preventing factor
from the anti-neuritic factor. Four other elements have
been partitioned off, and since 1927 the vitamin has been
known as vitamin B complex.

Constituents

Vitamin B4 antineuritic factor

Vitamin Bo (G) complex

1. Vitamin B2 or lactoflavin growth-producing factor

2. Vitamin By rat antidermatitis factor

3. P. P. factor (pellagra-preventing in man)

or Vitamin H of Gyorgy

Vitamin B.j chicken antipellagra factor

? growth-producing factor

Vitamin B4 .antiparalysis and anti-en-

cephalomalacia factor.
Perhaps a variation of
vitamin B4

Vitamin Bj including chicken anti-

pellagra factor

534

THE JOURNAL-LANCET

VITAMIN Bi (B)

Chemistry

Ci2Hi7N4 OS CL.HCL

Aneurin of Jansen, or Torulin

The hydrochloride of a pyridimine-thiazole compound.
Windaus first proposed the formula of C12H10N4OS —
when he isolated the crystalline vitamin B4 in 1931.
The vitamin is a base and reacts with acids to form
salts. The formula usually given at present is that
obtained by the action of hydrochloric acid on the free
base. There is still some doubt about the positions of
certain groups and double bonds. The sulphur linkage
is not that of cystine. Vitamin Bi has also been isolated
in crystalline form from baker’s yeast or rice polishings
by Jansen and Donath, by Peters, Odake and by Van
Veen, some with slightly different formulae. It has been
synthesized by Williams and Cline (1936).

Crystalline vitamin B4 — hydrochloride is water-solu-
uble. It is stable to heat in the dry state, but is rapidly
destroyed by moist heat at 100 C especially in alkaline
medium. Its melting-point is 245 °C. Its ultraviolet ab-
sorption band is at 250-260 mm. (Windaus) or 245-249
mm. (Peters) .

Standardization

The Sherman unit is that amount which when fed as
a daily allowance to a standard test animal (rat) pre-
viously depleted of vitamin Bi will suffice to cause a gain
in weight of three grams per week during an experi-
mental period of four weeks.

The International Unit is the vitamin Bj activity of
10 milligrams of the International Vitamin Bi Refer-
ence Standard which is an adsorbate prepared from rice
polishings by the method of Seidell as described by
Jansen and Donath.

Ten to twenty milligrams per day of this Reference
Standard are necessary to maintain normal growth in
young rats, or 20 to 30 milligrams for a cure of pigeon
polyneuritis.

N. N. R. Requirements — 1936

Foods claiming vitamin B4 content as a medicinal
source must provide at least 200 International units in
the quantity of food consumed daily.

Concentrates of vitamin B4 or a dehydrated natural
product must exceed a potency of 25 International units
per gram or per cubic centimeter.

Pathology

Human beriberi and pigeon polyneuritis show the
same pathologic changes: enlargement of the heart, par-
ticularly the right ventricle, edema, atrophy of muscles,
and degeneration of the nervous system. Wolbach be-
lieves that it is best to regard all the abnormal findings

thus far recorded as secondary effects, and to consider
the primary pathologic changes due to vitamin Bj de-
ficiency as not demonstrable at present.

The striking lesion is Marchi degeneration of the
myelin sheath of peripheral nerves — which appears late
in avitaminosis Bi. Further work is necessary to prove
that this is due to specific lack of vitamin Bi or to some
other factor, such as starvation. Other secondary
features are chronic passive congestion, and enlargement
of the islands of Langerhans in the pancreas.

Chief Symptoms of Avitaminosis Bt

A. In Man.

1. Beriberi

(a) Peripheral neuritis with paralysis of extremi-
ties and muscular atrophy or edema.

(b) Vasomotor symptoms: heart palpitation, dysp-
nea, enlargement of right side of heart.

2. Retarded growth and development.

3. Polyneuritis, especially of alcoholic origin; also in
pregnancy, in diabetes, and in malnutrition in children,
and in the malnutrition associated with chronic diseases
or some primary alimentary disease.

4. Gastro-intestinal disturbances: atrophy of lingual
papillae, achlorhydria, intestinal hypotonicity.

5. Ocular disorders: retinal hemorrhages, optic neuri-
tis.

6. Anorexia.

7. Impaired carbohydrate metabolism.

8. Failure of lactation.

B. In Animals (rat and pigeon).

1. Retarded growth and loss of weight.

2. Polyneuritis (pigeon).

3. Anorexia.

4. Paralysis and convulsions (rat).

5. Impaired oxidation of lactic acid and pyruvic acid
in carbohydrate metabolism, resulting in injury to the
central nervous system.

6. Bradycardia.

7. Disturbance of intestinal function; gastric atony.

8. Impaired reproduction:

(a) Atrophy of the testes.

(b) Atrophy of the ovaries.

9. Failure of lactation.

Laboratory Diagnosis

1. Urinary Excretion Test.

The amount of vitamin B4 excreted in the urine
(demonstrated by biological assay of the urine) may be
used as an index of the dietary intake.

A daily excretion of less than 12 International units
per day (for a 140 lb. man) and failure to show a res-
ponse to a test dose of 500 International units per day
are presumptive evidence that the diet is below normal
in vitamin B4 content. The normal output is from 12
to 35 International units.

2. Arakawa Test.

The maternal milk is tested for vitamin Bx content.
The Arakawa reaction is based on the close relationship
between the peroxidase reaction of the milk and the

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535

state of deficiency in vitamin Bj. If a blue color de-
velops when the milk is mixed with three reagent solu-
tions, a positive test for the presence of the vitamin is
obtained. If no blue color appears, the Arakawa test is
negative — indicating a lack of the vitamin in the milk.

3. Estimation of previous vitamin Bi intake and of
the requirements of the vitamin by CowgilFs formula.

Clinical Applications of Vitamin Bj

1. Prevention and cure of beriberi.

2. Promotion of normal growth in children.

3. Anorexia due to avitaminosis B.

4. In chronic alcoholism with vitamin B-deficiency
polyneuritis.

5. In pernicious vomiting and polyneuritis of preg-
nancy.

6. For nutrition in lactating women.

7. Valuable in concentrated form in conditions where
ordinary foods are poorly utilized.

8. In diabetic neuritis.

9. In cardiovascular disease (Weiss and Wilkins —
1936. Sure and Jones — 1937).

Daily Requirements

The requirement is related to the fuel value of the
food consumed and proportional to the metabolism

(Cowgill) .

1934 Cowgill

About 300 I. U.

1934 Jansen

1935 Vorhaus

About 200 I. U.

as minimum

4000 Sherman units.

therapeutic dose

10 mg. crystalline
vitamin

250 to 500 I. U.

1936 Harris
1936

About 1 mg. crystalline
vitamin

A. M. A.,

for infants

50 I. U.

Council on
Pharmacology
and Chemistry

for adults

To 200 I. U.

1937 Wilder and Wilbur

10-20 mg. crystalline
vitamin

Natural Sources — in order of potency

Brewer’s yeast and wheat germ are excellent concen-
trated sources.

Whole grain cereals and bread.

Liver and kidney.

Leafy vegetables have one-fourth the content of vita-
min Bi as in yeast.

Egg yolk.

Orange, the highest of the fruits, has one-fifth as
much as yeast. The concentration of vitamin Bi in
most raw foods is low and it may further be reduced by
heat and loss in solution in the discarded cooking water.
Milk, white flour and meat are very poor sources. Vege-
tables and fruits have but a small amount. Special
care should be taken to insure an adequate supply of the
vitamin.

VITAMIN B2 (G) COMPLEX

The antipellagra vitamin is now known to have at
least two and probably three factors. It was called
vitamin G by Goldberger, but is now generally accepted
as identical with pellagra in man. There is now thought
to be a separate P. P. factor in the vitamin Bo complex.
Gyorgy calls this fraction vitamin H.

Chemistry: Vitamin B2 (G)

The chemical formula was at first thought to be
Ci7H20N4O(i (Kuhn), but was later (1935) proved to
be CisHoiNaOo— 6.7 dimethyl — 9 isoalloxazin.

Vitamin B2 is the water-soluble and heat-stable
naturally occurring yellow pigment, lactoflavin. It is
bleached and destroyed by exposure to visible light, es-
pecially in the blue-violet portion, and by alkaline media.
It is relatively insoluble in alcohol. It is adsorbed by
fuller’s earth from acid solution and is precipitated by
lead acetate. The melting-point of the best natural and
synthetic preparations is 282°C. The specific rotation
is: 96.6° for a 0.15% solution in 0.05 N NaOH, and
90.0° for a 0.1% solution. In the presence of boric
acid, lactoflavin is dextrorotatory. It possesses an ultra-
violet absorption band at 260 mu. and also in the visible
range. Flavin dissolves in water giving a bright yellow
solution with a characteristic green fluorescence. Strong
reducing agents convert it into the colorless form, but
it is easily oxidized again by shaking it with air. Lacto-
flavin has been isolated from milk by Kuhn, Booher,
and Karrer, and has been synthesized by Stern and by
Kuhn (1934). Ovoflavin and hepaflavin are also
growth-producing and are similar chemically. Vitamin
B4 appears to increase the action of lactoflavin in pro-
motion of growth.

Gyorgy, Kuhn, and Wagner-Jauregg believe lacto-
flavin is closely related to the "yellow oxidation enzyme”
of Warburg. This enzyme seems to consist of flavin
in combination with a colloidal carrier, and acts as a
carrier catalyst taking up hydrogen from the substrate,
later being oxidized to the original enzyme. Since this
enzyme is probably necessary for the animal body, and
since flavin is not able to be synthesized in the body, it
is necessary to include vitamin B2 in the diet. In the
flavin enzyme is the best example hitherto known of
the relationship between an enzyme and its active group
of vitamin or hormone character.

536

THE JOURNAL-LANCET

Standardization

The Sherman unit for vitamin EC is that amount
which when fed daily to a standard test rat that has
been previously depleted of vitamin EC according to the
prescribed technique, will promote a gain in weight of
three grams per week over a period of from four to
five weeks.

Pathology

As in avitaminosis Bi, the pathologic effects seen in
vitamin BL> deficiency are probably only secondary. The
histology of human pellagra, black tongue in dogs, and
rat dermatitis throws little light on the subject. De-
generative lesions in nerve-cells and myelin sheaths are
characteristic of the deficiency — but may not be specific.
Lesions of the skin and mucous membranes are con-
sistently present. At autopsy, ulcerative lesions are
found in the intestines, similar to those in colitis.

Chief Symptoms of Avitaminosis Bj (G) Complex

A. In Man.

1. Pellagra — due probably to avitaminosis P. P. of
the vitamin Bo complex.

Brown, scaly, symmetrical dermatitis in exposed areas,
glossitis, soreness of mouth, indigestion, diarrhea, and
disturbances of the nervous system — at times leading to
dementia.

2. Acrodynia believed by some to be caused by the
lack of one or more of the factors in vitamin B com-
plex. Because of its cutaneous manifestations, acro-
dynia is often mentioned in connection with vitamin Bo
complex.

Irritability, insomnia, appearance of misery, anorexia,
acrocyanosis, itching and burning of hands and feet,
desquamation of palms and soles, marked perspiration,
photophobia, muscular hypotonicity, increased blood
pressure, and loss of teeth.

3. Little is known of lactoflavin deficiency in the
human subject.

B. In Animals (rat and dog).

1. Retarded growth and loss of weight (deficiency in
lactoflavin) .

2. Cataract formation.

3. Dermatitis with loss of fur and ulceration of the
skin — due to lack of vitamin By. (Acrodynia of rats)

4. Keratitis.

5. Black tongue (in dogs) — due probably to deficien-
cy in P. P. factor.

Laboratory Diagnosis

No tests are known.

Clinical Applications of Vitamin Bo

1. Prevention and cure of pellagra.

2. Promotion of growth and well-being (due to lacto-
flavin) .

3. Possible prevention of cataract formation.

4. Increase of vitamin Bo content of milk in lactation.

5. Cure of stomatitis and glossitis of chronic alcohol-
ism and of alcoholic pellagra — by early treatment with

a high caloric diet and 75 grams of yeast or of liver
extract daily. (Blankenhorn and Spies)

6. Treatment of acrodynia.

Pellagra is seen particularly in the southern part of
the United States, but in the northern sections one
should watch for secondary pellagra — due to organic
diseases of the digestive tract — as obstructing and ma-
lignant diseases, or to other gastro-intestinal disturbances
with faulty absorption: alcoholism, colitis, tuberculous
enteritis, celiac disease, etc.

The supply of protein may also have a significant
bearing upon the pellagra problem, and the vitamin B_.
complex may not be the only deficiency factor. This
has been demonstrated by Sherman, rats on high pro-
tein diet being less severely affected by the lack of vita-
min Bl. than animals on diets with lower amounts of the
same protein.

The relationship of vitamin B;. complex to pernicious
anemia has been stressed by Castle and others — claim-
ing that macrocytic anemias of several types are de-
pendent upon vitamin B^ complex deficiency. However,
it has been shown that this vitamin is neither the liver
anti-pernicious anemia principle nor the "extrinsic”
factor concerned in hemopoiesis.

Daily Requirements

Not yet determined.

Natural Sources

Brewer’s yeast and wheat germ — as for vitamin Bi.

Liver and kidney are the richest sources of flavin.

Egg white has high content of flavin but no P. P.
factor.

Milk and meat (one-fifth as much as yeast).

Leafy vegetables, tomato and banana (one-tenth as
much as yeast) .

Fish muscle rich in P. P. factor, but lacking in flavin.

VITAMIN B:i

Williams and Waterman claim that there is a pigeon
vitamin B;l necessary for supplementing a diet of pol-
ished rice to which vitamin Bj has been added. It is a
growth principle and seems to be a stored vitamin factor.
Musser reports that more recent work indicates that
vitamin B;i appears to be a more abundant supply of
vitamin Bi and therefore doubts the existence of vita-
min B;j. Another worker has found a "filtrate factor”
in vitamin B complex — a dietary essential for the chick
— which promotes growth and is probably not identical
with the antipellagra factor in chicks. This chick anti-
pellagra factor has been believed by some to be in vita-
min B,{ and vitamin B5. Further investigations are
necessary to establish any relationship of vitamin B:i to
human nutrition.

VITAMIN B4

Tentative formula — C4N4H.-,C1 or C4H4N4HCI . J/>
HoO. Barnes in 1932 isolated a heat-labile crystalline
preparation of vitamin B4. The crystals consist essen-
tially of adenine hydrochloride, but probably contain
some impurity which causes activation. The vitamin is
alkali-labile and is easily destroyed. It is closely as-

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537

sociated with vitamin B| and some workers suggest that
both vitamin Bi and vitamin B4 are necessary for the
prevention of beriberi, while vitamin Bo and vitamin B4
are necessary for the prevention of pellagra. Reader
thinks a third factor is necessary in the treatment of
pellagra and proposes two vitamin B4 factors — vitamin
B4a and vitamin B4b. It is not abundant in foods;
whole wheat is a source of vitamin B4 needed by the
rat in addition to vitamin B4 and vitamin Bo.

This intimate association between vitamin B4 and
vitamin B4 is not yet understood. Vitamin B4 seems to
be a variation of vitamin B4 since vitamin B4 cannot be
obtained free from vitamin B4 activity. The apparently
pure crystalline preparation of vitamin B4, as isolated
independently in different laboratories, is one of the
richest sources of vitamin B4 activity. The standard
procedure for producing avitaminosis B4 actually con-
sists in first subjecting the experimental animals to vita-
min B] deficiency. Vitamin B4 deficiency seems to re-
semble a state of chronic or persistent deficiency of vita-
min Bi, since it can always be cured by the administra-
tion of a sufficiently large dose of vitamin B4. Speci-
mens of supposedly pure crystalline vitamin Bj, pre-
pared in different parts of the world, having identical
properties, and giving no evidence of admixture with
impurity, when examined by X-ray analysis or other
means, all possess their characteristic vitamin B4 activity.

Gyorgy (1935) claims that in the absence of the vita-
min B4 fraction there occur lesions of the nervous sys-
tem with disturbances in coordination and ataxia, hence
the name, anti-paralytic vitamin. Elvehjem thinks that
it may prove to be important in nutrition in man and in
the treatment of certain disorders of the brain. He be-
lieves that the encephalomalacia of chicks prevented by
the addition of certain vegetable oils to the diet is due
to lack of vitamin B4 — and claims that the factor pre-
venting paralysis in chicks is identical with vitamin B4.
Others disagree with this on the basis that vitamin B4
is water soluble, while soy bean oil, which contains the
anti-paralytic factor, is a fat.

VITAMIN B5

This fraction of vitamin B complex in conjunction
with vitamin B;t has been thought to be the chick anti-
pellagra factor. At present our knowledge of vitamin
B.-, is quite nebulous.

VITAMIN B(;

The chemical composition and structure is unknown.
With lactoflavin it is one of the principle components
of vitamin Bo complex. Termed the rat antidermatitis
factor by Gyorgy (1934), it is identical with the Y
factor of Chick. The P. P. factor (pellagra-preventing)
is now thought by Gyorgy to be a third factor in the
complex — probably vitamin H.

Vitamin Be is in a filtrate which remains after re-
moval of the flavins from vitamin Bo complex, and is
responsible for the cure of the specific "acrodynia-like”
dermatitis developed by young rats fed on a vitamin
B-free diet supplemented with purified vitamin B4 and

lactoflavin. Vitamin B(j is not a true water-soluble vita-
min, being only partially soluble in that medium, but it
is soluble in ethyl alcohol. It is heat-stable, is inactivated
by visible light, is adsorbed on fuller’s earth from acid
solution, is precipitated by phosphotungstic acid, and
migrates toward the cathode on electrodialysis. Auto-
lysis, which yields 80-100% extraction from wheat germ,
is the method adopted as the standard procedure for
the preparation of active extracts of the vitamin. It is
suggested that the vitamin does not contain a primary
amino-group, but is of a basic nature and possibly con-
tains a hydroxyl group. Vitamin B(i has some similarity
to choline, though pure choline chloride does not cure
rat dermatitis.

This essential factor must be largely combined in
some way with the tissue in which it occurs, since the
greater part is not easily extracted by ordinary solvents.
No knowledge has been obtained concerning the nature
of the union between vitamin B,; and the tissue, but
possibly the vitamin is attached to the protein as an
active group which is not easily split off. Fat has a
sparing action on the vitamin. In rat dermatitis pro-
duced by vitamin B(1 deficiency, vitamin Bti alone does
not cure it, but extra fat (linseed oil) with vitamin B,;
will cure it. This curative factor in fats is probably
linoleic acid, and closely associated with the so-called
vitamin F which is necessary for the normal growth of
the young rat. The scaly tail and scurfy appearance of
the skin in vitamin F deficiency has often been noted in
vitamin B(i deficiency animals. The relation of vitamin
B(; to man is uncertain, as the "rat pellagra,” "chick
pellagra,” and "human pellagra” are apparently not
identical.

Standardization

The unit is the minimum daily dose necessary to cure
the rat of this specific "acrodynia-like” dermatitis.

Natural Sources — in order of potency

1. Wheat germ exceedingly rich in it — about 5 units
per gram.

2. Fresh fish muscle is a rich source (salmon, had-
dock, herring) . Fish muscle contains no vitamin Bj
(lactoflavin) .

3. Rice polishings.

VITAMIN C— History

Scurvy has long been known in history. In 1535
Jacques Cartier during a winter on the St. Lawrence
reported the cure of a disease, obviously scurvy, by a
decoction made from the bark and needles of the spruce
tree. A British naval surgeon in 1747 demonstrated the
striking effect of fresh lime-juice as an antiscorbutic
agent. Lime-juice later became a compulsory supple-
mentary food on all ships in the British navy. Barlow
differentiated infantile scurvy from rickets (1883). In
1907 Holst and Frohlich produced the disease in ex-
perimental animals (guinea pigs). The antiscorbutic
factor was called vitamin C in 1918 to distinguish it
from vitamin B complex, the other water-soluble factor.
Isolation in crystalline form as hexuronic acid was made

538

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from bovine adrenal glands in 1928 by Szent-Gyorgy
This later (1932) proved to be identical with King
and Waugh’s crystalline active factor derived from
lemon-juice. Vitamin C was synthesized by Reichstein
in 1932 starting with 1-xylose.

Chemistry

0 =

HO -
HO -

H -
HO - CH

1 — ascorbic or cevitamic acid.

Vitamin C is the lactone of threo-3-keto hexonic acid.
The properties of the crystalline acid are identical with
those of hexuronic acid: solubility in water, insolubility
in fat solvents, marked sensitivity to exposure to visible
light and to heat and oxygen, especially in alkaline
solution. Its melting point is 183 — 185 C, and the
optical rotation ( or ) DL’° = 25° (±1°). It has a single
broad absorption band at 263 mu. The essential con-
dition for the antiscorbutic activity in the ascorbic acid
group is the d-configuration of the fourth carbon atom.

Vitamin C has a very characteristic power of reduc-
tion, by oxidation losing two hydrogens in acid solution,
but retaining its vitamin activity. The chemical mecha-
nism of vitamin C activity in the body is not known.
Its biological significance is based on the fact that this
reaction is reversible. The oxidized vitamin can be re-
duced with relative ease by the tissues to its original
substance, and may thus act as an oxygen carrier. There
is more than a probability that vitamin C does not play
a specific organic functional role in the animal body,
but fulfills a general function in the life of protoplasm.
In the absence of this vitamin all cellular functions seem
to be injured to the same extent. Besides its activity *n
the respiratory function, vitamin C is fundamentally
important in the formation of normal intracellular sub-
stance. In avitaminosis C there is a failure to form this
substance with normal properties — possibly as a result of
reduced cellular oxidation. The mechanism of its activ-
ity in the prevention of hemorrhages is uncertain, al-
though it is thought to cause changes in the intracellular
substance of the capillaries. However, clinical results
with vitamin C therapy have been disappointing in the
hemorrhagic diseases, particularly in thrombocytopenic
purpura, leukemia, Schonlein’s pupura and hemophilia.

Rats, rabbits, calves and birds can synthesize vitamin
C in the body, but guinea pigs, swine, dogs, monkeys
and man require it in the diet.

Standardization

The International unit, which was formerly defined
as the vitamin C activity of 0.1 cc. of lemon- juice, has
now been defined as the vitamin C activity of 0.05 mg.
of 1-cevitamic (ascorbic) acid. This is the quantity of

1-cevitamic acid usually found in 0.1 cc. of lemon-juice.
An ounce of lemon-juice has a potency of 15 mg. of
cevitamic acid, while an ounce of orange juice has a
value of 20 mg. of the vitamin.

The claim that a food is valuable because of its vita-
min C content should be permitted only if it provides
a daily intake of at least 250 units of vitamin C.
(N. N. R.)

Pathology

The gross and microscopic pathologic changes in in-
fantile scurvy and experimental scurvy in guinea pigs
is practically identical. There is a striking inability of
the supporting tissue to produce and maintain inter-
cellular substances, hence the effect is on the cells of
mesenchymal origin. The intercellular substances con-
cerned are the collagen of all fibrous tissue structures,
the matrices of bone, dentin and cartilage, and all non-
epithelial cement substance, including that of the vas-
cular endothelium. Bone pathology is explained as due
to failure of osteoblasts to form osteoid tissue, and the
hemorrhage of scurvy as due to a failure of cement
substance in blood vessels.

Soft tissue changes are hemorrhages in regions deter-
mined by mechanical stresses and trauma, as well as
anasarca and degenerations of skeletal and cardiac mus-
cle. Secondary changes are hypertrophy of the heart,
degeneration of muscles, and anemia with bone marrow
destruction.

Gross pathologic changes are hemorrhages and bone
lesions: sub-periosteal hemorrhages and those in the
epidiaphyseal junctions of growing bones, resorption of
bone matrix, inactivity of the osteoblasts, osteoporosis,
the triimmerfeld zone of disorganization at the epiphy-
sis, and separation and displacement of the epiphysis.
In growing teeth formation of dentin ceases, enamel and
cementum fail to develop, and the pulp becomes sep-
arated from the dentin by liquid produced by the
odontoblasts.

Repair following vitamin C therapy is dramatic in
character and rapidity — all pathologic lesions soon chang-
ing to normal processes and normal tissues.

Chief Symptoms of Avitaminosis C
In Man and Animals (guinea pig):

1. Scurvy — increasing pallor, irritability, spongy and
bleeding gums, loosened teeth, sore and swollen joints,
petechiae and large superficial hemorrhages, epistaxis,
sore mouth, dyspnea, loss of energy, anorexia, loss of
weight, anemia, edema, fragility of bones and pseudo-
paralysis.

2. Less extreme deficiency.

a. Hemorrhagic tendencies.

b. Dental caries, pyorrhea.

c. Vague aches and pains.

d. Fatigue, pallor, anemia.

e. Abnormal cutaneous pigmentation.

f. Increased susceptibility to infection in general,
and to specific cases of diphtheria, poliomye-
litis, and tuberculosis.

THE JOURNAL-LANCET

539

g. Joint disease strikingly similar to rheumatic
fever.

h. Vagus nerve disturbance: increased pulse and
respiration.

i. Sensory nerve disorders (paresthesias).

j. Increased capillary fragility.

Total absence of vitamin C from the dietary is ex-
tremely rare in America and frank scurvy is not common
in adults, though somewhat more frequent in children.
Infantile scurvy occurs mostly between 6 and 18 months
of age, and particularly in the winter and spring follow-
ing a low intake of vitamin C. Subclinical avitaminosis,
that is, mild or partial deficiency causing ill-defined
symptoms, is rather widely accepted and is probably
very common.

Laboratory Diagnosis

1. Blood Plasma Test

Estimation of reduced vitamin C in blood by chemical
test. Blood plasma values of less than 0.75 to 0.80
milligram per cent of reduced vitamin C indicate sub-
normal vitamin C intake. Abt reports (April, 1937)
that his findings for normals was above 0.8 milligram
per cent, for prescorbutics between 0.8 and 0.6 milli-
gram per cent, and for active scurvy below 0.5 milli-
gram per cent.

2. Urinary Excretion Test

This test is based on determination by chemical titra-
tion with 2.6-dichlorophenal — indophenol of the amount
of vitamin C normally excreted in the urine; and the
response to a large test dose or doses of pure cevitamic
acid (saturation or retention test).

An excretion of 20 milligrams per day is the lower
limit of normal excretion (Youmans).

3. Capillary Resistance Test.

This method consists essentially in creating a pressure
on the arm of the patient and observing, in a small area,
the number of petechiae which appear in a certain length
of time. This test is not specific for avitaminosis C.

4. X-ray of Long Bones

Clinical Applications of Vitamin C

1. Prevention and cure of scurvy.

2. In dental caries, pyorrhea, certain gum infections
(Hanke), anorexia, anemia, and undernutrition — which
may be concomitant signs of vitamin C deficiency.

3. Maintenance of strength of capillaries.

4. Parenterally as sodium cevitamate in conditions
interfering with oral ingestion of vitamin C or its ab-
sorption in optimal amounts (persistent vomiting, diar-
rhea, etc.).

5. In infant feeding, routinely.

6. In cases of lowered intake of vitamin C due to a
restricted diet, either voluntary or imposed (Sippy diet) .

7. In certain infections which demand an increased
supply of vitamin C — as tuberculosis, rheumatic fever,
diphtheria, poliomyelitis, and pneumonia.

8. Prevention of peptic ulcer (Smith and McConkey) .

9. Demands of pregnancy.

10. Decrease in certain cutaneous pigmentations.

11. Acceleration of coagulation of blood in hemor-
rhagic diseases (value controversial).

12. Promotion of union of fractures — in conjunction
with vitamins D and B.

Vitamins A and C are anti-infectious only in the
limited sense that in their absence pathologic changes
occur which may open the way to secondary infection.
Rinehart in 1935 produced in guinea pigs typical heart
lesions of rheumatic fever — the Aschoff bodies, by in-
fection in addition to a partial vitamin C deficiency.

Daily Requirements

1935 Szent-Gyorgy

1936 King

1937 Youmans

in infants
in adults
in infants
in adults
as minimum

25 mg.
50 mg.
25 mg.
to 40 mg.
25-40 mg.

Natural Sources — in order of potency

Oranges and lemons, particularly.

Excellent sources: grapefruit, tomato juice, limes,

tangerines, lettuce, fresh strawberries, raw cabbage,
water cress, apples, bananas, paprika, spinach, carrots,
fresh pineapple, and grapes.

Good sources: potatoes, peas and string beans, if not
cooked too long.

Vitamin C has been called the vitamin of uncooked
foods. Nearly all fresh fruits and vegetables have anti-
scorbutic value — especially the citrous fruits. These
articles must be prepared with care, however, as vitamin
C is the most easily destroyed of any of the vitamins.
In foods this vitamin deteriorates rapidly on standing.
It is completely destroyed by boiling for thirty minutes
in the presence of air and moderately alkaline solution,
as when the cook adds soda to the water in which vege-
tables are boiled to preserve their green color. Oranges
from trees sprayed with certain chemicals, and tomatoes
artificially ripened by ethylene gas contain little of the
vitamin. Fruits or vegetables which have been cooked
at high temperatures with full exposure to air may have
had their vitamin C oxidized. The vitamin is more stable
in fruit than in vegetable juices. Certain metal con-
tainers also impair its potency, especially copper and tin,
while nickel, chromium, aluminum and glass are harm-
less. Canning of fruits, and vegetables can now be
done with little loss of vitamin C by exclusion of air.
Breast milk has four times as much vitamin C as milk
from cows on a summer diet.

Vitamin C is widely distributed in relatively high con-
centrations both in plants and in the tissues and secretions
of animals. Its content is highest in glandular tissues
and lowest in muscle and stored fat. The richest tissue
in vitamin C is the pars intermedia of the pituitary
gland, the adrenal comes next, and then the liver. It is
also found in the corpus luteum, pancreas, brain, lens,
aqueous humor, and intestinal wall. Its storage in the
adrenal has been a subject of controversy. It is now
believed that a liberal amount of vitamin C is necessary
for the normal working of this organ rather than that
it is stored there for usage of the rest of the tissues, as
the liver stores up vitamin A.

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VITAMIN D
History

Rickets was first described by Glisson in 1650. Ex-
cavation of Viking graves indicate that it existed before
that time. Mellanby in 1918 gave substantial evidence
that rickets was a deficiency disease, due to the lack of
a vitamin contained in cod liver oil, which was either
vitamin A or one of similar distribution. Four years
later, McCollum demonstrated the separate entity of the
antirachitic factor — vitamin D. Huldschnisky, in 1919,
found that the short ultraviolet rays of a quartz mercury
vapor lamp cured rickets. Hess and Steenbock (1924)
made certain foods antirachitic by irradiation, activat-
ing their cholesterol fraction, and later they and others
proved that this activatable impurity in cholesterol was
ergosterol. In 1927, it was believed that vitamin D was
irradiated ergosterol, and that ergosterol was the only
provitamin D. Recently, other precursors have been
recognized, and vitamin D has been found to consist of
a number of fractions.

Chemistry

Vitamin D is identical with calciferol, the vitamin
active substance produced by the action of ultraviolet
light on ergosterol. Calciferol is the most powerful
antirachitic agent known and is 400,000 times as effec-
tive as cod liver oil in curing rickets in the rat. Calci-
ferol is the most important form of vitamin D from a
practical standpoint.

Ten forms of vitamin D have been artificially pre-
pared— all sterols:

1. Cholesterilene sulphonic acid, isolated by Bills in
1925 through treatment of cholesterol with fuller’s
earth. It is not in fish oils and is only of theoretical
importance.

2. Irradiated cholesterol by Bills in 1928.

3. Heated irradiated cholesterol — by Koch and Hath-
away (1929).

4. Irradiated ergosterol — whose active principle is cal-
ciferol, isolated in crystalline form by Bourdillon and by
Windaus in 1932.

5. Non-irradiated ergosterol treated with alkyl ni-

trites by Bills and MacDonald in 1931. It is not in
fish oils and is of no practical significance.

6. Irradiated ergosterol treated chemically by Windaus
and Langer in 1933. It has an active substance, 22-
dehydro-calciferol.

7. Irradiated 7-dehydro-cholesterol synthesized by
Windaus and by Bills in 1935, more potent than 22-
dehydro-calciferol.

8. Irradiated 7-hydroxy-cholesterol synthesized by
MacDonald in 1936.

9. Irradiated provitamin derived from sitosterol, the
sterol of the higher plants corresponding to cholesterol
of animals, — by Bills in 1937.

10. Ergosterol activated by low velocity electrons has
been shown by McQuarrie, et al., to be effective in
rickets in human subjects (1937).

Vitamin D has been called the antirachitic vitamin,
the sunshine vitamin, or the calcium-phosphate metabo-
lizing vitamin. It is an isomer of ergosterol, the sterol
or higher alcohol found in ergot and yeast. The vita-
min is fat-soluble, and is very stable to heat and oxy-
gen, although it will be destroyed at temperatures of
180°C. or higher. It is not injured by slightly acid or
alkaline media. This vitamin is stored in the body. It
is the most important calcifying agent, promoting bony
growth by facilitating assimilation of calcium and phos-
phorus. It is of interest that the vitamin has a phenan-
threne nucleus, a structure common to several other
physiologically highly active substances such as the sex
hormone and the carcinogenic hydrocarbon. Further-
more, ergosterol, calciferol and especially neoergostero!
possess estrogenic activity; also some actively estrogenic
substances are definitely carcinogenic.

Standardization

The U. S. P. XI unit for vitamin D (equivalent to
the International unit) is the vitamin D activity of 1 mg.
of the International Standard Solution of irradiated
ergosterol (equal to 0.025 gamma of crystalline vitamin
D) or the equivalent amount of U. S. P. Standard
Reference cod liver oil. The U. S. P. XI requires that
I gram (15 grains) of cod liver oil shall contain at
least 85 U. S. P. units of vitamin D.

The Steenbock unit is that amount of vitamin D
which, when uniformly distributed into the Standard
vitamin D deficient diet, will produce a narrow and con-
tinuous line of calcium deposits on the metaphysis of the
distal end of the radii and ulnae of standard rachitic
rats. To convert this unit to the International unit, the
multiplying factor is 2.7.

The vitamin D content of average cod liver oil is
100 International units or 37 Steenbock units per gram.

Pathology

In rickets, calcium salts are incompletely deposited,
or even not at all, both in the maturing proliferative
cartilage and in bone which is in process of formation.
This failure in lime-salt deposition is the most striking
feature in the pathology of rickets and is the essential
cause of the gross changes in the skeleton. The only

THE JOURNAL-LANCET

541

change outside the skeleton is hypertrophy of the para-
thyroid glands.

The characteristic bone changes are due to the soften-
ing of the bones from loss of inorganic matter and to
the subsequent stress on the soft bones, which causes
marked deformities. Normally, there is about two-thirds
mineral matter in bone, and one-third organic matter.
This ratio is reversed in severe rickets. Most of the loss
is in calcium phosphate which ordinarily constitutes 85%
of the mineral content. Both long bones and flat bones
may be affected. Enlargement of the epiphyses of long
bones is most noticeable in the regions of most rapid
growth, at the wrists, knee and ankle, as well as at the
costochondral junctions. The metaphysis is greatly en-
larged in width and thickness. Osteoporosis causes cur-
vatures and fractures. Compensory thickening of the
cortex is often visible grossly. Large frontal and parie-
tal bosses and areas of rarefaction (craniotabes) are
characteristic in the skull.

In the microscopic picture, as in the gross, experi-
mental rickets in the rat resembles human rickets. The
pathologic conditions arise from retardation and sup-
pression of the usual sequences in normal ossification.
There is failure of provisional calcification of the inter-
cellular matrix, the transitional zone between cartilage
and bone becomes irregular and uneven, and the meta-
physis presents a disorganized appearance. The un-
calcified bone or osteoid tissue is particularly characteris-
tic in rickets. Following vitamin D therapy repair rapid-
ly takes place, the first effects being demonstrable in 24
hours.

The teeth also show pathologic changes, evidenced by
dental caries and irregularity in size, shape and position.
Marked disturbance of the blood calcium and phos-
phorus occurs. In infantile rickets, the serum calcium
is about normal, 10 to II mg. %, but the inorganic phos-
phorus may be reduced as low as 1.2 mg. % when
tetany accompanies the rickets, the serum calcium is di-
minished to between 5 and 7 mg. %, sometimes as low
as 4 mg. %. In active rickets, there is a great increase
in the phosphatase activity of the serum.

Chief Symptoms of Avitaminosis D

1. Rickets: irritability, craniotabes, prominent frontal
bosses, delayed closing of fontanelles, pigeon breast,
rachitic rosary, flaring ribs, epiphyseal enlargement at
wrists and elbows, marked perspiration, delayed erup-
tion of teeth, muscular weakness, protruding abdomen
and bowing of legs.

2. Spasmophilia or infantile tetany: carpopedal spasm,
laryngospasm and convulsions, and spasticity.

3. Osteomalacia: extreme softening of bones, especial-
ly in pregnancy.

4. Osteoporosis: failure of normal deposition of cal-
cium phosphate leading to impaired calcification of bone.

5. Cessation of growth.

6. Abnormal ratio of calcium and phosphorus in the
blood.

7. Dental malformation and caries.

Laboratory Diagnosis

1. X-ray examination of bones.

2. Determination of calcium and phosphorus in blood
serum.

3. Phosphotemic curve of Warkany.

4. Blood phosphatase test for active rickets. Phos-
phatase of blood increased (Smith, 1933). This method
has not been extensively used, but should be made the
subject of surveys on a large scale. The test may be
indicative of disturbances in calcium and phosphorus
metabolism other than rickets.

5. Erb’s sign for tetany.

Clinical Applications of Vitamin D

1. Prevention and cure of infantile rickets and tetany.

2. Prevention and cure of osteomalacia.

3. Formation and maintenance of normal tooth
structure.

4. In defective calcium and phosphorus metabolism.

5. Routinely during infancy and periods of rapid
growth, in pregnancy and lactation.

An adequate intake of calcium and phosphorus is also
necessary in all cases.

Daily Requirements

1936 prophylactic and 780-1020 1. U.

Eliot curative

1937 for normal infant not above 300 1.U.

McQuarrie for premature infant not above 540 I.U.

From a three-year study of five hundred and sixty-
seven full-term infants, Eliot believes that, for prophy-
laxis and for the prompt control of rickets, the vitamin D
equivalent of the usual dose of cod liver oil, namely,
two or three teaspoonsful daily, is indicated. Viosterol
in milk seems to be the most efficient antirachitic unit
for unit. According to her study, viosterol is somewhat
more effective than cod liver oil at the same dosage
level.

Jeans (1936) states that the amount of vitamin D
present from animal source in one standard teaspoonful
of average high grade cod liver oil or in milk contain-
ing 400 units to a quart is adequate for the infant from
the standpoint of calcium retention and growth. The
recent report by McQuarrie and his co-workers gives the
daily requirement of vitamin D as not above 300 I. U.
for normal infants and not above 540 I. U. for pre-
mature infants. In view of the fact that one cannot
always be certain of an optimal calcium and phosphorus
intake nor of the ability of the organism to absorb these
elements, he believes that it is probably better to give as
an antirachitic between 500 and 1000 I. U. daily.

Vitamin D is required especially during the period of
growth, during pregnancy and lactation, as well as in
acute and chronic infections, and wasting diseases. There
are as yet no controlled clinical reports on the subject.

Natural Sources

1. Fish liver oils: halibut, cod, burbot, percomorph,
salmon, haddock, herring, sardine, puffer fish, shark.

2. Egg yolk.

Foods are inadequate sources of vitamin D and can-
not furnish the daily requirement. Cereals have a defi-

542

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nite inhibiting effect on the vitamin. Sunshine is not
dependable because of the lack of exposure to it, due to
clothing, window glass, smoke, dust and fog which de-
stroy the effect of sunshine.

Antirachitics

1. Cod liver oil was the first reliable agent to be
established.

2. Direct irradiation of the body by means of ultra-
violet energy was next.

3. Irradiated food, particularly milk, was third.

4. Activated ergosterol from yeast.

5. "Yeast milk,” produced by feeding cows irra-
diated yeast, came next.

Since then, other antirachitics have also been used,
such as viosterol, haliver oil, percomorph oil, and crys-
talline vitamin D.

Hypervitaminosis

It is thought that vitamin D is the only vitamin which
can cause hypervitaminosis. However, the toxic dose is
so large, that this danger is rare. There is little need of
anxiety about the administration of viosterol in amounts
up to 150,000 International units daily. Except in cases
of hyper-sensitivity, one can give fifty to one hundred
times the minimum dose with safety. Vitamin D is
made more toxic when a large amount of calcium is
given with it. Experimentally, an excess of vitamin D
produces increased calcification of tissues, particularly of
the cardiovascular system. It increases calcium excretion
in the urine and causes loss of appetite and of weight,
diarrhea, cachexia and a disturbance in fat and calcium
metabolism. The cement substance of the teeth becomes
overgrown so that the teeth become ankylosed in the jaw
bone. There is over-calcification of the growing bones.

VITAMIN E
History

Evans and Bishop in 1922 announced the discovery
of a new fat-soluble substance essential in the diet for
reproduction, which they designated vitamin E. Evans
successfully isolated (1936) from wheat-germ oil a pure
crystalline substance possessing vitamin E activity.

Chemistry

Vitamin E is alpha-tocopherol, a higher alcohol con-
taining one or more hydroxyl groups, with a provisional
formula of C2nH.-,nOo, and a molecular weight of about
440. Reactions with iodine and hydrogen suggest the
presence of three reactive double bonds. The active frac-
tion is fat-soluble, extremely stable with regard to high
temperatures, ultraviolet ray, atmospheric oxygen, strong
alkali, acids, and hydration. It is not inactivated by
hydrogenation or saponification process, but is destroyed
by bromination, treatment with potassium permanganate,
and long exposure to ultraviolet light. It forms bio-
logically active esters with acetic acid and benzoic acid.
The activity is correlated with an absorption band at
294 mu. Nothing definite is known regarding the mech-
anism through which this vitamin brings about its phys-
iological action. This anti-sterility vitamin is thought to
be not only biologically but also chemically a female sex

hormone. It is stored in the body to a considerable
extent. Hill and Burdett, noticing that consumption of
"royal jelly” will convert the larva of a working-bee into
a queen-bee, suggest that this property is due to vitamin
E content.

Standardization

No standard unit has been established.

Pathology

The effect of vitamin E deficiency is on the repro-
ductive system. In female animals fed a diet lacking in
this vitamin, the fertilized ova are implanted in the
uterus apparently in the normal manner. However, the
fetuses die in the uterus and are resorbed. In the male
animal, there is a gradual degeneration of the germinal
epithelium.

Chief Symptoms of Avitaminosis E

A. In Man.

1. Habitual and threatened abortion.

2. Uterine hypoplasia, amenorrhea, sterility.

B. In Animals (rat and chicken).

1. Failure of reproduction.

(a) Female — resorption of young during gestation.

(b) Male — sterility with irreversible, incurable
lesions in the testes which do not respond to
a high vitamin E diet.

(1) Loss of fertilizing power.

(2) Absence of motility of spermatozoa.

(3) Loss of sperm.

(4) Loss of sex interest.

2. Paresis in young rats from maternal deficiency.

3. Muscular weakness, atrophy of voluntary muscles
in young animals.

The vitamin is held so tenaciously by the tissues, the
source is so varied, and the supply so abundant that de-
ficiencies are probably rare in man.

Laboratory Diagnosis

No test available for avitaminosis E.

Clinical Applications of Vitamin E

1. Treatment of sterility, habitual, and spontaneous
abortion in man. Vogt-Mpller successfully treated 17
out of 20 cases of habitual abortion with wheat-germ oil,
after noting favorable results in sheep and cows.

2. Possibly in hypoplasia and hypofunction of the
gonads.

Daily Requirements

Human requirement unknown.

Animal requirement — 0.1 mg. per rat per day as min-
imal dose (Drummond 1935).

Natural Sources — in order of potency

Wheat-germ oil.

Vegetable oils — cottonseed oil, corn oil, olive oil.

Lettuce.

Whole grain cereals.

Legumes and soy beans.

VITAMIN F

Vitamin F has become of practical importance because
of the great amount of propaganda in cosmetic litera-

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543

ture dealing with dermatological conditions. There has
been considerable question among investigators as to
whether the expression vitamin F should actually be used
in this connection.

In 1927, Burr working with Evans on vitamin E found
that animals reared on highly purified low-fat diets still
failed to attain normal development and nutrition. Sub-
sequent investigations by Burr and Burr revealed that
rats on fat deficient diets have early cessation of growth,
scaliness of feet and hands, scaliness of the tail so
marked that the tip frequently becomes necrotic and
falls off, hematuria, and early death. McAmis, Mendel,
and Anderson reported somewhat similar findings in
animals on a fat-free regimen. Burr and Burr were the
first to find that fats of high degree of unsaturation
given in relatively small amounts caused complete disap-
pearance of symptoms. Later, they definitely estab-
lished that esters of linoleic and linolenic acids were es-
sential for the normal nutrition of the rat; hence, the
expression, "the essential unsaturated fatty acids.” There
has been much controversy as to whether this type of
deficiency should be considered a type of avitaminosis.
Most reports in the literature term this disorder a fat
deficiency disease. Evans and his co-workers as well
as others have been referring to this essential factor as
vitamin F.

The lack of these unsaturated fatty acids has been
known to cause disturbances in gestation and lactation.
As regards the human subject little is known. Relatively
recently at the University of Minnesota, one of the work-
ers in this field maintained himself on a strictly fat-free
diet for a period of over six months — resulting in some
rather interesting but not entirely conclusive findings
(Brown, et al). In infants maintained on a diet other-
wise complete but strictly devoid of fat, it has been
shown that eczema developed. Several investigators have
found that certain infants suffering from outspoken
eczema of long duration have been found to be benefited
by internal administration of oils rich in unsaturated
fatty acids over a variable length of time (Hansen;
Cornbleet) .

VITAMIN H

Gyorgy in 1931 found a factor, insoluble in its na-
tural state, which is necessary for neutralizing the toxic
action of dried egg white. He called this principle
vitamin H, and now identifies it with the P. P. factor
which was later extracted from vitamin B-j complex.

However, the term vitamin H has been ascribed by
others to different essential constituents of the diet. The
vitamin H of McCay (1934) in the form of raw liver
or preserved raw meat cured trout who failed to thrive
on diets with all the known vitamins. Recently, Rich-
ardson and Hogan discovered a new vitamin (vitamin
H) not identical with vitamin BK, but which also cures
rat dermatitis. It is present in wheat-germ oil, yeast
or alcoholic extract of corn starch.

VITAMIN K
Chemistry

Formula is unknown.

The antihemorrhagic vitamin (clotting or coagulation
factor) is fat-soluble, relatively stable to heat and light,
destroyed by alkaline medium, and not readily absorbed
by activated magnesium oxide or activated carbon.

Dam, in 1935, noted a hemorrhagic tendency similar
to scurvy in chicks, not prevented by cevitamic acid but
by this new fraction which he called vitamin K. It is
neither vitamin A or vitamin D. Avitaminosis K pro-
duces a reduced prothrombin content in the blood of
chicks. The administration of vitamin K can restore the
clotting time to normal in three days. It is probably syn-
thesized in the lower intestinal tract — since it is found
in the feces of chicks not receiving this factor in the
diet.

Natural Sources

Pig liver, hemp seed, and alfalfa are the most potent
sources.

Green vegetables are a fair source.

Cod liver oil is devoid of vitamin K.

Isolation

Almquist (1936) reports progress in its isolation and a
rapid method of obtaining it in highly concentrated form
from alfalfa. A sterol-free oil is produced which is ade-
quate as a source of vitamin K at a level as low as 3 mg.
of oil per kilogram of diet.

A new accessory factor closely related to but not iden-
tical with vitamin K has most recently (1937) been re-
ported by Quick. He believes that this principle extract-
ed from alfalfa can cure the hemorrhagic tendency in
rabbits produced by feeding them spoiled sweet clover
hay. Some toxic substance appears to destroy prothrom-
bin or to inhibit the mechanism by which the body pro-
duces this clotting factor. The significance of vitamin
K or of this related factor of Quick in the hemorrhagic
tendencies of man has not been established.

VITAMIN P

Szent-Gyorgy, Rusznyak and Armentano in Germany
report a permeability vitamin which they temporarily call
vitamin P or citrin.

Chemistry

A diglucoside of a substance of the fiavone group.

Formula: Cl»sH:!s-:hsOi

It is hardly soluble in water or alcohol, but dissolves
ir> alkali.

Vitamin P — has been isolated from orange juice, but
is not cevitamic acid.

Action

This new principle seems to improve the symptoms of
guinea pigs on a scorbutogenic diet, but more studies
must be made on the vitamin character of the fiavone.
If the vitamin character can be proved, it would indicate
that the flavones, so important for the cellular metab-
olism of plants, have also a definite function in the hu-
man cell. The effects of the fiavone on human capil-
laries were studied, showing that it cures vascular pur-
pura. It is practically ineffective, however, in the throm-
bocytopenic forms of purpura. The citrin inhibits the
capillary permeability to proteins in many of the cases.

544

THE JOURNAL-LANCET

Natural Sources

In fruit juices and vegetables in association with cevi-
tamic acid.

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Represents the
MINNESOTA, NORTH DAKOTA,

;et

Medical Profession of

SOUTH DAKOTA and MONTANA

North Dakota State Medical Association
South Dakota State Medical Association
Medical Association of Montana

The Official Journal of the

The Minnesota Academy of Medicine
The Sioux Valley Medical Association

Great Northern Railway Surgeons’ Assn
American Student Health Association
Minneapolis Clinical Club

EDITORIAL BOARD

Dr. J. A. Myers Chairman, Board of Editors

Dr. A. W. Skelsey, Dr. C. E. Sherwood, Dr. Thomas L. Hawkins - Associate Editors

BOARD OF EDITORS

Dr. A. S. Rider
Dr. T. F. Riggs
Dr. J. C. Shirley
Dr. E. J. Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. D. F. Smiley

Dr. J. A. Evert

Dr. J. O. Arnson
Dr. Ruth E. Boynton
Dr. J . F. D. Cook
Dr. Frank I. Darrow
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis

Dr. W. A. Fansler
Dr. H. E. French
Dr. W. A. Gerrish
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. S. M. Hohf

Dr. A. Karsted
Dr. H. D. Lees
Dr. J. C. McGregor
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger

W. A. Jones, M.D., 1859-1931

LANCET PUBLISHING CO., Publishers

84 South Tenth Street, Minneapolis, Minnesota

Dr. C. A. Stewart
Dr. J. L. Stewart
Dr. E. L. Tuohy
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary

W. L. Klein, 1851-193!

Minneapolis, Minn., December, 1937

THE DOCTOR AND THE PRESS

A penetrating and even-keeled editorial "Better speak
up soon" appeared in the Cedar Rapids, Iowa, Gazette,
November 4, 1937:

"While the doctors inveigh against socialized medicine
in their own ethical but inarticulate way, the politicians
at Washington appear to be listening more and more
cordially to widespread popular demands that the social
security laws be expanded to make room for health in-
surance. Some of them say they don’t know why this
wasn’t done in the first place. It seems a virtual certainty
that Congress this winter will be asked to consider some
form of health insurance which, if not socialized medi-
cine in itself, is surely a step in that direction.

"For that matter, tax-supported medical service already
is a part of the More Abundant Life. The federal home
loan bank board set aside $20,000 to help 2,000 em-
ployees establish and maintain a clinic this year as an
experiment. If the board likes the results, the experi-
ment doubtless will be continued from year to year.

"Yet notwithstanding this unmistakable trend toward
state medicine in this country as a bulwark to a system
of health insurance, the theoretical arguments against
such a setup remain as strong as ever. An article in the
current issue of Nation’s Business cites some things about
health insurance that should have wider circulation.

'With dues paid and a doctor handy,’ the article
says, 'overdoctoring results. Pretenders and hypochon-
driacs are bred. Advertising for certain remedies creates

a medicine craze. A few years ago it was revealed in
Germany that four times as much money was used for
35,000,000 persons in insurance as for 30,000,000 un-
insured. ... In Germany in 1930 there were 36,000
panel doctors and 32,000 bureaucrats directing the doc-
tors. In 1936 there were 32,000 doctors and 36,000
bureaucrats. . . .

'England has hundreds of medical 'Approved So-
cieties’ with some 5,000 branches. ... It was assumed
that the panel doctors in these societies would detect
disease in its early stages and thereby reduce the tre-
mendous financial loss to workers from illness. A sur-
vey revealed that, in 1933, the loss through sickness had
increased to 12114 days per worker from nine before
health insurance. The record in Germany was much
worse. In fifty years of the system there the annual loss
from sickness increased from 5/4 days to 28. In the
United States the loss has remained the same, 6 1 4 days,
for twenty-five years.’

"Information like this confirms the belief of many
thoughtful citizens that socialized medicine would never
be all it is cracked up to be. It does not, however, blind
those same citizens to the indisputable fact that the pres-
ent prevailing system of medical service falls considerably
short of the ideal. The loss from illness, in time and
money alone, is altogether too large, considering that
the technical knowledge and skill to prevent it are
available.

546

THE JOURNAL-LANCET

"Something could he done to organize that knowledge
and skill on a more effective basis. Millions of laymen
realize something needs to be done, but they don't know
what. They are eager to listen to anyone who professes
to know what should be done. Just now the socialistic
reformers are doing the loudest, if not the most logical
talking — and they are making quite an impression.

"If medical men hope to counteract the plausible ar-
guments of these soothsayers, it behooves the medical
men to make a noise somewhere besides in their society
meetings and their technical journals. Abandonment of
some of the traditional aloofness of the profession will
be necessary, but that may be the lesser of the evils the
profession faces."

Every point which this editorial makes is pertinent to
the average doctor in particular as well as to the med-
ical profession in general. Medical men all too often
have confined their activities and writings to their own
society meetings and medical journals and have failed
to take their part in the health education of the public,
with the result that persons without medical education
have gone a long way toward disseminating propaganda
to their liking. For a long time many newspaper editors
have recognized the fact that the best health information
is in possession of the physicians and closely allied
groups. They have been desirous of publishing such
information in the columns of their papers and, thus,
disseminate reliable health education everywhere.

Unfortunately, all too often they have been discour-
aged on the ground that medical ethics did not permit
the use of such information in the newspapers. Medical
ethics attempts to protect the public against the occa-
sional physician whose practice borders on or actually
enters the field of quackery and who seeks undue pub-
licity and misinforms the public. However, medical
ethics should not be so construed as to interfere in any
way with close cooperation between ethical medical men,
their societies, and the newspaper men. The matter of
medical education is probably best handled through duly
elected or appointed committee members of medical
societies, who cooperate to the fullest extent with the
newspaper men of their communities. Most of those
who edit and publish our newspapers desire to print
authenticated news and facts, and no ethical members of
the medical profession should fail to cooperate with
them in every possible way.

J. A. M.

THE MEDICAL PROFESSION AND
ITS DISSENTERS

About the time our profession was recovering from
the onset of the Federal Security Act and its probable
results, and also from the latter broadside from U. S.
Senator Lewis of Illinois as to making us all Federalized,
etc., another cloud has arisen, this time also in the East,
and is spreading throughout the United States, i. e., the
so-called Medical Declaration of Independence, sub-
scribed to by what are claimed to be about four hundred

and thirty of the outstanding physicians and surgeons
of this land. As the last-named document will probably
be fully quoted and commented upon editorially in the
November 27th, 1937, issue of the Journal A. M. A.,
it will not be necessary to repeat here the proposals and
principles of that declaration.

This whole affair of medical practice, especially in
these past years of financial depression, with apparently
no real relief in sight for some several years at least,
is one that requires serious consideration. Already, in
rebuttal to the Declaration we are receiving protests
against it; one of the communications states positively
that some of the signers of said document admit that
they signed hastily, "by request,” and without seeing
the threats of political domination and abuse that lie
beneath the pleasing surface proposal of governmental
support. According to telegrams this week the national
Board of Trustees of the A. M. A., in special session,
state that they are not in full accord with the newly-
formed group of dissenters to the national A. M. A.
policy.

We must realize changed conditions, and how they
affect us, and the methods adopted by the political party
in power the past several years. It might have been
that some other political party could have handled the
depression better and not have found it necessary to
spend billions for relief of the unemployed, for the sus-
tenance and the care of the sick, as well as aiming to
devise social security methods that might help the public
at large. But we have had those conditions in extreme
form and apparently the end is not yet. Take the case
of North Dakota and its needs for some several years
past, especially the severe and unusual drouths that
have afflicted that state. There have been many thou-
sands of families made practically homeless due to those
drouths, and we have yet to find any political party able
to dodge extensive drouths, even by liberal use of pork-
barrel funds for irrigation schemes in this part of the
country. Through yearly understandings with the Fed-
eral and State governments the North Dakota medical
profession cooperated, so that by means of a sinking
fund the unfortunate families have been afforded what
is designated as emergency medical, surgical, and obstet-
rical relief; the doctors, the nurses, and the hospitals have
received some moderate financial compensation, which
otherwise never would have come to them.

It’s too late now to discuss the relative merits of re-
ducing by say at least one-half, the number of entering
medical students; too late to have in hand a liberal state
or interstate fund for the relief of indigent physicians;
nor can any one now utter a very dubious prophecy that
North Dakota, especially in the West, will ever come
to its own again with liberal crops. The other states
are having their problems, too. There should be formed
now committees of the conservative and of the liberal
physicians and surgeons, for the serious consideration
of all of our problems. This does NOT necessarily
mean State or Governmental Medicine.

A. W. S.

THE JOURNAL-LANCET

547

APPORTIONMENT OF SPECIALISTS

Will supply and demand take care of the matter, or
must we eventually have some regulatory arrangement
to limit and distribute medical specialists in proportion
to other members of the profession and according to
the needs of the population in general?

There has been so much sentimental gush about the
gradual disappearance of the old-time family physician
that even he feels that it has been overdone. At any
rate, it is high time for us to consider the problems of
the specialist who cannot with good grace decry these
panegvrics. He is dependent upon the general prac-
titioner in some measure for referred work. If the
ratio of the specialist to the general practitioner con-
tinues to increase, it will not be long before the lucrative
fees, that have no doubt attracted many, will be reduced
to the level of that of the general practitioner. Every-
one knows that it is impractical for a specialist to change
his field when it is overcrowded, and it is an embar-
rassing admission of failure to return to general work.

A. E.

WILLIAM C. PORTMANN, M.D
1858-1937

Dr. W. C. Portmann, born in Herpertswyle, Switzer-
land, on June 7, 1858, died of cardiac failure near
Jackson, Minnesota, on November 3, 1937. Dr. Port-
mann came to Jackson to practice in 1886, and was a
well-known pioneer physician in Jackson County. Re-
tired from active practice in 1927, Dr. Portmann had
served the Village of Jackson as council member, mayor,
school board president, and Jackson County as coroner.
He was graduated from the Western Reserve University
School of Medicine in 1881. Three sons: Dr. Ursus
V. Portmann, Cleveland, Ohio; Mr. Milton C. Port-
mann, Cleveland; and Mr. Arthur B. Portmann, Cin-
cinnati, survive him. Dr. Portmann was buried beside
his wife, who died in 1921, in Riverside Cemetery in
Jackson.

Hews Item *

Dr. John F. Turner, of Miller, South Dakota, has
removed to Canton to establish practice there. He has
been health officer for Hand County.

Dr. Adlai Alvin Brink, Baudette, Minnesota, has
moved to a new suite in the First National Bank Build-
ing of that town.

Dr. Angus L. Cameron, Minot, North Dakota, spoke
on "Cancer” before the Minot Woman’s Forum on
October 25, 1937.

Dr. Sidney A. Slater, of Worthington, was elected to
the presidency of the Minnesota Public Health Associa-
tion during November.

Dr. Robert Spencer Westaby, Madison, South Dakota,
and Dr. John Clinton Smiley, of Deadwood, attended
the recent congress of the American College of Surgeons
in Chicago, Illinois.

Dr. Paul William Freise, Bismarck, North Dakota,
attended the meeting of the Central Association of Ob-
stetricians and Gynecologists at Dallas, Texas, during
October.

Dr. E. L. Tuohy, of Duluth, Minnesota, presented a
paper, "The Conduct of Medical Staff Conferences,”
before the annual meeting of the American College of
Surgeons at Chicago on October 25, 1937.

Dr. Frank I. Terrill, medical superintendent of the
Montana State Tuberculosis Sanatorium at Galen, spoke
before the Butte Anti-Tuberculosis Society on Novem-
ber 18, 1937.

Dr. Stephen H. Baxter, Minneapolis, a former presi-
dent of the Hennepin County Medical Society, was
elected president of the Hennepin County Tuberculosis
Association on October 28, 1937.

Dr. Robert Bernard Radi, Bismarck, North Dakota,
has been granted a certificate in internal medicine by the
American Board of Internal Medicine. He has prac-
ticed in Bismarck since January 1, 1936.

Dr. Harry G. Irvine, Minneapolis, consultant in
venereal diseases to the University of Minnesota, spoke
on "Social Hygiene” at Carleton College, Northfield,
Minnesota, on October 22, 1937.

Dr. George Warren Setzer, Jr., of Malta, Montana,
attended the recent Congress of the American College
of Surgeons, of which he is an honorary member, in
Chicago, Illinois.

Dr. Russell Henry Brown, health officer for Coding-
ton County, South Dakota, spoke on "Syphilis” before
the Watertown Business & Professional Women’s Club
on October 25, 1937.

Dr. William James Gillesby, of Chicago, a graduate
of the University of Illinois College of Medicine in 1932,
has been named resident surgeon at the Chisholm Hos-
pital, Chisholm, Minnesota.

A 15-bed frame-and-stucco hospital will be erected at
Townsend, Montana, by Dr. Raymond G. Bayles and
an associate. It will have an operating room and lab-
oratories.

Dr. Hamlin Mattson, assistant in surgery in the
University of Minnesota Medical School, was made a
fellow of the American College of Surgeons in October.

Dr. Frederick Henry Dubbe, New Ulm, Minnesota,
has been made a fellow of the American College of
Surgeons.

The Upper Mississippi Valley Medical Society, the
Stearns-Benton County Medical Society, met in Little
Falls, Minnesota, on October 21, 1937. Speakers were
Dr. Waldemar T. Wenner and Dr. Francis John Schatz,
of St. Cloud; and Dr. Earl F. Jamieson and Dr. Lloyd
F. Hawkinson, of Brainerd.

548

THE JOURNAL-LANCET

Dr. Herbert Z. Giffin, professor of medicine in the
University of Minnesota Graduate School of Medicine,
was elected president of the staff of the Mayo Clinic,
Rochester, on November 15, 1937.

Codington County in South Dakota will have a full-
time physician and a hospital after January 1938, ac-
cording to assertions made recently by the board of
county commissioners.

According to the Mandan Pioneer, Dr. Arthur Con-
well Fortney and Dr. Verl Gideon Borland of Fargo,
North Dakota, will serve on the staff of the North
Dakota Agricultural College Students’ Health Service.

Dr. Elmer Oscar Steeves, 60, of Rugby, North Da-
kota, died on November 19, 1937, at his home. He
was graduated from the McGill University Faculty of
Medicine, Montreal, Canada, in 1901.

The Lyon-Lincoln Counties Medical Society held a
dinner meeting in the New Atlantic Hotel at Marshall.
Minnesota, on October 19, 1937. Mr. Arthur P. Dun-
nigan, bacteriologist for the Minnesota State Board of
Health, Minneapolis, spoke on "Typing Pneumonia.”

Dr. George Clarke Foster, a graduate of the North-
western University Medical School in 1929, has been
awarded the certificate of the American Board of Oph-
thalmology. Dr. Fester is a member of the Fargo
Clinic, Fargo, North Dakota.

Dr. and Mrs. Raymond B. Allen, Detroit, Michigan,
visited Dr. and Mrs. Angus Laverne Cameron at Minot,
North Dakota, recently. Dr. Allen, a former member
of the Northwest Clinic in Minot, is now dean of the
Wayne University College of Medicine in Detroit.

Dr. James Kerr Anderson, Minneapolis, instructor in
surgery in the LJniversity of Minnesota Medical School,
spoke before the Southwestern Minnesota Medical As-
sociation at Worthington on November 16, on "The In-
jection Treatment of Hemorrhoids.”

The treatment of dementia praecox by insulin injec-
tions has been inaugurated at the South Dakota State
Hospital for the Insane at Yankton, according to Dr.
George Sheldon Adams, superintendent. Dr. Frank
William Haas is in charge of the treatments; and Dr.
Ina Louise Moore-Freshour, senior physician, will also
assist when she returns from a six-weeks’ course at
Rochester, Minnesota.

Dr. Arlie R. Barnes, Rochester, professor of medicine
in the University of Minnesota Graduate School of
Medicine, spoke before the Southwest Medical Associa-
tion at Phoenix, Arizona, on November 19, 1937, on
the cardiac diseases.

Mr. R. F. Cranston, chairman of the Fergus County
Board of Commissioners in Montana, announces that
on December 9, 1937, in the Court House at Lewistown,
the board will open bids submitted by physicians wish-
ing to act as Fergus County physician for 1938. Duties
will comprise treatment of the sick, poor and infirm
of the county, and also of the inmates of the county jail.
The county physician must also furnish all medicines.

Dr. Alexander James Rudolf, Milwaukee, Wisccnisn,
who practiced in Waseca, Minnesota, for 10 years pre-
ceding the World War, died at Washington, D. C., on
October 5, 1937, of a heart attack. He was graduated
from Northwestern University Medical School in 1901.

An $8,000 addition to the former Burns and Christen-
sen Hospital at Two Harbors, Minnesota, has been an-
nounced for bidding. Present owners are Dr. Edward
P. Christensen of Two Harbors, and Dr. Edward E.
Webber, of Duluth.

Dr. Charles Lewis Sherman, of Luverne, Minnesota,
was elected president of the Southwestern Minnesota
Medical Association at Worthington on November 16,
1937. This association comprises Nobles, Jackson, Rock,
Pipestone, Murray, and Cottonwood Counties.

Dr. William A. O’Brien, associate professor of path-
ology and preventive medicine in the University of
Minnesota Medical School, Minneapolis, spoke before
the Kiwanis Club of Willmar, Minnesota, on November
23, 1937.

Harry Luther Day, Ph.B., M.D., a diplomate of the
National Board of Medical Examiners, and a resident
of Peterborough, New Hampshire, has been named
assistant editor of the publications of the Mayo Clinic
in Rochester, Minnesota.

Dr. Olaf Jenson Hagen, Moorhead, Minnesota, chair-
man of the executive committee of the National Gov-
erning Boards of State Universities and Allied Institu-
tions, attended the annual session of that association at
Amherst, Massachusetts, on October 13, 14 and 15, 1937.

Dr. Henry Edward Binet, of Grand Rapids, Minne-
sota, a graduate of the Northwestern University Med-
ical School in 1916, became a fellow of the American
College of Surgeons at the recent clinical congress in
Chicago.

Dr. Paul A. O’Leary, professor of dermatology in the
University of Minnesota Graduate School of Medicine,
Rochester, spoke before the Fort Wayne Medical So-
ciety in Indiana on November 2, 1937; and before the
Wisconsin State Dental Society at Madison on Novem-
ber 4.

Dr. Richard Charles Monahan, of Butte, Montana,
spoke on "Diseases of the Lungs” at the Butte High
School on November 11, and repeated it on November
18. The talk was sponsored by the Silver Bow County
Medical Society and the bureau of safety of the Ana-
conda Copper Mining Company of Butte.

Dr. Martin L. Mayland, 69, of Faribault, Minnesota,
for 44 years a practicing physician and for the past six
years coroner of Rice County, died on November 16 at
the Worrall Hospital in Rochester. He was graduated
from the University of Minnesota Medical School in
1892.

Dr. Clarence Melvin Peterson, 52, Sisseton, South
Dakota, died at Webster during October. A graduate
of the old Drake University College of Medicine in
1913, Dr. Peterson had practiced at Sisseton for 24
years.

THE JOURNAL-LANCET

549

Dr. Paul Ittkin, of Tolley, North Dakota, a graduate
of the McGill University Faculty of Medicine, Mon-
treal, in 1933, has agreed to visit Sherwood, North Da-
kota, each Wednesday until a regular physician can be
obtained for that town. Sherwood has not had a resi-
dent physician for some time.

Dr. James Donnell Weir, 73, of Brown’s Valley,
Minnesota, died at New York Mills on October 21,
1937. A graduate of the Trinity University Faculty of
Medicine, Toronto, Canada, in 1896, Dr. Weir had
retired from practice at Brown’s Valley, and was resid-
ing with his daughter at the time of his death.

Dr. William Leonard Renick, 68, of Long Beach,
California, a graduate of the University of Louisville
School of Medicine in 1892, died at Long Beach on
October 22, 1937. For some years he lived in Butte,
Montana, and was until 1930 a director of the Miners’
Savings Bank and Trust Company in Butte.

At the regular monthly meeting of the Miller Voca-
tional Hospital Alumnae Association in Minneapolis on
November 2, Miss Katharine E. Dougherty, R.N., in
charge of venereal diseases for the Minneapolis Depart-
ment of Health, spoke on "Syphilis and Its Control.”
It is announced that Dr. Rudolph C. O. Logefeil, Min-
neapolis, will speak on "Gastro-Intestinal Diseases” at
the next regular meeting on December 7, 1937.

Dr. Eugene Peyton Cockrell, a graduate of the Wash-
ington University School of Medicine in 1906, was
elected chief-of-staff of the Kalispell General Hospital,
Kalispell, Montana, on October 14, 1937. Dr. J. Arthur
Lamb was chosen vice-president; and Dr. Morris Wayne
Bottorf became secretary-treasurer. The new executive
committee has these members: Dr. Albert Brassett, and
Dr. Fayette Boyson Ross. Dr. Phoebe A. Bottorf and
Dr. Tom Benjamin Moore comprise the committee on
medical records.

Dr. Paul P. Ewald, Dr. Vernard R. Hodges, Dr. Nel-
son Wells Stewart, and Dr. Henry Everett Davidson,
all of Lead, South Dakota; and Dr. Fr Stewart
Howe, of Deadwood, have been designated as a tempo-
rary committee to arrange for the use of the new res-
pirator purchased by people of the Black Hills region
of the state. The respirator, expected to be delivered
on December 16, will be placed in Lead.

Dr. Oswald S. Wyatt, assistant professor of surgery
in the University of Minnesota Medical School, Minne-
apolis, and Dr. Robert L. Wilder, instructor in pediatrics
in the University of Minnesota Graduate School of
Medicine at Rochester, spoke before the Camp Release
District Medical Society at Dawson, Minnesota, on
October 28, 1937.

Dr. Walter A. Fansler, Minneapolis, associate clin-
ical professor of surgery in the University of Minne-
sota Medical School, spoke before the Lyon-Lincoln
County Medical Society at Marshall, Minnesota, on
November 16, on "Abscess and Fistula”; and before
the Hennepin County Medical Society in Minneapolis
on November 3, on "The Choice of Operation for
Cancer of the Large Bowel.”

Dr. Andrew Ekern, 72, who practiced medicine in
Grand Forks and Hatton, North Dakota, from 1887
until 1905, died at San Diego, California, on October
29, 1937. He was graduated from Rush Medical College
in Chicago in 1887, and had been imminent commander
of the Knights Templar of North Dakota, as well as
worshipful master of Acacia Lodge in Grand Forks.

The Minnesota State Medical Association’s broad-
cast for December over Station WCCO (810 kilocycles
or 370.2 meters) every Saturday at 9:45 A. M., are as
follows: December 4, "Nasal Obstruction”; December
11, "Typhoid Fever”; and December 18, "Tuberculosis.”
Dr. William A. O’Brien, associate professor of pathology
and preventive medicine in the University of Minnesota
Medical School, is the speaker.

Dr. John Franklin Walker, 64, of Lemmon, South
Dakota, died on October 29, 1937, in an Aberdeen hos-
pital. A graduate of the University of Minnesota Med-
ical School in 1908, Dr. Walker had been health officer
for Perkins County, and had served as president of the
Lemmon Board of Education. He came to Lemmon in
1928, having previously located at Bison in 1910.

Three sectional postgraduate medical meetings spon-
sored by the Medical Association of Montana were held
during November. The first was held at Billings on
November 8 and 9; the second at Anaconda on No-
vember 10 and 11; and the third at Havre on November
12 and 13. Speakers were Dr. Henry E. Michelson,
professor of dermatology in the University of Minne-
sota; Dr. M. G. Peterman, professor of pediatrics in
Marquette University, Milwaukee; and Dr. M. Edwards
Davis, associate professor of obstetrics and gynecology
in the University of Chicago Medical School.

Dr. E. A. Meyerding, executive secretary of the Min-
nesota Public Health Association, and secretary of the
Minnesota State Medical Association, was honored at
a banquet held for him at the Lowry Hotel in St. Paul
on November 11. Speakers included Dr. J. A. Myers,
Minneapolis, president of the National Tuberculosis
Association, Dr. A. W. Adson, Rochester, president of
the Minnesota State Medical Association, Dr. O. J.
Hagen, Moorhead, retiring president of the Minnesota
Public Health Association, and Dr. C. B. Wright, Min-
neapolis, a trustee of the American Medical Associa-
tion.

On September 30, 1937, Dr. J. Arthur Myers, pro-
fessor of medicine in the University of Minnesota Med-
ical School, spoke before the student body of the Med-
ical College of Virginia at Richmond; on October 13, he
participated in a postgraduate course for physicians at
Oklahoma City; and on October 22, he discussed "The
Treatment of Tuberculosis from the Rehabilitation Point
of View” before the New Jersey Tuberculosis League
at New Brunswick. On November 3, Dr. Myers spoke
before the Johnson County Medical Society at Oakdale,
Iowa, and the student body of the University of Iowa
College of Medicine at Iowa City; and on November
22, he spoke before the District of Columbia Tuber-
culosis Association in Washington.

550

THE JOURNAL-LANCET

Book Hoiiccs

A NORTHWEST DOCTOR’S ODYSSEY
Tramping to Failure: An Autobiography, by Thomas
Hall Shastid, A.M., M.D., LL.B., Sc.D., F.A.C.S.. F.
A.C.P.; 1st edition, red cloth, black-stamped and library label
on cover, 497 pages plus index, many illustrations; Ann Ar-
bor, Michigan: George Wahr: 1937. Price, #4.00 (rag

paper edition, #5.00).

Dr. Shastid's name last appeared in this book section in
September 1936, when Dr. Conrad Beren’s text, The Eye and
Us Diseases, was reviewed by Professor Kenneth A. Phelps.
Dr. Shastid had contributed to that excellent volume. T ramp-
ing to Failure is entirely the work of Dr. Shastid, who lives in
Duluth. It abounds with sharp satire and occasional flashes
of untempered sarcasm; but this is equibalanced by its shrewd
kindliness of tone and its sturdy Midwestern common sense.
The author, widely travelled and superbly educated, years ago
made pleas for corrections of abuses in medical practice and
ethics, abuses which today would not be tolerated by any con-
scientious practitioner. He was roundly cursed for his pains at
the time. The Journal-Lancet recommends this interesting
autobiography.

ENGLISH PEDIATRICS

Diseases of Childhood, by Robert S. Frew, M.D.: 1st edi-
tion, heavy red buckram, gold-stamped, 641 pages plus index,
illustrated; London, England: The Macmillan Company:

1936. Price, #11.00.

Dr. Frew, who is physician to the Hospital for Sick Children
in Great Ormond Street, London, has partitioned his work into
3 parts: the 1st dealing with the period from birth to one
month; the 2nd concerning one month to six months: and
the 3rd part considering the period from six months to
one year. Many diseases appear in two or all grouos; but the
changes in their character (since these diseases definitely vary
according to the age-levels) are pointed out. This work is the
more valuable because of the space given to diseases of ante-
natal origin; and because of its treatment of the physiology
of the embryo. Dr. Frew gives few references; and he advo-
cates changing the cow’s milk formula about 12 times before
the infant reaches the 18-pound mark. Yet this is a very val-
uable work to the student and practitioner; Dr. Frew has an
admirable style, smooth and flowing, making the work a
pleasure to consult. There is a fine index.

SPECIALIST’S VOLUME

Agnosia, Apraxia, Aphasia: Their Value in Cerebral

Localization, by J. M. Nielsen. B.S.. M.D., with the assist-
ance of J. P. Fitz Gibbon, A.B., M.D.; 1st edition, blue
cloth, gold-stamped, 201 pages plus bibliography, no index,
29 illustrations; Los Angeles. California: The Los Angeles
Neurological Society (Room 1253, 727 West Seventh Street):
1936. Price, #3.00.

This book has as its basis the clinical study of 240 cases, with
25 necropsies, 13 surgical verifications, and two roentgenological
corroborations.

The volume has an excellent historical survey of the field,
and good sections on eugnosia, eunraxia, euphrasia; and the
agnosias, apraxias, aphasias, etc. There is a sound section on
methods of examining the patient. Part III, which contains
an alphabetical list of symptoms with synonyms, annotations,
etc., is especially valuable.

Dr. NtELSEN is associate clinical professor of medicine (neur-
ology) in the University of Southern California Medical School;
Dr. Fitz Gibbon is resident in neurology in the Los Angeles
County Hospital. The Journal-Lancet is pleased to com-
mend this work.

SPEECH DISORDERS

The Rehabilitation of Speech, by Robert West, Ph.D.,
Lou Kennedy, Ph.D., and Anna Carr, M.A.; 1st edition,
tan cloth, gold-stamped, 14 plates, 28 figures, 373 pages plus
appendices, bibliography St index; New York: Harper &
Brothers: 1937. Price, #4.00.

Psychologists are accomplishing amazing results these days
in corrective work for persons afflicted with speech disorders,
and it behooves the physician to know what methods and
technics are being used. This book offers such explanation, and
may be read with much profit by nearly every physician. Dr.
West is professor of speech pathology in the University of
Wisconsin; Dr. Kennedy is associate professor of speech in
Brooklyn College, New York; and Miss Carr is clinical advisor
in speech at the Wisconsin State Teachers College in Mil-
waukee. Though non-medical, this work can be recommended.

AN ELEMENTARY PHYSIOLOGY-ANATOMY
TEXT

Physiology 8C Anatomy, by Esther M. Greisheimer, B.S.
(in education), Ph.D., M.D., third edition, revised, red
cloth, gold-stamped, 424 illustrations (48 in color), 637 pages
plus glossary and index; Plvladelphia: The J. B. Lippincott
Company: 1937. Price, #3.00.

Professor Greisheimer has written a text which is not in-
tended for students of medicine. It is rather a book for the
use of nursing students, medical technicians, hospital superin-
tendents, etc. It is well-written and organized, and is as com-
plete as one might judge, for the purpose to which it will be
put. The illustrations are acceptable, and many of them are
in color. Dr. Greisheimer formerly was an associate professor
of physiology in the University of Minnesota at Minneapolis;
she is now professor of physiology in the Woman’s Medical
College of Philadelphia.

PFTYSIOLOGIST’S EXPLANATION

Why We Do It, by Edward C. Mason, M.D.; 1st edition,
dark brown cloth, stamped in gold, 177 pages, no index, no
illustrations; Saint Louis, Missouri: The C. V. Mosby Com-
pany: 1937. Price, #1.50.

For a summary of a subject which is responsible for piles
and piles of literature — Why We Do It is a good job. The
author has applied the first principle of good writing: he has
learned the trick of omission. He discusses briefly but succinctly
the three fundamental motivations of human behavior, sex,
herd and ego interests. He emphasizes the importance of the
endocrinal and sympathetic systems in the production of the
total personality. The two chapters on sex are sane and useful.
The chapter on treatment is a brief review of the technics of
psycho-therapy which are in vogue today.

The author is professor of physiology in the University of
Oklahoma School of Medicine at Oklahoma City.

NEW EDITION OF MENNINGER
The Human Mind, by Karl A. Menninger, M.D.; 2nd edi-
tion, revised, heavy cloth, stamped in silver. 520 pages, illus-
trated; New York: Alfred A. Knopf, Inc.: 1937. Price, #5.00.

The interesting quality of this famous book, as Smith Ely
Jelliffe has pointed out, is that it is fully as scientific as if
it had been written in the stilted nomenclature of the prac-
ticing psychiatrist. This edition represents several changes in
Menninger’s attitude. He introduces a new conception of
suicide. He includes many divergent modern views on heredity
and environment in relation to personality formation. He does,
moreover, present suggestions as to the practical applications of
psychiatry in general practice. This is a beautiful book, and
is recommended by The Journal -Lancet without qualification
There is an especially good bibliography.

The author is chief -of-staff of the Menninger Clinic in
Topeka, Kansas.

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