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JournaMiancet
INDEX TO
VOLUME LXIII
New Series
January 1943 - December 1943
The Official Journal of the
North Dakota State Medical Association
South Dakota State Medical Association
Montana State Medical Association
Sioux Valley Medical Association
Great Northern Railway Surgeons’ Association
Minneapolis Academy of Medicine
North Dakota Society of Obstetrics and Gynecology
American Student Health Association
Lancet Publishing Co., Publishers
Minneapolis, Minn.
1943
INDEX OF AUTHORS
Si
A
Adams, John M.
Pneumonia in Infancy 121
Adson, Alfred W.
The Doctor of Medicine and His Responsibility 92
Alway, Robert, and Platou, Erling S.
Acute Bacterial Meningitis 125
Armstrong, W. D., and Knutson, J. W.
The Problems and Control of Dental Caries in Children 142
Arzt, Philip K. (Lieutenant, M.C.)
Neuropsychiatric Emergencies 409
B
Baker, A. B.
Guillain-Barre’s Disease (Encephalo-myelo-radiculitis) ,
A Review of 33 Cases 384
Baker, A. B., Hathaway, S. R., and Schiele, B. C.
The Minnesota Multiphasic Personality Inventory 292
Baker, George E.
Rocky Mountain Spotted Fever .... 207
Bell, Margaret, and Healey, Claire E.
Health Trends in University of Michigan Women
Students - — 172
Blain, Daniel, and Powdermaker, Florence
Convoy Fatigue and Traumatic War Neuroses
in Seamen 402
Blegen, H. M.
Wounds of the Heart 1
Boehrer, John J.
Nutrition Problems among College Students 40
Borden, Daniel L. (Colonel, M.C.)
War Wounds of the Abdomen ._ — 213
Borland, V. G.
Emergency Treatment of Lacerations 8
Burns, H. A.
An Analysis of 149 Tuberculosis Deaths During
1940-41 - 113
C
Caldwell, Hayes W., and Rosenow, Edward C.
Epidemic Encephalitis in North Dakota and Minnesota
1941 247
Carley, Walter A.
Differentiation of Functional and Organic
Neuropsychiatric Conditions — — — 415
Carlson, A. J.
The Growth of Scientific Knowledge on the
Vitamin Needs of Man 371
Christianson, Harry W.
Relief of Colonic Obstruction 21
Clarke, Eric K., and Jensen, Reynold A.
Old Problems in New Settings 129
Collins, L. L.
The Tuberculin Test in Tuberculosis Control 90
Const ans, G. M.
Glaucoma and the General Practitioner 35
Cox, S. L.
The Importance of Preventive Measures in the
Tuberculosis Program 88
Crawford, Rena, and Stewart, C. A.
Gastric Ulceration Complicating Erythroblastosis
Fetalis _. 131
D
Dam, Henrik
Medical Aspects of Vitamin K 353
Dennis, Clarence
Experience with Hematogenous Osteomyelitis
in Children 134
Dunlap, Lawrence G.
Safety in Cataract Extraction .... 170
E
Edwards, H. R.
The Examination of Rejectees 104
Ehrenberg, Claude J., and Haugen, John A. (Lt. Com.)
Induction and Stimulation of Labor with Ergot 290
Elvehjem, C. A.
Newer Members of the Vitamin B Complex 339
Emerson, Kendall
Tuberculosis — Post-War 87
F
Fleet, Joel, Pizzalato, Philip, and Sako, Wallace
Chronic Constrictive Pericarditis 147
Foard, Fred T.
The Medical Aspects of Civilian Defense 316
Foster, Geo. C.
Structive Surgery as Carried on in North Dakota 62
Fox, F. W.
Ascorbic Acid Intake and the Appearance of
Vitamin C Deficiency 349
G
Gellhorn, E.
Studies on Conditioned Reactions and their
Clinical Implications 307
Godwin, Julius G.
Dental Caries in the Expectant Mother 67
H
Hansen, Arild E.
Responsibilities of the Physician in the Problem of
Rheumatic Fever in Children 138
Hathaway, S. R., Schiele, B. C., and Baker, A. B.
The Minnesota Multiphasic Personality Inventory 292
Haugen, John A. (Lt. Com.), and Ehrenberg, Claude J.
Induction and Stimulation of Labor with Ergot 290
Healey, Claire E., and Bell, Margaret
Health Trends in University of Michigan Women
Students 172
Heersema, Philip H.
Employment of Mental Hygiene Principles in
Improved Selection of Armed Forces 405
Henschel, Austin F.
Vitamins and Physical Performance 355
Hill, Frank J.
Report on Health Achievements in North Dakota 53
Himler, Leonard E., and Raphael, Theophile
Complaint and Situation in College Health Work 182
Holt, L. Emmett, Jr., and Najjar, Victor A.
Clinical Diagnosis of Deficiencies of Thiamine,
Riboflavin and Niacin 366
J
Jensen, Reynold A., and Clarke, Eric K.
Old Problems in New Settings
129
K
Kamman, Gordon R.
The Depressed Patient 11
Kelly, LeMoyne Copeland
Psoriasis of the Nails Producing an
Arthritis-like Picture 19
Keys, Ancel
Introduction to the Symposium on Vitamins .... 338
Knutson, J. W., and Armstrong, W. D.
The Problems and Control of Dental Caries in Children 142
Koons, Melvin E.
Syphilis Serology in North Dakota 177
L
LaVake, R. T.
The Cause of Toxemias of Pregnancy 51
Lees, H. D.
Tuberculosis among College Students 98
Legge, Robert T.
Fifty Years of Students’ Health Work 16
December, 1943
■427-
Lemley, Ray E. (Captain, M.C.)
Observations on Selenium Poisoning in South and
North America — 257
Levinthal, Daniel H., and Logan, Catherine E.
The Orthopedic and Medical Management of Arthritis . 48
Logan, Catherine E., and Levinthal, Daniel H.
The Orthopedic and Medical Management of Arthritis 48
Lotz, Oscar
Don’t Give Up the Tuberculin Test 96
Lowry, Thomas
Bronchial Adenoma — 324
Lyght, Charles Everard
Tuberculosis on a Typical College Campus 108
M
Marshall, Wallace
Persistent Cough Produced by Ascariasis 72
Maxeiner, Stanley R.
Cholecyst electrocoagulectomy (Thorek) 328
'McKinlay, C. A.
Coronary Insufficiency Precipitated by Hemorrhage
from Duodenal Ulcer 3 1
Variable Pulmonary Infiltration Associated with
Boeck’s Sarcoid 185
McKinley, J. C.
Psychiatric Problem in War and Peace 383
Mickelsen, Olaf
Laboratory Methods of Evaluating Vitamin
Nutritional Status _ 360
N
Najjar, Victor A., and Holt, L. Emmett, Jr.
Clinical Diagnosis of Deficiencies of Thiamine,
Riboflavin and Niacin 366
Nessa, N. J.
Address of the President, South Dakota State
Medical Association 202
Nydahl, Malvin J.
A Report on the Heart Program of the Bureau
for Crippled Children Medical Unit 297
o
Office of War Information
Navy Doctors and Hospital Ships 265
P
Peterson, R. F.
Practical Problems in Blood Grouping and
Blood Transfusion 215
Phelps, Kenneth A.
Luxation and Avulsion of the Eye Ball . 329
Pizzalato, Philip, Sako, Wallace, and Fleet, Joel
Chronic Constrictive Pericarditis 147
Platou, E. S.
The Medical Aspects of Dental Health in Childhood 22
Platou, Erling S., and Alway, Robert
Acute Bacterial Meningitis 125
Powdermaker, Florence, and Blain, Daniel
Convoy Fatigue and Traumatic War Neuroses
in Seamen 402
R
Raphael, Theophile, and Himler, Leonard E.
Complaint and Situation in College Health Work 182
Richards, W. G.
War and Peace Neuroses 398
Ritchey, J. P.
Address of the President, Montana State
Medical Association 280
Remarks on Senate Bill 1161 3 15
Rosenow, Edward C., and Caldwell, Hayes W.
Epidemic Encephalitis in North Dakota and Minnesota
1941 247
S
Sako, Wallace, Fleet, Joel, and Pizzalato, Philip
Chronic Constrictive Pericarditis ...147
Sappington, Edith P.
Emergency Maternity and Infant Care Program 320
Scherer, L. Raymond
The Use of Sulphocyanate in Hypertension 321
Schiele, B. C., Baker, A. B., and Hathaway, S. R.
The Minnesota Multiphasic Personality Inventory 292
Shields, J. C.
Wagner-Murray-Dingell Social Security Plan
S. 1161, H R. 2861 __ 313
Simons, Irving
Neurogenic Bladder: Microcystometry and Treatment 74
Sorenson, A. R.
Presidential Address, North Dakota State
Medical Association 241
Stearns, Genevieve
Vitamin D .. 344
Stewart, C. A., and Crawford, Rena
Gastric Ulceration Complicating Erythroblastosis
Fetalis ... 131
Stoesser, Albert V.
The Early Diagnosis of Poliomyelitis 149
T
Taylor, Henry Longstreet
Climate and Vitamin Requirements 358
Todd, Lucius N.
The Tuberculin Reaction in Medical and
Nursing Students 102
Torres, Francisco E.
Echinococcus Cyst of the Lung ... 95
U
United States War Department Manuscript Board
Securing and Retaining Nursing Service During
the War Crisis _ 259
w
Watson, B. A. (Major, M.C.)
Nutrition Problems of University Students 59
White, S. Marx
The Medical Management of the Patient with
Arterial Hypertension 163
EDITORIALS
Acute Sinusitis in Childhood 156
Child Health and National Strength .... 155
Civilian Defense _ __ 82
Clemency for Inclement Weather 81
Climatic Physiology, Dog Days or Lunacy ... 263
Coroner or Medical Examiner 262
Diagnosis of Tuberculosis ...115
Emergency Maternity and Infant Care in North Dakota 379
How to Prevent Colds ... 379
Intrathoracic Interest 420
Latrinograms in Medicine ___ 24
Looking Ahead 23
Medical Investment in Freedom 190
Medical Meetings in 1943 55
Men Die But Ideals Live On 56
Military Service Opportunity 263
Morale in 1943 23
Neuropsychiatric Advances at the War Front ..... 419
Pediatrics Coming Back 332
Pediatrics in New Orleans 156
Postwar Medicine 189
Pressure and the Press . 333
Psychiatric Problem in War and Peace . 383
Storey, Thomas Andrew __ 420
Sunset Slope, The 303
Tuberculochemotherapy 116
Undulant Fever 302
Virus Pneumonia 220
Vitamins 378
Warrens of Boston, The ... 117
Wartime Psychoneuroses 82
Wassermann Problems 221
World Is Warned on Tuberculosis 333
43fr
Thh Journal-Lancet
North Dakota:
Report on Health Achievements in
Frank J. Hill
Epidemic Encephalitis in, and Minnesota, 1941
Edward C. Rosenow and Hayes W. Caldwell
Syphilis Serology in
Melvin E. Koons
North Dakota State Medical Association:
Alphabetical Roster
District Society Roster
Fifty-sixth annual Session, Transactions of
North Dakota Physicians in Military Service
Presidential Address
A. R. Sorenson
Nursing:
And Medical Students, the Tuberculin Reaction in ..
Lucius N. Todd
Service, Securing and Retaining, During the War Crisis
Nutrition Problems:
Among College Students
John J. Boehrer
Of University Students
B. A. Watson (Major, M.C.)
o
Obstruction, Colonic, Relief of
Harry W. Christianson
Orthopedic and Medical Management of Arthritis, the ...
Daniel H. Levinthal and Catherine E. Logan
Osteomyelitis, Hematogenous, Experience with, in Children
Clarence Dennis
P
Pericarditis, Chronic Constrictive
Wallace Sako, Joel Fleet and Philip Pizzalato
Physical Performance and Vitamins
Austin F. Henschel
Physician, Responsibilities of the, in the Problem of
Rheumatic Fever in Children ..
Arild E. Hansen
Pneumonia in Infancy *
John M. Adams
Poisoning, Selenium, Observations on,
in South and North America
Ray E. Lemley (Captain, M.C.)
Poliomyelitis, the Early Diagnosis of __
Albert V. Stoesser
Pregnancy, the Cause of Toxemias of .
R. T LaVake
Preventive Measures, the Importance of, in the
Tuberculosis Program
S. L. Cox
Problems:
Nutrition, P., of University Students ...
B. A. Watson (Major, M.C.)
And Control of Dental Caries in Children
J. W. Knutson adn W. D. Armstrong
Old, in New Settings
Eric Kent Clarke and Reynold A. Jensen
Blood Transfusion
R. F. Peterson
Psoriasis of the Nails Producing an Arthritis-like Picture
LeMoyne Copeland Kelly
Psychiatric Problem in War and Peace
J. C. McKinley
Pulmonary Infiltration, Variable, Associated with
Boeck’s Sarcoid
C. A. McKinlay
R
Rejectees, the Examination of
H. R. Edwards
Remarks on Senate Bill 1161
J. P. Ritchey
Responsibilities of the Physician in the Problem of
Rheumatic Fever in Children
Arild E. Hansen
Rheumatic Fever in Children, Responsibilities of the
Physician in the Problem of 1 38
Arild E. Hansen
Riboflavin, Niacin, and Thiamine, Clinical Diagnosis
of Deficiencies of 366
L. Emmett Holt, Jr., and Victor A. Najjar
Rocky Mountain Spotted Fever 207
George E. Baker
s
Sarcoid, Boeck’s, Variable Pulmonary Infiltration
Associated with 185
C. A. McKinlay
Seamen, Convoy Fatigue and Traumatic War
Neuroses in 402
Daniel Blain and Florence Powdermaker
Settings, New, Old Problems in _. 129
Erick Kent Clarke and Reynold A. Jensen
Selenium Poisoning, in South and North America,
Observations on 257
Ray E. Lemley (Captain, M.C.)
Senate Bill 1161, Remarks on 315
J. P. Ritchey
Serology, Syphilis, in North Dakota 177
Melvin E. Koons
Situation and Complaint in College Health Work 182
Theophile Raphael and Leonard E. Himler
Social Security Plan, Wagner-Murray-Dingell,
S. 1161, HR. 2861 (Analysis of Bill). 313
J. C. Shields
South and North America, Observations on Selenium
Poisoning in 257
Ray E. Lemley (Captain, M.C.)
South Dakota State Medical Association:
Address of the President 202
N. J. Nessa
Alphabetical Roster 205
Council Meeting, November, 1942, Report of .... 25
District Society Roster 203
Physicians of South Dakota in Armed Forces
of the United States 207
Sixty-second Annual Session, Transactions of the 193
Woman’s Auxiliary 201
Spotted Fever, Rocky Mountain, A Nine Year
Study of Wyoming Cases 207
George E. Baker
Stimulation and Induction of Labor with Ergot 290
Claude J. Ehrenberg and John A. Haugen (Lt. Com.)
Students:
College, Nutrition Problems among 40
John J. Boehrer
College, Tuberculosis among 98
H. D. Lees
Health Work, Fifty Years of 16
Robert T. Legge
Medical and Nursing, The Tuberculin Reaction in ... 102
Lucius N. Todd
University, Nutrition Problems of 59
B. A. Watson (Major)
Women, Health Trends in University of Michigan .172
Margaret Bell and Claire E. Healey
Studies on Conditioned Reactions and their Clinical
Implications 307
E. Gellhorn
Study Courses, Continuation . 28, 161, 58
Structive Surgery, as Carried on in North Dakota 62
George C. Foster
Sulphocyanate, the Use of, in Hypertension 321
L. Raymond Scherer
Surgery, Structive, as Carried on in North Dakota 62
George C. Foster
Syphilis Serology in North Dakota 177
Melvin E. Koons
53
247
177
.245
243
225
247
241
102
259
40
59
.. 21
48
134
147
355
138
.121
257
149
51
88
59
142
129
.215
19
383
185
104
315
138
December, 1943
T
V
Thiamine, Riboflavin and Niacin, Clinical Diagnosis
of Deficiencies of 366
L. Emmett Holt, Jr., and Victor A. Najjar
Toxemias of Pregnancy, the Cause of 51
R. T. LaVake
Transfusion, Practical Problems in Blood T.,
and Blood Grouping — 2 15
R. F. Peterson
Tuberculin:
Reaction, the, in Medical and Nursing Students 102
Lucius N. Todd
Test, Don’t Give Up the 96
Oscar Lotz
Test in Tuberculosis Control — 90
L. L. Collins
Tuberculosis:
Among College Students _ 98
H. D. Lees
Control, the Tuberculin Test in 90
L. L. Collins
Deaths, 149, an Analysis of, During 1940-41 113
H. A. Burns
On a Typical College Campus 108
Charles Everard Lyght
Post-War 87
Kendall Emerson
Program, the Importance of Preventive Measures in the 88
S. L. Cox
u
Ulcer, Duodenal, Coronary Insufficiency Precipitated
by Hemorrhage from 31
C. A. McKinlay
Ulceration, Gastric, Complicating Erythroblastosis Fetalis 131
Rena Crawford and C. A. Stewart
University of Michigan Women Students,
Health Trends in 172
Margaret Bell and Claire E. Healey
Vitamin:
B Complex, Newer Members of the 339
C. A. Elvehjem
C Deficiency, the Appearance of, and Ascorbic
Acid Intake 349
F. W. Fox
D 344
Genevieve Stearns
K, Medical Aspects of 353
Henrik Dam
Needs of Man, the Growth of Scientific Knowledge on 371
A. J. Carlson
Nutritional Status, Laboratory Methods of Evaluating 360
Olaf Mickelsen
Requirements and Climate 358
Henry Longstreet Taylor
Vitamins:
Introduction to the Symposium on .. 338
Ancel Keys
And Physical Performance 355
Austin F. Henschel
w
Wagner-Murray-Dingell Social Security Plan,
S. 1161, HR. 2861 (Analysis of Bill) 313
J. C. Shields
War:
And Peace Neuroses 398
W. G. Richards
Neuroses, Traumatic and Convoy Fatigue, in Seamen 402
Daniel Blain and Florence Powdermaker
Wounds:
Of the Heart 1
H. M. Blegen
War, of the Abdomen . 213
Daniel L. Borden (Colonel, M.C.)
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Wounds of the Heart
A Review of Seventeen Cases ivith Four Operations
H. M. Blegen, M.D.
Missoula, Montana
IN the past ten years there has been a gradually in-
creasing interest in the diagnosis and treatment of
wounds of the heart. Surgeons are becoming heart
conscious. Especially in the southern states, where the
negro population is high, cardiac tamponade from injury
is more frequently being properly diagnosed and treated.
However, in many hospitals the signs and symptoms still
go unrecognized, and the patient presenting himself with
the typical syndrome is often given up as beyond med-
ical aid. It is the purpose of this paper to review briefly
the subject with a study of 17 patients with cardiac in-
jury and to present in detail four of these who were
operated upon, all at St. Joseph Hospital, Lexington,
Kentucky, since 1928.
History1
Early treatment of wounds of the heart consisted of
plugging the wound to prevent hemorrhage and the ap-
plication of leeches and the use of venesection to reduce
the increased venous pressure. Larrey in 1829, when
presented with a man apparently dying from a stab
wound over the heart, passed a catheter into the wound
and drained off "three beakers of wine colored fluid.”
Subsequently he passed a sound and obtained five more
beakers of similar fluid. The patient recovered. Wheth-
er or not Larrey understood the pathological condition
present is not known. However, it is obvious now that
‘From the surgical service of F. W. Rankin and B. F. Robinson.
St. Joseph Hospital, Lexington, Kentucky. Read before the West-
ern Montana Medical society.
he saved this man’s life by relieving the tamponade.
The wound in the heart itself must have been small and
the active bleeding point occluded by thrombosis. Ten
years later Jobert, for the first time, accurately described
the condition which we now speak of as cardiac tam-
ponade.
In 1866 George Fisher presented a comprehensive
monograph on this subject reporting 452 cases of pene-
trating wounds of the heart with a mortality of 90 per
cent. In 1881 Roberts suggested that wounds of the
heart might be sutured, and one year later Block dem-
onstrated the suturing of hearts on rabbits. However,
the medical profession refused to believe that surgery
on the human heart was possible. Even Billroth, a pio-
neer in the realms of gastric surgery, made the state-
ment that any surgeon attempting to suture the living
human heart would lose the respect of his colleagues.
This was the attitude that prevailed until 1896 when
Rehn in Frankfurt, Germany, first successfully operated
upon a 22 year old man, releasing the tamponade and
subsequently suturing the hole in the right ventricle with
three silk sutures.
Since then it is estimated that between 600 and 700
cases have been reported in the literature. Ramsdellls
in 1932 reviewed the literature and collected 428 cases
reported by Rehn, Peck, Poole, Ballance, Smith, and
Warfield. The mortality in these groups varied from
24 to 75 per cent, with an average mortality of 50 per
cent. In 1939 Bigger,0 feeling that many cases were not
2
Thk Journal-Lancet
reported, sent out a questionnaire to members of the
American Association of Thoracic Surgery, The Ameri-
can Surgical Association, and the Southern Surgical As-
sociation and collected 124 cases that had been operated
upon by these men. To this he added 17 cases of his
own. Of these 141 cases the mortality was approximately
50 per cent. In 1940'1 Bigger reported a series of 25
cases operated upon at the Medical College of Virginia
Hospital with nine deaths or a mortality of 36 per cent.
Elkin18 in 1941 again reported his growing series of
38 cases with 16 deaths, a mortality of 42 per cent. In
1938 the mortality on the first 22 cases of this series was
50 per cent. Griswold1'1 in February 1942 reported a
summary of 40 cases seen at Louisville City Hospital.
Thirteen of these died within 20 minutes of admission,
5 were treated conservatively with 1 death, and 22 were
operated upon with 6 deaths. This gives a total mor-
tality of 50 per cent or an exceptionally good operative
mortality of 25 per cent. He and his staff have had only
one death in their last 13 operations. Streider20 and
Singleton19 have likewise reported cases in which recov-
ery occurred after pericardial aspiration alone but they
advise great caution in a conservative regime. Electro-
cardiographic observations have been made by Olim and
Hughes,1' Elkin,11 Griswold1'1 and others.
Much of our present knowledge of cardiac surgery
is due to the exhaustive experimental and clinical studies
of Claude Beck1-2-'1,4 on cardiac physiology, cardiac
suturing, and cardiac resuscitation.
Physiology
Death from penetrating wounds of the heart is due
either to direct hemorrhage or more frequently to the
results of acute cardiac compression as a result of cardiac
tamponade. A sudden accumulation of fluid in the peri-
cardial cavity gives rise to the acute cardiac compression
triad of Beck,2 which consists of, (1) falling arterial
pressure, (2) rising venous pressure, and (3) a small,
quiet heart. All other manifestations of acute cardiac
compression are secondary to this triad. Symptoms are
dependent not on the amount of fluid in the pericardial
sac, but rather on the suddenness of the rise of intra-
pericardial pressure produced by the fluid. A sudden
accumulation of as little as 200 cc. of blood and a pres-
sure of as little as 16 cm. of water may be fatal, whereas
a slow gradual accumulation of as much as 2000 cc. of
fluid and a pressure of 38 cm. of water has been known
to be compatible with life.4 As the intrapericardial pres-
sure rises, the cardiac pulsation becomes restricted. There
follows a decrease in the amount of blood entering the
heart with an associated decrease in the cardiac output,
resulting in a "piling up” of blood on the venous side
of the circulatory bed. This process results in a gen-
eralized anoxemia.
Signs and Symptoms
With an understanding of these principles, the symp-
toms and physical signs are self explanatory. There is a
history of injury occurring shortly before admission to
the hospital, usually a stab wound over the heart or a
gunshot wound of the thorax. There is an interval fol-
lowing injury (during which time blood is accumulat-
ing in the pericardium) in which the patient not un-
commonly continues to fight or possibly to walk a block
or more. Finally he collapses, becomes rather restless,
apprehensive, violent, and finally unconscious. Various
cerebral symptoms may manifest themselves as a result
of cerebral anoxemia. There may be varying amounts
of external bleeding, but at times in the case of a small
stab wound there may be none. Physical examination
reveals usually a picture of profound peripheral vascular
collapse out of proportion to the amount of blood loss.
Unconsciousness may or may not occur. The skin is
cold and moist. The pulse is very weak and feeble. The
blood pressure is low. The neck veins are engorged. The
heart sounds are faint or absent. If death fails to occur
in the first ten or fifteen minutes, there may be a period
of temporary adjustment in which the patient shows
slight improvement. It is in this period when operation
is best performed.
In cases where there is a large rent in the pericardium
and where there is a wide communication into the pleural
cavity or to the outside, the signs and symptoms of tam-
ponade are absent and the patient presents a picture of
profound shock from hemorrhage. In these cases exam-
ination of the lung fields shows the presence of hemo-
thorax or hemopneumothorax and careful auscultation
over the precordium frequently reveals a splashing,
churning sound which is a definite diagnostic sign of
cardiac injury. Cerebral symptoms as a result of pro-
longed anoxemia may produce paralysis, mental confu-
sion, unconsciousness, and death. Mayer11’ in 1936 pre-
sented two cases which show how these cerebral symp-
toms may confuse the diagnosis. The first case is that of
an ice pick wound of the chest. The patient had a con-
tusion of the left orbit and a right sided hemiplegia and
because of the strong evidence of a left cerebral lesion,
operation was delayed eighteen hours. The cardiac tam-
ponade was then relieved surgically but death followed
shortly afterward. Autopsy showed no fracture of the
skull and normal brain tissue. The second case was that
of a cardiac tamponade from a stab wound with a par-
tial paralysis of the right side of the body with marked
mental confusion. Following surgical release of the tam-
ponade, the paralysis gradually cleared up and the pa-
tient returned to work one month later. In both of these
cases the paralysis was due to cerebral anoxemia as the
result of tamponade.
Diagnosis
Usually, the diagnosis is made by careful examination
alone, further diagnostic measures being unnecessary.
However, in questionable cases the diagnosis can be veri-
fied by the use of two simple procedures: (1) Venous
pressure readings; (2) fluoroscopic examinations of the
heart shadow. The tension of the venous system is an
exact measurement of the intrapericardial pressure and
normally this tension is equal to about 8 or 10 cm. of
water. This can be measured easily with a venous ma-
nometer as described by Beck1 or by a spinal manometer,
intravenous needle, and an intravenous saline apparatus.
If the venous pressure is above 15 cm. of water, one can
January, 1943
3
feel highly suspicious of tamponade. The value of flu-
oroscopic examination in borderline cases was first point-
ed out by Bigger' in 1936, who showed that the peri-
cardium pulsations are obliterated and the shadow is
immobile.
Treatment
In direct contrast to primitive methods of therapy —
namely of plugging the stab wound and reducing venous
pressure by leeches and venesection — modern therapy is
aimed at increasing the venous pressure by the intra-
venous administration of fluids and reducing intraperi-
cardial pressure by aspiration or preferably operation.
Permanent relief cannot be obtained until the active
bleeding from the heart muscle or coronary vessels has
been controlled. Therefore, whenever the diagnosis is
suspected, preparation for operation should be made im-
mediately. While the operating room is being set up,
Bigger and Elkin recommend placing the patient in
Trendelenberg position and giving intravenous fluids and
blood if possible. In the most serious cases, pericardial
aspiration performed during this interval of delay may
be a life-saving measure. Seldom does a surgeon meet
with a condition which requires more immediate atten-
tion and where success of the operation is so dependent
upon the efficient cooperation of the hospital personnel.
The value of an alert resident staff, blood bank, and
adequate hospital facilities is paramount.
Recently Singleton, Strieder20, Griswold1'1 and oth-
ers have reported cases in which permanent relief was
obtained from pericardial aspiration alone. In these cases
recovery occurred only because the bleeding wound of
the heart muscle, coronaries, or pericardium had become
occluded by thrombosis. Such conservative procedures
should be performed in the operating room with the pa-
tient under close observation and if repeated venous and
arterial pressure readings show signs of recurring tam-
ponade, operation should be performed immediately.
Occasionally in cases with mild tamponade or in elderly
individuals suspected of having considerable myocardial
degeneration from coronary sclerosis, one is justified in
attempting to relieve the tamponade by aspiration in the
hope of preventing a more radical operation. However,
the immediate dangers of delay make conservative treat-
ment very hazardous.
Bigger1’ divides the cases entering the Medical College
of Virginia Hospitals into four groups:
1. Patients with moderate hemorrhage into the pleural
cavity or to the outside without tamponade. These
cases are treated conservatively even though peri-
cardial injury is proven by the presence of blood
and air in the pericardial sac by fluoroscopy.
2. Patients with mild tamponade who respond to con-
servative treatment. These cases are treated with-
out operation but are observed closely with fre-
quent venous and arterial pressure readings. Op-
eration is performed if the tamponade re-occurs.
It is this group in which conservative treatment is
hazardous.
3. Patients with severe tamponade who fail to re-
spond to conservative treatment. This group re-
quires immediate operative interference.
4. Patients without tamponade but with severe hem-
orrhage into the pleural cavity or to the outside.
These patients usually die on the table, but opera-
tion should be performed anyway with the hope of
saving a few.
Anesthesia
The choice of anesthetic varies with each case. When
the patient is conscious and cooperative, local anesthetic
may be used. In totally unconscious patients, the pro-
cedure may be begun without any anesthesia; however,
following the release of the tamponade, consciousness
will soon return and the patient is apt to be restless,
moving about on the table, and uncooperative at a stage
in the operative procedure that requires a minimum of
difficulty. Positive pressure inhalation anesthesia is often
desirable when there is an injury to the pleura or lung
with a pneumothorax. For these reasons, positive pres-
sure ether or gas inhalation anesthesia is usually pre-
ferred.
Operative Procedure
Various types of incisions have been advocated. What-
ever approach is used it is imperative to obtain adequate
exposure quickly. The median sternotomy of Duval-
Barasti gives good exposure, but is time consuming and
shocking. The Spangara incision gives less exposure but
is frequently used. It consists of a long left intercostal
incision between the two ribs giving best access to the
wound. A T-shaped extension is made along the border
of the sternum through the cartilages of the adjacent
ribs. Elkins12 suggests a transverse incision with resec-
tion of two or more ribs. The unconventional, long,
parasternal incision described in cases one and four be-
low was made rapidly and gave excellent exposure by
easily spreading the entire thoracic cage. For less ex-
perienced cardiac surgeons this incision is very satisfac-
tory in such an emergency. Regardless of the type of
incision the intercostal arteries must be ligated. The
lung and pleura, if not injured, are pushed laterally
exposing the pericardium which presents itself as a
tightly distended pulseless sac. This is opened widely
and the blood is removed. As soon as the pericardial
pressure is relieved, the contractions of the heart increase
in force. The left hand is gently introduced behind the
heart and the organ is lifted so that a traction suture
may be placed through the apex. Using this as a guide,
the wound is sought. Elkin suggests the use of fine
black silk in suturing heart muscle, and advises that the
stitch pass through the muscle but not through the
endocardium. Beck1 found, in experimental studies on
dogs, that wounds of the left ventricle were more diffi-
cult to control with suture than wounds of the right
ventricle. He suggests holding the traction suture be-
tween the middle finger and thumb of the left hand and
placing the index finger over the wound in the heart.
With the right hand as a control, a suture is then placed
on either side of the wound. The index finger is then
withdrawn and the control sutures are crossed and pulled
4
The Journal- Lancet
against each other. This controls the bleeding and allows
the operator to place his permanent sutures. However,
now that blood and plasma are available in blood banks,
one or more transfusions are running and unless the
cardiac laceration is extensive, one usually has time to
place the necessary sutures. Care must be taken not to
injure the coronary vessels. In case of an injury to the
right auricle, one must bear in mind that the sino-
auricular node and the atrioventricular node are located
in the posterior wall of this chamber.
After the wound is sutured, the pericardial cavity is
irrigated with saline solution and closed loosely with in-
terrupted sutures, space being allowed for the escape of
fluid. Elkin10 and Bigger'1 advise not draining the peri-
cardium. Griswold1 1 advises leaving a low opening in
the pericardium so that any postoperative bleeding or
accumulation might drain directly into the mediastinum
or pleural cavity, and, if necessary, later drained by
thoracentesis.
The postoperative care consists of restoration of blood,
administration of oxygen if necessary, and rigid bed rest
for a period of at least three weeks to prevent increase
in the intracardiac pressure and a resultant increase of
tension on the sutures. Blood in the pleural space may
or may not be removed, depending on the degree of
respiratory embarrassment. Morphine should be given
freely. Careful venous and blood pressure readings
should be made frequently so that any recurrence of
tamponade will be detected early. If there is such recur-
rence, pericardial aspiration should be done. Postopera-
tive pericardial effusion is a common occurrence. Big-
ger'1 advises the use of heparin in any case where the
coronary vessels are injured or where the chambers of
the heart are entered.
Death occurring during or immediately following op-
eration is due to hemorrhage, ligation of coronary ves-
sels, or injury to the neuromuscular bundles with the
prolonged cerebral anoxemia. Later complications most
frequently met with are pneumonia, pericardial effusion,
acute purulent pericarditis, empyema, atelectasis, wound
infection, mural thrombosis with pulmonary infarction,
and postoperative psychosis as a result of temporary
cerebral anoxemia.
In the past fourteen years four patients with cardiac
tamponade from penetrating chest wounds have been op-
erated upon at St. Joseph Hospital. The first of these
operations was performed in 1928 by W. O. Bullock0
and reported in the Annals of Surgery in 1936. The
second operation was performed in 1936 and the last two
were performed by the author in 1941. Two of these
four patients recovered, giving an operative mortality of
50 per cent. A review of the hospital records reveals that
during this period, seventeen patients were admitted with
cardiac injury. These patients were divided into four
groups:
No. of Cases Recoveries Deaths
Group I 4 2 2
Patients with cardiac tam-
ponade operated upon.
Group II 5
Patients dying in the emer-
gency room a few minutes
after admission before any
treatment could be given.
Group III 6
Patients with cardiac injury
treated but not operated
upon.
Group IV 2
Patients with cardiac injury
due to non-penetrating body
blows.
Of the entire group, there were fourteen deaths and
three recoveries. Excluding the five patients dying in
the emergency room before treatment could possibly be
given and also excluding one patient in Group IV who
died from causes other than his cardiac injury, the cor-
rected mortality reads: three recoveries and eight deaths
or a mortality of 73%. Had the admitting staff been
"heart conscious,” several patients in Group II and III
might have been saved by early diagnosis and operation.
Group I.
Patients with Stab and Gunshot Wounds of the
Heart with Tamponade Operated Upon
Case No. 1 was a stab wound of the heart with cardiac tam-
opnade, operated upon by H. M. B. with recovery. The pa-
tient, a colored man, age 26, was admitted at 3:50 P. M. on
Feb. 1, 1941, about 15 or 20 minutes after having been stabbed
over the heart. He was unconscious, with pulse imperceptible
and blood pressure unobtainable. The neck veins were markedly
distended, the skin cold and clammy. There was a small stab
wound in the fourth interspace just to the left of the sternum.
A second stab wound was found in the right mid-clavicular
line at the upper border of the liver. The lung fields were clear.
The heart sounds could not be heard. The patient was taken
to the operating room immediately. While on the stretcher he
aroused slightly and began waving his arms and shouting. It
was necessary to give him a few whiffs of ether. A left para-
sternal incision was made down through the skin and sub-
cutaneous tissue. At this point, air was sucked through the
stab wound in the chest wall proper, producing a pneumothorax
on the left side. This perforation was closed with gauze. The
incision was then carried through the second, third, fourth and
fifth costal cartilages. The thoracic cage was spread with a pair
of large, blunt retractors. The pleura contained a stab wound
about the size of the middle finger, but it had not been injured
in making the incision. The distended, pulseless pericardium
was opened widely, releasing a large amount of liquid and clot-
ted blood. The heart was beating very feebly at first, but the
contractions increased in intensity and the rate became slower.
At this point, the left hand was inserted into the pericardium
and the heart was lifted up, while a long traction suture was
placed in the apex. Using this as a guide, the heart was ex-
amined. A freely bleeding stab wound was found in the right
ventricle just to the right of the anterior descending coronary
near its base. Two interrupted chromic sutures were placed in
the heart muscle controlling the bleeding. The apical suture
was then removed. The pericardial cavity was emptied of clots,
and the pericardium was closed loosely. A small rubber tissue
drain was left down to the pericardium at the apex. The wound
in the pleura, which measured about 1 cm. in diameter, was
then closed. Considerable blood had drained into the pleural
cavity during the operation. Blood plasma and whole blood
were given intravenously during the operation. The blood pres-
sure at the end of the procedure was 90/60. The pulse was
between 80 and 90. The patient was returned to the ward at
4:45 P. M., about one hour after admission. He became con-
scious about one-half hour later. That evening he had consid-
erable respiratory distress and a large amount of air and some
0 5
1 5
0 2
January, 1943
5
blood was removed from the left chest by aspiration at this
time. His pulse the following day was 100, and the blood pres-
sure 130/90. His temperature ranged between 100 and 101,
gradually returning to normal on the sixth day. Venous pres-
sure readings were about 12 cm. of water. The roentgen ray on
the second day showed some fluid in the left chest with no air.
Eight days later this had cleared. A pericardial effusion oc-
curred, but gradually absorbed in about twenty-five days. On
the tenth day the patient complained of pain in the right chest.
Roentgen examination now showed what was thought to be a
patch of pneumonia in the right base. The temperature rose
to 102. Sulfathiazole was given and the fever again returned
to normal forty-eight hours later. The patient coughed no
blood and no friction rub was heard. However, the roentgen
findings persisted, possibly due to an infarct from a mural
thrombus, although probably pneumonia. The heart sounds
were at all times a little faint, but no murmurs were heard.
Electrocardiogram on the day after the operation showed a sinus
tachycardia, high origin of RTl and RT2. This was also pres-
ent on the fifth day. However on the seventeenth day the
Q.R.S. complexes were normal and the T waves were negative
in Leads 1 and 4. The wound healed by primary intention.
At no time was there evidence of any intrathoracic or intra-
abdominal injury as a result of the second stab wound, although
this was a risk we had to take.
Case No. 2 is that of a colored man who was operated upon
by W. O. B. with recovery. The patient, age 43, was admitted
to the hospital ten minutes after having been shot in the chest
with a small calibre bullet. The wound of entrance was seen in
the fourth interspace just to the left of the sternum. The pa-
tient was unconscious, gasping for breath. The pulse was im-
perceptible and the blood pressure unobtainable. The skin was
cool and damp. The patient was given 1 cc. of adrenalin in the
heart, and caffeine intramuscularly. Following this, the heart
could be heard faintly and the pulse barely felt. The patient
was taken to the operating room immediately. A curved in-
cision was made along the left border of the sternum and down
along the left costal margin. Costal cartilages of the ribs were
cut and the chest wall turned laterally, giving wide exposure.
At this point the pleura was accidentally opened. The peri-
cardium was opened widely, liberating a large amount of clot-
ted blood. The right ventricle was bleeding freely from a tan-
gental bullet wound 2 inches from the apex. This was closed
with interrupted chromic sutures. The pericardium was closed
with interrupted chromic sutures. No attempt was made to
close the pleura. The chest wall was sutured back in place. The
general condition was fair upon leaving the operating room.
During the operation the heart had apparently stopped beating;
respirations had dropped to about two a minute. After opening
the pericardium, 1 cc. of adrenalin was injected into the heart
muscle, and the cardiac pulsations were restored. The patient
was given 400 cc. of salt solution and 1 cc. of adrenalin intra-
venously during the operation. The patient regained conscious-
ness in twelve hours. His convalescence was complicated by an
acute purulent pericarditis and empyema of the left chest.
These were drained through the lateral half of the incision.
Three months later the patient was dismissed. Empyema con-
tinued to drain, but finally healed and he was apparently well.
Case No. 3. A stab wound of the heart with cardiac tam-
ponade, was operated upon by B. F. R. and J. A. S. The pa-
tient, a colored man of 26, died 20 minutes later. He had been
admitted with a stab wound in the third interspace in the left
mid-clavicular line. He was unconscious, perspiring freely, with
the skin cold, pulse imperceptible, and blood pressure 50/20.
There was evidence of hemothorax on the left. Operation was
begun 40 minutes after admission. Under local anesthesia four
ribs over the heart region were dissected out. The pericardial
sac was opened. Blood and clots were removed. The bleeding
wound in the left auricle was identified and clamped with for-
ceps and sutured over with interrupted catgut sutures. The stab
wound was satisfactorily closed. Intravenous dextrose was given
during the operation. The heart started beating rapidly after
the pressure was released. The patient was in extreme shock
and pulseless before and throughout the operation. He died
five minutes after having been removed to his bed. The opera-
tion had lasted one hour. The patient had been given coramine
and adrenalin. Death was due either to shock from blood loss,
or possibly to interference with the neuromuscular conduction
bundles.
Case No. 4, a gunshot wound of the heart with cardiac tam-
ponade, was operated upon by H. M. B. The patient, a colored
man 33 years of age, who had been shot shortly before admis-
sion, died on the operating table. There were multiple bullet
wounds scattered over the body and two bullet wounds in the
right anterior axillary lines at about the level of the nipple.
The patient was in shock, pulse imperceptible, and no heart
sounds could be heard. Breath sounds could be heard in both
lung fields. The blood pressure could not be determined. There
was no noticeable venous engorgement in the neck veins. Venous
pressure readings in the arm were 18 cm. of water. Fluoroscopy
of the chest showed a slightly enlarged immobile pericardium.
Lung fields were clear. Pericardial aspiration performed and
blood obtained. The patient was taken to the operating room
immediately. He was quite restless and it was necessary to give
him ether inhalation anesthesia under positive pressure. A left
parasternal incision was made through the third, fourth, fifth,
and sixth costal cartilages. The pericardium was exposed and
opened widely, releasing a large quantity of clotted and liquid
blood. Chromic suture was placed in the apex of the heart.
An enormous amount of blood continued to ooze up from the
pericardial cavity as fast as we could empty it. The great ves-
sels at the base of the heart were compressed with the fingers
and the heart lifted upward. A large wound was found in the
right auricle, about an inch and a half in diameter. This was
closed as quickly as possible with chromic catgut and in approx-
imately five minutes after the pericardium had been entered.
However, the patient died from massive hemorrhage occurring
in this interval of time, in spite of transfusions of blood and
plasma. Adrenalin was injected into the heart muscle and the
heart was pumped manually. Oxygen was given by positive
pressure inhalation, but to no avail.
Case No. 1 is typical of the numerous cases recorded
in the literature. Convalescence was uneventful except
for mild pericardial effusion and the development of
pathology in the base of the right lung. This was prob-
ably pneumonia, but could possibly have been an infarct
from a mural-thrombus in the right ventricle. Electro-
cardiograms showed the classical picture, with early ele-
vation of the ST segments and a later inversion of the
T waves with a return to normal in about one month.
Case No. 2, in which the patient was operated on by
W. O. Bullock in 1928, was reported by him in 1936. 9
The patient was thought dead before the pericardium
was reached. However, the operation was continued with
restoration of the heart beat and recovery.
Case No. 3 was a wound of the right auricle, with
death occurring 20 minutes after the operation. At that
time the hospital did not have a blood bank and blood
was not available. This might have been a vital factor
in this instance.
Case No. 4 was interesting from a diagnostic stand-
point. The bullet wounds were in the right axillary line
and a definite diagnosis was made by means of venous
pressure reading, fluoroscopy, and pericardial aspirations.
However, this patient had such a large wound in the
right auricle that death resulted from massive hemor-
rhage occurring in the time elapsing between the opening
of the pericardium and the suturing of this larger
wound.
The type of incision used in Cases No. 1 and 4 was
not usual, but it was easy to make and offered a sur-
prisingly good exposure. These two operations were per-
formed by the resident staff with the counsel of the vis-
6
The Journal- Lancet
iting surgeon on his arrival. This is emphasized only to
show again the importance of early recognition and early
treatment of the condition.
Group II.
Patients with Stab and Gunshot Wounds Dying
:n the Emergency Room Without Treatment.
(5 cases, 5 deaths)
Two of these cases were the result of stab wounds
directly over the heart and three were due to bullet
wounds. All of them died shortly after admission. One
of the patients had walked two and one-half blocks and
collapsed on the steps of the emergency room. Peri-
cardial aspiration was not attempted on any of these
patients and it is possible that such a procedure followed
by large amounts of intravenous fluids might have pro-
longed life for a short time while preparations were made
for an emergency operation. Bullock suggests0 that all
of these patients be submitted to a quick thoracic
autopsy” in the hope of possibly saving a few.
Group III.
Patients with Stab and Gunshot Wounds of
Heart Not Operated On
(6 cases, 1 recovery and 5 deaths)
This group includes six patients, all of whom lived
longer than one hour after admission.
Case No. 5: A 29 year old white man was admitted 30 min-
utes after injury with a small calibre gunshot wound over the
heart. He died two and one-half hours later. He was given
intravenous fluids, morphine, and adrenalin. Autopsy showed
a large amount of blood in the pericardial cavity with a small
wound in the intrapericardial portion of the vena cava.
Case No. 6: A 35 year old colored man was admitted with
a small calibre gunshot wound over the heart. Although in ex-
trem.s on admission, he responded to intravenous glucose and
stimulants and became so very restless and violent that large
doses of sedatives were required to control him. He died 19
hours after admission. Autopsy showed cardiac tamponade with
hemothorax. The bullet had passed through the intrapericardial
portions of the great vessels of the heart and was lodged in
the sixth vertebra.
Case No. 7: A 33 year old colored man was admitted with
a stab wound directly over the heart. He died one and one-
half hours later.
Case No. 8: A 29 year old colored man died one hour after
admission with a small calibre bullet wound below the left
nipple. This record was very scanty but the attending physician
stated that "the bullet apparently pierced the pericardium and
heart.”
Case No. 9: A 64 year old colored man was admitted with
a small calibre gunshot wound of the chest. Roentgen ray
showed a hemothorax of the left chest and the bullet lodged in
the upper part of the heart shadow. Following intravenous glu-
cose and stimulants, he improved somewhat; however, he died
36 hours after admission without regaining consciousness.
Case No. 10: A 24 year old colored woman was admitted
with a small calibre gunshot wound over the heart. She was
conscious on admission and her pulse was 100, but weak. The
blood pressure was 90/40. She had physical evidence of hemo-
thorax in the left. No venous pressure readings were made on
admission. Five days later roentgen rays and fluoroscopy showed
evidence of pericardial effusion and hemothorax with bullet
lodged in the heart shadow and pulsating. Recovery followed
repeated pericardial and pleural aspirations without operation.
She was seen again two years afterward with symptoms sug-
gestive of early pericardial constriction, mild precordial pain,
slight dyspnea, and edema of ankles.
All of these patients lived longer than one hour; one
lived 19 and another 36 hours. The lack of venous pres-
sure readings, fluoroscopy, and pericardial aspiration, as
diagnostic measures, makes it apparent that the signifi-
cance of tamponade and the possibility of surgical relief
was not considered by the admitting physician. The rec-
ords of these patients were very scanty and, when re-
viewing them, one feels that the attending medical opin-
ion held these patients as being beyond medical aid.
Group IV.
Wounds of the Heart Due to Non-penetrating
Chest Blows
(2 cases, 2 deaths)
This group includes two men, both of whom had
cardiac injury as the result of non-penetrating body
blows.
Case No. 11. A 40 year old white man was admitted shortly
after being in an automobile accident. He was in mild shock
on admission but conscious. Pulse was 130. He had multiple
lacerations about the face and extensive lacerations of the right
leg. He developed a gas bacillus infection in the right leg and
amputation was performed 48 hours later. He died on the
fifth day from gas bacillus infection. Autopsy revealed evidence
of gas bacillus infection of the amputation stump with toxic
degeneration of all the viscera. In addition, the mediastinal
tissues showed extensive hemorrhage throughout. There were
petechial hemorrhages in the pericardium and epicardium, but
no blood was found in the pericardial cavity. However, there
was a recent linear rupture of the endocardium of the right
auricle about 3 cm. long. This patient died of a gas bacillus
infection. His cardiac lesion was not discovered clinically and
there is no doubt but what he would have recovered from it.
Case No. 12 presented an undiagnosed traumatic rupture of
the heart with hemopericardium and tamponade. A white man,
age 40, was found in an automobile wreck and brought to the
hospital immediately. He was semi-conscious, pulse weak, and
blood pressure low. Because of a strong odor of alcohol on his
breath, the admitting physician treated him for alcoholism. His
stomach was lavaged and he was given 1,000 cc. of 5 per cent
glucose intravenously and various stimulants. He died five
hours after admission. Autopsy showed a transverse fracture
of the lower sternum and fractures of the third and fourth ribs
on the right near the sternocostal junction. There was some
extravasation of blood in the anterior mediastinum. The peri-
cardium was intact and contained 500 cc. of liquid and clotted
blood. There was a small linear tear in the posterior wall of
the right auricle near its junction with the inferior vena cava.
Both of these cases were caused by a blow on the ster-
num from the steering wheel of an automobile. In Case
No. II, the cardiac lesion was found unexpectedly at
autopsy, death occurring as a result of a gas bacillus in-
fection in an accompanying laceration of the foot. The
patient undoubtedly would have recovered from the car-
diac lesion. Case No. 12 had a typical cardiac tam-
ponade. Due to the absence of signs of external vio-
lence, and also to the strong odor of alcohol on this
breath, the diagnosis was missed and the patient was
treated for acute intoxication, dying five hours after
admission.
Bright and Beck8 in 1935 collected from the litera-
ture 168 cases of cardiac injury due to non-penetrating
body blows.' One hundred fifty-two of these patients
died as a result of cardiac rupture while 1 1 died of car-
diac failure. The rest recovered. However, many cases
similar to Case No. II are never recognized, making it
impossible to determine the incidence of non-fatal in-
juries (contusions or small lacerations) as a result of
January, 1943
7
severe body blows. Beck and Bright experimentally trau-
matized dogs’ hearts and found that recovery was the
rule rather than the exception. As yet, no cases have
been reported in the literature in which tamponade, as
a result of severe non-penerating body blows, has been
relieved by surgery. Patient No. 12 might have been
saved by operation. All cases of automobile injury with
cardiovascular collapse out of proportion to blood loss
or out of proportion to other injuries should be carefully
examined for signs of tamponade.
Summary
Seventeen cases of heart injury admitted to St. Joseph
Hospital over a fourteen year period are reviewed. In
this group thirteen were colored and four were white.
Nine were due to gunshot wounds, five were due to stab
wounds and two were due to non-penetrating body blows.
Sixteen of the patients were male, one was female. Seven
had cardiac tamponade proven at operation or autopsy.
Of these seven, the wounds were located in the right
ventricle twice, the right auricle three times and in the
intra-pericardial portions of the great vessels twice.
Four patients admitted with the typical signs and
symptoms of cardiac tamponade were operated upon.
Two of these recovered, giving an operative mortality of
50 per cent. Five patients died in the emergency room
shortly after admission before treatment could be given.
Six were not offered surgery in spite of the fact that
they lived longer than one hour. One of these recovered
with conservative measures alone. Two patients had car-
diac injury proven by autopsy as the result of non-
penetrating body blows. One of these had cardiac tam-
ponade as a result of a rupture of the right auricle,
living five hours after admission. The other had a rup-
tured auricular endocardium which was not detected clin-
ically and which would have been compatible with life
had not the patient died from a gas bacillus infection
in an accompanying laceration of the foot.
The operative mortality in this series is 50 per cent.
The corrected total mortality reads: three recoveries and
eight deaths or 73 per cent. This high mortality was due
in part to the fact that signs and symptoms of tam-
ponade frequently were not carefully sought for and
also to a lesser extent the fact that this series contained
a high percentage of severe gunshot wounds.
Conclusions
1. Modern surgical methods have reduced the mor-
tality of cardiac tamponade resulting from penetrating
chest wounds from 90 per cent in the untreated cases
to 50 per cent or lower in those properly handled.
2. Because of the fact that patients presenting them-
selves with this syndrome usually appear to be on the
verge of death and because of the fact that the resident
staffs in many smaller hospitals as yet are not acutely
conscious of the relief that might be obtained by early
diagnosis and operation, many patients admitted with
typical signs and symptoms are considered as being be-
yond medical aid. It is suggested that everyone treating
patients in the emergency rooms constantly be prepared
and encouraged to handle this type of case when the
emergency arises.
3. A definite diagnosis usually can be made by means
of three simple tests; namely, (1) venous pressure read-
ings, (2) fluoroscopy, or if necessary, (3) pericardial
aspiration.
4. Cardiac injury from non-penetrating body blows
is more frequent than is commonly suspected. Patients
with many of these milder injuries recover without being
detected clinically. While cardiac rupture with tampo-
nade following a body blow has been discovered occa-
sionally at autopsy, yet as far as I can determine, no
case has been diagnosed and relieved surgically. For this
reason it is further suggested that all patients especially
those injured in automobile accidents who show signs of
cardiovascular collapse out of proportion to blood loss or
other injuries, be examined carefully for tamponade with
the hope of saving some of them by early operation.
Bibliography
1. Beck, C. S.: Wounds of the heart and technic of suture.
Arch. Surg. 13:205-227 (Aug.) 1926.
2. Beck, C. S. : Two cardiac compression triads, J A M A.
104:714-715 (March) 1935.
3. Beck, C. S.: Pre- and postoperative care of patients with
lesions of the heart, Arch. Surg. 40:1151-1 163 (June) 1940.
4. Beck, C. S., and Cushing, E. H.: Pick syndrome, J.A.M.A.
102:1 543-1548 (May 12) 1934.
5. Bigger, I. A.: The diagnosis and treatment of wounds of
the heart. South. M. J. 33:6-11 (Jan.) 1940.
6. Bigger, I. A.: Heart wounds report of 141 cases with 17
patients operated upon, J. Thoracic Surg. 8:239-253 (Feb. 18)
1939.
7. Bigger, I. A.: The diagnosis of heart wounds, South. M. J.
29:18-23 (Jan.) 1936.
8. Bright, E. F., and Beck, C. S.: Non-penetrating wounds of
the heart, Amer. Heart J. 10:293-321 (Feb.) 1935.
9. Bullock, W. O.: Ultimate phase of life as it relates to
wounds of the heart, Ann. Surg. 103:696-697 (May) 1936.
10. Elkin, D. C.: Diagnosis and treatment of wounds of the
heart — 22 cases, J A.M.A. 1 1 1:1750-1753 (Nov. 5) 1939.
11. Elkin, D. C., and Phillips, H. S.: Stab wounds of the heart
electrocardiographic studies of 2 cases, J. Thoracic Surg. 1:113-
123 (Dec.) 1931.
12. Elkin, D. C.: Emergency surgery of the heart — Amer. J.
Surg. 46:551-561 (Dec.) 1939.
13. Elkin, D. C.: Diagnosis and treatment of cardiac trauma,
Ann. Surg. 1 14:169-185 (Aug.) 1941.
14. Griswold, R. A., and Drissen, E. M.: Wounds of the heart,
Kentucky Med. J. 34:471-474 (Oct.) 1936.
15. Griswold. R. A., and Maguire. C. H.: Penetrating wounds
of the heart and pericardium. Surg. Gynec. &C Obst. 74:406-418
(Feb. — No. 2 A ) 1942.
16. Mayer, J. M.: Clinical management of injuries to the heart
and pericardium — report of 7 cases, Surg. Gynec. & Obst. 62:852-
864 (May) 1936.
17. Olim, C. B., and Hughes, J. D.: Stab wound of heart
with coronary ligation, J. Thoracic Surg. 9:99-105 (Oct.) 193 9.
18. Ramsdell, E. G.: Stab wounds of the heart, Ann. Surg.
99:141-151 (Jan.) 1934.
19. Singleton, A. O.: Wounds of the heart, Amer. J. Surg.
20:5 1 5-541 (June) 1933.
20. Strieder, J. W.: Stab wound treated conservatively, J. Thor-
acic Surg. 8:576-577 (June) 1939.
8
The Journal- Lancet
Emergency Treatment of Lacerations
V. G. Borland, M.D., F.A.C.S.f
Fargo, North Dakota
IN a study of some of the recent literature on the
care of wounds, certain fundamental principles make
themselves apparent. One is impressed by the sound-
ness of these principles and wonders why their applica-
tion has been so long delayed. Among the papers of
special interest dealing with this subject are those of
Koch1"; Mason1; Coller and Farris11; McClure0; Ste-
venson and Reid10; Reid and Carter J; Whipple and
Elliott8; Jenson, Johnsrud and Nelson.0
Healing appears to be a natural property of living
tissue, which under certain optimal conditions proceeds
at a definite and measurable pace (Mason1). It should
be one’s purpose, in treating wounds, to make every
effort to aid nature in her tremendous urge to heal. To
this end, we should be ever watchful that we do no
further damage. One should take care, for example,
not to jeopardize the circulation of an extremity by over-
zealous efforts to control bleeding with a tourniquet,
when in most cases bleeding can be easily controlled by
pressure over the site of injury with a sterile pad ban-
daged firmly in place, together with elevation of the
part. Strict avoidance of the introduction of antiseptic
solutions into the wound itself is another way one can
prevent further damage. It seems only reasonable that
if bacteria can be damaged or killed by antiseptic solu-
tions, then tissue cells themselves, many of which are
much more delicate than most bacteria, will likewise be
greatly damaged. Bacteria thrive on dead and devitalized
tissue and conversely, healthy undamaged tissue cells
have a great natural tendency to combat invading organ-
isms. One is greatly impressed on a visit to Koch’s Hand
Clinic at Cook County Hospital by the kindly healing
taking place under the treatment used there. Koch and
Mason were among the first to preach widely against
the pernicious practice of pouring antiseptics into open
wounds, which, as Mason says, is a tribute to the drug
salesman’s efforts and not to our own good sense.
A special effort should be made to protect an open
wound from bacterial contamination by human sources.
These bacteria cultured in vivo are said to have acquired
more or less immunity to human natural protective mech-
anisms— antibodies, agglutinins, etc. Thus, the wound
may develop a virulent superimposed infection after in-
jury by the injudicious use of a handkerchief on the
wound, or from the noses and mouths of bystanders, or
from clumsy attempts at first aid, where unclean fingers
have been allowed to contaminate the wound. Every-
one, particularly including nurses and physicians, who
approaches a wound at any time, should have both nose
and mouth adequately covered.
Further damage can be prevented by careful splinting.
Even if a fracture is not suspected, rest of an injured
*Presented before the North Dakota State Medical Association
annual meeting, Jamestown, May 20, 1942.
t Fargo Clinic.
member is as important in extensive soft tissue injuries
as when bone is injured. The careful handling of tissue
at the time of repair with fine instruments, engaging
only small amounts of tissue, use of only the finest kind
of suture material, avoiding use of rough retraction, use
of frequent warm saline irrigations to prevent drying out
of tissues, and avoiding rough and frequent use of
sponges, all are aimed at the prevention of further
damage.
Careful removal of all foreign matter, of dead and
devitalized tissue is extremely important. Debridement
of the wound then means converting a dirty wound into
a clean one. This is a meticulous and time-consuming
procedure if properly done. A great deal of patience is
needed to remove every last particle of dirt, every tiny
bit of ischemic muscle, or devitalized fat or fascia.
Strong emphasis has been placed on this aspect of wound
treatment by many men, and its value is strikingly borne
out by the report of 225 cases of compound fractures
from the fracture service of Minneapolis General Hos-
pital, in which an especially thorough debridement was
carried out.14 In this series only five cases of infection
appeared, and of these, two developed gas gangrene and
both died. Postmortem study revealed in both cases small
deposits of gravel and other debris, indicating incomplete
debridement, in spite of the fact that a good deal of
time was spent in each case and a thorough debridement
thought to have been done. It is true that sulfanilamide
locally also was used in those cases, but debridement
when meticulously done is considered more important in
that institution than any other factor in their treatment.0
Particles of wool clothing introduced into wounds are a
great potential source for tetanus and gas infection. It
is of especial importance to remove these bits of clothing
and it has been said that, were it possible to substitute
cotton clothing for the wool clothing that soldiers now
wear, one of the great hazards to anaerobic infection
would be eliminated.
Stevenson and Reid1" have emphasized the difference
between a contaminated wound and an infected wound.
Every wound, whether made surgically or accidentally,
is contaminated. Studies by Meleny and Ives4,5 and
Hirschfield1 indicate that nearly 100 per cent of so-
called clean operative wounds yield positive cultures if
careful means of culturing bacteria are used. The fact
that the large majority of operative wounds heal by
primary intention emphasizes the great natural tendency
of tissue to fight off invading organisms. Bacteria which
contaminate a wound vary greatly in virulence. They
lie dormant for a time in order to accommodate them-
selves to their new environment, except possibly in the
case of contamination from human sources, when the
period of acclimatization is greatly shortened, since these
bacteria are already accustomed to human tissue fluids.
January, 1943
9
Up to this time, variously estimated at from four to
eight hours, the wound is simply contaminated. If one
can remove a sufficient number of these bacteria and
leave the tissues in the best possible shape to combat the
ones remaining, healing by primary intention will likely
take place. Once the bacteria have begun to multiply in
sufficient numbers to actually invade tissue, the wound
is infected, and active surgical measures may be dan-
gerous (Mason1).
Numerous are the enthusiastic reports of the value of
local implantation of the sulfonamides into wounds. Ex-
perimental and clinical evidence suggests that, unlike
antiseptic solutions, they are not harmful to human tissue
cells. Action of the sulfonamides on bacteria, although
not completely understood, appears to be one of inhibi-
tion. They are bacteriostatic, rather than bacteriocidal.
They interfere with the complicated manner in which
bacteria obtain their nourishment and thus delay and
inhibit their action and prevent their reproduction.1
Probably a combination of sulfanilamide and sulfathia-
zole in equal doses is most effective. The former is said
to provide a sudden high concentration in the wound,
up to 800 mg. per cent, but is rapidly absorbed. The
latter gives a more prolonged effect, being much more
slowly absorbed, but its local concentration does not go
above 50 mg. per cent. The recommended doses have
varied considerably, up to 20 gm. or more; possibly in
most cases 8 to 10 gm. is the optimum amount. Admin-
istration by other routes should be continued for five or
six days in most cases. Sulfathiazole must be introduced
in finely powdered form, preferably with an atomizer,
as it has the disadvantage of caking if not well distrib-
uted, and large portions of it remain unabsorbed for
long periods.
Protection against tetanus and gas gangrene should be
provided by prophylactic doses of antitoxin.
The simple incised wounds of the skin may be treated
by cleansing a wide area of the surrounding skin with
plain soap and water, followed by the application of an
antiseptic solution over the surrounding skin up to the
edges of the wound, but never allowing it to enter the
wound itself. Novocain infiltration may then be carried
out well away from the wound edges. The wound itself
may be gently cleaned and freshened with sterile gauze
moistened in warm normal saline solution. Any debris
present in the wound should be carefully removed. If
the skin edges are fresh they may be immediately
sutured, or if ragged and macerated they should be ex-
cised and then sutured. Suture of the skin is carried out
following the application of a thin layer of sulfathiazole
powder in the wound with an atomizer. A light pressure
dressing is applied to the wound and not disturbed again
until the sutures are to come out.
A more severe laceration of soft parts, involving deeper
structures, should be treated somewhat as follows: if seen
at the time of injury, no treatment is given except the
application of a copious sterile gauze dressing bandaged
firmly in place. Pressure at the site of injury will usually
suffice to control bleeding, especially if combined with
elevation of the part, thus avoiding the possible dam-
aging effects of a tourniquet hastily applied, although
pressure over the proximal artery at a suitable point may
be required.
The use of adequate splints will make the patient
more comfortable and possibly avoid further damage,
especially to bones, nerves and blood vessels. Morphine,
in doses of one-quarter to one-half grain, is almost always
indicated. It is the best means of preventing or com-
bating shock. Transportation to a hospital is then carried
out and there further examination made to determine
if other injuries are present, paying particular attention
to the possibility of nerve injury. This should be accom-
plished without removal of the dressings. At this time
also one can determine if the patient may be immediately
treated or if treatment must be delayed because of shock.
X-ray examination, if indicated, is then carried out.
Preparation is then made for treatment of the wound
in the same manner as for any major surgical operation,
the wound not being exposed until the personnel are
completely masked, the surgeon having scrubbed for ten
minutes and donned sterile gloves. The splint and dress-
ing are then gently removed and the wound packed light-
ly with a sterile gauze fluff. A wide area of the surround-
ing skin is shaved, using benzene and ether gently to re-
move grease and dirt. The surgeon himself then gently
scrubs the area surrounding the wound with plain white
soap and water for ten minutes, using sterile cotton,
which is less irritating to the skin than a ten-minute
scrub with gauze. A suitable antiseptic is then applied
up to the wound edges, again being careful not to allow
it to enter the wound. If an extremity is involved, much
time will be saved by application of a blood pressure
cuff, with pressure maintained at 250 mm. of mercury,
following elevation of the part for a few moments. Suit-
able sterile drapes are applied, and the surgeon and assist-
ants wear sterile gowns, gloves, and masks covering both
nose and mouth.
Local infiltration of novocain may then be carried out,
well away from the wound edges, but if the wound is
very extensive a general inhalation anesthetic or an intra-
venous anesthetic is more desirable. If the wound is so
situated that complete excision is feasible, this is then
quickly carried out. Reid and Carter2 have pointed out
that excision is possible with practically no contamination
of underlying structures. If the wound involves vital
structures, complete excision is of course not possible. In
that event, the superficial portions of the wound, that is,
the skin and subcutaneous tissue,3 are excised, and all
the obviously dead tissue and debris in the depth of the
wound is removed. With the blood pressure cuff in
place this can quickly be done with no bleeding and a
minimum of sponging. The wound is then copiously
irrigated with warm normal saline solution, using several
quarts of solution and being sure to irrigate the very
depths of the wound. A light gauze pack is re-inserted,
the surrounding areas dried and re-treated with anti-
septic solution; the wound is completely re-draped and
fresh gown, gloves and fresh instruments are secured.
A meticulous debridement is then carried out. This is
time-consuming. Every fine particle of foreign matter,
10
The Journal- Lancet
every bit of devitalized tissue is removed, using frequent
warm saline irrigations. Injured nerves and tendons are
then repaired, using interrupted sutures of fine silk. At
this time most of the cut blood vessels can be secured
without removing the blood pressure cuff. They will be
seen protruding slightly from the surrounding tissue.
These are caught with fine pointed forceps, engaging
only the blood vessel itself, and ligated with fine silk.
The blood pressure cuff is then removed and the remain-
ing bleeders secured similarly. Gentle pressure will con-
trol a great deal of minor bleeding and oozing, and thus
reduce to a minimum the total amount of necrosis and
foreign material with which the tissues will have to deal.
When complete hemostasis is obtained, a final irrigation
is done and the sulfonamide powders introduced, using
both sulfanilamide and sulfathiazole in equal doses. The
deep fascia is then approximated, using interrupted
sutures of silk, tied without tension, and the skin closed
similarly.
Mason1 feels that tight skin sutures are particularly
hazardous, where a linear necrosis may lead to a serious
infection. No drainage is used. A large sterile fluffed
gauze dressing covering a wide area and bandaged firmly
in place nicely prevents the postoperative oozing which
is always likely to take place otherwise, thus avoiding
accumulations of blood and serum.
The part is then adequately splinted, preferably in
plaster. Plaster fixation has long been recognized as a
valuable factor in treatment of compound fractures. It
should be equally valuable in extensive soft tissue in-
juries. A prophylactic dose of gas bacillus and tetanus
antitoxin is administered. A moderate elevation of the
part above heart level has been recommended by Wang-
ensteen13 and others, to prevent stasis edema. Wangen-
steen has reported several virulent infections of a phleg-
monous nature which were brought to satisfactory
conclusion with the use of complete immobilization and
elevation alone.
The wound is not disturbed until the sutures are to
be removed, unless a definite indication such as undue
pain, unexplained fever, or impaired circulation is pres-
ent. If closure of the wound cannot be accomplished
without tension, then one may employ relaxing incisions
on either side of the wound, being certain that they are
made in such a way that the blood supply to the skin
flaps is not disturbed. These incisions are sprinkled with
powdered sulfathiazole and covered with sterile vaseline
gauze and left alone, and usually heal without trouble.
If treatment has been delayed beyond the usually pre-
scribed optimum time for treatment of six to eight hours,
it may be debrided as described, treated with the sulfona-
mide powders and packed open with sterile gauze. De-
layed suture may then be accomplished in twenty-four
to thirty-six hours, if the wound looks clean, or it may
be repacked with plain sterile gauze every three or four
days and allowed to heal from the bottom by granula-
tion. The application of a firm pressure dressing as
advocated by Koch1-’ in these cases will prevent exuberant
granulations.
A recently recommended treatment for grossly infect-
ed wounds is the so-called "cocktail dressing.” This con-
sists of a pack, made up of gauze impregnated with cod
liver oil and equal parts of powdered sulfanilamide and
sulfathiazole, changed as required.
In summary, it seems well to remind ourselves once
again that there is nothing we can do to make tissues
heal. Healing can only be accomplished by the tissues
themselves, and proceeds at a definite pace under opti-
mum conditions. In attempting to promote optimum
conditions, we must treat tissues very gently at all times,
provide adequate rest, be ever mindful of adequate blood
supply, and be careful not to add injurious agents so
that the tissues have that additional obstacle to overcome.
Ambrose Pare in 1537 decried the use of hot oil in
open wounds which has its modern counterpart in the
misuse of variously colored solutions today. In other
words, to quote Coller once again, "The cycle has been
completed. Once more we are back to the time of Pare,
who said, "I treated him; God healed him.”
References
1. Mason. Michael: Surg., Gynec. Qc Obstet. 69:303 (Oct.)
1939.
2. Reid. M. E., and Carter, B. H : Ann. Surg. 114:4, 1941.
3. Ives. H. R., and Hirschfeld, J W.: Ann. Surg. 107:607,
1938.
4. Longacre, A. B., Jem, H. Z., and Meleny, F. L.: Surg.,
Gynec. Qc Obst. 70:1 (Jan.) 1940.
5. Meleny, F. L.: Am. J. Surg. 46:435 (Dec.) 1939.
6. Jenson, N. K., Johnsrud. L. W . and Nelson, M. C.:
Surgery 6:1 (July) 1 939.
7. Spink, W. W.: Sulfanilamide and related compounds in
general practice; Chicago, 111., Year Book Publishers, Inc.
8. Whipple, A. O., and Elliott, R. H. E., Jr.: Ann. Surg.
108:741 (Oct.) 1938.
9. McClure, R. D : Obst. 68:547 (June) 1939.
10. Stevenson, J., and Reid, M. R.: Am. J. Surg. 46:442
(Dec.) 1939.
11. Coller, F. A., and Farris, J. M.: Surg., Gynec. 6C Obst.
72:1 (Jan.) 1941.
12. Koch, Sumner L.: Surg., Gynec. 6C Obst. 68:961 (May)
1939.
13. Wangensteen. Owen H.: Minnesota Medicine 21:225
(April) 1 938.
14. Nelson, Maynard: Personal communication.
January, 1943
The Depressed Patient
Gordon R. Kamman, M.D., F.A.C.P.
St. Paul, Minnesota
"All the world is melancholy or mad, and every
member of it. I can but wish myself and all of us
a good physician and a better mind.''
THE above words were written in 1651 by Burton
in a treatise on The Anatomy of Melancholy.
Nearly three centuries ago this writer called mel-
ancholy "a universal malady, an epidemical disease.”
Nowadays, depression, anxiety, and pain, are still per-
haps the commonest symptoms in medicine; but depres-
sion and anxiety are often not mentioned by the patient
who is more apt to describe the physical discomforts
which result from these disorders of feeling. For this
reason the physician is in danger of overlooking the fun-
damental psychiatric condition that forms the real basis
for the patient’s complaints. Inasmuch as most cases
seen in general practice are of a relatively mild degree
the practitioner must be "depression conscious” in order
to avoid the mistake of treating the physical symptoms
and ignoring the psychiatric entity underlying it. Very
frequently a patient rationalizes the cause of his diffi-
culty and relates it to an organ. That is, there is "con-
version of the psychalgia.” The physician may accept
this rationalization and treat the organ, sometimes even
resorting to a surgical attack upon that portion of the
body referred to by the patient as being the seat of the
trouble. This invariably makes the patient worse because
it is ineffective and merely serves to confirm the patient’s
hopelessness about his condition. Furthermore, the treat-
ment usually is given half-heartedly so even the element
of suggestion is absent. Small wonder that the victim
gradually gravitates to the office of a chiropractor or a
practitioner of one of the other so-called "cults” of
healing.
The medical, public health, and social problems which
arise as a result of mental depression cannot be estimated.
In the public hospitals of the United States there are
more than 50,000 patients suffering from depressions of
various kinds. In addition to this there are probably five
times that number consulting practicing physicians for
varying degrees of mood disorders which are severe
enough to lessen the efficiency of the individual in all
of his contacts, and in that way lower the general morale
of society. It goes without saying that in these critical
times the general morale of our people is of paramount
importance. For this reason a study of the causes, charac-
teristics, and treatment of depressions becomes important.
At least, it will be helpful in correcting some of the
existing misunderstandings which interfere with the
proper management of the depressed patient.
Depression is a mood disorder which results from a
form of inhibition at the highest level of the nervous
system. It may vary in degree from simple retardation
*Read before the North Dakota State Medical Association annual
meeting, Jamestown, May 18-20, 1942.
to profound stupor. As one writer put it, "the patient
says he cannot, his friends say he will not, the truth is
he cannot will.” I wish to emphasize the fact that the
depressed patient is really sick. Just as a man suffering
from a dislocated ankle will limp physically in spite of
the most magnificent display of will power, a man suffer-
ing from a dislocated mood will limp psychologically.
All of his will power, all of the entreaties of his friends,
and all of the scolding ridicule and verbal abuse of his
attending physician are powerless to force the patient to
"snap out of it.” One may as well ask a patient with
pneumonia to "snap out” of his fever by the exercise of
sheer will power. No, the depressed patient is sick, and
his sickness must be understood in order to be properly
and successfully managed.
Although depression may result from a number of
causes some of which will be discussed later, there are
certain symptoms generally common to all depressions.
Lemere has divided these symptoms into mental and
physical somewhat as follows:
Mental Symptoms
1. Depressed spirits. The patient feels gloomy, he is
subject to crying spells, expresses ideas of hopeless-
ness, is worse in the morning, and is a potential
suicide. This last fact is very often disregarded, and
one regularly reads in the daily press accounts of
people having committed suicide with "despondency
over ill health” given as the cause.
2. Feelings of inadequacy. The patient says that he has
an "inferiority complex,” although in the Adlerian
sense his diagnosis of inferiority complex is not cor-
rect. At any rate the patient is sure that he is a
failure, he blames himself for all of the trouble that
has come into the lives of his family and friends, he
feels unworthy of any consideration or regard, guilt
reactions are prominent, and the patient is given over
to retrospection and self-accusation.
3. Inability to concentrate or to remember. This inter-
feres with the patient’s reading and it also impairs
his conversational powers. This causes him to fear
that he is losing his mind although he will not ex-
press this particular fear unless the physician asks
leading questions.
4. Loss of interest in everything but himself. This de-
tachment of interest (libido) from the external world
and its investment in the patient himself brings about
a qualitative as well as quantitative change in the
mood swing. Therefore, depression is something more
than a mere quantitative increase in the amplitude of
the down swing. It is also qualitative in that the ego-
superego relationship is profoundly disturbed.
5. Anxiety. This may take the form of a diffuse or a
specific preoccupation. By this is meant that the pa-
12
tient may complain merely of feelings of uneasiness
and general tension, or he may refer his symptoms to
some organ or system of organs. Douglas Singer once
said that an organ neurosis is the result of a patient’s
inability to get along as he is with his life situation
as it is. The organ selected for the expression of the
patient’s conflict will be determined to a large degree
by the previous experience of the patient. If he has
a family history of heart trouble, or if close friends
or prominent people in the community have died
suddenly and dramatically of heart trouble, he will
have a cardiac neurosis. If, on the other hand, the
idea of carcinoma has been impressed on his mind,
he might develop a cancerphobia. And so it is with
other parts of the body.
6. Apparent aversion to the ordinary duties of life.
I say "apparent” because I do not believe that this
manifestation is a true antipathy or aversion. In my
opinion it is excessive psychomotor inhibition coupled
with feelings of futility and hopelessness. It is like
a fine automobile in good running order but with the
brakes set. The power to go ahead is there but ex-
cessive inhibition prevents the machine from func-
tioning. Patients frequently have apparent aversion
to the doctor and to any form of treatment suggested.
What really happens is that the patient is so dis-
couraged that he cannot see any use in trying any-
thing which, according to his point of view, would
be just so much waste of time, effort, and money.
Furthermore, he usually feels that he isn’t worth the
trouble.
Physical Symptoms
1. Insomnia. This frequently is the earliest symptom
in depressions and may be present several months
before the appearance of other and more character-
istic manifestations. Following recovery many pa-
tients will say that, as they look back over their his-
tory, they can see where their illness was coming on
long before the time they gave as the date of onset
of their trouble. Therefore, every patient suffering
from a psychogenic insomnia should have a thorough
psychiatric investigation for the purpose of detecting
harbingers of an oncoming depression. Sometimes
psychotherapy reinforced by mild sedation at this
stage of the illness may prevent a future break.
2. Gastrointestinal symptoms. Anorexia, flatulence, con-
stipation, vague abdominal discomforts ofttimes can
be very deceptive. Unless the surgeon is "depression
conscious” he might fall into the error of performing
a laparotomy only to find normal organs and later
be ignominiously accused not only of having failed
to cure the patient, but actually of having made him
much worse. I might also add that the surgical mor-
tality is much higher in depressed patients than in
people who are emotionally normal. More than one
depressed patient has unexpectedly and inexplicably
died two or three days after a herniotomy, a simple
appendectomy, or some other standard surgical pro-
Thk Journal- Lancet
cedure in which the risk is ordinarily considered to
be comparatively slight.
3. Weight loss. As a result of the anorexia together
with defective digestion and assimilation most pa-
tients coming to us with depressions are from 5 to 40
pounds under weight. Studies on the weight curves
of patients under treatment indicate that few of them
begin to improve with respect to emotional tone until
the weight increases. This makes nutrition a very
important factor in the treatment of the depressed
patient.
4. Feelings of not being rested upon awakening in the
morning. Early morning awakening with feelings of
depression is one of the most characteristic symptoms
— so much so that in history taking I routinely ask
the patient if there is any particular time of the day
during which the mood symptoms are most disturb-
ing. If the patient replies that he invariably feels
worse in the morning but that his feelings improve
toward evening, one can be quite certain that he is
dealing with a depression. The exact explanation of
this phenomenon has never been given although there
are a number of theories.
5. Symptoms relating to the sexual life of the individual,
i. e., impotence and amenorrhea.
a. Impotence. Psychic impotence is characterized by
the profound disturbance in emotivity which ac-
companies loss of sexual power. In this way psy-
chic or functional impotence differs from that re-
sulting from organic diseases such as tabes dor-
salis and other neurologic lesions. Sufferers from
organic impotence rarely, if ever, show excessive
concern over their weakness. On the other hand,
patients with psychic impotence are emotionally
devastated. They complain bitterly about "lost
manhood,” frequently contemplate and sometimes
commite suicide, and present a picture of extreme
and pitiful dejection.
b. Amenorrhea in women is not accompanied by the
same degree of concern as is functional impotence
in men. The important point to be remembered
in connection with amenorrhea is that it does not
necessarily indicate the onset of a true physio-
logical menopause. Neither is it an uncontra-
dictable indication for the exhibition of one of
the estrogenic substances for therapeutic purposes.
While some of the tension states, hot flashes, and
other vasomotor symptoms of physiological meno-
pause are relieved by the administration of estro-
genic substance, one should not be too optimistic
about relieving mental depressions whether they
are associated with the climacteric or not. It is
important to remember that amenorrhea can be
a result of the depression, and when the depres-
sion lifts normal menstrual function returns. Too
often a patient is told that her depression is a
sign of her "change of life.” She recovers from
her depresion, begins again to menstruate regu-
larly, and then worries about having another
"change of life” with depression. I have seen a
January, 1943
13
number of women living in a state of constant
fear and anxiety in anticipation of a much dread-
ed second "change of life.”
6. Occipito-nuchal pain (ONP) . This has been dis-
cussed by me elsewhere. Suffice it to say here that
ONP is almost pathognomonic of depression if it is
continuously present during the day, never awakens a
patient from sleep at night, and is accompanied by
various fears, apprehensions, and disturbances in emo-
tivity. It is due to increased tension in the muscles
in the back of the neck ("base of the brain” to the
average layman) and it responds to reassurance,
physiotherapy, and mild sedation.
While there is no sharp dividing line between depres-
sions associated with constitutional diseases or organic
cerebral disorders on the one hand, and purely psycho-
genic depressions on the other, it might be well to con-
sider these two main groups independently. Depression,
aboulia, loss of interest, and emotional instability may
be the earliest manifestations of cerebral syphilis, cerebral
vascular disease, brain tumor, multiple sclerosis, thyroid
dyscrasia, metabolic diseases and pulmonary tuberculosis.
In these cases the serological, neurological, and physical
findings are helpful in establishing the diagnosis. De-
pressions characterizing the onset of senile dementia are
distinguishable by the age at which they occur plus the
fact that they soon are accompanied by signs of pro-
gressive memory impairment and mental deterioration.
The depressions accompanying metabolic diseases such as
gout, diabetes, and hypothyroidism are purely secondary
to the underlying constitutional disorder. In the condi-
tions just mentioned management of the primary dis-
order is all important, and the fact that the primary
disorder can easily be obscured by the heavy emotional
overlay makes a complete physical and neurological ex-
amination mandatory in every case of depression. The
more certain I am that a patient is suffering from a
functional or a neurotic disorder, the more painstaking
and complete is my examination.
Mrs. B. B., age 32, married and the mother of two children,
was sent to me because of severe emotional depression, irrita-
bility, and crying spells, associated with a persistent hacking
cough. Two months previously her chest had been examined
roentgenographically and declared to be normal. Her Mantoux
reaction was faintly positive, and a competent internist had made
a diagnosis of anxiety neurosis and hysterical cough. When she
came to see me, Mrs. B. had lost 15 pounds in weight (not
uncommon in anxiety states), she was severely depressed, could
not eat or sleep, wept profusely at mention of her cough, said
that she could not get her mind off herself and she wished she
were dead. Physical examination of the chest showed diffuse
crepitant rales throughout both lungs, and X-ray films showed
extensive miliary tuberculosis.
Mrs. F. C., a childless widow, was referred to me with a
diagnosis of hysterical dysphagia. She was irritable, uncoopera-
tive, severely depressed, had violent and noisy crying spells,
refused medicine and all other attempts to do anything for her,
and had lost 20 pounds in weight. Her past life had been filled
with enough grief and misfortune to cause almost anybody to
break down emotionally and a competent internist with the aid
of an excellent roentgenologist had ruled out all organic disease
of the gastrointestinal tract. I was consulted with regard to her
melancholia. The patient, however, had so much cardiospasm
that it was impossible for her to swallow food or medicine. After
consultation with a surgeon it was decided to dilate the lower
part of her esophagus. This was done and the patient died a
few hours later. At autopsy a carcinoma was found in the
cardia of the stomach with diffuse peritoneal metastases.
Mr. E. S., age 40, came to me in prohibition days when it
was the fashion for certain citizens to manufacture alcoholic
beverages in their own home. Mr. S. was depressed, apprehen-
sive, had crying spells and thought that the revenue agents were
spying on him through the walls of his home and listening to
him over a radio device. He labored under the delusion that his
family was going to be murdered by the government agents,
and that he, himself, would be shot. He attempted suicide by
drinking a quantity of cleaning fluid. The physical and neuro-
logical examinations were entirely negative for organic signs.
The Wassermann reaction on the blood was negative. Obvi-
ously Mr. S. was suffering from melancholia so he was sent to
the hospital and treated for the condition. However, he failed
to show any improvement. At the end of the second month
his wife arrived from New York to discuss the case with me.
I noticed that she had miotic and irregular pupils. I asked her
if I could examine her eyes and I found typical Argyll-Robert-
son pupils. The following day I obtained a specimen of my
patient’s spinal fluid, and the laboratory reported a four-plus
Wassermann reaction, and a typical paretic formula. Under
treatment with malaria followed by two years of intravenous
Tryparsamide the patient made a satisfactory adjustment and
is now well and happy, living with a second wife.
The functional depressions, i. e., those of purely psy-
chogenic origin and for which no physical or organic
basis can be demonstrated fall into two main groups.
These are the reactive (neurotic) depressions, and intrin-
sic (psychotic) depressions. Each kind has certain dis-
tinctive characteristics with respect to the prepsychotic
personality of the patient and also the clinical symptoms
he presents during the active phase of his disorder. It
is important to distinguish between a neurotic and a
psychotic depression because the psychodynamics, prog-
nosis, and management differ in the two types. How-
ever, there are some cases which cannot be identified
without the use of one of the several specialized technics
of personality analysis. The one I use is known as the
Rorschach experiment or test.
The Rorschach test is made by recording the verbal
responses of an individual to a series of ten standardized
ink blots. Formulation and interpretation of these re-
sponses according to the criteria established by the late
Herman Rorschach yields knowledge about the psychic
structure of the patient that can be put to diagnostic,
prognostic, and therapeutic use. The procedure is not
really a "test” as the word would be used in natural
science generally, or even in the looser sense in which
the word is applied to intelligence tests. Neither the
Rorschach nor any of the other "tests” is a technic from
whose results a trait or a trait complex can be read.
What we can expect from a number of personality tests
is that they reveal characteristics of personality structure
that afford opportunities for interpretive insight that
could not be developed without them. Rorschach’s genius
gave his procedure a definition and a precision which has
made it one of the most useful means of rapid analysis
of the individual personality. In each personality type,
whether it be healthy adult, problem child, schizophrenic,
depressed, hysteric, or any other type, certain psycho-
logical processes hang together. The Rorschach test cross-
sections these psychological processes, and from it we
can deduce many useful facts concerning them.
14
The Journal- Lancet
There are many technical details surrounding the ad-
ministration, scoring, and interpretation of the test. It
employs many symbols, and even some terms which are
almost a separate language. One of the criticisms of
the test is that it is too complicated, and that an expert
in the Rorschach technic must be a specialist on that
method only. I disagree with this point of view. It
seems to me that, as long as the results of any test can
be validated, and as long as they are useful and helpful
to the clinician, the test has merit. Merely to say that
it is too complicated misses the point.
On the basis of our clinical observations aided by such
procedures as the Rorschach experiment, we usually are
able to distinguish between the neurotic and the psychotic
depressions. The former are, for the most part, situa-
tional reactions. That is, they are reactions to some ex-
ternal life situation although the reason may not always
be known to the patient. These neurotic depressions
occur in superior adults who have introversive tendencies
(introverts). They are highly organized, sensitive per-
sonalities, and their pre-morbid reactions are character-
ized by perfectionism, meticulosity, and a hypersensitive
conscience. In the breakdown the patient never hallu-
cinates, never goes over into delusional formation, and is
always in contact with reality. He knows that he is sick
and usually is cooperative in his treatment. Physical ten-
sion and psychomotor unrest are apt to be more common
than severe inhibition. The patient frequently complains
of somatic symptoms which are nothing more or less than
"conversions” of the psychalgia into a form of physical
discomfort. The seriously conflicted victims of neurotic
depression are particularly prone to suicide. In Rorschach
experience, an adult of superior intelligence who is de-
pressed, and whose record shows evidences of neurosis
and deep conflict is, at some time or other during his
illness, almost certain to attempt suicide. The tragedy
of it all is that this danger so frequently is either un-
recognized or ignored by the family and friends of the
patient, even after they have been warned by the physi-
cian. Their reaction usually is, "Oh, he hasn’t got the
nerve!” or "She is too religious!” or "There never has
been anything like that in the family!” That is all
beside the point. The fact still remains that every neur-
otic depression is a potential suicide.
The psychotic depressions, rather than being a reaction
to some external life situation, are intrinsic in the indi-
vidual. They bear the same relationship to neurotic de-
pressions as diabetes mellitus bears to alimentary gly-
cosuria. The latter is a reaction to the ingestion of an
excess of carbohydrate, while the former is a disease
intrinsic in the individual and probably rests on a con-
stitutional basis. Whereas the person suffering from
neurotic depression knows that he is ill and is accessable
and willing to cooperate in treatment, the psychotic
depressive has no insight into his condition. He is sick
but he doesn’t know it. In doubtful cases the high or
low psychotic potential can be judged by the amount
of insight and the accessability of the patient. The pre-
morbid personality has been described as "bilious, rheu-
matic, gouty, vagotonic, and spasmophilic.” Anthropo-
logically the patients correspond to the "pyknic habitus”
described by Kretchmer. Their prepsychotic personality
is predominantly extravertive and they frequently give a
history of preceding episodes of elation or of depression.
The depression itself is characterized by the most painful
delusions of retrospection, self accusation, and impending
ruin. The delusions of ruin may relate either to the
spiritual life of the individual, his socio-economic status,
his physical body, or the welfare of his family. The
patient isolates himself in a hermetically sealed psycho-
logical cubicle of his own, and, until the depression
begins to lift, the most heroic attempts on the part of
the psychiatrist to enter this cubicle are to no avail. One
of the great contributions of shock therapy is that it
makes many patients accessable to psychotherapy. As in
the neurotic depressions, suicide is common.
Whether involutional melancholia is an independent
entity or whether it should be looked upon as a sub-
group of the manic-depressive psychoses is still a moot
question. However, it is a fact that many men and
women become depressed at some time during the invo-
lutional period of their lives. The diagnosis, prognosis,
and management conforms in general to that of the other
depressions.
When we come to consider the treatment of the de-
pressed patient I feel that our approach should be
eclectic. It should be borne in mind that no one school
of psychiatric thought has a monopoly on effective treat-
ment. Psychobiology has contributed greatly to our
knowledge of depressions. So has psychoanalysis. Neuro-
physiology, neuropathology, electroencephalography, en-
docrinology, and many other branches of medical science
all have had their share in the development of our pres-
ent philosophy of the depressions. Be all this as it may,
there are some general principles which should be fol-
lowed regardless of what particular technical approach
one selects in the treatment of depressions.
First comes the attitude of the physician toward the
patient and the establishment of what is known as proper
rapport. To tell the patient that there is nothing wrong
with him — that he should go home, forget himself, and
take a trip — is to get off to the worst possible start. This
advice, given to many patients suffering from depres-
sion, whatever the cause, not only fails to relieve them
but is actually harmful. It is harmful because it is not
constructive. Inferentially it is destructive criticism and
it merely tends further to depress the patient, and he
either goes to another doctor, a cultist, or he suffers
along with the one who has given him this advice. When
a patient goes to his doctor there really is something
wrong with him and he knows it. It may be an un-
reasoning fear, a phobia, a complex, something purely
functional, or an alcoholic hangover. Yet, to that par-
ticular individual it is something real, and should com-
mand the respect of the physician. A depressed patient
does not have a raging fever, and his symptoms cannot
be heard with a stethoscope, measured with a ther-
mometer, or seen by the X-ray. However, to him they
are none the less real and they mean that he must be
subjected to a most searching investigation of both his
January, 1943
15
psyche and his soma. In no other way can the symptoms
be evaluated.
Proper rapport having been established between the
depressed patient and his physician, it now becomes nec-
essary that the causes and the nature of his depression
be determined. In some cases this can be done at the
time of the first interview. In other cases, it is necessary
to employ a battery of psychological, psychiatric, phys-
ical, and laboratory tests. The presence or absence of
organic causes must be determined. If the depression is
functional (psychogenic) some test such as the Rorschach
may be necessary.
One of the most important decisions to be made is
whether the patient should be managed by a series of
office interviews or whether he should be sent to a hos-
pital. The practitioner’s decision will be influenced by
the duration, severity, and nature of the symptoms, as
well as by the likelihood of suicide. In doubtful cases
it is my practice to err on the safe side and send the
patient to the hospital or sanitarium. I find it more
effective and economical in the long run to hospitalize
a patient at least for a period of observation, than to
dally along with office treatment for several months only
to have to resort to hospital treatment after the patient
has become dissatisfied, discouraged, impoverished, or
has attempted suicide.
If the patient is to be treated by a series of office inter-
views it is important that the doctor set aside enough
time to give due consideration to the problem at hand.
What I have described as "bromide and pep talk” psy-
chiatry often is worse than nothing. Some doctors quote
Thomas a Kempis who said "It will pass. It has hap-
pened before, and if you live long enough, it will happen
again.” However, most depressed patients need some-
thing more than that. They must be seen two or three
times a week, and, some of them, daily. Each interview
requires from one-half to one hour. The patient must
be allowed to discuss his symptoms. The physician must
develop in the patient an interpretive insight into the
true nature and the meaning of those symptoms. Psycho-
desensitization, training in the fundamentals of the phys-
iology of the sympathetic nervous system, the doctrine
of ' 'conversion”, elements of psychobiology, philosophy,
and religion, all must be woven together into the pro-
cedure known as "psychotherapy”. In addition to this,
the patient’s physical condition should be given attention.
Malnutrition should be corrected, bowel function should
be regulated, and physical tension should be relieved by
the use of mild sedatives, frequently changed. For pa-
tients who are not sufficiently intelligent to grasp the
psychological and psychiatric principles involved, some
form of suggestive therapy in the form of high fre-
quency currents should be employed. (I sometimes sus-
pect that some of the marvelous cures attributed to vari-
ous hypodermic and intramuscular injections are the
result of suggestion. Something is being done for the
patient.) The important thing to remember is that no
single procedure can cure the patient. The patient is
cured by the cooperative and cumulative effect of a
variety of procedures, properly coordinated and admin-
istered according to the best knowledge, skill, and judg-
ment of the physician.
If the patient is definitely suicidal or if, as in many
cases, there are indications that he should be separated
from his family and friends, he should be sent to a hos-
pital, preferably one that is equipped to care for psychi-
atric cases. In the hospital the same psychotherapeutic
procedures are carried out as in office practice. However,
we now are in a position to take advantage of a number
of adjuncts to office procedure. These are physiotherapy
in the form of hot baths, packs, and continuous tub;
electrotherapy; dietotherapy; bibliotherapy; occupational
and recreational therapy; and a number of others. Each
one of these adjuncts is under the direction of a therapist
trained in that particular field, and each activity is cor-
related with the others into an integrated program. In
addition to the above, the several forms of shock treat-
ment can be used. Time will not permit a discussion of
the various types of shock therapy, but, as far as the
depressions are concerned, I favor electroshock. Electro-
shock is a form of convulsion therapy that has super-
seded Metrazol. It induces convulsions that are shorter,
safer, less distressing by the reason of the patient’s com-
plete amnesia for the treatment, and more effective than
any form of convulsion therapy with which I am fa-
miliar. There are other psychiatric conditions in which
insulin and other forms of shock therapy are useful, but
in the affective states I have obtained the best results
with electroshock. However, it is not a specific, and, in
spite of all the modern refinements and additions to the
treatment of depressed patients, psychotherapy still is
the principal foundation stone.
In conclusion I wish to emphasize the following points.
1. A depressed patient is really sick.
2. His sickness may be organic or it may be psycho-
genic.
3. The type of depression usually can be determined.
4. The technic of managing depressions is just as
objective and as rational as any other therapeutic
procedure.
5. No physician should undertake the treatment of a
depressed patient unless he has a clear idea of
what he is treating and of what procedure to
follow.
6. A depressed patient cured is among the most
grateful of all human beings.
References
Beck, S. J.: Introduction to the Rorschach Method, American
Orthopsychiatric Association, 1937.
Kamman. G. R.: Some painful conditions about the head and
face, Journal-Lancet 60:111-114 (March) 1940.
Lemere, F.: Diagnosis and treatment of mild depression, North-
western Medicine 38:177-180, 1939.
Reynell, W. R.: Depression, The Practitioner 1 37:49-69, 1936.
Kamman, G. R : A type of chronic nervous depression in women
relieved by the administration of thyroid extract, Minnesota Medi-
cine 22:97-100, (Feb.) 1939.
Strecker, E. A., Ebaugh. F. G.: Clinical Psychiatry; Philadel-
phia: Blakiston, 1935.
16
The Journal-Lancet
Fifty Years of Students* Health Work
Robert T. Legge, M.D.'j'
Berkeley, California
TO chronicle the development and promotion of
the student health movement in American col-
leges is of historical interest. The modern stu-
dent health movement resulted from the advancements
in scientific curative and preventive medicine, and the
trend of modern sociology, and evolved from the gym-
nastic or anthropometric stage. Thence it progressed to
the sanitation period, and on to the present organizations
providing a service for the health of all students by a
sustained program of health education, prevention of
illness, and the care of the sick.
From the great period of Pericles in Ancient Greece
down through the ages the athlete was a living symbol
of health. In the Scandinavian and Germanic countries
mass gymnastic exercises were cultivated. These later
were introduced and became popular in this country dur-
ing the twenties and thirties of the nineteenth century,
first at Harvard, then at Yale, Amherst, Williams, and
other New England colleges. After Folin of Harvard
introduced gymnastics, there sprang up gymnasiums on
many college campuses, which were the pioneer labora-
tories for determining the future need of health pro-
grams for college students. The historian of physical
education, Eugene Leonard of Williams, is said to have
stated that "our students for the lack of exercise will
no longer leave college with emaciated frames and coun-
tenances.” As earnest workers were developing health
values, perceived through the teaching of physical cul-
ture in wholesome activities promoting neuromuscular
skills and interest in play and recreation, the develop-
ment of new social and moral standards was also
achieved.
As early as 1856 President Stearns of Amherst Col-
lege realized the fact that the students of our colleges
demanding higher education have bodies, too, which
need care and culture. In 1859, through his recommenda-
tions, the Barrett Gymnasium was erected and Dr. Ed-
ward Hitchcock became the first appointed professor of
physical culture and hygiene. It is of particular interest
to review the duties of the director during that pre-
Pasteur era: He was to teach gymnastics, oversee the
general health of the students, and teach elocution, hy-
giene, and physical culture. After sixteen years of labor,
in 1877 Dr. Hitchcock published his first monograph,
entitled The Hygiene at Amherst College, in which he
stated that the principal health activity consisted of vari-
ous body exercises. To prove that this requirement was
not irksome to students, whereby they would shirk his
department, it was found by statistical evidence, that,
comparatively, the attendance at the gymnasium was 84
per cent and at the Chapel 80 per cent. Lectures on
*Read before Pacific Coast Section of the American Student
Health Association meeting at the Semi-Centennial Celebration of
Stanford University.
f Professor of hygiene and university physician (Emeritus), Uni
versity of California
hygiene and elementary anatomy were provided for the
entering freshmen.
Observations showed the time lost by illness per stu-
dent annually had been 2.64 days. During this period
forty-eight students, an average of three annually, had
left college because of such physical disabilities as con-
stitutional disability, typhoid, consumption, injured eyes,
and other infirmities. Of the sixteen deaths that occur-
red, ten were from typhoid, two from consumption. The
fact that typhoid had been the principal cause of death
at Amherst he used for a comparison with the Massa-
chusetts mortality tables, finding that 28 per cent of all
deaths had been due to the zymotic class in which
typhoid fever is placed, and that typhoid stood fourth
in order of all causes, consumption, pneumonia and old
age outranking it in the number of victims. Still fur-
ther, this observer noted that 42 per cent of the deaths
from this cause occurred between the ages of 15 and 30
years, the average Amherst student being just over 21
years. Forty-four per cent of these deaths occurred dur-
ing the months of September, October, and November,
a large part of the college term. His conclusions from
this study were that, "as the students are not at home,
and are at the daring and inconsiderate age, it seems a
wonder that there has not been rather more than less
of this malady among college students.” Dr. Hitchcock
then reports the maladies which had visited Amherst,
recorded in order of their frequency which is of interest
to this 1941 assemblage; note the nomenclature and the
diseases of yesterday, to wit: colds, including lung fever
and influenza (35 per cent), physical accidents, boils
and eye conditions being most prevalent. He also reports
in a decreasing ratio of such numbers as fibricula, ty-
phoid, quinsy, debility, mumps, bilious fever, diphtheria,
stomach irritation, intermittent fever, measles, etc. He
is of the opinion, further, that the work in gymnastics
was beneficial to his students; that they carried them-
selves in their walk with more erectness and elasticity,
not to say grace, than did the former students at college,
and that it had done much to improve their health. He
introduced the play spirit in this work, but failed to re-
port how elocution benefited a college health program.
In recognition of Dr. Hitchcock’s pioneer work in stu-
dent health, the American Student Health Association
in 1932 awarded Amherst College a memorial, the pre-
sentation being made by Professor Raycroft of Princeton
University.
It can be safely stated that, from Hitchcock’s pioneer-
ing era to this day, medicine has made greater progress
than in all preceding time since man appeared on our
planet. The foundation was laid in the discovery of the
causes of infectious diseases and immunity, making pos-
sible modern surgery, public health, and preventive medi-
cine. These discoveries opened every avenue of medicine,
created the inductive, in contrast to the speculative,
January, 1943
17
method of reasoning by experimentation, and as a result
the period of longevity and happiness of mankind was
progressively increased. Likewise student health became
a reality.
During these various decades it was natural that sani-
tation should be linked with the physical culture pro-
grams; thus sanitary inspections to control smells and
miasmas were maintained. Health lectures were pio-
neered by Dr. Jackson as early as 1818 at Harvard, in
1834 at Horace Mann State Teachers College, in 1836
at Mt. Holyoke, in 1854 at Williams, in 1859 at Am-
herst and in 1865 at Vassar. Other institutions of learn-
ing followed. Several colleges introduced practical mea-
sures endeavoring to control infectious diseases; quaran-
tine was instituted, and later, in the beginning of the
twentieth century, elementary bacteriology was taught
in the health programs. Some colleges employed a physi-
cian to be on call in the event of an emergency. It was
during this era that men with medical degrees were
attracted by the idea of teaching, becoming professors
of physical education and hygiene: men such as Mc-
Kenzie of Pennsylvania, Raycroft of Chicago, Sargent
of Harvard, Reinhardt of California, and Storey of the
College of the City of New York, whose contributions
paved the way for the student health services of today.
I am paying my respects to my predecessor, Dr.
George F. Reinhardt of Berkeley, in saying that with his
foresight, experience, and untiring effort he laid the
foundation of the twentieth century, modern students’
health service at the University of California. Reinhardt
in 1895 became assistant in the department of physical
culture at the University of California. It was in this
field that he received the inspiration that caused him to
study medicine, and upon receiving his degree in 1902
he became assistant in medicine, and in 1906 Professor
of Hygiene and University Physician. That same year the
great fire and earthquake took place in San Francisco.
The emergency needs of this time gave him the impetus
to establish the pioneer infirmary on the campus, where
students could receive examination and early treatment
at the dispensary and were provided with bed care under
the same roof. He had realized from his experiences in
physical education that, while the results included im-
proved functional health, physical education could not
control communicable diseases nor establish immunity
against infection. The health service was then supple-
mented by a compulsory course in informational hygiene;
and so was developed a college infirmary which cor-
related functional body building and health education
with curative and preventive medicine. To be able to
control infectious disease, to observe patients when dis-
ease is curable, in the early stages before grave path-
ology ensues, is modern preventive and curative medi-
cine. In Reinhardt’s first Report to the President of the
University of California in 1906 he said: "The existence
of such a system would be an immense relief to the
mind of every student of limited resources; a great com-
fort to all parents and the means of saving many lives.”
After his death in 1914, his successor £ developed from
this excellent beginning a group specialist’s staff, and
JDr. Robert T. Legge.
organized a standardized hospital and out-patient de-
partment which culminated in the planning and building
of the Cowell Memorial Hospital Health Service, an
almost ideal organization.
Time and space do not permit listing all the outstand-
ing health services in the various universities, whose di-
rectors and staffs have contributed much in research and
have developed a system of preventive and curative prac-
tice which constitutes a triumph of American medicine.
McCosh Infirmary at Princeton, 1892, University of
Michigan, 1913, Yale, 1916, Minnesota, 1918, Wash-
ington, 1916, et al., are some of the fine examples of
well equipped, well staffed infirmaries for sick students.
In passing, one cannot but pay tribute to the men and
women who, as pioneers, have made such valuable con-
tributions and have made possible the perfecting of stu-
dent health activities in the colleges of this country: such
men as Drs. Bradshaw, Canuteson, Chenoweth, Diehl,
Forsythe, Ferguson, Hall, Kingsford, Raycroft, Reed,
Smiley, Shrader, Shepard, Storey, and Sundwall. The
women physicians, too, not to be forgotten, are Drs.
Baldwin, Boynton, Cunningham, Gove, Paroni, Rea,
Richardson, and Snow, whose administrative services and
publications on problems of health of college women
students are contributions of much merit.
The American Student Health Association was ini-
tiated on March 4th, 1920, when twenty representatives,
interested in student health in American colleges, met
at Chicago. The first annual meeting was held on De-
cember 31st, 1920, in the same city, with fifty-three col-
leges listed as charter members. Today about two hun-
dred institutions are represented in the membership. To
provide opportunities for more schools to participate in
this field, fifteen local sections have been organized.
These hold annual sessions. The Pacific Coast Section
includes California, Oregon, Washington, Nevada,
Idaho, and Arizona. It was organized and held its first
meeting on December 2, 1933, on the campus of the
University of California with Dr. R. T. Legge as presi-
dent and Dr. T. A. Storey as Chairman of the Organiza-
tion Plan.
Student Health Work is an American activity but its
success and influence has stimulated interest in other
countries. Already four international university confer-
ences devoted to this field have been held in Europe. At
Syracuse University in New York state in 1931, under
the sponsorship of the President’s Committee of Fifty
on college hygiene, the American Student Health Asso-
ciation and the National Council of Health held its first
conference. The meeting was called by the late Presi-
dent Livingstone Farrand of Cornell University. This
historic meeting made a profound impression on admin-
istrative officers of our colleges in regard to the impor-
tance of the organization of health for students. To
attempt to cite the able contributions in research, teach-
ing, and administration procedures offered by members
of the parent association would be in vain, as the content
would fill many volumes. To mention three alone will
suffice to show the quality of the productions: a sum-
mary of the study of Longevity of College Athletes,
18
The Journal- Lancet
The American Youth Commission report on Health of
College Students, and The Committee Study on Tuber-
culosis among Students.
What stands before us in the future? This is a mat-
ter dependent on whether the present world’s upheaval
will end in retrogression and return to a period of me-
dievalism, or whether democracy will survive and the
present advancement in science be maintained. The
knowledge we have acquired through research and ex-
perience can only be salvaged and advanced under con-
ditions of peace in a world devoted to the social well-
being of mankind. As man is the greatest asset in the
world, all efforts must be devoted entirely to his better-
ment, and the sciences of medicine, sociology, economics,
politics, and jurisprudence must be devoted to the most
vital problem the world has ever undertaken.
In conclusion, it is a privilege to participate with this
great institution of learning in its semi-centennial cele-
bration. We pay our respects and extend our greetings.
With pride we congratulate President Ray Lyman Wilbur
and his faculty on this occasion. We shall always remem-
ber the many men and women, members of our society,
who received their education in these halls, and the fac-
ulty who have contributed much to the health activities
of college students, names which we revere such as Drs.
Thomas D. Wood, Ray Lyman Wilbur, William Snow,
C. W. Hetherington, Thomas A. Storey, Walter H.
Brown, Charles E. Shepard, Clelia D. Moser, and such
graduates as Lillian R. Titcomb, E. H. Coleman, Bertha
and Marshall Mason, D. S. MacKinnon, and others.
Hail Stanford University! Accept our salutations for
the next fifty years of progress.
International Society of Surgery Reorganized
By a vote of the delegates from all of the affiliated societies
of the Americas, representing Argentina, Brazil, Canada, Cuba,
Ecuador, Guatemala, Mexico, Paraguay, Peru, United States,
Uruguay and Venezuela, the headquarters of the International
Society of Surgery was provisionally transferred from its Euro-
pean headquarters in Brussels, Belgium, to the United States.
More specifically, the headquarters have been established in the
Inter-American Division of The New York Academy of Medi-
cine in New York City.
In explaining the need for the change in headquarters, Dr.
Rudolph Matas of New Orleans, Acting Secretary and Treas-
urer of the International Society of Surgery, said:
"The German occupation of Belgium and the Nazi devasta-
tion of the rest of Europe and all the other war torn nations,
had virtually restricted the international relations of the Society
to the Western Hemisphere where its fellowship is widely
spread through its affiliated branches in North, Central and
South America.
"The Executive Committee of the United States Division,
the largest, most active contributor to its transaction, felt it
their duty conjointly with their Latin American colleagues to
rescue the Society out of the perils of the European conflagra-
tion. The first steps were taken November 1941 at Boston but
no final action could be taken to transfer the official sanctum in
Brussels to America without the concurrence and approval of
all the affiliated branches in America.”
The act by which the transference of the International So-
ciety of Surgery from Europe to the United States was effected,
was signed either personally or by proxy by the delegates from
all the affiliated societies of the Americas.
By the action of the Council of Delegates, the official seat of
the Society will be established in the Inter-American Division
of the New York Academy of Medicine, directed by Dr. Mah-
lon Ashford, where Dr. Enrique J. Cervantes, assistant secre-
tary-treasurer of the executive committee, editor of America
Clinica, the official organ of the society, and editor and sec-
retary of the Hispanic-American Medical Society, will be able
to render service to the Fellows of the Society and medical vis-
itors hailing from the Latin American countries.
The affairs of the International Society of Surgery are to be
administered by an executive committee composed of the fol-
lowing: Dr. Elliott C. Cutler, Col. M. C., U. S. Army, Chair-
man in Absentia, Dr. Eugene Pool, Dr. Arthur W. Allen and
Dr. Rudolph Matas, Acting Secretary and Treasurer.
The meeting was presided over by Dr. Eugene Pool, who
serves as acting chairman of the executive committee for the
United States, in the absence of Colonel Elliott C. Cutler, now
at the front.
Dr. Jose Arce, Dean of the University of Buenos Aires, will
serve as acting president of the International Society of Surgery
in the absence of Professor L. Meyer of Brussels, detained in
Belgium by Nazi compulsion.
The revision of the constitution adopted on Thursday, No-
vember 12, 1942, was prepared by Dr. Rudolph Matas of New
Orleans, former president of the Society and now acting secre-
tary-treasurer. A representative group of Fellows from New
York and elsewhere signed the Act of Reorganization, as wit-
nesses of the signing of the Act by the delegates of the Gov-
erning Council, among whom were Dr. Mahlon Ashford, di-
rector of the Inter-American Division of the Academy, Dr.
Archibald Malloch, librarian of the New York Academy of
Medicine; as fellows and guests were Drs. Walter Estell Lee
of Philadelphia, Russell S. Fowler, Ralph Colp, Edwin G.
Ramsdell, Frederick W. Bancroft, Howard Lillienthal, Charles
Elsberg, Seward Erdman, Carl Eggers, Henry Lyle and others
elsewhere, by proxy.
The establishment of an Inter-America Division of the New
York Academy, directed by Dr. Ashford, with the opening of
the editorial offices of A merica Clinica, the most widely read of
Spanish-Portuguese medical publications in South, Central
America and Mexico and the opening of an Inter-American
Bureau to render a free service for medical information, has
proved probably the most valuable of all the practical contri-
butions that the United States has made to the cause of Latin
American good will and friendship.
January, 1943
19
Psoriasis of the Nails Producing an Arthritis-like
Picture
Report of a Case with a Seven-Year Follow-up
Le Moyne Copeland Kelly, M.D., F.A.C.P.
New York City
A GREAT deal has been written regarding the
relationship of arthritis and psoriasis and there
has been considerable controversy in the literature
as to whether or not psoriatic arthritis is a definite clin-
ical entity.'1’*'’'4 Alibert,1’ one hundred twenty years ago,
was the first to call attention to the occurrence of joint
pains in psoriasis, and in 1860 Bazin4 differentiated rheu-
matism with psoriasis from that without associated skin
lesions. At the turn of the century, Adrian1 reviewed
the subject thoroughly and did much to establish it as
a syndrome. Since then several contributions have ap-
peared yearly, mainly by foreign authors. A compre-
hensive study of the literature discloses only a few reports
from this country. One of them is by O'Leary1 1 who
saw 8 cases of arthritis in 1400 patients with psoriasis
at the Mayo Clinic. One of them was reported in detail
by Hench."2 In 1938, Dawson and Tyson' analyzed
1000 cases of rheumatoid arthritis and found 26 cases
of psoriasis — whereas, in the same number of osteo-
arthritics they found only three. This led them to con-
clude that there must be a direct relationship between
rheumatoid arthritis and psoriasis, while in the hyper-
trophic type the association is, probably, purely coinci-
dental. Twelve cases were considered to be "classical”
in that they showed the clinical features and X-ray
changes usually associated with rheumatoid arthritis, and
two-thirds of these had involvement of the nails. In
75 per cent of all of their cases with psoriasis, the skin
lesions preceded the development of the arthritis by a
considerable period.
Crawford,1’ in studying more than 200 cases of pso-
riasis without arthritis, found that half had lesions in
the nails, the finger nails being affected twice as often
as the toe nails. He frequently observed disturbances
in the nail bed and stated that treatment of the nails
was of little avail until attention was directed to the dis-
ease as a whole.
Diagnosis
Hench et al13 maintain that true arthropathia psori-
atica is the result of a long continued and uncontrolled
psoriasis and that it usually develops months or years
after the onset of skin lesions. They state that, as a
rule, it is an asymmetrical peripheral arthritis in which
the terminal phalangeal joints of the fingers and toes
are most frequently involved. Garrod and Evans40 feel
that the diagnosis depends principally on the close rela-
tionship in time between the increase and subsidence of
both skin and joint manifestations. They state that
severe and symmetrical involvement of the fingers and
toes is common and characteristic and in the proportion
*From the arthritis clinic, Knickerbocker Hospital, New York,
New York.
of five females to one male. O’Leary1 1 says that the
parallelism between the severity of the skin and joint
symptoms seems to support the theory that the^"arthritis
is due to toxic products absorbed from these skin lesions.”
White10 states that "psoriasis of the nails is character-
ized by punctuate erosions or small thimble-like depres-
sions which by their very multiplicity can be distinguished
from the nail changes in syphilis.” He believes that these
erosions prove incontestably that this is a disease of in-
ternal origin which begins in the matrix of the nail and,
after passing through an erythrodermic phase, attacks
the soft tissues of the fingers. This opinion is shared by
Biischer.4
Discussion
Popp and Addington ls reported 24 cases of psoriasis
of the nails (8 in the hands alone and 16 in the hands
and feet) , in which the symptoms had persisted for an
average duration of seven years. In nine of these (38
per cent) the appearance of skin and nail lesions aggra-
vated previously existing rheumatic symptoms. However,
roentgenographs showed only periarticular swellings.
There were no changes of any kind in the underlying
bone. Of eighteen patients given X-ray therapy six had
complete remission of nail changes and four of these
also reported relief from joint symptoms. Ten others
were much improved and the benefits lasted from six
months to five years.
Case History
A 28 year old barber was first seen in an arthritis clinic in
October, 1935, at which time he gave the story that he had
been well until about four years previously, when, after an
appendectomy, he noticed fleeting pains in his finger joints.
These gradually increased in frequency and had become much
more severe in the preceding six months. The patient com-
plained also of some pain in his neck, shoulders, back and feet.
Physical examination revealed a scaly, silver-white rash on the
elbows and behind the ears, and some roughening and pitting
of the nails. The tonsils and left antrum were found to be
infected. His heart and lungs were normal. The tips of the
fingers were swollen and tender and the nails were surrounded
by a dull red zone of inflammation in the soft tissues. Labora-
tory examinations at that time revealed a normal sedimentation
rate. This test was repeated at regular intervals and was never
elevated. The uric acid was 3.6 mg. per cent; roentgenographs
of the teeth and chest were negative. The fingers showed only
soft tissue swelling without any changes in the bones. A diag-
nosis was made of possible early rheumatoid arthritis with pso-
riasis and treatment was instituted. The tonsils were cleanly
removed by dissection and snare in November, 1935, and soon
after this a left antrotomy was done.
Thereafter, the patient was not seen again for a period of
two years, whereupon he returned complaining of an increase
in the pain in the fingers, associated with an exacerbation of the
psoriatic lesions in his nails. The roentgen-ray examination of the
fingers still showed no bony change. Six months later he stated
he was much better; but, at his next semi-annual check-up he
20
The Journal-Lancet
Fig. i •
reported that "the ends of his fingers were just as painful as
ever.” We decided at this time to try some general X-ray ther-
apy. Accordingly, he received 28 treatments over a period of
14 months, but this was without apparent benefit. Since no
treatment had proven effective in this case during a time inter-
val of five years, and since benefit from chrysotherapy had been
reported in a few cases showing both arthritis and psoriasis,
,'SI we then began a course of gold salts. This consisted
of 1025 mg. of myochrysine (gold thiomalate) administered
over an interval of four months. However, at the end of this
time the drug was discontinued in view of the fact that its only
effect seemed to be to aggravate the pain. He was also placed
on a low fat, high vitamin diet as suggested by Madden,1'' but
there was no change in his symptoms or in the character of the
lesions.
Summary
1. Certain patients with psoriasis have definite ar-
thritis. Others have only joint pains without demonstra-
ble changes in the underlying bone.
2. As a rule, appearance of the skin and nail lesions
antedates the joint symptoms by a considerable period.
Whether or not there is a causal relationship between
the two diseases is still in question.
3. Psoriasis can, in some individuals, cause such
marked changes in the nail bed and disturbances in cir-
culation that the patient may complain of "arthritic
pains” in the hands. It is important to differentiate these
cases from true arthritis as the prognosis and treatment
vary widely.
4. In general, local treatment of the psoriasis in the
nails is of little avail. The therapy must be directed to
the disease as a whole.
5. To date, this patient has not responded to any of
the accepted methods of therapy.
References
1. Adrian, C.: Mitt. a. d. Grenzgeb. d. Med. u. Chir.
1 1:237-83, 1903.
2. Alibert (quoted by O’Leary).
3. Bazin, A.: Affections Cutanees Paris, 154, I860.
4. Biischer, B. : Rontgenpraxis 11:288 (May) 1939.
5. Castex, M. R., Maggi, A.. Lorenzo, R.: Bol. Acad. nac. de
Med. de Buenos Aires, p. 658 (Sept.) 1939.
6. Crawford, G.: Arch. Derm. &C Syph. 38:583 (Oct.) 1938.
7. Dawson, M. H., and Tyson, T. L.: Tr. A. Am. Physicians
53:303, 1938.
8: Ferond, M.: Bruxelles - med. 17:375 (Jan. 10) 1937.
9. Francon, F.: Rev. beige sc. med. 11:109 (March) 1939.
10. Garrod, A. E., and Evans, G.: Quart. J. Med. 17:171
(Jan.) 1924.
11. Gouin. J., and Bienvenue, A.: Bull. soc. franc, de dermat.
et syph. 46:55 (Jan.) 1939.
12. Hench, P. S.: Proc. Staff Mayo Clinic 2:90 (April 27)
1 927.
13. Hench, P. S., Bauer, W., Boland, E., Dawson, M. H..
Freyberg, R. H., Holbrook, VOL P., Key, J. A., Lockie, L. M.,
McEwen, C.: Eighth Rheumatism Review, Ann. Int. Med. 15:1066
(Dec.) 1941. . „ 4
14. Jeghers, H., and Robinson, L. J.: J.A.M.A. 108:949
(March 20) 1937.
15. Madden, J. F.: J.A.M.A. 1 15:588, 1940.
16. Marin, A., and Boulais, F. L.: Can. M. A. J. 29:189
17. ^ O’Leary, P. A.: Proc. Staff Mayo Clinic 2:89 (April 27)
1 927.
18. Popp, W. C., and Addington, E. A.: Radiology 36:98
(Jan.) 1941.
19. White, C.: Urol. &C Cut. Rev. 42:592 (Aug.) 1938.
20. Zitske, E.: Dermat. Ztschr. 63:249 (March) 1932.
January, 1943
21
Relief of Colonic Obstruction
Harry W. Christianson, M.D., F.A.C.S.
Minneapolis, Minnesota
COLONIC obstruction frequently presents a per-
plexing problem because of the difficulty in de-
termining the cause and location of the obstruc-
tion and of the knowledge that a quick decision must
be made if one is to obtain either temporary or lasting
benefit to the patient.
Usually the patient is seen for the first time with a
greatly distended abdomen and it is vitally important
that the nature and location of the obstruction be de-
termined without delay so that the necessary treatment
may be instituted. The obstruction may be caused by
conditions in the upper intestinal tract, the lower intes-
tinal tract, or by such extrinsic factors as tumors outside
the intestinal tract, strangulated hernia, mesenteric
thrombosis, as well as factors of neurogenic origin. To
reach such a conclusion a careful evaluation of the his-
tory and symptoms is essential and this in correlation
with the roentgenographic studies, proctoscopic examina-
tion, et cetera, should determine the location and nature
of the obstruction.
'If a patient gives a history of a sudden onset with
severe pains and accompanying symptoms of intestinal
obstruction, one should be suspicious of a strangulated
internal hernia, mesenteric thrombosis, or volvulus. If,
however, the history is one of increasing constipation or
constipation alternating with diarrhea or bleeding with
a bowel movement, a sigmoidoscopic examination should
be made immediately, as in all probability, these symp-
toms are caused by a growth in the rectum or the distal
portion of the sigmoid. Barium by mouth definitely is
contraindicated in such cases because the administration
of barium would tend to impede any method of reliev-
ing the obstruction by a simple treatment and might
result in the death of the patient if an operation were
undertaken.
The Wangensteen suction and the Miller-Abbott tube
have given relief in many of these conditions. There is
also a method, to be described later, which I have found
successful in several cases which had not been relieved
by either of these treatments.
If immediate relief is not obtained by the above meth-
ods, especially when the obstruction occurs in the large
bowel, colostomy, cecostomy or appendecostomy should
be performed without delay. It is a well known fact
that if an obstruction in the large bowel is not relieved
it is apt to cause a perforation of the cecum, as anatom-
ically the cecum is the weakest portion of the large
bowel and is, therefore, the site of perforation due to
distention of that portion. Occasionally a colostomy
fails to relieve the distention due to an obstructing growth
located caudal to the colostomy and a perforation of the
cecum results. For this reason it is well to remember that
if the right side of the bowel is still distended after a
colostomy has been performed and the non-operative
methods have failed to give relief, cecostomy or appende-
costomy should be done immediately. The explanation
of the distention of the right portion of the bowel fol-
lowing a colostomy is considered by many to be due to
a kinking of the bowel resulting in retention of gas in
the cecum.
Recently I have seen three cases of intestinal obstruc-
tion caused by a carcinoma of the rectosigmoid or the
distal portion of the sigmoid. These cases were seen for
the first time when the patients were in an almost mori-
bund condition with large distended abdomens.
Sigmoidoscopic examination revealed growths in the
rectosigmoid or distal sigmoid which completely obstruct-
ed the lumen. In each of these cases I was able to pass
a catheter into the lumen of the bowel beyond the mass
and in each case the obstruction was relieved by a vio-
lent expulsion of gas and feces through the tube. After
the catheter was passed beyond the obstructed area it
was fixed in place and frequent warm irrigations and
suctions were used to keep the tube open and the bowel
irrigated.
On two of these cases the Wangensteen suction ap-
paratus had been used without relief and the Miller-
Abbott tube had been inserted in the other case but ap-
parently it had not passed through the duodenal cap.
In one case the distention had completely disappeared
by the following day and in a few more days we were
able to restore the fluid and electrolyte balance making
it comparatively safe for a colostomy. The other two
patients refused operation but they have been free from
obstruction for a period of several months.
It is my contention that many cases of intestinal ob-
struction due to carcinoma of the rectum, rectosigmoid
or distal colon can be relieved quickly by this method.
The obstruction in many cases is brought on by edema
and infection of the growth which can be greatly dimin-
ished by warm irrigations through the catheter. This
method is only applicable in cases where the growth is
within reach of the sigmoidoscope and much care must
be exercised in passing the catheter so that it will not
penetrate the bowel wall as the carcinomatous tissue is
very fragile.
22
The Journal- Lancet
The Medical Aspects of Dental Health
in Childhood
E. S. Platou, M.D.
Minneapolis, Minnesota
MUCH has been written and said about the med-
ical aspects of dental health in childhood, but
such an important subject can hardly be over-
emphasized. Maldevelopments and defects have their
onset and perhaps their greatest effects on health in the
formative years and the responsibility for proper prophy-
laxis and care should fall to the lot of physicians and
dentists jointly.
It is beyond the scope of this discussion to more than
mention such extremely formidable factors as healthy
genetical anchorage and proper antepartum prophylaxis
in dental health. The former is all too frequently defi-
cient as is evidenced by common anomalies of develop-
ment and dento-facial deformities. Since all the decidu-
ous teeth are partially calcified at birth and even the first
permanent molars calcify soon thereafter it is obvious
that prenatal influences likewise have an important bear-
ing on proper odontoblastic, ameloblastic and other func-
tions that are vital to sound teeth.
From earliest infancy, defects which are manifest or
those which progress insidiously deserve the most care-
ful cooperation of dentist and physician. Deformities,
developmental defects, congenital disease and deficiency
states are no doubt our first consideration. It has been
repeatedly demonstrated that dental hypoplasia and
caries can be influenced by diet and that children with
"optimum” nutrition have less of such defects than those
with ordinary or poor nutrition. The so-called "coeliac”
type of diet with extremely high protein, monosaccharide
and vitamin values (meat, egg, dairy products, banana,
simple fruits, vegetables and cod liver oil) has been
shown to better effect "optimum” nutrition than one rich
in starches, fats and complex carbohydrates. Balance
studies have further demonstrated that such a diet is
adequate in calcium, phosphorus and iron and that ex-
cessive ingestion of these elements in some forms at least
may result in reciprocal losses in the body which may
become detrimental.
In spite of our increased knowledge regarding nutri-
tion, we find as in other applications of fact that prac-
tice is axiomatically slow. Adherence to a diet of essen-
tials over the long period necessary for good results is
difficult and the desires and whims of a child usually
come to take precedence all too often. We must, there-
fore, remind our patients that calcification of the teeth
is now regarded as a more or less continuous process.
Biochemical changes from deficiency states, deformities
and disease may not be evident in the tooth until very
late.
The physician must be especially concerned with the
known effects of inadequately treated prenatal disease,
with refractory anemia and rickets attendant to pre-
maturity and even with rickets occurring in apparently
healthy babies receiving cod liver oil. Other vitamin de-
ficiencies though quite uncommon may have an indirect
effect on dental health.
In the appraisal of a child’s health, one familiar with
normal attributes can and should recognize thyroid, pit-
uitary and other hormonal deficiencies early enough to
preclude by treatment such sequences as late dentition,
poor calcification and early caries.
That these and especially the nutritional inadequacies
mentioned have much to do with the etiology of dental
caries can no longer be denied. A lack of proper bal-
ance of all these factors deprives the enamel of its abil-
ity to oppose the disintegrating effects of acids and bac-
teria in the mouth. The source of these harmful acids
has been the subject of a great deal of speculation. If
they result, as some contend, from the effect of bacteria
on certain complex carbohydrates or on "fractions” of
certain cereal grains fermenting in the oral cavity it
would seem prudent to employ a dietary regimen in
which these possible offending factors have been elim-
inated before consumption.
If caries has already begun in a child lacking in "op-
timum” nutrition complete cooperation on the part of
dentist and physician is especially important.
Correction of nutritional and endocrine faults and of
diseased states affecting the child’s teeth may task the
ingenuity of one well equipped to understand child
health. Painstaking operative dentistry on deciduous
teeth and careful orthodontia have become recognized as
fundamentals in a sound foundation for general health.
The pathologic results of dental caries on the human
organism are of course immediate and remote and the
loss of effective masticating surfaces not only interferes
with proper trituration of food but leads eventually to
pulp decay and loss of the tooth.
Infected teeth and alveoli serve as potent sources of
disease and may be the cause of profoundly debilitating
states. Despite the fact that the permanent teeth depend
on the deciduous teeth for jaw growth and prevention
of caries, when one is confronted with the question of
removal of deciduous teeth before their natural time for
exfoliation, it must be remembered that early removal is
much to be preferred over possible disability from sys-
temic invasion of bacteria.
If we will regard sound teeth as but one index of well
ordered skeletal growth and treat them with the same
care as we would any other skeletal part we will have
done much to advance child health in general.
Serves the
MINNESOTA, NORTH DAKOTA
Medical Profession of
SOUTH DAKOTA and MONTANA
American Student Health Ass’n
Minneapolis Academy of Medicine
Montana State Medical Ass’n
The Official Journal of the
North Dakota State Medical Ass’n
North Dakota Society of Obstetrics
and Gynecology
South Dakota State Medical Ass’n
Sioux Valley Medical Ass’n
Great Northern Ry. Surgeons’ Ass’n
Montana State Medical Ass’n
Dr. E. D. Hitchcock, Pres.
Dr. A. C. Knight, V.-Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Ass’n
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, V.-Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, V.-Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, T reas.
ADVISORY COUNCIL
North Dakota State Medical Ass’n
Dr. A. R. Sorenson, Pres.
Dr. A. O. Arneson, Vice-Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Ass’n
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, V.-Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Ass’n
Dr. N. J. Nessa, Pres.
Dr. J. C. Ohlmacher, Pres.- Elect
Dr. D. S. Baughman, Vice-Pres.
Dr. C. E. Sherwood, Secy.-T reas.
Great Northern Railway Surgeons’ Ass’n
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. J. H. Fjelde, Pres.
Dr. E. H. Boerth, V.-Pres.
Dr. R. E. Leigh, Sec. -Treas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. J. F. D. Cook
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. A. R. Foss
Dr. W. A. Fansler
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secrttary
LANCET PUBLISHING CO., Publishers
W. A. Jones, M D., 1859-1931 84 South Tenth Street, Minneapolis, Minn.
W. L. Klein, 1851-1931
Minneapolis, Minnesota, January, 1943
LOOKING AHEAD
The Year 1943 finds many Journal-Lancet readers
in military service. They are making personal sacrifices
in having temporarily given up their chosen work and
locations. At the same time, they are contributing enor-
mously to the war effort. Many of them will have op-
portunities to gain experience which could be afforded
in no other way and, thus, their communities will be
greatly benefited on their return.
In the absence of these physicians, those who remain
at home because of age, physical disabilities, etc., must
do much more work in order to provide adequate care
for the sick and to keep communicable diseases under
control. Even they will learn through the large volume
of medical work being conducted in various branches of
the military service, at home, and in defense plants.
Physicians, whether in the military service or not, will
be made better because of sacrifice, hard work, and
opportunities to learn. Thus, we look forward to the
time when members of the medical profession are re-
assembled, each in the place of his choosing throughout
the nation, relieving suffering and increasing the length
of human life.
In extending its best wishes for 1943, the Journal-
Lancet promises to put forth every effort to present to
its readers authoritative and timely articles.
J. A. M.
MORALE IN 1943
This thing we call morale, what is it? A state of
mind which may be good or bad, according to circum-
stances. It may be called normal when an individual,
through self-control, can maintain a healthy mental
attitude toward his surroundings, in any circumstances.
We shall need a lot of it this year in this country, when
stresses and strains will predominate. Our armed forces,
24
The Journal- Lancet
in constantly increasing numbers, are all over the world
and everything points to the fact that it will be a year
of maximum effort on their part to wage offensive and
effective combat against heavy resistance by relentless
and fanatically driven foes who until very recently have
been stimulated by almost unbroken successes. Inevitably
there must be heavy losses in our forces, keenly felt by
every family in the land, since each one, even now, has
a relative or a friend directly involved in the conflict. Of
the ultimate outcome there can be no doubt; anyone with
pencil and paper can figure it out, as the New York
Times did long before the end of the last war. What
we are concerned with is what will happen in the mean-
time, and afterwards, especially if, as seems most likely,
it is a long drawn out affair.
History affords an extreme example in the case of the
Black Death, which, in the Middle Ages, wiped out one-
fourth of the population of England and Central Europe.
The people, stunned and staggering, were an easy prey
to mass hysteria which manifested itself as a curious
religious frenzy known as dancing mania. A wave of
spiritualism swept over England after the last war. Many
people believed that the sudden snuffing out of young
lives must thin the veil between this life and the next
and eagerly grasped the chance to try to communicate
with their loved ones. It is nothing new for those who
have been through prolonged harrowing experiences to
turn to bizarre religious practices for mental relief.
The medical profession can render definite service in
the present situation. Every physician who is worthy of
the title is a potential psychologist. Without the ability
to inspire confidence he is helpless to accomplish any-
thing, no matter how competent he may be otherwise.
That is why people often go to him with their personal
problems instead of to a lawyer or a clergyman and since
they know him and trust him he can often do them
more good. He will have plenty of opportunity to use
this faculty during the emergency which now confronts
us and it will be appreciated by those who need it. It
also constitutes a strong argument against socialized
medicine, for the impersonal service of that type of
practice has certainly nothing to offer in this connection.
But that is another story. G. C.
LATRINOGRAMS IN MEDICINE
The Army has a nomenclature all its own, very telling
at times, very appropriate. While visiting an airfield
somewhere in our fair land last year, we learned that
rumors in that unique language were known as latrino-
grams.
It strikes you at once as an improvement on the com-
mon term. It is more descriptive, more signifying, a
trifle longer but somehow more pat, and above all, it
definitely suggests a malodorous source.
To a man of science, nothing is nauseating. It may
be stinky, but not nauseating, and in like manner this
holds true of a soldier. A rumor isn’t sickening to him.
He has been warned against propaganda and hears idle
gossip with a becoming attitude of contempt. That is
why he has coined the word latrinogram. It is a splendid
accompaniment to his shrug of the shoulder which de-
notes doubt even as he stands alert.
We also have medical latrinograms. There is a rather
benign, because well intentioned but nevertheless mislead-
ing, type based on unconfirmed reports about diseases
and remedies. You may hear it in any drawing room. It
is not slyly spoken. It does not have a mischievous pur-
pose and while sometimes disgusting to the well in-
formed, it is more amusing than harmful.
On the other hand, there is a form of malicious gos-
sip that Osier described in a paper on "Charity and
Fraternity in Medicine.” He referred to "the wagging
tongues of others who are too often ready to tell tales
and make trouble between doctors,” and concluded with
the admonition, "never believe what a patient tells you
to the detriment of a brother, even though you may
think it to be true.”
There has been some talk of establishing a rumor
clinic in the psychology department at the University
of Minnesota to study the origin and method of propa-
gation of this vile disorder and although prompted no
doubt by the present war interest, it is to be hoped that
much lasting good may come from this effort.
A. E. H.
BmU Reviews
The Making of a Surgeon: A Midwestern Chronicle, by
Ernest V. Smith, M.D., D.Sc., F.A.C.S.; first edition, blue
fabricoid, gold-stamped, 344 pages, 45 illustrations, no index.
Fond du Lac, Wis., Berndt Printing Co., 1942. Price, $3.00.
Dr. Smith, for some years the chief surgical assistant to Dr.
William J. Mayo at Rochester, is a graduate of the University
of Minnesota College of Medicine and Surgery, Class of 1907,
and has contributed to The Journal-Lancet (Smith, E. V.:
Tetanus and its Treatment, Journal-Lancet 42:141-146 [Mar.
15] 1922). Left to his own resources at an early age, he
worked his way through the University of Minnesota to be-
come a physician, a feat which would be virtually impossible
today. He then became one of the first fellows of what is now
the Mayo Foundation for Medical Education and Research at
Rochester. His training there, as he freely says, provided him
with new insight as to how a surgeon should be trained and
how he should conduct himself in the performance of his serv-
ices. When he founded a clinic at Fond du Lac, Wisconsin,
with an internist as partner, he put his principles into active
practice, and they have guided his actions to this day.
Although he does not pretend to be a Savonarola, Dr. Smith
does not believe surgery in the United States is as good as it is
possible to make it. His reasons for such a view are set forth
convincingly, and few could find fault with his suggestions
aimed at correction of the defects he perceives. He spares no
one, not even himself, in his arguments for better surgical prac-
tice, and in doing so produces an interesting and certainly un-
usual autobiography.
January, 1943
25
SOUTH DAKOTA STATE MEDICAL
ASSOCIATION
MONTANA STATE MEDICAL
ASSOCIATION
The Council of the South Dakota State Medical Association
convened in the private dining room of the Marvin Hewitt
Hotel in Huron on Wednesday, November 25, at noon. Fol-
lowing the luncheon the meeting was called to order by the
chairman, Dr. D. S. Baughman. Roll call followed. Members
present were Drs. N. J. Nessa, D. S. Baughman, J. L. Calene,
G. E. Whitson, C. E. Robbins, W. H. Saxton, W. E. Donahoe,
R. E. Jernstrom and C. E. Sherwood. Dr. J. F. D. Cook, su-
perintendent of the State Board of Health, and Karl Gold-
smith, Association attorney, were also present.
There being a quorum present, the meeting was duly opened.
The chairman called for the reading of the minutes of the pre-
vious meeting. The secretary called attention to the fact that
the minutes had been printed in the August, 1942, issue of the
Journal-Lancet on page 284. It was moved by Dr. Calene
and seconded by Dr. Whitson that the minutes be approved as
printed without the formality of re-reading. The motion car-
ried and was so ordered.
Discussion was held relative to the advisability of postponing
the annual session scheduled for spring in Rapid City. After
considerable discussion it was moved by Dr. Donahoe that the
meeting for next year be postponed and that the incumbent
officers should remain in office until their successors be elected
and qualified, and that meetings of the Council (and/or) the
House of Delegates be at the call of the executive officers as
conditions should seem to indicate. Motion was seconded by
Dr. Saxton and carried with one opposing vote.
Communication from Mrs. Tollevs, state commander of the
Women’s Field Army of the Society for the Prevention of
Cancer was read, asking the South Dakota State Medical As-
sociation to endorse membership campaign and a mail campaign
for funds. It was brought out that the purpose of the Wom-
en’s Field Army is to educate the laity on the necessity of early
recognition, diagnosis and treatment of cancer. It was moved
by Dr. Jernstrom and seconded by Dr. Saxton that the Council
of the State Association endorse the program of the Women’s
Field Army. Motion was carried. It was moved by Dr. Nessa
and seconded by Dr. Whitson that Mrs. Tollevs be informed
that the State Association approved her plans of raising funds
to carry on the work and recommend that the funds received
this year shall be ear-marked for work organization in the state.
Dr. Robbins, speaking for the Pierre district, asked the Coun-
cil for an expression relative to a continuance of their contract
for the Pierre District Medical Aid Association. Dr. Saxton,
also, speaking for the Huron district, discussed the possibility
of entering into some such arrangement. After the discussion
it was moved by Dr. Whitson that the Council does not object
to the Pierre and Huron district societies continuing with local
medical aid projects that permit of free choice of physicians.
This motion was seconded by Dr. Jernstrom and carried. Dis-
cussion brought out the fact that the unit in the state associa-
ion was the district society and that it was perfectly within the
function of the district to formulate and operate pre-payment
plans of medical care insurance, provided they were carried on
in an ethical manner.
Dr. Cook discussed venereal clinics and also the new pro-
gram carried out through the State Board of Health of med-
ical aid to needy wives of soldiers in service.
The possibility of increasing the top limit for medical care
in compensation cases was also discussed, no specific action be-
ing taken.
Karl Goldsmith called attention to the recent action of the
Supreme Court in establishing a new ruling relative to Expert
Witnesses. The court appoints witnesses either on its own mo-
tion or on request of either side in the litigation. The Rule
reads by title: A Rule of Court to appoint Expert Witnesses in
Civil and Criminal proceedings, providing for conferences and
joint reports of Expert Witnesses and the compensation of Ex-
pert Witnesses.
There being no further business, the meeting was adjourned.
Supplemental List of Members in Armed Forces and
Public Health Service of the United States
R. A. Bussabarger
R. L. Casebeer
P. S. Cannon
John Clancy
Raymond Eck
A. N. Grossboll
D. D. Gnose
D. T. Harpo
I. D. Hays
W. L. Jones
R. C. Kane
L. A. Knese
F. H. Malee
G. J. McHeffey
F. L. McPhail
J. E. Murphy
W. M. Peterson
J. A. Pearson
W. A. Rulein
J. J. Scanlon
R. M. Sealey
V. G. Snow
E. L. Techenor
H. M. Teel
John Vasko
R. E. Walker ..
V. A. Weed ...
J. A. Whitlinghill
M. S. Wessel
„ Missoula
Butte
Conrad
Ennis
Lewistown
Philipsburg
.... Broadwater County
Deer Lodge
Mamouth
Missoula
Butte
Yellowstone County
Butte
Billings
Great Falls
Flathead County
Plentywood
Livingston
Jefferson County
Deer Lodge
Broadwater County
Lincoln
Blaine County
Poison
Great Falls
Livingston
Kalispell
Lewis & Clark County
Ravali
SAYS THE U. S. TREASURY ON BONDS:
"Economists and financial leaders everywhere urge that living
essentials be slashed in order that all citizens may buy Victory
bonds. It is a vital responsibility of Americans to invest all
they possibly can NOW in the securities of Uncle Sam. Even
with high taxes, there is more spending money than ever — and
therein lies a grave danger.
"To avert this threat of inflation, and at the same time, bor-
row enough money to pay the mounting war costs, the U. S.
Treasury offers the public for purchase nine billion dollars of
Victory Bonds bearing interest as high as 2 14 per cent. Every
individual, every family, every industry, business and institution
in America is urged to put all available dollars into these Vic-
tory Bonds. 'We can! We will! We must!’ ”
FROM THE WAR MANPOWER COMMISSION
"It is of the utmost importance that the Procurement and
Assignment Service for Physicians, Dentists, and Veterinarians,
immediately has the name of any doctor who really is willing
to be dislocated for service, either in industry or in over-
populated areas, and who has not been declared essential to his
present locality. This is necessary if the medical profession is
to be able to meet these needs adequately and promptly. We
urgently request that any physician over the age of 45 who
wishes to participate in the war effort send in his name to the
State Chairman for the Procurement and Assignment Service
in his State.”
26
Hews Items
Dr. R. F. Peterson, Butte, Montana, was elected presi-
dent of the Silver Bow County Medical society at a
meeting of the group December 22. Dr. J. E. Garvey
was named vice president, Dr. C. R. Canty, treasurer,
and Dr. S. V. Wilking, secretary.
Dr. Edward Parnall, formerly on the staff of the
Northwest clinic, Minot, North Dakota, now in the
Army Medical Corps with the rank of major, has been
transferred for duty outside the United States. He had
been stationed at Camp White, Oregon.
Dr. O. Charles Erickson, Sioux Falls, South Dakota,
was elected president of the Seventh District Medical
society at the annual meeting held December 15. He
succeeds Dr. Edwin S. Stenberg. Dr. George A. Stevens
was elected vice president and Dr. C. J. McDonald, sec-
retary-treasurer. Dr. Stenberg, Dr. McDonald, both of
Sioux Falls, and Dr. Otto Hanson, Valley Springs, were
elected delegates to the board of directors of the South
Dakota State Medical association.
Dr. Leo D. Crowley, a member of the Montana men-
tal hospital staff at Warm Springs for the past 14 years,
has resigned to accept a west coast post with the U. S.
public health service.
Dr. Arthur A. Nichols, Fargo, North Dakota, has
been appointed Cass county physician to complete the
unexpired term of Dr. Arthur C. Burt. Dr. Burt now
is a lieutenant, senior grade, in the U. S. navy.
Dr. A. P. Scheib, formerly of Brookings, South Da-
kota, is now practicing in Watertown.
Dr. Howard Claydon of Red Wing has been elected
president of the Goodhue County Medical society. Dr.
M. Flom of Zumbrota, is vice president; Dr. J. F. Bruse-
gard, secretary-treasurer; Dr. R. F. Hedin, delegate, and
Dr. H. T. McGuigan, alternate delegate.
Dr. J. M. Spatz, formerly of Cut Bank, Montana,
is now in the Army Medical Corps.
Dr. O. K. Behr, Crookston, Minnesota, has been
awarded a fellowship by the College of Surgeons. The
award was made by the national organization on De-
cember 13, on the recommendation of the credentials
committee.
Dr. H. A. Burns, superintendent of the state sani-
tarium at Walker, Minnesota, has been appointed head
of the tuberculosis control unit in state mental hospitals.
Dr. Burns, who has been at Walker for 13 year, will be
succeeded by Dr. F. F. Callahan, superintendent of the
Pokegama sanitarium.
Dr. W. O. B. Nelson, Fergus Falls, Minnesota, has
been appointed city health officer to fill the vacancy
caused by the death of Dr. W. A. Lee.
The Journal- Lancet
Dr. J. D. J. Pemberton was reelected president of the
Mayo Clinic staff recently.
Lieutenant Harold C. Freedman, formerly a resident
physician at Minneapolis General hospital, now at Gard-
ner Field, California, has been promoted to captain.
Dr. Paul B. Monroe, formerly of Two Harbors, Min-
nesota, has joined the staff of the Raiter hospital, Clo-
quet, Minnesota.
Dr. S. A. Cooney, Helena, Montana, has been re-
appointed county physician for the coming year.
Dr. Herbert A. Carlson, formerly of Minot, North
Dakota, is now making his home in Los Angeles.
Dr. A. Veitch, Cavalier, North Dakota, has been
commissioned Captain in the medical corps reserve.
Dr. W. C. Hills, Bonesteel, South Dakota, has accept-
ed a position in the state hospital at Yankton.
Dr. C. T. Helmey, Menno, South Dakota, has been
appointed vice president of the County Board of Health.
Dr. R. H. Waldschmidt, Bismarck, North Dakota, is
the new president of the Sixth district medical society.
He succeeds Dr. George Monteith of Hazelton. Dr.
M. S. Jacobson, Elgin, is vice president; Dr. W. B.
Pierce, Bismarck, secretary-treasurer; Dr. F. B. Strauss,
Bismarck, censor; and Dr. C. C. Smith, Mandan, dele-
gate to the state association.
Dr. Frank O. Robertson, East Grand Forks, North
Dakota, has been promoted to the rank of Major in the
Army medical corps. He is stationed at the Fitzsimmons
General hospital, Denver, Colorado.
Dr. Harry J. McGregor, Great Falls, Montana, has
been named county physician. He succeeds Dr. L. R.
McBurney.
Dr. Charles A. Aling, Minneapolis, Minnesota, has
been commissioned a Captain in the Army medical corps.
Dr. J. F. Schmid, Worthington, Minnesota, has been
commissioned a First Lieutenant in the Army medical
corps.
Dr. Walter E. Hatch, Duluth, Minnesota, is the new
president-elect of the St. Louis county medical society.
Dr. Michele Gerundo was recently named assistant
professor of pathology on the medical school faculty at
the University of South Dakota, Vermillion. He suc-
ceeds Dr. Fred Dick who is now doing war research.
Dr. Gerundo formerly served on the faculty of medi-
cine, University of Paris, France, and attended the Uni-
versity of Guitemala City Medical school and the In-
stitute of Medical Sciences in Mexico.
Dr. F. O. Hanson, superintendent of Swedish hos-
pital, Minneapolis, for nearly ten years, has resigned
his position to become director of appeal at Gustavus
Adolphus college, St. Peter, where he will conduct a
campaign for funds for a new college library.
January, 1943
27
Dr. Philip Rains Beckjord, Willmar, Minnesota, has
been promoted to the rank of Major in the Army
medical corps. At present he is Executive Officer in a
medical battalion at Camp Van Dorn, Mississippi.
Dr. G. B. Wright, Kalispell, Montana, is the new
county health officer and county physician. He succeeds
Dr. A. A. Dodge who held the position for 21 years.
Dr. W. V. Accola, formerly of Bowbells, North Da-
kota, is now practicing in West Virginia.
Dr. M. R. Snodgrass, Anaconda, Montana, was elect-
ed president of the Mount Powell Medical society at
the regular meeting of the group, December 14. Other
officers are: Dr. J. L. O’Rourke, vice president; Dr. L.
G. Dunlap, secretary; Dr. W. E. Long, censor; Dr.
Gladys Holmes, treasurer.
Lt. John H. Peterson, Duluth, a medical officer on
the destroyer Hammann, has been awarded a Silver Star
medal, the Navy announced December 10. After the
Hammann was sunk, Lt. Peterson struggled to a life-
boat and picked up wounded seamen. He also was cited
for his work "for three days after the action when he
exerted himself to the point of exhaustion in providing
medical attention to the 100 wounded men” in addition
to steering the lifeboat.
Dr. G. T. Notson has resigned as administrator of
the Chamberlain Hospital and Sanitarium, Chamberlain,
South Dakota.
Dr. Jean J. Darius, formerly of Lame Deer, Mon-
tana, is now senior physician at the Indian hospital,
Bemidji, Minnesota.
Dr. C. G. Johnson, Rugby, North Dakota, has been
promoted to the rank of Major in the Army medical
corps.
Dr. R. P. Frink, formerly of Wessington Springs,
South Dakota, is now in Redffeld where he is assistant
doctor at the State School for Feeble Minded.
Dr. Emory J. Bourdeau, Missoula, Montana, has re-
ported for duty as a lieutenant, senior grade, in the
Navy.
Dr. Stuart Grove is now practicing in Sioux Falls,
South Dakota. A graduate of the University of Minne-
sota medical school, Dr. Grove took his internship at
Ancker hospital, St. Paul, and spent the past eight years
there specializing in surgery.
Dr. J. E. Curtis, Lemmon, South Dakota, is the new
president of the Sixth District medical society.
Dr. Charles B. Darner, Fargo, North Dakota, has
been commissioned a lieutenant, senior grade, in the
U. S. Navy.
Dr. Hugh J. Brown, Butte, Montana, is now a Lieu-
tenant at the Naval hospital, Bremerton, Washington.
For the past ten years, he was engaged in private prac-
tice at Tillamook, Oregon.
University of Minnesota has been chosen as one of
the institutions to provide a special series of intensive
courses to qualify additional medical and dental officers
to overcome an "acute shortage” in several groups of
medical and surgical specialists. Officers selected for
training will be under 50 and only those with a mini-
mum of 12 months’ full time training of practical ex-
perience in general surgery will be chosen.
Dr. Edward Lieurance, 63, Warm Springs, Montana,
assistant superintendent of the Montana State hospital
for 13 years, died January 2, 1943. A veteran of the
Spanish-American War and the World War, Dr.
Lieurance was resident physician in Indian Agencies in
Oregon and Montana before coming to Warm Springs.
Dr. C. A. Kelly, 33, Taylors Falls, Minnesota, was
killed in a hunting accident recently.
Dr. A. O. Arneson, 63, McVille, North Dakota,
died at his home December 11, 1942. Coming to North
Dakota in 1904, he had practiced in McVille in 1906.
He was state representative from the 17th district (Nel-
son county) at the time of his death.
Dr. A. L. Garner, 57, former resident of Dickinson,
North Dakota, died December 28 in Devils Lake after
a month’s illness. He practiced at Dickinson for 20
years before going to Texas to operate a ranch about
ten years ago.
Dr. Arthur J. Rolling, 42, Minneapolis, died Decem-
ber 13.
Dr. Ralph E. Weible, 64, one of the founders of
and president of the Dakota Clinic, Fargo, North Da-
kota, died November 8, 1942, in Minneapolis. An out-
standing surgeon, Dr. Weible studied in Europe and in
the British Isles. He was a charter member of the list
of accredited surgeons of the American College of Sur-
geons and served the American Board of Surgeons as
its North Dakota examiner.
Dr. T. H. Hanbidge, 85, Darby, Montana, who prac-
ticed medicine in Missoula, Victor and Darby for more
than 45 years, died at his home December 1, 1942.
Dr. K. Olafson, Cando, North Dakota, died Decem-
ber 2, 1942. He formerly lived at Gardner, North
Dakota and was a graduate of the University of Mani-
toba medical school.
Dr. Harlan Nelson, 35, of Brooten, Minnesota, a
former surgeon in Minneapolis where he spent five years
on the staff of General hospital, was killed December 6.
His car hit a stretch of loose gravel near Braham, Min-
nesota. He had returned to Minneapolis recently from
Los Angeles to join the Navy as surgeon.
Dr. W. A. Lee, Fergus Falls, Minnesota, died No-
vember 22.
Dr. Hiram J. Lloyd, 65, of Mankato, Minnesota, died
December 14.
28
The Journal- Lancet
CONTINUATION STUDY COURSES
Medicine, Hospital Service, Public Health
Winter 1943
CENTER FOR CONTINUATION STUDY
University of Minnesota
Minneapolis
Hospital Administration
General Practice
Hospital Nursing
Blood and Blood Substitutes
Internal Medicine
Anesthesiology
Dietetics
Medical Social Service
Rheumatic Fever
General Surgery
Hospital Administration — January 11-16
Lectures, discussions, panels, movies, and demonstrations.
Program will provide answers to wartime problems of hospitals.
Nursing service, personnel, food restrictions, purchasing sup-
plies and equipment, civilian defense, and post-war planning.
Distinguished hospital leaders will serve on faculty. Tuition
#10.
General Practice — January 18-23
Society must rely on general practitioners in middle and late
life to care for most civilian medical needs. This course has
been arranged for physicians who have been relatively inactive
or have limited the scope of their services. Will review recent
developments in medicine, surgery, obstetrics, pediatrics, and
various specialties. Lectures, clinics, and round table question
and answer periods. Practitioners who must resume active
service or those who must broaden scope of service will find this
course of great assistance. Tuition #25.
Hospital Nursing — January 18-20
Many nurses have become inactive through marriage or other
reasons. There is great need for nurses to teach classes in
home nursing and to assist in hospital service. Many changes
have occurred in last few years in nursing. This course will
show most major changes. A repeat course — the first one hav-
ing been given last fall with great success. Tuition #5.
Blood and Blood Substitutes — January 21-22
Special course for physicians, technologists, and nurses in use
of blood and blood substitutes. Intravenous use of blood and
blood substitutes, no longer limited to teaching hospitals, is now
being used in all institutions. Voluntary hospital problems are
many. The course will give detailed instruction in collection,
preservation, and use with special reference to avoiding reactions.
Repeat course as one given last fall had excellent results.
Tuition #4.
Internal Medicine — January 25-30
Course in internal medicine arranged for members of Ameri-
can College of Physicians and others with similar training and
interest. Enrolment limited to college members, diplomates
of American Board of Internal Medicine, physicians studying
for special examinations in internal medicine, and others whose
practice is mainly internal medicine. Specialists in internal
medicine now on active military duty will be admitted without
payment of tuition for #20 (room and board). Others will
pay #45 for tuition, room and board. Registration limited.
Anesthesiology — February 8-10
Course for nurse anesthetists. Because of large numbers of
physicians in military service more anesthetics are being given
by nurses. Course will review recent developments with especial
emphasis on safety factors. Enrolment limited to members of
American Association of Nurse Anesthetists and others with
equal training and experience. Program last year was of great
value to nurse anesthetists at that time. Study is being made
of special needs at present time. Please send for special in-
formation card. Tuition #5.
Dietetics — February 18-20
Course for dietitians and nutritionists. Dietitians employed
in hospitals, community agencies and institutions as well as
home economists in teaching or administrative positions will
find this course of value. Program will deal exclusively with
nutritional problems growing out of wartime difficulties.
Tuition #5.
Medical Social Service — February 18-20
Course for medical social workers on special wartime prob-
lems in their field. Medical social service has also been affected
by new developments in medical practice. Program will con-
sist of lectures, discussions, and demonstrations. Tuition #5.
Rheumatic Fever — February 22-24
One of the most important diseases of children with poten-
tially serious effects in childhood and later life. Course for
public health nurses to help them understand the disease. Pro-
gram will cover practical aspects of rheumatic fever problem as
it affects children and adults. Inclusion of heart disease in
crippled children’s program is reason for offering course at
present time. Tuition #5.
General Surgery — March 8-13
Course will consist of lectures, clinics, demonstrations, and
round table question and answer periods. Subject matter will
deal largely with surgical problems of emergency nature. Rec-
ommended for all who must give surgical service in these
times. Outstanding leaders in surgical thought and practice
will take part. There will be no opportunity to acquire opera-
tive skills, but demonstrations and discussions will bring out
modern surgical teaching. Tuition #25.
Other Courses
Arrangement will be made to offer other special courses.
Please send your suggestions.
January 11-16
January 18-23
January 18-20
January 21-22
January 25-30
February 8-10
February 18-20
February 18-20
February 22-24
March 8-13
January, 1943 29
LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS
ON NOVEMBER 13, 1942
OCTOBER EXAMINATION
Name
School
Address
Armstrong, Wallace David
Arzt, Philip Klaus
Babb, John William ...
Baker, Jeannette L.
Banner, Edward Arthur
Bechtel, Martin John
Bernstein, Irving C.
Black, Albert Seward, Jr.
Blackmore, Sidney Charles
Carmona, Manuel Gumersindo
Connolly, Coleman Joseph
Copsey, Harvey Gayle
Dahleen, Henry Cross
DeVall, Lois Valborg
Dougherty, Charles Joseph
Faber, William Max
Frear, Rosemary R.
Golden, Peter Bernard
Grant, John Carton
Hawkins, William John
Heinrich, Weston Ackland
Heise, Paul von Rohr
Heller, Ben Irwin
Humphrey, Irving Leslie
Janecky, Allen Gustav
Kirkwood, Roger Tom
Kratzer, Guy Livingston
Kuhlmann, Lawrence Bernard
Leemhuis, Andrew Joseph
Lemon, Willis Edward
Long, Gabe Celsor
Lucking, Bernard Anthony
Metcalfe, Robert Matthew
Miller, Richard Cramer
Murphy, Michael E.
Mussey, Mary Elizabeth
Payne, John Hilliard
Reid, Lewis Miller .
Reinecke, Roger M.
Ritt, Arnold Elmer Frederick
Roach, Francis Xavier, Jr.
Rowe, Clarence John, Jr.
Sauer, William George
Scholten, Roger Adrian
Sidell, Richard Huntington
Simmonds, Frank Lawrence
Spencer, George Norton
Stahr, Aubrey Cecil
Stotler, John Francis
Turner, Thomas Richard
U. of Minn., M.B. 1937, M.D. 1937
—Creighton U., M.D. 1937
U. of Western Ont., M.D. 1941
-Indiana U., M.D. 1929
Loyola U., M.D. 1940
_U’. of Minn., M.B. 1942
.... U. of Minn., M.B. 1942
Rush Med. Col., M.D. 1940
U. of Minn., M.B. 1941, M.D. 1942
...Jefferson Med. Col., M.D. 1941.
U. of Minn., M.B. 1942
__U. of Neb., M.D. 1941
Stanford U., M.D. 1940
..Rush Med. Col., M.D. 1941
Jefferson Med. Col., M.D. 1938
,_U. of Wis., M.D. 1938 ...
. U. of Minn., M.B. 1934, M.D. 1942
U. of Wis., M.D. 1940
_..U. of Minn., M.B. 1942
...Rush Med. Col., M.D. 1939
Northwestern, M.B. 1941, M.D. 1942 ...
.. Marquette U., M.D. 1941
. U. of Minn., M.B. 1941, M.D. 1942
...Harvard U., M.D. 1940
.... U. of Minn., M.B. 1942
...Northwestern, M.B. 1942
Temple U., M.D. 1935
-_U. of Neb., M.D. 1942
_U. of Minn., M.B. 1942
...U. of Minn., M.B. 1942
-U. of III., M.D. 1938 ...
U. of Minn., M.B. 1941 ..
... U. of Colo., M.D., 1940
Harvard U., M.D. 1941
.... U. of Minn., M.B. 1941, M.D. 1941
. U. of Minn., M.B. 1940, M.D. 1941
„. U. of Cincinnati, M.B. 1940, M.D. 1941
__.U. of Minn., M.B. 1941
__ U. of Minn., M.B. 1940, M.D. 1941 ....
__U. of III., M.D. 1932 .
. U. of Minn., M.B. 1942
. U. of Minn., M.B. 1942
...U. of Cincinnati, M.B. 1939, M.D. 1940
Jefferson Med. Col., M.D. 1937
Rush Med. Col., M.D. 1940
. -U. of Minn., M.B. 1941
...Marquette U., M.D. 1942
U. of Minn., M.B. 1938, M.D. 1939—
... Rush Med. Col., M.D. 1940
.Baylor U., M.D. 1941
310 Cecil St., S.E., Minneapolis, Minn.
2057 Portland Ave., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Fergus Falls, Minn.
Mayo Clinic, Rochester, Minn.
..Mpls. General Hospital, Minneapolis, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
St. Mary’s Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
St. Mary’s Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mpls. General Hospital, Minneapolis, Minn.
745 Belgrade Ave. N., Mankato, Minn.
Mayo Clinic, Rochester, Minn.
Asbury Hospital, Minneapolis, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mercy Hospital, Pittsburgh, Pa.
Mayo Clinic, Rochester, Minn.
. Mpls. General Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
. Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Ancker Hospital, St. Paul, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mpls. General Hospital, Minneapolis, Minn.
.St. Barnabas Hospital, Minneapolis, Minn.
4528 Fremont Ave. S., Minneapolis. Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Anderson, Leo Eugene .....
Blumgren, John Edgar
Davis, Edward Valentine
Swickard, George Yeagley
Watson, Thomas Leonard, Ji
BY RECIPROCITY
U. of Neb., M.D. 1941 __ Mayo Clinic, Rochester, Minn.
U. of Iowa, M.D. 1941 St. Mary’s Hospital, Duluth, Minn.
U. of Neb., M.D. 1933 Kirksville, Mo.
Ohio State U., M.D. 1931 Gopher Ordnance Works, Rosemount, Minn.
U. of Virginia, M.D. 1930 Gopher Ordnance Works, Rosemount, Minn.
Alway, Sophia Chamberlin
Balfour, William Mayo
Blumenthal, Lester Sylvan
Manning, John Joseph
Meyers, Ward Carl
Sweeney, Alvin Randolph, Jr.
White, John Donald
NATIONAL BOARD CREDENTIALS
Yale U., M.D. 1941
U. of Minn., M.B. 1939, M.D. 1940
Geo. Wash. U., M.D. 1941
U. of Pa., M.D. 1941
Northwestern, M.B. 1940, M.D. 1941
Harvard U., M.D. 1939 ...
U. of Buffalo, M.D. 1940
803 University Ave., S.E., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Classified Advetiisentetats
FOR SALE
Office equipment consisting of instruments, electrical
appliances, hospital equipment for three beds, treatment
lamps; together with the location and good will of the
late Dr. George B. Ribble. Terms can be made attractive
and convenient. It is very much the desire of Mrs. George
B. Ribble to dispose of this practice. Address her at La
Moure, North Dakota.
EXCEPTIONAL OPPORTUNITY
for beginning or established physician to share suite of
offices with another physician or dentist. Individual treat-
ment room or laboratory, in new office building located
in very best residential retail section. Address Box 714,
care this office.
PHYSICIAN WANTED
To join staff of mental institution. Must be United
States citizen, qualified to take North Dakota state board.
Substantial salary and full maintenance in comfortable
quarters for party who is unencumbered, fitted by experi-
ence and inclined to make the post his permanent work.
Address Box 738, care of this office.
Advertiser's AteMutiteHtewts
A DOCTOR S PLEA IN WARTIME
The doctor’s life, in times like these,
Is not exactly one of ease.
For, on the home front, each M.D.
Is busier than any bee!
He’s shouldering the burden for
The other docs, who’ve gone to war.
This leaves your doctor precious little
Time to sit around and whittle.
And indicates the reason why
You ought to help the poor old guy.
HOW?
1. By keeping yourselves in the best of condition,
Thus avoiding the ills that demand a physician.
2. By phoning him promptly when illness gives warning,
But — unless very serious — waiting till morning.
3. By cheerfully taking whatever appointment
He makes for prescribing his pills or his ointment.
4. By calling on him where he works or resides
Instead of insisting he rush to your sides.
(Of course, he’ll come round when there’s need for
his service —
But spare him the trip when you’re nothing but
nervous.)
5. And, last but not least, you can help in this crisis
By carefully following Doctor’s advices.
If these commandments you’ll adhere to
A doctor’s heart you will be dear to!
Copyright 1942, by The Borden Company
UPJOHN’S "SCOPE” HONORED IN
ANNUAL OF ART
Included in the 21st Art Directors’ Annual of Advertising
Art is a cover design from the first issue of Scope, seasonal
magazine of The Upjohn Company, which is mailed to active
physicians and ethical pharmacies. Working closely with Dr.
A. G. Macleod, editor, and G. I. Zupanic, technical advisor to
the promotion department of The Upjohn Company is Will
Burtin of New York, designer whose honored composition is
reproduced here. Burtin is original and inventive; and, while
most artists would be baffled by having to work with such
themes as bacteriology, this subject only stimulated Burtin to
the point of triumph.
j
The composition and design of this cover has broad signifi-
cance. The baby, taken from Leonardo Da Vinci’s Madonna of
the Rocks, portrays through its health and vigor the hope man
has for the fulfillment of his aspirations. Health is being ob-
tained through scientific research, symbolized by the test tube.
Background for the test tube is an herb, indicating that em-
pirical knowledge of the curative properties of certain plants is
medicine’s heritage from ages past, behind which is Nature, of
which science is but the unravelling.
Burtin’s dogma is that clarity and brevity are the essence of
good portrayal and his philosophy of art and expression is in
perfect harmony with the tone The Upjohn Company aims to
achieve in all of its advertising and sales promotion work.
THANKS TO THE YANKS
Actual records of cigarette sales in service Post Exchanges
and Canteens show that Camel is the favorite smoke with men
in the Army, Navy, Marines, and Coast Guard.
For the convenience of those who wish to send Camel cig-
arettes to relatives and friends in the armed services, cartons of
Camels are available in a special wrapper all ready for mailing.
Dealers have complete forwarding instructions.
Coronary Insufficiency Precipitated by Hemorrhage
from Duodenal Ulcer"
C. A. McKinlay, M.D.
Minneapolis, Minnesota
THE effect of one disease upon another, particu-
larly if the cardiovascular system is involved, may
not only present interesting problems in diagnosis
and treatment, hut may also permit analysis of patho-
physiologic factors somewhat comparable to methods of
the experimental laboratory. This paper reports a case
of hemorrhage from asymptomatic duodenal ulcer which
first manifested itself as coronary insufficiency, with an-
gina pectoris as the presenting symptom.
Katz1 states that anemia may make an asymptomatic
coronary sclerosis manifest itself as coronary insufficiency.
Bean’sJ analysis of over 200 cases of myocardial infarc-
tion discloses three in which collapse with attendant fall
in blood pressure seemed to precipitate fresh infarcts.
One was in a patient with severe hemorrhage from peptic
ulcer and in another with severe epistaxis. McLaughlin3
reports a fatal case of hemorrhage from peptic ulcer in
which the clinical severity of the course of disease end-
ing in death could not be accounted for on the basis of
hemorrhage alone. Absence of coronary thrombosis was
noted at necropsy although acute upon chronic myo-
cardial infarction was considered to be present. Master
and Jaffee4 report a case of a young woman who died
of massive hemorrhage from ulcerative colitis. The elec-
trocardiograph showed RS-T depression in standard
leads and low T wave in all leads. Necropsy revealed
in addition to ulcerative colitis, necrosis of the papillary
*Presented before the Minneapolis Academy of Medicine, Octo
ber 8, 1942.
muscles without coronary thrombosis. Master, Dack,
and Jaffee5 differentiate acute coronary insufficiency, re-
sultant from prolonged ischemia of the heart muscle,
with focal and disseminated myomylacia, localized in the
subendocardium and in the papillary muscles of the left
ventricle, from coronary thrombosis which is a complete
occlusion of a coronary artery with massive infarction
as a rule. Priest6 states that other factors in collapse,
shock or severe hemorrhage, such as changes in the phys-
ical and chemical properties of the blood, diminished
oxygen carrying power (reduced hemoglobin and ery-
throcyte count) increased oxygen need and tachycardia
may play a part in precipitating thrombosis or infarction,
that however, a common factor in a large percent is a
sharp fall in blood pressure; that it seems that if the
low blood pressure persists the chances of thrombosis
and infarction are increased. Blumgart, Schlessinger and
Zoll7 note in a series of 11 cases out of 350 reported in
elderly patients particularly those with coronary sclerosis
that shock in one instance due to severe gastrointestinal
hemorrhage led to the development of frank coronary
occlusion. Blumgart, Schlessinger and Davis8 in their
study of the relation of the clinical manifestations of
angina pectoris to the pathologic findings note that in
the hearts of several patients in which the coronary blood
flow was already reduced and presumably slowed because
of occlusions and narrowing, the sudden fall in blood
pressure which accompanied postoperative shock evi-
dently led to further stagnation, anoxemia and deposi-
32
The Journal-Lancet
tion of multiple coronary thrombi. These authors em-
phasize the importance of avoiding a fall in blood pres-
sure, whatever the cause, in cases of coronary arterio-
sclerosis. Anoxia, infarction and fibrosis of the myo-
cardium and their accompanying clinical manifestations
arise whenever there is a discrepancy between the nutri-
tional requirements of the heart muscle on one hand
and factors governing nutritional supply on the other.
Case Report
The patient, a male, age 58, married and an office manager,
was first examined six years previously during an attack of
biliary colic, episodes of which had been noted for eight years.
The patient stated that about six years previously he had been
treated for peptic ulcer with relief of symptoms after a period
of several weeks. The examination when first observed revealed
X-ray findings of nonfunctioning gall-bladder with multiple
calcified stones. After recurrent attacks of abdominal pain the
patient consulted the staff of the Mayo Clinic where cholecystec-
tomy was performed, five years prior to the present illness. Scar
of the duodenal bulb from previous ulcer was noted at the op-
eration. In the interval before the present illness there were no
outstanding complaints; fatigue tendency was occasionally noted.
Hypertension had not been present. One year previously the
patient appeared with the complaint of epigastric distress noted
before meals, but did not consent to further study; the episode
was of brief duration. Under all occasions the patient’s response
to usually painful stimuli appeared to be minimal.
The Present Illness
Episode 1. The patient, examined at his home, complained
of aggravation of chest pain of two days duration. The pain
was described as pressure sensation localized in the substernal
region. The patient appeared to be gray and in pain. The pulse
rate was 108, regular, the blood pressure 136/80. The heart
tones showed some loss of timber. There was no pericardial
friction rub. The impression gained was angina without shock
symptoms of myocardial infarction. The patient was admitted
immediately to the hospital. On entrance the blood pressure
was 128/70. Electrocardiogram (fig. 1) showed low amplitude
of T waves in all leads and otherwise was not remarkable. The
leucocyte count was 8,000 cells per cmm. and the sedimentation
rate was 4 in one hour. The pain tended to subside. Two days
after admission weakness was the outstanding symptom without
pain or marked dyspnea. The erythrocyte cell count of 2,070,-
000 per cmm. and hemoglobin of 38 per cent, suggested hem-
orrhage and directed attention to the gastrointestinal source.
The occurrence of dark tarry stools of four days duration was
then established. There had been nausea but no pain at onset.
Tarry stools disappeared after a few days; occult blood was
demonstrated for several days. The hemoglobin reached a low
of 37 per cent on the fourth day after admission; under sup-
portive treatment and dietary management by the sixth day the
hemoglobin had increased to 49 per cent, and five days later
reached 55 per cent and one day later there were 2,720,000 ery-
throcytes per cmm., and 24 days later the hemoglobin was 84
per cent and the erythrocytes 4,360,000 per cmm. X-ray
findings 17 days after admission showed deformity of the duo-
denal cap which was believed to be secondary to duodenal ulcer.
The six foot heart film showed slight accentuation of the left
ventricular border. The measurements were within normal
limits. The interpretation of events of this episode was (1)
hemorrhage from symptomatically silent duodenal ulcer (2)
angina due to anoxemia of myocardium precipitated by acute
hemorrhage and anemia.
Episode 2. About five months after onset of present illness
the patient was seen at 3 A. M. in his home complaining of
substernal pain with radiation into both arms, and weakness.
The blood pressure was 146/98. The patient was removed to
the hospital, pain continued, pallor was ashen, and about six
hours later, there was some degree of shock and the blood
pressure was 84/66. The heart tones showed loss of timber,
there was no pericardial friction rub. The sedimentation rate
was increased, the hemoglobin was 67 per cent and the erythro-
cytes 4,975,000 per cmm. The nature of the pain, prostration,
fall of blood pressure and increased sedimentation rate (70
mms. in one hour) indicated myocardial infarction; the electro-
cardiogram showed alterations of Q:; T.-, type consistent with
posterior infarction (fig. 1). Within two days marked pallor
was noted, and the hemoglobin dropped to 49 per cent and
hemorrhage from duodenal ulcer was suggested. Later tarry
stools were noted. The blood pressure continued to be low and
periods of increased weakness and shortness of breath occurred.
The therapy consisted of blood transfusions and dietary and
alkali management for duodenal ulcer in addition to the use of
xanthine derivatives, and iron and vitamin supplementation. The
temperature record while in the hospital showed a maximum
elevation of 101.2 degrees on the second hospital day with only
minor recrudescence. The pulse rate varied from 78 to 120,
usually below 100. When discharged on the forty-third hospital
day the blood pressure was 142/100. The last recorded hemo-
globin was 63 per cent. The patient became ambulatory and re-
sumed business activity and within three months the hemoglobin
reached 100 per cent. Later the patient was examined on ac-
count of abdominal distress not characteristic of ulcer; this dis-
appeared within a few days. The patient had not stayed under
close supervision except in the emergencies.
Episode 3. The patient was reeexamined in his home four
months later because of weakness that had developed during
the day. The pulse rate was 120, blood pressure 135/88, and
on admission to the hospital within about eight hours of onset
on complaint, the hemoglobin was 75 per cent, and the ery-
throcyte count 3,800,000 per cmm. Recurrent gastrointestinal
hemorrhage was suggested. The electrocardiogram showed T
wave inversion in lead I (fig. 1). The hemoglobin dropped
to 64, 45, and 42 per cent on succeeding days and the stools
contained gross blood. Under therapy as outlined previously,
the hemoglobin increased to 59 per cent within 1 1 days and
the stools became negative to occult blood. Since discharge
from the hospital the hemoglobin became normal and the pa-
tient has carried on his occupation under restricted hours.
X-ray study showed duodenal deformity without evidence of
crater.
Discussion
In an individual with low threshold of pain response,
hemorrhage occurred from asymptomatic duodenal ulcer
and precipitated angina pectoris. It is postulated that in
this individual, coronary arteriosclerosis may be presumed
to have been present prior to the present illness, but
that the provocation of coronary insufficiency depended
upon the ischemia and impaired myocardial respiration
secondary to hemorrhage and rapidly developing anemia.
The nutritional demands of the myocardium had been
satisfied at all times at the patient’s level of physical
activity except after hemorrhage with its reduction in
hemoglobin and erythrocytes and with resultant reduced
oxygen carrying power of the blood. It is considered
that this pathophysiologic experiment is the counterpart
of the anoxemia test for diminished coronary reserve
proposed by Levy and coworkers.0 In this test individ-
uals showing any one of certain electrocardiographic
changes and sometimes angina alone during a period of
anoxemia of the myocardium induced by breathing oxy-
gen poor ( 10 per cent) atmosphere are considered to
have diminished reserve of the coronary circulation. The
electrocardiographic criteria suggested10 are (1) the
arithmetic sum of RS-T deviation in all four leads totals
3 mms. or more; (2) there is a partial or complete re-
versal of the direction of the T wave in lead I, accom-
panied by an RS-T deviation of 1 mm. or more in this
lead; (3) there is a complete reversal of the direction of
February, 1943
33
mijii 1 1 awJJ- mSSSSm^t
■; iiU! — ,; -,“
A . D tctmber 8, 1940
B. Jqnuorn 3, 194!
Fig. 1 Serial electrocardiograms: A. At first episode of hemorrhage with angina pectoris, low amplitude
T waves all leads. B, Interval tracing, left axis deviation C, At second episode of hemorrhage, posterior myo-
cardial infarction Q3 T3 type. D, Later stage (38 days) F, Interval tracing. F, At third episode of hemor-
rhage, inversion T wave lead I.
the T wave in lead IV F regardless of any associated
RS-T deviation in this lead.
The second episode differed in that the patient was
seen with severe substernal pain, within six hours showed
shock, prostration and marked reduction of blood pres-
sure to 84/66. This lowering of blood pressure was
more than would have been anticipated from the degree
of hemorrhage alone as the hemoglobin was only mod-
erately reduced to 67 per cent and the erythrocytes were
reported to be normal. The electrocardiographic changes
were consistent with posterior myocardial infarction. The
abruptly developing anemia with hemoglobin of 49 per
cent, which was demonstrated within two days of the
attack of pain, would not seem to be fortuitous but
would appear to be related to development of myocardial
infarction. It is considered reasonable to assume that in
the presence of coronary sclerosis, myocardial infarction
was hastened or precipitated early in this episode of
gastrointestinal hemorrhage. The events suggested would
be beginning hemorrhage, reduced hemoglobin and ery-
throcyte count and diminished oxygen carrying power,
diminished coronary flow and reduced blood pressure,
and precipitation of myocardial ischemia and infarction
without the necessity of assuming that coronary occlu-
sion had occurred. However, the delayed (48 hours)
evidence of marked hemorrhage does not allow dogmatic
conjecture. In the third episode of acute gastrointestinal
hemorrhage without angina the electrocardiogram showed
T wave negativity in lead I not present in the last pre-
ceding tracing. It might be assumed that myocardial
respiration was adequately maintained due to the de-
velopment of anastomotic arterial channels. The work
of Blumgart and coworkers8 has emphasized the extraor-
dinary significance of the collateral circulation in bridg-
ing the discrepancy between nutritional supply and de-
mand. They conclude from the study of the coronary
arteries of diseased human hearts injected postmortem
that gradual coronary occlusion, if accompanied by the
development of anastomotic circulation does not neces-
sarily produce clinical manifestations.
34
Thf. Journal-Lancet
Conclusions
A case is reported in which episodes of hemorrhage
from duodenal ulcer had at onset predominately cardiac
manifestation. In the first episode coronary insufficiency,
not noted previously, was suggested with angina pectoris
first appearing at this time. Within five months (prob-
ably early in a recurrent episode of hemorrhage) the
features of acute myocardial infarction of the posterior
wall type with Q:i T:s electrocardiographic pattern ap-
peared. After recovery there were persistent electrocar-
diographic changes of myocardial damage. In a third
period of hemorrhage nine months later angina pectoris
did not supervene although T wave negativity in lead I
occurred. The pathophysiologic relationships in the case
reported are considered to represent a clinical disease ex-
periment similar in principles involved to those of the
induced anoxemia test, and a possible explanation of the
sequence of events is proposed. This and other reports
referred to emphasize that hemorrhage, shock, and causes
of fall in blood pressure occasionally appear to precipi-
tate coronary insufficiency and myocardial infarction, and
necessitate especial effort for their control in patients
with coronary arteriosclerosis.
Discussion
Dr. Karl Anderson: A private patient of mine entered
University Hospital in November 1933 with a bleeding duo-
denal ulcer. He was ready to be discharged the first of the
year, because he had improved so markedly, and I happened
to go over there on New Year's Eve about nine o'clock to see
him, purely as a friendly gesture To my surprise I found him
in a semi-unconscious state apparently having a very severe
coronary attack. I instituted emergency therapy immediately
and put him under oxygen, and he gradually made an improve-
ment. He was discharged from University Hospital in April.
His electrocardiogram showed a coronary occlusion associated
with his duodenal ulcer. During the period of his hospitaliza-
tion his electrocardiograms showed flutter at times, fibrillation,
and then went back to regular rhythm. He had negative T’s,
and before he was discharged from the hospital his electro-
cardiograms became normal. I have had the opportunity of
watching this man continuously since He has had numerous
attacks of duodenal ulcer, but he has had no recurrence of his
coronary affair.
Because of the recurrence of his ulcer syndrome and the fact
that he has persistently had very high total acids, we have been
insistent that he have a gastric resection done, but not too in-
sistent in the light of his previous coronary affair. He remem-
bers it almost too vividly and will not subject himself to such
an operation in the light of his past history.
This case appears to be very similar to Dr. McKinlay’s, ex-
cept that this man seems to have enjoyed fairly good health
in between his episodes of ulcer syndromes.
Dr. Jay Davis: I have seen several patients who have gone
through this same course of events. All of them were patients
with coronary sclerosis and duodenal ulcer who hemorrhaged.
They all recovered with transfusions, and as soon as the hemo-
globin came up the anginal pain ceased.
The electrocardiogram changes were similar to the tracings
shown by Dr. McKinlay. Some had negative Ti and T/s which
returned to normal with the rise in hemoglobin.
Dr. C. A. McKinlay: Such cases as the one here reported
and those mentioned by Doctors Karl Anderson and Jay Davis
emphasize the hazard of acute hemorrhage and fall of blood-
pressure in persons with coronary arteriosclerosis, and suggest
particular care in such emergencies. Differing from cases men-
tioned by Dr. Davis, the one reported had the criteria of myo-
cardial infarction with evidence of myocardial change thereafter.
References
1. Katz. L. N.: Electrocardiogram of coronary disease; Elec-
trocardiography; Lea 6c Febiger, 1941, page 160.
2. Bean. W. B.: Infarction of the heart; a morphological and
clinical appraisal of three hundred cases. Am. Heart J. 14:684.
1937.
3. McLaughlin, C. W.: Baker, C. P.; Sharpe. J. C. : Bleeding
duodenal ulcer complicated by myocardial infarction. Nebraska M.
J. 25:266 (July) 1940.
4. Master, A. M.; Jaffee, H. L.: Coronary insufficiency in
myocardial necrosis due to acute hemorrhage, J. Mt. Sinai Hosp.
7:26 (May. June) 1940.
5. Master, A. M.: Dack, S.; Jaffee. H. L.: Premonitory symp-
toms of acute coronary occlusion. Int. Med. 14:1155 (Jan.) 1941.
6. Priest, W. S.: Sudden fall in arterial pressure as a precipi-
tating factor in acute coronary thrombosis and myocardial infarc-
tion; Modern Concept of Cardiovascular Disease, Am. Heart Assoc.
Vol . XI (Feb.) 1941 No. 2.
7. Blumgart, H. L.; Schle>singer. M J.; Zoll, P. M.: Multiple
fresh coronary occlusions in patients with antecedent shock. Arch
Int. Med. 68:181 (Aug.) 1941
8 Blumgart, H. L.; Schlessinger. M J.; Davis, D.: Studies
on the relation of the clinical manifestations of angina pectoris,
coronary thrombosis, and myocardial infarction to the pathologic
findings; with particular reference to the significance of the collat-
eral circulation; Am Heart J. 19:1 (Jan.) 1940.
9. Levy, R. L.: The ''anoxemia test” as an index of the coro-
nary reserve, J.A.M.A. 117:2113 (Dec. 20) 1941.
10. Levy, R. L.: A comparison of electrocardiographic changes
observed during the "anoxemia test” on normal persons and on
patients with coronary sclerosis. Am. Heart J. 23:837 (June) 1942.
February, 1943
35
Glaucoma and the General Practitioner
G. M. Constans, M.D.f
Bismarck, North Dakota
IT may seem odd to bring to the attention of physi-
cians at a general meeting such a distinct eye subject
as glaucoma. It is in fact a disease primarily con-
fined to and concerned with the eye. It is also an estab-
lished fact that glaucoma left alone will result in blind-
ness and when this has occurred or nearly occurred, there
is no cure for the disease and the restoration of vision
is impossible.
Glaucoma is not uncommon in our state. According
to the statistics from the Aid to the Blind Program in
North Dakota we have 10.3 per cent of the blind cases
receiving care under that program listed as glaucoma.
Chandler, in the New England Journal of Medicine,1
states that glaucoma is the cause of one-third of all
blindness in patients past middle life. Gradle2 estimates
that glaucoma probably constitutes about 15 to 20 per
cent of the eye diseases in the United States, although
the usual figures given are lower, being about 6 per cent,
so you may see that it is not a rare condition.
As before stated, glaucoma left alone results in blind-
ness. Vision is prolonged and maintained when glau-
coma is recognized early and properly treated. Hence,
this appeal to you as physicians for the early recognition
and care of this disease.
It is unfortunate that the term glaucoma sounds so
much like trachoma to the laity, for they confuse the
terms, the diseases, and their outcomes.
As you know, glaucoma is due to an increase in intra-
ocular pressure too high for the eye to withstand safely,
varying with the individual and resulting in damage to
the fibers of the optic nerve. When such damage does
occur, it is irreparable even though the tension is reduced
and the progress of the disease stopped. Thus, if we can
recognize and treat glaucoma in its incipient or early
stages, very little loss will occur. The problem is to rec-
ognize these early cases and this is the reason for my
bringing this subject to your attention.
Who may have glaucoma? Generally speaking, except
for a few forms mentioned later, it is a disease occurring
in persons over 35 years of age. It is intimately con-
nected with worry, nervousness, and physical ill-health,
though not directly attributable to the same. It may be
present in conjunction with other acute or chronic dis-
ease, or with cataract. Truly, it is often hard to diagnose
the early case and often doubly hard to make patients
realize the seriousness of their condition and to keep
them under observation and treatment. Frequently, they
see no improvement and get discouraged and neglect
their care. When they finally note the loss of vision,
so much is gone that a favorable prognosis is nearly
hopeless.
‘Presented before the North Dakota State Medical Associat.on,
Jamestown, May 19, 1942.
tFrom the department of ophthalmology. Quain and Ramstad
Clinic.
I hope that all of you will become glaucoma conscious.
It is often a sad story, so let me illustrate a typical case.
First, the patient notes dimming of vision or poor
night vision, and in some types dull eye pain. He con-
sults his doctor, optometrist, or oculist and too often is
given a sedative, vitamin A, a pair of glasses, or he is
told that he has cataracts and is sent home to wait until
they are "ripe”. Later, when he has tried all the glasses
he can pay for, or has waited until he has to be led
about, he seeks help and finds that it is not a refractive
error, presbyopia, or cataract, but glaucoma with or with-
out these other conditions. Now, it is too late to save
his vision and he is doomed to blindness for his remain-
ing years. Not a pleasant picture! But it happens!
When a patient consults you with a handful of glasses,
when he has had attacks of pain or redness of the eyes
and blurred vision and the pressure feels hard to the
finger touch, or he has no light projection, beware! Look
for something besides a cataract.
There are different types of glaucoma and different
terminologies. I will give you some of the simple and
familiar ones, so we may have a common understanding.
They are juvenile, absolute, secondary, and primary
glaucoma.
Juvenile or congenital glaucoma is present from or
shortly after birth. It is noted by loss of vision and an
enlarged pupil. Examination of the optic discs shows
pallor and cupping. No treatment helps and preparation
for blind training is to be recommended. Congenital
anomalies, such as buphthalmos or large eye, are usually
in this group. A case illustrating this condition is as
follows:
Case 1. C. M., infant aged 1, was seen on May 28, 1930.
The parents stated that the child apparently did not see; other-
wise he was well. The family history was irrelevant. Examina-
tion revealed no vision. There were aimless and nystagmoid
movements of the eyes. The pupils were large and dilated and
did not react. Ophthalmoscopic examination showed marked
pallor of the discs with cupping. No treatment was given. Blind
school education later was advised.
Absolute glaucoma is a term describing the result
of glaucoma, either primary or secondary, untreated or
treated unsuccessfully so that all vision is lost. These
cases are terminal ones insofar as vision goes, that is,
it is nil and because of the pain, enucleation is per-
formed.
The history these patients give is of preceding attacks
of glaucoma or of gradual loss of vision. These cases
have often been mistakenly diagnosed as cataracts and
told to wait for ripening before operation. Sometimes
cataracts are present, but they are not the primary cause
of visual loss and operation does not restore vision.
Among the symptoms of absolute glaucoma, pain is
usual and may be severe, often accompanied by head-
ache. There is a total loss of vision. There is usually
36
The Journal-Lancet
a cloudy cornea and media and a dilated and fixed pupil.
The sclera has a peculiar whitish appearance; the an-
terior ciliary vein is dilated and there is atrophy of the
iris. A cataractous lens is frequently present, but if the
fundus can be seen, it shows atrophy and deep excavation
of the optic disc. The tension is very high and occa-
sionally may result in rupture of the globe.
These unfortunate people are often melancholic be-
cause of the loss of vision and seek relief because of the
intolerable pain. As heretofore stated, removal of the
eye is the treatment. Let me cite one case as illustrative
of this condition and of the course of uncontrolled glau-
coma which we will discuss more in detail later.
Case 2. Mrs. A. S., age 64, was seen on October 13, 1936.
This patient came in because of blindness, having noted poor
vision at night two and one-half months previously. She found
that the left eye was blind and the right practically so, but
stated that she could read and sew prior to this time. Sub-
sequently, the eyes became painful and sore. She used medicine
in them which was prescribed by her local physician, but with
no improvement.
Upon further inquiry she stated that she had noted a gradual
diminution of vision in the left eye for a long time. One year
previously she had consulted an ophthalmologist who told her
that she had lens opacities in this eye and a mild type of
cataract was developing. He refracted her, gave her glasses,
and told her there was nothing more to do at that time.
Upon examination vision in the right eye was light percep-
tion; left eye nil. Externally, there was a conjunctival injec-
tion; the pupils were widely dilated and did not react to light,
accommodation, or in convergence. Perimetric fields could not
be obtained. The cornea and media were hazy and there were
lens opacities in both eyes. The fundi were seen indistinctly
but definite cupping and marked pallor were made out. The
tension with the Schiotz tonometer was 75 in the right and
92 in the left eye. Her general physical examination was nega-
tive except for hypertension, with a blood pressure of 170/110.
Her family insisted that something be done because of the
pain in the right eye. It was explained that the case was
hopeless from a visual standpoint and enucleation was advised,
but was not consented to. Upon insistence by the family a
trephining was performed on the right eye and massage of
the eyes ordered.
One month later the tension in the right eye was 32 and
in the left 60. There was a good filtering bleb in the right eye
with light perception. Vision in the left eye was nil. She still
had pain in the left eye. The lens opacities were present and
the fundi were as heretofore noted. Later the left eye was
enucleated.
One year later she had a mature cataract of the right eye
and wished extraction, but this was refused as there was no
chance to improve the vision. She was now consulting a min-
ister who claimed he could "cure” eye diseases. The family
was advised that it was reprehensible to give her false hopes
as to restoration of vision.
Secondary glaucoma, as its name implies, is secondary
to some other disease. It is usually acute in form, though
it may become chronic and most often follows iritis or
trauma, or may occur postoperatively following cataract
extraction. Here, the recognition and treatment often
depend upon the underlying causes, and a definite patho-
logical factor is present.
In the acute types such as iritis, iridocyclitis and kera-
titis, atropine is indicated. Chronic inflammation of the
uveal tract may also occur and cause adhesions of the
pupil and closure of the angle of the anterior chamber.
Secondary glaucoma may be due to changes from
trauma with a swelling or dislocation of the lens.
Lastly, there are types due to anomalies of the retinae,
such as from hemorrhage, detachments, thrombosis, and
tumors.
An illustration of this type is demonstrated briefly as
follows:
Case 3. L. C. G., age 51, was seen on October 13, 1934.
This patient came in complaining of pain in the left eye with
redness and diminution of vision. His trouble had started eight
years previously. Vision in the right eye was 6/6-3 with cor-
rection; in the left eye 6/20 with correction. The right eye was
clear and showed pallor of the disc. The left eye had a marked
injection, the cornea was hazy, and the pupils contracted. The
tension was 23 in the right eye and 30 in the left eye. A diag-
nosis of acute iritis with secondary glaucoma was made. The
patient was hospitalized and treated with salicylates, hot com-
presses, instillations of atropine and adrenalin, intravenous ty-
phoid vaccine, etc. He made a good recovery.
The treatment is, of course, directed, if possible, at
the underlying cause and, as heretofore noted, the diag-
nosis is paramount.
When secondary to uveal disease, then mydriatics,
such as atropine together with heat and other supportive
treatment, are used. Iridectomy may be necessary. If
due to lens swelling or dislocation, extraction of the
same may be indicated. In cases which are postopera-
tive, say to cataract extraction, the treatment is difficult
although miotics often serve the best.
Primary glaucoma may be divided into the acute or
chronic, or in newer terms, it is classified as non-com-
pensated and compensated. The acute primary glau-
coma is the most dramatic, and also frequently the easi-
est to diagnose. Its exciting causes are often emotional,
or may follow acute physical crises due to the instability
of the vasomotor system. It rarely occurs below 35 years
of age. Often there are intermittent prodromal attacks.
These frequently come after vasomotor upsets, worry,
fatigue, etc. They are characterized by temporary misty
vision and localized frontal headaches; often by light
flashes and halos about lights. Sometimes there is a
slight pericorneal flush or even a steamy cornea. These
may lead later into the acute phase with the following
symptoms.
These start with the usual acute onset in the early
morning involving one eye with marked pain and tender
globe. There is accompanying edema of the lids and
lacrimation and a marked reduction of vision. A circum-
corneal and later a diffuse injection of the eye is pres-
ent, the iris blurred, the anterior chamber shallow and
the cornea steamy, like frosted glass. The pupil is dilated
and does not react to light and if the fundus can be seen,
papilledema and engorged retinal vessels are present.
There is marked increase in intraocular tension and all
this is accompanied by nausea and vomiting and marked
prostration (the patient is very ill).
Acute Primary Glaucoma :
1. Usual acute onset in the early morning.
2. Marked pain.
3. Tender globe to touch.
4. Edema of the lids and lacrimation.
5. Circumcorneal and later diffuse injection of
the eye.
February, 1943
37
6. A steamy cornea (like frosted glass).
7. Iris blurred and a shallow anterior chamber.
8. Dilatation of the pupil and no reaction to light.
9. Fundus seen poorly. If it can be seen, papill-
edema and engorged retinal vessels are present.
10. Marked reduction of vision.
11. Marked increase in intraocular tension.
12. Usually unilateral.
13. Nausea and vomiting and marked prostration.
The two cases cited are illustrative of this disease.
Case 4. Mrs. F. T., age 57, was seen on January 8, 1932.
This patient gave a history of slight pain and redness of the
eyes for three years. She had noted halos about lights and blur-
red vision on close work. She had been refracted here by an
associate four years previously; vision was 6/6 with correction.
The tactile tension was normal and the fundi were negative
at that time. When seen she was ill in bed, and was worried,
fatigued, and depressed from a recent death in the family. Her
doctor had been giving her sedatives and miotics, but with little
effect.
The patient was apprehensive and had her eyes covered.
Externally, they were negative and the vision was poor with only
light perception. The tension was 47 in the right eye and 32
in the left (Schiotz) . The fields could not be obtained. The
conjunctivae were injected, the right more than the left. Cor-
neae were cloudy and the pupils irregular, dilated, and fixed.
The fundi were not seen. There were scattered lens opacities
in both eyes. The blood pressure was 165/100. A diagnosis of
acute glaucoma was made.
She improved slightly under treatment but the right eye
went on to absolute glaucoma and was enucleated, while an
iridectomy was performed in the left eye. When she was last
seen, the right socket was normal, the vision in the left eye
was 3/60 and the tension was 14 with a Schiotz tonometer.
Case 5. Mrs. J. K., age 70, was seen on November 6, 1929.
She complained of poor vision in the right eye. This had failed
suddenly and progressively five weeks previously. Five days
before she had had pain in the right eye with lacrimation and
redness. She was seen by her local doctor who used atropine
and heat, and she became worse.
When examined she was able to count fingers at a distance
of one foot with the right eye and at three feet with the left
eye. There was redness and edema of the lids with photophobia
and lacrimation. Corneae were insensitive and clear and a green-
ish reflex was present in the pupillary area. The media was
cloudy and there was no cupping of the disc. The tension in
the right eye was 31 and in the left 14 (Schiotz). Miotics
helped.
An iridectomy was performed on the right eye and because
of marked contraction of the perimetric fields, trephining was
advised on the left eye, but refused. When she was last seen
five years later, the vision was light perception in the right eye
and 6/6 -3 in the left. The tension was 12 in the right eye
and 52 in the left (Schiotz). There was still marked contrac-
tion for form and colors in the left eye. She was advised to
have an operation. Her diagnosis was acute glaucoma of the
right eye and chronic simple glaucoma of the left eye.
These are only a few illustrations of the acute cases
which are seen from time to time.
Now, let us consider the differential diagnosis in acute
glaucoma from the two most confusing diseases, acute
conjunctivitis and acute iritis. Such an error in diagnosis
was present in the above case. The importance of a cor-
rect diagnosis is self-evident, especially when treatment
is to be undertaken. Consider a case of a few hours or
days standing with the patient acutely ill and the diag-
nosis and treatment resting between acute glaucoma and
acute iritis, possibly complicated by secondary glaucoma.
The treatment in the first, among other things, is mi-
otics and in the other the exact opposite, mydriatics. To
help determine the diagnosis, let me recount the points
of differential diagnosis.
I doubt if any of you will confuse acute conjunctivitis
with acute iritis or acute glaucoma. In acute conjunc-
tivitis there is no pain or tenderness, but only discom-
fort. The vision is good and the pupil and tension are
normal. The media is clear. A mucopurulent secretion
is present. The onset is gradual and the superficial in-
jection starts in the fornix and is not circumciliary.
However, this is not true in acute iritis and acute
glaucoma, at will be noted in Table I:
TABLE I.
Differential Symptoms Between Acute Iritis and Acute Glaucoma
Symptoms
Acute Iritis
Acute Glaucoma
Pain
Moderate. In eye
and first branch of
5th nerve
Very severe. In eye
and neuralgia 5th
nerve to jaw and
beyond
Tenderness
Marked
Marked
Injection
Deep ciliary
Deep ciliary
Pupil
Small and irregular
Large and oval
Tension
Usually normal or
low
High
Media
Opacities in pupil
Cornea steamy
Secretion
Watery
Watery
Vision
Fair
Poor
Onset
Usually gradual
Sudden
Systemic
complications
Few
Prostration and
vomiting
It chiefly is a question between acute iritis and acute
glaucoma. As noted in Table I, they both have pain
which is more marked in glaucoma. Both have tender-
ness and deep ciliary injection and lacrimation. In iritis
there may be pupillary opacities and in glaucoma a
steamy cornea. The onset of acute glaucoma is sudden,
the vision is poor. High tension is present, with a large,
oval pupil in contradistinction to a small, irregular one
in iritis. The vision is poor and the prostration and
malaise profound in acute glaucoma.
The treatment of all types of glaucoma can be divided
into general and special. The general treatment is to
correct the fundamental causes. Attention should be
paid to the patient’s hygiene and habits and the counter-
acting of constitutional diatherms. Thus, treatment gen-
erally is directed toward the control of the elements of
emotion, anxiety, fatigue, sudden temperature changes,
excesses in food and drink and head congestion. The
avoidance of dark glasses and dark places is recom-
mended. Specifically, try to maintain the intraocular
tension within normal limits by medicinal or surgical
means.
Acute glaucoma is an emergency and immediate treat-
ment is necessary to control the attack and enable op-
erative procedure to be undertaken. Bed rest and the
relief of pain by morphine sulphate should be started
at once together with general elimination by sweats,
purges, etc. Heat or long or short wave diathermy is
used. Retrobulbar injections may help. Miotics, such as
38
The Journal-Lancet
eserine, pilocarpine, mecholyl, etc., in large and frequent
doses should be used. Retrobulbar adrenalin and novo-
cain can be injected sometimes followed with one cubic
centimeter of 50 per cent alcohol. Try to get the eye
quiescent within twenty-four to forty-eight hours; then
operate with a broad base iridectomy. The eye always
suffers permanent damage.
The second type of primary glaucoma is the so-called
chronic simple or compensated glaucoma. It has the
same predisposing factors as acute glaucoma. However,
it seems as if the anatomic causes are more important
than the instability of the vasomotor system. A slow rise
in tension, even if not high, will cause damage to the
nerve fibers. Its occurrence is five times more frequent
than acute glaucoma. This type is the insidious thief
in the night that destroys vision before the patient is
aware of the disease. It is remarkable how many people
do not know the vision has failed in one eye. The fol-
lowing is a report of a recent case seen at the Clinic.
Case 6. A. A., age 73, male, retired, was seen on March 22,
1942, when he came in for operation to restore his sight. He
stated that he had been blind in the right eye for twenty years.
He was able to see a light flash in the left eye. The first part
of the year he had noted slight cloudiness of the left eye. Two
days later he had no vision. He was told by a doctor that he
had a cataract and to wait. His general health was good. Ten-
sion was 31 in the right eye and 19 in the left (Schiotz) . The
pupils were widely dilated, the reflexes poor, and the anterior
chambers shallow. There was a central cataract in the right eye,
the disc was cupped and pale and arteriolar sclerosis was pres-
ent. The left eye showed a few lens opacities, optic atrophy,
and cupping with a hazy retina and marked arteriolar sclerosis.
The causes of chronic simple glaucoma are unknown,
but it occurs in persons over middle age who have some
vascular disability, either of sclerosis or dysfunction.
Some predisposing factors are seasonable cold, hyper-
metropia, systemic diseases, focal sepsis, vascular and
metabolic disturbances, and an unstable neuro-vegetative
system or an endocrine imbalance. Often it is preceded
by intermittent prodromal attacks with vasomotor up-
sets, fatigue, localized headache and halos, light flashes,
and misty vision.
Provocative tests may make an otherwise obscure diag-
nosis possible.
Pain is rare though there is sometimes a dull aching
and congestion is usually absent. There is a gradual loss
of vision of which the patient is often unaware until late
in the progress of the disease. The pupils are sometimes
moderately dilated and sluggish with a shallow anterior
chamber. After tension has existed sometime, cupping
of the optic disc is visible; this is often the earliest sign
seen by the ophthalmologist during a routine eye exam-
ination.
Although a cataract may complicate the picture, the
media is usually clear, though at times a slight corneal
edema is noted by slit lamp examination.
A lowering of the light sense is present and the ten-
sion elevated but not often as high as in acute glaucoma.
The condition is bilateral, but one eye may be affected
earlier than the other and lastly the visual fields show
typical changes in every case.
Classified, these symptoms of chronic simple (non-
congestive or compensated glaucoma) are:
1. Pain rare; sometimes a dull aching.
2. Gradual loss of vision. Patient often unaware
of it until late in the disease.
3. Congestion usually absent.
4. Sometimes anterior chamber shallow.
5. The pupil is sometimes moderately dilated and
sluggish.
6. Cupping of the optic disc not visible until tension
has existed sometime. Often it is the earliest sign
seen routinely by the ophthalmologist.
7. Media usually clear, unless a cataract complicates
the picture. Sometimes slight corneal edema is
seen with the slit lamp.
8. A lowering of light sense.
9. Tension is up but not as in acute glaucoma.
10. Usually bilateral, though one eye may be affected
earlier than the other.
11. Visual fields show typical changes in every case.
These are often the so-called gun barrel type.
a. Enlarged blind spot, sickle-shaped scotoma
(Bjerrum’s sign).
b. Peripheral field contraction in one or more
quadrants. Ronne’s step.
c. A paracentral scotoma which may break
through to join the peripheral field defect
forming a large quadrant defect.
d. Later large portion of field may disappear
leaving central vision. Sometimes the quad-
rants are normal and central fields are affected.
Here are typical cases illustrative of this condition:
Case 7. Mrs. G. J., age 63, was seen on June 9, 1930. She
came in because she was bothered for near work. She had had
some dizziness but no headaches. She had noted colors about
lights, and had worn her present bifocals for two years.
When examined, externally the eyes were negative. The
vision was 6/60 without correction, both eyes; with correction
the right was 6/7+4 and the left 6/7+2. She was able to
read A M. A. 14/24.5 at 34. She was myopic and presbyopic.
Her tension was 30 in both eyes (Schiotz). The fundi showed
a deep cupping of the discs with the lamina cribrosa visible.
The perimetric fields showed central vision only. Miotics were
used. The tension came down but was variable and operation
was advised.
The right eye was trephined on September 16, 1933, and the
left eye about 2 Z> months later. She was under observation
with frequent and systematic check-ups. When last seen, the
fields were contracted, but holding steadily. The tension was
14 in the right eye and 6 in the left (Schiotz). Vision was
6/6 - 1 right eye and 6/7 - 2 left eye with correction, and for
reading as heretofore. There were good filtering blebs. The
fundi showed pallor of the discs with deep cupping.
Case 8. Mrs. G. K., age 50, was seen on March 13, 1935.
This patient came in for refraction. She had noted the summer
previously that at times she had poor vision. Her present glasses
had been changed a number of times; the last time by an op-
tometrist who saw a spot in her eyes, but couldn’t help her. Her
vision was worse at night. She had been very nervous since an
only child died four years previously, and she had also had
financial worries.
Her vision was 6/6-1 both eyes with correction and normal
for close work. The glasses needed no change. The fundi
showed pallor of the discs and cupping. Tension was 38 in the
right eye and 44 in the left with Schiotz tonometer. Perimetric
February, 1943
39
fields showed marked contraction of form fields and enlarge-
ment of the blind spot. Blue was contracted and she had cen-
tral vision only for red and green. Her tension was lowered
with miotics, but operation was advised.
A trephining was performed on both eyes and she was kept
under supervision and observation. She was last seen on Feb-
ruary 6, 1942. Her vision was 6/6 - 3 in the right eye and
6/60 in the left with correction. The tension in the right eye
was 15 and in the left 16 (Schiotz) . The perimetric fields
were the same as heretofore and good filtering blebs were
present.
The general treatment in this type of glaucoma is the
same as heretofore outlined under acute glaucoma, that
is, good hygiene, physical fitness, and absence of worry.
If medical treatment is undertaken, the patient must
lead the so-called "miotic life,” that is, under the con-
stant use of miotics and general care as noted above.
This treatment is aimed at keeping the pupil small
and thus lowering the tension. Some miotic drugs, such
as pilocarpine and histamine, act directly upon the mus-
culature. Others such as doryl act on the parasympa-
thetics as supplements, and eserine and prostigmine in-
hibit the acetyl-choline esterase.
Physical measures used are to promote osmosis as with
sorbital, intravenous glucose, sodium chloride, and also
by local massage and diathermy to the eye.
Surgical treatment, the most frequent procedure,
should be done early even though the vision is good.
The fields fail later and cannot be restored. It is not
the purpose here to discuss the different operative tech-
nics. These are determined by the case and the pref-
erence of the ophthalmic surgeon.
That glaucoma is a serious and timely problem is evi-
denced by the attention that has been paid to it in oph-
thalmological circles. The Section in Ophthalmology of
the American Medical Association and the Ophthalmo-
logical Societies have made it a major project/ It is
being brought before general societies, groups and Fed-
eral and state agencies, such as the "Aid to the Blind’
program of the Public Welfare Boards. The work of
the National Society for the Prevention of Blindness is
especially notable. It is important to keep adequate case
records, to instruct and properly train social workers and
nurses in follow-up work, and to make yearly surveys
and reports of cases. The two most important sugges-
tions, I think, are: (1) the education of the patient as
to complete cooperation; (2) an educational campaign
to inform the public about the results of inadequate
treatment of glaucoma.
Today earlier diagnosis and control of glaucoma is
made possible by such aids as perimetry, tonometric
graphs, provocative tests, slit lamp microscopy, gionosco-
py and other aids which all ophthalmologists should have
available. We must utilize these tests together with the
recognition of cases and follow-up by social workers,
nurses, etc.
Remember, do not send away the patient who com-
plains of visual disturbances unless you can definitely
tell what is wrong and why. Listen to the complaint of
poor vision at night or in the movie. Be suspicious of
many pairs of glasses in a short time. Look for a dilated
pupil. Check the patient who has cataracts to be sure
something else is not present. Take the tension by hav-
ing the patient look down and use the tips of your fore-
fingers on the globe. Look at the fundus.
Every glaucomatous patient is a potential victim of
partial or total loss of vision and this loss is preventable
in many cases. Such prevention depends on, first, early
diagnosis and early persistent treatment, and second,
upon the patient’s cooperation, understanding and ability
to carry out his instructions. To get such results, that is,
the prevention of visual loss, I am sure each patient needs
to have individual care and a thorough study made of
his medical and social environment in order to properly
advise and outline his treatment.
Dr. Harry Gradle of Chicago, in a discussion of this
problem and in a personal communication,2 states that
he thinks "the chief problem is to contact the patient
who might have glaucoma and thus get him under treat-
ment.” The optometrist doesn’t know glaucoma and if
he does, he does not refer the patient to an ophthalmolo-
gist. By and large, the general practitioner sees the case
first and he should be able to recognize early glaucoma
and get the patient under treatment. That is the purpose
of this paper. If the problem is to be handled adequately
and vision retained for these unfortunate victims of this
disease, early recognition and proper care and follow-up
are imperative. This is not easy for any of us, I know.
It is not easy to recognize or suspect early glaucoma.
Remember the early signs and symptoms which were
outlined.
To care for these cases, once diagnosed, careful oph-
thalmological studies need to be made. Many times these
are negative and seem a useless waste of time, but if one
unsuspected case is found, they are not. We must not
tell the patient that nothing is wrong until it is so proven,
or that he has cataracts and to wait, or if he has glau-
coma that later operation is all right. As I have shown,
many of them do wait, and when they finally come in,
it is then too late and they are tragically blind.
Bibliography
1. Chandler, Paul A.: Glaucoma and the general practitioner,
New England Journal of Medicine 225:16:61 5 (Oct. 16) 1941.
2. Gradle, Harry: Personal communications.
3. Schoenberg, Mark J.: The problem of preventing partial or
total loss of vision in glaucomatous patients of eye clinics (some
suggestions for remedial measures), Transactions American Acad-
emy of Ophthalmology and Otolaryngology, pages 61-68, 1941.
4o
Thu Journal-Lancet
Nutrition Problems Among College Students"
John J. Boehrer, M.D.
Minneapolis, Minnesota
IN recent years the relationship of proper nutrition
to health and disease has been a subject of ever-
widening scope. Studies based on analyses of food
purchases such as those reported by Stiebeling and
Phipard,1 of the Federal Bureau of Home Economics,
have indicated that only about 25 per cent of the urban
and rural families of the United States have wholly
adequate diets; that about 40 per cent have diets rated
as "fair”; and that about 35 per cent have diets rated
as "poor”. Essentially similar results have been reported
in studies conducted by the Millbank Memorial Fund~
and by the Council on Nutrition in Canada.''
Collateral evidence which suggests the possible con-
sequences of such widespread deficiency has been con-
tributed by Williams and Wilder and their co-workers,4
who have investigated the results of experimental thia-
mine restriction in man. The startling resemblance of
the syndrome which they produced to that of neuras-
thenia has been responsible for the popular designation
of vitamin B as the "morale” vitamin. Whether that
term is justified or not remains to be seen, but they did
watch a group of previously healthy, cheerful young
women become transformed coincident with a moderate
restriction of thiamine to a group of "morose, depressed,
fearful, irritable, uncooperative, slovenly individuals who
made numerous vague complaints of eye-strain, head-
ache, palpitation of the heart, dyspnea on exertion, capri-
cious appetite, anorexia and distress after meals.” This
seems a truly remarkable change, but it is reported that
these symptoms entirely disappeared when thiamine was
restored.
Similar studies on the effects of sub- or pre-clinical de-
ficiencies have been made by McLester’ in pre-pellagrous
states, by Sydenstricker1' in general vitamin B complex
deficiency, and by Lund and Crandon' in experimental
human scurvy. All these workers stress the frequency of
these mild deficiencies and the protean pattern of the
resultant symptoms. Any physician after surveying such
evidence as this must be led inevitably to the conclusion
that here is a vast new sector of knowledge which he
must explore for the benefit of those for whom he cares.
In no instance is this added responsibility more plain
than in the case of the university and its health service
personnel. Our universities are the richest source of our
country’s leaders, leaders not only in peace but in war.
The diets which those future leaders eat during the for-
mative and strenuous years of college represent a prob-
lem which demands our most careful and searching
thought. This is especially true in those institutions
where the food of many students is chosen entirely in
accordance with the harsh realities of an empty purse.
Even brief reflection on this problem suffices to reveal its
multiple aspects.
*Taken from the records of the Students’ Health Service, Uni-
versity of Minnesota, Minneapolis, Minnesota Presented before the
American Student Health Association.
We are first of all concerned with what our students
eat. The answer to this question is not easily obtained
except possibly in those schools where meals are supplied
to all students as a part of the college program. And
even in this group the dietitian who plans the menus
is not often aware of the exact quantities of minerals
and vitamins which are being supplied. The paucity of
quantitative individual dietary surveys in the literature
is indicative of their laborious and time-consuming na-
ture, but they are essential to a clear understanding of
dietary habits.
In large, urban universities such quantitative studies
are even more urgently required and are the only way
in which one may measure the food intake of large frac-
tions of the student population. At the University of
Minnesota only 7.4 per cent of our students live in dor-
mitories and eat food prepared by the University. In
addition, 60 per cent of our student population is either
wholly or partially self-supporting, with all that that
implies in food-selection. We have attempted to obtain
a picture of the dietary habits of certain student groups
at the University of Minnesota in the following manner:
As a yardstick for the study to be presently described,
the first step was to make a complete analysis of the
menus of two university dormitories, one for boys and
one for girls. This procedure was followed instead of
the more accurate individual menu analysis method be-
cause it was felt that these diets were so liberal that the
inaccuracies due to variation in individual consumption
would be of little consequence. This opinion was
strengthened by the results of the analysis and by the
observations of. dining hall attendants, who reported
that the menus represented minimum rather than maxi-
mum food intakes.
In the case of the boys' dormitory the analysis extend-
ed over 14 consecutive days, and in the girls’ the interval
was 13 successive days. The results of the analysis are
given in Tables I and II. The theoretical daily require-
ments listed are the most recent ones advised by the
Committee on Food and Nutrition of the National Re-
search Council.
It will be noted that these diets are exceedingly lib-
eral and more than adequate from the standpoint of
energy content and specific vitamin and mineral require-
ments, with the exception of the vitamin Bi intake in
Comstock Hall (girls) , which is slightly below the rec-
ommended quantity. This, of course, is what one might
expect in a group which has the double advantage of
an above-average economic status plus the services of
competent dietitians.
With this analysis as a basis for comparison, an at-
tempt was then made to obtain a quantitative estimate
of the dietary habits of a lower economic level of the
student population. The plan of this study was as
follows:
February, 1 94 ^
41
TABLE I.
Menu Analysis Pioneer Hall Boys
1st Week
Calories
CHO (G)
PRO (G)
FAT (G)
CA (G)
P (G)
FE**
VIT. A*
Bi*
c**
D*
G***
Monday
3489
275.15
105.7
218.5
2.208
2.167
15.65
8658
636
88
123
753
Tuesday
3983
371.00
127.0
222 3
2.429
2.858
22.16
11367
576
71
160
952
Wednesday
4283
459.75
126.3
215.51
2.776
2.765
31.115
10984
528
104
126
884
Thursday
3607
312.00
120.6
208.3
2 008
2.337
22.58
8408
817
63
200
890
Friday
4395
525 . 00
121.4
201.4
2 679
2.879
26.31
10070
625
30
123
1031
Saturday
4004
390.30
139.5
209.4
2 282
2.636
18.08
7993
734 ,
78
132
916
Sunday
4289
455.40
131.3
216.0
2.012
3.211
13.56
5296
722
63
160
782
Daily Average
4007
398.37
124.5
213.1
2.342
2 693
21.35
9968
662
71
146
886
Requirements
3000
70.0
.8
1.32
12.00
5000
600
75
300?
600
2nd Week
Monday
4158
439.4
116.6
214.9
2.460
2.599
22.15
6239
825
156
124
909
Tuesday
4001
386.4
137 4
220.2
2 224
2.617
20.63
8370
570
25
120
927
Wednesday
4811
521.9
140.1
240.3
2.590
2.912
25.13
17018
884
135
151
1362
Thursday
3335
257.3
126.0
200.2
2.383
2.628
17.94
9949
557
65
166
386
Friday
3608
352.94
123.65
189.1
2.287
2.119
15.41
8046
633
79
128
770
Saturday
3729
380.25
125.3
189.7
2.262
2.564
30.11
8137
487
118
126
926
Sunday
3822
309.40
126.9
230.8
2.330
2.373
15.09
9350
662
75
166
1288
Daily Average
3924
378.22
128.0
213.2
2.362
2.463
20.92
9587
659
93
140
938
Requirements
3000
70.0
.8
1.32
12 00
5000
600
75
300?
600
2 Week Average
3966
388.30
126 3
213 2
2.352
2.578
21.14
9778
661
82
143
912
^International Units
**Milligrams
***Riboflavin — Sherman-Bourquin Units.
With the cooperation of Mrs. Dorothy Johnson, Di-
rector of the Employment Bureau of the University of
Minnesota, we obtained the names of two hundred stu-
dents who were receiving aid from the National Youth
administration. These students were selected only in that
students were chosen who were living away from home
and whose payment for their part-time work did not
include their meals. In other words, this group consisted
of two hundred students of low economic level who were
forced to purchase their own meals with no guidance
other than their own. The relative economic status of
this group is measured by the fact that their average
monthly expenditure for all purposes during this school
year, as calculated by the National Youth Administra-
tion, is $46.92. In addition a supplementary list of 25
names was drawn up from those students who had ap-
plied for N.Y.A. aid too late to receive it, and whose
income was thought to be even less than that of the
preceding group.
A letter was sent to each of these 225 students, out-
lining the purpose of this investigation. They were
frankly told that if they felt they could not cooperate
to the fullest extent we would prefer that they did not
participate in the survey. There was not the slightest
element of compulsion, for obvious reasons. With the
letter were enclosed seven post-cards. Each was divided
into four columns, headed "Breakfast”, "Lunch”, "Din-
ner”, and "Other”. Each card was dated, and the stu-
dent was instructed to carry the proper card with him
on each day of the seven-day period. As soon as he
finished each meal he was to record it in minute detail
in the proper space. Careful instructions were given in
regard to the description of the kind, quantity, and
method of preparation of foods. In addition the cost
of each meal was to be noted. At the end of the day
the self-addressed card was to be dropped in the mail.
From this group of 225 students we obtained a total
of 88 complete sets of seven cards, representing a total
of 1,848 meals. While data was thus received from only
39 per cent of the original group, a study of the sex
ratio, and the range of income and dietary intake in
this 39 per cent leads us to believe that they are a repre-
sentative sample of the group originally queried. Eighty
of these were from N.Y.A. students and eight from the
supplementary list of non-N.Y.A. students. Differences
between these groups were not considered significant be-
cause of the small number of non-N.Y.A. students, and
they are hereafter grouped together as "low income”
students. Individual food analysis sheets were then set
up for each day for each student. The various items of
food were then translated into their individual fractions
of the basic quantities being studied and the totals added
and a daily average obtained. These figures, together
with the average cost figures, comprise the raw data.
42
The Journal-Lancet
Monday
Calories
CHO (G)
PRO (G)
FAT (G)
CA (G)
P (G)
FE**
VIT. A*
Bi*
C**
D*
G***
2880
279 1
84.7
158.7
1 279
1 620
26.56
3948
788
89
68
705
Tuesday
2891
294.1
77.2
155.2
1.328
1.490
14.13
7600
544
68
90
497
Wednesday
2714
236.8
76.5
132.0
1.452
1 . 700
26.32
4532
543
72
31
494
Thursday
3395
317.5
97.1
1918
1 . 250
1.821
16.94
5542
407
62
100
417
Friday
2529
266.65
64.54
132 42
1.215
1 262
11.95
4952
351
82
281
427
Saturday
2863
323.6
74 0
148.7
1.301
1 497
11 14
6936
378
90
140
631
Sunday
2824
283.9
79.3
151.63
1 326
1 723
14.75
5647
428
67
138
530
Daily Average
2866
285.9
79.0
152 9
1 307
1.587
17.39
5593
491
75
121
528
Requirements
2500
60
.8
1 32
12.00
5000
500
70
300?
600
2nd Week
Monday
2657
291 . 1
88.1
141 .32
1.207
1.752
18.11
6084
310
43
106
568
Tuesday
3306
350.6
86 75
172 9
1.404
1.688
14 33
11433
886
78
106
589
Wednesday
3436
311.5
92 1
119.16
1 215
1.555
17.96
16065
508
110
110
1373
Thursday
2559
271 0
81 9
128.45
1 203
1.477
13 82
10066
417
99
100
570
Friday
3220
368 9
81.5
157 1
1.538
1.710
13 31
5173
380
90
71
533
Saturday
2525
222 9
92.7
135.8
1 198
1 560
14 37
5626
406
100
106
692
Daily Average
2950
302 6
73 5
142 4
1 294
1 623
15.31
9074
484
86
99
720
Requirements
2500
60
.8
1 32
12.00
5000
500
70
300?
600
13 Day Average
2908
294.3
76 3
147.7
1.301
1.605
16.35
7334
488
81
110
624
international units.
**Milligrams.
***Riboflavin — Sherman-Bourquin units.
The figures in these tables speak for themselves, and
only a few points need to be re-emphasized. The first
is that not a single diet was adequate in every factor
studied, and that in ten cases, or 11.3 per cent (both
boys and girls) the diets were inadequate in every factor
studied. The distressing implications of these findings
need no further comment.
The second point of importance is that while the av-
erage amount spent for food is perhaps the primary con-
trolling factor in determining the adequacy of the diet
obtained, it is nevertheless true that examination of the
individual cases reveals the fact that in the low income
group the correlation between amount spent and ade-
quacy of diet obtained is practically non-existent.
A mathematical expression of this lack of relationship
has been obtained, using the rank-difference method of
obtaining a coefficient of correlation. Each member of
the low-income group was ranked in terms of the
amount which was spent for food, and for each of the
eight dietary factors studied. The average rank in terms
of the remainder of the group for these eight dietary
factors was then obtained, and the coefficient calculated
in terms of the following formula:
r — 1 d~ equals sum of rank
differences squared.
N (No — 1) N equals No. in group.
For boys, r, the coefficient of correlation, was plus
.185, and for girls it was plus .118. These coefficients
indicate the almost complete lack of relationship between
cost and diet obtained. The obvious inference, of course,
is that knowledge of nutrition in this group is inade-
quate, and that we should urge an increased emphasis
upon practical nutrition in our curricula.
A question which is perfectly proper to raise at this
point is: What evidence do we have that these arbitrary
dietary requirements which we have set up are correct?
In other words, do we have any objective evidence that
these inadequate diets have produced any changes in
these students? Unfortunately, we cannot answer this
question now. Within the near future, all of these low
income students will have a careful periodic health ex-
amination. In addition, we intend to obtain such labora-
tory indices of nutrition as hemoglobin, red blood cell
count, hematocrit, plasma proteins, ascorbic acid satura-
tion tests, together with biophotometer and slit lamp
examinations. These data will then be compared with
similar studies on a group from the dormitories. With
this in hand we hope to be able to answer the above
question.
In spite of this lack of objective evidence, however,
the presumption even now must be that diets such as
those described above are definitely harmful, even
though the relatively crude laboratory methods available
today may not confirm that belief.
II.
The second aspect of the problem of nutrition among
college students is to examine the incidence of nutri-
tional disease in a college population. In this respect
we are concerned not only with actual deficiency states,
February, 1943
43
TABLE III.
Diet Analysis — Low Income — Boys
Name
PRO
FAT
CHO
CAL
CA
P
FE
A*
Bi*
c**
D*
G***
Avge.
Daily
Cost
R. A.
106.2
152.0
298 8
2988
1.335
1 799
17.06
11665
495
51
182
649
.75
W. R. A.
78.9
100.2
265.0
2277
1 . 146
1.478
11.02
4608
460
64
53
446
.40
Rt. A.
128.5
193.1
439.6
4010
2.399
2 679
18.74
8951
649
81
132
906
.76
K. B.
88.3
137.0
342.0
2954
1.129
1 534
14.27
4484
439
53
69
409
.82
M. B.
86.9
140.0
292.8
2779
1.175
1.614
16.49
7109
457
93
147
582
.60
I. E.
75.9
84.5
180 8
1787
.870
1 178
11.06
3210
259
57
175
355
.73
H. E.
99.3
171.5
441.4
3706
1.704
1 992
16.43
6445
523
65
116
660
86
G. E.
86.7
128.5
297.4
2693
1.121
1.778
13 96
4878
322
31
78
426
1 13
H. G.
80.2
138.7
326.2
2874
1.069
1.254
10.49
5097
410
45
75
433
.73
D. G.
102.5
143.7
289.6
2862
1.274
1.927
15.57
5706
714
49
89
586
95
K. W. H.
99.3
136.3
297.0
2812
1.212
1.784
17.00
4817
616
56
79
526
.92
A. H.
84.1
155.3
340.8
3097
1.200
1.531
13.31
4299
413
35
82
417
95
W. H.
119.6
197.3
334.1
3591
1.882
2.200
16.20
8210
556
86
13
645
.73
R. J.
80.5
155 8
288.8
2879
.808
1.241
17.27
6247
394
51
183
424
.71
V. J.
80.5
128.2
241.4
2441
1.001
1 452
11.64
6014
426
52
68
448
.83
J. K.
76.3
112.0
266.3
2378
1 . 110
1.551
16.82
5395
379
39
97
439
.67
L. K.
89 8
123.9
282.8
2606
.777
1.412
12.51
4928
426
77
85
375
.60
A. K.
81.6
119.8
222.3
2294
.750
1 205
12.02
4299
497
35
63
392
.90
R. K.
102 3
119.9
377.7
2999
1.367
1 859
22.61
1216
551
94
95
693
1 . 00
L. L.
122.9
168.3
373.7
3501
2.069
2 560
18 86
7973
1695
73
226
756
.87
F. L.
94.1
139.9
332.5
2965
2.077
1.679
14.40
5838
460
55
72
494
.78
D. L.
81.5
140.7
372.4
3982
.970
1.630
14.05
5092
435
46
52
442
.86
G. M.
115.1
192.6
378.4
3707
1.678
4 948
13.27
8186
454
50
165
593
.70
P. M.
78.1
89.0
262.8
2165
.844
1 286
12 22
2732
420
51
74
392
.80
W. M.
56.8
70.5
179.2
1579
.956
1.266
9.82
12600
252
70
63
608
.84
R. M.
93.9
138.7
378.3
3137
1.353
1.657
12.34
3590
500
24
44
533
.79
A. M.
108.8
165.6
388.8
3481
1.461
1.877
18.80
6384
590
74
69
672
89
M. C.
107.0
127.2
319.7
2852
1.199
1.589
8.64
8843
377
68
78
552
.73
R. W. H.
68.8
121.9
218.2
2245
581
1.082
11.61
3132
341
34
37
313
83
M. R.
100.1
151.7
424.3
3463
1 838
2 . 086
15.62
9200
416
72
56
599
1.03
M. L.
65.4
103.0
306.0
2413
.953
1 273
12.60
7970
359
53
46
453
.78
D. A.
67 2
108.9
226 2
2154
.680
1.098
12.22
5225
399
56
147
357
.63
R. A. A.
106.1
153.0
345.6
3183
1.144
1.675
16.36
5498
555
60
85
531
.80
R. B.
115.4
162.7
319.2
3203
2.130
2 214
13.61
6360
544
63
81
739
1.12
E. C.
97.9
142.4
312.4
2923
1.373
1.708
14.95
6386
547
80
69
553
.76
D. W.
71.0
126.1
311.9
2667
.978
1.109
13.00
17513
312
45
47
469
.75
L. H.
78.2
111.5
271.2
2301
1.213
1.803
15.21
5539
342
31
43
440
.91
W. L.
91.5
101.9
196.1
2066
1 .005
1.530
15.01
3800
629
58
52
530
.60
R. M.
68.7
109.2
282.3
2386
.990
1.402
14.26
5467
354
62
84
483
.83
G. M.
66.6
94.5
279 1
2254
1.037
1 .306
10.56
5670
352
115
32
476
.66
A. J. O.
99.6
147.4
284 . 9
2865
1.380
1.688
19.37
5331
833
57
94
528
.60
D. C.
82.9
109.0
197.0
2461
.896
1.298
12.65
3826
370
37
51
415
.79
M. C.
96.2
155.1
318.3
3054
.885
1.705
17.58
6176
339
51
83
481
.68
M. P.
130.9
197.9
335.6
3647
2.081
2.409
18.49
20925
475
55
107
925
1.24
W. N.
97.0
145.6
281.0
2822
.998
1.475
15.06
4326
324
48
67
355
.51
W. Nr.
87.9
162.0
296.4
2995
.957
1.518
19.45
6329
486
69
125
546
.71
D. C.
103.4
189.2
395.1
3696
1.180
1.613
16.45
6570
452
92
524
538
96
E. D.
89.9
142.5
360.3
3055
1 259
1.853
12.43
7806
851
59
68
525
81
44
The Journal-Lancet
TABLE HI. -Continued
Diet Analysis — Low Income Boys
Name
PRO
FAT
CHO
CAL
CA
P
FE
A*
B,*
C**
D*
G***
Avge.
Daily
Cost
L. G.
108.4
164.3
332.3
3242
1 662
2.029
17.15
14075
417
58
76
559
.81
R. M.
98.9
131.4
339.0
2934
1 250
1.759
15.59
5747
404
57
121
530
1.32
Rd. M.
94.7
125.7
239.5
2390
1.195
1.617
14 94
9935
401
79
146
659
.65
M. G.
62.3
135.6
293.8
2645
.797
1 . 205
11.12
3919
260
47
57
341
.42
W. S. H.
94.2
119.5
309 6
2691
1 109
1.754
17 24
6651
477
72
43
627
98
E. R. J.
104.09
161.8
358.9
3308
1 527
1 949
15.87
4823
541
49
82
576
.95
M. M.
102.5
147.5
302 9
2949
983
1.713
18 18
5734
436
51
103
546
.75
R. M. P.
100.7
165.2
361.3
3335
1 236
1.627
20.06
10629
503
80
89
691
.71
L. M.
73.4
118.7
270.3
2443
.807
1.254
12.08
3684
259
13
53
280
.78
R. P.
78.1
135.1
270.9
2612
985
1.508
11.92
5321
714
31
84
317
.79
L. R.
104.1
162 9
348 1
3275
1 276
1.778
12.60
5616
769
73
139
478
.39
W. G.
91.8
125.2
253.1
2505
.951
1.506
16.21
5016
409
45
79
488
.50
o. o.
71.0
127.7
235.3
2375
.680
1.191
11 83
3610
445
29
53
370
.85
N. P.
55.1
84.6
214.7
1841
.435
.846
10.47
3219
338
24
54
280
.75
T. O.
61 .8
95.3
214 6
1963
.744
1.202
10 48
5025
273
95
47
400
.80
S. P.
60.0
97.2
287.7
2266
.514
.940
8 73
3895
265
37
41
245
.75
R. H.
103.5
146.3
315 2
2992
1 247
1.781
22.42
5777
505
57
90
534
61
E. I.
89.9
147.6
404.0
3304
.832
1 529
16.78
7520
457
119
118
462
1.05
Average
90.1
136.3
304.9
2823 . 0
1.178
1 545
14.65
6394.9
464
58.2
92.4
507.5
.79
% of Standard
129
94
147
117
122
128
77
78
31
85
♦International units. **Milligrams. ***Riboflavin — Sherman-Bourquin units.
TABLE IV.
Diet Analysis — Low Income — Girls
Name
PRO
FAT
CHO
CAL
CA
P
FE
A*
B,*
C**
D*
G***
Avge.
Daily
Cost
E. B.
54.4
71.4
226.0
1764
.838
1.020
10.68
7283
280
57
31
424
.35
M. B.
67 2
87.4
164.3
1712
.979
1.347
10.79
4595
331
45
28
339
.90
Mn. B.
58.8
81.8
138.6
1526
.763
1.439
11.06
3675
270
60
14
321
.50
L. B.
34 2
62.2
156.2
1321
.267
.536
6.42
2783
178
41
17
177
.49
c. c.
66 6
94.6
212.7
1969
819
1.215
11.20
4204
742
25
34
338
.71
S. F.
66.1
101.9
248.5
2176
.890
2.109
10.98
4008
231
33
65
379
.54
T. G.
48 2
68.0
127 4
1314
525
795
8.35
2580
237
35
65
250
.70
A. H.
40 6
89.5
157.3
1597
389
.804
7.41
2653
210
42
29
189
1.00
A. L.
66 8
98.1
238 . 0
2102
1.025
1 230
9 47
3970
339
54
48
341
.40
J. L.
68 3
123 2
294.7
2561
.977
1.254
13.56
4809
361
86
171
376
.72
E. M.
71.1
131.8
302.1
2679
.991
1.327
16.32
7821
670
73
60
559
.61
D. H.
90.4
235.9
262 1
3533
1.281
1 669
12.57
6164
418
58
61
523
.51
M. M.
81.2
122.6
308.3
2661
1.135
1.483
11.08
5236
386
83
67
435
.90
D. K.
67.81
159.3
362.9
3157
.829
1 . 164
17.40
5328
308
68
40
390
.95
O. K.
62 2
98.4
192.7
1413
.566
.844
9.09
3674
331
56
51
257
.33
K. K.
55.2
87.1
210.0
1845
.595
.838
8.80
3949
353
73
44
275
.39
E. E.
77.8
142.3
210.5
2434
.863
1.167
12.34
5573
341
46
69
355
.39
I. M.
71.6
113.3
268.1
2379
1.110
1.349
12.23
7086
302
53
51
432
.63
R. L.
106.0
160.9
303.8
3087
1.667
2.039
15.40
8061
502
69
93
616
.84
M. P.
89.3
185.1
308.7
3258
1.523
1.725
11.87
4436
369
54
67
477
.36
A. J.
86.5
137.6
358.3
3018
.990
1.457
14.09
8045
378
61
158
458
.80
Z. O.
55.7
81.1
242.4
1922
.355
.754
9.61
3190
196
38
30
257
.85
Average
67.5
115.2
240.6
2246.7
.881
1.253
11.40
4960
351.0
55.0
58.9
371.3
.63
^ of Standard
113
90
110
95
95
99
70
79
20
62
♦International units.
♦♦Milligrams.
♦♦♦Riboflavin- Sherman-Bourquin units.
February, 1943
TABLE V.
Average Diets— All Groups
45
Calories
Protein
Calcium
Iron
A
B,
C
G
Low Income — Boys
2823
72.7
1 178
14 65
6395
464
58
508
Pioneer Hall — Boys
3966
126 3
2.352
21.14
9778
661
82
912
Low Income — Girls
2247
67.5
.881
11.40
4960
351
55
371
Comstock Halls — Girls
2908
76.3
1 301
16.35
7334
488
81
624
TABLE VI.
Extent of Dietary Deficiency
Per Cent of Diets Adequate in Each Dietary Factor
Calories
Protein
Calcium
Iron
A
B,
C
G
Low Income — Boys
31.8
84.8
86 8
75.8
68.2
12.1
18 2
19 7
Low Income Girls
36 4
68 2
68.2
36 4
40.9
13 6
18 2
4 5
TABLE VII.
Extent of Dietary Deficiency
No. of Factors
Adequate
LOW INCOME— BOYS
LOW INCOME— GIRLS
No.
%
Cumulative %
No.
%
Cumulative %
0
5
7.6
7.6
5
22.7
22.7
1
1
1.5
9.1
2
9.1
31.8
2
5
7.6
16.7
4
18.2
50.0
3
13
19.7
36 4
2
9.1
59.1
4
16
24 2
60.6
2
9.1
68 2
5
14
21.2
81.8
5
22.7
90.9
6
8
12.1
93 9
0
0
90.9
7
4
6.1
100.0
2
9.1
100.0
8
0
0
0
0
Total
66
100
22
100
TABLE VIII.
Daily Cost of Diets University of Minnesota 1941
Average
Range
Low Income — Boys
$0.79
$0.39 - $1 32
Pioneer Hall
1.00
Low Income — Girls
.63
0.33- 0.95
Comstock Hall
.85
TABLE IX.
Nutrition Problems In a College Population
University of Minnesota — 1937-40
Number
Incidence Per 10,000
College Students
Overweight — 120% or more*
1310
761.72
Underweight — less than 80%*
270
156.99
Anemia**
110
107.68
Peptic Ulcer
167
97.10
Diseases of Colon
90
52.33
Diabetes
34
19.77
Diseases of Gall-bladder and Liver
18
10.47
Miscellaneous
3
1.74
but in a larger sense with all diseases in which nutri-
tional factors may be of importance. With this in mind
we have examined our records in order to determine the
frequency of these conditions as they have been seen
at the University of Minnesota in recent years.
Some discussion of these abnormalities is necessary.
It should be noted first of all that the position of over-
weight as the most frequent nutritional abnormality in
our student population does not permit any inference
as to the average nutritional status of the whole college
group, nor is one even safe in assuming that there is
an adequate intake of all nutritional factors in the over-
weight group itself.
From this distribution one sees that only a relatively
small fraction of our students are overweight, in spite
of the predominance of this condition in the frequency
distribution of nutritional abnormalities. The further
investigations which we intend to make of the physical
and laboratory status of the low income group will, we
hope, answer the question as to whether nutritional
deficiency may co-exist with normal or overweight.
In view of the modern concepts of iron metabolism,
and the pathogenesis of iron deficiency, the inclusion of
anemia in the list of nutritional abnormalities might be
questioned. We are well aware of the fact that the
primary factor in the production of iron deficiency
♦Based on 18,717 entrance examinations.
**Based on 10,215 periodic health examinations.
46
The Journal-Lancet
TABLE X.
Incidence of Overweight and Underweight
Entrance Examinations 1937-40
University of Minnesota
Men
Women
Number
Per Cent
Number
Per Cent
More than 20% underweight
86
0.8
184
2.5
11% to 20%
1150
10.1
1427
19.4
Normal weight
7668
67.6
4521
61 .4
10% to 19% overweight
1646
14.5
725
9.8
20% to 29% overweight
510
4.5
304
4.1
30% to 39%
195
1.7
100
1.4
40% to 49%
47
0.4
48
0.7
50% and more
49
0.4
57
0.8
Total :
11351
7366 1
anemia is blood loss. In the adolescent and young adult
the most frequent cause of such blood loss and resultant
anemia of iron deficiency type is the menstrual period.
This is well shown in our experience by the fact that
2.7 per cent of our entering girls have hemoglobins
below 70 per cent, as opposed to 0.1 per cent of our
entering boys. It is equally true, however, that in the
presence of adequate iron intake and normal absorption,
physiological blood loss rarely if ever results in anemia.
In this sense, anemia of this type is a true deficiency
disease.
A final point which should be noted in connection
with this pattern of nutritional abnormalities is the
absence from it of instances of outspoken, classical vita-
min deficiency. We have not seen, to our knowledge,
any cases of frank xerophthalmia, beri-beri, ariboflavino-
sis, pellagra, scurvy, or rickets. These syndromes are
rare even in the public clinics of the North Central
states, and it is not surprising that they should not be
found in our group. It should be emphasized again,
however, that the absence of such clinical entities can
never permit us to ignore the possible presence of milder
degrees of deficiency. As in many other conditions their
ultimate detection doubtless awaits merely the introduc-
tion of more refined diagnostic methods.
III.
A third and final aspect of this question which I
would like to discuss is the matter of what we student
health physicians can do when confronted with the vast
implications of this interrelationship of nutrition and
health.
Certainly, we can insist upon the proper analysis and
regulation of dormitory menus, a responsibility which
will be increasingly important in the future of rising
food costs which is at hand. We can and must insist
that the diets of impoverished students eating outside
the sphere of university supervision be subjected to scru-
tiny. It may be that arrangements for a proper diet
while at college should be as much a requirement for
admission as the proper number of high school credits.
Certainly there is very little value to an education which
is obtained at the price of possible constitutional weak-
ening which, for all we know, may be permanent in its
damaging effects.
The problems of specific nutritional diseases are more
easily appreciated. Any student health physician is
acutely aware of the difficulties which often impair his
attempts to provide proper dietary treatment of such
relatively common ailments as diabetes mellitus and
duodenal ulcer. The fixed diets of boarding houses and
dormitories often result in the student’s discouraged con-
clusion that the cards are stacked against him, with the
result that he leaves school, to his own and society’s loss.
Recognition of this situation by Dr. Ruth Boynton,
Director of the Students’ Health Service of the Univer-
sity of Minnesota, resulted in the creation of a diet
table in 1939. A portion of the Health Service with
an adjoining kitchen was set aside for this purpose. The
services of a graduate dietitian and kitchen help were
obtained, with the whole service under the supervision
of a member of the full-time medical staff.
From the beginning this experiment has been an un-
qualified success. The normal capacity of the table is
30 students, but in case of necessity this can be expanded
to 35. Normally, the table runs at capacity, the num-
ber of overweight students receiving treatment being
reduced in the event more serious conditions require
treatment, and increased ordinarily quite readily when
the number of cases of other conditions drops below
normal. At the beginning, the charge for this service
was $0.90 per day for three meals. This year we have
been forced to increase the charge to $1.00, which is
the same as the cost of food at the boys’ dormitory.
It is unfortunate that this charge cannot be less, but
the high cost of handling a small number of varied diets
makes a lesser fee impossible.
Any physician on the Health Service staff may, of
course, recommend the diet table to a student for a
specific purpose. In practice, however, it has been found
best to route such requests and students through the
staff member supervising the diet table, and he assumes
the responsibility for the character of their diets and the
length of their period of treatment there.
Since the establishment of the diet table in 1939,
148 students have been treated.
TABLE XI.
University of Minnesota Diet Table
Conditions Treated — 1939-41
Condition
Number
Per Cent
Overweight
60
40.5
Diabetes Mellitus
33
22.2
Peptic Ulcer
28
18.8
Allergy
7
4.7
Underweight
5
3.3
Ulcerative Colitis
3
2.0
Miscellaneous (liver, kidney, blood disease, etc.)
12
8.1
Total:
148
99.6
February, 1943
47
The predominance of obesity as a nutritional problem
is again noted here, and although this paper is not in-
tended to include a discussion of therapy, I should like
to point out that the diet table is in our experience by
far the best method of treatment in these cases. The
character of dormitory and boarding house diets makes
a balanced reduction diet extremely difficult for a stu-
dent to obtain. Diet table treatment is ordinarily re-
served for students who are more than 40 per cent
overweight, but even in this group the results are far
superior to that obtained when the student is merely
given a diet and left to his own devices. In a study of
a group of 120 cases of obesity who voluntarily request-
ed treatment in 1940-41, 30 cases were treated on the
diet table for an average period of 10.9 weeks. The
average weight loss for this period was 18.2 pounds.
The remaining 90 cases were treated in the usual fash-
ion by the prescription of a specific diet which they were
to follow at home or elsewhere. This group was fol-
lowed for an average period of 11.7 weeks, and the
average weight loss was 2.4 pounds. It is of considerable
interest to note that 57 of this latter group returned
to the physician only once after their initial visit. Their
discouragement is presumed if not proved.
The advantages of the diet table in the treatment
of such conditions as diabetes mellitus, peptic ulcer, and
ulcerative colitis are too obvious to require discussion.
We have also found it of inestimable value in the treat-
ment of obscure allergic states by elimination diets.
In conclusion, I should like to reiterate the urgent
necessity of our full recognition of the importance of
nutrition in our own sphere of activity. We must con-
tinually remember the almost certain existence of defi-
cient diets in large segments of our student bodies, with
all that that implies. We must strive to diagnose mild
nutritional deficiency; we must constantly consider the
effect of such deficiency in the pathogenesis and prog-
nosis of other disease; and we must, in our capacity as
advisers to administrative officers, attempt to improve
the nutritional knowledge and the nutritional oppor-
tunities of our low income students. And, finally, we
must review again the importance of dietary treatment,
with full appreciation of the vast gulf which frequently
lies between the prescribing and the taking, in the hope
that such a review may effectively narrow that gulf for
the benefit of those who are in our care.
References
1. Stiebeling, Hazel K., and Phipard, Esther F.: Diets of
Families of Employed Wage Earners and Clerical Workers in
Cities, U. S. Dept. Agriculture Circular 507, Washington, D. C.,
January, 1939.
2. Wiehl, Dorothy G.: Diets of Low-Income Families Sur-
veyed in 1933, Public Health Reports 51:77-97, January 24, 1936.
3. (a) Young, E. Gordon: A Dietary Study in Halifax,
Canad. Pub. Health J. 32:236-240 ,(May) 1941. (b) Sylvestre,
J. Ernest, and Nadeau, Honore: Enquete sur 1’ Alimentation Habi-
tuelle des Families de Petits-Salairies dans la Ville de Quebec,
Ibid. 32:241-250 (May) 1941. (c) Patterson, Jean M., and
McHenry, E. W.: A Dietary Investigation in Toronto Families
Having Annual Incomes Between $ 1 ,500-$2,400, Ibid. 32:251-
258 (May) 1941. (d) Hunter, George, and Pett, L. Bradley:
A Dietary Survey in Edmonton, Ibid. 32:259-265 (May) 1941.
4. (a) Williams, R. D., Mason, H. L., Smith, B. F., and
Wilder, R. M.: Observation on Induced Thiamine (Vitamin Bi )
Deficiency in Man, Arch. Int. Med. 66:785-799 (October) 1940.
(b) Williams, R. D., and Mason, H. L.: Further Observations on
Induced Thiamine (Vitamin Bt) Deficiency and Thiamine Require-
ment of Man: Preliminary Report, Proc. Staff Meet., Mayo Clinic
16:433-438 (July 9) 1941.
5. McLester, J. S.: Borderline States of Nutritive Failure,
J .AM. A. 112:2110-2114 (May 27) 1939.
6. Sydenstricker, V. P. : The Clinical Manifestations of Nico-
tinic Acid and Riboflavin Deficiency (Pellagra), Ann. Int. Med.
14:1499-1517 (March) 1941.
7. Lund, C. C., and Crandon, J. H.: Human Experimental
Scurvy and the Relation of Vitamin C Deficiency to Postoperative
Pneumonia and to Wound Healing, J.A.M.A. 116:663-668
(February 22) 1941.
8. Committee on Food and Nutrition, National Research Coun-
cil: Recommended Daily Allowances for Specific Nutrients,
J.A.M.A. 116:2601 (June 7) 1941.
48
The Journal-Lancet
The Orthopedic and Medical Management
of Arthritis*
A Preliminary Report
Daniel H. Levinthal, M.D.f
Catharine E. Logan, M.D.ff
Chicago, Illinois
CLOSELY related to arthritis and frequently
associated with it are fibrositis, myositis and myo-
fasciitis. Gouty arthritis, senile osteoporosis, and
the arthritic manifestations associated with osteitis defor-
mans (Paget’s) and acromegaly are forms of arthritis
often overlooked. An accurate diagnosis is obviously a
prerequisite to successful management.
A certain number of patients with early arthritis im-
prove with or without treatment. Because of this occa-
sional tendency to recover spontaneously, some patients
with early arthritis improve regardless of the remedy
used. On the other hand, it is our opinion that proper
intensive medical and orthopedic management of these
patients may do much to hasten the alleviation of pain,
prevention of deformities and restoration of these per-
sons to activity. In addition, those patients who show no
tendency to improve spontaneously and regress towards
chronicity may also be materially benefited with ade-
quate treatment.
With this thought in mind, a treatment clinic for
patients with arthritis was established at the Cook Coun-
ty Hospital in April, 1941. One hundred eighty arthritic
patients are included in the present series. Of this series,
30 private cases and 80 clinic patients who have not been
under treatment for our minimal study requirements
(six months) have been excluded from this preliminary
report. The 70 patients who constitute the basis for the
present report, have been under management for a
period of six months or longer.
This series of 70 cases, for the most part, is comprised
of patients with rheumatoid arthritis, osteoarthritis, or
mixed arthritis. It also includes cases of Marie-Strum-
pell disease, gouty arthritis, Paget’s osteitis deformans,
senile osteoporosis and arthritis associated with acro-
megaly. All of the severe arthritic patients entering the
general orthopedic clinic were assigned to the arthritis
division. The early arthritics with only mild symptoms
were not included in this clinical investigation. In all
but 13 of the patients chosen for this study, arthritis
was present longer than two years.
Diagnosis
The criteria for the diagnosis of the various types of
arthritis were those suggested by the Subcommittee on
Arthritis of the Committee on Chronic Illness, Welfare
Council of New York City.
The patients with rheumatoid arthritis were usually
thin and anemic, with systemic involvement. In prac-
tically all of the cases the proximal interphalangeal joints
*From the Fantus Out-patient Clinic, Cook County Hospital
i Attending orthopedic surgeon. Cook County Hospital,
ttci inical assistant. Cook County Hospital.
of the fingers were affected, giving the characteristic
spindle-shaped fingers. Muscular atrophy occurred too
early and was too well marked to be due entirely to dis-
use. There was a tendency to symmetrical polyarticular
involvement. Subcutaneous nodules, when they occur,
are pathognomonic for both rheumatoid arthritis and the
arthritis of rheumatic fever. In advanced cases deform-
ity, subluxation, joint disorganization and ankylosis are
also characteristic.
In cases of ankylosing spondylitis (Marie-Strumpell)
the patients are usually thin young men with definite
symptoms of chronic systemic disease, frequently with
low-grade fever and leukocytosis, "poker-back”, stooped
shoulders, and head held rigid with the neck flexed.
X-ray findings are characteristic and show generalized
osteoporosis, fusion of the small intervertebral joints,
and calcification of the longitudinal ligaments. The
sacroiliac joints are frequently involved.
In degenerative arthritis the patients are frequently
over-weight and do not show evidence of systemic dis-
turbance. It is much more common in middle-aged or
elderly people. The joints involved are enlarged due to
overgrowth of bone and also to soft tissue swelling. For
the diagnosis of degenerative arthritis, the X-ray findings
are frequently pathognomonic. Lipping or osteophytes
occur at the margins of the joints. Cyst-like areas of de-
generation are sometimes seen in the region of the ar-
ticular surfaces. Decalcification usually does not occur.
Contact sclerosis or eburnation is evident.
In the diagnosis of gouty arthritis, both acute and
chronic, the history is of primary importance. The meta-
tarsophalangeal joint of the big toe may be the first in-
volved. The early attacks occur usually at night with
severe pain and purplish discoloration of the joints. The
attack is of short duration and there is complete remis-
sion of symptoms between attacks. Small punched-out
areas may be seen along the line of attachment of the
joint capsule. A high blood uric acid is frequently en-
countered. Repeated tests should be made.
In the diagnosis of all forms of arthritis, the history,
clinical symptoms, lesions, disturbed function, blood
chemistry, sedimentation rate, and X-ray findings may
each be important. The characteristics and value of each
of these factors will be discussed in a future publication.
Procedure
A comprehensive history of each patient was obtained.
The various methods of treatment prior to admission to
our clinic were recorded. A complete orthopedic and
medical examination was given to each patient. The
weight was recorded and complete laboratory work
February, 1943
49
ordered. The latter consisted of blood count and blood
chemistry, including non-protein nitrogen, sugar, uric
acid, calcium, phosphorus, phosphatase, total protein,
creatinine, Wassermann, Kahn, erythrocyte sedimenta-
tion rate and urinalysis. Basal metabolic rates were de-
termined when indicated. Dynamometer readings were
made in instances in which arthritis affected the upper
extremities. When indicated, electrocardiograms were
ordered.
A careful examination of the laboratory data suggests
that there is no correlation between the blood chemistry
and the progress of the arthritic process. In order to
simplify the management of these patients, we intend
to eliminate all laboratory procedures which we have
found superfluous. The determination of the uric acid,
Kahn, Wassermann and sedimentation rate is essential
in each case. Other tests should be performed only when
specifically indicated.
Roentgenograms of involved joints and photographs
and motion pictures were made of many patients as
their treatment progressed. The colored motion pictures
vividly portray the degree of limitation of joint move-
ment, swelling about joints, difficulty in locomotion and
abnormal posture.
After the physical examination and laboratory tests
were completed, the data obtained was summarized and
carefully studied. Some patients required referral to
special clinics, such as dental, ear, nose and throat, gy-
necology, genito-urinary and vascular. The diagnosis
having been made, and contributing factors evaluated,
therapy was instituted.
Management
In every patient an attempt was made to eliminate
contributory etiological factors, bearing in mind that in
these chronic cases secondary residual foci may remain
in the synovial membrane. Unless incriminating evidence
presented itself, a relatively conservative attitude was
assumed regarding focal infection. However, abscessed
teeth and tonsils, showing evidence of pathology or con-
sidered responsible for severe recurrent infection, were
eliminated. Constipation, when present, was corrected.
Genito-urinary or gynecological conditions were given
special consideration. The obese patients were placed
on a gradual weight reduction diet while the emaciated
were given a higher caloric diet.
Mechanical factors, such as pronated flat feet and
knock-knees were treated in the Out-patient Clinic by
proper corrective shoes and supports.
Patients with circulatory deficiency or varicose veins
were referred to the Vascular Clinic.
Deformities of the large joints were treated by hos-
pitalization in the orthopedic wards. Recumbency, trac-
tion, wedge casts, gentle manipulation under anesthesia,
molded casts, corsets, braces and physical therapy were
used when necessary on in-patients. Surgical measures,
such as synovectomy, arthroplasty, capsulotomy and
tenotomy, were occasionally required.
Patients presenting visceroptosis and dorsum rotundum
with poor vital capacity were given corrective exercises.
Occasionally blow bottles were prescribed to increase rib
excursion and improve costo-vertebral movement.
Patients with bursitis, especially subdeltoid and tro-
chanteric, were given multiple punctures of procaine and
aspiration treatment. Many patients with myofasciitis,
especially those with lumbo gluteal involvement were
given focal point injections of 1 per cent procaine.
Each patient received the specific systemic treatment
which his condition required. Patients with gouty arthri-
tis received low-purine diets. Those with hypothyroidism
received thyroid and those with menopausal symptoms
were given hormone therapy. Most of these patients had
been under observation and had proven resistant to many
of the known forms of antiarthritic therapy before they
were accepted for this investigation.
Many of these patients were treated in the orthopedic
and other clinics for more than two years before being
admitted to this special research series. If, after the
maximum response to the routine therapeutic measures
was obtained and if after the concomitant diseases were
adequately controlled, the arthritic process still progressed
or warranted additional treatment, the patient was then
included in this special arthritic clinic.
In addition to the routine treatment, all of the patients
in this series received electrically activated vaporized er-
gosterol (Whittier Process.)* The treatment was ini-
tiated with one capsule (50,000 units) three times daily.
The dose was increased by one capsule daily, every three
days, until the patient was receiving six capsules daily.
This dose was then continued, unless signs of intolerance
developed, which occurred in very few instances. All
patients were encouraged to drink one glass of milk after
each dose of activated ergosterol, not with any idea of
increasing the therapeutic effectiveness of the medication,
but to furnish calcium and phosphorus. The medication
was not taken in the milk.
Signs of Intolerance
Since all previous publications1-12 on the subject have
emphasized the safety of this activated sterol therapy,
we have not been concerned very greatly with the possi-
bility of any toxicity. In 7 of the clinic patients, some
nausea and anorexia occurred. This may, or may not,
have been due to the medication. In the obese patients,
there was a rather high incidence of gallbladder disease
and in the rheumatoid group a rather large majority of
the patients had disturbed liver function,12-17 impaired
gall-bladder activity,12-18 or disturbance of the secretion
of gastric hydrochloric acid.12 For this reason, digestive
upsets may occur as a result of the systemic involvement
rather than from the medication which the patient is
receiving. In patients with either nausea, anorexia or
nocturia, the medication was stopped for a few days and
then started again at a slightly lower dosage. Many of
the older patients had nocturia prior to the administra-
tion of vitamin D therapy. The gastric symptoms were
persistent only in 2 patients who had had peptic ulcers
for many years.
Summary
This series of 70 patients consists of 44 clinic patients
and 26 private cases. Of the 44 clinic patients, 25 were
*This investigation was made possible by a grant from the Nu-
trition Research Laboratories, Chicago, Illinois, who furnished the
Ertron for this study.
The Journal-Lancet
only 4 were males and 22 were females. These patients
varied in age from 10 years to 77 years.
Various types of chronic arthritis were included,
namely: rheumatoid arthritis, degenerative arthritis,
Still’s disease, spondylitis rhizomelique (Marie-Strum-
pell), gout, traumatic arthritis, and arthritis associated
with osteitis deformans (Paget’s disease), and senile
osteoporosis.
In evaluating the results obtained in the management
of these arthritic patients, it is important to keep in mind
the fact that in addition to the arthritic process, there
were frequently other disease processes which necessitated
care. In this series of patients the following were the
most commonly encountered concomitant pathological
processes: disturbed gall-bladder and liver function, ab-
sence or lack of gastric acidity, colitis, gastric and duo-
denal ulcers, dietary deficiencies, arteriosclerosis, neu-
ritis, hypertrophy of the prostate, salpingitis and oophori-
tis, faulty body mechanics, pronated feet, bursitis, etc.
It is evident that these patients did not respond favor-
ably to previous therapy, otherwise they would not seek
additional medical attention for relief.
Most of these patients had had one or several recog-
nized types of therapy. Among the procedures listed
were surgical removal or treatment of foci of infection
including teeth, tonsils, sinuses, prostate, gall-bladder and
appendix. Other therapeutic measures which had been
tried were bed rest, colonic irrigations, casts, braces and
orthopedic appliances, physiotherapy, spa therapy, gold,
vaccines, fever therapy, salicylates, cincophen, colchicine,
and special diets. Many had had treatment by cultists of
various types before coming to our clinic.
Discussion
It is recognized that the period of management of
these patients is, as yet, much too short to permit any
conclusions as to the permanency of the results obtained,
nor is any specificity claimed. Nevertheless, the improve-
ment attained by the large majority of the group has
been such as to warrant a preliminary report.
The outstanding feature of the management was the
improved sense of well-being manifested by the patients
within a varying period after the institution of therapy.
In most of the cases, it became noticeable within three
to four weeks, and in others, after two or three months.
Following the general systemic improvement, there
was diminution of pain, decrease of soft tissue swelling,
increase in range of motion, better muscular tone and
greater endurance.
As was to be expected, the management, in approxi-
mately 5 per cent of the patients, did not bring the de-
sired benefits. These patients are still under observation
and the treatment is being continued and supplemented.
The ultimate result in these instances will be reported
in a later publication, which will include a much larger
group of patients.
It is our hope that this management which we have
found satisfactory to date can be continued for a long
enough period and on a large enough group of patients
to fully establish its value. In view of the number of
patients who, to date, have been restored to activity and
relieved of discomfort, the type of management em-
ployed would appear to have definite therapeutic value
in the treatment of chronic arthritis.
The mode of management employed is based on the
individualization of the patient. In each case, an attempt
is made to treat the patient as a separate and distinct
problem. The only common factor which all of the pa-
tients received was Ertron. In this series, each patient
received adjuvant treatment such as diet, orthopedic mea-
sures and physiotherapy, which seemed to be indicated in
each particular case. For this reason, our results were
better and the improvement occurred more rapidly and
in a larger percentage of patients than in such a purely
research series as reported by Snyder and Squires.10,11 •
We feel that it is only fair to point out that since it
was their intention primarily to determine the therapeutic
value of one medicinal agent, they selected only old
chronic cases and, once therapy was instituted, no adju-
vant measures were employed.
The writers wish to express their gratitude to the ad-
ministrators of the Cook County Hospital and Fantus
Clinic and laboratories and to the late Dr. M. Hubeny
of the X-ray department. Dr. D. Kobak of the Physical
Therapy department and those clinicians in the special
clinics for their whole-hearted cooperation and team work
so necessary in the treatment of arthritis.
Bibliography
1. Livingston, S. K.: Vitamin D and Fever Therapy in Chronic
Arthritis, Arch. Phys. Therapy 17:704 (Nov.) 1936.
2. Farley, Roger T.: Management of Arthritis, Illinois M. J.
71:74 (Jan.) 1937.
3. Farley, Roger T.: The Treatment of Arthritis with Massive
Dosage Vitamin D, J. Am. Inst. Homeop. 31:405 (July) 1938.
4. Reed. C. I., Struck, H. C., and Steck, I. E.: Vitamin D:
Chemistry, Physiology, Pharmacology, Pathology; Experimental and
Clinical Investigations, Chicago: Univ of Chicago Press, p. 389
(1939).
5. Farley, Roger T.: The Influence of Prolonged Administra-
tion of High Dosages of Vitamin D Upon the Serum Calcium of
Adults, Journal-Lancet 59:401 (Sept.) 1939.
6. Vollmer, Herman: Treatment of Rickets and Tetany with
a Single Massive Dose of Vitamin D, J. Pediat. :49l (April)
1939.
7. Farley, Roger T., Spierling, H. F., and Kraines, S. H.:
A Five-Year Study of Arthritic Patients, Ind. Med. 10:341 (Aug.)
1941.
8. Wolf, Israel J.: Treatment of Rickets with A Single Mass-
ive Dose of Vitamin D, J. Med. Soc. New Jersey 38:436 (Sept.)
1941.
9. Krafka, Joseph: Vitamin D Therapy in Psoriasis, J. M. A.
Georgia 30:398 (Sept.) 1941.
10. Snyder, R. G.. and Squires, W. H.: A Preliminary Report
on Activated Ergosterol, New York State J. Med. 40:708 (May 1)
1940.
11. Snyder, R. G., and Squires, W. H.: Follow-up Study of
Arthritic Patients Treated with Activated Vaporized Sterol, New
York State I. Med. 41:2332 (Dec. 1) 1941.
12. Snyder, R. G., Squires, W. H., Forster, J. W., Traeger, and
Wagner, L. C.: The Treatment of Two Hundred Cases of Chronic
Arthrities with Electrically Activated Vaporized Sterol Whittier
Process (Ertron), Ind. Med. 7:1 1, 295-316 (July) 1942.
13. Hench, P. S.: Effect of Jaundice on Chronic Infectious
Arthritis and in Fibrositis: Further Observations: Attempt to Re
produce the Phenomena, Arch. Int. Med. 61:451, 495, 1938.
14. Rawls, W. B., Weiss, S., and Collins, V. L.: Liver Func-
tion in Rheumatoid (Chronic Infectious) Arthritis: Preliminary
Report, Ann. Int. Med. 10:1021, 1937.
15. Rawls, W. B., Weiss, S., and Collins, V. L.: Liver Func-
tion in Rheumatoid (Chronic Infectious) Arthritis:: Ann. Int.
Med. 12: (March) 1939.
16. Davis, John S.: The Liver, An Etiological and Therapeutic
Factor in Certain Types of Blood Disease and in Gout and Gouty
Arthritis, Talk Given at Eight Annual Meeting of the Am. Rheu-
matism Assn., June 2, 1941, Hotel Cleveland, Cleveland, Ohio.
17. Collins, V. L.: Relation of Liver and Gall-Bladder Disease
to Arthritis, Rev. Gastroenterol. 6:344 (July-August) 1939.
18. Pemberton, R., Spackman, E. W., Bach, T. F., and Scull,
C. W.: Complete Roentgen Ray Studies of the Gastrointestinal
Tract in 400 Arthrities, Am. J. M. Sc. 202:68 (July) 1941.
February, 1943
51
The Cause of Toxemias of Pregnancy
R. T. La Vake, M.D.
Minneapolis, Minnesota
AT the October meeting of this Society in 1932,
a report was given concerning the most probable
^ cause of the true toxemias of pregnancy, a report
based upon a comprehensive review of literature and
clinical observations. It was maintained that all evidence
converged upon the hypothesis that the primary cause
originated from antigens or toxins, call them what you
will, arising from the cells of the products of conception.
The data of serology indicate that as the cells of the
products of conception develop, they gradually become
bristling with lipo-carbohydrate and likely protein anti-
gens. These antigens are harmless to the cells from
which they arise and harmless to any organism to which
they gain access if the cells of that organism possess these
antigens. But, if the cells of an organism, to which these
antigens gain access, do not possess these antigens, and
do not possess inherited antibodies, the cells of this or-
ganism develop these antibodies, which first neutralize
the antigens; then, if in excess strength, these antibodies
will act to kill the cells from which the antigens arise,
if they gain access to the organism from which they
arise. The very fact that a cell produces antibodies
against an antigen is prima facie evidence that the an-
tigen is harmful to it.
That the cells of the products of conception are sel-
dom if ever absolutely consonant with those of the
mother seems to be suggested by the finding that the
maternal organism reacts to the products of conception
much as it does to a low grade bacterial infection,
namely, by showing a leucocytosis, an increased sedimen-
tation rate, at times a fever, and again, at times, anemias
similar to those found in bacterial infection.
This observation, together with the impetus given by
experiences with blood transfusions, groupings, and cross-
matching, in the last war, led a number of us to inves-
tigate the question of incompatibility of bloods in its
possible relationship to the toxemias of pregnancy. At
that time, the A and B factors were alone envisaged.
Some of us soon abandoned the work, because, in many
of the worst early and late toxemias encountered, in
which eventually both the baby and mother were saved,
the bloods of mother, baby and even the father proved
to be compatible, by methods of crossmatching then
used. In 1923, our colleague, Dr. Irvine McQuarrie,
published in the Johns Hopkins Bulletin, observations
on 180 mothers and their babies as regards the incidence
of late toxemia among incompatible and compatible
bloods. He found that toxemia occurred 1614 times
more frequently when the fetal and maternal bloods
were incompatible. Ninety-three and three-tenths per
cent of the toxemia cases were found where bloods were
incompatible, and only 6.7 per cent where the bloods
were compatible. This was arresting evidence. His re-
search also brought out an important finding, and that
*Presented before the Minneapolis Academy of Medicine,
December meeting, 1942.
was that in 23.7 per cent of the cases the mother’s blood
agglutinated that of her offspring, whereas in only 2.7
per cent did the blood of the offspring agglutinate the
blood cells of the mother. This 2.7 per cent may be
interpreted as a high chance figure because in 1929,
Polayes, Lederer, and Wiener in 500 cases found not a
single newborn whose blood agglutinated that of the
mother. Allowing for technical errors and chance, it
may thus be assumed that disease in the mother cannot
be attributed to antibodies from the fetus, because seldom
is a child born with antibodies other than those of the
mother. In 1928, it was shown by Smith that whatever
antibodies are found in the fetus at birth, they diminish
or disappear during the first ten days of life. The dis-
appearing antibodies came from the mother’s blood. The
antibodies pass through the placenta by filtration as
occurs with syphilitic reagins. These reagins disappear
and if the fetus really has syphilis, it later develops its
own reagins.
On the other hand, antigens from the fetus may get
into the maternal circulation either by the breaking off
of villi, as suggested by Veit in 1902, by bleeding from
the vessels of the villi, as first suggested by Dienst in
1905, or by partial separations of the placenta, infarc-
tion and necrosis, as suggested by James Young in 1914.
It is pertinent to observe here, that in 1930 Kemp
showed that iso-agglutinogens could be first demonstrated
in fetal blood on the thirty-seventh day. This is about
the time that nausea and vomiting or other signs of
early toxemia begin. From the standpoint of possible
fetal destruction, this observation is again pertinent, be-
cause, if natural or acquired antibodies can gain entrance
to the fetus from the mother, the fetal blood cells can
be subject to attack from the thirty-seventh day. It is
obvious that this antigen-antibody reaction could explain
some early abortions and miscarriages, apart from the
morphological defects described by Mall. That the fetus
is not more frequently killed in this manner could be
explained by the finding of Kemp: that the red cells
of the newborn infant generally have only 20 per cent
of the sensitivity to agglutination that adult cells have.
As some factor other than the A and B antigens had
to be found to make the antigen hypothesis tenable in
those cases of toxemia in which it was found that the
A and B incompatibility was not involved, an attempt
was made to assess the possible part played by placental
infarcts as regards antigens in general. A skin test was
devised whereby placental infarcts were aseptically tritu-
rated with sterile normal saline solution immediately after
birth, and this placental juice was used to form an intra-
dural bleb on the mother, a control bleb being made with
the sterile normal saline solution. In some instances a
marked skin reaction appeared within twelve to twenty-
four hours, especially marked in cases of fulminating
toxemia. The possible implications of this test, where
The Journal-Lancet
52
positive, were discussed at the February meeting of this
Society in 1937. At best, the test is crude and not quali-
tative and quantitative as are serological studies in which
known antibody titers can be accurately tabulated.
In 1927, Landsteiner and Levine found the iso-agglu-
tinogens M and N, with the interesting finding that the
iso-agglutinin M is almost never found naturally in hu-
man blood, and the iso-agglutinin N never so found.
In 1928 the agglutinogen P was found by Landsteiner
and Levine. Again in 1935, Andresen found another
agglutinable property in human blood which he desig-
nated as X. This he found in 94 per cent of a series of
200 bloods. These data are informative from the stand-
point of the antigen hypothesis of toxemia because they
show that there are likely an infinite number of undis-
covered antigens, any one of which may not only account
for the toxemia found in cases where A and B compati-
bility exists, but may throw a different light on a more
basic cause where A and B incompatibility obtains.
In 1940, Landsteiner and Wiener brought to the fore
the Rh factor, and, early in 1941, Levine, Katzen, and
Burnham showed the relationship of the Rh factor to
erythroblastosis, toxemia, repeated abortions, miscarriages,
stillbirths, and macerated fetuses. Since then, much
work has been done on the Rh factor in relation to
transfusion and erythroblastosis. The findings and ap-
proximate figures to date are as follows: Around 85
per cent of the population are Rh positive and 15 per
cent are Rh negative, irrespective of other group specific
substances. The Rh factor is a dominant and appears
in the fetus with an Rh father. The Rh antigen in the
fetus stimulates the production of Rh antibodies in a Rh
negative mother; and these antibodies, gaining access to
the fetus, Cause the condition known as erythroblastosis,
characterized by varying degrees of anemia, hemorrhage,
icterus, and hydrops, that may lead to intrauterine or
neonatal death of the fetus. In the mother, the titers
of the Rh antibodies can be watched. Rapid increase in
the Rh titer is a grave sign for the fetus. The finding
pertinent to our subject is that in approximately 30 per
cent of these cases, a clinical toxemia appears in the
mother. That a subclinical toxemia does not exist in
the remainder is not known.
This is one more indication that where fetal antigens
are not present naturally in the mother, a clash is pre-
cipitated between fetus and mother that may injure or
destroy the fetus, the mother or both.
One of the main reasons for seeking to establish
beyond question the cause of a disease is to permit the
formulation of some means of prophylaxis or to permit
the assessment of unfavorable conditions that may result
in the disease and thus stimulate vigilance in watching
for the first signs of its accession. Now, clinical, labora-
tory, and theoretical data point strongly to the conclu-
sion that the most practical prophylaxis against late tox-
emia is the elimination of focal infection and the pre-
vention of acute infections. Apart from any deleterious
action that the infection itself may exert on the maternal
organs, it may raise the titer of maternal antibodies to
the point where increased antigen-antibody reaction at
the placental site may seriously damage the placenta and
the subsequent necrosis may bring about increased ab-
sorption of antigens by the mother. For many years it
has been suspected, and in the past two years, where the
Rh factor is concerned, it has been demonstrated to a
high degree of probability that antigen-antibody reaction
is a not infrequent cause of abortions, miscarriages, still-
births, and macerated fetuses, and is accompanied by a
substantially high percentage of late toxemias; but over
a much longer period of years, clinical observations have
indicated that focal infection and particularly acute in-
fections of any type are frequent precursors of these
entities. In reviewing histories taken in cases of late
toxemia one will often find no mention of clinical infec-
tion shortly antedating the accession of toxemia, either
because it was not considered important, or because no
care was taken to elicit the evidence.
The following sequence of events occurs too frequently
to be a mere chance occurrence: a pregnancy is pro-
gressing with apparent normality, when suddenly the
mother develops some form of acute infection; you vis-
ualize that a shower of placental infarcts may be taking
place. Shortly after, an acute toxemia develops, and at
birth the placenta will show outstanding infarcts with
distinctive characteristics, and, as accurately as it is pos-
sible to estimate the age of infarcts, it is estimated that
they occurred during the infection. The large number
of cases in which you may have infection not followed
by toxemia and possibly showing widespread placental
infarction do not invalidate the above findings and de-
ductions, because, the characteristics of the infarcts are
not the same, and, if the hypothesis that the toxin arises
as an antigen from the products of conception is true,
it is likewise true as a corollary that no amount of pla-
cental infarction can cause a true toxemia if the prod-
ucts of conception are not specifically toxic to the mother.
The following case well illustrates what an infection
may do. Dr. R. W. Koucky of this city showed me the
titer records of a mother who five weeks previously had
delivered an erythroblascotic child. This mother proved
to be an Rh positive and in group O. The baby was in
group B. At the first examination, five weeks after de-
livery, the mother’s B antibody titer was 1-1600. This
titer gradually diminished until eight months after de-
livery it had fallen to 1-500. She then developed an
infection, whereupon the titer rose to 1—2500. One week
after the infection the titer fell to 1-800. This case is
being followed to eventually establish her normal B anti-
body titer, so that if she becomes pregnant again with a
B group child, the pregnancy may be terminated after
viability of the child in time to save the child if the
maternal B antibody titer ascends rapidly.
Now, how does this hypothesis of cause, under dis-
cussion, affect treatment of the toxemia and are there
any important connotations that can be drawn from
findings in connection with it?
At present, in so far as treatment is concerned in the
interests of the mother alone, it makes little difference
what hypothesis a physician chooses to accept as the most
probable hypothesis of primal cause so long as he follows
approved treatment and indications for terminating the
pregnancy. Fiowever, if one envisages the toxin as com-
February, 1943
53
ing from the products of conception and realizes the
possibility of its extreme virulence, instead of believing
that the primal cause in early toxemia is a psychosis, a
hypoglycemia, a dehydration phenomenon, a starvation
acidosis or an avitaminosis, he is less likely to place too
prolonged confidence in the proper early and intensive
treatment of these important entities and less likely to
procrastinate in removing the products of conception
until it is too late. By the same token, in late toxemia,
it would seem that one is more likely to use more rea-
soned judgment in choosing the best time and type of
intervention, according to the conditions obtaining.
Again, where a pregnancy is superimposed upon a cardio-
vascular or kidney lesion, or an essential hypertension,
the prognosis and course of treatment must obviously be
greatly influenced by the reasoned possibility that the
products of conception in this particular pregnancy may
not be clinically toxic.
The serologists have given us data that should permit
us to save many babies that, following past technics, we
have often lost. Not alone in erythroblastosis, where in
the past we have followed largely the antenatal X-ray
findings in regard to the condition of the child, but in
late toxemias in general, we will now not have to de-
pend entirely upon weakening fetal heart sounds to tell
when we should step in and attempt to rescue the baby
before it is too late. The course of carefully followed
known antibody titers of the mother should aid us in
this decision. As experience increases, these titers may
aid us in deciding more accurately when pregnancy
should be terminated in the interests of the mother. At
present, the connotations are: that in all cases giving a
history of repeated abortions, a history of an erythro-
blastotic baby, or a history of a dead baby in late tox-
emia, we should have the Rh and A and B antibody
titers followed closely. This may become a routine in
be exercised in the crossmatching of even the first donor
chosen to transfuse a woman who gives a history of a
all severe late toxemias. What must still be determined is
just how much any one of these antibody titers should
be allowed to change in strength before intervention is
indicated, after the period of infant viability has been
reached. This recent data makes many of us who have
had opportunities of examining the external facies of
uteri in cesarean sections associated with late toxemia
and premature separations, suspect that both infarcts
in toxemia and subperitoneal ecchymoses, etc., in pre-
mature separations may very likely be antigen antibody
reactions. That many premature separations are asso-
ciated with toxemia is well known, and if we could, by
the careful following of antibody titers, get some clue
as to their likelihood, we might be able to circumvent
some of the worst of them. You will likely recall cases
of severe separations in which if the child had been re-
moved a few days earlier, not only would the child likely
have lived, but the mother would have been spared the
necessity of multiple transfusions, or likely saved from
death. In some of these cases, the difficulty of finding
donors who crossmatched properly, even though belong-
ing to compatible groups, makes it seem likely that an
antibody was present in that mother’s blood which might
have forewarned us that intervention should be instituted
many days before the catastrophy, had the titers of the
mother’s antibodies been followed.
These data are of especial importance to all who, for
any condition, are called upon to give transfusions to
women. It must be remembered that special care must
pregnancy within the previous two years. Levine, as you
know, has developed a special incubation technic that
makes crossmatching more sensitive.
Of all hypotheses of the cause of the toxemias of
pregnancy, the hypothesis that the toxin arises from the
products of conception seems still to hold the highest
degree of probability. It is the only hypothesis upon
which all clinical and laboratory findings converge, and
conversely, it is the only hypothesis that will account for
all the clinical and laboratory findings.
REPORT ON HEALTH ACHIEVEMENTS
IN NORTH DAKOTA
Frank J. Hill, M.D.t
Bismarck, North Dakota
Since 1900, fourteen years have been added to the average
life span in the United States. In 1940 the average life expect-
ancy at birth was 63 years for males and 66 years for females.
This increased life expectancy is due in a large degree to the
control of diseases made possible by the great strides in medical
science and public health service. Deaths from various com-
municable diseases have been markedly decreased. Medical diag-
nosis and surgical skill have been greatly improved and hospital
facilities have been increased and improved.
Along with these health achievements have come advances in
standards of living and in the knowledge and practical applica-
tion of facts about nutrition. Similarly industry has provided
clean, well ventilated factories and shops in which the hazards
of the various occupations have been reduced to a minimum
In 1939 the National Resources Board rated North Dakota
as the healthiest state in the union. Newer methods of diag-
nosis and treatment have reduced the average time a patient
spends in the hospital from twenty-eight days in 1890 to
•Presented before the Fargo Rotary Club, November 25, 1942.
t Acting state health officer.
twenty-two days in 1915 and to nine days in 1941. This repre-
sents a tremendous saving in money and a marked alleviation
of suffering. One of the best examples can be found in the
modern treatment of pneumonia. In past years a person who
became sick with pneumonia had to spend from ten days to
three weeks in a hospital. At a recent meeting of the State
Medical Association’s Pneumonia Committee our attention was
called to the fact that at the present time pneumonia patients
rarely stay in the hospital more than a week.
During the year 1940 North Dakota had the lowest mater-
nal mortality rate in the United States. This rate, 1.7 per
thousand live births, was also the lowest rate ever recorded for
our State and although we did not have the lowest infant mor-
tality rate in the United States during 1940 we did attain the
lowest rate ever recorded for North Dakota.
In 1940 we had the distinction of having the lowest death
rate from both alcoholism and syphilis. The blood testing of
selectees showed that the prevalence of syphilis is 5 per thou-
sand placing our State in the group of states having the lowest
venereal disease rates in the country.
In tuberculosis deaths, North Dakota was also able to attain
distinction. We were sixth from having the lowest in the
United States and we ranked first in the number of new
cases of tuberculosis discovered for each death. The latter
54
The Journal-Lancet
achievement speaks well for the interest which the medical pro-
fession has taken in case finding and reporting. Only two states
in the union have more beds for hospitalization per tuberculosis
death than North Dakota.
As the population of our State was only about one thousand
higher in 1925 than it was in 1940 it will be of interest to make
the following comparison: The crude death rate in 1925 was
7.8 as compared to 8.2 per thousand population for 1941. This
increase does not represent an actual increase but rather an in-
crease in the efficiency of reporting deaths. A full time state
health department was established in North Dakota in 1923
and the apparent increase in the rate, no doubt, represents better
recording of deaths rather than an increase in the actual death
rate. The crude death rate, 8.2 per thousand population, was
the lowest in the United States.
Health achievements are reflected also when one compares the
deaths in various age groups during two periods. During 1940
there were twelve hundred fewer deaths in the age group under
45 years of age as compared to 1925. In the age group over
45 years of age there was an increase, or thirteen hundred more
deaths in 1940, as compared to 1925. Let us see what these
figures mean. It simply means that an increase in the life
span will increase the number of aged people in the popula-
tion. For this reason we are experiencing an increased number
of deaths due to diseases of advanced age such as heart dis-
ease, intracranial lesions of vascular origin (strokes) , cancer,
and kidney disease. Medical science will, no doubt, be able to
retard the onset of these diseases even more in the future when
better diagnosis and treatment are available and when the pop-
ulation has gained and will put into practice the newer knowl-
edge of nutrition. Then we can increase the productive span of
life even more.
In spite of the fact that in 1940 North Dakota had a birth
rate higher than that of the west northcentral states, 20.8 per
thousand, and for the United States as a whole, our infant
death rate, 45 per thousand live births, was among the lowest
in the area.
Infancy was safer in North Dakota in 1941 than during any
previous year with a new low rate of 38 per thousand live
births. It is impossible to name all the agencies which have
added to the enviable health record of North Dakota. In our
public health achievements we owe much credit to the med-
ical profession, the dental profession, public health agencies, and
other, health agencies, both private and public. All agencies
whose objectives are to develop a healthier people in North Da-
kota can have a just pride in our achievements because their
tireless efforts daily give the command "Go down death.” We
owe much to the physicians who strive daily to attain more
scientific knowledge and who are willing to pass on its prac-
tical applications through inculcating health habits early in preg-
nancy. We have reason to believe that some contribution has
been made through the efforts of the Maternal and Child Hy-
giene Division and nurses who teach the public the value of
these services.
Motherhood was safer in North Dakota during 1940 than in
any other state. Back in 1925 the maternal mortality rate for
North Dakota and the United States were about the same.
The rate for North Dakota dropped from 6.2 to 1.7 per thou-
sand live births during the past 15 years. In 1940 the rate for
North Dakota was just about half that for the United States
as a whole. This outstanding record has been accomplished
through the years of effort of the medical profession, its Ma-
ternal and Child Hygiene Committee, and the educational
efforts and activities of the state and local health departments.
Over 94 per cent of the births in North Dakota were attend-
ed by physicians during 1940. In the cities 75 per cent had the
benefits of hospital facilities while in rural communities only
50 per cent had these advantages. Further reductions in ma-
ternal and infant mortality will occur in the future as facilities
to meet all emergencies are made available to a greater per-
centage of mothers and their infants.
Many communicable diseases are on the decline in North
Dakota. The application of the known preventive procedures
such as smallpox vaccination, diphtheria immunization, and
similar preparations have resulted in a tremendous saving of
human lives, suffering, and expense to the taxpayers. During
the period 1902 to 1925 the reports of county health officers
indicate that counties were spending from two to five thousand
dollars annually for the care of smallpox and typhoid patients.
At the present time such expenditures have been almost elim-
inated. A comparison with 15 years ago reveals that tubercu-
losis deaths dropped from 309 to 121; pneumonia deaths from
500 to 251; diphtheria from 83 to 5; scarlet fever from 66 to 3;
whooping cough from 70 to 16; smallpox from 7 to none.
Although the smallpox deaths have dropped to none during the
past 20 years we had more than 5,000 cases of smallpox in our
State. This suffering from smallpox could be prevented if all
individuals were vaccinated against smallpox. At the present
time we have a law which makes it illegal to require smallpox
vaccination as prerequisite for school attendance. If we were to
replace our present law with a compulsory vaccination law we
could eliminate smallpox from the state of North Dakota.
Typhoid fever is another disease which has been relegated in
many counties to the position of a medical curiosity. This has
been accomplished through the persistent efforts in water and
milk sanitation and in our program of typhoid fever carrier
control. Typhoid deaths decreased from 24 in 1924 to 1 in
1941. Education in regard to the danger of taking laxatives
for stomach ailments and advancements in treatment have de-
creased about 63 per cent the deaths from appendicitis during
the past 15 years. Appendicitis deaths have dropped from
136 to 50.
Influenza and pneumonia were among the five leading causes
of death in all age groups except those between 25 and 44.
Heart disease has been among the five leading causes in all ages
except those under 5. Cancer was among the five leading causes
of death in all age groups over 25 years. Intracranial lesions
of vascular origin (strokes) and kidney ailments are among the
leading causes of death in all groups over 45 years of age.
Tuberculosis remains among the leading causes of death for
the age groups 5 to 44 years. Motor vehicle deaths (accidents)
are one of the leading enemies for the age groups 1 to 4 and
15 to 44. Appendicitis takes a striking toll in those between
1 and 25 years. Diarrhea and enteritis are leading public health
problems in all under 5 years.
The five principal causes of deaths in 1941 in North Dakota
were (1) heart disease, (2) cancer, (3) intracranial lesions of
vascular origin (strokes), (4) influenza and pneumonia and
(5) kidney diseases. These causes of death accounted for almost
60 per cent of all the deaths in the State. Almost half of the
total deaths occurred in those over 65 years of age. Nearly one-
fourth of the total deaths occurred between 45 and 64 years
of age.
Diseases arising as a result of advanced years are one of our
major public health problems at the present time because peo-
ple are living to be older as a result of our health gains in the
lower age groups. These are diseases which must be reduced
through personal hygiene. To cope with them requires the
individual attention of a physician. They can not be attacked
by mass treatment methods. Education of the public through
the combined efforts of the individual physicians, State Health
Department and North Dakota Women’s Field Army for the
Control of Cancer, is our present method of attack on cancer.
According to Surgeon General Thomas Parran "almost every
year additions are being made to the scientific knowledge which
makes it possible for us to do more than was previously pos-
sible in the prevention of disease. We have every reason to
believe that we should accomplish more now than we did in
the past. We must find ways to shorten the lag between what
we know and what we do in prevention and treatment.” Ex-
amples of applying our newer knowledge and surer weapons
are illustrated in such diseases as rickets, pneumonia, diphtheria,
syphilis, typhoid fever, cancer, heart disease, diabetes, smallpox,
tuberculosis. We are finding surer weapons such as the Kenny
treatment for poliomyelitis, new methods of saving teeth, newer
knowledge of vitamins, minerals, and other nutritional elements.
The trend of our progress is upward. We must all join the
fight if the trend is to remain upward.
American Student Health Ass’n
Minneapolis Academy of Medicine
Montana State Medical Ass’n
The Official Journal of the
North Dakota State Medical Ass’n
North Dakota Society of Obstetrics
and Gynecology
South Dakota State Medical Ass’n
Sioux Valley Medical Ass’n
Great Northern Ry. Surgeons’ Ass’n
Montana State Medical Ass’n
Dr. E. D. Hitchcock, Pres.
Dr. A. C. Knight, V .-Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Ass’n
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, V .-Pres.
Dr. Ralph I. Canuteson, Secy.-Treas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, V .-Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Treas.
ADVISORY COUNCIL
North Dakota State Medical Ass’n
Dr. A. R. Sorenson, Pres.
Dr. A. O. Arneson, Vice-Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Ass’n
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, V .-Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Ass’n
Dr. N. J. Nessa, Pres.
Dr. J C. Ohlmacher, Pres. -Elect
Dr. D. S. Baughman, Vice-Pres.
Dr. C. E. Sherwood, Secy.-T reas.
Great Northern Railway Surgeons’ Ass’n
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. J. H. Fjelde, Pres.
Dr. E. H. Boerth, V .-Pres.
Dr. R. E. Leigh, Sec. -Treas.
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. J . F. D. Cook
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. A. R. Foss
Dr. W. A. Fansler
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary
W. A. Jones, M.D., 1859-1931
LANCET PUBLISHING CO., Publishers
84 South Tenth Street, Minneapolis, Minn.
W. L. Klein, 1851-1931
Minneapolis, Minnesota, February, 1943
MEDICAL MEETINGS IN 1943
As a contribution to the nation-wide effort to conserve
all resources, the larger medical meetings are being can-
celled for 1943. It is a logical thing to do, from every
standpoint, and will meet with universal approbation.
Not only will many material essentials be saved, but the
physical and mental energy involved can well be diverted
into channels more directly concerned in the business
of winning the war. There can be no dispute about that.
That these meetings are highly useful in normal times
must also be admitted. What we must try to do now
is to see that their value, while in a state of suspense,
is not wholly lost. This means that we who are not in
the armed forces must put forth every effort to keep the
medical home fires burning. Every type of local meet-
ing must be kept up to the best level of efficiency and
made attractive as well as useful. There is in every com-
munity a wealth of interesting clinical material and those
who are capable of developing its scientific value. Splen-
did programs can be made up from this source, either
on the basis of contributed papers or round table dis-
cussions. It should be a good training school for those
who have modestly concealed their talents or through
unwarranted diffidence kept in the background. Hospital
staff meetings afford an unusually good opportunity for
useful and interesting presentation of clinical and patho-
logical material. Now is the time to make the most of it.
For the duration, then, let us merely consider our
larger medical contacts as decentralized. The time will
come when we can travel again and perhaps we shall
enjoy it more for having to depend on our own resources
in the meanwhile.
G. C.
56
MEN DIE BUT IDEALS LIVE ON
The death of Alexander Woolcott on January 23.
1943, brings to mind a tribute he paid to "a general
practitioner” in his compilation of masterpieces from the
literature of his day in his first volume of The Woolcott
Reader.
Woolcott was not a plagiarist but probably the great-
est raconteur of his time. While this often called for a
repetition of formerly told stories, it must be admitted
that he added much by his choice of narratives, appro-
priate comments and charming rendition. He was a
master of the long descriptive sentence spoken in a low
dulcet, story-telling tone, with slight but gentle inflection.
It suggested few punctuation marks and no dyspnoea.
In Woolcott’s comments on the chronicle of Dr. Mc-
Lure of Drumtochty, written by Ian Maclaren, a Liver-
pool clergyman who died in Iowa in 1907, he made this
statement: "If in some crisis of flood or fire, I knew I
could keep, in my flight to safety, but one out of all the
sacred writings in this book, there would be no moment
The Journal-Lancet
of hesitation. I should choose A Doctor of the Old
School.”
Nearly everyone is familiar with Beside the Bonnie
Brier Bush. Woolcott admitted having read it forty
times; but each is far too prone to think of it as a tale
of experiences that could only befall an humble doctor
in an humble community in the humble past. On the
contrary, the same altruism that characterized the life
of Dr. McLure continues to operate in our profession
today and it is not confined to the general practitioner.
Recently when an orthopedist was asked to view the
roentgenograms in a case of fracture at the neck of the
femur in a patient in her nineties, the referring physician
felt it only fair to tell him that she had no money.
"How much difference would that make if he were to
operate?” The answer came back ringing clear "Not a
bit.” There was no hesitation, no mercenary quibbling.
Instances of this kind occur every day and many times
a day. Hippocrates is dead and that rugged Scotsman
of Drumtochty is dead but their ideals live on.
A. E. H.
Book Reviews
What the Citizen Should Know About Wartime Medicine,
by Joseph R Darnall, M.D., United States Army, and
Viola Irene Cooper; New York: W. W. Norton Co., Inc.
Tan fabrikoid, gold-stamped, 222 paces, plus bibliography
and index. Price #2.50.
This is a well organized and well written book on medicine
as it is practiced in the military services of our country at war.
The authors cover the field of medicine completely, that is,
both preventive and therapeutic, in the short span of the book.
They have read, digested and presented in a very readable form
practically all medical subject matter that has anything to do
with wartime medicine in its many phases.
Air medicine is given an important position; military sanita-
tion and hygiene, communicable diseases, infectious diseases,
as well as venereal diseases are all discussed with a very modern
concept.
This book portrays the present status of medicine in the
United States, not only in military service, but also in civilian
service and in educational and public health service fields. The
authors are to be congratulated on the readability of the book
as well as the concise inclusion of subject matter.
Anatomy of the Human Body, by Henry Gray, F.R.S.;
edited by Warren H. Lewis, B.S., M.D., assisted by Earl
T. Engle, Ph.D.; Joseph C. Hinsey, Ph D.; Normand L.
Hoerr, Ph D., M.D.; Karl E. Mason, Ph D.; David McK.
Rioch, M.D.; and Roy G. Williams, M.D.; red pebbled
buckram, gold-stamped, 1380 pages of text plus index of 47
pages, 1,256 engravings (many in color); Philadelphia, Lea
and Febiger, Ed. 24, 1942. Price, #12.00.
Mr. Henry Gray, F.R.S., (1827-1861) wrote his famous
Anatomy in 1858, when he was only 31 years old. Three years
later, at 34, he was dead of confluent smallpox. Since that time
the work of the brilliant demonstrator and lecturer on anatomy
at Saint George’s Hospital in London has been issued in twenty-
eight editions in England and twenty-four in the United States.
Should there yet remain those who believe that anatomy as a
basic science is largely static, the words of a distinguished Min-
nesota cardiologist may be recalled in refutation: the carotid
• n :s, represented anatomically by an enlargement of the ter-
minal part of the common carotid artery and of the internal
carotid artery as it leaves the common carotid artery, has been
included and described in textbooks of anatomy only within very
recent years, whereas it was originally demonstrated functionally
and topographically by physiologists and has been known to
cardiologists longer than it has been known to anatomists. It is
described, for instance, in the current (twenty-fourth) edition
of Gray’s Anatomy , but is not pictured. In another textbook
of anatomy, published within a year, it is neither depicted nor
described.
Osier’s well-known contention that "More than any others,
radiographers need the salutary lessons of the dead-house . . . ,”
has been applied in reverse to the present work: thirty new
roentgenograms added to the section on surface and topographic
anatomy testify to the assistance which roentgenology can ren-
der to anatomy as well as to diagnosis and therapeutics. The
volume is forty-seven pages longer than its predecessor, and has
had the benefits of the addition of six associate editors or col-
laborators. Dr. Engle, of Columbia University, writes on the
ductless glands. Dr. Hinsey, of Cornell University, writes on
the peripheral and autonomic nervous systems. Dr. Hoerr, of
Western Reserve University, writes on the blood bascular sys-
tem. Dr. Mason, of the University of Rochester, writes on the
respiratory and digestive systems. Dr. Rioch, of Washington
University, writes on the central nervous system, and Dr. Wil-
liams, of the University of Pennsylvania, writes on the uro-
genital system. The general editor, Dr. Lewis, is a member of
the Wistar Institute of Anatomy and Biology of Philadelphia.
To say at this time that Gray’s Anatomy of the Human
Body is a valuable textbook would be supererogatory, for it
has been recognized as being preeminently such for more than
seventy-five years. It can be said, however, that the latest edi-
tion of the work, with the extensive revision it has undergone
and the emendations it has received from the new editors, is a
notable descendant of Henry Gray’s volume of only 750 pages
which first appeared in 1858.
A Short History of Science to the Nineteenth Century,
by Chas. Singer; Oxford at the Clarendon Press; 392 pages.
This history of science, in spite of its brevity, covers a span
of over 2500 years. The author discusses in a really simple
form the development of an amazing number of subjects, such
as geography, medicine, public health, mathematics, physics,
religion, astronomy, etc. He has succeeded admirably in inter-
digitating and narrating the material in a fashion that makes
for most instructive and interesting reading. This small volume
should make a constructive addition to most libraries.
February, 1943
57
Hem Items
Dr. Alfred Blalock of Baltimore, Maryland, professor
and director of the department of surgery at the Johns
Hopkins Hospital, will give the tenth E. Starr Judd lec-
ture at the University of Minnesota in the Museum of
Natural History Auditorium on Thursday, March 11,
1943, at 8:15 P. M. The subject of Dr. Blalock’s lecture
is "Traumatic Shock with Particular Reference to War
Injuries.” The late E. Starr Judd, an alumnus of the
Medical School of the University of Minnesota, estab-
lished this annual lectureship in Surgery a few years
before his death.
Dr. Fred W. Ferguson, Kulm, North Dakota, and
Dr. W. H. Long, Fargo, are the new members of the
state board of medical examiners. The appointments
were made by Governor John Moses of North Dakota,
who at the same time reappointed Dr. W. H. Sihler,
Devils Lake.
Dr. H. C. Joesting, formerly of Butte, Montana, is
now in Seattle where he is director of the Clein Chil-
dren’s clinic. Dr. Joesting practiced in Butte for 12
years.
Dr. William H. Griffith of Hollywood, California,
formerly of Huron, South Dakota, is now a captain in
the U. S. Army medical corps.
Major Robert Cochran, formerly of Plankinton, South
Dakota, is taking a three months’ postgraduate course
in plastic surgery at Columbia university, New York.
Dr. J. J. Kane, Butte, Montana, has been reappointed
Silver Bow county physician.
Dr. Theodore Loken, Ada, Minnesota, is the new
president of the Red River Valley medical society. He
succeeds Dr. V. V. Boardman of Twin Valley who is
now in the Army. Dr. C. H. Homstrom, Warren, is
vice president and Dr. C. L. Oppegaard, Crookston,
secretary.
Dr. George H. Holt, Jamestown, North Dakota, is
the new president of the Stutsman County medical
society.
Dr. Charlotte J. Morrison, Minneapolis, is the first
woman ever appointed Hennepin County physician.
Dr. E. D. Risser, Winona, Minnesota, is the new
president of the Winona County medical society.
Dr. George Bergh, Montevideo, Minnesota, has been
promoted to the rank of major in the U. S. Army med-
ical corps.
Dr. A. C. Fortney, Fargo, North Dakota, has joined
the Army medical corps as a captain.
Dr. O. O. Larsen, Detroit Lakes, Minnesota, has been
elected president of the Clay-Becker County medical
society. Dr. H. G. Rice, former president, is now in the
navy.
Dr. John G. Thompson, Helena, Montana, is the new
president of the St. John’s hospital association.
Dr. Frank Towers, Minneapolis, said to be the oldest
living member of Hennepin County medical society, ob-
served his ninety-fourth birthday recently. Former Hen-
nepin county coroner and Minneapolis city physician,
Dr. Towers retired 25 years ago after having maintained
a local practice since graduating from medical school.
Dr. Erling S. Fugelso, Minot, North Dakota, has
been promoted to the rank of lieutenant colonel in the
medical corps of the U. S. Army. The promotion fol-
lowed a period of training at the command and general
staff school, Fort Leavenworth, Kansas. At present he is
stationed at Camp Grant, Illinois.
Lieutenant Commander B. C. Shearer of Helena,
Montana, officer in charge of the medical department of
the main Montana navy recruiting station, has been
transferred to a new navy hospital in New Orleans, La.
Dr. Emory J. Bordeaux, Missoula, Montana, is now
a lieutenant in the navy.
Dr. N. O. Monserud, Cloquet, Minnesota, a member
of the Raiter hospital staff, has received a commission as
first lieutenant in the medical corps of the Army.
Dr. Lewis Miller Reid of Minneapolis has taken over
the practice of Dr. H. C. Arey, Excelsior, Minnesota,
who is now a medical officer in the navy.
Woman’s Auxiliary to the South Dakota
State Medical Association
The Seventh District medical auxiliary met at the
home of Mrs. N. J. Nessa recently. Co-hostesses were
Mrs. M. A. Stern, Mrs. O. V. Opheim and Mrs. C. J.
Mac Donald. Two communications, one from the state
president, Mrs. J. C. Hagin, Miller, and one from the
state program chairman, Mrs. C. E. Sherwood, Madi-
son, were read. Both stressed support of the auxiliary
program as approved by the South Dakota State Med-
ical association. It embraces a varied scope including
active participation in all phases of Red Cross and War
Defense work, promotion of health education, legisla-
tion and a thorough survey of the Bulletin, official or-
gan of the national auxiliary. It was decided that "Doc-
tor’s Day” be observed March 30.
Announcement of a $1,000 Award for Outstand-
ing Research on Alcoholism During 1943
1. The research for which the award will be granted
must contribute new knowledge, in some branch of medi-
cine, biology, or sociology, important to the understand-
ing or prevention or treatment of alcoholism.
2. Any scientist in the United States, Canada or
Latin America is eligible for the award.
3. The project may have been inaugurated at any
time in the past or during the year 1943, provided (a)
that a substantial part of the work be carried on during
the year 1943, (b) that it be developed to a point at
which significant conclusions are possible before the end
of the year, and (c) that a report on the work has not
been previously announced and described before a scien-
tific body or previously published.
4. It is desirable, but not necessary, that those plan-
ning to work for the award send to the Council before
58
The Journal-Lancet
March 1, 1943, a statement of such intention. If the
Council receives such information, it can be helpful in
the prevention of undesirable duplication of effort. If
a research project is conceived and inaugurated later in
the year 1943, a statement of intention may be sent to
the Council at a later date.
5. A report on the work and resulting conclusions
must be submitted to the Research Council on Problems
of Alcohol on or before February 15, 1944. The Council
will provide an outline for use in the preparation of
reports.
6. The award will be in cash, and will be given to
an individual scientist whose work is judged sufficiently
outstanding and significant to merit the award.
7. The Committee of Award will consist of five per-
sons— an officer of the American Association for the
Advancement of Science, and four representatives of
the Scientific Committee of the Research Council on
Problems of Alcohol.
8. If the Committee is not convinced of the outstand-
ing merit of the research done during 1943, as described
in reports submitted, it may, at its discretion, postpone
the award until another year, or until such time as work
of such merit has been performed.
The Director,
Research Council on Problems of Alcohol,
Pondfield Road West,
Bronxville, New York.
huMUqtf
Resolution Drafted in Death of Dr. F. H. Malee
The Silver Bow County Medical society recently
adopted the following resolution on the death of one of
its members, Dr. F. H. Malee, prominent Butte physi-
cian, who died at Los Angeles while on duty with the
United States Army:
"Whereas, our member and colleague, Dr. F. H.
Malee, has volunteered his services with our armed
forces during this time of national and international
crisis, and
"Whereas, while on duty with our armed forces Dr.
Malee’s life was taken,
"Be it resolved that we, the members of the Silver
Bow County Medical society, pause in our deliberations
to remember his life with us and to pay our respects to
his character, ability and personality.
"Be it further resolved that we remember those of his
family who are still with us, and offer them the consola-
tion of knowing that their husband, father and brother
died in the service of his country and our country in her
hour of need.
"Be it further resolved that a copy of these resolutions
be spread upon the minutes of this society and a copy
be sent to the press and to the bereaved family.
"(Signed) D. L. Gillespie, M.D.; J. E. Garvey, M.D.;
Harold W. Gregg, M.D.”
CONTINUATION STUDY COURSES
Medicine, Hospital Service, Public Health
Winter 1943
CENTER FOR CONTINUATION STUDY
University of Minnesota
Minneapolis
Anesthesiology February 8-10
Dietetics February 18-20
Medical Social Service February 18-20
Rheumatic Fever February 22-24
General Surgery March 8-13
Anesthesiology — February 8-10
Course for nurse anesthetists. Because of large numbers of
physicians in military service more anesthetics are being given
by nurses. Course will review recent developments with especial
emphasis on safety factors. Enrolment limited to members of
American Association of Nurse Anesthetists and others with
equal training and experience. Program last year was of great
value to nurse anesthetists at that time. Study is being made
of special needs at present time. Please send for special in-
formation card. Tuition $5.
Dietetics — February 18-20
Course for dietitians and nutritionists. Dietitians employed
in hospitals, community agencies and institutions as well as
home economists in teaching or administrative positions will
find this course of value. Program will deal exclusively with
nutritional problems growing out of wartime difficulties.
Tuition $5.
Medical Social Service — February 18-20
Course for medical social workers on special wartime prob-
lems in their field. Medical social service has also been affected
by new developments in medical practice. Program will con-
sist of lectures, discussions, and demonstrations. Tuition $5.
Rheumatic Fever — February 22-24
One of the most important diseases of children with poten-
tially serious effects in childhood and later life. Course for
public health nurses to help them understand the disease. Pro-
gram will cover practical aspects of rheumatic fever problem as
it affects children and adults. Inclusion of heart disease in
crippled children’s program is reason for offering course at
present time. Tuition $5.
General Surgery — March 8-1?
Course will consist of lectures, clinics, demonstrations, and
round table question and answer periods. Subject matter will
deal largely with surgical problems of emergency nature. Rec-
ommended for all who must give surgical service in these
times. Outstanding leaders in surgical thought and practice
will take part. There will be no opportunity to acquire opera-
tive skills, but demonstrations and discussions will bring out
modern surgical teaching. Tuition $25.
Other Courses
Arrangement will be made to offer other special courses.
Please send your suggestions.
/
Nutrition Problems of University Students
Maj. B. A. Watson, M.C.
Minneapolis, Minnesota
THE main nutritional problems encountered in the
general student body of the University of Min-
nesota are obesity and undernutrition. Sixty-six
and four-tenths per cent (66.4%) of the students are
of normal weight;+ 17.1 per cent are overweight; and
16.5 per cent are underweight, according to a survey of
4,652 consecutive records of students.
One should never presume that a patient is over- or
underweight because his weight is reported as 80 to
120 per cent of normal. The fact that the bony frame-
work and body build are important in determining
whether an individual is truly over- or underweight has
not received enough consideration. The writer has seen
persons of both sexes placed in under- and overweight
groups by statistical computation when one glance at the
individuals in question would have indicated that no such
disturbance existed. Hence, before dietary measures for
nutritional disturbances are recommended, the physician
should give careful consideration to body build.
Calculation of Ideal Weight
Dr. Diehl, in his book, Healthful Living, gives a for-
mula which is as accurate as any and enables the physi-
cian to calculate ideal weight rapidly. It should, how-
ever, not be used in calculating the ideal weight for sub-
jects under 15 years of age. The formula is as follows:
*From the Nutrition Clinic, University of Minnesota Students’
Health Service.
tNormal weight, 90 to 110 per cent variation from the ideal
weight, as calculated from standard height-weight tables. Under-
weight, less than 90 per cent of ideal weight. Overweight, 110
per cent or more of ideal weight.
Ideal weight for males: Age + 100 + 3 lbs. per
inch over 5 feet. Example: Male age 20, 5 feet
10 inches tall: 120 + 30 = 150 lbs.
Ideal weight for females: Age + 100 + 3 lbs.
per inch over 5 feet minus 5 lbs. Example: Female
age 35, 5 feet 6 inches tall; 135 + 18 — 5 = 148
lbs.
Variations of 10 to 20 per cent above or below these
calculated ideal weights may be allowable, depending on
body build, before the state of obesity or undernutrition
is diagnosed. The real age is used up to 35 years, but
after that the figure remains at 35 for both sexes.
Types of Obesity
Obesity may be divided into two groups on the basis
of etiology:
A. Gluttony: In this type the individual consumes
more calories each day than are expended in normal
activity.
B. Glandular Disturbance: In this type the increased
weight is due to conditions beyond the control of the
patient, and is usually the result of an underfunction of
the thyroid gland or dysfunction of the pituitary or
gonads.
Gluttony is responsible for approximately 85 to 90
per cent of overnutrition and can best be treated by
dietary restriction. One should remember that under
basal conditions the adult human body requires about
10 calories pier pound per 24 hours to maintain itself in
a fasting state at complete rest. Depending on activity,
60
The Journal-Lance i
one must add approximately 40 to 100 per cent to the
basal caloric requirements to arrive at the proper estima-
tion of total caloric intake for a given individual:
Example A. Office worker wno should weigh 150
pounds: 150 X 10 calories per pound = 1,500 calories
for basal requirement. 1500 50 per cent above basal
for activity = 1,500 -(- 720 = 2,220 calories to main-
tain health and activity.
Example B. Ditch digger who should weigh 160
pounds: 160 X 10 calories = 1,600 calories for basal
requirements. 1,600 -)- 100 per cent — 1,600 -j- 1,600
= 3,200 calories to maintain health and activity.
If an individual requires only 2,200 calories a day and
eats 3,000 there is a daily caloric excess of 800 calories.
In one month this would mean that 24,000 calorics in
excess of normal requirements had been consumed. As
the excess calories are stored as fat and in 1 gram of
fat there is the equivalent of 9 calories, then 24,000
calories — 9 calories = 2,666.6 grams, or 5.8 pounds,
added during the month. This is an extreme example,
but nevertheless illustrates that consistent overeating,
even though in small quantities, can result in obesity.
Glandular obesity , fortunately, occurs in a compara-
tively small number of cases. The so-called "pituitary
type” of obesity can be diagnosed clinically, but rarely
if ever is it completely corrected with our present knowl-
edge of endocrinology. It should be noted that this type
of obesity does respond to some extent to restricted ca-
loric intake.
Hypofunction of the thyroid gland may aid in the
development of another type of glandular obesity. How-
ever, this type of obesity is in our experience exceed-
ingly uncommon. It should be noted that markedly over-
weight individuals have almost uniformly low basal meta-
bolic rates, but this does not imply the presence of true
hypothyroidism. It has been repeatedly observed in our
clinic that individuals with a basal metabolism rate of
— 20 or —30 who are obese will, by reducing weight
(and body surface), be found to have a gradually rising
basal rate in the absence of any thyroid therapy. The
routine prescription of large doses of thyroid extract to
obese patients has two detrimental effects: (1) it tends
to increase metabolism, thereby increasing appetite; and
(2) it gives the patient a false sense of security that
medicine rather than diet will reduce weight.
I believe that the giving of thyroid extract to an obese
patient should be reserved for those cases in which other
signs and symptoms of definite, even though mild, clin-
ical or subclinical myxedema exist.
Dietary Management
The use of an excessively restricted caloric intake in
weight reduction is ill-advised and may result in actual
harm to the patient. A reducing diet should fulfill two
needs: (1) it should be readily available to the subject;
(2) it should contain minimal essential requirements for
the patient’s health. Many reducing diets that are de-
ficient in vitamins, iron, calcium, etc., produce an in-
herent craving for certain foods, making it extremely
difficult for the patient to follow the diet.
The speed of the reduction is not nearly so important
as continued reduction, and at the same time the educa-
tion of the patient, so that when the desired weight is
reached it can be maintained. This last point is too often
disregarded.
In the Nutrition Clinic at the University of Minne-
sota Students’ Health Service it has been our practice
to give patients a basic diet of approximately 56 grams
carbohydrate, 56 grams fat, and 45 grams protein
(Table I). This basic diet meets minimal requirements
for health. It has been used for as long as nine months
by a patient with no detrimental effect. The patient
soon learns this basic diet. When the time for increas-
ing the diet comes, the patient is told to add one slice
of bread or its equivalent (Table II). As the patient
reduces, more bread is gradually added until a mainte-
nance diet is approached. Butter, bacon and cream may
be added if desired, though too high a fat intake reduces
the bulk of the diet and the patient may feel extremely
hungry, and tend to dietary indiscretions.
Thus by diet and education an obese individual can
reduce and ultimately attain a diet which maintains ideal
weight and health.
The patient should be warned that weight loss may
occur in two ways: (1) continuous, gradual loss may
occur; or (2) there may be periods of five to seven days
when no apparent loss takes place, then in 24 hours
five or six pounds may be lost. This is due to fluid re-
tention in tissues of the body, but it is discouraging to
the patient if he is unprepared for it. One should also
tell the patient that the closer ideal weight is approached
the slower will be the weight loss. Strenuous exercise
should be discouraged, as it tends to increase the ap-
petite and cause weakness in an individual who is on a
restricted caloric intake.
Undernutrition
Undernutrition, unfortunately, is more difficult to cor-
rect than overnutrition. Experience in our nutrition
clinic has shown that unless a patient is 15 to 20 per
cent underweight very little can be gained from treat-
ment. Underweight patients can usually be classed in
one of two groups:
Group A. Patients who are underweight in spite of
adequate food intake.
Group B. Patients who are underweight because of
an admittedly poor appetite or a sense of fullness shortly
after taking even small quantities of food.
Group A. It is extremely difficult to obtain satisfac-
tory results with treatment in this group. Infrequently
one will be able to suggest an increase in the fat content
of the diet, such as cream, butter, etc.; and by reducing
the amounts of salads and other low-calorie, high-fiber
foods one can assist the patient in making a satisfactory
gain in weight. Usually, however, a careful diet inven-
tory reveals adequate intake of high-calorie foods. Hy-
gienic measures, such as increased periods of sleep be-
yond seven to eight hours and less exercise, serve, in our
experience, no lasting purpose.
Group B. Those individuals with poor appetites or
sense of fullness after eating should be divided, so far
March, 1943
61
as treatment is concerned. Individuals with poor ap-
petites should:
Be given lists of foods of high caloric value.
Be given certain gastric stimulants, such as alcoholic
elixirs.
Restrict fluids at meal times.
Thoroughly masticate the food so it may be properly
utilized.
Those individuals with a sense of fullness shortly after
even minimal amounts of food are taken should be
placed on a diet having high caloric foods and taken in
four to six feedings rather than three.
General Considerations
In this discussion it has been assumed that the patient
has had a complete physical examination to rule out defi-
nitely any apparent cause for nutritional disturbance.
Such an examination should include a Mantoux test fol-
lowed by an X-ray of the chest if the Mantoux is
positive.
Vitamin B| (thiamin chloride) has been recommended
by some as being particularly valuable in stimulating
appetite. During the last year a careful study has been
carried on at the University of Minnesota Students’
Health Service to determine if the vitamin B complex
was efficacious in stimulating appetite. Three hundred
International Units of vitamin B,, riboflavin, 15 Sher-
man-Bourquin units of vitamin G were given in divided
doses daily.* The controls were given inert tablets of
the same size in the same dosage. Patients with admit-
tedly poor appetites who were 20 per cent or more
underweight were chosen. The appetites were stated as
improved in about 50 per cent of the treated and control
series. However, maximum weight gain over a three-
month period in the treated group was 2 pounds, and
in the control group, L3 pounds. Thus one must con-
clude from this series that vitamin therapy is of no value.
Insulin therapy has been suggested by some authors to
increase weight by producing low blood sugars with a
resultant increase in appetite. This method has been used
at our clinics. There is usually an increase in appetite
with a resultant increase in weight during the active
treatment, but on cessation of therapy the appetite re-
turns to its former level, and the weight is usually lost.
Thus this method cannot be recommended.
In summary, there are certain underweight patients
who will gain on a definite regime and others whose
weight it is impossible to increase with our present knowl-
edge of metabolism and nutrition.
Conclusions
1. Obesity occurs in 17.1 per cent and undernutfi-
tion in 16.5 per cent of the general student population.
2. Careful inspection of the patient should be made
before a diagnosis of over- or underweight is made, re-
* Acknowledgment is hereby made to the White Laboratories,
Inc., Newark, New Jersey, for their cooperation in furnishing both
the vitamin and inert tablets.
gardless of the rating given by standard height-weight
charts.
3. A formula for rapid calculation of ideal weight is
presented. Variations from the calculation of 10 to 20
per cent must be allowed in the college age group before
treatment is considered necessary.
4. Thorough physical examination, including a Man-
toux test, should be made of all patients before attempt-
ing to treat nutritional disturbances.
5. Obesity due to gluttony is best treated by low-
calorie diets. Education of the patient as to caloric values
of common foods is essential.
6. Glandular obesity is rare in occurrence; prescribing
thyroid extract in the presence of only a low basal meta-
bolic rate, when no other symptoms of hypothyroidism
exist, is not recommended.
7. Undernutrition presents many problems in man-
agement. Vitamins, in our experience, are of no value
in stimulating appetite or the gaining of weight.
8. The use of insulin, in the writer’s opinion, is not
justified in the average patient with undernutrition.
TABLE I
Basic Diet Leading to 4 V2 *0 1 Ratio of Carbohydrate to Fat
Carbohydrate = 5 6 Fat = 56 Protein = 42
Breakfast: 1 orange or 1 apple or Y2 medium-sized grapefruit.
1 egg (prepared in any form; no extra butter allowed
for frying).
slices bread (1 slice weighs 1 oz.) .
1 portion butter (average size pat or 1/3 oz.).
1 2 glassful whole milk ( V2 glassful =: 3/g cup).
Tea or coffee (no cream).
Lunch: Fat-free broth of any kind.
1 cooked portion lean meat or fish (about size of 1 >
slice bread or 1 V2 oz.).
2 portions vegetables from list allowed ( 1 portion ~ ~
3 oz. ) .
1 portion fruit from list allowed (3 oz.).
1 2 glassful milk ( 3/g cup).
1 portion butter (1/3 oz.).
slices bread.
Tea or coffee.
Dinner: Same as lunch, substituting various meats, fish, fruits,
vegetables, and allowing slices of bread.
TABLE II
Increase in Basic Diet
St 2p
Carbohydrate
Fat
Protein
56
56
42
1
84
45
2
92
48
3
1 10
5 1
4
128
54
5
1 46
57
. 6
164
60
7
182
63
8
200
66
9
218
69
10
236
72
1 1
244
56
75
Total calories ~ 1,780
62
The Journal-Lancet
Structive Surgery
A.s Carried On in North Dakota
George C. Foster, M.D.
Fargo Clinic, Fargo, North Dakota
INASMUCH as a large number of cases presented
in this paper were taken care of under the Crippled
Children’s Program of the Child Welfare Division
of the Public Welfare Board of North Dakota, I wish
in beg nning to pay tribute to the truly great work of
this combined federal and state movement, which makes
it possible for handicapped children to receive aid and
correction at a time in their lives when it will do them
most good toward making them useful members of
society.
Even though the desired result in the operative cor-
rection of strabismus is functional as well as cosmetic,
I am including a few such cases together with the lips,
palates, rhinoplasties, lid and mouth cases. The major-
ity of cases of strabismus are of the convergent type.
Again, the majority of these patients are farsighted,
and it is the extreme stimulation for accommodation
required to overcome the farsightedness which carries
with it the closely associated stimulation for convergence,
causing the resulting convergent strabismus. The treat-
ment of these cases should begin as soon as a definite
strabismus becomes established.
If, before the age of two, fixation is carried out by
one eye exclusively, the other crossed eye will not de-
velop acute vision because nature suppresses the image
in the crossed eye. Babies are not born with acute vision,
but develop it through use. If this use entails only one
eye, acute vision is not developed in the other eye.
Therefore, during this period, as soon as one eye is
found to be dominant and fixing all of the time, that
eye is covered all of the time by a patch, forcing use of
the eye which has been crossed and thus forcing develop-
ment of acute vision in that eye. After a varying period
of tire it will usually be found that the formerly crossed
eye has now become the dominant eye. It is then wise
to uncover the patched eye and again allow the use of
both eyes, un:il one eye definitely shows a dominancy.
That eye is then pitched and the performance is re-
peated. Thus we are able to develop acuity of vision in
each eye at approximately the same rate.
At the age of two, or before, if it seems practicable,
refracdon is done under atropine cycloplegia, and a com-
plete correction in the form of glasses is prescribed. It
is amazing how the very small children tolerate the
glasses when patience is used at the start in directing
their use. The program of patching is continued as be-
fore if a definite dominancy persists.
The old custom of doing nothing and hoping that
the child will outgrow a strabismus is completely falla-
cious and often postpones adequate treatment until the
desired results cannot be obtained by the simplest and
most effective methods. Before the age of six visual
^Presented at the Southern District Medical Society, Mar, on.
North Dakota, April 30. 1942.
acuity can be developed quite readily. After this age,
although it is known that it can be developed, the time
that it takes to achieve the end, and the practical diffi-
culties of interference with school and other activities,
make the patching procedure almost hopeless. It is for
this reason that these patients should come under the
care of a specialist as early as possible. It is generally
accepted that if the eyes do not straighten after six
months of the wearing of a full refractive correction,
such means will be ineffective and surgery must be re-
sorted to.
The preceding program has been followed out in all
of the cases which are illustrated. Figure 1 depicts a boy
with convergent strabismus, before and after surgery.
The girl shown in Figure 2 showed particularly gratify-
ing results. She had alternating concomitant esotropia
associated with hypermetropic astigmatism. Vision in
each eye was normal with proper correction. Wearing
of the proper correcting lenses over a period of years
brought no improvement in the strabismus. A bilateral
recession of the medial recti produced both a perfect
cosmetic and functional result. In this case there is
binocular single vision with stereopsis.
Figure 3 shows an elderly man with a senile ectropion
of the left lower lid. This was corrected by a Kuhn:-
Szymanowski1 operation.
The patient pictured in Figure 4 suffered traumatic
rupture of the left eyeball, comminuted fracture of the
left superior maxilla and zygoma, and fracture of the
mandible. An enucleation was performed and, because
of the depression of the floor of the orbit, packing was
introduced into the left maxillary sinus through the
canine fossa approach. However, the floor of the left
orbit remained somewhat depressed, and the left lower
lid was relaxed, so that the left lid aperture was markedly
lower. Figure 4C shows the result following a Kuhnt-
Szymanowski procedure on the left lower lid and the
procurement of a better prosthesis.
The boy pictured in Figure 5 got hold of some lye
at the age of eighteen months. Fortunately for him, it
apparently got no further than his lips, as the micro-
stomia caused by the heavy ring of scar tissue is the
only evidence of lye burn which can be found. Surgical
correction had been twice attempted elsewhere, with the
result shown in Figure 5A. Figure 5B shows the result
seven days following surgery. Ferris Smith’s- modifica-
tion of Werneck’s operation for microstomia was used
on the right side of the mouth and simple horizontal
incision with vertical suture was used to obtain the small
effect necessary on the left side. Figure 5C, taken about
two years later, shows how benign nature frequently is
in smoothing the results of structive surgery.
Figure 6A shows a young man with a perfectly formed
ear cartilage, which a vestigial muscle or tendinous
March, 1943
63
attachment insists on pulling out of its sac of skin and
up beneath the scalp. At operation the cartilage was
delivered into its proper place, the redundant tissue ex-
cised, the vestigial attachment severed (and the remain-
ing tissue shirred), so that the cartilage remained in its
proper place. Figure 6B, taken rather shortly after op-
eration, shows a rather rough result. The parents write
me, however, that at the present time the ear cannot be
distinguished from its fellow.
The patient in Figure 7 dislocated the cartilaginous
portion of her septum, very likely by falling upon her
nose, in early childhood. She came for cosmetic im-
provement. Fdowever, as demonstrated in Figure 7C,
the right nostril was completely occluded by the dis-
located septal cartilage and the anterior edge of the
septal cartilage protruded into the left nostril, being
completely dislocated from its proper position in the
columella. The first procedure was to replace the car-
tilage in the midline by the procedure of Metzenbaum.
Removal by the ordinary submucous resection would have
been unsatisfactory because the support of the septum
was imperative. The next procedure was the implanta-
tion of a piece of costal cartilage. The satisfactory pro-
file is demonstrated in Figure 7E. Since this procedure
was carried out, I have been narrowing the noses, and
at the present time I should not consider the broad nose
shown in 7 D to be satisfactory.
Figure 8 shows a young lady who had had a non-
specific pyogenic abscess of the septum when she was
eight years of age, which destroyed portions of the bony
and cartilagenous septum with the pictured result. The
septum was no: deviated and required no preliminary
work. The result was obtained in one procedure by
means of an implant of costal cartilage.
Figure 9 shows a young lady who suffered a trau-
matic dislocation of the nasal septum in infancy. In
addition to the external deformity, she presented a com-
plete obstruction of the left nostril by the septum. A
plastic straightening of the anterior portion of the sep-
tum, retaining the cartilage for support of the bridge
of the nose, resection of the posterior deviated portion
of the septal cartilage and bone, removal of most of the
hump, and reposition of the lower portion of the nose
in relation to the face, were all done in one step. The
result as pictured in Figures 9C and 9D was quite good.
However, the profile was not perfect and the nose was
too broad. A year later I reoperated on this young lady,
narrowing the nose and improving the profile.
In the repair of cleft lips I follow the principle of
Blair and Brown"* of repairing the muscular elements as
early as possible so that, by their continuous molding,
they may gradually force the bony elements into their
proper relationship. It has been repeatedly demonstrated
that in almost every case the molding thus performed
produces a more perfect result than can be obtained by
forceful correction and position of the bony elements at
operation. It is thus easily seen that the earlier the lip
is repaired, the greater will be the molding effect from
its muscular elements. Repair is sometimes carried out
when the infant is a few hours old. As a matter of fact,
passage through the birth canal is an exceedingly shock-
ing procedure and nature has prepared the fetus well for
this occurrence. It is well known that in the first day
or two following birth, the infant is relatively shock-
proof, and one may perform the repair of a cleft lip
without anesthesia, and with relative impunity. At the
present time the period of jaundice with its increased
bleeding tendency can be well controlled by the use of
vitamin K. However, if the infant is not operated on
within a day or two of birth, it is probably wisest to wait
until it has regained its birth weight and is satisfactorily
established on a feeding schedule.
Repair of the palate4,'>,t> is postponed to some time
between the ages of 18 and 36 months, as the repair of
the palate is a rather shocking procedure and the patient
should be as strong as possible to withstand the opera-
tion.
Figure 10 shows a simple cleft of the soft palate
before and after repair. Figure 11 shows what can be
accomplished in the repair of wide clefts of the palate
in adults.
Figure 12 shows an example of the worst type of
deformity. This is a bilateral cleft of the lip and of the
alveolar ridge, with the prolabium and the premaxilla
projecting almost straight out from the tip of the nose,
and associated complete cleft of the palate. This child
died shortly after the picture was taken, from an asso-
ciated congenital heart lesion. Its father had a cleft lip
which had been repaired in infancy, and an unrepaired
complete cleft of the palate.
The baby illustrated in Figure 14 is a cousin of the
baby illustrated in Figure 12, with identically the same
deformity. Figure 14B illustrates the result obtained
after a repair following the method of Harry P. Ritchie4
of St. Paul, which, I believe, gives the most artistic repair
of these bilateral clefts of the lip. A repair of this type
obviates the rather unsightly notch which almost invaria-
bly accompanies the repair according to the method of
Hagedoorn.
Enough of my patients have been from families where
there are instances of similar deformities to persuade me
that the tendency toward this lesion is to some degree
hereditary. The baby illustrated in Figure 15 with the
same extreme bilateral cleft is the child of a woman with
a repaired cleft of the lip and an unrepaired cleft of t! -
palate. The repair of the first side of the lip was done
at approximately six weeks of age, and the second side
was repaired at about fourteen weeks of age. Figure
15E shows the effect of the action of the orbicularis oris
muscle in pulling the premaxilla down into place and
producing a tip to the nose and a columella in a rela-
tively normal position. As this baby grows the protru-
sion of the upper lip will be lessened markedly, until it
assumes its normal position.
The young man illustrated in Figure 13 demonstrates
a minimal cleft, i. e., that cf the muscle body without
much cleft of the skin or mucous membrane. It is easy
to notice the effect which the non-union of the muscle
bodies has had upon the right nostril, causing it to
stretch so that it is twice as wide as the opposite one.
Repair of this cleft necessitates just the same operation
as a much more extensive cleft, in that the cleft must
M
Thi Journal-Lancet
March, 1945
65
Fig. 10
Fig. 12.
Fig. 8.
Fig. 9.
The Journal-Lancei
66
Fig. 14
be converted into a complete one and the floor of the
nostril narrowed to make it like its mate. The post-
operative picture shows some remaining induration which
will shortly disappear.
The baby in Figure 14 was operated on at the age of
three months. The second picture was taken seven days
after the first one. The baby illustrated in Figure 14
demonstrates that repair of the nostril is an essential
part of the repair of a cleft lip; in fact, it is frequently
the most difficult part of the problem.
The baby shown in Figure 15 was repaired elsewhere,
somewhat inadequately, the line of incision being too
short, causing a marked asymmetry of the mouth, and
some vermilion tissue in the scarline. The nostril is also
too large. This operation was completely redone, with
the result illustrated.
The baby in Figure 15 draws our attention to the
fact that it frequently takes multiple steps to obain a
satisfactory result in cosmetic surgery. This baby was
three months of age at the time of the original opera-
tion. As Figure 15B shows, the immediate result was
rough, and the nose not quite straight in relation to the
rest of the face. The baby was returned one year later,
when an operation on the septum improved the position
of the nose in relation to the face. Figure 15C shows
this child two years later. The scar includes some ver-
milion tissue and is too prominent. The left ala is too
wide and down too far. Therefore, another procedure
was undertaken, with the result shown in Figure 15D.
References
1. Meller, Josef: Ophthalmic Surgery; Philadelphia. P. Blakis-
ton’s Son & Co.
2. Smith, Ferris: Reconstructive Surgery of the Head and
Neck. Thomas Nelson &C Sons.
3. Metzenbaum. Myron: Arch. Otolaryngology 9:282 (March)
1929.
4. Blair. Vilray P , and Brown, J. B.: Mirault operation for
single harelip, Surg., Gynec. Obst. 5 1:81 (July) 1 930.
5. Ritchie, Harry P.: Congenital clefts of face and jaws. Arch
Surg. 28:617 (Apr.) 1934
6. Blair, Vilray P., and Brown, J. B.: The Dieffenbach-War-
ren operation for closure of the congenitally cleft palate, Surg .
Gynec. & Obst. 59:309 (Sept.) 1934.
7 Wardill. W. E. M : The technique of operation for cleft
palate, Brit. J. Surg. 25:117 (July) 1937.
March, 1943
67
Dental Caries in the Expectant Mother
A Critical Analysis
Julius G. Godwin, D.D.S.t
Houston, Texas
THE opinion that women’s teeth are rendered more
susceptible to dental decay during or as a result
of gestation is widely held and discussed. Con-
trary to belief, however, there is little authentic evidence
on which to base such a conclusion. Few experimental
studies concerning the relationship of pregnancy to dental
caries are available in the literature, in sharp contrast to
the large body of opinionated literature with little basis
for the conclusions reached.
"If the problem of pregnancy and caries is analyzed,
it resolves itself into two questions: Is there actually an
increase in the amount of caries during pregnancy? and,
if there is such an increase, how can it be explained?”1
The answer to the first question can be given only by
statistical data. Studies on the occurrence of dental caries
in a great number of pregnant women are essential. The
results of these observations have to be compared with
the incidence of caries in an equal number of non-preg-
nant women of the same age, the same race, and the
same social level. Only such data can merit general
acceptance.1
A leading proponent of the theory of increased caries
susceptibility during gestation is Gerson.J He made ob-
servations on 50 pregnant women first examined between
the second and fourth months, and as a control 50 non-
pregnant women of the same age and social standing.
Six months later he examined the whole group again.
His results showed that the increase in caries suscepti-
bility of the pregnant group was considerably over 100
per cent that of the non-pregnant group. His conclu-
sions are that "if pregnant and non-pregnant women
have the same number of good teeth to begin with, the
harmful influence of pregnancy on the teeth is readily
seen at a later period.” In an analysis of Gerson’s fig-
ures Ziskin'1 points out that "he does not record the
number of teeth present to begin with. Hence, his con-
clusion that 'if pregnant and non-pregnant women have
the same number of good teeth to begin with’ is merely
a postulation. Caries frequency is shown in an age range
of ten years — too long a period for comprehensive com-
parison; the average age, an essential element, is lacking.
Progress of decay is measured by the number of extrac-
tions necessary in both groups — an erroneous measure-
ment inasmuch as extraction may be necessitated by
toothaches or abscesses without progressive tooth decay.”
Lintz, quoted by Weintraub,4 reported on a study of
229 consecutive cases — 179 pregnant women and 50 non-
pregnant controls. Among his conclusions were the fol-
lowing: The pregnant patient lost more teeth and had
greater caries incidence. Women lost an average of two
teeth for every pregnancy. The more pregnancies a
•Thesis, Washington University D?ntal School, St. Louis,
Missouri.
+ Jefferson Davis Hospital, Dental Department, Houston, Texas
woman had, the more teeth she lost. It is important to
note here that many considerations bearing directly on
the problem have been ignored. For instance, Lintz made
no observations on the actual progress of dental disease
during gestation and lactation.
Hardgrove'’ states that in pregnancy the endocrine
glands are thrown out of balance and the expectant
mother is the victim of decalcification of her teeth in
most instances.
Bodecker0 is still more vague on the subject when he
says: "We frequently note an increase of dental caries
during pregnancy. This may be caused by a reduction
of the mineral salts in the teeth, which would increase
their permeability.”
Weintraub4 "feels convinced from personal observa-
tion in hospital and private practice and from the fre-
quency with which prenatal patients complain of dental
d fficulties, that there is an increased disposition to dental
disintegration during gestation.” However, no exact ex-
perimental data are given. Likewise Greenstone' writes
of a marked increase in the number of cavities and the
rapidity with which caries develops during pregnancy.
Therefore, despite the old adage, "A tooth for every
child,” the literature of our own times gives relatively
scant proof, on a strictly scientific basis, to establish this
proposition. In fact, some authorities deny it.
Further Studies
Klein* found only one out of five studies on humans
suggesting a positive correlation of pregnancy with an
increased tendency toward dental decay. Biro9 in his
studies of 400 maids and cooks, of whom 200 had been
pregnant and 200 non-pregnant, found no significant
differences in the amount of dental disease. In both
groups, which were of the same social level, the number
of decayed teeth increased with increase in age.
Ziskin111 studied 599 pregnant and 205 non-pregnant
women. Only pregnancy was considered as a causative
factor, any other theory which may have had a bearing
on the cause of caries of pregnancy being excluded.
Both groups were comparable as to age and class. His
data show an ascending rate of frequency of caries with
an increase in age and no positive correlation between
frequency of caries and the number of pregnancies. On
his graph one curve shows average carious and missing
teeth according to pregnancy order, the other average
carious and missing teeth according to age divisions.
He observes, "The curves rise in about the same degrees.
This tends to show that age is the determining factor
in the increase in caries rather than pregnancy; for, if
pregnancy order would influence the frequency of caries,
we would expect a much steeper curve.”
In 1937 Ziskin and Hotteling'4 made another attempt
to throw further light on the problem. Three hundred
68
The Journal-Lancet
and twenty-four pregnant women were studied. The
factor of dietary instruction was eliminated in many
cases by mouth examinations when patients first applied
for routine prenatal care. By means of the Bodecker
caries index they found that pregnancy does not incite
caries. They observed that more teeth may be extracted
during pregnancy than in the non-gravid state, but that
the causes for extraction are not related to the progress
of decay. Teeth with large cavities may be free from
pain for some time before the pregnant state, but be-
come painful during the term, necessitating extraction.
Starobinsky’- sees an explanation of this in that "the
hyperemia of the head usually present in pregnancy
evokes a hyperemia of the dental pulp, and on this
account the toothache, whether due to caries or chronic
pulpitis, is the more violent.” The method of least
squares was used by Ziskin and Hotteling to analyze
their data, with the conclusion that pregnancy actually
prevents decay to a significant extent. This is brought
out in the following table (Ziskin and Hotteling) :
No
Primi-
Secundi-
Multi
Pregnancy
parae
parae
parae
Age
27.7
23.6
27.1
29.1
Caries index
42.9
3 1 .0
35.9
39.0
Caries index per year
Percentage of carious surface
per year aft?r deducting
values for fillings and
1 .54
1.3 1
1.32
1.31
missing teeth
7.9
5.3
5.1
6.7
The mean caries index of their non-pregnant group is
much higher than are those of the pregnant groups.
This is interpreted by Ziskin and Hotteling to mean
either that pregnancy prevents caries, or that cases were
not selected at random. It is clear at any rate that in
the pregnant group repeated pregnancy is in some way
associated with a condition which prevents tooth decay.
Starobinsky’- reports a study of 216 pregnant and
150 non-pregnant women. He divided the pregnant
group into primtparae (average age 25.8 years), secundi-
parae (average age 28.6 years), and multiparae (average
age 31.4 years). He noted that the second group showed
an increase in caries of 4.4 per cent over the first; there
was a similar increase in the third group over the sec-
ond. He also divided the pregnant and the non-pregnant
cases into three age groups (20-25, 25-30, 30-36). He
found the increase in caries to be about the same in each
age group, the non-pregnant group showing slightly
larger numbers of decayed teeth than the pregnant.
Mull, Bill, and Kinney1'1 reported dental findings in
358 women who were examined during pregnancy and
after delivery. The incidence of new cavities during this
period did not exceed the average incidence for all
women of identical age range during the same length of
time. They concluded that "there is no appreciable
change in the teeth of women during pregnancy or the
first few weeks of lactation other than that which would
probably occur in a similar group of non-pregnant wom-
en during the same period of time. Only 15 per cent
of the cases studied showed change.” Assuming that
bearing children is a major cause of tooth destruction,
there should be a consistent rise in the average number
of missing and carious teeth with the number of preg-
nancies. No rise of any degree can be demonstrated
from their table, which is given below:
Para
1
2
3
4
5
6
7-10
No. of cases
232
120
51
23
1 5
15
9
No. of missing teeth
i 62
2.24
2.64
2.74
3.24
2.8
1.66
No. of carious teeth
5.54
5.77
7.03
6.91
5.1
6.1
5.33
It will be noted that in the following table, where
Mull and co-workers made the distribution on the basis
of age, there is a marked rise in the number of carious
and missing teeth. This is in complete agreement with
the work of Ziskin:
13-17
18-22
23-27
28-32
3 3 40
yrs.
yrs.
yrs.
yrs.
yrs.
No.
of
cates
45
220
131
50
19
No.
of
missing
teeth
1 .04
1.5 1
2.62
3.62
3.63
No.
of
carious
teeth
4.1 1
5.24
6.41
7.88
8.21
Oral Conditions During Pregnancy
The second part of the problem is how a slight in-
crease in caries incidence in pregnancy could be ex-
plained, if such an increase were actually demonstrated.
The question arises: What are the factors that may in-
fluence the oral conditions during pregnancy? These
may be classified as local environmental and metabolic
factors.
A complication occurring during the early months of
pregnancy is the pernicious vomiting of pregnancy, or
hyperemesis gravidarum. Vomiting begins about the
sixth week of pregnancy and may last through the third
or fourth month. This condition has been considered as
a possible cause of tooth destruction. Daro'4 in 1940,
writes "that just at the time (fourth month) when the
fetus begins to make great demands for calcium, phos-
phorus, iron and other minerals, the system is lacking in
these important elements, lost during the vomiting period.
It would be logical therefore to assume that the vom-
iting of this early period of pregnancy plus the increas-
ing demand for minerals is the cause of tooth decay in
the early months of pregnancy.” However, how calcium
is actually lost by vomiting is not demonstrated. Simi-
larly Weintraub4 comments on vomiting during preg-
nancy, but with no specific data.
Mull, Bill, and Kinney1'1 found that of the 54 patients
who showed active tooth decay, exactly half experienced
vomiting in various degrees while the others were free
from it. On the other hand, 60 per cent of all patients
observed reported vomiting although only 15 per cent of
the total showed active tooth decay. Vomiting therefore
can probably not be considered as a primary cause of
caries. Perhaps additional data would provide more sub-
stantial basis for conclusions.
In connection with vomiting during pregnancy we
often hear patients complain of a disagreeable taste,
especially a change in the normal alkalinity of the saliva.
Shulmanlu considers the marked hyperacidity of the secre-
tion and the frequent vomiting in the early months of
gestation as an important factor in the incidence of
caries. According to Weintraub4 this increasing acidity
of the saliva in combination with neglected mouth hy-
giene is an important contributing local factor in the
destructive effects of pregnancy on the teeth. Both
March, 1943
69
writers fail to substantiate their statements with tests or
figures.
The above hypothesis is not supported by the studies
of Karshan, Krasnow and Krejci10 or of Stern,1 ' who
demonstrated that there is no direct connection between
the pH of the saliva and the formation of caries.
Mull, Bill, and Kinney,13 working with the idea that
there might be a change in the buffering power of saliva
during pregnancy, found upon experimentation no in-
crease in the titrable acidity of the saliva. Ziskin3,53
found the saliva slightly more acid during pregnancy,
a condition which he links up with the existing gastric
hyperacidity. However, the fact that more caries was
found in his non-pregnant group (saliva pH means
6.61) indicates that the salivary pH at these levels has
little or no influence on caries frequency and may be
disregarded.
Jay, Hadley, Bunting, and Koehne,18 using a quanti-
tative method devised by Hadley,19 have reported that
the concentration of lactobacilli in the saliva is a reliable
index of the acidity of dental caries in the mouth. Boyd,
Zentmire, and Drain1'0 and others failed to confirm the
general trend of these findings, which may be owing to
faulty technic or interpretation. The specificity of lacto-
bacilli in the production of caries is therefore still de-
batable. Assuming caries is due to the action of this
bacillus and pregnancy promotes caries, we should find
an increasing concentration of the bacilli in the mouth
as pregnancy progresses. With this idea in mind. Mull
et al.13 cultured B. acidophilus from saliva of pregnant
women. They found that B. acidophilus is not con-
sistently present in the mouths of pregnant women, nor
always maintained throughout the term of pregnancy.
However, the method they used is that described by
Bunting01 in 1926 and since revised.
Before leaving the subject of hyperacidity in preg-
nancy, we mention the concept of Broderick, who has
attempted to show that caries and pyorrhea are simply
opposite conditions caused by variations in the pH con-
tents of the saliva. In acidosis, calcium salts are removed
from the teeth into the saliva by a process of osmosis,
and in alkalosis calcium salts are similarly deposited into
the teeth from the saliva. This condition, thinks Brod-
erick,11 might account for the various dental disorders
of pregnancy, as it seems to cover any fluctuations in
the general conditions of pregnancy, and not only a few
odd months.
There has often been noticed a general laxity in oral
hygiene as pregnancy progresses. Mull, Bill, and Kin-
ney13 are of the opinion that no particular importance
should be attached to such observations, since it has
been fairly well proven that oral hygiene has little to
do with the developing of caries in any case.11'13
We must not forget that in pregnancy we often find
gingivitis, which increases food retention. The studies
of Rosebury, Karshan, and Foley in rats14 and of Rose-
bury and Karshan among Eskimos10 suggest that dental
caries in man may be caused primarily by food particles
rich in carbohydrates and having a physical character
that favors forcible impaction into the recesses of the
teeth. (Coarsely ground raw cereals induced caries in
rats even though the diet as a whole was fully adequate
in all nutritional elements.) It seems clear that preg-
nancy in itself could only modify other conditions which
cause caries.
Metabolic Factors
Next there is the problem of the metabolic factors,
which has been debated again and again. In considering
the subject from this angle, calcium metabolism, diet,
and endocrine function assume a great importance.
Serum calcium tends to decline during the later
months of pregnancy. This is clearly brought out by
Mull and Bill,16 who performed nearly 5,000 determina-
tions on a group of 900 subjects. The decline is pro-
gressive as pregnancy advances, but is interrupted six to
seven weeks before delivery, when there is a slight rise
until delivery, followed by a sharper elevation after de-
livery. Oberst and Plass17 observed no change of serum
calcium early in pregnancy (average 10.4 mg. per 100
cc.) , but during the eighth and ninth months the con-
centrations varied between 8.8 and 10.8 mg. During
labor the average was restored to 9.9 mg. and remained
at this level during the succeeding seven to nine days
of observation. Bodansky’s18 results in this respect con-
firm those of both Oberst and Plass17 and Mull and
Bill.26
Mull, Bill, and Kinney,13 who studied the blood and
teeth of a large series of pregnant women, found that
the calcium and the inorganic phosphorus of the serum
bear no direct relation to the condition of the teeth. The
small percentage of their cases that showed evidence of
active tooth destruction were abnormal neither in the
calcium nor in the phosphorus findings.
Just what significance is to be attached to the low
serum calcium is not clear. An explanation may lie in
the nutritional status of the patient. The lowest values
reported in human subjects which may be definitely-
attributed to calcium deficiency were those obtained by
Maxwell'0 in his studies of osteomalacia among pregnant
Chinese women. The general experience, however, has
been that within comparatively wide limits the level of
calcium in the food has little effect on the serum cal-
cium concentration.30'31 It is not improbable that even
moderate degrees of hypocalcemia may be caused by
dietary calcium deficiency.18
Dietary Factors
What influence does diet have on dental caries in
pregnancy? In animals it has been shown by Rosebury
and Foley14 that pregnancy and lactation, despite the
feeding of diets deficient in calcium and vitamin D, did
not cause caries. Changes were found only in the cal-
cification of bone and the new dentin. Klein’s8 study of
700 rats revealed about the same amount of caries in
the molars of both sexes, pregnancy not being a factor.
Toverud,31 on the other hand, reported a noticeable
difference in the microscopic appearance and chemical
composition of normal rats as compared with those
whose diet was deficient in calcium. However, Toverud
studied the incidence of dental decay only in the in-
cisors and in the molars of rats.8 This fact must be
clearly pointed out; for the growing incisor of the rat
70
The Journal-Lancet
can be influenced by dietary means — in contrast with
man’s fully developed teeth.
Fish33 kept a pregnant dog on a calcium-deficient diet.
At the end of the experiment the bones were soft and
decalcified to such an extent that they were hardly visible
in the radiograph and could be cut with a knife; the
teeth, however, showed an unchanged density radio-
graphically. As to the chemical composition, the teeth
were unchanged either by dieting, increasing or with-
holding vitamin D, deprivation of calcium during preg-
nancy, or by giving calcium carbonate.
The recent study of Day and others'14 showed an av-
erage of only 1.54 cavities in women who had high inci-
dence of rickets and osteomalacia and definite vitamin D,
calcium and phosphorus deficiencies in their diets. More-
over, their diets consisted mainly of carbohydrate food,
which is supposed to be a very important causative factor
in caries, according to Bunting and co-workers. In this
connection Jay*’2 emphasizes the fact that their diets did
nor contain any refined sugar.
A number of investigations have been interpreted as
indicating that improvement in the diet (especially by
including vitamin D) results in reduction of the inci-
dence of dental caries in children.3’-3' This points to an
effect of mitigation rather than of prevention. The evi-
dence certainly does not show that caries is caused by
dietary deficiency. "This subtotal reduction of caries
induced by vitamin D feeding may indicate that the
'protective’ effect of dietary changes counteracts but
does not remove other conditions of a directly causative
nature.”38
Teel, Burke, and Draper3*1 have shown that the ex-
pectant mother needs appreciable greater amounts of
vitamin C. Well, Howe,40-41 and others observed
changes in the odontoblastic layer as well as in the pulp.
None, however, reported the development of dental
caries.
These few examples may suffice to show that the only
tooth whose structure and calcification can be influenced
is the growing tooth. After the tooth has erupted, no
internal changes can be expected from dietary measures.
A nutritionally sound diet is, of course, necessary and
desirable. Unlike the bones, the teeth are not subject
to calcium withdrawal.
Endocrine Function
It is also conceivable that so high a frequency of hypo-
calcemia reflects relatively impaired function of the en-
docrine organs. Among them the parathyroids appear
to be most important as far as calcium metabolism is
concerned. Even on an adequate calcium intake, the
parathyroids increase in size and apparently in func-
tional activity during pregnancy. It is logical to assume
that a calcium deficiency may occur, with the necessity
of maintaining a more active calcium metabolism than
at other times. The evidence for it is not established at
present. Bodansky28 was unable to attribute hypocal-
cemia specifically to parathyroid deficiency or to explain
it on the basis of nutritional deficiency alone. It may be
assumed that an intrinsic calcium-depressing factor exists
in pregnancy to maintain a subnormal calcium level. The
sharp rise in the maternal calcium level after delivery
and the decline in that of the newborn suggest such a
factor.81
In considering the influence of the parathyroids from
the dental standpoint, we know that upon removal of
these glands the calcification of dentin is disturbed and
enamel hypoplasia is produced. Schour, Chandler, and
Tweedy42 removed the parathyroid glands from rats.
In those that survived over four months repeated preg-
nancies and lactations failed to produce any histologic
evidence of calcium withdrawal from the teeth. In an-
other direction, Thoma43 made a histologic study of
the teeth of a boy aged 15 years who had a parathyroid
tumor and found no evidence of resorption in the teeth.
Albright, Aub, and Bauer44 reported the clinical and
laboratory findings of seventeen patients with hyper-
parathyroidism and decalcification of the bones. They
state: "The teeth do not take part in the generalized de-
calcification. They may fall out because of disease of the
jaws but they themselves remain well calcified.”
Concerning the influence of the gonads, Tandler and
Grosz4-' made a careful study of eunuchs and found no
changes in their teeth. This is not surprising, since the
castrations were, as a rule, performed when the develop-
ment of the teeth was practically completed. The ef-
fects of injections of gonadal or gonadotropic hormones
upon the teeth have to my knowledge not been reported.
The response of the gums to hormonal treatment has
been demonstrated by Ziskin4'1 and others.
The data available on the function of other endocrine
glands and their effect on adult teeth are scarce.
Lactation and Tooth Decay
In regard to lactation, an abundance of data indicates
that it may produce greater mineral disturbance than
gestation.4 ,-'>1 It has been shown that the calcium con-
tent of the mother’s milk remains the same regardless
of the lack of calcium in her diet. ’2 Here, as in preg-
nancy, then, unless the intake is made sufficient, the sup-
ply will be drawn from the reserve store in the mother’s
bones. The possible direct influence of lactation on the
incidence of tooth decay has been studied to some extent.
The few experiments of Day and Daggs,''3 Rosebury,24
and others in rats brought out no positive correlation.
Hunscner ’2 observed no change in the teeth of three
women after six months of lactation. On the other hand,
Mull, Bill, and Kinney13 and others observed that
especially following delivery, when the care of the child
makes an increased demand upon the mother’s time,
less and less attention is paid to the care of the mouth.
This might increase the incidence of decay in a caries-
susceptible mouth.
Discussion
From the foregoing it is evident that there is no basis
for designating pregnancy as a cause of dental caries.
The question arises, Why do so many physicians and
dentists observe a tremendous amount of dental caries
in the pregnant? Probably on the basis of subjective
observations. The decay noted would probably have
occurred in a similar group of non-pregnant women dur-
ing the same period of time.13 Very often a necessary
March, 1943
71
treatment has been neglected. The observation has been
made that more teeth may be extracted during pregnancy
than ordinarily, but such extractions may become neces-
sary for reasons other than progress of tooth decay. ’ In
the undoubted individual instances in which pregnancy
is associated with a marked increase in caries the reason
apparently lies in some circumstance not related to preg-
nancy in any essential way.
On the contrary, Ziskin’s analysis may indicate "some
factor operating during pregnancy” which somehow
tends to prevent tooth decay. Whether such a factor is
to be found in the serum, the saliva, or elsewhere is sub-
ject to speculation and research.
Encouraging are the recent studies on human saliva.
Hill,54 Weinmann,'’'1 and others speak of special constit-
uents of the saliva that stimulate or inhibit growth of
oral bacteria. Such a substance may be more active dur-
ing pregnancy to prevent decay. If Bunting’s'1' theory
is correct, experimental studies should show a definite
correlation between carbohydrate content of the diet, the
occurrence of L. acidophilus and incidence of dental
caries during pregnancy. However, Mull, Bill, and Kin-
ney14 -could not find such a correlation. It might be of
value to carry out tests during pregnancy similar to those
made by Fosdick, Hansen, and Epple.''0,11 They found
that saliva, sugar, and enamel mixtures would form acids
at varying rates and that the rate of acid formation was
related to the caries activity. Saliva from caries-suscep-
tible persons was found to contain large amounts of add-
ed calcium, whereas the saliva of the caries-free group
showed little or no change. The recent findings of Kar-
shan ’1 show that the solubility of enamel depends largely
on the concentration of calcium and phosphorus ions in
the surrounding medium. Stimulated and unstimulated
saliva gave higher mean values in a caries-free than in
a caries-active group (1) for CO_. capacity, (2) for total
calcium and inorganic phosphate and (3) for the per-
centage of calcium and phosphate removed from saliva
on shaking with tri-calcium phosphate, the last probably
being the reflection of a difference of the forms in which
calcium and phosphorus exist in saliva. In reviewing the
literature nothing was found about tests of this type in
relation to the subject here discussed. If pregnancy
actually prevents decay, as brought out by Ziskin,'’ such
tests should indicate a saliva which would protect enamel
against solution by acids to a greater degree.
Several reports suggest that changes in certain of the
salivary characteristics discussed above can be brought
about by dietary means. In other studies, however,
attempts to alter the composition of saliva by dietary
means have yielded negative results.1'" Further studies
on this important subject are needed.
Conclusions and Summary
1. Pregnancy per se might not be considered as a
cause of dental caries.
2. There is apparently no appreciable change in the
teeth of women during pregnancy or the first weeks of
lactation other than that which would probably occur in
a similar group of non-pregnant women during the same
period of time (Mull, Bill, and Kinney).
3. Data indicate an increase in the number of miss-
ing and decayed teeth with advancing age.
4. According to Ziskin, repeated pregnancy may be
associated in some way with a condition which actually
prevents tooth decay.
5. General laxity in oral hygiene, especially following
delivery, may or may not have a bearing on the condi-
tion of the teeth.
6. The slightly lower pH values of the saliva during
pregnancy are probably not sufficient to cause caries.
7. The present experimental facts show that there is
no confirmed relationship between levels of calcium and
inorganic phosphorus in serum and the occurrence of
caries during pregnancy.
8. Evidence points to the conclusion that the addi-
tions of calcium and phosphorus preparations do not im-
prove the structure of the teeth and decrease dental caries
during pregnancy, except in known cases of calcium de-
9. There is no evidence to show that endocrine dys-
function has any effect on the fully calcified tooth struc-
ture.
10. Factors which might be effective in the improve-
ment of oral health during pregnancy form a part of
the problem.
The author wishes to thank Dr. Karl John Karnaky, Hous-
ton. Texas, for his constructive criticism of this paper.
Bibliography
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rounding Structures, Philadelphia, Lea dC Febiger, 1939. pp. 34-36
2. Gerson, S.: Caries and pregnancy, Internat. J. Orthodontia
7:459, 1921 .
3. Ziskin, D. E., and Hotteling, H.: Effects of pregnancy on
dental caries, J. Dent. Research 16:507-5 19 (Dec.) 1937.
4. Weintraub, F. : Considerations of interest to the dentist and
obstetrician. Dental Cosmos 74:660 (July) 1932.
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Obst. 6C Gynec. 27:679, 1934
14. Daro, A. F.: Teeth in pregnancy, J. Am. Dent. A. 27:5 1-57
(Jan.) 1940.
15. Shulman, H. S.: The relationship of dentistry to obstetrics.
Dental Cosmos 67:73 (Aug.) 1925.
16. Karshan, M., Krasnow, F., and Krejci, L.: A study of blood
and saliva in relation to immunity and susceptibility to dental
caries, J Dent. Research 1 1:573, 193 1.
17. Stern. A. R.: The H-ion concentration of normal renting
saliva in children and its relation to dental caries. Dental Cosmos
73: 1017, 193 1.
18. Jay. P., Hadley, F. P., Bunting, R W , and Koehne. M.:
Observations on relationship of Lactobacillus acidophilus to dental
caries in children, J. Am. Dent. A. 23:846, 1936.
19. Hadley, F. P. : A quantitative method for estimating B
acidophilus in saliva, J. Dent. Research 1 3:41 5, 1 93 3.
20. Boyd, J. D., Zentmire, Z., and Drain, C. L.: Bacterio-
logical studies in dental caries, J. Dent. Research 1 3:443, 193 3.
21. Broderick, F. W.: The Principle of Dental Medicine, St.
Louis, C. V. Mosby Co., 1939, p. 524.
22. Alexander, S.: Nutrition, dentition and maintenance of
teeth, Dental Items Interest 54:597, 1932.
23. Hanke, M. T.: Diet and Dental Health, University of Chi-
cago Press, 1933; Nutrition and dental disorders, Dent. Survey,
vol . 7. 1931.
24. Rosebury, T., Karshan. M , and Foley, G.: Studies in the
rat of susceptibility to dental caries, J Dent. Research 12:463,
1932.
72
25. Rosebury, T., and Karshan. M.: The mechanism of dental
caries, Ann. Dent. 4:205-212, 1937.
26. Mull, J W., and Bill, A. H.: Variations in serum Ca
and P. during pregnancy, Proc. Soc. Exper. Biol. 6c Med. 30:854-
856 (Apr.) 1933.
27. Oberst. W. F., and Plass, E. D.: The variation in serum
Ca. protein and inorg. P in early and late pregnancy, J. Clin. In-
vestigation 11:123 (Jan.) 1932.
28. Bodansky, M.: Changes in serum Ca, inorg. P and phos-
phatase activity in the pregnant woman. Am. J. Clin. Path. vol. 9,
no i 1939
29. Maxwell, J. P.: Osteomalacia and diet. Nutrition Abstr. 6c
Rev 4: 1 (July) 1934.
30. Pyle, S. I., Potgieter, M.. and Comstock. G.: On certain
relationships of Ca in the blood serum to Ca balance and B. M.
during pregnancy. Am. J. Obst. 6C Gynec. 35:283 (Feb.) 1938.
31. Bodansky, M., and Duff, V. B.: Regulation of the level of
Ca in the serum during pregnancy, l.A.M.A. 11 2:223 (Jan. 21)
1 939.
32. Toverud, G.: The influence of pregnancy on teeth. Dental
Cosmos 44:121 3, 1 927.
3 3. Fish. E. W An Exper. mental Investigation of Enamel,
Dentin and the Dental Pulp. London. John Bale Sons 6C Daniel-
son, 1 9 3 2.
34. Taylor. Geoffrey F.. and Day, C. D. M.: Osteomalacia and
dental caries. Brit. M. J. 2:221-2 22 (Aug. 17) 1940.
35. Boyd, J. D . Drain. C. L., and Nelson, M. V.: Dietary con-
trol of dental caries. Am. J. Dis. Child. 38:721, 1929.
36. McBeath, E. C.: J. Dent. Research 1 3:243, 1 932.
37. Schoenthal, L., and Brodsky, H. R.: Am. J. Dis. Child.
46:91, 1933.
38. Gordon. S M.: Dental Science and Dental Art, Philadel-
phia, Lea 6c Febiger. 1 938, p. 293.
39. Teel. H. M.. Burke. B. S.. and Draper, R.: Vitamin C in
human pregnancy and lactation. Am. J. Dis. Child. 56:1011-1019,
1938.
40. Wells, F. M.: Sound Teeth in a Sound Body, Montreal,
Desbareshs Printing Co., 1926, p. 98.
41. Howe, P. R.: Effects of some vitamin deficiencies on the
teeth. Temple Dent. Rev., vol. 4 (May 9) 1 933-34.
42. Schour, I., Chandler, S. B . and Tweedy, W. R.: Changes
in the teeth following parathyroidectomy. Am. J. Path. 13:945-
970 (Nov.) 1937.
The Journai.-Lancei
43. Thoma. K. H.: Clinical Pathology of the Jaws, Springfield,
111.. Charles C. Thomas, 1 934.
44 Albright, F., Aub, J. C., and Bauer, W.: Hyperparathy-
roidism. JAMA 102:1276, 1934
45. 7 andler, J., and Grosz, S.: Ueber den Einfluss der Kastra-
tion auf den Organismus, Arch. f. Entwicklungsmech. d. Organ.,
Leipzig. 27:35, 1909.
46. Ziskin, D. E., Blackberg, S. N., and Slanetz, C. A.: Effects
of subcutaneous injections of estrogenic and gonadotropic hor-
mones on gums and oral mucous membranes of normal and cas
trated Rhesus monkeys, J. Dent. Research 15:407. 1936.
47. Hunscher. H. A.: J. Biol. Chem. 86:37 (March) 1930.
48. Macy, I. G., Nims. B., Brown, M.. and Hunscher. H. A :
Am. J. Dis. Child. 42:569 (Sept.) 1931.
49. Mory, A. E.: J. Can. M. A. 26:160, 1932.
50. Sherman, H. C.: and Quinn, E. J.: J. Biol. Chem. 67:667
(March) 1926.
51. Shuers, C. F.. et al.: J. Nutrition 4:399 (Sept.) 1931.
52. Hunscher, H. A.: Metabolism of women during the repro
ductive cycle, J. Biol. Chem. 86:55, 1930.
5 3. Ziskin, D. E.: in Dental Caries, compiled for the Research
Committee of the American Dental Association, New York, 1939,
p. 171.
54. Hill, T. H.: Annual Report, Carnegie Institution of Wash-
ington, 193 7.
5 5. Weinmann, J. P.: in Dental Caries, compiled for the Re
search Committee of the American Dental Association, New York.
1939, p. 165.
56. Fosdick, L. S., Hansen, H. L., and Epple, C.: J. Am. Dent.
A. and Dental Cosmos 24:1275, 1937.
57. Karshan, M.: Factors in saliva correlated with dental caries.
J. Dent Research 18:395 (Oct.) 1939.
58. Forbes, J. C.. and Curley, W. B J. Dent. Research
1 2:637, 1 932.
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acid-neutralizing power of the saliva, J. Dent. Research 18:409
(Oct.) 1 939.
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Child. 48:6, 1934.
61. Bunting, R. W.: J. Am. Dent. A. 1 2:381, 1 925.
62. Jay, P.: Personal communication.
63. Day, C. D. M.. and Daggs. R. G.: High sugar diet and
dental caries in the white rat. J. Am. Dent. A. 22:91 3. 1935.
Persistent Cough Produced by Ascariasis
With a Case Report
Wallace Marshall, M.D.
Appleton, Wisconsin
THE eelworm or roundworm, technically called
A scans lumbricoides, is encountered frequently
in moist or tropical climates. Tice' claims that
children, miners, and persons who work in the soil are
most liable to infection from this source. He adds that
the disease is more common in rural districts than in
cities. It is said to be much more common in children
than in adults. Furthermore, negroes are more often
infested than whites, according to Tice, and females are
more prone to the disease than males.
Many times no symptoms are caused by the infection.
If symptoms occur, these are mainly gastrointestinal in
nature. Tice states that indefinite pain and weight in
the epigastrium may be present with flatulence. There
may be vomiting or diarrhea and the appetite may be
diminished. Vertigo or fainting may be present. Nerv-
ous symptoms are common, probably owing to the toxic
manifestations of the worms. Convulsions, paralyses,
pruritus (nose and anus) may occur.
Symptoms of the pulmonary system are not too com-
mon, but Tice1 mentioned Pantin, who stated that in
Fukien province in China coughing is frequently ob-
served in persons severely infested with ascaris, and that
the bronchitis is frequently cured with a vermifuge.
Voegtlin2 reported a case of ascaridiasis in which the
patient complained of a sensation of something crawling
through her chest. This sensation was also present at
intervals in the throat region.
Stahr3 reported two patients who complained of occa-
sional cough, dyspnea, and bronchial asthma. Estrada
and Garcia4 described a case in which the later symp-
tom was pain in the right hypochondrium radiating to
the right chest and back. Africa’’ claims that this nema-
tode can actually enter the human heart, liver, pancreas,
trachea, bronchi, and other organs more or less accessible
to the alimentary tract.
Debdas’4 mentioned Patterson’s observations (no quo-
tation given) in pulmonary abscesses caused by round-
worms. A patient expectorated a female ascaris 8 inches
in length but there was no mention of eggs in the
sputum.
March, 1943
73
The toxic or allergic factor due to this infestation has
been mentioned by Williams,1 who wrote that children
with this infection are particularly subject to attacks of
urticaria, asthma, bronchitis, and pneumonia. He feels
that their pulmonary complaints may be due to some ex-
tent to the passage of larval forms through the lungs.
Osier* quotes from German autopsy statistics published
by Heller and Muller, in which 9.67 per cent of males,
13.41 per cent of females, and 17.29 per cent of children
were infected with ascaris.
Case Report
The following case report of an eelworm infection is
unique in that it occurred in a male, age 34, whose only
complaint was a persistent cough of about three months’
duration. This subsided for about a month, then re-
turned and has been present since. The cough is "tight”
in nature and "deep.” The past winter the patient com-
plained of diarrhea (three to four times a day). He has
never complained of pain anywhere. After a day’s work,
he felt tired but not markedly. He has never been nerv-
ous. He has not noticed worms in his bowel movements.
History by systems, except for the above, was negative.
The patient had had no acute illnesses nor operations.
The family history was also negative. He had under-
gone a tonsillectomy in childhood. Repeated recent phys-
ical examinations were negative.
Recently, in vomiting and coughing, a worm was pro-
duced. This was found to an Ascaris lumbricoides fe-
male which measured 8 inches in length. The sputum
was examined for ova, but the report was negative. The
patient’s stools were carefully watched, and several large
roundworms were noted.
An unusual feature of this case report is the fact that
no eosinophiles were noted in the patient’s blood count.
The white cells numbered 11,000. The hemoglobin was
88 per cent, and the red blood count was 3,820,000. The
differential white blood count was within normal limits.
Repeated urinalyses showed no abnormal findings.
This patient had spent seme time in a German con-
centration camp about four years ago. It is questionable
whether he acquired the infection there, for his symp-
toms were rather recent in their origin.
Treatment
The patient was given 15 minims of oil of cheno-
podium in 30 minims of olive oil. This was followed
with 1 ounce of castor oil. This produced six bowel
movements which, upon examination, showed no ascaris.
The following day the patient took a soapsuds enema,
and the stool was examined for ova. None were noted.
The cough persisted after the above therapy. This
distressing symptom might have still been due to the
absorption of the toxic material from the roundworms,
or these might still have been present in other parts of
the body. However, an X-ray plate of the chest showed
no evidence of the presence of such an infection.
Since the cough persisted even after the foremen-
tioned purge, the patient was given "Crystoids” Anthel-
mintic (Sharp and Dohme) , five 0.2 Gm. pills on an
empty stomach. The same day he had many bowel
movements which produced countless numbers of smaller
roundworms. Other dead worms were evacuated follow-
ing the administration of soapwater enemas, repeated for
three evenings on his return from work. Since then, the
cough has subsided markedly.
Comments
This case is unusual in its symptomatology. A per-
sistent cough was the only complaint which caused the
patient to seek medical advice. Repeated complete phys-
ical examinations revealed nothing of clinical importance.
The X-ray chest plate showed no abnormal findings.
There were some calcified peribronchial lymph nodes,
but nothing was noted which would explain the patient’s
chronic cough.
The answer to the problem became obvious when the
patient coughed up an 8-inch female Ascaris tumbri-
coides. Since there is evidence clinically and experimen-
tally that the roundworm produces a toxic material which
acts as a gastrointestinal and pulmonary irritant, it is
presumed that this caused the chronic cough.
References
1. Tice, F.: Practice of Medicine. W. F. Prior Co., Hager.*>
town, Md., 1922, vol. 5, p. 160.
2. Voegtlin. W.: Some novel manifestations of ascaridiasis.
Northwest Med. 37:182, 1938.
3. Stahr, R.: Unusual symptoms due to roundworm infesta
tion.
4. Estrada. J., and Garcia, E.: Ascaris lumbricoides in the
common bile duct: report of a case, J. Philippine M A. 21:33 1,
1941.
5. Africa, C\: Parasitological oddities, J. Philippine M A
17:83, 1937.
6. Debdas, N.: Intestinal obstruction caused by roundworms,
Indian I. Pediat. 8:36, 1941
7. Williams, C.: Clinical ascariasis in children, Arch. Dis.
Child. 13:235. 1938.
8. Osier, W.: Modern Medicine, Lea Bros. &i Co., Philadel
phia and New York, 1907, vol. 1, p. 596.
PHYSICIANS WANTED — BOTH MALE AND FEMALE
As contract surgeons at Army-operated industrial plants and depots in the states of Colo-
rado, Missouri, Nebraska, Kansas and South Dakota. Pay, with dependents, approximates
$3400 per annum. For further information address: The Surgeon, Headquarters Seventh
Service Command, Federal Building, Omaha, Nebraska.
R. W. Allen, Lt. Colonel, Med. Corps.
Headquarters Seventh Service Command, Office of the Surgeon.
Omaha, Nebraska, March 13, 1943.
74
Thk Journal-Lancet
Neurogenic Bladder: Microcystometry and Treatment
Studies in Bladder Function XI
Irving Simons, M.D.t
New York, N. Y.
CYSTOMETRY is the clinical study of the phys-
iology of the detrusor of the urinary bladder.
The several layers of the bladder acting as one
are referred to as the detrusor.
Cystometry is performed by filling the bladder with a
series of increments of fluid (usually 50 cc.) and mea-
suring the intravesical pressure after each filling with a
manometer. During the course of the fillings the patient
experiences certain sensations, such as (1) desire to void,
(2) distress or pain and (3) severe pain. These three
sensory points occur normally at fairly fixed intervals and
are interpolated into the numerical manometric chart.
They are of as much importance as the manometric ob-
servations, as they vary in dystonias of the bladder of
either myogenic or neurogenic causation. Without them
the record is incomplete. The record, termed a cysto-
metrogram, may be converted into a graphic chart, if
desired.
Variations from the normal are known as hypertonia
and hypotonia. These reflect an increase or decrease in
intravesical pressure, due to hypertrophy or atrophy of
the vesical musculature or to a more or less continual
state of increased or decreased tonus of the musculature
of neurogenic causation.
The former types may be caused by pathological ob-
struction at the vesical outlet, as the concomitant hyper-
trophy or atrophy may be due to a muscular compensa-
tion sometimes followed by decompensation; these types
are as a rule of urologic causation and show little or no
change in the position of the sensory points. We have
termed these non-neurogenic (myogenic) hypertonias
and hypotonias. The latter types are caused by changes
in pathologic physiology and are found in various dis-
eases of the nervous system.
Neurogenic increase in tonus may be due to various
causes, such as essential increases in autonomic impulses
or interference with inhibitory impulses destined for cer-
tain cord centers. Likewise neurogenic decrease in tonus
may be due to the destruction of certain cord centers or
to interference with certain afferent impulses from the
bladder. These types in addition to the increase or de-
crease in tonus show marked increase or decrease of sen-
sitivity, manifested by the very early or very late appear-
ance of their sensory pioints. We have insisted on both
sensory and motor factors in determining neurogenic
hypertonias and hypotonias.
I: is, of course, self-evident that acute inflammation
of the bladder causes hypertonia and hence cystometry is
of little value in acute cystitis. As the cystitis becomes
subacute or chronic it does not interfere, particularly in
neurogenic cases that have subsensitive bladders, as may
occur in tabes. It is also self-evident that there may be a
t Associate Urologic Surgeon, Hospital for Joint Diseases; ahd
Associate in Neurology, Montefiore Hospital, New York.
Fig. 1 . The Microcystometer.
Fig. 2. The Sphincterometer
combination of neurogenic and urologic obstruction, so
that other methods of bladder study should not be dis-
carded in favor of cystometry alone. These mixed cases
have caused us to advocate a combined type of treatment.
Criteria for Cystometry and Cystometers
Cystometry is an artificial procedure and by no means
simulates intravesical conditions, as urine gradually col-
lects in the bladder. With each increment of filling the
autonomic phasic reflex of the detrusor is elicited. We
prefer a mercury manometer, but water and anaeroid
manometers may be used. The fillings must be done in
a few seconds to prevent the physiologic relaxation of
the detrusor. We therefore object to a drip method or
a continuous inflow method of filling. The reflex must
be elicited by a sudden impulse such as is used in elicit-
ing the knee-jerk.
The Simons’ Microcystometer and
Sphincterometer
The cystometer shown in figure 1 is compact, portable,
accurate and inexpensive and is capable of delivering any
quantity of fluid under controllable pressure. It has one
advantage over all other cystometers, in that it can be
used with the Sphincterometer, £ the only clinical instru-
ment by means of which the tonus cf the internal and
external sphincters of the bladder can be estimated.
The method of using these instruments has been
described in detail by the author.•,•',
The Sphincterometer shows that:
The norm of tonus is 15 mm. of mercury for the
internal sphincter and 23 mm. for the external
sphincter.
Hypertonic detrusors show an elevation in tonus of
the internal sphincter.
t Manufactured by the Elm Sales Co., 1M0 Broadway. New
York. N. Y . U S A
March, 1943
75
Incondnence of urine is probably based on the bal-
ance between the tonus of the detrusor and the
external sphincter.
Retention of urine and residual urine are probably
caused by a disturbance in balance between the
detrusor and the internal sphincter.
Normal Micturition
Until disproven, we subscribe to the idea of a dual
autonomic innervation of the bladder. As fluid grad-
ually accumulates in the bladder the sympathetic (thoraci-
columbar) centers are in control. These "nerves of fill-
in” through the presacral nerves relax the detrusor and
keep the internal sphincter in a state of tonus.
Normally the bladder is able to empty itself com-
pletely. When it has accumulated about 200 cc. of urine
or fluid there is desire to void and the sacral parasympa-
thetic (conus medullaris) center begins to be called upon.
The "nerves of emptying” are the pelvic nerves from the
conus; they contract the detrusor and relax the internal
sphincter. Due to afferent impulses one of the higher
centers, probably in the paracentral lobule, sends an im-
pulse downward to the conus, which is relayed to the
detrusor via the pelvic nerves.
With a bladder content below the "desire to void”
point, there can be a voluntary instigation of micturition.
In this orderly sequence the detrusor gently contracts
and the internal sphincter opens, but not due to the force
exerted by the detrusor or the voluntary pressure of the
abdominal muscles and fluid enters the deep urethra.
An afferent-efferent impulse through the pudic nerves
then relaxes the external sphincter and at the end of mic-
turition the sphincters close.
The Anatomy of the Autonomic Spinal
Reflex Arc
This has been well outlined by Learmonth.- The supra-
segmental centers of instigation and regulation in the
cortex and in the fourth ventricle and their connections
with the spinal centers by way of the corticospinal tracts
have been outlined by Simons and Emanuel.11 There is
also some connection between the extrapyramidal centers
and those in the cord.
Tables 1 and 2 show average charts of the two neuro-
genic and the two non-neurogenic (or myogenic) dys-
tonias of the bladder encountered in neurogenic and
urologic diseases. Typical case reports have been pub-
lished. 1 ‘ - 1 -
Dystonias of the Bladder
Dystonias are defined as aberrations of function of
the bladder musculature. They can be revealed only by
cystometry. Since the beginning of cystometry it has
seemed probable that there was some connection between
the action of the detrusor and its control by the nervous
system; which if accurately recorded by instrumental
means might be of clinical value. These dystonias may
be of local (urologic) and of neurologic causation.
Studies of local or urologic causation have been re-
ported.10•'’• 7
Neurogenic Dystonias of the Bladder
Dystonias that occur in neurologic disease are not all
due to cord involvement. Some are due to involvement
of suprasegmental and cerebral centers ani others seem
to be due to involvement of the autonomic nervous sys-
tem.11 ■ 1 J For this reason we prefer to substitute for c rd-
bladder the term neurogenic bladder.
Many neurologists have assumed in bladder involve-
ment caused by injuries or diseases of the nervous sys-
tem, that the bladder and/or its internal sphincter were
paralyzed; that the bladder was flaccid and due to this
it could not act very well and residual urine developed
in lesser or greater amount. The term overflow or para-
doxical incontinence was coined and has been very loosely
used. Incondnence was assumed to be due to paralysis
of the sphincters. Cord-bladders and other types of dys-
tonia that occur in cases of disease of the central nervous
system were never suspected of being hypertonic at any
stage.
Cystometric investigations in a series of neurologic
cases1 J we found that, aside from certain luetic cases and
some transverse myelopathies, subtonic or paralyzed
detrusors were a comparative rarity; that most neurogenic
bladders were hypertonic; that incontinence of urine was
usually associated with hypertonic detrusors; that most
cases of incontinence of urine were associated not with
76
"I’mi Jounnai.-Lan< i i
TABLE I
Composite cystometrogram records of groups I. II. Ill, IV and V
Hypertonia :
I.
Neurogenic: 3, *33, P56, SP62
MVP
90
II.
Non-neurogenic: 2, 5, 8, •M. 18; 23. P3 1 .
27. SP30.
36
MVP
98
Ill
Normal: 1, 3. 4. *5. 6; 8, 9, P10, 11. SP15;
16, 24
MVP
62
Hypotonia :
IV.
Non-neurogenic: 1. 2, 2, 3, 4; *4. 5, P6. 12,
SP9; 10.
12, 13. 14. 11: 15
MVP
77
V.
Neurogenic: 0, 1, 2, 2, 3; 3, 4, 5, 6, *6; 7,
9. P10, 1
2, 14; SPI0, 14. 11, 18. 22
MVP
85
TABLE II
Sensory analysis of cystometrograms in groups I, II, III, IV and V
•Desire
Obser-
vations
Cc.
P-Pain
Obser-
vation
Cc.
SP-
Severe
Pai n
Obser-
vation
Cc.
MVP
Hypertonia:
I. Neurogenic
2
1 00
3
150
4
200
100
II. Non-neurogenic
4
200
7
350
9
450
98
III. Normal
4
200
8
400
10
500
62
Hypotonia :
IV. Non-neurogenic
6
300
8
400
10
500
77
V. Neurogenic
10
500
13
650
16
800
85
•The Groups 1 to V were made on clinical grounds in an at-
tempt to interpret the results obtained by cystometric examination
In explaining, for example, the cystometrogram of Group 1:
Neurogenic Hypertonia: 3. *33, P56. SP62; MVP 90. The num-
bers 3, 3 3 etc. represent the manometric pressure recorded in mm.
of mercury recorded as the detrusor contracted upon the successive
increments (50 cc, 100 cc etc.) as the bladder was filled; the sen
sory points are represented by * (first desire to void), P (pain or
discomfort). SP (severe pain); and MVP represents the maximum
voluntary pressure recorded by the patient when he used all of his
accessory muscles of micturition. It might be here remarked that
this last is not an autonomic action of the detrusor and should not
be incited except at the end of the cystometry, as it may bring on
detrusor spasm, and interfere with the production of the cystometro
gram. It is also not to be confused with detrusor spasm termed by
some 'the stretch-reflex’’ from a study of which reflex deductions
have been drawn by other investigators. For further details see:
Simons. I., Studies I, II and IV.
From this it is seen that compared with Group III. the normal:
Group I. True neurogenic hypertonias have very short charts
with sensory points shifted markedly to the left.
Group V. True neurogenic hypotonias have very long charts
with the sensory points shifted markedly to the right.
Groups II and IV have hypertonia and hypotonia at times almost
as great as Groups I and V respectively, but their sensory points
are normally or nearly normally placed. Their deviation in tonus
is purely myogenic and can usually be explained by local findings
in the lower urinary tract. Likewise there are no neurologic clin-
ical findings in the somatic nervous system in cases that fall into
Groups II and IV
For more detailed methods of using Tables I and II in differ-
entiating neurogenic from non-neurogenic cystometrograms. see
Simons, I. and Bisher, W.: Study III. in which abstracts of typical
cases of each of the five groups are given and discussed.
Fig. 4. Graphic record of cystometrograms.
Sensory symbols: (*) desire to void; (P) pain; (SP) severe
pain; (MVP) maximum voluntary pressure.
Cystometrogram date:
mm.: MVP
cc. : 50 250 500 750 1000
subtonic or paralyzed sphincters, but on the contrary the
internal sphincters were normal or hypertonic.
We have begun to question the term paradoxical in-
continence as applicable only to paralytic bladders with
residual urine, because we have found that even very
hypertonic detrusors and even those with incontinence
had residual urine. We have also found that latent
luetics and even non-luetics, urologically negative to
cystoscopy, could develop a subtonic or atonic bladder,
which was not associated with neurologic findings. It
seems probable that such bladders are due to involve-
ment of the autonomic nervous system.
Bladders in manifest neurologic disease as a rule show
some degree of dystonia, even though the patient does
not complain of dysuria. Neurogenic dystonias (tables
1 and 2) are either hypertonic or hypotonic.
Hypertonia neurogenica shows a diminution in vesical
capacity to four increments (200 cc.) or less. There is
hypersensitivity on filling and the sensory points are
shifted to the left. Clinically this type of hypertonia has
been found very often in cases with corticospinal tract
interference. We feel that the parasympathetic conus
center is overactive due to interference with descending
regulatory impulses. Therefore we prefer the term
"efferent neurogenic bladder.”
March, 1943
77
TABLE HIi-
Cystometric studies of neurologic cases
Group
1
Group
II
Group
III
Group
IV
Group
V
Total
Hyper-
reflex-
ias (con-
firmed )
Tabes and taboparesis
1
5
19
25
Cerebrospinal lues
4
9
9
22
1
Lues latens
5
10
15
Hemiplegia
10
6
16
16
Combined sclerosis ..
2
4
1
7
7
Multiple sclerosis
n
2
4
21
21
Lateral sclerosis
3
3
3
Amyotrophic lateral sclerosis -
2
8
1
1 1
9
Syringomyelia . -
8
2
1
11
10
Transverse myelopathy
1 1
2
1
14
7
Friedrich’s ataxia .
4
4
4
Spinal cord neoplasm
6
1
1
8
6
Extra-pyramidal tract disease
6
>
5
2
16
9
72
U 1
173
93
27
6
206
Of 93 cases with true hyperreflexia :
74 (79.5%) had vesical hypertonia (Groups I -f- II)
64 (68.8%) had hypertonia neurogenica (Group I)
Hypotonia neurogenica is the opposite of the above.
Due to hyposensitivity the "desire to void”(*) point is
markedly shifted to the right, occurring at an average
of 500 cc. and the manometric pressure is low. The
capacity of these bladders approaches twenty increments
(1000 cc.) and may exceed this. These bladders may be
even completely asensitive. They may have overflow in-
continence. This is the clinical picture of the so-called
tabetic bladder. As the hyposensitivity is of earlier occur-
rence and is in our opinion the causative factor in the
dystonia, we prefer the term "afferent neurogenic
bladder."
Afferent Neurogenic Bladder
The afferent neurogenic bladder is the first dystonia
of the bladder that was suspected of being neurogenic.
It is also called Hypotonia neurogenica (Group V) —
(tables 1 and 2). The criterion is that it must be hypo-
sensitive and it usually is hypotonic. It was thought to
be exclusively due to luetic infection and the resultant
involvement of the posterior columns (Goll and Bur-
dach) . However, cystometric studies have shown that it
is rare even in tabes, in which the posterior columns are
completely scarred; that it may occur in lues latens in
which there are no somatic neurologic signs; that it may
or may not occur in cerebrospinal lues without posterior
column signs; that it may occur in non-luetics after horse-
serum injection (the allergic type) and in diabetes with-
out adequate neurologic signs (pseudo-tabes) ; that it has
been found in syringomyelia and multiple sclerosis, but
rarely; and we have seen it recover completely in tabo-
paresis after malarial therapy, although the posterior
column signs did not disappear.
For these reasons and on account of the findings in
certain animal experimentation, we are inclined to be-
lieve that: (1) the afferent impulses from the bladder
ascend chiefly, if not entirely, by paths other than the
posterior columns; (2) that the lesion is of the auto-
nomic nervous system and is carried by sacral roots to
the cord and then possibly by the spinothalamic tracts;11
that the etiology is primarily sensory (afferent) and that
the hypotonia is a later result due to degeneration of the
bladder musculature from disuse and the stretching by
the accumulation of chronic residual urine.
Luetic Neurogenic Bladder
Table 3 shows that while hyposensitive hypotonic blad-
ders (Group V) are the commonest finding in luetics
with neurogenic bladder, this does not always occur. In
fact it occurred in only 38 of the 62 cases studied. Hy-
pertonia neurogenica was not found in tabes at all. But
there were 4 cases of it in cerebrospinal and 5 cases of
it in latent lues, although the latter condition showed
hypotonia in 10 of 15 cases.
This hypertonia might mean cortical lesions which give
no other signs (see Efferent neurogenic bladder) . In the
38 cases of hypotonia, only 19 had posterior column in-
volvement in the cord; the other 19 cases showed none
at all. This of course suggests that afferent impulses
do not travel or certainly need not travel upward via the
posterior columns. And also that the lesion is probably
outside the cord in the autonomic nervous system, or
else that it is absolutely confined to the sacral ganglia
and roots 2, 3 and 4. At any rate tabetic bladder is
not synonymous with luetic neurogenic bladder, even
if it is never hypertonic. Certainly the studies tabulated
in table 3 show that afferent neurogenic bladder occurs
without tabetic involvement of the cord.
78
Efferent Neurogenic Bladder
The meaning of true somatic hyperreflexia with con-
firmatory pathological reflexes, such as Babinski, etc., is
well understood. It is due to corticospinal tract inter-
ference.
There are two autonomic spinal reflex arcs from the
bladder. One passes through the conus center; the other
through the thoracico-lumbar centers. The former is
the more important as to function, as it has to do with
the emptying of the bladder. In cystometry it is used in
order to elicit autonomic phasic reflexes, using the detru-
sor as a means to an end, just as the neurologist uses
the quadriceps femoris and other muscles for eliciting
reflexes.
A study of 93 cases in which there was true hyper-
reflexia (table 3) showed hypertonia of the detrusor in
79.5 per cent, suggesting concomitant interference with
cortico-spinal tracts with resultant hypertonia neuro-
genica. In other words, due to lack of inhibition, the
conus center overacted producing hypertonia of the
detrusor, just as occurs in voluntary muscles. While we
cannot at present explain this, there were certain cases
(e. g. amyotrophic lateral sclerosis, Friedrich’s ataxia,
etc.) in which hypertonia of the detrusor seldom or never
occurred. Yet of more importance is the fact that there
were some cases of neurologic disease in which hyper-
tonia of the detrusor was very marked and yet cortico-
spinal tract signs were slight or absent, which suggests
the possibility of using such hypertonia as a physical sign
in the neurologic examination.
Such uninhibited conus action has a tendency to pro-
duce urgency and frequency of micturition and even in-
continence, which is a common symptom in most of the
neurologic diseases in which these descending tracts are
interfered with, such as multiple sclerosis, transverse my-
elopathy, hemiplegia, etc.
While the tonus of the internal sphincter is not forc-
ibly overcome by detrujor action in the act of micturi-
tion, we believe that this does occur in hypertonia of the
detrusor in neurologic disease. It is of interest to note
that in these cases the internal sphincter is moderately
or markedly hypertonic (20 to 30 mm. of mercury),
probably a defense reaction, yet this is apparently not
enough to withstand detrusor pressures of 100 to 200
mm. It is of interest and importance to note that in-
continence of urine is in these cases not associated with
paralyzed internal sphincters but with sphincters more
powerful than the normal. This type of incontinence is
certainly not an ischuria paradoxa, a retention with in-
continence due to overfilling of a large flabby bladder as
soon as intravesical pressure rises beyond a certain point.
On the contrary it is an active, not a passive type of in-
continence. The detrusor overcomes the internal sphinc-
ter intermittently or continuously. These are usually
complete types of incontinence and are often associated
with rectal incontinence.
The Role of the Sphincters
Before the invention of the sphincterometer the tonus
of the sphincters could not be estimated either together
or separately. Their role in the production of retention
The Journal-Lancet
of (residual) urine and of incontinence is still only
partly understood.
The internal sphincter is apparently controlled by
adrenergic impulses. Residual urine may be caused by
internal sphincteric tonus, which even though normal
may be too strong for a weak detrusor. This does not
explain the fact that even in the case of hypertonia of
the detrusor, which is apparently controlled by choliner-
gic impulses, there is still at times considerable residual
urine. The only explanation, that we can at present sug-
gest, is that micturition, whether normal or pathological,
can not be entirely explained by a dynamic or physical
theory. The physiological element is apparently too strong
and too important to be ignored. There must be team-
play between detrusor and internal sphincter, the latter
relaxing as soon as the former goes into action. Without
such team-work the emptying of the bladder is not
smoothly performed. Hence the residual urine in hyper-
tonic neurogenic bladders.
After the urine passes the internal sphincter into the
posterior urethra a reflex is set up relaxing the external
sphincter, as the latter cannot long withstand a strong
desire to void. If the team-play is continuous a normal
complete emptying of the bladder occurs. If not normal
there may be a stoppage of the stream before the act of
micturition proceeds very far; or as often occurs the act
is never completed and there is residual urine, as occurs
fairly regularly in hypertonia neurogenica. The balance
between the detrusor and external sphincteric tonus prob-
ably determines incontinence.'1
Therapy of the Neurogenic Bladder
This may be divided into the therapy of retention of
urine, of residual urine, of urgency and incontinence
of urine and of infection of the genitourinary tract.
In retention of urine after abdominal operations and
after opening of the dura of the cord, various drugs have
been advocated, both cholenergic and those said to en-
hance the action of these drugs. In acute injuries of the
brain and especially of the cord, whether by trauma or
hemorrhage, there is a period of "spinal shock” with
complete retention of urine, which latter lasts from a
few days to a month or so. During this retention inter-
mittent or in-dwelling catheterization is necessary. Ap-
parently there is a sympathetic (adrenergic) preponder-
ance. As a rule this period can be shortened by remov-
ing the retention catheter rather soon and in some cases
giving Trasentin, as many of these are hypertonic. Mixed
cases of course occur in which there is also some uro-
logical obstruction at the vesical neck, which indicates
transurethral resection; the latter has even been advocated
in tabetic bladder.
In cases in which catheterization is very difficult or
impossible, suprapubic vesical puncture is indicated and
in some cases trocar drainage may be necessary with an
in-dwelling Malecot catheter, which may or may not be
later removed.
Many of the patients with acute retention in trans-
verse and other cord lesions develop incontinence which
may last for months or years. They are usually hyper-
tonic and we have had excellent results in some cases
79
March, 1945
with Trasentin, 600 mgm. by mouth daily.1 Some
have been improved and some completely relieved. It
has not proven toxic up to 900 mgm. daily for periods
of two to three weeks, and has none of the disagreeable
untoward effects of atropine. In irremediable cases of
complete incontinence suprapubic trocar puncture and
permanent drainage is indicated.
The drug treatment of the hypotonic or atonic blad-
der with large residual urine is still under study.
Infection of the bladder is the greatest problem in
neurogenic bladder. Tidal drainage through the urethra
is indicated but an in-dwelling urethral catheter over a
long period is unsatisfactory. The procedure may be car-
ried out through a Malecot catheter left in place after
suprapubic puncture drainage.
The use of Transentin for neurogenic bladder is indi-
cated only in those patients who are cystometrically
hypertonic. We have shown that the tonus can be re-
duced and that improvement of the clinical symptoms
can follow or often outstrip the reduction of the hyper-
tonia. The complete relief of incontinence after Trasen-
tin§ has persisted in some cases.
Summary
Microcystometry and Sphincterometry furnish a phys-
iologic clinical approach which checks and augments the
cystoscopic anatomic findings in neurogenic bladders.
Microcystometry has been so simplified that it may
be done by neurologists and even by general practi-
tioners.
Micturition is controlled chiefly by the lower auto-
nomic neurone. The center is in the conus medullans.
Normally the conus center is initiated and inhibited
from the paracentral lobules; and it is also controlled by
hind-bratn and extrapyramidal centers.
The sympathetic (thoracicolumbar) center is of im-
portance but is still of lesser importance in micturition.
The term cord-bladder should be replaced by neuro-
genic bladder.
Microcystometry can differentiate vesical dystonias of
non-neurogenic (myogenic) from those of neurogenic
§The Trasentin, used for these studies, was furnished by the
Ciba Pharmaceutical Products, Inc., of Summit, N. J.
causation. The latter are preferably termed Afferent
(hypotonic) and Efferent (hypertonic) Neurogenic
Bladders.
It seems probable that the Afferent Neurogenic Blad-
der, which includes the tabetic bladder, is not due to
posterior column involvement of the cord.
The Efferent (hypertonic) Neurogenic Bladder is far
more commonly found. It is due to lack of inhibition
of the conus center, usually because of lesions in the
corticospinal (pyramidal) tracts. This causes urgency
and often incontinence.
Considerable relief and often cure can be obtained by
the use of parasympathetic depressants. Trasentin has
proven of value.
The medicinal treatment of the subtonic neurogenic
bladder is still under study.
Urologic and semisurgical measures like tidal drain-
age, transurethral resection of the vesical neck and supra-
pubic catheter drainage by means of vesical puncture are
still of value in combating retention, incontinence and
infection, until better methods are evolved.
1 1 4 East 54th St..
New York, N. Y.
References
1. Barrington, F. J. F.: Paths subserving micturition in spinal
cord of cat. Brain 56:126, 1933.
2. Learmonth, J. R.: A contribution to the neurophysiology
of the urinary bladder in man. Brain, Part II (June) 1931.
3. Simons, I.: Studies in bladder function I. The micro
cystometer, J. Urol. 34:493, 1935.
4. Simons, I.: Studies in bladder function II The sphincter
ometer, J. Urol. 35:96, 1936.
5. Simons, I.: Studies in bladder function IV Advances in
rhe field of cystometry due to clinical studies with the sphincter
ometer, J. Urol. 36:88, 1936
6. Simons, I.: Studies in bladder function VI A critical re
view with special reference to microcystometry and sphincterometry
Brit. J. Urol. 9:132, 1937.
7. Simons, I.: Studies in bladder function VII Neurologic
studies by means of the microcystometer and the sphincterometer.
J Urol 39:791, 1938.
8. Simons, I.: Treatment of neurogenic urinary incontinence
with trasentin, Bull Hosp. Joint Dis. 3:1. 1 942.
9. Simons, I.: Studies in bladder function XII The treat
ment of neurogenic dysuria with trasentin (in preparation).
10. Simons. I., and Bisher, W.: Studies in bladder function
III Recent advances in clinical cystometry by means of the micro
cystometer. New York State J. Med. 36:16, 1936.
11. Simons, I., and Emanuel, M.: Studies in bladder function
IX. The neuroanatomy and neurophysiology of the bladder, Urol.
SC Cutan. Rev. 44:667, 1940.
12. Simons, I.: Studies in Bladder Function X. Further neuro-
logic studies by means of the microcystometer and the sphincter-
ometer, J. Urol. 48:331, 1942.
TRANSACTIONS OF
THE MINNEAPOLIS ACADEMY OF MEDICINE
Founded January 17, 1920
Meeting Held on Thursday, October 8, 1942, Dr. Roy E. Swanson Presiding
A paper on "Coronary Insufficiency Precipitated by Hemor-
rhage from Duodenal Ulcer’’ was presented by Dr. C. A. Mc-
Kinlay. (The text of this paper was published in the February
issue of Journal-Lancet.)
INAUGURAL THESIS
The inaugural thesis, "Technic of Thyroidectomy," was pre-
sented by Dr. D. C. MacKinnon. Since this presentation con-
sisted essentially of colored lantern slides, and the text is of
little value without the illustrations, it is not presented for pub-
lication. After the paper, the following discussion took place:
Dr. Robert Caron: "I would like to compliment Dr. Mac-
Kinnon on his very excellent presentation, which entailed a great
deal of preparation. I should like to know if general anesthesia
is employed. Does he allow the patient to awaken in between
sides in order to ascertain whether or not there has been any
involvement of the recurrent laryngeal nerve?
"It appears to me that the use of Ochsner forceps for the
immobilization of the strap muscles is somewhat of a harsh
treatment to the strap muscles. Bainbridge forceps are much
less traumatic. They are very narrow, and their use facilitates
an easy closure.”
Dr. R. C. Webb: "I wish to congratulate Dr. MacKinnon
on this very excellent detailed presentation of the technic of
thyroidectomy. His pictures have shown the technic in a clear
80
The Journal-Lano-i
and interesting manner.
"The surgical technic of the operation for goiter typifies the
supreme triumph of the surgeon’s art. The operation was con-
ceived a thousand years ago, but the technic was not perfected
until about fifty years ago. Other operations more delicate, and
sometimes more difficult, have only naturally followed in the
paths made clear for them by the early masters of goiter sur-
gery.
"Those interested in the technic of the thyroid operation
would enjoy reading the Operative Story of Goiter, a 300-page
monograph published in 1919 by William S. Halsted. In this
book Doctor Halsted shows the goiter instruments designed by
him for the Johns Hopkins Hospital in 1889.
"Dr. Caron has emphasized local anesthesia. I personally pre-
fer very much to use local anesthesia for all goiter operations.
I use general anesthesia only when the patient insists upon it.
"About five years ago I discontinued using catgut in goiter
operations and have used fine silk. The wounds heal more
kindly; drainage usually stops at twenty-four hours, and I
occasionally close the wounds without drainage.
"Dr. MacKinnon has shown a useful point in the dressing
with the use of towels. I have found it helpful to ask the nurse
for 'a piece of 2-inch adhesive as long as the bed is wide.’
When a gauze dressing is placed in the center of a piece of
adhesive of this width and length, and the center is placed on
the back of a patient’s neck, the two ends will fold across in
front of the dressing, and fasten to the patient’s chest so that
one piece of adhesive will suffice.”
Dr. Karl Anderson: "It has been my impression in under-
writing thyroid cases that there has been a marked decrease in
this type of impairment. At least, we do not see it nearly as
frequently among insurance applicants as previously. Have you
any figures that would prove or disprove this impression clin-
ically?”
Dr. Donald C. MacKinnon: "First, I wish to make it
clear that the technic of thyroidectomy that I have just dem-
onstrated with colored slides is that used at the Lahey Clinic.
It is not my original claim, although I approve of it, accept it,
and use it regularly.
"Dr. Caron asked the question concerning the choice of anes-
thesia, and the use of local anesthesia for thyroidectomy. It is
probably a matter of personal choice as to whether one wishes
to use local or general. Personally, I prefer to use a general
anesthetic that carries a high concentration of oxygen, such as
cyclopropane. Patients with severe hyperthyroidism demand and
use more oxygen than those individuals with mild hyperthyroid-
ism In patients given cyclopropane the blood is alway bright
red, in patients having other gas anesthetics it is darker or
more dusky in appearance.
"Patients under local anesthesia are usually aware of the fact
that surgery is being done, and this may be a factor in causing
postoperative reactions in the more toxic cases. However, some
surgeons are very clever local anesthetists, and are able to do
the operation with very little discomfort to their patients.
"The matter of adequate preoperative sedation is very im-
portant, whether one uses general or local anesthesia. If large
doses of nembutal, morphine, and scopolamine are given pre-
operatively, according to the age, size, and toxicity of the pa-
tients, they will usually be well sedated when they enter the
operating room.
"Just a few nights ago, at a Minneapolis Surgical Society
Meeting, Dr. Rae made a statement that impressed me, con-
cerning the preoperative sedation of patients with hyperthyroid-
ism. He suggested that the patient be put to sleep in bed with
pentothal, without announcing the time of operation, and then
removed to the operating room for surgery.
"Incidentally, Dr. Rae also is using spinal anesthesia in hyper-
thyroidism to forestall a postoperative thyroid crisis. This was
brought to his attention by the successful treatment of a few
cases of severe postoperative thyroid storms with spinal anes-
thesia.
"Dr. Caron asked the question as to whether one should
awaken the patient before starting to operate on the other lobe.
I presume that he has in mind the testing of recurrent laryn-
geal nerve injury of the side just operated upon. I think it is
very difficult to determine nerve injury by the quality of the
voice while the patient is on the operating table. Frequently the
voice is husky or hoarse due to irritation of the larynx or tra-
chea, mucus, or laryngeal spasm. Furthermore, the procedure
is very disturbing to the patient. If the surgeon understands
the anatomy and course of the recurrent nerves, identifies them,
and avoids injury to them, it is not necessary to arouse the
patient to test the voice.
"If there is injury to one recurrent nerve, there will usually
be a little hoarseness that persists for several weeks or months
after the operation. If both recurrent nerves have been injured,
the patient will first have hoarseness after the operation, fol-
lowed by obstruction of the glottis, which may follow imme-
diately, or weeks, or months later. It may become necessary to
do a tracheotomy if the obstruction is severe.
"If the patient has had a previous thyroidectomy, it is most
important to do a thorough laryngoscopic examination of the
vocal cords to determine recurrent nerve injury before doing
further surgery. If a recurrent nerve has been injured, and a
vocal cord is paralyzed, it is very important to know it so that
one can take special care not to injure the normal nerve. Like-
wise, in doing the second stage of a two-stage procedure, it is
important to examine the cords to make sure that the right
recurrent nerve was not injured while doing the first stage, or
right hemithyroidectomy.
"There is only one advantage in allowing the patient to
awaken during a thyroidectomy, and that would be to give the
surgeon an opportunity to see if any of the ligatures would
come off the blood vessels while the patient was straining and
coughing. One might then ligate any bleeding vessel, and avoid
serious postoperative hemorrhage.
"Dr. Caron also asked about special clamps used on the cut
prethyroid muscles. I am not acquainted with the use of those
clamps, and cannot make any remarks about them. I have used
heavy Ochsner forceps for this purpose, and found them to be
very satisfactory.
"A question was asked about the use of various suture ma-
terial in thyroidectomy. At the Lahey Clinic plain catgut is
still being used. It frequently causes wound induration. Fine
silk is popular with many surgeons, and does not produce wound
induration. However, if a wound infection does occur, there is
a disadvantage in having used it, since it may be extruded from
the wound for some time. I think there are fewer serum col-
lections in the wound when silk is used, and when infection does
not occur.
"I cannot answer the question as to whether or not there are
fewer cases of hyperthyroidism at the present time.”
Dr. C. A. McKinlay: "It seems to be common experience
that there are fewer cases of hyperthyroidism presenting them-
selves for treatment. Thyroidectomy continues to be the treat-
ment of choice.”
Dr. Karl W. Anderson: "I had the opportunity of follow-
ing a series of thyroid cases with Dr. Stenstrom at University
Hospital, in which we used deep X-ray as a mode of therapy,
giving most of the patients Lugol’s during the period of the
X-ray therapy. I must admit that I was quite disappointed with
the results, although I do not think Dr. Stenstrom was quite as
disappointed as I. I personally felt that in most of these cases
better results would have been obtained with surgery. There
were a few mild cases which X-ray seemed to help, and there
were also some postoperative cases that we didn't want to sub-
ject to surgery a second or third time.”
Dr. Donald C. MacKinnon: "As to the question of recur-
rent hyperthyroidism, and cures in these patients, I have a feel-
ing that some just cannot be cured. In some individuals no
matter what one does, they will continue to have hyperthyroid-
ism. I recall one woman who had a typical picture of recurrent
hyperthyroidism, with weight loss, high pulse rate, high basal
metabolism, and other symptoms and signs of hyperthyroidism.
She had been operated upon three times, and when operated on
for the fourth time there was no gland to remove, but she con-
tinued to exhibit hyperthyroidism. Perhaps there is some other
cause for this symptom complex outside of the thyroid gland.
Serves the Medical Profession of
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Dr. A. R. Foss
Dr. W. A. Fansler
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Dr. A. E. Hedback
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BOARD OF EDITORS
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Minneapolis, Minnesota, March, 1943
CLEMENCY FOR INCLEMENT WEATHER
Who would change our climate for any other? Change
is the most outstanding thing about it as it is. It is some-
times said that we have more weather than climate and
anyone who does not like it at the moment needs but
to wait for another change. In spite of any effort at
levity and local loyalty, we must admit that these often
severe changes do cause much havoc to the chronically
afflicted. These poor souls may have been too brave at
some earlier period of their lives and neglected the little
precautions and adjustments necessary to protect them-
selves against exposure. Now they have greater suscep-
tibility to upper respiratory infections, chilly sensations
that forebode an oncoming change, rheumatic pains or
acute exacerbations of some other chronic affliction like
that of bronchitis. They must exercise great care on the
advent of the inclement weather that comes with abun-
dant frequency at this time of the year.
We should like to recommend the use of some cov-
ering of the nose and mouth in damp and frosty wea-
ther. We would advocate a return to the fascinator —
some have never heard the word except as a synonym
for charmer. In this case, however, we refer to that soft,
knitted little shawl worn on the head by sensible women
of old who also learned to adjust it over a cold nose on
sleigh rides. With the present popularity of the Russian
babuseka, the time would seem propitious to bring back
the American scarf with the fascinating name. When
worn to cover the face, as did our mothers of old, it
wins hands down in open air competition with any other
contraption ever devised. We air condition our homes,
our offices and our shops but when we step outside we
unhesitatingly stick our necks out, leading with an un-
covered proboscis known by everyone to be the chief en-
trance of infection to the human body. We should like
here and now to enlist the sympathetic interest of an en-
lightened profession in promoting a return to the simple
faith of our mothers. A. E. H.
82
The Journal-Lancet
CIVILIAN DEFENSE
Recent advices from Washington indicate a radical
change in the organization of medical units for air-raid
disaster. Originally, squads of doctors, nurses and nurses’
aides, with adequate equipment, were allocated for first-
aid posts, casualty stations and base hospitals, very much
in the same manner as provided for the evacuation of
battle casualties by all modern armies. Admirable as it
is for strictly military purposes, this arrangement has
been found wholly unfitted for air-raid casualty relief,
where the situation in all its details is so different.
"The experiences of Britain under air-raid conditions
have dispelled many preconceived notions concerning
first aid,” reports Dr. George Baehr, Chief of OCD’s
Medical Division, who recently returned from England.
Most raids occur at night. Victims are pinned beneath
debris and are either killed or severely injured. All seri-
ous casualties are moved directly to hospitals, never to
first-aid posts. The darkness under which the rescuers
must work, the general confusion during a raid, the dust
and dirt in the air, and the need for immediate hospi-
talization of those seriously injured generally eliminate
the possibility of applying the usual first-aid measures.
Open wounds are merely covered until the patient
reaches the hospital, traction splints are not used, and
blood transfusions are likewise delayed until the patient
reaches the hospital. First-aid parties (stretcher teams)
are considered a waste of manpower. Increasingly, first-
aid parties are being merged with rescue squads. Four-
stretcher ambulances are essential. They have been made
in England and Scotland by stripping used cars and
mounting a simple ambulance body on the chassis. At
least one of these ambulances is required for every
10,000 persons in target area cities.
Under this new plan, the basic unit dispatched to the
site of a bombing will be an "express party,” consisting
only of a rescue team, a "mobile medical team,” and am-
bulance and possibly a passenger car or station wagon.
Such an express party will usually be sufficient to handle
a major incident or a group of neighboring minor inci-
dents with casualties. Additional medical and rescue per-
sonnel, ambulance and passenger cars for sitting cases
should be held in reserve and dispatched by the control
center only on request of the doctor at the incident. The
mobile medical team, as heretofore, will consist only of
one doctor, a trained nurse and two auxiliaries, and,
as stated, will be ample for most contingencies, in place
of the larger units originally provided.
The foregoing, quoted freely from the directive issued
by Director Landis on December 5, implies an enormous
simplification of air-raid disaster relief. It will be
especially welcome and applicable to the inland areas,
where the likelihood of mass bombing is more remote
than in the coastal and more thickly populated regions.
It will greatly lighten the burden of those who have the
responsibility of handling these problems in the smaller
places, where trained personnel is more scarce and yet
equally necessary for quick action. It appears to us to
be a very sensible and practical modification of the plans
for the whole country.
WARTIME PSYCHONEUROSES
In a time of stress such as the present, it is obvious
that many persons are suffering from a sense of in-
security, apprehension or frustration relative to increased
work and responsibilities, changed family life, altered
finances, possible loss of loved ones and the like. The
fundamentally stable individual tends to remain for the
most part composed and functioning; the poorly in-
tegrated person tends to add these new factors to and
weave them in with his usual neurotic tendencies. The
result is often an accentuation of hypochondriacal or
hysterical symptoms and a visit to the physician.
Since the patient commonly interprets the symptoms
in terms of serious illness, one should perform a rea-
sonably careful general physical examination even though
the history seems clearly to indicate a predominately
neurotic component in the case. The quick history and
physical examination make it possible for one easily to
bring up the question of the patient’s worries and fears,
and provides for the physician a position of authority so
that the patient’s concern over his health can be at least
partially allayed.
Cases of acute anxiety commonly clear up with fair
promptness under conditions allowing for an unburden-
ing of the patient’s reasons for the anxiety. This may
indeed take an extra bit of the physician’s time but it is
time well spent in that many of these patients who seem
severely disabled on an emotional basis alone, can be
rehabilitated quickly if encountered sufficiently early and
given suggestion, reassurance and persuasion by one
whose statements can be accepted as authoritative. Ap-
propriate handling of insomnia by mild sedation and,
when feasible, by out-of-doors’ exercise, is commonly of
great aid. There is likely then to be improvement in
appetite. The patient usually should be returned to his
ordinary occupational status as rapidly as possible unless
the occupation itself has seemed to be one of the etio-
logic factors in the anxiety.
The conditions are quite different in cases of the more
involved hypochondriacs, reactive depressives and long-
standing hysterics. While treatment methods like the
foregoing will commonly give this group of patients a
certain amount of assistance in the acute situation, these
cases usually require much more protracted management
and psychotherapy, often beyond the time allotment that
can be spared by the busy practitioner. If the severity
of the case is not too pressing, one may reasonably try
to act as a crutch through office interviews. In severely
psychoneurotic cases, it is commonly advisable to remove
the person from his home to a hospital environment
where the usual irritants associated with the development
of the neuroses are no longer immediately at hand.
One can do little to alter the personal distress of the
actual situations involved in the entrance of a brother,
husband or son into military service but one can assist
his patients to stand courageous and functioning in the
face of such experiences and thus add his bit to the pub-
lic morale and the efficiency of the home group of citi-
zenry as a whole.
G. C.
J. C. M.
I
March, 1943
83
Book ilwUws
Synopsis of Diseases of the Skin, by Richard L. Sutton,
M.D., and Richard L. Sutton, Jr., M.D.; St. Louis: C. V.
Mosby Co., green fabrikoid, gold-stamped, 460 pages, plus
index of 20 pages and 413 illustrations. Price $5.50.
The Drs. Sutton have written a very practical book, as the
title indicates. Especially interesting is Chapter One, which has
numerous clear-cut anatomic and histologic illustrations.
Brevity, although a prime purpose in a book of this type,
has not prevented the authors from including all essentials.
Allergic manifestations of the skin are itemized. Therapeutic
medicaments, both internal and topical as well as roentgen,
radium, and physical therapy, are all discussed. Inflammatory
diseases, diseases due to bacterial infections of the skin, and
fungus diseases are all dealt with. A revised treatment of
syphilis is presented. Outlines of all topics including precan-
ceroses are brief but quite inclusive.
The book is valuable to a busy general practitioner from a
standpoint of concise, factual information. To a specialist or a
teacher it is a pleasure to observe the completeness of the out-
line in the various topics discussed by the authors. The re-
viewer can recommend this book very highly to medical stu-
dents not only for the subject material, but also for the illustra-
tions of the various diseases.
Vitamin Values of Foods: A Compilation, by Lela E.
Booher, Eva R. Hortzler, and Elizabeth M. Hewston;
New York: Chemical Publishing Co., Inc. Price $2.75.
This very detailed and excellently edited compilation sum-
marizes the vitamin A, thiamin, ascorbic acid, vitamin D and
riboflavin values of foods as recorded in the literature from the
date of establishment of the latest international standards for
vitamins through December, 1940. Values of the foods are ex-
pressed in terms of International Units or absolute weights of
these vitamins per 100 grams of edible portions of foods. The
periodicals drawn upon by the authors for their data comprise
thirty-four of the leading scientific and medical journals, both
American and foreign.
Vitamin Values of Foods presents vitamin data in relation
to (1) places of production or source of material; (2) method
of cultivation or feeding practice and degree of maturity; (3)
variety and part of plant or breed of animal; (4) method of
cooking, processing, and storage; and (5) method of analysis.
This reference volume should be of interest and use to any
biochemist or clinician engaged in vitamin research. It sum-
marizes in a detailed and painstaking manner much informa-
tion which had heretofore been at loose ends. The nutritionist,
dietitian, teacher, and housewife may also learn many valuable
facts from this compilation. The practical usefulness of the
material, quite apart from its general theoretical significance,
may be judged by the following typical specific observation:
One hundred grams of unpared New York Northern Spy
apples will lose 3 mg. of vitamin C upon standing one hour
after paring and quartering, or 27 per cent of the total vitamin
C value. Likewise heavily toasted bread loses 21 per cent of
its vitamin Bi value. There is a greater destruction in the
vitamin C value of tomato juice when a space is left in the
bottle on canning than when the bottle is completely filled.
There is 42.8 per cent more vitamin C in the "sunny side” of
an apple than in the "shady side.”
The authors are Lela E. Booher, formerly senior nutrition
chemist of the Bureau of Home Economics, Eva R. Hortzler,
formerly assistant chemist, and Elizabeth M. Hewston, asso-
ciate chemist. Miss Booher is now director of the Institute of
Nutrition, Milwaukee Children’s Hospital, and Miss Hortzler
is now with Bio-Chemical Research Laboratories, Parke, Davis
and Co., Detroit. The volume includes a bibliography of the
298 studies relied upon in its compilation.
LEGISLATION
Grand Forks North Dakota District Medical Society, com-
prising counties of Grand Forks, Walsh, Pembina, Cavalier,
Nelson and Traill, went on record as disapproving of Senate
Bill Number 434 introduced into the U. S. Senate by William
Langer, senator from North Dakota. This bill, which proposes
"to prohibit experiments on living dogs in the District of Co-
lumbia” was introduced by the North Dakota senator only by
request and was withdrawn promptly as soon as the committee
appointed by the president of the district society wrote the
senator regarding it.
RED CROSS APPOINTMENT
Dr. Albert McCown, Director of Medical and Health Serv-
ice of American Red Cross, writing from national headquarters
at Washington, D. C., announces the appointment of Dr. G.
Foard McGinnes as Director of Medical and Health Service of
the Midwestern Area, headquarters for which are in St. Louis
and which includes Minnesota, North Dakota, South Dakota
and Montana. Dr. McCown says: "Dr. McGinnes comes to
the Red Cross from the Tennessee Department of Public Health
where since 1929 he was Director of Venereal Disease Control
Service, Associate Professor of Preventive Medicine of the
University of Tennessee and Chief of the Department of
Siphilology, Meharry Medical College. Previous to 1929 he was
with the Virginia State Department of Health, Director of
Bureau of Communicable Diseases. It is important that sound
and constructive relationships be maintained between the Ameri-
can Red Cross and the medical profession in the several states.
Doctor McGinnes’ clinical background and viewpoint will pro-
mote such relationships. Officers of county medical societies are
asked to note his appointment and availability in the discussion
and promotion of medical-Red Cross relationships.”
SOUTH DAKOTA MEDICAL AUXILIARY
DISTRICT MEETINGS
The February monthly dinner meeting of Seventh District
(Sioux Valley) Medical Auxiliary, held in Sioux Falls, South
Dakota, and attended by twenty-four members, devoted a por-
tion of its deliberations to arrangements for the annual Doctors’
Day dinner to be held March 30. Chairman for the occasion
will be Mrs. Chas. J. McDonald. Speaker of the February meet-
ing was Mrs. Joseph Smith, missionary, of Burma. The auxil-
iary is actively engaged in making Red Cross items. Ninety-six
wool squares for an afghan were turned in and work on a
second has begun.
The Women’s Auxiliary to the Huron South Dakota District
Medical Society met February 24th at the Hotel Marvin
Hughitt with state president, Mrs. Jno. C. Hagin, Miller, as
its guest. Mrs. B. T. Lenz, district president, was in the chair.
Plans were made for the observance of Doctors’ Day and for
the remaining ten months of 1943
HOSPITAL TRAINING SPEEDED UP
Ernest L. Olrich, district director of Training Within In-
dustry agency of the War Manpower Commission, is reported
to have set a new pattern in faster, more effective training of
hospital personnel by transplanting methods developed to assist
war plants in adapting new workers to unfamiliar industrial
operations. Hospitals participating are Abbott, Fairview, Dea-
coness, General, Northwestern, St. Barnabas, Swedish and Uni-
versity in Minneapolis and Ancker, Miller, Northern Pacific,
St. John’s and St. Joseph’s in St. Paul.
84
Thk Journal-Lancet
Views Items
Dr. L. G. Dunlap, Anaconda, Montana, addressed the
Montana Academy of Eye, Ear and Nose and Throat
Surgeons in Butte on February 22nd. He had been
awarded an honorary degree in eye and ear surgery
earlier in the month at the conclusion of a two-week
mid-winter postgraduate course held in Los Angeles for
eye, ear, nose and throat surgeons at which 250 surgeons
studied.
Dr. W. N. McPhail, Missoula, Montana, has been
appointed director of the health service at Montana
State University for the winter quarter. He is a grad-
uate of that institution as well as of the medical school
at McGill University, Montreal, Canada.
Dr. Wm. Knoll, for two years a member of the Battle
Mountain Sanitarium medical staff at Hot Springs,
South Dakota, has taken a post with the Veterans’ Ad-
ministration Facility at Indianapolis, Indiana. He and
Mrs. Knoll will make their home in that city.
Dr. Jos. D. Craven was elected president of the Ko-
tana Medical society at the annual meeting held at
Williston, North Dakota. Dr. C. M. Lund was elected
secretary-treasurer and Dr. Willard A. Wright delegate
to the state meeting expected to be held in Bismarck.
Dr. R. J. Jackson, Rapid City, South Dakota, has
been appointed physician for Pennington county by the
commissioners of that county and Dr. D. L. Kegaries
county coroner by the same body at that meeting.
Dr. D. S. MacKenzie, Jr., Havre, Montana, son of
Dr. D. S. MacKenzie, Sr., has been promoted to the
rank of major. In the army two years he is stationed
at Camp Grant, Illinois.
Dr. Walter M. Boothby, director of Mayo Aero Med-
ical Unit, recently visited Williams Field, the air base
at Chandler, Arizona, where he is recovering from an
attack of pneumonia. Mrs. Boothby made the visit with
the doctor.
Dr. B. K. Kilbourne, state epidemiologist of Montana,
reports that last year was the most healthful in the his-
tory of the state. With great declines in the number of
cases of communicable diseases in 1942 from 1941, there
were only a limited number of diseases in which increases
were shown.
1943 Elections to date for chiefs-of-staff at hospitals
in this region disclose the following selections: Dea-
coness at Grand Forks, Dr. H. W. F. Law; Hibbing
General, Dr. Robt. L. Bowen; Miller Memorial at Du-
luth, Dr. P. G. Boman; St. Mary’s at Duluth, Dr. F.
N. Knapp; Union Hospital of New Ulm, Dr. C. A.
Saffert; Loretto Hospital, Dr. F. H. Dubbe; Kalispell
General, Dr. A. Brassett.
Dr. W. E. G. Lancaster, Fargo, North Dakota, presi-
dent of the Cass County Medical society, has joined the
Fargo clinic, carrying on his practice of internal medi-
cine and pediatrics.
Dr. Curtis W. Wilder, Lewistown, Montana, in an
action taken by the board of commissioners of Fergus
county, has received the appointment to succeed the late
Dr. C. C. Wallin as county health officer. Dr. Wallin
held simultaneously the position of county health officer,
Lewistown city health officer and full time school physi-
cian. The two latter posts are yet to be filled.
Dr. Jno. A. McIntyre, Owatonna, Minnesota, was
elected president of the Steele County Medical society.
Other elections included Dr. E. J. Nelson, vice-president,
Dr. D. H. Dewey, secretary-treasurer, Dr. D. E. More-
head, delegate to the state society meeting.
Major Robt. B. Radi, after serving as medical officer
at Fraine Barracks, Bismarck, North Dakota, has been
transferred to Minnesota state selective service head-
quarters at St. Paul. The major and Mrs. Radi were
honor guests at a farewell dinner given by doctors of
the Quain and Ramstad clinic, Bismarck.
Dr. Geo. E. Baker, Casper, Wyoming, health officer
of Natrona county, is engaged in a special study of
"tick” fever as differentiated from "Rocky Mountain
Spotted Fever” which is not confined to the region de-
noted by its name. This disease was the subject of the
1942 Journal-Lancet Lecture at the Medical School
of the University of Minnesota.
Dr. Willard L. Burnap, Fergus Falls, Minnesota, was
elected president of the National Conference on Med-
ical Service, held in Chicago. Among the speakers on
the conference program were Dr. A. W. Adson of the
Mayo clinic, Rochester, and Dr. E. J. Carey, dean of
Marquette Medical School, Milwaukee.
Dr. Donald C. Balfour, Rochester, Minnesota, spoke
at Chicago recently before the council on medical edu-
cation and hospital, sponsored by the American Medical
Association. He said he believed that one effect of the
war would be the restriction of graduate training in
medicine and the curtailment of research and clinical
investigation.
Dr. Maude Gerdes of the Mississippi State Board of
Health, graduate of the Medical School of University
of Minnesota and formerly of the United States Health
Service, presented a paper on "Syphilis in Pregnancy”
before the January meeting of the Yellowstone Valley
Medical Society meeting at Billings, Montana. Dr.
Cedric H. Nelson of that city presided. Present were
members from Billings, Hardin, Columbus and Laurel.
Dr. Raymond F. Peterson, Butte, Montana, addressed
the Mount Powell Medical society of Anaconda on
blood groupings in relation to transfusions on the occa-
sion of the mid-February meeting. Members of the
society in Granite, Powell and Deer Lodge counties
attended and were joined by doctors from Helena,
Butte, Missoula and Dillon.
Dr. L. J. Alger, Grand Forks, North Dakota, has re-
turned from a month of postgraduate work in the De-
partment of Ophthalmology, Columbia University.
Dr. Howard L. Saylor, Huron, South Dakota, re-
ceived the state department of health’s appointment to
the position of Beadle county health physician.
March, 1943
85
Dr. Russell Wilder of Mayo Clinic, Rochester, has
accepted an appointment to serve on the national health
advisory council organized in Washington in February
hy the Chamber of Commerce of the United States.
The council will project and carry out a broad program
looking to health conservation as one of the most impor-
tant factors in winning the war.
Ernest L. Olrich, district director of Training Within
Industry agency of the War Manpower Commission, is
reported to have set a new pattern in faster, more
effective training of hospital personnel by transplanting
methods developed to assist war plants in adapting new
workers to unfamiliar industrial operations. Hospitals
participating are Abbott, Fairview, Deaconess, General,
Northwestern, St. Barnabas, Swedish and University in
Minneapolis and Ancker, Miller, Northern Pacific, St.
John’s and St. Joseph’s in St. Paul.
Dr. E. Klaveness, St. Paul, physician, surgeon and
dermatologist, has completed the manuscript, in Nor-
wegian, of his second book, a series of biographies of
the doctors who received their medical education in Nor-
way and practised in the United States in the last 100
years. The stories of 116 practitioners appear. Eleven
are still living of whom two have retired. The work will
receive a translation into English shortly.
Major Wayne S. Hagen, M. C. of Minneapolis is
stationed in Brooklyn, N. Y. His promotion to a ma-
jority took place a year ago. He is the chief of the
medical service at Ft. Hamilton, N. Y.
Recent elections to chief-of-staff at Minneapolis hos-
pitals are: Asbury, Dr. Leonard K. Buzzelle; Eitel, Dr.
E. W. Bedford: Deaconess, Dr. N. T. Johnson; Ma-
ternity, Dr. Edward C. Maeder; St. Andrews, Dr. Law-
rence Cady; St. Barnabas, Dr. Wm. B. Roberts; St.
Mary's, Dr. [no. T. Litchfield; Swedish, Dr. E. F.
Lundquist.
Dr. F. E. Harrington, health commissioner of the city
of Minneapolis, faces retirement June 19th of next year
under the terms of a pension hill just passed by the
Minnesota state legislature. Accordingly he has warned
the board of public welfare of the city to give thought
to a successor.
Dr. Miland E. Knapp, Minneapolis, University of
Minnesota professor of physiotherapy, and Dr. E. J.
Huenekens, Minneapolis, professor of pediatrics at that
institution, will serve under Dr. Wallace H. Cole, St.
Paul, chief of staff at the Twin Cities polio hospital
opened Sunday, February 21, by the St. Barnabas hos-
pital organization of Minneapolis.
AMERICAN UROLOGICAL ASSOCIATION
Dr. Miley B. Wesson, chairman Committee on Re-
search, American Urological Association, reports that
the $500 Research Prize annually offered by the Associa-
tion will not be awarded this year. The government hav-
ing again discouraged the holding of medical conven-
tions, except those primarily of military interest — and at
which there is to be a ban on social events — plans for
the June meeting of the American Urological Associa-
tion in St. Louis have been cancelled.
VluMtoQy.
Dr. Lorenzo Nelson Grosvenor, 74, of Huron, South
Dakota, died November 26 at a hospital in Rochester,
Minnesota, of a cardiac attack following an operation
performed on November 14.
Dr. Grosvenor was a graduate of Chicago Homeo-
pathic Medical College, 1889, and Rush Medical Col-
lege in 1902. He practiced in Chicago prior to coming
to Huron in 1913. He was a Fellow of the American
College of Surgeons, specializing in Eye, Ear, Nose and
Throat, president of the South Dakota State Medical
Association in 1930, past-president of the Tri-State Oph-
thalmological Society and member of the Ophthalmo-
logical Society of Chicago, member and past-president
and secretary of the Huron District Medical Society,
and at the time of his death was superintendent of the
Beadle County Board of Health.
Dr. John Franklin Dufferin Cook, 71, of Pierre, South
Dakota, died January 27 at Pierre of postoperative com-
plications.
Dr. Cook was graduated from the University of
Illinois College of Medicine in 1897. He was licensed
in 1897 and for many years practiced medicine in Lang-
ford, South Dakota. He was a. Fellow of the American
College of Surgeons, member of the South Dakota State
Medical Association and First District Medical Society.
He was secretary-treasurer of the state medical associa-
tion from 1925 to 1937, president of the South Dakota
State Medical Association in 1938 and. at the time of
his death, was Superintendent of the State Board ol
Health and Director of Medical Licensure. These latter
positions he had held for several years.
Dr. George H. Barbour, 81, Helena, Montana, retired
physician, died in a Helena hospital. He practised from
1889 until 1939.
Dr. Nels Werner, 63, Eau Claire, Wisconsin, associate
at Middlefart Clinic of that city, died suddenly at Eau
Claire, February 26. A 1904 graduate of Rush Medical,
Dr. Werner began his practise at Barron, Wisconsin,
whence he removed to Eau Claire.
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86
Thk Journal-Lancet
LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS
ON FEBRLJARY 13, 1943
BY EXAMINATION
Name
Altman, Richard Fortune
Arnescn, John Francis
Black, William August
Chesler, Merrill David
Ellingson, Eugene Andrew
Flickinger, Frederick Miles
Gilbertson, Eva Labelle
Godward, Alfred Charles
Green, Walter Stanley
Hagan, Edward Jordan
Hanlon, George Henry
Hartwich, Roger Frank
Heim, Delmar John
Henderson, Lowell Lawrence
Hinz, Walter Ernest
Hoyer, Louis Paul Jr.
Kabat, Herman
Leibold, Edwin Francis
Leitschuh, Thomas Henry
Lewis, Richard Edwin
Long, Russell C.
McKibbin, John Philip
Malbin, Morris .
Melton, Thomas June Jr.
Menold, William Fredrick
Miller, Sidney ...
Monahan, Robert Hugh Jr.
Morton, Paul Vanderhoff
Nesset, Lawren Blane
Peterson, Carl Andrew
Phares, Otto Carmony
Regan, Joseph Michael
Remington, John Paul
Rossberg, Raymond Arnold
Rowland, Willard Daniel
Ruch, Donald Merrill
Sheridan, Richard Brinsley
Smith, Scott Meadows
Watkins, David Hyder
Clarkson, William Rycroft
O’Connor, William Benedict
Tosseland, Noel Everett
Sengpiel, Gene William
Thomas, John Fulton
Tice, George Irving
School
U. of Nebraska, M.D. 1942
U. of Minn., M B. 1942
Temple University, M.D. 1940
U. of Minn., M.B. 1942
U. of Texas, M.D. 1940
Ohio State, M.D 1941
Temple University, M.D. 1941
U. of Minn., M.B. 1942
U. of So. Calif., M.D. 1942
Rush, M.D. 1942 .
Jefferson, M.D. 1941
U. of Minn., M.B. 1942
Wayne, M.D. 1942
Indiana U., M.D. 1941
Northwestern, M.B. 1942
U. of Pa., M.D. 1940
U. of Minn., M.D. 1942
Marquette, M.D. 1942
U. of Minn., M.B. 1942 ....
U. of Minn., M.B. 1942
U. of Cincinnati, M.D. 1941
Northwestern, M.D. 1941
Rush, M.D. 1938
.Tulane, M.D. 1940
U. of Minn., M.B. 1942
Johns Hopkins, M.D. 1940
U. of Minn., M.B. 1942
McGill, M.D. 1940
___U. of Minn., M.B. 1942 ...
U. of Minn., M.B. 1942
U. of Minn., M.B. 1942
Marquette, M.D. 1941
...U. of Minn., M.B. 1942
U. of Minn., M.B. 1942
Washington U., M.D. 1940
U. of Rochester. M.D. 1941
Yale, M.D. 1941
U. of Louisville, M.D, 1939
Address
St. Joseph's Hospital, St. Paul, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
5104 Colfax Ave. S., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Milwaukee Co. Hosp., Wauwatosa, Wis.
1210 Lowry Med. Arts Bldg., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
1512 — 7th St. S. E., Minneapolis, Minn.
St. Mary’s Hosp., Duluth, Minn.
St. Mary’s Hosp., Duluth, Minn.
Ancker Hosp., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
LJ Hosp. Cancer Inst., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
St. Joseph's Hosp., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Miller Hosp., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
General Hosp., Minneapolis, Minn.
Ancker Hospital, St. Paul, Minn.
General Hosp., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Ancker Hospital, St. Paul, Minn.
Ancker Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
University Hosp., Minneapolis, Minn.
BY RECIPROCITY
U. of Colorado, M.D. 1940 Mayo Clinic, Rochester, Minn.
Hah. Pa., M.D. 1940 Mayo Clinic, Rochester, Minn.
St. Louis U., M.D. 1942 1163 Hague Ave., St. Paul, Minn.
St. Louis U., M.D. 1942 St. Mary’s Hosp., Duluth, Minn.
NATIONAL BOARD CREDENTIALS
Marquette, M.D. 1941 .... Mayo Clinic, Rochester, Minn.
_U. of Pa., M.D. 1940 ... ... Mayo Clinic, Rochester, Minn.
U. of Iowa, M.D. 1940 Mayo Clinic, Rochester, Minn.
Classified AdveAtisetnewU
OFFICE FOR RENT
Physician’s office at 3801 Nicollet Ave.. Minneapolis. Three
rooms, laboratory and waiting room Formerly occupied (for 12
years) by prominent physician. S. A. Otness, 5341 Clinton Ave.
Telephone: Colfax 7017.
FOR SALE
Practice of 12 years, substantially all in one Midway (between
Minneapolis and St. Paul) location. Offers excellent opportunity
for specialist or g. p. wishing establish himself in live Twin Cities
neighborly community. Will dispose of equipment also, if desired.
Address Box 75 4, care this office.
FOR SALE
Complete Simmons hospital bed, new, posture control operation,
crank handles, side rails, attached irrigation rod: inner spring mat-
tress. Over-bed table. Commode to match, walnut finish. Also in
valid’s automobile wheel chair; chrome plated, rubber tired, width
of seat open 24 inches, closed 1 0 V2 inches: two large wheels, two
small, hand rims on large wheels. Used only two weeks. Cost
new #122. Will sacrifice. Address Box 75 3, care of this office.
EXCEPTIONAL OPPORTUNITY
for beginning or established physician to share suite of offices with
another physician or dentist. Individual treatment room or labora-
tory, in new office building located in very best residential retail
section. Address Box 65 3, care of this office.
AdvsiU&ti's AwouHeetnesds
CURDOLAC FOODS OFFER CHARTS
For the first time dietitians, physicians, and people on sugar
and starch restricted diets have available to them a booklet that
lists the complete analysis of every food manufactured by the
Curdolac Food Company of Waukesha, Wisconsin. Not only
are Curdolac foods analyzed chemically in percentages but the
protein, fat, carbohydrate, and calories are figured on a gram
basis, and in addition the caloric content of an average serving
of Curdolac food is incorporated in this analysis chart.
As far as is known, Curdolac Food Company of Waukesha
is the only special-diet food company in the world to have pre-
pared and completed a scientifically accurate measurement of
the inherent values of its food for the ease and accurate use of
physicians, dietitians, and dieters.
The Curdolac analysis charts are available to interested par-
ties who will request them on their letterhead.
T uberculosis - - Post- W ar
Kendall Emerson, M.D.f
New York City, New York
Carlyle wrote, "No little hope sufficeth — in the face of universal destruction.” Tubercu-
losis fighters in the invaded lands of Asia and Europe are facing the universal destruction of
their life work at the ruthless hand of half-civilized conquerors. It demands no little faith,
no meagre courage, to carry on. Yet reports of their undaunted heroism are drifting in.
From an old friend in Belgium comes a piteous cry for a few vitamins to eke out the
starvation ration allowed him for his patients. Dr. Lim and his devoted colleagues are promot-
ing more than a semblance of public health work in China in addition to the overwhelming
demands made on their time and strength by emergency war duties. Despite their efforts the
white plague rides again in these and all other occupied countries.
Must we too expect a recrudescence of our ancient enemy? The war has rendered us
short-handed in doctors and nurses to care for the sick and in public health personnel to main-
tain established preventive measures. Extra burdens fall on those of us destined to fight the
war along the home front. It is for us who remain to take up the guage of battle, to assume
double duty, to join forces in guarding the public safety.
The Early Diagnosis Campaign this year is an appeal to the loyalty and patriotism of all
practising physicians to contribute their full strength and interest toward fighting the spread
in this country of those communicable diseases which add a further disaster to the grim tra-
gedy of war. We are especially grateful to the Journal-Lancet for continuing its fine rec-
ord of public service by emphasizing this national danger and by pointing out our professional
responsibility to combat any decline in our standards of tuberculosis control.
t Managing Director, National Tuberculosis Association
The Journal-Laneei
88
The Importance of Preventive Measures in the
Tuberculosis Program
S. L. Cox, M.D.*
Seattle, Washington
IT is a well-known fact that a majority of the clin-
ical cases of tuberculosis that are definitely diagnosed
and placed under treatment are moderately or far
advanced at the time such diagnosis is made and treat-
ment instituted. According to Drolet’s1 survey of 99
institutions for the five-year period, 1937-41, covering
218,723 patients, 176,798 were discharged alive and
41,925 (or 19 per cent) died while under institutional
treatment. "In some regions the ratio was as low as
13 per cent, and in one it rose to 26 per cent; New
York City institutions experienced a 20 per cent mor-
tality.” Many patients leave various institutions against
medical advice, and a rather large percentage of these,
as well as a smaller proportion of those regularly dis-
charged, die of tuberculosis within five years after leav-
ing the sanatorium. So it can readily be seen that the
total mortality (those dying while under institutional
treatment plus those who die within a few years after
leaving the sanatorium) is very high.
While it is true that modern use of the tuberculin
test, followed by roentgenograms of the chest in the case
of reactors to tuberculin, results in the discovery of more
cases of clinical tuberculosis than formerly — and in the
earlier diagnosis of many of these cases — there are still
large numbers of persons with clinical tuberculous dis-
ease who are not discovered early enough for successful
treatment to be instituted, the patient restored to good
health and enabled to resume a gainful occupation. It
would seem desirable, if not imperative, that some pro-
gram be instituted that will either prevent these indi-
viduals from ever contracting active clinical disease, or
will facilitate the discovery of their tuberculosis at a
sufficiently early stage so that successful treatment can
be provided and the patients restored to health.
One method, and a very effective one, for the early
diagnosis of tuberculosis is the use of miniature films
or paper films for x-raying the chests of certain groups,
such as college or university students, enlisted personnel
in the Army and Navy, employees in industrial plants,
etc. This method is very efficient and satisfactory where
the persons to be x-rayed are already assembled and can
be examined as a unit. In smaller establishments, in rela-
tively small schools — whether high schools or colleges —
and in rural communities mass x-raying is not so feasible
as in the larger cities. It is in these smaller communi-
ties, where the percentage of positive reactors to the
tuberculin test is quite small, that Mantoux tuberculin
testing, as a preliminary screening process, seems to have
special value.
In the State of Washington the Tuberculosis Asso-
ciation has sponsored, and carried out to a rather large
degree, Mantoux tuberculin testing as an educational
and preventive procedure in tuberculosis control. The
•Clinician, Washington Tuberculosis Association
work has been done primarily in the public schools
throughout the state and has been a definite part of our
program since 1932. During this ten-year period some-
thing over 100,000 tuberculin tests have been given by
the author. These were distributed as follows:
High school pupils 50,629
Junior high and grade school pupils 37,149
Col l«*gt* students 4,497
I eachers 3,904
Miscellaneous (adults, contacts, etc.) 4,307
[*otal 100,486
We stress the preliminary educational work in the
schools before the date for the actual tuberculin testing.
A regulation of the state department of health requires
all teachers and school employees to have an x-ray film of
the chest at regular intervals, so that teachers throughout
the state have some information concerning tuberculosis
as a possible menace to health. School superintendents,
high school principals, certain members of the teaching
staff, and in some instances a parent-teacher organization
in the community, are contacted before any testing is
done in a given school. A talk on tuberculosis before
the student body, given by a trained worker, and the
showing of one or more films on the subject of tuber-
culosis and its prevention are utilized as methods of pro-
viding dependable information to the pupils prior to the
actual testing itself.
While giving the tests, and also when reading them,
we take time to explain different points about the test —
the material used, the significance of a positive reaction,
the necessity for those who are negative to have the test
repeated later on, etc. After reading the tests, the physi-
cian has a personal interview with each reactor. These
reactors are assured that they do not necessarily ever
need to experience actual illness or difficulty simply be-
cause they are positive to the tuberculin test. They are
urged, however, to take reasonable precaution as regards
general health habits and to have periodic re-examinations
(including an x-ray of the chest) at least until they have
reached adulthood.
In recent months we have been doing our tuberculin
testing with an intermediate strength of purified protein
derivative. Previously the great majority of our tests
were done with old tuberculin in a dilution of I to 1,000.
In regard to the dosage of purified protein derivative,
Esmond R. Long2 of the Henry Phipps Institute, Phila-
delphia, states: "The question of a suitable dosage of
purified protein derivative has been lengthily studied by
investigators in the U. S. Public Health Service. The
investigations of Furcolow, Hewell, Nelson and Palmer2, 1
show that an overwhelming majority of all patients with
clinical tuberculosis react to small doses of the purified
protein derivative, and that relatively small doses are
effective in the majority of tuberculous contacts who
might be assumed to have acquired infection if not actual
April, 1943
89
clinical disease. On the other hand, it appeared clear
from their results that increasing dosage soon brings the
test into the range of nonspecificity, where persons pre-
sumably free from present or past contact with tubercu-
losis react. Their results indicated that 0.0001 mg. of
purified protein derivative represents approximately the
critical level, lesser doses being highly specific and higher
doses causing an increasing percentage of nonspecific
reactions. Studies at the Henry Phipps Institute have
repeatedly demonstrated the effectiveness of the stand-
ard first dose of the purified protein derivative in elicit-
ing a positive tuberculin reaction in cases of clinical
tuberculosis.”
In our experience in the State of Washington there
has been a slow, but very definite, decline in the per-
centage of positive reactors during the past ten years.
The results among high school students are as follows:
Sept. 1931 — April
1 1935 ....
No. of Tests
17,191
Positive
2,356
Per Cent
Positive
13.70
May 1935 — May
1938
15,929
1,890
11.86
June 19 38 — May
1941
17,509
1,759
10.04
Total
50,629
6,005
1 1.85
It will be noted that the drop in percentage of positive
reactors for the two three-year periods was almost iden-
tical— 1.84 per cent from 1935 to 1938 and J. 82 percent
during the three years 1938—41.
During the same ten-year period the following results
were noted among younger pupils (junior high and
grade school pupils) :
Per Cent
No. of Tests Positive Positive
Sept. 1931 — April 1935 8,026 867 10.80
May' 1 935 — May 1938 13,156 1,065 8.09
June 1938 — May 1941 15,967 889 5.56
Total 37,149 2,821 7.59
No city children are included in the 87,778 pupils
shown in the preceding tabulations. Testing in the cities
of Seattle, Tacoma, and Spokane has been done by the
tuberculosis organizations and local health authorities in
those cities.
Comparison of the four different age groups — grade
and junior high school pupils, senior high school stu-
dents, college students, and finally an adult group
(teachers) shows very definitely an increase in positive
reactors as the age of the group advances. Of the 4,497
college students tested, a total of 874, or 19.43 per cent,
were positive. Teachers showed a percentage almost
twice that of the college students — 37.65 per cent posi-
tive (1,470 positive reactors out of 3,904 teachers given
the tuberculin test) .
As do similar organizations in other states, the Wash-
ington Tuberculosis Association carries on a general edu-
cational program not only in the public schools and
colleges but also among the general population of the
state. For the past two years a large part of the chest
clinic work in Washington has been conducted by the
state department of health, particularly in those counties
in which there is a full-time county health unit. The
county tuberculosis organizations cooperate in the clinic
program, and in many instances where the family in
question is unable to pay for x-ray service they pay for
chest films requested by the clinician. These chest clinics
afford opportunity for re-examination of many of the
ten thousand or more positive reactors that have been
found in our tuberculin testing program during the past
ten years.
As a result of the program of health education in the
high schools, the tuberculin testing procedure itself and
the follow-up after the tests, a very definite amount of
active tuberculosis should actually be prevented, and a
considerable number of deaths from tuberculosis in later
life avoided. If a total of 500 cases of clinical tubercu-
losis can be prevented by the testing and education of
100,000 individuals, the number tested in the State of
Washington, the saving in actual money alone would
eventually be more than $1,000,000. This is at the very
low estimate of $2,000 per case — $1,000 for sanatorium
care and $1,000 for loss of earning capacity during the
period of illness and treatment. If the educational and
preventive work were not done, and these 500 cases went
on to develop moderately or far advanced tuberculosis,
the mortality would reach at least 100, many of the
deaths among young people.
The campaign against tuberculosis calls for sustained
and varied effort along many different lines. Procedures
that help find the open cases of tuberculosis, and get
these patients isolated and under scientific care and
treatment, should of course be increasingly utilized. In
the long view, however, education of the general popu-
lation concerning this age-old disease would seem to be
one of our best methods of approach to the problem.
The very encouraging fact that tuberculosis really is
preventable, and also curable when found early, should
direct our plans and energies more and more toward
finding the cases earlier, or better still, discovering the
potential cases by widespread use of the tuberculin test
and greater employment of all available x-ray facilities.
References
1 Drolet, G. J.: Trends in the frequency and type of surgical
procedures in the treatment of pulmonary tuberculosis, Dis. of
Chest 8:392, 1942.
2. Long, Esmond R.: The present status of the tuberculin
test. Journal-Lancet 62:376 (Oct.) 1942.
3. Furcolow, M. L., Hewell, B.. Nelson, W. E., and Palmer,
C. E. : Quantitative studies of the tuberculin reaction: 1. Titration
of tuberculin sensitivity and its relation to tuberculous infection.
Pub. Health Reports 56:1082, 1941.
4. Furcolow, M. L., Hewell, B., and Nelson, W. E.: Quanti
tative studies of the tuberculin reaction: III. Tuberculin sensitivity
in relation to active tuberculosis. Am. Rev. Tuberc. 45:504, 1942.
DO SOMETHING FOR A SERVICE DOCTOR
If you have a doctor friend or relative in the Armed Forces who you have reason to
believe is not receiving the Journal-Lancet but who would like it, subscribe for him. He
will receive it, and like it. Thanks to the Army and Navy Postal Services, subscribers can be
assured that service men will get deliveries wherever the Army and Navy Post Offices function.
And that means every place on earth where American soldiers and sailors are stationed and
fighting.
The Journal-Lancf.t
90
The Tuberculin Test in Tuberculosis Control
L. L. Collins, M.D.*t
Ottawa, Illinois
An examination of the chest by x-ray only may be
satisfactory if the purpose of the examination is
L merely to determine the presence or absence of
pulmonary pathology at the time of the examination.
But I think it is a serious mistake to eliminate the tuber-
culin test as part of an examination if the purpose of
that examination is to control tuberculosis. I hold to
this belief even where it is less costly to x-ray the entire
group than to first administer the tuberculin test to the
entire group, then x-ray the reactors.
In December, 1937, a program to control tuberculosis
was started in De Kalb County, Illinois, and in Septem-
ber, 1938, a similar program was started in La Salle
County. The program is the practical application of the
principles of tuberculosis control advocated for the past
fifteen years by several specialists in the field.
Previous to the introduction of this program, minimal
tuberculosis in these two counties had not been recog-
nized. During 1941, 53 per cent of all the new cases
of pulmonary tuberculosis discovered in De Kalb County
were found while still in the minimal stage; 43 per cent
of those in La Salle County were minimal cases.
In 1937, Da Kalb County had 15 deaths from pul-
monary tuberculosis, or a tuberculosis death rate of about
45 per 100,000. In 1938 La Salle County had 48 deaths
from pulmonary tuberculosis, or a tuberculosis death rate
of 48 per 100,000. These figures vary but little from the
tuberculosis death rate of the state for the same period.
There were 3 deaths from pulmonary tuberculosis in
Da Kalb County in 1940, a rare of 9 per 100,000; 2
deaths in 1941, a rate of 6 per 100,000. To November,
1942, we have had 3 deaths; two of these cases were
first diagnosed as pulmonary tuberculosis before 1937.
LaSalle County had a death rate of 18 per 100,000
in 1940, 25 per 100,000 in 1941; to November, 1942,
there have been 6 deaths from pulmonary tuberculosis
and one from tuberculous meningitis. One of the six
patients who died had been in the county only six weeks
before death, having spent the previous four years at
a state hospital.
Our success during the past few years in reducing
the death rate from pulmonary tuberculosis in these two
counties can be attributed in a large measure to the use
of the tuberculin test.
Unity of medical thought concerning tuberculosis is
important in a tuberculosis control program. The med-
ical profession in these two counties represented not only
the tuberculosis teaching of different medical schools,
but the ever-changing tuberculosis teaching at the same
medical school during the evolution of our present-day
concepts of this disease.
The tuberculin-testing surveys were used primarily for
their educational value. Doctors were hired in rotation
*LaSalle County Sanatorium.
t Read before Mississippi Valley Conference on Tuberculosis,
Chicago, 111.. September, 1942.
to conduct the testing clinics in the high schools of the
county. From this experience these physicians learned
the technic of tuberculin testing and became familiar
with the various reactions to tuberculin. Not merely did
they discover that only about 20 per cent of these young
adults reacted to tuberculin, but also that among the
reactors were a large number who had no known history
of contact to tuberculosis.
These facts plus the recently acquired familiarity with
the tuberculin test induced the doctors to give tuberculin
tests to their private patients. It was not long before
they discovered active pulmonary tuberculosis in patients
who had never been suspected of having the disease,
from either the history, the symptoms, or the physical
examination. The lesions, however, could be definitely
demonstrated on the x-ray film, and some of the patients
even had advanced tuberculosis. The doctors soon recog-
nized the importance of an x-ray examination of the
chest for diagnosing pulmonary pathology, particularly
early tuberculosis. Most of the doctors thus became con-
vinced of the importance of the tuberculin test in dis-
covering reactors and of the importance of x-raying all
reactors for possible active tuberculosis.
A few of the doctors, as is true in any community,
held to the ideas about tuberculosis that they had been
taught in medical school and did not readily accept the
tuberculin test as a method for discovering tuberculous
infection; nor did they accept the idea that patients could
have active tuberculosis yet appear healthy and have
physical findings that they could not detect.
This small group learned the hard way— by experi-
ence. I shall present a few cases relating these ex-
periences.
Case Reports
Case 1. F. S., a girl aged 20, worked daily in a factory and
attended about three dances a week. She had been under the
care of her family physician for about three months, became
dissatisfied and changed doctors. The second physician placed
her in a hospital for observation. His examination included the
tuberculin test, which showed her to be a reactor. The sub-
sequent x-ray film revealed evidence of extensive disease, which
proved to be far-advanced tuberculosis and which required two
and one-half years of sanatorium care. The patient had a posi-
tive sputum. She is now working and living a normal life —
a patient of the second doctor.
Case 2. A. R., a man aged 72, had been seeing his family
physician for two years because of a cardiac lesion. He finally
changed doctors on advice of friends. The second physician
included the tuberculin test in his first examination, and the
patient was found to be a reactor. Examination including x-ray
inspection of his chest revealed advanced tuberculosis. His
sputum was positive. The doctor then gave tuberculin tests to
the patients’ children and grandchildren, all of whom reacted.
Although none was found to have clinical tuberculosis, these
several families are being examined regularly by the second
doctor.
Case 3. L. P., a girl aged 20, under the care of her family
physician for six months, became dissatisfied and so changed
doctors. The second physician included the tuberculin test in
his first examination and, finding her to be a reactor, x-rayed
April, 1943
91
her chest. Far-advanced pulmonary tuberculosis with a posi-
tive sputum was diagnosed. This patient died two years later.
Her family was also given the tuberculin test; all of them
reacted. Further examination, including x-rays of their chests,
revealed that two of her sisters had active tuberculosis. The
husband of this patient refused to change doctors and later
died from tuberculosis. It is believed that he was the original
source of infection in this family. The bitterness of the fam-
ily toward the first doctor can be excused.
Case 4. D. J., a woman, aged 26, married, and with one
child, called her family doctor because of fever, cough, gen-
eralized aching, and other symptoms. The doctor diagnosed in-
fluenza, which was prevalent at the time. There being no im-
provement, three weeks later her mother called another physi-
cian. The second doctor included the tuberculin test as part of
his first examination. The woman reacted to tuberculin, and
other phases of the examination revealed advanced tuberculosis.
Her sputum was positive. After 18 months at the sanatorium,
she is now home and caring for her family.
Case 5. P. G., aged 20, married, worked as a waitress. She
is 5 feet, 5 inches tall and weighed 185 pounds. She complained
of tiredness, pain in the lower back, and frequency of urina-
tion. Her family physician treated her for nine months for a
kidney condition. A friend advised that she try another doctor;
this second physician included the tuberculin test as part of his
examination. She reacted and was found to have far-advanced
pulmonary tuberculosis. She had a positive sputum. She has
been in the sanatorium for the past 14 months, and it will be
some time before she can go back to normal living.
Case 6. L. R., a man aged 21, was being treated for chronic
bronchitis. A year-old baby in a home at which this patient
was a frequent visitor died from a tuberculous meningitis. He
worked in a food locker and was requested to have a tuberculin
test and, if found to be a reactor, to have an x-ray of his chest.
H's doctor did not think this was necessary for chronic bron-
chitis, since his only symptom was a cough which he had had
for two years. He lost the job at the food locker and entered
a barber college in Peoria. The Peoria health authorities were
notified and insisted on a chest examination; this showed ad-
vanced tuberculosis with positive sputum. He entered the La
Salle County Sanatorium, where he is at the present time I
have presented this case because it has a direct bearing on the
next case.
Case 7. E. F., a woman aged 28, complained of mental
symptoms and sinus trouble. She had visited some twelve doc-
tors in and about Illinois during a six-month period, with no
results. She then visited a doctor who gave her a tuberculin
test as a routine measure. She was found to be a reactor, and
a subsequent x-ray film of the chest revealed chronic tubercu-
losis. Her sputum contained tubercle bacilli. A thoracoplasty
was done. She is now physically well and her mental condition
has cleared. The doctor who discovered her true illness is the
same doctor who did not think it necessary to give the previous
case a tuberculin test. He has benefited from that experience.
Case 8. L. S. The wife of the patient under discussion
worked temporarily in the health department, where she came
in contact with the tuberculosis program. Upon learning that
we advocate routine tuberculin testing of all adults, she and
two nephews who live with her were tested and found to be
reactors. X-ray films of all three showed no evidence of active
tuberculosis. Her husband had never had the tuberculin test,
but had been examined frequently during the past ten years
for a chronic cough. Sputum examinations on two or three
occasions were reported as containing no tubercle bacilli and a
diagnosis of chronic bronchitis had been made. The patient
weighed 190 pounds and had never lost any time from work.
His wife nevertheless urged him to have a tuberculin test. He
was found to be a reactor The x-ray film revealed evidence
of a large cavity in the right apex. The sputum contained 50
tubercle bacilli per field. He is in the sanatorium at present
waiting for thoracoplasty.
Each of the doctors who missed the diagnosis of pul-
monary tuberculosis in the above cases, and thus lost
their families as patients, is now giving the tuberculin
test to most of his patients and is an ardent supporter
of the tuberculosis program.
These cases illustrate the type of experiences that will
be encountered by those doctors who are reluctant to
accept the tuberculin-testing program. They also illus-
trate how the tuberculin test can be used to ferret out
cases of pulmonary tuberculosis. In a community where
the tuberculin test is widely used all the doctors will
ultimately use it as a diagnostic aid, if for no other rea-
son than self-protection.
It has been of interest to note from our experience
how many family doctors became interested in tuber-
culosis only after talcing an active part in a tuberculin-
testing survey. Such surveys in the schools make the
doctors tuberculosis-conscious; tuberculin-testing their pa-
tients serves to keep them tuberculcsis-minded.
The tuberculin-testing program has created a common
opinion concerning tuberculosis rather than the diversi-
fied opinion that previously prevailed among the medical
profession in the two counties under discussion. Tuber-
culin-testing surveys and the tuberculin testing of private
patients, plus a common opinion about tuberculosis
among the members of the medical profession, create a
tuberculosis-minded public and a unified op nion of the
public about tuberculosis. We believe that this is im-
portant for the success of any control program.
It has been our experience that contact cases who have
had a negative x-ray picture of the chest rarely come
back for further check-up unless pressed to do so by the
public health worker. A patient who has had a tuber-
culin test is much more apt to be interested in and con-
cerned about tuberculosis than is the patient who has
no: been tested. Many patients who do not react to
tuberculin have the test repeated each year.
In our experience several from this group became re-
actors in later years; one case of active pulmonary tuber-
culosis was found, and in two cases the source of infec-
tion was discovered. O. W., a young boy, who was first
tested in high school, had three annual negative tests.
On the fourth, he reacted and the x-ray film revealed a
minimal lesion. His mother was found to be the source
of infection. She had a far-advanced lesion and a positive
sputum. A teacher, who was a nonreactor when first
tested, became a reactor two years later. A study of her
recent contacts revealed a previously undiscovered active
case of tuberculosis in a friend with whom she had vaca-
tioned the previous summer.
A large percentage of the reactors continue to have
an annual x-ray check-up of the chest as a precautionary
measure. Several cases of active tuberculosis have been
discovered in this group.
An incorrect diagnosis of pulmonary tuberculosis may
react detrimentally to the tuberculosis control program.
We had a patient with active pulmonary tuberculosis
who refused sanatorium care because she thought she
could get well at home. A friend had been diagnosed
as having advanced pulmonary tuberculosis, refused to
go to a sanatorium, and recovered in a short period at
home. On the other hand, the patient knew several
people who had gone to the sanatorium and died. This
patient later died from tuberculosis; four of her five
I
92
The Journal-Lancet
children also died from pulmonary tuberculosis between
the ages of 16 and 19. A tuberculin test might have
prevented this tragedy by revealing this woman’s friend
to be a nonreactor.
If the patient fails to react to tuberculin, the diag-
nosis of tuberculosis should be withheld until definitely
proved by a confirmed positive sputum. We find the
tuberculin test a most reliable and valuable diagnostic
aid. The recent procedure of x-raying the chest without
doing a tuberculin test is producing many incorrectly
diagnosed cases of pulmonary tuberculosis. A study of
the draft rejectees for tuberculosis will confirm this
statement.
Two industries in our county routinely x-ray all em-
ployees, but do no tuberculin testing. Quite frequently,
a patient sent to the sanatorium with a diagnosis of pul-
monary tuberculosis fails to react to tuberculin. The
patient is refused employment or discharged because of
an incorrect diagnosis. In another industry all employees
and applicants are given tuberculin tests; only the posi-
tive reactors are x-rayed. Not a single case of far-
advanced tuberculosis has been discovered in this industry
since the adoption of this plan. In this as in other in-
stances the tuberculin test has proved to be the most
effective single factor in the program for the control of
tuberculosis in the two counties under consideration.
The use of the tuberculin test made it possible to con-
trol tuberculosis in cattle and the use of the same test
may prove to be the most effective agent we have for
controlling tuberculosis in man.
The Doctor of Medicine and His Responsibility*
Alfred W. Adson, M.D.
Rochester, Minnesota
EMBERS of the North Central Medical Con-
ference, representing the states of North Da-
kota, South Dakota, Minnesota, Wisconsin,
Nebraska, and Iowa, have entrusted me with the respon-
sibility of addressing this National Conference on Med-
ical Service concerning medical problems that are of both
local and national interest.
It is the duty of every doctor of medicine to prevent
illness, to supply adequate medical care to those who
are ill, to perpetuate the science of medicine, and to en-
courage medical investigation. It is true that the average
physician would prefer to go unregimented among his
sick and administer to their needs, irrespective of race,
color, creed, or financial status, rather than busy himself
with administrative and political problems. However,
since the courts have ruled that group health is a busi-
ness and have found that medical societies are guilty of
restraining trade when attempting to maintain the stand-
ards of the practice of medicine, a challenge has been
issued to the medical profession: Is there a necessity for
lay groups and the federal government to take over the
control of the practice of medicine?
Has the science of medicine reached its zenith? Have
the men and women of medicine become so decadent
that they are unable to assume their responsibilities? Are
the doctors of medicine no longer able to conduct their
practice without government control? Do they lack
ability to appreciate their problems? Or are they in-
capable of constructive leadership in the solution of the
numerous responsibilities that are confronting the med-
ical profession today? The reply is, "No”.
The science of medicine has been nurtured by men
and women who have advanced the knowledge of reliev-
ing pain, correcting deformities, lowering infant mor-
tality, prolonging life, and preventing illness by sanitary
*Read at the meeting of the National Conference on Medical
Service, February 14, 1943,
and public health measures. This progress must con-
tinue if civilization is to survive.
The medical profession is conscious of social and eco-
nomic changes and stands ready to cooperate with, and
offer leadership to, state and federal agencies in the solu-
tion of medical problems. It further believes that better
medical service can be rendered by offering advice and
leadership to welfare agencies than by serving as a tool
of political bureaus.
The medical profession recognizes the necessity of state
and federal control of communicable diseases and med-
ical services to inmates of state and federal institutions.
It appreciates its responsibility to the armed forces and
expects to supply the needed personnel. It is willing to
cooperate with welfare agencies in providing adequate
medical care for the low-income and indigent groups of
the population; but in providing this care, it believes
that the medical service is augmented when the patient-
physician relationship can be maintained by permitting
the patient, whenever possible, to choose his own physi-
cian. In order to protect the public from worthless, so-
called medical procedures and unnecessary operations by
unscrupulous individuals, it likewise believes that high
standards of medical education and practice must be
maintained. This applies not only to the practice of
medicine in the office; it applies to the practice of medi-
cine in the humble home or in the most modem hospital.
Although medical education begins in the medical
school, it is never completed as long as the physician
continues his practice. Medical schools have adopted
standards of education and have required certain courses
of study in order that the public might avail itself of
the best practices of medicine. Medical licensing boards
have further protected the public by requiring of their
candidates for licensure prescribed courses of study.
State laws governing the practice of medicine and con-
April, 1943
93
duct of physicians further protect the public from irreg-
ular practices and charlatans.
Medical societies, county, state, and national, have
been organized to further the education of the physician
by acquainting him with the advances and new discov-
eries in the science of medicine. They likewise serve as
administrative units in the consideration and solution of
medical problems. It is obvious that the responsibilities
of the respective state organizations are greater than
those of the county organizations, and that the national
organization is charged with greater responsibilities than
those of the state organizations. However, it is also
obvious that the activities of all groups must be integrated
if medical problems are to be solved effectively. In some
states, such as Minnesota, the administrative and the
legislative bodies have the confidence of the medical pro-
fession. Likewise the medical profession has the confi-
dence of the state administrative and legislative bodies.
This confidence has made it possible for representatives
of both groups to attack and solve the medical problems
which are of mutual interest.
The national organization, through its respective bodies
and committees, has done excellent work in furthering
medical education. It has crystallized the standards of
medical education for the medical student as well as for
the practitioner of medicine; it has investigated the
claims of new and nonofficial remedies, foods, and thera-
peutic measures and has further protected the public by
approval or disapproval of the articles investigated. It
has taken active steps through its Procurement and As-
signment Committee in providing medical men for the
armed forces, without robbing communities of adequate
medical personnel, and has made provisions for reloca-
tion of physicians where more medical service is needed.
It has acquainted the public with the important role that
the science of medicine plays in their daily lives, but
apparently it has not gained the confidence of the na-
tional administrative and legislative bodies as have some
of the state medical societies. The National Physicians’
Committee has made some progress in acquainting the
public with the necessity of medical science, but it too
has not obtained the confidence of the national admin-
istrative and legislative branches of our government.
Therefore, the recent court decision has emphasized the
weakness of the educational program so far conducted
for the purpose of acquainting the public, the adminis-
trative and legislative bodies of certain states, and the
national institutions with the important function of the
science of medicine in our civilization. It is our duty, as
physicians and citizens, to assure those in administrative
positions and legislative bodies that we are familiar with
the social and economic changes that have thrown great-
er responsibilities on the medical profession and that we
stand ready to cooperate with these agencies in offering
leadership in the solution of the numerous problems
which nonmedical personnel are trying to solve.
The chief medical problem that concerns doctors of
medicine and welfare agencies is that of providing ade-
quate medical care to those who are financially unable
to procure this care. This group includes those who are
indigent and those with low incomes. Medical care, in
its true sense, embraces more than emergency treatment
for a particular illness, since it should include a rehabili-
tation program, such as the correction of deformities and
ailments that impair the efficiency of individuals. The
rehabilitation program should also provide for adequate
and proper diets, physical training, recreation, protective
clothing and housing. In most of the cities the indigent
are provided with proper medical care through the chari-
ty hospitals, where competent physicians give of their
services. This same group in the rural districts is not
always so fortunate, since local welfare boards are reluc-
tant to provide this care. It is in these situations that
the physicians have been overburdened in assuming all
the responsibility of providing necessary medical care.
Prior to the more recent economic changes, physicians
were willing to assume this obligation because those who
could afford to pay for professional services attempted
to meet their obligations. However, as a result of the
recent social and economic changes, the government has
taken over more and more control of the civilian’s activi-
ties, and those with moderate and low incomes have been
less willing to assume their obligations of medical care
and are insisting that it is the government’s duty to pro-
vide medical care and that it is the individual’s privilege
to squander his extra change.
The problems of this group cannot be solved by physi-
cians alone or by federal, state, and local welfare agencies
alone. Ours is a joint responsibility. Conscientious lead-
ership by physicians working in cooperation with county,
state, and federal agencies can and will bring forth a
solution of the problem. Medical service must be ren-
dered, and the physician is willing to give a good portion
of his services. But the government must provide rea-
sonable funds for the care of its indigent, as it must pro-
vide for catastrophic illness in the low-income group.
Nevertheless, those who come within the low-income
group should be made to realize that they too owe a
responsibility to their local, state, and federal govern-
ments and should be encouraged and advised in budget-
ing their incomes.
Industrial compensation has accomplished much in
providing proper medical care and the necessities of life
during illness for those employed in industrial institu-
tions. However, there still remain a large group of indi-
viduals who receive moderate or low incomes and are
desirous of securing the assurance of adequate medical
service in the event of illness. Insurance companies have
offered this protection through policies covering accident
and illness disabilities, but again this protection only
partially solves the problem, since many an insuree ex-
pects more for his premium than the insurer is able to
give. In several states medical societies have attempted
to develop medical service plans whereby the insuree may
purchase from the doctors within the group full medical
protection or medical protection for unexpected serious
illnesses. In some states, under the farm security pro-
gram, experimental medical service plans are being tested
out in an attempt to find the solution of the problem of
supplying medical care to farmers and their families who
are being rehabilitated. In some instances physicians are
hired to render medical service to indigent and coopera-
94
The Journal-Lance i
tive groups. Even though physicians, welfare agencies,
and low-income groups are struggling with the problems
of medical service plans, as yet no satisfactory plan for
all classes has been developed. The recipients expect
more than the vendors can supply for the premiums paid.
These controversies give rise to discussions on the ne-
cessity of compulsory medical insurance. Should such a
program evolve, results would be disappointing from the
patient’s as well as the physician’s points of view if
placed under the control of political bureaus, and the
patient would be deprived of his free choice of physician.
Therefore, we as physicians believe that a more equita-
ble solution of the perplexing medical problems referred
to will be reached if we are permitted to consult and
advise administrative officials, legislative bodies, and wel-
fare agencies, since we are more familiar with the med-
ical needs of our respective communities than are those
who have a casual knowledge of the medical necessities.
It is befitting to quote the statement found in the
opinion written by Justice Miller of the United States
Court of Appeals of the District of Columbia, in the
case of the United States of America versus the Ameri-
can Medical Association, and the case of the United
States of America versus the Medical Society of the
District of Columbia. The italics are mine.
"It may be regrettable that Congress chose to take
over in the Sherman Act the common law concept
of trade, at least to the extent of including therein
the practice of medicine. Developments which have
taken place during recent decades in the building
up of standards of professional education and licen-
sure, together with self-imposed standards of dis-
cipline and professional ethics, have, in the belief
of many persons, resulted in substantial differences
between professional practices and the generally
accepted methods of trade and business. As we
pointed out in our earlier decision, the American
Medical Association and other local medical asso-
ciations have undoubtedly made a profound contri-
bution to this development. However , our task is
net to legislate or declare policy in such matters ,
but rather, to interpret and apply standards and
policies which have been declared by the legislature.
That Congress did use the common law test there is
no doubt. That Congress was not otherwise advised
was perhaps because of the failure of the profes-
sional groups to insist upon the distinction and to
secure its legislative recognition .”
Does the medical profession of this country need a
stronger invitation or a more direct challenge to take an
intelligent, helpful, and fair stand in the enactment of
legislation that concerns not only the public welfare but
the welfare of medicine itself? Does not the medical
profession of this country, as citizens and taxpayers,
have a right to express its opinion in these matters before
legislation is enacted and rules and regulations adopted
by some bureau? I do not share the opinion that the
time for the medical profession to speak up is after such
things Save taken place. Neither do I believe that Con-
gress would be resentful of intelligent, courageous, and
fair advice on such matters. What better proof can be
asked than the quotation from Justice Miller’s opinion
that the Court is not responsible for the absence of advice
from the medical profession when Congress is drafting
a law?
It is not the purpose of this paper to criticize the
efforts of our national medical organization nor to criti-
cize the efforts of the National Physicians’ Committee,
but it is the desire of the members of the North Central
Medical Conference to express a wish that a more active
program be conducted to acquaint the public, govern-
ment officials, and legislative bod'es with the necessity of
medical science and the important role it plays in our
civilization. It is essential that we as physicians dispel
the fear that government administrative agencies and
legislative bodies have of our medical organizations and
that they be assured of our cooperation in solving the
social and economic problems that confront us as a
nation.
The functions of acquainting the public on matters
of medical interest, assisting bureaus in formulating
plans on medical care, and offering constructive advice
on proposed medical legislation rightfully belong to the
national organization known as the American Medical
Association. They could be assigned to the National
Physicians’ Committee, or they might even be under-
taken by unifying the activities of the various state com-
mittees on public policy and legislation. Representative
committees could be appointed for each of the compo-
nent societies, county, state, and national. These could
all be so integrated that national opinion and advice
could be obtained and made available for committee hear-
ings on legislation within a few hours’ time. Through
the national, state, and county committees the entire pro-
fession could be informed of proposed medical legisla-
tion. Thus the local constituents of the respective state
and federal legislators could express their views before
legislation is enacted. Some states already have medical
advisory committees from each county. They also have
state medical committees on public policy with a physi-
cian as part-time executive chairman assisted by legal
counsel. A national committee constructed on the same
plan as these state committees would have to be created.
A physician who has practised medicine should be chosen
as the executive chairman. Both he and his legal counsel
would need to be stationed in our national capital. The
expense of the national committee on public policy could
be financed by one of three agencies, the American Med-
ical Association, the National Physicians’ Committee, or
the respective state organizations bearing the expense
jointly. It would appear more equitable if each physician
would be assessed each year for the specific purpose of
maintaining a national committee on public policy and
legislation.
Our problems are not unlike those of dentists and
hospital associations. Therefore, unified effort of med-
ical, dental, and hospital associations should further the
welfare of the patient.
April, 1943
95
Echinococcus Cyst of the Lung
Francisco E. Torres, M.D.*
Cordoba, Argentina
THE purpose of this short article is to present
some illustrations showing echinococcus cyst in the
lungs. These cases were found during routine ex-
amination for tuberculous infection of inhabitants of the
mountains of Cordoba, Argentina. The altitude here is
8,000 feet above sea level. The chief occupation of the
persons included in the survey is the herding of sheep.
Echinococcosis of the lungs can be primary or sec-
ondary. It is primary when the infection of the lung is
produced by an embryo hexacante which originates from
a Taenia echinococcus egg in the organism derived from
vegetables or contaminated water. Secondary echinococ-
cosis occurs when the pulmonary involvement is produced
by organisms which belong to another hydatid cyst
already developed in the body. Generally speaking, the
primary echinococcosis of the lung is single, the sec-
ondary is multiple.
When the hexacante embryo finds a place where it
can live in the lung, a hydatid cyst is developed. The
cyst is formed by a laminated membrane and a paren-
chymatous layer and contains hydatid fluid. The primary
function of the laminated membrane is to protect the
delicate development of scoleces within the cyst. It also
has very special properties of permeability which serve to
retain the specific fluid and to prevent the entry of nox-
ious substances into the cyst. The germinal layer lines
the interior of the laminated membrane. This germinal
layer is variously called endocyst, parenchymatous or em-
bryonic membrane; it produces germinal buds (scoleces).
In the interior of the cyst there is a colorless limpid
fluid described by the French as I’eau de roche, water of
rock. Its function is to act as a protective buffer to the
developing scoleces and as a nutritive medium. In addi-
tion, toxic substances are present in variable amounts;
anaphylactic symptoms can also be produced by its in-
jection into sensitized subjects and antibodies form in
the blood of the host.
As the cyst enlarges it may exert pressure on various
structures. Since practically any organ may be affected,
it can readily be understood that bizarre and protean
manifestations may be produced. The development of
the cyst in critical centers is usually detected early be-
cause of the symptoms produced. Owing to the extreme-
ly slow growth and to the fact that infestation occurs
most frequently during the growing period, compensa-
tory changes frequently occur. This is one of the expla-
nations of the latency of even the enormous, uncompli-
cated cysts sometimes observed. As the cyst enlarges it
may encroach on the natural channels, such as bile ducts
or bronchi; it may rupture into a hollow viscus or even
discharge through the external skin, though the latter
occurrence is rare. It is easy to understand that the rup-
ture of the cyst may be followed by the introduction of
a micro-organism and suppuration may follow.
*Of the University of Cordoba, Argentina.
Distribution of Cysts in Adults and Children
Man may be infected by eating contaminated mutton
or vegetables or drinking contaminated water. It is well
known that dogs and sheep are the most important
sources of infection. Unlike the cyst stage of other
cestodes, which is often restricted to a particular tissue,
hydatid cyst has been recorded in practically every tissue
of the body. Transport of the embryo by means of the
circulation explains all the facts concerning distribution.
The great majority of embryos carried by the portal
blood stream are arrested in the liver, and about 70 per
cent of primary cysts are found in that organ. How-
ever, owing to the relatively small size of the embryo,
it may pass through the liver capillaries and lodge in the
lungs, which are next in frequency of affection.
The distribution of cysts in children under the age of
fifteen reveals some striking differences from the figure
for adults. Doubtless such figures give a much truer
conception of the distribution of primary cysts. While
the liver and the lungs account for more than 80 per
cent, the percentage of intracranial cysts is much higher
than in adults. It will be noted that cysts of the brain
are about seven times more frequent in children than in
adults. This fact has recently been emphasized by sev-
eral South American writers.
Clinical Aspects
Simple uncomplicated cysts are most frequently seen
in children or young adults. The latency of the disease
is striking and many cases have been recorded in which
enormous cysts have existed for years without causing
serious symptoms. In general the health of the patient
is remarkably good; not infrequently the disease is dis-
covered by an observing mother or during a routine ex-
amination for some other reason, as in our cases.
Diagnosis
Diagnosis can be made from: (1) high eosinophilia
in the presence of other symptoms; (2) the complement
fixation test; and (3) the intradermal test. If the cyst
is in the lung, it may be detected by its radiological
aspect. Of importance is the residence of the patient
and the kind of work he performs. It is also pertinent
to know if he is a sheep-raiser or if th ere are dogs where
he works.
Complement Fixation Test: The principles of the
Bordet-Gengou reaction were first applied to this disease
by Ghedini. Weinberg investigated these reactions in
various helminthic infections, including hydatid disease
in sheep, and later called attention to the value of this
diagnostic method in human cases. It is a specific test
and depends on the presence of a specific antibody in the
serum of patients who have absorbed hydatid antigen.
This antibody, in the presence of specific antigen, com-
bines with normal complement; the latter cannot be dem-
onstrated by means of a sensitized system of red blood
cells and specific hemolysin. The test is performed in
the same way as the Wassermann test, the presence of
hemolysin indicating that the complement has not been
fixed.
Intraderma! Reaction of ( d<oni: The occasional occur-
rence of urticaria, erythema, and other symptoms sug-
gestive of anaphylaxis, following the rupture or explora-
tory puncture of a cyst, directed attention to the presence
of skin sensitiveness in cases of hydatid infestation. A
cutaneous test, carried out like that of Von Pirquet,
yielded indefinite results hut Casom was able to obtain
a high percentage of positive cases in patients with hy-
datid disease when hydatid fluid was injected intrader-
mally. This test is the most satisfactory.
Complications
As echinococcus cyst may develop in any part of the
body, complications are in accord with the location:
that is, evolution in the lungs produces suppurative ab-
scess, which, if it opens into the pleural cavity, causes
hydatid pleurisy, suppurative pleurisy and often pyopneu-
mothorax. Development in the abdomen causes hydatid
peritonitis, or growth of a cyst in the brain induces pyo-
hydatid peritonitis, meningitis and all the symptoms of
brain tumor.
Treatment
Benign hydatid cyst can be removed if it is in an op-
erable site. If possible, the cyst must he enucleated;
otherwise, it should he drained by aspiration and made
the marsupialization of the cavity. No known chemo-
therapy is of any avail.
Don’t Give Up the Tuberculin Test
Oscar Lotz, M.D.*
Milwaukee, Wisconsin
FOR a Badger medic to remind Gopher medics not
to give up the tuberculin test certainly suggests
"carrying coals to Newcastle.” With Minnesota’s
splendid record in the eradication of bovine tuberculosis;
with its widespread case-finding program reaching out
from every sanatorium to the highways and byways of
the state; with well-organized student health services in
its colleges; and with its recently inaugurated program
*Executive Secretary, Wisconsin Anti-Tuberculosis Association.
of county accreditation — all of which projects are funda-
mentally based upon the use of the tuberculin test — it
does seem a bit out of order for Wisconsin to shout the
warning, "Don’t give up the tuberculin test!” to our
progressive and friendly neighbor across the Mississippi.
I may perhaps be accused of shouting "Wolf, Wolf”
without real cause. Nevertheless, I believe there are cer-
tain signs and indications which warrant our attention
and which, if permitted to develop unheeded, may result
April, 1943
97
in the loss of one of the important — if not the most
valuable — educational measure in the entire program for
the control of tuberculosis.
In our anxiety to bring tuberculosis under control it is,
of course, perfectly natural that whenever and wherever
possible we make use of the best and most modern
means available. Case-finding by means of mass surveys
of fertile groups is the order of the day and without
question has brought to light many minimal cases which
might have gone on to advanced involvement but for
the newer diagnostic methods. Modern equipment,
especially the miniature films produced by the photo-
fluorographic units, has made these mass studies econom-
ically possible. Their value cannot be overestimated. In
this statement I am assuming that today no physician is
justified in assuring his patient that active pulmonary
tuberculosis is not present unless the patient has been
fluoroscoped by a person with considerable training or
has had a chest film interpreted by a person of ex-
perience.
For many years the intradermal tuberculin test has
been used as a screen to separate the infected from the
noninfected. Today the miniature film is used as a
screen; unfortunately, for very good practical reasons,
no testing is done. This is particularly true in industry.
With all plants geared to top speed, and with maximum
production the chief objective, employers are reluctant
to give up any more of their employees’ time than is
absolutely necessary, even for so valuable a project as
health examinations. In one of our recent studies all
examinations had to be done during the change of work-
ing shifts, so that for several nights our workers — nurses
and technician — had to be on the job from 1 1 P. M. to
1 A. M.
In brjef, the omission of the tuberculin test in favor of
the mobile photofluorographic unit has been the chief
cause for my concern.
Two recent incidents tend to confirm or at least to
strengthen these fears. One was a well-authenticated
report that a health officer of one of our north-central
states informed his audience, consisting of public health
nurses and tuberculosis workers, that "the tuberculin test
today is passe, and since the only method of making a
diagnosis of minimal tuberculosis is by means of the
x-ray, to do the tuberculin test is a waste of time and
money.” The other occurrence was the impression of
one of our clinic workers. For many years an assistant
in stethoscopic, tuberculin-testing, and fluoroscopic clinics,
she recently had occasion to assist at a 35-mm. photo-
fluorographic clinic, where a large number of chest films
were taken within a comparatively short time. Fder re-
action was anything but favorable and was based entirely
on the feeling that while many more persons could be
examined during the miniature film clinic, the speed at
which these patients were rushed through gave no oppor-
tunity to educate the individual in matters of tubercu-
losis. She has always felt that these personal contacts
between workers and clients were of the greatest edu-
cational value.
Value of the Tuberculin Test
And now, as to the value of the intradermal tuberculin
test. Space does not permit going into detail, but just a
word or two as to its various possibilities may act as a
reminder of its real value.
As a Diagnostic Measure: Properly given and used in
sufficient dosage, the tuberculin test, we believe, is spe-
cific for tuberculous infection. There are exceptional
cases, but no test that I recall is 100 per cent infallible.
The tuberculin test gives information that no other
diagnostic measure provides. The x-ray film is necessary
to find the early lesion, but in the majority of cases it
will not reveal the presence of tuberculous infection. If
we are to carry through our program of tuberculosis
control to the point of eradication we must know who
harbors the germ.
Because of the relatively low incidence of infection,
compared to that of years ago, the value of the test is
now greatly enhanced. Formerly the infection rate among
children was high, and among adults almost universal.
Today, especially in our mid-central and western states,
the infection rate is low. This makes the negative re-
action an important factor in differential diagnosis.
Modern research in medicine has, during recent years,
recognized and identified many general diseases with pul-
monary involvement simulating pulmonary tuberculosis.
The tuberculin test is absolutely essential in diagnosing
these cases.
In Case-Finding: The small film produced by means
of the modern photofluorographic unit is, without ques-
tion, the most economical and easiest method of finding
cases with pulmonary lesions. However, to be thorough
we must go beyond the finding of the active case. The
tuberculin test will bring to light many carriers of tu-
bercle bacilli missed by the x-ray. Following the reactors
through to their possible sources, especially in children,
will result in finding many more cases than the films
alone will unearth. The younger the children, the more
productive the results.
As an Educational Measure: The program for the
control of tuberculosis advanced by the National Tuber-
culosis Association and its affiliated branches is based pri-
marily on education as the principal weapon. In our
campaign against this disease, literature, exhibits, lectures,
moving pictures, demonstrations, etc., by means of which
the story of tuberculosis is brought home to child or
adult, to the individual or the masses, are all of unques-
tioned value. However, I sincerely doubt if any of these
carry the same significant lessons and the long-lasting
impression that does the intradermal tuberculin test. The
entire procedure — the presence of the nurse and the
doctor, the actual skin injection, the anxiety as to the re-
sult and, if positive, the need of the x-ray — is all so im-
pressive to both child and adult that it by far exceeds
in value any other educational measure.
That the newer methods of case-finding with the tuber-
culin test are a great addition to our program is not
questioned for a moment, but I do wish to sound the
warning that by the omission of the tuberculin test we
may at some future time have to pay dearly for our
neglect to use this valuable agent in the education of
coming generations.
Don’t give up the tuberculin test!”
98
The Journal-Lancet
Tuberculosis Among College Students
H. D. Lees, M.D.
University of Pennsylvania
Philadelphia, Pennsylvania
IN times of war our attention quite naturally becomes
more sharply focused on physical fitness. Under con-
ditions imposed upon us through involvement in
"total’’ war, the demands for physical ahd emotional
stamina extend far beyond the ranks of our armed forces.
Our entire civil population is being called upon for
greater effort and greater efficiency. Moreover, this chal-
lenge comes at a time when we face various restrictions
which make necessary certain readjustments in our accus-
tomed routine of living. It is conceivable that conditions
more exacting than those which now confront us may
dominate our national life for an extended period of
time. Although such an outlook provides no sound basis
for undue alarm, there is obviously a clearly defined
need for intelligent medical planning. Measures for the
protection of the public health should be provided on a
broader front than ever before.
Numerous warnings have been issued recently to the
effect that increased death rates from various diseases
may be anticipated during the next few years. It is well
known that tuberculosis mortality increased tremendously
in many European countries following the first World
War. In the United States, however, in the absence of
extreme conditions of deprivation, exposure, and starva-
tion so prevalent among European nations, it is hardly
to be expected that a sharp rise in tuberculosis deaths
will occur. It is quite probable, however, that a slight
increase in the mortality rate' may be observed, or at least
the steadily downward trend evident in recent years may
be halted temporarily.
Progress in tuberculosis control in this country during
recent years has been most encouraging. According to
a recent report by the Metropolitan Life Insurance Com-
pany1 the tuberculosis death rate for white males of all
ages declined 80 per cent during the interval between the
drafts of World War I and the present conflict. For
men at the selective service ages the decline was almost
90 per cent. This achievement is all the more noteworthy
in view of the fact that our armamentarium for combat-
ing tuberculosis has not been fortified by new develop-
ments such as vaccine, an antitoxin, or effective chemo-
therapy. It represents one of the outstanding accom-
plishments in the entire field of public health since the
turn of the century.
Ten Years of College Testing Programs
The sustained and far-reaching educational campaign
directed against tuberculosis over a long period of years
has been one of the most important factors contributing
to the markedly improved death rate. In college health
circles the practical value of such an educational pro-
gram is clearly in evidence. The first organized effort to
develop a comprehensive program of tuberculosis control
among the nation’s college students had its inception in
‘‘Twelfth annual report of the Tuberculosis Committee, Ameri-
can Student Health Association, for the academic year 1941—42
1931. Since that time the number of institutions which
have set up case-finding programs has increased in a
striking manner. The report of Ferguson1’ shows that
from a modest beginning in 1931, when six colleges re-
ported a tuberculosis program, the number increased
steadily during the next five years. For the second five-
year period, as reported by Lyght,'* further substantial
gains were made. In the school year 1940-41 there were
304 institutions conducting active programs for the con-
trol of tuberculosis among their students.
During the academic year 1941-42, with which this
report deals, many colleges and universities experienced
a decrease in student enrollment due to enlistment in the
armed forces of a considerable number of college men.
Many student health departments suffered rather heavy
losses in personnel and there were other disturbing fac-
tors. In spite of these unfavorable influences and con-
trary to our expectations, we are able to report a slight
net gain in the number of case-finding programs over
last year. Also, the number of colleges reporting to our
committee reached a new all-time high. Of 860 insti-
tutions contacted by letter and questionnaire, replies were
received from 488, or 56.7 per cent. Much credit is due
to many of our state tuberculosis associations for their
most helpful cooperation during recent years. In numer-
ous instances they have made it possible for certain insti-
tutions to establish programs of tuberculosis case-finding
by enlisting the aid of the state health department or
other health agency. Undoubtedly there are many more
colleges which would welcome such assistance. It should
be remembered, of course, that not all colleges have an
organized health program and many college communities,
because of their location, do not have access to adequate
x-ray facilities. It would seem that this group of insti-
tutions merits special consideration by the Tuberculosis
Committee during the coming years.
We realize that much remains to be done when we
remember that this year 372 colleges failed to respond
to our two requests for a report on their activities. Of
860 institutions contacted by the Committee, 311 report-
ed some form of tuberculosis program in effect during
the year. This means that 549 colleges, or approximately
64 per cent of the country’s total, presumably do not
employ modern tuberculosis case-finding methods. The
total enrollment at these institutions is probably in ex-
cess of 300,000 students. Since the prevalence of tuber- j
culosis among university students is approximately 2 per
1,000, we are justified in assuming that on the campuses
of these 549 colleges there are some 600 students who
have unrecognized pulmonary tuberculosis. This is not
a pleasant picture when we think of the future in store
for many of these young men and young women. Few
diseases impose such costly and far-reaching penalties
for failure of early diagnosis as does tuberculosis. The
years of disability and suffering and the financial costs
April, 1943
involved will reach staggering proportions. The number
of persons who will be infected by certain members of
this group will undoubtedly be large. Numerous deaths
will occur.
Since the cost of a tuberculosis survey of the student
group is not infrequently given as the reason for failure
to sponsor such a program at some colleges, let us con-
sider this item as applying to these 549 institutions.
Based on average costs of surveying such a group, in-
cluding tuberculin tests and x-raying positive reactors,
an expenditure of $100,000 divided among these institu-
tions would provide an adequate case-finding program
for their 300,000 students. On this basis, the cost of
finding each of the estimated 600 undiagnosed cases
would be $166. No one familiar with the problem will
question the tremendous values which accrue to the indi-
vidual and to the community through the early diagnosis
of tuberculosis. A program designed for the early detec-
tion of the disease among students may, by some, be
deemed expensive. Failure to provide such a program,
however, will invariably prove infinitely more costly.
Decrease in Tuberculosis Rates
The tuberculin test provides the most sensitive and
reliable index of the prevalence of tuberculous infection
in a young adult group. In view of the sharp decline
in tuberculosis mortality among white persons in this
country between 1920 and 1940, 73 per cent in females
and 63 per cent in males, one would naturally expect
that the number of persons becoming infected with tu-
bercle bacilli during this period would also show a sig-
nificant decrease. Unfortunately, there are no published
data on the incidence of tuberculous infection among
college students dating back to 1920. One of the earliest
reports on the results of tuberculin testing of a student
group was based on a study conducted at the University
of Minnesota1 in 1928. Tests with the Pirquet method
showed the incidence of positive reactions among approxi-
mately 2,000 students to be 31 per cent. At the same
institution in 1941-42, using the two-dose Mantoux tech-
nic, the incidence of infection among 5,481 students was
17 per cent. This represents a reduction of 45 per cent
over a period of thirteen years. At the University of
Pennsylvania 48 per cent of entering students reacted to
tuberculin in 1932 as compared with 38.5 per cent in
1942.
Table IV presents the results of tuberculin testing at
104 colleges located in all parts of the United States,
1941-42. The reports from all of the institutions includ-
ed in this summary indicate that an adequate dosage was
employed. It will be noted that for the country as a
whole 21.8 per cent of students react to tuberculin, a
rather surprisingly low figure. Comparing these results
with those reported by Long'’ for the year 1934, it is
apparent that tuberculous infection is becoming defi-
nitely less prevalent among college students. This no
doubt reflects the generally improved conditions which
prevail today with reference to tuberculosis, especially
among persons of the social and economic group repre-
sented by college students. As will be seen in Table IV,
99
the east and west coast areas have a higher infection
rate than other sections of the country.
Table VI presents a summary of the new cases of
tuberculosis discovered at universities and colleges
throughout the country during the college year 1941-42.
Here is substantial proof of the real value of the tuber-
culosis program for the nation’s institutions of higher
learning. A total of 817 cases of tuberculosis were diag-
nosed during the year; this number includes only those
formally reported to the Committee. No doubt many
additional cases were discovered at institutions which,
for various reasons, have never filed a report. Of the
817 newly discovered cases, 755 were among students,
22 among food-handlers and 40 among faculty members,
administrative officers, and employees. Clinically active
cases among students numbered 263, and 246 students
withdrew from college to undergo treatment.
Adequate Methods of Investigation
In previous reports by this Committee, attention has
been called to the strikingly different results obtained by
those colleges with and these without a modern case-
finding program. Unfortunately, many of the older
ideas relating to tuberculosis seem tc be still firmly en-
trenched in the minds of many people. The belief is all
too prevalent that early tuberculosis gives rise to the
early symptoms of the disease. We receive reports of
various procedures used at certain institutions for the
follow-up of "suspects”. "Weighing at frequent inter-
vals,” "frequent temperature readings,” are among the
more common of these. The "suspects” are usually those
students who are rather markedly underweight. It
would seem, therefore, that the Committee is justified
in again emphasizing the fact that the tuberculin test
and the chest x-ray provide the only adequate means
for the early detection of tuberculosis in the vast ma-
jority of cases.
As shown in Table VI, the 311 colleges which rou-
tinely provided supervision for their students, using
modern and accepted methods, found 744 new student
cases of tuberculosis. On the basis of total enrollment
at these institutions, which does not indicate a true prev-
alence since the entire group was not examined, this is
a rate of 133.5 new cases per 100,000 students. This
is indeed in striking contrast to the 1 1 cases diagnosed
at 177 institutions where no case-finding program was
employed, the rate here being 7.53 per 100,000. In
other words, colleges with a definite control program
discovered new cases of pulmonary tuberculosis almost
eighteen times as frequently as did those colleges with no
program. Such evidence, provided year after year by
the Committee, should leave no doubt as to what con-
stitutes an adequate program of tuberculosis control for
a student group.
Is there any evidence which indicates a decrease in
the prevalence of tuberculosis among college students?
Although, as pointed out above, we cannot speak in
exact terms of prevalence of tuberculosis as applying to
the country’s student population, reports available to the
Committee over a period of years seem to indicate rather
definite improvement. In the 1940-41 annual report of
100
TABLE I
Questionnaire Survey of Tuberculosis Case-Finding in American
Colleges and Universities, 1941—42
Institutions
Contacted
Replies
Received
Programs
Reported
Maine
- - 7
4
2
New Hampshire
7
3
3
Vermont
6
2
1
1 husetts
41
22
1 4
Rhode Island
6
4
4
< on net ti< ut
1 2
12
8
79
47
32
Ni'w York
59
25
14
Pennsylvania
64
32
20
New Jersey .. .. ...
20
14
1 1
Delaware .
1
Maryland
1 7
8
4
District of Columbia .....
9
5
3
170
84
52
Virginia
18
9
7
North Carolina
22
10
7
South Carolina
1 5
8
3
Georgia
15
6
5
1 lorida
- - 7
5
4
77
38
26
Oklahoma
1 6
9
6
Arkansas
1 1
4
3
Tennessee
27
1 1
2
Mississippi
9
6
2
Alabama .
1 3
4
1
Louisiana
1 3
1
Texas
32
1 1
2
121
46
16
North Dakota
9
6
5
South Dakota
8
3
2
Minnesota
21
1 5
15
Wisconsin
27
21
16
Michigan ....
24
22
13
Ohio
47
34
22
West Virginia
14
12
9
Indiana
27
20
14
Illinois ....
43
27
1 5
Iowa
26
1 4
7
Nebraska
16
10
5
Kansas
2 1
1 1
7
Missouri
22
1 5
6
Kentucky
1 7
7
6
322
217
142
Montana
6
6
3
Idaho
3
3
1
Wyoming
1
1
1
Nevada
1
1
1
Utah
4
1
Colorado ..
9
8
7
Arizona
3
2
2
New Mexico .
4
3
2
31
25
17
Washington
16
9
7
Oregon
11
4
4
California
33
18
15
60
31
26
Grand Total
860
488
311
(56.7%)
TABLE II
States With Highest Percentage of Colleges Reporting Tuberculosis
Control
Programs, 1941—42
No. of
No.
Institutions
Reporting
Contacted
Programs
Per Cent
Group I ( States w ith less
than
10
accredited institutions ) :
Wyoming
1
1
100
Nevada
1
1
100
Colorado
9
7
77.7
Arizona
3
2
66.6
Florida .
7
4
57.0
North Dakota
9
5
55.5
Montana
6
3
50
New Mexico
4
2
50
Group II (States with more than
10 accredited institutions!
Minnesota
21
1 5
71.4
Connecticut
12
8
66.6
West Virginia
14
9
64.2
Wisconsin
27
16
59.2
The Journal-Lancet
New Jersey
20
1 1
55.0
Michigan
24
13
54.1
Indiana
27
TABLE III
14
51.8
Testing Technics
in 254 Colleges Reporting
Programs, 1941—42
Tuberculin
Testing
Testing Method:
Mantoux intradermal
1 82
Vollmer patch test . ._
54
4
3
1 1
Testing Material:
93
89
Testing Dosage:
63
35
37
37
2
Testing Routine:
New students and all negative reactors annually 6 3
29
47
Other testing routines
46
TABLE IV
Tuberculin Testing of College Students in 104 Colleges
(By States and Various Geographical Areas, 1941—42)
No.
Tested
No. Per Cent
Positive Positive
Maine, New Hampshire, Connecticut,
Vermont, Massachusetts, Rhode
Island 3,390
New York, Pennsylvania. New Jersey,
Maryland, Virginia, West Virginia 7,143
North Carolina, South Carolina,
Georgia, Tennessee, Alabama,
Mississippi, Florida 4.208
Ohio, Kentucky, Indiana, Illinois,
Michigan, Wisconsin, Missouri,
Minnesota, Iowa 37,665
North Dakota, South Dakota. Kansas,
Idaho, Montana, Utah, Wyoming,
Colorado, Nebraska 6,775
Arkansas, New Mexico, Louisiana,
Oklahoma, Arizona, Texas 5,122
Washington, Oregon, California 8,744
1,164 34.3
2,072 29.0
719 17.1
7,230 19.4
1,279 19.0
951 18.5
2,542 29.0
Total 73.047
15,957 21.8
TABLE V
X-Ray Procedures Reported by Various Institutions, 1941—42
254 Colleges Reporting Tuberculin Testing Program:
66
60
X-ray optional (acceptance not satisfactory).
.......... 10
19
Fluoroscope used routinely to supplement x-ray 38
Fluoroscope used exclusively (chest x-ray when indicated) 12
57 Colleges Reporting No Tuberculin Testing Program:
Chest x-ray for all students annually
Other routine x-ray programs
9
26
TABLE VI
New Cases of Pulmonary Tuberculosis Diagnosed Among
College Students, 1941—42
Institutions with SOME Organized Tuberculosis
Program:
259
485
744
No. of students who left college because of
tuberculosis 240
311
558.075
1 33.5
Institutions with NO Organized Tuberculosis Program:
7
„ 11
No. of students who left college because of
tuberculosis 6
177
Approximate total enrollment
... . 146,000
... 7.53
Total Cases of Pulmonary Tuberculosis Diagnosed 1941—42:
Student cases newly diagnosed 75 5
40
Total, new- cases
817
April, 1943
101
the Committee by Lyght,*’ 304 institutions with organized
tuberculosis programs reported 966 newly diagnosed
cases of tuberculosis. This represents a rate of 177.2
new cases per 100,000 students, based on an enrollment
of 545,000. For the five-year period 1936-41, this case-
finding rate stood at 190.5 per 100,000. This year the
corresponding rate is 133.5. This apparent reduction of
approximately 30 per cent may actually be on the con-
servative side. For during this period, reports from many
of our larger institutions conducting excellent case-find-
ing programs indicate an extension of these procedures
to include a higher percentage of their students. In
terms of total enrollment, therefore, it is evident that
more students are being examined each year, and the
technics employed have improved and become more
effective.
New Studies in Progress
During the present school year the Committee has
enlisted the cooperation of a group of eastern colleges
in a study of entering students. Students matriculating
at these institutions number approximately 10,000 an-
nually. It is planned to obtain accurate individual rec-
ords on all first-year students at these colleges over a
period of years. The information to be recorded for
each student includes age, home address, name and loca-
tion of secondary school attended and whether a private,
public, or parochial school; tuberculin test technic and
results; and chest x-ray findings. If such a large group
is studied in this manner over a considerable period of
time, much valuable information will be obtained. We
shall be permitted to observe differences in the prevalence
of tuberculous infection among students from various
states and various home communities, and accurate com-
parisons may be made from year to year. It is hoped
that this survey may continue without interruption for
a period of ten years or longer. If this is possible, the
available data should provide a rather sensitive index of
any changes in the prevalence of tuberculous infection
and disease among students in this area. The Committee
wishes to express its appreciation to the following uni-
versities and colleges, and especially to their health serv-
ice physicians, who have consented to participate in this
new project. We realize the effort and expense which is
involved.
Amherst College
Bennington College
Bryn Mawr College
Bucknell University
Dartmouth College
Goucher College
Haverford College
New Hampshire,
University of
North Carolina, Woman’s
College of
Pennsylvania State College
Pennsylvania, University of
Princeton University
Rutgers University
Smith College
Syracuse University
Virginia, University of
Wake Forest College
Wesleyan University
This report would be incomplete without mention of
the immeasurable educational value of the tuberculosis
programs now being carried on so effectively in many
colleges and universities. And we in the colleges are
fully aware of the same fine work being done in an ever-
increasing number of secondary schools. This year over
half a million young men and women are enrolled in
colleges where modern procedures are employed routinely
for the early detection of tuberculosis. During the past
ten years millions of students have been brought into
intimate contact with these programs. Fortunately,
through the student, the parents are being made aware
of the protection thus being provided for their sons and
daughters. In this way we are building up a formidable
army of intelligent men and women, many of whom will
be the future leaders in the campaign against tuber-
culosis.
Summary
Three hundred and eleven colleges and universities,
with a total enrollment of 558,075 students, report tuber-
culosis case-finding programs during the academic year
1941-42.
Seven hundred and forty-four new cases of tubercu-
losis were diagnosed among the students at these insti-
tutions, a rate of 133.5 new cases per 100,000 students.
At 177 colleges which provided no case-finding pro-
grams, 11 new cases of tuberculosis were diagnosed
among 146,000 students, a rate of 7.5 per 100,000.
The incidence of tuberculous infection among college
students has shown a gradual decline during the past
ten years. Among 73,000 undergraduate students tuber-
culin tested in all sections of the United States in
1941-42, there were 21.8 per cent positive reactors.
Reports available to the Committee during the past
six years indicate a decline of approximately 30 per
cent in the prevalence of tuberculosis among college
students during this period.
The Tuberculosis Committee:
Paul B. Comely, M.D., Howard University, Wash-
ington, D. C.
Harold D. Cramer, M.D., University of Idaho, Mos-
cow, Idaho.
Charles E. Lyght, M.D., National Tuberculosis Asso-
ciation, New York, New York.
Orville Rogers, M.D., Yale University, New Haven,
Connecticut.
H. D. Lees, M.D., Chairman, University of Penn-
sylvania, Philadelphia, Pennsylvania.
Advisory Members :
J. Burns Amberson, M.D., Bellevue Hospital, New
York, New York.
H. D. Kleinschmidt, M.D., American Red Cross, New
York, New York.
Esmond R. Long, M.D., The Henry Phipps Institute,
Philadelphia, Pennsylvania.
J. A. Myers, M.D., University of Minnesota, Minne-
apolis, Minnesota.
Henry Sweany, M.D., Municipal Sanatorium, Chi-
cago, Illinois.
References
1. Health Bulletin for Teachers, Metropolitan Life Insurance
Company, voi. 3, Sept., 1941-June, 1942.
2. Ferguson, Lee H.: A five-year review of tuberculosis in col
lege students, Am. Rev, Tuberc. 36:478 (Oct.) 1937.
3. Lyght, Charles Everard : Tuberculosis in college students.
Am. Rev. Tuberc. 46:227 (Sept.) 1942.
4. Lees, H. D., and Myers, J. A.: Tuberculous infection
among adults. Am. Rev. Tuberc., vol. 21 (April) 1930.
5. Long, Esmond R.: Tuberculosis in college students, with
special reference to tuberculin testing, Journal-Lancet 55:201
(April 1 ) 1935.
6. Lyght, Charles Everard: Eleventh Annual Report of the Tu-
berculosis Committee, American Student Health Association, Jour
nal-Lancet 62:125 (April) 1942.
102
The Journal-Lancet
The Tuberculin Reaction in Medical and Nursing
Students
A Five-Year Study
Lucius N. Todd, M.D.f
Augusta, Georgia
IN the fall of 1937 we began yearly routine tubercu-
lin testing of all students entering the University of
Georgia School of Medicine and the University Hos-
pital School of Nursing. Each new class is tested soon
after enrollment; the negative reactors are retested at the
beginning of the succeeding school year and at the end
of their period of training. All positive reactors are either
fluoroscoped or x-rayed at least once each year.
The Mantoux intracutaneous test is employed, using a
standard old tuberculin (Lilly O. T.) in strengths of
0.10 mg. and 1.0 mg. All students negative to 0.10 mg.
O. T. receive the 1.0 mg. test.
In the accompanying tables the percentages of positive
reactions are given in round figures; the positive reactors
for each year represent the total reactors from the pre-
ceding year plus the new ones; e. g., if in a given class
there are 20 positive reactors the freshman year and 25
the sophomore year, the number of conversions from
negative to positive during the year would be 5.
Medical Students
Table I gives the result of our study with the medical
students. A total of 316 freshmen have been tested.
Eighty of these, comprising two classes, have been fol-
lowed through from entrance to graduation. Forty of
this group, or 50 per cent, were positive on admission
and approximately 56, f or 70.5 per cent, at graduation.
tSee footnote to Table I.
In addition, the succeeding classes are tabulated up to
the present time.
An interesting fact is observed in studying the table:
namely, the largest number of conversions from negative
to positive take place in the preclinical years. Since only
the senior students work in the tuberculosis wards and
in the chest clinic, other factors must be considered, as
has been suggested by previous workers.'1 Among these
is the possible role of the autopsy room and the labora-
tory.
For the past seven years, owing to limited facilities,
only residents of Georgia have been admitted to the med-
ical school. The average age on entrance has been
twenty to twenty-one years. Students live in fraternity
and boarding houses since there are no dormitories. No
student included in this study has developed reinfection
tuberculosis while in school. A member of the class of
1941 who entered school with a positive reaction was
recently diagnosed by Army officials as having minimal
disease. Two x-rays, one on graduation and one in St.
Louis, where he was serving his internship, were both
*Read before the Southern Tuberculosis Conference. Memphis,
Tennessee, October 5-7, 1942.
tOf the Department of Tuberculosis. University of Georgia
School of Medicine. Augusta.
interpreted as negative. He is now a patient in the state
sanatorium.
Table II summarizes the findings at several other
schools and compares them with ours.
Student Nurses
The University Hospital is a 325-bed general hos-
pital consisting of an administration building, a wing
for white patients, a wing for colored patients, an isola-
tion wing, and a new tuberculosis unit of 50 beds. Both
private and charity patients are admitted, the wards be-
ing used for clinical instruction by the medical school.
Prior to February, 1942, tuberculous patients were ad-
mitted to the isolation wards. These patients were
attended by student nurses of all classes, particularly the
seniors.
Student nurses come chiefly from Georgia, South
Carolina, and Florida and average eighteen years of age
on admission. The white nurses are about evenly divided
in residence between urban and rural communities, where-
as the colored nurses practically all come from urban
homes. They attend the same classes, eat the same food,
and have similar living quarters. The chief difference in
their opportunity for exposure is the fact that the type
of case the colored nurses come in contact with is ad-
vanced and acute, as distinguished from the less ad-
vanced, less acute white patient nursed by the white girls.
Table III gives in detail our findings with nurses. A
unique feature is the inclusion of colored trainees. In
our study of available literature we have been unable to
find a similar recording.
Three classes have been checked from entrance to
graduation. Of the 90 white girls in this group, 30 per
cent were positive on admission and 81 per cent at grad-
uation. Of 49 colored girls, 49 per cent were positive
on admission and 97 per cent on graduation. Two of
the colored classes were 100 per cent positive before their
senior year.
Three white members of the 1940 class have developed
reinfection tuberculosis, two while in training and one
within the past two months. Of the two girls reinfected
during training, one entered with a positive test. She
did well under collapse therapy and was able to re-enter
training after a year and recently graduated. The other
student entered with a negative test, which became posi-
tive only during her senior year and was demonstrated
about a month before graduation. An x-ray revealed
moderately advanced disease. Gfllapse therapy was in-
stituted but convalescence was slow. She returned this
fall to complete the month needed for graduation.
The third reinfected nurse also had a negative test
April, 1943
103
until a month before graduation. X-rays at that time
showed no evidence of parenchymal disease. Since grad-
uation she has been employed as a supervisor in the hos-
pital. An x-ray taken in August, 1942, disclosed bilateral
upper lung pathology.
Two colored students also of the class of 1940 de-
veloped reinfection disease during training. Both were
negative on admission and developed allergy during their
first year. One of them developed a moderately advanced
disease which responded well to collapse therapy. The
other girl had a pleurisy with effusion which cleared on
bed rest. She was out of training for a year, then re-
turned and completed her course. Since graduation she
has worked in the hospital and a recent check-up shows
her to be in excellent condition.
A colored member of the class of 1943 who entered
with a positive reaction also developed pleurisy with effu-
sion in the winter of 1941. Several thoracenteses were
necessary to control the fluid. No evidence of parenchy-
mal disease was seen. She has returned to her home and
abandoned training.
During the preparation of this paper we have seen an
x-ray of another colored girl of the class of 1943, which
shows definite parenchymal disease in the left upper lobe.
Her tuberculin on admission to training was negative
and was still so last fall. Recently, however, it was posi-
tive and her chest was x-rayed. She is now receiving
pneumothorax.
Table IV compares figures from some other training
schools with ours.
W.P.A. Workers
We have not had the opportunity to study the tuber-
culin reaction in other white collar groups, but recently
we tested 1,000 W.P.A. workers. Their ages ran from
twenty-five to forty-five years and both urban and rural
residents were included. The following positive results
were obtained: white men 64.5 per cent, white women
71 per cent, colored men 80.5 per cent, and colored
women 81 per cent. When it is remembered that these
individuals are from the lower economic strata, where
tuberculosis is common, the comparison of the figures
with those of the groups we are reporting is arresting.
Preventive Measures
All medical cases admitted to the wards of the Uni-
versity Hospital have an x-ray of the chest on admis-
sion. This tends to prevent unsuspected cases of open
tuberculosis from being administered to by students,
nurses, and hospital personnel. We believe this to be a
most progressive policy and hope to see it extended to
include every patient admitted, not only medical, but
surgical, obstetrical, and all others, both paying and
indigent. All patients with respiratory symptoms are sup-
plied with disposable tissues and an effort is made to
have them cover nose and mouth when coughing or
sneezing. Food-handlers are routinely checked by test
and fluoroscope.
Nurses are required to wear gowns and masks when
nursing tuberculous cases. In addition they are urged
to wash their hands frequently. Medical students wear
TABLE I
Positive Reactors Among Medical Students
Fresh-
men
Sopho-
mores
Seniors
Class
No.
Juniors
Beginning
of Year
End of
Year
1941
37
16 (43%)
17 (46%)
21 (57%)
22 (60%)
23 (62%)
1942
43
24 (56%)
26 (60%)
32 (74%)
32 (74%)
33* (79%)
Total
80
40 (50%)
43 (53%)
53 (65%)
54 (67%)
56(70.5%)
(Mar.) 1943
46
22 (49%)
28 (60%)
29 (63%)
35 (76%)
(Dec.) 1943
46
23 (50%)
26 (56%)
32 (70%)
(Sept.) 1944
68
30 (44%)
46 (68%)
(June) 1945
76
50 (66%)
Total Tested
Total Positive
316
165 (52%)
240
142 (59%)
172
114 (66%)
126
89 (70%)
80
56(70.5%)
*Four negative reactors failed to take the final test.
TABLE II
Comparison of Table I with Oiher Studies
Hahn4
Myers8
Stiehm10
Keller*
Class
(Cornell)
(Minn.)
( Wis.)
(Vanderbilt)
Freshman
82%
36%
45%
60%
Senior
92%
68%
55%
69.5%
Class
Baker3
(La. State)
Soper9
(Yale)
Blackford"
(Emory)
U. of Ga.
Freshman
68%
77%
48%
52%
Senior
98%
94%
70.5%
TABLE III
Positive Reactors Among Nursing Students
Seniors
Proba-
tioners
Class
Race
No.
Juniors
Beginning
End of
of Year
Year
1940
White
21
5
(23%)
11
(52%)
12 (57%)
17 (81%)
Col.
24
7
(30%)
20
83' ,
21 (90%)
22 (91%)
1941
White
35
9
(25%)
22
(62%)
28 (80%)
30 (86%)
Col.
10
5
(50%)
8
(80%)
10 (100%)
10 (100%)
1942
White
34
14
(41%)
19
(56%)
23 (70%)
26 (76%)
Col.
15
10
(67%)
15 (100%)
15 (100%)
15 (100%)
Total
White
90
28'
(30%)
52
(57%)
63 (69%)
73 (81%)
Col.
49
22.
(49%)
43
(88%)
46 (96%)
47 (97%)
1943
White
Col.
35
16
21 (60%)
10 (62%)
27 (77%)
13 (81%)
1944
White
40
18 (45%)
Col.
22
13 (59%)
Total Tested, White
165
125
90
90
Total Tested, Colored
87
65
49
49
Total Positive, White
67 (39%)
79 (62%)
63 (69%)
73 (81%)
Total
Colored
45 (54%)
56 (86%)
46 (96%)
47 (97%)
TABLE IV
Comparison of Table III with Other Studies
Class
Phila.
General5
New
York4
Boston
City2
Vander-
bilt6
U. of Ga.
Probationers
57%
78%
57%
54%
White 39%
Colored 54%
Seniors
100%
91.5%
90%
58%
White 81%
Colored 97%
104
The Journal-Lancet
masks and are also urged to wasli their hands. Medical
students have a series of lectures on tuberculosis in the
third trimester of the junior year and the nurses during
their second year of training. The importance of self-
protection is stressed to both these groups.
Discussion
We are convinced that annual checking of students
and nurses, particularly nurses, is entirely inadequate to
properly safeguard health. Tuberculin tests should be
made every three or four months and all positive reactors
routinely examined by x-ray at the same intervals.
In spite of the fact that preventive measures are in
force, it is obvious from a study of the figures pre-
sented that too many students and nurses are infected
with tubercle bacilli during their period of training. We
have also observed that a large number of these recent
conversions have very strongly positive reactions. This
phenomenon has been previously commented upon.1 The
most severe reaction we have ever seen occurred in a
Jewish girl, a member of the class of 1941. Her test was
negative on admission but the next fall, in response to
0.10 mg. O. T., her arm swelled to about twice its nor-
mal size. At the site of inoculation there was a bleb
about the size of a fifty-cent piece accompanied by
marked edema. Two axillary glands became quite palpa-
ble and tender and she had a temperature of 104° F.
The symptoms subsided without untoward effect, but
she was so unnerved by her experience she gave up
training.
What further steps should be taken to protect these
girls? They take their training during the years when
tuberculosis is the chief cause of death. Should only
girls with positive tuberculin reactions be admitted to
training? We have the impression, though so far it is
only an impression, that the positive reactors are in a
little better position to cope with the infection than those
whose reaction has recently been converted from nega-
tive to positive. We are doubtful, however, if a sufficient
number of positive reactors could be recruited to fill the
rolls. Then, too, this would place an insurmountable
obstacle in the path of those negative reactors wishing to
take up training.
Since February, 1942, the tuberculous patients in our
hospital have been cared for in a separate building by
practical nurses under graduate supervision. It will be
extremely interesting to see what effect this move has
upon the infection rate of succeeding classes of nurses.
Summary
In making this five-year study of the tuberculin reac-
tion in medical students and nurses, including figures on
colored nurses, two classes of medical students and three
classes of nurses have been followed throughout their
period of training.
Fifty-two per cent of the medical students were posi-
tive on admission and 70.5 per cent on graduation; 39
per cent of the white nurses were positive on admission
and 81 per cent on graduation; 54 per cent of the col-
ored nurses were positive on admission and 97 per cent
on graduation.
In addition, a comparison with local W.P.A. infec-
tion rates is given. Preventive measures practiced in the
University Hospital are outlined and further measures
for more effective control are discussed.
References
1. Amberson, J. B., Jr., and Riggins, H. M.: Ann. Int. Med.
10:1 56, 1936.
2. Badger, T. L.. and Spink, W. W.: Am. J. Nursing 26:110,
1936.
3. Baker, Alice E., and Holoubek, J.: Am. Rev. Tuberc.
43:288, 1941.
4. Hahn, R. G.. Muschenheijn. C., and Freund. J.: Am. Rev.
Tuberc. 43:600, 1941.
5. Israel, H. L., Hetherington, H. W.. and Ord, J. G.:
J.A.M.A 1 17:843, 1941.
6. Keller, A. E., and Kampeier, R. H.: Am. Rev. Tuberc.
39:657, 1939.
7. Quoted by Long, E. R., and Seibert, F. B.: J.A.M.A.
108:21. 1761. 1937
8. Myers, J. A.. Deihl, H. S., Boynton, Ruth E., Ch’iu, P. T.
Y., Streukens, T. L.. and Trach, B. : Ann. Int. Med. 14:1575, 1941.
9. Soper, W. B., and Wilson, J. L.: Am. Rev. Tuberc. 26:548.
1932.
10. Stiehm, R. H.: Am. Rev. Tuberc. 32:171. 1 935.
The Examination of Rejectees"
H. R. Edwards, M.D., F.A.C.P.t
New York, New York
THE Department of Health of New York City
has provided a complete chest examination for
approximately 94 per cent of the men rejected
for pulmonary defects at local Army physical examina-
tion centers since the first draft call on November 25,
1940. The men examined are those who have been re-
jected in whole or in part on the basis of pathology as
seen in the chest x-rays at the Army physical examina-
tion stations. From November 25, 1940, to October,
1942, the Army stations examined approximately 500,000
*Read at the Metropolitan Sanatorium Conference, December 9,
1942, New York City.
tDirector, Bureau of Tuberculosis, New York City Department
of Health.
individuals, or about five-sixths the number (600,000)
examined by us in mass surveys between 1934 and 1942.
There is every indication to show that within the coming
two years an equal or greater number will be examined
by the Army; consequently the flow of rejectees to us
will not diminish.
The potentialities of this service were fully realized by
the Department of Health well before the actual draft-
ing of men started in the fall of 1940. The Army, prior
to the actual drafting of men, was committed to the
principle of a chest x-ray of each man before acceptance
into the armed services. However, the Army was not
able to provide the x-ray equipment, nor find men to
April, 194?
105
interpret the films at that time. Accordingly, the De-
partment of Health offered to set up and operate this
service for the Army until such time as the military
auhorities could arrange to assume full responsibility.
This offer was promptly accepted by the Surgeon of the
Second Corps Area. It should be stated at the outset
that the effective and efficient program that has been
developed here in New York City is in large measure
a tribute to the enthusiastic assistance and cooperation
of Second Service Command Surgeon, Col. C. M. Wal-
son, and his staff, and as well the Medical Director of
Selective Service, Dr. Samuel J. Kopetsky, and the chair-
men of the local draft boards.
The Department of Health provided the entire service
for the stations in New York City proper without cost
to the Army from November 25, 1940, until January 1,
1941; at this time the Army assumed the cost of the
x-ray service, and on January 15, 1941, assigned clinicians
to interpret the films. The Department, however, has
continued from the outset to provide an examination for
the rejectee suspected of having tuberculosis.
There has been the closest cooperation and understand-
ing between the clinicians working in the Army station
and those in our clinic. Primarily, this was due to the
fact that most of the physicians first assigned by the
Army to do this work at stations in New York City were
the same men we had assigned during the initial phase
of the service, and who had helped to establish the pro-
cedures that were adopted. Some of these men were in
the Reserve Corps and were placed on active duty by
the Army, others served as civilian interpreters on a per
diem arrangement. Usually, there have been one or more
men serving both at the Army induction board and in
our Central Chest Clinic. Also, several men previously
connected with our services, and therefore conversant
with our routine, have served as civilian interpreters for
the Army. Our bureau has also assisted the Army in
selecting many of its civilian interpreters. Thus there
has been an unusually close understanding between the
physicians of the Army induction boards and our clinic
as to methods, diagnostic standards, and purposes of the
two services.
During the period when the entire service was pro-
vided by our department, financial assistance was secured
as follows: The W.P.A. project in case-finding being di-
rected by the Department of Health was diverted to this
purpose. The Queensboro Tuberculosis and Health Asso-
ciation paid for the x-ray service for the Borough of
Queens, and provided some funds to pay for the addi-
tional time worked by some clinicians beyond our bud-
getary allowances. The Bronx Committee of the New
York Tuberculosis and Health Association also gave
assistance in physicians’ compensation beyond our bud-
getary limits.
Examination Methods at Induction Centers
In order to include a chest x-ray as part of a complete
examination in the Army induction station, the report
on a film would have to be made within a few moments
of its exposure. As each induction station was sched-
uled to handle from 300 to 500 men per day, it became
obvious that entirely new procedures would have to be
devised. The roll-paper methods used in our routine sur-
veys were not possible in this work. The equipment was,
however, elaborated to permit a continuation of exposures
at the rate of 120 per hour, using 14"x 17" paper films,
which could be developed and made available for wet
reading in an average of twenty minutes. Later there
was employed at the induction station of Governors
Island a battery of five 4"x 10" fluorographic x-ray units,
each capable of covering 50 to 55 individuals per hour,
or 100 to 110 exposure per hour as each individual has
stereo pair. Each unit was capable of taking 14"x 17"
celluloid films when desired.
It was clearly obvious that if men had to be com-
pletely examined and cleared by the Army within a mat-
ter of a few hours, it would be impossible in all instances
to render a final and sound opinion on the pathology
shown in their chest films. The majority of lesions would
be well defined and no further study would be needed
from the standpoint of the Army. A goodly number,
however, would be of an equivocal nature demanding
further study to determine etiology, activity, and accepta-
bility. As the Department of Health was anxious to
realize the maximum benefits from this service as a case-
finding method, it was obvious that some plan should be
devised to have all men with borderline or disqualifying
x-ray pathology referred to us for further study. Thus,
this mass survey could be made to render a real service
to the Army and the community at the same time.
Lesions Referred to Chest Clinic
Thus, in the initial plans worked out with the Corps
Area Surgeon and the Selective Service, it was proposed
that men showing the foregoing types of x-ray lesions
at time of examination should be referred to a Depart-
ment of Health clinic for further study. The Central
Chest Clinic of the Department, located at 125 Worth
Street, and convenient to all transportation lines within
the city by direct route or transfer, was designated as
the point of examination. These plans also provided that
reports from our clinic on each case examined be sent to
the local draft board and the induction station. These
reports would indicate whether the lesion noted at the
Army examining station had been confirmed, thus defi-
nitely rejecting the man for future consideration, unless
the maximum acceptable standards defined in M.R. 1-9
should be changed later. If the diagnosis was not con-
firmed, it would permit the reclassification of the man
by his draft board as acceptable under the provisions
of M.R. 1-9.
Once the Army rejected a man, it had no further
supervision over him. He was, however, still under the
control of his local draft board and could be called again
for reclassification at their discretion. A simple referral
slip was provided by the Army. This form gave the
rejectee’s name, address, local draft board number, and
his x-ray diagnosis by code. It also indicated that he was
to report within two to four days to our clinic. The
Army further strengthened the effect of this gesture by
seeing to it that this slip was given to the rejected man
upon conclusion of his examination.
106
T he Journal-Lancet
It is quite likely that the men receiving these referral
slips accepted them as an Army order to appear, as
approximately 75 per cent reported promptly to the
clinic, although the fact that previously unsuspected pul-
monary pathology was found must have been an addi-
tional urge to find out what it was all about.
Of the 25 per cent not reporting within two weeks,
the clinic sent a reminder by postal card, which was suf-
ficient to bring in the majority. When this failed, a
report was sent to the local draft board, which wrote the
man a letter requesting him to report to our clinic for
examination. Through these three steps we have been
able to secure examinations of about 94 per cent of all
New York City men rejected in whole or in part on the
basis of x-ray pathology as noted at the Army center.
We receive daily from the Army a list of all New York
City rejectees in which chest x-ray pathology is involved
and are thus able to check off the men as they appear.
All films have not been sent to the Department of
Health because M.R. 1—9 requires the distribution of
such films to the state directors of Selective Service.
Accordingly, in obvious cases, no duplicate film was
available to send to the Department of Health, but in
borderline cases, a 14”x 17” film was always taken in an
effort to establish the diagnosis and acceptability; in such
cases, the large film was forwarded to the Department
of Health.
Procedure at the Chest Clinic
When the man is admitted to our clinic, he is given
a complete chest examination, including history, phys-
ical, fluoroscopy, chest x-ray, sputum by concentrate
method, and any other examination indicated and pos-
sible on an ambulatory basis necessary to arrive at a
final diagnosis. At the time of this examination the man
is instructed to return in seven days for final advice. At
this later date he is interviewed by a physician who ex-
plains his condition and its significance. A conference
nurse also amplifies this advice and endeavors to get him
started on the road to proper supervision. Thus, by the
time the individual leaves the Central Chest Clinic, we
have endeavored to educate him as to the importance of
his x-ray findings and what he should do about them.
At the time of admission to the clinic, a search is made in
a master roster of cases gathered in previous surveys and
kept at the Central Chest Clinic. Not infrequently we find
a previous record and series of x-rays that is of the great-
est assistance in evaluating the man’s condition at this
time. If a definite lesion is noted in the Army film, a
search is made in the master case roster of the Depart-
ment, which contains over 60,000 names of previously
registered cases. About 20,000 of these cases are under
some form of active supervision, and the remainder are
known to be arrested. This check also reveals previously
known cases and provides valuable records for compari-
son with current films.
In a small percentage of cases we find open bacillary
lesions in need of prompt hospitalization, and in many
such instances the cases go directly from the clinic to
the hospital as emergency patients. The majority of
those showing reinfection forms of tuberculosis, how-
ever, are not urgently in need of care. In about two-
thirds of this group the lesions have all the characteris-
tics of arrest, while the remaining one-third are classified
as clinically significant and in need of further super-
vision. Our experience indicates that we are perhaps
overly cautious regarding this latter group, as subsequent
supervision has revealed about 50 per cent to be stable
so far as x-ray appearance is concerned. We know no
way of making a closer selection of these lesions, as they
are usually completely negative to physical examination,
constitutional symptoms, or known exposure to the
disease.
It is the purpose of the examinations in the Central
Chest Clinic to arrive at a definite diagnosis. Any sub-
sequent supervision becomes the problem of the man’s
physician or the district clinic. If the man indicates he
has a physician, a report is made to him, providing he
requests it. Our records and x-rays are not loaned to
the physician but he may review them at the clinic. Fur-
ther supervision of the case is entrusted to the physician
if he is willing to assume the responsibility under our
Sanitary Code, just as in any other case.
If the man has no physician, he is referred to the
clinic serving the district in which he lives, and all rec-
ords and x-rays are transferred to that clinic. Regard-
less of whether the need is for prompt supervision or a
periodic examination a month or so hence, the man is
urged to call at the clinic within a few days so that he
may become acquainted with the physician and nurse and
they with him. The district clinic then places the case
under the indicated supervision and, if there are con-
tacts to be examined, the routine procedures are fol-
lowed, just as if the case had originally been found at the
clinic. The majority of men examined as rejectees later
become district clinic cases. It is obvious, therefore, that
all men rejected and examined by us have been offered
adequate facilities for supervision of their condition, as
well as their contacts. The majority cooperate readily;
some, as would be expected, become delinquent.
Reports to the Army
As previously indicated, reports of our iinal classifi-
cation are sent to the induction station and the local draft
board through the Office of the Medical Director of Se-
lective Service. These reports may indicate a confirmation
of the Army findings, or they may indicate that a lesion
apparent at the time of the Army examination has since
cleared, as in the case of a resolved pneumonia; or the
lesion found originally may now be considered as accept-
able under the limits prescribed in M.R. 1-9. The num-
ber of cases falling in this latter category average about
8 per cent. Such reclassifications are inevitable because
of the speed with which men must be cleared by the
Army, and the fact that a single x-ray frequently is in-
sufficient evidence to arrive at a final conclusion. It has
been our policy never to recommend a man with a lesion
as eligible for Army service unless we feel reasonably
sure of its etiology or stability. It is our opinion that
many of the lesions which are of a disputed character
or appear to exceed the limits prescribed by M.R. 1-9,
and therefore cause the individual to be rejected on-~the
April, 1943
107
basis of a single examination, will later be found to be
stable and acceptable without undue risk.
When our examination of a rejectee indicates that a
change should be made in the classification based upon
the original examination made by the Army, we send our
report to the local hoard and the Army examination sta-
tion, and also provide for our records and series of x-rays
to be sent, if desired, so that these authorities may re-
view our evidence. They make a notation of these find-
ings on their records so that when the man returns for
examination the records will carry the complete medical
history. In the majority of instances there is agreement
between the two staffs on the reclassification, though
occasionally the Army decides that its best interests will
he served if the man is permanently rejected. In any
event, it is the responsibility of the Army to determine
eligibility, and our service merely endeavors to assist in
accumulating as much medical information as is pos-
sible on a given problem case.
Assistance to Rejectees
In the majority of instances, the discovery of a lesion
by x-ray is the first evidence the man has that his chest
is not normal. It is a matter of considerable concern
to him and not infrequently mitigates against his re-
turning to his old job. Fortunately, most of the lesions
found are of minimal extent and arrested, and while they
may be just cause for rejection for military service, they
should have no effect on ordinary activities. Thus men
with healed primaries, or with well-healed reinfection
forms of the disease, are promptly discharged from fur-
ther supervision and requested to report back only in the
event of intercurrent respiratory symptoms. The prob-
lem created in relation to their jobs is a serious one, and
the action of many employers in refusing to re-employ
the men is unwarranted. In many instances, we have
been able to assist the men in re-employment, but there
is need for more health education on this subject. This
could well be a special project for the tuberculosis and
health associations, whose chief function is the dissem-
ination of sound health education to the public.
The Bureau of Tuberculosis has established another
vitally important service in cooperation with the Corps
Area Surgeon. Not infrequently an individual formerly
found at our clinic is inducted into the service without
any apparent knowledge of his previous condition.
Usually these men have not cleared through the local
physical examination centers as selectees; they may have
enlisted locally before all such men were x-rayed, on the
basis of a physical examination; others have enlisted in
other centers, and either purposely or through neglect
have failed to divulge their past medical records at the
time of examination. On the other hand, a few men
with previous bacillary lesions now have only a minimal
productive process, the volume of which is within the
limits prescribed by M.R. 1-9.
Whenever such a case comes to our attention, usually
through the district nurses, a complete report is submit-
ted to the Corps Area Surgeon. He then endeavors to
locate the man in the service and secure a current re-
port from the local medical authority. On request from
the local authority we loan our x-rays or other data to
assist in the appraisal of the case. As a result, some of
these men are mustered out of the service; others who
appear to be good risks are retained. In any event, the
Army’s record of the man carries the full tuberculosis
record so far as the known facts are concerned.
Increase in Number of Examinations
The volume of work done by the Department of
Health in the first nine months of 1942 increased over
100% as compared with the entire year of 1941. It is
to be pointed out that the cases rejected because of pul-
monary pathology include all forms of pulmonary and
pleural changes as well as lesions obviously of a tuber-
culous character. This large increase is due to a great
extent to the fact that the procedure of induction ex-
amination was changed subsequent to January 1, 1942.
Prior to that date, each selective service registrant under-
went a careful, complete examination by his local board,
and a great many cases of chest pathology were thus
identified and rejected without being referred to the
Army. Since that time, the examination given by the
local board has been cursory and is responsible for the
fact that the percentage of cases rejected by the Army
examining stations has doubled. Thus, the number of
pulmonary rejectees referred to the Department of
Health in the first nine months of 1942 was about four
times as great as the number referred in all of 1941.
Figures on the exact ratio of pulmonary tuberculosis and
other forms of pulmonary pathology are not available
at this time.
Other causes for the increase in the number of rejec-
tions for pulmonary causes in 1942 may be stated as fol-
lows: The registrants examined in 1942 were of an older
average age group — in which we expect to find more
tuberculosis and other pulmonary pathology. Also with
the increase in the number of individuals being exam-
ined, physicians were assigned to induction examining
teams without being sufficiently familiar with the inter-
pretation of 4”x 10” stereoscopic films; they therefore
leaned over backwards in disqualifying registrants who
presented defects of little or no significance. This con-
dition is becoming less of a problem as the roentgeno-
logic interpreters gain experience with the newer methods.
Contrary to common belief, there is nothing to indicate
that the amount of pulmonary tuberculosis disclosed by
examination of selective service registrants in the City of
New York indicates an increased prevalence of tubercu-
losis in the community, as the indction station is now
examining many cases previously known to the Depart-
ment of Health.
Now that the number of men needed for the Army has
been decided upon, it is obvious that in New York City
we may expect no reduction in the numbers examined by
the Army for some months to come. However, as many
of the selectees to be examined will be in the 18 to 20-
year-old group, it is to be expected that the percentage
of rejected men will be lower.
The Army has recently transferred its induction sta-
tion from Governors Island to Grand Central Palace in
New York City. This station provides facilities for con-
Thk Journal-Lancet
108
ducting physical examinations of Selective Service regis-
trants by ten individual teams, each geared to accom-
plish 200 physical examinations in an eight-hour day.
The x-ray units now in use produce 4”x 10” stereoscopic
celluloid film, with additional facilities for producing
14”x 17” films when indicated, of the chest or for other
diagnostic purposes.
Thus far the Department of Health has not co-
operated with the Navy in such examinations, as its
recruits are usually x-rayed at the naval stations. We
have, however, provided the same reports as to the Army
on men known to have previous histories of tuberculosis.
We have also examined many men applying for com-
missions in the Army who have been rejected on the
basis of chest pathology. In some instances, we have
been able to get together additional information for the
consideration of the Army.
Summary
The Department of Health in New York City, from
the outset of the draft in October, 1940, has worked in
close relationship with the Army and Selective Service in
providing through our facilities a complete chest exam-
ination service for rejectees.
This program has been of value to the Army and
Selective Service in that more complete examination,
usually requiring a protracted period, has recertified
about 8 per cent of the rejectees as satisfactory for mili-
tary service under M.R. 1-9. From the viewpoint of the
Department of Health, it has provided a mass survey of
numbers far beyond our ability to provide, and therefore
has been a potent instrument in getting cases of tubercu-
losis under proper supervision.
The generous and understanding cooperation of the
Corps Area Surgeon and the Medical Director of Selec-
tive Service has made it possible to set up and operate a
far-reaching service with the maximum efficiency and at
a minimum of expense.
As all rejectees are referred directly from the Army
physical examination center to our chest clinic, it has
been possible to complete their examinations within a
few weeks after the lesion is found. There has been ex-
cellent cooperation on the part of the rejectees, for 75
per cent report on the basis of a recommendation by the
Army. Of the remaining number, a reminder either
from us or their local draft board has made it possible
to examine approximately 94 per cent of those rejected.
Tuberculosis on a Typical College Campus
Charles Everard Lyght, M.D.*
Northfield, Minnesota
AT Carleton College, Northfield, Minnesota, a tuber-
culosis case-finding program has been in progress
L for several years. Since the autumn of 1936,
when the writer assumed charge, this has included the
annual tuberculin testing of every student and of all
food-handlers and other employees coming into intimate
contact with students. Individuals reacting to the Man-
toux test have been x-rayed at once and annually or
oftener thereafter while on the campus, with appropriate
physical examination, clinical and laboratory studies pro-
vided for those whose findings indicated need for de-
tailed follow-up.
The eleven annual reports of the Tuberculosis Com-
mittee of the American Student Health Association have
traced the phenomenal development of tuberculosis con-
trol in our colleges and universities. The results have
emphasized the success possible in the search for pre-
clinical tuberculosis whenever and wherever modern
methods are employed.
In a recently published five-year survey of the accom-
plishments in the college field, it was brought out that
seven times as many cases were discovered in those
schools with early diagnosis programs as in colleges where
diagnoses are based on the final development of definite
symptoms.
^Professor of Health and Physical Education and Director of the
College Health Service, Carleton College, Northfield. Minnesota.
(Now Director of Health Education, the National Tuberculosis
Association, New York.)
It is the purpose of this communication to discuss the
experience on a campus where the recommendations of
the Tuberculosis Committee have been followed for
seven consecutive school years, and to report on the en-
couraging results obtained. Carleton being a typical mid-
western liberal arts college, our data represent a reliable
cross-section of young American adults of college age
and the tuberculous infection among them.
Examination Routine
The enrollment at Carleton has ranged from 792 to
898 during the seven years of our program, averaging
853 per term, and divided almost evenly between the
sexes. Each student is examined completely upon en-
trance, and in addition receives a careful check-up each
year through the Health Service. Early in October the
whole student body and the employees mentioned above
are tuberculin-tested. We use mostly the purified pro-
tein derivative of tuberculin, administering an initial dose
of 0.00002 mg. If, after 48 to 72 hours, this gives a
negative reading, the second dose of 0.005 mg. is given,
to be read after a similar interval. A smaller number of
students were tested with Saranac Lake old tuberculin,
employing a first-strength dose of 0.1 mg. and a second-
strength dose, where necessary, of 1 mg.
In our experience, a single small dose fails to discover
a considerable number of truly positive reactors, while a
single large dose is apt to cause an undue number of
April, 1943
109
sore arms or constitutional reactions in highly allergic
subjects. Admittedly more bother to all concerned, as
well as costing more, the two-dose method still impresses
us as safer and as clinically more accurate.
Positive reactors immediately receive a standard 14 x 17
chest roentgenogram, made at the Health Service and
financed, like the entire program, from the medical fee
included in the tuition charges. Films revealing suspi-
cious findings call for stereoscopic studies, fluoroscopic
viewing, and additional examination for possible phys-
ical signs. Other scrutiny includes sputum examinations,
smear, culture, and guinea-pig inoculations of the fasting
gastric sediment, three or more days of observation in
bed at the infirmary, with five-minute temperature deter-
minations and one-minute pulse counts recorded every
two hours, and laboratory tests that embrace complete
blood counts, erythrocyte sedimentation rates by Cutler’s
method, and a blood Wassermann.
Cases which, upon initial study or repeated follow-up,
betray evidence of a pathologically progressive lesion are
advised to withdraw from college and place themselves
under the best possible care at once, looking toward an
early arrest of the process and a return to full or rea-
sonable function as rapidly as their own future welfare
and the safety of their associates will permit.
In exceptional cases, where the evidence is entirely re-
assuring that tubercle bacilli are not being disseminated
by the patient among his fellow students, and where the
clinical picture, evaluated by college physicians in consul-
tation with chest experts, promises satisfactory progress
with less than complete rest, a student may be allowed
to remain in college under very close surveillance, some
type of collapse therapy perhaps being attempted, and
always upon a sharply restricted schedule of academic
work and a regimen of extra rest and release from phys-
ical education requirements; such students, of course,
live in a single room.
Tuberculin Results
Carleton students, coming predominantly from the cen-
tral regions of the nation, show a somewhat smaller per-
centage of positive reactors than experience would predict
for an eastern, southern, or southwestern institution.
Along with the encouraging decline in the incidence of
infection as revealed by a dwindling frequency of reac-
tion to the Mantoux test throughout American collegiate
communities, Carleton figures show that in the autumn
of 1936 the positive reactors among our students num-
bered 3 out of every 10 tested, while in October, 1942,
the ratio had dropped to 1 in 5. We have found that,
relatively, the male positive reactors will slightly outnum-
ber the females in that category — roughly 12 to 10.5 —
comparing similar age groups. (Later it will be shown
that our diagnosis revealed 5 cases of active tuberculosis
in men students as against 2 among student women.)
During a period of four years, from September, 1938,
to June, 1941, a special statistical analysis was made, the
results being summarized in Table I. It will be noted
that in that time, 1,863 students were tested and fol-
lowed. A downward shift in positivity from year to year
is seen, and a regional selectivity is also apparent. The
lowest incidence of positive reactions occurred among
students from Minnesota (19.8 per cent). Those com-
ing to Carleton from other portions of the midwest
showed a slightly higher percentage (23 per cent), those
from more distant parts of the country a still higher one
(27.9 per cent) ; while of students born and reared out-
side the United States, 3 out of 4 proved to be positive
reactors.
When we classified the young people into those com-
ing from communities of over 2,500 population and those
from towns of less than that or from farming communi-
ties, we again encountered figures which indicate that the
multiplied chances of exposure in the more densely crowd-
ed areas had resulted in a heightened incidence of infec-
tion. Urban dwellers averaged 29.2 per cent positive,
rural students only 17.6 per cent reactive.
Similarly, checking the environmental factors against
the tuberculin results, we noted that students with one
or both parents of foreign origin were more apt to be
positive reactors than those whose parents were both born
in this country — 32.9 and 21.9 per cent respectively.
Viewed from a different angle, but with the same
points in mind, we sifted our positive reactors to find
that those coming from cities in excess of 2,500 popula-
tion totalled 62.5 per cent of the group, while among
our negative reactors, students from rural areas held the
majority (53.6 per cent). Again, among the positive
reactors, 81.2 per cent were of entirely American par-
entage, the percentage among negative reactors being
88.3 per cent. All of which substantiates the well-recog-
nized fact that the more frequent or intimate the expo-
sure to likely sources of infection, the greater the proba-
bility of infection.
It must be conceded we are assuming that in an urban
center multiple exposures will be the lot of the individual,
that in contact with the foreign-born they will be favored.
But certainly all studies tend to indicate that the United
States compares favorably with Europe and Asia in re-
gard to tuberculosis infection and mortality rates, and
that in general rural America contains infinitely less tu-
berculosis per 100,000 citizens than do our cities. Our
present data seem to bear out these suppositions, even
though our groups have not been large.
However, when we come to examine the answers re-
ceived when we questioned students directly as to known
actual exposure to tuberculosis, we discover that the av-
erage individual in an intelligent group remains bliss-
fully ignorant of such contact.
Significant exposure, therefore, was reported by a re-
markably small fraction of our student body, only 5.6
per cent. Nevertheless, we again observed that the knowl-
edge of exposure was to some extent paralleled by the
finding of a positive Mantoux, whereas a negative reac-
tion was more apt to occur in those who recalled no ex-
posure. The figures were as follows: Contact with a case
of recognized tuberculosis definitely known to negative
reactors, 1 in 33 individuals; to all students tested, 1 in
18; to positive reactors, 1 in 7. Even the last and best
figure, however, blasts the idea that a history of contact
is reliable, easy to secure, or would offer a suitable basis
for the selection of persons requiring clinical observation.
The Journal-Lance
110
X-Ray Results
During the period of detailed analysis, 1938 to 1942,
437 positive reactors were given chest x-rays. Of this
number, as shown in Table II, 279 were interpreted as
revealing no macroscopically detectable evidence of lesion.
These "negative” films represented 63.8 per cent of those
examined. The findings in the remaining 158 cases were
regarded as indicative of various radiological evidences of
pulmonary tuberculosis, viewed in the light of accepted
criteria. Doubtful cases were fluoroscoped to determine
whether shadows appearing on the films were due to cal-
cified deposits, pleural granularities, and the like. Our
final tabulation revealed we had read the films as follows:
Roentgenograms thought to show the presence of calcium
in the lungs, 123, or 28.1 per cent of all students x-rayed,
these being further broken down into 64 individuals with
characteristic Ghon’s tubercles in the parenchyma and 59
whose visible organized deposits seemed confined to the
hilar areas; films thought to reveal purely pleural changes,
such as apical caps, localized haze, diaphragmatic irregu-
larities, or obliteration of the normal sulcus, 32 cases, or
7.3 per cent of those filmed; and, finally, those interpret-
ed as compatible with a diagnosis of reinfection tubercu-
losis in a progressive form, 3 cases, or 0.7 per cent of
the entire positive reactor group.
The vast majority of these individuals having remained
in college, so that there are anywhere from two annual
films to several such studies in the series, we have had
opportunity to check on and compare our findings from
year to year; we have seldom had to revise previous opin-
ions. If the limitations of radiological appraisal of intra-
thoracic pathology are kept constantly in mind, it will be
apparent that these figures are, at their best, well in keep-
ing with those reported by several other investigators;
at their worst, they are probably more reliable than those
of studies based solely on x-rays without benefit of prior
tuberculin screening. From the experience of other ob-
servers, too, we feel that our findings, based on 14 x 17
films, are somewhat more accurate than if small pictures
of the fluoroscopic image had been employed, with larger
films used only in suspicious cases.
Clinical Results
Leaving the special four-year study and returning to
a consideration of what the seven-year period of search
has actually accomplished in finding early cases of tuber-
culosis, we are able to report having discovered no less
than 7 student cases in a progressive phase of the disease,
as well as one young food-handler who, undiagnosed,
might have secured employment through which she could
have passed her disease on to additional students and
fellow workers. This average of 1 case per school year
impresses us as ample justification for the program, if
not actually sufficient reason for the college’s maintain-
ing on its campus a Health Service only one of whose
duties is the ferreting out of unsuspected tuberculosis.
In Table III will be found the essential data concern-
ing these 8 cases, so that a separate case history for each
is unnecessary. Attention should be directed to the fol-
lowing points:
1. Only 1 of these individuals knew definitely of close
contact with "open” tuberculosis. This was the food-
handler, and her exposure had occurred eleven years
earlier, when her mother had died of tuberculosis. Most
of the intervening years had elapsed without medical
follow-up, and she had had no x-ray for at least five
years. Case No. 2 had worked in a hospital laboratory
the summer preceding the October when his Mantoux
was first found positive (it had been negative the pre-
ceding February) . Opportunity for exposure was not
lacking in this instance, nor in Case No. 7, a student of
American parentage, born and reared in Japan, though
the specific contact remained undetermined in both cases.
Another boy, Case No. 6, had had occasional contact
with a cousin supposedly suffering only from bone tuber-
culosis. The remaining cases were unable to relate their
infection to known exposure.
2. As regards previous history, 4 cases could provide
no significant clues; 2 had had previous attacks of pleuri-
sy, one on two occasions, but neither patient had received
the benefit of a chest x-ray. One boy, Case No. 5, had a
known lesion of minimal extent, under observation at
home and under control when admitted to college. We
did not discover his lesion, therefore, but did ascertain
its reactivation and spread. Another case had been in-
formed that he had "healed childhood tuberculosis,” but
this was not mentioned on the matriculation medical
blank submitted by the family physician, so that the
process was found only when we x-rayed his lungs on
the basis of his former positive tuberculin reaction.
3. Symptoms, when present at all, were slight in every
case. Three patients were symptomless. Two others ad-
mitted slight but definite and unusual fatigue; two re-
lated their cough, chest discomfort, and general malaise
to recent upper respiratory infections. The observation
case that broke down and developed cavitation and a sys-
temic reaction during our period of close follow-up
thought that his illness had been two rapidly successive
attacks of influenza, one at home during the Christmas
recess, one in January at college, during which latter ill-
ness we determined the true explanation of his toxemia.
4. Two patients came to us with a history of a pre-
viously positive Mantoux test; 1 of the others kept her
former positive reaction concealed, turning up with a 1 +
during our testing; of the remaining 5 cases, 2 were 1+,
1 was 2+ and 1 was 3+ to the first dilution, while 1
showed a 2+ reaction upon receiving the second-strength
dose. Dismissal as a supposedly negative reactor follow-
ing the initial dose would have led to this case being
overlooked. In no instance in the past seven years have
we encountered a 4+ reaction to tuberculin.
It was possible to record minimal physical findings
upon careful examination of the chests of 6 of these 8
people, though in at least 4 it must be emphasized that
two competent examiners confess to the fact that the ex-
tremely scanty aberrations from normal would have been
missed had it not been for directive roentgenological
clues. Usually the physical findings consisted of no more
than barely noticeable lag or restriction of expansion of
the affected apex, occasionally a minor impairment of
percussion note, in 2 instances a definite increase in vibra-
April, 1943
111
TABLE I
Analysis of Four- Year Study of Tuberculin Testing.
Carleton College, 1938—1942
Men i Women j Total
Students Mantoux-tested 928 935 1,863
Positive reactors 231 206 437
College Y’ear
Number Tested
Per Cent Positive
Positives bv years
1938-39
871
26.5
1939-40
319 new -F old neg.
24 «
1940-41
339 new -j- old neg.
22.6
1941-42
334 new -j- old neg.
22 2
Region
Number
Tested
Per Cent
Positive
Origin of students
Minnesota
769
19.8
Other midwest states
898
23.0
Remainder of U. S.
147
27 9
Foreign
49
75 5
Homes of students
Cities over 2,500
934
29.2
Suburban or rural areas
929
17 6
Family background
One or both parents foreign-born
249
32 9
Both parents American-born
1,614
21 9
Cities over 2,500
Suburban or Rural
Derivation:
Positive reactors
Negative reactors
Parentage:
Positive reactors
Negative reactors
62 5' ;
46 4co
37 5r;
53 6' ,
Both American-born
One or Both Foreign-born
81. 2r;
88 3ro
18 8 cr
11 7r;
History of contact:
Among all tested
Among all negative reactors
Among all positive reactors
Definitely Known to Student
5.6<v
3 2r;
13 . 7(~,
tory phenomena. Unequivocal fine rales after cough were
heard in but 3 patients. One of these latter cases also
presented a transient friction rub over the involved hilar
region. Four cases had no fever; 4 had a daily rise in
temperature, none going above 99.8°F. Pulse and respi-
ration rates were virtually unaffected.
5. Laboratory findings included the following: Only
1 case could produce sputum, and this was negative for
tubercle bacilli. All the student cases were checked by
gastric lavage of the fasting stomach contents. In 2 cases
this showed the presence of acid-fast bacilli upon imme-
diate smear, in the remainder not. Guinea-pig inocula-
tion was done in 6 instances, with negative results in 2.
definite tubercle development in 2, death of the animal
from intercurrent infection in 1, and 1 still incomplete.
This portion of the investigation was done for us by the
TABLE II
Four-Year Study of Roentgenograms of Positive Tuberculin
Reactors, 1938—1942
Interpretation of Films— Predominant Features
Positive
Reactors
X-rayed
No Evi-
dence of
Pulmonary
Tubercu-
losis
Calcified Deposits
Ohon’s
Primary
Tubercle
Hilar
Nodes
Only
Pleural
Changes
Only
Progressive
Reinfection
Type TB
64
59
Number
437
279
123
32
3
Per Cent
100
63 8
28 1
7.3
0.7
TABLE III
Data in 8 Cases* of Progressive Reinfection-Type Tuberculosis, 1936—1942
No. 1
No. 2
No. 3
No. 4
No. 5
No. 6 No. 7
No. 8
Sex
Age
( -lass
Date
F
20
Sen.
1936
M
20
•lun.
1936
M
18
Soph.
1937
F
, 18
Fresh.
1939
M
19
Fr°sh.
1940
M
18
Fresh.
1941
M
18
Soph.
1942
F
19
Employee
1942
Contact known
No
Hospital
lab. (?)
No
No
No
Cousin,
bone TB
No
Mother died
of TB
Past medical history
Pleurisy twice
Pleurisy once
Clear
Clear
Lesion known
•Healed Ch.TB"
Clear
Clear
Symptoms present
Easy fatigue
Slight fatigue
Pain, cough,
fatigue
Cough from
“cold"
Recent “flu",
fatigue
None
None
None
Mantoux results
3+ (1st)
1+ (1st)
1+ (1st)
2+ (2nd)
Prev. pos.
Prev. pos.
2+ (1st)
1+ (1st)
Physical findings:
Found prior to x-ray
Recognizable after
x-ray
No
Definite
No
With difficulty
No
Gradually
No
No
Definite
Definite
No
No
No
With difficulty
Suspicious
Definite
Laboratory findings:
Sputum
Gastric lavage smear
Guinea-pig inoc.
Sed. rate (1 hr.)
Hgbn (Sahli)
RBC (million)
WBC (thousand)
Pmn.
Lymph.
Miscel.
Wass. & Kahn
Urinalyses
None
Neg.
Neg.
23 mm.
68%
3.9
8 0
62',
38%
None
Neg.
None
Normal
80%
4 5
6.8
68%
32%
None
Neg.
Died (non-TB)
Normal
80%
4 9
8.3
52%
47%,
1%
Neg.
Neg.
TB
12 mm.
70%
4 3
12 I
55%
43%
2cr
” ' All ne
All no
None
Neg.
Neg.
14 mm.
90°;
4.9
9.8
70f7
29r;
l°f
gative
rmal
None
Plus
TB
Normal
93%
4.6
8 5
75%
22%
3%
None
Plus
In orogress
Normal
88r;
4.4
6 4
70r,
27°,
3C;
None
None
None
18 mm.
85'',
4 3
7.9
75?;
23°,
X-ray findings
Left
IstlS
Later.
Cavit’n
Calc.
Hilum
Left
let &
2nd IS
Calc.
Hilum
Left
2ndIS
Ghon
Hilar
Calc. &
Infilt’n
PI. Caps
Left
IstlS
PI. Caps
Left A'
Rt. IstlS
Later.
Cavit’n
Calc.
Hilum
PI. Cap
Lef*
IstlS
Calc.
Hilum
PI. Cap
L“ft
IstlS
Calc.
Hilum
Left A
Rt. IstlS
Cavit’n
Left Upper
Calc.
Hilum
*A ninth case, a foreign student with tuberculous synovitis of the knee, is not included
112
The Journal-Lancet
Minnesota State Department of Health, Division of
Preventable Diseases. The hematological findings are
given in Table III and show mild secondary anemia in
a few instances, a favorable leukocyte response in all
cases, and usually an erythrocyte sedimentation rate that
provided little useful information, being normal or very
slightly increased.
6. The roentgenographic findings revealed a minimal
infiltration in all but 1 case at the initial filming. This
case, No. 8, the food-handler, had a bilateral process of
moderately advanced proportions. One boy, Case No. 5,
had a bilateral involvement, predominantly confined to
his left apex. This individual and a girl, Case No. 1,
developed cavitation while under observation; the em-
ployee presented it when first examined. A curious co-
incidence is provided by the location of the lesion in the
left upper lobe in every one of the 8 cases, with some
further involvement of the right upper lobe in 2 of them.
7. All 8 patients have made or are in process of mak-
ing satisfactory progress. Case No. 1, being a senior,
was allowed to finish her course, meanwhile remaining
under the constant scrutiny of a noted specialist in chest
diseases. In spite of a reduced schedule of studies and
what appeared adequate rest, this individual soon showed
central excavation in her lesion. This responded favor-
ably to pneumothorax therapy, and the girl completed
work for her A.B. degree. The following year, how-
ever, demonstrating that her lesion was still capable of
causing trouble, an abdominal operation at Rochester,
Minnesota, revealed the presence of spread in the form
of an acute tuberculous peritonitis. This cleared up, and
the patient is now in excellent health, married, and in
no way disabled.
Case No. 2 withdrew from college promptly, entered
a Minnesota sanatorium, and was soon placed on pneu-
mothorax treatment which was continued for eight
months. He returned to college the succeeding year,
graduated, entered medical school, and now holds his
M.D. degree. Frequent check-ups have shown his lungs
to be in good condition.
Case No. 3 could not be induced to consider sana-
torium training and care, but rested in bed at home for
seven months. He then resumed his studies and is at
present in medical school, free from further chest trouble,
as proved by frequent re-examinations.
Case No. 4 immediately entered an Iowa sanatorium,
remaining there for about one year. She is now a stu-
dent at a state university and is in good health, as
proved by x-ray every three to four months.
Case No. 5 left school to enter a Minnesota sana-
torium, was subjected to a successful pneumothorax
regimen, and is now enrolled in another college, his health
being reported as good but his activities still somewhat
limited.
Case No. 6 followed the same course as Case No. 5,
remained in another Minnesota sanatorium not quite
a year, is still receiving refills periodically, and is attend-
ing a state college part-time.
Case No. 7 has barely begun his treatment in a Mas-
sachusetts sanatorium at the time this report is being
completed.
Case No. 8 is now in her sixth month of care at a
Minnesota tuberculosis hospital and doing very well.
Comment
In the opinion of the writer the early diagnosis of
pulmonary tuberculosis is neither difficult nor costly. In
a college or university, made up of undergraduates
between the ages of 17 and 23 and graduate students a
few years older, failure to make a determined and re-
peated search for tuberculosis is inexcusable, for this dis-
ease is known to be the chief cause of death in this age
group.
Where modern methods are followed, gratifying re-
sults will be obtained. Every preclinical case of tubercu-
losis turned up will be to the credit of the institution,
to the salvation of the victim, and to the benefit of those
who otherwise would be needlessly exposed to infection.
The advantages of treating early rather than late cases
of tuberculosis are so well recognized today that they
need no elaboration. It is enough to emphasize the
shorter term of treatment, the more favorable prognosis
as to ultimate cure and lasting function, the minimizing
of suffering and of spread, the saving of family and
taxpayer from multiplied expense.
In anticipation of possible queries whether these early cases
might not have healed without any treatment, it should be
noted that Cases No. 1, 3, 5, 6, 7, and 8 in this series are
known to be examples of breakdown from previously demonstra-
ble lesions, while Cases No. 2 and 4 may well also be, save that
the traces of their first infection seem to have been too micro-
scopic or too obscurely situated to cast shadows on a roentgeno-
gram. In view of this circumstance, it seems fair to assume that
the predictable course of these 8 cases would have been un-
favorable and not benign had nobody succeeded in finding them
when they were found, or had their reactivation not been
picked up by a system of frequent rechecks.
It is felt that Carleton College, through its tuberculosis case-
finding effort, has contributed signally and intelligently to the
public health, the public economy, and the public education,
and that any college, industry, or other unit can achieve com-
parable success by adopting and enforcing similar safeguards.
Summary
Seven years of tuberculosis case-finding at Carleton College
between 1936 and 1942 are summarized and discussed.
The routine for examining students and employees is out-
lined; tuberculin-testing results and x-ray findings are analyzed.
History of contact with tuberculosis is revealed as inaccurate
and unreliable in a search for new cases.
Ordinary methods of physical examination, short of chest
x-ray, are shown to be insufficient to diagnose the majority of
cases of preclinical tuberculosis.
The findings and the satisfactory courses of 8 cases of pro-
gressive reinfection-type tuberculosis discovered by the program
are presented.
References
Annual Reports of the Tuberculosis Committee of the American
Student Health Association, I— XI, Proc. Am. Student Health A..
I 93 1-1941.
Ferguson, L. H.: A five-year review of tuberculosis in college 1
students. Am. Rev. Tuberc. 36:478 (Oct.) 1937.
Long, E. R.. and Seibert. Florence B. : The incidence of tuber- |
culous infection in American college students, J A M. A. 108:1761 1
(May 22) 1937.
Lyght, C. E.: Tuberculosis in college students, a second five- J
year review. Am. Rev. Tuberc. 46:227 (Sept.) 1942.
Myers, J. A., and Torp, Inez: Value and limitation of x-ray in i
the diagnosis of chest diseases, Journal-Lancet 55:204 (Apr.) 1935. I
Plunkett, R. E.. et al.: Comparative value of roentgen-photo- j
graphic methods. Am. J. Pub. Health 31:772 (Aug.) 1941.
Stiehm. R. H.: Subclinical pulmonary tuberculosis; a presenta- j
tion of 40 cases, Ann. Int. Med. 13:2285 (June) 1940.
April, 1943
113
An Analysis of 149 Tuberculosis Deaths During 1940-41
H. A. Burns, M.D.*
St. Paul, Minnesota
TUBERCULOSIS deaths are to be expected as a
normal sequence of tuberculosis disease. Yet,
paradoxical as it may seem, it has been our obser-
vation that deaths due to tuberculosis are usually inci-
dental or accidental. Tuberculosis, except in certain forms
of the invasion of the tubercle bacillus such as miliary,
meningitis, and bilateral renal infection, is in itself not
usually a killing disease.
An analysis of our group of cases ending in death
would indicate that there is much left to be done in
order to postpone if not to alleviate the conditions lead-
ing up to death in these patients. Both the chronicity of
tuberculosis and its tendency to fibrose, calcify, and re-
activate are common among those who have eventually
died of this cause. Yet it would appear that the pres-
ence of the tubercle bacillus and its tissue reactions are
often no more than a paralleling coincidence to the de-
termining cause of death. Had therapeutic procedures
been applied when indicated much good might have been
accomplished. It is evident from the study of our cases
that the prognosis becomes more serious with the delay
in beginning treatment. Many of our patients who could
not be benefited by the application of known therapeutic
measures were those who, following a long prodromal
period without recognition, finally were found with ex-
tensive pathology. The remaining group with few excep-
tions constitute a residue of therapeutic and surgical
failures which, if treated at an earlier date, would have
yielded more satisfactory results.
There were 149 fatalities at the Minnesota State Sana-
torium during 1940-41 out of a total of 926 patients
cared for in the hospital; of this group 113 were admitted
to sanatorium care for the first time, while 36 gave his-
tories of previous admissions. The fatalities can be
divided into four groups:
1. Tuberculosis deaths due primarily to pulmonary
tuberculosis, 57 cases.
2. Pulmonary tuberculosis in which death was chiefly
due to nonpulmonary tuberculosis, 57 cases.
3. Nontuberculous cause of death in patients with
chronic tuberculosis, 26 cases.
4. Tuberculosis deaths secondary to childbirth, 9
cases.
There were four deaths in the hospital that are not
included in this study. These patients were admitted but
a short time before death and were found to be non-
tuberculous.
Quite generally, regardless of the grouping, there is
a history of a variable prodromal period. The patient
is frequently conscious of this change in his sense of
well-being for a period of weeks or months before pre-
senting himself to his physician. At times, too, the prod-
romals may be so obscure that the physician is not able
to arrive at a satisfactory diagnosis except through the
•Chief, Tuberculosis Control Unit, Minnesota Division of Insti
tutions.
aid of the skin reaction to tuberculin and the chest
roentgenogram.
In our experience the earlier in the prodromal period
that clinical investigation is made, the earlier the diag-
nosis is arrived at and treatment begun. It would seem
from our observations that this so-called prodromal peri-
od does not constitute a true prodromal period but rather
a preclinical phase of tuberculosis, and that active clin-
ical tuberculosis disease as such begins much earlier than
has been thought. The "prodromal period” must extend
much farther back in the case history to cover the period
from establishment of allergy to the beginning of signs
now identified as prodromal.
A satisfactory history of a prodromal period was ob-
tained in 70 of our cases. The data would indicate that
many of our patients had actually been carrying on their
usual family, social, and industrial responsibilities while
suffering with active tuberculosis for months or intermit-
tently for years, a period which we must now identify
as prodromal.
Group I
This group includes 57 cases in which progressive pul-
monary tuberculosis was the cause of death. Fifty-six of
these were admitted as Stage III cases, 52 of them show-
ing evidence of cavitation. Six were preterminal at the
time of admission. Collapse therapy was attempted in
33 cases, and was to some degree successful in 14; while
in 24 no attempt at collapse therapy was made. Deaths
occurring in this group must be credited to pulmonary
tuberculosis because of the advanced stage of the disease
on admission. Much might have been done to convert
a case with a questionable prognosis into a cure if therapy
had been given when indicated.
TABLE I
Duration of Prodromals in 32 Cases of the 56 Admitted
as Stage III
Age
1 5—1 9
9
3
Duration
mo., 3 mo
of Prodroma
, 8 mo.
20-24
3
25-29
1
30-34
4
6
mo., 1 yr.
35-39
2
4
, 1 yr., 2 yr.
4 yr., 10 yr.
4 yr.. 5 yr..
40-49 .
4
1
yr., 2 yr.,
yr.. 1 yr.,
yr., 2 yr.
50-59
... 3
1
60-69 .
10
1
70 and over
1
yr.
The prodromal period seems to be somewhat longer in
the older age groups (see Table I). To a large extent
this can be explained by the closer check-up among
younger people. Eight months is the longest reported
prodromal period up to the age of 29; from this time on
the period lengthens, so that among the older patients
prodromals are often recalled in terms of years rather
than months.
The number of cases showing a long period of symp-
toms leading up to the final diagnosis partially explains
the increase in tuberculosis deaths among the aged. This
no doubt is because we are looking for the disease in the
aged more often than we formerly did, rather than be-
1 14
cause tuberculosis is now attacking this age group oftener
than in former years. The fact that in the past this age
group frequently concealed carriers who exposed and in-
fected younger members of the family gave credence for
generations to the idea that consumption was an heredi-
tary disease.
The prodromal period at one time extended up to the
consumptive state; now we frequently observe it extend-
ing into the clinical course of the disease to the point of
cavity formation.
Group II
In our study there were 57 deaths actually caused by
tuberculosis involving parts of the body other than the
lungs. Of these 25 gave a history of a prodromal period
prior to breakdown. Thirteen of these were under 35
years of age, while 12 were 50 years or over (see Table
II).
TABLE II
Deaths Due to Tuberculosis Disease Other Than of the Lungs
Age
D
uration
of
Prodromal
15-
l 9
2 mo.
, 5
mo., 6
mo
. . 6 mo., 1 0 mo.
20-
25
1 mo.
, 2
mo., 8
mo., 5 yr.
3 0-
44
1 yr..
3 5
'r., 2 mo..
I yr.
5 0-
59
6 mo.
. 1
yr., 2 yr..
1 yr., 1 yr., 2 yr.
60-
80
1 mo.
. 6
mo., 3
yr..
1 yr.. 1 yr., 5 yr.
These pulmonary and nonpulmonary forms of tuber-
culosis were advanced when first presenting themselves
for treatment. There were 40 cases classed as Stage III,
36 of whom showed evidence of cavity formation when
admitted. Some form of collapse therapy was attempted
in 24 of these cases. Twenty-seven suffered from laryn-
gitis or enteritis. These complications presented many
difficult problems of treatment, coming as they did late
in the course of the disease.
Group III
This group includes those who were ill with pulmo-
nary tuberculosis but who died from a nontuberculous
disease. There were 26 deaths falling in this classifica-
tion, 23 of whom were in Stage III on admission. Sev-
enteen showed evidence of cavity formation when admit-
ted. Collapse therapy was attempted in 13 of these cases,
4 of whom recovered following thoracoplasty and suf-
fered cardiac deaths. These cases, too, had progressed
beyond the point where therapy might hold out promise
of permanent relief.
Three patients had had previous sanatorium care with
later reactivation. One patient had been hospitalized
since 1918. He had succeeded in gaining a negative spu-
tum status which he maintained for two years prior to
death. The second patient with reactivation tuberculosis
left the sanatorium in 1932 and was employed steadily
until readmitted with pneumomycosis. The third patient
who reactivated left the sanatorium in July, 1936, and
was readmitted in August, 1939. Prodromal periods in
the cases of Group III were usually longer than in
Groups I and II.
TABLE III
Nontuberculous Cause of Death in Cases with Chronic Tuberculosis
Age Duration of Prodromal
3 0-34 .... „ 1 yr.
40-44 1 yr.
*>0— 54 1 yr., 1 yr., 1 yr., 2 yr.
55—59.— 1 yr 2 vr.. 4 yr.
60—64 2 mo.. 1 yr.. 5 yr.
70-74 2 yr.
The Journal-Lancet
Group IV
Deaths in this group occurred among young mothers,
aged 20 to 27, whose histories showed a close relation-
ship between childbirth and tuberculosis. More careful
history-taking during the prenatal period as well as at
the time of confinement would have indicated the need
for a Mantoux test and roentgenogram of the chest in
each of these young mothers. In order that an early
diagnosis can be made in these cases it is well to bear in
mind that the more obvious symptoms are frequently the
ones that, being overlooked, permit the disease to become
too extensive for our present therapy to influence.
There were 9 deaths in young women 20 to 27 years
of age in which the development of tuberculosis was
closely associated with childbirth. Thus of the 17 deaths
among young women of this age group in our series,
over half of them associated their breakdown from tuber-
culosis with pregnancy and childbirth.
Other Data
The 4 nontuberculosis deaths were all among patients
who were very ill on admission and died soon after. The
deaths were due to lung abscess, to perforation of an
incarcerated bowel in diaphragmatic hernia, to carcinoma
of the stomach, and to pneumonia.
The successful use of any therapeutic agent in the
treatment of tuberculosis depends upon the stage in the
development of the disease that diagnosis is made and
treatment started. Deaths among the 1 13 patients ad-
mitted to the sanatorium for the first time showed the
following conditions to be contributing factors:
Addison’s disease 2 Empyema 1
Arteriosclerosis 2 Enteritis ] -4
Cerebral hemorrhage 3 Laryngitis .
Cardiorenal ... 5 Meningitis 5
Carcinoma 1 Miliary ]
Childbirth 9 Silicosis 1
Coronary disease 2 Soontaneous pneumothorax 4
Diabetes ... 4 Terminal on admission 12
Many of these cases when first admitted had already
passed beyond help other than symptomatic or domi-
ciliary care. We are still unable to apply adequate ther-
apy at the time the disease is usually found.
The incidence of enteritis and laryngitis among our
patients was an important factor in the number of fatal
terminations. Of the 149 cases, enteritis developing
before the patient passed into a terminal state was re-
ported in 21, with laryngitis in 15, the two conditions
being combined in 13. These complications all occurred
in far-advanced cases of pulmonary disease. Frequently
the laryngitis and less often the enteritis was the chief
complaint, and remained the most distressing condition
during the patient’s illness. When both laryngitis and
enteritis developed in the same patient it was usually late
in the terminal stage. There was seldom cessation in
severity of symptoms once the lesions became established.
Conclusions
1. During much of the prodromal period the patient should
be under treatment.
2. By the time most patients present themselves for treat-
ment, they have passed beyond the care of the clinician to that
of the surgeon.
3. Many deaths from tuberculosis might have been avoided
if it had been possible to have the patient under control at the
time treatment was indicated.
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Minneapolis, Minnesota, April, 1943
DIAGNOSIS OF TUBERCULOSIS
The diagnosis of tuberculosis has passed through im-
portant evolutionary stages since the time of the ancient
physicians. The examinations made by Hippocrates and
those who followed for many centuries were limited
largely to naked eye inspection. Certain symptoms and
signs were observed, such as emaciation; hence the names
phthisis and consumption. Thus, this disease was usually
diagnosed after it had reached the terminal stage.
Auenbrugger in 1761 introduced immediate percus-
sion but it was little used until 1809 when Corvisart
(Napoleon’s private physician) called attention to its
value in diagnosis.
When Laennec invented the stethoscope in 1816
sounds from within the chest were first distinctly heard
by the human ear. Laennec carefully described ausculta-
tory signs and often had an opportunity to interpret
them at the postmortem table. Thus, the stethoscope
became a valuable instrument in diagnosing the presence
of disease.
With the invention of the compound microscope by
the Janssens in 1590 physicians were provided with a
most valuable instrument. However, it furnished no aid
in the diagnosis of tuberculosis in the living body until
1882, when Koch announced the discovery of the tu-
bercle bacillus. This was the first time in the entire his-
tory of medicine that the physician had a reasonably
accurate procedure in differential diagnosis. Many con-
ditions then and now cause the human body to enter into
a consumptive state. The symptoms are almost identical
for several diseases of the lungs; no symptom is pathog-
nomonic. This is also true of physical signs. The find-
ing of tubercle bacilli was the only specific information
that could be obtained with reference to tuberculosis.
Koch’s discovery was hailed with glowing enthusiasm
because it was believed that in every case of tuberculosis
the physician would be able to detect the presence of
tubercle bacilli in the secretions or excretions. Time and
experience dampened the ardor, however, when it was
learned that tubercle bacilli do not appear in the sputum
116
The Journal-Lancet
of most patients until the disease is moderately or far
advanced. Moreover, by the time they are found with
the microscope, the disease is contagious and may have
spread to others.
Further difficulty in microscopic interpretation arose
when bacteriologists discovered numerous acid-fast saph-
rophytes which have the same appearance as tubercle
bacilli under the microscope. Thus, animal inoculation
became an important diagnostic procedure: First, to de-
termine whether tubercle bacilli were present when the
microscope did not reveal them in certain materials; sec-
ond, whether acid-fast bacilli were pathogenic. When
tuberculosis was suspected, and there was no expectora-
tion, a number of methods was devised for producing
sputum, such as gagging the patient and the administra-
tion of large doses of potassium iodide. Later the exam-
ination of gastric washings was found valuable.
The most important step of all time in diagnosis was
taken in 1890 when Koch made tuberculin available.
The tuberculin test is highly specific for tuberculosis.
If an individual does not react to this test, the physician
has the satisfaction of knowing that tubercle bacilli are
not present unless they have entered within the past few
weeks or the disease is in an extremely acute or terminal
stage. On the other hand, when the individual reacts
to tuberculin the physician knows that living tubercle
bacilli are present in the body in lesions which may vary
from microscopic to gross proportions. The tuberculin
reaction indicates that the individual already has tuber-
culosis but whether clinical lesions are present or sub-
sequently develop must be determined by other phases
of examination.
When Roentgen presented his discovery of a new light
ray in 1896, there was so much mystery associated with
it that exaggerated predictions were made concerning its
future value in diagnosis. This was also hailed with
fervor, which was partially justified, as far as the detec-
tion of areas of disease in the lung were concerned, but
the enthusiasm was restrained when it was realized that
inspection of an x-ray him fails to reveal lesions below
the range of vision of the unaided eye, that only 75
per cent of the lung is visualized on the ordinary x-ray
him, that shadows of disease are not specific hndings,
and that extensive extrathoracic tuberculosis may be pres-
ent while the chest appears clear. The etiological diag-
nosis of any disease can not be determined with certainty
by the shadow it casts on the x-ray him.
The bronchoscope, introduced by Killian in 1898, has
become an extremely important instrument in differen-
tial diagnosis. Through the bronchoscope, material may
be obtained for microscopic inspection and, thus, tuber-
culosis and other diseases are frequently diagnosed ac-
curately when all other phases of examination are of no
avail.
Thus, the physician is limited to two medical hndings
that are specific; namely, the tuberculin reaction and the
recovery of tubercle bacilli. In the absence of one or
both of them, there is no reason to diagnose tuberculosis,
regardless of symptoms, physical signs, and x-ray shad-
ows. The medical profession has erred seriously in recent
years by conducting surveys which are limited only to
the tuberculin test and x-ray him inspection of the chest.
Indeed, these two procedures are anly screens for the
purpose of selecting those persons who are in need of
adequate medical examination.
By complete examination, beginning with the tuber-
culin test, inspecting x-ray hlms of the chests of the
reactors, and completely examining by clinical and lab-
oratory procedures (as well as periodic x-ray him inspec-
tions) the physician can now diagnose nearly all chronic
pulmonary tuberculous lesions long before they cause
illness and usually before they are contagious. When
found in this early stage, the majority of cases can be
treated successfully and the disease is prevented from
perpetuating itself.
J. A. M.
TUBERCULOCHEMOTHERAPY
Modern chemotherapy dates from 1909, when Ehr-
lich’s studies culminated in the epochal discovery of
arsphenamine. The spectacular benehts issuing from
Ehrlich’s researches were responsible for the expecta-
tion that most, if not all, infectious diseases would quick-
ly, or eventually, be brought under control or subdued
by specihc chemical agents. These hopes have remained
far short of realization. An outstanding example of a
disease that has remained stubbornly resistant to chem-
ical agents is tuberculosis. Although innumerable drugs
have been tried for experimental tuberculosis, by many
investigators since the time of Koch, the results until
recently have failed to supply sufficient promise to war-
rant enthusiasm for chemotherapy as a future weapon
for combating the disease. With the advent of the more
recent era of chemotherapy ushered in by prontosil in
1935, new impetus was furnished for renewal of the
attack on this important problem.
The wide use and relative effectiveness of sulfonamide
compounds, such as sulfanilamide, sulfapyridine, sulfa-
thiazole and sulfadiazine, for certain acute infections jus-
tified trial of these agents for combating experimental
tuberculosis. The results have been generally disappoint-
ing. While the experimental form of the disease can
to some extent be influenced favorably by the sulfona-
mide compounds, none of these drugs is sufficiently effica-
cious to satisfy the exacting criteria demanded for a suc-
cessful tuberculochemotherapeutic agent. None of the
known sulfonamide drugs actually will arrest the prog-
ress of experimental tuberculosis in guinea-pigs.
With another group of chemicals known as "sul-
fones,” the results have been definitely more encourag-
ing.1 Experimental evidence now available indicates that
several drugs having a diphenyl-sulfone nucleus are
capable of strikingly favorable effects in tuberculosis of
guinea-pigs. Most of the sulfones tried have been de-
rivatives of 4,4’-diaminodiphenylsulfone. The parent
compound has a high tuberculotherapeutic efficacy but
its potential toxicity limits its clinical application. The
data accumulated during the past three years reveal that
tuberculosis in the highly susceptible guinea-pig can be
successfully arrested by several drugs of the sulfone
series. This has been demonstrated repeatedly, even
when treatment has been delayed until six weeks after
April, 1943
117
the animals had been infected, and the drug has been
administered daily thereafter by the oral route.
At present the problem of chemotherapy in experi-
mental tuberculosis has been narrowed to a specific group
of compounds that appear to offer the most likely possi-
bilities of being satisfactory agents. It is not an over-
statement to say that more encouraging results have been
obtained in solution of this problem during the past five
years than during the previous fifty. The prospect for
future gain seems impressive.
Experimentalists have established evidence that the
tubercle bacillus must be added to the growing list of
organisms which are vulnerable to chemotherapeutic
attack. However, it remains to be proved that tubercu-
losis of man can be added to the list of diseases which
can be cured by chemotherapy. Experience with the
acute streptococcal and pneumococcal diseases cannot be
strictly applied to such a problem, except that in such
diseases chemotherapy appears to arrest the multiplica-
tion of organisms and to permit natural defenses to cor-
rect the damage inflicted on the host. When treatment
in these diseases is delayed long enough to permit exten-
sive destruction of tissue, the response to chemical treat-
ment is not likely to be spectacular. Early pneumonia
is rapidly cured but late pneumonia may or may not be
benefited; postpneumonic empyema or pulmonary ab-
scesses are not likely to respond at all; although in all
instances the infecting organism may be the same. If
this analogy holds in the case of tuberculosis, much more
definite response to treatment should be anticipated
when lesions are in earlier rather than later stages of
development. Present experience suggests that this may
be true in fact.
The most convincing evidence for tuberculothera-
peutic effect would be afforded if it were possible to
cure clinical tuberculosis in some of its irreversible forms,
such as tuberculous meningitis, miliary tuberculosis or
terminal stages of pulmonary tuberculosis; yet it may be
as illogical to anticipate this result as to expect arsphena-
mine to cure neurosyphilis or sulfonamides to cure lung
abscesses.
It will probably require great patience, rare judgment
and long experience to define what role chemotherapy
may play in the treatment of clinical tuberculosis. As
progress continues an unprejudiced point of view should
be maintained. Skepticism but not cynicism should be
the attitude, with judgment based squarely on evidence.
Until abundant and convincing evidence of safety and
efficacy is available no drug should be released for com-
mercial exploitation. In the meantime, Federal regula-
tions restrict distribution of these drugs to a few research
centers. The following statement by the late Dr. Paul
Lewis" deserves repetition and emphasis: "Certainly it
will be a most unfortunate thing for the progress of
tuberculosis research if every substance showing interest-
ing properties in the laboratory is immediately rushed to
the clinic regardless of consequences. In this situation
patience is to be taken more than usually as an evidence
of virtue.” W. H. Feldman
H. C. Hinshaw
References
1 . Queries and Minor Notes: Suifone compounds for pulmonary
tuberculosis, J.A.M.A. 121:798 (March 6) 1943.
2. Lewis, Paul: Quoted by Wells, H. G., and Long, E R.:
The chemistry of tuberculosis, Ed. 2, Baltimore, Williams & Wil
kins Company. 1932, p. 450.
THE WARRENS OF BOSTON
There used to be an old building on the Harvard cam-
pus in Cambridge, Massachusetts, a trifle larger to be
sure but otherwise very much like the red schoolhouse
that every country boy is familiar with. It had housed
the medical school in years gone by and was familiarly
spoken of as the Anatomy Building. It was here that
Dr. John Warren was teaching in 1776 when the news
came that his brother, Dr. Joseph Warren, a major-gen-
eral of the line, had been killed at the battle of Bunker
Hill. Dr. John, without ado, hastened out of the hall,
shouldered a musket and joined the troops. There were
two sons, both of whom became physicians. One, Dr.
John Collins Warren, graduated from Harvard in 1797.
He was one of the founders of the Massachusetts Gen-
eral Hospital and its chief surgeon the remainder of his
life. He performed the first public operation in which
ether was used as an anesthetic in October, 1846. The
elder Dr. Reginald Fitz chose up to the very last to give
his medical clinics in the same rickety old amphitheater
where that epoch-making event had taken place. Dr.
Fitz used to enliven his clinics by correcting errors of
syntax in responses from his senior students, for although
this was holy ground, was it not also cultured Boston?
Another Dr. John Collins Warren was born in Boston
May 4, 1842, and died November 11, 1927. Many now
living will remember this charming gentleman who grad-
uated from Harvard in 1866 and served as professor of
surgery until he reached the established age of retirement
in 1907. He felt this inexorable rule very keenly, and
mournfully expressed his regrets to the single visitor who
attended his last operation while serving under that title
at the Massachusetts General Hospital. It was an ampu-
tation of the breast for malignancy. He left the final
closure to his assistants and graciously came over to one
side of the room to visit. There was some rivalry at that
time between Halsted of Johns Hopkins and Warren of
Boston in this particular; each had developed a distinct
technic in radical amputation of the breast, and Warren
was naturally enthusiastic in explaining his method to
others. There was no word of resentment, no sign of
discouragement, but what the heart is full of the mouth
speaketh, and so he expressed in simple language the
opinion that he was now at his best. He probably was;
no one could deny him that opinion. The visitor shook
hands with a brave man but sensed a note of sadness in
the parting. He lived twenty years after that.
A. E. H.
The Journal-Lance
I 18
VUws Ittms
Dr. R. C. Sherwood, St. Paul, food chemist, has been
named by Dr. Russell M. Wilder, Rochester, Minne-
sota, as his assistant chief in the civilian food require-
ments branch of the food distribution administration at
the department of agriculture in Washington.
Dr. R. F. Peterson, pathologist at Murray hospital,
Butte, Montana, is the first physician from that state
to be elected to the board of directors of the American
Society for the Control of Cancer. His election took
place at the annual meeting held in New York the first
week in March.
Lt. I. L. Schuchardt, M.C., former Aberdeen, South
Dakota doctor has returned to this country from New
Guinea where he has been serving with the army.
Dr. R. T. Edward, Elysian, Minnesota is terminating
his residence there after nearly thirty years of practice,
to make his home with his sister at Bigfork, Montana.
Dr. A. W. Paulson, Dell Rapids, South Dakota, has
been promoted to Lieutenant Colonel at Lubbock, Texas,
where he is in command of the hospital of South Plains
army flying school. This is his second promotion since
his transfer to Lubbock from Randolph Field.
Dr. E. L. Tuohy, Duluth, introduced Dr. William
O’Brien, director of postgraduate education at Univer-
sity of Minnesota on the occasion of the latter’s public
address "Recent Advances in Medicine” given March
8th. Dr. O’Brien urged Duluthians to support the anti-
tuberculosis campaign, the cancer drive, the blood donor
movement and health activities in general.
The Montana state legislature, in session at Helena,
by action of a joint investigating committee, recom-
mended the appointment of more trained doctors and
the addition of needed equipment for the state hospital
at Warm Springs. The report characterized the insti-
tution as understaffed. It asserted that psychiatric treat-
ments should be stressed.
Dr. Irving Mauss, formerly of Hot Springs, South
Dakota, has succeeded to the United States Health De-
partment post at Rapid City left vacant by the transfer
of Dr. F. H. Redewill to Sioux Falls, the latter city now
rating fulltime health service because of the heavy influx
of soldiers to the air base two miles outside the city.
Dr. Paul Bunker, president of Aberdeen District
Number 1 Medical Society presided at the first Spring
meeting of the district society in the Alonzo Ward hotel,
at Aberdeen, South Dakota. The meeting was addressed
by Dr. Paul Dwan, Minneapolis, head of the Univer-
sity of Minnesota human serum laboratories and tech-
nical supervisor of the blood donor centers of Minne-
apolis and St. Paul. Dr. Dwan explained the blood
plasma program and illustrated his discourse with motion
pictures.
Dr. Mario Fischer, Duluth city health officer and
county welfare medical advisor, has filed a report with
the St. Louis county board of commissioners on prelim-
inary steps taken by health agency leaders toward the
establishment of a semi-official health organization for
the purpose of coordinating anti-tuberculosis activities
in St. Louis county. This will be known as the "Advis-
ory Committee of Tuberculosis” and Dr. Fischer will act
as chairman. The committee will present a ten-year plan
for the county which has one of the highest tuberculosis
death rates in the state.
Dr. Herbert T. Caraway, Billings, Montana, has been
named by Governor Ford to be chairman of the Mon-
tana war health committee, established in February. Also
appointed were Drs. Wm. F. Cogswell, Helena, secre-
tary of the state board of health and Ernest D. Hitchcock,
Great Falls, president of the State Medical Association,
as well as Maj. Chas. F. Jump, Helena, medical officer
of the state draft board and the secretary of the state
dental association. The committee was created at the
suggestion of the war man-power commission.
Dr. Reuben H. Waldschmidt, president of the Sixth j
District Medical association of North Dakota, presided
at the monthly meeting of the association held March 2 ;
in the Grand Pacific Hotel, Bismarck. Papers delivered
were "Treatment of Acute Respiratory Diseases of the
Child,” Dr. Edmund Vinje, Beulah; "Summary of Trop- I
ical Diseases,” Dr. Alton C. Grorud, Bismarck; "Relation
of the Physician to the Selective Service,” Dr. Arthur C. I
Fortney, Fraine Barracks, state selective service medical
officer; and "Relation of the Physician to the Procure-
ment and Assignment Services of the Army and Navy,”
Dr. L. W. Larson, Bismarck, secretary of North Dakota
Medical association. Program chairman was Dr. Carl
Baumgartner, Bismarck.
Dr. W. F. Cogswell, Helena, Montana, was author-
ized by the state board of examiners to attend the 41st 1
annual meeting of the United States public health serv-
ice in Washington, D. C., March 24 and 25.
Dr. Douglas L. Jacobs, Willmar, Minnesota, has been
commissioned a Lieutenant (Senior grade) in the United j
States Navy Reserve and ordered to report to aviation |
headquarters of the Navy at its San Diego California J
base.
Lieutenant Lynn M. Hammerstad, Minneapolis, flight !
surgeon attached to the naval aviation cadet selection
board of that city, has been ordered to duty in the west- I
ern Pacific war theater.
Dr. F. M. Knierim, Glasgow, Montana, who practised j
in eye, ear, nose and throat ailments at Lewistown prior)
to removing to Glasgow in 1934, has been commissioned i
a lieutenant commander in the Navy and has gone to J
headquarters of the Thirteenth naval district at Seattle, J
Washington, for assignment.
First Lieutenant T. G. Wellman, M.C., Lake City,
Minnesota, the fourth doctor to have left the Lake I
Pepin community for service with the Armed Forces, 1 1
is now stationed with the medical corps of the Army Air
Corps at Miami Beach, Florida.
April, 1943
119
The annual meeting of the Montana State Medical
Association will be held in Billings July 7th and 8th.
Dr. E. C. Person, Roundup, Montana, has been de-
tached from the battleship Idaho, on which he served
nearly two years and has been assigned to graduate work
in reconstruction surgery at the Mayo clinic, Rochester,
Minnesota.
Dr. Gordon C. MacRae, Duluth, has been promoted
from major to lieutenant colonel, according to word re-
ceived from Camp White, Oregon, where Lt. Col. Mac-
Rae is serving with the 81st General Hospital unit.
Dr. Reinhard Schmidtke, Montevideo, Minnesota, has
been appointed assistant to Dr. Frank Burch, St. Paul,
mainly at Miller Hospital and at the Wilder Dispensary.
Dr. Edw. Burch is serving with the Armed Forces.
Dr. Herbert A. Burns, Minneapolis, who resigned last
fall as superintendent of Ah-Gwah-Ching sanatorium to
head a tuberculosis survey of state hospitals, under the
direction of the division of state institutions, is about to
disclose the findings of the work which has been in prog-
ress five months. It is expected that it will point toward
obtaining legislation to shelter tuberculosis patients
among the insane, feebleminded, epileptic and inebriate
groups in state hospitals. Treatment of such patients in
their present situation is limited; their death rate is higher
than from the disease in other elements of the state
population: they constitute a health hazard when re-
leased to return to their homes.
Mrs. I. H. Mauss, Rapid City, South Dakota, wife
of the public health officer of Pennington county, has
been conducting a pinworm survey among school stu-
dents in Fall River and Custer counties. 400 students
were examined, all with parental consent. The results
are expected to be released for publication very shortly.
The Montana Academy of Oto-ophthalmology met in
Butte on Feb. 21-22 at its 40th semi-annual meeting. A
scientific program was presented and at the business
meeting, the officers elected for 1943 were: President,
Dr. Wm. Morrison, Billings; secretary-treasurer. Dr.
F. D. Hurd of Great Falls.
VlUMloW
Dr. Henry Lombert Knight, 81, of San Pedro, Cali-
fornia, former staff member of Eitel hospital Minne-
apolis for ten years and later Mower county physician,
died February 2 of carcinoma of the hip. Dr. Knight
was graduated from Rush Medical College in 1884, spent
two years each in two study periods in Berlin and Vienna
and practised in Minneapolis from 1906 to 1928.
Dr. Andrew Clark, 78, of Billings, Montana, died
March 7th at a Billings hospital of a heart ailment.
His wife, also a doctor, died in 1934.
Dr. H. F. Bright, 65, of Elk Point, South Dakota,
died March 22. He had practised 44 years at Blunt,
White Lake, Mitchell, Alcester and Elk Point.
Dr. Arter Wayne Deal, 60, of Lewistown, Montana,
died March 13 at Lewistown following nearly fifteen
years of failing health. Dr. Deal was a graduate of the
college of physicians and surgeons of the University of
Maryland and for four years prior to 1907 was chief
resident physician of Mercy Hospital in Baltimore. He
served from 1907 to 1911 as superintendent of Mon-
tana state hospital at Warm Springs after which he re-
sided in Lewistown and practiced there until his retire-
ment some years ago. Dr. Deal was appointed surgeon
for the Great Northern Railway in 1917, was made chief
of staff of St. Joseph’s hospital, Lewistown, in 1919,
member of the Montana state board of medical exam-
iners in 1920 and, in 1925, became president of that
board.
Dr. Francis Gustave Lagerstrom, 67, of Minneapolis,
died March 13 at Minneapolis. He was born in Sweden,
graduated from Kansas medical college, Topeka, and
practised at Lindstrom, Minnesota for seven years before
coming to Minneapolis where, for the past twenty-five
years he has been a physician and surgeon.
Dr. Chas. Frederick McComb, 85, of Duluth, eight
times elected coroner of St. Louis county, died at his
home March 13. He had been a Duluth resident and
physician for sixty years.
Dr. Thos. J. O’Leary, 61, of Superior, Wisconsin,
died February 26 after he had been stricken by a heart
attack the night before. Dr. O’Leary was a native of
Wabasha, Minnesota, whence he removed to Superior in
1906. At the time of his death he was serving as coun-
cillor of the Wisconsin State Medical society.
Dr. Otoniel Trejos Flores, 54, of Dodge Center, Min-
nesota, died March 6 at St. Mary’s hospital, Rochester,
where he had been a patient for three weeks. Born in
Herdia, Costa Rica, Dr. Flores came to the United
States 35 years ago and enjoyed a fellowship at the
Mayo clinic for three years before practicing.
IMMEDIATE COMMISSIONS OPEN TO
200 MEDICAL TECHNICIANS
It was announced recently at the headquarters of
Major Gen. Kenyon A. Joyce, commanding general of
the Ninth Service Command at Fort Douglas, Utah
that first-lieutenancies will be granted to medical tech-
nicians able to meet special requirements. Parisitologists
with four years of clinical practice or an equivalent in
graduate study and who are particularly qualified for
studies involving malaria and other tropical diseases are
sought. Unless unusually qualified the maximum age
limit is 48.
Biochemists, also, able to make chemical analyses of
body fluids and to identify poisons of various types of
origins though those examinations will be accepted be-
tween the ages of 35 and 55; excepting that nutritional
specialists in biochemistry are not invited. The call is
specifically for Montanans and Idahoans in this area and
applications are to be submitted to the field office of
the Salt Lake City Officer Procurement District, 449
Federal Building, Salt Lake City, Utah.
120
NORTH DAKOTA
STATE MEDICAL ASSOCIATION
Fifty-Sixth Annual Session
May 9, 10, 11, 1943
Bismarck, North Dakota
Sunday, May 9th:
First Meeting of the House of Delegates, 8 P. M.
Monday, May 10th:
Second Meeting of the House of Delegates, morn-
ing.
Beginning of Scientific Program, 1 P. M.
Buffet supper through courtesy of the commercial
exhibitors, 5:30 to 8 P. M.
Scientific Program, 8 to 10 P. M.
Tuesday, May 11th:
Scientific Program: morning.
Round Table luncheon meetings: noon.
The meeting will close at the conclusion of round
table meetings in time for those who travel by
rail to catch late afternoon train.
In addition to several papers to be given by North
Dakota physicians, the out-of-state guest speakers will
include Dr. W. L. Benedict of Rochester, Dr. W. M.
Spink of the University of Minnesota, Dr. L. G. Rigler
of the University of Minnesota, Dr. P. K. Arzt from
St. Paul, Dr. W. T. Peyton from the University of
Minnesota, and Dr. Bryng Bryngelson, (Ph.D.), Uni-
versity of Minnesota.
Several interesting motion pictures will be shown dur-
ing the day and a half Scientific Session.
Book Reviews
The Answer Is . . . Your Nerves, by Arnold S. Jackson,
M.D.; Madison, Wisconsin: Jackson Publications; 200 pages.
Price #2.
Th is little book is a chatty discourse principally on the sub-
ject of the neuroses. The point of view is that of the busy
practitioner who is attempting to explain to his patient in sim-
ple terms the origin, symptoms, and management of the neur-
oses. Addressed as it is to the layman, it tends to emphasize
the brighter side of the situation and to avoid much mention of
the diagnostic pitfalls which plague the medical man over and
over in dealing with these cases.
For the most part a psychiatrist would not quarrel with the
statements made though a few passages strike one as poorly
considered; for example: "Surely a visit to a hospital with in-
curable diseases such as cancer or advanced tuberculosis would
help to cure melancholia and self pity." (page 150). It might
also increase a melancholia and generate a whole new train of
hypochondriacal symptoms.
The following excerpt regarding shattered nerves hardly fits
in with modern neurologic and psychiatric concepts: "Why do
people seek operations unnecessarily? It is not an easy question
to answer, but usually it is because they wish to escape from
some distressing condition. They feel abused; they crave sym-
pathy; they enjoy attention; their nerves are shattered . . . , ”
(page 36) .
The book is interestingly written and is illustrated by some
amusing drawings of cartoon type. It may well have a certain
amount of utility as reading matter for patients but the physi-
cian who recommends it should prepare himself for discussion
The Journal-Lancet
with his patient on some of the mechanisms touched upon and
only superficially clarified.
Clinical Immunology, Biotherapy and Chemotherapy in
the Diagnosis, Prevention and T reatment of Disease, by John
A. Koi.mer, M.S., M.D., Ph.D., Sc.D., L.L.D., F.A.C.P.,
and Louis Tuft, M.D.: Philadelphia: W. B. Saunders Com-
pany, 941 pages, 6x91 j, Illustrated, 1941, Price, #10.
This is not a laboratory book but a complete compendium of
all important diseases responsive to biotherapy or chemotherapy
with full descriptions of the prophylactic and immunologic
methods applicable thereto, specific advice on the employment
of sera, vaccines, and antitoxins (including prevention and han-
dling of reactions) and detailed instructions, including exact
dosage, on the use of the four sulfa drugs. Described in full
are the technics of the tests that a physician may be called on
to perform, together with instructions on how to interpret find-
ings of tests essential in diagnosis and treatment. Blood transfu-
sion and blood storage are dealt with extensively. The book is
substantially a clinical discussion, pared to the bone and unim-
peded by theory. It is the essence of practise and, as such, be-
comes an "assistant” to the practitioner.
The plan of the book is to state the general aspects of infec-
tion and immunity, biotherapy and chemotherapy; then to take
up the various diseases and conditions, symptomology and in-
dications; to follow with the several methods of treatment that
have been proved successful, informing when and why each was
indicated. The quick-reference summary at the end of each
chapter highlights each disease, and is presented graphically in
the form of boxed tables. There is a practical table of end-
results, as well.
Volume Number I, Military Surgical Manual of Standard
Practise of Plastic and Maxillofacial Surgery: prepared
and edited by Robt. H. Ivy, (chrm.), Jno. Staige Davis,
Jos. D. Eby, P. C. Lowery, Ferris Smith, Brig. Gen. Leigh
C. Fairbank, Medical Department, U. S. Army, Lt. Col.
Roy A. Stout, Dental Corps, U. S. Army, and contributed
to by Jno. Scudder and Fredk. P. Haugen; Philadelphia:
W. B. Saunders Company, 432 pages, 259 figures containing
899 illustrations, 1942, Price, #5.
Each subject is covered from immediate care and manage-
ment on the field to the last surgical service performed in the
hospital, describing each technic, step by step and elucidating by
means of the illustrations, which constitute one of the chief fea-
tures of the book. The contents are divided into four sections:
Reconstructive Surgery, Maxillary Surgery, Maxillofacial Pros-
thesis and Anesthetic Technics. Typical is the first of these
divisions. Beginning with general considerations it involves con-
densed discussions of important procedures, cheiloplasty, melo-
plasty, rhinoplasty, blepharoplasty, otoplasty, defects of scalp
and cranium, cervicoplasty, loss of hard palate and premaxillary
portion of alveolar process. The latter portions of the volume
are likewise complete. Treatment of shock, control of bleeding,
prevention of infection, supportive therapy — including use of
chemotherapy — are developed to meet the needs of the medical
officer under combat conditions.
Volume II, Military Surgical Manual, Ophthalmology
and Otolaryngology; 331 pages, W. B. Saunders Com-
pany, Philadelphia, 1942. Price #4.00.
The timeliness of this condensed volume dealing with oph-
thalmology and otolaryngology recommends it. The principles
of military surgery and medical care relating to these specialties
are treated concisely and practically. There has been an avoid-
ance of subjects of a debatable character. Particularly, noted
are specific methods of treatment which will lessen the com-
plications in acute cases pending the availability of a specialist.
Primarily written for use by the military surgeon the emergency
conditions described in this volume often present themselves to
the civilian practitioner for whom this volume would be a prof-
itable investment. The work is excellently illustrated and the
contributors are outstanding in their respective fields.
Pneumonia in Infancy
Pathogenesis and Pathology
John M. Adams, M.D.f
Minneapolis, Minnesota
PATHOGENESIS
THE origin of pneumonia and the logical under-
standing of the pathogenic processes involved are
still unsolved problems. Although the upper air
passages are assumed to be the natural route of invasion,
their significance in the pathogenesis of pneumonia be-
comes questionable when one considers that pathogenic
organisms are found there frequently in the normal sub-
ject. Kneeland and Dawes' found an increase in pneu-
mococci in the nasal cultures after a common cold; Knee-
land" further showed that infants begin to harbor pneu-
mococci at 2 to 3 months of age, but not necessarily
associated with symptoms. Recent experiences recorded
by Smillie' demonstrate that even infants can harbor
pathogenic pneumococci for some time without develop-
ing pneumonia, unless some additional factor (such as
an acute infection of the upper respiratory tract) lowers
the resistance of the host, making possible invasion of
the tissues of the lung. These studies indicate that some
additional factor other than the presence of pneumococci
must operate in producing pneumonia. Experimental
studies by Robertson4 on dogs list certain conditions as
"essential for the production of the pneumonia lesion:
first, the implantation of pneumococci in the terminal
airways; second, a fluid but viscous medium which pre-
vents their rapid expulsion from this region of the lung;
tFrom the Department of Pediatrics, University of Minnesota,
Minneapolis.
and third, the presence of local irritation.” Local irrita-
tion appears more significant than obstruction in deter-
mining whether or not infection occurs. Robertson con-
cludes that the escape of infected fluid exudate from the
upper respiratory tract beyond the epiglotic barrier plays
a much more important role in the inception of pulmo-
nary infection than does the inhalation of bacteria-con-
taining droplets.
Anatomically, the respiratory passages of the infant
are absolutely smaller than in older children and adults,
thus adding to the problems of obstruction and elimina-
tion of infected exudate. In addition, the infant lung is
physiologically immature, so that the mechanisms of elim-
ination such as cough and ciliary and muscular actions
are not fully developed.
Preventing infected exudate from passing the epiglotic
barrier appears to be a vital factor in the prophylaxis of
pneumonia, with gravity undoubtedly playing a large
role. By elevating the foot of the infant’s crib, much
can be accomplished toward avoiding gravitation of in-
fected exudate into the air passages. Since the general
direction of the trachea and primary bronchi is down-
ward and backward, placing the infant on its abdomen
with the foot of the crib elevated (as shown in Figure 1)
facilitates drainage of infected mucus and exudate in
the upper respiratory passages out through the mouth
and nose. Gray’s textbook of anatomy shows that the back-
ward slope of the trachea is 25 degrees or more from
122
The Journal-Lance i
Fig. 1 A six months old infant showing postural drainage.
the vertical line of the ventral surface of the body
(Fig. 2). By elevation of the crib approximately 15 de-
grees, the angle of the trachea with the horizontal ap-
proximates 40 degrees. I have found that infants suffer-
ing from respiratory infections are more comfortable on
their abdomens as this position alone allows drainage of
exudate from upper air passages by way of the nose and
mouth. Elevation of the foot of the bed increases this
drainage and seems to be well tolerated by the infant.
The danger of choking on obstructing mucus is dimin-
ished as is the need for expelling this material by cough-
ing. The mattress under the infant should be firm and
flat, allowing free movement of the head to one side or
the other. Robertson4 advises elevation of the foot of
the bed for several hours postoperatively to get rid of
material aspirated during operation and to prevent flow
of more fluid into the lung. Dr. Clifford Sweet has em-
phasized the importance of postural drainage in the treat-
ment of respiratory infections.
The most frequent diseases predisposing to and pre-
cipitating pneumonia are the common cold, influenza,
measles and whooping cough. These infections are re-
sponsible for local irritation and congestion which appear
to be essential factors in the pathogenesis of most of the
pneumonias of early life. The factor of inherited or neo-
natal immunity has been shown to be important, experi-
mentally and clinically. Woolpert, Dettwiler and co-
workers■’•,’ were able to infect the lungs of embryo guinea
pigs with the influenza virus more readily than the lungs
of full term offspring. In a previous study, Adams,
Green, Evans and Beach pointed out the increased su-
sceptibility of the prematurely born human infant to the
virus of primary virus pneumonitis, with an 85 per cent
mortality among these infants as compared with an 8 per
cent fatality of full term babies.' In a study of inter-
stitial pneumonia, GiesenbauerN reported postmortem ob-
servations in 46 cases, 33 of which were prematurely
born.
In patients with chronic cystic fibrosis of the pancreas,
death often results from secondary pneumonia or bron-
chiectasis. Careful study by Anderson11 has shown a rela-
tively high incidence, 23 per cent, of severe vitamin A
deficiency in these infants. The pathologic change con-
sists of a metaplasia of the epithelial linings of the pul-
Fig. 2. Roentgenogram of the lung showing the slope of the
trachea and main bronchi with respect to the ventral surface of the
body.
monary system and other organs, associated with xeroph-
thalmia. It is possible that these lung changes prepare
the ground for the invasion of secondary pyogenic or-
ganisms. Blackfan and Wolbach1" state that "the early
effect of the deficiency (Vitamin A) upon the respira-
tory mucosa is a satisfactory explanation of the fre-
quency, severity, and persistence of the pneumonias that
have been in most instances responsible for death.”
Prematurity, cleft palate, and debilitating diseases are
only too obvious as contributing factors in aspiration
pneumonia. The aspiration of contaminated amniotic
fluid may occur prior to or during birth, producing pneu-
monia.11 Occasionally, through the same mechanism,
thrush pneumonia is produced in the infant.
A pathogenic and eriologic classification of the pneu-
monias of infancy follows:
I. Aspiration Pneumonia
(Lipoid Pneumonia)
(Thrush Pneumonia)
II. Tuberculosis
(First infection type of Pneumonia)
III. Eosinophilic Pneumonia
(Loeffler’s Syndrome)
IV. Non-specific Interstitial Pneumonia
(Pertussis, Measles,
Atypical Pneumonia)
V. Primary Virus Pneumonitis
VI. Secondary Virus Pneumonia
(Goodpasture)
VII. Primary Pyogenic Pneumonia
VIII. Secondary Pyogenic Pneumonia
IX. Syphilitic Pneumonia
(Pneumonia Alba)
Pathology
The predominating pathologic change in most of the
pneumonias in early infancy is an interstitial mononuclear
reaction. Sprunt12 points out that an interstitial mono-
nuclear pneumonia is only one phase of the lung reaction
to almost all agents causing pulmonary disease. The only
partial exception is in the primary and secondary pyo-
genic pneumonias, which on occasion will produce a pre-
dominantly mononuclear change.12
May, 1943
123
philia is diagnostic of Loeffler’s pneumonia. The blood
eosinophiles are larger than normal, with unusually large
granules which are fewer in number than normal.14,1’’
Von Meyenburg11’ recently reported autopsy studies in
senbauer8 and Roulet1 1 have recently described the de-
tailed pathologic changes in larger series of cases. Giesen-
bauer8 states that the exudate presents a honey-comb ap-
pearance, resembles fibrin, but does not take the same
stains. The exfoliated alveolar cells frequently contain
fatty and lipoid granular inclusions.
Primary virus pneumonitis of infants offers a singular
opportunity to study the primary pathologic changes
most probably produced by a virus in human lung tissues.
Necrosis, ulceration and proliferation of bronchial epi-
thelium are conspicuous changes, the exudate being pre-
dominantly epithelial and mononuclear, with no bacteria
and few polymorphonuclear leucocytes. A mononuclear
peribronchiolar infiltration adds to the microscopic pic-
ture (Figure 6). The specific distinguishing feature in
these cases is the presence of characteristic cytoplasmic
inclusion bodies in the epithelial cells of the bronchial,
bronchiolar and alveolar tissues. These bodies have defi-
nite features, varying in size from three to six microns,
stain acidophilic with the hematoxylin and eosin stain,
are frequently surrounded by a clear zone or halo and
sometimes have vacuoles within the substance of the
inclusion (Figure 7).
Secondary virus pneumonia was first described by
Goodpasture and his coworkers18 in 1939 as a virus in-
fection of the lungs following measles, and in one in-
stance whooping cough. The unusual pathologic features
are the presence of hemorrhage in the lung, isolated, or
situated about areas of definite inflammatory consolida-
tion, a stringy mucoid exudate, ulcerated areas in the
Therefore, in order to compare and differentiate these
various forms of pneumonia, the specific histologic dif-
ferences will be considered in relation to the etiology and
development of each entity. Fat-laden macrophages and
foreign body giant cells set apart the pneumonias result-
ing from aspiration of oils 13 (Figure 3). In tuberculosis,
the epithelioid cell and typical giant cell are characteris-
Fig. 3. Photomicrograph of section of lung showing consolida-
tion due in part to complete filling of the alveoli with solid masses
of oil-laden macrophages (courtesy of Dr. I. Ikeda).
tic (Figure 4). Wide-spread pulmonary infiltration of
the eosinophilic cell, coinciding with high blood eosino-
Fig. 4. Section showing tuberculosis of the lung with epithelioid
cells and giant cell.
this disease and found eosinophilic infiltrations in other
organs as well as the lung.
The thickening of the various constituents of the pul-
monary system seen in interstitial pneumonia is distinc-
tive. Bronchiolitis and peribronchiolitis, thickening of in-
terlobular and alveolar septa and infiltrations of lympho-
cytes and plasma cells are conspicuous (Figure 5). Gie-
Fig. 5. Section from the lung demonstrating the peribronchio
litis and small round cell infiltration with thickening of connective
tissue elements in interstitial pneumonia.
124
r he Journal-Lano i
Fig. 6. Section from the lung showing bronchiolus filled with
epithelial exudate, necrosis and proliferation of lining epithelium,
peribronchiolar mononuclear cell infiltration in primary virus pneu-
monitis.
trachea and scattered areas of necrosis in the mucous
glands. "The specific feature of the process was the
presence of intranuclear inclusions, which were almost
entirely restricted to epithelial cells’’ (Figure 8) . "These
involved cells rapidly underwent necrosis and this was
the essential cause of the extensive ulceration.”18
The changes in the lungs caused by the pyogenic or-
ganisms are well known. MacCallum1'1 in the epidemics
in 1918 and 1919 was able to differentiate the pneumo-
nias by the distinctive pathologic anatomy produced by
the various pyogenic organisms. This led him to the
conclusion that epidemic influenza was probably due to
a virus and not to bacterial agents acting as secondary
and tertiary invaders in a host weakened by coincident
or antecedent disease.
In syphilitic pneumonia the lungs are pale and spe-
cifically demonstrate extensive hyperplasia of the fibrous
tissues of the interlobular and interalveolar tissues. Trep-
onema pallidum are found in the large mononuclear
cells.
Sudden death in infants previously well is still a very
perplexing problem. The importance of pneumonia as
a cause of sudden death in infants deserves special em-
phasis. The etiologic factor has seldom been determined,
but the almost complete lack of polymorphonuclear leu-
cocytes and bacteria in the microscopic sections of many
of these lungs suggests a virus as a possible causative
factor. Rivers-1' points out, "The fact that inflammation
occurs in many virus diseases cannot be denied, and,
despite the acute nature of some of the diseases, if sec-
ondary infections do not intervene, the inflammatory
process is usually characterized by an infiltration of
mononuclear cells.” Sprunt12 states that in "virus dis-
eases the mononuclear reaction occurs in the acute phase
of the disease and in others, as in pneumococcus pneu-
monia, in the stage of resolution.” McCordock and
>*
Fig. 7. Photomicrograph of section of lung showing bronchial
cells containing typical cytoplasmic inclusion bodies from a case of
primary virus pneumonitis (oil immersion).
Muckenfuss21 showed that in animals, viruses produce
an interstitial mononuclear pneumonia. The distinctive
change noted in the cases studied at the University of
Minnesota is the presence of patches of mononuclear
cells scattered throughout the hemorrhagic and congested
areas of the involved lung (Figure 9).
Fig. 8. Photomicrograph of section of lung showing typical I,
intranuclear inclusions in secondary virus pneumonia (courtesy of .1
Dr. E. W. Goodpasture).
Summary
Logical understanding and management of pneumonia
in infancy require a study of the pathogenesis of the dis-
ease. Anatomic and physiologic factors play a large role
in the causation of these pneumonias. Postural drainage
of infants is suggested as an important factor in pre-
venting infected fluid exudate from reaching the lower
May, 1943
125
Fig. 9. Section of lung from a case of sudden death due to
pneumonia showing edema, hemorrhage and patches of mono-
nuclear infiltration.
respiratory passages and, thus, in preventing pneumonia.
Aspiration of irritating oils, vitamin A deficiency, and
| antecedent diseases are undoubtedly of great significance
in the pathogenesis of some cases of pneumonia. Lack
of inherited immunity plays a role in the development
of pneumonia, especially in prematurely horn infants.
Careful study of the distinctive histologic features will
j aid in determining the specific cause of death.
Sudden unexpected death in infants may be due to
pneumonia. The suggestions regarding postural drain-
age (such as sleeping on the ventral surface of the body)
i may aid in preventing these distressing deaths.
Bibliography
1. Kneeland, Y., Jr., and Dawes, C. F.: Studies on the com
mon cold; the relationship of pathogenic bacteria to upper respira
tory disease in infants, J. Exper. Med. 55:1 35, 1 932.
2. Kneeland. Y., Jr.: Studies on the common cold; upper
respiratory flora of infants, J. Exper Med 51:617, 1930.
3. Smillte, W. G.: The epidemiology of pneumonia, Tr. Assn.
Am. Phys. 56:1 28, 1941 .
4. Robertson. O. H.: Newer knowledge concerning the incep-
tion of pneumonia and its bearing on prevention, Ann. Int. Med.
18:1 (Jan.) 1 943.
5. Woolpert, O. C., Gallagher, F. W., Rubinstein, L., and
Hudson, N. P.: Propagation of the virus of human influenza in
the guinea pig fetus, J. Exper. Med. 68:3, 3 1 3, 1938.
6. Dettwiler, H. A., Judson, N. P., Woolpert, O. C.: The
comparative susceptibility of fetal and postnatal guinea pigs to the
virus of epidemic influenza, J. Exper. Med. 72:6, 623, 1940.
7. Adams, J. M., Green, R. G., Evans, C. A., and Beach. N
Primary virus pneumonitis. J. Pediat. 20:4. 405 (April) 1942.
8. Giesenbauer, Wilhelm: Uber die sogenannts interstitielle
(plasma cellulare) pneumonie fruhegeborener und schwachlicher
kinder, Monatsschrift fur Kinderheilkunde 8:1-138 (Mar.) 1941.
9. Anderson, D. H.: Cystic fibrosis of the pancreas and its
relation to celiac disease. Am. J. Dis. Ch. 56:344, 1 938
10. Blackfan, K. D.. and Wolbach, S. B. : Vitamin A deficiency
in infants, J. Pediat. 3:679 (Nov.) 1 933.
11. Johnson, W. C., and Meyer, J. R.. A study of pneumonia
in the stillborn and newborn. Am. J. of Obst. QC Gynec. IX: 2,3
(Feb.) 1925.
12. Sprunt, D. H.: The significance of interstitial mononuclear
pneumonia, South. M. J. 31:4, 362, 1938.
13 Ikeda, Kano: Oil aspiration pneumonia (lipoid pneumo
nia ) , Am. J. Dis. Ch. 49:985, 1935.
14. Freund, R., Samuelson. S.: Transitory infiltration of the
lung with eosinophilia, Arch. Int. Med. 66:1215, 1940.
15. Botsztejn, Von Anna: Diepertussoide, eosinophile pneu-
monie des saugling, Ann. Paedit. 157:28, 1941.
16. Von Meyenburg, H.: Eosinophilic pulmonary infiltration,
Schweiz. Med. Wchnschr. 72:805 (July 25) 1942.
17. Roulet. F.: Ueber die interstitielle plasmozellulare, pneu-
monie im sauglingsalter, Schweiz. Med. Wchnschr. 71:1313 (Oct
25) 1 941.
18. Goodpasture. E. W.. Auerbach. S. H.. Swanson. H. S..
Cotter, E. F.: Virus pneumonia of infants secondary to epidemic
infections. Am. J. Dis. Ch. 57:5, 997. 1 939.
19. MacCallum. W. G.: Pathological anatomy of pneumonia
associated with influenza, Johns Hopkins Hosp Rep. 20:149, 1921.
20. Rivers, T. M.: Some general aspects of pathological condi-
tions caused by filterable viruses. Am. J. Path. 4:2, 91, 1928.
21. McCordock, H. A., and Muckenfuss, R. S.: The similarity
of virus pneumonia in animals to epidemic influenza and interstitial
bronchopneumonia in man. Am. J. Path. 9:221-252, 1933.
Acute Bacterial Meningitis
Robert Alway, M.D.j
Erling S. Platou, M.D.y
Minneapolis
BACTERIAL infections complicated by meningitis
are of especial interest at the present time because
of the greater ease of spread during military and
industrial mobilization with its attendant concentration
and transfer of large numbers of persons. The acute
meningitides due to the meningococcus, pneumococcus,
streptococcus, staphylococcus and Haemophilus influen-
zae present a serious threat. Conflicting reports regard-
ing the best therapeutic measures for the acute meningi-
tides continue to appear in the literature. Any logical
treatment should be from two fundamental angles:
immunologic and chemotherapeutic.
TFrom the Department of Pediatrics, University of Minnesota,
and the Minneapolis General Hospital.
, Minnesota
In the following communication the desire is to em-
phasize the fallacy of assuming that the sulfonamides
are always adequate and that serotherapy need be used
only when chemotherapy is failing. Not only has the
treatment suggested for meningitis often been over-sim-
plified but too many far-reaching claims have been made
for chemotherapy alone. Any consideration or evaluation
of the host’s immune response is conspicuously absent in
almost all reported studies.
The problems of treatment are directly related to the
peculiarities of the pathogenesis of the disease and the
biologic characteristics of the particular organism. The
bacteria responsible for meningitis usually reach the men-
126
The Journal-Lancet
inges by the hematogenous route. Rarely, there may be
direct traumatic implantation or direct extension from
the middle ear, mastoid or paranasal sinuses. Burman
and others1 present evidence that even otorhinogenic
meningitis results from the entrance of bacteria into the
blood stream from the accessory sinuses or the temporal
bone. In meningococcus meningitis bacteria invade the
blood stream from a minute focus in the upper respira-
tory tract or from a purulent focus. The toxic products
of the meningococcus cause a loss of integrity of the
small blood vessel walls, thus allowing the entrance of
bacteria into the blood stream,5' and into the meninges
through injured capillary walls.
The meningococcus, pneumococcus, and H. influenzae
constitute an immunological group, in that they possess
a similar pattern of chemical components acting as an-
tigens.-' Each of these organisms is surrounded by a cap-
sule containing a specific carbohydrate (specific soluble
substance) , which is excreted into the surrounding me-
dium. The quantity of free capsular carbohydrate is an
index of the severity of the infection and is apparently
correlated with the amount of anticarbohydrate (anti-
body) necessary for neutralization and recovery. Free
capsular carbohydrate is excreted in the urine but that
which remains in the body must be inactivated by natural
or acquired antibody before the substance in the capsule
of the bacteria can be neutralized. There is every reason
to believe that the biology of the meningococcus and
H. influenzae closely simulates that of the pneumococcus.
The available evidence suggests that the protective anti-
body in both anti-meningococcus and anti-type B H. in-
fluenzae serum is the anticarbohydrate antibody. This
antibody is an essential part of the recovery process even
though its fabrication may be by the host. There is no
evidence that sulfonamides influence the production of
antibody. Since the capsular carbohydrate seems to be
the invasive factor in the pneumococcus, meningococcus,
and H. influenzae, any effective treatment must contrib-
ute to the elimination and neutralization of this sub-
stance.
The Gordon and Murray meningococcus types 1, 2,
3 and 4 are classified by Branham5 into groups I (1, 3),
II (2), III (4). The group II meningococcus differs in
that its type specificity is intimately connected with a
protein rather than a carbohydrate.4 Group II meningo-
coccus occurs more frequently in sporadic cases and ts
more apt to produce bacteremia and infection without
meningitis. The meningococcus exotoxin, which Ferry0
claims to have identified, has many of the characteristics
of the capsular substance and in some types a capsule has
been demonstrated. The biologic features of the pneu-
mococcus are too well known to warrant description here.
Pneumococcic meningitis is almost invariably secondary
to a primary focus, and no specific type appears to be
meningotropic. The type B H. influenzae, which is almost
always that responsible for influenzal meningitis, is defi-
nitely encapsulated and grows in smooth colonies. Spinal
fluid smears showing pleomorphic organisms should be
considered strongly suggestive of H. influenzae. Lance-
field Group A streptococci are the usual ones responsible
for human disease. Like the pneumococcus, they are
encapsulated and any one of the 33 types can be the
causative organism in meningitis. The staphylococci re-
sponsible for meningitis cannot be separated solely on the
basis of colony pigment production, but virulent strains
may be identified by coagulase production.1'
Sulfonamides and antisera are the specific agents avail-
able for the treatment of acute bacterial meningitis. The
part played by immune bodies has been largely over-
looked in the general enthusiasm for the more easily used
and generally more effective sulfonamides.
Antibody is an essential part of the recovery mech-
anism whether it is formed by the host as the result of
infection or introduced by serum therapy. There is as
definite a correlation between antibody production and
recovery in the drug treated patient, as in those who get
well spontaneously. The mode of action of the sulfona-
mides is bacteriostatic (i. e., interference with the metab-
olism of bacteria'), facilitating the defense mechanism
of the host. Many patients will recover with chemo-
therapy alone, but some, because of the severity of the
infectious process, and others because of an insufficient
immunologic response, will need additional help in the
form of specific antiserum. The antisera for the pneu-
mococcus and H. influenzae act against the capsular car-
bohydrate. The available meningococcic antisera con-
tain group "antitoxin" as well as specific antibacterial
factors against the prevailing four types (Gordon) of
organisms and they probably exert their influence against
the capsule. Potent staphylococcal antitoxin is now avail-
able and although it has no antibacterial or known anti-
capsular effect, it probably has value. Pooled convalescent
scarlet fever serum contains some type specific, anti-
invasive antibodies as well as erythrogenic antitoxin, and
the use of this serum is an important adjunct in the
treatment of Group A streptococcal meningitis.8
The appraisal of a therapeutic agent in acute menin-
gitis is difficult. The many factors governing prognosis
and the statistics relative to result obtained must be in-
terpreted critically in order to reach a clear understand-
ing of therapeutic effectiveness. Meningitis varies greatly
from patient to patient and from time to time in a
community. The age of the individual and the duration
of the illness before treatment is initiated play significant
roles in the outcome. When a treated case recovers, a
little search may reveal instances of the same type of
infection recovering without any specific measures having
been employed. Moreover, as has recently been shown
by Pittman9 for the influenza bacillus, strains with the
same virulence for mice show marked variation in suscep-
tibility to sulfonamides. The outcome in any case of
acute meningitis depends on the dosage of pathogenic
organisms, the virulence of the organisms and on factors
contributing to the resistance of the host. Also, the viru-
lence of the pneumococcus, meningococcus and influenzal
bacillus varies with different types.
New therapeutic agents may bring about dramatic
improvement in the general fatality rate. For example,
the fatality rate in streptococcus meningitis prior to the
introduction of sulfanilamide was close to 100 per cent;
it is now reported to be as low as 15 to 25 per cent.10,11 • 12
The fatality rate for meningococcus meningitis, in spo-
May, W43
127
radio groups of cases, is reported to have decreased from
50 per cent to about 10 per cent since 193713 although
similar reduction was previously shown with massive in-
travenous serum therapy alone. United States govern-
ment reports show a drop from 55 per cent to 45 per
cent between 1933 and 1936, but only from 39 per cent
to 35 per cent between 1937 and 1941. Sulfonamide
therapy is generally given credit for the apparent marked
improvement but other factors must be seriously con-
sidered.
Group I meningococci account for the majority of
epidemic cases, while in carriers and sporadic cases, the
Group II meningococcus is usually found.14 The latter
is less invasive and more apt to produce chronic infec-
tion. Group I meningococci constituted 90 per cent of
the strains isolated in 1936, 3 but have been less frequent
each year since with a corresponding increase of Group
II. A lowered fatality rate also has been claimed for
pneumococcus and H. influenzae meningitis during this
period. 12,10,16 A critical analysis of large groups of
cases does not substantiate the claim of marked reduction
in mortality implied in some reports following drug
therapy alone. Separation of reported cases into age
groups, reveals that in the extremes of life, particularly
infancy, the least improvement prevails.1 1 ,ls Public
Health Service reports since 1939 show a greater number
of meningitis deaths from birth to five years than in any
other age group. Top in Detroit has found no reduction
in the fatality rate of meningococcus meningitis in chil-
dren under 3 years of age since sulfonamides have been
used.1 1
The high case mortality in the extremes of life is not
due to variation in virulence of pathogens of the same
type or to inability of the host to use conferred anti-
bodies.1'1 Frequent failure of meningitis to manifest itself
as such in early infancy and the failure to make an
early bacteriologic diagnosis in patients over one year of
age, as well as the probable effects of anatomic, physio-
logic, and immunologic differences contribute to the high
mortality. The immune response of a host varies with
age, as has been shown by Sutliff,20 Fothergill,21 Hodes22
and others. A definite lack of immunity to the pneumo-
coccus exists between 10 days and 2 years of age.23 The
blood of children between 2 months and 3 years of age
has been shown to have no antibacterial antibodies against
influenzal bacilli.21 Hodes22 attempted to immunize chil-
dren against the type I pneumococcus; all the children
over 2 years of age showed a sharp rise in antibody titre,
while a significant rise occurred in only one case under
2 years of age. Similar and more common clinical exam-
ples of poor antigenic response can be found in infants
under 6 months of age, who have been inoculated too
early against pertussis and diphtheria.
At the onset of meningeal infection when possible, an
evaluation of the immune status of the host should be
carried out so that complete therapy can be instituted
at once instead of at a point where irreparable damage
may have already been done. Since the amount of anti-
body essential for recovery varies with the severity of
the disease, quantitative evaluation by determination of
the amount of antibody in some serums in terms of milli-
grams of antibody nitrogen per unit volume is desirable.
In the case of type B H. influenzae serum and pneumo-
coccus serum results of analysis by this method parallel
that by mouse protection methods; dosage of serum can
be determined by amount of spinal fluid sugar. In men-
ingococcus and H. influenzae meningitis, when no organ-
isms can be found, a rapid diagnosis can be made by
means of the precipitin reaction.19,24,2'1 The need for
and adequacy of serum therapy can be similarly deter-
mined. Cleared spinal fluid is used to overlay a few
drops of diagnostic serum; a positive test consists in the
formation of a white ring at the interface. Alexander
feels that the time of appearance of the ring is an index
of the amount of free specific soluble substance and there-
fore a measure of the severity of the infection. A severe
infection is believed to be present if a ring appears with-
in ten minutes. The Francis test in pneumococcus infec-
tions and an analogous test in H. influenzae meningitis
when positive indicates the presence of excess free anti-
carbohydrate antibody. A further method of determining
antibody excess is capsular swelling — identical with the
one used to type the organism except that the patient’s
serum is used in place of diagnostic serum. The aim is
to build up such an excess of antibody that a 1:10 dilu-
tion of the patient’s serum will produce capsular swelling.
The discovery of some effective prophylactic agent or
procedure against meningococcus infections obviously
would be of great value in the event of an epidemic, par-
ticularly since the disease is spread almost entirely by
carriers and not by patients with the disease.26 The cur-
rent concentration of large groups of men increases the
likelihood of an epidemic. It is believed that an increase
of the carrier rate to over 20 per cent is definite warning
of an impending epidemic.
There are several reports suggesting that the sulfona-
mides may be of value prophylactically, but more exten-
sive trials are necessary before acceptance is warranted.
Meehan and Herrillees-1 were unable to control a series
of outbreaks of cerebrospinal fever in a foundling hos-
pital until they gave sulfapyridine to all the carriers.
Fairbrother_s believes that sulfonamides will have only a
limited application for wholesale use, but that they are
of definite worth in clearing proven carriers if used in
adequate dosage. Gray and Gear21' used sulfapyridine
prophylactically during an epidemic in a military camp,
the carrier rate dropping from 22 per cent to none.
These reports are suggestive but do not warrant op-
timism without more extensive trials.
Statistics should be interpreted very carefully in men-
ingitis because of the many factors previously mentioned
which affect the prognosis. The results obtained at the
Minneapolis General Hospital before and after the ad-
vent of sulfonamide therapy are tabulated below without
fatality rates.
ACUTE MENINGITIS 1922 THROUGH 1942
1922-1936 1937-1942 Total
No. No. No. No. No. No.
Cases Deaths Cases Deaths Cases Deaths
Meningococcus 240 92 34 5 274 97
Pneumococcus 85 85 20 17 105 102
H. Influenzae 17 17 6 4 23 21
Streptococcus . 137 1 35 1 3 3 1 50 1 38
Staphylococcus 15 15 3 1 18 16
128
The Journal-Lancei
The most striking improvement has been in strepto-
coccus meningitis, while some reduction in the case fatali-
ty rate has occurred in each of the others. Prompt eval-
uation of the patient’s immune status, i. e., precipitin
tests, spinal fluid sugar, and capsular swelling, insofar as
possible at the time of admission plus the more frequent
judicious use of combined sulfonamide-serum therapy
and eradication of focus have given improved results.
Organisms resembling pneumococci, meningococci, or
H. influenzae may be typed by the Neufeld technic. As
previously mentioned, in those cases in which the spinal
fluid shows no organisms, cleared spinal fluid may be
tested for type B H. influenzae and meningococci by
means of the precipitin reaction.
Meningococcus Meningitis
One lumbar puncture for diagnosis is usually suffi-
cient, although additional punctures may be done after
24 hours, if there is reason to doubt the efficacy of the
treatment or if signs of increased intracranial pressure
appear.
All the common sulfa drugs appear to be effective in
the treatment of meningococcus meningitis. The dosage
used should be sufficient to maintain a blood level of
between 5 to 15 milligrams per hundred cubic centi-
meters. It is not evident that higher levels are more
effective (Bank’s series).'*0 The route of administration
depends in part on the condition of the patient. The
initial dose should be given intravenously to obtain the
optimum blood concentration quickly. A one to 5 per
cent solution of the sodium salt of sulfapyridine, sulfa-
thiazole or sulfadiazine in normal saline may be used.
The 1 per cent solution seems preferable for two rea-
sons: it maintains the blood concentration at a higher
level over a longer period of time and it also provides
additional fluid. The sodium salts also may be given as
a 0.4 to 0.8 per cent solution in physiologic saline sub-
cutaneously. The use of the intravenous or subcutaneous
routes is an additional advantage in patients unable or
unwilling to cooperate. The crushed tablets or a solution
of the sodium salt may, of course, be given through an
indwelling gastric tube. The drug is probably best con-
tinued until the patient has been afebrile 4 to 5 days and
then gradually decreased, although recent reports advo-
cate prompt withdrawal with the first normal spinal fluid.
Serum should be given to any patient with meningo-
coccus meningitis in the extremes of life and to any pa-
tient seriously ill.30,'!1 Experimentally, combined chemo-
serotherapy is definitely superior.* 4,':-’'3'* The practice so
far has been to employ serum mainly in those cases which
are severe or which have been refractory to sulfonamides.
This point should be kept in mind when evaluating series
of cases treated with sulfonamide alone or with combined
sulfonamide-specific serum therapy, and should prevent
arriving at unwarranted conclusions regarding the inferi-
ority of combined therapy.'*4 It is advisable to give in-
travenous fluids containing one of the sulfonamides for
a period of three to four hours before the serum. The
reasons and details for this will be referred to in connec-
tion with influenzal meningitis. The intrathecal adminis-
tration of serum is not indicated,'*^’31’ as it seems unrea-
sonable to rely on the circulation of the spinal fluid to
transport antibodies, when the blood can do it more
quickly and directly; in addition, horse serum intrathecally
produces an intense meningitis.11 If within 24 hours the
patient does not show definite increase in the spinal fluid
sugar, 100,000 units antimeningococcus serum should he
given intravenously after sensitivity tests prove negative.
This delay appears to be reasonably safe, at least in non-
epidemic cases.
The patient’s fluid and electrolyte balance should be
maintained by oral fluids if possible, and parenterally if
necessary. Repeated small blood transfusions are helpful.
Freshly drawn blood is preferable to stored bank blood
because of its greater antibody activity.
Influenzal Meningitis
At the Minneapolis General Hospital the treatment
for influenzal meningitis recommended by Alexander10
has been followed as closely as possible. A continuous
intravenous drip of 0.1 gram of drug per kilogram of
body weight in saline or Ringer’s solution is started at
once. Sulfadiazine appears to be the drug of choice. This
is given over a 4 hour period for the purpose of inhib-
iting further formation of free carbohydrate and accel-
erating the excretion of the free carbohydrate already
present.
Anti-type B influenzal rabbit serum is then given in-
travenously, diluted in 200-300 cc. of sulfonamide-con-
taining saline or Ringer’s solution over a 2 hour period.
The initial dose of serum is determined by the spinal
fluid sugar level as follows:10
Spinal fluid sugar (mgm.' i ) Mgm. antibody nitrogen
Under 15
100
15 to 25
75
25 to 40
50
Over 40
25
The adequacy of the dose is determined one hour later
and every 24 hours, by testing the ability of the patient’s
serum to produce capsular swelling. The original spinal
fluid kept on ice after adding 0.4 per cent formalin will
serve as a source of encapsulated organisms. The aim is
to have sufficient antibody so that a 1:10 dilution of the
patient’s serum will produce capsular swelling. If no
swelling occurs, an additional 50 mgm. antibody nitrogen
is given. Lumbar puncture should be repeated 24 hours
after the original tap for determination of sugar, cell
count, and culture. Need for additional punctures de-
pends on the patient’s course. Repeated small transfu-
sions will furnish hemoglobin and antibodies. Sulfona-
mide therapy should be continued for one week after the
first sterile spinal fluid is obtained or for two weeks after j
fever has subsided, for recurrences are not infrequent. '
A febrile response to the serum is not uncommon and is
misleading. In those cases not responding to the above
mentioned treatment the intrathecal administration of
5 cc. of human complement may help.
Pneumococcus Meningitis
The same outline of treatment applies to pneumococcus I
meningitis as described for influenzal meningitis. Sulfa-
diazine or sulfapyridine and type specific rabbit serum i
May, 1943
129
should be used. In determining the initial dose of type
specific serum, 1 mg. antibody nitrogen is equivalent to
1000 units, and the dosage is then determined on the
basis of the spinal fluid sugar level. Chemotherapy should
be continued in full dosages at least one week after the
spinal fluid becomes sterile. Particularly in this type of
meningitis, foci of infection should be looked for and
eradicated if possible. The adequacy of the serum admin-
istered should be determined by the Francis test and cap-
sular swelling. The intrathecal administration of comple-
ment may be of value in this type of meningitis.
Streptococcus Meningitis
Sulfadiazine or sulfanilamide in doses sufficient to
maintain blood levels of 10 and 15-20 mg. respectively
should be given and continued one week after the patient
is afebrile and spinal fluid is sterile. Pooled human scarlet
fever convalescent serum should be given if available. s
Repeated small transfusions and the eradication of foci
of infection are important.
Staphylococcus Meningitis
The principal points in treatment are the same as
mentioned for streptococcus meningitis. Sulfadiazine, as
in each of the others, appears to be the best drug,
although sulfathiazole is probably very effective. The
use of staphylococcus antitoxin intravenously is recom-
mended. The initial dose should be 100,000 units.
Bibliography
1. Burinan, H. S., Rosenbluth, M., and Burman, D.: Arch.
Otolaryng. 35:687, 1942.
2. Alexander, H. E.: Bull. New York Acad. Med. 17:100,
1941 .
3. Branham, S. E., and Carlin, S. A : Proc. Soc. Exp. Biol. &C
Med. 49:141, 1942.
4. Menzel, A. E. O.. and Rake, G. J : Exper. Med. 75:437,
1 942.
5. Ferry, N. S., Norton, J F., and Steele, A. H. Immunol.
21:293, 1931.
6. Spink, W. W.: Internat. Clinics 4:236, 1941.
7. Woods, D. D.: Brit. J. Exper. Path. 2 1:74, 1940.
8. Platou, E. S., Dwan, P. F., and Hoyt, R E.: J.A.M.A.
116:11, 1941.
9. Pittman, M.: Public Health Reports 57:50 (Dec. 11) 1942.
10. McCasky, C. H.: Surg. Gynec. Qc Obst. 68:377, 1939.
11. Carey, B. W.: J.A.M.A 1 15:924, 1940.
12. Hamilton, D. E.: M. J. Australia 2:342, 1940.
13. Cushing, H. B., and Clein, D.: Am. J. D.s, Child. 62:1 322,
1941.
14. Branham, S. E.: J. Pediat. 18:217, 1941.
15. Lindsay, J. W., Rice, E. C., and Selinger, M. A : J Pediat.
17:220. 1940.
16. Mitchell, H. J.: Proc. Staff Meet. Mayo Clin. 16:298, 1941
17. Top. F. H.: Personal Communication.
18. Obtained from U. S. Pub. Health Service Reports, 1939.
19. Alexander, H. E., Ellis, C., and Leidy, G.: J. Pediat.
20:673, 1942.
20. Sutliff, W. D., and Finland. M.: J. Exper. Med. 55:837,
1932.
21. Fothergill, L. D., and Wright. J.: J Immun. 24:273, 1933.
22. Hodes, H. L., Ziegler, J. E. Jr., and Zepp, H. D Am. J
Dis. Child. 64:189, 1942.
23. Maegraith, B. G.: Lancet 1:545, 1935.
24. Rake, G. J.: Exper. Med. 58:375, 1933.
25. Feldman, H. A.: War Medicine 2:995, 1 942
26. Rundlett, E., Gnassi, A. M., and Price, P.: J.A.M.A
1 19:695, 1942.
27. Meehan, J. F., and Merrillees, C. R.: M. J. Australia
2:84, 1940.
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29. Gray, F. C., and Gear, J.: South African M. J. 15:139,
1941.
30. Banks, H. S.: Lancet 2:7, 1938.
31. McLeod, J. H.: J. Pediat. 18:210, 1941.
32. Branham, S. E., and Rosenthal, S. M.: Pub. Health Rep.
52:685, 1937.
33. Powell, H. M., and Jamieson, W. A.: J. Immunol. 36:459,
1939.
34. Editorial: J.A.M.A. 121:5 16, 1943.
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37. Shaw. E. B.: J. Pediat. 2:865, 1937.
Old Problems in New Settings
Eric Kent Clarke, M.D.f
Reynold A. Jensen, M.D.f
Minneapolis, Minnesota
AS the field of psychiatry developed its understand-
ing of human behavior and perfected its technics
k in treating patients with adjustment difficulties,
the early formative years of the individual’s life assumed
increasing importance. At the same time the pediatrician
was learning that emotional and personality problems
were an important part of his practice and could no
longer be ignored. This mutual emphasis has led to the
formulation of a program designed to integrate the two
fields more closely. It is natural that this should be de-
veloped in the medical schools. The Psychiatric Clinic
for Children, established as a part of the University of
Minnesota Medical School in October, 1938, is in line
with this progressive trend in the field of medicine and
medical education.
In the four and one-half years of the clinic’s existence
tFrom the Psychiatric Clinic for Children and the Department of
Pediatrics, University of Minnesota.
a total of seven hundred children has been accepted for
study. It is significant that 34 per cent (238 children)
were referred by the Department of Pediatrics because
they presented problems psychosomatic in character. In
addition, another 15 per cent were referred directly to
the Psychiatric Clinic for Children by practicing physi-
cians, because of complaints that did not seem to be pro-
duced entirely by physical disease. The problems includ-
ed emotional and behavior disorders resulting from or
related to organic disease or defect, emotional or person-
ality disorders expressed through organic symptoms of
dysfunction, behavior problems related to habit training
and management, and difficulties related to intellectual
development. This is contrary to the general experience
of child guidance clinics where problems of medical in-
terest constitute less than 10 per cent of the referrals.
The explanation is the closer identification of these other
130
The Journal-Lance
clinics with organized community social agencies such as
courts, schools, or case working agencies in which the
medical practitioner has had little interest.
The neurotic manifestations encountered in these chil-
dren fall into more or less clearly defined categories. In
the young child, refusal to eat, negativism, temper out-
bursts, whining, attention-getting behavior, and the recur-
rence of such infantile characteristics as soiling and
enuresis predominate. In the school age group neurotic
tics, enuresis, daydreaming and vague persistent physical
complaints are frequent. In this group there has been
a high incidence of school maladjustment, either as aca-
demic failure or achievement at a level far below poten-
tial capabilities. The physical symptoms that brought
the child for study often proved to be devices uncon-
sciously assumed to win sympathy or afford opportunity
to evade responsibility and to avoid competition with con-
temporaries. In the adolescent group, there has been
accentuation and perpetuation of these same character-
istics, with clearer definition of the patterns of evasion,
more pronounced complaints of pain, and, more than
occasionally, hysterical reactions and anxiety states in
addition to aggressive rebellion.
Throughout all age groups there has been a high in-
cidence of intrafamilial conflict that induced a sense of
insecurity within the child. Rejection by parents, un-
favorable comparison with others within or without the
family, expectation of superior performance in school
and athletics, and the imposition of harsh demands and
standards have been precipitating factors commonly en-
countered. Experience in this clinic confirms the often-
expressed contention that the primary needs for normal,
well-rounded emotional development in childhood must
include strong and satisfactory affectional relationships,
security and protection, and the opportunity for experi-
mentation that will lead to eventual emancipation. Any
lack in this basic constellation contributes to the produc-
tion of frustration that may find expression in neurotic
manifestations. These reactions may be encountered at
an extremely early age, even before the child is intellec-
tually capable of appreciating or evaluating conscious
reaction. For instance, one infant of three months came
to the Pediatrics Clinic because of persistent projectile
vomiting. Thorough physical studies failed to substan-
tiate the provisional diagnosis of pyloric stenosis. This
child was the only child, born to middle-aged parents
after many years of marriage. Both parents possessed
many neurotic characteristics, were tense and apprehen-
sive, feared that the child might not survive, and felt
guilty lest the lateness of the pregnancy had "marked
the child.” Parental anxiety was obvious in every action
toward the child, who was permitted no opportunity to
relax and be peaceful. The child was brought into the
hospital for a short period during which time the parents
were reassured and their many questions answered in an
effort to allay their anxiety. Separation of parents and
child brought about a gradual release of tension. Better
understanding and handling of the child was then pos-
sible and did much to overcome the persistent pyloro-
spasm. Since so much has been written about the cor-
rection of feeding problems, negativism and tantrums in
the preschool period it will suffice to comment that our
experience confirms the findings of others, namely, that
intrafamilial tension producing insecurity and doubt in
the child’s mind as to his affectional acceptance is of
great importance.
The period of the school years is a vital one, not well-
understood and often inadequately managed. The divi-
sion of responsibility between the school, the home and
physician leaves many loopholes through which difficul-
ties may develop. The tendency to consider each separate
segment of the child’s career as a detached entity with-
out looking at the total integrated picture is the greatest
weakness. It is during this period that vague and per-
sistent physical symptoms growing out of the child’s
sense of inadequacy for competition may appear and
become the foundation for a confirmed neurosis later on.
The immature child cannot evaluate his experiences,
is unable to verbalize his anxieties, and consequently is
prone to express his sense of futility in physical com-
plaints that are accepted with greater sympathy and
promise of action. Characteristic of this group is a nine-
year-old girl, the fourth child in a family of five, re-
ferred for examination because of increasingly severe
headaches and visual changes suggestive of a rapidly
growing brain tumor. She was highly suggestible, and
daily added new symptoms as a result of repeated med-
ical examinations. The child’s illness complicated an
acute family situation, the war having eliminated the
father’s occupation that for many years produced a com-
fortable income. His present earnings from a night shift
in a defense plant barely covered running expenses and
provided little reserve for medical expenses incurred
through the child’s illness. The oldest child of this fam-
ily was subnormal as a result of birth trauma. Natural
chagrin led the parents to overemphasize the importance
of school marks in their children. The second, third and
fifth children, immediately older and younger than our
patient, were of superior intelligence, while she was of
average endowment. The mother had suffered a turbu-
lent pregnancy with our patient, with prolonged perni-
cious vomiting that caused the father to suggest a thera-
peutic abortion. The physician’s refusal to consider this
proposal left a strong sense of guilt in the father. Be-
cause of her average intellectual endowment she found
difficulty in equalling the achievement of her superior
siblings. She was further handicapped by a progressive
visual defect exaggerated by poorly fitted glasses. The
resulting symptoms were steadily exacerbated by the over-
anxious parents and the child’s fears that she would fall
still farther behind in the strenuous, unequal competition
with her more brilliant siblings and be identified with
the subnormal oldest child whom they had all been
taught to protect. Careful neurological study revealed
no evidence of tumor. The ophthalmologist established
an exceedingly high refractive error which was corrected
by properly fitted glasses. Psychological testing substan-
tiated her average intellectual capacity but indicated
severe retardation in reading and arithmetic achievement.
The relief of parental anxiety and the substitution of a
carefully considered school program that eliminated com-
petition with the siblings and offered an opportunity for
May,
131
achievement in school work has gone far in re-establish-
ing this child on a healthy level. This type of patient
does not require prolonged, specialized treatment, but
the important points to be considered are the emotional
factors that enter into the attitude of the parents and
the relationships between this child, her siblings and the
school program. A successful treatment plan must take
account of all these elements. It would have been easy
in a busy practice to limit attention to the provision of
adequate glasses, which was only part of the difficulty.
The unequal competition between the children, the over-
emphasis on academic achievement, the child’s fear of
identification with the subnormal older sister, and the
obvious hyperanxiety of the parents were of equal impor-
tance in the production of this child’s problems.
In older children the physical symptoms have an even
wider variation than in the pre-adolescent group. More
mature reactions are expected, more responsibilities call
for independent decisions, and often the child is not
equal to the new burden. Under such pressures many
purely neurotic manifestations without demonstrable or-
ganic pathology have been encountered. There have been
many carefully controlled studies of the influence that
emotional pressure may play in the production of such
conditions as ulcerative colitis, gastric and duodenal ulcer
and asthma in adults. It is our impression that the find-
ings would hold equally true in children. We have ob-
served repeatedly the increase in frequency of convulsive
attacks on a well-established organic basis during periods
of emotional stress. It is strongly suspected that in some
persons with diabetes more insulin is required to main-
tain equilibrium during periods of sustained emotional
tension. Such findings suggest that much greater con-
sideration must be given to these phases of medical prac-
tice than has been customary.
The results of the routine examinations of men appear-
ing at the induction stations, preliminary to military serv-
ice, are disturbing. A rejection rate of 35 per cent unfit
for service because of physical or psychiatric defects
should prove a challenge to medicine for years to come.
The largest single group rejected, 9 per cent, have been
those in the neuropsychiatric classification, the majority
being of the psychoneurotic type. In medical practice,
this group has been notoriously unresponsive to treat-
ment. Part of the difficulty has been due to the physi-
cians’ lack of training and consequent disinterest in un-
derstanding these patients. In addition, the problem is
too often complicated by the length of time symptoms
have persisted before treatment is initiated.
The experience of the Psychiatric Clinic for Children
staff has been that the most effective results can be ob-
tained by preventive measures carried out with children
who early show evidence of maladjustment expressed in
physical symptoms without organic basis. Careful con-
sideration of the emotional factors within and surround-
ing the child and efforts to eliminate the sources of fric-
tion will generally bring a satisfactory response. A con-
sideration of emotional factors in every patient situation,
but more particularly in those where complaints are not
confirmed by physical studies, will yield increasing satis-
faction to the profession as well as to the patients. While
in the beginning this procedure may prove somewhat
time-consuming it will prevent the consolidation of symp-
toms and evasions that become chronic. Viewed from
that angle it is actually a time saver.
Probably better than half of the cases encountered in
this clinic since its establishment could have been ade-
quately cared for in the office of the general practitioner.
The balance of the cases have been so complicated and
of such long standing that they require the specialized
service of a unit such as this. We feel the greatest con-
tribution which a unit such as ours can make is to em-
phasize to the practitioner and the medical student the
importance of considering emotional factors in every pa-
tient situation. As this goal is achieved there will be less
need for referral to a clinic reserved for specialized cases.
Gastric Ulceration Complicating Erythroblastosis
Fetalis
•
Rena Crawford, M.D.j
C. A. Stewart, M.D.t
New Orleans, Louisiana
PEPTIC ulceration occurs in children at all ages,
but gastric ulcer coexisting with erythroblastosis
fetalis has not been previously reported. Two such
cases are presented in this paper, as well as brief sum-
maries of the records of two additional infants with in-
testinal ulceration.
In a splendid review of the literature Bird, Limper,
and Mayer1 collected reports of peptic ulceration of the
stomach and duodenum in 245 children under the age
tFrora the Department of Pediatrics, Louisiana State University
School of Medicine and Charity Hospital, New Orleans.
of sixteen years. They also presented the record of one
patient upon whom they had operated successfully at the
age of 34 hours for a perforated duodenal ulcer. Of
these 246 patients 43 were two weeks of age or less when
the ulcerations were discovered. The collected data indi-
cate, therefore, that at no period during childhood does
the incidence of peptic ulcer equal that recorded for the
newborn period. The published reports also disclose a
distinct tendency for peptic ulcers in young infants to
bleed profusely and to perforate. As a consequence,
132
Thi: Journal-Lanc.i-i
melena, hematemesis, abdominal distension, cyanosis, and
symptoms of prostration and shock comprise some of
the more important manifestations of peptic ulceration
in the early weeks of life. Subsequent to perforation the
presence of free air in the peritoneal cavity may be dem-
onstratd by x-ray study, and is of great diagnostic sig-
nificance.
Since Bird et al, published their survey, a few addi-
tional instances of peptic ulcer in children have been
reported by Bastman,* Moore,'1 and Conklin,4 showing
that in practically all of the recorded cases the ulcerations
were grossly visible. In 1924, however, Kennedy0 discov-
ered a peptic ulcer of microscopic size in an infant with
melena. This observation suggests the probability that
peptic ulcers in infants may easily escape detection, and
that their incidence may be appreciably higher than is
indicated by the literature on the subject.
Apparently multiple ulcerations of the gastric mucosa
are relatively rare in childhood. Cases of this character
have been reported by Ritter,' Homen,s Delore,0 Bar-
ber,10 Butka,11 Dunham,1- Smythe,13 Dunham and
Shelton,14 Mills,1" and Kunstadter and Gottelman.10
To this small group we add two additional cases. Fur-
thermore, the gastric ulcerations present in the two in-
fants under our observations coexisted with erythroblas-
tosis fetalis. We are not aware of other reports of peptic
ulceration complicating this disease.
The first patient was a full term male infant. The
mother was well throughout pregnancy and the delivery
was normal. Her Wassermann reaction was negative
and the infant was exclusively breast fed. Previously the
mother had given birth to two premature infants who
died at the ages of eight and thirty-two hours respec-
tively, the deaths being attributed to prematurity.
On the first day of life her third baby had a pro-
nounced jaundice and twitchings of the muscles of the
face. When admitted to the hospital at the age of three
days he was distinctly dehydrated, apathetic, limp and
icteric. The physical examination disclosed coarse moist
rales over both lung fields and a definite enlargement of
the spleen and liver. There was no evidence of inflam-
mation of the stump of the umbilical cord and the re-
mainder of the physical examination was normal. Three
hours after admission to the hospital he regurgitated a
small quantity of dark red fluid and this recurred peri-
odically until the infant expired on the fourth day of
life. Vitamin K was administered following the first
hematemesis. Throughout the period of hospitalization
the infant remained afebrile.
Examination of the blood made shortly before death
revealed a count of 1.5 million red blood cells with
marked anisocytosis, poikilocytosis and polychromato-
philia. The incidence of normoblasts was 22 per cent.
According to our laboratory studies the mother was
Rh positive, indicating that some other factor was re-
sponsible for her infant’s erythroblastosis.
The necropsy was performed immediately following
death and was limited to the thorax and abdomen. It
disclosed no evidence of inflammation of the peritoneum,
pleura, pericardium or umbilical region. The spleen and
liver were enlarged and in the latter, centers of hemo-
Plate 1.
poiesis were observed. Small hemorrhages were found in
the medulla of each adrenal and many petechial pulmo-
nary hemorrhages were present. The gastric mucosa was
studded with numerous ulcerations measuring 3 to 5 mm.
in diameter (Plate 1). Some of the ulcers extended
through the muscularis but none penetrated the serosa.
No evidence was found of thrombosis of blood vessels
adjacent to the ulcerations. The remainder of the gastro-
intestinal tract presented no gross evidence of ulceration.
The second patient with multiple gastric ulcers com-
plicating erythroblastosis fetalis was born in Charity Hos-
pital, November 11, 1941, and died twenty-four hours
later. The mother’s Wassermann reaction was negative,
and our laboratory study indicated that she was Rh posi-
tive. In this instance, also, the infant’s condition was not
related to the Rh factor.
The infant, a full term white female, weighed 8
pounds 7 ounces at birth. She was deeply jaundiced at
the time of birth and shortly following delivery she de-
veloped attacks of cyanosis which recurred periodically
until death ensued. The respirations were labored dur-
ing these attacks but the heart sounds were normal. The
liver and spleen were considerably enlarged. Examina-
tion of the blood revealed a red blood cell count of 2.4
million with a total of 101,000 nucleated red blood cells
per cu. mm. During the brief period the infant was
alive she received one blood transfusion.
The necropsy was performed two hours after the pa-
tient’s death. It disclosed no evidence of inflammation,
either of the umbilical region or of the serous mem-
branes. Small petechial hemorrhages were observed in
the thymus, epicardium, and in the lungs, and a small
amount of clotted blood was present in the left middle
cranial fossa. Since no torn intracranial blood vessels
were seen the origin of this clot was not determined.
The heart, pancreas, adrenals, kidneys, and lungs were
normal and the bile ducts were patent. The liver and
spleen weighed 295 and 80 grams, respectively, and ex-
tramedullary centers of hemopoiesis were noted in these
organs as well as in the thymus and lymph nodes. Mul-
tiple small erosions about 2 mm. in diameter were pres-
ent on the greater curvature of the stomach, but none
had perforated the serosa. The remainder of the gastro-
intestinal tract appeared to be normal.
In addition to the cases of multiple gastric ulcerations
complicating erythroblastosis fetalis, we have observed
two infants with intestinal ulcerations which perforated.
The first patient was born of a mother who at the
time of delivery was suffering from a severe diarrhea
May, 1943
133
which had been present for 24 hours. On the second
day of life the baby had six blood-streaked stools. Forty-
eight hours after the onset of the diarrhea the blood dis-
appeared from the stools but their frequency continued.
The abdomen became greatly distended and tympanitic
but this complication failed to respond to therapeutic mea-
sures. Subsequent to the development of diarrhea the
infant’s rectal temperature ranged irregularly in the
neighborhood of 103° F. The Flexner type of dysentery
bacillus was isolated from the infant’s and from the
mother’s stools, and the former was given polyvalent
dysentery serum. On the seventh day of life the baby
died following a series of attacks of cyanosis.
The postmortem examination was normal except for
changes within the abdomen. On opening the peritoneal
cavity there was an escape of gas that was evidently
under moderate pressure. The cavity contained about
100 cc. of fibrino-purulent exudate, and fecal material
was observed in the region of the ascending and trans-
verse colon.
The mucosa of the entire intestinal tract was erythema-
tous and numerous ulcerations were present in the termi-
nal ileum, cecum, and the ascending and transverse seg-
ments of the colon. In addition, two perforations mea-
suring 5 mm. in diameter were noted in the ascending
and transverse portions of the large intestine.
The second infant with intestinal ulceration was deliv-
ered by Dr. Ada Kilbingerin of New Orleans. The
mother was well throughout pregnancy and her Wasser-
mann reaction was negative.
The infant seemed to be well until it was eighteen
hours old when a rectal temperature of 101 F. developed
along with a definite abdominal distension. The fever
persisted and the distension increased but the cause of
the infant’s symptoms was not determined. The child
died at the age of forty-eight hours.
At autopsy foul-smelling gas escaped from the abdomi-
nal cavity. An acute generalized peritonitis was present,
and fecal matter was seen over the ascending colon and
small bowel. The appendix was normal but on the an-
terior aspect of the cecum about 3 cm. above the base
of the appendix a perforation with a diameter of 5 mm.
was seen. Aside from the single perforation no evidence
of intestinal ulceration was observed. The remainder of
the postmortem examination was normal, no explanation
being found for the perforation of the cecum.
In 1926 Kennedy’ 1 reported the presence of bacteria
in the crater of a duodenal ulcer in an infant three days
of age, and in 1933 Dunham1" published the records of
a newborn infant with multiple gastric ulceration due
presumably to an infection with staphylococci. In one
of our patients a perforated intestinal ulceration accom-
panied an infection with the Flexner type of dysentery
bacillus. These observations provide a rather conclusive
indication that a variety of bacteria may cause ulceration
of the stomach and intestines, but in many instances
these conditions seem to be entirely independent of in-
fection. The coexistence of gastric ulceration and ery-
throblastosis fetalis observed in two of our cases may
have been an accidental rather than a causal relationship.
This deduction derives support from the infrequency
with which erythroblastosis has been observed in infants
with peptic ulceration.
Our small group of cases provides a fair illustration of
the chief manifestations of ulcerations of the gastro-
intestinal tract and their complications in young infants.
These manifestations include hematemesis, melena, ab-
dominal distension, convulsions, cyanotic attacks and the
appearance of free air in the peritoneal cavity following
perforation.
Ulcerations of the stomach and intestine occur with
appreciable frequency particularly during the early weeks
of life, indicating the need for careful consideration of
this condition when young infants present typical or
suggestive symptoms. The disease is serious, but by no
means hopeless. In a few instances perforated peptic
ulcers have been operated upon successfully in the new-
born period, and it is probable that a larger number can
be treated satisfactorily provided the condition is recog-
nized promptly.
Summary
1. Four instances of ulceration of the gastro-intestinal
tract during the neo-natal period are reported.
2. In two of the infants multiple gastric ulcers co-
existed with erythroblastosis fetalis.
3. The coexistence of these conditions is considered
to be an accidental coincidence.
4. Two of our patients had perforated ulcerations of
the colon. In one instance the condition was due to an
infection with the Flexner type of dysentery bacillus. The
etiology of the other perforated intestinal ulcer was not
determined.
Literature Cited
1. Bird, C. E.. Limper, M. A., and Mayer, J. M.: Ann. Surg.
1 14:526, 1941.
2. Bastman, L.: Acta Pediat. 28:3 14, 1941.
3. Moore, O. M.: Canad. M. A. J. 44:462. 1941.
4. Conklin, C. B.: Internat. Clin. 2:79, 1941.
5. Kennedy, R. L. J.: Am. J. Dis. Child. 28:694, 1924.
6. Ritter, H.: Aextzl. Mitt, a Baden. 36:15, 1882.
7. Homen, E. A.: 189 (cited by Dunham and Shelton”).
8. Delore: Lyon Med. 94:301, 380, 1900.
9. Barber, C. F.: Brooklyn M. J. 16:519, 1902.
10. Butka, H. E.: J .A M. A. 89:198, 1927.
11 Dunham, E. C.: Am. J. Dis. Child. 45:229, 1933.
12. Smythe, F. W.: Am. J. Surg. 24:818, 1934.
13. Dunham, E. C., and Shelton. M. T.: J. Pediat. 4:39, 1934.
14. Mills, S. D.: Am. J. Dis. Child. 48:108. 1934.
15. Kunstadter, R. H., and Gottelman, E.: J.A.M.A. 106:207,
1936.
16. Kennedy, R. L. J.: Am. J. Dis. Child. 3 1:631, 1926.
The Journal-Lancet
Experience with Hematogenous Osteomyelitis
in Children
At the University of Minnesota Hospitals
Clarence Dennis, M.D., Ph.D.t
Minneapolis, Minnesota
ACCORDING to Key1 one-half of one per cent of
all general hospital admissions are for osteomyeli-
L tis. The age group most often afflicted is that
between 9 and 14, and boys are afflicted about twice as
often as girls. If the disease were a short-term indisposi-
tion, it would therefore not be of great economic impor-
tance, but it is still true that, for the majority of cases,
those afflicted with the disease have it for the rest of
their lives. Although the onset usually comes in the age
period indicated, no age group is immune to the disease.
Green and Shannon- collected 95 cases o f the disease in
infants under 2 years of age in 21 years at the Children’s
Hospital and the Infants’ Hospital in Boston. At the
other age extreme, Maxfield and Mitchell ’' reported five
cases in five years in private practice. At the University
of Minnesota Hospitals we have seen nine cases in the
past five years, at least one of which started in the acute
fashion of childhood osteomyelitis.
Bacteriology
Staphylococcus is by far the most important organism
in osteomyelitis. Of 697 cases collected from the litera-
ture by Key, 89 per cent yielded staphylococcus on cul-
ture; less than 5 per cent showed streptococcus; 2'A per
cent showed pneumococcus and 2 Vi per cent showed
mixed staphylococcus and streptococcus; the remainder
were typhoid and influenza bacillus. Infants differ from
other osteomyelitic patients in that they suffer from strep-
tococcic infections twice as often as from staphylococcic."
The Development of Osteomyelitis
It is generally agreed that hematogenous osteomyelitis
is the result of a combination of circumstances. In 25
per cent of cases it is possible to demonstrate a definite
lesion somewhere in the body from which a low grade
bacteremia has resulted; in the remainder of cases such
a lesion undoubtedly exists or has existed, but is of so
minor a grade as to have been overlooked by the pa-
tient.1
Trauma is usually considered to be the deciding factor
which leads to hematogenous osteomyelitis once a low
grade bacteremia has developed; a definite history of
trauma can be obtained in about 25 per cent of cases.
The question of why bacteremia results in infection in
the bones has been studied by Hobo (cited by Key) , who
found that if India ink is injected intravenously into
rabbits, it settles chiefly in the reticuloendothelial system
and in the wide capillaries of the diaphysis of the long
bones adjacent to the epiphysis. Key summarizes these
*This research was supported by a grant from the Graduate
School of the University of Minnesota. Minneapolis, Minnesota.
Through the courtesy of Dr Irvine McQuarrie and Dr. Wallace
Cole, heads of the Departments of Pediatrics and Orthopedics, re
spectively. the data presented in this paper are taken from their
records as well as from those of the Department of Surgery,
f rom the Department of Surgery, University of Minnesota.
facts thus: "If we correlate this with the fact that epi-
physeal strains are especially apt to occur in growing chil-
dren and that these may produce minute asymptomatic
hemorrhages adjacent to the epiphyseal line, then we
have a fairly rational explanation of the development of
osteomyelitis in this position."
Advance of the Disease
Deposit and growth of pyogenic organisms in the ends
of the long bones is followed by pus formation; and it
is thought that infection is more severe, spreads more
widely, and causes more toxemia than an abscess in the
soft tissue because of the rigid walls that surround it.
For the same reason, thrombosis of blood vessels also is
more extensive. The abscess gains in size and follows
the course of least resistance, until a means of escape is
found, until the patient dies in toxemia, or until the re-
sistance of the patient overcomes the disease without
drainage.
Bone necrosis occurs, and much of this necrotic bone
is absorbed, but if sufficiently large pieces become necrotic
and are surrounded by pus instead of being in contact
with osteoclasts and fixed tissue cells, absorption fails to
occur, and sequestra form. The pus escapes by virtue of
this destruction, most often into the marrow cavity, next
most often through the haversian canals of the cortex to
the subperiosteal space. From this position it may elevate
the periosteum over wide areas, escaping into the soft
tissues by virtue of perforation of the periosteum or even
back into the bone at other levels through other haversian
canals. Usually the periosteum is firmly attached at the
epiphyseal line, and pus does not therefore escape into
the joint adjacent; an exception to this is the hip joint,
where the anatomical arrangement is different. Rarely,
the infection passes directly through the epiphysis to the
joint.1
New bone production occurs wherever living osteo-
blasts retain a good blood supply and are in relation to
the infection. Such a situation obtains on the elevated
periosteum, and here new bone is formed to make the
involucrum. New bone also is believed to form through-
out the haversian canal system, leading to gradually in-
creasing density of the bone as the process becomes
older.1
The Clinical Picture in Acute
Osteomyelitis
In the typical case of acute hematogenous osteomyeli-
tis, the boy becomes severely ill in the course of a very
few hours. The temperature rises steeply, usually with
chills, and prostration quickly appears. The patient may
or may not have had pain in the involved bone or bones
prior to the onset of the symptoms of septicemia. If the
May, 1943
135
patient survives, Roentgen changes in the bone appear
in from 7 to 12 days, leaving a moth-eaten appearance
in the bone involved. Earlier changes are not apparent
because the picture depends upon resorption of bone,
which proceeds slowly. There is great variability in the
manner of onset of the disease, and some patients do
not appear acutely ill at any phase of the disease, but
the majority are extremely ill, and prostration is marked;
this is true also of infants.
It is the rule that blood culture reveals many colonies
of "coagulase positive” staphylococcus. The local signs
include exquisite tenderness in the region of the involved
bone, but this is usually not well enough localized to per-
mit certainty as to the bone involved until days have
passed. Local tissue swelling and heat and even redness
may be equally confusing, particularly in the younger
child. Definite differentiation from suppurative arthritis
may be impossible for days.
Chronic Osteomyelitis
If spontaneous or surgical drainage of the pus occurs,
usually there develops a cavity within the bone filled with
infected granulation tissue. Sclerosis of the bone occurs,
and the bone becomes less well supplied with blood than
normal and therefore less able to combat infection. From
time to time minor traumata lead to exacerbations asso-
ciated with fever, pain, and abscess formation. In some
instances, sinuses to the skin form and drain for months
or years; in others, the lesion becomes quiescent, and the
skin heals, only to become reactivated at a later date.
Coupled with these changes, sequestration occurs, and
bits of dead bone either are extruded spontaneously or
remain within the bone or soft tissues to keep the infec-
tion active until they are removed surgically. The course
in chronic osteomyelitis differs little, whether hemato-
genous in origin or due to direct contamination from the
outside.
Ultimately these patients may die of a variety of
causes, such as septicemia, metastatic suppurative proc-
esses, amyloid disease, intercurrent infections, etc.
Treatment of Hematogenous Osteomyelitis
in Children at the University of
Minnesota Hospitals
One hundred twenty-two patients under 21 years of
age were treated for osteomyelitis at the University of
Minnesota Hospitals from January 1, 1938, to January
1, 1943. It is proposed to discuss the results of a variety
of the treatments advocated in the light of this experi-
ence.
Experience with Acute Osteomyelitis. Prophylaxis is
possible to some extent in those known to have a low
grade bacteremia, following the drainage of abscesses, in
furunculosis, etc. In this group of patients, the likelihood
of development of osteomyelitis should be considerably
diminished by administration of sulfathiazole for a period
and studious avoidance of trauma. This procedure has
been followed in several cases in the recent past, but will
be impossible to evaluate until a large series has been
attained.
With regard to the management of fully developed
acute osteomyelitis, opinion is divided into several groups,
those advocating immediate radical surgery, 1 .* those
advocating operation after an interval of some days,9
those advocating nonoperative management with drain-
age of pus when it becomes apparent in the soft tissues,111
and those advocating nonoperative treatment through-
out. 11,12 Crossan1’' made a summary in 1938 of all the
methods of therapy advocated for acute osteomyelitis and
reached the conclusion that the prognosis was poor by
any method of therapy, implying that the very variety
of treatments at that time indicated the inadequacy of
any of them.
In a review of "Progress in Orthopedic Surgery in
1941,” the American Academy of Orthopedic Surgeons
concluded that neither complete conservatism nor radical
surgery is in order.11 It favors conservative operative
measures when indicated, and supportive measures, in-
cluding plaster. This policy has many advocates.2,1’,u
For several years the policy on the surgical service here
was that of immobilization and elevation in plaster until
pus became apparent in the soft tissues, demanding
drainage.10
Our experience with this method in the past five years
is portrayed in Table I. Twenty-eight cases of acute
20
£ 15
*n
O
u
° 10
k.
jQ
E
2 5
0-2 2-5 5-9 9-14 14-21
Aqe in qears
Fig. I. Relation of age of patient to the result in 37 cases of
acute osteomyelitis in children.
osteomyelitis in children treated in this fashion all went
on to chronic osteomyelitis with the exception of 2 cases
— disease in a humerus in a 2 /2 year old infant, and
in two digits in a 1 week old infant. Of the 26 cases
which went on to chronic disease, 1 died later of staph-
ylococcus septicemia with terminal meningitis, 14 have
failed to heal, and 1 1 have healed, 6 with continuation of
conservative measures, 2 with the Orr method, 2 with
the use of lucite drains, and 1 with saucerization and
sulfathiazole implantation.
Orrs and Trueta11' favor opening the bone, sauceriz-
ing, packing with vaselined gauze, and applying plaster,
changing plaster and dressings only when the odor neces-
sitates it. Orr reported a considerable series of success-
ful cases, but few others have been as successful with the
method. Pyrah and Pain1 ' lost both of the patients on
whom they tried the method.
At the University of Minnesota Hospitals, the Orr
method was applied in 4 cases of acute osteomyelitis in
the period under study; all became chronic, and all have
failed to heal.
Combinations of sulfathiazole and surgical interven-
tion have been used by many surgeons for acute osteo-
a-Hoqt treotment
b-Conservative
i mmobi I ization
c-Orr treatment
□ Chronic
ED Healed in acute phase
E3 Healed in chrome stage
■ Died in chronic stage
\ \-
a. b
b c
t
UIL
Ji
136
myelitis, 1 s. 1 but there have been few cures. It is felt,
however, that sulfathiazole helps to prevent the develop-
ment of metastatic foci during surgical procedures.
Sulfathiazole was used as the sole therapeutic measure,
aside from bed rest, by Hoyt and coworkers, in 8 cases.11
Diagnosis was established by Roentgen film, blood cul-
ture, aspiration of abscesses, or, more often, by two or
more of these measures. Even when fluctuation indicated
pus in the soft tissues, they continued with nonoperative
management, and found the abscesses usually resorbed
without drainage. There were no deaths, only one case
drained spontaneously, and 7 of the 8 were apparently
healed completely at the time of the report. The blood
levels were kept at about 3 to 4 milligrams per 100 cc.
of blood for a period of some two months on the average.
Since publication of the original article, this group has
increased the number of cases to 17 with equally encour-
aging results.12
Up to January 1, 1943, 5 cases of acute osteomyelitis
have been treated at the University Hospitals with bed
rest, with or without plaster, and sulfathiazole by mouth
over fairly long periods. This treatment, initiated by
Drs. Spink and Paine in April, 1940, has been used with
some success since in a few cases, although the tendency
has been to drain when Roentgen changes have occurred.
Of 5 cases so treated, 4, all under 5 years of age, healed
without going into the chronic stage, and one became
chronic.
A still more recent development is the use of penicillin
in the treatment of the disease. This drug is particularly
valuable because many times the organism becomes re-
sistant to the sulfonamides as shown by Spink.21 Florey
and his group have given penicillin to 3 patients with
osteomyelitis, with apparently some benefit in each of
them.22 The chief drawback is the tremendous cost of
the drug.
Studies with the more specialized methods of chemo-
therapy are in progress under Spink at this hospital.
Among the whole group of patients with acute osteo-
myelitis seen, a most striking observation has been the
difference in results associated with differences in age.
Of 7 patients under 5 years of age, 6 healed without
passing into the chronic stage, and the seventh healed
later (after saucerization and sulfathiazole implantation) .
This experience tends to support the statements of Green
and Shannon, that osteomyelitis in infancy is a disease
from which recovery under conservative management is
the rule.
Experience with Chronic Osteomyelitis. Baer’s maggot
treatment for chronic osteomyelitis23 and the Carrel-
Dakin therapy have been widely abandoned, and neither
has been used at all here in the past five years. The bulk
of the patients suffering from chronic osteomyelitis have
been treated here in an expectant fashion, paying no
attention to drainage as long as incapacitation did not
result. Sequestrectomies have been performed, whenever
drainage or fever has increased and Roentgen evidence of
sequestra has been present. Plaster immobilization has
been employed whenever increased fever, tenderness, or
drainage has been manifest.
Chart II indicates our experience under this regimen.
Aqe in qears
Fig. II. Lack of relation of age of patient and end result in
chronic osteomyelitis treated by conservative measures.
Although the number of patients in the younger age
groups is small, it seems apparent that the situation of
the younger patients with the chronic disease is not as
much more favorable than that of the older ones as is
the case in acute osteomyelitis. This general impression
is borne out under other treatments of the chronic dis-
ease also.
Our experience with all the chronic group is por-
trayed in Chart III. Of 47 patients treated expectantly,
4 died (one amyloid disease, 2 septicemia, and one men-
ingitis), and 17 healed. The period of treatment required
for healing usually was a period of several years, although
a very few healed in a matter of months. Of the group
of 26 cases which remained in the chronic stage, the bulk
were followed for years. A most impressive observation
on this group has been the great likelihood of recurrence,
even after years of remission.
Nine patients with chronic osteomyelitis were treated
here by the Orr treatment, and 3 of these ultimately
healed. In 5 cases entire bones were removed, with or
without sulfonamide implantation, and apparently com-
plete healing has occurred in 3 of them.
One of the earliest reports on the use of sulfathiazole
for chronic osteomyelitis in the literature is that of Paine
and Spink from this clinic.21 They saucerized the tibia
in a 7 year old girl, and implanted 5 grams of sulfa-
thiazole, closing the wound primarily. The wound healed
primarily, and the patient is still symptom-free. A sec-
ond patient was similarly treated, but at the time of the
report it was too early to know what the result would be;
this patient ultimately failed to heal.
Dickson and associates20 reported 18 cases so treated;
14 healed primarily, 2 failed to heal, and 2 were too re-
cent to allow judgemnt. Key20 has had similar results,
securing primary healing in 14 out of 17 cases. Baker2'
has observed that primary closure after saucerization and
implantation of sulfathiazole is usually successful, but
that if the wound is packed open after the implantation
of the drug, results are no better than if the sulfonamide
were not used at all. This observation may explain the
failure of a case which was so treated by Spink and the
author in February, 1940, apparently one of the first
cases to receive sulfathiazole implantation.
137
May, 1943
at time of treatment.
33 other children are still under treatment all are promising.
5 adults have also been treated with encouraging results. Ref.:
"Treatment of Chronic Osteomyelitis by Prolonged Dependent
Drainage."
N. B.: In addition, 2 patients received no therapy and remained
with drainage: one received sulfathiazole locally without sauceriza-
tion without benefit, and 2 were treated with chemotherapeutic
means to be reported by Dr. W. W. Spink.
Our complete experience with the Paine-Spink-Dick-
son treatment is summarized also in Chart III. Of 6
children, 5 are apparently completely healed. Several
adults have also been so treated; and the total figures for
hematogenous osteomyelitis show rapid and clinically
complete healing in 7 of 12 cases, but in no instance has
the Roentgen appearance returned to normal. Of 2 addi-
tional adults, with chronic osteomyelitis resulting from
fractures of the lower end of the femur, one has healed
and one has not.
Seven patients with chronic osteomyelitis have been
given bed rest and sulfathiazole by mouth for prolonged
periods. In no instance has healing resulted, but in 2
cases with pain but no drainage, the pain has been re-
lieved.
Finally, prolonged dependent drainage with "lucite”
drains has been used in a series of 7 children and 5
adults. ~s The period for healing seems to be about 13
to 18 months. Of 4 children in whom this therapy has
been adequately applied, complete healing seems to have
occurred in 3. This method is of particular value in
sites in which insufficient soft tissues are present to fill
the defect after saucerization and sulfathiazole implanta-
tion.
Comment
In view of the small number of cases studied, and the
fact that each type of treatment was selected expressly
for the case in hand, one cannot draw statistically sound
conclusions concerning all the measures discussed. Nev-
ertheless, it does seem justifiable to conclude on the basis
of the figures presented and observation of the cases dis-
cussed that acute osteomyelitis in very young children is
a more benign disease than in older individuals. It ap-
pears, also, that prolonged bed rest, best with plaster fixa-
tion, with oral maintenance of a sulfathiazole blood level
of 3 to 3 milligrams per 100 cc. is the most effective
measure in early acute osteomyelitis, regardless of the
age of the patient. In the chronic disease, the choice
would appear to lie between saucerization, sulfathiazole
implantation, primary closure, and plaster on the one
hand, and prolonged dependent drainage with lucite
tubes on the other.
References
1. Key, J. Albert: Osteomyelitis, System of Surgery by Dean
Lewis, Hagerstown. Maryland, W. F. Pryor Co., 1941.
2. Green, W. T., and Shannon, G.: Osteomyelitis of infants:
a disease different from osteomyelitis of older children. Arch. Surg.
32:462 (March) 1936.
3. Maxfield, J. E., and Mitchell, C. L.: Acute hematogenous
osteomyelitis in the adult, J. Bone Joint Surg. 24:647 (July)
1942.
4. Hart, V. L.: Acute hematogenous osteomyelitis in children,
J.A.M.A. 108:524, 1 937.
5. Fraser, J.: Acute osteomyelitis, Brit. M. J. 2:539 1934
(cited by Key) .
6. Robertson, R. C.: Acute hematogenous osteomyelitis: analy
sis of 75 cases. J.A.M.A. 107:1 193, 1 936 (cited by Key).
7. Conwell, H. E., and Sherrill, J. D.: Acute osteomyelitis in
childhood: diagnosis and treatment. South. M. J. 30:171, 1937
( cited by Key ) .
8. Orr, H. Winnett: The treatment of osteomyelitis and other
infected wounds by drainage and rest, Surg. Gyn. 6c Obst. 45:446
(October ) 1 927.
9. Wilson, J. C. : The delayed operative treatment of acute
hematogenous osteomyelitis. Surgery 9:666 (May) 1941.
10. Wangensteen, O. H.: The importance of immobilization
and posture in the treatment of acute infections of the extremities,
Minn. Med. 21:225, 1938.
11. Hoyt. W. A.. Davis, A. E., and Van Buren. G.: Acute
hematogenous staphylococcic osteomyelitis: treatment with sulfathia
zole without operation. J.A.M.A. 117:2043. 1941.
12. Kramer, James G.: Personal communication. (821 2nd
National Bank Bldg., Akron, Ohio.)
13. Crossan, E. T.: Conservative treatment of acute hematoge-
nous osteomyelitis, Ann. Surg. 103:605 (April) 1936.
14. American Academy of Orthopedic Surgeons: Progress in
orthopedic surgery for ’41. Arch. Surg. 45:792 (Nov.) 1942.
15. Wilensky, A. O.: Value of chemotherapy in the treatment
of osteomyelitis. Arch. Surg. 44:234. 1942.
16. Trueta, J.: Treatment of War Wounds and Fractures with
Special Reference to the Closed Method as Used in the War in
Spain, New York City, Paul Hoeber (Harper Bros.), 1940
17. Pyrah. L. N., and Pain, A. B.: Acute infective osteomyeli
tis; a review of 262 cases, Brit. J. Surg. 20:590, 1933.
18. Key, J. Albert: The early operative treatment of acute
hematogenous osteomyelitis. Surgery 9:657 (May) 1941.
19. Penberthey, G. C.. and Weller, C. N.: Chemotherapy as an
aid in the management of acute osteomyelitis, Ann. Surg. 44:129,
1941.
20. Melton, G.: Sulfathiazole in staphylococcic infections,
J.A.M.A. 115:471 (August) 1940.
21. Vivino, J. J., and Spink, W. W.: Sulfonamide-resistant
strains of staphylococci; clinical significance, Proc. Soc. Exp. Biol.
6c Med. 50:336, 1942.
22. Abraham, E. P., Chain, E., Fletcher, C. M., Gardner, A. D.,
Heatley. N. G., Jennings, H. A., and Florey, H. W.: Further ob-
servations on penicillin. Lancet 2:177 (August) 1941.
23. Baer. W. M.: Treatment of osteomyelitis with maggots,
Jour. Bone 8c Joint Surg. 1 3:438 193 1.
24. Spink, W. W., and Paine, J. R.: Local use of sulfathiazole
in treatment of staphylococcal infections; preliminary report, Minn.
Med. 23:615 (September) 1940.
25. Dickson, F. D., Diveley, R. L., and Kiene, R.: The use of
sulfathiazole in the treatment of subacute and chronic osteomyelitis,
J. Bone 8c Joint Surg. 23:516 (July) 1941
26. Key, J. A.: Use of sulfanilamide and sulfathiazole in ortho-
pedic surgery, J.A.M.A. 113:409 (August 9) 1941
27. Baker, L. D.: Acute osteomyelitis with staphylococcic septi
cemia; clinical report on use of chemotherapy and staphylococcic
antitoxin in its treatment, South. M. J. 34:619 (June) 1941.
28. Dennis, Clarence: Treatment of chronic osteomyelitis by
prolonged dependent drainage, Surgery. In press.
138
The Journal-Lance i
Responsibilities of the Physician in the Problem of
Rheumatic Fever in Children
Arild E. Hansen, M.D., Ph.D.f
Minneapolis, Minnesota
IN light of the great progress made during the past
two decades in securing public and professional sup-
port for extensive programs aimed at the control of
two other serious diseases of childhood, namely, tubercu-
losis and poliomyelitis, it is difficult to understand why
recognition of rheumatic fever as a major devastator of
our children has been so tardy. Again it is the war which
has compelled us to give attention to an important prob-
lem, admittedly neglected in peace time. Examination of
the figures of the Selective Service, as presented by
Roundtree et al.1 reveals that defects of the cardiovas-
cular system are responsible for the largest number of
rejections among young men who are disqualified for
any military service. It is well known that most of the
individuals who survive acute rheumatic infection in
childhood carry scars in the heart valves. This fact, to-
gether with the knowledge of the high incidence of rheu-
matic disease in school children, justifies the assumption
that rheumatic infections during the childhood period
play the major role in producing the total physical unfit-
ness due to cardiovascular disease in young adults.
The practicing physician is fully aware of the impor-
tance of the social, educational, economic, public health,
geographic and military aspects of the rheumatic fever
problem. He is likewise thoroughly sympathetic with
investigative work which promises to clarify the funda-
mental etiology of the disease. However, his greatest re-
sponsibility at the present time is that of learning to
diagnose the disease in its early stages. Being aware of
its protean manifestations, he will welcome the time when
more specific diagnostic tests are developed which will
enable him to direct the care of his patients more suc-
cessfully. He, above all p>eople, is cognizant of the need
for a really effective form of specific therapy for the
active disease. In lieu of such a boon, however, he must
be content, for the present, with measures which amel-
iorate the condition in any way. The fact that methods
have been brought forth which appear to be effective in
preventing recrudescences of the disease offers some en-
couragement. The purpose of the present paper is to
consider those aspsects of the rheumatic fever problem for
which the physician has direct responsibility, namely,
diagnosis, treatment and prevention of recurrences.
Diagnosis
Of prime necessity in the diagnosis is thorough famil-
iarity with the extremely variable manifestations of rheu-
matic fever in children. These have been discussed at
length by many writers, so only cursory mention of the
main categories is given here for orientation: (a) chorea
minor, (b) subcutaneous fibroid nodules, (c) rheumatic
arthritis, (d) rheumatic carditis (pericarditis, myocardi-
tis, endocarditis-pancarditis) , (e) rheumatic erythema or
tOf the Department of Pediatrics, University of Minnesota.
purpura, (f) miscellaneous tissue — throat, kidneys, and
serous membranes, (g) general evidences of infection.
Valuable information in making the diagnosis of rheu-
matic fever is obtained by routine laboratory studies, sedi-
mentation rate of the erythrocytes, electrocardiographic
and roentgenologic findings. Text books and various ar-
ticles mention about fifty different conditions whose
manifestations are such that they may be considered in
the differential diagnosis of rheumatic fever. ~ The author
has tried to simplify the diagnosis of rheumatic fever
from a practical pioint of view by studying hospital rec-
ords; first, by consideration of disorders which were be-
lieved to be rheumatic fever and subsequently found not
to be, and second, by consideration of diseases thought
to be responsible for the symptoms which were actually
due to rheumatic infection.
The case records of 982 children admitted to the p>e-
diatric wards of the University of Minnesota Hospital
during the year 1941 were studied in regard to the diag-
noses made on admission by the intern and resident staff
members and referring physicians. Over one-half of
these children were between 5 and 15 years, the usual
age incidence of rheumatic infection. Rather surprising
was the fact that rheumatic fever was mentioned in the
differential diagnosis on 20 occasions. The conditions
which proved to be responsible for the symptoms in these
children were:
Acute osteomyelitis 4
Hyperthyroidism 3
Leukemia 2
Acute glomerulonephritis 2
Poliomyelitis 1
Hodgkin’s disease 1
Hysteria 1
Catarrhal jaundice 1
Chronic infectious arthritis 1
Recurrent tonsillitis 1
Idiopathic hypoprothrombinemia
(symptomatic purpura) 1
Purulent pericarditis 1
Toxic myocarditis following scarlet fever with
mastoiditis and lateral sinus thrombosis 1
It is evident from the foregoing list that a wide variety
of disease states may present symptoms which simulate
those of rheumatic infection. Patients having such symp-
toms constituted nearly 3 per cent of the total number
of school-age children admitted to the Hospital. If ob-
viously non-rheumatic patients, such as those admitted
for treatment of congenital deformities, fractures, dia-
betes and epilepsy, are excluded from consideration, the
incidence of cases in this series presenting signs or symp-
toms suggestive of rheumatic infection is found to be
slightly more than 10 per cent.
It may be very difficult at times to ascertain the true
diagnosis early in the course of acute osteomyelitis; that
this occurred on four occasions during the period studied
May, 1943
139
is significant. In three children with hyperthyroidism
there was sufficient similarity in the manifestations to
cause chorea minor to be mentioned as a diagnostic pos-
sibility. Children in the early stages of acute lymphatic
leukemia may present symptoms and signs suggesting
acute rheumatic fever, such as arthritic-like pain, hemic
murmurs, epistaxis, and fever. During the year 1941,
two such cases were encountered and another was seen
during the past winter. Similar cases have been reported
in detail by a number of authors. In one instance in this
series, acute rheumatic fever was the diagnosis given
when the patient was suffering from infantile paralysis.
This is especially likely to occur in the non-epidemic cases
of poliomyelitis, because of the prominence of joint and
muscle pain.
From a somewhat different point of view, namely that
of cardiac involvement, confusion arose because of ne-
phritis. Cardiac failure may occur in children with acute
glomerulonephritis, a phenomenon which has been
stressed by Rubin and Rapaport,4 and this fact explains
the mistaken diagnosis of acute rheumatic fever in the
two cases here encountered. The child with Hodgkin’s
disease had complained of pain in various parts of the
body for some weeks before the diagnosis was finally
established by histologic examination of a biopsy speci-
men. The 10 year old boy in whom rheumatic fever was
strongly suspected but who proved to have hysteria, com-
plained of polyarthralgia for a period of several months
before coming to the hospital. Previous administration
of salicylates had been ineffective. On admission to the
hospital the sedimentation of the erythrocytes was found
to be normal. Rather dramatically in a few days the
symptoms subsided without the aid of therapeutic mea-
sures and further questioning by the interns and psy-
chiatric staff revealed distinct conflicts in the child’s life.
The diagnosis of hysteria seemed fully justified in view
of later findings.
There is a little more difficulty in understanding why
the child with jaundice was thought to have rheumatic
fever although he had complained of abdominal and
body pain for some time before the icterus was noted.
Confusion of acute rheumatic fever with chronic infec-
tious arthritis is not unusual during the early phase of
the latter disease as was the situation in the patient in
this series. The association of body aches and pains with
upper respiratory infections, no doubt explains why one
boy was thought to have a rheumatic infection when he
had closely recurring episodes of acute sore throat. Re-
moval of the tonsils in this patient seemed to be dis-
tinctly beneficial. In the case of the young girl with
purpura, epistaxis, and pains in the extremities who was
believed to have a rheumatic infection, the diagnosis was
determined mostly by exclusion. This was a most un-
usual type of case, in that there was prolongation of the
prothrombin time in the absence of other evidence of
liver disease. Rheumatic fever was present in several
members of the family and one brother now has a severe
rheumatic infection. Detection of a friction rub led to
the diagnosis of rheumatic fever in the child with puru-
lent pericarditis, but pericardial tap revealed an exudate
containing pus and staphylococci. Recovery followed
treatment with sulfapyridine. In the last of the 20 pa-
tients in whom the diagnosis of rheumatic fever was con-
sidered a possibility, the child had a hemolytic strepto-
coccal infection; a loud cardiac murmur caused the diag-
nosis of rheumatic fever to be made.
Many other conditions exist which may present symp-
toms similar to those found in children suffering from
various rheumatic infections. Some of these are rare.
Meningococcemia may cause symptoms of polyarthritis
and present a clinical picture simulating rheumatic fever.
No such case was encountered during the time this study
was made, although Dysorn' recently had an example in
which the findings so strongly suggested rheumatic fever
that sulfonamide drugs were avoided until three weeks
later when blood cultures revealed the causative organ-
ism. The response to chemotherapy was prompt, and re-
covery ensued. No children with undulant fever were
seen during the time of this study.
Apparently, difficulty in differential diagnosis results
chiefly from failure to recognize rheumatic infection in
children. I recently reported * a review of the diagnoses
made by admitting interns and practicing physicians in
271 children with rheumatic fever who were referred to
the Department of Pediatrics of the University of Min-
nesota Hospital over a period of 12 years. There was
agreement between the diagnoses made on admission and
those finally made in two-thirds of the cases. In only
19 of the 96 cases with chorea minor was there not com-
plete agreement in the diagnoses. Of especial interest
are the remaining one-third, 90 cases of all types in which
there was no agreement between the admitting and refer-
ring diagnoses. Of these, diagnoses could well have been
made in 15 instances. The conditions causing confusion
in making the correct diagnoses in the other 75 cases are
outlined below without referring to the actual number of
cases in each group.
A. Nervousness, as a symptom of chorea minor.
B. Skin lesions, erythema, purpura.
C. Nephritis.
D. Low grade infections.
E. Acute fulminating illness.
F. Osteomyelitis.
G. Poliomyelitis.
H. Appendicitis.
Chorea minor is readily diagnosed. However, it would
appear that the diagnosis could well have been made
earlier in the course of the disease in a number of in-
stances. To detect evidence of the disturbed muscle
tonus in the early stage of the disease and in the mild
cases, we employ the procedure popularized by Dr. Ir-
vine McQuarrie. Although a number of methods of ex-
amination are useful, this test seems to fit readily into
the routine physical examination. The examiner places
his hands, palms upward, in front of the patient, and the
child while sitting comfortably is first requested to place
his hands palms downward upon the hands of the exam-
iner, then to place his tongue between his lips without
touching the teeth. The subject is asked to sit as still as
possible for a few moments. Even the six-year old child
is able to remain very quiet under these conditions. One
140
The Journal-Lancet
may observe evidences of jerking of certain muscle
groups, facial grimacing or feel the dystonia in the fin-
gers. Evidence of weakness of muscle may be obtained
by asking the child to grasp the fingers of the examiner
and to hold firmly. The patient with chorea usually
grasps firmly, loosens the hold, and grips tightly again,
often with much gusto. Repeated use of the so-called
finer tests soon acquaints one with normal responses. If
the physician becomes suspicious of the reaction, he
should inquire directly and indirectly of the mother for
evidence of emotional instability or personality change in
the patient. By the use of such procedure, many of the
cases of chorea may be detected earlier and unsuspected
mild cases may be brought to light.
There are other types of conditions which appeared to
cause confusion in the diagnosis of rheumatic fever in
the cases studied. Erythematous and purpuric skin lesions
may occur in children with rheumatic fever, which may
often be of value in arriving at the diagnosis. Albumin-
uria and microscopic hematuria may be found in acute
rheumatic fever. Oftentimes other manifestations of the
disease may be so mild that nephritis may be suspected.
A real problem is found in those patients who have low
grade rheumatic infection yet are not diagnosed as such.
One must be aware of the fact that many patients with
rheumatic fever, before they have a severe episode, will
have a preceding history of such symptoms as slight an-
orexia, loss of or failure to gain in weight, weakness, per-
sonality change, easy fatiguability, occasional epistaxis,
pallor and mild pains in the muscles and joints. On the
other hand, there are times when the patient with rheu-
matic fever is so acutely ill that he is suspected of having
sepsis of some type. Often a case of carditis is diagnosed
as "flu” or pneumonia from which recovery is slow. Un-
der these conditions rheumatic fever should be suspected
and the heart carefully examined. In this general group
were six patients who were sent to the hospital with the
diagnosis of subacute bacterial endocarditis, all of whom
were actually suffering from severe rheumatic infection
without this complication. Subacute bacterial endocarditis
may occur in the child but far less frequently than in the
adolescent or young adult. The fact that during the in-
terval the study was made, four children were sent in
with the diagnosis of poliomyelitis is significant. During
the past two years a number of children have been re-
ferred to both the University Hospitals and the Minne-
apolis General Hospital because of possible poliomyelitis
but they were actually suffering from acute rheumatic
fever. We believe the reason for this is the apparent
desire on the part of the physician or parent to obtain
the Sister Kenny treatment being carried on at these in-
stitutions. Finally and most surprising in this series of
cases, was the fact that appendicitis was frequently con-
fused with rheumatic fever. In 25 per cent of the 75
cases in whom the diagnosis was missed, the presence of
abdominal pain caused the diagnosis of appendicitis to
be given or strongly suspected. Abdominal pain fre-
quently occurs in patients suffering from rheumatic in-
fections, but its appearance as the prominent symptom
in so many instances was amazing.
On the basis of this study of case records in the De-
partment of Pediatrics at the University of Minnesota,
the conditions which most frequently must be consid-
ered from a practical point of view in the differential
diagnosis of acute rheumatic infection in children are:
1. Appendicitis.
2. Poliomyelitis.
J. Osteomyelitis.
4. Acute glomerulonephritis.
5. Leukemia.
6. Hyperthyroidism.
7. Skin manifestation (erythema, purpura).
8. Evidences of low grade infection.
9. Acute fulminating infections, such as septicemia
Treatment
The methods of treatment of acute rheumatic fever in
children have shown very little change in the past few
years. The most important single fact emphasized by
many writers is that the sulfonamide drugs are ineffec-
tual in the treatment of the active disease. The most sig-
nificant effective measure is strict bed rest. Whether
dealing with pain, choreiform movements, or cardiac de-
compensation, the treatment is symptomatic and in each
case must be individualized. Of more interest in recent
years is the matter of the prevention of recrudescence,
which is perhaps the most characteristic feature of rheu-
matic infection. The physician must therefore assume
responsibility for continuous care and advice for any
patient who has suffered a rheumatic episode.
Recognition of recurrence: Not only should the physi-
cian be able to detect evidence of the recrudescence in
its incipiency, but he should also acquaint the parents
with the fact that it is likely to occur and should request
that the parents bring the patient in for examination
periodically whether or not any suspicious symptoms
arise. Flare-ups of rheumatic fever are especially likely
to occur following upper respiratory infection, such as a
sore throat, scarlet fever, measles, varicella and rubella.
Extensive studies have shown that continuous observa-
tion materially reduces the mortality of this disease.
Nutritional and hygienic factors: Patients who have
suffered an attack of rheumatic fever should at all times
be maintained on a complete nutritious diet (milk, meat,
eggs, butter, vegetables, fruits, whole wheat or enriched
cereals and breads, and cod liver oil or its equivalent in
vitamins A and D and iron, if anemia is present) . This
must be done, even if it is necessary to request help from
the rationing board or social agencies. Regular sleeping
habits, preferably with an afternoon rest period, should
be prescribed. Advice regarding the avoidance of fatigue,
needless exposure to the elements or to infections and in
the use of proper clothing should be given.
Removal of foci of infection: Removal of the tonsils
and adenoids will not prevent further attacks of rheu-
matic fever, but, if indication for their removal exists
independent of the rheumatic infection, the procedure
should be done, and sulfonamide compounds used pro-
phylactically during this time. Infections in the teeth
and the sinuses should be eradicated.
Change of climate: There is considerable evidence that
recurrences are less likely to develop, if the patient can
May, 1^43
14 1
live in such localities as Southern Florida, Cuba or
Puerto Rico, Arizona and Southern California. In most
cases, however, moving to a more favorable climate is
out of the question.
Social and economic conditions: At times, the physi-
cian in certain cases can make recommendations to rela-
tives or social agencies to keep the patient in more favor-
able environmental conditions. If physicians assume full
responsibility in regard to the rheumatic infections, they
can help to prevent too great expansion in the direction
of governmental control of those patients in the relatively
less favored social and economic conditions.
Sodium salicylate as a prophylactic agent: Recently
Coburn'’ of Columbia University has used sodium salicyl-
ate (4-6 gms. daily to adults and 2-4 gms. daily to chil-
dren) to prevent recrudescences in certain subjects who
have had rheumatic infections. If, at the time the patient
suffers an acute upper respiratory infection, hemolytic
streptococci Group A are cultured from the throat, sal-
icylates are prescribed for use continuously for a period
of one month. By so doing, according to this worker,
the chances of a flare-up of the disease are greatly re-
duced. The matter of obtaining satisfactory throat cul-
tures during each respiratory infection in children would
be difficult in private practice, so that this type of pro-
phylaxis may be more valuable in institutions.
Sulfonamides in the prevention of recurrences: A num-
ber of investigators have shown that recrudescences of
rheumatic fever are far less likely to occur if one of the
sulfonamide compounds is taken daily throughout the
season (October to June) that recurrences usually de-
velop. Most workers recommend sulfanilamide 10 grains
(0.67 gms.) twice daily for this purpose, and almost uni-
formly favorable results are reported. If this type of
therapy is to be used, the situation should be discussed
with the patient and the parents in order that they may
understand the purpose of the procedure, to insure
proper cooperation. The aim is to prevent a recurrence
which may prove fatal or at least render additional dam-
age to the heart. Absence of active rheumatic infection
must be determined before the drug is used. It is well
to begin with smaller doses, 5 grains (0.3 gms.) once or
twice daily, and to check the hemoglobin, white cell
count, differential white cell count and urine at bi-
weekly or at least weekly intervals for the first three or
four weeks. If toxicity to the drug is to develop it
usually does so within the first two or three weeks.
Levels of the drug in the blood should be determined
if at all possible, 2 to 3 mg. per 100 cc. of blood being
desirable. Knowledge of the levels of sulfanilamide helps
to detect those patients who are not cooperating or are
careless in taking the drug regularly. If leucopenia,
neutropenia or anemia occurs, the drug should be dis-
continued. This type of regime, will not prevent recur-
rences during the first two weeks. If signs of a flare-up
should appear shortly after the use of the drug has been
instituted it is presumptive that the rheumatic infection
was still active. So far sulfanilamide prophylaxis seems
to be the most practical of the measures employed to pre-
vent recrudescences of rheumatic fever, but with it, the
physician should keep the patient under observation at
all times.
References
1. Roundtree, L. G., McGill, K. H., and Folk. O. H.: Health
of selective service registrants, J.A.M.A. 1 18:1223, 1942.
2. Hansen, Arild E.: The differential diagnosis of rheumatic
fever, Nebraska M. J. 26:159, 1941.
3. Hansen, Arild E.: Conditions causing confusion in the
diagnosis of rheumatic fever in children, J.A.M.A. 121:987, 1943
4. Rubin, M. I., Rapoport, M.: Cardiac complications of acute
hemorrhagic nephritis. Am. J. Dis. Child. 55:244, 1 938.
5. Dyson, James Everett, Des Moines, Iowa: (personal com-
munication ) .
6. Coburn, Alvin F., and Moore, Lucile V.: Salicylate prophy
laxis in rheumatic fever, J. Pediat, 21:1 80, 1 942.
Third Annual Journal-Lancet Lecture
University of Minnesota
Medical School
The Third Annual Journal-Lancet Lecture in the
Medical School of the University of Minnesota will be
delivered by Professor Ernst Gellhorn, M.D., of the
Medical School of the University of Illinois. The lec-
ture will be delivered at 8 P. M., Wednesday, May 19,
1943, in the Amphitheater, Room 15, of the Medical
Sciences Building of the University. Professor Gell-
horn’s subject will be "Experimental Studies on Condi-
tioned Reactions and Their Implications for Medical
Problems.”
The 1943 Journal-Lancet Lecturer has been Pro-
fessor of Physiology at the University of Illinois since
1933. Prior to that time he held a similar post at the
University of Oregon, and earlier at the University in
Halle, Germany. He has been for eight years liaison
Professor between the Departments of Psychiatry and
Physiology, working under a Rockefeller Foundation
grant to the University of Illinois. His main field of
investigation has been neurophysiology, with especial ref-
erence to clinical physiological problems. He is the
author of many important original research papers, and
several books, the last of which was published in 1942
and is entitled Autonomic Regulations — Their Impor-
tance to Physiology and Psychiatry.
Professor Gellhorn has made particularly important
contributions to the study of specific physiological dis-
orders in patients with nervous and mental diseases. He
has been a pioneer in the endeavor to bring psychiatric
problems into the scope of study by physiological
methods.
The first Journal-Lancet Lecturer was Dr. Rene
Dubos, Professor of Comparative Pathology at Harvard
University, and the second, Dr. Herald R. Cox of the
United States Public Health Service.
142
Thk Journal-Lanci:i
The Problems and Control of Dental Caries in
Children
J. W. Knutson, D.D.S., Dr.P.H.f
W. D. Armstrong, Ph.D., M.D.t
Minneapolis, Minnesota
ALMOST half of the first two million men exam-
ined under the present Selective Service Act were
k rejected because of physical defects. In com-
menting on this finding, Ciocco, Klein and Palmer state,1
"Complacency about the Nation’s health engendered in
late years by emphasis on the declining mortality and
the so-called increase in longevity received something of
a shock recently when the results of physical examina-
tions of selectees were made public. . . . The immediate
reaction based on the exigencies of the moment has been
to consider the 'rehabilitation’ of men found defective.
However, in keeping with the objectives of modern med-
ical science it is appropriate to inquire into the possibili-
ties of preventing the conditions which led to disqualifi-
cation of men as soldiers.” Since dental defects, the lead-
ing cause of rejection, was responsible for 20.9 per cent2
of all rejections, and since the disease, dental caries, is the
principal cause of dental defects in persons below age
35 years, it becomes of major importance to examine our
present knowledge of the problem and control of dental
caries.
The findings of several dental surveys3,4,5 indicate
that dental caries is the most prevalent chronic disease of
children in the United States. The data in Tables I
and II on the prevalence of dental caries in children of
Nicollet County, Minnesota, were collected recently
(1940-41) by the United States Public Health Service
in cooperation with the Minnesota Department of
Health. These data illustrate the common finding that
more than 90 per cent of children aged 6 years have
dental caries in the deciduous teeth and that more than
90 per cent of children aged 14 years have one or more
carious permanent teeth. The average number of carious
teeth per child for each age group indicates the manner
in which carious defects accumulate with age.
Although the etiology of dental caries is not fully
known, the chemicobacterial theory proposed by Miller*'
in 1887 is generally accepted as a broad fundamental
description of the carious process. The theory holds that
dental decay is a progressive decalcification of the enamel
and dentin by lactic acid formed as a result of fermen-
tation of carbohydrates. On the basis of this broad con-
cept of the disease, four major methods for the preven-
tion and control of dental caries have been advocated
and promoted. These are: (1) oral hygiene, (2) nutri-
tion, (3) restriction of carbohydrates in the diet, (4) in-
terruption of the carious process by treatment with dental
filling materials.
The first three of these represent preventive methods
which have been promoted in this country for the past
t Passed Assistant Dental Surgeon, Division of Public Health
Methods, National Institute of Health, United States Public Health
Service.
tFrom the Dental Research Laboratory, University of Minnesota.
two or three decades. However, since available evi-
dence1, 4,i>, 1 indicates that the incidence of dental caries
has not decreased in this country, it is generally agreed
that singly or in combination these preventive procedures
have failed. Failure may have been due to basic defects
in the methods or to deficiencies in their application.
Considerable evidence has been accumulated in recent
years which partially explains why these measures have
not been successful in reducing the incidence of caries.
The oral hygiene method is founded on the assump-
tion that caries is caused by acids formed by mouth or-
ganisms from foods adherent to tooth surfaces and there-
fore the process can be prevented by removing the sub-
strate by proper use of the toothbrush. Although the
sale and use of toothbrushes and tooth cleansing agents
have increased tremendously, the expected reduction in
dental decay has not yet been demonstrated. Recent find-
ings of Fosdick and co-workers8 have a significant bear-
ing on this subject. These workers found that when free
sugar was placed in an open cavity or in a so-called
caries-susceptible area, the pH dropped to levels as low
as 4.0 in three minutes. This fact, together with the
finding that saliva or dissolved enamel neutralizes the
acids in a comparatively short time, indicates that most
of the damage to the tooth is done during or shortly
after meals. In general the timing of the toothbrushing
habit has not been in conformity with these observations.
The second method, nutrition, is based on a common
approach to the prevention of many diseases, namely,
increasing the resistance of the host. Since teeth are cal-
cified structures, it seemed likely that resistance to de-
calcifying forces could be increased by fortifying the diet
with calcifying elements for the proper formation of the
teeth and for the maintenance of their integrity. Defec-
tive tooth structure may be produced in laboratory ani-
mals by feeding them on diets markedly deficient in one
or more of the calcifying components, calcium, phos-
phorus, and vitamin D. Rigidly controlled experiments
have failed to prove, however, that dental caries can be
prevented by fortification of the diet.3,10,11,14 Further-
more, studies12,13 on population groups indicate that per-
sons with evidence of gross deficiencies in nutrition, such
as rickets and osteomalacia do not have more dental
caries than other members of the same population groups
who are without signs of dietary deficiency diseases.
The third method for the prevention of dental caries —
restriction of carbohydrates in the diet — might be includ-
ed under the discussion of nutrition. However, this
method is concerned solely with an attempt to withhold
from the diet the nutrient substance required by mouth
organisms for the rapid production of acids. The work
of Bunting and Jay14 indicated that prevention of dental
Mav, 1943
143
caries by rigid restriction of carbohydrates in the diet is
possible. Confirmatory evidence has been presented by
several independent investigators.1 0,16 Forces operating
to render this method of caries prevention impractical
can be noted from the fact, for example, that in the
United States the annual consumption of sugar per per-
son has shown a steady increase from 8 pounds in 1823
to 108 pounds in 1940.
Although we have not been successful in reducing the
incidence of dental caries in children of this country by
preventive measures, either because of basic defects in
the methods or in their application, long clinical experi-
ence has established that the loss of teeth attacked by
caries can be prevented or indefinitely postponed by
proper treatment and placement of dental filling ma-
terials. Quantitative evidence presented recently sup-
ports the acknowledged effectives of this procedure for
the prevention of tooth loss. For example, Nicollet
County school children had slightly more carious perma-
; nent teeth than children in Hagerstown, Maryland, yet
they had lost only half as many permanent teeth as the
Hagerstown children. The only reasonable explanation
of this reversal in the expected tooth mortality was the
finding that Nicollet County children had approximately
twice as many carious teeth filled as had Hagerstown
children.1 '
Since this method of controlling dental caries and pre-
venting tooth loss is based on early detection of the cari-
ous lesions and treatment with dental fillings, some con-
cept of the size and nature of the job can be gained from
a study of the prevalence figures presented in Tables I
and II. The data in Table II indicate, for example, that
the average number of carious permanent teeth per child
increases relatively uniformly from 0.5 at age 6 years to
11.2 at age 18 years. The average child in Nicollet
County is developing slightly less than one carious per-
manent tooth per year during the age span 6 to 18 years.
A similar analysis of the data in Table I indicates that
Nicollet County children develop slightly less than two
carious deciduous teeth per year per child during the
age span 2 to 6 years.
At present, then, the only known practical method of
preventing tooth loss from dental caries is to have chil-
dren’s deciduous teeth examined and needed fillings
placed at 2 years of age and at regular intervals there-
after until 10 to 12 years of age when exfoliation of
the deciduous teeth is completed. Care of the permanent
teeth should begin at age 6 and continue throughout life.
This system is not only effective in preventing tooth loss
but is far more economical than dental neglect which
results in the loss of teeth and the need for elaborate
and costly replacement appliances. Because of these
facts the method has been called Protective Dentistry by
Brekhusls — it does not prevent dental caries but pro-
tects against loss of teeth attacked by caries.
Relation of Fluorine to Control of Caries
A number of elements which produce toxic effects
when ingested in large amounts are now known, through
the feeding of highly purified diets, to be required in
trace quantities for the nutrition of laboratory animals.
In the case of fluorine, three independent lines of evi-
dence, two of which refer to the human, have been pro-
duced for the beneficial role of this element in the preser-
vation of the integrity of the teeth. First, chemical anal-
yses of the enamel of teeth which resist caries and those
which succumb to decay; second, epidemiological surveys
of the incidence of caries in children in relation to the
amount of fluorine in communal water supplies; and
third, demonstration that extra fluorine fed to rats in-
hibits the initiation of molar caries in this species under
a variety of experimental conditions. In the light of
recent evidence, it is now realized that observations with
respect to the effect of fluorine on developing teeth have
been recorded over a period of 40 years, but only since
1937 has the evidence warranted any conclusion other
than that fluorine produced deleterious effects on the
teeth.
McKay,111 thoroughly described a condition of perma-
nent teeth occurring in the Rocky Mountain regions
characterized by mottling of the enamel with chalky
white patches and frequent secondary discolorations rang-
ing from yellow to brown. Eager, of the then U. S.
Marine Hospital Service, first described this condition
in 1902 when he noted its occurrence near Naples, Italy.
In addition to foci in other countries, about 400 areas
have since been located in the United States in which
mottled enamel occurs endemically in varying degrees of
severity. McKay was able to demonstrate certain facts
with reference to endemic mottled enamel which have
been thoroughly confirmed, viz.: (a) only those children
born in the community or who lived there from early
infancy developed this condition, (b) children born in
other regions and who moved to a region of endemic
mottled enamel during the age period of enamel calcifi-
cation developed the lesions on all teeth calcified after
taking up residence in the second communtiy, but those
teeth calcified before residence in the endemic region
were entirely normal and remained so, (c) the etiological
factor responsible for the development of mottled enamel
was associated with the communal water supply, (d) the
etiological factor was commonly present only in water
derived from deep wells or springs and was usually ab-
sent from surface water, and (e) mottled teeth were
apparently no more susceptible or even less susceptible
to decay than normal teeth. After the classical work of
McKay 15 years elapsed before the presence of unusual
quantities of fluorine in drinking water was indicted and
proven to be the cause of mottled enamel."1’'2 It has
now been established through the work of Dean and
associates21 that the concentration of fluorine in drinking
water required for the production of a mild degree of
mottled enamel in 10 per cent of the children who use
the drinking water continuously from early infancy is
1.0 mg. per liter (1.0 p.p.m.) .
From 1931 to 1937 fluorine was almost universally re-
garded as an undesirable constituent of communal waters
since mottled enamel is unesthetic and, when the condi-
tion is severe, the teeth are structurally inferior. Several
communities in which mottled enamel occurred changed
the source of the common water supply to one of a lower
fluorine content with the result that mottled enamel
144
The Journal-Lance
failed to appear in the permanent teeth of the children
horn subsequently to the introduction of the new drink-
ing water. However, as mentioned above, there is now
strong circumstantial and direct evidence that optimum
quantities of fluorine ingested during the period of
enamel calcification confers upon the teeth a lasting and
considerable degree of increased resistance to caries.
Armstrong and Brekhus whose data24 are quoted in
Table III found no significant difference in the compo-
sition of the enamel of sound teeth and that of carious
teeth with respect to calcium, phosphorus, magnesium
and carbonate. The same workers in a later publication2 '
demonstrated (see lower line of Table III) that a posi-
tive relationship exists between the fluorine content of
enamel and the resistance of teeth to caries. It is unlikely
that the lower fluorine content of the enamel of the
carious teeth is a secondary effect of the carious process
since no such result was produced by caries in the case
of the other constituents of enamel. The enamel of the
very severely mottled teeth of a woman who had lived
for the first nineteen years of her life in a region of
endemic mottled enamel were found to contain 0.033 to
0.036 per cent fluorine. 2<> This amount is about three
times that present in the enamel of the average sound
non-mottled tooth. These results demonstrate that rela-
tively small quantities of fluorine in enamel produces, or
is accompanied by, profound changes in the character of
the enamel. Since the woman had lived in Minneapolis
for the twenty years preceding the extraction of her
teeth, the results also indicated that fluorine once com-
bined in enamel structure is not susceptible of appre-
ciable reduction.
The inhabitants of the Island of Tristan da Cunha
which lies in the South Atlantic Ocean have long been
known to be unusually free from dental caries. The
cause of this remarkable condition, until recently, had
been uncertain. About six years ago, Dr. Reider F.
Sognnaes visited this island as a member of a Norwegian
expedition. He obtained a number of sound exfoliated
deciduous crowns and a few permanent teeth, most of
the latter being carious. The enamel and dentin of these
teeth were subjected to fluorine analysis2' with the results
summarized in Table IV. The significant finding was
the relatively high fluorine content found in the enamel
of both the deciduous and permanent teeth as compared
with the results obtained with specimens collected in
Minnesota. Furthermore, the fluorine content of the
dentin of the Tristanites was considerably higher than
that of Minnesotans. All of these facts served to indi-
cate that the Tristanites continued to ingest throughout
life an unusually high amount of fluorine. It thus ap-
peared that Tristan da Cunha was yet another locality
in which the inhabitants were accidentally receiving dur-
ing the period of active tooth formation about the op-
timum quantity of fluorine for the preservation of the
integrity of their teeth. This conclusion was strength-
ened by the clinical observations made by Dr. Sognnaes,
who noted that about 16 per cent of the Tristanites dis-
played very mildly mottled enamel. 2S
Mention has been made that there had been some
suspicion in the minds of dentists who saw mottled
enamel that such teeth may be more resistant to caries
than teeth not so affected. Dr. H. Trendley Dean and
his collaborators of the United States Public Health
Service have compiled evidence which amounts to an
almost certain demonstration that such is the case. Dean
and his co-workers have also shown that the teeth of
persons who throughout childhood ingested drinking
water containing exceptional amounts of fluorine defi-
nitely gained in caries resistance irrespective of whether
the teeth were mottle. These investigations have fur-
nished the second line of evidence in support of the
beneficial role of fluorine.
Table V shows the results of a study made by Dean’s
group in Wisconsin. 211 Note the unusually low incidence
of dental decay observed in Green Bay as compared with
seven other towns and cities in Wisconsin. Note also
that the water supply of Green Bay contained much
more fluorine than was found in the public water of
the other communities.
Two other similar, but more thorough studies, were
carried out in Illinois. The results of these investigations
are shown in Table VI. Only those children who had
used their local communal water supplies throughout
life, thirty calendar days in any one year excepted, were
included in the final tabulation. The first of these com-
pared the caries incidence in Galesburg, Monmouth, Ma-
comb, and Quincy.4" Observe the very much lower inci-
dence of caries found in Galesburg and in Monmouth
as compared to the incidence of this disease in Macomb
and Quincy. A much larger proportion of the children
were caries-free in the two towns whose communal water
supplies contained respectively 1.8 and 1.7 p.p.m. of
fluorine. The amount of fluorine found in the drinking
water of Macomb and Quincy, 0.2 p.p.m., was very close
to the quantity found in Minneapolis city water.
In a more recent investigation the dental caries experi-
ences observed in eight towns near Chicago were com-
pared.41 These results are shown on the lower part of
Table VI. The water of Evanston, Oak Park, and Wau-
kegan was obtained from Lake Michigan and was re-
ported to contain no fluorine. In the other five towns
beginning with Elmhurst, the water was obtained from
deep wells and contained unusual quantities of fluorine.
The caries incidence observed in Elmhurst, Maywood,
Aurora, and Joliet was very low — namely, 252 to 323
caries per 100 children. These caries attack rates were
less than one-half those seen in the towns whose public
water supplies contained no fluorine. The localities char-
acterized by a low caries incidence were those where pub-
lic water supplies contained 1.2 p.p.m. or more of flu-
orine. A more recent study112 by the Public Health Serv-
ice workers was a re-examination of the teeth of residents
of Bauxite, Arkansas, who, as children, drank a high
fluorine water. Twelve years after the water supply was
changed to a nearly fluorine-free source, the teeth of the
persons just mentioned were found to have developed
fewer caries than either those of persons who were never
exposed to high concentrations of fluorine or those of
children born in Bauxite since the water supply was
changed.
May, 1943
145
Day'*'1 in India, and Wilson'14 in England, have also
noted a decreased incidence of caries in regions charac-
terized by high fluorine content in the drinking water.
The low caries attack rate in Deaf Smith County, Texas,
has recently attracted considerable attention in the public
press. The water in this county contains 2.2 to 2.7 p.p.m.
of fluorine. McClendon'15 has very recently produced
data which led to the conclusion that dental caries varies
inversely with the fluorine content of cow’s milk.
The third line of evidence indicating that fluorine pro-
motes resistance to dental decay has been derived from
studies in experimental animals. Space will not permit a
description of the significance of caries in rat molar teeth
or an exposition of the details of these experiments. Sev-
eral investigators in other laboratories demonstrated that
the addition of relatively large quantities of fluorine to a
dietary regime which was known to produce caries of rat
molar teeth greatly reduced the incidence of such lesions
below the number which appeared in the teeth of control
cation of fairly strong solutions of sodium fluoride to
the teeth. The same conclusion had already been reached
by Volker and co-workers.3s The evidence which we have
at hand indicates that the topical application of fluoride
solutions to the teeth would be an entirely safe pro-
cedure if carried out in a systematic manner by dental
TABLE I
Percent of Children
Deciduous Teeth
Teeth per Child,
Minnesota.
with 1 or more Carious (Decayed or Filled)
and Average Number of Carious Deciduous
by Age, for 664 Children, Nicollet County,
Age last birthday
<1 i
2 3
4
5
6
Number of children
7 43
36 61
83
1 66
268
Percent of children wi
th
1 or more carious
deciduous teeth
0.0 4.6
13.9 59.0
66.3
74.
1 91.4
Average number of
carious deciduous
teeth per child
0.0 0.4
0.5 , 2.5
4.1
5.
4 7.3
TABLE II
Percent of Children with 1
or More Carious ( Decayed,
Teeth per Child, by Age, for
Missing
2,627
or Filled) Permanent Teeth and Average N
School Children, Nicollet County, Minnesota
umber
of Carious Permanent
Age last birthday
6
7
8
9
10 1 1
12
1 3
14
15
16
17
18
Number of children
259
252
276
282
276 265
289
231
159
1 42
93
79
24
Percent of children with 1 c
>r more
carious permanent teeth
24.3
53.6
75.7
8 4.0
86.2 89.8
92.7
95.2
94.3
98.6
97.8
93.7
1 00.0
Average number of carious
permanent teeth per child
0.5
1.4
2.3
2.8
3.4 4.2
5.5
6.3
7.7
9.6
9.6
10.8
1 1.2
; animals not receiving the extra fluorine. Recently Dr.
, Rudolph Norvold carried out in our laboratory a well-
controlled study in which he demonstrated the positive
i effect of fluorine in reducing the initiation of rat molar
caries under three conditions.'10 These three conditions
j were: (1) when extra fluorine was supplied to the ani-
I mals only during the stage of tooth formation, and
; before the animals were put on the caries-producing diet;
(2) when the extra fluorine was supplied to the animals
concurrently with a caries-producing food; and (3) when
the fluorine was given in high concentration in drinking
water to mature rats for a period preceding, but not
during the caries-producing regimen.
What application of these facts can be made to the
reduction of dental caries in the human? One obvious
way would be to treat public water supplies with fluorine
to the extent that the product should contain 1.0 p.p.m.
of fluorine. Probably this method could be employed
i with safety if carried out under rigid control. However,
the water intake of individuals varies and the intake in
warmer climates is higher than in the cooler climates.
There is some risk, until evidence to the contrary is pro-
duced, that the addition of fluorine to communal water
supplies might cause toxic results. Furthermore, any
benefit to be derived from this procedure would accrue
only to those persons who use the high fluoride water
during the time of the formation of their teeth.
An accidental observation which we made in connec-
tion with another investigation3' has indicated that the
; fluorine content of the enamel of fully formed, erupted
teeth of rats can be increased by a relatively brief appli-
TABLE III
Composition
of Enamel of Sound
and Carious
Teeth
Enamel — Sound Teeth
Mean
Standard
Number of
Per Cent
Deviation
Analyses
Per Cent
Calcium
35.35
0.977
43
Phosphorus
1 7.43
0.360
4?
Magnesium
0.30
0.041
34
Carbonate —
(CO-,)
3.00
0.187
41
Fluorine
0.011 1
0.0020
50
Enamel — Carious Teeth
Calcium
35.63
0.638
15
Phosphorus
17.21
0.145
15
Magnesium
0.32
0.026
15
Carbonate —
(C02).
3.01
0.129
! 4
Fluorine
0.0069
0.001 1
50
TABLE IV
FI
uorine Content of Enamel and Dentin of
Da Cunha and Minnesota
Teeth from
Tristan
Tristan Da Cunha
Enamel
Per Cent
Dentin
Per Cent
10
Deciduous teeth, caries-free
0.0140
0.0196
8
Permanent teeth
0.0140
0.0270
3
Minnesota
Deciduous teeth
0.0072
50
Sound permanent teeth
0.0111
0.0163
50
Carious permanent teeth
0.0069
0.0163
2
Mildly mottled permanent teeth
0.0248
0.0395
146
The Journal-Lancet
TABLE V
Dental Cories Attack
Rates in Permanent Teeth in White Children
Aged 12 to 14
Y ears
Number of
Fluorine
Number of
Carious Teeth
Content of
City
Children
per
Water Supply
1 00 Children
p.p.m.
( yreen Bay
687
275
2.3
Sheboygan
244
710
0.5
Manitowoc
661
682
0.35
Two Rivers
382
646
0.3
Milwaukee
2,645
917
0.3
West Allis
160
831
0.3
Baraboo
1 19
733
0.2
La Crosse
47
731
0.12
TABLE VI
Dental Caries
Experience in Children Aged 12 to 14 Years
City
Number
of
Children
Caries
per 1 00
Children
Percent
Children
Caries-
Free
Fluorine
Content
of Water
p.p.m.
Galesburg
319
201
35
1.8
Monmouth
1 48
205
35
1.7
Macomb
1 1 2
401
1 4
0.2
Quincy
306
633
4
0.2
Elmhurst
1 70
252
25.3
1 .8
Maywood
171
258
29.8
1.2
Aurora
633
281
23.5
1 .2
J oliet
447
323
1 8.3
1 .3
Elgin
403
444
1 1 .4
0.5
Evanston
256
673
3.9
0.0
Oak Park
329
722
4.3
0.0
Waukegan
423
810
3.1
0.0
—
,
—
—
—
practitioners. It must be demonstrated, however, whether
fluorine introduced into the teeth in this manner is
effective in reducing the caries susceptibility of the teeth.
This effect can he proven only by a well-controlled ex-
periment employing children as the subjects. Bibby has
made two reports'™ and Cheyne a single report4" of
success in reducing the caries attack rate in children by
the use of this method. We have at present 300 school
children in Arlington, North Mankato and St. Louis
Park, Minnesota, whose teeth received in May, 1942,
up to 16 topical treatments with sodium fluoride. We
believe that the number of cases and treatments em-
ployed in this study will permit a definite assessment of
the practical value of this procedure as a means of con-
trol of dental caries.
Bibliography
1. Ciocco, A., Klein, H., and Palmer, C. E.: Child health
and the selective service physical standards. Pub. Health Rep.
56:2365-2375 (Dec. 12) 1941.
2. Rowntree, L. G., McGill, K. H., and Folk. O. H.: Health
of selective service registrants, J.A.M.A. 118:1223 — 1227 (April 4)
1942.
3. Messner, C. T., Gafafer, W. M., Cady, F. C., and Dean,
H T.: Public Health Bulletin No. 226, U. S. Government Print
ing Office. Washington, D. C., 1 936.
4. Klein, Henry, Palmer, C. E., and Knutson, J. W.: Studies
on dental caries; I — Dental status and dental needs of elementary
school children, Pub. Health Rep. 53:75 1—765 (May 1 3 ) 1938.
5. Sloman, E. G., and Sharp, J. B. : Extent of dental caries
and condition of teeth of San Francisco high school students: re-
print from The Journal of the California State Dental Association
16:3 (May-June) 1940.
6. Miller, W. D.: Die Mikro-organismen der Mundhohle,
ed. 2, Leipsic: George Thime. 1892.
7. Brekhus, P. J : Your Teeth, Their Past. Present and Prob-
able Future. The University of Minnesota Press. Minneapolis, Mm
nesota, 1941.
8. Fosdick, L. S.: The etiology and control of dental caries,
J A D A. 29:21 32-2139 (Dec.) 1942.
9. Schour, Isaac: Calcium metabolism and teeth, J.A.M.A,
110:870-877 (March 19) 1938.
10. Lund, A. P., and Armstrong, W D.: Effect of low calcium
and vitamin D-free diet on skeleton and teeth of adult rats, J. Dent.
Res. 21:513 (Dec.) 1942.
11 Lilly, C. A.: Dental Caries, American Dental Association.
2nd edition, p. 164, Lancaster Press, Inc., Lancaster. Pa.. 1941.
12. Taylor, G. F., and Day, C. D. M.: Osteomalacia and dental
caries, British M J. 2:221 (Aug. 17) 1940.
13. Bengochea. L. : Dental Caries, American Dental Association,
2nd edition, p. 50, Lancaster Press, Inc., Lancaster, Pa
14 Bunting. R. W.. and Jay P.: Dental Caries, American
Dental Association, 2nd edition, pp. 76—79. Lancaster Press, Inc.,
Lancaster, Pa.
15. Collins, R. O.: Jensen. A. L., and Becks. Herman: Studies
of caries-free individuals, J.A.D.A. 29:1 169 (July 1) 1942.
16. Fosdick, L. S.: Carbohydrate degradation by mouth organ
isms, J.A.D.A. 26:415 (March) 1939.
17. Knutson, J. W.: Appraising the dental health program.
J.A.D.A. 29:543-556 (April) 1942.
18. Brekhus. P. J.: Protective dentistry. Dentistry a Digest of
Practice 2:158-1 59 (Nov.) 1941.
19. McKay, F. S.: The relation of mottled enamel to caries.
J.A.D.A 15:1429, 1928.
20. Dean, H. T.: Geographical distribution of endemic dental
fluorosis (mottled enamel). Fluorine and Dental Health, pp.6— 11,
1942: A A.A.S., Washington, D. C.
21. Churchill. H. V.: Occurrence of fluorides in some waters
of the United States, Ind. and Eng. Chem. 23:996, 1931.
22. Smith. M. D.. Lantz. E. M.. and Smith, H. V.: The cause
of mottled enamel a defect of human teeth. Univ. Arizona Agric
Exp. Sta. Tech. Bull. No. 32, 193 1.
2 3. Dean, H. T.. and Elvove, E.: Some epidemiological aspects
of chronic endemic dental fluorosis. Am J. Public Health 26:567,
1936.
24. Armstrong. W. D., and Brekhus. P. J.: Chemical composi-
tion of enamel and dentin: I — Principal components, J. Bio. Chem.
120:677. 1937.
25. Armstrong. W. D., and Brekhus, P. J.: Possible relation
ship between the fluorine content of enamel and resistance to dental
caries. J. Dent. Res. 17:393, 1938.
26. Armstrong, W D.. and Brekhus. P. J.: Chemical composi-
tion of enamel and dentin; II Fluorine content, J. Dent. Res.
17:27, 1938.
27. Sognnaes, R. F., and Armstrong. W. D.: A condition sug-
gestive of threshold dental fluorosis observed in Tristan da Cunha;
II Fluorine content of the teeth, J. Dent. Res. 20:3 1 5. 1 941.
28. Sognnaes, R. F.: A condition suggestive of threshold dental
fluorosis observed in Tristan da Cunha: I — Clinical condition of
the teeth, J. Dent. Res. 20:303, 1941.
29. Dean, H. T : Endemic fluorosis and its relation to dental
caries. Pub. Health Rep. 53:1443, 1 938.
30. Dean, H. T., Jay. P., Arnold. F. A., McClure, F. S.. and
Elvone. E. : Domestic water and dental caries including certain epi-
demiological aspects of Oral L. Acidophilus. Pub. Health Rep.
54:862, 1939.
31. Dean, H T , Jay, P.. Arnold, F. A., and Elvove, E.: Do-
mestic water and dental caries. Pub. Health Rep. 56:761, 1941.
32. Dean, H. T., Jay. P.. Arnold, F. A., and Elvove, E.: Do-
mestic water and dental caries. Pub. Health Rep. 56:365, 1941.
3 3. Day, C. D. M.: Chronic Endemic Fluorosis in Northern
India. Brit. Dent. J. 68:409. 1940.
34. Wilson, D. C.: Fluorine and dental caries. Lancet 1:375.
1941 .
35. McClendon, J. F.. Foster, W. C.. and Supplee. G. C. : The
inverse ratio between fluoride in food and drink and dental caries.
Arch. Biochem. 1:51, 1942.
36. Norvold, R. W.. and Armstrong, W. D.: Mechanism of
fluorine inhibition of caries in the rat, J. Dent. Res. (in press).
3 7. Perry, Mable W., and Armstrong, W. D.: On the manner
of acquisition of fluorine by mature teeth, J. Nutr. 21:3 5, 1941.
38. Volker, J. F., Hodge, H. C.. Wilson, H. J., and Van Voor-
his, S. N.: The adsorption of fluorides by enamel, dentin, bone and
hydroxyapatite as shown by the use of the radioactive isotope,
J. Biol. Chem. 134:543, 1 940.
39. Bibby, B. G.: Preliminary report on use of sodium fluoride
applications in caries prophylaxis, J. Dent. Res. 21:3 14, 1 942.
Second preliminary report at Chicago (1943) meeting Inter. Assoc.
Dent. Research.
40. Cheyne, V. D.: Human dental caries and topically applied
fluorine, J.A.D.A. 29:804. 1942.
May, 1943
147
Chronic Constrictive Pericarditis
Wallace Sako, M.D., Ph.D.v
Joel Fleet, M.D.f
Philip Pizzalato, M.D.f
New Orleans, Louisiana
THE pericardium may be involved in various path-
ological processes, but in children, pericarditis is
most often associated with rheumatic fever. Pecul-
iarly, however, rheumatic fever seldom gives rise to scar-
ring of the pericardium to such an extent that it causes
obtsruction to the heart. In fact, the etiology of the typi-
cal syndrome produced by chronic obstructive or con-
strictive pericarditis is often obscure. This condition,
although not very common, is occasionally seen in chil-
dren. A recent fatal case which we encountered in an
eleven year old boy is the basis of this report.
C. K., an 11 year old white male was admitted to
Charity Hospital on June 6, 1942.
History. In February, 1942, the patient experienced
generalized body aches, cough, increased sweating, poor
appetite, and began to lose weight. He was treated by
his family physician for "influenza” and improved in
about two weeks but did not recover completely. The
poor appetite persisted and he failed to regain the
weight lost during his illness. During convalescence his
physician told the family that he had "heart trouble.”
In March, 1942, the patient vomited frequently for a
period of one week. At that time his physician noted an
enlarged liver, ascites, and fluid in the right chest, in
addition to edema of the lower extremities and face. In
May, 1942, the patient became quite dyspneic and fluid
was removed from his chest. He seemed to become worse
after this and had to be placed in an oxygen tent. Later
a paracentesis was done and a clear straw-colored fluid
was removed. The patient was then referred to Charity
Hospital, the physician believing that the patient had
some form of malignancy.
Past History. The patient had always been anemic
and weak but especially so during the past four years.
He contracted pertussis and measles during infancy and
typhoid fever in 1938. Tonsillectomy was done at the
age of six.
Physical Findings. On admission the patient was un-
dernourished, pale and weak. Edema was present on the
face and lower extremities. Ascites was a prominent fea-
ture. The neck veins were distended and pulsating. The
abdominal veins were noticeable. The heart revealed
nothing abnormal by auscultation except for an increased
rate of 125 per minute. The liver was markedly enlarged,
extending down 6 cm. in the region of the right lobe
anteriorly and 7 cm. over the left lobe. It was smooth
and rather firm to palpation. The spleen was not palpa-
ble. The right chest showed diminished excursion and
bulging of the interspaces. Tactile fremitus and reso-
nance were diminished over the right chest. Flatness to
percussion was also elicited over this same area. The
blood pressure was 110/90.
tFrom the Department of Pediatrics, Louisiana State University
School of Medicine and the Charity Hospital of New Orleans.
Fig. 1. Gross diss^fcon of heart, lungs and pleura. Note ex-
tensive thickening of the pleura as well as the pericardium.
Laboratory Studies: Blood studies showed a hemo-
globin of 60 per cent of normal, red blood cell count
5.1 million, white blood cell count 18,000, 60 per cent
polymorphonuclear cells, 23 per cent lymphocytes, 1 1 per
cent monocytes, 2.5 per cent eosinophils, and 2 per cent
basophils. Urinalysis revealed normal findings. Tuber-
culin test 1:10,000 to 1:10 was negative. Blood urea
was 8.3 mg. per 100 cc., total protein 6.2 grams per
100 cc., with albumin 3.2 grams and globulin 2.95 grams.
Wassermann test was negative, blood glucose 103 mg.
per 100 cc., and stools were normal. The phenolsulfo-
naphthalein test showed 60 per cent return in two hours.
X-ray studies revealed the left chest to be clear. The
right pleural cavity contained air and fluid, the fluid ex-
tending to the level of the fourth rib anteriorly. The
right pleura was thickened, and the right lung was ate-
lectatic. Repeated fluoroscopic examinations revealed a
heart of normal size, with diminished pulsations of all
borders of the heart. Intravenous and retrograde pyelo-
grams revealed the kidneys normal. The skull and long
bones appeared normal on x-ray studies. The saccharin
circulation time was 27 seconds. The venous pressure
was 240—270 mm. of water. Kidney and liver function
tests were normal. Electrocardiogram showed slight right
axis deviation, inversion of the T-waves in all leads, sinus
tachycardia, and occasional ventricular premature beats.
Repeated examinations of the sputa, abdominal, and
pleural fluids for tubercle bacilli were negative by smear,
culture, and guinea pig inoculations.
Hospital Course. Thoracentesis was done soon after
admission, and about 100 cc. of clear straw-colored fluid
was obtained. Repeated thoracentesis was done subse-
quently with the same findings. Cultures of the fluid
revealed no growth. Smears from the sediment showed
large macrophages filled with fat droplets. Repeated
paracentesis of the abdomen revealed a similar straw-
colored fluid, which on culture revealed no growth.
Edema of the lower extremities and face disappeared
after the removal of the ascitic fluid. On August 12,
148
The Journal-Lance
Fig. 2. Gross appearance of heart, pericardium and liver. An-
terior surface of heart successfully freed of adhesions by operation.
Liver enlarged.
1942, an operation was performed. The pleura and peri-
cardium were thickened and presented many adhesions.
Approximately half of the pericardium over the anterior
portion of the heart was removed. About twenty-eight
hours after the operation the patient became markedly
dyspneic. The pulse was weak and the skin clammy.
Examination suggested atelectasis of the left lung. A
thoracentesis was done in the left posterior interspace
but only air was obtained. Another thoracentesis was
done anteriorly at the site of the incision, and air and
about 80 cc. of straw-colored fluid were obtained. One
and a half hours after the second thoracentesis, or
thirty-four hours after operation, the patient died.
Pathologic Observations. There was marked thicken-
ing of the pleura bilaterally but more extensively on the
right side. There were some adhesions between the pleura
and the chest wall. On the right side, there was a large
empyema cavity filled with thick fibrinous material. (See
Figure 1).
The mediastinal structures were densely bound down
by adhesions. Both the parietal and visceral pericardium
was markedly thickened, completely encasing the heart
except over a small area anteriorly where surgical excision
was carried out. The liver was markedly enlarged and
congested. (See Figure 2).
Discussion
History. The first clinical description of the disease is
attributed to Richard Lower.1 Subsequently, various
authors recognized and adequately described the clinical
signs, symptoms and pathogenesis of chronic constrictive
pericarditis: Chevers,2 Wilks,'1 Pick,4 Kussmaul,0 and
Volhardt and Schmieden.6
The surgical procedure of pericardiectomy was first
suggested by two Frenchmen, Weill' and Delorme, s but
was first carried out by Rehn1' and Hallopeau.10 The
first successful operation for constrictive pericarditis in
America was reported by Churchill.11 Later Beck,12
Burwell,12 and others claimed similar successes. Prior to
the recommendation for decortication, Bruer' * suggested
cardiolysis, a procedure consisting of the removal of pre-
cordial bony structures so the tug of the heart would be
on the soft structures instead of on the bony chest wall.
This operation, however, has been found to be ineffective
in chronic constrictive pericarditis.
Etiology. The etiology is usually obscure, as in our
case. Some cases are apparently due to tuberculous in-
fection while others are secondary to respiratory infec-
tions. Rheumatic fever is not a primary factor.
Clinical Manifestations. For the sake of brevity, the
important clinical manifestations will be tabulated in
outline form:
1. Loss of weight, weakness, easy fatiguability.
2. Dyspnea on exertion.
3. Epigastric distress and anorexia.
4. Slight anemia and decreased blood proteins.
5. Normal temperature.
6. Faint heart sounds, no murmurs.
7. Heart of normal size or small.
8. On fluoroscopy, decreased pulsations of heart borders
especially on the right side.
9. Tachycardia especially on exertion.
10. Paradoxical pulse, thready during inspiration.
11. Blood volume increased 30 to 40 per cent above normal.
12. Cardiac output diminished.
13. Circulation time delayed.
14. Venous pressure consistently high.
15. Dilatation of jugular veins with or without pulsations.
16. Systolic pressure low, usually 100-110, diastolic pres-
sure normal or elevated, usually 80.
17. Pulse pressure diminished, usually 20.
18. Electrocardiogram shows low voltage, inversion or flat-
tening of the T-waves in two or more leads.
19 Calcified plaques in pericardium seen in 20 per cent
on x-ray.
20. Ascites usually precedes edema of face and extremities
by several weeks or months.
21. Liver markedly enlarged.
22. Impairment of liver function.
23. Pleural effusion.
24. Triad of Beck: Small quiet heart, venous hypertension,
ascites and enlarged liver.
Pathogenesis. The symptoms of chronic constrictive
pericarditis can be explained on the basis of obstruction
arising from compression exerted by the constricting scar
tissue. Beck12 has experimentally determined that the
significant point in the obstruction is the thickening of
the pericardium and not necessarily the adhesions between
the heart and pericardium. Cardiac failure arises because j
of the inability of the heart to hold, in diastole, sufficient t
blood to maintain an adequate arterial circulation. The Ji
cardiac output is thus diminished and the blood is dam-
med back into the venous and arterial beds, increasing
the blood volume. The heart tries to compensate by in-
creasing its rate but this attempt is limited. Hypertrophy
and dilatation of the heart are limited by the thick en-
circling scar tissue around it, causing the patient to com-
plain of weakness, easy fatiguability, and dyspnea on
exertion.
As decompensation increases, the blood begins to pile
May, 194 5
up in the vena cava and dam back into the systemic ven-
ules. The venous pressure increases, its height giving an
index of the severity of the cardiac compression. The sys-
temic veins although bearing a tremendous back pres-
sure can stand it far better than the hepatic veins which
are without valves. The liver thus suffers from a portal
decompensation, becoming large, tender, and congested.
With continued back pressure, liver damage occurs, lead-
ing ultimately to cirrhosis if the patient survives long
enough. Portal decompensation gives rise to ascites.
As the pathologic process continues, generalized edema
results from venous stasis. Pleural effusion can similarly
be attributed to venous congestion of the parietal pleura.
The high degree of obstruction to the heart produced
by the constricting scar tissue is possible only because the
pathogenesis arises slowly. The greatest compression force
noted by Beck1" was from 40 to 45 cm. of water. Beck
has observed that an acute compression pressure of 15 to
20 cm. of water will be fatal. In our case, it is difficult
to determine what part the empyema in the right pleural
cavity played in the etiology of the pericarditis. It is
possible that a pneumonia and empyema antedated the
process in the pericardium.
Surgical Considerations. Operative intervention con-
sists essentially in extrapleural exposure of the heart, and
release of the constricting membranes in a one-stage op-
eration. It is important to free the apex of the heart,
when adherent to the diaphragmatic surface, and to re-
move the scar from the left ventricle, first because of
danger of dilatation of right ventricle if excision is
started on the right side.
149
Preoperative Treatment. Preoperative treatment con-
sists in external heat before, during, and after operation.
The fluid from the abdomen and chest should be aspi-
rated before operation is performed. Anemia and mal-
nutrition should be corrected by transfusions and a high
caloric diet.
Postoperative Care. Postoperative care includes con-
tinued oxygen therapy and limitation of fluids. Intra-
venous fluids should be given with caution because of
the severe, sudden strain thrown on the heart, incident
to the operative procedure.
Summary
A fatal case of chronic constrictive pericarditis occur-
ring in an eleven year old boy is reported. The patho-
logic observations and a discussion of the disease are
briefly presented.
References
1. Lower, Richard: Tractatus de Corde, Amsterdam. 1669.
2. Chevers, N.: Guy s Hosp. Reports 5:387, 1842.
3. Wilks, S.: Guy’s Hosp. Reports, Third Series 16:196,
1870-71.
4. Pick, F.: Zeits. f. Klin. Med. 29:385, 1896.
5. Kussmaul, A.: Berlin Klin. Woch. 10:433, 461, 1872.
6. Volhardt, F., and Schmieden, V.: Klin. Wchschr. 1:5, 1923
7. Weill, E.: Traite Clinique des Maladies du Coeur Chez
les Enfants, Paris, 1895.
8. Delorme, E.: Bull. et. mem. Soc. de Chirurgiens de Paris
24:918-922, 1898.
9. Rehn, L.: Arch. f. K.nderh. 68:179-195, 1920.
10. Hallopeau. M. P.: Bull, de Mem. Soc. de Chirurgiens de
Paris 47:1 120, 1921.
11. Churchill, E. D.: Arch. Surg. 19:1457-1469, 1929
12. Beck, C.: J.A.M.A. 97:824-830, 1931. Am. Heart J
1 4:51 5-525, 1 937.
13. Burwell. C. S., and Blalock. A.: J.A.M.A. 1 10:265-271.
1938.
14. Brauer. L.: Arch. f. Klin. Chir, 71:258-267. 1903-04
The Early Diagnosis of Poliomyelitis
Albert V. Stoesser, M.D.J
Minneapolis, Minnesota
RECENT interest in the Kenny treatment of polio-
myelitis has made the early diagnosis of the dis-
ease most important. Miss Kenny has repeatedly
stated that the more quickly her treatment is instituted,
the shorter the period of special care, and the better the
results. Much has been written concerning the diagnosis
of infantile paralysis, but many practitioners still do not
have a clear clinical picture of the disease during the
acute period. A careful study of the records of 259
acute cases admitted to the Minneapolis General Hos-
pital during the past six years has revealed the early
symptoms and signs listed in Table I and offered a rather
simple description of infantile paralysis. The majority
of the patients were children ranging in age from 1 to
14 years with the highest incidence appearing between
5 and 9 years. Starting with a few cases in July of each
year, there was a rapid increase in the number until the
peak was reached in September, following which there
tFrom the Contagious Disease Division of Minneapolis General
Hospital and the Department of Pediatrics. University of Minne-
sota.
was a gradual decline for the next three or four months.
The number of patients varied greatly from year to year.
The early symptoms of poliomyelitis may not indicate
that the disease is present. Usually the first sign is fever
which averages 101“ F., but may be as high as 104“ F.
After the fever has been present for a short period of
time, patients complain of headache of moderate severity
but with no characteristic localization, since it may be
frontal, lateral, or occipital. Nausea and vomiting occur
indicating a gastro-intestinal upset. The patient becomes
restless and irritable. This completes the initial phase,
and only a suspicion of infantile paralysis exists.
The disease progresses into a second phase which may
reveal that the child has poliomyelitis. The headache be-
comes more severe and the nausea and vomiting disap-
pear to be followed by constipation. Stiffness of the neck
and pain on flexion of the neck and spine appear. The
patient is unable to touch the knee with his head owing
to the spasm of the spine muscles. Pain becomes more
extensive and severe. It is not located in the skin but
150
essentially in the muscles of the extremities which still
may he moved by the child.
Soon the severity of the headache lessens. Drowsiness
develops. The patient now makes little or no effort to
move certain groups of muscles. Close inspection of these
muscles reveals that they are painful, tender, irritable,
shortened, and firm, indicating spasm. The principal loca-
tions of the demonstrable muscle spasm are the back,
posterior neck, thigh, and calf of leg. The pectoral,
quadriceps and biceps muscles and muscles of respiration
are also frequently involved. This situation is the most
characteristic feature of the disease and represents the
third phase. Further examinations of the child should be
limited since they can aggravate the spasm, thereby re-
tarding treatment which must be started immediately.
If all the cases of infantile paralysis would follow the
course described, the diagnosis would not be difficult.
However, there are patients who have a slight rise in
temperature, a mild headache, and then, in a very short
period of time, they develop rigidity of the neck, marked
pain on motion of the back, and loss of function in some
of the muscles of the extremities. A positive Kernig’s
sign may be present. These cases are referred to as hav-
ing the meningeal type of onset.
Occasionally the disease progresses rapidly to stupor,
prostration or delirium. This is the cerebral form of
poliomyelitis (also called the Striimpell type).
Almost as frequent as the meningeal type of onset is
the one which ushers in the disease with marked gastro-
intestinal symptoms. Following the initial spell of nausea
and vomiting, the child complains of a generalized ab-
dominal pain with or without tenderness. If the former
is present a spasm of the recti muscles may be detected.
Diarrhea can occur and usually is not severe, but in a
few cases it has caused prostration. The diagnosis of
infantile paralysis often is not established until the char-
acteristic spasm appears in the muscles of the trunk and
extremities.
Another group of patients has the symptoms and signs
of an acute attack of coryza which may lead on to acute
pharyngitis or tonsillitis with fever and headache. The
upper respiratory infection continues for a few days or
for as long as a week before it subsides. Then the head-
ache usually becomes more severe and stiffness of the
neck appears, frequently followed rather quickly by pain
on flexion of the neck and the spine. In spite of the lat-
ter signs of poliomyelitis, the diagnosis of the disease is
uncertain. It is not until the respiratory infection has
disappeared almost completely that the remaining phys-
ical findings warrant a more definite diagnosis of infan-
tile paralysis.
In the majority of the cases the course of the disease
is progressive with the patient passing from one phase to
the next. However, in about one-fourth of the children
there is an initial phase of general systemic symptoms
such as fever, headache, nausea and vomiting, with or
without any evidence of an upper respiratory infection.
Improvement appears but after a period of two to seven
days, the fever returns, often rising to a high level. The
headache becomes more severe and the disease progresses
rapidly to the final phase with widespread muscle involve-
The Journal-Lancet
ment. This diphasic type of course is sometimes called
the "dromedary” type.
An examination of the spinal fluid cannot be neglected
as an aid in the diagnosis of polimyelitis. If the fluid is
collected during the first phase of the disease, it may
reveal little. No cells or only a small number are found,
usually all polymorphonuclear cells. During the second
phase, the spinal fluid cell count increases and has risen
as high as 1000 although the average range is between
50 and 150. The shift is to the mononuclear cells, and
during the third phase of the disease, the majority of
the cells are lymphocytes. Soon after this, the count may
drop rapidly to zero even though extension of the loss
in muscle function has not ceased.
The spinal fluid sugar level changes little, always being
close to 60 milligrams per 100 cc. of fluid. Even in the
more severe cases there is only an insignificant elevation.
During the first and second phases the protein content
of the spinal fluid is usually around the normal level of
40 milligrams per 100 cc. of fluid, but in the final phase
of the acute period of infantile paralysis it may rise to
80 milligrams or slightly higher in the more severe cases.
The delayed rise in the spinal fluid protein is often too
late to assist greatly in the early diagnosis of the disease.
During the period of seasonal prevalence and especially
if the disease is epidemic, the advantages of an early rec-
ognition of poliomyelitis lead the practitioner to make a
tentative diagnosis of that disease at the onset of many
illnesses which are not infantile paralysis. At the Minne-
apolis General Hospital one out of every six cases admit-
ted as poliomyelitis proved to be another disease. Table
II reveals that upper respiratory infections, meningitis,
Guillain-Barre syndrome, pneumonia, encephalitis, and
rheumatic fever head the list of diseases which have
been incorrectly diagnosed as infantile paralysis. The
reason for this is that these diseases have simulated the
different clinical pictures produced by the variation in
severity of the early symptoms and signs.
Acute upper respiratory infections with fever, head-
ache, nausea, vomiting, and restlessness appearing in
autumn frequently can be diagnosed as the onset of polio-
myelitis. If no loss in muscle function occurs and a
spinal fluid examination is normal, the diagnosis may be
dropped. Some of the patients are referred to as having
abortive type of infantile paralysis, but there is no way
at the present time to prove that this diagnosis is correct.
However, with the more careful inspection of the chil-
dren by the Kenny method, a few of the cases are con-
sidered poliomyelitis since muscle spasm is demonstrated.
Furthermore, repeated spinal puncture often reveals in
these patients the characteristic pathologic changes in
the spinal fluid in spite of the fact that the first exam-
ination is normal.
Meningitis may easily be confused with infantile paral-
ysis chiefly because the latter can have a rather insignifi-
cant onset to be followed by the sudden development of
meningeal symptoms such as a severe headache and stiff-
ness of the neck. The rigid neck of meningitis does not
relax while that of poliomyelitis is more or less a volun-
tary mobilization of the neck muscles which can be over-
come by moderate and constant resistance on the part of
May, 1943
the examiner. The examination of the spinal fluid is
most important as a means of differential diagnosis. The
hacteriologic study should not be omitted. The cell
count in meningitis is much higher than in infantile
paralysis and the polymorphonuclear cells predominate
throughout the course of the disease. The only excep-
tion is tuberculous meningitis in which the onset is in-
sidious and usually accompanied by other evidence of
tuberculosis.
Occasionally a rather mild pharyngitis or tonsillitis
will be followed by a symmetrical and bilateral loss of
muscle function in the extremities. The latter condition
may appear suddenly or it may extend over a period of
weeks or months. The proximal muscle groups are more
severely involved than the distal. Hyperesthesia to super-
ficial touch is more annoying to the child than muscle
pain. Although poliomyelitis is considered, this diagnosis
is questioned because the motor impairment does not
have the localized and asymmetric distribution noted fre-
quently in infantile paralysis. Furthermore, the hyper-
esthesia is more prominent than that usually observed in
poliomyelitis. The clinical picture resembles that of in-
fectious polyneuritis or the Guillain-Barre syndrome, the
diagnosis of which can be made more certain by exam-
ination of the spinal fluid. The cell count is low, rang-
ing from a few cells to 50 throughout the course of the
disease. The majority of the cells are always lympho-
cytes. The protein content is high, the average range
being between 100 and 300 milligrams per cent.
The onset of pneumococcus pneumonia in young chil-
dren can simulate infantile paralysis. This is especially
true if an upper respiratory infection with symptoms re-
sembling those of the initial phase of poliomyelitis is
present just before the patient has a sudden rise in tem-
perature to 104 c F. followed by stupor, prostration or
delirium. Rigidity of the neck appears, but there is little
or no pain on passive motion of the neck or spine. The
characteristic muscle pain of poliomyelitis cannot be dem-
onstrated. Convulsions are common, and they are rare
in infantile paralysis. Further examination usually re-
veals the characteristic lung findings of pneumonia and
the roentgenogram confirms the diagnosis. Nevertheless,
a spinal puncture is indicated. The fluid is under in-
creased tension; as a rule there are no bacteria; and there
is either a slight increase in cells and protein, or none
at all.
Encephalitis may be confused with the cerebral type
of poliomyelitis when the latter progresses rapidly to the
third phase and leads to extreme drowsiness. However,
the drowsiness of encephalitis is much more profound
than that of infantile paralysis; once the patient with
poliomyelitis is aroused he is quite alert. The spinal fluid
reveals an early, moderate increase in cells. An occa-
sional case of encephalitis may have a spinal fluid cell
count as high as 200, mostly lymphocytes. The poly-
morphonuclear cells never predominate. There is little
or no increase in the protein content of the spinal fluid.
An acute attack of rheumatic fever with irregular distribution
of joint involvement and pain referred in part to the adjacent
areas of the extremities may be inaccurately diagnosed as infan-
ti e paralysis, especially when the rheumatic infection appears
during the season when poliomyelitis is prevalent. The child
with rheumatic fever may not move the extremities on account
of the severity of the pan, but this immobilization is voluntary
No muscle spasm develops, and with new methods of demon-
stration this absence is significant in indicating that the disease
is not infantile paralysis. The sedimentation rate usually is in-
creased and the spinal fluid remains normal. There is a good
response to salicylate which never occurs in poliomyelitis.
One-fourth of the cases studied had difficulty in swallowing
or in breathing or both. In these patients the course of the dis-
ease is gradual through the various phases leading to regurgita-
tion of fluids through the nose, accumulation of mucus in the
pharvnx. and a weak cough. Occasionally the infection is quirp
fulminating in character with the early symptoms signs and
loss of muscle function being synchronous. The diagnosis is
not difficult whenever muscle spasm can be demonstrated in the
extremities or back, and rhe spinal flu'd h’s rhe cha-acterlstic
abnormalities of poliomyelitis already described.
Summary
The early diagnosis of infantile paralysis now is essential since
the Kenny method of treatment gives the best results when it
can be instituted as soon as muscle spasm appears.
To aid in the daignosis. 259 cases of poliomyelitis admitted
to M'nneaoohs General Hospital were reviewed and from a tab-
ulation of the earlv svmotoms and signs, the average course of
the disease was found to fall into the following phases'
Phase 1 — cever, headache, nausea and vomiting rest'ess-
ness or irritability.
Phase 2 — headache continues sdff neck, pain on flexion
of neck or spine, muscle Dam esoe-'allv on motion.
Phase 3 — pain on flexion of neck and spine continues,
drowsiness, muscle spasm and no motion.
Spinal fluid exam-notion diirjncr the second and rh'rd ohas«s
usually revpals thp character-stic changes which mav confirm
diagnosis. Therefore th s diagnostic procedure should not be
om'tted.
Some of the symptoms and s’gns mav be more severe In on«
case than another and lead to various tvpes of onset — men'ng'vff
or cerebral, gastrointestinal, and respirator’'.
Manv diseases have b»en confused with infantile nara'"s <■
chiefly because some of their wmotoms have been exaggerated
to the extent that thev resemble the characteristic features of
the various tvpes of ooliomvelitis.
The more careful inspection and palpation of the muscles as
recommended by Miss Kenny reveal muscle soasm earlv in In-
fantile parab'sis and save the patient a great deal of suffering bv
shortening the period during which a definite diagnosis is made
Earlv Symntomoloey
Minneapolis General
TABLE I
in 250 Cases of Infantile Paralysis
Hospital. 1937 to 1942. inclusive.
No.
No.
Svmotoms and Signs
Cases
‘ivmitonis and S'°ns
Ca*»s
Fever and malaise
730
Difficultv in swallowing
65
Headache
2 1 Q
li o0r . Drostration
7 5
Stiff or ricrid neck
1 7?
D*ff;cuhv in breathing
7 Q
Nausea and vomEinp
1 69
Abdominal pain
7 7
Pain on flex’on of neck
Diarrhea
19
or soine {backache
1 IQ
Acute pharvneitis-tonsillitis
1 5
^estl^'sness or irritab»l;r
v P'
1 Tr inary retention
Q
Muscle DA*n (extremt’e^
oi
Oulu
7
Drowsiness
8 3
Delirium
s
Muscle soasm
83
Sweating
5
Constipation
77
Photophobia
A
Acute corvza
Positive Kernig’s sign
7*7 Convulsions
69
TABLE II
1
Diseases Admitted with Jororrect Diagnosis of Poliomyelit
(52 Cases)
is
Minneapolis Genera
1 Hospital, 1937 to 1942, inclusive
No.
Cases
No.
Ca^es
Acute uoper respiratory
Aopendicitis
2
infections
1 1
Cardiac disease
2
Meningitis
8
Malaria
2
Guillain-Barre syndrome
5
Equine encephalo-
Pneumonia
4
myelitis
1
Fncephalitis
3
Transverse myelitis
1
Rheumatic fever
3
1
1
Chorea (paralytic type)
. 2
Typhoid fever ...
Brain tumor
2
1
Lymphocytic chorio-
meningitis
2
Measles - -
1
The Journal-Lanc i
1 *>2
AMERICAN STUDENT HEALTH ASSOCIATION MONTHLY NEWS-LETTER
(The Council of the American Student Health Association met at the Palmer House in
Chicago, March 6 and 7, 1943. At this meeting the Editorial Committee was asked to provide
a monthly digest of medical and Association news for distribution to the member institutions
either by mail or through the columns of the Journal-Lancet. This month’s digest has been
prepared by Dr. Dean F. Smiley, Cornell University, now Lieutenant Commander in the
U. S. Navy. Other action that was taken in two morning sessions and afternoon session is
recorded below Dr. Lyght’s editorial.)
STUDENT HEALTH AND THE WAR
Charles E. Lyght, M.D.
Director, Health Education, National Tuberculosis Association
If sometime a graph is drawn to show the growth of
student health services in American colleges and univer-
sities, the line will not trace an uninterrupted ascent from
zero to saturation. Several rests and an occasional
stumble will mark its climb to the peak.
Historians of the student health movement have re-
corded how slowly the idea caught on among educators
that institutions of higher learning owe it to their stu-
dents to provide facilities for health instruction and
health protection as well as a reasonable degree of cam-
pus medical care. After college presidents and boards
had accepted the challenge and had begun to set up
admirable departments, there ensued a period of cool-
ness on the part of the medical profession toward the
new project. Student health physicians have witnessed
the gradual dissipation of suspicion and unfriendliness
as they demonstrated to their medical colleagues that
they were not in competition with traditional forms of
practice. They proved that their activities closed this
hiatus in health coverage and that they were educating
large numbers of prospective American leaders to the
advantages of prompt and adequate medical care.
Following World War I there was a gratifying and
prompt increase in the number and quality of college
health services, while in the years of the great depression
the advance faltered as budgets grew slender and admin-
istrators cautious. Latterly there has been another spurt
of development, mirrored by a sharp upswing in mem-
bership of the American Student Health Association.
The recent appointment by the American Medical Asso-
ciation of a Committee on Student Health stresses the
importance of the movement and the warm acceptance
it is now privileged to enjoy.
At the moment we come to what may appear even-
tually as another plateau on our graph. The heavy im-
pact of the global war upon colleges and universities is
too well realized to need elaboration. Certainly the col-
leges cannot escape their share of the dislocation of nor-
mal plans and functions that war brings to all men and
all systems. Nor would they wish to assume less than
their allotment of obligations, even tribulations, in win-
ning the war.
However it is well known that physical fitness and
mental health are prerequisites to maintaining a war-
winning army, navy or civilian front. It is also known
that the government has seen fit, in many cases, to
choose colleges and universities possessed of modern stu-
dent health facilities, when establishing training centers
for young men and women preparing for special branches
of service. Only the healthy can meet government stand-
ards, and too many of those rejected because of health
defects have been found to be the victims of health
neglect. Colleges must lead in avoiding these mistakes
in the future.
Accordingly, with their staffs shrunken by the demand
for doctors and nurses elsewhere, and faced by the un-
certainties of material supply and budgetary adequacy,
the nation’s student health services are needed as never
before — needed to keep a wary eye on the effects of
vastly accelerated programs of study and of sometimes
overly enthusiastic "toughening” processes; needed to
prevent campus epidemics, to weed out tuberculosis from
the apparently health and to carry out a well rounded
plan of immunization against other communicable dis-
eases. Although hope for expansion seems futile, thought
of retrenchment must not be entertained. A plateau,
perhaps, but no downhill course is permissible.
If the student health physician can help his govern-
ment, his institution and his uniformed or civilian
charges to weather this storm, he will have contributed
significantly toward winning the war, and, in the peace
that we work and wait for, he will see his efforts and
his record rewarded by a tremendous increase in the
vitality and scope of the college health movement, until
none can be found oblivious to the importance of stu-
dent health.
The following institutions were voted into member-
ship in the Association which now numbers 195 insti-
tutions:
Queens College, Flushing, Long Island, New York,
Montana State Teachers College, Bozeman, Montana,
University of Dayton, Dayton, Ohio,
Southwest Missouri State Teachers College, Spring-
field, Missouri,
Emory University, Emory University, Georgia,
Earlham College, Richmond, Indiana,
The following changes were made in the Standing
Committees:
Dr. E. Lee Shrader replacing Dr. D. F. Smiley, now
in the Navy, as Chairman of the Committee on
Local Sections.
Dr. C. E. Turner replacing Dr. A. G. Gould, now in
the Army, as Chairman of the Committee on Health
Instruction.
Dr. M. L. Durfee replacing Dr. W. B. Brown as
Chairman of the Committee on Administration.
May, 1943
153
Dr. E. Lee Shrader, returning to the Chairmanship of
the Committee on Research, replacing Dr. Llew-
ellyn R. Cole (acting Chairman).
Dr. C. C. Fry replacing Dr. Helen P. Langner on the
Committee on Mental Hygiene.
Dr. R. W. Bradshaw was appointed to draw up a reso-
lution on the death of Dr. Lee H. Ferguson. Dr. Dan
G. Stine was appointed to draw up a resolution on the
death of Dr. W. B. Brown. Both Dr. Ferguson and Dr.
Brown have been active members and have made impor-
tant contributions to the work of the Association.
After a canvass of the experiences of the institutions
represented at the meeting it was the concensus of opin-
ion that in contracting with the military authorities for
medical care of military trainees a provisional figure of
$3.50 per student per month was a reasonable one. Where
less than complete medical services are provided, deduc-
tions would, of course, be made from that figure. It is
assumed that all such contracts are tentative ones and
that adjustments calling for a return to the government
of any profit on the contract, or of refunding to the col-
lege for any loss on the contract will be made each quar-
ter.
It was voted to send a letter to the Surgeon General
of the Navy inviting attention to our already existing
health services and urging their utilization for the care
of Navy trainees. The necessity for providing naval per-
sonnel to maintain the rather intricate Health Records
of the Navy was pointed out.
The Committee on Tuberculosis through its Chair-
man, Dr. H. D. Lees, reported that among approxi-
mately 500,000 students included in the Association’s
tuberculosis program in 1942, active pulmonary tubercu-
losis of the adult type was found in approximately 0.2
per cent.
It was voted to leave the question of a 1943 meeting
of the Association open for the time being.
Since there was no 1942 meeting, it was voted to hold
over such papers and committee reports as had been sub-
mitted for publication in the 1943, or 1944 Proceedings
and omit publication of any proceedings for 1942.
It was voted to continue membership dues as usual
utilizing the funds usually devoted to the proceedings
for providing other services to the member institutions.
Personnel Changes: Dr. Ann Tompkins Gibson has
been named resident physician at Wilson College, Cham-
bersburg, Pennsylvania, replacing Dr. Agnes Lyon Brown
who has entered the United States Public Health Serv-
ice.
Dr. M. W. Husband has returned to direct the Stu-
dent Health Service at Kansas State College, Manhattan,
Kansas, relieving Dr. J. W. Hanson who has accepted
directorship of the Health Service at Carleton College,
Northfield, Minnesota. Dr. C. E. Lyght, former director
at Carleton College, is now Educational Director for the
National Tuberculosis Association.
Dr. Kenneth Christophe has replaced Dr. Nathan
Garrick at Boston University.
Dr. Herbert Ratner replaces Dr. Earl E. Kleinschmidt
(Head of the Public Health Department of the Loyola
Medical School) as a full time director of Loyola LJni-
versity Health Service. This is the first time in the his-
tory of this school that a full time director has been
employed.
Dr. Daniel L. Borden, formerly of George Washing-
ton University at Washington, D. C., is now a Colonel
in the Army Medical Corps and is located at Fort Eustis,
Virginia.
Dr. Charles E. Shepard of Stanford University is
now in the United States Public Health Service and is
stationed in California.
Dr. Dean F. Smiley, in the Navy, is located in Wash-
ington, D. C., and Dr. A. G. Gould is in the Army,
located at Camp Breckenridge, Kentucky. Dr. Jennette
Evans is the acting head of the Health Service at Cor-
nell University.
Dr. William L. Holt is located at Massachusetts State
College at Amherst, Massachusetts, while Dr. E. J.
Radcliffe is with the Armed Forces.
A.S.H.A. DIGEST OF MEDICAL NEWS
Aid in controlling noise. The January, 1943, Scientific
American reports the development of a plaster ear stop-
per. A physician or qualified technician makes an im-
pression of the external auditory canal with a special
plaster material. The mold is sent to the company for
the preparation of the device in plastic. With the device
in the ears there is said to be a diminution in sound
intensity of 10,000 times and a reduction of 40 decibels
in sound.
Yellow fever prevented in British troops. Only three
cases of yellow fever have been reported among British
troops since the beginning of the war. Inoculation of
all troops going to endemic areas was required before
the war and has been consistently maintained, according
to the British Secretary of the State for War.
Epidemic kerato-conjunctivitis. The Subcommittee on
Ophthalmology of the National Research Council re-
ports this disease occurring in certain larger industries of
the west coast, the east coast and recently, New York
State and the middle west. There is an average of 18
days loss of work per case and corneal infiltrates occur
in 90 per cent of the cases. The conjunctivitis tends to
clear spontaneously in less than two weeks, but the cor-
neal infiltrates tend to persist for weeks or months. In-
fected individuals should be isolated immediately and
the spread of the virus by the physicians’ hands scrupu-
lously avoided.
Hypertonic saline in burns. Tosenthal of the National
Institute of Health finds that hypertonic saline by mouth
or parentally, if administered promptly after severe burns
has remarkable value in preventing fatal burn-shock in
mice. He has not yet applied the principle to humans.
Suitable antiseptic for frst-aid use. The Committee on
Surgery of the National Research Council recommends
a 1-1000 solution in water or 15 per cent alcohol of pro-
flavine monohydro chloride dispensed in a brown bottle
to prevent deterioration by light. It is not patented.
(Continued on ninth page following)
154
The; Journal-Lanckt
Book Reviews
Advances in Pediatrics, Volume I, edited by Adolph G.
De Sanctis, M.D.; 306 pages. New York, New York: In-
terscience Publishers, Inc., 1942, price #4.50.
This book reveals the recent progress in the field of pediatrics
by means of a collection of papers written by a group of pediatri-
cians. Some of the authors have presented articles which include
their own research studies, others have written reviews as volun-
teers. All papers are well planned and fairly complete, but all
the writers are not authorities or leaders in the fields of pediat-
rics. The book is of definite value to the general practitioner as
well as to the practicing pediatrician. However, it is important
that the editor make every effort to keep the future volumes up
to the standard of the first one. This is a difficult task and if
not well performed will lead to a lack of interest in this type
of publication.
Abdominal Surgery of Infancy and Childhood, by Wm.
E. Ladd, M.D., and Robt. E. Gross, M.D. Philadelphia:
W. B. Saunders, 455 pages, 614 illustrations and 268 fig-
ures, 1941, price #10.
For the first time in the history of American surgery such a
work is presented and it was long overdue. It could have been
produced only with the magnanimous gift of the Godfrey M.
Hyams Trust Fund. It is exceedingly well written, the illustra-
tions and charts excellently executed. Outstanding features are
chapters on Congenital Hypertrophic Pyloric Stenosis, with par-
ticularly well handled matter on pre-operative care and well de-
scribed and illustrated operative procedures, and on Congenital
Atresia and Stenosis of the Intestine.
The following sections contain original and helpful material:
Appendicitis, Diseases of the Spleen, Umbilical Hernia, In-
guinal Hernia, Undescended Testicle, Embryoma of the Kidney.
The references at the end of each chapter are timely and help-
ful to those inclined toward more extensive reading on the sub-
jects. The book deserves a place on the active bookshelf of doc-
tors who operate on infants and children and will save some
lives that might otherwise be lost.
The Prevention of Deformity in Childhood, A Primer by
Richard Beverly Raney, N.A., M.D., and Alfred Rives
Shands, Jr., B.A., M.D. Elyria, Ohio: National Society for
Crippled Children, Inc., 188 pages, 1941, price #1.00.
With increasing interest being shown by the medical profes-
sion in deformities of children, the small monograph is most
helpful in aiding the physician to obtain orientation as to
whether certain diseases will cause deformities and if so, just
what the doctor should do to prevent them or reduce their
severity. Neglect has led to deformity. Often the physician does
not know that a disease can cause a certain deformity. This
book is comprehensive enough to instruct him as far as possible
in the prevention of deformity for practically every condition
he might encounter in his practice.
Handbook of Treatment, by E. A. Mullen, M.D. Phila-
delphia: F. A. Davis Co., 707 pages, 1942, price #4.50.
This volume has again been revised and reprinted as of
January, 1942. There will always be demand for a book of this
kind and especially at the present time. The advent of sulfanil-
amide and its derivatives has driven physicians to the use of
reference works giving tables of dosage and methods of use.
Vitamins with their perplexing combinations require a daily
peek at the latest information. We would be inclined to criti-
cize the many examples of polypharmacy in the formulary but
without polypharmacy, there would be no need of a formulary
and these impressive prescriptions will delight the souls of
many.
Carcinoma and Other Malignant Lesions of the Stomach:
by Waltman Walters, Howard K. Coray, James T.
Priestley and associates of the Mayo Clinic and Mayo Foun-
dation, notably Alvarez, Eusterman, Kirklin, MacCarty
and Snell. Philadelphia: W. B. Saunders, 576 pages, 1942,
price #10.
By assembling the total experience of the Staff of the Mayo
Clinic over a period of thirty-one years, the authors have made
available to the medical profession a body of information con-
cerning cancer of the stomach, which, if carefully used and judi-
ciously acted upon, should lead to early, accurate diagnosis and
courageous treatment of a disease which, through neglect and
pessimism still exacts too large a toll of human life. Eleven
thousands cases of malignant disease of the stomach, (99 per
cent cancer), with 6,352 operations is a mass of material from
which valuable help should certainly be derived. And in char-
acteristic manner, statistical data constitutes an important part
of the book.
Following chapters on methods of diagnosis and on pathology
summarizing the well known opinions of MacCarty and Broders.
the middle one-third of the book is taken up with surgical
procedure and technic. A good deal of extraneous matter has
been included in this part, much of it not germane to the sub-
ject, but no doubt of some interest.
The chapter on roentgen treatment is, by the nature of the
disease in question, general and inconclusive. The concluding
sections on progressive and end results should be of actuarial
value.
The index is elaborate and historical references to well known
sources are given.
May 24-27, at Rochester, New York: four-day War
Conference of the American Association of Industrial
Physicians. Dr. Wm. A. Sawyer, Medical Director of
Eastman Kodak Company, is general chairman.
May 28, at Omaha, Nebraska: The department of
Obstetrics and Gynecology of the University of Nebras-
ka College of Medicine presents a symposium on ob-
stetrical analgesia and anesthesia with guest speakers
F. S. Hartman. M.D., Detroit, Michigan, R. A. Hing-
son, M.D., Staten Island, New York, N. R. Kretz- j
schmar, Ann Arbor, Michigan, A. H. Parmalee, M.D., :
Chicago, Illinois. Advance registrations should be sent
to Dr. Willis E. Brown, University Hospital, Omaha, ]
Nebraska.
July 6—7, at Billings: annual convention of the Mon-
tana State Oto-Ophthalmological Academy. Dr. W. R.
Morrison of Billings, president.
July 7-8, at Billings: State Medical Association sixty- j
fifth annual meeting. Session of House of Delegates, j
Scientific Session, Meeting of the Council, Meeting of
Women’s Auxiliary.
August 16-26, at the Michael Reese Hospital, Chi-
cago: cardiovascular department, a graduate course in
Electrocardiography for physicians; Dr. Louis N. Katz,
conducting.
October 12-14, at New York: American Public
Health Association three-day Wartime Public Health
Conference and 72nd annual business meeting of the
Association.
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MINNESOTA, NORTH DAKOTA
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SOUTH DAKOTA and MONTANA
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Montana State Medical Assn.
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Dr. E. D. Hitchcock, Pres.
Dr. A. C. Knight, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-Treas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Treas.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
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ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. A. R. Sorenson, Pres.
Dr. A. O. Arneson, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons' Assn.
South Dakota State Medical Assn.
Dr. N. J. Nessa, Pres.
Dr. J. C. Ohlmacher, Pres. -Elect
Dr. D. S. Baughman, Vice Pres.
Dr. C. E. Sherwood, Secy.-T reas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. J. H. Fjelde, Pres.
Dr. E. H. Boerth, Vice Pres.
Dr. R. E. Leigh, Secy.-Treas.
Dr. J. O. Arn^on Dr. A
Dr. H. D. Benwell Dr. Ja
Dr. Ruth E. Boynton Dr. A.
Dr. Gilbert Cottam Dr. E.
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Dr. H. S. Diehl Dr. A.
Dr. L. G. Dunlap Dr. W
Dr. Ralph V. Ellis Dr. O.
Dr W. A. Fansler Dr.J.
W. A Jones, M.D, 1859 1931
R. Foss
mes M . Hayes
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Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
LANCET PUBLISHING CO., Publishers
84 South Tenth Street. Minneapolis. Minnesota
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thomas Ziskin
Secretary
W. L. Klein, 1851-1931
Minneapolis, Minnesota, May, 1943
CHILD HEALTH AND NATIONAL
STRENGTH
A perusal of the articles contributed to this special
Pediatrics number of the Journal-Lancet strengthens
our conviction that more attention should be given to
the problems of child health during the war, as well as
in peacetime. The exigencies of national defense quite
naturally demand first consideration for those among us
who are engaged in or are soon to be engaged in military
service. However, when our needs beyond the immediate
present are considered, we are forced to admit that the
emphasis in the medical field must be changed in the
future from the reparative to the preventive point of
view. The appalling incidence of necessary rejection of
men from the armed services because of physical and
mental disabilities is a sober challenge to American citi-
zens and particularly to the medical profession.
The special emphasis accorded the subject of child
health by Prime Minister Winston Churchill in his most
recent radio message to the British people indicates that
our friends on the other side of the Atlantic have en-
countered problems similar to our own in the matter of
health deficiencies in their young adult population.
Rather tardily, the British, like ourselves, have come to
recognize the paramount importance of making improve-
ment in child health a major feature of any future pro-
gram to be set up for furtherance of national security
and social betterment.
The free peoples of the western democracies have
long tacitly recognized that "the child is father of the
man” and have made sporadic efforts to make him a
worthy "father”. However, in proportion to its real im-
portance we have been niggardly in our attention to the
most serious responsibility that individuals and states fall
heir to upon their arrival at maturity, namely, that of
producing a new generation of men superior to the one
preceding it. Our present enemies, the totalitarian axis
countries, in preparation for forced expansion, organized
child health and training programs on a grand scale, be-
156
The Journal-Lancet
cause they recognized the close relationship between good
health and national strength. That foresight on their
part makes them far more formidable enemies today
than they would otherwise have been.
Our own laissez fane attitude toward child health and
training during the same period places us at a disadvan-
tage. It is true that we have had the benefit of such pri-
vate youth organizations as the Boy Scouts and Girl
Scouts of America and other groups sponsored by indi-
vidual schools and churches primarily for the purpose of
"character building,” but the nation’s halting program
for improving child health has obviously been inadequate.
Even our own enlightened profession is still overwhelm-
ingly "cure-minded” or "therapy-minded” instead of be-
ing predominantly "prophylaxis-minded”.
Those members of the medical profession who partici-
pated in the comprehensive, non-governmental program
of Mr. Hoover’s White House Conference on Child
Health and Development in 1929-1930 can recall with
what thoroughness and enthusiasm the first phase of the
undertaking was carried out. The fact that such a bril-
liantly conceived and carefully planned program was
allowed to succumb merely because it lacked the financial
support needed for carrying out its wise recommenda-
tions, stands as a testimony to our shortsightedness. It is
interesting to speculate on the possible advantages that
we might be enjoying today, had wise governmental or
private agencies provided adequate support for its full
operation over the years which have intervened. Since
the data collected and the recommendations made by the
White House Conference are as sound today as when
they were first brought forth, they should form the basis
of a new program to be placed in operation at the earliest
possible date. I. McQ.
PEDIATRICS IN NEW ORLEANS
New Orleans has a group of well-trained and capable
pediatricians engaged in private practice. In addition to
providing their private patients with services of superior
quality they also conduct many well-baby clinics which
are supported by the New Orleans Bureau of Child Wel-
fare. In these clinics they supervise the feeding of sev-
eral thousand infants and children each year, and admin-
ister the Bureau’s immunization program, including
Schick and tuberculin testing, small pox vaccination, and
immunization against pertussis, diphtheria, tetanus and
typhoid fever. The total of 708 immunizations and tests
performed during February, 1942, provides a fair esti-
mate of the volume of the work being done by the
pediatricians working in these free clinics.
With respect to the type of disease seen most com-
monly in children, conditions in New Orleans closely
resemble those in Minneapolis. Seasonal waves of chicken
pox, measles, pertussis and scarlet fever occur, and dur-
ing the winter months upper respiratory infections and
pneumonia are common in children. In the warm months
of the year the incidence of diarrhea increases, but its
prevalence here is far less than I expected.
In some respects diseases seen in children in the South
differ from those seen in the North. Physicians deal
daily with a variety of intestinal parasites, and summer-
time brings its crop of furuncles. Rheumatic fever is
common in New Orleans and when it occurs in a col-
ored child the difficulty that may attend its diagnosis is
increased if sicklemia is present. In the land where or-
anges grow, florid scurvy is occasionally encountered, and
our experience with congenital syphilis is particularly
rich. But strange to say, malaria in children is a curiosity
in New Orleans. C. A. S.
ACUTE SINUSITIS IN CHILDHOOD
Aggressive treatment of acute sinusitis was once a pop-
ular procedure. That is no longer so. The trend is defi-
nitely in the reverse direction.
No one knows better than the conscientious physician
how necessary it is for him to be alert to the changes in
medical thought and practice that occur from time to
time. He may ridicule some archaic form of treatment
in the distant past, but he cannot be oblivious to the fact
that any transition from the old to the new has come
about gradually. Progress has been made through a rec-
ognition of failure as well as success. Truths as we
accept them today have come down slowly through a
long grind of research and toil. Careful observation,
painstaking examinations, discussions and consultations
have contributed to point the way. There may not be
complete agreement, but the trend against active surgical
intervention in cases of acute sinusitis has nearly com-
pleted its cycle. Its status may be compared to the pres-
ent well established dictum of nonintervention in cases'
of acute salpingitis.
We are pleased to find that pediatricians, aware as
they naturally are of the minute Size of their little pa-
tients’ sinuses, appear to be in full accord with the mod-
ern teaching of more gentle and persuasive methods,
based on mild astringents to reduce turgescence at the
sinus opening, and steam. A.E.H.
OFFICIAL CALL
The House of Delegates of the South Dakota State
Medical Association will meet to transact the business of
the Association on Friday, May 28, at the Marvin
Hughitt Hotel in Huron. The first session of the House
of Delegates will convene at 9:30 A. M., the second
session at 1:30 P. M.
The Council will meet at 8:00 P. M. on Thursday,
May 27, for its first session. The second session will be
immediately following the secofid session of the House
of Delegates, at which time the newly elected Councilors
will be seated, and the chairman elected for the ensuing
year.
The secretary-treasurer’s term of office expires at this i
time, and the matter of electing a secretary-treasurer for
a three year term will be taken up by the Council at the
second meeting. The following Councilors’ terms expire
this year: the 9th District, 10th District, 11th District,
and the 12th District. Councilors are elected by the
House of Delegates for a three-year term. Will those
districts whose Councilor terms expire please take note
and instruct your delegate as to your desire for candi-
date. Clarence E. Sherwood, M.D.,
April 28, 1943. ’ Secretary.
14/OijS- TO GIVE INFANTS AND CHILDREN
7 THEIR DAILY VITAMIN REQUIREMENTS
1. FORMULA. One of the easi-
est ways to give vitamins is
to add Vi-Penta Drops to
the baby's formula ormilk.
2. ORANGE JUICE, tomato
juice, or any fruit juice
makes an excellent vehicle
for Vi-Penta Drops.
3. MILK. The flavor of even
such a bland food as milk
is not affected by the ad-
dition of Vi-Penta Drops.
4. CEREALS are good bases
to which to add the child’s
needed additional vita-
mins at breakfast time.
5. VEGETABLES served with
the noon or evening meal,
can be enriched with
Vi-Penta Drops, too.
6. FRUITS. Vi-Penta Drops
seem to have a natural
affinity for stewed fruits —
apricots, apples, prunes, etc.
7. DESSERTS. Many mothers
enrich desserts and pud-
dings with Vi-Penta
Drops.
. . . using easy-to-use Vi-Penta Drops
that do not affect the flavor of food
j^/ere is a remarkable liquid multivitamin preparation which
makes it possible for the physician to prescribe a liberal vitamin
regime that the mother can easily carry out. Not only do
Vi-Penta Drops contain 5 principal vitamins (see chart), but
these drops also possess the remarkable advantage of mixing
readily with various foods, without affecting the taste. When
you prescribe Vi-Penta Drops, suggest their use in the several
ways pictured here. Mothers will appreciate the information.
10 minims
Vi-Penta
contain
inims of )
nta Dtopsk
ntain : J
A
4000 U.S.P.
units
Bi
333 U.S.P.
units
Bz
100 gamma
riboflavin
C
500 U.S.P.
units
Vi-Penta Perks — tiny gelatin globules, each containing the same amount of the
vitamins as 10 minims of the Drops. Supplied in packages of 25, 100, and 250.
VI-PENTA DROPS
1'lccLc
HoffmoruvLa Roche, Inc., Nutley, N. J.
SUPPLIED IN 15-CC GLASS VIALS WITH CALIBRATED DROPPERS. ALSO 40-CC UNIT PACKAGE CONTAINING FOUR 15-CC VIALS
158
The Jouknal-Lance i
Views Items
The American College of Surgeons, holding in abey-
ance plans for a Clinical Congress this year, offered the
last of twenty regional war sessions for physicians and
surgeons of Montana, Washington, Oregon, and British
Columbia on April 20 at Seattle.
The South Dakota state board of health has conduct-
ed clinics for immunization against typhoid fever in Ft.
Pierre and Herried following the recent flood period.
The municipal water supply systems in all areas affected
have been under constant surveillance by members of the
Division of Public Health Engineering preceding, dur-
ing and after the floods.
Dr. Melvin W. Binger of the Mayo Clinic, Rochester,
Minnesota was guest speaker at a recent meeting of the
Winona County Medical Society. His subject was
"Nephritis and Edema.”
Capt. Jas. D. Morrison, M. C., was granted a fur-
lough from Fort Geo. G. Meade, Maryland, to attend
and present a paper at the Butte, Montana, meeting of
eye, ear, nose and throat specialists. Dr. Morrison prac-
tised in Billings.
Dr. F. K. Waniata, Great Falls, Montana, has become
associated with Drs. Irwin, MacGregor, Lord and Little
where he will assist in clinical activities and continue his
private practise.
Dr. Jno. S. Kilbride, who left Canby, Minnesota, in
1936 after 30 years of practise to join his son, Dr. Edwin
A. Kilbride in Worthington, has reopened his office in
Canby.
Dr. Dolson W. Palmer, former physician at the Fort
Totten Indian Agency, North Dakota, and more recently
with the veterans administration near Oakland, Califor-
nia, has removed to Cando, North Dakota, to take over
the practise of the late Dr. Kristinn Olafson.
Dr. H. H. Parsons, a retired major in the United
States Medical Corps who recently resumed private prac-
tise in Sidney, Montana, his earlier home, has accepted
an appointment as surgeon in the government hospital
at Oklahoma City, Oklahoma.
Dr. T. J. Bloedel, practising in Gaylord, Minnesota,
for the past year, closed his office there on April first
to become associated with Dr. Arthur Neumaier at
Glencoe.
Drs. Daniel W. Wheeler, Peter S. Rudie, Mark Tib-
betts and Lawrence R. Gowan, all of Duluth, Minne-
sota, and all of whom were lieutenant commanders in
the Minnesota naval reserve, after twenty months on the
staff of the Navy hospital at Bremerton, Washington,
have been promoted to the rank of commander.
Capt. Thos. E. Corcoran, M. C., of Rock Rapids,
Minnesota, has been reported missing in action in North
Africa.
Dr. Fred W. Rankin, once head of a Mayo Clinic
section in surgery, has been elevated to the rank of a
brigadier general in the army medical corps which was
the rank held by his father-in-law, the late Chas. H.
Mayo, and Dr. Mayo’s brother, the late Dr. William J.
Mayo, in their service in the World war.
Dr. Emmett R. Samson of Stillwater, Minnesota, has
been commissioned a lieutenant commander in the med-
ical corps of the Navy and has entered the service at
San Diego, California.
Dr. j ames R. Kingston of Coleraine, Minnesota, one-
time practitioner at Deer River and later a member of
the State Health Board, now in active service in control
of a Southern Pacific malaria unit, has been promoted
to lieutenant commander.
Dr. Milo H. Larson of Nicollet, Minnesota, has been
ordered to the Army Air Corps at Carlisle Barracks,
Pennsylvania.
Dr. Gaylord W. Anderson, head of the division of
preventive medicine and public health, serving in a public
health capacity in the office of the surgeon general of the
army, has been made head of the army’s division of
medical intelligence, the so-called "health spies” who
compile health, climatic and sanitation evidence with re-
spect to all areas to which United States troops may be
sent.
Dr. Edward A. Hackie of Hallock, Minnesota, a Cana-
dian by birth, as the culmination of two years of effort
has found it possible to enlist in the United States army
and will assume military duties as a lieutenant at Camp
Grant, Illinois.
Maior Michael L. Mitchell is the new post surgeon
and director of the medical division at Fort William
Henry Harrison, Helena, Montana, succeeding Major
Lester Besecker who became surgeon of the First special
service.
Lieutenant Wm. M. Thebaut, for eight months med-
ical officer at the main Montana navy recruiting station
in Helena has been transferred to the naval hospital at
Bremerton, Washington, the replacing officer being Lieu-
tenant Walter Mauther who has been serving as post
surgeon at the Bremerton marine barracks. The home
of the former is Oakland, California; that of the latter,
Milwaukee, Wisconsin.
Dr. Chas. J. Bresee, Great Falls, Montana physician,
named to succeed the late Dr. Enoch M. Porter, Great
Falls, on the state board of health.
Dr. Lester McLean, former Bismarck, North Dakota j
resident and at present city and county health officer at
Vallejo, California, now heads a staff of twelve doctors,
nurses and inspectors as chief of the new Vallejo health
center dedicated in March.
Dr. Ralph Rossen, superintendent of the Hastings,
Minnesota, State Hospital foe the past five years, will
leave for Bethesda, Maryland, for active duty as a past
assistant surgeon Lieutenant Senior grade in the Navy.
He has been given a military leave of absence.
YOUR gift of cigarettes to men
in service is the most welcome
of all remembrances. And the pre-
ferred brand, according to actual
survey, is Camel.*
Send Camel the cigarette noted
for mellow mildness and appealing
flavor. It’s one way, and a good way,
to express your appreciation of the
sacrifices being made by our fighting
forces.
Camels in cartons are featured at
your local tobacco dealer’s. See or
telephone him — today — while you
have the idea in mind.
*With men in the Army, Navy, Marine
Corps, and Coast Guard, the favorite
cigarette is Camel. < Based on actual sales
records in Post Exchanges and Canteens.)
Remember, you can still send Camels to
Army personnel in the United States, and to
men in the Navy, Marines, or Coast Guard
u'herever they are. The Post Office rule
against mailing packages applies only to
those sent to men in the overseas Army.
CAM E L COSTLI E R TOBACCOS
BUY WAR BONDS AND STAMPS
j
V
'V'
160
Dr. R. R. Hendrickson, Bismarck, North Dakota, for
the past eighteen months superintendent of the sana-
torium at Sand Beach near Lake Park, has been com-
missioned a major in the United States public health
service and will be stationed at Juneau, Alaska.
Dr. Byron L. Pampel, formerly of Livingston, Mon-
tana, has been re-appointed by the governor to be super-
intendent of the state hospital at Warm Springs. His ad-
ministration of the institution is regarded as a progressive
one.
Dr. John S. Floyd, Butte, Montana, has been appoint-
ed by the board of county commissioners to fill the post
of county physician left vacant by the resignation of
Dr. Jos. J. Kane.
Dr. Thos. E. Flinn of Redwood Falls, Minnesota, has
been appointed county coroner, an elective office for
which there were no filings and which was filled tempo-
rarily by a Redwood Falls resident non-professional who
later resigned.
Dr. George Friedell of Ivanhoe, Minnesota, elected to
the presidency of the Lyon-Lincoln Medical Association.
Dr. Frank M. John, Coleraine, Minnesota, re-elected
president of the Itasca County Hospital staff.
Dr. Herbt. H. James of the staff of Murray hospital,
Butte, Montana, delivered a slide-illustrated lecture on
"Cancer and its Control” to the members of the Red
Cross home nursing class of Silver Bow County Women’s
Field Army for Cancer Control.
Dr. Arthur R. Kintner, Missoula, Montana, has ad-
dressed several bodies, among them the Rotary Club, on
the advance of the sulfonamides in the field of infection
treatment.
Dr. L. G. Dunlap, Butte, Montana, discussed progress
in medicine and surgery before Rotarians at Anaconda in
respect to medication of battle casualties, operations for
cataract, blood transfusion and storage of plasma, frac-
ture treatment for broken legs, employment of sulfa
drugs for treating infection and the contributions of Dr.
Herald Cox who was the Journal-Lancet lecturer at
University of Minnesota in 1942. Dr. Cox’s work in
manufacturing sera with eggs was explained.
South Dakota physicians who attended the New Or-
leans Graduate Medical Assembly meeting in March:
Dr. O. Charles Ericksen, Sioux Falls, Drs. Wm. A.
Delaney, O. F. Mabee, E. W. Jones and F. J. Tobin,
Mitchell.
Dr. F. W. Hennings of Dickinson, North Dakota,
and M iss Beth Barnes, formerly of Cannon Falls, Min-
nesota, and lately of Seattle, were married in Seattle and
the couple is living in Pacific Beach, Washington, where
Dr. Hennings for the last ten months has been a lieu-
tenant in the naval medical corps.
Dr. Frank Darrow, Fargo, was elected president of
North Dakota Medical association at the annual meeting
in Bismarck. Dr. F. L. Wicks, Valley City, was elected
president-elect. Dr. James Hanna, Fargo, was named
first vice president and Dr. A. E. Spear, Dickinson, sec-
ond vice president. Fargo was named 1944 convention
city.
The Journal-Lancet
huMtotyf
Dr. Campbell Sansing, 70, formerly of Fargo, North
Dakota, where he had served on the staff of the Vet-
erans hospital between the period of his practising in
Valley City and in Courtenay and his transfer to the
government hospital in Muskogee, Oklahoma, died April
4 at his home in Blossom, Texas. He retired last August.
Dr. A. L. Lloyd, 76, of Rapid City, South Dakota,
who had been in ill health for three years, died at his
home March 27. He had practised in the state since
1898, successively at Leola, Custer, Newell, Belle
Fourche, Rapid City and Nisland, returning to Rapid
City six years ago.
Dr. Frank A. Moore, 70, pioneer physician and mayor
or Yankton, South Dakota, and brother of Dr. D. V.
Moore of Sioux City, Iowa, died March 22 after twenty
years residence in Yankton, seventeen of which were
spent in medical practise and the last three in office.
The cause of death was coronary thrombosis.
Dr. Bertha Brainard McElroy, 49, of Jamestown,
North Dakota, died at Rochester, Minnesota, March 12.
Graduating from the University of North Dakota a
Phi Beta Kappa and spending nine years as a high
school teacher and principal she resigned to pursue a
course in medicine, a lifelong ambition. Dr. Brainard,
her marriage to Mr. Jno. E. McElroy having taken place
only in 1941, was a graduate of Rush Medical college,
city health officer of Jamestown, and a staff member of
the student health service of Oregon State College, Cor-
vallis, Oregon, after serving one year’s internship at the
Women’s and Children’s hospital in San Francisco and
a year at Los Angeles General hospital. She was state
president of the American Association of University
Women and a member of many civic and professional
organizations.
Dr. Francis E. Butler, 62, of Menomonie, Wisconsin,
president of the Wisconsin State Medical Society and a
practitioner in Menomonie for nearly forty years, died
there March 12.
Dr. August Kuhlmann, 67, of Melrose, Minnesota,
died April 4th, ending thirty-seven years of practise in
that community.
Dr. Henry Porter Johnson, 88, of Fairmont, Minne-
sota, died March 31 after several invalid months. His
career as a family physician dated back sixty-four years,,
all of which were spent in Minnesota. In addition to an
active practise in medicine and surgery Dr. Johnson
found time for postgraduate work, hospital management,
service on boards of education and church bodies as well
as fraternal affiliations and service to business clubs.
Dr. Anton Herman Luedtke, 73, of Fairmont, Min-
nesota, died March 18 at his home in that city. He was
a graduate of the University of Minnesota Medical
School and had served in World War I, leaving his
practise at the age of nearly fifty years and attaining the
rank of Major. His death was due to cancer.
MERCK INSTITUTE’S TENTH ANNIVERSARY
Leading scientists in government, universities, and industry
stressed the tremendous contributions to victory made by the
research laboratories of this country, at ceremonies commemor-
ating the tenth anniversary of the opening of The Merck In-
stitute for Therapeutic Research on April 26.
The Institute, a non-profit corporation under the laws of the
State of New Jersey, was founded in 1933 for the purpose of
conducting investigations into the causes, nature, and mode of
prevention and cure of diseases in men and animals. The deter-
mination of the therapeutic value and safety of new drugs is
one of its principal duties.
The tenth annual report, presented by the Director, Dr.
Hans Molitor, pointed out that, since 1933, the size of the
Institute has increased almost six times, and its personnel
eighteen times. Vitamins and Chemotherapy are the principal
fields of research. Since the outbreak of the war, only problems
of immediate importance to the war effort were permitted to
remain on the Institute’s research program. Notable among
these are Penicillin, the most powerful and least toxic germ
killer ever discovered, and new antimalarial products.
George W. Merck, President of Merck & Co., Inc., presided
at the dinner and introduced the speakers, each of whom em-
phasized the importance of continuous research in the fields of
chemotherapy and nutrition during wartime as well as to meet
the problems of postwar rehabilitation.
The Merck Institute was included in the Army-Navy "E”
Award for Excellence in Wartime Production which was pre-
sented to Merck & Co., Inc., on February 9, 1943.
TWO NEW LEDERLE ITEMS
Hemostatic Globulin, a constituent isolated from blood and
possessing enhanced power to clot blood (thrombic activity),
has proved highly efficient in staunching the flow of blood
from wounds. This originated in Lederle research. Its impor-
tance lies in the fact that the blood of many persons may be,
or may become through disease, deficient in natural clotting
ability. To such persons even minor wounds and cuts are dan-
gerous through hemorrhage. Shaving, pulling of teeth and
even the simplest of surgery present hazards to "bleeders” that
may even be fatal. Hemostatic Globulin effectively erases this
danger. When applied either as a spray or as a wet dressing,
Hemostatic Globulin causes clotting of blood in the capillaries
within as short an interval as five seconds. A severed vein or
artery must be subjected to surgical treatment as heretofore, but
dentists and surgeons find the new material invaluable in cases
of stubborn bleeding.
A new effective treatment for ivy poisoning is marketed by
Lederle as Rhulitol. Applied on a wet dressing, this prepara-
tion quickly relieves itching and local symptoms, prevents sec-
ondary infections and promotes complete healing in a few days.
Its principal active ingredient is tannic acid.
NEW G-U ANALGESIC AND ANTISEPTIC
INTRODUCED BY SQUIBB
A new analgesic and antiseptic for use in genito urinary con-
ditions has been added to the line of E. R. Squibb & Sons under
the name, "Cajandol”. A preparation of 5 per cent oil of
cajeput dissolved in peanut oil, with 0.1 per cent propylpara-
hydroxybenzoate as preservative, Cajandol was developed at the
Brady Urological Institute, Johns Hopkins Hospital, and has
been in use there during the past several years.
Clinical experience has shown that Cajandol alleviates pain
md distress due to instrumentation and fulguration. It is also
aeneficial in many types of acute and chronic cystitis and other
pathologic conditions of the bladder.
In treating these conditions, 10 cc. to 15 cc. of Cajandol are
nstilled into the bladder through a catheter at daily or bi-
veekly intervals. In a few cases, Cajandol has been injected up
he ureter during the use of the Councill stone extractor and
'as facilitated withdrawal of this instrument when there has
>een difficulty due to spasm of the ureter.
Cajandol is supplied in one-pint bottles only.
Your patients may have a preference for
either Red Label or Blue Label KARO.
If their grocers are temporarily out of
their favorite flavor, you may assure
them that flavor is the only difference
between these two types of karo for
infant feeding.
Each contains practically the same
amount of dextrins, maltose and dex-
trose so effective for milk modification.
How much KARO for Infant Formulas?
The amount of KARO prescribed is 6 to 8% of
the total quantity of milk used in the formula —
one ounce of KARO in the newborn’s formula is
gradually increased to two ounces at six months.
CORN PRODUCTS REFINING CO.
17 Battery Place • New York, N. Y.
LIQUID SILOMIN: A palatable, creamy
suspension of magnesium trisilicate —
80 grains to each fluid ounce. For the
reduction of gastric acidity.
K-B UNCTION: Analgesic, counter-irritant
and stimulant of local capillary circula-
tion, bringing prolonged subcutaneous
warmth to painful areas.
THEODIATAL CAPSULES: Logical, con-
servative therapy, in the management
of cardiovascular diseases including
high blood pressure and arteriosclerosis.
TRIODYDE: Alterative expectorant for the
non-narcotic control of bronchial cough.
To mildly stimulate and facilitate the
expulsion of bronchial mucus.
PRODUCTS are useful in
the Physician's daily prac-
tice. They are prepared,
for use under his supervision and avail-
able only on his prescription.
KUNZE & BEYERSDORF, INC.
Milwaukee, Wisconsin
SYMBOL"
For Purity and
Softness
Does not alter the
flavor or bouquet of
your favorite drink.
Highly Carbonated
Demand Chippewa
at Your Club or Bar
CHIPPEWA
Sparkling
WATER
Delivered to your Door
1 2 quarts $ <4 50
24 pints ■■
or
Call Your Local Store
The Medical Management of the Patient with
Arterial Hypertension"
S. Marx White, B.S., M.D., F.A.C.P.
Minneapolis, Minnesota
A NIMAL experimentation and newer methods of
physiologic study of kidney function in man have,
■A. A. in the past decade, increased our knowledge of
the hypertension problems to a remarkable degree.
Whether our means of relieving the patient subject to
this malady have been greatly increased, thereby, remains
yet to be seen. In the meantime, we should continue to
avail ourselves of all the methods by which amelioration
of the process can be secured and by which diminution
of its consequences can be brought about.
In order that his therapy may be basically sound and
fully abreast of the times, it is requisite that the physi-
cian have a knowledge of the pathology and pathologic
physiology of the disorders he treats. For that reason,
the briefest possible discussion of our knowledge of
hypertension, including recent trends, is presented.
It is generally accepted that increased peripheral re-
sistance, the effective site of which is in the arterioles,
is the predominant factor in the disorder. Increased force
of the heart beat, called by Page1 "cardiac augmenta-
tion” is a phenomenon familiar to all clinicians. Given
sufficient time for its development, cardiac hypertrophy
\ occurs without exception. Other factors which might be
considered, such as increased viscosity and volume of the
blood, and increased cardiac output, appear not to play
a uniform or essential role. Page1 states that these three
are normal in experimental hypertension.
Arterial hypertension occurs in connection with many
conditions, apparently unrelated. Page1 has given a
*Presented at the meeting of the Kansas City Southwest Clinical
Society, Kansas City, Mo., October 5, 1942.
classification of hypertension which I shall attempt to
simplify for our consideration.
A. Renal: (a) Affections of the vessels, such as peri-
arteritis nodosa, arteritis, anomalies, obstructions, throm-
boangiitis obliterans and Wilm’s tumor, (b) Affections
of parenchyma, acute nephritis, chronic nephritis, pyelo-
nephritis, hydronephrosis, polycystic disease, toxemia of
pregnancy, x-ray lesions and renal stones, (c) Affections
of perinephric structures; perinephritis, tumors, hemat-
oma. (d) Affections of the ureter; obstruction at the
pelvis, in the ureters, prostate, urethra, etc.; pyelitis.
B. Cerebral: Increased intracranial pressure, such as by
trauma, tumor and inflammation; stimulation of the di-
encephalon, anxiety states, lesions of the brain stem.
C. Cardiovascular: Heart failure, arteriovenous aneur-
ysm, coarctation of the aorta, lead poisoning and poly-
cythemia. D. Endocrine: Pheochromocytoma, pituitary
adenoma, pituitary basophilism, acromegaly, hyperthy-
roidism, the menopause (natural or artificial) and ar-
rhenoblastoma. E. Unknown: Essential hypertension,
malignant hypertension.
It seems clear that some of the above act by toxic fac-
tors, others, principally through a nervous mechanism,
and still others, through a humeral mechanism. How
far we can go in finding a common denominator, me-
diated through the nervous system and/or by humeral
factors, remains yet to be seen.
Attempts to correlate disturbances in the endocrine
system with essential hypertension have failed so far,
despite the occurrence of hypertension in certain disor-
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The Journal-Lancet
ders involving that system. Animal experiments, how-
ever, show that the endocrines have a place in the sum
total of the processes on which arterial tension depends.
The role of the hypophysis is not yet clear, although
there is evidence supporting the suggestion that it acts
indirectly through a hormone to stimulate the adrenal
cortex, and does, on occasion, excite a form of hyper-
tension. The thyroid and gonads are shown to play no
essential part. The incidence of hypertension in the
menopause remains unexplained.
The fact that so-called emotional factors play a part
in causing hypertensive reactions has been recognized for
many years. Page1 expresses the view that in maintain-
ing the blood vessels in a reactive state, as well as in
contributing towards the vaso-constriction by vasomotor
impulses, it is possible that in some cases these emotional
factors initiate the steps leading to hypertension of hu-
meral nature, and may thus play a subsidiary though
important role in the mechanism of hypertension.
Surgical removal of a portion or portions of the sym-
pathetic nervous system, a mode of attack on the prob-
lem of hypertension begun by Rowntree and Adson,"
was followed by various types of operation on the nerv-
ous system and on the adrenal gland by many surgeons,
and the results have been followed up with careful study.
There are reports of many cases of partial disappearance
of hypertension and relief of symptoms. Recurrence of
the hypertension is not uncommon. Relief of the ocular
manifestations of malignant hypertension in certain in-
stances has been gratifying. While the surgical attack
on the sympathetic nervous system may have limited ap-
plication, it is not a curative measure and is, fortunately,
not being generally adopted.
Koch and Mies'1 produced protracted arterial hyper-
tension in rabbits by removal of the nerve of the carotid
sinus and the aortic depressor nerves, but their work does
not appear to have been followed up; and it seems clear
that damage to the aortic depressor nerve and the carotid
sinus are not a source of hypertension in man.
Turn for a moment to the pathology and pathologic
physiology of our subject. Bell,4 summarizing the results
of many years of study of the pathology, states that the
form of arteriolosclerosis seen in "primary hypertension"
is characterized by the presence of a subintimal deposit
of hyaline material; this change is seen particularly in
the afferent arterioles of the glomeruli. It usually forms
only a thin layer, but is sometimes very thick. There is
also elastic intimal thickening in the small arteries. How
widespread are the characteristic histologic changes of
arteriolosclerosis throughout the body, appears to be still
controversial. Fishberg,'1 studying 72 cases of essential
hypertension, found arteriolosclerosis present in the kid-
neys in 100 per cent, in the spleen in 66 per cent, in the
pancreas in 49 per cent, in the liver in 30 per cent, in
the brain in 19 per cent, and in gastrointestinal tract,
skin and myocardium in small percentages only. He
found none in the skeletal muscles and lungs. Histo-
logic studies by many writers vary the picture, but this
is fairly representative. Whether the intimal thickening
in the arterioles, i. e., a pathologic process, antedates the
development of hypertension, or whether the increased
intravascular pressure with arteriolar constriction is the
primary factor, does not appear to be fully settled, as yet.
Experimental work, of the type begun effectively by
Goldblatt and followed up and confirmed by many oth-
ers, seems to have established, however, that changes in
the renal circulation are the primary cause. Hyperten-
sion begins promptly, as a rule, after the circulatory
changes have been induced experimentally in animals.
From the physiologic side, based on studies of glom-
erular filtration rate and renal blood flow, the studies of
Smith, et al*’ indicate that in patients with arterial hyper-
tension, the characteristic change in circulation in the
kidney must be constriction of the efferent glomerular
arteries, by which intraglomerular pressure is increased.
Again, Page1 states that the conditions for the liberation
of renin from the kidneys involves the release of this
substance, a large molecular protein, from the tubular
cells of the kidney, and that this release can be brought
about in animal experiments by reduction of pulse pres-
sure, i. e., the partial conversion of pulsatile to a con-
tinuous flow. His statement, that blood from the renal
veins of many patients with essential hypertension is rich
in renin, suggests some such change in the circulation of
the renal tubules.
These points should not be labored. They are intro-
duced here chiefly to call attention to the studies now
under way. They show that complete correlation of path-
ologic and physiologic data has not yet been attained,
though it seems to lie very near. Studies of glomerular
filtration rate, effective renal blood flow, clearance of
various substances by the kidney, are yielding valuable
information to the physiologist and the clinician. It is
suggested that the physician, to keep his therapy up to
date, must follow closely this field of work.
An enormous amount of experimental work has been
stimulated by the discovery of Goldblatt, Lynch, Hanzal
and Summerville,1 who were the first to produce chronic
arterial hypertension in animals by application of ad-
justable clamp to the main renal arteries. Pages has also
produced a similar hypertension by compression of the
parenchyma of the kidneys, either by the perenephric
scar which results from application of silk or cellophane
to the kidneys, or by preventing the hypertrophy which
results when one kidney is removed.
Correlation of experimental and clinical observations in
the study of arterial hypertension has been presented by
Corcoran and Page.1' They point out that a substance,
renin, derived from the kidneys, when activated by a sub-
stance present in normal plasma, forms an active vaso-
constrictor substance, angiotonin. This substance, when
injected in experimental animals or in man, produced the
effects which characterize arterial hypertension in man,
such as cardiac augmentation, arteriolar constriction, and
constriction of the efferent glomerular arterioles in the
kidney. While suggesting the possibility that angiotonin
is involved in the pathogenesis of essential and malignant
hypertension in man, they point out the part that the
endocrine and nervous systems play in maintaining the
blood vessels and heart in a state receptive to hyperten-
sive stimuli. They maintain the attitude, also, that in
some types of hypertension in man, the high state of
June, 194?
165
nervous organization may even make it a prepotent
factor.
Search for a substance which would inhibit the action
of the substances capable of producing hypertension in
animals has been successful, both in the hands of Groll-
man, Williams and Harrison10 and of Page, et al.11 This
inhibitor substance, derived by extraction from the kid-
ney, has been used in treatment of essential and malig-
nant hypertension in man by Page.1 Given by injection,
it has caused striking remission of the hypertension and
accompanying symptoms, of the ocular manifestations in
the malignant phase, and of the circulatory disturbances
in the kidney. Difficulties in administration have not as
yet been entirely overcome; the workers do not consider
it as yet a practical treatment.
Another result of the advance initiated by the experi-
mental method of Goldblatt has been the search, in man,
for cases in which hypertension caused by a unilateral
renal involvement might be relieved by removal of the
offending kidney. Crabtree and Chaset,12 in a study of
kidneys examined after unilateral nephrectomy, reported
failure to correlate hypertension and renal vessel change,
and they, therefore, discourage employment of nephrec-
tomy in hypertensive cases. Braasch, Walters and Ham-
mer,1' in discussing a large series of cases in which pa-
tients had been subjected to various renal surgical pro-
cedures, state that the discovery of a unilateral renal
lesion in the presence of hypertension does not indicate
that operation is advisable in every case, since other fac-
tors are often present which would contraindicate it.
They found, however, that hypertension was relieved
more often by unilateral nephrectomy than by conserva-
tive operation. The application of surgery in unilateral
renal disease has been reviewed by Abeshouse.14 Among
his conclusions, we find that, while in certain types of
chronic advanced unilateral renal disease, there may be
a causal relation to hypertension, the same type of lesion
occurs in many patients without elevation of blood pres-
sure; and that, as yet, there appears to be no justification
for considering nephrectomy a panacea for the cure of
hypertension in every case of chronic, unilateral disease
of the kidney. I am already seeing too many cases in
which unilateral nephrectomy has been advised without
sufficient evidence or adequate study. I would advise
that a diseased kidney which still retains some function
should be left in place, rather than its removal, which
places an unbearable burden on its remaining fellow.
In a recent report of the Council on Pharmacy and
Chemistry, Goldblatt, Kahn and Lewis1, have reviewed
the results of treatment of experimental hypertension in
animals, and suggested certain relations to the results of
treatment in man. It is recognized, of course, that the
problem in the experimental animal may have little rela-
tion to the problems in man. The interest lies, however,
in the fact that these experimental methods of approach
are possible. The last paragraph is worthy of quotation,
"The results so far observed from the treatment of ex-
perimental renal hypertension in dogs and rats, do not
yet justify much optimism about the possible efficacy of
such treatment for human hypertension. For the pres-
ent, the most that can be said is that a faint note of hope
has been sounded for the possible medicinal treatment of
the most common type of so-called essential hypertension
associated with renal vascular disease. Progress in this
respect will be hastened, because it is now possible to
carry out tests on hypertensive animals before they are
tried out on man. Empiricism has given way to experi-
mental demonstration, but the final acceptance of the
value of this contribution must and will depend on the
results obtained in the treatment of human hypertension.”
Treatment of Essential Hypertension
It is difficult to appraise the results of medicinal treat-
ment in essential hypertension. The effect of the confi-
dence the patients have in the physician, the multiplicity
of methods used at one and the same time, the unknown
and sometimes unknowable factors operating in the en-
vironment, and the variable capacity of the physician for
critical judgment, all together operate to produce con-
fusion. Mistletoe, garlic and watermelon seeds, together
with scores of other remedies which have had their ad-
vocates, have failed to produce the results necessary for
acceptance by the Council on Pharmacy and Chemistry.
The physician can no longer afford hit and miss drug-
ging as suggested by the detail man whose product is
not properly controlled.
The use of vitamins and of organ extracts, except pos-
sibly those of the kidney along lines similar to those de-
veloped by Page, does not seem to have made any effec-
tive contribution. Deprivation of sodium chloride in the
diet has failed in the hands of most observers. Dietary
restrictions, except such as prevent the frequent over-
filling of the stomach or prevent obesity, have been gen-
erally abandoned. The concept held at one time, that
a high protein diet played a part in producing hyper-
tension, is no longer held. It has become recognized and
is now supported by experimental evidence in dogs, that
the reduction of overweight and obesity will often be
accompanied by reduction in the degree of hypertension.
The results are sometimes striking, but, on the other
hand, may be nil. In any case, there is nothing to be
lost by careful slow reduction of weight in the obese.
A limit of average reduction of 4 to 6 pounds pier month
is usually desirable, for reasons which need not be dis-
cussed here. Even though considerable reduction in pres-
sure should fail to occur, the reduction in the work of
the heart is certainly an advantage. The use of thyroid
products in these cases is contraindicated, except in the
presence of definitely pathologic low metabolism, and
in myxedema.
Drugs known to have some effect on arterial hyper-
tension may be roughly classified into three groups: ( 1 )
Vasodilators. (2) Sedatives and hypnotics. (3) Empirical
remedies. While certain of the known vasodilators, such
as amyl nitrite by inhalation, and nitroglycerine under
the tongue, are of great value in angina pectoris, their
effect is evanescent, and, in general, they are useless in
the treatment of hypertension. For the most part, sodium
nitrite and erythrol tetranitrate are of little use here,
often producing, when effective, disagreeable symptoms
and vasomotor collapse. I have not been able to get
results by the use of bismuth subnitrate, even though
166
Tin Journal-Lancet
used over long periods of time as proposed by Stieglitz.
Rather than use the vasodilators in a case in which it is
desired to lower blood pressure in an emergency situa-
tion, with normal or high hemoglobin values, I prefer the
removal of 300 to 500 cc. of blood by venipuncture,
which can be repeated as indicated and will have fewer
undesirable effects.
The degree to which we use sedatives and hypnotics is
largely a measure of failure in our management. It is
not quite fair to say that the failure is more often on the
part of the patient than of the physician. We, as physi-
cians, must accept a certain part of the responsibility. It
seems clear that any effect in reduction of hypertension
is by diminution of nervous and muscular tension, and
by aiding to secure relaxation, rest and sleep. The past
decade has seen the development of so many barbital
compounds that there is more confusion than certainty
about them, but certain principles underlie their use.
Some of the compounds are principally oxidized in the
body; and others, usually producing a longer action, are
principally excreted in the urine. Chief of these latter
are barbital, phenobarbital, their more soluble sodium
derivatives, and Ipral calcium. I do not use any of these
primarily for the effect on blood pressure, but only from
compulsion, when sedation or hypnosis is otherwise not
procurable. Toxic and damaging effects are not uncom-
mon, are in fact altogether too common. If the use of
these remedies seems unavoidable, their continuance by
the patient should not be allowed, except under frequent
control, with examination for depressant effects on the
cerebrum and on the blood making organs. The shorter
acting barbiturates, oxidized largely in the body, require
the same control, but are less likely to have cumulative
effects. Those in most common use are amytal, alurate
and neonal. It seems particularly unfortunate that the
drug houses have wasted so much ingenuity in combin-
ing the barbital preparations with other remedies. The
exhibition of the drugs should be kept separate and not
in predetermined combinations. The bromides and chloral
hydrate continue to be useful for sedation and hypnosis,
on occasion, and I find myself using them more often,
in the desire to get away from the barbitals.
Among the empirical drugs, the greatest interest
attaches to the revival of thiocyanate therapy, following
the demonstration of Barker,11’ that the level of the drug
in the blood plasma can be determined, and the amount
in the circulation thus carefully controlled. Previous to
this demonstration, these drugs, sodium and potassium
thicyanate, had been in restricted use, but were discarded
because of their toxicity. Even with the control of thio-
cyanate levels in the blood serum, great caution is neces-
sary because of individual variation in susceptibility. The
effective therapeutic level is generally stated to lie be-
tween 8 and 12 milligrams per cent; one should be on
guard against toxic effects at levels from 15 to 20 milli-
grams per cent. However, I have seen severe toxic effects
at a level of 10 milligrams per cent, and repeatedly
found, as have others, that when toxic effects develop,
the drug may be retained in toxic amounts in the circu-
lation for many days, and even weeks, after its with-
drawal. A few patients do not require the levels of 8
to 12 milligrams per cent for good effect. I have seen a
very satisfactory reduction in blood pressure at persis-
tently lower levels; in one instance, even as low at 5 milli-
grams per cent. This is especially true when the environ-
ment can be controlled and the patient trained in relaxa-
tion. The practice of giving the patient a supply of the
drug and allowing him to go without frequent chemical
control is pernicious. I have had a number of patients
present themselves because of the toxic symptoms, when
this practice has been followed by others. Even when
under control, patients should be repeatedly and persis-
tently warned to stop the drug immediately and present
themselves for examination, if there is weakness, nausea,
the development of purpuric spots, a skin eruption, or
severe symptoms of vomiting, confusion and delirium.
The repeated reports of convulsions, coma and death
should emphasize to us the necessity for watchfulness.
While the treatment of symptoms is not the primary
object in this paper, there is one on which a very recent
report may be of interest. Marshall1’ has used graded
doses of histamine phosphate at intervals of three to
seven days. Care was exercised to prevent development
of tolerance or a high threshold. The systolic and dias-
tolic blood pressures were temporarily reduced 20 to
40 mm. Hg. This reduction persisted for but a few
hours, but the dizziness was alleviated until the time of
the following treatment.
Much time might be given to the consideration of the
treatment of the malignant phase of hypertension and
its complications, but that would lead us too far afield.
The earlier phases, which we call essential hypertension,
yield to persistent and studious management to a degree
so satisfactory in many patients, that special consideration
is desirable. In 1935 and 1936, the writer18,10 outlined
the concepts concerning essential arterial hypertension up
to that time. Emphasis was given to the need for consid-
eration of the psychological, emotional and environmental
background in each patient. Guidance in relation to their
daily lives, their problems, and their attitudes is neces-
sary.
That there is a large group of patients with a de-
r onstrable hyper-irritability of the vaso pressor mechan-
ism, is a concept advanced by Von Monakow-11 in 1920.
The management and training of these individuals is
productive of a measurable control and reduction in the
hypertension, and it is to this topic that the writer desires
to direct special attention. Whatever the relation of cir-
culatory conditions in the kidney may be to the develop-
ment of essential hypertension, one objective in t eat-
ment is clearly indicated. It is to shorten the periods dur-
ing which the blood pressure is up, and to lengthen the
periods during which it may be decreased. Of greatest
interest and importance in this connection is the discovery
of hypertension in the early labile phase. Some of these
individuals are presumably on the border of normal, ex-
hibiting excessive pressor responses to certain stimuli of
a so-called emotional character. Attempts have been
made to devise tests, such as the inhalation of carbon
dioxide and the application of cold to the ha id and
wrist, which would bring out the characteristic, cr maxi-
mum pressor response on the part of any given individ-
Junk, 1943
167
ual. The cold pressor test of Hines and Brown11’-1
gave promise of usefulness in discovering hyper-reactors,
and while I still use it on occasion, one of its chief uses
would appear to he in the discovery of hyper-reactors in
groups of individuals, presumably normal in other re-
spects. The skilled physician will find that there are few
hypertensives or hyper-reactors, who do not manifest the
tendency without the test, on the first examination, if
this is properly done.
Patients appearing for examination in the doctor’s
office will often show an elevated pressure during the
initial examination, and the physician should pay partic-
ular attention to this, attempting to learn the highest
point of systolic and diastolic pressure readings. It is
common to find this situation, when the blood pressure
is taken immediately after the taking of the history. The
procedure usually causes considerable stress and is about
as good an effector of pressor hyperreaction as I know.
In hyperreacting individuals and in hypertensives, it is
seldom possible at the first examination, even by rest and
relaxation, to get the same lowering of blood pressure as
may be secured later, when a certain degree of confi-
dence in, and understanding of the physician have been
developed. It is important in the early contacts to de-
velop the highest readings obtainable, as well as the low-
est. In fact, these higher readings are of extreme impor-
tance as showing the degree of response that can be
obtained. Often on the second interview, marked reduc-
tion in the figures may be shown. This is especially true
in individuals in the earlier labile phase. In this second
interview, and in fact at the time of any study in which
an attempt is made to discover the lowest pressures to be
obtained, it is necessary that several conditions be ob-
served, and certain of them should be explained to the
patient before he comes for study. 1. He must come on
a day or at a time of day without preceding stress of
business or social activity, without hurry, not after a full
meal, and without subsequent appointments to be met
shortly. Such a small thing as the fear that the parking
meter will need another nickel soon, can prevent the de-
sired relaxation. 2. The patient must be recumbent on a
comfortable table in a room which can be partially dark-
ened at will, is free from distracting noises, and is com-
fortably warm. He should not be exposed to chilling.
3. The observer should be unhurried and should have
explained the purpose of the procedure before the study
is begun. It seems too simple to require statement, but
is a fact often overlooked, that the patient during the
examination is usually anxious to know what the results
may be. This of itself may interfere with any considera-
ble drop in pressure. Therefore, he is told that such is
the case, and that unless he can relax completely and
dismiss this from his mind, the desired lowering of pres-
sure cannot be obtained. A promise is given that at the
end of the examination, he will be told what the exact
figures are, both the highest and the lowest.
In the process of training, it is my custom to tell the
patient, at the end of a session, what the entire series of
blood pressure readings have been, using the exact read-
ings, with an explanation for the difference. I have, at
once, secured his interest in a procedure novel to him;
have secured his confidence; and have shown him some-
thing he does not know about blood pressure. The effect
is usually profound, and the attempt at cooperation be-
comes real. At this point, it might be well to state why
the exact readings are given. Many physicians disagree
with this procedure. They claim that it causes worry and
concern, and that it is better to reassure without too
much frankness. However, the best education requires
the truth, and the radical drops in pressure secured by
relaxation in the examination room, give the patient an
understanding of what he can do himself throughout his
day, or at least in portions of the day, and this is the
reason for the demonstration.
More than medicines, more than ablation of a portion
of the sympathetic nervous system, or removal of a sup-
posed renin-producing kidney, the great majority of
hyperreacting patients require reassurance, education, and
training in relaxation. If the physician is unable to ac-
complish these objectives, he is nb more fitted to treat
the hypertensive patient than is the internist fitted to per-
form a cholecystectomy or the surgeon fitted to treat a
patient with coronary occlusion. A successful operation
requires time and unhurried procedure. One practicing
in the field under discussion must proceed in like man-
ner. Each case is to be approached with a consideration
of the patient’s temperament, background of education
and training, and capacity for understanding. The doctor
is now a teacher, leader, trainer and mentor, and cannot
drive.
For reassurance, it is necessary first to dispel many of
the impressions current concerning hypertension, and to
forestall as much as possible the misinformation soon to
be brought to the patient, by friends and relatives, as
well as by newspaper columnists. One must first attempt
to convince the patient that the problems and course of
some other patient, whose disorder has the same name,
or who may have one or more of the same symptoms,
are in no sense his problems and course. I forewarn
against the suggestions and importunities with which the
patient is sure to be pestered, immediately he spreads
abroad the nature of his malady. I have often succeeded
in getting an amused tolerance by the patient towards
the many suggestions and directions to be brought from
many sources, by the following suggestion: "Whenever
your friends or relatives bring you this or that suggestion
about diet or medicine, or some doctor’s method of cure
for your trouble, ask them this question, 'How long
have you practiced medicine?’ ” Not many patients have
ever thought of it, and some, even when told, cannot
realize that only the informed and reliable physician,
thoroughly acquainted with all of the problems in the
case under consideration, can outline and pursue a proper
course of treatment and management. The average pa-
tient is more than ready to follow the suggestions ob-
tained without cost from a talkative neighbor. One of
the suggestions I implant early is that one of the most
vicious effects of neighborhood medicine and advice is to
wreck many well thought out and intelligently conceived
medical program, which would be otherwise effective.
One of the most effective measures in the management
of hypertension, particularly in the earlier labile phases,
168
The Journal-Lancet
is to furnish the patient with knowledge of, and repeated
experience in the lowering of blood pressure by relaxation.
Brief recital is given of conditions under which pressure
in the normal, but more so in the hypertensive, is ele-
vated. Anger, fear, worry, scurry, too great concentra-
tion, over-exercise, fatigue, and an over-filled stomach,
each act to raise the pressure. Equanimity, serenity, rest,
relaxation and sleep contribute to its lowering. If the
effect of these factors can be demonstrated on the patient
himself, he will have an understanding of the benefit
to be secured, and, through his own knowledge, will be
ready to cooperate. This education by demonstration is
begun early in the management, and requires, at least in
the beginning, frequent repetition. A little treatise on
relaxation by Edmund Jacobson-'* has been put out for
popular reading, but it is very valuable for the physician,
even more so than his earlier and more scientific book on
Progressive Relaxation. Some patients learn quickly,
some slowly and haltingly, and some try one’s patience
almost to the breaking point. I said "almost”. At this
juncture the physician requires equanimity as much as
does his patient. It is sometimes necessary to let the
patient do a little talking, in an attempt to find out why
one’s education does not take. All this takes time. The
"busy doctor,” who cannot give the time when needed,
has no place in the management of essential hyperten-
sion.
The technic of relaxation requires that the subject be
recumbent and comfortable in a room which is free
from distraction and so arranged that it can be partially
darkened at will. The blood pressure cuff is adjusted
and allowed to remain throughout the period of study,
which can be completed, as a rule, within 15 or 20 min-
utes. The subject is asked to dismiss the problems of
the day and to relax as if he were about to take a nap.
The physician’s voice is low, and his movements unhur-
ried. The patient is instructed to relax every part of the
body, neck, back, arms and legs. Gentle palpation of
muscle regions will often reveal that some parts are not
relaxed, and this can be indicated to the patient. He
may be asked to relax each part in turn. Frequent rec-
ords of blood pressure are made as the time goes on.
When it seems that good relaxation has been secured, it
may be well for the physician to leave the room for a
brief period; but in so doing, it is necessary to explain
to the patient that he must remain relaxed, even upon
the physician’s return. It is well to explain that he will
not be forgotten and left for an indefinite period.
By repeated exercises of this kind, the patient is trained
in relaxation, and, at the end of the session, a recital of
the pressure changes makes clear the benefits in the
reduction of arterial pressure. At some sessions, the re-
duction may be unsatisfactory. This should be the occa-
sion for inquiry. Environmental or personal reasons may
be found. Persistent failure suggests the stabile phase
of hypertension and may provide the guide to further
and other measures.
Factors in the environment will often play a large part
in preventing relaxation. Factors of crucial significance
have been found in many cases. Elimination, or at least
reduction in their influence, may play a vital role in man-
agement. The physician cannot change a patient’s en-
vironment; but he can suggest changes, and he may point
out ways in which needed changes may be brought
about, or an unfavorable influence reduced. The degree
and character of change must be left to the patient and
to those immediately concerned. Details are not possible
here, but a few principles may be stated. Each individual
is geared to a certain tempo and method of most suc-
cessful performance and I abandoned, long ago, attempts
to change these. Hours of work may require modifica-
tion. Work must be left in the place of working and
not carried home. Hours of rest and relaxation must be
detailed and scrupulously observed. Relaxation for a
short period after meals has a most salutary effect, both
on arterial pressure and on digestion. When an hour of
relaxation, and better, an hour of sleep, can be secured
after the noon lunch, it may act almost as a life pre-
server. An occasional— very occasional — vivacious indi-
vidual can be induced to relinquish the role of entertainer
on every possible occasion and assume the role of by-
stander and listener.
There are occasions on which it is advisable to begin
management by a period of rest in bed. This period
should be utilized to the full by the physician for train-
ing in relaxation. Demonstration of the advantages of
relaxation can be made during it. Consecutive Saturdays
and Sundays in bed have helped many to reorganize
their drive, in preparation for lessening hyperreactivity.
Vacations and weekends may require prolongation. It
may require a bit of argument with a strained executive
to convince him that over a ten, fifteen, or twenty year
period, he would probably do better work, have better
health and more money in the bank, if he worked ten,
rather than twelve months out of the year.
A minor and sometimes major change in employment
or position may be successfully engineered. Some pa-
tients have been willing to accept reduced incomes in
order to slow up the progress of the hypertension. The
most unhappy and strained individuals are those tied to
an occupation or routine they do not like, not to say
love. In younger and still adaptable individuals, a study
of aptitudes, and the practice of occupational guidance
may be worthwhile, this, of course, by trained practi-
tioners in the field. A gross, unnecessary and shameful
error may be made in answering the question of retire-
ment. It is often advised unnecessarily and with distinct
harm to the patient. Lessening the drive will often be
of greater benefit than surrendering an objective and
usefulness. This is particularly true in those individuals
without great resources within themselves, or without
a hobby.
Sleep has well-known arterial depressor effects. Fa-
tigue from preceding emotional over-activity or stress is
a common cause for restlessness and sleeplessness. To
convince a patient of this sometimes requires argument
and even demonstration. Many patients, tense from
these causes, scheme to get tired enough to sleep, by
going to bed later and later at night. They often require
schooling in the three R’s, relaxation, repose and rest.
A short and not too brisk walk out of doors just before
retiring at night, will sometimes release enough emo-
Junk, 1943
169
tional stress to accomplish the desired effect. Many peo-
ple who have difficulty in getting to sleep, or who waken
early, will find their problem solved, or solved at least,
in part, by getting a mid-day nap or period of rest, and
by getting to bed early, rather than staying up in the
evening until the last dog is hung. Hot milk or other
liquid may be taken on retiring, unless it increases or
causes the discomfort of nocturia. A hot drink, taken
under proper regulations, if one wakens during the
night, will sometimes be an excellent somnifacient. When
success has not been attained otherwise, sedatives and
somnifacients may be employed with care. They may be
useful in tiding a patient over a restless period of two
or three nights, with the direction to abstain from them
then until one or two restless nights have again been ex-
perienced, then repeated to get another good night’s rest.
The care necessary in their use may require explanation.
This intermittent use may forestall the cumulative effect
to be avoided especially with the use of the barbiturates
and bromides.
Individualization is the master word in the entire pro-
gram. Above all, the hyperreactor and hypertensive are
not to be dismissed with a casual, "Forget it; it won’t do
any harm; you’ll get over it after awhile.”
The physician has a profound responsibility beyond
that of surgical operation, subcutaneous injections and
drugging. It is necessary that he assume his proper role,
too easily forgotten and too often evaded, of teacher,
mentor, philosopher and guide.
References
1. Page. Irvine H.: The nature of clinical and experimental
arterial hypertension. The Edward Gamaliel Lecture, J. Mt. Sinai
Hosp. 8:1, 3-25, 1941.
2. Rowntree. L. G., and Adson, A. W.: Bilateral sympathetic
neurectomy in the treatment of malignant hypertension: report of
a case, J.A.M.A. 85:959-961, 1925.
3. Koch, Ef, and Mies, H.: Krankheitsforschund 7:241, 1929.
4. Bell, E. T.: A Textbook of Pathology. 4th edition, Lea Qc
Febiger, Phila., 1941.
5. Fishberg, Arthur M.: Hypertension and Nephritis, Lea &£
Febiger, Phila., 4th edition, 1939.
6. Smith, H. W.. Goldring, W.. and Chasis, H.: J. Clin. In-
vestigation 17:273, 1938.
7. Goldblatt, H., Lynch, J.. Hanzal, R. F.. and Summerville,
W. W.: J. Exper. Med. 59:347. 1 934.
8. Page, H.: Science 89:273, 1939.
9. Corcoran, A. C., and Page, Irvine H : Arterial hyperten-
sion: correlation of clinical and experimental observations, J.A.M.A
116:8:690-694.
10. Grollman, A., Williams, J. R. Jr., and Harrison, T. R.
J. Biol. Chem. 134:1 15, 1940.
11. Page, Irvine H., Helmer, O. M.. Kohlestaedt. K. G.. Fouts,
T. J., Kempf, G. F., and Corcoran, A. C. : Proc. Soc. Exper. Biol.
6c Med. 43:72, 1940.
12. Crabtree, E., Granville, and Chaset, Nathan: Vascular
nephritis and hypertension, a combined clinical and clinicopatho-
logic study of 150 nephrectomized patients, J.A.M.A. 1 15:1842—
1846 (Nov. 30) 1940.
13. Braasch, Wm. F.. Walters. Waltman, and Hammer, Howard
J.: Hypertension and the surgical kidney, J.A.M.A. 115:22:183 7 —
1841 (Nov. 30) 1940.
14. Abeshouse, B. S.: Hypertension and unilateral renal dis-
ease, Surgery 9:942—9 77 (June) 1941. and 10:147—200 (July)
1941.
15. Goldblatt, Harry, Kahn, Joseph R., and Lewis, Harvey A
Studies on experimental hypertension, xvii. experimental observa
tions on the treatment of hypertension, J.A.M.A. 119:15:1192-
1208 (Aug. 8) 1942.
16. Barker. M. H.: The blood cyanates in the treatment of hy-
pertension, J.A.M.A. 106:762 (March 7) 1936.
17. Marshall. Wallace: Dizziness from hypertension. Northwest
Med. 41:9:305-308 (Sept.) 1942.
18. White, S. Marx: The status of the essential hypertension
problem. The Andrew P. Biddle Oration at the annual meeting of
the Michigan State Society, J. Michigan M. S. (Dec.) 1 935.
19. White, S. Marx: The medical problems and management in
essential hypertension. Surg., Gynec. QC Obst. 62:332—339 (Feb.
15) 1936.
20. Monakow, T. Von: Blutdrucksteigerung und Niere, Deutsche
Arch. f. klin. Med. 133:1 29-152. 1920.
21. Hines, Edgar A., and Brown. George E.: A standard test
for measuring the variability of blood pressure; its significance as
an index of the prehypertensive stage, Ann. Int. Med. 7:209, 1933.
22. Hines, Edgar A., and Brown. George E.: The cold pressor
test for measuring the reactibility of the blood pressure; data con-
cerning 571 normal and hypertensive subjects, Am. Heart J.
1 1 : 1—9, 1936.
23. Jacobson. Edmund: You Must Relax: a practical method of
reducing the strains of modern living, Whittlesey House. 1934.
DONATE DRUGS AND INSTRUMENTS FOR MARITIME DISASTER
To help the Medical and Surgical Relief Committee of Amer-
ica continue its vital work of providing emergency medical kits
to Coast Guard patrol boats and Navy sub-chasers, an urgent
appeal for drugs and instruments has been issued by the Com-
mittee to surgeons, physicians, and medical supply houses.
Among the items sorely needed to equip the emergency kits
are artery clamps, splinter forceps, scalpels, probes, grooved
directors, sulfadiazine tablets, sulfadiazine ointment 5%, sulfa-
thiazole tablets, and sterile shaker envelopes of crystalline sulfa-
nilamide. Any other spare medicines or surgical instruments
are, of course, equally welcome.
Specially designed for sub-chasers and patrol boats, the med-
ical kit is a small portable case filled with essential medications
and emergency instruments. It is complete enough to cover acci-
dents and war casualties until the ship reaches a base hospital.
Many of these small craft carry a considerable complement of
men, including often a pharmacist’s mate. Appreciative letters
from their officers to the Committee indicate that the kit is a
vital adjunct to the ship’s equipment. This project represents
an invaluable service not undertaken by any other organization.
The Medical and Surgical Relief Committee of America, con-
ducted for nearly 3 years by a nationwide group of distin-
guished physicians, has distributed over a half-million dollars
worth of medical and surgical supplies, concentrated foods and
vitamins to the people — civilian and fighting — of the United
Nations.
Along with medical equipment, the patrol boat and sub-
chaser emergency kit contains a simple fishing outfit, prepared
bait, signalling mirrors, ready to be used in time of disaster
when the crew must resort to life-rafts.
Contributions should be sent to Dr. Claude C. Kennedy, 807
Physicians & Surgeons Bldg., Minneapolis (At. 1030), or Med-
ical and Surgical Relief Committee of America, 420 Lexington
Avenue, New York.
170
Thk Journal-Lancki
Safety in Cataract Extraction
Lawrence G. Dunlap, B.S., M.D., F.A.C.S.
Anaconda, Montana
A FTER more than 25 years in the practice of oph-
L 1 thalmology and, as one of my confreres expresses
■A. M* it, as one who also practices otolaryngology, I am
a general practitioner in the specialty of eye, ear, nose,
and throat. One’s opinions are of necessity a composite
picture of one’s teachings, experiences, studies, observa-
tions, and own personal logic. One of your great past-
presidents, the late Doctor George W. Swift, said that
he had seen all of the complications of ophthalmic sur-
gery and only then took to brain surgery. I have had
all of the conceivable complications of ophthalmology,
and, after more than 25 years, have evolved a system of
examination, operative technic, and postoperative care in
an effort to avoid complications. I claim no originality
for this presentation and reiterate that the following
statements form my own personal opinion at this partic-
ular time.
Certainly, every prospective cataract patient should
have a complete ocular and physical examination, pref-
erably done by the ophthalmologist. After a careful his-
tory, the light perception, projection, tension, and vision
of the eyes having been determined, and an estimate of
the visual fields made, the retinal function should be
tested with a 1 mm. red light at 1 to 3 feet and with
the 3 mm. red light at 20 feet, or as far away as it can
be seen. It was my sad experience to operate on three
cataract patients in succession, all of whom had no mac-
ular function, but this was not known until after the
extractions. Rod O’Connor of Oakland then told me of
the two-light test, which is made by holding a cardboard
with two 1-inch holes 4 inches apart before a light bulb.
If two lights are perceived simultaneously, macular func-
tion is present. Only one case in many years has failed
to conform to this test.
Patency of the canuliculi and naso-lachrymal duct is
determined by irrigations. I then examine the ears, nose,
and throat, and still believe that dental infections should
be cleared up before operation. The blood pressure is
taken, and urine analysis made; and after all the find-
ings, the patient, preferably in the company of a relative
or close friend, is visited with, until all of his questions
about the operation are answered. This visit ordinarily
consumes one-half hour, but I think that very few, if
any, cataract surgeons are so busy that they haven’t time
for this most human approach to the patient’s problem.
Actually, very few of us do such an enormous amount
of cataract surgery that we can’t take this time. Pro-
fessor Emeritus, Walter R. Parker, of the University of
Michigan, some years ago reported on 1,389 cataract
operations which he did in 40 years. This is less than an
average of 35 operations per year.
My practice is to give the patient 2 per cent mercuro-
chrome to drop into the conjunctival sacs four times
^Presented at the 30th annual meeting of the Pacific Coast Oto-
ophthalmological Society, Portland, Oregon, May 1 1-1 3, 1942.
daily for four days before operation, and then to do a
preliminary iridectomy in my office surgery. This tells
me how the patient reacts, and how his particular eye
reacts to operative interference. A very narrow keratomc
intracorneal incision is made as recommended by O’-
Connor, Meyer Wiener, and others. Six per cent cocaine
in adrenalin is used as an anesthetic. Atropine, mety-
caine, and merthiolate ointments are used after the nar-
row keyhole iridectomy. A patch is applied and the pa-
tient is asked to return the next day. In cases of irreduci-
ble high blood pressure, 500 to 1000 cc. of blood is re-
moved by venesection one hour preoperative. In unruly
patients, nembutal and O’Brien akinesis are used.
When the eye is quiet after a week or so, the mercuro-
chrome is again used as before, the patient admitted to
the hospital the afternoon before the operation, given a
bath, the head washed and the brow shaved. The patient
is encouraged to wander around his wing of the hospital,
so that he may become orientated and know where vari-
ous sounds and noises originate, and the locations of
doors, windows, stairs, etc. This keeps him mentally ad-
justed to sounds during the period of binocular occlusion,
thus reducing postoperative dementia. The patient is
given a light liquid supper and one nembutal capsule
before bedtime. On awakening the next morning, he is
given one nembutal and a soapsuds enema. Blue Mass
gr. 1 t.i.d. is given as an intestinal antiseptic before, and
for a week after the operation.
The extraction is done early in the morning. I prefer
my own thoroughly trained and experienced office nurse
as my assistant and always rehearse the operation with
her the day before. She then prepares the patient, sets
up the operating table, and there are no questions to up-
set the surgeon at the time of the operation. Also, I
believe that extra instruments should be laid out to take
care of any possible emergency. O’Connor taught me to
sharpen and test all of my cutting instruments per-
sonally. I also use his method of putting on a focal light
over the left side of my forehead to angle at and focus
on the eye while I wear magnifying lenses. This gives
perfect illumination without depending on someone else
to hold a light, and the angular position prevents reflect-
ed light shining back into the operator’s eye from the
cataract knife while making the incision.
Then, while I am scrubbing up and getting on sterile
gown, etc., the nurse is dropping 6 per cent cocaine in
adrenalin into the patient’s eye. I also do an O’Brien
akinesis with the greatest of satisfaction, then inject the
superior lid with 2 per cent procaine, trim the lashes with
ointment-covered scissors so that none fall loose, paint
the exposed area again with tincture of merthiolate, and
never irrigate the conjunctival sac. I then place O’Con-
nor lid stitches by two wide superficial bites of the needle,
1 mm. above the upper lid margin; hugging the globe
with tooth forceps, put in the Elschnig superior rectus
Junk, 1943
171
stitch; check that the O’Brien has caught the facial nerve
so that the lids cannot be squeezed or nipped together;
then insert a mosquito forceps, one blade in the outer
canthus and one blade on the skin; clamp together for
15 seconds; release the forceps; and do an external can-
thotomy. Just before beginning the operation, a retro-
bulbar injection is made through the conjunctiva, in the
inferior temporal quadrant 4 cm. deep toward the muscle
cone. The patient’s head is elevated about 30 degrees.
Despite the fact that I was taught to operate from the
head of the table, I learned from Elschnig that the phys-
ical comfort and vision of the surgeon is much better
from the side of the table, so I face the patient and make
the incision holding the knife in the left hand on the
right eye and in the right hand on the left eye.
Years ago, before akinesis was an accepted and gen-
erally approved procedure, one day I had completed the
corneal section and was just making a long conjunctival
flap, when the patient squeezed and the lens presented
under the conjunctival bridge. I then made a conjunc-
tival bridge on the next case and thought I had stumbled
on something new. However, Doctor Harry Woodruff
of Joliet and Chicago kept me from reporting this "new”
procedure, by referring me to an 1894 edition of de
Schweinitz, where he described the conjunctival bridge
method. I still use it, as the postoperative astigmatism
rarely exceeds two diopters, whereas, in my hands, the
corneal section or the conjunctival flap section is followed
by an average of over twice as much postoperative astig-
matism. Anyone who attempts to do a combined extrac-
tion under a conjunctival bridge will readily understand
why the preliminary iridectomy is done.
Many years ago, the elder Fuchs laid down the dictum
(with which many of you perhaps will differ) that all
one-eyed patients with cataracts should be operated upon
by combined extraction and the extracapsular method.
If it is safer than the intracapsular method, I believe
that all patients with cataracts, even those with two eyes,
should be operated upon by this method. Contraindica-
tions to intracapsular operations include inexperienced
and occasional operators, high myopia, increased intra-
ocular tension, and hypermature cataracts, so why not
stick to the extracapsular technic?
After making the corneal section which includes half
the cornea, and after making a large and broad conjunc-
tival bridge, a large semicircular cystotome incision of the
anterior capsule is made with small jerky motions, from
the lens equator at 3 to 12 o’clock or vice versa, or a
large bite is taken out of the anterior capsule with a
tooth forceps. The lens is then expressed with due re-
spect for the laws of hydrodynamics, as illustrated so
perfectly in William A. Fisher’s book on Senile Cataract.
The assistant, holding up the conjunctival bridge with a
small squint hook, stands ready with a Fisher needle to
push the lens when it presents under one side of the
bridge. Then the anterior chamber is most thoroughly
but most carefully irrigated with warm normal saline, to
remove every last possible remnant of cortex that seems
consistent with safety at this time. The bridge is
smoothed down into place, stroking the cornea first,
which procedure will usually reposit the iris nicely. Oth-
erwise, it is reposited carefully. The superior rectus su-
ture is cut close to the point of insertion; the speculum
is removed; meanwhile the lower lid is held down, while
the assistant gently pulls out on the upper lid with the
O’Connor lid stitches. Then 1 per cent atropine, mety-
caine, and merthiolate ointments are inserted, lid closed,
and the O’Connor stitches plastered to the cheek with
two strips of adhesive. A fluffy cotton patch wet with
normal saline is applied and fastened with adhesive.
With eyes gently closed as in sleep, merthiolate ointment
is freely applied to the other eyelid and after a thin
dressing, a Ring’s mask is applied. The patient is then
put to bed in semi-sitting position for the next four days.
Nembutal may be given for sleep or distress. On the
fourth day, the patient is allowed to use his unoperated
eye; the operated eye is dressed with atropine, metycaine,
and merthiolate ointments and a patch. He is also
allowed out of bed and given an ounce of castor oil to
clear the intestinal tract. The eye is dressed every other
day until he is sent home on the eighth day, at which
time the lid stitches are removed. The Ring’s mask is
kept over the operated eye for three weeks.
Using a dull knife, or inserting it upside down, or
using instruments not in perfect condition for grasping
or cutting, or what not, are all absolutely inexcusable.
One of the most brilliant and illuminating movies on
cataract surgery is the technicolor picture taken by Wat-
son Gailey of Bloomington, and shown at the last Acad-
emy meeting in Chicago, demonstrating his mistakes.
It is worth the time of everyone to study it. He spoke
of hideous complications. Another recent paper discussed
the complications of cataract surgery. I think this is the
wrong psychological approach, and that technic and pro-
cedures should be stressed to prevent such complications.
From Doctor A. F. Ryan of Los Angeles, I learned
a most valuable and important thing. The surgeon
should not operate unless he has prepared himself per-
sonally for several days by refraining from coffee, alco-
hol, tobacco, loss of sleep, or mental worry. I believe it
important for the surgeon to take a nembutal or seconal
the night before the cataract operation, and a half one
the next morning, as this quiets the surgeon’s nerves and
does away with tremor and irritability without sacrificing
his good judgment. Naturally the operating room per-
sonnel must be absolutely quiet. This is why some op-
erators consider it unfair to operate before a crowd.
One of my patients vomited and had an expulsive
hemorrhage which necessitated enucleation, probably be-
cause the cocaine leaked into his nose. Another had an
expulsive hemorrhage 10 hours after the operation, when
she did her daily vomiting from a gastric ulcer, about
which she purposely had not told me. Chronic gall-blad-
der infection and other abdominal conditions may cause
such vomiting. Another patient had the corneal flap fold-
ed back on itself at the first dressing, and although the
eye was saved, vision was practically nil. Three developed
prolapsus iridis at the first dressing in forty-eight hours.
Obviously, careful instillation of drops would have avoid-
ed the first complication, a careful history, the second, a
conjunctival bridge, the third, and delayed dressings, the
others.
172
Thk Journal-Lancet
My preoperative and postoperative directions consist
of three typewritten pages and are reviewed by the nurses
and hospital attendants, and also by myself, so that no
step will be omitted. Also, because of the strict training
which the surgeon should undergo before intraocular
operation, every effort is made to schedule two or three
operations at once and have them out of the way and off
one’s mind and worry list for another week or two.
I recommend to your review the masterly article on
Cataract Complication, by Kirby, published in the May,
1941, Archives of Ophthalmology.
Please note that the foregoing remarks contain no
"shalls” or "musts” and are offered solely in the hope of
making cataract extractions simpler and safer for some
of you.
I have never heard of anyone losing more than a bead
of vitreous. Ruedemann had seen everything up to
feathers coming out of an eye.
As O’Connor says, "As to cataract operation itself,
I’ve not much doubt that I’ve done more than 500, in-
cluding my Philippine experience in 1907-08-09, which
isn’t many in 28 years of work. Of course, one has all
the possible mishaps in his first 100. From there on it is
more of the same, possibly — Piled Higher and Deeper.”
Health Trends in University of Michigan Women
Students
Margaret Bell, M.D., F.A.C.P.
Claire E. Healey, M.D.
IS the average university woman as well equipped
physically at the time of graduation as she was at
the time of her entrance to the University? This is
a question which we have frequently asked ourselves,
but for which we have had no definite answer. In seek-
ing the answer, we decided five years ago to study in-
tensively a group of Senior women, making use of all
statistical material which might reveal their comparative
health status. It was realized that no clear cut and ob-
jective standards exist whereby "health status” can be
judged. But it was hoped that, by a detailed study of
a sufficiently large number of students and their rec-
ords, a reliable indication of "health trends” might be
obtained.
Data on which this study is based are tabulated in the
following Series:
Series A — from the entrance medical examinations
and histories of 2,000 Freshmen women who entered
during the fall semesters of 1934-1937 inclusive (Stu-
dent Group A) .
Series B — from the entrance medical examinations
and histories of 538 Freshmen women of Group A
who entered the University during the fall semesters
of 1934-1937 inclusive and who later completed four
consecutive years of University work. (Student
Group B).
Series C — from the reexamination and record re-
view at the end of the Senior year of the above 538
women who as Seniors had completed four consecu-
tive years of University work. (Student Group B).
Comparison of Freshmen data concerning 538 Fresh-
men women who entered the University during the years
1934-1937 inclusive, and who later completed four con-
secutive years of University work (Student Group B ) ,
*From the University Health Service, University of Michigan.
with the same items for the entire entering Freshmen
classes of identical years (Student Group A).
Table I furnishes a comparative study of the family
and personal histories of 2,000 Freshmen women who
entered the University during the fall semesters of 1934-
1937 inclusive, with 538 Freshmen women entering at
the same time and later finishing four consecutive years
of University work. The average entering age of the
Freshmen over this four year period who later finished
four consecutive years of University work was 17.7
years, while that of the entire entering Freshmen classes
was 18.2 years.
Cardio-vasculo-renal disease, allergic disease, and can-
cer constituted the most frequent illnesses in the family
histories of both groups. In each instance, the occur-
rence of these diseases was slightly higher in the family
histories of the group finishing four consecutive years
of University work than in the group constituting the
entering Freshman class as a whole. Difference in the
incidence of allergic disease was the most marked. In
the four year group, 66.2 per cent of the students re-
ported a family history of allergy, while the entire en-
tering class reported an incidence of 59.7 per cent. In
general, it will be noted from Table I, Series A and B,
that the incidence of illness in the family histories of the
four year group was, on the whole, slightly higher.
From an analysis of data in Table I, Series A and B,
based on the student’s history, it appears that the group
which finished four consecutive years of University work
had, on the whole, a lower incidence of previous illness.
The consistency of the difference in the percentages in-
volved is more notable than the amount of difference
in respect to each separate condition. The four year
group were in the habit of getting more sleep and in-
dicated that they had less difficulty with their studies.
The necessity, or probability of necessity, for outside
June, 1943
173
work for financial support was approximately tlie same
in both groups.
From the data in Table II, Series A and B, based
upon entrance physical examination, it appears that the
group who finished four consecutive years of University
work was in slightly better physical condition on enter-
ing than the entire entering group as a whole. Emphasis
is again placed on the consistency of difference, rather
than any marked variation in findings. One may also
obtain from Table II, Series A and B, an indication of
the general health of the two groups based on both the
physician’s and the student’s estimate. Ninety-six and
one-tenth per cent of the four year group considered
TABLE I.
Family and Personal History
Selected items from health histories from Freshmen entrance exam-
inations 1934-1937 inclusive. Data Series A from 2000 Freshmen
(Student Group A) compared with data Series B from 5 38 stu-
dents from Group A who completed 4 consecutive years of Uni-
versity work (Student Group B) . One item compared with Student
Group B as Seniors, data Series C.
ITEM
Data Series A
from Student
Group A
( Rate per 100)
Data Series B
from Student
Group B
( Rate per 1 00 )
Age on entering
18.2
1 7.7
Family Health:
Cardio-vasculo-renal disease
69.3
73.1
Allergic disease
59.7
66.2
Cancer
22.0
24.8
"Sick” headaches
1 8.9
1 9.5
Diabetes
15.8
17.6
Gastrointestinal disorders
14.2
1 5.5
''Nervous" trouble
1 5.7
14.7
Tuberculosis
1 3.8
1 3.7
Epilepsy or convulsions
1 .6
1 .9
History of Past Illness:
Rheumatic Syndrome
7.0
5.38
Acute Infectious Disease:
Scarlet Fever
20.3
20.4
Measles
91 .6
91 .0
Diphtheria
4.4
3.8
Influenza
21.8
22.3
Pneumonia
1 1 .8
1 1 .5
Typhoid Fever
Infantile Paralysis
0.95
0.57
0.5 5
0.3 8
Frequent Colds,
more than 3 yearly
1 8.7
21.0
Frequent Sore Throats,
more than 3 yearly
9.4
6.9
Discharging Ears
5.9
5.9
Deafness
2.0
1.3
Tuberculosis
0.5
0.38
Pleurisy
2.2
0.76
Gastrointestinal Disturbance:
Digestive upsets
"Sour" stomach
5.0
4.8
2.8
1 .9
Gas on stomach
6.3
5.2
Constipation
16.4
13.5
Nausea and vomiting
4.8
4.2
Allergic Disease:
Asthma _
2.0
3.2
Hay fever
8.6
8.4
Eczema
4.6
3.8
Hives —
7.0
6.7
Appendectomies
9.6
8.2
Nervous Disorders:
Nervous breakdowns
1.4
0.57
Nervousness
12.2
10.1
Tendency to worry
15.4
12.6
Vasomotor Disturbances:
Fainting spells
1 .8
1.3
Dizziness
3.8
2.3
Headaches
27.4
25.0
Amount of Sleep:
Under 8 hours
8.3
6.6
8 hours or over
91.7
93.4
Difficulty with Studies:
Yes
29.8
25.3
No _
70.2
74.7
Outside Work for Financial Support
18.3
17.7
Probability
33.0
33.2
44.5
55.5
their health to be good or excellent compared with 94.6
per cent of the entering group as a whole. Sixty-three
and two-tenths per cent of the four year group had a
health rating of "A” compared with 57.8 per cent of the
entire Freshman class. Seventy-eight and three-tenths per
cent of the four year group were recommended for un-
limited activity compared with 74.8 per cent of the entire
group.
In summary, one may say that as judged by history
of past illness, physical examination and status of health
and hygiene on entrance, the Freshman who later fin-
ished four consecutive years of University work had a
slightly better physical background than the entering
classes as a whole.
Comparison of data for 338 women who finished four
consecutive years of University work (Student Croup
B) as Freshmen and as Seniors.
The data concerning the physical examination of the
Seniors who had been in the University for four con-
secutive years, compared with the examination of the
same group as Freshmen brought out a few interesting
facts. The data are recorded in Table II, Series B and C.
Forty-five and four-tenths per cent of the Seniors were
considered "normal” in weight as against 41.4 per cent
of the same group as Freshmen. Seven per cent under-
weight to 5 per cent overweight, using Diehl’s height-
weight-age tables, was considered a "normal” range.
It is realized that there are fallacies in this method of
judging so-called "normal” weights, but it does give a
rough estimate of the trend.
The nutritional status of 56 per cent of these four
year Senior women and 56.8 per cent of the same group
as Freshmen was considered "average” by the examining
physicians. The group as a whole had grown and in-
creased in weight during their four years at the Uni-
versity, 89 per cent of the Senior group being over 62
inches in height as Seniors and 81.4 per cent as Fresh-
men, while as Seniors, 10.8 per cent weighed under 106
pounds as against 14.2 per cent of the same group as
Freshmen.
Noticeably fewer Senior students had a normal visual
acuity without lenses — 40.1 per cent being normal on a
basis of 20/20 for both eyes, compared with 55.5 per
cent of the same group as Freshmen. As Freshmen, 24.0
per cent of these students had a thyroid gland which
was enlarged in some degree, while as Seniors, 17.8 per
cent had thyroid glands designated as enlarged. Sixty-
six and eight-tenths per cent of these four year Seniors
had had their tonsils removed cleanly, compared with
53 per cent so designated as Freshmen. Thirteen per
cent of the Seniors had tonsil tags compared with 19.5
per cent of the same group as Freshmen. Six per cent
of the Freshmen had septic tonsils while 3 per cent of
the Seniors were so diagnosed. We should hope to have
so obvious a defect remedied among all students.
Acne vulgaris is always a problem in this age group.
Sixty-nine per cent of this group of students had no
acne as Freshmen or as Seniors. Of the number who had
acne, it was judged that the condition had shown no
change in 7.1 per cent. Fourteen and five-tenths per
cent had either shown improvement or the condition had
174
The Journal-Lancet
TABLE II.
Physical Examination and Health Status
Selected items from records concerning physical examination and
health status. Data Series A from 2000 Freshmen entering during
the years 1934-1937 inclusive (Student Group A) compared with
data Scries B from 5 38 students from Group A who completed 4
consecutive years of University work (Student Group B), and with
Student Group B as Seniors.
ITEM
Data Series A
i from Student
Group A
( Rate per 1 00 )
Data Series B
from Student
Group B
( Rate per 1 00 )
Data Series C
from Student
Group B
( Rate per 1 00 )
Visual Acuity without Lenses —
Both eyes normal
55.5
55.5
40.1
Nose:
Normal
80.0
83.0
Nasal defects
20.0
17.0
T eeth :
Devitalized teeth with X-ray
assurance
61.7
50.0
Carious — one or more
42.1
37.4
Tonsils:
Out well
52.4
53.0
66.8
Septic
8.4
6.0
3.0
Tags
16.2
19.5
13.1
Thyroid Gland:
Normal
74.0
76.0
82.2
Enlarged
26.0
24.0
17.8
Acne:
None .
72.8
76.1
77.5
Present
27.2
23.9
22.5
Acne as Fr. no acne as Srs.
8.5
Acne as Fr. — improved as Srs
6.0
Acne as Fr. — same as Srs..
7.1
Acne as Fr. — worse as Srs -
1 .9
No acne as Fr. acne as Srs.
7.5
No acne as Freshmen or Seniors.
69.0
Heart Normal .. ....
92.9
94.6
95.5
Pulse Normal (60 — 79)
40.9
42.7
33.0
Blood Pressure (Systolic):
99 and under
12.2
1 3.7
8.9
100 - 109
31.9
31.3
20.9
110-149
55.5
54.6
69.9
1 50 and over ..
0.4
0.38
0.38
Weight Variations:
Normal weight
40.7
41 .4
45.5
Under — 7% or more ..
27.9
26.2
30.6
Over 5% or more
3 1.4
32.4
23.9
Weight in Pounds (under 106)
14.83
14.2
10.8
Height in Inches:
Under 62 inches
2 0.3
1 8.6
1 1 .0
62 inches and over
79.7
8 1 .4
89.0
Nutrition (Physician’s estimate):
Average
57.8
56.8
56.0
Under ---------
2 2.0
22.0
27.1
Over
20.2
21.2
16.9
Hemoglobin (Tallqvist)
< 100% = 13.8 gm.) :
80% and over
86.0
85.8
70% - 79%
13.2
1 3.0
69 % and under
0.8 1
1.2
Hemoglobin (Sahli)
(100% = 14.5 gm.) :
11.6 gm. and over
1 1 .5 gm. and under
82.9
Health (Student’s Estimate):
17.1
Good or excellent
94.6
96.1
95.1
Fair
5.3
3.7
3.9
Poor
0.1
0.2
0.19
Health (Physician’s Estimate):
Good or excellent
86.8
87.4
89.6
Fair
1 3.0
12.1
9.9
Poor
0.2
0.5
0.58
Health Compared with Entrance
(Student’s Estimate):
Improved
24.9
Same ....
62.6
Worse
12.5
Health Compared with Entrance
(Physician’s Estimate):
Improved .
36.0
51.2
Worse
12.9
"A” Health Rating
57.8
63.2
78.3
"Unlimited Activity”
recommendation
74.8
78.3
91.5
disappeared entirely. Seven and five-tenths per cent had
no acne as Freshmen, hut had developed it during their
four years at the University. One and nine-tenths per
cent had acne as Freshmen which had become worse by
their Senior year.
The condition of hearts of these students as Seniors
so far as could he judged by physical examination, was
approximately the same as it was when they were Fresh-
men, although the blood pressure readings tended to be
slightly higher and the pulse less frequently within "nor-
mal” range.
With only a few exceptions, pelvic examinations were
done on all of these four year Senior women at the time
of the Senior physical examination. Thirty-five per cent
of these students had cervical lesions of varying severity.
The largest percent of these lesions were cervical ero-
sions. The question of the relationship of these findings
to the promiscuous use of vaginal tampons by young
women consequently becomes significant.
It was learned from an attempt at the comparison of
data concerning results of laboratory procedures that
much could be done in standardizing our methods. For
example, the usual range of hemoglobin for women is
considered to be 12-17 grams per 100 cc. of blood. How-
ever, standards used by different hemoglobinometers vary
in the number of grams representing 100 per cent. Con-
sequently, a reading of 80 per cent on a hemoglobinom-
eter which was standardized so that 100 per cent was
the equivalent of 13.5 grams would not be comparable
to a reading of 80 per cent on a hemoglobinometer
whose 100 per cent standard was 15.0 grams. Over the
four year period included in this study, three different
hemoglobinometers were used at the time of various ex-
aminations— Tallqvist, Sahli, and the Klett instrument.
The picture is further complicated because the number
of grams representing 100 per cent varies with different
Sahli instruments. At the time of the entrance physical
examinations, the Tallqvist was necessarily used because
speed was important. This hemoglobinometer is stand-
ardized so that 13.8 grams is the equivalent of 100 per
cent. Fourteen and two-tenths per cent of the entering
Freshmen group had a hemoglobin estimate below 80
per cent. Since 1937, all of the hemoglobin estimations
done at the time of the entrance examinations which
were below 75 per cent on the Tallqvist have been
checked on either the Sahli or the Klett instruments. At
the time the same group was examined as Seniors, either
the Sahli or the Klett were used and the hemoglobin was
reported in grams. It was found that 17.1 per cent of
these Senior students had readings below 11.5 grams
per 100 cc. of blood. It is usual to follow cases with
periodic examinations of hemoglobin and red blood cell
counts.
In studying urinalyses it was found that about 8.5
per cent had an albuminuria, varying from a trace to a
4-plus at the time of the entrance physical examination.
In only 0.79 per cent was the albumen found to be per-
sistent on further detailed examinations. This procedure
is mentioned in order to emphasize the fact that it is a
very painstaking and time consuming task to establish
the presence of a true albuminuria, either orthostatic or
June, 1943
175
TABLE III.
Selected items of illness experience and Health Service attention
given 2000 Freshmen women entering during the years 1934 1937
inclusive (Student Group A) compared with the same items for
5 38 Senior women who had completed 4 consecutive years of Uni-
versity work during the years 1938-1941 inclusive and who were
reexamined as Seniors (Student Group B) ; and also with the same
items for 872 Senior women graduating during the years 1938-
1941 inclusive after completing 4 consecutive years of University
work. (Student Group C) .
Note: Student Group B constitutes a portion of
Student Group C.
ITEM
Student Grp. A.
2000 Fr. Women.
Experience as Fr.
( Rate per 100)
Student Grp. B.
538 Sr. Women.
Experience as Srs.
( Rate per 1 00 )
Student Grp. C.
872 Sr. Women.
Experience as Srs.
( Rate per 1 00 )
Dispensary Calls
1064
976
949
Hospital and Infirmary Days
84
124
93.5
Upper Respiratory Infections
64
46
48
Had Room Calls
14
—
1 1.5
pathologic, when the initial test is positive in such a
large percentage of instances in women.
The student’s subjective estimate of her own health
as good or excellent, fair or poor, tended to be the same
as a Freshman and as a Senior. As seen by Table II,
Series B and C, the students by this rough standard rate
themselves higher than did the physician following ex-
Iamination. For example, 96.1 per cent of the Group B
Freshmen considered their health to be good or excellent
on admission, while the examining physician considered
87.4 per cent of them to be in the good or excellent
range. Approximately the same difference in percentage
prevailed at the time of the Senior examinations. How-
ever, by subjective evaluations of health as Seniors, as
compared with health as Freshmen, physicians were
somewhat more optimistic than students. Twenty-four
and nine-tenths per cent of the students thought their
health had improved during the past four years, while
the physicians considered 36 per cent of the students to
be in better health on graduation than on admission.
This is in line with the fact that the physicians gave
78.3 per cent of the Seniors "A” health ratings, as com-
pared with 63.2 per cent at the time of the entrance
physical examinations, while 91.5 per cent Seniors were
recommended for unlimited activity, as compared with
78.3 per cent of the same group as Freshmen.
We believe that these figures carry some weight, for
the University physicians have a fairly close contact with
most of the women students who have been at the Uni-
versity for four consecutive years. By far the larger per-
centage have made free use of the Health Service facili-
ties for all reasons concerning their physical and mental
health. This fact will be brought out in the discussion
of the data in Table III. The students considered the
correction of physical defects to be the most important
cause of health improvement. Healthful activity as evi-
denced by interest in sports is also a contributing factor
to health improvement. Of the sports well enough learned
while in the University so that the student felt she
would be able to use them later for recreation, badmin-
ton, tennis, bowling, and golf had the largest number of
adherents; 42.6 per cent having learned badminton, 37
per cent tennis, 33.5 per cent bowling, and 25.1 per cent
golf. Bowling and badminton showed the greatest in-
crease in popularity over the four year period, during
which these students were in the University.
In one respect at least, the hygiene of these students
was distinctly worse. On admission, only 6.6 per cent
of these four year Senior women were getting under
eight hours of sleep, while as Seniors 44.5 per cent were
averaging less than eight hours (table I, series B and C) .
Seventy-two and six-tenths per cent were going to bed
after 1 1 o’clock. An inadequate amount of rest and
sleep constitutes a real problem among college students.
No college physician can consult with students day after
day and not be convinced that much of the illness en-
countered is due at least in part to this one factor.
We considered the amount of outside work carried
by the student to have some bearing on her health and
hygiene. Fifty and nine-tenths per cent of these four
year Senior women indicated when entering as Fresh-
men that outside work would be necessary, or probably
necessary for their financial support. Actually, 48.3 per
cent of these students did outside work for financial sup-
port at some time during their four years at the Uni-
versity. Twenty and one-tenth per cent earned more
than 20 per cent of their entire expenses.
In summary, it may be said that the graduating group
of Senior women who had been in the University four
consecutive years were at least as fit physically as they
were on entrance, their physical status having improved
noticeably in some respects. Certain habits of hygiene,
chiefly the marked tendency to get an inadequate amount
of sleep and rest, had been acquired. If not corrected,
these may well lead to a serious impairment of health
and a loss of efficiency of function.
Comparison of data concerning illness experience of
2,000 Freshmen women entering during the years 1934-
1937 inclusive (Student Group A) with the same items
for 338 Senior women who completed four consecutive
years of University work during the years 1938-1941 in-
clusive (Student Group B) and who were reexamined
as Seniors; also with 872 Senior women who graduated
during the years 1938-1941 inclusive after completing
four consecutive years of University work (Student
Group C). (Note: Student group B constitutes part of
Student Group C).
The comparative data concerning these groups was
relatively meager. It was concerned almost entirely with
with illness experience and amount of service rendered
and brought out several interesting points, as seen in
Table III.
The three above groups averaged approximately the
same number of calls at the Health Service per year.
There was no marked variation in the number of Hos-
pital and Infirmary days, although the Senior groups
had a slightly higher average than the Freshman group.
There were noticeably fewer upper respiratory infections
among the Seniors than among Freshmen severe enough
to bring the student to the physician. Approximately
50 per cent of the Student Group B had had one or
more eye refractions during their residence at the Uni-
176
The Jouknal-Lanc.kt
versity. Approximately 90 per cent of the same group
had had one or more partial or complete physical exam-
inations, exclusive of the Freshmen and Senior examina-
tions, 21.4 per cent having been examined three times.
Approximately 90 per cent of the same group had their
health rerated one or more times, implying at least a
health conference and appraisal of their physical status.
Eight and seven-tenths per cent of Student Group B had
operations under Health Service supervision. These op-
erations include chiefly tonsillectomies, submucous resec-
tions and appendectomies. The most frequent laboratory
services were hemoglobin estimations and urinalyses, the
group averaging 3.3 per student for both estimations
over the four year period.
White blood cell counts came next with an average
of 1.6 per student, followed by basal metabolic rates, for
which the average was 0.6 per student, both over the
four year period. On entrance, the average number of
correctable defects for Student Group B was 2.5 per
student. Approximately 79.5 per cent of these defects
were corrected completely or partially. Of the defects
which were partially corrected, the larger number such as
hay fever, asthma, and some forms of dysmenorrhea,
were incapable of complete correction. A few remediable
defects were not completely corrected because of lack of
complete understanding or appreciation of the signifi-
cance of her health situation, on the part of the student.
Such a sampling of service given women students in-
dicates the extensive amount of time and effort involved
in their care. So far as it is possible to judge from sta-
tistics, the amount of medical attention given annually
to the 538 women students who completed four consecu-
tive years of University work (Student Group B) was
considerable, but not appreciably more than that accord-
ed the average woman student.
While the supervision of the health of the women stu-
dents involves the care of many acute conditions, every
effort is made to make the program as a whole educa-
tional. With the background of a thorough entrance
physical examination and medical history, the physician
is in a position to advise the student of her total health
situation and to point out to her the unusual facilities
she has at the University of Michigan for attaining and
maintaining a state of physical fitness. Patience and
skill on the part of the physician are necessary in mak-
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ing such an original appraisal and in making necessary
reappraisals at the time of later contacts. There is ample
evidence that students learn through their Health Serv-
ice experience what constitutes a good medical examina-
tion and adequate medical care. At the time of the Sen-
ior examination, every girl knows what the extent of her
recheck should be and it is the unusual girl who does not
request that a pelvic examination be included. At all
Health Service contacts during her University experi-
ence, the student is well advised that the responsibility
for making use of services within her reach at the Uni-
versity and of the facilities which will be within her
reach after her graduation, rests entirely within herself.
After the physician is assured that the student under-
stands her total health situation and what procedures to
follow to improve or maintain it, no student is followed
unless her situation is acute or of such a nature that it
may be detrimental to those with whom she comes in
contact. The extensive use made by students of Health
Service facilities is in a measure an index of the success
of such an educational process. It is hoped that a wider
significance of the program may be found in an intelli-
gent attitude toward health and its maintenance and an
intelligent use of available medical service after the stu-
dent leaves the University.
Conclusions
1. The women at the University of Michigan who
complete four consecutive years of University work
have a slightly better physical background on entering
than the entering classes as a whole.
2. The amount of medical attention required by
women who complete four consecutive years of Univer-
sity work is considerable, but not appreciably more than
that accorded the average woman student.
3. Under the conditions of adequate health service,
the University experience is not hazardous to the health
of women at the University of Michigan.
4. Seniors appear to have improved in regard to the
condition of the thyroid gland, tonsils, skin, height and
weight and knowledge of what constitutes adequate med-
ical service. The physician’s judgment of their total
health situation indicates improvement.
5. Seniors appear to have lost a certain degree of
visual acuity and desirable habits of sleep.
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June, 1943
177
Syphilis Serology in North Dakota
Melvin E. Koons, M.Sc., M.P.H.f
Grand Forks, North Dakota
THE total volume of work done in the North
Dakota Public Health Laboratories has shown
a significant increase during the past eight years.
Although the factors accounting for this are of little
interest in this paper, the fact remains that serologic
blood tests for syphilis now constitute approximately
80 per cent of the total volume of laboratory work. This
inordinate proportion of total activity devoted to syphilis
serology can be explained as owing to (1) national and
state educational and control programs for the eradica-
tion of venereal disease, resulting in a better understand-
ing of such diseases by the general public; (2) the
North Dakota Premarital Law; (3) the Selective Service
Act of the National Defense Program; (4) realization
by the medical profession of the importance of labora-
tory tests in the detection of syphilis.
Syphilis is generally considered as one of the most
serious public health problems in the United States.
Until about thirty-five years ago not even the cause of
syphilis was known. However, since 1905 progress in
knowledge of its cause, in methods of diagnosis, and in
means of treatment has been rapid. In the days before
the twentieth century, the clinical diagnosis of syphilis
was based chiefly on the history of the case and the find-
ings of a complete physical examination. Early in the
twentieth century laboratory tests adaptable to general
medical practice were introduced and assumed a place
of importance in the diagnosis of syphilis. That ade-
quately controlled serology is a necessary factor in the
establishment or confirmation of a diagnosis of syphilis
is now widely recognized.
Today serologic tests are the most widely used of all
procedures in public health laboratories. There is a con-
siderable proportion of cases in which a definite decision
as to the presence or absence of syphilitic infection is
impossible without a knowledge of the laboratory find-
ings. The successful application of such laws as those
governing premarital examination and prenatal examina-
tion depends upon the proper performance of serologic
tests, as do the control of syphilis in industry and the
recognition of latent disease.
In North Dakota approximately 95 per cent of all
syphilis serology is being done in the public health lab-
oratories. The results of a recent survey regarding the
distribution of serologic work in the state are shown in
Table I. One can clearly see that there is relatively little
serology being done outside the public health labora-
tories. There are only four private clinics doing an
appreciable amount of syphilis serology and one of these
sends duplicate specimens to the public health labora-
tories for check. Seven hospital laboratories perform
serologic tests only on blood donors when there is an
emergency transfusion. Fifteen other hospitals which
maintain laboratory service do not attempt any serology
at all.
t Director, Division of Laboratories, North Dakota State Depart-
ment of Health.
TABLE I
Syphilis Serology in North Dakota
Routine Test
Used
No. of
Labora-
tories
Av. No. of
Specimens
per Month
Source of
Antigen
Kahn standard and
Kolmer simplified
2
5,000-5,500
Prepare Kahn,
purchase Kolmer
Kahn standard and
Kolmer (3-tube)
1
90-100
Purchase from
commercial house
Kahn standard
1
100-120
Purchase from
commercial house
Kahn standard
1
30-40
Purchase from
commercial house
Kahn standard and
Kolmer
1
3 5-45
Purchase from
commercial house
Kahn standard
4
Only on
blood donors
Purchase from
commercial house
Kline standard
2
Only on
blood donors
Purchase from
commercial house
Mazzini
1
Only on
blood donors
Purchase from
commercial house
No test
15
Types of Tests in Use
At the present time in the United States there are
two groups of tests employed for the diagnosis of syph-
ilis: (1) complement-fixation and (2) flocculation or pre-
cipitation. Both tests are more or less dependent upon
similar biologic factors, but they differ considerably in
technical procedures.
"The original Wassermann test is so entirely different
from some of the highly sensitive and efficient comple-
ment-fixation tests for syphilis which are in use at the
present time that when the term 'Wassermann reaction’
is used without a detailed explanation of the mechanism
and technic involved in carrying it out, it can only create
confusion and misunderstanding. There are now a great
many modifications of the original Wassermann test
which are known either by the name of the person who
has worked out a definite modification or another to suit
the taste or convenience of the user and to which he
refers simply as a 'modified Wassermann test.’ ” 1
Today the term "Wassermann” is used in its generic
sense to mean the serodiagnosis of syphilis by laboratory
examination of a patient’s blood serum or spinal fluid,
using a "standard” serologic test. (This includes all
serologic tests which are in common use and which have
shown acceptable specificity and sensitivity in the various
serologic conferences conducted under the auspices of
the Committee on Evaluation of Serodiagnostic Tests for
Syphilis.)
The complement-fixation test is based upon the Bordet-
Gengou phenomenon (first reported in 1901) of the fix-
ation of complement. The application of this phenom-
enon was first used in the diagnosis of syphilis by Was-
sermann and his confreres in 1906. The diagnostic value
of the Wassermann reaction was soon amply confirmed.
178
During the next fifteen years much work was done
with the Wassermann reaction, until Kolmer published
his modification in 1922. Except for slight changes in
the amount of serum employed, improvement in the sen-
sitivity of the antigen, and the adoption of an improved
method for titrating antigen in determining the optimum
dose to employ, no important changes in the test have
been made. Modified and refined to a great extent from
the original, the complement-fixation test has been uni-
versally adopted as an amazingly sensitive and specific
test for syphilis.
Soon after the development of the Wassermann re-
action, Michaelis (1907) observed that a precipitate
sometimes formed when the aqueous liver extract used
in that test was added to syphilitic serum. Since this
original work much has been done to further the use of
precipitation tests. The development of precipitation
tests has been very rapid — so much so that they are now
almost universally used and in many instances have re-
placed the more complex complement-fixation test.
There are a number of such tests employed in the
United States: the Kahn, Kline, Hinton, Eagle, Mazzini,
etc., — all carrying the name of the author. There is no
fundamental difference between the various precipitation
tests. The differences lie in the variability of adjustment
to those factors which determine the sensitivity and spe-
cificity of the reaction. In 1922 Kahn first published a
modified precipitation test which has attained national
popularity. Most originators of the flocculation or pre-
cipitation tests have put great emphasis on the simplicity
and ease of performance of these types of tests as com-
pared with the complement-fixation tests.
Regardless of the procedure used, it has become appar-
ent that three qualities are desirable in any diagnostic
test for syphilis. First, it should be as nearly specific as
possible, reducing false positives to a minimum. Second,
it must be so sensitive that it will not fail to give a posi-
tive reaction when syphilis is present. Third, it must be
adaptable — a method which can be applied accurately by
all trained technicians instead of a mere technical trick
which can be performed reliably only by its originator.
Serologic tests should be adaptable to the diverse, and
at times unfavorable, conditions existing in ordinary prac-
tice. Tests which are reliable when performed with hem-
olyzed, anticomplementary, contaminated serums, or
spinal fluid specimens are obviously of more value to the
clinician than those which cannot be used under such
conditions.
In laboratories performing serology routinely, such as
public health laboratories, the use of at least one floc-
culation or precipitation test and one complement-fixa-
tion test for diagnostic work seems to be good practice.
In recent years various surveys have shown that no one
test for syphilis is satisfactory and that the serum diag-
nosis of syphilis is best served by testing every serum by
at least two methods when conditions permit. Both com-
plement-fixation and precipitation reactions are due to
the same reagin, but owing to technical conditions, one
test may give a correct positive and another a false nega-
tive reaction. For this reason it is felt advisable to use
both a complement-fixation and a precipitation test rou-
The Journal-Lance i
tinely — each possessing the maximum of sensitivity con-
sistent with specificity.
In North Dakota the public health laboratories have,
for the past seven years, performed routinely on all blood
specimens submitted the Kahn standard precipitation
test and the Kolmer complement-fixation test. It has also
been the policy of the laboratories to adhere strictly to
the standard procedure as laid down by the originators
of the tests. In no instance has any attempt been made
to deviate from the standard technics as used in routine
testing.
No test can be better than the laboratory conducting
it. The efficiency of laboratory serologic tests on which
the medical profession places major reliance in the diag-
nosis of syphilis is a problem of utmost importance. For
this reason, too much emphasis cannot be placed on the
subjects of sensitivity and specificity, especially the latter.
This has become more significant in recent years with
the functioning of premarital and prenatal laws. It is
certainly far better to miss the serum diagnosis of occa-
sional cases of chronic latent syphilis than to incur un-
necessary risks of false positive reactions with all that
these mean to the individuals concerned. No one can
deny that occasional false positive reactions will occur in
the best of laboratories, including those of the author-
serologists. Kolmer,- one of the country’s leading syph-
ilologists, recently stated that the "harm done by a mis-
taken diagnosis of syphilis based upon a false positive
reaction outweighs any number of false negative re-
actions. To inform the patient may do irreparable harm,
as the 'syphilitic scars of the spirit’ are more difficult to
cure than the disease itself.”
It is not necessary that the practitioner have a detailed
knowledge of the principles and technics of the tests
used; it is much more important that he have a knowl-
edge of the character of the laboratory making the tests,
the particular variety of the test, and the record of the
laboratory for accuracy in both positive and negative
cases. Properly performed tests, when positive, are a
reliable evidence of syphilis.
Evaluation Studies
The need for a system of gauging the efficiency of
laboratory tests has been evident for a number of years.
"In 1934 the Surgeon General of the United States Pub-
lic Health Service appointed the Committee on Evalua-
tion of Serodiagnostic Tests in the United States, con-
sisting of two clinical pathologists (chosen by the Ameri-
can Society of Clinical Pathologists) , two syphilologists,
and two officers of the United States Public Health
Service, to develop a method for the evaluation of sero-
diagnostic tests for syphilis in the United States. The
plan decided upon was to collect samples of blood ob-
tained from patients in various stages of syphilis, from
normal nonsyphilitic persons, from patients with various
diseases, and from pregnant nonsyphilitic women. These
samples were then to be redistributed to the laboratories
of participating serologists. The serologists participating
in this evaluation study were those who had described an
original serologic test or a modification of a preexisting
test.”1 Without going into detail, suffice it to say that
the results of this first study showed that seven serologic
Junk, 1943
179
TABLE II
Results of the Interstate Evaluation of Serodiagnostic Tests,
North Dakota, 1938—1942
Kahn Standard
Year
Laboratory
Sensitivity
Specificity
Control
70.5
100
1938
Bismarck
71.8
100
Control
77.4
1 00
1939
Grand Forks
81.2
96.5
Control
71.2
100
1940
Grand Forks
72.1
100
Control
79.2
100
1941
Bismarck
73.4
100
Control
80.7
100
1942
Grand Forks
80.9
100
Kolmer Complement-Fixation
Y ear
Laboratory
Sensitivity
Specificity
Control
78.2
100
1938
Bismarck
61.6
100
Control
83.4
100
1939
Grand Forks
77.1
99.1
Control
68.1
100
1940
Grand Forks
73.6
100
Control
77.6
100
1941
Bismarck
74.4
100
Control
84.9
100
1942
Grand Forks
82.7
100
tests qualified as satisfactory, although far from perfect.
The following year a somewhat different evaluation
study was carried out by the same agencies which plan-
ned the first one. Since the criterion by which any lab-
oratory procedure may be expected to stand or fall is its
efficiency in hands other than those of its originator, it
was decided in this second project to send samples of
each specimen to several laboratories, including the lab-
oratory of the originator of the test under consideration.
The result of such an evaluation would be a much better
indicator of the efficiency of the various tests under every-
day working conditions in the serologic laboratory. It
was evident from the results of this study that only a
comparatively few laboratories were performing serologic
tests which could compare with those made by the
originator.
The Assembly of Laboratory Directors and Serologists
held in Hot Springs, Arkansas, October, 1938, recom-
mended that, to qualify as satisfactory, a laboratory
should attain a sensitivity rating not more than 10 per
cent below that of the control laboratory, and a specifici-
ty rating of not less than 99 per cent. This recommen-
dation was adopted, and since the 1939 survey a labora-
tory entered in the study cannot be rated as satisfactory
unless these standard requirements are met.
In October, 1938, the Conference of Laboratory Di-
rectors and Serologists also requested that the Surgeon
General assume the evaluation of serologic tests as a
function of the Public Health Service. This plan was
adapted by the Surgeon General and the Conference of
State and Territorial Health Officers.
There are definite indications that this approach to
the problem has been a helpful one. The need for cross-
TABLE III
Premarital Blood Tests, July 1, 1939, to December 31, 1942
Year
Total
Blood
Specimens
Positive Individuals
Total
Percent
Positive
Male
Female
1939. 6 mo.
4.640
2
9
11
0.23
1940
9,152
17
18
35
0.38
1941
9,256
20
22
42
0.45
1942
6,799
14
19
33
0.48
Total
29,847
53
68
121
0.40
checking results under controlled conditions with other
laboratories performing the same technical procedure is
recognized. The annual survey is not the final answer
to the problem, as many factors encountered in routine
specimens are not present in the controlled group. How-
ever, such surveys constitute a definite step in the right
direction and a foundation is being laid upon which a
more comprehensive system can be erected.
There is not the slightest doubt that these evaluation
studies have greatly increased the efficiency of serologic
tests in state laboratories throughout the country. It is
also apparent that one or even several official evaluation
studies do not finally establish the comparative value of
any single test. In other words, although the results of
official evaluation studies are no doubt of great value,
they cannot be said to be absolutely final. Such results
should be considered in the light of all that is known
about the serologic diagnosis of syphilis.
The first serodiagnostic evaluation study in which most
of the state laboratories participated (1937) demonstrat-
ed conclusively that far too many were operating at low
levels of efficiency. Since that time the number of lab-
oratories reporting satisfactory results has increased
manyfold.
Most of the laboratories failing to give satisfactory
results did so because of one or all of the following fac-
tors: (1) the use of outmoded technics; (2) use of
short cuts and time-saving devices; (3) inferior quality
of essential ingredients; and (4) nonadherence to stand-
ard technics of the originators.
North Dakota has been entered in the evaluation
studies since 1938. The results obtained in these sur-
veys are shown in Table II. As noted, the sensitivity
rating of the Kolmer test in the first study (1938) was
low as compared to that of the control laboratory. Steps
were taken to correct this fault and the results of sub-
sequent studies indicate that that goal was achieved. The
evaluation study was directly responsible for discovery of
the defects in that particular test. The only other time
North Dakota failed to qualify as satisfactory was in
1940, when the specificity of the Kahn test was not ap-
proved. It was apparent that specificity was sacrificed
in favor of high sensitivity. This fault was also correct-
ed, as is borne out by the fact that since then a 100 per
cent specificity has been obtained with the Kahn test.
The results shown in Table II indicate that the per-
formance of serologic tests in North Dakota shows a
maximum of specificity and a high degree of sensitivity
when compared with control laboratories. This can be
1X0
The Journal-Lancet
05
60
fiscal Years
Annual Increase in Specimens Submitted for
Syphilis Serology
interpreted in a general way to mean that the physicians
of North Dakota are receiving as reliable results on
specimens submitted as is possible with current serologic
rests.
Volume of Serologic Tests
Figure 1 shows the total number of blood specimens
submitted to the public health laboratories for the diag-
nosis of syphilis from July 1, 1935, to June 30, 1942.
It is apparent from this figure that there has been a
significant increase in this phase of laboratory work.
On July 1, 1939, the North Dakota Premarital Ex-
amination law became effective. This has accounted in
part for the increase in syphilis serology. The law pro-
vides that each applicant for a marriage license must
submit to the licensing authority a certificate from a
licensed physician and surgeon stating that the appli-
cant has "been given such examination, including a stand-
ard serological test, as may be necessary for the discov-
ery of syphilis.” The law defines a standard serologic
test as "a laboratory test for syphilis approved by the
State Health Officer and performed by the State De-
partment of Health. Table III shows the number of
blood specimens examined since the inception of the law
and the number of individuals with positive serology.
The number of positives is broken down into male and
female.
• Since November, 1940, when the first blood specimens
were received from Selective Service draftees, a total of
55,987 have been examined. Of this total 292 selectees
have been found to have positive serology. This is 0.52
per cent of the total number examined, or 5.2 infections
out of every thousand examinations.
iSince paper was submitted for publication, the law has been
amended to that serologic tests can be performed by any state pub-
lic health laboratory approved by the North Dakota state health
officer.
Reporting Results of Serologic Tests
The method of reporting the results of serologic find-
ings in North Dakota has undergone several changes in
the past few years. At one time the actual plus marks
were used exclusively; i. e., a Kolmer or Kahn test would
be reported as 4+, 3+, 2+, etc. Then the system of
reporting was changed so that the combined routine tests
(Kolmer and Kahn) were reported together as positive,
doubtful, and negative. This meant that the technician
was, in a sense, interpreting the laboratory findings. For
example, if the Kahn test was negative and the Kolmer
positive a report of doubtful would be sent out. How-
ever, during the past year the actual laboratory findings
of each individual test are reported as positive, doubtful,
and negative. This means that each test is reported sep-
arately, for example: Kolmer positive, Kahn negative,
etc.
The recommendation that plus marks be dropped in
the reporting of serologic tests for syphilis, and that the
words "positive”, "doubtful”, and "negative” be used
instead, was first made at the League of Nations Sero-
logic Conference at Copenhagen in 1923. These desig-
nations were also used at the other conferences sponsored
by the League of Nations and were later adopted by the
American serologic conferences.
Moore3 has pointed out that the reporting of results
of serologic tests in terms of plus marks is inaccurate
and misleading. He states that "4+” does not neces-
sarily mean "strongly positive,” since all tests in current
use are qualitative or only roughly quantitative; that is,
they are performed with a fixed amount of whole serum
related to the total bulk of the test and ranging from
0.1 to 0.025 cc. A test may be positive with as little as
0.00005 cc. of whole serum. In such a case, if plus
marks are to be used in reporting, the result might prop-
erly be expressed as "4,000+” instead of "4+”. He
thinks it is obvious therefore that plus marks and the
qualifying objective "strongly” should be eliminated from
routine serologic terminology and should be replaced by
the single word "positive”. He goes on to say that
though "positive” covers an extreme range of variation
in terms of the amount of patient’s serum employed in
the test, the other symbols, "3+, 2+, 1 + , and ± ”,
which are commonly used to describe a "partially posi-
tive” or "doubtful” result, cover instead an extremely
minute range of variation, this range being only between
the limits of 0.2 and 0.02 cc. of whole serum in the
Wassermann test. With this wide range there is no
valid excuse for the attempt to report minute variations
in the degree of positiveness and all such results should
be expressed by the word "doubtful”.
At the present time there seems to be no generally
accepted basis for the classification into positive, doubt-
ful, and negative results. From the literature one finds
that each laboratory has its own definite basis for re-
porting, which may not agree with that of any other.
As mentioned before, North Dakota is now reporting
results as positive, doubtful, and negative; 4+, 3+, and
2+ are considered as positive, 1+ and — as doubtful,
and — as negative. The only exception is that for the
benefit of the clinicians who are interested in the treat-
June, 1943
181
ment of syphilis the actual readings of the test are
given, i. e., Kahn test, positive (3 + ).
Interpretation of Results
How to interpret laboratory reports is a question which
is often asked of laboratory personnel. No set rules
of interpretation can be postulated. A laboratory can
only report its exact findings on any given case, leaving
the evaluation of the result to the physician, who is con-
versant with the history and clinical findings. The lab-
oratory report in general should be considered only as
a portion of the evidence, contributory to the final diag-
nosis; such things as clinical findings and history play an
important role. In carefully controlled serologic tests, the
positive blood reaction is good evidence of syphilis, espe-
cially if other findings are in agreement. However, if
syphilis is not suspected clinically, the physician should
never jump to the conclusion that the disease is present.
The presence of a positive blood in such cases may be
the only evidence indicating a latent syphilis; therefore,
repeat tests should be made to exclude the possibility of
technical error and to determine whether the serologic
condition is transient or persistent.
The terms positive, doubtful, and negative have the
following laboratory significance: positive — complete fixa-
tion of complement in the Kolmer test or complete pre-
cipitation in the Kahn test: doubtful — incomplete fixa-
tion of complement; negative — no fixation of complement.
However, to the clinician these terms have a different
significance. On the back side of the laboratory report
the following interpretation is printed:
1. A diagnosis of syphilis should not be made on the basis
of a single positive serological reaction alone. If the serological
result is not supported by the case history and clinical symp-
toms, one or more additional specimens of blood should be sub-
mitted and a note made that a check examination is desired.
If the result of the check test confirms the original result, syph-
ilis is indicated with a high degree of probability.
2. A doubtful serological reaction may or may not indicate
syphilis. If the patient is known to have been infected with
syphilis and particularly if he has been treated, a doubtful re-
action may be regarded as positive. If there is no history or
clinical evidence of syphilis, a doubtful serological reaction indi-
cates the necessity of making a very careful examination of the
patient. An additional specimen should be sent in and a note
made that a check examination is desired. If the result of the
check examination is likewise doubtful, the serological examina-
tion should be repeated in this and other laboratories; and if
necessary, several different serological methods should be used
before the possibility of syphilis is dismissed.
3. A negative serological report does not exclude the possi-
bility that a patient has syphilis. Positive reactions are not
usually found until the second to the fifth week after the ap-
pearance of the initial lesion and frequently not in the first
stages of the disease or before secondary symptoms appear.
Negative reactions may occur after treatment has been insti-
tuted. If there is reason to suspect syphilis, a negative reaction
should be checked by a second blood specimen.
Discrepant Serologic Results
In any laboratory where serologic tests are being run
on a large scale, such things as false positives, false nega-
tives, and contradictory results between two tests are
always a serious problem with which to contend. Un-
fortunately, in most instances the physician fails either
to follow up such cases or to give any adequate history
which may help the laboratory in supplemental studies.
The false positive reactions are generally classified
under two groups: (1) technical false positives due to
some error in the performance of the test and (2) bio-
logic false positives which occur in conditions other than
syphilis. Technical false positives can be reduced to an
absolute minimum by careful training and sincere
thoughtfulness on the part of the technician. However,
a diagnosis of syphilis in the absence of a history or
clinical findings should never be made on the basis of a
single positive test. In such cases the test should be re-
peated in the same laboratory, and if possible in another
laboratory, with more than one type of test.
The biologic false positives generally present a more
difficult problem. Diseases which definitely give false
positive reactions for syphilis are yaws, relapsing fever,
and trypanosomiasis. There are, however, certain other
conditions which may give false positive serologic re-
actions. They are leprosy, malaria, tuberculosis, infec-
tious mononucleosis, and febrile diseases. In the litera-
ture there are variable reports as to the incidence of
false positives in the above-mentioned conditions and
also differences in the type of test used. The two tests
which are used routinely in North Dakota have in most
evaluation studies been highly specific.
There is no justification for the assumption that there
is no possibility of the presence of syphilis because of a
single negative serologic reaction. It is a known fact
that there are certain periods of syphilis when serologic
reactions are negative. They are early primary syphilis,
late syphilis, syphilis in early infancy, interstitial kera-
titis, and a limited number of neurosyphilitic and cer-
tain other cases under treatment. All of these false nega-
tive reactions are no doubt brought about because of
the lack of sufficient reagin in the blood. Technical
error could also account for false negative reactions, but
these are not the common finding in properly controlled
tests.
The bugbear of the serology of syphilis is a situation
in which one test gives a positive and the other a nega-
tive reaction. This discrepancy in results obtained with
different tests on the same serum is an unexplained phe-
nomenon and is often referred to as the "serologic tech-
nicians’ headache.” Literature is replete with histories
of such reactions and no attempt will be made here to
explain such occurrences. Most serologists are agreed
that the use of several serologic test methods increases
the accuracy and lessens the danger of reporting false
positive results. For this reason it is advisable to use one
test which is found to be very specific in conjunction
with a test of high sensitivity.
Syphilis serology is a never-ending attempt to approach
perfection which at present shows no possible chance of
achieving that goal. After obtaining the best in equip-
ment, making the proper choice of a test, raising quali-
fications of the personnel, paying intelligent attention to
details of the test, and constantly checking technic by
means of evaluation studies, the laboratory must still
report a certain percentage of contradictory results. The
unpleasant task of interpreting reports is wholly the bur-
den of the physician. Final judgment and responsibility
rest fairly and squarely with the physician and he can
182
The Journal-Lancet
only expect the laboratory serologist to report reactions
exactly as observed and not as he (the physician) expects
or may desire.
Necessary Precautions
In the collection of suitable blood specimens for syph-
ilis serology several precautions are necessary, birst, an
ample specimen (at least 5 cc.) should be obtained.
Hemolysis and contamination of the specimen with bac-
teria or foreign matter (drugs, disinfectants, dyes, etc.)
and chylous specimens (collected too soon after a meal)
must be prevented.
In North Dakota a certain percentage of hemolyzed
specimens is always expected during the severe cold wea-
ther, owing to the freezing of the blood in transit. How-
ever, for a number of years blood specimens have been
received badly contaminated or hemolyzed when tem-
perature would have no effect. Shortly after the pre-
marital law went into effect, hemolyzed specimens were
a problem of great concern. In many instances, because
of the condition of the blood specimens when received
in the laboratories, there were delays which caused incon-
venience to everyone concerned.
This condition was alleviated to a great extent in
April of 1940, when the Venereal Disease Committee
of the State Medical Association recommended that the
Division of Laboratories of the State Department of
Health purchase a number of Kimble venules. These
tubes are furnished without charge to all licensed physi-
cians in the state on request to the Public Health Lab-
oratories at Bismarck or Grand Forks.
The Kimble venule has introduced great simplicity
and sterility into the process of taking blood specimens.
Its design and construction eliminate all danger of infec-
tion to the patient or operator. The venule is ready for
immediate use by the collector without any preliminary
sterilization. The proper use of these tubes assures the
laboratory of receiving a specimen free from bacterial
contamination and hemolysis.
References
1. Hinrichsen, J.: Modern serologic tests for syphilis and their
interpretation by the physician, Ven. Dis. Inform., suppl. 14, U. S.
Public Health Service.
2. Kolmer, John A.: The interpretation of serological tests in
relation to the diagnosis and treatment of syphilis, Porto Rico
Health Bull. (Sept.) 1941.
3. Moore, J. E.: (Editorial) The americal evaluation of sero
diagnostic tests for syphilis from the clinician s standpoint. Am. J.
Syph., Gonor., and Ven. Dis. 30:207-21 3, 1936.
4. Eagle, H.: Laboratory Diagnosis of Syphilis, C. V. Mosby
Co., 1937.
5. The serodiagnosis of syphilis, Ven. Dis. Inform., suppl. 9.
6. Parran et al. : J.A.M.A. 117:1 167, 1941.
7. Moore, J. E., ct al.: Management of syphilis in general
practice. Ven. Dis. Inform., suppl. 6.
8. Moore, J. E.: The Modern Treatment of Syphilis. Charles
C. Thomas Co., 1941.
9 Parran, T., Hazen, H. H., et al.: A comparative study of
serodiagnostic tests for syphilis as performed by thirty-nine state
laboratories. Ven. Dis. Inform. 18:273-279, 1937.
10. Parran, T., Hazen, H. H., et al.: The efficiency of state
and local laboratories in the performance of serodiagnostic tests for
syphilis. Ven. Dis. Inform. 18:4-1 1, 1937.
11. Kahn. R. L.: Serology in Syphilis Control, Baltimore, Wil-
liams Qc Wilkins Co., 1942
12. The serodiagnosis of syphilis, Ven Dis. Inform., suppl. 9,
1 939.
13 Senear, F. E., Cumming. H. S., et al.: The evaluation of
serodiagnostic tests for syphilis, South. M. J.. 1 936. pp. 68-74.
14. Hazen. H. H.: Address before the Southern Medical Asso
ciation, Memphis, Tenn., 1939.
Complaint and Situation in College Health Work*
Theophile Raphael, M.D.f
Leonard E. Hinder, M.D.f
Ann Arbor, Michigan
THE role of the psychological and emotional, in
other words, the participation of the total person-
ality in cases coming to medical attention, discloses
itself most strikingly, through contrast between the origi-
nal complaint made by the patient and the actual situa-
tion found to obtain. Emergent through this, also, is
the functional place of psychiatry or mental hygiene as
a natural, implicit, and integral element of the complete
medical approach, whether to college students or others,
a matter not yet as apparent or as clear as might be. By
so many, psychiatry is still reacted to, consciously or
unconsciously, as a rather separate, not explicitly medical
concern, pertaining exclusively to a special group, the
strikingly odd or mentally grossly disordered and not,
human nature being constituted as it is, applying to all.
This point, of course, is not a new one.1 However, in
view of its really considerable importance and the rapid
development of the concept of psychosomatic medicine,
it was felt that the presentation of such a series of
protocols from student case material would here be both
*Read at the twenty-first annual meeting of the American Stu-
dent Health Association, Ann Arbor, Michigan, December 28, 1940.
t Mental Hygiene Unit, Student Health Service, University of
Michigan.
appropriate and opportune.
In this way, through allowing the cases to speak for
themselves, as it were, the point in question, i. e., the sig-
nificance of non-"physical” problems and issues in rela-
tion to states and complaints of ill health, would seem
most simply and directly portrayable. These cases, inci-
dentally, are not particularly exceptional or unusual, but
rather quite representative of the experience of the stu-
dent Mental Hygiene unit.
Case 1: Graduate woman student. Age 27. Presenting Com-
plaint: Severe headache, fatigue, generalized pains, and fear
that these were related to previous illnesses — rheumatic fever,
Malta fever, injury in a fall, and "kidney stone.” Situation:
We find an impulsive, infantile, highly strung, hysterical, "self-
willed”, self-centered, "spoiled”, unstable young woman who ex-
pects more than life can give her; who has over-estimated her
ability; does not learn from experience; cannot accept her own
limitations; and tries to force situations her own way. There is
a background of family discord; and the patient is resentful
toward her father, an osteopath, who opposed her going to
college. Uncertain as to vocation, she changed from art to teach-
ing. Thwarted in her social and marital aspirations, she returned
to college, expecting to obtain a fellowship in botany, as well as
opportunities to meet "ideal men.” As before, she planned her
affairs loosely and in conformity with her own wishes. Dis-
regarding practical considerations and with limited finances, she
183
June, 1943
again finds Herself, when the plan is put into effect, in frustrat-
ing reality instead of the anticipated Utopia. No physical dis-
order can be found to account for her dramatic, hypochondriacal
complaints, and further medical inquiry does not substantiate
the previous illnesses as having been organic in nature. When
the possibility of success began again to elude her, under stress
of adjustment to a new reality situation, illness offered the only
escape. The situation reveals itself essentially as a frustration
collapse with great focus on physical symptoms. There is, fur-
ther, much question as to this individual’s suitability for, and
real interest in, the present University project, which had clearly
brought into relief her unpreparedness and uncertainty as to
just what she wants and can make out of life. The distressing
personality dynamics or, if you will, the psychiatric component,
is here clearly obvious, as the story of the case is assembled —
incidentally quite a far cry from the original complaint, "head-
ache”.
Case 2: A Jewish boy, a freshman in the College of Literature,
Science and the Arts. Age 19. Presenting Complaint: "Chills”,
with generalized tremors and attacks of nausea and palpitation,
related to eating. Situation: We find an extremely dynamic, im-
mature, tensional and worrisome, explosive, egocentric youth of
high pressure type, driven by insecurity and fear, with a "big-
shot” complex. He enters aggressively into all manner of enter-
prises, and as part of his distorted scale of values, strives to play
a Don Juan role in relation to sex exploits, a potency mechanism
which is pretty much his basic trend in all fields. Fixation on
physical aspects has been conditioned by an over-solicitous, wor-
risome mother and a hypochondriacal father who has similar
"nervous spells.” In the college environment, because of con-
stant pressure to maintain and extend his "big-shot” status, he
became increasingly tense, and his need for attention expressed
itself in a negative way through being sick. His physical con-
dition is normal except for a mild residual poliomyelitis defect,
of which he was "proud ”, he stated, since it identified him with
great individuals who had similar handicaps. Discovering him-
self only semi-effective, despite every exertion, he became con-
fused and fearful of "losing face,” and developed panic and
anxiety reactions channeling into a type of hysterical attack,
ready-made in his pattern, which satisfied his need for attention
and served as an escape for possible defeat of his "big-shot”
project.
Case 3: Male freshman in the College of Literature, Science,
and the Arts. Age 19. Presenting Complaints: Fear of heart
failure, pulsations in arms, headaches, dizziness, pains in joints,
and chronic "colds”. Situation: Here we find a sensitive, "soft”,
infantile, worrisome, fearful, insecure youth, taking life very
seriousLy and anxious to do well, although intellectually not too
bright. He had had a mild cardiac defect in early life, not at
all serious or handicapping except under strenuous physical ex-
ertion, but much over-interpreted and over-emphasized med-
ically, with resulting semi-invalidism and tendency to over-
exaggerate and over-attend minor illnesses. He was over-pro-
tected by his mother, but pushed forward by his father with
exhortations to "step out and be a man.” With his background
of over-dependence upon the home and retarded maturation, he
soon found the college situation too much for him. His in-
security became heightened, and he developed marked feelings
of inferiority, with striking lack of confidence. Not able to meet
the situation alone, and in an intolerable dilemma between dis-
appointing his parents and hurting himself, he found over-atten-
tion to mild "colds” and his "bad heart” the only approved
escape. Although the actual organic handicap was minor, and
the general physical findings were entirely negative, reassurance
on those points alone, without exploration and appreciation of
the dynamics involved, would be of no value whatsoever. In
fact, such reassurance is not wanted or accepted, the symptoms
being too precious to the patient himself. As the situation stood,
it would have been intolerable for him to be well.
Case 4: South American male graduate student, holding a
medical degree. Age 29. Presenting Complaint: Lassitude, heavy
sensation in abdomen after meals, swelling of eyes, and fear of
some obscure metabolic disorder. Situation: Here we have a shy,
sensitive, "tender-minded”, timid, withdrawing, basically schi-
zoid, dreamy idealist, who recognized his own unsuitability for
general practice after completing his medical training. He ap-
parently had a schizophrenic episode (dementia praecox) during
his third year in the medical school, and although he has found
a haven in a protected, scholarly vocation (research in botany) ,
he still has periods of cloudy mental function and vague phys-
ical complaining. He then explains his "fatigue” and somatic
discomforts on the basis of far-fetched, untenable physiological
suppositions, in spite of the fact that detailed clinical and lab-
oratory studies revealed normal findings. The present situation
is one of moderately well-adjusted schizophrenia, with tensions
and conflicts channeling into obscure and grotesque physical
complaints and speculations. The presenting complaint, while
seeming to point simply to physical pathology, is, in reality, the
emanation of a serious chronic mental disease.
Case 5: Senior married woman. Age 29. Presenting Com-
plaint: Inability to use the fingers of the left hand, because of
numbness and weakness. Situation: This patient is a physically
small, immature, highly strung, delicate, hypersensitive young
woman, who was over-protected and "spoiled” by solicitous par-
ents and brought up as a "child prodigy,” because of her early
talent as a violinist. Not well socialized in her early training,
she lived like a "princess in an ivory tower,” with a career as
musician the magical center of her life. At the age of 21 she
impulsively married a man she scarcely knew, and subsequently
never made a satisfactory sex adjustment. The husband is a
dominant type, rather an intellectual, and demands much atten-
tion and nursing, due to his own physical ailments. The pa-
tient’s sense of frustration in the marriage crystallized the im-
passe between her golden fairy dream of a career and its realiza-
tion. Difficulty which developed in the use of the fingers while
practicing, grew into a fixation and was used as justification for
abandoning plans for a professional career. Disappointed and
disillusioned, unhappy and physically afraid of her husband, her
sense of frustration and futility is made tolerable only by the
conviction that the difficulty with her fingers, for which no
organic basis is found, is the cause of her failure to realize her
girlhood hopes. This complaint, then, offers the only acceptable
solution to her impasse; and actually, seen in this light, cure
is not entirely welcome, entailing as it does, the necessity of
special work in a disturbing and confused milieu with, in addi-
tion, lack of personal preparedness and question of sufficient
talent for its complete consummation.
Case 6: Sophomore girl in the College of Literature, Science,
and the Arts. Age 19. Presenting Complaint: Chronic head-
aches, irregular menses, overweight. Situation: In this case we
have a simple, childish, primitive, elemental, unformed, hysteri-
cal personality, not too bright, with physical characteristics sug-
gesting endocrine dysplasia. Infantile, hyperemotional and un-
disciplined, seeking only her own pleasure, she is unreliable and
irresponsible in all her behavior, including cooperation with re-
spect to the treatment of her complaints. Wishes and desires,
not permitted by conscience and reason, are given expression by
using her complaints for attention and escape. Unstimulated by
her rather colorless home life and the resigned attitude of her
parents, yet lacking a real interest in education, she devoted her-
self in college almost exclusively to a round of trivial social
activities and affairs with boys. When the academic and dis-
ciplinary pressures, incident to the University setting, made de-
mands beyond her capacity and interest, her infantility and in-
stinctive pattern of childish living became manifest in fugue
states and increasing physical complaints, especially headaches.
Clinically no outstanding somatic pathology is found. The sit-
uation is essentially an escape reaction in an individual who is
constitutionally, that is, morphologically, psychologically, and
emotionally, inferior.
Case 7: An 18 year old Jewish girl, a sophomore in the Col-
lege of Literature, Science, and the Arts. Presenting Complaint:
Diarrhea, weakness, lack of appetite, nausea, vomiting, irregular
menses, and insomnia. Situation: In this case we find a very
highly strung, tense, sensitive, introvert type — an unstable, hys-
terical, infantile, impatient young girl, quite dependent and in
need of demonstrated affection and support. Precocious, and
excessively focussed by her parents on intellectual attainments,
she is serious and over-mature in some ways, yet basically very
immature and childlike, never having learned how to play and
get along with others of her own age, and having been kept
from active participation by numerous early illnesses. Both par-
ents are highly-strung and imposed adult perfectionistic stand-
184
ards. The father, a physician, is particularly lacking in un-
derstanding and insight. Home life was marked by many quar-
rels and scenes, and the patient felt very antagonistic toward
her younger brother who, she felt, was favored over herself.
Feeling socially inferior and isolated, the patient had dieted to
lose 80 pounds in the past year, then felt quite desolate, when
the coveted attention from the other sex still failed to appear.
Physically weakened, worried over her studies, and feeling in-
creasingly misunderstood at home, symptoms evidenced by a
gastrointestinal upset finally brought a solution to her unbear-
able state, in the form of an acute illness which demands atten-
tion, ministration, and release from responsibilities.
Case 8: Male freshman in the Engineering School. Age 19.
Presenting Complaint: Diarrhea, fatigue, dizziness. Situation:
We find an intelligent, in many ways attractive, but highly
strung, extremely dynamic, impetuous, egocentric, naive, undis-
ciplined personality of cyclothymic type, sensitive, ambitious,
and with marked drive to succeed, to be "tops” and in a "big
way,” which had been the case in high school. He had been
poorly trained by parents who understood him very slightly,
and, aside from summary disciplinary attempts, had left him
largely to his own devices; through their own limitations and
ineffectuality they contributed but little to the home setting as
a constructive sphere of influence. From the beginning of school
in the fall, the patient had been operating under great pressure
in the challenging, demanding, complicated and competitive uni-
versity milieu, attempting many things with some initial success.
The situation became one of progressive busyness and stress,
tension and fatigue, culminating in a frank manic attack of
manic-depressive type, ushered in by a mild gastrointestinal in-
fection whose major symptom, diarrhea, represented the pre-
senting complaint and which, with the effects of the stress and
pressure of the patient’s living, was undoubtedly of precipitating
effect respecting the real trouble, i. e., the manic episode. That
is, we have here a condition of acute mental disorder in an in-
dividual of special type, dynamics, and conditioning, caught up
in a very trying and unhealthy life situation — a very different
matter from diarrhea, and hardly inferable from that complaint
alone, which, nevertheless, was a definite part of a pathologic
whole.
Case 9: Married male graduate student. Age 32. Presenting
Complaint: Discomfort and pain in lower abdomen, worse after
meals; bowel movements "not right.” Situation: This man is
a sensitive, egocentric, opinionated, defiant and critical indi-
vidual, compensating for his sense of inferiority and fear by an
aggressive drive to impress others with his personal importance.
In all his contacts, he is tense, touchy, and irritable, confessing
that, at times, he is tyrannical and sadistic toward his wife, but
attributing this entirely to his physical illness. His early family
life was characterized by instability and discord, and he had
frequent temper outbursts as a boy. After studying business
administration, he had a checkered employment record because
of his explosive nature and defensive attitude. He blamed his
erratic performance and personality difficulties on his periodic
abdominal discomfort, changing physicians often and playing
the advice of one against another. His physical examination was
negative except for some allergic reactions, and, although he
had previously been given sensitization diets, he had no faith
in them. When he returned to college he was still unsure and
in a dilemma vocationally, but tried to hide this by insisting he
had found a new interest in scholarly research. His hypochon-
driacal symptoms were again accentuated when, after several
months, he began to sense his unpreparedness and unsuitability
for a career in his newly chosen field of paleontology. He com-
plained insistently and dramatically of his intense suffering and
demanded immediate relief on a physical basis.
Case 10. Married male graduate student. Age 31. Present-
ing Complaint: Tremor of hands, insomnia. Situation: Here we
find a shy, self-conscious, sensitive, tense, fearful, self-pitying,
asthenic, introvert personality, egocentric and rigid, yet soft in
response to life blows and obstacles. He is naive, idealistic and
self-loving, yet dependent and must lean on somebody (usually
a woman), childish in judgments and sulky in the face of ob-
struction. Physical examination is essentially negative. Func-
tioning largely in an unreal world of phantasy, he over-estimated
he strives to be a great, strong, admired person, as it were,
The Journal-Lancet
his intelligence and capacity. Despite fear of social situations,
"Caesar with the soul of Christ.” His wife, a wealthy "spoiled ",
"self-willed” girl, who had decided to marry him on an impulse,
now looked down upon him for his unimportant position as a
school teacher, and for his relative inadequacy as measured by
other men in her social set. The climax of impending divorce
was not alleviated by an unwanted pregnancy Goaded by po-
tency drive and strong desire to impress his wife and society in
general, he set a high position in the scientific world as his goal,
beginning by enrolling as a candidate for a Ph.D. degree, a plan
about which, now that he has started it, the patient has serious
misgivings. The present situation is one of acute frustration in
volving all fronts, personal, professional, vocational, and marital.
H is functional tremor and other complaints are largely a re-
action to an excruciating dilemma and impasse, representing a
focus and diversion from a life situation which calls for un-
tangling rather than for treatment of specific physical symptoms.
Conclusion
The foregoing, it is hoped, has served to give concrete
emphasis to the significance of the "mental” in health
complaint situations. Considering the individual as an
organic whole as opposed to the anomalous mind and
body bifid of tradition, the point becomes only too ob-
vious. Equally obvious is the necessity for the most care-
ful scrutiny of all aspects of personal function, i. e., the
psycho-affective as well as the so-termed, physical, if a
true appreciation of the presenting case is to be achieved.
And in the absence of such an approach, of course, fully
adequate therapeutic procedure is impossible.
Also apparent is the fallacy, even danger, of accepting
the presented complaint at its face value. So often is it
merely a front or a focal point for pathology really quite
different and more complicated. As is well known, at
least theoretically, because of protective mechanisms or
lack of awareness, or both, fundamental and essential
psychologic and emotional elements are very frequently
omitted or minimized by the patient — not to mention the
effects of the blind spot the physician himself may have
for these areas. Too, as we are all aware, there is the
natural human tendency in the formulation of complaint
to focus on the concrete physical as opposed to the seem-
ingly less tangible psycho-emotional, albeit the latter may
be basic to the occurring difficulty. And, through fear,
there may be withholding even of certain physical as-
pects, where the implications are especially disturbing.
In short, to epitomize, just as the individual in health
constitutes and operates as a biologic totality, with
thoughts and feelings as well as tissues, so does he in ill
health or disease; and this fact must be fully realized if
medicine is to fulfill adequately its function as a curative
science and art. Actually, this is a statement of the
premise of psychosomatic medicine, perhaps the most
forward of recent developments in medical thought.
In furthering this realization, the psychiatrist naturally
can play, and has played, an important part, both by his
own work and through his contacts with other physicians.
And in this, of course, added significance becomes mani-
fest for the psychiatric approach in college health work,
as well as in other fields of practice.
’Among others, the following references seem here particui
pertinent: Meyer, Adolf: The "complaint” as the center of gen.
dynamic and nosology teaching in psychiatry. New England I. Mi
199:360—370 (Aug. 23) 1928. Muncie, Wendell, S.: The ho
pital psychiatric consultant. The Mod. Hosp. 43:3, 41—44 (Sent.)
1 934.
Grateful acknowledgment is made herewith to The Ear hart
Foundation, for financial assistance which made this report
possible.
185
June, 1943
Variable Pulmonary Infiltration Association with
Boeck’s Sarcoid
Case Report
C. A. McKinlay, M.D.
Minneapolis, Minnesota
THE occurrence of marked and variable pulmo-
nary infiltration in a case of Boeck’s Sarcoid is
considered noteworthy in view of increasing em-
phasis upon the visceral lesions.
W. M., male, age 47, married, office worker, was ex-
| amined in June, 1942, by Dr. Paul Forgrave, with com-
i plaint of nodules under the skin of the upper left arm,
; of a few months duration. The past history included
pneumonia in 1921. In 1931 the patient had Pasteur
i treatment following dog bite, at which time two inocula-
; tions were given in the right arm and the remaining
twelve or fourteen in the left arm at a site corresponding
to the nodules. The nodules were increasing in size and
were not painful or discolored. The patient had no sys-
temic complaints, was able to work without tiring and
had had no pain in the chest, cough or hemoptysis.
There had been 6 to 8 pound weight loss, regained dur-
ing period of observation. The tuberculin patch test was
1 said tc be positive.
Examination showed a normal appearing individual.
There were scattered nodules, two on the right arm, ten
or twelve on the left arm over the area of the insertion
: of the deltoid. The nodules were in the subcutaneous
tissue and apparently attached to the skin and were re-
I moved in January, 1943. There had been no recurrence
two months later. Sections were examined by Dr. E. T.
Bell, and diagnosis of Boeck’s Sarcoid was made.
Discussion
A case is reported in an adult male, in apparent good
health, showing skin nodules of Boeck’s Sarcoid. The
; x-ray films showed bilateral pulmonary infiltration. These
I were considered to be consistent with sarcoidosis by Dr.
'< R. W. Morse before the tissue diagnosis was established.
i Fig. 1. March 2, 1942, Areas of infiltration throughout both
■ ung fields.
Fig. 2. June 22, 1942, Clearing of infiltrated areas.
Noteworthy features are the extent of the infiltrations
and their partial clearing and reappearance over a ten
months period. The variable nature of the pulmonary
infiltrations in the case reported is in keeping with Long-
cope’s description1 of the disease, as running a chronic
relapsing course producing comparatively mild constitu-
tional symptoms but sometimes causing great damage to
many structures. Spontaneous recovery is common.
Reference
1. Longcope, Warfield T.: Sarcoidosis, J A M. A 117:16:1321
(Oct. 18) 1941.
^Report and films supplied by Dr Paul Forgrave, St. Joseph,
Missouri, to whom the writer is indebted for permission to make
this report.
Fig. 3. January 23, 1943, Increased infiltration again noted.
Thi Journai.-Lanc I I
186
AMERICAN STUDENT HEALTH ASSOCIATION MONTHLY NEWS-LETTER
Introduction of the Army and Navy specialized training programs into several hundred
colleges is imposing new problems in health service administration. How these problems are
being met will be the substance of forth-coming reports.
At the present time it appears that the immediate question is how to maintain adequate
staffs. Recently a letter was sent to all schools holding membership in our Associaion inquiring
into the availability of personnel that might be transferred to schools with depleted trained
staffs. The replies received indicated: (1) That there are no surplus staff members imme-
diately available for relocation in other health services, (2) There are many vacancies, par-
ticularly for physicians.
Dr. Stephen A. Forbes, formerly on the staff of Pennsylvania State College and of the
University of Michigan, has recently assumed
University.
A.S.H.A. DIGEST OF MEDICAL NEWS
The Diagnosis of Orthostatic Albuminuria. In the
April, 1943, issue of The Military Surgeon, Hugh H.
Young, John S. Haines and Charles L. Prince set up the
following criteria for the diagnosis of orthostatic albu-
minuria:
1. There must be no history of renal disease in the
past.
2. Normal blood chemistry (non-protein nitrogen,
blood urea, total protein, and albumin-globulin
ratio) .
3. Normal kidney function (phthalein, urea clearance,
and dilution and concentration tests) .
4. No white blood cells, red blood cells or casts in the
urine, except intermittently and in small numbers.
5. No elevation of blood pressure.
6. Negative plain x-rays and intravenous urograms.
7. Absence of albumin in the urine secreted and void-
ed when in the recumbent position.
Persons whose condition meets these criteria should be
acceptable for military service without question so far as
their albuminuria is concerned.
Beta Hemolytic Streptococci Isolated from Public
Room Floors. W. G. Walter and G. J. Hucker report
in the November and December, 1942, issue of the Jour-
nal of Infectious Diseases isolating beta hemolytic strep-
tococci from the floor sweepings in 22 of the 37 rooms
investigated in 6 schools, a boy’s dormitory, a theatre and
a hotel. Physiological and serological tests done on 17
representative cultures resulted in classifying 7 in Lance-
field’s group A, 2 in group B, 1 in group C, and 7 pos-
sibly in group G. A seasonal variation was observed;
from February until May hemolytic streptococci could be
readily obtained from certain floors, but this was not the
case during the cold months of the year.
Conservation of Rubber Gloves by Chemical Steriliza-
tion. K. P. A. Taylor in the October, 1942, issue of the
U. S. Naval Medical Bulletin recommends the following
methods as effective in sterilizing gloves without heat:
(a) After use in ordinary surgical cases:
1. Washing in running water and soap for 1
minute.
2. Full immersion in 1:1000 mercuric chloride
for 10 minutes.
directorship of the Health Service at Wooster
3. Full immersion in 70 per cent alcohol for 1
minute.
(b) After use in cases infected with tetanus, anthrax
or gas bacilli:
1. Complete immersion in 1:1000 mercuric chlor-
ide for 18 hours or,
2. Complete immersion in 1:100 mercuric chlor-
ide for 1 hour on three successive days.
All of these methods according to the tests reported
provide a reasonable margin of safety.
Limitations in Use of Tinted Eyeglasses. Blain in the
September, 1942, issue of L’Union Medicate du Canada
suggests that the use of tinted eyeglasses should be lim-
ited (1) to avoiding glare in foundries, motion picture
studios, at high altitudes, on the sea or seashore, in des-
erts or snowfields, (2) to protecting persons with certain
ocular diseases and those recuperating from eye opera-
tions. The vast majority of people do not need tinted
glasses except on rare occasions, and, if such glasses are
worn indiscriminately for indoor work, they may throw
an increased burden on the eyes.
The Absorption of Sulfa Drugs. The Journal of Clin-
ical Investigation of September, 1942, reported that sulfa
drugs given as the sodium salt orally before a meal result
in blood levels and amounts recovered in the urine nearly
comparable to those obtained from intravenous injec-
tions. Absorption of the drugs given after a meal is
slower and less complete. Peritoneal absorption of the
sodium salt is rapid and nearly complete, sulfanilamide
leading all others in this respect.
A Method for Evaluating ’Flat-Foot”. Tracy D.
Cuttle in the January, 1943, issue of the U. S. Naval
Medical Bulletin suggests a simple apparatus (as de-
veloped by Osgood) for measuring the strength of the
"everters” of the feet as compared with that of the "in-
verters”. By means of this test, feet are classified into
four classes as follows: (1) inverters stronger than
everters in the ratio of 5 to 4 — symptomless, normal feet,
(2) pull of inverters and everters approximately equal
but slightly greater for the everters — symptomless, slight-
ly pronated feet, (3) pull of everters definitely greater
than of inverters — pronated feet with symptoms of foot
strain, (4) pull of everters greater than that of inverters
in ratio of 5 to 4 — "acute flat feet.”
Streptococcal Infection of Wounds Transmitted by
June, 1945
187
Surgeon. A. Fingerland reports in the Z.ent. F. Chirur-
gie of October 10, 1942, an epidemic of hemolytic strep-
tococcal infection, involving, over a period of eight days,
7 cases with 5 deaths. All the cases had been operated
upon by one surgeon, who was found to have just recov-
ered from a cold and to be a carrier of streptococci (in
the nasal secretions) , which closely resembled the strep-
tococci recovered from the patients. This surgeon had
been engaged in giving verbal instructions to his assistant
surgeons while he operated. Tests showed the type of
two-layered calico mask worn by the surgeon to be prac-
tically worthless. The author recommends that surgeons
operate in silence in order to avoid moisture droplet in-
fection of the operative wounds.
Sulfathiazole for Impetigo. G. A. G. Peterkin and E.
C. Jones in the March 13, 1943, issue of the British
Medical Journal conclude that "Sulfathiazole seems to
be the drug of choice in the local treatment of impetigo.”
Of 120 cases analyzed, 93 were cured in an average time
of six to eight days. Recommended are a 10% sulfa-
thiazole in cream, a 5% sulfathiazole in cream or a 5%
sulfathiazole in 15% starch and 15% zinc oxide paste.
Results with sulfadiazine, sodium sulfathiazole and sulfa-
methazine were disappointing.
Drinking Fountains. A. P. Hitchins and O. A. Ross
in the Journal of the American Water Works Associa-
tion of February, 1943, conclude that a high proportion
of drinking fountains now in use are insanitary, and
that certain types of these fountains are potentially more
dangerous than the outmoded common drinking cup.
Epidemic of Influenza in 1943? In the Science News
Letter of March 20, 1943, Dr. Thomas Francis, Jr.,
warns that a world-wide epidemic of influenza similar to
that of 1918 is "a very definite possibility in 1943.”
Overcrowding is the hazard which Dr. Francis feels was
an important factor in the production of the 1918 epi-
demic and which may prove an important factor in pro-
ducing an epidemic of influenza in 1943. He particu-
larly warns of the dangers of close contact and moisture-
Clinical Cardiology, with Special Reference to bedside Diag-
nosis, by William Dressler, M.D. New York: Paul B.
Hoeber, Inc., 692 pages, 108 illustrations, 1942, price $7.50.
I In this book the author has presented the subject of clinical
cardiology in a clear and concise manner. Particular emphasis
is placed on the older and simpler diagnostic methods of clin-
ical observations. While the new laboratory methods of diag-
nosis are mentioned, they are not gone into in great detail, as
the author feels that for the general practitioner in the city and
country, it is important to learn to arrive at sound decisions by
using the simplest diagnostic methods and by accumulating clin-
ical experience. For this reason the book should be of value to
students and practitioners who wish to develop and improve
their diagnostic acumen by clinical experience.
An appendix of forty pages on "Important Points to Re
member” should be of invaluable aid to everyone interested in
heart disease.
i
droplet infection in our crowded war production plants,
buses and trains.
As opposed to this forecast should be placed the fol-
lowing facts: (1) Preceding the 1918 influenza epidemic,
there were several months of definitely increased inci-
dence of influenza; such increased incidence has not been
noted in recent months, (2) Unparalleled overcrowding,
fatigue and unsanitary conditions have not resulted in
influenza epidemics in England or other bombed or war-
torn countries in the present war.
Passive Tetanus Immunity and Its Effect on Active
Immunization. J. V. Cooke and F. G. Jones in the April
10, 1943, issue of the Journal of the American Medical
Association conclude as the result of tests on 9 children
with clinical tetanus and 30 children, age 8 to 15 years
in good health and under orthopedic treatment, as fol-
lows:
1. Passive immunization with 1500 or less units of
tetanus antitoxin produces immunity for only about
three weeks.
2. Passive immunizations with 100,000 or more units
resulted in the production of immunity for eight
to eleven weeks (assuming that a titer of 0.01 units
of passively introduced antitoxin is sufficient to
guarantee immunity) .
3. An attack of clinical tetanus did not produce anti-
toxin immunity upon recovery, nor did it produce
primary antigenic stimulation comparable to that
produced by a first injection of toxoid.
4. When passive immunity was produced with 10,000
or more units of antitoxin, the conversion of pass-
ive immunity to active by means of toxoid was
possible only in eight to twelve weeks, irrespective
of whether the toxoid injections were started at the
time of antitoxin injection or delayed two, four or
even six weeks.
5. The presence of any considerable quantity of het-
erologous antitoxin prevents the usual sensitization
of the body cells by toxoid, and renders it inert as
an antigen.
The Physiology of Domestic Animals, by H. H. Dukes
and Others. Ithaca, N. Y.: Comstock Publishing Co., 5th
edition, 721 pages, 168 figures, 1942.
The appearance of a fifth edition of this standard text is an
indication of its usefulness in the field of veterinary education.
The book is also useful as a concise source of reliable informa-
tion about the comparative physiology of common domestic ani-
mals and man. Most of our detailed knowledge of physiology
has been derived from studies on animals other than man, and,
therefore, every textbook of physiology includes much informa-
tion which is really comparative. But this book stresses the
peculiarities of function which arise, for example, from the ana-
tomical characteristics of the ruminants, from the absence of
sweat glands in certain animals, and other similar problems.
The problems of reproduction, including artificial insemination,
of nutrition and digestion are particularly well handled. As a
detailed account of everything known about physiology, this
book is not as complete as many of the standard texts for med-
ical students, but it is nevertheless a very useful supplement to
such other books because of its coverage of so much material
in comparative physiology. It is well arranged, well printed and
adequately supplied with references to the basic literature.
188
The Journal-Lancet
The Year Book of Industrial and Orthopedic Surgery —
1942, edited by Charles F. Painter, M.D. Chicago: The
Year Book Publishers, Inc., price $3.
The 1942 Year Book gives proper emphasis to war medicine,
in addition to including the outstanding findings in the field of
traumatic and orthopedic surgery during the past year. It is a
handy book serving the respective interests not only of the doc-
tor in civilian practice but also the physician attending the
Armed Forces. The material, obtained from a number of
authors, is presented in a clear and concise manner.
Osier’s "Principles and Practice of Medicine,” rewritten,
revised, reorganized, 1942, by Henry A. Christian, M.D.,
F.A.C.P. New York: D. Appleton-Century Co., 14th semi-
centennial edition, 1500 pages, price $9.50.
The medical profession is fortunate in having had McCrea,
and in now having Christian to carry on the Osier tradition in
medical literature. Christian as the editor of the 14th semi-
centennial edition of the Principles and Practice of Medicine,
recognizes that there are advantages in such continuity of author-
ship. The value of single authorship lies in the circumstance
that conclusions and opinions, both explicitly stated and implicit
in choice of treatment of material, come within the observation
of one widely experienced clinician. For Osier, McCrea and
Christian, by the similarity of background, training, opportuni-
ties, and mental equipment may be considered to be a compo-
site individual.
There has always been, in the Osier Principles and Practice,
a proper balance between empiricism, experiment and proved
clinical fact in the consideration of etiology, symptomatology,
physical and laboratory data, and therapy. It is to be hoped
that some one may always be at hand to carry on the tradition.
Diseases of the Liver, by S. S. Lichtman, M.D., F.A.C.P.;
Philadelphia: Lea & Febiger, 906 pages, 122 engravings and
a colored plate, with index, 1942, price $10.
This book is written for both student and practitioner. It
should fulfill a great need in its field. Although the liver is
the largest organ in the body, its functions are so various and
its reserves so great, that even major disturbances of function
from advanced pathologic states can often be diagnosed only
with great difficulty. Physiologic experiments have shown that
as much as 90 per cent of the organ can be destroyed without
interfering greatly with the usual functions. This explains why
liver diseases are frequently misdiagnosed. Even the most elab-
orate liver function tests may fall short of establishing liver
dysfunction.
It is for this reason that this new book on liver diseases is
most welcome. This book will prove exceedingly helpful in un-
derstanding the functions, the liver function tests, the patho-
logical changes and the symptomatology of diseases of the liver.
Treatment is also adequately discussed. In the first chapter,
there is an excellent presentation of the structure of the liver
functional unit, the lobule or hepaton, suggesting the analogy
to the anatomical unit of the kidney, the nephron.
The commonest symptom of liver disturbances is, of course,
jaundice. This subject is very thoroughly covered, although
the basis for the various types of jaundice could stand clarifica-
tion. An element of confusion is the inclusion of Chapter 15,
which deals with acholuric or familial hemolytic jaundice. This
disease properly belongs among diseases of the blood, since the
presence of the jaundice is not the result of liver damage or
liver insufficiency. The jaundice is due to excessive hemolysis
resulting from defective blood formation. The topic of cirrhosis
is given too much prominence. It comprises more than 100
pages in the book. There is considerable unnecessary repetition.
The chapter on the liver in hyperthyroidism is very good. It is
not generally appreciated how much the liver can be damaged
in severe cases of hyperthyroidism.
As a whole, the book is well written and should prove helpful
as a guide to a better understanding of the diseases of the liver.
It can be highly recommended for students and practitioners
alike.
Views Items
Dr. Rudie J. Carlson has left Merrill, Iowa, to open
offices in Sisseton, South Dakota, for the general prac-
tice of medicine and surgery.
Dr. Hans Jacoby, recently resident physician at the
New York City Cancer Institute, is the latest acquisition
to the staff of the Huron Clinic and Sprague Hospital,
as roentgenologist, announced Dr. J. C. Shirley, Huron,
South Dakota.
Drs. A. R. Varco and Jas. R. Thompson of Miles
City, Montana, have dissolved their partnership with the
retirement of Dr. Varco from active practice.
Dr. Neil T. Norris of Caledonia, Minnesota, where
he is associated with Dr. Garnett B. Belote, has leased
the Caledonia Hospital, operated for fifteen years by
Mrs. Selma Browning.
Capt. G. Stein of the Army Air Force Technical
Training Corps, stationed at Sioux Falls, South Dakota,
and Dr. N. J. Nessa of that city presented a number of
x-ray cases at a meeting of the Seventh District Medical
Society at the Cataract hotel, May 11.
Dr. Harold W. Gregg of Butte, Montana, delivered
an address, "Factors in Prognosis in Coronary Disease,
Old Hearts Under the Strain of War” at the annual
meeting of the Montana-Wyoming region of the Ameri-
can College of Physicians, held May 1 in Great Falls,
and presided over by Dr. E. D. Hitchcock of Great
Falls. Other speakers included Dr. Geo. E. Baker, Cas-
per, Wyoming, on "Rocky Mountain Fever”; Dr. F. R.
Schemm, Great Falls, "Water Balance in Consideration
of Edematous Patients”; Dr. A. R. Foss, Missoula, "Gly-
cosuria, Blood Sugar Curves”; Dr. Thos. F. Walker,
Great Falls, "Chemoprophylaxis”; Dr. M. A. Shilling-
ton, Glendive, "Allergy”; Dr. Earl L. Hall, Great Falls,
"Management of the Menopause with Special Reference
to the Newer Synthetic Estrogens.”
From the Army came Lt. Col. Scott M. Smith, base
surgeon, with "Air Evacuations of Battle Casualties,”
and 1st Lt. P. B. Candela on "Use of Blood Groups in
Tracing Racial Origins and Migrations.” The U. S.
Public Health Service was represented by Dr. Mason V.
Hargett, Hamilton, past assistant surgeon, the topic —
"Yellow Fever Prophylaxis.” Dr. W. G. Richards, Bill-
ings, read a paper, "Hyperthyroid and the Neurotic, as
Illustrated by Shakespeare’s Characters of Macbeth and
Hamlet.”
Dr. Gilbert Cottam of Sioux Falls has been appointed
superintendent of the South Dakota State Board of
Health, a post so long held by the late Dr. J. F. D.
Cook.
At the nineteenth annual meeting of the North Da-
kota Health Officers Association, Dr. H. G. Huntley
of Kindred was elected president, Dr. Percy L. Owens
of Bismarck, vice president and Dr. F. J. Hill re-elected
secretary and treasurer.
(Continued on page 190)
JOURNAL
LANCET
Serves the
MINNESOTA, NORTH DAKOTA
Med teal Profession of
SOUTH DAKOTA and MONTANA
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
Montana State Medical Assn.
Dr. E. D. Hitchcock, Pres.
Dr. A. C. Knight, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
M inneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Trcas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr H. S. Diehl
Dr. L. G. Dunlap
Dr Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. E. D Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. Irvine McQuarrie
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres.-Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J . C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
W. A. Jones. M.D.. 1859-1931
LANCET PUBLISHING CO., Publishers
84 South Tenth Street. Minneapolis, Minnesota
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H M. N. Wynne
Dr. Thomas Ziskin
Secretary
W. L. Klein. 185 1 193 1
Minneapolis, Minnesota, June, 1943
POSTWAR MEDICINE
In the last war, 31,251 physicians from civil life were
commissioned in the Medical Corps, in addition to the
2,089 already in the service and in the reserves. Many
of these went in as general practitioners and came out
specialists, through the unusual opportunities they had to
receive training and experience under competent guid-
ance. Many enjoyed their first contact with group prac-
tice in the various hospital organizations, and not a few
liked the service so well that they secured permanent
commissions and became members of the regular estab-
lishment. But, as time went on, most of the others re-
turned to their former locations and began to pick up
the loose threads of their old connections, gradually find-
ing their way back into the old grooves, and generally
getting reestablished as best they could. It was not easy,
and many who remembered the pleasures and advantages
of group practice in the army tried the experiment in
private life, with varying degrees of success. In some
states, like Iowa, for example, the idea became so preva-
lent that most communities of any size had from one
to three or more such organizations, and it is entirely
possible that many of them would have survived, had not
the prolonged period of depression which followed the
short postwar boom played havoc with their finances.
Uncle Sam was no longer paying the bills. Ultimately,
thanks to the comparatively short duration of our par-
ticipation in the war, most of those who went into service
found themselves fairly well rehabilitated in practice and
would be willing to go again, if the addition of twenty-
five years to their lives had not made them ineligible.
The situation in the present war is quite different. It
will last much longer, and a vastly larger armed force
will be necessary to bring it to a successful conclusion.
Many more medical officers will be needed, not merely
for the duration, but for years afterwards. This time we
shall surely not demobilize down to peace-time strength
as we did before, and leave the rest of the world to its
190
The Journal-Lancet
own devices. Wc shall have to maintain sizable forces in
various parts of the world to keep order long after the
whistle blows, and these will need their full quota of
medical officers.
The inevitable increase in the size of the Veterans Ad-
ministration and all its facilities will require a considera-
ble augmentation of its medical personnel. However, the
demands of private practice will be somewhat lessened by
the fact that all veterans will be entitled to hospitaliza-
tion and treatment for all ailments, whether service-con-
nected or otherwise. Incidentally, all physicians from
now on will need to know more about tropical diseases
than has heretofore been the case. Right now, most of
the fighting in which our forces are engaged is in the
tropics, or in countries where tropical disease abounds,
and some of it is bound to turn up here when they come
back.
There are some bright spots in the outlook. Thanks
to experiences gained in the last war, the organization of
the medical personnel is now on a much better footing.
The establishment of the Medical Administrative Corps
to take care of most of the paper work leaves the med-
ical corps much freer to carry on its professional duties,
without spending a lot of time in making out reports,
etc. The training and background of medical officers is
being considered much more carefully in assigning them
to duties for which they are especially fitted. The equip-
ment furnished is much better and in more ample quan-
tity. Medical science itself has advanced since the last
war, so that medical officers can have the advantage of
sulfa drugs, plasma and refinements of anesthesia technic,
such as intravenous pentathol, in their work, to mention
just a few. They will return to private life fortified by
a world of experience.
At home, regardless of the fact that our numbers are
being reduced and we are handicapped by shortages of
supplies and equipment, we must do everything possible
to maintain high professional standards, and keep our
organizations functioning as well as they can. We are
in the best position of any nation in the world to do this,
and it is the least of the contributions we can make
toward winning the war.
G. C.
MEDICAL INVESTMENT IN FREEDOM
The manner in which the medical profession has re-
sponded to the call to the colors is an heroic tribute to
the great nation that United States citizens know theirs
to be. One must pry far back in his memory to find a
professional sacrifice to equal it.
Doctors are realists. They recognize that their earn-
ing years, limited usually by the natural period of vigor,
now are cut by participation in the drama of war. So
that when there is suggested an investment cushion upon
which it is possible for the physician to rest his financial
problems after the peace is won, the thought merits con-
sideration. United States War Savings Bonds are just
such a cushion.
War Bond dollars buy for the government medical
supplies, without which all the effort of the army or
navy doctors and surgeons would be sadly handicapped.
War Bond dollars normalize the national commercial
temperature and reduce the inflation fever because when
they are taken from the channels of trade they have no
opportunity to be used for the purchase of scarce ma-
terials, driving prices upward. War Bond dollars are
sane, disciplined, potent; indicated by the situation, pre-
scribed for current and future distress. As the master
of his dollars the physician is asked to devote them to
the stirring and splendid service of buying United States
War Savings Bonds; all the bonds that he possibly can.
M. H.
NEWS ITEMS
(Continued from page 188)
Dr. Thomas J. Kinsella was announced as the newly
elected president of the Hennepin County Medical So-
ciety, at a meeting honoring 137 of its members now in
the Armed Forces, held May 3.
Dr. W. H. Bodenstab of Bismarck, North Dakota,
entertained fellow physicians and dentists of Bismarck
and Mandan on the occasion of his completing fifty
years of practice, most of them spent in the state.
Dr. Harry Dickey Sewell, associated with the Huron
Clinic since 1919, has removed to Rochester, New York,
to join the medical staff of the Eastman Kodak Com-
pany whose chief is a college classmate of Dr. Sewell.
Dr. J. J. Malee of Anaconda, Montana, completing
military training at the medical field service school, Car-
lisle Barracks, Pennsylvania, about June 1, will be com-
missioned a captain and proceed to Barnes General Hos-
pital in Vancouver, Washington.
Major L. D. Besecker, post surgeon and director of
the medical division at Fort William Henry Harrison,
Helena, Montana, for eleven months, has been trans-
ferred to the first special service force as force surgeon.
Major Michael L. Mitchell, who replaces him and who
has been successively at Brooklyn, New York, and Cleve-
land, Ohio, was in Montana ten years ago on CCC duty
in Glacier National Park.
Captain E. Ted Keller, flight surgeon for a veteran
bomber squadron at Guadalcanal and the Solomon Is-
lands, spent a mid-May furlough at Rugby, North Da-
kota, where he practiced before entering service.
Dr. Nels N. Sonnesyn, Le Sueur, Minnesota, joined
the staff of the Fitzsimmons General Hospital in Denver,
Colorado, May 15th, as captain.
Dr. Arnold O. Swenson of West Duluth, recently
promoted to lieutenant commander in the U. S. Navy,
spent a leave at home on transfer from Bremerton naval
hospital in Washington to Norfolk naval hospital in
Portsmouth, Virginia.
Dr. Byrl R. Kirklin, director of the division of radi-
ology at Mayo Clinic, Rochester, Minnesota, has been
appointed x-ray consultant in the office of the surgeon
general of the army with the rank of colonel, in which
capacity he will leave for a tour of duty, reporting to
Washington.
Lt. Col. Wm. J. Eklund, Duluth surgeon, veteran of
World War I, has been appointed base surgeon of an
overseas command with jurisdiction over a number of
posts.
(Continued on page 192)
In A STUDY of various barbiturates, Allonal s hypnotic
component, allyl-isopropyl-barbituric acid, was found
to have a wide margin of therapeutic safety — twice that
of barbital and nearly three times that of phenobarbital.
Because of this relatively wide margin of safety— because
it produces restful sleep, even in the presence of pain,
Allonal deserves to be your routine sedative-hypnotic of
choice. Hoffmann - La Roche, Inc. • Nutley, N. J.
ALLONAL 'ROCHE'
192
NEWS ITEMS
(Continued from page 190)
The office of the Minnesota state director of public
institutions has announced the appointment of Dr. Henry
Hutchinson, assistant superintendent of Moose Lake
state hospital for the last five years, as superintendent
of the Hastings state hospital.
Dr. V. J. LaRose of Quain & Ramstad clinic, Bis-
marck, was elected a representative director of the Naj
tional Tuberculosis Association at a meeting of the board
of the Association in St. Louis, the first week of May.
He will serve for two years.
Dr. E. Mendelssohn Jones, St. Paul, was chosen pres-
ident-elect of the Minnesota State Medical Association
at its annual meeting in Minneapolis, May 16.
yiMoiow
Dr. William T. Thornton, 65, of Missoula, Montana,
died April 29 at his home after a lingering illness. He
had practiced in Missoula for twenty-six years and was
credited with having performed 15,000 major operations
since graduating from the American Medical College at
Battle Creek, Michigan, in 1903.
Dr. Cynthia Estella Pingree Macnider, 85, of James-
town, North Dakota, died May 4 at the Jamestown hos-
pital, following an illness of nearly a year. She was a
native of Denmark, Maine. Coming to North Dakota
in 1888 shortly after graduation, she practiced there con-
tinuously, except for one year in Mississippi and two in
California. She resided successively at Fort Yates, Em-
monsburg, Linton, Spiritwood, Bismarck and Jamestown.
Dr. Gulick O. Bundy, 86, of Barton, North Dakota,
died May 1 in a hospital at Rugby. He was born at
Spring Grove, Minnesota, and had been a resident of
North Dakota about forty-three years, thirty of which
were spent in Barton.
Dr. L. F. Hall, 55, of Helena, Montana, died there
May 10. Dr. Hall was Lewis and Clark county health
officer for some years, retiring from that office a year ago
because of ill health.
Dr. Walter Byron Scott, 70, of Ray, North Dakota,
died at his home May 12, after a long period of declin-
ing health. Dr. Scott came to the state forty-six years
ago from Canada, settling at Crystal whence he removed
to Ray. He performed his first appendectomy in a sod
shack by candle-light, and in early homestead days made
professional calls on skis and by saddlehorse. Dr. Scott
held degrees in both pharmacy and medicine and at one
time was the mayor of Ray.
Dr. E. T. W. Boquist, 51, of Minneapolis, chief med-
ical officer at Minnesota Soldiers’ Home where he had
been stationed for a year, died suddenly there April 26.
Dr. William Vardenab Lindsay, 69, of Winona, Min-
nesota, died suddenly April 24 while making a profes-
sional call. He was health officer and member of the
board of health for twenty-one years.
The Journal-Lancet
Adui\tisi* 's
DEFENSE INDUSTRIES AND TARBONIS CREAM
Industrial dermatoses including folliculitis, eczematoid derma-
toses, defatted conditions, etc., are becoming a national problem
today, as more and more people unused to factory conditions are
exposed to chemical irritation, sulfonated mineral oils, resins,
sulphurs, chlorines, strong detergents and abrasives in industry.
Where the industrial exposure is concerned, simple preventive
ointments are not effective and the so-called chemical gloves are
not advised because of their interference with perspiration and
the possibility of tearing and losing their effectiveness entirely.
Tar preparations have long been recognized as effective in the
treatment of eczema, seborrheic dermatitis, eczematoid derma-
titis, and related skin conditions, as well as infantile eczema.
Tarbonis Cream is essentially a tar ointment, but it is radi-
cally different from older tar preparations in that it is free from
the irritating qualities previously associated with tar products.
It is clinically nonallergic due to a special means of selection of
the base tars, and a method of extraction that produces an
active therapeutic agent that is nonirritating. It is carried in the
vanishing type cream base that is beneficial in the frequently
found defatted conditions of the epidermis accompanying der-
matitis conditions.
Tarbonis Cream is based on a formula, developed in the phar-
macy of Johns Hopkins University, that has been in successful
use in that hospital’s dermatological and pediatrics departments
for over eight years. Its composition is Liquor Carbonis, Deter-
gens, Lanolin U.S.P. and Menthol in a cream base. It is
greaseless, stainless, and odorless.
SCHERING MARKETS PRIODAX
A Tablet Preparation for Gall-Bladder Visualization
Priodax, a new type preparation in tablet form for x-ray vis-
ualization of the gall-bladder, is being distributed by Schering
Corporation, Bloomfield, New Jersey. Research reports show
clearly certain differences between Priodax and the several dyes
in powder form now in use. As a tablet, Priodax can be swal-
lowed whole, thus eliminating the obnoxious symptoms associated
with powders. Patient reactions and nausea are infrequent. Be-
cause Priodax contains no phenolphthalein, severe diarrhea is
rare. Vomiting, which often follows the use of the older prepa-
rations, is said to occur in less than 3 per cent of the cases who
receive Priodax.
Chemically Priodax is beta- (4-hydroxy-3, 5-diiodophenyI) -
alpha-phenyl-propionic acid containing 51.5 per cent of iodine
firmly bound in a stable organic molecule. After being absorbed
from the enteric canal, the iodine molecule passes through the
liver and is excreted into the gall-bladder providing an excellent
contrast medium for diagnostic x-ray visualization.
Because Priodax presents a concentration of iodine which is
better tolerated by the patient, physicians have found that a
single dose will almost invariably result in clear pictures. For
the average adult, the dose is six tablets (3 grams). This
amount is generally adequate even with considerable variations
in weight of the patient. If the dose is to be adjusted to body
weight, one tablet may be allowed for each twenty-five pounds.
There is no contraindication to giving a double dose (six tablets
at one time and six tablets several hours later, or six tablets on
one day and six tablets the next) , if this is desired. It has
rarely been found necessary with Priodax.
The tablets may be swallowed whole with sips of liquid, such
as water, fruit juice, or skim milk, either in immediate suc-
cession or at intervals as determined by the physician. This
method of administration is generally found to be agreeable and
convenient, and it assures that the entire dose is taken. The
tablets should not be chewed.
Priodax Tablets are supplied in cellophane-protected envelopes
of six tablets, each containing 0.5 gram (7.7 grains) of beta-
(4 - hydroxy - 3, 5 - diiodo - phenyl) - alpha - phenyl - propionic acid.
Boxes contain 1, 5 and 25 envelopes.
Transactions of the South Dakota State Medical
Association
Sixty-Second Annual Session
Huron, South Dakota
May 27 and 28, 1943
OFFICERS, 1943-44
PRESIDENT
J. C. OHLMACHER, M.D. Vermillion
PRESIDENT-ELECT
D. S. BAUGHMAN, M.D. ....... Madison
VICE PRESIDENT
WM. DUNCAN, M.D. Webster
SECRETARY-TREASURER
R. G. MAYER, M.D. Aberdeen
DELEGATE TO A. M. A.
N. J. NESSA, M.D ... Sioux Falls
ALTERNATE DELEGATE TO A. M. A.
J. C. OHLMACHER, M.D. Vermillion
COUNCILORS
FIRST DISTRICT
J. L. CALENE, M.D. Aberdeen
SECOND DISTRICT
j H. R. BROWN, M.D. Watertown
THIRD DISTRICT
G. E. WHITSON, M.D. Madison
FOURTH DISTRICT
C. E. ROBBINS, M.D. Pierre
FIFTH DISTRICT
W. H. SAXTON, M.D. Huron
SIXTH DISTRICT
J. H. LLOYD, M.D. Mitchell
SEVENTH DISTRICT
W. E. DONAHOE, M.D. Sioux Falls
EIGHTH DISTRICT
E. M. STANSBURY, M.D Vermillion
NINTH DISTRICT
R. E. JERNSTROM, M.D. Rapid City
TENTH DISTRICT
R. V. OVERTON, M.D. Winner
ELEVENTH DISTRICT
C. E. LOWE, M.D. ... Mobridge
TWELFTH DISTRICT
D. A. GREGORY, M.D. Milbank
COUNCILOR AT LARGE
N. J. NESSA, M.D. .. Sioux Falls
STANDING COMMITTEES
SCIENTIFIC WORK
J. C. OHLMACHER, M.D. Vermillion
D. S. BAUGHMAN, M.D. . _. Madison
R. G. MAYER, M.D. ... ... Aberdeen
PUBLIC POLICY AND LEGISLATION
J. C. OHLMACHER, M.D. .. Vermillion
The Council
PUBLICATIONS
R. G. MAYER, M.D. ... Aberdeen
The Council
MEDICAL DEFENSE
W. H. SAXTON, M.D. (1944). Huron
T. H. RIGGS, M.D. (1945) Pierre
c. j. McDonald, m.d. (1946) s.oux Fails
MEDICAL EDUCATION AND HOSPITALS
T. P. RANNEY, M.D. (1944).. . Aberdeen
R. A. BUCHANAN, M.D. (1945) Huron
E. M. STANSBLJRY, M.D. (1946) Vermillion
MEDICAL ECONOMICS
H. A. MILLER, M.D. (1944) Brookings
C. E. ROBBINS, M.D. (1945) .. Pierre
D. A. GREGORY, M.D. (1946) Milbank
PUBLIC HEALTH
A. TRIOLO, M.D. Pierre
Sub-committee on Cancer
JOHN L. CALENE, M.D. (1944).. . Aberdeen
O. S. RANDALL, M.D. (1945) Watertown
iL
194
The Journal-Lancet
R. E. JERNSTROM, M.D. (1946) Rapid City
GILBERT COTTAM, M.D., Supt. of State Board
of Health Pierre
Sub-committee on T uberculosis
LYLE HARE, M.D. (1944) Spearfish
W. E. MORSE, M.D. (1945) ... Rapid City
Sub-committee on Mental Hygiene and Child Welfare
MYRTLE S. CARNEY, M.D. (1944) Pierre
GOLDIE ZIMMERMAN, M.D. (1945) .... Sioux Falls
M. W. PANGBURN, M.D. (1946) Miller
Sub-committee on Syphilis Control Program,
U. S. P. H. Service
GILBERT COTTAM, M.D. (1946), Supt. of State
Board of Health Pierre
FRED P. BESTGEN, M.D. (1944) Rapid City
ANTON HYDEN, M.D. (1945) Sioux Falls
NECROLOGY
R. V. OVERTON, M.D. (1944) Winner
E. JOYCE, M.D. (1945) .. Hurley
J. A. I IOI IF, M.D. (1946) Yankton
MEDICAL BENEVOLENCE
D. S. BAUGHMAN, M.D. (1944) Madison
W. E. DONAHOE, M.D. (1945) ... Sioux Falls
W. H. SAXTON, M.D. (1946) .. ... Huron
SPECIAL COMMITTEES
RADIO BROADCAST
W. E. DONAHOE, M.D. Sioux Falls
S. M. HOHF, M.D. Yankton
R E. JERNSTROM, M.D Rapid City
EDITORIAL
N. J. NESSA, M.D Sioux Falls
J. C. SHIRLEY, M.D. Huron
J. C. OHLMACHER, M.D. Vermillion
C. E. SHERWOOD, M.D. Madison
GILBERT COTTAM, M.D. Pierre
D. S. BAUGHMAN, M.D. ... Madison
R. G. MAYER, M.D. Aberdeen
MEDICAL LICENSURE
G. W. MILLS, M.D Wall
F. H. COOLEY, M.D Aberdeen
F. J. ABTS, M.D. ... Yankton
ADVISORY women’s AUXILIARY
J. C. SHIRLEY, M.D. Huron
C. E. SHERWOOD, M.D. Madison
J. H. HAGEN, M.D. ... Miller
ALLIED GROUP
N. K. HOPKINS, M.D Arlington
E. A. PITTENGER, M.D. Aberdeen
J. A. HOHF, M.D. . Yankton
MILITARY AFFAIRS
WM. DUNCAN, M.D. Webster
H. T. KENNEY, M.D. ... Watertown
D. A. GREGORY, M.D. . Milbank
RADIOLOGY
N. J. NESSA, M.D. . .... Sioux Falls
J. R. FUCHLOW, M.D. Rapid City
J. H. LLOYD, M.D. Mitchell
SPAFFORD MEMORIAL FUND
FOR SCHOLARSHIP AT UNIVERSITY OF SOUTH DAKOTA
W. H. FAIRBANKS, M.D. ... Vermillion
Advisory to Departments of State Board of Health
OPHTHALMOLOGY AND OTOLARYNGOLOGY
WM. SAXTON, M.D. Huron
H. D. NEWBY, M.D. Rapid City
JOHN B. GREGG, M.D. Sioux Falls
ORTHOPEDICS
W. A. DELANEY, M.D. Mitchell
G. E. VAN DEMARK, M.D. ... . Sioux Falls
F. W. MINTY, M.D. Rapid City
SOCIAL SECURITY
W. A. DAWLEY, M.D. Rapid City
A. J. SMITH, M.D Yankton
R. A. BUCHANAN, M.D Huron
MATERNAL AND CHILD WELFARE
W. E. DONAHOE, M.D. Sioux Falls
E. T. LIETZKE, M.D Beresford
J. E. STUDENBERG, M.D. Gregory
ANNUAL MEETING OF THE COUNCIL OF THE
SOUTH DAKOTA STATE MEDICAL
ASSOCIATION
First Meeting of the Council
May 27, 1943
The meeting of the Council of the South Dakota State Med-
ical Association was called to order by the Chairman, Dr. D. S.
Baughman, on Thursday evening, May 27, 1943, at the Marvin
Hughitt Hotel at Huron, South Dakota.
The roll call was read by the Secretary, Dr. C. E. Sherwood.
The following Councilors were present: Chairman, D. S.
Baughman, and Councilors John L. Calene, H. R. Brown, C. E.
Robbins, Wm. H. Saxton, J. H. Lloyd, W. E. Donahoe, R. E.
Jernstrom, Wm. Duncan, R. V. Overton, N. J. Nessa, J. C. i
Ohlmacher, and C. E. Sherwood. The Councilors absent were:
Councilors Geo. E. Whitson, E. M. Stansbury, and C. E. Lowe.
Mr. Karl Goldsmith, legal advisor for the Society, was also
present at this meeting.
The minutes of the last meeting were read by the Secretary.
It was moved by Dr. Calene, seconded by Dr. Jernstrom, that
the minutes be approved as read. The motion was carried.
A report of the Secretary-Treasurer was given, and it was
moved by Dr. J. C. Ohlmacher, seconded by Dr. W. E. Dona-
hoe, that the report of the Secretary be adopted and that the
financial report be referred to the Auditing Committee for
checking. The motion prevailed.
A report was given of the Farmers Aid Corporation funds.
It was brought to the attention of the Councilors that the
Inter-allied Council has petitioned the Court that the Farmers j
Aid Corporation be dissolved and the remaining assets be turned
over to the Inter-allied Council for their disposal among the
professional interests, and that the further assets, uncollected
notes and accounts be marked off. Discussion ensued, but there
was no formal action taken.
Mr. Karl Goldsmith gave an informal report on the recent
legislative session and the legislation passed which affected the
medical profession. Matters were discussed, but there was no
formal action taken.
Dr. Wm. Duncan called to the attention of the Councilors
the fact that Dr. W. H. White, osteopathic physician, styles j
himself as a physician and surgeon, and that he is practicing as j
an itinerant physician. Dr. Duncan also stated that this matter
had been taken up by the State Board of Medical Examiners
who referred it to the Attorney General for his opinion. The
Attorney General ruled that the law regarding itinerant physi-
cians does not apply to osteopathic physicians. Further discus-
sion followed, but there was no formal action taken.
Mention was made of a recent circular letter sent out over
the signature of Dr. W. R. Giedt, Assistant State Health Offi-
cer, in which he suggested that, in order to make people more
health conscious, there should be more publicity given to the I
part the State Board of Health plays in matters of health in I
the various communities. He suggested that when clinics were y
given, the fact that the State Board of Health furnished the I
biologicals and help should be mentioned. Dr. Duncan felt g
that this thought was worthy of consideration of the Society.
The Chairman appointed an Auditing Committee consisting (
of Dr. H. R. Brown, Dr. R. E. Jernstrom, and Dr. Wm.
Duncan.
There being no further business, a motion was made by Dr.
Wm. Duncan, seconded by Dr. J. H. Lloyd, that the meeting
adjourn. The motion was carried.
C. E. Sherwood, M.D., Secretary.
Second Meeting of the Council
May 28, 1943
The second meeting of the Councilors was called to order by
the Chairman, Dr. D. S. Baughman, on Friday afternoon,
May 28, 1943.
The roll call was read by the Secretary, Dr. C. E. Sherwood.
The following Councilors were present: Chairman, D. S.
July, 1943
195
Baughman, and Councilors John L. Calene, Wm. Duncan, R.
V. Overton, H. Russell Brown, C. E. Robbins, Wm. H. Saxton,
J. H. Lloyd, W. E. Donahoe, R. E. Jernstrom, C. E. Lowe,
N. J. Nessa, J. C. Ohlmacher, and C. E. Sherwood. The Coun-
cilors absent were: Geo. E. Whitson, E. M. Stansbury, D. A.
Gregory. Mr. Karl Goldsmith, legal advisor for the State Med-
ical Association, was also present at this meeting.
The minutes of the last meeting were read by the Secretary.
It was moved by Dr. C. E. Lowe, seconded by Dr. C. E. Rob-
bins, that the minutes be accepted as read. The motion was
carried.
The first item of new business was the nominations for Chair-
man. Dr. Wm. Duncan was nominated. There being no fur-
ther nominations, a motion was made by Dr. John L. Calene,
seconded by Dr. C. E. Lowe, that the nominations for Chair-
man be closed. The motion was carried, and Dr. Wm. Duncan
was named Chairman.
The next item of business was the election of Secretary-
Treasurer for a term of three years. Before any nominations
were made, it was moved by Dr. R. E. Jernstrom, seconded by
Dr. C. E. Lowe, that the salary of the Secretary-Treasurer
would be $600.00 per year, with the understanding that this
salary may be raised after one year. The motion was carried.
The following were nominated for Secretary-Treasurer: Dr.
R. G. Mayer of Aberdeen and Dr. Gilbert Cottam of Pierre.
At this time Dr. Cottam was paged, and asked whether
or not, if elected, he would accept the position at the salary
named. Dr. Cottam stated that if another man could be found,
he would rather not accept this work, as he was very busy with
his duties as Superintendent of the State Board of Health.
Discussion followed regarding the election of Dr. R. G.
i Mayer. It was moved by Dr. J. H. Lloyd, seconded by Dr. R.
E. Jernstrom, that Dr. John L. Calene be authorized to call
Dr. Mayer by telephone, asking whether he would accept the
position if elected. Upon completion of the telephone call, Dr.
! Calene reported that Dr. Mayer would accept the appointment.
A motion was made by Dr. R. E. Jernstrom, seconded by
Dr. J. H. Lloyd, that the nominations be closed, and that Dr.
Mayer be named as the Secretary-Treasurer of the South Da-
kota State Medical Association. The motion was carried.
It was agreed on suggestion of the Secretary that the new
Secretary take over his duties on July 1, 1943.
There being no further business, the meeting was adjourned.
C. E. Sherwood, M.D., Secretary.
Report of the Auditing Committee,
South Dakota State Medical Association
May 28, 1943
1. Cash taken in and accounts received were checked against
deposit slips and found correct.
2. All bills paid were checked against cancelled checks and
the books and found correct.
3. Legislative account checked and found correct.
4. Benevolent fund checked and found correct.
The auditing committee, on behalf of the Council, wishes to
thank the secretary, Dr. C. E. Sherwood, for his efficient ac-
counting of the funds of the State Association.
H. R. Brown, M.D.
R. E. Jernstrom, M.D.
Wm. Duncan, M.D.
Financial Report of Benevolent Fund
Deposited Savings Account 816, Northwest Security National
Bank, Madison Branch.
Date Cash Received
Jan. 10, 1942 — Minneapolis Draft 3108. Huron
Branch. Total savings and interest Jan. 1, 1942 $694.87
Nov. 7, 1941 — Rapid City Auxiliary 2.00
Oct. 8, 1941 — Rapid City Auxiliary 4.00
Feb. 13, 1942 — Madison District 45.00
May 12, 1942 — Rapid City District 19.00
May 12, 1942 — Huron District 30.00
May 12, 1942 — Pierre District 20.00
May 12, 1942 — Mitchell District 10.00
May 12, 1942 — Watertown District 15.00
May 12, 1942 — South Dakota State Med. Assoc 153.00
May 12, 1942 — Total $992.87
May 15, 1942 — Sioux Falls District $ 57.27
Yankton District 6.00
Collection box at meeting 2.60
May 23, 1942 — Arnold Schyzer 20.00
March 31, 1943 — Interest — 14.68
April 10, 1943 — South Dakota State Med. Assoc 145.00
Watertown District 10.00
April 12, 1943— Dr. Sherwood, prize bond auction 5.00
May 18, 1943- — Sioux Falls District 5.75
May 21, 1943 — Black Hills District 5.00
Total $1,264.17
April 15, 1943 — Series "F” Bonds — Maturity value
1955, $1,675.00, purchased for $1,239.50
Leaving a balance on hand of 24.67
$1,264.17
Clarence E. Sherwood, M.D.,
Secretary-T reasurer .
Secretary’s Report to the Council
Your secretary has endeavored to keep the members of the
Association acquainted with things affecting the practice of
medicine. To that end, during the year mimeographed bulletins
were issued and sent out. Information relative to ration of tires,
new cars, speed and other things affecting us as physicians was
procured and passed on.
We were in touch with measures coming up in the recent
session of the legislature, and, through our attorney, Karl Gold-
smith, were able to accomplish some things and advise on word-
ing of other things which might otherwise have worked to our
detriment. A full resume of measures before the legislature
affecting us has been sent to each of you in a bulletin.
The principal officers of the association acted in an advisory
capacity to the governor in the matter of filling the vacancy left
in the State Board of Health by the death of Dr. Cook.
We have contacted our representatives in Congress on nu-
merous occasions relative to legislation there affecting us. It is
our opinion that American medicine should be more strongly
represented in Washington. We should endeavor to find out
what is coming up there before it does. Most of the time, as
our reporting system works, by the time we are informed of
matters and we can contact our representatives, the matter is
an accomplished fact.
The Annual Secretaries Conference in Chicago was attended
in November as was the North Central Medical Conference in
Minneapolis. Both of these conferences considered many prob-
lems of interest to the profession.
Only one meeting of the Council has been called this year
due to the difficulties of travel, etc., but many conferences over
the telephone and through the mail have been had with Coun-
cilors and officers of the Association on matters affecting the
welfare of the medical profession.
And now for a personal note. I have enjoyed working with
the various officers of the Association during the past six years.
The contacts have meant much to me and I feel that I have
come to know and have the friendship of many men that other-
wise would have been impossible. However, the position of
Secretary-Treasurer of this organization makes many demands
on the time of its incumbent, which I have found increasingly
harder to meet. I sincerely feel that I have made my contri-
bution of time to the Association in serving it two terms and
would, therefore, ask that when you have under consideration
the election of Secretary-Treasurer for the next three years, my
name be not considerd.
The following is the analysis of the active membership by
districts, showing a comparison of last year’s figures at conven-
tion time and total membership attained by the close of the
fiscal year.
196
The Journal-Lancet
May December May
1942 1942 194?
District 1 15 29 26
District 2 16 19 19
District 3 23 23 20
District A ...... 14 16 12
District 5 14 15 12
District 6 27 27 30
District 7 43 46 45
District 8 29 34 29
District 9 44 47 39
District 10 8 8 6
District 11 10 11 11
District 12 14 16 10
257 291 259
Report of Secretary-Treasurer
May 25, 1943
May 12, 1942, balance on hand $1,943.77
Receipts:
Back dues received for 1942 (37) 370.00
Exhibits, Sioux Falls convention 108.00
Social Security tax, C. E. Sherwood 12.00
Withholding tax, C. E. Sherwood 7.20
1943 dues, 260 members 2,600.00
$5,040.97
Disbursements:
Committee expense $118.81
Speakers expense 179.66
Journal-Lancet 578.00
Inter allied Council 16.00
Stenographer „ 10.00
Hotel expense, annual session 45.88
Telephone 36.65
Office supplies 18.99
Postage 57.51
Karl Goldsmith — retainer 300.00
Karl Goldsmith — legislative 108.41
Social Security and withholding tax 31.20
A. M. A. Directory 15.00
Bond, Secretary-Treasurer 5.00
Council expense .... 211.34
C. E. Sherwood, Sec’y-Treasurer salary 1,200.00
Delegate, A. M. A. 122.50
Flowers, Dr. Cook 8.16
Benevolent Fund 145.00
Float and exchange 4.11
$3,242.22
Balance on hand, May 25, 1943 1,798.75
$5,040.97
LEGISLATIVE FUND
Receipts:
Balance on hand Mav 12, 1942 $276.38
Interest May 30, 1942 1.03
Interest Sept. 30, 1942 1.04
Interest Dec. 31, 1942 1.04
Interest March 31, 1943 1.04
Balance on hand May 25, 1943 $280.53
Savings Account 631, Northwest National Bank
of Sioux Falls, Madison Branch.
Clarence E. Sherwood, M.D.,
Secretary-T reasurer.
HOUSE OF DELEGATES. SOUTH DAKOTA
STATE MEDICAL ASSOCIATION
May 28, 1943
The meeting of the House of Delegates was called to order
bv the President, Dr. N. J. Nessa, on May 28, 1943, at the
Marvin Hughitt Hotel in Huron, South Dakota.
The roll call was read by the Secretary and the following
members were present: Chairman N. J. Nessa, John L. Calene,
H. Russell Brown, C. E. Robbins, Wm. H. Saxton, J. H. Lloyd,
W. E. Donahoe, R. E. Jernstrom, C. E. Lowe, Wm. Duncan,
R. V. Overton, D. S. Baughman, J. C. Ohlmacher, C. E. Sher-
wood, M. W. Larsen, M M. Morrissey, J. C. Shirley, F. J.
Tobin, O. J Mabee, L. G. Leraan, L. J. Pankow, C. J. Mc-
Donald, F. J. Abts, and G. W. Mills. The following members
were absent: Geo. E. Whitson, E. M. Stansbury, J. D. Alway,
J. D. Whiteside, L. E. Jordan, B. T. Lenz, E. W. Jones, E.
Stenberg, E. Joyce, R. B. Fleeger, F. C. Totten, and L. E.
Lande. The Alternates absent were: E. A. Rudolph, F. H.
Cooley, J. B. Vaugh, R. A. Buchanan, S. R. Wallis, W. J.
Maytum, A. P. Reding, and F. W. Haas.
Following the reading of the roll call, the President appoint-
ed the following on the Reference Committees:
Committee on Nomination of Officers: Dr. J. L. Calene, chair-
man, Dr. H. R. Brown, Dr. G. E. Whitson, Dr. C. E. Rob-
bins, Dr. W. H. Saxton, Dr. J. H. Lloyd, Dr. L. J. Pankow,
Dr. J. C. Ohlmacher, Dr. G. W. Mills, Dr. R. V. Overton,
Dr. C. E. Lowe, and Dr. Wm. Duncan.
Committee for Reports of Officers: Dr. Wm. Duncan, chair-
man, Dr. L. G. Leraan, and Dr. F. J. Tobin.
Committee on Resolutions and Memorials: Dr. C. J. Mc-
Donald, Dr. F. J. Abts, and Dr. D. S. Baughman.
Committee on Amendment of Constitution and By-Laws:
Dr. M. M. Morrissey, chairman, Dr. M. W. Larsen, and Dr.
C. E. Lowe.
Committee on Credentials: Dr. R. E. Jernstrom, Dr. C. J.
McDonald, and Dr. C. E. Sherwood.
The President, Dr. Nessa, gave a brief address of welcome
to the members of the House of Delegates, and also reported
for the Committee on Scientific Work and Public Policy. He
also submitted a report which was given to him by Mrs. Tol-
levs, State Commander of the Women’s Field Army on the
Control of Cancer.
The minutes of the 1942 Session were read by the Secretary.
Dr. R. E. Jernstrom moved that the minutes be approved. The
motion was seconded by Dr. F. J. Abts. The motion prevailed.
A report of the Secretary-Treasurer was given. The financial
part of the report was audited by the Auditing Committee of
the Council; this Committee consisting of Drs. H. R. Brown,
R. E. Jernstrom and Wm. Duncan. Following the report of the
Secretary-Treasurer, the report of the Auditing Committee was
called for by the President. Dr. Brown, chairman of the com-
mittee, gave the report, stating that the committee approved the
report of the Treasurer; and it was moved by Dr. J. C. Ohl-
macher, seconded by Dr. John L. Calene, that the report of the
Auditing Committee be adopted. The motion was carried.
The president called for reports of the various committees,
the first being the Committee of Scientific Work and and Pub-
lic Policy. Because a full report had been given by Dr. Nessa,
President, in his address to the members, there was nothing fur-
ther to report at this time.
Dr. R. E. Jernstrom inquired about the radio programs on
Public Health problems which have been sponsored by the
State Medical Association. There was some informal discussion
on this subject, and it was agreed that, should the members of
the Association have any opportunity to obtain publications
which may be used for radio broadcasts, this opportunity should
be used to their advantage.
The Radio Committee report was made by Dr. W. E. Dona-
hoe. He informed the members that as in the past, the radio
programs had been carried on during the year, and that talks
were given by Dr. Hummer over KSOO. He also mentioned
that he thought Dr. Hummer should be sent a letter of thanks
for his aid in these radio programs, and stated that the com-
mittee desired that these programs be continued, and that mem-
bers contribute any papers they may have which might be pre-
sented over the radio.
The President asked for a vote on whether or not the mem-
bers wished to have these radio programs continued, and the
majority of the members agreed to continue the programs. It
was moved by Dr. Wm. Duncan, seconded by Dr. L. J. Pan-
kow, that the Secretary draft a letter of thanks to the reader
of the papers used in the past for the radio programs, and that
a letter of thanks also be sent to the radio station. The motion
July, 1943
197
prevailed. The report of the Radio Committee was referred to
the Reference Committees.
The report of the Committee on Publications was given by
Dr. C. E. Sherwood, chairman of the committee. Dr. Sher-
wood stated that the five-year contract with the Journal-
Lancet had expired, and that the Association had been paying
two dollars ($2.00) per subscription. The President suggested
that this subject be transferred to the item of new business for
i discussion at that time. The report was referred to the Ref-
erence Committees.
Dr. L. J. Pankow, chairman of the Committee on Medical
l Defense, submitted the report of the committee and also read
; letters he received from Dr. W. H. Saxton and Dr. T. F.
j Riggs. These letters are filed with the report, but not as a
part of it. The report was referred to the Reference Committees.
Dr. F. J. Tobin submitted the report of the Committee on
) Medical Education and Hospitals. The committee approves of
| Spanish and Portuguese being taught in the medical schools,
I in order that the doctors may be better educated. He gave, as
a part of his report, a letter from the American Ethnological
j Association. He also submitted a letter received from Dr. Sher-
wood, and one received from Dr. T. P. Ranney. Dr. Ranney’s
[ letter is to be filed with the report, and not as a part of it.
Dr. Tobin’s report was referred to the Reference Committees.
At this time. Dr. Wm. Duncan mentioned medical educa-
i tion in connection wtih the Army and Navy, and stated that
many of the doctors are not getting the training that is neces-
sary. Dr. J. C. Ohlmacher also discussed this subject, and in-
dicated that the Army and Navy have greatly reduced the re-
quirements of pre-medical education as well as advanced train-
ing in medicine. Informal discussion continued, but there was
no action taken.
The Medical Economics Committee report was given by Dr.
Geoffrey Cottam. He informed the members that the committee
had considered and approved the Health and Accident Insur-
ance Policy offered by the Loyalty Group of Underwriters.
There was some discussion on this subject, whereupon Dr. L. J.
Pankow rose to the point of order, stating that this was to be a
committee report rather than a discussion. The President stated
that this subject would be transferred to the item of new busi-
ness. The committee report was transferred to the Reference
Committees.
A report of the Committee on Public Health was given by
Dr. Sherwood in the absence of Dr. A. Triolo, chairman. The
report was referred to the Reference Committees.
The committee report on Necrology was not given at this
time. There was also no report of the Editorial Committee.
A report of the Committee on Medical Licensure was given
by Dr. G. W. Mills, chairman. He stated that the Association
had not taken any action to change any of the laws covering
medical licensure. The committee suggested that a special com-
mittee be appointed to investigate legislation in other states.
It was also suggested that a program demanding the national
licensing of physicians whereby they would be allowed to prac-
tice in any state, would be satisfactory. Dr. Mills also informed
the members of the change in the Basic Science Law which took
place at the last legislative session. The report was referred to
the Credentials Committee.
Dr. D. S. Baughman, chairman of the Advisory Committee,
informed the President that there was no formal report to be
made.
The report of the Allied Group was read by the Secretary
and referred to the Committee.
Dr. Wm. Duncan, chairman of the Military Affairs Committee,
gave an informal report, stating that the number of South Da-
kota physicians in the armed forces at the present time is fifty-
nine. However, all of these physicians were not members of the
State Medical Association. This report was referred to the
Reference Committees.
There was no formal report given of the Radiology Com-
mittee or the Committee on Spafford Memorial.
No committee reports were necessary on the Advisory De-
partments of the State Board of Health.
Following the reports of all the committees, the next order
of business was old business.
Dr. Sherwood, Secretary, called attention to the fact that at
the meeting a year ago a motion was made by Dr. Stevens that
the proposal for an increase in the dues of each member be
tabled, and referred to the local Society and brought up at a
later date. This subject was transferred to new business.
Dr. L. J. Pankow submitted a financial statement of the
State Medical Association for the past three years, 1941, 1942,
1943. He called attention to the fact that the funds have
steadily been decreasing, and that in order to remedy this, the
dues of each member should be raised. It was moved by Dr.
Pankow, seconded by Dr. C. J. McDonald, that the dues of the
South Dakota State Medical Association be raised from $10.00
per year to $25.00 per year. Considerable discussion followed
indicating that the members believed there should be an increase
in the dues, but not to such a great extent.
Dr. Pankow again appealed to the members and made a mo-
tion to amend his first motion to read: "The dues of the South
Dakota State Medical Association should be increased from
$10.00 per year to $17.50 per year.” The motion was seconded
by Dr. C. J. McDonald.
Dr. H. R. Brown moved that the first motion of Dr. Pan-
kow be amended to read: "The dues of the South Dakota
State Medical Association should be increased from $10.00 to
$15.00 per year.” Dr. Pankow withdrew his motion to amend
the first motion and seconded the motion made by Dr. Brown.
The motion was carried by a vote of fourteen ayes and six nays.
The President then called for a vote on the original motion
made by Dr. Pankow as amended. There were twelve ayes and
six nays. The motion carried.
Dr. C. E. Robbins moved that Dr. B. M. Hart be made an
honorary member from the fourth district. Dr. R. E. Jernstrom
seconded the motion, and the motion prevailed.
It was moved by Dr. D. S. Baughman, seconded by Dr. R.
E. Jernstrom, that Dr. R. S. Westaby also be admitted as an
honorary member. The motion was carried.
Dr. C. E. Sherwood presented a resolution, to be acted upon
by our House of Delegates, instructing our delegate to the
American Medical Association to support a resolution sponsored
by the National Medical Conference. This resolution asks that
the American Medical Association create a committee on med-
ical service, and that they maintain an office in Washington,
D. C., with the employment of a full time executive director
whose duties, in brief, should be to look after the interests of
American medicine in Washington. Dr. Sherwood moved that
the resolution be referred to the Committee on Resolutions for
their action. Seconded by Dr. J. H. Lloyd.
Dr. L. J. Pankow moved that instead of referring the reso-
lution to the Committee on Resolutions and Memorials, it
should be referred to a special committee. There was no second
to this motion, and the original motion of Dr. Sherwood was
voted upon and carried.
A letter was brought to the attention of the members regard-
ing U. S. Children’s Bureau’s program of Medical Care for
wives and infants of enlisted men. Discussion followed, but no
formal action was taken.
It was moved by Dr. L. J. Pankow that the meeting be ad-
journed to reconvene at 2:00 p. m. The motion was seconded
by Dr. Wm. Duncan. The motion was carried.
MINUTES OF THE AFTERNOON SESSION OF
THE HOUSE OF DELEGATES
The meeting of the House of Delegates reconvened at 2:00
p. m., May 28, 1943.
The roll call was read by the Secretary. The following
members were present: Chairman, N. J. Nessa, John L. Calene,
H. Russell Brown, C. E. Robbins, Wm. H. Saxton, J. H.
Lloyd, W. E. Donahoe, R. E. Jernstrom, C. E. Lowe, Wm.
Duncan, R. V. Overton, D. S. Baughman, J. C. Ohlmacher,
C. E. Sherwood, M. W. Larsen, M. M. Morrissey, B. T. Lenz,
J. C. Shirley, F. J. Tobin, O. J. Mabee, L. J. Pankow, C. J.
McDonald, G. W. Mills, and L. G. Leraan. The following
members were absent: Geo. E. Whitson, E. M. Stansbury,
F. J. Abts, J. D. Alway, J. D. Whiteside, L. E. Jordan, E.
W. Jones, E. Stenberg, E. Joyce, R. B. Fleeger, F. C. Totten,
and L. E. Lande. The Alternates absent were: E. A. Rudolph,
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F. H. Cooley, R. A. Buchanan, J. B. Vaugh, S. R. Wallis,
W. J. Maytum, A. P. Reding, and F. W. Haas.
Dr. John L. Calene gave the following report of the Com-
mittee on Nominations of Officers:
President-Elect: Dr. N. J. Nessa and Dr. D. S.
Baughman.
Vice President: Dr. Wm. Duncan and Dr. R. E.
Jernstrom.
Councilor, Black Hills District No. 9: Dr. R. E.
Jernstrom.
Councilor, Rosebud District No. 10: Dr. R. V.
Overton.
Councilor, Northwest District No. 11: Dr. C. E.
Lowe.
Councilor, Whetstone Valley District No. 12: Dr.
Wm. Duncan, or Dr. D. A. Gregory, if Dr. Dun-
can is elected Vice President.
The place of meeting chosen by the committee was Huron.
Dr. R. E. Jernstrom withdrew his nomination for Vice Presi-
dent. Dr. R. V. Overton withdrew his name for Councilor for
the Rosebud District No. 10 and placed the name of Dr. R.
J. Quinn.
The members voted by ballot. Dr. Wm. Duncan and Dr.
F. J. Tobin were appointed by the President as tellers. The
results of the election are as follows:
President-Elect: Dr. D. S. Baughman, 18; Dr. N. J.
Nessa, 2.
Vice President: Dr. Wm. Duncan, 19; Dr. R. E.
Jernstrom, 2.
Councilor, District No. 9: Dr. R. E. Jernstrom, 17.
Councilor, District No. 10: Dr. R. J. Quinn, 20;
Dr. R. V. Overton, 1.
Councilor, District No. 11: Dr. C. E. Lowe, 19.
Councilor, District No. 12: Dr. D. A. Gregory, 19;
Dr. Wm. Duncan, 3.
The place of meeting chosen was Huron.
Mr. L. M. Cohen of the Journal-Lancet was called on to
say a few words to the members of the Council and House of
Delegates.
Dr. Wm. Duncan gave an informal report on the Com-
mittee on Procurement and Assignment. He stated that at the
present time there are 315 active practitioners in the state, and
that there were 59 men in the armed forces from South Da-
kota. The Secretary called attention to the fact that 301 had
paid the regular assessments for 1942.
Dr. Nessa, Chairman, called for the reports of the Reference
Committees.
Dr. Duncan presented the report of the Committee on Re-
ports of Officers and moved that the report be adopted. The
motion was seconded by Dr. John L. Calene and carried.
The report of the Committee on Resolutions and Memorials
was read. They recommend that the resolution relative to the
establishment of a committee on medical service be approved,
and that our delegate be instructed to support it at the meeting
of the House of Delegates of the American Medical Associa-
tion. They also recommend the continuance of the radio pro-
gram. They disapprove of the report of the Inter-allied group
relative to the proposed disbursement of F.A.C. funds. They
approved Dr. Mills’ suggestion that a study be made of the
various state laws relating to medical licensure, and suggested
that the American Medical Association sponsor the drawing up
of a model licensure law to be introduced in each state legis-
lature. They recommended the renewal of the five-year contract
of the Journal-Lancet at the two dollar rate. They recom-
mended that the matter of the introduction of Spanish and
Portuguese into the curriculum of medical schools be given
further consideration, and that no action be taken at this time.
Dr C. J. McDonald moved that the report of the Committee
on Resolutions and Memorials be adopted. Dr. Baughman sec-
onded the motion and the motion was carried.
Dr. M M. Morrissey, chairman of the Committee on Amend-
ment of the Constitution and By-laws, stated that there was
no report to be made.
Dr C. E. Sherwood, chairman of the Credentials Committee,
reported that Sioux Falls was entitled to three delegates instead
of two. He also informed the members that Dr. O. J. Mabee
of Mitchell, South Dakota, was an alternate in place of Dr.
E. W. Jones, and that Dr. L. G. Leraan was the alternate in
place of Dr. E. Stenburg. Dr. Sherwood moved that this re-
port be adopted. The motion was seconded by Dr. J. H. Lloyd,
and the motion prevailed. -
At this time, the President called on Dr. Gilbert Cottam,
superintendent of the State Board of Health, who spoke a few
words to the members of the House of Delegates.
Dr. Cottam expressed his thanks to the members for their
endorsement to the Governor just before his appointment as
Superintendent. He gave the members a report on the activi-
ties of the State Board of Health Office, giving an outline of
each Division, namely, the Division of Epidemiology, Division
of Maternal and Child Health, Division of Crippled Children,
Division of Engineering, Division of Public Health Nursing,
Division of Vital Statistics, Division of Public Health Educa-
tion, the Auditing Divison, and the Division of Laboratories.
Dr. Cottam also outlined his plans for developing the State
Department. One of the programs which he mentioned was
the Cancer Program. The Auditing Department has budgeted
a sum of money to cover the expense involved in making the
pathological reports on various cancer cases. He expressed his
desire to have the State Board of Health hold cancer clinics
throughout the state.
Another of the programs mentioned was his plan to estab-
lish a legislative file. In this way he expects to be able to pre-
sent worthwhile bills to the legislative body at the next session.
Dr. Cottam expressed the hope that he would be able to
make arrangements to bring to the state a capable lecturer on
tropical diseases, cooperating with the District Medical Societies
in various parts of the state to hold special meetings at which
he could be heard. Dr. Cottam regards the development of a
tropical disease program as very important at this time, because
there is sure to be a large amount of that type of disease
brought back to South Dakota by the return of the soldiers.
Dr. Geoffrey Cottam explained the insurance policy to the
members, which the Committee on Medical Economics consid-
ered and recommended. Dr. Cottam also called on Mr. An-
thony, who is the salesman for the Insurance Company. Mr.
Anthony explained the provisions of this policy. After some
discussion, it was moved by Dr. Saxton, seconded by Dr. Ca-
lene that the policy be referred to the legal advisor, Mr. Karl
Goldsmith for his consideration, and if found to be satisfactory,
this policy would be referred back to the Society. The motion
was carried.
There being no further business, the meeting was turned
over to the new President, Dr. J. C. Ohlmacher.
A motion was made and seconded that the meeting adjourn.
The motion prevailed.
C. E. Sherwood, M.D., Secretary.
REPORT OF COMMITTEE ON REPORTS
OF OFFICERS
To the Officers of the South Dakota State Medical
Association:
Your Committee on Reports of Officers has carefully re-
viewed the reports of the elective officers of the Association,
and wishes to commend them for faithful and efficient service
in performing the duties of their offices. We wish to call the
attention of the Association to the report of the Secretary, Dr.
C. E. Sherwood, who has indicated that he would prefer not
to continue in that office, and to especially commend and thank
him for the careful and efficient conduct of his office during
the past few years.
William Duncan, M.D., Chairman.
REPORT OF COMMITTEE ON RESOLUTIONS
AND MEMORIALS
We approve the resolution presented, regarding the estab-
lishment by the American Medical Association of a committee
on medical service.
We approve the continuance of radio programs.
We disapprove the disbursement of money still on hand in
the Farm Aid Corporation as suggested by the inter-allied
group, because some of this money is owing to persons not
July, 1943
199
members of any of the inter-allied groups, and recommend that
this matter be given further consideration.
We approve the recommendations made by Dr. Mills regard-
i ing the advisability of our delegate to the American Medical
Association suggesting a committee to study the various state
licensure laws and to draw up a model licensure law to be pre-
sented to each state legislature.
We further recommend the acceptance and renewal of the
i contract with the management of the Journal-Lancet.
We recommend that a study of the Spanish and Portuguese
languages in medical schools be given further consideration.
F. J. Abts, M.D.
C. J. McDonald, M.D.
R. V. Overton, M.D.
REPORT OF COMMITTEE ON MILITARY AFFAIRS
j The duties of the Military Affairs Committee were taken
care of by the South Dakota Committee for Procurement and
Assignment of Physicians.
South Dakota physicians have no quota to furnish the
Armed Forces for 1943, and at present it is impossible to de-
clare anyone available for military service, unless they are able
to replace themselves by another physician.
The South Dakota physicians who are now in the Armed
Forces are listed as follows:
Gelber, M. R., Aberdeen
| Kruzich, S. J., Aberdeen
McCarthy, Paul V., Aberdeen
Schuchardt, I. P. L., Aberdeen
Bloemendall, G. J., Ipswich
Wayne, D. M.,Redfield
Adams, M. E., Clark
Cooper, George M., Watertown
Rousseau, M. D., Watertown
VanHeuvelan, G. J., Pierre
Salladay, I. R., Pierre
Burgess, R. E., Gettysburg
Adams, H. P., Huron
Ferris, W. T., Chamberlain
Athey, G. L., Chamberlain
Jones, J. P., Mitchell
Tobin, L. W., Mitchell
Lovre, S. C., Humboldt
Billion, T. J., Jr., Sioux Falls
, Craig, Allen, Sioux Falls
Fitzgibbon, T. G., Sioux Falls
Nietfeld, A. B., Sioux Falls
Duimstra, Fred, Sioux Falls
Thompson, Arnold, Sioux Falls
Zellhoffer, H. W.K., Sioux Falls
Bliss, R. J., Sioux Falls
: Olson, Orland, Sioux Falls
Hanson, O. L., Jr.,
|, Valley Springs
Boyd, F. E., Flandreau
William
Andre, Hugo C., Vermillion
Dick, Fred, Vermillion
Hanson, H. F., Vermillion
Williams, F. E., Wakonda
Hill, W. H„ Centerville
Sackett, R. F., Parker
Bushnell, J. W., Elk Point
Auld, M. A.. Yankton
Hubner, R. F., Yankton
Malloy, J. F., Yankton
Kittelson, Otis, Yankton
Sherrill, Sion, Belle Fourche
Hayes, P. W., Hot Springs
Smiley, J. C., Deadwood
Zarbaugh, G. F., Deadwood
Davidson, H. E.. Lead
Hummer, F. L., Lead
Soe, Carl A., Lead
Clark, B. S., Spearfish
Nyquist, Roy H.. Ft. Meade
Sherman, K. E.. Sturgis
Stewart, M. J., Sturgis
Lampert, A. A., Rapid City
Lemley, R E., Rapid City
Merryman, M. P., Rapid City
McGonigle, J. P., Rapid City
Owen, Stanley, Rapid City
Duncan, C. E.. Pollock
Catey, Robt., Mobridge
Pfister, Faris, Webster
Duncan, M.D., Chairman.
REPORT OF THE COMMITTEE ON MEDICAL
DEFENSE
Your committee begs to report that each of us has made
enquiry and has failed to find any evidence of any suits seri-
ously threatened or instigated.
We further wish to call to the attention of the association
that this condition is probably due to the fact that there is at
present a definite shortage of Doctors of Medicine in the state,
and not to any change in the nature of our patients or any
great improvement in our abilities or techniques. This is men-
tioned so that the association here assembled will not lose sight
of certain legislation that was proposed several years ago by
j. this committee, in regard to medical defense, and to urge that
I this legislation be not forgotten or deemed entirely unnecessary
■ because of present conditions of apparent safety.
L. J. Pankow, M.D., Chairman.
REPORT OF COMMITTEE ON INTER-ALLIED
ACTIVITIES
The committee of this association for the Allied Group
wishes to report as follows.
On April 26, 1943, there was a meeting of the Inter-Allied
Council held at Huron for the purpose of closing up the trus-
teeship of the old Federal Security Administration. There is a
small amount of money still in the trust which is so small that
it will not pay to divide it among the individual physicians,
druggists and dentists of the state, so the court has been peti-
tioned to divide the money among the state societies and let
the societies use the money as their various controlling boards
may deem advisable. The matter is Still in the hands of the
court so no definite report can be given at the present time.
Other than that the committee has nothing to report.
N. K. Hopkins, M.D., Chairman.
REPORT OF EDITORIAL COMMITTEE
It has not been possible for the members of the Editorial
Committee to meet in person. Through correspondence, each
member has been advised of the report that is to be made and
suggestions invited from each of them.
During the past two years there has been greater use made
of our official Journal, the Journal-Lancet, than previously.
Besides the regular reports of our annual meeting, some advan-
tage has been taken by our Secretary of the facilities offered by
the Journal-Lancet to send information to the membership.
The ladies’ auxiliary has contributed items of interest carried to
the membership through the Journal. It is the desire of the
Officers of our official Journal that greater use be made of the
facilities offered.
The five year contract with the management of the Journal-
Lancet expires July 1, 1943. It is the opinion of the Editorial
Committee that a new contract be entered into for a period of
years at the rate of $2.00 per member per year. This is the
same fee schedule that has been in effect during the past two
years.
J. C. Shirley, M.D., Chairman.
REPORT OF THE ECONOMICS COMMITTEE
The only business to be considered by this committee is the
matter of Health and Accident Insurance for members of the
Society. In this connection, we point out that this has nothing
to do with Society dues but it is strictly an individual consid-
eration. However, at least 50 per cent of the membership must
apply for policies before this Loyalty group will take over the
job of carrying this insurance.
The amount of insurance may vary according to the desires
of each member. The annual premiums begin at $30.00 a year
and go on up according to the amount of coverage.
Your committee recommends that the Society adopt this in-
surance for the following reasons:
1. The companies of the Loyalty group are financially
sound.
2. They offer more protection and coverage than any
other companies and the rates are more reasonable.
3. It protects all age groups up to age 70.
We recommend that we accept this program, on the condi-
tion that there be a rider attached, to the effect that the indi-
vidual members have the privilege of continuing with their in-
dividual policies, in the event that the State Society drops below
50 per cent to make the agreement invalid.
Geoff. Cottam, M.D., Chairman.
C. E. Robbins, M.D.
Harold Miller, M.D.
REPORT OF COMMITTEE ON PUBLIC HEALTH
I have contacted all the members of the Sub-Committees on
Public Health in an attempt to present some kind of a report
for the Council meeting. The answer has been practically the
same from each one — "I regret that we have nothing to report.
Due to the shortage of physicians it has been very difficult to
find time for any outside activities or the holding of any meet-
ings.” They all assured me that they would cooperate in any
manner possible. However, that is the extent of the cooperation
that was given.
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The Journal-Lancet
It has been very difficult for me to make the contacts that I
no doubt should have made, because, as you know, with the
extreme shortage of personnel in the Health Department, we
have been kept busy with the ordinary details. I hope that in
the future I shall be able to prod these committees along
towards some sort of activity.
Dr. Cottam will be present at the meeting of the House of
Delegates and I am sure that he will actively participate in
any discussions concerning public health activities. I feel that
the State Medical Association should continue with these com-
mittees, because it will offer an opportunity to consult with
various groups concerning public health problems, and even-
tually the activities of the committees might, with a little prod-
ding, bear fruit.
5{« H4
REPORT OF COMMITTEE ADVISORY TO DEPART-
MENTS OF STATE BOARD OF HEALTH
The advisory committees to the State Board of Health, name-
ly the Committees on Ophthalmology, Orthopedics, and Ma-
ternal and Child Health, are used even though regular meetings
are not held. Individual members are consulted on problems of
inter-society relationships and policy. I would therefore suggest
that the committees be continued.
Concerning the committee on Social Security, I really do not
know what use has been made of it. Dr. Cook, I believe, had
occasion to consult them relative to the medical care set-up and
also in review of Aid to Dependent Children cases.
These committees have not met as a committee this year.
However, the members have individually been consulted in sev-
eral instances. I doubt if committee reports would be necessary.
A. Triolo, M.D., Chairman.
COMMITTEE ON MEDICAL LICENSURE
Your committee on Medical Licensure wishes to report that
owing to the wide geographic distribution of its members no
meetings were possible. As we knew only this month that we
were on the committee, there has been insufficient time to make
any extended study of licensing laws and licensing boards with
a view to recommending any changes in our own.
In view of the fact that there is a strong tendency now in
state legislatures to pass uniform laws governing matters that
should be more or less uniform throughout the various states,
it might be advisable that our delegate to the American Med-
ical Association present to that body a suggestion for a com-
mittee to study the various state licensure laws, and to draw up
a model license law, which could be presented to each state
legislature. With such endorsement, most legislatures would
make the necessary changes, and reciprocity would be greatly
facilitated.
During the present emergency with the migration of popula-
tions, migration of physicians is being hampered somewhat by
differing state license requirements. This is apt to bring about
a demand on the part of the public for national licensing of
physicians, so that the states would lose control of this function.
The same end could be attained through uniform state licens-
ing laws and no state authority surrendered. At the same time,
migration of physicians from one state to the other could be
freely made, and we would not be put in the position of saying
that a man who is a good doctor in one state is not a good
doctor in any other state.
In 1942, there were five licensed to practice medicine by ex-
amination and five by reciprocity in South Dakota. In the last
five years there have been a total of 45 licenses to practice
issued in the state. Of those taking examinations, none has
failed to pass.
There are now seventeen states that have basic science laws
and require a basic science certificate as one of the prerequisites
to obtaining a license to practice any healing art. Our law has
now been in effect since July 1, 1939. No osteopath or chiro-
practor took the examination in 1942.
Seven physicians or medical students were issued certificates
by reciprocity or endorsement and thirteen by examination, two
having taken the examination and failed. Seventeen osteopaths
and one chiropractor were issued certificates by reciprocity or
endorsement.
G. W. Mills, M.D., Chairman.
REPORT OF COMMITTEE ON EDUCATION
AND HOSPITALS
The American Urological Association in its annual executive
session, New York City, June 3, 1942, adopted the resolution
recommending the teaching of a minimum of two years of Span-
ish and/or Portuguese, in all educational institutions which
prepare students for the study of medicine, and that medical
schools of the United States require for entrance a minimum
of two years of Spanish and/or Portuguese. The purpose of
this action is to establish a better mutual understanding between
the Latin American and English-speaking countries of the
Western Hemisphere, and to encourage the training of Latin
American students, both undergraduate and postgraduate, in
the schools of the United States and Canada. It is recognized
that, previous to the present world crisis, the movement of
South American students has been toward the European med-
ical centers.
The Committee on Education of the South Dakota State
Medical Association recommends the support of this action by
the American Urological Association, and urges the adoption
by this Association of the following resolutions:
Whereas, The close association of the physicians of the West-
ern Hemisphere for the purpose of facilitating the interchange
of scientific knowledge would afford one basis for mutual under-
standing and good will; and
Whereas, The South Dakota State Medical Association de-
sires to contribute to the establishment of such a relationship;
and
Whereas, The members of the South Dakota State Medical
Association believe that one of the obstacles in the way of mu-
tual understanding is the difference in languages;
Therefore, Be It Resolved, That the South Dakota State
Medical Association in executive session, May 28, 1943, recom-
mends:
(a) That all of the educational institutions of the United
States which prepare students for the study of Medicine teach a
minimum of two years of Spanish and/or Portuguese;
(b) That the medical schools of the United States require
for entrance a minimum of two years of Spanish and/or Portu-
guese;
(c) That a minimum of two hours a week, during the scho-
lastic year, of conversational Spanish and/or Portuguese be re-
quired as a part of the entire term of the medical curriculum;
(d) That attempts be made to encourage physicians who
speak Spanish and/or Portuguese to conduct courses of lectures
in these languages for students of Medicine;
(e) That an attempt be made by the medical schools of the
United States, both undergraduate and postgraduate, to stimu-
late and foster by every means possible, including the student
exchange program, the training in the schools of the United
States and of Canada of Latin American students;
(f) That a copy of these resolutions be mailed to the Med-
ical Department of the State University of South Dakota and
to all educational institutions of the state which prepare stu-
dents for the study of medicine.
F. J. Tobin, M.D., Chairman.
REPORT OF COMMITTEE ON NECROLOGY
During the year just passed since our annual session, the
Divine Ruler of the Universe has, in His inscrutable wisdom,
seen fit to call from this earth a number of our brother physi-
cians. May we here pause for a few moments to pay our re-
spects to their memory. They have done their bit to make this
world of ours a better place in which to live and have given un-
selfishly of themselves that suffering of humanity may be alle-
viated. Let us, as we pause, rededicate ourselves to that un-
finished task — service to mankind, which they have left to us.
JOSIAH COATES LLOYD. M.D., Platte, S. D. Died
May 25, 1942.
RAY ARTHUR KELLY, M.D., Mitchell, S. D., was bom
in 1882. Graduated from the University of Iowa College of
Medicine in 1907. Licensed in 1908. Was a diplomate of the
American Board of Otolaryngology. He was a member of the
South Dakota State Medical Association at the time of his
death, June 6, 1942.
THOMAS CRUICKSHANK, M.D., Vermillion, S. D.,
July, 1943
201
was born in 1864. Graduated from the Barnes Medical Col-
lege in St. Louis in 1899, being licensed in the same year. He
practiced in Vermillion for many years and at the time of his
death, August 5, 1942, was retired. He was a member of the
South Dakota State Medical Association.
THOMAS JEFFERSON CASE, M.D., Delmont, S. D.,
j was born in 1862. Graduated from the Rush Medical College
in 1889. Was licensed in 1920. He died Sept. 4, 1942.
LORENZO NELSON GROSVENOR, M.D., Huron, S. D
Graduate of Chicago Homeopathic Medical College 1889 and
Rush Medical College in 1902. He practiced in Chicago prior
to coming to Huron in 1913. Dr. Grosvenor was a Fellow of
the American College of Surgeons, specialized in Eye, Ear,
Nose and Throat. He was president of South Dakota State
Medical Association in 1930, past president of the Tri-State
Ophthalmoiogical Society and a member of the Ophthalmo-
logical Society of Chicago, member and past president and sec-
retary of the Huron District Medical Society and, at the time
of his death, Superintendent of the Beadle County Board of
Health. Dr. Grosvenor died November 26, 1942, in a hospital
in Rochester, Minnesota, of a cardiac attack following an op-
eration performed on Nov. 14, at the age of 74.
JOHN J. AHERN, M.D., Oldham, S. D„ was born in
, 1868. He was graduated from the Physiomedical College of
Indianapolis, Indiana, in 1896, licensed in Illinois in 1897 and
in South Dakota in 1910. He was retired at the time of his
death, January 14, 1943.
JOHN FRANKLIN DUFFERIN COOK, M.D., Pierre,
! S. D., was graduated from the University of Illinois College
of Medicine in 1897. He was licensed in 1897 and for many
years practiced medicine in Langford, South Dakota. He was
a Fellow of the American College of Surgeons, the South Da-
kota State Medical Association and First District Medical So-
ciety. He was secretary-treasurer of the State Medical Associa-
tion from 1925 to 1937, was president of the South Dakota
I State Medical Association in 1938 and, at the time of his
death, was Superintendent of the State Board of Health and
director of medical licensure. These positions he had held for
several years. His death occurred in Pierre on January 27,
1943, of postoperative complications at the age of 71.
I HENRY F. BRIGHT, M.D., Alcester, S. D., died March
22, 1943.
FRANCIS ALDEN MOORE, M.D., Yankton, S. D., was
born in 1872. Graduated from the Minneapolis College of
Physicians and Surgeons in 1898. Licensed in 1898. He re-
tired in 1940 and died at his home in Yankton, March 24,
1943.
ALBERTUS L. LLOYD, M.D., Rapid City, S. D., was
born in 1866. Graduated from Baltimore Medical College in
1898 being licensed in the same year. He was retired at the
time of his death, March 27, 1943.
REPORT OF THE RADIO COMMITTEE
This is probably the only committee making a report wherein
individual effort and time is expended. Regularly each and
every Sunday a physician is at the studio for a fifteen minute
medical broadcast under our auspices. We do not think the
physicians of the state know enough of this program nor do
they realize the significance of it, yet, as heretofore, we are
going to ask this body to continue its radio program.
For the past year the broadcast has been from KSOO at
Sioux Falls only, each Sunday afternoon. Aberdeen did not
continue the program this year, nor was it possible to establish
one in the Black Hills section.
As originally planned, the only papers read were from physi-
cians of the state, but, as time went on, these papers became
increasingly difficult to obtain, so the past year all papers have
been obtained elsewhere.
Appended to this report is a letter from Dr. H. R. Hummer
of Sioux Falls who has so faithfully radioed these papers. This
committee requests that letters of acknowledgment and appre-
ciation be sent to Dr. Hummer, and also to the management of
the KSOO station, and further recommends a continuance of
the program.
Will E. Donahoe, M.D., Chairman.
Sioux Falls, S. D., May 12, 1943.
W. E. Donahoe, M.D.,
City.
Dear Doctor Donahoe: —
Complying with your request I am sending you a line anent
the matter of the weekly broadcasts sponsored by the State
Medical Association, the State Board of Health and through
the courtesy of Station KSOO. While unable to give, with any
reasonable degree of accuracy, the value of these talks to the
public, nevertheless it is my sincere conviction that considerable
good has been done for many individuals in sending them to the
medical fraternity when the greatest good might be accom-
plished for them and also in re-establishing that patient-physi-
cian relationship which has proven so valuable in the past and
which might, in the future be entirely lost if we supinely per-
mit the threatened regimentation. I feel that these broadcasts
have nearly the same value to the public as the syndicated ar-
ticles appearing in the daily press to which the name of Dr.
Irving S. Cutter is attached. Comments from many individuals
and numerous letters asking advice, reference to physicians and
requesting copies of papers for educational purposes have given
me the impression that a continuation of these broadcasts, which
give so much to the public without cost to them, is strongly in-
dicated. Sometimes it is a small hardship to give up personal
engagements to meet the time of these broadcasts, but having
done so for about three and one-half years it has practically be-
come habitual. So long as these papers can be secured at a
nominal cost, and so long as someone is willing to sacrifice his
own time to read them, again without cost, I see no other course
to pursue except the continuation of the present course. Ac-
cordingly, I so recommend.
Sincerely yours,
H. R. Hummer, M.D.
(Appended to report of Radio Committee, May 28, 1943).
WOMAN’S AUXILIARY
TO THE SOUTH DAKOTA STATE
MEDICAL ASSOCIATION
Following the policy of the South Dakota State Med-
ical Asociation, its women’s auxiliary dispensed with the
annual meeting and confined itself to a session of the ad-
visory board and officers at Hotel Marvin Hughitt,
Huron, May 28. Yearly reports were read and the terms
of the officers renewed for a year. They are Mrs. John
C. Hagin, Miller, president; Mrs. D. S. Baughman,
Madison, president-elect; Mrs. G. S. Adams, Yankton,
first vice president; Mrs. A. E. Rudolph, Aberdeen, sec-
ond vice president; Mrs. E. S. Stenberg, Sioux Falls,
recording secretary; Mrs. E. T. Stout, Pierre, correspond-
ing secretary and treasurer. Present were Mmes. Hagin,
Baughman; M. W. Larsen, Watertown; J. C. Shirley,
Agnes Grosvenor, H. L. Saylor and B. T. Lenz, Huron;
G. E. Burman, Carthage, chairman public relations and
publicity; N. J. Nessa, Sioux Falls, bulletin; M. W.
Pangburn, Miller, exhibits.
202
ADDRESS OF THE PRESIDENT
N. J. Nessa, M.D.
Sioux Falls, South Dakota
The Journal-Lancet
To the House of Delegates, Members of the Council,
and Membership at Large of the South Dakota State
Medical Association, ... as your President, I bid you
welcome and extend kind greetings.
Another year has rolled by since our society met in
Sioux Falls during May, 1942, in conjunction with the
South Dakota Inter-allied Professional Council. In my
address as President-Elect at that time, I made mention
of my apprehension that quite likely our annual meet-
ing this year would prove to be different . . . and such
it has proven to be . . . inasmuch as it was decided at
the Councilor’s Meeting held here in Huron on Novem-
ber 25, 1942, that the scientific part of this year’s pro-
gram should be omitted on account of the war, with its
trail of sundry regulations which would prove so con-
flicting in arranging and securing the usual invited nota-
ble guest speakers from beyond our state border lines,
also with the anticipated poor attendance of our member-
ship due to difficulty of travel and the hardship of leav-
ing their practices. This is the 62nd annual session of
the South Dakota State Medical Association and our
Secretary informs me as follows:
"I have made a search of the records of the State As-
sociation and find that it was organized as the Dakota
Medical Association at" a meeting in Milbank on June 3,
1882. It was incorporated as the South Dakota State
Medical Association in 1891, and meetings were held
every year with the exception of 1893 when no meeting
was held. The next year’s meeting was called for June
13, 1894, at Huron and was adjourned for one week
same place, I presume because of lack of a quorum.
Some of the early meetings were held with five and six
in attendance. One meeting report read no business was
transacted for lack of a quorum. Those days in the early
eighties were no doubt trying because of the transporta-
tion difficulties.”
So much for a past history of our organization.
It was my wish and hopeful expectation that I could
have visited most of the integral societies during the past
year . . . but a busy practice, no available assistance-
ship, and traveling regulations definitely precluded such
ambition. I have, however, represented our society on
two different occasions at a National Conference in St.
Paul, Minnesota, for the purpose of becoming acquaint-
ed with and learning the facts regarding a pending reso-
lution to be introduced at the coming A.M.A. delegates’
meeting in Chicago. This matter will be brought up
(under New Business) at this meeting for instruction
to your delegate.
During the year, our dearly beloved President of the
State Board of Health, who was also an ex-President of
this society, Dr. W. F. D. Cook, passed on to the great
beyond and thereby caused a vacancy in that office. Our
genial and capable legal advisor, Mr. Karl Goldsmith,
at that time suggested that the officers come to Pierre
for consultation with the governor relative to the pend-
ing appointment to fill the vacancy, and also to give us
the opportunity to visit the legislative bodies as well.
Your President-Elect, Secretary, Vice President, and my-
self made the trip and consulted with the members of
the Health Department and the governor. It was felt
that the salary for the office of President of the State
Board of Health at $3200 was too low, and we felt that
a new bill should be introduced at this session which
would properly remedy the same. As you quite likely
know, the legislators did see fit to raise the salary to
$3600 a year. Dr. Cook’s vacancy has only recently been
filled by the governor, by the appointment of Dr. Gilbert
Cottam of Sioux Falls for this position, and Dr. Cottam
is also an ex-President of this society. I, personally, feel
that the State Health matters will be carefully and well
managed under this appointment.
I desire also at this time to give you a short resume of
the Session Laws for 1943 of interest to our profession,
as furnished by Mr. Karl Goldsmith. They are as fol-
lows:
SB 41 — Repeals the South Dakota Income Tax Law.
SB 19 — Changes the present law relating to pharma-
cies. It restricts the issuance of a permit to conduct a
pharmacy to a pharmacist in good standing, registered
under the laws of this state; provides for the transfer of
such permits; and sets up certain sanitary requirements
and the keeping of an adequate supply of pharmaceuti-
cals, together with the necessary instruments and utensils
to conduct a pharmacy.
SB 129 — Amends the Basic Science Law so that
those exempted under the present law are exempted only
so long as their treatments do not infringe, invade, en-
croach or intrude upon, or simulate the therapy of those
required by the Act to obtain a Basic Science Certificate,
and further providing that the exemptions in the present
law shall apply only to those persons and to the extent
specifically mentioned therein.
HB 32 — Requires osteopaths to pay an annual regis-
tration fee and to attend an annual clinic.
HB 145 — Raises the salary of the Superintendent of
Public Health from $3200 to $3600 per year, but added
the provision that he should receive no other pay or com-
pensation from any source whatsoever.
HB 84 — Raises the maximum medical and surgical
fees in compensation cases from $100 to $200.
HB 157 — Raises the minimum wages for women in
towns or cities having a population over 2500 from $12
to $15 per week. The bill is expressly limited to expire
at the close of the next legislative session.
HB 206 — Provides for the sterilization of certain of
the inmates of the State Hospital at Yankton.
I am sure it has been the ambition of all past Presi-
dents of this society to propose some service to the mem-
bership and profession which would prove helpful. I,
myself, have such a desire, and it manifests itself in a
report, which I hope will be favorably recommended by
the Economics Committee and your vote in this House
of Delegates.
./
1
t
•
'iv
'•
*
j
203
July, 1943
It consists of an opportunity to all members of our
State Society to be qualified to obtain non-cancelable
Health and Accident protection, in a strong company, at
a reduced rate, with liberal coverage and protection, with
the only qualification necessary for obtaining same, a
membership in this association. I cannot claim this idea
all my own as it was your President-Elect, Dr. Ohl-
macher, who called my attention to the matter, but I
was thoroughly sold on the idea and turned it over to
the proper committee for their report. If there is any-
one in our society who is unable to secure such a policy
or who is interested in obtaining additional protection,
then here is his opportunity. We have heard a great
deal about the "Four Freedoms” of late, namely, Speech,
Worship, Want and Fear .... but a recent writer,
Herbert Hoover, also adds Economic freedom. Surely
when a doctor is stricken with illness or accident to the
extent of physical disability, this fifth or "Economic”
freedom becomes a kind and benevolent guest.
Some loose talk is filtering through the press regard-
ing "Social Security from the cradle to the grave” or
"from the womb to the tomb.” The politicians foster-
ing this utopia, of course include medical service and
supervision. Again quoting Hoover . . .
"When a government goes into business in competi-
tion with citizens . . . bureaucracy always relies on
tyranny to win . . . and bureaucracy never develops
that competence in management which comes from the
mills of competition. Its conduct of business inevitably
lowers the living standards of the people. Nor does bu-
reaucracy ever discover or invent. A Milliken, Ford, Edi-
son, or Mayo never came from a bureaucracy. An in-
herent characteristic in a bureaucracy is the grasping
spirit of more and more power. One of the illusions of
our time is that we can have totalitarian economics and
personal freedoms . . . but ten nations on the conti-
nent of Europe tried it and wound up with dictators and
no liberty. Liberty has its greatest protection from local
and not centralized government.”
I also wish to pay tribute to the work in our state
rendered by the Woman’s Field Army dealing with the
dissemination of knowledge relative to the control of
cancer. Mrs. Tollevs, our state director, is an active and
enthusiastic worker, and by the distribution of literature
furnished from headquarters through her to the people,
I am sure that a great benefit will result ... as only
by attacking this enemy of the human race by honest
and truthful information can progress be attained.
In conclusion, I wish to thank you one and all most
sincerely for the great honor and kind cooperation you
have given me during the year to act as your humble
president; and I extend to our incoming president, Dr.
Ohlmacher, my best wishes for a coming successful year
to our society. I thank you.
SOUTH DAKOTA STATE MEDICAL ASSOCIATION
ROSTER- 1943
PRESIDENT
Paul Bunker Aberdeen
SECRETARY
J. E. Bruner Aberdeen
; Aldrich, H. H. .... .... Wessington
Alway, J. D. Aberdeen
*Bates, W. A. Aberdeen
★ Bloemendall, G. J. Ipswich
Brenckle, J. F. , Mellette
Brinkman, W. C. Veblen
Bruner, J. E. Aberdeen
Bunker, Paul Aberdeen
PRESIDENT
R. T. Maxwell Clear Lake
SECRETARY
M. W. Larsen Watertown
Mdams, M. E. Clark
Bartron, H. J. Watertown
Bates, J. S. .... Sioux Falls
Brown, H. R. Watertown
Christensen, A. H Clark
PRESIDENT
E. H. Grove Arlington
SECRETARY
C. M. Kershner Brookings
Baughman, D. S. Madison
★Boyd, F. E. Fland reau
Davidson, Magni Brookings
Drobinsky, Miguel Estelline
*Engelson, C. J. Brookings
MEMBERSHIP BY DISTRICTS
ABERDEEN DISTRICT No. 1
Calene, J. L. Aberdeen
Cooley, F. H. Aberdeen
Drissen, E. M. Britton
Eckrich, J. A Aberdeen
*EIward. L. R. .... Doland
Farrell, W. D. . Aberdeen
^Freyberg, F. W. Conde
★Gelber, R. M. Aberdeen
Graff, L. W. . Britton
King, H. I. Aberdeen
Kositzky, A. Leola
★Krugich, S. J. .. Aberdeen
Marvin, Thomas R. Faulkton
WATERTOWN DISTRICT No. 2
★Cooper, Geo. Watertown
Crawford, J. H., Jr Watertown
Hammond, M. J Watertown
Hickman, G. L. . Bryant
Jorgenson, M. C. . Watertown
Kenney, H. T. Watertown
Kilgaard, R. M. .... Watertown
Larsen, M. W. .... ___ _ Watertown
Magee, W. G. Watertown
Maxwell, R. T. Clear Lake
MADISON DISTRICT No. 3
Grove, E. H. Arlington
Gulbrandsen, G. H. Brookings
Hofer, E. A. Howard
Hopkins, N. K. Arlington
Jordan, L. E. Chester
Kershner, C. M. Brookings
Miller, H. A. Brookings
Muggly, J. A. Madison
Peeke, A. P. Volga
Sherwood, C. E. Madison
Mayer, R. G.
Aberdeen
★McCarthy, Paul ...
Aberdeen
Murdy, B. C.
Aberdeen
Murdy, Robert ....
Aberdeen
Newkamp, Hugo
Hosmer
Pittenger, E. A.
Aberdeen
Ranney, T. P.
Aberdeen
Rudolph, E. A. ..
Aberdeen
Scallin, P. R.
Redfield
★Schuchardt, I.
Aberdeen
Weishaar, Chas.
.... Aberdeen
White, W. E.
Ipswich
Whiteside, J. D.
. Aberdeen
McIntyre, P. S.
. Bradley
Randall, O. S.
.... Watertown
Richards, Geo.
Watertown
★ Rousseau, M. C. ....
Watertown
Schieb, A. P.
.... Watertown
Sherwood, H. W. ...
Doland
Vaughn, J. B
... Castlewood
Walters, S. I
.... Watertown
Willen, Abner
... Clark
Tank, M. C.
Brookings
Tillisch, H.
Brookings
*Torwtck, E. E.
Volga
Torwick, E. T.
Volga
Watson, E. S.
Brookings
Westaby, J. R.
Madison
* Westaby, R S
Flint, Mich.
Whitson, G. E.
. ... Madison
Willoughby, F. C. ..
Howard
204
The Journal-Lancet
PIERRE DISTRICT No. 4
PRESIDENT
E. H. Collins
Gettysburg
SECRETARY
M. M. Morrissey . ... Pierre
Burgess, R. E. . Gettysburg
Carney, J. G. Ft. Pierre
Collins, E. H. Gettysburg
PRESIDENT
Harry Sewell
Huron
SECRETARY
R. A. Buchanan
Huron
★ Adams, H. P.
Huron
PRESIDENT
E. M. Young Mitchell
SECRETARY
Robert Weber
Mitchell
Alcott, F. B.
... Chamberlain
Auld, C. V.
... Plankington
Ball, W. R.
Mitchell
Beukelman, W. H.
Stickney
Bobb, B. A.
Mitchell
Bobb, C. S.
Mitchell
Bollinger, Wm. F.
Parkston
Cochran, F. B.
... Plankington
PRESIDENT
O. C. Erickson
Sioux Falls
SECRETARY
C J. McDonald
Sioux Falls
Billingsley, P. R.
Sioux Falls
Billion, T. J. -
Sioux Falls
★ Billion, T. J., Jr
Sioux Falls
Bliss, R. J.
Sioux Falls
Carney, Myrtle S.
Pierre
Clark, J. C.
Sioux Palls
Cottam, G. I W.
Sioux Falls
*Cottam, Gilbert
Pierre
★Craig, Allen —
Sioux Falls
*Craig, D. W. ....
Sioux Falls
*Culver, C. F.
Sioux Falls
Cunningham, R. S
Sioux Falls
Dehli, H. M.
Colton
DeVall, F. C.
Garretson
Donahoe, S. A.
Sioux Falls
Donahoe, W. E.
Sioux Falls
★ Duimstra, Fred
Sioux Falls
Creamer, F. H.
Dupree
Northrup, F. A.
Cowan, J. T.
Pierre
Riggs, T. F.
★ Dyar, B. A.
. Atlanta, Ga.
Robbins, C. E.
Pierre
*Hart, B. M. . Los Angeles, Calif.
★Salladay, I. R.
Pierre
Kimble, O. A.
Murdo
Schultz, S.
Martin, H. B.
Harrold
Triolo, A.
Morrissey, M. M. .
Pierre
★Van Heuvelen, G. J
Pierre
Murphy, Joseph ....
Murdo
HURON DISTRICT No. 5
Buchanan, R. A.
Huron
Saxton, W. H.
Fluron
Burman, G. E.
Carthage
Saylor, H. L.
Fluron
Hagin, J. C.
Miller
Sewell, FI. D.
Lenz, B. T.
Lightner, C. M.
Alpena, Mich.
Tschetter, J. C.
Huron
Pangburn, M. W.
.. Miller
Tschetter, Paul
DeSmet
MITCHELL DISTRICT No. 6
DeVries, A.
Platte
McGreevy, J. V.
Delaney, Wm. A.
Mitchell
Mabee, D. R.
Mitchell
Dick, L. C
Spencer
Mabee, O. J.
Mitchell
★ Ferris, W. T.
.. Chamberlain
Maytum, W. J. .....
Alexandria
Gifford, A. J.
Alexandria
Reib, W. G
Parkston
Gillis, F. D. .....
Mitchell
Stegeman, S. B.
Holleman, W. W. .
Corsica
Tobin, F. J.
Mitchell
Hoyne, A. H.
Salem
★ Tobin, L. W.
Mitchell
Jones, E. W.
Mitchell
Wallis, S. R.
Armour
★Jones, J. P.
Mitchell
Weber, R. A
Mitchell
Jones, T. D.
Chamberlain
Wilson, Frank D.
Chamberlain
Keene, F. F Wess
ington Springs
Young, E. M.
Mitchell
Lloyd, J. H.
. Mitchell
SIOUX FALLS DISTRICT No. 7
Dulaney, C. H.
Canton
Nelson, J. A.
Sioux Falls
Erickson, O. C.
Sioux Falls
Nessa, N. J.
. Sioux Falls
Erickson, E. G.
Sioux Falls
★Nietfeld, A.
. Sioux Falls
Fisk, R. R.
Flandreau
Nilsson, F. C.
. Sioux Falls
^Fitzgibbons, G
Sioux Falls
^Olson, Orland
_ Sioux Falls
Gage, E. E.
Sioux Falls
Opheim, O. V.
. Sioux Falls
Gregg, J. B.
.... Sioux Falls
Pankow, L. J.
Sioux Falls
Groebner, O. A. ....
Sioux Falls
Parke, L. L.
Canton
Grove, A. F.
Dell Rapids
*Posthuma, Anne
. Sioux Falls
Hanson, O. L.
Valley Springs
Reagan, Resin
Sioux Falls
Hummer, H. R.
.. . Sioux Falls
^Roberts, W. P.
Sioux Falls
Hofer, E. J.
Freeman
★Sackett, R. F.
Rapid City
Hyden, Anton
.— Sioux Falls
Sercl, W. F.
. Sioux Falls
Keller, S. A.
. .. Sioux Falls
Stenberg, E. S.
. Sioux Falls
Kemper, C. E. .
Viborg
Stevens, R. G.
Sioux Falls
Kittleson, J. A.
Sioux Falls
Stevens, G. A.
. Sioux Falls
Lamb-Barger, H. H
Sioux Falls
Stone, J. G.
Montrose
Lanam, M. O.
.... Sioux Falls
Van Demark, G. E.. .
Sioux Falls
Leraan, L. G.
Sioux Falls
Volin, H. P.
Lennox
★ Lovre, S. C.
Humboldt
Zimmerman, Goldie
Sioux Falls
McDonald, C. J
_ ... Sioux Falls
★ Zellhoffer, H. W. K.
Sioux Falls
Mullen, R. W.
... Sioux Falls
PRESIDENT
F. J. Abts Yankton
SECRETARY
J. A. Hohf Yankton
Abts, F. J. Yankton
Adams, G. S. ... Yankton
★Andre, H. C. Vermillion
Blezek, F. M. Tabor
Brookman, L. J. Vermillion
★ Bushnell, J. W. Elk Point
Bushnell, Wm. F. Elk Point
Bury, Chas. F. Geddes
Conner, E. I. Pasadena, Calif.
★ Dick, Fred Vermillion
YANKTON DISTRICT No. 8
Duggan, T. A. Wagner
Fairbanks, W. H. Vermillion
Greenfield, J. C Avon
Giedt, W. R Pierre
Haas, F. W. Yankton
★Hanson, H. F. Vermillion
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
Lacey, V. I. Yankton
Landmann, G. A. Scotland
Leonard, B. B Yankton
Lietzke, E. T. Beresford
★Malloy, J. F. Yankton
Morehouse, E. M. Yankton
★Neisius, F. A Platte
Ohlmacher, J. C. Vermillion
Reding, A. P. Marion
Schwartz, E. R. Wakonda
Smith, A. J. Yankton
Stansbury, E. M. Vermillion
Willhite, F. V. Redfield
★Williams, F. E. Wakonda
Wynegar, D. E Chattahoochee, Fla.
July, 1943
205
PRESIDENT
W. E. Matlock Deadwood
SECRETARY
J. D. Bailey Rapid City
Bailey, J. D. Rapid City
Bailey, S. G. Hot Springs
Bestgen, Fred P. Grand Island, Neb.
Bilger, F. W. Hot Springs
Butler, J. M. . Hot Springs
★Clark, B. S. Spear fish
Clark, O. H. Newell
Crane, H. L. L’Orya, Peru
★ Davidson, H. E. Lead
Dawley, W. A. Rapid City
★ Dickinson, John H Buffalo
Doyle, J. I. Rapid City
Ewald, P. P. Lead
Fleeger, R. B. Lead
Fuchlow, J. R. . Rapid City
Hare, Lyle — Spearfish
PRESIDENT
J. E. Studenberg Gregory
SECRETARY
R. V. Overton Winner
PRESIDENT
J. E. Curtis Lemmon
SECRETARY
L. D. Harris ... Mobridge
★Catey, Robert Mobridge
PRESIDENT
SECRETARY
D. A. Gregory Milbank
Cliff, F. N. .... Milbank
* Honorary or Affiliate Member.
★Member of the Armed Services.
BLACK HILLS DISTRICT No. 9
★ Hayes, P. W.
_. Hot Springs
Howe, F. S. ....
Deadwood
Hultz, E. B.
Hill City
★ Hummer, F. L. .
Lead
Jackson, A. S.
Lead
Jackson, R. J
Rapid City
Jernstrom, R. E.
Rapid City
Kegaries, D. L.
Rapid City
★ Lemley, R 1
.. Rapid City
★ Lampert, A. A.
Rapid City
Manning, F. E.
Custer
Matlock, W. E.
. Deadwood
★McGonigle, J. P.
Rapid City
McKie, John F.
Sturgis
Mattox, N. E.
Lead
★ Merryman, M. P.
Rapid City
Meyer, W. L.
Sanator
Mihran, M. K.
... Rapid City
Mills, G. W.
Wall
Minty, F. W.
Rapid City
Morse, W. E.
Rapid City
ROSEBUD DISTRICT No. 10
Carmack, A. O.
... Colome
Lande, L. E.
Winner
Malster, R. M.
Carter
Overton, R. V. ....
Winner
NORTHWEST DISTRICT No. 1 1
Curtis, J. E. ...
Lemmon
Christie, Roy E.
Eureka
★ Duncan, C. E.
Pollock
George, W. A.
Selby
Harris, L. D.
Mobridge
Lien, H. D.
... Chicago, 111.
Morsman, C. F.
Hot Springs
Newby, H. D.
.... Rapid City
★ Nyquist, Roy H
Ft. Meade
O'Toole, T. F. New Underwood
★Owen, G. S.
Rapid City
Pemberton, M. O. __
Deadwood
Phillips, Samuel
Sanator
Radusch, Freida
Rapid City
Richards, F. A. ....
Sturgis
Shapiro, B
Rapid City
★Sherman, K. E. ....
Sturgis
★Sherrill, S.
Belle Fourche
★Smiley, J. C.
Deadwood
★Soe, Carl A. .. .
Lead
Spain, M. L.
Hot Springs
*Stewart, J. L.
Spearfish
★Stewart, M. J.
Sturgis
Stewart, N. W.
Lead
Sundet, N. J.
Kadoka
Threadgold, J. O
Belle Fourche
★Zarbaugh, Guy F.
Deadwood
Quinn, R. J. ......
Burke
Studenberg, J. E. ...
Gregory
Lima, Frank Mobridge
Lowe, C. E Mobridge
Sawyer, J. G. Mobridge
Spirey, A. W. . Mobridge
Totten, F. C. Lemmon
Karlins, W. H. Webster
Murphy, T. W. Bristol
Peabody, P. D., Sr. Webster
Peabody, P. D., Jr. Webster
★ Pfister. Faris .... Webster
WHETSTONE VALLEY DISTRICT No. 12
Duncan, Wm. Webster
Flett, Chas. Milbank
Gregory, D. A. Milbank
Hedemark, T. A. Revillo
Jacotel, J. A. . Milbank
Judge, W. T. _. Milbank
ROSTER
South Dakota State Medical Association-- 1943
Abts, F. J.
Yankton
Adams, G. S.
Yankton
Alcott, F. B.
. .. Chamberlain
Aldrich, H. H.
Wessington
Alway, J D.
Aberdeen
Auld, C. V.
Plankington
Bailey, J. D.
Rapid City
Bailey, S. G. .
... Hot Springs
Ball, W. R.
Mitchell
Bartron, H. J.
Watertown
Bates, J. S.
Sioux Falls
* Bates, W. A.
Aberdeen
Baughman, D. S.
Madison
Bestgen, Fred
Rapid City
Bilger, F. W. .......
.... Hot Springs
Billingsley, P. R.
Sioux Falls
Billion, T. J.
Sioux Falls
Blezek, F. M. ...
Tabor
Bobb, B. A.
Mitchell
Bobb, C. S. ....
Mitchell
Bollinger, W. F.
Parkston
Brenckle, J. F.
Mellette
Brinkman, W. C ..
Veblen
Brookman, L. J. ...
Vermillion
Brown, H. R
Watertown
Bruner, J. E.
Aberdeen
Buchanan, R. A. ...
Huron
Bunker, Paul
Aberdeen
Buekelman, W. H.
Stickney
Bury, Chas. F.
Geddes
Burman, G. E. ...
- . .. Carthage
Bushnell, W. F. .....
Elk Point
Butler, J. M.
Hot Springs
Calene, J. L.
Aberdeen
Carmack, A. O.
Colome
Carney, G. J. ...
Ft. Pierre
Carney, Myrtle S. ._
Sioux Falls
Catey, Robert
Mobridge
Christie, Roy
Eureka
Clark, J. C ......
Sioux Falls
Clark, O. H. Newell
Cliff, F. N. .. ... Milbank
Cochran, F. B. .... Plankington
Collins, E. H. Gettysburg
Conner, E. I. Pasadena, Calif.
Cooley, F. H. Aberdeen
Cottam, G. I. W. Sioux Falls
*Cottam, Gilbert ... Pierre
Cowan, J. F. - Pierre
*Craig, D. W. Sioux Falls
Crane, H. L. L’Orya, Peru
Crawford, J. H., Jr. Watertown
Creamer, F. H Dupree
*Culver, C. F. Sioux Falls
Cunningham, R. S Sioux Falls
Curtis, J. E. Lemmon
Davidson, Magni . ... Brookings
Dawley, W. A. Rapid City
Dehli, H. M. Colton
Delaney, Wm. A. Mitchell
206
The Journal-Lancet
DeVall, F. C.
Garretson
Dick, L. C.
Spencer
DeVries, A.
Platte
Donahoe, S. A.
.... Sioux Falls
Donahoe, W. E. ...
. Sioux Falls
Doyle, Jas. I.
Rapid City
Drissen, E. M.
Britton
Drobinsky, Miguel
Estelline
Duggan, Thos. A.
Wagner
Dulaney, C. H.
Canton
Duncan, C. E.
St. Louis, Mo.
Duncan, Wm.
Webster
Eckrich, J. A.
Aberdeen
*Engelson, C. J. ...
Brookings
Erickson, E. G
Sioux Falls
Erickson, O. C.
Sioux Falls
Ewald, P. P.
Lead
Fairbanks, W. H.
Vermillion
Farrell, W. D
Aberdeen
Fisk, R. R.
Flandreau
Fleeger, R. B.
Lead
Flett, Chas.
Milbank
Fuchlow, J. R.
Rapid City
Gage, E. E
Sioux Falls
George, W. A. ....
Selby
Giedt, W. R.
Pierre
Gifford, A. J.
Alexandria
Gillis, F. D.
Mitchell
Graff, L. W.
Britton
Greenfield, J. C.
Avon
Gregg, J. B.
Sioux Falls
Gregory, D. A.
Milbank
Groebner, O. A.
Sioux Falls
Grove, A. F.
Dell Rapids
Grove, E. H
Arlington
Guldbrandson, G.
H. Brookings
Haas, F. W.
Yankton
Hagin. J. C,
Miller
Hammond, M. J.
Watertown
Hanson, O. L.
Valley Springs
Hare, Lyle
Spearfish
Harris, L. D.
Mobridge
*Hart, B. M. Los Angeles, Calif.
Hedemark, T. A.
Revillo
Hofer, E. A.
Howard
Hofer, E. J.
Freeman
Hickman, G. L. .
Bryant
Holleman, W. W.
Corsica
Hohf, J. A.
Yankton
Hohf, S. M.
Yankton
Hopkins, N. K. ....
Arlington
Howe, F. S.
Deadwood
Hoyne, A. H
Salem
Hultz, E. B.
Hill City
Hummer, H. R. ....
.... Sioux Falls
Hyden, Anton ....
Sioux Falls
Jackson, A. S.
Lead
Jackson, R. J .
Rapid City
Jacotel, J, A.
Milbank
Jernstrom, R. E.
.... Rapid City
Johnson, G. E.
Yankton
Jones, E. W.
Mitchell
Jones, T. D.
.... Chamberlain
Jordan, L. E.
Chester
Jorgenson, M. C. .
Watertown
Joyce, E
Hurley
Judge, W. T.
Milbank
*Kalayjian, D. S. ..
Parker
Karlins, W. H.
Webster
Kauffman, E. J. ...
Marion
*Keeling, C. M. ...
Springfield
Keene, F. F Wessington Springs
Kegaries, D. L. ....
Rapid City
Keller, S. A.
Sioux Falls
Kemper, C. E.
Viborg
Kenney, H. T.
Watertown
Kershner, C. M.
Brookings
Kilgard, R. M.
. Watertown
Kimble, O. A.
Murdo
King, H. I. ..
Aberdeen
Kittelson, J. A.
.... Sioux Falls
Kositzky, A.
Leola
Lacey, V. I.
Aberdeen
Lamb-Barger, Hazel
Sioux Falls
Lanam, M. O. ....
.... Sioux Falls
Lande, L. E.
Winner
Landmann, G. A.
Scotland
Larsen, M. W.
... Watertown
Lenz, B. T.
Huron
Leonard, B. B. ....
Yankton
Leraan, L. G.
.... Sioux Falls
Lien, H. D.
. Chicago, 111.
Lietzke, E. T.
Beresford
Lightner, C. M.
Alpena, Mich.
Lima, Frank
Mobridge
Lloyd, J. H.
Mitchell
Lowe, C. E.
Mobridge
McDonald, C. J. ....
Sioux Falls
McGreevy, J. V. ...
Mitchell
McIntyre, P. S.
Bradley
McKie, John F.
Sturgis
Mabee, D. R.
Mitchell
Mabee, O. J.
Mitchell
Magee, W. G.
Watertown
Malster, R. M.
Carter
Manning, F. S.
Custer
Martin, H. B.
Harrold
Marvin, Thos. R. ....
Faulkton
Matlock, W. L. ..
Deadwood
Mattox, N. E. ...
Lead
Maxwell, R. T.
.... Clear Lake
Mayer, R. G.
Aberdeen
Maytum, W. J.
... Alexandria
Meyer, W. L.
Sanator
Mihran, M. K. ....
.... Rapid City
Miller, H A.
Brookings
Mills, G. W
. Wall
Minty, F. W .
Rapid City
Morehouse, E. M. ..
Yankton
Morrissey, M. M. ...
Pierre
Morse, W. E.
.... Rapid City
Morsman, C. F.
. Hot Springs
Muggly, J. A.
Madison
Mullen. R. W.
... Sioux Falls
Murdy, B. C. ... ._ .
Aberdeen
Murdy, Robert
Aberdeen
Murphy, Joseph
Murdo
Murphy, T. W.
Bristol
Nelson, J. A.
Sioux Falls
Nessa, N. J.
Sioux Falls
Newby, H. D.
... Rapid City
Newkamp, Hugo ....
Hosmer
Nilsson, F. C.
... Sioux Falls
Northrup, F. A.
Pierre
Ohlmacher, J. C
Vermillion
Opheim, O. V.
.... Sioux Falls
O'Toole, T. F. ... New Underwood
Overton, R. V ... ..
Winner
Pangburn, M. W. ...
. .. .... Miller
Pankow, L J.
.... Sioux Falls
Parke, I . L
Canton
Peabody, P. D., Jr.
Webster
Peabody, P. D., Sr. .
Webster
Peeke, A. P.
Volga
Pemberton, M. O. ...
Deadwood
Phillips, Samuel
Sanator
Pittenger, E. A. Aberdeen
*Posthuma, Anne Sioux Falls
Quinn, R. J. Burke
Radusch, Freida Rapid City
Randall, O. S. Watertown
Ranney, T. P. Aberdeen
Reagan, R. Sioux Falls
Reding, A. P. Marion
Richards, F. A. Sturgis
Richards, G. H. Watertown
Rieb, Wm. G. Parkstown
Riggs, T. F Pierre
Robbins, C. E. Pierre
Roberts, W. P. Sioux Falls
Rudolph, E. A. Aberdeen
Sawyer, J. G . Biloxi, Miss.
Saxton, W. H Huron
Saylor, H. L. Huron
Scallin, P. R. ... Redfield
Scheib, A. P. Watertown
Schultz, S. Phillip
Schwartz, E. R. ..... Wakonda
Sercl, W. F. Sioux Falls
Sewell, H. D. Huron
Shap iro, Barnet . Rapid City
Sherwood, C. E Madison
Sherwood, H. W. Doland
Shirley, J. C. Huron
Smith, A. J. Yankton
Spain, M. L. — Hot Springs
Spirey, A. W. Mobridge
Stansbury, E. M. Vermillion
Stegman, S. B. Salem
Stenberg, E. S. Sioux Falls
Stewart, J. L. Spearfish
Stewart, N. W. Lead
Stevens, G. A. Sioux Falls
Stevens, R. G. Sioux Falls
Stone, J. G. Montrose
Studenberg, J. E. Gregory
Sundet, N. J. Kadoka
Tank, M. C. Brookings
Threadgold, J. O. Belle Fourche
Tillisch, H. — Brookings
Tobin, F. J. Mitchell
*Torwick, E. E. Volga
Torwick, E. T. Volga
Totten, F. C. Lemmon
Triolo, A. Pierre
Tschetter, J. S. ..... Huron
Tschetter, Paul .... DeSmet
Van Demark, G. E._ Sioux Falls
Vaughn, J. B. Castlewood
Volin, H. P. Lennox
Wallis, S. R. Armour
Walters, S. J Watertown
Watson, E. S. Brookings
Weber, R. A Mitchell
Weishaar, C. H. Aberdeen
Westaby, J. R Madison
'•'Westaby, R. S. Flint, Mich.
White, W. E Ipswich
Whiteside, J. D. Aberdeen
Whitson, G. E. . Madison
Willen, Abner Clark
Willhite, F. V. Redfield
Willoughby, F. C. Howard
Wilson, F. D. . Chamberlain
Wynegar, D. E. Chattahoochee, Fla.
Young, E. M. ... .... Mitchell
Zimmerman, Goldie .... Sioux Falls
* Honorary or Affiliate Member.
July, 1943
207
PHYSICIANS OF SOUTH DAKOTA IN ARMED FORCES OF THE UNITED STATES
Adams, H. P. Huron
Adams, M. E. Clark
Andre, Hugo C. . Vermillion
Athey, G. L. Chamberlain
Auld, M. A. Yankton
Billion, T. J., Jr. Sioux Falls
Bliss, R. J. Sioux Falls
Bloemendall, G. J. ... Ipswich
Boyd, F. E. Flandreau
Burgess, R. E. Gettysburg
Bushnell, J. W. Elk Point
Catey, Robert Mobridge
Clark, B. S. Spearfish
Cooper, Geo. Watertown
Craig, Allen Sioux Falls
Davidson, H. E. Lead
Dick, Fred Vermillion
Duimstra, Fred .. Sioux Falls
Duncan, C. E. Pollock
Ferris, W. T. Chamberlain
Fitzgibbon, T. G.
Sioux Falls
Gelber, M. R.
. Aberdeen
Hanson, H. F Vermillion
Hanson, O. L., Jr. Valley Springs
Hayes, P. W. Hot Springs
Hubner, R. F.
Yankton
Hummer, F. L.
Lead
Jones, J. P.
Mitchell
Kittelson, Otis
Yankton
Kruzich, S. J.
Aberdeen
Lampert, A. A.
Rapid City
Lemley, R. E.
Rapid City
Lovre, S. C.
Humboldt
McCarthy, Paul V.
Aberdeen
McGonigle, J. P
Rapid City
Malloy, J. F.
Yankton
Merryman, M. P.
Rapid City
Nietfeld, A. B.
Sioux Falls
Nyquist, Roy H.
Ft. Meade
Olson, Orland
Sioux Falls
Owen, Stanley
.. Rapid City
Pfister, Faris
Rousseau, M. D.
Sackett, R. F.
Webster
... Watertown
Parker
Salladay, I. R.
Pierre
Schuchardt, I.
Aberdeen
Sherman, K. E.
Sturgis
Sherrill, S. ... .
Belle Fourche
Smiley, J. C. . ..
... Deadwood
Soe, Carl A.
Lead
Stewart, M. J.
.... Sturgis
Thompson, Arnold
Tobin, L. W.
Sioux Falls
Mitchell
Wayne, D. M.
Redfield
Williams, F. E.
Van Heuvelan, G. J.
Zarbaugh, G. F. ...
Zellhoffer, H. W. K
Wakonda
Pierre
Deadwood
Sioux Falls
Rocky Mountain Spotted Fever
A Nine Year Study of Wyoming Cases
George E. Baker, M.D., F.A.C.P.
Casper, Wyoming
Introduction
DURING the first week of May, 1941, the writer
was called to see a patient, a middle-aged rancher,
who had been brought to town for the purpose of
medical care. He complained of a continuous, severe
frontal headache, generalized aches and pains through-
out his body most marked in the back and lower extremi-
ties, and a dry, hacking cough existent for a period of
one or two days. This had followed a short period of
two or three days during which he had not felt up to
par and had noticed an unusual degree of fatigue. At
the time he became ill, the patient had been engaged in
lambing activities and had worked for long periods of
time under inclement weather conditions, without an
opportunity to change his clothes or bathe.
Examination revealed him to be quite ill. The tem-
perature was 104° F. The pulse of 90 was full and
bounding. The patient appeared anxious and yet dis-
played mental confusion. The face was flushed and the
eyes injected. The fauces and oropharynx were red-
dened and bronchial accentuation was found. The spleen
was palpable and tender. There were no changes in the
superficial or deep reflexes, but muscle tonus over the
body was definitely increased. Firm pressure over the
calf muscles or movement of them caused the patient to
wince from pain. He was markedly suntanned on the
exposed portions of the body, but close inspection re-
vealed the presence of a discrete, rose-red, petechial erup-
tion involving the wrists and ankles only. No crawling
or attached wood ticks were found. The patient admit-
ted that for a period of several weeks prior to becoming
ill he had found them in large numbers on his clothes
and person and had removed them without further pre-
cautions. Inasmuch as he had ranched in the present
locality for a period of forty years and had never con-
tracted tick-borne infections, it was his assumption that
he was immune to them. He had never received tick vac-
cine for the purpose of protection against tick fever.
To physicians practicing medicine in the western en-
demic localities, the obvious diagnosis would be that of
Rocky Mountain Spotted Fever, a disease commonly re-
ferred to as "tick fever” for the sake of brevity. Con-
tinued observation of the patient for a period of the
next few days, during which time the petechial eruption
spread over the remainder of the body, confirmed the
diagnosis. This in turn was substantiated by special
laboratory procedures. Had this particular patient pre-
sented himself for care to a physician not familiar with
the manifestations of the disease, or had he contracted it
in a locality where its presence was not anticipated, con-
siderable confusion as to the nature of the illness might
have ensued. Rocky Mountain spotted fever is no longer
considered to be a medical curiosity, limited to the west-
ern states and portions of adjacent areas, but is known
to be existent in many other sections of the country, far
removed from its once supposed locale. Many of those
who encounter it in the newly identified regions are un-
familiar with its manifestations. The subject of tick
fever is an extensive one. No attempt should be made
in a single article to deal with its many phases, but
rather to emphasize those of major significance in a dis-
ease entity, which may well in time assume proportions
of national importance.
208
Thf Journal-Lanc.ft
Symptomatology
Tick fever has a usual incubation period of from four
to eight days, the extremes being two to twelve. The
prodromal manifestations resemble those of any febrile
illness, there being malaise, headache, anorexia and chilly
sensations. They vary in degree, lasting an average of
two or three days.
The disease usually has an abrupt onset, initial symp-
toms often appearing in the late afternoon or early eve-
ning. There is a definite chill, pronounced frontal head-
ache, and severe aches and pains in the muscles, bones
and joints. The latter are more pronounced in the back
and lower extremities. Firm pressure over the calf muscles
or free motion of them often elicits pain. Crawling or
attached ticks are sometimes detected on the patient, but
usually none are found. Indurated sites of former attach-
ment may be palpated. Inspection of the bite areas re-
veals nothing unusual, with the exception of occasional
discolorations from subcutaneous blood extravasation.
There may be tenderness and palpability of the regional
lymph nodes.
An initial, elevated macular, rose-colored eruption is
sometimes found. Its presence is not distinctive. The
characteristic petechial eruption first appears on the ankles
and wrists twenty-four to forty-eight hours after the
onset of the disease. It is the most reliable early mani-
festation. It may be overlooked in individuals of the
dark-skinned races or ones severely tanned on the ex-
tremities from overexposure to the elements. It soon
becomes sharply outlined in character and commences to
spread from the initial locations in a centripetal fashion
over the chest and abdomen, and then to the remainder
of the body. It is always more marked on the extremi-
ties than elsewhere. Extension is complete in two or
three days. The associated generalized aches and pains
are then somewhat relieved, but the temperature remains
elevated. The petechial eruption is thought to be the
most classical finding in tick fever, but the disease must
not be diagnosed alone from its presence. Some cases,
particularly very mild ones, or those previously vaccinat-
ed, show no rash or only a slight one, others die from
toxemia before its appearance, and yet others demonstrate
atypical or bizarre eruptions. Petechiae do not disappear
on pressure except during the initial stages of the dis-
ease. They are accentuated by tourniquet application.
They may eventually involve the palms of the hands,
soles of the feet, and mucosa of the inner cheeks and
throat. A patient so erupted is truly speckled or spotted,
having a rash which often covers the entire body. Pe-
techiae may appear in successive crops, each of which has
a life cycle of two weeks.
The eruption tends to remain discrete in milder cases
of tick fever, but does not remain so in more severe ones.
It is first rose-red and later bluish-red in color. The
petechiae increase in size and become confluent, finally
coalescing and then becoming purpuric. A mass of such
areas may involve the entire body. If terminal gangrene
ensues, with sloughing of the soft palate, scrotum or
dependent portions of the body, the afflicted individual
presents a sad and tragic appearance.
The eruption gradually fades as the temperature falls
and the individual recovers, the process taking much
longer in severe cases than in mild ones. There may be
desquamation, either branlike in character or so complete
that casts of body parts are exfoliated. Pigmentation re-
mains at former petechial sites. It may be followed by
formation of minute cicatrices. For several months after
recovery from tick fever, overexposure to heat or cold
often brings out temporary manifestations of the erup-
tion. They last only a short while and clear when normal
skin temperatures are re-established.
Temperature rises abruptly within the first 24 hours
of the onset of the disease. There are but one or two
slight remissions, a fastigium of 103° to 105° F. being
reached by the beginning of the second week in mild
cases, by the second or third day in more severe ones.
With recovery from acute manifestations of the illness,
it falls either by rapid or slow lysis, rarely by crisis unless
the case is an abortive one. There may be slight tem-
perature remissions in mild cases, but it is constant to
slightly rising in more severe ones. It is sometimes dis-
tinctly remittent after the first few days, particularly in
moderately severe protracted cases, but never ceases until
terminal lysis has occurred. The temperature may be
normal from the first, or subnormal in very severe forms
of the disease, to rise sharply in the twenty-four hours
preceding death, or it may be high from the first, then
drop to normal and rise again before death occurs. If the
temperature drops uneventfully to normal, and later
shows a secondary rise without apparent justification,
complications must be sought for.
Early in the disease the pulse is of good volume, and
is slow, averaging 90 beats a minute. Early disproportion
of pulse and temperature ratios is one of the character-
istic findings of tick fever at its onset. When myocardial
weakening ensues in severe cases as a result of toxemia,
loss of strength and volume of the pulse occurs. It rises
out of proportion to the temperature. As a result of
cardiac involvements, the blood pressure falls, and the
first heart sound becomes muffled and indistinct.
The respirations are at first normal or but slightly in-
creased. With acceleration in severe cases, the respira-
tion change accompanies alterations of the pulse and
temperature ratio. Increase in rates often signifies the
development of bronchopneumonia.
The above manifestations are considered to be the
most typical ones in tick fever. There are other findings.
They exist in various combinations, depending for their
intensity upon the severity of the existent disease process.
Patients moderately or severely ill with tick fever are
severely prostrated. The senses are dulled. Although
afflicted individuals appear rational to superficial exam-
ination, close inspection reveals them to be mentally con-
fused. There is amnesia; it may persist until the erup-
tion is complete, or for some time afterward. Patients
appear anxious and are concerned over their illnesses.
The eyes are injected and the cheeks flushed. There may
be photophobia. Nervous disturbances such as lethargy,
restlessness or nervous irritability are frequent. Children
are prone to convulsions and may succumb during them.
Insomnia is at times troublesome. There can be active
July, 1943
209
delirium, particularly in severe cases during terminal
stages of the illness. Muscular twitchings or fibril latory
tremors are common. Muscle tonus is definitely increased
throughout the body. Aches and pains in the muscles
persist throughout the disease. At times the distress
from them is agonizing. When located in the muscles of
the abdomen, an acute surgical condition can be simu-
lated. Movement of the neck muscles often elicits slight
stiffness.
The tongue is swollen and moist early in the disease.
In severe cases it becomes dry and coated, with a dark-
ened border and prominent papillae. The tongue often
protrudes from the mouth when profound swelling en-
sues. It becomes fissured and covered by sordes if coma
occurs. There is pharyngeal engorgement, accompanied
by a dry, hacking, nonexudative cough, indicative of
bronchial irritation. There is often profound chilliness.
It is not shaking or chattering in character, but tends to
be most persistent and drawn out, frequently lasting for
a period of from two to four hours.
The skin is tender. Many patients complain bitterly
of pressure from light bed coverings or drafts of air.
As the disease progresses the skin becomes dark red, or
bluish in more severe cases, the color changes being most
evident on the back and thighs. An ill-defined bluish dis-
coloration is often detected beneath the skin surfaces,
when patients are examined under satisfactory light con-
ditions. Dependent portions of the body, such as the
scrotum or soft palate may slough in severe cases. Necro-
sis can occur, commonly affecting the prepuce, toes, fin-
gers or ear lobes. Alopecia sometimes occurs; it may be
permanent.
There is anorexia. Nausea and vomiting take place in
some cases, the regurgitated material at times containing
blood. Diarrhea occasionally occurs; the stools may be
bloody. Constipation is usual and can be most obstinate
and difficult to overcome. Sphincter control is often lost
in severe cases. The spleen is enlarged and tender, the
liver sometimes demonstrating similar findings. There is
jaundice, which is nonobstructive in type and tends to
deepen markedly in the terminal fatal stages.
Increased muscle tonus may result in an inability to
void. At times there is incontinence. Urination can be
distinctly painful. A lessened secretion of urine some-
times occurs. It is caused either by changes in the kidney
or by a failing circulation and is frequently accompanied
by edema. There may be total repression of urine forma-
tion at the end, in fatal cases of tick fever.
The blood findings are not unusual. There is a low-
ered red blood cell count and hemoglobin content later
in the disease, resulting in a secondary anemia. The total
white blood cell count averages 12,000 to 15,000. It may
be as high as 30,000. A relative mononucleosis is com-
mon, the average being 10 to 12 per cent.
The urine may be highly colored and has an increased
specific gravity. Old or debilitated individuals show albu-
min in varying amounts, together with acetone bodies
and microscopic alterations. Younger persons or those
who have previously enjoyed good health do not mani-
fest urinary changes so frequently.
Blood chemistry studies in tick fever have never been
conclusively worked out. There are no significant spinal
fluid findings. Demonstrations of the causative micro-
organism of the disease in blood smears are so inconstant
that the results are not worth the time and energy ex-
pended in search for them. 1’2’3’4’6’9,10’1 1,13
Diagnosis
Tick fever may be confused with various other infec-
tions, particularly when it appears unexpectedly in a
locality or is encountered by those unfamiliar with its
manifestations. It is not within the scope of this paper
to discuss these conditions, with the exception of typhus
fever. For the most part, confusing diseases can be ruled
out by careful histories, examinations, and repeated ob-
servations of infected individuals, together with confirma-
tory laboratory studies. The three diagnostic procedures
ordinarily employed are the infection test, Weil-Felix
agglutination reaction and the protection or virus neu-
tralization test. They are not dealt with in this article.
Typhus fever is a rickettsial infection, strikingly simi-
lar in many of its clinical manifestations to tick fever.
It exists in two forms, the epidemic transmitted by the
body louse, and the endemic, by the rat flea. Although
both have been identified in the United States, the his-
toric louse-borne type is essentially an Old World dis-
ease, and has not, as yet, become of major importance
here. It is commonest in localities where human beings
reside under conditions of crowding, when sanitation
facilities are poor. Endemic typhus is present in many
sections of the eastern and southern United States. It is
most prevalent in individuals whose occupations bring
them into rat-infested premises, for that reason being
frequent among handlers of foodstuffs.
In studies of tick fever as related to typhus fever
there are many interesting possibilities. The majority of
army training centers, resettlement camps and alien isola-
tion areas in the west are located in regions but recently
reclaimed from their native state. There ticks abound.
The bringing together of large numbers of individuals
under conditions of concentration and crowding invites
the development of typhus, should sanitation be faulty,
or rat carriers be present.
Endemic typhus fever and tick fever resemble one
another closely. Typhus appears for the most part dur-
ing the late summer and fall, tick fever of the eastern
type during the summer and early fall, of the western
type in the spring and early summer. Endemic typhus
fever usually occurs among food handlers who are urban
residents. Tick fever appears for the most part in those
having rural contacts. Even though the symptomatology
is quite similar in both diseases, the general clinical fea-
tures are intensified in tick fever: the incubation period
is shorter; the onset more explosive and severe; the tem-
perature rises more rapidly; although it recedes in both
diseases by lysis, the fall is much slower. The petechial
eruption appears first on the body in typhus, spreading
from there to the extremities. In tick fever, the original
site and manner of spread are the opposite. In tick fever,
the eruption tends to be more extensive and cyanotic,
being more profuse in distribution. The pulse tends to
be higher in proportion to temperature, particularly in
210
The Journal-Lancet
severe cases. Nervous and mental symptoms are more
profound and delirium is more often encountered, coma
preceding a fatal outcome. In tick fever, convalescence
is more slowly established.
Routine laboratory procedures do not furnish much
assistance in differentiating the two diseases, agglutina-
tion with bacillus proteus strains tending to be positive
at some time during the course of both. In order to
establish absolute identification, it may be necessary to
study the effect of virus on laboratory animals. Observa-
tions of the clinical pictures obtained by guinea pig inoc-
ulations, or of typical histological alterations produced in
the brains of laboratory animals may be necessary. Cross
immunity tests are sometimes used. Their significance
depends upon the finding, that animals which have re-
covered from typhus fever remain susceptible to tick
fever, and that animals which have recovered from tick
fever remain susceptible to typhus fever, but not to fur-
ther inoculations of tick fever virus. 1'2,3'4,6'9’10'1 1,13
Prevention
Tick fever could be eradicated were it possible to dis-
pose of vectors of the disease, but the undertaking is an
impossible one. Conditions favorable to ticks exist in all
localities where the disease is found and allow hosts for
both immature and adult forms to flourish in abundance.
Vegetation and physical conditions exert an indirect in-
fluence, because they afford suitable surroundings for ani-
mals serving as tick hosts. Once established in a locality,
ticks continue to thrive if there are sufficient numbers of
wild or domestic animals present.
Prevention of exposure to infection is assured only by
remaining out of localities where ticks abound, but this
is not at all times possible or feasible. Those entering in-
fested localities should wear trousers, gathered by some
means at the bottom, in order to prevent vectors from
crawling up the legs. Ticks do not jump on those who
pass their vantage points; they lie in wait on low vegeta-
tion, not over a foot and a half above the surface of the
ground, actively moving their numerous serrated legs, by
which means they seek transfer to objects that brush by.
Clothing should have a minimum of seams and openings,
in order to prevent their ingress to the body surfaces.
Smooth clothes prevent ticks from gaining footholds,
yet those with a rough nap impede their progress, once
they have gotton on the body covering. It is a good plan
while in tick infested localities to occasionally pass the
hand over the back of the neck in order to detect crawl-
ing ticks. They may gain access to the body by working
themselves beneath the collar.
Clothing should be removed two or three times a day,
and the body examined for the presence of crawling or
attached ticks. Inasmuch as they hide away in body
folds, crevices or hairy portions free from rubbing, a
diligent search must be conducted. Camps should be
located where rodents are few, preferably in places where
no low grass, sagebrush or small bushes are growing.
Wooded areas along creek banks and the vicinities of
old trails and roads are best avoided. Ideal camping spots
are usually where standing timber is present, with a mini-
mum of low vegetation. Individuals must again inspect
their persons, clothing and bedding, before retiring for
the night in the open. The precaution is most important
when two individuals sleep in close proximity. The first
individual may escape infection or be but mildly ill, the
second one more seriously so, from reactivation of virus
in the tick vector by blood ingestion from the first victim. |
While in tick infested localities, it is unwise to leave bed- I
ding spread on the ground during the day, as it attracts ‘
ticks, often from a considerable distance. After return
from trips, clothes and bedding should be carefully gone j
over, aired and then removed to buildings not used for
human habitation. Once ticks have taken up their abode
in a location, eradication is apt to prove most difficult f
and uncertain.
When ticks gain access to the body surfaces they move
slowly about for a variable length of time, during which '
they seek suitable locations for attachment. The process
is not noticeable to victims, nor are they usually aware
of crawling ticks. It is supposed that vectors of the dis-
ease are not actively infectious until several hours have
elapsed, but little reliance can be placed in this conten-
tion. When located, attached ticks must be removed
without delay. The procedure is one requiring consid-
erable skill and perseverance, if it is to be safely accom-
plished. As a rule, the head of the tick is embedded
beneath the surface of the skin, the body remaining free
and protruding at an angle from it. The head is held
firmly in place by the mouth parts, so that hasty or care- I
less plucking often serves to remove the body alone,
leaving the remainder in place to serve as a potential j
source of infection. Gentle traction may be successful in
removing the tick. Close inspection then reveals it to be ;
intact, often with a small fragment of epidermis caught
in the mouth parts. Failing in this procedure, a small
piece of epidermis in which the tick’s head lies embedded
must be elevated with a pair of tweezers, and a tentlike
wedge of tissue snipped with a fine pair of scissors. This
maneuver is accomplished quickly and insures complete
removal. Resultant wounds from tick extraction are to '
be thoroughly cauterized, using iodine, phenol, silver
nitrate or similar agents. A light dressing can then be >
applied. Care must be exercised so as not to crush ticks.
If the accident occurs, the discharged contents should be
thoroughly washed from the hands by means of soap and
water, care being exercised not to irritate the skin. Since
the virus is apt to be highly infectious, even on unabrad-
ed skin surfaces, precautions for its removal are most
important. Removal of engorged ticks with bare hands j
is a dangerous practice.
Tick vaccine gives protection against tick fever. It is ;
prepared by the Rocky Mountain Laboratory of the Na- j;
tional Institute of Health, Division of Infectious Dis- j
eases, at Hamilton, Montana, and is dispensed to physi-
cians desiring it, for the purpose of immunizing those
who run the danger of being exposed to the disease.
Tick vaccine is prepared in two types, the older one
from tick tissues, and the more recent one from embry- |
onic chick tissues. The chick-embryo type has not super-
seded the vaccine prepared from ticks; and, although it
is less likely to cause reactions, evidence regarding its im-
munizing value is not so certain. Recommended dosage
July, 1943
211
of tick tissue vaccine for those who have never pre-
viously been vaccinated is 2 cc., repeated at an interval
of from 7 to 10 days. If the particular locality is one
in which serious cases of tick fever are known to origi-
nate, the second injection must be followed by a third,
administered after the same time interval. Children
receive a proportionate amount of material, 1 cc. being
recommended for those 10 years of age or younger.
Dosage of the chick-embryo type is slightly different, in
that three injections of 1 cc. each, administered at the
same time interval, are recommended. For individuals
who have been vaccinated each of the past three years,
two injections of 1 cc. each of either the chick-embryo
or tick-tissue types, are suggested.
The degree of protection afforded by vaccine, and the
duration of such protection varies with vaccinated indi-
viduals and the virulence of the infection to which they
are exposed. As a rule, those vaccinated in the spring of
the year retain a considerable degree of immunity for
at least the remainder of that year. This is usually suf-
ficient to afford full protection against relatively mild
strains of the disease, but is progressively less effective
as virulence of the virus is increased. Nevertheless,
against even the more severe forms of tick fever, it is
usually adequate to ameliorate markedly the usual
stormy course of the infection, so as to insure ultimate
recovery. It is probable that a certain proportion of in-
dividuals carry an indefinite degree of immunity into
the second year, even against highly virulent strains of
virus. The degree of protection appears to be greater in
those who have been vaccinated for two or more succes-
sive years. Evidence does not indicate that any consid-
erable degree is carried into the third year. In order to
afford the greatest degree of protection possible, it is rec-
ommended that immunization be performed each year.
Intramuscular administration of vaccine is not known
to bring about more than a slight constitutional reaction.
The same precautions must be observed as with the in-
jection of any biological product intended for an immu-
nization procedure. Immediately there ensues a sensa-
tion of fullness at the site, followed by one of smarting
or stinging. Itching may occur, exacerbated by scratch-
i ing or rubbing the part. A generalized malaise is some-
times noticed, often with a slight febrile reaction. The
[ manifestations are usually transitory, subsiding before
subsequent administrations of the material. These usually
result in much milder symptoms, or none at all. 1 .23,7,8,-
9,10,12,13
Treatment
Treatment of tick fever is purely symptomatic and
j supportive in character. There is no specific, but its ab-
sence must not predispose to an attitude of helplessness
and hopeless inactivity on the part of those caring for
the disease. Carefully directed symptomatic care and
supportive measures aid patients to eliminate toxins from
their bodies, support them during the period of invasion,
and assist them by every means possible to overcome their
illnesses. Vigorous, yet well directed procedures, bring
about successful outcomes in many patients who appear
hopeless as regards recovery at the time first placed
under care.
Bed rest with good nursing care are necessary from
the beginning, in order to conserve strength as much as
possible. At the onset of tick fever, patients frequently
do not appear ill enough to make the precautions neces-
sary, but the rapidity with which serious manifestations
appear make those in attendance thankful that they had
been insisted upon. Patients must be kept as quiet as
possible, both mentally and physically. Baths, packs and
simple sedation are often effective. If codein or morphine
are indicated, they must be used as freely as necessary.
Bath temperatures should be 70° F., or above, to be
safely tolerated. Cold or tepid bathing is wrong, because
it often results in shock to seriously ill victims of the
disease.
The gastrointestinal tract needs careful watching. Reg-
ular elimination may be facilitated by mild enemas or
cathartics. The diet should be nourishing, adequate and
yet easily digestible. Frequent urinary examinations are
indicated; they often disclose pathological alterations at
their onset. Fluids must be given freely, by mouth, if
tolerated, by other routes if there is excessive vomiting.
Adequate amounts combat the ever present trend to
acidosis.
It may be necessary to support the heart should myo-
cardial weakening appear imminent. Care to the skin is
important. Sponging with equal parts of witch hazel and
alcohol in water, once or twice a day, often comforts and
invigorates severely ill patients, and removes soreness
from muscles. Patients are less mentally dulled and ap-
pear considerably stronger for several hours following
the procedure. Mouth hygiene is important. Oral anti-
septic washes rid the region of accumulated waste prod-
ucts, so that sufferers are made more comfortable during
the acute phases of the illness.
Convalescent sera and transfusions have been resorted
to, apparently without beneficial effect. Autohemotherapy
has been used by some physicians, 10 to 20 cc. of citrated
blood from the patient being administered intramuscu-
larly, the procedure being repeated as often as necessary.
Drugs without number have been lauded, from time to
time, as specifics in the treatment of tick fever. It is
agreed that the actions of the majority of them are so
uncertain as to cause them to be generally discarded.
Drugs of the sulfonamide series have little or no value
in the management of tick fever, according to informa-
tion available on them at this time. If bronchopneu-
monia, phlebitis or other complications due to secondary
invaders appear, their use is certainly justified, the drugs
of choice depending on the nature of the invading micro-
organisms. Recently, Topping has produced an immune
serum in rabbits, using tick virus as the antigen. The
rabbit serum has been shown to contain large amounts
of antibodies. Satisfactory results have been achieved
from its use, at first, in animal experimentation, and
later, in an increasing number of human beings. Tick
vaccine must never be used for treatment; it has no bene-
ficial action when used for this purpose. In milder cases,
its use is too drastic to be justified; in more severe ones
it may prove dangerous as regards ultimate recovery.
1,2,3,4,5,9,10,13,14
212
The Journal-Lancet I
Neosalvarsan in Metaphen Solution
Tick fever appears to have a cyclic tendency, more
cases appearing during some years than others. The rea-
son for the trend is unknown, but it is believed to de-
pend upon local and regional conditions. The number of
individuals exposed, the abundance of ticks, the percent-
age carrying infection, the capability of virus to produce
frank infections, and the possible relationship between
the prevalence of ticks and animal hosts seem to play a
part.
The highest incidence of tick fever in the western area
is from the early spring into the early summer months.
In the mountainous regions, it is highest during the late
spring months, owing to delay in the advent of warm
weather. In the eastern areas, the disease is more prev-
alent in the late spring and early summer months, but
cases can occur in the fall of the year.
The virulence of tick fever varies greatly in different
areas, but appears to remain fairly constant in any one
region. Reasons for the variance are not known. It is
supposed that repeated passages of the virus through suc-
cessive animal hosts play a part. It is justifiable to speak
of mild, moderately severe, or severe types of the dis-
ease, in view of the great differences in virulence of the
infection in various localities and sections of the country.
The writer has had occasion to make extensive study
of the various aspects of tick fever, inasmuch as he prac-
tices medicine in the western endemic area, in a section
of Wyoming where the disease occurs with considerable
frequency. Tick fever in this locality is moderately severe
to severe in type. For a period of the past 17 years,
from 1927 through 1942, during which accurate statis-
tics on tick fever have been kept by the Wyoming State
Health Department, the average mortality for the state
has been 19.5 per cent; 1,070 cases have been reported,
with 209 deaths. During the same period of time, mor-
tality for our (Natrona) county has been 20 per cent.
Both of the figures are considerably higher than those
for the nation as a whole. It is believed that the mor-
tality for the entire country approximates 12.5 per cent.
Symptomatic and supportive measures offer much in
treatment of tick fever, but they are not sufficient in
themselves to insure recovery. Prognosis depends ulti-
mately upon the ability of infected individuals to with-
stand ravages of the disease, particularly in reference to
myocardial and renal intoxication. Bad omens are con-
fluent purpuric eruptions with terminal sloughing, marked
temperature and pulse reactions, severe intoxication of
the brain and central nervous system, and the develop-
ment of complications, particularly in older or debili-
tated individuals, or those ill with intercurrent conditions.
In 1934, the late Dr. J. C. Kamp of Casper and the
writer received encouraging reports of responses obtained
by use of neosalvarsan dissolved in aqueous solution of
metaphen, administered intravenously in the treatment
of typhus fever. That year, we began original investiga-
tions with their use in the treatment of tick fever. In
the spring and summer of 1934, we used them on nine
moderately severe cases of the disease. None of the in-
dividuals succumbed to their illness. Response was grati-
fying enough to warrant their future use in all cases
which came under our supervision.
Since that time, an average of three to four cases of I
tick fever have been under the writer’s care each season.
During the past eight years, all cases so treated have re-
covered. Local physicians and those practicing in other i
sections of Wyoming, also have resorted to use of the I
two drugs in combination, as an adjunct to care for indi- ■
viduals seen by them. Those contacted by the writer j
report equally gratifying responses, many of them join- I
ing him in the firm conviction, that neosalvarsan in !
metaphen solution has proven itself a definite thera- j
peutic aid in treatment of the dread disease.
It is not thought that they exert specific action on the I
manifestations of tick fever, and it must be admitted
that their approach is uncertain. Benefits derived from
their use may be credited to direct action on rickettsiae
in infected tissues. A combination of the bactericidal
action of metaphen together with the spirocheticidal
action of neosalvarsan, upon a microorganism which is
bacterium-like in character, yet has staining properties
similar at least to those displayed by spirochetes may be
the secret of their success. It is certain that those treated
show less evidence of intoxication, minimal damage of
the heart and kidneys and a more discrete, brighter col-
ored eruption, which does not become hemorrhagic, and
is usually more sparse in distribution. There is less men-
tal depression; the nervous symptoms are more mild.
The entire clinical picture is less alarming in every re-
spect. Convalescence is more rapidly established, being
of shorter duration and accompanied by a minimum of
complications. None of the individuals had ever re-
ceived tick vaccine for the purpose of immunization
against the disease.
In the performance of the procedure, 0.3 gram of neo-
salvarson is dissolved thoroughly in 10 cc. of an aqueous
solution of 1:1000 metaphen (Abbott). The mixture
which results is yellow and turbid, and changes but
little in appearance on standing. It is warmed and in-
jected slowly by vein, the same precautions being neces-
sary as with any chemotherapeutic agent intended for
intravenous administration. Solution is administered and
blood alternately withdrawn into the syringe until the
entire amount has been given. The procedure usually
consumes a period of from 5 to 10 minutes. No re-
actions, local or constitutional, either immediate or de-
layed, have thus far been noted.
Administration of the two drugs is repeated at three
or four day intervals. Three or four injections have cus-
tomarily been sufficient to ameliorate the clinical picture
so as to insure ultimate recovery. Continued or recur-
rent manifestations would apparently justify additional
administration of neosalvarsan in metaphen solution.
A word of warning appears indicated to those who
might contemplate use of the two drugs in combination
for treatment of tick fever. Should a case of the dis-
ease demonstrate severe renal injury as a result of the
infection, careful consideration must then be given the
question as to whether their use is justified. The inherent
risks associated with drugs of considerable potency on an
already damaged kidney must be weighed against bene-
July, 1943
213
fits to be derived from their administration. It has been
customary for the writer to secure, first, morning speci-
mens of urine for examination on the day the material
is to be given. They have never shown sufficient altera-
tions to indicate severe renal pathology. For that rea-
son, neosalvarsan in metaphen solution has been given
routinely at the time scheduled for its use.
Summary and Conclusions
Rocky Mountain Spotted Fever is widespread in dis-
tribution throughout the United States. It has possi-
bilities for far greater dissemination, and is a disease of
serious potentialities. Although the clinical picture is
fairly typical, there is the possibility for confusion with
j other diseases. Prevention of infection may be secured
by means of simple precautions and the use of vaccine.
Treatment is essentially symptomatic and supportive.
Neosalvarsan dissolved in aqueous metaphen solution has
j been used intravenously as an adjunct to treatment. As
a result of satisfactory results obtained in a number of
cases over a period of the past eight years, it is believed
that the drugs in combination exert a definite beneficial
action on the course of moderately severe cases of the
disease.
References
1. Baker, G. E.: Rocky Mountain spotted fever, with reference
to prevention, recognition and treatment, Rocky Mountain M. J.
35:35, 1938.
Baker, G. E.: Rocky Mountain spotted fever, Ann. Int. Med.
17:247, 1942.
3. Carey, L. S., and Duncan, G. G.: Rocky Mountain spotted
fever in the east, J.A.M.A. 1 10:175, 1938.
4. Clinical Notes: Observations on rickettsial diseases, Sem-
inar 4:6, 1942.
5. Clinical Notes: Insect incendiaries. What’s New 66:7, 1943.
6. Cohen, M. H.: Unusual case of Rocky Mountain spotted
fever in southeast Pennsylvania, J.A.M.A. 1 15:17, 1940.
7. Cox, H. R.: Use of yolk sac of developing chick embryo as
medium for growing rickettsiae of Rocky Mountain spotted fever
and typhus groups, Pub. Health Rep. 53:2241, 1938.
8. Cox, H. R.: Rocky Mountain spotted fever, protective value
for guinea pigs of vaccine prepared from rickettsiae cultivated in
embryonic chick tissues, Pub. Health Rep. 54:1070, 1939.
9. Hutton. J. G.: Rocky Mountain spotted fever, J.A.M.A.
117:413, 1941.
10. Parker, R. R.: Rocky Mountain spotted fever, J.A.M.A.
1 10:1 185, 1273, 1938.
11. Pincoffs, M. C., and Shaw, C. C. : Eastern type of Rocky
Mountain spotted fever, report of a case with demonstration of
rickettsiae, M. Clin. North America 1 6:5, 1 933.
12. Ricketts, H. T., and Gomez, L. : Studies in immunity in
Rocky Mountain spotted fever. J. Infect. Dis. 5:221, 1908.
13. Symposium: Rocky Mountain spotted fever, Internat, M.
Digest 41:312, 1942.
14. Topping, N. H.: Rocky Mountain spotted fever, treatment
of infected laboratory animals with immune rabbit serum. Pub.
Health Rep. 55:41, 1940.
War Wounds of the Abdomen
Daniel L. Borden, Colonel, M. C.f
Ft. Eustis, Virginia
WHEN, through the process of evolution, man
assumed the upright position, he exposed a
large, soft, unprotected target to his enemy.
Modem warfare has taken advantage of this inherent
weakness and now directs its attention to this potential
mark. On the training fields, on the battle ground, yes,
even with the unprotected civilian, the abdomen is the
bullseye of the bayonet and the bullet. Difficult as it is
to understand the brutality of man, we are faced with
facts that cannot be ignored. In self-defense, amidst
trained hatred, we hear the command on our own train-
ing fields, "Gut ’em.” Not a pretty picture and certainly
a far cry from the art of healing, but in all corners of
the world this problem faces the medical profession — we
must meet it, and not now ask the reason "why”.
Penetrating and explosive wounds of the abdomen
have a terrific mortality rate. Let us not be misguided
and lulled into security by a recent advertisement appear-
ing in a national publication analysing the Pearl Harbor
disaster with the following quotation, "Every man with
an abdominal wound who reached the operating table
alive is still alive.” Although true at Pearl Harbor, this
will not necessarily apply to the field of battle where
ground exposure enters the picture.
The battlefield and the civilian front, both subject to
high explosive missiles and the bayonet, call for the keen-
est judgment from first aid to surgical exploration. It is
tChief of Surgical Service, Station Hospital, Fort George G.
Meade, Maryland. Professor of Clinical Surgery, George Washing-
ton University.
imperative to use care in the immediate attention to ab-
dominal wounds, the combating of shock, relief of pain
and, if necessary, the immediate control of hemorrhage.
Careful and meticulous transportation of the abdominally
wounded is essential to lessen risk.
On the field where intervals of time must elapise before
surgery can be offered, or in massive civilian bombing
where the injured are so numerous as to make immediate
operative attention impossible, we must depend upon the
administration of sulfanilamide as an adjunct to surgical
measures. Anticipating wounds, every soldier is equipped
with sulfanilamide as a part of his first-aid field kit.
Accepting the grave risk in all abdominal wounds as
a foregone conclusion, the time to operate is always as
early as possible, in keeping with a reasonable chance of
the patient surviving surgical interference. To this end,
a keen sense of surgical judgment must determine the
verdict. Under no circumstances is the judgment of a
good surgeon taxed more heavily than in arriving at a
clear understanding of a desperately injured patient, with
a penetrating wound of the abdomen.
Once in the operating room, practically all abdominal
wounds call for exploration. Recognizing the grave dan-
ger involved, exploration, when undertaken, must be ade-
quate even in the presence of hemorrhage and shock;
complete and thorough intra-abdominal repair is essential.
I can well remember in the last World War how the
French surgeon opened the abdomen from the ensiform
214
Thk Journal-Lancet
cartilage to the pubic bone to insure complete visualiza-
tion of the abdominal field and how, after his repair was
completed, he filled and washed the abdominal cavity
with ether. Truly an astonishing revelation to an Ameri-
can eye-witness. I do not advocate such a radical ap-
proach, as an accepted rule, in all penetrating wounds of
the abdomen, but I do make a plea for adequate inspec-
tion.
The immediate toilet of the average intra-abdominal
exploration involves the difficult elimination of blood and
fecal contamination. This is always messy but impera-
tive. Every surgeon knows that the cleaning out of a
blackout in the abdomen, where the site of bleeding and
perforation is unknown, is an art in itself that requires
systematic sponging, aspiration and, if necessary, a nor-
mal saline bath.
In massive injury to the bowel or in multiple perfora-
tions where anastomosis will involve time and shock,
extraperitonealizing of the involved gut must be seriously
considered as a life-saving procedure. The use of the
Murphy button, with its time-saving technic, is too often
a forgotten art. A proven blessing of the old school, it
offers, without suturing, a quick, safe and dependable
type of intestinal anastomosis.
To elucidate the repair of all possible injuries within
the abdomen does not fall within the scope of this paper.
In all contaminated cases, it is advisable to complete the
surgical care with the instillation of sulfanilamide crys-
tals into the abdominal cavity. This drug in the form of
crystals is far more soluble than in the powdered prepa-
ration. Powdered sulfanilamide, sulfathiazole or sulfa-
diozine tends to cake and may act as a foreign body.
Reliance upon the sulfa drugs cannot take the place
of good surgery, nor must it ever be the excuse for
sloppy technic. I do not want to underestimate the very
great value of instilling crystalline sulfanilamide in ab-
dominal wounds and in the peritoneal cavity, but I do
warn against too great a reliance on the drug without
proper surgical attention. Eight grams of the sulfanila-
mide crystals can be instilled in the peritoneal cavity
with safety.
Especially desirable, however, is the infiltrative, absorp-
tive effect of sulfanilamide in abdominal wounds, where
the explosive effect of a rapidly moving missile has ex-
erted its action upon serous surfaces and condemned
them to tissue death. All surgeons are familiar with the
searing of peritoneal surfaces that have been subjected
to explosive pressure, leaving behind an ideal culture me-
dium for any and all bacterial invaders.
Drainage, as a rule, is contraindicated on the theory
that the entire peritoneal cavity cannot be reached. Ex-
perience has shown conclusively that the average closed
case reacts better than one drained.
A summary of the generally accepted rules pertaining
to the treatment of war wounds of the abdomen may em-
phasize the outstanding principles of this field of surgery.
Obviously, only the highlights of so vast a subject can
be elucidated; they may be stated as follows:
1. Adequate first-aid approach with control of hem-
orrhage is imperative.
2. Immediate transportation of abdominal wounds to
the operating room. Where transportation is not avail-
able, or where great numbers of wounded make imme-
diate operation impossible, the use of the sulfa drugs to
build up resistance should be started at once.
3. In choosing cases for operation, where stress of
time for any reason makes selection necessary, wounds
of the upper abdomen stand less risk of fecal contamina-
tion than those of the lower abdomen.
4. All penetrating wounds of the abdomen call for
a urinalysis before surgery to rule out or rule in the kid-
ney, ureter or bladder injury.
5. X-ray is always indicated where possible and may
be of inestimable value to analyse the possible course of
a penetrating missile.
6. Shock must be combatted, and no war abdominal
wound should be kept cn the operating table over one
hour; 40 minutes is the inside limit of safety.
7. Perforations of the intestine or hollow viscus call
for the exploration of both the wound of entrance and
exit. In other words, perforating wounds of hollow or-
gans run in even numbers. The two exceptions to this
rule are a nicking of a viscus, or the finding of the pene-
trating missile within its lumen.
8. Overlooking a perforation is an ever-present haz-
ard. Complete visualization of the entire intestinal tract
is warranted whenever possible.
9. Cotton suture for war surgery is being advocated
with a sound basis of reasoning. It is inexpensive, com-
pact and of proven value, even in infected wcunds.
10. Drainage of the abdomen is to be avoided as a
rule, but the instillation of sulfanilamide crystals in the
peritoneal cavity and abdominal wound is indicated in all
contaminated perforated abdominal injuries.
Finally, good surgery supported by ample transfusions
of blood or plasma, use of sulfonamide therapy, with the
aid of adequate preoperative first-aid assistance, and post-
operative care, should lower the high mortality rate of
perforated war wounds of the abdomen.
July, 1943 215
Practical Problems in Blood Grouping and
Blood Transfusion
R. F. Peterson, M.D.
Butte, Montana
IN 1900 when Landsteiner discovered the iso-agglu-
tinins causing fatal reactions after some blood trans-
fuses, he laid the foundation for our extensive
knowledge enabling us to give so many blood transfu-
sions a: present with relative immunity. Many reactions
still occur, some of which we are able to obviate by newer
discoveries, many of which have been made by Land-
steiner and his co-workers. It was discovered that there
were four main blood groups which were classified 1, 2,
3 and 4 by Jansky in Europe in 1907, and also by Moss
in the United States in 1909. These two groupings were
; the same, except that the numbers 1 and 4 were trans-
J posed in the two groups, thereby leading to confusion
I and some mistakes. These groupings are rarely used
any more and should be completely eliminated from use.
All recent literature uses the International classification,
which will be described below. Anyone who has noted
the tags which the soldiers, sailors and marines have
around their necks, will have noticed one of the letters
| of this classification stamped after the serviceman’s name.
The investigators in blood agglutinins have found the
following factors:
Chart
A
B
A,
A;
M
N
P
Q
Rh
All human red blood cells have been found to have
either A or B, both of them, or neither of them, which
results in the four main blood groups as listed in
Chart 2.
Chart 2
AB A B O
1 2 3 4 Moss classification
4 2 3 1 Jansky classification
In Chart 2 it will be noted that the International classi-
fication takes its name from the agglutinogens found in
the red blood cells. The Moss and Jansky classifications
are included for orientation. In these four main blood
groups, the serum of every person contains the agglu-
tinin against the agglutinogen or agglutinogens not
found in that person’s red blood cells. This holds true
only for the four main blood groups, as all the other
subgroups listed in Chart 1 contain no natural agglu-
tinins in blood serums, except in occasional rare reported
cases. Agglutinins can be built up against the sub-
groups, however, which becomes a very important point
to be discussed later.
Chart 3
AB ABO International classification
o b a ab of Landsteiner
5% 40% 10% 45%
In Chart 3 are noted the agglutinins in the correspond-
ing sera as described above. The percentages given under
^Presented at the Mount Powell Medical Society meeting. Ana-
conda, February 1 5, 1 943.
these groups are approximate percentages as found in
the United States population. These blood characteris-
tics are transmitted according to definite Mendeiian laws,
and it is interesting to note how these percentages vary
throughout the world.
Chart 41
AB
A
B
O
United States
.... 5%
40%,
10%
45%
Chinese
10%
25%
35%
30%
English
... 5%
40%,
15%.
40%
Filipino
- 1 %
15%
20%
64%
Bush Negroes, Dutch Guinea
... 0
0
17%
83%
Tibetans
...25%'
47%
13%
15%
The A and B when pres:
:nt are
dominant over the
O. An interesting speculation results when noting the
groups of bush negroes of Dutch Guinea. Their pro-
genitors apparently contain no A factor. Reviewing a
little genetics, we find that a person’s characteristic are
all derived from his parents, and are transmitted through
the genes, so that each person’s characteristics, whether
demonstrable or not, are his genotype. The demonstra-
ble characteristics are the phenotype, thus a person of
blood group B, which is the phenotype, can be either a
BB or a BO, which is the genotype. Of course an O
can be only an OO, because A and B are dominant.
These are the genotypes and no method is known at
present for the determination of genotypes.
Chart 5
B — BB BO
O — OO OO
Chart 6-
Parents Children Possible Children Not Possible
OxO O A, B, AB
Ox A O, A B, AB
O x B O, B A, AB
Ax A O, A B, AB
BxB... O, B A, AB
A x B O, A, B, AB
O x AB A, B O, AB
Ax AB A, B, AB O
B x AB A. B, AB O
AB x AB A, B, AB O
Chart 6 shows how these characteristics are transmit-
ted and the children which can result from the union of
certain types of parents. We see from this chart that
children do not have to be of the same blood groups as
their parents. In fact, when O and AB parents have
children they cannot be of the same groups. They do,
however, have one of the genes of each parent, and no
matter how one crosses these genes, no children of O
and AB parents will result in the same group as the
parents. See Chart 7.
Chart 7
One parent AB AB
II X
Other parent OO OO
This knowledge is important in paternity cases and
baby mix-up cases. It should be remembered that these
216
tests are exact in exclusion cases of a limited number of
possibilities, and not determination cases, as one main
blood group cannot be identified from another of the
same type. You will recall the baby mixup case in Chi-
cago a few years ago when Mr. and Mrs. B came home
with a baby labeled W, and Mr. and Mrs. W came
home with a baby labeled B.
Mr. B. AB
Mrs. B. ... O
Baby labeled W. O
Mr. W. O
Mrs. W. O
Baby labeled B. - A
Blood tests revealed what is found in Chart 8, proving
that the labels on the babies were correct.
Recently we were called to investigate a murder case,
in which a man was found with his head crushed by an
axe which was lying nearby. There was a pool of blood
on the floor and blood on the axe handle and head. The
dead man was found to be in Group B, as was the blood
on the axe head. A suspect was found, who had many
blood stains on his overalls. The suspect was found to
be in Group A, and he claimed that the blood on his
overalls was from a cut on his hand. He demonstrated
the cut, and his alibi held good because the blood from
the overalls also proved to be Group A. It was then de-
cided to test the blood on the axe handle, which was
found to be Group A. When confronted with this in-
formation the suspect confessed, thereby saving the coun-
ty an expensive trial. It must be emphasized again, how-
ever, that any Group A person’s blood on the axe handle
would have given the same test, and the finding was only
one of possibility or probability used in conjunction with
other known facts. In paternity identification, in approxi-
mately 16 per cent of cases, and in about 40 per cent of
cases of interchange of infants, when the main blood
groups fail, the subgroups are often of valuable help;
for instance, in Chart 9 we see that the M and N fac-
tors are of further help.
Chart 9-
Parents
Children
M
xM
M
N
X N
N
M
xN .
MN
M
x MN
M, MN
N
x MN
N, MN
MN
x MN
M, N, MN
Using all the subgroups and the main groups, it is
now possible to determine the paternity in approximately
40 per cent of cases, and settle about 70 per cent of the
cases of interchange of infants. J
Applying the knowledge we have to transfusion re-
actions, we know now that the following are the causes
of most of such reactions:
Chart 10
1. Pyrogens in apparatus.
2. Wrong blood type.
3. An O donor to a different blood type when the O blood
has a high ab titre and the patient is very anemic.
4. Repeated transfusions of Rh-positive donor to a Rh-negative
patient, possibly some other subgroups also.
5. An Rh-sensitized mother.
Apparatus for giving transfusions must be thoroughly
The Journal-Lancet
and properly cleaned, with boiling for five minutes in
5 per cent sodium hydroxide solution a very important
step. We have had one recent series of 128 transfusions
without any reaction; previously mild reactions were com-
mon, which we feel were due to small amounts of dry
blood and pyrogens not removed from the apparatus.
Using the wrong blood type is, of course, an inexcusable
error. No. 3 of Chart 10 reminds us that O blood can
give reactions, whereas this group has been called the
universal donor. Why is Group O called the universal
donor and Group AB the universal recipient? One of
the fundamental precepts of serology is that when an
agglutinogen meets its corresponding agglutinin under
favorable conditions, AND IN SUFFICIENT TITRE,
agglutination results. The Widal test is a common ex-
ample.
You will note in Chart 3 that O blood, the so-called
un versal donor, contains the ab agglutinin in its serum.
The reason that the ab of this blood does not cause ag-
glutination, when given to the A, B, AB of the other
blood groups, is that it is usually diluted so that it can-
not react IN SUFFICIENT TITRE. The reason that
AB blood is the so-called universal recipient is because
it has no agglutinin in its serum to react with the A and
B agglutinogen. And the ab, a, b agglutinins are suffi-
ciently diluted so as to be unable to react on the patient’s
AB. If, however, the donor’s serum is of a high titre
and in sufficient amount, it could cause agglutination of
the AB. This is one of the reasons why O blood is not I
always a universal donor, nor AB blood always a univer-
sal recipient. In preparing plasma, all the A, B, and AB '
factors are removed, leaving only the agglutinins a, b and ,
ab. The plasma is pooled, thus diluting the strength of I
each one, and there is some deterioration in its strength 1
on standing. These two factors, plus the dilution in the I
patient’s blood, usually make plasma perfectly safe to ’
administer in rather large amounts. However, cases4
have been reported where it is believed that these agglu- ;
tinins have caused reactions. It will be recalled that the
body contains no natural agglutinins against the sub-
groups. Wiener and Peters,'1 in 1940, made a very im-
portant discovery of a new factor in blood which they
called Rh. They called it Rh because they used blood of
macacus rhesus monkey to produce the antibody in
other animals. They found that 85 per cent of humans
carried this antibody and 15 per cent did not. This has
been verified in further studies.1'
Cases of fatal reaction have been reported many times,
though the blood was completely compatible as far as
the four main blood groups were concerned.'4•',•,, The
Rh studies were applied to some of these cases, and it
was found that an Rh-negative person can be sensitized
to build up an antibody against Rh-positive blood by re-
peated transfusion of Rh-positive blood, even though in
the same blood group.1 The old erroneous impression
that a person’s blood group changed after several blood
transfusions probably had its origin in cases of Rh sensi-
tization. This rarely occurs after the first transfusion,
but usually becomes increasingly severe with each follow-
ing one. This antibody is built up much the same way
as typhoid antibody is built up after repeated typhoid
July, 1943
217
vaccine inoculations. This is of extreme importance in
pregnant or postpartum women, and is important many
years postpartum, as well. Given a susceptible Rh-nega-
tive woman, married to an Rh-positive man, she becomes
pregnant and carries an Rh-positive child. Some of the
child’s Rh positive seeps through . a defective placenta
into the mother’s blood, and immunizes her against the
Rh factor. By diffusion, this antibody passes back into
the fetus, causing hemolysis of its blood. If this reaction
starts early, and is severe, the fetus dies in utero and a
stillborn results. A certain number of these stillborns are
hydrops fetalis; some are accompanied with hydramnios.
Surviving infants have hemolytic anemia neonatorum, or
icterus gravis type of erythroblastosis. A certain number
of the survivors are unable to overcome the agglutinin
and die. Henderson* recently studied 53 cases of erythro-
blastosis and found the following: 20 per cent were still-
born, 45 per cent died, and 35 per cent recovered. Six-
teen of the mothers had two cases each, and four mothers
had three cases each. The latter bears out the impression
that erythroblastosis is familial.
Within the past two years we had a case10 in the hos-
pital which brought to us forcibly the danger of trans-
fusion in a pregnant or postpartum woman. This woman,
aged twenty-eight years, Para I, was brought in some 60
miles, with the diagnosis of partial placenta previa, be-
cause of severe hemorrhage after rupture of the mem-
branes. She was delivered of a living male child, and a
diagnosis of extensive premature separation of the pla-
centa was made. Because of anemia and the possibility
of infection due to several vaginal examinations, the
attending physician advised a transfusion. The patient
was Group AB (the so-called universal recipient). Blood
was matched and cross-matched, and she was given 500
cc. from an AB donor. No reaction resulted until about
four hours later, when she developed pain in the back,
and a chill. The urine at first was black, filled with albu-
min and hemoglobin. She developed anuria, became
jaundiced, and died approximately forty-six hours later
in spite of all treatment. Blood was taken before death,
rematched and cross-matched with the donor, and found
to be compatible. At that time we were unable to check
for the Rh factors, but our assumption is that it was the
cause of this fatality.
This reaction can, however, probably be explained by
the fact that the process builds up further agglutinin
with each pregnancy. An important advance in the treat-
ment of erythroblastosis has resulted from these investi-
gations. The mother’s blood should not be used in trans-
fusing the baby, because further agglutinin will be added.
The infant should have large amounts of compatible
Rh-negative blood, and it is expected that in the future
the percentage of survival in erythroblastosis will be
greatly increased. We have at present a recently born
infant1 1 in the hospital who is recovering from erythro-
blastosis under this treatment. For about two weeks after
birth the infant’s nucleated cells were 18,000 per cubic
millimeter, one-half of which were normoblasts. We
are now using this mother’s serum for Rh tests, because
it is strong in the anti-Rh agglutinin.
Whenever possible, in pregnant or postpartum women
or any person receiving repeated transfusions, the patient
should be tested for anti-Rh agglutinin. A rather simple
cross-match as described by Levine12 and Weiner13 is
probably as valuable or even more so, because it might
pick up other irregular iso-agglutinins. This method is
described below.
In a small clean test tube put 2 drops of the patient’s
serum with 1 drop of a 2 per cent suspension of the
donor’s cells in physiological saline. The cells should be
washed once in saline solution. Incubate at 37° for 30
minutes and centrifuge slowly for 1 minute. Rh agglu-
tination is usually not marked but a wrinkled or granular
edge of the sediment is positive. Further inspection can
be made by very gently shaking the tube as the agglu-
tination is easily broken up.
Since this paper was written, the author had a personal con-
versation with Dr. Wiener in which Dr. Wiener described a
biologic test for incompatibility. It is carried out by starting an
intravenous injection of isotonic glucose or saline, and giving
50 cc. of the donor’s blood in this solution. Wait one hour and
draw 5 to 10 cc. of the blood into an equal amount of 2!4 per
cent sodium citrate in saline. Centrifuge or allow to settle out
by standing, and if there is any definite yellow or orange tint
to the supernatant liquid, it is probably unsafe to give the blood.
Conclusions
1. The old numbered classifications of blood groups
should be discarded for Landsteiner’s, the International
classification of Ab, A, B, and O, which has universal
usage and a scientific interpretation.
2. O blood is not always a universal donor, and blood
of the same group is probably preferable in most cases.
3. In cases receiving multiple transfusions, or in preg-
nant or postpartum women, the Rh factor must be con-
sidered and guarded against.
4. More cases of erythroblastosis can probably be
saved if Rh-negative blood is used.
Bibliography
1. Wiener, A. S.: Blood Groups and Blood Transfusion, 2nd
edition, Charles C. Thomas, Publisher, Baltimore, Md.
2. Krocke, Roy R., and Garver, H. E.: Diseases of the Blood
and Atlas of Hematology, J. B. Lippincott Co., Philadelphia, Pa.
3. Klendshoj, N. C., and McNeil, Crichton: A transfusion
reaction following the use of universal blood, J.A.M.A. 118:528
(Feb. 14) 1942.
4. Levine, Milton, and State, David: A and B substances as
a cause of reaction following human plasma transfusions, J.A.M.A.
120:275 (Sept. 26) 1942.
5. Wiener, A. S., and Peters, R. H.: Hemolytic reactions fol-
lowing transfusions of blood of the homologous group, with three
cases in which the same agglutinogen was responsible, Ann. Int.
Med. 13:2306-2322, 1940.
6. Levine, P., and Stetson, R. E. : An unusual case of inter-
group agglutination, J.A.M.A. 1 1 3:126—127, 1939.
7. Landsteiner, K., and Wiener. A. S.: Studies on an agglu
tinogen ( Rh ) in human blood reacting with anti-rhesus sera and
with human iso-antibodies, J. Exper. Med. 74:309—320, 1941.
8. Henderson, J. L.: Observations on erythroblastosis and its
differential diagnosis from congenital syphilis, J. Obst. &C Gynec
Brit. Emp. 49:453-580 (Oct.) 1942.
9. Foord, A. G., and Fisk, R. T.: Observation on the Rh ag-
glutinogen of human blood. Am. J. Clin. Path. 1 2:545 (Nov.)
1 942.
10. Carmichael, Glenn, Butte, Mont.: Fatal case of transfusion
reaction in a postpartum woman (personal communication).
11. Gillespie, Don G., Butte, Mont.: Case of erythroblastosis
with recovery (personal communication).
12. Levine, P.: Role of isoimmunization in transfusion acci-
dents in pregnancy and in erythroblastosis fetalis, Amer. J . Obst.
Qc Gynec. 42:165 (July) 1941.
13. Wiener, A. S.: Hemolytic transfusion reactions preven-
tion, with special reference to the Rh and cross-match tests, Am. J.
Clin. Path. 12:302 (June) 1942.
218
The Journal-Lancet
AMERICAN STUDENT HEALTH ASSOCIATION MONTHLY NEWS-LETTER
ARMY SPECIALIZED TRAINING PROGRAMS
Pursuing our stated policy of circulating reports from
various schools on plans adopted to provide medical serv-
ice for Army Specialized Training Programs, we quote
the following from a letter dated June 11, 1943, from
Dr. O. N. Andersen, General Director of the School of
Health and Director of the Men’s Health Service at
Stanford University:
"Because of the proximity of regular Army facilities
to the Stanford Campus, we have arranged, with the
approval of the Army Medical Corps representatives, to
supply only daily sick call, ambulatory service, and minor
emergency service to the Army units stationed on the
campus. At present there are approximately 1400 here
in engineering, language area studies, psychology, and
for reclassification.
The plan under which we are now operating has the
following characteristics:
Dispensary service:
(a) Treatment in dispensary by competent physi-
cians of sick or injured persons, and all phys-
ical examinations and advice connected there-
with, daily including Sunday.
(b) Furnishing of medicines, surgical dressings,
and other supplies incident to the foregoing,
excepting vaccination and inoculation ma-
terials.
(c) Routine laboratory procedures incident to
diagnosis and treatment of ambulatory cases,
including fluoroscopic examinations.
(d) Treatment facilities of Stanford Physical
Therapy Division.
(e) Conduct of routine and special physical ex-
aminations, examinations of food handlers, inocula-
tions, and sanitary inspections.
All hospitalization except severe emergency cases is at
regular Army facilities in the area. Severe emergency
cases are hospitalized in our local Palo Alto Hospital.
Army facilities also furnish specialized examinations,
refractions and lenses, and routine dental work.
The cost to the Army for this service has been esti-
mated to be approximately $1.04 per soldier per month.
However, this figure is subject to adjustment from time
to time as our experience with costs increases. We under-
stand there may be a re-examination and adjustment
after each three-months period.
The physical education program has been patterned
after the recommendations of the War Department
Training Circular No. 87, which, no doubt, is being fol-
lowed by most of the colleges with Army specialized
training units. This calls for six hours per week, with
specified requirements in four general areas, that is,
combatives, team sports, gymnastics and obstacle course,
and aquatics. Beginning with the summer quarter, one
hour of the six will be devoted to a course in military
hygiene.”
PERSONAL ITEMS
Dr. Ruth Stephenson resigned as director of the
Health Service, New Jersey College for Women, to en-
ter war work with the Edward G. Budd Manufacturing
Company in Philadelphia, June 1st.
President Carter Davidson of Knox College reports
the appointment of Dr. George H. Musselman, for sev-
eral years Medical Director of the People’s Gas, Light
and Coal Company of Chicago, as College Physician,
Professor of Hygiene and Director of the Student
Health Service.
Dr. B. I. Bell has recently been appointed Student
Physician at the College of William and Mary, succeed-
ing Professor L. Tucker Jones, who died December 1,
1942.
Succeeding the late Dr. Lee H. Ferguson, Dr. A. B.
Denison has been appointed acting director of the Health
Service at Western Reserve University.
Dr. Henry J. Pleasants, Medical Director of the West
Chester State Teachers College the past two years, re-
signed June 1st.
Dr. Charles M. Rieber is on leave from Queens Col-
lege for military service.
H. F. Kilander, former Professor of Health Education
at Panzer College, is now with the Federal Security
Agency as Nutrition Representative. Warren H. South-
worth, D.P.H., succeeds him at Panzer.
Dr. Embree R. Rose is acting director of the Ohio
University Health Service in the absence of Dr. E.
Herndon Hudson, who is now a Lieutenant Commander
in the Navy.
Dr. Eleanor Nelson, College Physician, is the repre-
sentative in our Association from Mills College replacing
Miss Edith Lindsay who is now on the faculty at Stan-
ford University.
A.S.H.A. DIGEST OF MEDICAL
NEWS
Enormous Doses of Chlorine Necessary to Kill E. his-
tolytica Cysts in Water. F. J. Brady, Myrna F. Jones,
and Walter L. Newton in the April 1943 issue of War
Medicine conclude as the result of 1894 examinations of
1233 cultures that:
( 1 ) The doses of chlorine now recommended for kill-
ing Endamoeba histolytica cysts in drinking water (3.77
mg. calcium hypochlorite per liter) cannot be relied
upon.
(2) The use of 7.54 mg. per liter of calcium hypo-
chlorite for 20 minutes killed the majority of cysts but
not all.
Pandemic Influenza Not Distinct From Ordinary Epi-
demic Influenza. At the National Conference on Plan-
ning for War and Postwar Medical Services in New
York City March 15, 1943, Dr. Thomas Francis, Jr.,
expressed the belief that pandemic influenza, such as we
experienced in 1890 and 1918, is not a strange infection
arising spontaneously in a population but rather a modi-
fication of our ordinary virus-caused epidemic influenzas.
In this belief Dr. W. G. Smillie concurred, adding the
July, 1943
219
observation that our frequent exposure to ordinary epi-
demic influenza in community living in temperate cli-
mates built up a "mosaic of overlapping antigens which
produces a relative degree of community immunity to
epidemics.” Dr. Smillie stated that when the 1918 epi-
demic of influenza struck the village of Okkak on the
Labrador coast the population of the whole village was
wiped out with the exception of the Moravian Mission-
ary and his wife.
Supply of Physicians Greater in U. S. Than Else-
where. In the May 1, 1943, Journal of the American
Medical Association, Dr. Fishbein made the following
estimate of the supply of physicians for the civil popula-
tion:
In U. S. at beginning of war, 1 physician to every
700 persons.
In U. S. Jan. 1, 1943, 1 physician to every 1500
persons.
In Great Britain Jan. 1, 1943, 1 physician to every
3000 persons.
In Sweden Jan. 1, 1943, 1 physician to every 2500
persons.
In Germany, Jan. 1, 1943, 1 physician to every 8000
to 12000 persons.
Numbers of Immigrants Admitted to U. S. Much
Below Quota. F. P. Keppel, a member of the two-man
board of appeals set up to pass on applications for immi-
gration stated, at the National Conference on Planning
for War and Postwar Medical Services, "There seems to
be a widespread impression that great hordes of un-
washed and ignorant foreigners are beating at our doors.
The facts are that, if every single application received in
the year 1942 had been approved and if every single
holder of a visa had been able to get here, the total
would have been less than 10 per cent of the immigra-
tion under the quota system in a normal prewar year.
But less than half the applications are actually approved,
and a high proportion, I should say fully one-half of
those who were granted visas, have not been able to use
them.”
American Longevity Continues to Increase. Tables are
presented in the April, 1943, issue of the Metropolitan
Life Insurance Company’s Statistical Bulletin which
show the following facts:
(a) In Continental U. S., for white males, the expec-
tation of life at birth in 1941 was 63.39 years; the ex-
pectation at age 40 was 30.13 years.
(b) In Continental U. S., for white females, the ex-
pectation of life at birth in 1941 was 68.08 years; the
expectation at age 40 was 33.53 years.
(c) In Continental U. S., for colored males, the ex-
pectation of life at birth in 1941 was 53.48 years; the
expectation at age 40 was 25.41 years.
(d) In Continental U. S., for colored females, the ex-
pectation of life at birth in 1941 was 56.77 years; the
expectation at age 40 was 27.64.
Sulfonamide Treatment of Shigella dysenteriae Infec-
tions. A. V. Fdardy et al. in the April 30, 1943, issue of
Public Health Reports state that, though prevailing med-
ical opinion appears to favor the use of the poorly ab-
sorbed sulfonamides, their findings indicate that the use
of the readily absorbed sulfonamide must also be consid-
ered. In these cultural and clinical studies, sulfadiazine
appears to be a promising chemotherapeutic agent
against the Shigella dysenteriae infections.
Ascorbic acid content of Tomatoes Differs with Va-
riety of Tomato. Eugene C. Auchter stated in a series
of lectures in Washington, March 11 and April 15,
1942, that studies made by the Department of Agricul-
ture Regional Vegetable Breeding Laboratory at Charles-
ton, S. C., had shown a variation in the ascorbic acid
content of 33 varieties of tomatoes from 10 mg. per 100
grams to 22 mg.
Malaria a World-Wide Menace. Dr. L. T. Cogge-
shall at the National Conference on Planning for War
and Postwar Medical Service held in New York City,
March 15, 1943, stated "We must conclude that the
potential danger of malaria during the present war is a
greater worldwide menace than ever before.” To combat
this hazard, the speaker advised (a) at the first sign of
malarial outbreaks in this country an all out effort by
local, state and federal public health authorities (b) more
training centers for malariologists and more opportunity
for fundamental research in malariology.
Salmonella in Retail Meat Products. Cherry, Scherago,
and Weaver in a recent investigation have found Salmo-
nella in 5.2 per cent of a large variety of retail meat
samples. Because they were able to isolate Salmonella
from the mesenteric lymph glands of 10 per cent of ap-
parently normal slaughtered hogs, the authors feel that
the source of Salmonella in retail meats may often be the
animals themselves. (Am. J. Hyg., Mar. ’43.)
Limitations of X-ray Film Inspection of Chest. J. A.
Myers in a review of an article in the May 1943 Journal
of School Health concludes as follows:
X-ray film inspection of the chest, alone, is an ex-
tremely unsatisfactory procedure for the following rea-
sons: (1) It detects possible evidence of tuberculosis in-
fection in not more than one-fourth to one-third of the
persons actually infected. (2) It aids one in visualizing
only 75 per cent of the lungs. (3) It misses extrathoracic
lesions which may be eliminating large numbers of tu-
bercle bacilli through urine or discharging sinuses. (4)
Many cases are on record with tubercle bacilli in the spu-
tum, whose x-ray films reveal no evidence of disease in
the lungs. (5) It does not permit a diagnosis of etiology
of pulmonary lesions, since shadows cast by tuberculosis
often are identical with those cast by other diseases.
Many persons have lost their positions and have been
admitted to sanitariums because of this fact.
Survival of Tubercle Bacilli in Books. C. R. Smith in
the American Review of Tuberculosis as abstracted in the
Journal of the American Medical Association of January
23, 1943, reports, as the result of his experiments, that
tubercle bacilli in sputum placed on the leaves of books
remain alive, if the books are closed with the pages still
wet and stored in a dark unheated cupboard, for two
weeks to three and one-half months. Books used by pa-
tients with a positive sputum should not be used by oth-
ers until they have been stored at least one month.
Serves the
MINNESOTA, NORTH DAKOTA
Medical Profession of
SOUTH DAKOTA and MONTANA
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
Montana State Medical Assn.
Dr. E. D. Hitchcock, Pres.
Dr. A. C. Knight, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, T reas.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, T reas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres. -Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
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 84 South Tenth Street, Minneapolis, Minnesota
W. L. Klein, 185 1-1 93 1
Minneapolis, Minnesota, July, 1943
VIRUS PNEUMONIA
Osier, borrowing the term that John Bunyan had ap-
plied to consumption, said that pneumonia was then the
"Captain of the Men of Death.” It is undoubtedly the
most widespread and fatal of all acute diseases. The
greatest progress in the past fifty years has been in the
realm of infections and anything new must command
our interest.
We must admit that the most conscientious observers
felt that pneumonia was pretty much a self limited dis-
ease, with a fairly definite crisis on the eighth to the
tenth day and that little could be done to shorten this
period. In Germany the use of digitalis was popular, but
it was usually administered symptomatically when the
pulse showed weakness, when as a matter of proven fact
it should have been given in heroic doses at the onset of
the congestion. Ice cold compresses to the entire chest
like a jacket, and generous amounts of cognac consti-
tuted the most widely used treatment in Sweden. At the
Postgraduate Hospital in New York, pneumonia patients
were put on the roof where snow and wind were permit-
ted to sweep over the unsheltered patients’ beds, and for
a few years this practice came into vogue in other parts
of the country. The greatest reaction came with the ad-
vent of flu-pneumonia which definitely did not do well
in a cold temperature. Then, typing came along and we
had thirty-two varieties in this classification, and bio-
logical chemists scurried about to supply sera appropriate
to each case. There was a gleeful cry of "Eureka”,’ but,
with sufficient reserve, as becomes our scientific guild, no
oxen were sacrificed. Then with dramatic suddenness the
sulfozones were born and gave some promise of being a
panacea in every form of infection. Now, with all this
progress, we are finding a pneumonia that cannot be
typed, that cannot be classified by any known organism,
and that does not behave like any previously known
pneumonia. It is due to a virus. It has an insidious,
febrile onset with no significant findings for some days,
July, 1943
negative sputum, an unproductive cough and at first a
peribronchial infiltration recognized by roentgenological
study only. Later, this extends to a pseudofibrosis, also
referred to as a "wire-grass” type of infiltration. We
must be on the lookout for this condition. In spite of
i sera and sulfa drugs, the Metropolitan Life Insurance
Company has reported considerable increase in pneumo-
nia mortalities. It may be that this filtrable virus, through
further animal inoculation studies, will furnish an ex-
planation.
A. E. H.
WASSERMANN PROBLEMS
It is rare to meet a man these days who hasn't had a
recent physical examination. There never was a time
when so many people were being examined so many times
for so many things. The name of Wassermann is ap-
proaching that of Santa Claus in household parlance, but
Dr. Wassermann is not always the last authority on what
a man has, any more than Santa is on what he is going
to get.
Serological tests for syphilis should be and are included
in all complete physical examinations. Doctors remaining
in civilian practice who do a great many examinations for
1 local defense industries are beset continually by prob-
lems in connection with routine blood tests.
Foremost, is the problem of false positives. There is
nothing so embarrassing or time-consuming as the expla-
nation of a false positive test turned up in the course of
routine examinations. Benjamin S. Kline, M.D., of
Cleveland, wrote an article for the Ohio State Medical
Journal for May, 1943, which is brief, clear, and per-
tinent. There is also an excellent article "The Interpreta-
tion of Serologic Reactions” by George V. Kulchar,
M.D., in the California and Western Medicine for De-
cember, 1941. No doubt there are others which have not
come to our attention.
False positive reactions may be "technical” or "bio-
logic”. The former is due to error in technical perform-
ance and should be fairly easy to trace and exclude. The
latter is also rare, but is usually due to some condition
other than syphilis which, temporarily at least, provokes
a positive response to some or all of the serological tests.
Aside from yaws and leprosy, which we are little con-
cerned with at the present time, malaria at some time in
its course is very apt to produce positive serology. Mono-
nucleosis is said to offend in as high as 20 per cent of
cases. Vaccinia was reported as the cause of 16 per cent
positive reactions in a group of 263 persons tested before
and after primary vaccination. Scarlet fever, Rocky
Mountain spotted fever, subacute bacterial endocarditis,
lymphopathia venereum, are only a few of the many dis-
eases which occasionally give rise to false positive reac-
tions. To these must be added hyperproteinemia with in-
creased serum globulin from any cause as a possible
source of serological confusion.
Suggestions for following up the indeterminant reac-
tions have been made by Moore, Eagle, and Mohr, and
are briefly stated: First, by means of questioning, phys-
ical examination, blood smears, heterophile titer, and sedi-
mentation rate, a search is made to disclose recent or
221
intercurrent infections. Then, a complete serological study
is instituted, examining the spinal fluid where indicated.
Positive tests with increasing titer usually mean early
syphilis, whereas those which are less positive and have
decreasing titers probably do not.
Pre-employment examinees occasionally remark that
they have already had several blood tests within the
month, and the question arises if we are not wasting time
and material when the tests are made at the same lab-
oratory. Inquiry at the Minnesota State Board of Health
Laboratories indicates that it is less costly to repeat the
tests than to check and clear the names of the thousands
of negative reactors. In the positive or questionable
cases, the record is always checked for previous serologic
tests.
To use a Hibernianism, the "doubtful positive” is one
of those rare conditions that we run into every day.
There is, however, an orderly procedure, which followed,
dispels the doubt.
L. M.D.
Book Reviews
Chemotherapy of Malaria, a review of the biological and sta-
tistical background of malaria, and of the literature on anti-
malarial chemotherapeutic agents , by Dr. James H. Wil-
liams, Stamford Research Laboratories, American Cyanamid
Company. New York, 1943, by Lederle Laboratories, Inc.,
814x11, bound in heavy blue paper, sent free on request to
research workers in the malarial field.
Dr. Williams and the Lederle Laboratories have rendered a
great service to the community in the publication of this val-
uable compilation.
For several centuries, malaria has been and still is mankind’s
"Public Enemy No. 1,” whether considered from the standpoint
of distribution, morbidity or mortality. For over 300 years
quinine, or its source material (cinchona bark) , has been the
chief remedy for the disease, and it is unquestionably true that
no drug in the history of mankind has relieved so much suffer-
ing or saved so many human lives. In recent years 90 per cent
of the world’s supply of quinine, and 95 per cent of our own
requirements, have come from Java. The occupation of that
island by the Japanese has, therefore, resulted in a serious situa-
tion for our Allies as well as for ourselves. Some useful syn-
thetic remedies already have been developed and are now avail-
able, but the Surgeons General of the Army, Navy and Public
Health Service have requested intensive and concerted efforts
to find new and superior antimalarials.
Certain governmental laboratories, as well as those of many
universities and research institutions, and pharmaceutical plants,
are busily engaged in this task at present. Such investigations
can be conducted intelligently, and without waste of time, en-
ergy and money through duplication and overlapping, only when
based upon a thorough knowledge of what has already been
done in this field. The literature on the chemotherapy of ma-
laria is so extensive and so widespread that its compilation, class-
ification and publication is a laborious, difficult and onerous un-
dertaking. It is therefore a great boon to all workers in this
field to have now placed at their disposal this thorough and
scholarly review, and it will be warmly welcomed by organic and
biochemists, pharmacologists, and members of the medical pro-
fession.
The work is presented in five parts: I. Introduction and Bio-
logical Background, II. Sulfonamide Compounds and Sulfones
as Antimalarials, III. Amidines as Antimalarials, IV. Quinoline
Compounds (exclusive of the cinchona derivatives) as Anti-
222
The Journal-Lancet
malarials, and V. Acridine Compounds as Antimalarials. Each
part begins with an itemized Table of Contents, followed by a
detailed discussion of individual compounds, with graphic for-
mulas, tables, etc., and concludes with a bibliography of patents
and literature references.
Essentials of Proctology, by Harry E. Bacon, B.S., F.A.C.S.,
F.A.P.S. Philadelphia: J. B. Lippincott Co., 361 pages, 168
illustrations, 1943, price $3.50.
Essentials of Proctology , by Harry Bacon, will be accepted by
proctologists who are personally acquainted with the author
with a feeling of great satisfaction, because of the knowledge
that the author is in a unique position by virtue of training and
experience to present such a book. On the other hand, those
physicians who are in the habit of referring to Dr. Bacon’s
original textbook. Anus, Rectum, Sigmoid Colon, will probably
continue to use that book rather than the new abridged volume.
The innovation by the author of an index of symptoms and
signs in the fly-leaves of the book is indeed a worthy contribu-
tion and will be appreciated by those who become accustomed
to its use. This type of index could well be adopted in many
other texts.
Dr. Bacon has carried out his systematic approach to the
different subjects in the same careful manner as he has in his
original text. The book is replete with excellent photographs
and diagrams. It must always be kept in mind that in this par-
ticular volume the author has attempted to present his own
ideas chiefly. This is in contrast to his original book in which
he has so very ably presented the many and diverse ideas on the
different subjects.
The chapter on lymphogranuloma venereum has been pre-
sented very well and it would do most physicians a great deal
of good to recognize the fact that this disease is more prevalent
than generally thought and can be recognized if its possibility
is kept in mind.
The general practitioner in particular will find this book an
excellent help-mate in treating ano-rectal diseases.
Brucellosis in Man and Animals, by I. Forest Huddleson,
D.V.M., M.S., PhD. New York: The Commonwealth
Fund, revised edition, 379 pages, 39 illustrations and 3 col-
ored plates, with index, appendix, and bibliography, 1943,
price $3.50.
Nine years ago Dr. Huddleson published his first treatise,
Brucella Infection in Animals and Man, which was rewritten,
greatly expanded, and published in 1939 as Brucellosis in Man
and Animals. The appearance of a revised edition attests to the
success of this book. This edition presents important changes
that have been made in laboratory methods of diagnosis and
new facts pertaining to the nature of the disease. Three co-
authors have contributed to the book. A. V. Hardy wrote the
section Brucellosis in the United States; J. E. Debono, of Malta,
discusses Brucellosis in Malta; and Ward Gilner wrote the
chapter on the eradication and control.
In addition to these subjects, Huddleson discusses the bru-
cella organisms, their characteristics, methods of isolation and
differentiation. The clinical aspects of the disease, as well as the
various methods of diagnosis and treatment, receive clear and
interesting presentation. Huddleson presents a chapter on bru-
cellosis in animals, and a chapter on laboratory diagnosis, divid-
ed into three parts: serologic methods, allergic methods and the
opsonocytophagic test. Wisely, the author has left out super-
fluous laboratory procedures, limiting this section to methods
that are of practical importance to the physician.
In an appendix, 26 cases of brucellosis are reviewed with clin-
ical and laboratory findings. A bibliography of 485 references
appears at the back of the book.
Tables and charts are well arranged and valuable. The book
is easy to read, and should be of value to the physician inter-
ested in this important disease, as well as to the laboratory and
experimental scientist.
Views Items
Dr. S. A. Slater of Worthington, Minnesota, a past
president of the Sioux Valley Medical Association, has
been elected to the executive committee of the National
Tuberculosis Association.
Dr. I. R. Vaughn, assistant director of the division of
vital statistics of the South Dakota health department,
will head the recently established division of public health
education for that state.
Dr. Tula Wilhelmina Gronewald, a member of the
staff of the North Dakota state hospital for the insane,
at Jamestown, has been elected a member of the Ameri-
can Psychiatric Association. She spent five years at Fer-
gus Falls, Minnesota, before going to Jamestown in
1940.
Dr. Jno. F. Montroy, a native of New York state and
for 18 months with the Indian service at Fort Thomp-
son, South Dakota, has taken over the duties of physi-
cian at Fort Totten Indian Agency to fill the vacancy
left by Dr. M. S. Burdick, resigned because of ill health.
Dr. Ralph R. Parker, director of the Rocky Mountain
laboratory of the U. S. Public Health Service at Hamil-
ton, Montana, and successor to Dr. Herald R. Cox,
Journal-Lancet lecturer for 1942 at University of
Minnesota, was awarded the honorary degree of doctor
of laws on May 23 by Massachusetts State College at
Amherst, of which institution he is a 1915 graduate.
Dr. Parker is a world authority on Rocky Mountain
spotted fever. His research on that subject and on tula-
remia often have been cited as models to be followed by
investigators who study similar diseases in different parts
of the world. In the May 14, 1943, issue of Public
Health Reports, Dr. Norman H. Topping, past assistant
surgeon of the United States public health service, writ-
ing on Rocky Mountain spotted fever as studied in the
division of infectious diseases, National Institute of
Health, acknowledges gratefully the advice and assist-
ance furnished by Dr. Parker. Since leaving college, Dr.
Parker has spent all his professional life in his special
branch of medical entomology, relating to ticks and tick-
borne diseases. He was co-discoverer, with Dr. Roscoe
Roy Spencer of Bethesda, Maryland, of a prophylactic
vaccine, the use of which, in more than ten years, has
proved its value in saving human lives endangered by the
virus of the fever carried from animal to animal. He
discovered the presence of bubonic plague among the
rodents of southwestern Montana.
Dr. W. R. Geidt, assistant state health officer at Pierre,
South Dakota, and recently acting superintendent of the
board of health, has resigned to accept a position as epi-
demiologist for the state health department of Wash-
ington.
Dr. Theodore E. Bratrud of Minneapolis received the
Marquette University alumni award for a paper submit-
ted at an alumni clinic of the university’s medical school.
His topic was "Congenital Adrenal Hyperplasia.” Dr.
Bratrud is a member of the faculty of the University of
Minnesota medical school.
July, 1943
223
Recent service transfers include Lt. Robert M. Catey
of Mobridge, South Dakota, from reception center at
Jefferson Barracks, Missouri, to station hospital at Camp
Phillip, Salina, Kansas, thence to overseas service; Dr.
G. Alfred Dodds of Valley City, North Dakota, from
infirmary at Ft. Rosecrans, San Diego, California, to
Seattle, Washington, point of embarkation; Lt. Col.
Ralph B. Kettlewell of Sauk Centre, Minnesota, Divi-
sional Surgical Officer, to A.P.O. from Los Angeles;
Dr. Marvin Nerseth of Klamath Falls and Chiloquin,
Oregon, from Fort Lewis, Washington to Camp Mc-
Quade, California.
Lieutenant Julius Winer of Minneapolis, incorrectly
reported at Dale Malry Field, Florida, is at Grand Cen-
tral Palace induction station, New York City.
Dr. Virgil Lundquist of Willmar, Minnesota, grad-
| uated from University of Minnesota school of medicine
March 18, is now stationed at Camp Farragut, Idaho.
Dr. R. Wynn Kearney, practicing as a physician at
Mankato, Minnesota, for the last several years, was
; commissioned a captain in the medical corps on his en-
1 listment and is attending Harvard University medical
school for a surgery course before going into active duty.
Dr. Jno. G. Lamont, formerly of Minneapolis, now
superintendent of Grafton (North Dakota) state school,
attended the annual convention on mental deficiency in
New York City, May 12 to 15.
Dr. P. O. C. Johnson of Watford City, North Da-
kota, has resumed medical practice after a period of ill
health during which the city and McKenzie county were
without the services of a resident physician.
Dr. Rudie J. Carlson of Merrill, Iowa, has removed
to Sisseton, South Dakota, and will practice medicine
and surgery at that point.
Dr. John G. Lohmann, physician and surgeon of Jas-
per, Minnesota, has purchased the equipment of Dr.
Eugene F. McElmeel of Pipestone, Minnesota, a former
i associate, and will begin his practice at Pipestone, July 1,
at which time Dr. McElmeel will enter upon a three year
fellowship in ear, nose and throat work in Minneapolis.
I Both doctors have been in practice for six and a half
years.
Dr. Orio K. Behr of Crookston, Minnesota, a member
of the Crookston clinic, will assume the medical respon-
sibilities of Dr. Geo. W. Bohl of Ada, dividing his time
between the two communities. He has taken over the
residence and office properties of Dr. Bohl, who will
locate in the west.
Dr. Theo. O. Wellner of Anoka, Minnesota, has
opened a practice in Rochester in the quarters formerly
I occupied by Dr. John A. Paulson.
Dr. Carl A. Peterson of Chisago City, Minnesota, who
was the attending physician of the Minneapolis Sym-
phony Orchestra on tour for two years, has added to his
practice that of Dr. Lorin Olson. Dr. Olson has left
to join the nation’s fighting forces.
Dr. Joseph R. Lenz, of Morton, Minnesota, expects
to divide his time between Morton and Fairfax with
headquarters at Morton.
Dr. Aloys F. Branton of Willmar, Minnesota, has
been re-elected executive secretary of the Minnesota Hos-
pital Association which entertained Dr. Durval Vianna,
director of the Miguel Couto Hospital of Rio de Ja-
neiro, Brazil, at the association’s annual convention at
Hotel Nicollet, Minneapolis, the last week in May.
Dr. Wm. C. Fawcett of Starkweather, North Dakota,
member of the state board of medical examiners and for-
mer president of the state medical society, was the sub-
ject of notice in the Devil’s Lake Journal of May 18.
This consisted of a picture of Dr. Fawcett and his four
doctor sons, reproduced from The Diplomate, February
issue, together with comment on the medical records and
distinctions of all five men.
At Sioux Valley Medical Hospital, Sioux Falls, South
Dakota, all members of the present active and associate
medical staffs were re-elected for the coming year at the
annual meeting of the board of directors, held May 24.
On recommendation of the staff, Dr. Jno. A. Kittelson,
president; Dr. Emil G. Ericksen, vice president, and Dr.
Wm. F. Sercl, secretary, were approved as officers.
The Veterans’ Bureau of the United States govern-
ment has settled a ten-years suspense by fixing Sioux
Falls as the site of the proposed new hospital for South
Dakota. Other cities to the number of seven, all east
of the Missouri river, which had sought the allocation,
are Madison, Brookings, Watertown, Aberdeen, Pierre,
Huron, Mitchell and Yankton. President Roosevelt ap-
proved the bureau’s recommendation May 14.
Dr. Earl Carlson of New York, specialist in physio-
therapy applied to spastic condition of muscles, conduct-
ed a clinic at the crippled children’s school of Jamestown,
North Dakota, June 3 and 4.
The state of West Virginia Merit System Council an-
nounces unassembled examinations for higher positions
in the state health department, notably director of com-
municable diseases and assistant director of communica-
ble diseases (venereal), applications for which will be re-
ceived continuously. Information and blanks are obtain-
able at any local office of county or state departments of
health or by writing the merit system supervisor, Robt.
Bingaman, Atlas Building, Charleston 1, West Vir-
ginia.
The American College of Chest Physicians, through
its executive secretary, directs attention to the proposed
plan for a United States military tuberculosis commis-
sion to be appointed by the surgeon general of the U. S.
Army looking toward world planning for tuberculosis
control, the proponent being Dr. Chas. M. Hendricks
of El Paso, Texas, chairman of the council on military
affairs and public health of the College. Dr. Robert E
Plunkett, another distinguished member, has character-
ized tuberculosis as the delayed-action bomb of the dis-
eases of war.
Dr. Fred L. Adair, formerly of Minneapolis, heads
the list of members of the editorial board of the new
Quarterly Review of Obstetrics and Gynecology, an ab-
stract journal about to make its appearance, with Wash-
ington, D. C., as its place of publication.
Dr. James F. Craig of Circle, Montana, presided at
the annual convention of the Montana Public Health
Association at Bozeman, June 7 and 8. Out-of-state
speakers included Dr. Erval R. Coffey of Washington,
D. C., assistant surgeon general of the United States;
Dr. Fred T. Ford, medical officer of the ninth civilian
defense office at San Francisco; Dr. Carl P. Buck of
New York City, field director of the American Public
Health Association, and Dr. A. B. Price, venereal con-
trol officer of the public health service office at Denver.
Dr. John Brody of the Murray Clinic of Butte, Mon-
tana, delivered an address entitled "Practical Application
of Oxygen Therapy” at a meeting of the Silver Bow
Medical Society Monday, May 24, in the Finlen Hotel,
Butte. Present were officers of the Montana State Med-
ical Association, Dr. E. D. Hitchcock, Great Falls, presi-
dent; Dr. J. R. Ritchey, Missoula, president-elect, and
Dr. Thomas F. Walker, Great Falls, secretary.
Lieutenant Harold P. Adams of the medical corps of
the U. S. Army who was on the staff of the Huron
(South Dakota) Clinic before joining the service, vis-
ited in Huron en route from Philadelphia to Boise,
Idaho, where he will work in surgery at Gowan Field.
TRIODYDE
Expectorant
Anti- Asthmatic
yietMloty}
Dr. William M. Coptenhaver, Jr., 37, of Helena,
Montana, died May 23 following a series of operations
and protracted periods of illness caused by injuries re-
ceived in a motor accident eighteen months before. For
six months prior to his death, he attempted to carry on
his practice. He was born in Bristol, Virginia, came to
Helena at the age of five and was a graduate of Helena
public schools and the University of Minnesota, having
transferred to the latter from Dartmouth college. Dr.
Copenhaver was active in civic affairs, the Y.M.C.A.,
the Red Cross, the medical society and his church, in
many of which he held important offices.
Dr. Olaf O. Haraldson, 58, of Minot, North Dakota,
director of the Minot-Ward county public health unit
and former Northwood physician, died June 6. He was
stricken two days previous while en route with a party
of Minot Shrine club members to attend a ceremonial
at Grand Forks. Taken to the home of his brother at
Northwood, he suffered a second stroke. He practiced
at Watertown, South Dakota, and at Northwood before
coming to Minot where he has been for twenty years.
Dr. Henrik Tillisch, 65, of Brookings, South Dakota,
died June 20. He was born in Bergen, Norway, and
came to this country at an early age. He received his
pre-medical education at the University of Wisconsin
and his medical degree from Northwestern University
in 1901. He practiced for many years in Canby, Minne-
sota, removing to Brookings in 1926 where he was the
senior member of the Brookings Clinic. He had been a
member of the South Dakota State Medical Association
since moving to the state. About eight months ago he
had a coronary episode and was out of practice for sev-
eral months. He had recently been in the office part
time but died from another attack.
INDICATIONS: Spasmodic bronchial coughs;
certain asthmatic conditions; non-specific in-
fections of the upper respiratory tract.
Triodyde is non-narcotic and non-alcoholic.
It can be efficaciously administered to children
as well as adults in water, milk or fruit juice.
K-B UNCTION
ANALGESIC
OINTMENT
K-B UNCTION stimulates capillary circula-
tion, helps to normalize local metabolism.
Its actions are aimed at ridding the con-
gested tissues of fatigue toxins, thus hast-
ening tissue rehabilitation.
KUNZE & BEYERSDORF, INC.
MILWAUKEE, WISCONSIN
Transactions of the North Dakota State Medical
Association
Fifty-Sixth Annual Session
Bismarck, North Dakota
May 10 and 11, 1943
OFFICERS, 1942-43
PRESIDENT
A. R. SORENSON Minot
PRESIDENT-ELECT
FRANK D ARROW Fargo
FIRST VICE PRESIDENT*
F. L. WICKS Valley City
SECOND VICE PRESIDENT
JAMES HANNA Fargo
SPEAKER OF HOUSE OF DELEGATES
JOHN H. MOORE Grand Forks
SECRETARY
L. W. LARSON Bismarck
TREASURER
W. W. WOOD Jamestown
DELEGATE TO THE A. M. A.
(1943)
A. P. NACHTWEY Dickinson
ALTERNATE DELEGATE TO A. M. A.
(1943)
O. T. BENSON Glen Ullin
*Interim appointment by Council to fill vacancy caused by
death of Dr. A. O. Arneson, McVille.
COUNCILLORS
Terms Expiring 1943
SECOND DISTRICT
W. C. FAWCETT Starkweather
SEVENTH DISTRICT
P. G. ARZT Jamestown
EIGHTH DISTRICT*
F. W. FERGUSSON Kulm
TENTH DISTRICT
A. E. SPEAR Dickinson
*Interim appointment by Council to fill vacancy caused by
death of Dr. G. B. Ribble, LaMoure.
Terms Expiring 1944
FIRST DISTRICT
PAUL BURTON Fargo
THIRD DISTRICT
G. M. WILLIAMSON .. Grand Forks
SIXTH DISTRICT
N. O. RAMSTAD Bismarck
Terms Expiring 1945
FOURTH DISTRICT
A. D. MC CANNEL Minot
FIFTH DISTRICT
F. L. WICKS Valley City
NINTH DISTRICT
A. E. WESTERVELT Bowdon
HOUSE OF DELEGATES
CASS COUNTY MEDICAL SOCIETY
W. E. G. LANCASTER Fargo
J. B. JAMES - Page
G. W. HUNTER Fargo
ROLFE TAINTER, Alternate Fargo
H. J. FORTIN, Alternate Fargo
A. C. FORTNEY, Alternate Bismarck
DEVILS LAKE DISTRICT MEDICAL SOCIETY
JOSEPHINE STICKELBERGER Oberon
J. C. FAWCETT, Alternate ----- Devils Lake
GRAND FORKS DISTRICT MEDICAL SOCIETY
W. A. LIEBELER Grand Forks
P. H. WOUTAT Grand Forks
C. R. TOMPKINS, Alternate Grafton
KOTANA DISTRICT MEDICAL SOCIETY
W. A. WRIGHT Williston
I. S. AB PLANALP, Alternate Williston
NORTHWEST DISTRICT MEDICAL SOCIETY
D. J. HALLIDAY — _ Kenmare
R. T. O’NEILL -- Minot
L. H. KERMOTT, Alternate ..._ _ Minot
H. L. HALVORSON, Alternate Minot
226
The Journal-Lancet
RICHLAND COUNTY MEDICAL SOCIETY
A. H. REISWIG Wahpeton
C. V. BATEMAN, Alternate Wahpeton
SHEYENNE VALLEY MEDICAL SOCIETY
C. J. MEREDITH Valley City
A. W. MAC DONALD, Alternate Valley City
SIXTH DISTRICT MEDICAL SOCIETY
R. H. WALDSCHMIDT Bismarck
C. C. SMITH Mandan
O. T. BENSON Glen Ullin
Alternates — None.
SOUTHERN DISTRICT MEDICAL SOCIETY
J. P. MERRETT ... Marion
R. W. VAN HOUTEN, Alternate Oakes
SOUTHWESTERN DISTRICT MEDICAL SOCIETY
A. P. NACHTWEY Dickinson
R. W. RODGERS, Alternate ... ... Dickinson
STUTSMAN COUNTY MEDICAL SOCIETY
T. L. DE PUY Jamestown
WM. A. GERRISH, Alternate ... ... Jamestown
TRAILL -STEELE COUNTY MEDICAL SOCIETY
GUNDER C. CHRISTIANSON Sharon
A. A. KJELLAND, Alternate ... Hatton
TRI-COUNTY DISTRICT MEDICAL SOCIETY
L. J. SEIBEL Harvey
R. W. MEADOWS, Alternate Carrington
PERSONNEL OF STANDING COMMITTEES
SCIENTIFIC PROGRAM
(1943)
J. O. ARNSON, Chairman Bismarck
H. A. WHEELER .. Mandan
P. L. OWENS Bismarck
L. W. LARSON, ex-officio Bismarck
A. R. SORENSON, ex-officio Minot
MEDICAL EDUCATION
H. E. FRENCH, Chaiman Grand Forks
W. C. FAWCETT Starkweather
MAGNUS RUUD .. Grand Forks
C. R. TOMPKINS ... Grafton
NECROLOGY AND MEDICAL HISTORY
JAMES GRASSICK, Honorary Chairman Grand Forks
G. M. WILLIAMSON, Chaiman Grand Forks
F. L. WICKS Valley City
L. H. KERMOTT Minot
ROLFE TAINTER Fargo
O. C. MAERCKLEIN Mott
CHAS. MAC LACHLAN ... New Rockford
M. W. ROAN Bismarck
JESSE W. BOWEN Dickinson
IRA S. AB PLANALP Williston
PUBLIC POLICY AND LEGISLATION
W. C. FAWCETT, Chairman Starkweather
A. P. NACHTWEY Dickinson
FRANK DARROW Fargo
G. M. WILLIAMSON .... Grand Forks
E. G. SASSE Lidgerwood
G. F. DREW Devils Lake
PUBLIC HEALTH
F. J. HILL, Chairman Bismarck
P. L. OWENS _...._ Bismarck
T. Q. BENSON Grand Forks
L. H. LANDRY Walhalla
F. O. WOODWARD Jamestown
WM. CAMPBELL Valley City
KENNETH MALVEY Bottineau
E. J. BEITHON Hankinson
H. B. HUNTLEY Kindred
R. C. LITTLE Mayville
A. R. SORENSON Minot
N. W. FAWCETT Devils Lake
J. A. SMITH Noonan
H. T. SKOVHOLT Williston
A. S. CHERNAUSEK _. Dickinson
COMMITTEE ON TUBERCULOSIS
J. O, ARNSON, Chairman Bismarck
J. P. CRAVEN Williston
PAUL J. BRESLICH Minot
VICTOR FERGUSSON Edgeley
C. V. BATEMAN ... Wahpeton
J. C. FAWCETT Devils Lake
F. O. WOODWARD Jamestown
V. J. LA ROSE Bismarck
F. E. WEED ... ....... Park River
A. F. HAMMARGREN Harvey
M. M. HEFFRON Bismarck
W. L. WALLBANK ... San Haven
EDITORIAL COMMITTEE ON OFFICIAL PUBLICATION
J. O. ARNSON, Chairman Bismarck
H. D. BENWELL Grand Forks
W. H. LONG Fargo
G. W. TOOMEY Devils Lake
COMMITTEE ON CANCER
L. W. LARSON, Chairman .... Bismarck
PAUL BRESLICH Minot
G. W. HUNTER Fargo
J. H. MOORE Grand Forks
COMMITTEE ON FRACTURES
R. H. WALDSCHMIDT, Chairman
R. D. CAMPBELL
J. C. FAWCETT
J. W. BOWEN
C. J. MEREDITH
J. P. CRAVEN
JOS. SORKNESS .......
H. J. FORTIN
A. F. HAMMARGREN
MEDICAL ECONOMICS
W. A. WRIGHT, Chairman ._ Williston
W. A. LIEBELER _.... Grand Forks
F. E. WOLFE Oakes
W. H. LONG Fargo
A. D. MC CANNEL Minot
R. H. WALDSCHMIDT Bismarck
R. W. R. RODGERS Dickinson
MATERNAL AND CHILD WELFARE
J. H. MOORE, Chairman Grand Forks
T. L. DE PUY Jamestown
P. W. FREISE Bismarck
J. D. GRAHAM Devils Lake
J. F. HANNA Fargo
P. H. WOUTAT _ Grand Forks
E. M. RANSOM Minot
M. D. WESTLEY Cooperstown
F. J. HILL Bismarck
CRIPPLED CHILDREN
A. R. SORENSON, Chairman Minot
HARRY J. FORTIN Fargo
J. C. SWANSON Fargo
R. H. WALDSCHMIDT Bismarck
W. W. WOOD Jamestown
RADIO
A. C. FORTNEY, Chairman Fargo
G. M. CONSTANS Bismarck
R. O. GOEHL Grand Forks
B. M. URENN Fargo
COMMITTEE ON VENEREAL DISEASE
FRANK I. DARROW, Chairman Fargo
H. D. BENWELL _ Grand Forks
NORVEL BRINK Bismarck
D. J. HALLIDAY Kenmare
T. L. DE PUY Jamestown
F. J. HILL Bismarck
C. J. MEREDITH Valley City
G. W. TOOMEY Devils Lake
Bismarck
Grand Forks
Devils Lake
Dickinson
Valley City
Williston
Jamestown
Fargo
Harvey
August, 1943
111
COMMITTEE ON PNEUMONIA CONTROL
PAUL ROWE, Chairman .... — — Minot
L. H. FREDRICKS _ - Bismarck
O. W. JOHNSON __ Rugby
F O. WOODWARD Jamestown
J. E. HETHERINGTON Grand Forks
W. E. G. LANCASTER Fargo
W. H. GILSDORF New England
INDUSTRIAL HEALTH
C. J. GLASPEL, Chairman — - Grafton
W. H. BODENSTAB __ - Bismarck
W. A. GERRISH Jamestown
SPECIAL COMMITTEE
(1943)
COMMITTEE ON WAR PARTICIPATION
L. W. LARSON, Chairman Bismarck
N. O. RAMSTAD Bismarck
C. J. GLASPEL Grafton
F. W. FERGUSSON - Kulm
A. R. SORENSON - Minot
FRANK I. DARROW ___ Fargo
P. G. ARZT — - Jamestown
A. E. SPEAR Dickinson
W. A. WRIGHT Williston
C. J. MEREDITH „ Valley City
PROCEEDINGS
of the
HOUSE OF DELEGATES
FIFTY-SIXTH ANNUAL MEETING
of the
NORTH DAKOTA STATE MEDICAL
ASSOCIATION
First Session, Sunday, May 9, 1943
The House of Delegates convened in the Rose room of the
Patterson Hotel, Bismarck, North Dakota, and was called to
order at 8:20 P. M. by the Speaker, Dr. John H. Moore.
Dr. C. C. Smith, Mandan, chairman of the committee on
credentials, announced that sixteen delegates with proper creden-
tials had registered.
The Secretary called the roll; fifteen delegates and one alter-
nate delegate responded, and the Speaker declared a quorum
present. The delegates present were: Doctors W. E. G. Lan-
caster, Fargo; G. W. Hunter, Fargo; J. B. James, Page; P. H.
Woutat, Grand Forks; C. R. Tompkins, Grafton; W. A.
Wright, Williston; D. J. Halliday, Kenmare; R. T. O’Neill,
Minot; A. H. Reiswig, Wahpeton; C. J. Meredith, Valley City;
R. H. Waldschmidt, Bismarck; O. T. Benson, Glen Ullin; C.
C. Smith, Mandan; W. W. Wood, alternate, Jamestown; A. P.
Nachtwey, Dickinson; G. C. Christianson, Sharon.
The Speaker introduced the President, Dr. A. R. Sorenson,
who delivered the following address:
Mr. Speaker; Members of the House of Delegates. I am
glad to welcome you here to this meeting, because, due to the
changing conditions of the world today under which we are
practicing, many important subjects will come up for discussion
and settlement in this meeting. I am sure you will give your
careful attention and study to these things, particularly the
medical-economics side. The world is changing; the socialistic
order is trying to come in — it may succeed. If we can govern
and control the method of the practice of medicine from now
on, we may escape a great deal of grief later on. I am sure you
will have many things to settle and think of today — and not
only today but in the future. You will undoubtedly be taking
some of these thoughts with you. We will be much happier if
they are settled by us rather than by some bureaucrat. I thank
you for presenting this opportunity to me, Mr. Speaker.
On motion made by Dr. A. P. Nachtwey, Dickinson, second-
ed by Dr. R. T. O’Neill, Minot, and carried, the House dis-
pensed with the reading of the minutes of the 1942 session and
adopted the minutes as published and circulated in the Septem-
ber, 1942, issue of the Journal-Lancet.
REPORT OF THE SECRETARY
Dr. L. W. Larson, Secretary, presented his report as printed
in the Handbook, which was referred to the Reference Com-
mittee on Reports of the Secretary and Special Committees. The
Secretary announced that the dues of a few members had been
received since the Handbook was printed raising the number of
paid-up members to 320. He also announced that the dues of
one additional member had been cancelled because of Military
Service.
The total membership for 1942 was 408. Of this number,
366 were paid-up members (one was admitted during the last
half of the year and paid one-half the annual dues), 10 were
Honorary Members and the dues of 32 members were can-
celled because of military service. Table 1 shows the member-
ship figures for 1939, ’40, ’41, and ’42.
Table 1
Comparison of Annual Membership
1939
1940
1941
1942
Paid memberships
394
387
374
366*
Honorary memberships
3
11
12
10
Dues cancelled, military service
14
32
Total
397
398
400
408
*One paid one-half year.
Membership dues for 1943 have been arriving satisfactorily.
To date, 316 have paid their dues, 10 are Honorary Members
and the dues of 58 have been cancelled because of military serv-
ice. Table 2 shows comparative figures for 1943 and the pre-
ceding two years. The total is lower this year because one is
eligible for Honorary Membership, three 1942 members have
been forced to retire because of illness, 10 are active but delin-
quent; six members died; and 11 out-of-state members have
failed to pay their 1943 dues, making a total of 31. A substan-
tial number of the delinquents will undoubtedly pay
their dues
before the year is over.
Table 2
May 5
May 5
April 20
1941
1942
1943
Paid-up members
339
352
316
Honorary members
... 12
10
10
Dues cancelled, military
service
31
58
Total 351
393
384
Field Work- Again your Secretary is sorry to report that he
has been unable to visit every district society in the state during
the past year, mainly because of the burdens placed upon him
as chairman of the Procurement and Assignment Service for
Physicians in the state. Reports from the Councillors, as well
as from District Society officers, indicate that the component
societies, particularly the larger ones, are in good condition and
have had good scientific programs during the past year. One
observation merits comment and that is the very apparent in-
terest in scientific programs which is being displayed by the
older members of our profession, who are doing a magnificent
job of taking over the medical practices vacated by their youn-
ger confreres who have gone into military service.
Distribution of Physicians. The past decade has seen a con-
centration of physicians in the larger centers throughout the
United States. This trend has also been true in North Dakota,
especially in the western two-thirds of the state. The entrance
of a large number of our physicians into the service has not
only depleted the reserve of physicians in the state but has
seriously decreased the number of physicians available to the
public in a few rural districts. This is true in spite of the ef-
forts of the Procurement and Assignment Service to prevent
such a situation. It is the duty of our organized profession to
do what it can to relocate on a voluntary basis those few physi-
cians who can be spared from their present locations in the
larger centers.
Medical Economics. The greatly improved economic condi-
tions in our state during the past two years have solved our
problems in medical economics for the present. But we must
recognize two possibilities in the future and be prepared to meet
them. The first is the annual possibility of a crop failure, and
the second is the apparent growth in support of some form of
228
Thf. Journal-Lancet
socialized medicine. Unfortunately, we cannot control the ele-
ments and crop failures will occur, but the experience we gained
during the recent drouth years will help us to weather that
storm when it comes. The problem of socialized medicine is
more difficult. It is a part of the "changing order” of which we
hear so much these days. Change in our way of living is in-
evitable, but we, as an organized profession, must see to it that
our National Legislators do nothing that will decrease the high
standard of medical practice which is available to the American
public today. To do this, there are many physicians throughout
the land who believe that the American Medical Association
should assume a more aggressive role in Washington, by the
establishment of a Bureau whose duty it would be to inform
congressmen and the public as to the facts of medical economics.
The resolution covering this subject is worthy of your earnest
consideration.
Prepayment Medical Insurance. Numerous plans, some spon-
sored by state medical societies and others not, are in operation
throughout the country. Some of the former appear to be suc-
cessful, although it is too early to be sure. The latter may be-
come dangerous, because they are not always dominated by the
medical viewpoint and are inclined to be more interested in the
provision of cheap medical care for their clients than in good
medical service. Attempts on the part of certain hospital insur-
ance plans to include medical and surgical coverage should be
scrutinized carefully, for they may eventually result in a control
over the practice of medicine by groups of lay or professional
individuals who have little regard for the effect their programs
may have on the private practice of medicine.
Your Secretary was surprised to learn last November, while
attending the conference of state secretaries in Chicago, that a
survey conducted by the American Medical Association revealed
considerable success on the part of Farm Security Administra-
tion medical care plans throughout the nation to provide med-
ical care to Farm Security Administration clients, to the satis-
faction of both clients and participating physicians. It is evi-
dent that the trials and errors of the Farm Security Adminis-
tration plans in North Dakota have given government officials,
as well as physicians, a good lesson in what "not to do.” If the
survey of the American Medical Association is indicative of the
true sentiment throughout the country; if it is the policy of the
Farm Security Administration to provide a sound medical care
program for its clients; and if there is a demand for such a
program in North Dakota by a substantial number of Farm
Security Administration clients, our Association should consider
the problem carefully and not be prejudiced by earlier ex-
periences.
Our Committee on Medical Economics should continue its
study of the various medical service plans which are in opera-
tion in scattered areas of the country. They are doing the spade
work and providing the actuarial experience out of which may
evolve some system of voluntary, medically controlled, health
insurance which will satisfy our low-income-group citizens, even
though it will not satisfy our politicians.
Recommendations
1. That Dr. A. B. Fields of Forest River be elected to Hon-
orary Membership of our Association. Dr. Fields was licensed
to practice medicine in Walsh county, in July, 1892. He is rec-
ommended for Honorary membership by the Grand Forks Med-
ical Society.
2. That the President be authorized to appoint a small Com-
mittee on Nursing Education. This committee should study the
problem of nursing education in North Dakota and cooperate
with the State Hospital Association and the State Board of
Nurses Examiners, so that they may have the benefit of our
viewpoint, which I am assured they will welcome.
L. W. Larson, M.D., Secretary.
REPORT OF THE TREASURER
Dr. W. W. Wood announced that his report had been incor-
porated in the report of the Council. He suggested that an in-
vestigation be made of the reported discrepancies between the
subscription rates for the Journal-Lancet for members of the
Montana State Medical Association and members of the North
Dakota State Medical Association. On motion duly made, sec-
onded and carried, the question of subscription rates for the
Journal-Lancet was referred to the editorial Committee on
Official Publication.
REPORT OF THE CHAIRMAN OF THE COUNCIL
1942-1943
Dr. N. O. Ramstad, chairman, presented the following re-
port which was referred to the Reference Committee on Reports
of the Council, Councillors and Delegates to the American
Medical Association:
Annual Meeting of the Council.
First Session, May 18, 1942
The Council met in Jamestown during the 1942 Session of
the North Dakota State Medical Association.
The Auditing Committee reported that it had examined the
Treasurer’s accounts and found them to be correct. The Treas-
urer’s report was accordingly approved.
The contract with the Journal-Lancet was renewed for
three years. The annual subscription for the Journal-Lancet
remains at $2.00.
The Chairman of the Council was authorized to send flowers
and appropriate greetings to Drs. MacGregor and MacLachlan,
former members of the Council, who were ill.
Second Session, May 19, 1942
The Council, with its newly elected members, met and organ-
ized. Dr. N. O. Ramstad was re-elected Chairman and Dr. G.
M. Williamson was re-elected Secretary.
The bonds of the Secretary and Treasurer were ordered re-
newed. The Treasurer was instructed to invest $3,000.00 of the
Association funds in United States War Bonds.
The following budget for the fiscal year 1942-1943 was au-
thorized, it being agreed that none of the amounts should be
exceeded, without the approval of the Council.
Committee on Tuberculosis . $ 50.00
Emergency Funds for the Council 250.00
Stenographic service, 1943 Session 150.00
Delegate to A. M. A - 200.00
President of the State Association 50.00
Emergency Funds for Chairman of the Council 100.00
Secretary of the State Association:
Postage and office supplies 150.00
Telephone and telegraph 75.00
Travel expense 200.00
Journal-Lancet 800.00
Allotment for Jamestown meeting 200.00
The salary of the State Secretary was set at $1,200.00 for
the coming year, to include his expense for stenographic help.
Drs. W. H. Long, H. D. Benwell, J. O. Arnson and G. W.
Toomey were appointed to the Editorial Committee on Official
Publication.
Drs. N. O. Ramstad, J. O. Arnson and L. W. Larson were
authorized to edit and approve the transactions of the 1942
Session, to be published in the Journal -Lancet.
Interim Session
The Council met in Fargo on January 6, 1943. The follow-
ing business was transacted:
The problem of relocation of physicians to areas in the state
in which there is a shortage of physicians was thoroughly dis-
cussed. The State Secretary was authorized to advertise in sci-
entific journals, if necessary, to obtain physicians, it being un-
derstood that any such candidates must meet the professional
and ethical qualifications demanded by the State Board of
Medical Examiners.
A joint meeting was held with representatives of the State
Dental, Veterinary, and Pharmaceutical Associations at which
Mr. A. B. Crisler of the Federal Bureau of Narcotics discussed
the advisability of enacting a uniform narcotic act and also a
law to control the sale of barbiturates in North Dakota. The
Council favored the introduction and support of these measures
as did all the representatives of the other allied professions who
were present.
It was decided not to send a representative of the state
society to the Annual Industrial Congress in Chicago.
The deaths of Dr. G. B. Ribble, Councillor, and Dr. A. O.
Arneson, First Vice President, were officially acknowledged with
August, 1943
229
deep regret. The State Secretary was instructed to send appro-
priate notes of condolence to Mrs. Arneson and Mrs. Ribble.
Dr. F. W. Fergusson of Kulm was appointed to succeed Dr.
Ribble as Councillor for the Southern District until the next
meeting of the blouse of Delegates. Dr. Wicks of Valley City
was named First Vice President to succeed Dr. A. O. Arneson
until the next meeting of the House of Delegates.
It was unanimously agreed that a meeting of the State Asso-
ciation, including a Scientific Program, should be held in 1943
in Bismarck.
The Council agreed that the State Association should not
sponsor any medical legislation during the 1943 Session of the
Legislature. It was agreed that several proposed bills to
strengthen the State Health Department should be supported
and that the Committee on Public Policy and Legislation should
vigorously oppose any legislation that would increase the field
of practice of the irregulars, or recognize any new form of ir-
regular practice. Inasmuch as Dr. Fawcett, chairman of the
Committee on Legislation, was ill, the Council authorized the
State Secretary and Dr. H. A. Brandes to direct the activities
of the Legislative Committee during the legislative session.
The Council unanimously agreed that no committee of the
State Association should agree upon fees for medical work, such
fees being the result of studies and activities sponsored by a
committee, until the fee schedule has been approved by the
Committee on Medical Economics. The State Secretary was in-
structed to notify each committee chairman to this effect.
Inventory of Property Owned by the Association
as of March 31, 1943
Office equipment: typewriter, letter file, fan, ledger,
mailing tray, staplemaster. Net cost $129.45
Less 12 54% depreciation 16.18
$113.27
N. O. Ramstad, M.D.,
Chairman of the Council.
REPORTS OF COUNCILLORS
The following reports of Councillors were referred to the
Reference Committee on Reports of the Council, Councillors
and Delegates to the American Medical Association.
First District
The Cass County Medical Society, at the present writing,
has 63 members in the group. These are full members and
while all of them have not as yet submitted their 1943 dues,
there is no reason to expect that they will not do so soon. Of
these, 51 reside in Fargo.
Fourteen of the active members are now with the armed
forces. Dr. Skelsey, one of the senior members, is stationed
here locally at the Officers’ Candidate School, commissioned as
a First Lieutenant in the Medical Corps. No doubt his friends
throughout the state will be interested in this.
At present the Society has one probationary member, one
associate member and an application pending for probationary
membership. During the past year, six new members were put
on the roster. These are: Drs. E. L. Sederlin, now of Valley
City, L. A. Nash, C. B. Darner, A. C. Burt, F. A. DeCesare,
and M. J. Geib.
Dr. J. O. Sigurdsson of West Fargo, who was a probationary
member in 1942, received a commission in the Army prior to
election to full membership and his address is unknown. One
member retired this year, Dr. T. P. Rothnem, who is now con-
fined to his home because of ill health. One member, Dr. D.
L. Peterson, discontinued practice about a year ago. As you
know, Dr. R. E. Weible passed away last fall, while in active
practice and while a member of our society. Drs. J. P. Aylen
and Murdock McGregor also passed away, both of whom were
in a retired status at the time.
Interest has been reasonably good in the Cass County Med-
ical Society since the last state meeting. Presumably, due to
increased and improved economic conditions, the problem of the
care of indigent patients has not had as much discussion as
previously. The scientific portions of the meetings have been
outstanding. During the past year, several physicians from
other centers have been on our programs.
Two steps were taken by the Society during the past two
meetings which are timely. Due to the curtailment of travel
and the fact that the doctors are all much busier now, the
society has made an effort to secure outstanding scientific pro-
grams to aid in keeping up with current medical trends. To
date, this has been successful. The Society, likewise, is attempt-
ing to secure or enlist the interest of doctors from neighboring
counties in these programs.
The Secretary has discussed the matter of making some ar-
rangement with the members of the staff of the North Dakota
Veteran’s Hospital to join the State Society. This group will
become more powerful nationally in the future and I suggest
that steps be taken to have these men under the wing of or-
ganized medicine, both in North Dakota and nationally.
The Richland County Society has had twelve active mem-
bers. However, it has always been a rather active society. The
Army has taken two members; namely, Dr. J. H. Hoskins,
who is now in India, and Dr. L. T. O’Brien, who is in Alaska.
Dr. C. T. Olson of Wyndmere is disabled and Dr. Durkee of
Abercrombie passed away. The Richland County Medical So-
ciety now has only eight members.
Arrangements have been made to attend as many medical
meetings of the Cass County Society this year as is possible.
The members have been grouping together and sharing cars
and have taken advantage of the meetings in Fargo. The pres-
ent members are trying to hold the Society together so that
when the rest of the men return, they will find a smoothly act-
ing society.
Some of the members have stated that they would be glad to
join up with the Cass County Society and become members of
that society. The plan is to have a meeting soon at which this
subject will be more fully discussed.
Paul W. Burton, M.D., Councillor.
Third District
Grand Forks District Medical Society has had a success-
ful year; the chief reason is that it is well officered, with a real
live President and Secretary, who are always on the job, provid-
ing interesting programs. This means good attendance and
promotes good fellowship.
There are sixty-nine licensed physicians and surgeons in this
district, seven of whom are serving in the Army. Five are
Honorary Members, having been in practice more than fifty
years; namely, Drs. Grassick, Burrows, Glaspel, Welch and
Field. Another man has retired from practice; one belongs to
the Traill-Steel Society and lastly we have one man who has
never become a member — a good fellow, but he apparently pre-
fers to go alone. There are 52 paid members and those, of
course, serving in the Army remain in good standing for the
duration.
I continue to advocate the amalgamation of the Traill-Steele
Society with the Grand Forks District. There are but eight
members in said society and regular meetings are not held.
I hope that the boys there will unite. They would be benefitted
by being in a larger society. As suggested in my report last
year, I believe that a redistricting of societies in this state based
on auto roads instead of county lines would be an improvement.
Why not have a committee appointed to look into that ques-
tion with authority to act or bring in a report at the next
annual meeting.
Drs. Gerald Brown, E. A. Canterbury, V. M. Griffin, R. E.
Mahowald, Louis Silverman, Fredrick Vollmer, F. Robertson
and H. R. Ransom, all of Grand Forks, are serving in the
Army.
G. M. Williamson, M.D., Councillor.
Fourth District
The Northwestern District Society has had a very good
year. We have six new members, and thirteen members are now
in the service. The total enrollment is fifty-nine.
We have had a meeting every month during 1942 except
May. At the meeting of January 29, officers were elected for
the year.
February 26, our speaker was Dr. John E. Faber from the
Mayo Clinic.
On March 26, we had a symposium on pneumonia at which
Dr. P. H. Rowe discussed "The Pneumonia Program of the
230
The Journal-Lancet
State of North Dakota.” Dr. P. J. Breslich spoke on "Newer
Aspects of Pneumonia Immunology.” Dr. R. E. Dyson gave a
speech on "Atypical Bronchopneumonia.”
On April 28, our speaker was Major Radi who spoke on
"Selective Service System.”
On June 25, Dr. Paul F. Dwan of the University of Min-
nesota, spoke on "Blood Substitutes.”
The July and August meetings were both held at the picnic
grounds of the Minot Country Club and Dr. Wheelon, who is
famous for his picnic suppers, was in charge of the food at both
meetings and served two delicious meals.
On September 24, Dr. Olaf Haraldson and Mr. Bavone of
the Public Health Unit discussed "The Milk Situation” in
Minot.
October 29, Dr. H. A. Carlson of Minot gave a splendid
talk on the "Surgical Conditions of the Chest.”
On November 19, the speaker was Dr. Fred Hoffbauer, of
the University of Minnesota, who spoke on "Clinical Experi-
ences with Brucellosis.”
On December 17, we had a symposium on cancer at which
Dr. W. W. Wall spoke on "X-Ray Therapy of Skin Cancer,”
Dr. R. Woodhull on "Cancer of the Uterus,” and Dr. P. J.
Breslich on "Pathology of the Above Types of Cancer.”
The meetings have all been well attended, in spite of the fact
that our members have all been exceptionally busy as are all
civilian doctors everywhere.
Archie D. McCannel, M.D., Councillor.
Fifth District
Sheyenne Valley Medical Society has had a further re-
duction in the number of its doctors during the past year.
There are eight men in Valley City at present holding mem-
bership; of the four practicing outisde Valley City, three are
members.
Dr. R. K. Dodd, formerly of Wimbledon, has relocated at
Lisbon.
Dr. Paul Cook entered the service in the early fall and after
training at Las Vegas, Nev., is now at Randolph Field, Texas,
taking the course at the Flight Surgeons School. Dr. Cook is
a First Lieutenant.
Dr. R. G. White, formerly in charge of the district health
office in Valley City, is now a member of the State Public
Health Department and located at Bismarck. His place in Val-
ley City has been taken by Dr. E. L. Sederlin, previously of
Fargo. Dr. Sederlin has applied for membership in our Society
and has the recommendation of the Cass County Society.
Dr. G. A. Dodds has been made a Major and is located at
Seattle.
Our annual meeting was held January 11, at Mercy Hospital,
preceded by a banquet served by the Sisters of the Hospital.
The following doctors were elected to office:
President, Wm. Campbell, Valley City; vice president, F. L.
Wicks, Valley City; secretary-treasurer, C. J. Meredith, Valley
City; delegate, C. J. Meredith, Valley City; alternate delegate,
L. Almklov, Cooperstown.
F. L. Wicks, M.D., Councillor.
Sixth District
During the past year our Society has had four interesting
and well-attended meetings. Our paid-up membership, includ-
ing those serving in the Army and the Navy, is sixty-seven.
Good, helpful programs have been presented at each of the
meetings. At the April, 1942, meeting the following program
was given: (1) Paper on "Vomiting of Pregnancy,” by Dr. C.
J. Baumgartner; (2) Presentation of home-made instruments
and equipment, including a respirator, by Dr. H. A. Wheeler
of Mandan; (3) Report of the pediatric course at the Contin-
uation Center, University of Minnesota, by Dr. A. M. Brandt.
At the September meeting, the program consisted of: (1)
Paper by Dr. Joseph Sorkness of Jamestown on "Perineal Pros-
tatectomy,” which was discussed by Dr. V. J. LaRose and Dr.
N. O. Brink; (2) A report by Dr. L. W. Larson on the pres-
ent status of the Procurement and Assignment Program in
North Dakota; (3) A review of the Pneumonia Program in the
state by Dr. L. H. Fredricks.
At the December meeting, the program consisted of a sym-
posium on Cancer of the Stomach: (1) Medical history and
diagnosis, by Dr. J. O. Arnson; (2) Multiple x-ray demonstra-
tions and discussion of the diagnostic problems, by Dr. H. M.
Berg; (3) The laboratory and pathological findings presented
by Dr. L. W. Larson.
Dr. R. G. White transferred his membership from the Shey-
enne Valley District Medical Society. Dr. E. Salomone was
elected to membership.
Officers elected for the coming year were: Dr. R. H. Wald-
schmidt, president; Dr. M. S. Jacobson, vice president; Dr. W.
B. Pierce, secretary and treasurer. Censors: Drs. F. B. Strauss,
G. R. Lipp and W. H. Bodenstab. Delegates elected: Dr. C.
C. Smith for 3 years, Dr. R. H. Waldschmidt for 2 years, Dr.
O. T. Benson for 1 year.
In February the following program was presented: (1) Re-
spiratory Infections in Children, by Dr. E. G. Vinje; (2) Trop-
ical Diseases, by A. C. Grorud, M.D.; (3) Relation of Physi-
cians to the Selective Service, by Captain A. C. Fortney; (4)
Relation of Physicians to the Procurement and Assignment
Service, by Dr. L. W. Larson.
During the year, the business affairs of the Society have been
efficiently administered, and harmony and good will have pre-
vailed.
N. O. Ramstad, M.D., Councillor.
Seventh District
In the Stutsman County Medical Society, at present, we
have eighteen members that are fully paid up, two members in
the service, Major R. D. Nierling and Major Jesse H. Roth,
and two physicians of the county who are not members.
During the year, we lost one of our much esteemed and ac-
tive members, Dr. Justin L. Conrad. The Lord, in His infinite
wisdom, has seen fit to call the Doctor home. We will miss the
service and guidance of Dr. Conrad in this Society.
During the year we have had mostly business meetings. This
was due to the fact that it was our privilege to entertain the
State Medical Society during their annual meeting. However,
we had one very interesting meeting in March, 1942, at which
time Dr. Kenyon of St. Paul was the speaker. He presented a
very interesting pathological resume of common conditions.
The officers elected for the ensuing year are: Dr. George
Holt, president; Dr. T. L. DePuy, vice president; Dr. E. J.
Larson, secretary-treasurer; Dr. T. L. DePuy, delegate; Dr. W.
A. Gerrish, alternate.
This year has been rather uneventful, and peace and har-
mony and good will prevail.
P. G. Arzt, M.D., Councillor.
Eighth District
Two meetings were held during the past year, one at Marion
and the second at Oakes. The attendance has been good. Lieu-
tenant Commander George Ribble, son of the late Dr. G. B.
Ribble, of LaMoure, was a guest at the Marion meeting.
We have at present seven members. There are four other
physicians in the district who are eligible for membership.
We lost, by death, one of the pioneer physicians of this
district, Dr. G. B. Ribble of LaMoure.
F. W. Fergusson, M.D., Councillor.
Ninth District
The Tri-County Society met February 4, 1942, and dis-
cussed once more whether it was better to keep the Society go-
ing or split up and join larger societies adjoining. It was de-
cided that, with a little more effort, we could hold more fre-
quent meetings and we would try to have better programs.
Pursuant to this idea, six meetings have been held in the
past year.
In April, Dr. Wallbank appeared and discussed the treatment
of tuberculosis.
In June, Dr. Harry Fortin discussed fractures and the Kenny
treatment of infantile paralysis.
In September the Society met to present Dr. Charlie Mac-
Lachlan with an electrically-driven wheelchait on behalf of nu-
merous contributors throughout the state. While I do not know
whether the Doctor’s friends planned that his chair be used as
a tractor, my latest report from Dr. Moore is that Doctor Mac
was raking the lawn with it.
In December we met for election of officers.
August, 1943
231
In February we had a discussion of the legislative program
and had a film furnished by John Wyeth & Company on peptic
ulcer.
In April of this year, Dr. Archie McCannel appeared to dis-
cuss glaucoma as well as Army Medicine and Surgery.
At all of these meetings, dinner was served.
Respectfully submitted,
A. E. Westervelt, M.D., Councillor.
Tenth District
The Southwestern District, in spite of adverse circum-
stances, is still going strong.
We held three regular meetings during 1942, the fourth
meeting, which was to be held in December, was postponed
twice due to impassable roads, but was finally held February
27th of this year. At that time, the following officers were
elected: President, Dr. Oscar Smith, Killdeer; vice president,
Dr. Fdans E. Guloien, Dickinson; secretary-treasurer, Dr. H. L.
Reichert, Dickinson; delegate, Dr. A. P. Nachtwey, Dickinson;
alternate, Dr. R. W. Rodgers, Dickinson.
Since 1940, when we had 26 members, our membership has
dropped to 18. In spite of the decrease in numbers and the
fact that half of our members are over 60 years of age, we
think we are doing a good job in looking after the welfare of
the 40,000 widely scattered people in our territory.
During the year, Dr. A. J. Gumper has left us to join the
service of his country and Dr. M. W. Lyons has moved to
Minneapolis.
There are three doctors in the territory who are not mem-
bers of the Society: Dr. Iver Linson, who is in the Federal In-
dian Service at Elbowoods; Dr. William Schumacher, Jr., of
Hettinger, who, due to poor health, is not in active practice,
and Dr. Clarence A. Bush of Beach, whose application for
membership has been laid on the table pending further action.
Repeated efforts of the F.S.A. to force upon us a plan of
medical care for their members have so far been successfully
opposed.
As long as there is a job to do, the Southwestern District
Medical Society will be on hand to do it.
Respectfully submitted,
A. E. Spear, M.D., Councillor.
REPORTS OF STANDING COMMITTEES
The following reports of Standing Committees were referred
to the Reference Committee on Reports of Standing Com-
mittees.
Medical Education
At the time this report must be written, there are many
points of uncertainty as to the relation of the School of Medi-
cine of the University to the Specialized Training Division of
the United States Army and Navy. Orders of this winter and
spring indicate decided changes in the plans of that depart-
ment, as you know, but full and detailed orders are not yet
available. It is quite possible that many of these points will be
cleared up by the time of the annual meeting.
In regard to the work of the past year, it can be said that
the organization, points of view, and work of the school have
all continued along the lines that are familiar to you. It might
be emphasized that it has been the policy of the school to limit
its admissions to candidates from our own state or reasonable
territory, rejecting, at once, the applications of students from
the state or reasonable territory of another medical school; also
that it has always been the hope and effort of those connected
with the school to take care of all promising candidates from
North Dakota who care to begin their training here. With the
great demand for admissions, as well as the limit to the possi-
bilities of other schools to accept our students for their clinical
work, we are compelled, even if we were otherwise inclined, to
demand a high standard of entrance qualifications. All stu-
dents finishing the two year medical curriculum at the Univer-
sity in 1942 are now continuing their training in other schools.
The classes of this year are full. With only two exceptions, all
of the 53 students of this year hold commissions in the Special-
ized Training plan of the Army or Navy that is just passing.
H. E. French, M.D.,
Chairman.
Necrology and Medical History
In hearty accord with the ideals and traditions of the tradi-
tional medicine, it seems fitting that we pause in the midst of
our activities and decorously pay our tribute to the memory of
those of our number who since last we met in annual session
have finished their tasks; for "The night cometh when no man
can work.”
To friends and near of kin, we offer our meed of sympathy,
coupled with the thought that Hope peers through the mists,
sees the stars beyond and points the upward way.
MURDOCK MACGREGOR
Dr. MacGregor was born in Kintail, Ontario, of Scottish par-
ents, December 8, 1871, and died at the home of his son,
Gordon MacGregor, at Dickinson, North Dakota, December
20, 1942. His academic studies were pursued in the schools of
his native province and his medical degree was obtained from
Trinity College (later merged with the University of Toronto),
in 1897. He was licensed to practice in North Dakota the
same year. He kept well abreast of the times by frequent grad-
uate courses at Chicago, New York, Baltimore and other
centers.
He began the practice of medicine at Emerado, N. Dak., in
1897, where he remained two years. Then he moved to Fessen-
den for nine years, and then to Fargo, where he made a per-
manent home.
Dr. MacGregor was very active in organized medicine, was
charter member and first secretary of the Tri-County Medical
Society, president of the Cass County Medical Society and of
the North Dakota Medical Association. He was a member, for
a number of years, of the State Board of Medical Examiners,
and was one in the first group of North Dakota surgeons ad-
mitted to fellowship in the American College of Surgeons. For
many years he was North Dakota Councillor for the College.
In the midst of a busy professional life, he found time to
devote to social and economic problems and held many offices
of trust and responsibility. He was held in high repute by his
Fellows as an honorable, ethical, capable practitioner. Dr. Mac-
Gregor was a consistent member of the church of his choice and
was active in its affairs. He is survived by a son, a brother and
a sister.
His abiding worth is his monument.
RALPH E. WEIBLE
Dr. R. E. Weible was born in Warren county, Pennsylvania,
December 21, 1878, and died at a Minneapolis hospital, No-
vember 8, 1942.
His father, James S. Weible, was a pioneer oil prospector
and came with his family to North Dakota in 1894 and en-
gaged, near Hunter, in wheat farming.
Dr. Weible was a graduate of Fargo High School, took col-
lege and medical work at the University of Minnesota, was
graduated in medicine from Rush, Chicago, in 1901, and was
admitted to practice in our state the same year.
He began practice at Grandin, North Dakota, where he re-
mained for about a year. He then removed to Fargo, where he
became associated with the late Dr. E. M. Darrow, and later
was one of the founders of the Dakota Clinic of which he was
president at the time of his death.
Dr. Weible was recognized as a surgeon of skill. He made
many original contributions to the profession; he was a fre-
quent and valued contributor to medical and surgical literature.
Dr. Weible perfected himself in his art by frequent visits to
medical and surgical centers at home and abroad. He was a
Fellow of the American College of Surgeons.
Dr. Weible held many positions of trust and honor in med-
ical, social and fraternal circles. He will be missed by the pro-
fession he honored, by the public whom he served, and by his
associates.
He is survived by Mrs. Weible, two sons, one daughter and
two brothers. To these he leaves a rich legacy of treasured
memories.
Dr. Weible was one of those "whose sun went down in the
sweet hour of prime.”
JUSTIN L. CONRAD
Dr. J. L. Conrad was born at Greenbriar, Missouri, and died
at Rochester, Minnesota, May 28, 1942.
He was a graduate of the College of Idaho and the Univer-
232
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sity of Colorado. Thus equipped, he taught school for three
years and then entered Northwestern University for the study
of medicine. After graduation, he interned for two years at
Wesley Hospital, Chicago, and six months at the Lees Lying-In
Hospital at Chicago.
On coming to North Dakota he became associated with the
Jamestown Clinic, July 3, 1930, where he remained, specializing
in obstetrics and pediatrics. He is survived by his widow and
three children.
GEORGE B. RIBBLE
Dr. G. B. Ribble was born at Detroit, Michigan, June 22,
1878, and died at Jamestown, N. D., October 20, 1942.
He graduated in Liberal Arts at the University of Minnesota
in 1900 and in medicine in 1903. After interning at St. Luke’s
Hospital, St. Paul, Minnesota, he located at LaMoure, North
Dakota, and there did his " Day’s Work,” giving 37 years of
active service to the community he chose as his home and
workshop.
He was County Health Officer for several terms and County
Coroner for a score or more years.
Surviving him are a widow, two sons and a daughter to
whom he has left a legacy of sweet and pleasant memories.
Dr. Ribble was a man of high ideals in professional and
community life and lived his convictions. At his funeral serv-
ices, it was said: "Dr. Ribble has been a good neighbor, an un-
selfish public servant and a trusted personal counselor to a great
many in their troubles. Like his Master, 'he went about doing
good.’ ”
A. O. ARNESON
Dr. A. O. Arneson was born October 26, 1879, at Beaver
Creek, Minnesota, and died at his home in McVille, North
Dakota, December 11, 1942.
He received his academic course at Augustana College, Sioux
Falls, South Dakota, and his medical degree from the Univer-
sity of Minnesota.
He was admitted to practice in our state in 1904 and located
at Northwood. Later he moved to Aneta and finally to Mc-
Ville, where he made his permanent home.
Dr. Arneson was public-spirited and took a great interest in
community welfare activities. A short time before his death
he was elected for the third time as Representative of the 17th
District. He was so favorably regarded that in 1937 the people
of McVille and surrounding country held a countryside dem-
onstration in appreciation of his services as a physician and
citizen.
Surviving him are two sons and a daughter. To such as he,
humanity is a debtor.
K. OLAFSON
Dr. K. Olafson was born of Icelandic parents at Edinburg,
North Dakota, April 2, 1902, and quietly passed away at his
home in Cando, North Dakota, during the night of December
1-2, 1942.
He was educated in the public schools and the state univer-
sity and was later graduated in Medicine from the University
of Manitoba, at Winnipeg. He interned at General and Grace
hospitals, Winnipeg, and further at Ninette Tuberculosis Sana-
torium. He practiced at Cando and Egeland, North Dakota,
for eight years.
Dr. Olafson was a fine example of a native son giving the
best of which he was capable, to those seeking his help among
his own people.
He was honored by his fellows by being elected president of
his district medical society and a member of the staffs of Mercy
and General hospitals at Devils Lake. He was city health officer
of Cando for many years.
He is survived by Mrs. Olafson.
BERTHA BRAINARD MCELROY
Dr. Bertha B. McElroy was born January 8, 1894, in Ana-
mosa, Iowa, and died at Rochester, Minnesota, March 12, 1943.
She came with her parents to North Dakota at an early age
and "grew up” with the country. She was graduated in 1906
from the Arts Department, University of North Dakota, and
was a member of Phi Beta Kappa. She was principal of Wal-
halla High School for three years and head of the English
Department of the Jamestown High School until 1927, when
she began the study of Medicine at the University of North
Dakota, and in due time graduated from Rush Medical Col-
lege. After interning in San Francisco and Los Angeles, she
entered private practice at Jamestown, N. D., in 1933, contin-
uing until 1940.
Dr. McElroy, in addition to her medical work, took an active
interest in social and economic problems and held many offices
of trust and responsibility in the interests of human welfare.
Dr. McElroy was progressive, could see beyond the clouds,
and recognized that the best is yet to be. She was a finely
poised, professional woman!
James B. Grassick, M.D.,
Honorary Chairman.
George M. Williamson, M.D.,
Chairman.
Public Policy and Legislation
Due to the illness of its chairman, Dr. W. C. Fawcett, the
Council appointed the Secretary to assume his duties during the
1943 Session of the State Legislature.
The Council decided, at its interim meeting in Fargo last
January, not to sponsor any medical legislation this year. It
approved a vigorous campaign of opposition to any legislation
which would recognize naturopathy or increase the limits of
practice of the irregulars. It approved the passage of several
bills which were to be introduced at the request of the State
Health Department and also a Uniform Narcotic Act.
The 1943 Legislative Session was one of the quietest in re-
cent years so far as medical legislation was concerned. The bi-
ennial attempt to legalize the practice of naturopathy in North
Dakota was soundly trounced in the House, 75 to 32.
A word of explanation is due on the Committee’s activities
relative to Senate Bills 57 and 63. The former was a bill to
re-enact the present State Narcotic and Drugs Statutes to con-
form with the Federal Act, and the latter would have prohib-
ited the sale of barbiturates except on written prescriptions.
Both bills were written and suggested by representatives of the
Federal Department for the Enforcement of the Harrison Nar-
cotic Act. They were approved by our Council, and also by
authorized representatives of the North Dakota State Pharma-
ceutical and Dental Associations. The bills were sponsored by
the Legislative Committee of the Pharmacists and were intro-
duced in the Senate. Protests soon developed from pharmacists
throughout the state. As a result the bill (S.B. 63) to control
the sale of barbiturates was withdrawn and the Uniform Nar-
cotic Act (S. B. 57) was defeated in the House after it had
passed the Senate by a large majority. There is a possibility
that the Uniform Narcotic Act may have been included in the
laws which were recodified and therefore, has become a state
statute, but this will have to be determined for a certainty by
the courts, it would seem. It should be emphasized that these
two bills were not "Medical Bills”; they were not sponsored by
our Association, but merely approved as good legislation. Any
unpleasant or embarrassing circumstances which arose over this
legislation were due entirely to differences of opinion as to the
merits of the bills between some of those who were responsible
for the introduction of the bills and the organization which
they represented.
Our thanks go to Senator E. C. Stucke who, as usual, was
a tower of strength in the Legislature in behalf of the medical
profession, and to Dr. H. A. Brandes, who gave much of his
time and energy as a "listening post” in the Capitol Building
during the Session.
L. W. Larson, M.D.,
Chairman.
Committee on Tuberculosis
There has been no unusual activity of the Committee this
year. We decided to follow the same program we followed the
year before. We have had excellent cooperation from the State
Health Department and the North Dakota Anti-Tuberculosis
Association.
J. O. Arnson, M.D.,
Chairman.
Editorial Committee on Official Publication
A meeting of this Committee was held at Jamestown during
the annual meeting there. However, no report can be made this
year because the Committee will meet during the Session in
May.
August, 1943
233
The Committee recommends that the present relationship
between the Journal-Lancet and the North Dakota State
Medical Association, being satisfactory, be continued.
J. O. Arnson, M.D.,
Chairman.
Committee on Pneumonia Control
The Committee on Pneumonia Control met with members of
the State Department of Health in the Capitol Building at
Bismarck on September 20, 1942.
Since establishment of the Pneumonia Control Program in
December, 1939, there has been a marked improvement each
year in the reporting of cases of pneumonia to the State De-
partment of Health. During the three years preceding the
establishment of the program, an average of 312 cases of pneu-
monia were reported to the Health Department annually. In
1940, the first year of the control program, 1284 cases of pneu-
monia were reported; in 1941, 1413 cases of pneumonia were
reported; and in 1942, 2944 cases of pneumonia were reported
to the Department of Health. Of these 2944 cases, 1926 pa-
tients were treated in the non-control group and 1018 patients
were treated in the control group.
Mortality from pneumonia continues to decline in North Da-
kota. Before establishment of the control program, there were
approximately 400 deaths annually from this disease in the
state. In 1940, there were 288 deaths from pneumonia; in 1941,
200 deaths; and in 1942, 202 deaths were caused by pneu-
monia in spite of the great increase in the number of cases of
the disease reported in that year. As in preceding years, the
mortality rate in 1942 continued higher in the non-control
group than in the control group of patients. There were 181
deaths in the non-control group, a mortality rate of approxi-
mately 2.1 per cent. The combined mortality rate for both
groups was 6.8 per cent, compared to combined mortality rates
of 16.5 per cent in 1941 and 22.4 per cent in 1940.
Eleven hundred eighty-five cases were diagnosed as lobar
pneumonia; 1271 cases as bronchopneumonia; and the rest as
virus, influenzal or non-specified types of pneumonia.
The predominant types of pneumococci found were Types
1, 2, 3, 6, 7, and 8. Typing stations were unable to type the
organisms in many sputum samples this year because of the
large number of cases of atypical bronchopneumonia or so-called
"virus” pneumonia. The average dose of antipneumococcic
serum was 73,971 units; the average dose of sulfapyridine was
14 grams; the average dose of sulfathiazole was 19.75 grams;
and the average dose of sulfadiazine was 18.4 grams. The cost
per patient of treatment under the program was $5.60, as com-
pared to $25 per patient for each of the two preceding years.
The pneumonia control program, originally established for
a trial period of six months, has been continued for three years
through an appropriation from the United States Public Health
Service. The United States Public Health Service will not con-
tinue the appropriation for the entire program unless the state
supplies at least part of the funds. The program will have to
be discontinued unless half the expense is born by the state.
The Committee feels that the pneumonia control program
should be continued, and makes the following recommenda-
tions:
1. The State should assume the responsibility of providing
part of the funds to continue the program.
2. The State Department of Health should continue to fur-
nish serum, sulfadiazine and sulfathiazole, but should dis-
continue the supply of sulfanilamide and sulfapyridine.
3. Only Types 1, 2 and 3 antipneumococcic serum should
be supplied by all typing stations. All other types of
serum should be obtained from the Public Health Labora-
tories at Bismarck and Grand Forks.
4. The fee for roentgenograms of chests of children up to
and including eleven years of age should be reduced to
$3.00 in order to continue the x-ray service for all patients
in the control group of cases.
5. The typing stations should continue to be used as depots
for distribution of serum and sulfonamide drugs and
should continue to type sputum specimens, carry out
sulfonamide determinations and perform blood cultures.
6. The conference for technicians of control stations should
be held each year, in order to keep laboratory procedures
standardized.
Paul H. Rowe, M.D.,
Chairman.
Committee on Cancer
Cancer continues to be a leading cause of death in North
Dakota, as elsewhere throughout the Nation. The slogan "Can-
cer is Curable” demands early diagnosis and modern treatment.
The Women’s Field Army of the Society for the Control of
Cancer is emphasizing the early danger signs of cancer and the
need for periodic health examinations. The diagnosis of early
cancer is the responsibility of the physician once he is consulted
by the patient. It will be made only by those physicians who
are familiar with the symptoms and signs of early cancer and
who always consider the possibility of cancer in every patient,
regardless of age.
Your Committee is cognizant of these facts and continues to
support the excellent work of the Women’s Field Army in
North Dakota and to urge all district medical societies to in-
clude papers and symposia on cancer in their programs.
L. W. Larson, M.D.,
Chairman.
Committee on Fractures
A meeting of the Fracture Committee was held during the
annual meeting of the State Association in Jamestown, North
Dakota, on May 20, 1942. The Committee unanimously agreed
to continue the program as outlined in our annual report to the
House of Delegates in May, 1942.
A portion of the State Medical Association program was
given over to the subject of fractures. On May 20, 1942, Dr.
Stanley R. Maxeiner of Minneapolis presented a paper on "The
Emergency Treatment of Fractures.” He also conducted a sym-
posium on fractures at our noon luncheon and this was very
well received by members of the State Association.
We have had several communications from Dr. Charles Scud-
der of Boston requesting a continuation of the fracture work
in the various hospitals as previously outlined.
R. H. Waldschmidt, M.D.,
Chairman.
Medical Economics
During the past year, the physician has been mostly con-
cerned with the successful prosecution of the war and his en-
deavors to keep up with the added burdens he has assumed.
There has been little time or need for time to devote to prob-
lems in the economic sphere. Hence your committee has not
met and no problems have been presented to it.
Consideration of economic questions has been largely put
aside for the duration of the war, yet it must be remembered
that in the postwar period we will probably acquire new and
pressing problems which must be met. We, as physicians, must
look ahead and take active measures to see that such problems
as may arise are solved in a manner which will be in the best
interest of the patient and the profession.
W. A. Wright, M.D.,
Chairman.
Maternal and Child Welfare
Your Committee on Maternal and Child Welfare met in
Grand Forks, North Dakota, on August 2, 1942.
Dr. Ralph Pray has resigned from the Committee, as he is
now practicing in California. Dr. J. L. Conrad of Jamestown,
a member of the Committee since its formation, died on May
28, 1942, and we take this occasion to express our sense of per-
sonal loss at his passing. Dr. Conrad was always very much
interested in the problems of maternal and child welfare and
gave freely of his time to furthering the work of your Com-
mittee. His wise counsel will be missed in its deliberations.
Dr. T. L. DePuy of Jamestown was appointed a new member
of the Committee by President Sorenson.
We had the rare good fortune to be addressed by Dr. James
Grassick. In connection with the entire program sf Maternal
and Child Welfare, one pertinent quotation from his remarks
should be emphasized, "Fundamentals of a good program are
wise legislation, well trained physicians and nurses and a people
made intelligent through education.” In this one sentence Dr.
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Grassick summed up the aims and aspirations of your Com-
mittee and we were most appreciative of his presence and wise
counsel.
Representing the State Department of Health at this meet-
ing were Viola Russell, M.D., Director of the Division of Ma-
ternal and Child Hygiene, and Carl J. Potthoff, M.D., clinician.
Dr. Russell has since left the state to assume a similar position
in the State Department of Health of Vermont. Your Com-
mittee wishes to express its appreciation for her services in
North Dakota.
Particular attention was paid to the information revealed by
preschool child health conferences, particularly with regard to
old and new cases of rickets. Present studies will be compared
with similar ones collected in 1937, and the comparative find-
ings will be submitted to the Committee for consideration as to
their value. The purpose is to determine how much corrective
work on rickets and other remedial defects has been done
through follow-up technique, and it was particularly recom-
mended that this survey be developed at the conferences to be
held in 1943.
We recommend that the attention of the State Medical As-
sociation be called to the recommendation of the American
Academy of Pediatrics that diphtheria and smallpox immuniza-
tions be done during the first year of life.
A study of the Maternal Mortality Survey revealed several
important facts:
1. The problem of the toxemias is one of more accurate
classification. After this is done, the treatment must be indi-
vidualized before there will be any further appreciable decrease
in deaths due to this cause. Your Committee would again call
attention to the importance of the study and adoption of the
classification of the toxemias as presented by the American
Committee on Maternal Welfare, Inc. While it is not always
possible to accurately classify the toxemias when they are first
seen, an attempt should nevertheless be made to do so, because
this has an important bearing on prognosis and treatment.
2. Deaths from puerperal and postabortal infections show an
increase. Case histories of fatal cases show for the most part
that, while sulfon drugs are being used rather generally, blood
transfusion is not employed as extensively as possible. We
would again call attention to the fact that small and frequent
blood transfusions are of the utmost importance in severe cases
of sepsis and, while the sulfon drugs are most valuable, the
best results will be obtained through a combination of sulfon
therapy, small frequent blood transfusions and other supportive
measures.
3. Deaths due to obstetric hemorrhage appear to be on the
increase. Your Committee was impressed by the neglect of
adequate treatment in placenta previa. This neglect frequently
originates first with the patient in that she often reports after
several hemorrhages have occurred. We urge careful and re-
peated blood examinations in all cases of obstetric hemorrhage
and the prompt securing of donors suitably grouped and cross
matched in advance of the need for transfusions. We would
also call attention to the fact that blood serum and/or plasma
should be available for immediate use in the emergency case.
Public Health Nursing in the field of maternal welfare came
in for considerable discussion and the extension of present pre-
partum nursing service was carefully considered. It was pointed
out that in some areas, where the war emergency has still fur-
ther depleted our already limited supply of physicians, certain
patients may not be able to get important phases of their pre-
partum care satisfied. Specifically, we referred to urinalysis,
blood pressure readings, weight and hemoglobin determination.
It is recommended that, in certain local areas, where the need
is great, public health nurses be instructed to render these serv-
ices to the pregnant woman in her home, but only upon the re-
quest of her physician. They would then be required to make
their report in duplicate, one to the physician and one to the
Maternal and Child Hygiene Division. It was felt by your
Committee that potential or actual bleeders and incipient tox-
emias could thus be checked earlier and more frequently.
Considerable discussion was devoted to the question of post-
graduate courses in Obstetrics and Pediatrics for physicians dur-
ing the war emergency and the Director of the Division of Ma-
ternal and Child Hygiene was asked to query North Dakota
physicians as to whether they preferred these courses to be
given at the Center for Continuation Study at the University
of Minnesota or in various cities throughout North Dakota.
This study is now under way and the results will largely deter-
mine the activities of your Committee in the future. It was felt
that this phase of our work was very important and should
not be neglected, but we wanted the opinions of our North
Dakota physicians before starting a new schedule at this time.
The problem of neonatal mortality came in for careful study.
A questionnaire has been prepared at the recommendation of
your Committee by the Division of Maternal and Child Hy-
giene covering all cases of neonatal death and we urge upon
our physicians the prompt completion of this questionnaire,
whenever any neonatal death occurs in their practice. It is
hoped, through a case study of these combined reports, to arrive
at some conclusions which will result in the saving of infant
lives.
John H. Moore, M.D.,
Chairman.
Supplemental Report on Medical Economics
The Committee received the following proposal from repre-
sentatives of the Farm Security Administration.
"The Farm Security Administration requests of the North
Dakota State Medical Association, through its Medical Eco-
nomics Committee, approval for the organization of prepaid
medical care plans, the exact provisions of which will depend
upon local needs in any area or locality, but, in each instance
in which such a plan is organized, operation of the plan will be
delayed until approval is obtained from the State Medical Eco-
nomics Committee.
"In any instances in which plans have already been organized,
operation and solicitation of membership will be delayed until
approval is obtained from the State Medical Association.
"It is further requested that the Economics Committee pre-
pare agreements embodying such provisions as are here set
forth and that the agreements be signed by the State Medical
Association and the Regional Director of the F.S.A.”
The Committee approved this proposal and recommends its
adoption by the House of Delegates.
We met with Mr. Willson, Executive Secretary of the Public
Welfare Board, and adopted plans for the general revision of
all Welfare Board fee schedules. This will be done as quickly
as possible.
Mr. Willson suggested that he would welcome the appoint-
ment of a Medical Advisory Committee to the State Public
Welfare Board. We recommend that such a committee be ap-
pointed and that it consist of five members, three from the
Economics Committee, one from the Committee on Crippled
Children, and one from the Committee for the Blind.
The following suggested changes in fee schedules were pre-
sented:
The Pneumonia Committee recommended that the fee for
x-rays in children under the age of 11 years be reduced to
$3.00. We recommend that the fee be retained at $5.00 so that
x-ray fees may be kept uniform throughout.
The Committee on Crippled Children recommended that
x-ray fees be the same as that in the general Welfare Board fee
schedule, viz.: 80 per cent of the Workman’s Compensation
Bureau schedule. We recommend that this fee schedule be
adopted.
The following Resolution was passed and we recommend it
for approval:
RESOLUTION
Whereas, a resolution will be introduced in the House of
Delegates of the American Medical Association during their
annual assembly convening June 7, 1943, in Chicago, Illinois,
which provides for the creation of a committee to be known as
the Committee on Medical Service, and
Whereas, the House of Delegates of the North Dakota State
Medical Association in annual assembly May 9, 1943, are
heartily in accord with the principles expressed in that resolu-
tion:
Therefore, Be It Resolved, that the House of Delegates of
the North Dakota State Medical Association urge the House of
August, 1943
235
Delegates of the American Medical Association to adopt the
resolution.
Be It Further Resolved, that the Constitution and By-Laws
of the American Medical Association be amended if necessary
in order that the aforementioned resolution can be adopted.
And Be It Further Resolved, that the Delegates of the North
Dakota State Medical Association to the House of Delegates
of the American Medical Association are hereby instructed to
do all in their power to effect the adoption of the resolution
and if necessary amend the Constitution and By-Laws.
Respectfully submitted,
W. A. Wright, M.D,
Chairman, Medical Economics Committee.
Joint Supplemental Report of Committees on Medical
Economics and Maternal and Child Welfare
Your Committee on Maternal and Child Welfare submits
the following from its meeting of May 9, 1943:
It was moved by Dr. Woutat and seconded by Dr. Hanna
that the plan presented by Dr. Robert G. White, Director of
the Division of Maternal and Child Hygiene of the North Da-
kota State Department of Health embodying the proposed plan
of the Children’s Bureau for Maternal and Infant Care for the
Wives and Children of Men in the Armed Forces be rejected
for the following reasons:
1. Said plan involves fixed obstetric and pediatric fees with-
out regard to the individual merits of each case.
2. From information given us, no state in this district has
been able to have a plan accepted by the Children’s Bureau
establishing a fee schedule above the maximum indicated in the
proposed plan for North Dakota, thus allowing no opportunity
for free negotiation between the physicians and the Federal
agency administering these funds regarding the amount of said
fees.
3. It tends to set up an artificial and false standard of ob-
stetric and pediatric fees, contrary to the commonly accepted
practice of organized medicine.
4. It seems reasonable to suppose that if this plan is accepted
attempts might be made to extend similar arrangements to other
fields of medical practice.
Appreciating the sacrifices being made by the men in the
armed forces, we recommend to the medical profession of this
state that the wives and children of men in the armed forces
of the fourth, fifth, sixth and seventh grades be extended ma-
ternal and infant care as contemplated by the above mentioned
program, without thought as to their ability to pay.
We also recommend that the action of this Committee to-
gether with a copy of the plan, whose rejection we recommend,
be referred to the Committee on Medical Economics for their
opinion and reference to the House of Delegates of the North
Dakota State Medical Association.
Public Health
A meeting of the Committee on Public Health of the State
Medical Association was called to order at 10:00 A. M., Sun-
day, March 7, 1943, in the offices of the State Department of
Health, by the chairman, Dr. F. J. Hill. The following mem-
bers of the Committee were present: Frank J. Hill, M.D.,
chairman; P. L. Owens, M.D., Bismarck; William Campbell,
M.D., Valley City; H. B. Huntley, M.D., Kindred; Sam Cher-
nausek, M.D., Dickinson.
An agenda was presented, which included special problems in
communicable disease control in relation to our present national
emergency.
Dr. F. J. Hill, Acting State Health Officer, presented statis-
tics which pointed out the problems remaining to be solved in
North Dakota. Attention was called to the Report on Health
Achievements in North Dakota which appeared in the Febru-
ary issue of the Journal-Lancet. In this article the medical
profession is given much of the credit in making these health
achievements possible.
The Committee selected Drs. Huntley, Owens and Hill to
appear before the House of Delegates on behalf of various
proposals.
After extensive discussion, the Committee recommended that
the following resolutions be adopted:
1. That the State Department of Health request aid from
the U. S. Public Health Service to make arrangements accept-
able to the medical profession, for the x-ray examination of all
Mexicans employed at present in North Dakota.
2. That a resolution be prepared and sent to the Beet Grow-
ers’ Association, and others concerned, that no Mexican laborer
be hired, unless he can present a clean bill of health, particu-
larly freedom from tuberculosis as determined by an x-ray ex-
amination.
3. That the House of Delegates give careful consideration to
the provisions of Senate Bill No. 77, which is permissive legis-
lation for providing fulltime health districts and request the
members of the North Dakota State Medical Association to
cooperate in promoting fulltime public health units.
4. That the State Department of Health be requested to
organize immunization services in the counties without physi-
cians, by utilizing private physicians from neighboring counties
under compensation plans now operating in other counties,
where immunization services are available.
F. J. Hill, M.D.,
Chairman.
Industrial Health
Industrial health has reached an all-time high in importance.
This is due to the tremendous industrial expansion which has
resulted because of our war effort. Briefly, the program for
industry advocated by the Council of Industrial Health is to
encourage more adequate medical service within industry, to
investigate and record reports of occupational disease and in-
jury, and to provide hygienic instruction to industrial groups on
the prevention and control of communicable and occupational
disease.
This Committee has obviously a most important duty to car-
ry out, because the health of the war worker is second only to
the health of the members of the armed forces.
Industrial health was first emphasized during the First World
War and now, in this global war, it reaches its greatest field of
usefulness. It must be appreciated that proper care of the sick
and injured worker is a responsibility, not only of medicine but
also of management and labor, and it is only by active co-
operation between each of these three groups that the best re-
sults will be obtained. While the larger industries are well or-
ganized and functioning efficiently, the smaller plants still do
not have similar advantages and their entire medical program is
often provided by the general practicing physician.
The reported figures on time lost from industry may be in-
teresting — first is the 15 per cent due to injury and occupa-
tional diseases, then comes the 85 per cent lost by illness aris-
ing outside the plant. Some of this is due to improper food,
crowded unsanitary housing and the improper use of leisure
time.
As stated in our report last year, North Dakota is not a
highly industrialized state, however, what industries we do have,
fall in the so-called smaller plant groups where the medical and
health service is not organized as well as in the larger industries.
The farmer has recently assumed the same importance as the
defense worker in the war effort, and in this state the health of
the farmer is essential to the production of food. As stated in
our report of last year, agriculture is an occupation attended by
serious risks, and the medical men of the state must be of suffi-
cient numbers and so trained as to properly care for the health
of the agricultural worker.
The Annual Congress on Industrial Health was held in Chi-
cago in January of this year. Unfortunately, no member of
your Committee was able to attend this meeting. Some of the
subjects discussed included symposiums on employee-manage-
ment cooperation for industrial health; women in industry; op-
timum hours of work; rehabilitation; medical relations in work-
men’s compensation; medical testimony; and nutrition in in-
dustry.
C. J. Glaspel, M.D.,
Chairman.
Report of the Committee on Venereal Diseases
At the meeting of the Venereal Diseases Committee at Grand
Forks November 8, 1942, at which the State Health Depart-
ment was represented, and present were representatives of the
United States Public Health Service, it was recommended that:
1. The fee for gonorrhea cases under treatment be raised
from $1.00 to $2.00 (total not to exceed $10.00).
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2. The fee for treating infectious indigent cases of less than
four years’ duration, or cases not having had a total of forty
treatments, should be $2.75 for intravenous and $1.20 for intra-
muscular treatments, when material is furnished by the state.
When material is not furnished by the state, the fee should be
$3.34 for intravenous and $1.67 for intramuscular injections.
3. Postgraduate courses in dermatology and syphilology
should be arranged for at the University of Minnesota, as in
the past.
4. Any proposed legislation should be discussed with the
Committee on Public Policy and Legislation of the State Med-
ical Association.
5. It was decided that a questionnaire be sent to the physi-
cians of the state to get their opinion on some venereal disease
problems. A review of the answered questionnaires indicated
as follows:
(a) A favoring of postgraduate courses, preferably in the
various districts.
(b) Routine serologic tests for: (1) all marriage license
plicants; (2) all patients of doubtful diagnosis; (3) as
part of every complete physical examination; (4) in all
prenatal cases.
(c) Only 50 per cent were in favor of routine serologic tests
on all hospitalized patients.
(d) More than 75 per cent of physicians answering believed
that a prenatal blood test should be added to our pres-
ent premarital law, and that reports from other State
Health Department Laboratories should be accepted in
administering the present law.
(e) The present reporting and treatment forms, the outline
of treatment presented by the cooperative clinical group,
and the present arrangements for paying for diagnosis
and treatment of indigents received approval of a vast
majority of those answering the questionnaires.
(f) Consultants for difficult cases, and follow-up services by
lay or professional personnel employed by the State
Health Department for those who are delinquent, was
welcomed by the majority of physicians.
Frank L. Darrow, M.D.,
Report of the Delegate to the American
Medical Association
Dr. A. P. Nachtwey, Delegate, submitted the following re-
port, which was referred to the Reference Committee on the
Reports of the Council, Councillors, and Delegate to the Amer-
ican Medical Association.
Your Delegate to the American Medical Association begs
leave to submit the following report:
The American Medical Association held its ninety-third an-
nual session in Atlantic City, June 8 to 12, 1942.
There were 8238 physicians registered.
The transactions of the House of Delegates were marked by
harmony and expedition. Reference committee reports were con-
sidered in a serious and earnest fashion and, with few excep-
tions, harmoniously and expeditiously dispatched.
The outstanding feature of 1942 was the attendance of physi-
cians from Latin America. There were 140 physicians who
registered from other American nations. Many of them par-
ticipated in the program of various sessions and in the various
scientific meetings. They added greatly to both the interest and
glamour of the occasion.
The House of Delegates in Atlantic City was concerned
largely with the problems of organization leading to improved
functions of the organization, problems related to the war and
medical service plans.
One of the general scientific meetings was devoted to ad-
dresses by the inter-American guests. Another was devoted to
war problems, and a third to problems of general clinical im-
portance.
Mr Paul V. McNutt was the chief speaker at a dinner given
to the House of Delegates by the Atlantic County Medical So-
ciety. Mr. McNutt’s address was concerned solely with the
utilization of man power as related to physicians needed in the
service. He tendered great praise to the organization for the
excellent work that had been done by the Committee on Med-
ical Preparedness. While there were some shortages apparently
at that time, your Association committee has remedied this de-
fect -and is looking for no further immediate trouble in that
regard.
There was an address by the President, Frank H. Lahey, of
Boston, who paid high tribute to the officers of the Association
and especially to your Secretary, Dr. Olin West, for their
wholehearted cooperation in conducting the year’s affairs.
Surgeon General James E. Magee of the United States Army
addressed the House of Delegates and paid high tribute to the
character of men in organized medicine who were in the Army.
The Committee on Distinguished Service Awards for the
American Medical Association submitted three names to the
Board of Trustees for the award of the Distinguished Service
Medal. They were Dr. George W. Crile, Dr. Ludvig Hecton
and Dr. Elliot P. Joslin. Dr. Ludvig Hecton received a ma-
jority of votes cast and was selected to receive the Distinguished
Service Award of the American Medical Association.
Without opposition, the House selected as President-Elect,
Dr. James E. Paullin of Atlanta, Georgia, who has long been
identified with the Association’s activities in field and graduate
education.
The Scientific Exhibit was well attended and again and again
one heard the comment that the Scientific Exhibit of the Ameri-
can Medical Association is the greatest postgraduate course ever
assembled anywhere in the world.
The House of Delegates adjourned sine die 4:10 P. M. on
June 11, 1942.
A. P. Nachtwey, M.D.,
Delegate.
REPORT OF SPECIAL COMMITTEE
Committee on War Participation
Dr. L. W. Larson, chairman, submitted the following report
which was referred to the Reference Committee on the Report
of the Secretary and Special Committees.
This Committee has continued the work of the Committee on
Medical Preparedness. Its membership has been increased to
ten, in order that every area in the state might be more ade-
quately represented.
A year ago our Nation’s effort to produce a large armed
force was in its infancy. A staggering number of medical offi-
cers was demanded by the Army and Navy. Physicians, par-
ticularly in the younger age groups, were slow to enlist. Drastic
measures to meet the shortage of medical officers had to be in-
augurated. Directives were issued from National Selective Serv-
ice Headquarters to local Selective Service Boards, whereby
physicians, dentists and veterinarians were to be classified regard-
less of dependencies. Medical Officer Recruiting Boards were
sent into each state during May to expedite the commissioning
of medical officers. In spite of the fact that the Allotment Bill,
which was signed by the President in June, countermanded the
directive referred to above, and gave physicians the same provi-
sions for deferment because of dependents as other citizens, the
response in North Dakota was so prompt that the Recruiting
Board was withdrawn in less than three months. Our quota of
29 was reached by September. It was 114 per cent in October.
Sixty-one North Dakota physicians are in Military Service
according to government reports and reports of the District
Medical Society secretaries. A list of their names can be found
following the Alphabetical Roster of North Dakota physicians
in this issue of the Journal-Lancet.
The major function of this Committee has been to cooperate
with the Procurement and Assignment Service for Physicians in
determining the "availability” and "essentiality” of every phy-
sician in the state. In some instances, this has been a difficult
task. A few mistakes have been made, particularly in permitting
young physicians to apply for commissions, only to find when
they had left for service that they could not be replaced at
home. However, the medical profession in North Dakota
should feel proud of the record it has made to date in provid-
ing our Armed Forces with Medical officers. There are very
few areas in the state where the services of a physician are not
available on comparatively short notice. A survey of such areas
reveals that the inhabitants were none too loyal to their local
physicians in prewar days.
August, 1943
237
The duties of this Committee in the future, as in the past,
will be to provide the number of physicians for the Armed
Forces demanded by the government, and also safeguard the
medical care of the civilian population in the state. Recruit-
ment of medical officers to date in 1943 has been largely lim-
ited to those few states that failed to reach their quotas in 1942,
but states such as ours may be called upon to fill a quota dur-
ing the late months of this year.
The relocation of physicians to those few areas in which there
is a critical need for physicians has become a difficult problem.
A few physicians who, a few years ago, would gladly have
moved to some other location in the state, are now loathe to
do so because of improved economic conditions in their own
localities and the uncertainties incident to a change in location.
The importation of physicians from other states presents nu-
merous difficulties, particularly that of obtaining physicians who
have the professional ability and physical stamina to carry on
in a rural practice. Your Committee does not favor the estab-
lishment, in any area in North Dakota, of a health service such
as is functioning in some states and in which a commissioned
officer of the United States Public Health Service is assigned
to an area and practices medicine under the sponsorship of a
state defense or health authority, until all other attempts to
solve the problem have failed.
L. W. Larson, M.D.,
Chairman.
NEW BUSINESS
Dues
Upon motion duly made, seconded and carried it was agreed
that the annual dues remain the same as last year, or $10.00
per capita.
Nominating Committee
The President announced the appointment of Drs. P. G.
Arzt, O. T. Benson and D. J. Halliday to the nominating com-
mittee.
Reference Committees
The Speaker announced the personnel of the Reference Com-
mittees as follows:
To consider the Reports of the Secretary and of Special Com-
mittees: A. H. Woutat, chairman, Grand Forks; G. C. Chris-
tianson, Sharon; G. W. Hunter, Fargo; R. T. O’Neill, Minot;
W. A. Wright, Williston.
To consider the Reports of the Council, Councillors, and
Delegate to the A. M. A.: O. T. Benson, chairman, Glen
Ullin; D. J. Halliday, Kenmare; J. B. James, Page; W. A.
Liebeler, Grand Forks; J P. Merrett, Marion; L. J. Seibel,
Harvey; J. C. Fawcett, Devils Lake.
To consider the Reports of the Standing Committees: T. L.
DePuy, chairman, Jamestown; W. E. G. Lancaster, Fargo; A.
H. Reiswig, Wahpeton; C. C. Smith, Mandan; R. H. Wald-
schmidt, Bismarck; C. J. Meredith, Valley City.
Committee on Resolutions
A. P. Nachtwey, chairman, Dickinson; D. J. Halliday, Ken-
mare; C. J. Meredith, Valley City.
Committee on Credentials
C. C. Smith, chairman, Mandan; L. J. Seibel, Harvey; J. C.
Fawcett, Devils Lake.
Adjournment
The first meeting of the House of Delegates was adjourned
at 8:55 P. M. on motion made by Dr. R. H. Waldschmidt,
seconded by Dr. G. Wilson Hunter and carried. It was agreed
that the second session of the House would be called at 9:30
A. M., Monday, May 10.
SECOND SESSION
of the
HOUSE OF DELEGATES
Monday, May 10, 1943
The Second Session of the House of Delegates was called to
order by the Speaker, Dr. John H. Moore, at 9:45 A. M. in
the Rose Room, Hotel Patterson, Bismarck, N. Dak.
The Secretary called the roll. Fifteen delegates responded,
and the Speaker declared a quorum present. The following
delegates and alternates responded: Doctors W. E. G. Lan-
caster, Fargo; G. W. Hunter, Fargo; P. H. Woutat, Grand
Forks; C. R. Tompkins, Grafton; W. A. Wright, Williston;
D. J. Halliday, Kenmare; R. T. O’Neill, Minot; A. H. Reis-
wig, Wahpeton; C. J. Meredith, Valley City; R. H. Wald-
schmidt, Bismarck; C. C. Smith, Mandan; O. T. Benson, Glen
Ullin; A. P. Nachtwey, Dickinson; L. J. Seibel, Harvey; G. C.
Christianson, Sharon.
The Secretary read the Minutes of the First Spssion, which
were approved as read.
Dr. D. J. Halliday, member of the Nominating Committee,
presented the following report, moved its adoption and that the
nominees be declared unanimously elected.
Dr. R. H. Waldschmidt stated that the Governor had re-
peatedly requested the Association to nominate six candidates
for appointment to the State Board of Medical Examiners each
year instead of only three candidates as has been the custom in
the past. Dr. Waldschmidt suggested that the Nominating
Committee respect the Governor’s request this year. There being
no further nominations, the motion of Dr. D. J. Halliday was
seconded by Dr. R. T. O’Neill and carried unanimously. Those
elected to office for 1943-1944 were:
President — Frank Darrow, Fargo.
President-Elect — F. L Wicks, Valley City.
First Vice President — James F. Hanna, Fargo.
Second Vice President — A. E. Spear, Dickinson.
Speaker of the House — John H. Moore, Grand Forks.
Secretary — L. W. Larson, Bismarck.
Treasurer — W. W. Wood, Jamestown.
Delegate to A.M.A. — A. P. Nachtwey, Dickinson.
Alternate Delegate to A.M.A. — O. T. Benson, Glen Ullin.
COUNCILLORS:
Second District — J. C. Fawcett, Devils Lake.
Seventh District — P. G. Arzt, Jamestown.
Eighth District — F. W. Fergusson, Kulm.
Tenth District — W. H. Gilsdorf, New England.
Dr. F. L. Wicks, Councillor for the Fifth District, submitted
his resignation, because he had just been elected President-Elect
of the Association. Dr. A. P. Nachtwey moved that Dr. Wicks’
resignation be accepted. The motion was seconded by Dr. C.
R. Tompkins and carried.
Dr. D. J. Halliday moved that Dr. C. J. Meredith of Valley
City be elected Councillor for the Fifth District to fill the un-
expired term of Dr. F. L. Wicks, resigned (term expires in
1945). The motion was seconded by Dr. A. P. Nachtwey and
carried unanimously. The Speaker declared Dr. C. J. Meredith
elected Councillor for the Fifth District.
The Secretary announced that no invitations had been re-
ceived for the 1944 Session. A general discussion followed in
which it was emphasized that the Association may not be able
to convene in 1944. Dr. A. H. Reiswig moved that Fargo be
selected as the next meeting place. The motion was seconded
by Dr. L. J. Seibel and carried unanimously.
REPORTS OF REFERENCE COMMITTEES
Report of Committee on Reports of
Secretary and Special Committees
Dr. P. H. Woutat, chairman, presented the following report
which was adopted as a whole on motion of Dr. Woutat, duly
seconded by Dr. R. H. Waldschmidt and carried.
Your Committee to consider the report of the Secretary of
the State Association, recommends the adoption of the Secre-
tary’s Report, including the recommendations that Dr. A. B.
Fields of Forest River be elected to Honorary Membership in
our Association and that the President of the State Association
appoint a small committee on Nursing Education to cooperate
with the State Hospital Association and the State Board of
Nurses Examiners.
Your Committee wishes to commend the excellent work of
the Secretary during the past year.
Your Reference Committee recommends the adoption of the
report of the Committee on War Participation and wishes to
commend the Committee for its work. We recommend that the
Committee continue its policy of trying to maintain adequate
medical personnel to care for the people of the state.
Council, Councillors, and Delegate to A.M.A.
Dr. O. T. Benson, chairman, presented the following report,
which was adopted section by section and as a whole, on mo-
tions of Dr. Benson, duly seconded and carried.
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1. Report of Chairman of Council. Your Reference Com-
mittee has carefully considered the report of the Council as sub-
mitted by its chairman, Dr. N. O. Ramstad. It heartily ap-
proves the investment of State Association Funds in war bonds
and commends the thoughtful action of the Council in sending
notes of condolence to the widows of Drs. A. O. Arneson and
George B. Ribble, who were valued and respected members and
officers of our Association.
We find the affairs of the State Association have been effi-
ciently administered by the Council. Your Reference Committee
recommends the adoption of the report of the Council.
2. Reports of Councillors. Your Reference Committee is
pleased to note that all the Councillors report harmony and
good will prevailing in their districts.
The report of Dr. Williamson, Councillor for the Third Dis-
trict, in which he suggests the amalgamation of the Traill-
Steele County Society with the Grand Forks Society and the
report of Dr. Paul Burton, Councillor for the First District, in
which he suggests the amalgamation of the Richland County
Society with the Cass County Society, were carefully consid-
ered by your Reference Committee. We believe that the ques-
tion of redistricting the state should receive careful consideration
on the part of the House of Delegates in the near future, be-
cause of the apparent difficulty which some of the smaller so-
cieties are experiencing in maintaining interest in their society.
The question raised in the report of Dr. Burton, Councillor
for the First District, relative to arrangements which might be
made whereby the members of the medical staff of the North
Dakota Veterans Hospital could oin the State Association was
carefully considered by your R Terence Committee. It was
agreed that these physicians should be encouraged to affiliate
with organized medicine, but that no special concessions be
made to them.
Your Reference Committee believes that the reports of the
Councillors indicate that all the district societies are well organ-
ized so that interest and enthusiasm is being maintained.
The statement of Dr. Spear, Councillor for the Tenth Dis-
trict, which reads, "If there is a job to do, the Southwestern
Society will handle it,” would appear apropos for all the district
societies, according to the reports of the Councillors.
Your Reference Committee recommends the adoption of the
reports of the Councillors for the First, Third, Fourth, Fifth,
Sixth, Seventh, Eighth, Ninth and Tenth Districts, as amend-
ed. These Councillors are as follows: Drs. Burton, Williamson,
McCannel, Ramstad, Arzt, Wicks, Westervelt and Spears.
3. Report of Delegate to the American Medical Association.
This Committee believes that the report of Dr. Nachtwey, dele-
gate to the A M. A., is outstanding in that it contains a concise,
interesting report of the deliberations of that governing body.
This Committee recommends the adoption of the report of Dr.
Nachtwey.
Report of Reference Committee to Consider the
Reports of Standing Committees
Dr. R. H. Waldschmidt, chairman, presented the following
report, which was adopted section by section and as a whole,
on motions of Dr. Waldschmidt, duly seconded and carried,
after discussion:
1. Report of Committee on Medical Education. Your Ref-
erence Committee recommends the adoption of the report of
the Committee on Medical Education.
2. Report of Committee on Necrology and Medical History.
Your Reference Committee recommends the adoption of the
report of the Committee on Necrology and Medical History
and wishes to take this occasion to commend Dr. James Gras-
sick for the excellent manner in which he prepares the reports
on Necrology.
3. Report of the Committee on Public Policy and Legislation.
Your Reference Committee recommends the adoption of the
report of the Committee on Public Policy and Legislation. It
also wishes to commend Drs. Stucke and Brandes for their ex-
cellent efforts in behalf of the Medical Profession during the
last session of the Legislature.
4. Report of Committee on Tuberculosis. Your Reference
Committee recommends the adoption of the report of the Com-
mittee on Tuberculosis.
5. Report of the Editorial Committee on Official Publication.
Your Reference Committee recommends the adoption of the re-
port of the Editorial Committee on Official Publication.
6. Report of Committee on Pneumonia Control. Your Ref-
erence Committee recommends the adoption of the report of
the Committee on Pneumonia Control except that the #3.00
fee for x-rays of the chests of children be changed to #5.00 as
recommended by the Committee on Medical Economics.
7. Report of the Committee on Cancer. Your Reference
Committee recommends the adoption of the report of the Com-
mittee on Cancer.
8. Report of the Committee on Fractures. Your Reference
Committee recommends the adoption of the report of the Com-
mittee on Fractures.
9. Report of the Committee on Industrial Health. Your
Reference Committee recommends the adoption of the report
of the Committee on Industrial Health.
10. Report of the Committee on Venereal Disease. Your
Reference Committee recommends the adoption of the report
of the Committee on Venereal Disease.
11. Report of the Committee on Medical Economics with its
Supplemental Report. Your Reference Committee recommends
the adoption of the report of the Committee on Medical Eco-
nomics as printed in the handbook, and also the supplemental
report of the Committee on Medical Economics as presented at
the First Session of the House of Delegates. Your Reference
Committee moves the adoption of this portion of the report.
12. Report of the Committee on Maternal and Child Welfare.
Your Reference Committee recommends the adoption of the
report of the Committee on Maternal and Child Welfare as
printed in the Handbook.
13. Joint Report of Committees on Maternal and Child Wel-
fare and on Medical Economics. Your Reference Committee
recommends the adoption of the Joint Report of the Commit-
tees on Maternal and Child Welfare and Medical Economics,
pertaining to the emergency maternity and infant care program
for wives and dependent children of service men in the fourth,
fifth, sixth and seventh grades.
14. Report of the Committee on Public Health. Your Ref-
erence Committee recommends the adoption of the report of
the Committee on Public Health with the following amend-
ments:
1 . That paragraph two under Resolutions be amended to
read "The State Health Department prepare a resolution and
send it to the Beet Growers Association and others concerned,
that no Mexican laborer be hired unless he can present a clean
bill of health, particularly freedom from tuberculosis as deter-
mined by an x-ray examination.”
Your Reference Committee believes that as a public health
measure these individuals should not be admitted into the
United States until it is known that they are free from tuber-
culosis as determined by an x-ray examination.
2. That paragraph three in reference to Senate Bill No. 77,
providing permissive legislation for fulltime health districts, and
requesting the cooperation of the North Dakota State Medical
Association in promoting fulltime health units, be not approved.
Committee on Resolutions
Dr. A. P. Nachtwey, chairman, presented the following re-
port, which was adopted on motion of Dr. Nachtwey, duly sec-
onded and carried:
Your Committee on Resolutions begs leave to submit the fol-
lowing report: Your Committee gave careful and long consid-
eration to the Resolution to be presented to the House of Dele-
gates of the American Medical Association at its next Annual
Meeting for establishment of a committee on Medical Service.
Your Committee approves this Resolution in toto and moves its
adoption.
NEW BUSINESS
Redistricting of Component Medical Societies
Dr. A. P. Nachtwey: Dr. Hunter brought up the amalga-
mation of the Societies. Would any special recommendation be
made on this at this meeting?
Dr. O. T. Benson: Drs. Burton and Williamson made a
suggestion, but the inference was that it was up to the Society
to decide this.
August, 1943
239
Dr. Frank Darrow: Would you not recommend that there
should be a redistricting of the Association?
Dr. O. T. Benson: Yes, We thought that should be left to
the House of Delegates. Dr. Williamson suggested that a com-
mittee be appointed. We thought that the Council was author-
ized to act as a committee as a whole, to redistrict the societies
of the State Associaion. We thought that should be discussed
here.
Dr. G. Wilson Hunter: Could we have a statement from
Dr. Reiswig, who is a member of the Richland County Society?
Dr. A. H. Reiswig: We discussed that before, in our society.
We feel that most of the members would like to become mem-
bers of the Cass County Society. Some of the local men raised
the question of having some sort of a committee to deal with
the problems of the local society, but according to Dr. Burton,
this could be left to the society anyway. For instance, we had
a little trouble with an irregular coming in; our society got busy
and took care of him. Some of the members wondered if we
joined the Cass Society, could we get that service. We are sure
that it would be beneficial for our members, because we have
not a very large membership and have not been having very
many meetings. We have, most of us, been attending the meet-
ings of the Cass Society.
Speaker: May I clarify the point that Dr. Benson raised, by
calling your attention to your Constitution and By-Laws? Dr.
Benson is perfectly correct. It is the function of the House of
Delegates, not a province of the Council. One point deals with
the organization of the various district societies and then in
Section 2, of Chapter 12 of the By-Laws, it states "Charters
shall be issued only upon approval of the House of Delegates
and shall be signed by the President and the Secretary of this
Association. The House of Delegates shall have authority to
revoke the charter of any component district society, whose ac-
tions are in conflict with the letter or spirit of this Constitution
and By-Laws.” In Dr. Williamson’s district they have been hav-
ing some difficulty. The Traill-Steele Society wants to continue
with some of their own problems, but many of the members feel
it may not work out. It is the problem of this House to solve
this.
Dr. Frank Darrow: Then it is up to the individual society
to get together and request a new Charter.
Speaker: I think that is entirely correct. If the society would
come to Cass and request a change in the charter, this body
would issue that charter upon the request of the delegates. The
same thing holds true with the Grand Forks and Traill-Steele
Districts. Does that answer the question? It is the function of
this House of Delegates, but we have no request for such a
change in charter before us, as Dr. Darrow has said. It would
be my feeling that at present the situation should remain as it
is, and let a request come from a local community.
Dr. L. J. Seibel: I do not believe it is the right thing to do,
to let the members drift away and then finally kill the Society.
Speaker: That is right.
Dr. G. C. Christianson: I would like to speak for the mem-
bers of the Traill-Steele Society. I would like to take issue with
the statement of Dr. Williamson that we do not hold regular
meetings. We do hold these meetings. We have four meetings
a year and have outside speakers for our programs. They are
educational programs. One of the issues that come up before
our group is distance. I am about 60 or 75 miles away from
Grand Forks, but as far as I am concerned, I could drive those
miles to meet with the Grand Forks District. However, our
members are made up of older men who have practiced 30 or
40 years. Last summer, the question was brought up as to
whether we should join the Grand Forks group, and the older
members were very much against it at that time. I think the
only way anything could be done about it would be in redistrict-
ing, because if it is just left up to the Society to join, I do not
think they will.
Speaker: Thank you very much for your remarks. I am
very glad you brought that up. This makes two expressions of
opinion from members of the societies under question, and the
very pertinent remarks of Dr. Seibel. I feel from what has been
said here, that this House probably would not want to take any
action at this time to force an amalgamation. Certainly, we
know that the Traill-Steele Society has been very active. They
have had their programs regularly. And while they are always
welcome to come to the meetings of the Grand Forks Society,
I do not think that the House of Delegates would want to
force such an amalgamation.
Dr. W. E. G. Lancaster: Could not the House take action
to make it permissible for any Society to change, if they want
to?
Speaker: That is all worked out. The initiative should come
from the society. We have issued charters, and as long as the
societies are fulfilling their functions and would like to continue
to do so, any change should be up to them.
Dr. L. J. Seibel: Suppose the society acts on it, and the
majority are for retaining its organization. Is it proper for the
few to drift away?
Speaker: I can only answer that from what little knowledge
I have been able to pick up in the last few years, sitting up
here, I think probably that the majority still rules, and, when
a majority decides that they want to keep their society, I have
seen nothing to indicate that this House of Delegates would
attempt to over-rule the majority’s wishes. The problem of the
minority comes in, not only in the local society but in this State
Association. It came in on one of the objections that Dr. Nacht-
wey’s committee made to a resolution. There are always a few
who do not quite come in. We have, in a democratic body like
this, to be governed by the wishes of the majority.
Dr. A. FT Reiswig: It is quite often true that those who do
not want to join up with the other society do not attend our
own meetings, except when such a problem comes up. I think
this should be discussed within our own society, so that if the
majority votes for it, we would be cleared.
Dr. P. H. Woutat: It seems to me that the small district
societies should be maintained, primarily for handling their local
situations which differ a little in such states as ours. Problems
in our part of the state differ from those in the western part of
the state. If the reason these societies wish to join is purely to
present better scientific programs, there is nothing to prevent
any member from attending any scientific program and meeting.
I think if these small societies have problems, they would rather
thresh these out and then, if they care to, attend scientific meet-
ings of some of the other societies.
Dr. Darrow: There is always a little financial obligation,
even to a scientific session. Perhaps these members of other
societies want to bear their part of it. I think this could be
handled on a local basis and this problem could be solved. The
question that came to my mind was, whether it would change
the delegate proposition, and there you have a real problem.
They might not have enough in their society to add the extra
delegate, which would be necessary for the House of Delegates.
Speaker: That is true. It may be one of the reasons why a
society wishes to retain its own identity.
Dr. Frank Darrow: We do have an arrangement in Fargo
whereby the men from Moorhead may come to our meetings
and pay a small fee, because they insisted that they share the
financial burden of putting them on. The members from Rich-
land Society, no doubt, wish to bear the burden financially also,
and that is why this question came up.
Speaker: I feel, from listening to this most excellent dis-
cussion, that it is the concensus of this House of Delegates that
nothing should be done at this time, regarding the recommen-
dation to amalgamate these societies. Is that your feeling?
Dr. O. T. Benson: Is that also true about redistricting?
Speaker: Yes.
Dr. G. W. Hunter: Would it be in order to suggest that
the larger society make it a practice to send out notices to all
adjacent societies? In the past year, we have adopted the prac-
tice of sending out notices of our meetings to every society
within a radius of sixty miles, even including those in Minne-
sota. We have had an excellent response and the men have
come from Fergus Falls, Devils Lake, Wahpeton, Breckenridge,
Crookston and several other points. We feel it is a good prac-
tice and we have had better meetings as a result.
Speaker: I might call your attention to the Constitution and
By-Laws which state that the function of the House of Dele-
gates is to give diligent attention to and foster the scientific
work and spirit of the Association. I think that this discussion
is pretty much a matter of local invitation and the function of
240
The Journal-Lancet
the various local societies. Any further discussion on this point?
Dr. D. J. Halliday: Would it be out of order to have the
House of Delegates appoint a special committee to give a year’s
study and bring in a report next year as to what individual
members of the various societies think of this matter?
Speaker: It would seem a little easier, now that this has
been crystallized by this discussion, for the representatives of
the smaller societies to take this matter up within their societies.
There has not been a request from any interested society for
amalgamation, and if the matter could sort of develop along for
a year, it would not take an extra committee to bring this to
the House next year. It would come in very properly under
items of business. But, if you feel that it is important enough
at this time to make a special study of it; if you feel that the
situation is important enough to make a special study of re-
districting, then I think it is important enough to move the
appointment of a committee.
Dr. D. J. Halliday: We are only expressing our own opin-
ions. We are not getting the view of the men who do not
attend these district meetings. They may wish to attend the
larger society meetings.
Speaker: This body may appoint a committee, if you wish
to present it that way.
Dr. L. J. Seibel: Have not we been discussing this for the
past few years? We have in our Tri-County Society. It is not
a new problem at all.
Speaker: No, it is an old problem, but it is having an excel-
lent discussion this morning. It may be that out of this dis-
cussion something may develop in regard to redistricting, but
I do not think we need to be in a hurry about it. We have
enough objections raised this morning to redistricting, so I feel
very sure that this House would not want to ride rough-shod
over the wishes of the members of any society.
Dr. G. C. Christianson: I would like to ask, so I can carry
back the information to our society, what is the reason for the
larger society wanting the smaller society to join them. Is there
someone here that would give a reason for it? What are the
advantages?
Secretary Larson: I think that the two councillors who sug-
gested this did so because they were a little bit concerned over
just how thriving your society and Dr. Reisweig’s society are.
Perhaps they are shooting too high; perhaps they are trying to
apply the standards set by such large societies as the Cass and
Grand Forks County societies to your smaller district societies.
Dr. Frank Darrow: I think it was more of an invitation;
not a request.
Secretary Larson: It was an invitation, I am sure. They are
not trying to railroad any society into joining a larger society.
They are a little concerned lest these small societies die out,
and it is perfectly proper for them as Councillors to worry
about that. If you people feel that you are getting along all
right, then a change should not be made.
Dr. A. H. Reiswig: I know that at first some of the mem-
bers in our society were against joining up with the Cass County
Society, but some of them are now for it. What Dr. Darrow
brought up is correct; the members did not want to sponge on
other societies and wanted to carry their share of the burden.
If arrangements could be made whereby we could attend the
meetings and still have a society at home, we would like to
have this done.
Secretary Larson: No member of a large society should make
a member of a smaller society feel that he is sponging. We are
tickled to death here in Bismarck to have anyone attend from
any other society.
Speaker: The delegates from the small society certainly have
the floor of this assembly at their disposal. I am sure that they
would feel they have been adequately heard in the House. If
that point can be brought out, it would do much to solve this
problem.
Dr. C. R. Tompkins: I do not have the special problem at
this time but I do have the advantage of having been a mem-
ber of a smaller society, the Tri-County Society, and am a
member of a larger society, the Grand Forks Society, at this
time. I think I have a little insight into the way these men
feel about their situation. In the first place, the Tri-County
Medical Society always functioned very well, I thought, while
I was there. And, I want to say, that we were always made to
feel very welcome to attend the Devils Lake District Society
meetings at any time we were able to do so. I think that holds
good for all the societies. I think, too, that the local problems l
can better be handled by their own society; personally, I would
be in favor of having them consider rather seriously before unit-
ing with a larger society. They have all the privileges of the i
scientific meetings held in the larger societies, as they are always j
welcome without a special card being sent to them. I am sure
that holds good for all societies. I do not think this is the best I
time to consider redistricting societies. After the war, we might ;
have quite a change in the number and location of medical men
in the state. It may be that when these men come back from
war, there may be more in some of the smaller communities
and it may work out that four or five years from now, there
would be plenty of men in the local districts where they do not
have them now. I am sure it would be wise not to do too much
about it at the present time. Any man who would like to
attend any scientific meeting is very welcome to attend. I can
not see where redistricting the societies is going to make any
more or better scientific meetings, and because of the change in
the districts which might occur, it might be better not to do
the redistricting until later.
Remarks by the President
I have enjoyed the Session here with you. I know that things
have been very well thought out and worked out. The sugges-
tion that I have to make is that you take home these discus-
sions to your local societies and at the next district medical
meeting go over these matters with your district society, and
present to them the problems that have been presented here.
Only by careful thought and study by the individual societies
of reports of these groups, transmitted to the Central Associa-
tion, can we work out a suitable and economical problem for
this society. That is my Benediction.
Adjournment
On motion made by Dr. Waldschmidt, seconded by Dr.
Tompkins and carried, the House of Delegates adjourned sine
die at 11:15 A. M.
SPECIAL SESSION OF HOUSE OF DELEGATES
Monday, May 10, 1943
A special meeting of the House of Delegates was called by
the President of the Association, Dr. A. R. Sorenson. The
House was called to order by the Speaker at 12:55 P. M. in
the main dining room of the Patterson Hotel, Bismarck, North
Dakota.
The Secretary called the roll. Thirteen delegates responded
and the Speaker declared a quorum present. The following
delegates and alternates responded: Drs. C. C. Smith, Mandan;
C. R. Tompkins, Grafton; W. A. Wright, Williston; C. J.
Meredith, Valley City; W. W. Wood, Jamestown; W. E. G.
Lancaster, Fargo; A. P. Nachtwey, Dickinson; L. J. Seibel,
Harvey; R. T. O’Neill, Minot; R. FT Waldschmidt, Bismarck;
O. T. Benson, Glen Ullin; D. J. Halliday, Kenmare; A. H.
Reiswig, Wahpeton.
The Speaker announced that the purpose of the Special Ses-
sion was to receive a supplementary report of the Nominating
Committee, which was made necessary by a request from Gov-
ernor Moses, that six physicians be named as candidates for the
three vacancies on the State Board of Medical Examiners in-
stead of only three names as has been the usual custom.
Report of Nominating Committee
Dr. P. G. Arzt, chairman, presented the names of six nom-
inees for the three vacancies on the State Board of Medical Ex-
aminers, which will occur on July 1, 1943. They are: Drs. Paul
Rowe, Minot; G. M. Williamson, Grand Forks; W. A. Wright,
Williston; A. D. McCannel, Minot; C. J. Meredith, Valley
City; C. R. Tompkins, Grafton.
Dr. Waldschmidt moved the adoption of the Nominating
Committee Report. The motion was seconded by Dr. Halliday
and carried. The Special Session adjourned at 1:15 P. M.
August, 1943
241
SCIENTIFIC PROGRAM
Monday, May 10, 1943
1:00 P. M. — Colored Sound Movie, "Peptic Ulcer.”
2:00 — "Recent Advances in the Treatment of Hypertension,”
Dr. O. A. Sedlak, Fargo, North Dakota.
2:30 — "The Laboratory of the Physician and the Small Hos-
pital,” Dr. W. A. Wright, Williston, North Dakota.
3:00 — "The Roentgen Manifestations of Acute Abdominal Dis-
eases,” Dr. Leo Rigler, professor of radiology, Univer-
sity of Minnesota.
3:50 — "Sulfonamide Therapy in General Practice,” Dr. W. W.
Spink, associate professor of medicine, University of
Minnesota.
4:30 — "Herniation of the Intervertebral Disc,” Dr. William
Peyton, professor of surgery, University of Minnesota.
5:30 to 8:00 — Smoker and Smorgasbord Supper- — Exhibit Hall,
Memorial Building.
8:00 — "The Celiac Syndrome in Children,” Dr. R. E. Dyson,
Minot, North Dakota.
8:45 — "A Reconsideration of Focal Infection as a Cause of
Disease of the Eyes,” Dr. W. L. Benedict, Mayo Clinic,
Rochester, Minnesota.
9:30 — "Etiological Investigations in Dysphemia, and Its Symp-
tom (Stuttering),” Bryng Bryngelson, Ph.D., director
of speech clinic, University of Minnesota.
Tuesday, May 11, 1943
8:00 A. M. — Colored Movie, "Skin Grafting of War Wounds
and Observations on Wound Healing.”
9:00 — "Hemorrhagic Diathesis of the Newborn: Vitamin K
Prophylaxis and Therapy,” Dr. L. G. Pray, Fargo,
North Dakota.
9:30 — "Acute Pulmonary Lesions and Their Early Diagnosis,”
Dr. Leo Rigler, professor of radiology, University of
Minnesota.
10:15 — Presidential Address — Dr. A. R. Sorenson, Minot,
North Dakota.
10:30 — Intermission to visit Exhibits. Lunch served in Exhibit
Hall.
11:15 — Introduction of New President, Dr. Frank Darrow,
Fargo, North Dakota, and Installation.
11:20 — "Neuropsychiatric Emergencies,” Dr. P. K. Arzt, St.
Paul, Minnesota.
12:00 P. M. — "The Use of Small X-Ray Films in Tuberculosis
Case-Finding,” Dr. H. L. Hiebert, director of division
of tuberculosis control, State of Kansas.
1:00 — Round Table Luncheon — Hotel Patterson.
Subjects for Discussion: "Problems in Sulfonamide
Therapy,” Dr. W. W. Spink, leader; "Cranio-Cerebral
Injuries,” Dr. William Peyton, leader.
INSTALLATION OF PRESIDENT
Tuesday, May 11, 1943 — 11:15 A. M.
Dr. A. R. Sorenson: Gentlemen, at this time we have the
pleasure of inaugurating our new President, Dr. Frank Darrow.
If I am not mistaken, this is the first time in the annals of the
North Dakota Medical Association that there has been a father
and a son to hold the office of President. I will ask Dr. Ram-
stad and Dr. Williamson to escort Dr. Darrow to the platform.
Dr. Williamson: Dr. Sorenson, I am very happy to bring
Dr. Darrow to this position, and I hope, Dr. Darrow, that you
will enjoy your duties and I know the Association will benefit
by having you as President.
Dr. Frank Darrow: Thank you very much. It certainly is
a great pleasure for me to be in this position. I am afraid that
we can not have three generations of Darrows as President, be-
cause both my sons turned out to be daughters. However, I can
assure you, I will do all in my power to follow in the footsteps
of the illustrious predecessors in the office. I believe we can
now go on with the Scientific Program.
PRESIDENTIAL ADDRESS*
Dr. A. R. Sorenson
Minot, North Dakota
To the Members of the North Dakota State Medical
Association and Guests: I want to take this opportunity
to thank the Medical Association for the privilege of
heading the Association for one year. I assure you I have
enjoyed it very much and hope I have done some little
thing during my term of office on behalf of the Medical
Association. I would also like to thank the Sixth District
Society and the Committee on Arrangements for the
most splendid entertainment they have given us.
Since the last meeting of the North Dakota State
Medical Association, there has been a great change (up-
heaval) in the lives of all American people, due to the
rapid progress of the war efforts. This change is reflect-
ed in all the phases of our daily lives and in no phase
more than in the care and prevention of illness and in-
juries both in civilian and military life. Upon those of us
who are unfortunately unable to serve with the Armed
Forces, because of age or physical disability, will devolve
the added burdens of caring for the civilian population.
There can be no doubt but that these added burdens will
be arduous for many. However, I believe that every
doctor who remains in his post at home can justly regard
himself as an American soldier and, as such, will make
all the sacrifices and extend himself to the limit of his
powers to fulfill his duties when called upon to do so,
^Presented before the North Dakota State Medical Association,
Tuesday, May 11, 1943, 10:15 A. M.
just as the soldier in the field accepts his obligations even
to the sacrifice of his all.
What part North Dakota physicians have played in
answering their country’s call and what part must yet be
played by those remaining at home can best be realized
by giving a few statistics. At the outbreak of the war,
there were 460 medical doctors in North Dakota serving
approximately 300,000 people — a ratio of 1 to 800, which
was the ratio generally prevailing in the United States.
Of our number, 61 have enlisted in the Army or Navy,
leaving 400 to care for the civilian population. This
would not seem like a great change in ratio, but when
one considers that those who remain are mostly in the
advanced age group and some are handicapped by phys-
ical disability, notably that of cardiac origin, it can be
readily understood that many will have to accept added
responsibilities which will tax their physical powers to the
utmost. No one believes for a moment that any man
will shirk his duties. Undoubtedly, a few more men will
be called from our ranks, but, in view of the fact that
we have at this time exceeded our quota, it is not likely
that enough more will be taken to hamper us seriously.
On the brighter side of the picture, I can say that our
state is particularly fortunate in the distribution of its
medical and hospital facilities. I would like to go into
this in a little more detail, as I believe that it is necessary
242
The Journal-Lancet
for each one of us to be familiar with the picture, not
only for our own information but in order to answer
questions put to us by lay people and particularly to an-
swer the argument frequently put forth that, in view of
the so-called medical shortage, the bars be let down for
the cults. If you will call before your mind’s eye a pic-
ture of our state, I will give you a geographical distribu-
tion of its hospital facilities which, of necessity, includes
the medical facilities. Beginning in the northwest corner
and traveling the northern tier of counties, you will find
the following cities and towns provided with hospitals:
Williston, Ambrose, Noonan, Powers Lake, Kenmare,
Minot, Bottineau, Rolette, Rolla, Rugby, Devils Lake,
Grafton, Park River, and Grand Forks. Then in the
middle tier: Northwood, Carrington, New Rockford,
and Harvey. In the southern tier: Fargo, Wahpeton,
Valley City, Jamestown, Bismarck, Dickinson, and so
forth. You can see from this that medical and hospital
facilities are so strategically situated that no one need
suffer for want of medical care, with the possible excep-
tion of some counties in the Missouri Valley where two
counties with a combined population of 14,000 are with-
out a doctor. I mention this specific case, as it is being
used as an example of the inadequate medical care.
However, this situation is temporary — due to the illness
of the one doctor who, single-handed, served these people
for years. He expects to resume practice again. But
despite his absence, inquiry reveals that there has been
no great hardship worked upon the inhabitants, as autos
and good roads render it rather simple to transport the
ill to hospitals within easy driving distances. As a matter
of fact, a great number did this very thing even with a
practitioner in residence. Taking it all in all, our state is
in a very good medical position, and there is no need to
import alien physicians or to admit the cults and to prac-
tice indiscriminately. These are the points which I would
like to impress upon you, so that you may intelligently
combat adverse criticism of our profession.
Now what about conditions after the war. There are,
without question, plans being made by lay uplifters, to
govern the practice of medicine in the new order under
which we are expected to live and work. An appeal will
be made to the economic side of the population to estab-
lish a system of practice that will guarantee to everyone
medical and hospital care from the cradle to the grave at
nominal cost to the patient. Who will supplement the
costs is not stated, but it will be the well known taxpayer
who is already being ground to dust between the mill-
stones of extravagance above and idealogy below. We
must ever be on guard to protect our rights and preserve
a system which has given to the American people a med-
ical care superior to and in greater abundance than any
other country in the world. There must, of necessity, be
some changes, for as the times change, we must adapt
ourselves to new conditions, but this does not mean that
we must surrender our medical freedom and become
servants of a socialistic order. We will welcome ever-
changing methods for the advancement of medicine; we
will accept new orders of financial arrangements such as
hospital insurance and prepayments; but we will forever
hold fast to the idea that we are free men, who have
the right to live and work as we see fit within the limits
of precedents set down by our illustrious predecessors.
Furthermore, we should try to safeguard to the people,
the right of free choice of medical attendant, which we
all know by experience means so much to them and is
the very basis of our present mode of practice. The ful-
fillment of these aims should not be left to a handful of
chosen officers but should be accepted by each physician
as a personal responsibility. I urge each and everyone of
you to become students of the economic side of practice;
talk these matters over between yourselves and in your
society meetings; pass your thought on to your central
association; for only by free discussion and summed-up
results of good thinking, can we arrive at a solution of
these problems which will be fair to all concerned.
I want, particularly, at this time, to call to your atten-
tion the "National Physicians Committee for the Exten-
sion of Medical Service.” This committee is composed
of fellow physicians of the highest caliber, who are not
only devoting a great deal of time to the study of eco-
nomic problems as they affect us, but who are also doing
a great deal of actual practical work to preserve to us
the benefits of our present system of practice. I will read
to you extracts from their latest bulletin which will give
you some idea of what is being done:
"PROGRESS REPORT:
(a) Under war conditions, with food rationed and all busi-
ness and industry operating under strict priorities, medi-
cine has retained its autonomy and the right of self-
administration through Procurement and Assignment
Service.
(b) Continuous, intensive and systematic efforts of so-called
Social Planners' to enact Compulsory Health Insurance
legislation have been thwarted. No such legislation has
been enacted.
(c) The National Physicians’ Committee, through physician
and professional committees, in more than three hundred
ninety congressional districts, interviewed more than 800
congressional candidates prior to the election on Novem-
ber 3rd, 1942.
It is estimated that more than 300 congressmen out of
435 in the House of Representatives publicly pledged
themselves: (1) to preserve professional status for physi-
cians; (2) as unalterably opposed to compulsory health
insurance; (3) to avoid — at any cost — the sacrificing of
the sacred doctor-patient relationship.
Almost unbelievable progress has been made. We approach
a time of final determinations. The efforts of the National
Physicians’ Committee must be sustained and intensified. It
should have, at this time, the unqualified moral support of
and financial aid from every practicing physician.”
No doubt you have all been circularized by this com-
mittee, but I am afraid many of you have not fully ap-
preciated what it is doing. Therefore, I urge you to get
behind it and give it your financial support. If you have
not already contributed, do so at once. Send whatever
you can afford, be the sum large or small. You can
spend it in no more useful cause.
This struggle will be carried on for many years to
come, well past the time that some of us older members
will be in the fray — so to you younger men who will
follow us — may I quote from the immortal poem "In
Flanders Fields” these words:
To you from falling hands we throw the torch —
Be yours to hold it high.
August, 1943
243
NORTH DAKOTA STATE MEDICAL ASSOCIATION
ROSTER-- 1943
MEMBERSHIP BY DISTRICTS
PRESIDENT
W. E. G. Lancaster ..
Fargo
SECRETARY-TREASURER
L. A. Nash
Fargo
Bacheller, S. C.
Enderlin
Baillie, W. F.
Fargo
Boerth, E. H.
_ Buffalo
Bond, J. H.
Fargo
Borland, V. G.
. Fargo
★ Burt, A. C.
Fargo
Burton, P. H.
Fargo
★Clark, I. D. Jr.
Casselton
Clay, A. J.
Fargo
★ Darner, C. B.
Fargo
Darrow, F. I.
Fargo
Darrow, Kent
Fargo
DeCesare, F. A.
Fargo
★ Dillard, J. R. ....
Fargo
★ Elofson, C E.
Fargo
Fjelde, J. H.
Fargo
Fortin, H. J.
Fargo
★Fortney, A. C.
Fargo
CASS COUNTY MEDICAL SOCIETY
★Geib, J. M. Fargo
Gronvold, F. O. Fargo
Hanna, J. F. .... _ Fargo
Haugen, H. ... Fargo
★Haugrud, E. M. Fargo
★Hawn, H. W. Fargo
★Haynes, G. H. Lisbon
Hendrickson, G. _. Enderlin
Hunter, G. W. __ _ Fargo
Huntley, H. B. Kindred
★Ivers, G. U. .... Fargo
James J. B. Page
Joistad, A. H. Fargo
Kaess, A. J. Fargo
Klein, A. L. Fargo
Lancaster, W. E. G. Fargo
Larson, G. A. Fargo
Lewis, T. H. Fargo
Limburg, A. M. Fargo
Long, W. H. Fargo
Mazur, B. A. Fargo
Miller, H. W. Casselton
Morris, A. C. Fargo
Nash, L. A. Fargo
Nichols, A. A. ...
Fargo
Nichols, W. C. ..
.... Fargo
Oftedal, Axel
Fargo
Oftedal, Trygve
Fargo
Ostfield, J. R.
Fargo
Patterson, T. C.
Lisbon
Pray, L. G.
Fargo
Richter, E. H
Hunter
Rostel, H. R.
Fargo
Sand, O
Fargo
★Schatz, George
Fargo
Sedlak, O. A.
Fargo
★Sinner, B. L.
Fargo
Skarshaug, H. J. ....
Washburn
★Skelsey, A. W. ____
Fargo
Stafne, Wm. ...
Fargo
Stolinsky, A.
Boise, Idaho
Swanson, J. C.
Fargo
Tainter, Rolfe ...
Fargo
Tronnes, N. L.
Fargo
Urenn, B. M.
Fargo
Watson, E. M. ....
Fargo
★ Weible, R. D. ...
Fargo
Winn, W. R.
._ Fargo
KOTANA MEDICAL SOCIETY
PRESIDENT
AbPIanalp, I. S.
Williston
Jones, Carlos S.
Williston
Craven, John P.
Williston
Korwin, Justin J. ....
Williston
Joseph D. Craven
.... Williston
Craven, Joseph D. _
Williston
Lund, Carroll M.
Williston
Dockterman, L. B.
Williston
Skovholt, H. T.
Williston
SECRETARY-TREASURER
★Johnson, M. H. D.
Watford City
Wright, Wm. A.
Williston
C. M. Lund
Williston
Johnson, P. O. C.
Watford City
NORTHWEST DISTRICT
MEDICAL SOCIETY
PRESIDENT
★ Fischer, V. J.
Towner
Knudson, K. O.
Glenburn
Minot
Flath, M. G.
Stanley
Lampert, M. T.
★ Fulton, A. M.
Minot
LeMieux D.
Rolla
SECRETARY -TREASURER
Gammell, R. T
Kenmare
Malvey, Kenneth
Bottineau
Woodrow Nelson
. .... Minot
★Garrison, M. W.
Minot
McCannel, A. D.
Minot
★ Gerber, Louis D.
Stanley
Moffat, George
Crosby
★ Beck, Charles
Harvey
Goodman, Robert
Powers Lake
Moreland, J W. ....
Carpio
Baltherwick, W. E.
. Van Hook
Grangaard, H. O. ...
Ryder
Nelson, Leslie F.
Bottineau
__ .... Minot
Greene, E. E.
Westhope
Nelson, Woodrow
Brunner, Harmon
Minot
★Halverson, Clayton
H Minot
O’Neill, R. T. .....
Minot
Cameron, A. L.
Minot
Halverson, H. L. ....
Minot
★ Parnall, Edward
.. Minot
Minot
Halliday, D. J.
Kenmare
Pence, R. W.
Carr, Andy
Minot
Hammargren, A. F.
. Harvey
Ransom, E. M. .
Minot
Carr, A. M., Sr. . .
Minot
Hanson, George C. .
... Minot
Ray, R. H.
Craise, O. S.
Towner
Haraldson, O. ....
Minot
Rollie, C. O.
Drake
★Cronin, D. J. .
Minot
Ittkin, Paul
.... .... Mohall
Rowe, Paul H. ..
Minot
★ Devine, J. L , Jr.
Minot
Johns, S. M Long Beach, Calif.
Sorenson, A. R.
Minot
Devine, J. I . Sr
._ Minot
★Johnson, C. G. ....
Rugby
★Stone, Oral H.
Bottineau
★ Downing, W. M.
Minot
Johnson, J. A
Bottineau
Timm, John F
Makoti
★Durnin, W. G.
Bottineau
Johnson, O. W.
Rugby
Wall, W. W. ..
Minot
Dyson, R. E.
Minot
Kaufmann, Mark I.
H. Velva
Wall bank, W. L.
.. San Haven
Erenfeld, F. R.
Minot
Kelsey, C. M.
Minot
Woodhull, Robert B.
Minot
Erenfeld, H. M. .... ...
Minot
Kermott, L. H.
Minot
Yeomans, T. N.
Minot
DEVILS LAKE MEDICAL SOCIETY
PRESIDENT
Fawcett, J. C.
... Devils Lake
McDonald, J. A.
Cando
J. D. Graham
Devils Lake
Fawcett, N. W.
— Devils Lake
McIntosh, G. J.
.. Devils Lake
SECRETARY-TREASURER
J. C. Fawcett Devils Lake
Call, A. M Rugby
dayman, S. G San Haven
Drew, G. J Devils Lake
Engesather, J. A. D. Brocket
★Fawcett, D. W. Devils Lake
Fox, W. R. Rugby
Graham, J. D. Devils Lake
★Greengard, Milton Rolla
Horsman, A. T. Devils Lake
Hughes, Bernard ... Rolla
★Keller, E. T Rugby
Kohlmeyer, F. C Lakota
Mattson, R. H McVille
McKeague, D. H. Maddock
★ Reed, Paul Rolette
Serhus, L. N. Rolette
Sihler, W. F Devils Lake
Smith, Clinton Devils Lake
Stickelberger, J. S Oberon
Toomey, G. W. Devils Lake
Vigeland, J. G. Brinsmade
244
The Journal-Lancet
GRAND
FORKS DISTRICT
MEDICAL SOCIETY
PRESIDENT
★Griffin, Vernon
Grand Forks
★ Ransom, Robert
Grand Forks
T. Q. Benson
Grand Forks
Grinnell, E. L.
Grand Forks
★ Robertson, Frank
Grand Forks
SECRETARY-TREASURER
Goehl, R. O.
Grand Forks
Ruud, M. B.
Grand Forks
Haagenson, E. C.
Grand Forks
Ruud, H. O
Grand Forks
Walter C. Dailey
Grand Forks
Hardy, N. A.
Minto
Rystad, O. H.
Grand Forks
Haugen, C. O.
Larimore
★Silverman, Louis
Grand Forks
Alger, L. J.
Grand Forks
Hetherington, J. E.
Grand Forks
St. Clair, Robert
Northwood
Bartle, J. P.
Langdon
Irvine, V. S. ....
— Park River
Stratte, J. J.
Grand Forks
Benson, T. Q.
Grand Forks
Jenson, A. F. ....
Grand Forks
Thorgrimson, G. G.
Grand Forks
Benwell, H. D.
Grand Forks
LaMont, J. A.
Grafton
Tompkins, C. R.
Grafton
★ Brown, Gerald
Grand Forks
Landry, L H.
Walhalla
Vance, R. W. ...
Grand Forks
Burrows, F. N.
Bathgate
Law, H W. F.
Grand Forks
★ Veitch, Abner
Cavalier
Campbell, R. D.
Grand Forks
Leigh, R. E. ...
Grand Forks
★ Vollmer, Fredrick
Grand Forks
★Canterbury, E. A. ...
Grand Forks
Liebeler, W. A
Grand Forks
Wagar, W. D.
Michigan
Caveny, K. P.
Langdon
Lohrbauer, L. T.
Grand Forks
Waldren, Geo. ... .
Cavalier
Countryman, G. L.
Grafton
Lommen, Clarence ...
Fordville
Waldren, H. M., Jr.
Drayton
Dailey, W. C. ....
Grand Forks
★Mahowald, R.
Grand Forks
Waldren, H. M., Sr.
Drayton
Deason, F. W.
Grafton
Moore, J. H.
Grand Forks
Weed, F. E. ..
Park River
Field, A. B.
Forrest River
Mulligan, V. A. .. .
Langdon
Welch, W. H.
Larimore
Flaten, A. N. ....
Edinburg
Muus, O. H.
Grand Forks
Williamson, G. M. __
Grand Forks
French, H. E.
Grand Forks
Panek, A. F.
Milton
Witherstine, W. H.
Grand Forks
Glaspel, C. J
Grafton
Peake, Margaret
Grand Forks
Wold, Howard
Grafton
Glaspel, G. W.
.... Grafton
Quale, V. S.
Grand Forks
Woutat, P. H.
Grand Forks
Grassick, James
Grafton
Rand, Charles
Grafton
Youngs, Nelson A. _.
Grand Forks
RICHLAND COUNTY MEDICAL SOCIETY
Bateman, C. B. ....
.... Wahpeton
Olson, C. T.
. Wyndemere
PRESIDENT
Beithon, E. J.
Hankinson
Quick, J. V.
Wahpeton
I. W. Kellogg
Fairmount
★ Hoskins, H. J.
... Wahpeton
Reiswig, A. H. ...
Wahpeton
Kellogg, I. W.
.... Fairmount
Sasse, E. G.
Lidgerwood
SECRETARY-TREASURER
Miller, H. H.
Wahpeton
Thompson, Andrew
Wahpeton
A. H. Reiswig
Wahpeton
★O’Brien, Louis ...
Wahpeton
SHEYENNE VALLEY MEDICAL SOCIETY
PRESIDENT
Brown, Fred ...
. Valley City
Nesse, S. A.
Nome
Wm. Campbell
Valley City
Campbell, Wm.
Valley City
Platou, C. A. ...
Valley City
★Cook, Paul T.
. Valley City
Sederlin, E. L.
. Valley City
SECRETARY-TREASURER
★ Dodds, G. Alfred .
__ Valley City
Van Houten, J.
.. Valley City
C. J. Meredith
_ Valley City
Macdonald, A. C.
. Valley City
Westley, M. D.
Cooperstown
Macdonald, A. W
_ Valley City
Wicks, Fred L.
. Valley City
Almklov, L.
Cooperstown
Meredith, C J
_ Valley City
PRESIDENT
R. H. Waldschmidt Bismarck
SECRET ARY-TREASURER
W. B. Pierce Bismarck
★Arneson, C. A. Bismarck
Arnson, J. O. Bismarck
Baer, DeWitt Steele
Barrette, J. H. Wishek
Barthell, J. H. Hazen
Baumgartner, C. A. Bismarck
Benson, O. T. Glen Ullin
Berg, H. M. Bismarck
Bertheau, H. J. Linton
Bixby, Harriet- Middletown, Conn.
Bodenstab, W. H. Bismarck
Brandes, H. A Bismarck
Brandt, A. M. Bismarck
Breslin, R. H. Mandan
Brink, N. O Bismarck
Buskingham, T. W. Bismarck
Constans, G. M. Bismarck
DeMoully, O. M. Flasher
Diven, W. L. Bismarck
PRESIDENT
George Holt .... Jamestown
SECRETARY-TREASURER
E. J. Larson Jamestown
Artz, P. G Jamestown
Carpenter, G. S. Jamestown
★Christianson, H. A — Jamestown
SIXTH DISTRICT MEDICAL SOCIETY
★D river, D. R Bismarck
Fredricks, L. H. Bismarck
Freise, P. W. Bismarck
Gaebe, O. C. New Salem
Griebenow, F. Bismarck
Grorud, A. C. Bismarck
Heffron, M. M. Bismarck
Heinzeroth, George . Turtle Lake
★Henderson, R. W. Bismarck
Hetzler, A. E. Mandan
Hill, F. J. Bismarck
Jacobson, M. S. Elgin
Larson, L. W. Bismarck
LaRose, V. J. Bismarck
Leavitt, R. H. Kenmare
Linker, K. R. E. Bismarck
Lipp, G. R. Bismarck
McReynolds, C. E. Strasburg
Monteith, George Hazelton
Moyer, L. B. Bismarck
Nickerson, B. S. Mandan
★Nuessle, R. F Bismarck
Orr, August C. Bismarck
Owens, P. L. Bismarck
Perrin, E. D. Bismarck
STUTSMAN COUNTY SOCIETY
Culbert, M. H Medina
Depuy, T. L Jamestown
Fisher, A. M. Jamestown
Gerrish, Wm Jamestown
Gronewald, T. M. Jamestown
Holt, George Jamestown
Larson, E. J. Jamestown
Longstreth, E. H. Kensal
Pierce, W. B. Bismarck
Quain, E. P. Eugene, Ore.
Quain, F. D. ____ „ Bismarck
★ Radi, R. B. Bismarck
Ramstad, N. O. Bismarck
Rice, P. F. Solen
Roan, M. W. Bismarck
Rosenberger, H. P. .. Bismarck
Schoregge, C. W. Bismarck
Smith, C. C. Mandan
Solomone, E. J. Elgin
Soules, Mary E. Bismarck
Spielman, George Mandan
Strauss, F. B. Bismarck
★Swingle, A. J. Mandan
Thompson, R. C. Wilton
Vinje, E. G. Beulah
★Vinje, Ralph Beulah
Vonnegut, F. F. Hague
Waldschmidt, R. H. Bismarck
Weyrens, P. J. Hebron
Wheeler, H. A. Mandan
White, R. G. Bismarck
★Williams, Mark Linton
★Nierling, R. D. Jamestown
Peake, Francis Jamestown
Robertson, C. W. Jamestown
Rollefson, C. I Jamestown
★Roth, J. H Jamestown
Sorkness, Joseph Jamestown
Wood, W. W Jamestown
Woodward, F. O. Jamestown
1
August, 1943
245
PRESIDENT
H. A. LaFleur Mayville
SECRETARY-TREASURER
Syver Vinje Hillsboro
PRESIDENT
E. J. Schwinghamer New Rockford
SECRETARY-TREASURER
M. J. Moore ... New Rockford
TRAILL-STEELE MEDICAL SOCIETY
Christianson, G. C. Sharon
Cuthbert, W. H. Hillsboro
Dekker, Omar D. Finley
Kjelland, A. A. Hatton
Knutson, O. A. .... Buxton
TRICOUNTY MEDICAL SOCIETY
★ Beck, Charles Harvey
Boyum, P. A. Harvey
Donker, A. E. Carrington
Ford, F. W. New Rockford
MacLachlan, Charles New Rockford
Matthaei, D. W. Fessenden
SOUTHERN DISTRICT SOCIETY
LaFleur, H. A. Mayville
Little, R. C. Mayville
Savre, M. T. Northwood
Vinje, Syver Hillsboro
Meadows, R. W. Carrington
Moore, M. J. ... .... New Rockford
Schwinghamer, E. J. New Rockford
Seibel, L. J. Harvey
Van de Erve, H. Carrington
Westervelt, A. E. Bowdon
PRESIDENT
Fergusson, F. W. ..
.... Kulm
★Miller, Samuel
Ellendale
F E. Wolfe
Oakes
Fergusson, V. D.
Edgley
★ Mitchell, George
Milnor
Lynde, Roy
Ellendale
Van Houten, R. W. ...
Oakes
SECRETARY-TREASURER
Merrett, J. P. ....
LaMoure
Wolfe, F. E.
Oakes
H. J. Meunier
Oakes
Meunier, H. J.
Oakes
SOUTHWESTERN DISTRICT SOCIETY
PRESIDENT
Dukart, C. R.
Richardton
Maercklein, O. C.
Mott
Oscar Smith ...
Killdeer
^Gilsdorf, A. R.
Murray, K. M.
Scranton
SECRETARY-TREASURER
Gilsdorf, W. H.
New England
Nachtwey, A. P.
... Dickinson
H. L. Reichert ...
Dickinson
Guloien, Hans E
Dickinson
Olesky, E.
Mott
★Gumper, A. J.
Dickinson
Reichert, H L. ...
Dickinson
Bloedau, E. L.
.... Bowman
Gumper, J. B.
Belfield
Rodgers, R. W.
Dickinson
Bowen, J. W.
. Dickinson
Hill, S. W. .... .....
Regent
Schumacher, N. W. ...
... Hettinger
Chernausek, S. ....
Dickinson
Linsin, Ivan
Killdeer
Dach, J. L. ...
Hettinger
Lyons, M. W.
.... Minneapolis
Spear, A. E. ...
Dickinson
★ In Military Service.
•
ROSTER
North Dakota State Medical Association-- 1943
AbPlanalp, Ira S. Williston
Alger, L. J. Grand Forks
Almklov, L. .... Cooperstown
Arneson, Chas. A. Ayer, Mass.
Arnson, J. O. Bismarck
Arzt, Philip G. ... Jamestown
Bacheller, Stephen Enderlin
Baer, DeWitt Steele
Baillie, W. F. Fargo
Barrette, J. H Wishek
Barthell, J. H. Hazen
Bartle, J. P. Langdon
Bateman, C. V. Wahpeton
Baumgartner, Carl Bismarck
Beck, Charles Harvey
Beithon, E. J. Hankinson
Benson, O. T. Glen Ullin
Benson, T. Q. Grand Forks
Benwell, H. D. Grand Forks
Berg, H. M. Bismarck
Bertheau, H. J. Linton
Bixby, Harriet Middletown, Conn.
Blatherwick, Wilfred E. Van Hook
Bloedau, E. L. .... .... .. Bowman
Bodenstab, VCL H Bismarck
Boerth, E. H. Buffalo
Bond, John Harvey .... .. Fargo
Borland, V. G. Fargo
j Bowen, J. W. Dickinson
Boyum, P. A. Harvey
Brandes, H. A. Bismarck
Brandt, Albert M. Bismarck
Breslich, Paul J. Minot
Breslin, R. H. Mandan
Brink, Norvel O. Bismarck
Brown, Fred Valley City
Brown, Gerald F Grand Forks
Brunner, Harmon Minot
Buckingham, T. W. .. Bismarck
Burrows, F. N. Bathgate
Burt, A. C. ._ Fargo
Burton, Paul H. Fargo
Call, A. M. — Rugby
Cameron, A. L. Minot
Campbell, R. D. .... Grand Forks
Campbell, William Valley City
Canterbury, E. A. Grand Forks
Carlson, H. A. Minot
Carpenter, G. S. Jamestown
Carr, A. M., Sr. Minot
Carr, Andy Minot
Caveny, K. P. Langdon
Chernausek, S. Dickinson
Christianson, Gunder .... Sharon
Christiansen, H. A. Jamestown
Clark, Ira D., Jr. Casselton
Clay, Albert James Fargo
dayman, Sidney ... San Haven
Constans, George M. Bismarck
Cook, Paul T. Valley City
Countryman, G. L. Grafton
Craise, O. S. Towner
Craven, J. P Williston
Craven, Joe D. Williston
Cronin, Donald J. Minot
Culbert, M. H. Medina
Cuthbert, William H. .. Hillsboro
Dach, John L. ... Hettinger
Dailey, Walter C. Grand Forks
Darner, C. B. Fargo
Darrow, Frank I. Fargo
Darrow, Kent Edward Fargo
Deason, Frank W. Grafton
DeCesare, F. A. Fargo
Dekker, Omar D. Finley
DeMoulIy, Oliver M. Flasher
DePuy, T. L. Jamestown
Devine, J. L., Jr. Minot
Devine, J. L., Sr. Minot
Dillard, J. R. Fargo
Diven, W. L. Bismarck
Dochterman, L. B. Williston
Dodds, G. A Valley City
Donker, Adrian E. Carrington
Downing, W. M. Minot
Drew, G. F. Devils Lake
Driver, Donn R. Bismarck
Dukart, C. R. Richardton
Durnin, W. G. Bottineau
Dyson, Ralph E. Minot
Elofson, Carl E. Fargo
Engesather, J. A. D Brocket
Erenfeld, F. R. .... Minot
Erenfeld, Harris M. Minot
Fawcett, D. W. Devils Lake
Fawcett, J. C. Devils Lake
Fawcett, Newton W Devils Lake
Fergusson, F. W. . Kulm
Fergusson, V. D. Edgeley
Fields, A. B. Forrest River
Fischer, V. J. .... Towner
Fisher, Albert M. Jamestown
Fjelde, J. H. Fargo
Flaten, A. N. Edinburg
Flath, M. G. Stanley
Ford, F. W. New Rockford
Fortin, Harry J. Fargo
Fortney, A. C. Fargo
Fox, W. R. Rugby
Fredricks, L. H. Bismarck
Freise, P. W. Bismarck
French, H. E. Grand Forks
Fulton, A. M. Minot
Gaebe, O. C. New Salem
Gammell, R. T. Kenmare
Garrison, M. W Minot
Geib, M. J. Fargo
Gerber, L. S Crosby
Gerrish, W. A. Jamestown
Gilsdorf, A. R. Dickinson
246
The Journal-Lancet
Gilsdorf, Walter H. New England
Glaspel, C. J. Grafton
Glaspel, G. W. .. Grafton
Goehl, R. O. Grand Forks
Goodman, Robert Powers Lake
Graham, J. D. Devils Lake
Grangaard, Henry O. Ryder
Grassick, James Grand Forks
Greene, E. E. .... Westhope
Greengard, M. _ Rolla
Griebenow, Frederick Bismarck
Griffin, V. M. Grand Forks
Grinnell, E. L. Grand Forks
Gronewald, T. VCL .Jamestown
Gronevold, F. O. Fargo
Grorud, Alton C. ... Bismarck
Guloien, Hans E. Dickinson
Gumper, A. J. Dickinson
Gumper, J. B. .. .. Belfield
Haagensen, E. C. Grand Forks
Halliday, D. J. Kenmare
Halverson, C. H. ........ Minot
Halverson, Henry L. Minot
Hammargren, A. F. ... ... Harvey
Hanna, J. F. Fargo
Hanson, Geo. C. ... . Minot
Haraldson, O. . Minot
Hardy, N. A. Minto
Haugen, C. O. ... Larimore
Haugen, H. .. Fargo
Haugrud, Earl M. Fargo
Hawn, Hugh Fargo
Haynes, G. H. Lisbon
Heffron, M. M. ... .... ... Bismarck
Heinzeroth, Geo. E._ Turtle Lake
Henderson, R. W. Bismarck
Hendrickson, G. .... Enderlin
Hetherington, J. E.._ Grand Forks
Hetzler, A. E. Mandan
Hill, F. J. Bismarck
Hill, S. W. ._ Regent
Holt, George H. ... Jamestown
Horsman, A. T Devils Lake
Hoskins, J. H. Wahpeton
Hughes, Bernard J. Rolla
Hunter, G. Wilson ... Fargo
Huntley, H. B. Kindred
Irvine, Vincent S. Park River
Ittkin, Paul .... Mohall
Ivers, G. U. Fargo
Jacobson, M. S. Elgin
James, J. B. page
Jensen, August F. — Grand Forks
Johns, Stephen M.
Huntington Park, Calif.
Johnson, C. G. ..... _ Rugby
Johnson, J. A. Bottineau
Johnson, M. H. D.. . Watford City
Johnson, O. W. Rugby
Johnson, P. O. C Watford City
Joistad, A. H. Fargo
Jones, Carlos S. Williston
Kaess, A. J Fargo
Kaufman, M. I. H. Velva
Keller, E. T. Rugby
Kellogg, I. W. Fai rmount
Kelsey, C. M. Minot
Kermott, Louis H. Minot
Kjelland, Andrew A Hatton
Klein, A. L. Fargo
Knudson, K. O. Glenburn
Knutson, O. A. Buxton
Kohlmeyer, F. C. Lakota
Korwin, J. J. Williston
LaFleur, H. A. Mayville
LaMont, John G. Grafton
Lampert, M. T. .. Minot
Lancaster, W. E. G. Fargo
Landry, L. H. ... Walhalla
Larson, E. J. Jamestown
Larson, G. A. .... Fargo
Larson, Leonard W. Bismarck
LaRose, Victor J. ... Bismarck
Law, H. W. F. Grand Forks
Leavitt, R. H. Los Angeles, Calif.
Leigh, R. E. ... Grand Forks
Lemieux, Darie Rolla
Lewis, T. H. .. _ Fargo
Liebeler, W. A. .. Grand Forks
Limburg, Albert M. Fargo
Linker, K. R. E. Bismarck
Linsin, Ivan . Elbowoods
Lipp, Geo. R. Bismarck
Little, R. C. ... Mayville
Lohrbauer, L. T. Grand Forks
Lommen, Clarence E Fordville
Long, W. H. .. __ Fargo
Longstreth, W. E. Kensal
Lund, C. M. Williston
Lyons, M. W. _ Beach
Lynde, Roy Ellendale
McCannel, Archibald D. Minot
McIntosh, G. J. . Devils Lake
McKeague, D. H. . Maddock
McReynolds, C. E. .... Strasburg
Macdonald, A. C. .... Valley City
Macdonald, A. W Valley City
Macdonald, J. A . . Cando
MacLachlan, Chas. New Rockford
Maercklein, O. C. Mott
Mahowald, R. E. Grand Forks
Malvey, Kenneth Bottineau
Matthaei, D. W. Fessenden
Mattson, Roger H. McVille
Mazur, B. A. Fargo
Meadows, R. W. Carrington
Meredith, C. J. Valley City
Merrett, J. P. Marion
Meunier, H. J. ... Oakes
Miller, FI. H. Wahpeton
Miller, H. W. ..... Casselton
Miller, Samuel Ellendale
Mitchell, George Milnor
Moffat, George Crosby
Monteith, George Hazelton
Moore, John H. Grand Forks
Moore, M. J. New Rockford
Moreland, J. W. . Carpio
Morris, Arthur C. Fargo
Moyer, L. B. Bismarck
Mulligan, V. A. Langdon
Murray, K. M. Scranton
Muus, O. H. Grand Forks
Nachtwey, A. P. Dickinson
Nash, Leo A. Fargo
Nelson, L. F. Bottineau
Nelson, Woodrow Minot
Nesse, S. A Nome
Nichols, Arthur A. Fargo
Nichols, Wm. C. Fargo
Nickerson, Bernard S Mandan
Nierling, R. D. __ _ Jamestown
Nuessle, Robert F. Bismarck
O’Brien, L. T. Wahpeton
Oftedal, Axel Fargo
Oftedal, Trygve .... Fargo
Olesky, E. Mott
Olson, C. T. Wyndmere
O’Neill, R. T. Minot
Orr, August C. Bismarck
Ostfield, J. R. Fargo
Owens, P. L Bismarck
Panek, A. F.
- Milton
Parnall, Edward
Minot
Patterson, T. C.
Lisbon
Peake, Francis M.
Jamestown
Peake, Margaret F.
Grand Forks
Pence, R. W.
... Minot
Perrin, E. D.
Bismarck
Pierce, W. B.
Bismarck
Platou, C. A.
Valley City
Pray, L. G.
Fargo
Quick, Jacques V.
Wahpeton
Quain, E. P.
Eugene, Ore.
Quain, Fannie Dun
Bismarck
Quale, V. S. ..
Grand Forks
Radi, Robert B.
Bismarck
Ramstad, N. O.
Bismarck
Rand, C. C.
Grafton
Ransom, E. M.
Minot
Ransom, H. R.
Grand Forks
Ray, R. H
Garrison
Reed, Paul
Rolla
Reichert, H. L. ....
Dickinson
Reiswig, A. H.
Wahpeton
Rice, Paul F.
Solen
Richter, E. H.
Hunter
Roan, Martin Wm...
Bismarck
Robertson, C. W. ....
Jamestown
Robertson, F. O
East Grand
Forks, Minn.
Rodgers, Robt. W. ...
Dickinson
Rollefson, C. I.
Jamestown
Rollie, C. O.
Drake
Rosenberger, H. P
Bismarck
Rostel, Hugo
Fargo
Roth, J. H.
... Jamestown
Rowe, P. H.
Minot
Ruud, H. O.
Grand Forks
Ruud, M. B.
Grand Forks
Rystad, Olaf H. ...
Grand Forks
Sand, Olaf
Fargo
Sasse, Ernest G.
Lidgerwood
Savre, M. T.
Northwood
Schatz, George
. West Fargo
Schoregge, C. W. ...
Bismarck
Schumacher, N. W.
Hettinger
Schwinghamer, E. J.
New Rockford
Sederlin, E. L
Fargo
Sedlak, Oliver A. ...
Fargo
Seibel, L. J.
Harvey
Serhus, L. N.
Rolette
Sihler, W. F.
Devils Lake
Silverman, Louis
Grand Forks
Sinner, Bernard L. _.
Fargo
Skarshaug, H. J.
Washburn
Skelsey, Albert Wesley Fargo
Skovholt, H. T.
Williston
Smith, Cecil C.
Mandan
Smith, Clinton
.. Devils Lake
Smith, Oscar M.
Killdeer
Solomone, E. J.
Elgin
Sorenson, A. R.
Minot
Sorkness, Joseph
.... Jamestown
Soules, Mary E.
Boston, Mass.
Spear, A. E.
Dickinson
Spielman, George H.
Mandan
Stafne, Wm.
.. . Fargo
Stickelberger, Josephine S.-.Oberon
St. Clair, Robert T...
.. Northwood
Stolinsky, A. _
Boise, Idaho
Stone, Oral H., Jr.._.
...Bottineau
Stratte, Jos. J.
Grand Forks
Strauss, F. B.
Bismarck
Swanson, J. C. Fargo
Swingle, Alvin J. Mandan
Tainter, Rolfe Fargo
Thompson, Andrew M. ..Wahpeton
247
August, 1943
Thompson, Roy C.
Wilton
Thorgrimson, G. G.
Grand Forks
Timm, John F.
Makoti
Tompkins, C. R.
Grafton
Toomey, G. W.
Devils Lake
Tronnes, Nels
Fargo
Urenn, B. M. .
Fargo
Vance, R. W
Grand Forks
Van De Erve, Herbert. Carrington
Van Houten, J.
. Valley City
Van Houten, R. W.
Oakes
Veitch, Abner ....
_ Cavalier
Vigeland, J. G.
Brinsmade
Vinje, Edmund G.
Beulah
Vinje, Ralph
Beulah
Vinje, Syver
Hillsboro
NORTH
Arneson, Charles A.
Bismarck
Beck, Charles
Harvey
Brown, G. F . .
Grand Forks
Burt, A. C. ...
Fargo
Canterbury, h. A
Grand Forks
Christianson, H. A.
..Jamestown
Clark, Ira D. Jr. ....
Casselton
Cook, Paul T.
. Valley City
Cronin, Donald J.
Minot
Darner, C. B.
Fargo
Devine, J . L. Jr. ...
. Minot
Dillard, J . R. __
Fargo
Dodds, G. A.
. Valley City
Downing, W. M.
.... . Minot
Driver, Donn R
Bismarck
Durnin, W. G.
Bottineau
Elofson, C. E.
Fawcett, D. W.
Fargo
Devils Lake
Fischer, V. J.
Fortney, A. C
. Towner
Fargo
Fulton, A. M.
Minot
Vollmer, Frederick J . Grand Forks
Vonnegut, Felix F. .... Hague
Wagar, Wm. D. __ Michigan
Waldren. G. R. Cavalier
Waldren, Henry M., Jr Drayton
Waldren, Henry M., Sr Drayton
Waldschmidt, R. H. Bismarck
Wall, Willard W. ... Minot
Wallbank, W. L. San Haven
Watson, H. M. Fargo
Weed, F. E. Park River
Weible, Ralph Darrow Fargo
Welch, W. F. ... ... .. Larimore
Westervelt, A. E. Bowdon
Westley, Martin D. Cooperstown
Weyrens, Peter J. ... Hebron
DAKOTA PHYSICIANS IN MILITARY
Garrison, M. W. Minot
Geib, M. J. West Fargo
Gerber, L. S. Crosby
Gilsdorf, A. R. Dickinson
Greengard, M. ... Rolla
Griffin, V. M. Grand Forks
Gumper, A. J. Dickinson
Halverson, C. H. Minot
Haugrud, Earl M. Fargo
Hawn, Hugh W. Fargo
Haynes, G. H. Lisbon
Henderson, R. W. ... Bismarck
Hoskins, J. H. __ Wahpeton
Ivers, G. U. Fargo
Johnson, C. G. Rugby
Johnson, M. H. D Watford City
Keller, E. T. Rugby
Mahowald, R. E. .... Grand Forks
Miller, Samuel Ellendale
Mitchell, George Milnor
Nierling, R. D. Jamestown
Wheeler, H. A. __ Mandan
White, Robert G. Valley City
Wicks, F. L. Valley City
Williams, Mark F. Linton
Williamson, Geo. M. Grand Forks
Winn, W. R. Fargo
Witherstine, W. H Grand Forks
Wold, H. R. Grafton
Wolfe, F. E Oakes
Wood, Wm. W. Jamestown
Woodhull, Robert B. Minot
Woodward, F. O. Jamestown
Woutat, P. H. Grand Forks
Wright, W. A. Williston
Yeomans, T. N. ... ... Minot
Youngs, Nelson A Grand Forks
SERVICE
Nuessle, Robert F. Bismarck
O’Brien, L. T. Wahpeton
Parnall, Edward Minot
Radi, R. B. Bismarck
Ransom, H. R. Grand Forks
Reed, Paul Rolette
Robertson, F. O. East Grand Forks
Roth, J. H. Jamestown
Schatz, George West Fargo
Sigurdsson, J. O. West Fargo
Silverman, Louis Grand Forks
Sinner, Bernard L. Fargo
Skelsey, A. W. Fargo
Stone, Oral H. Jr. .... Bottineau
Swingle, Alvin J. Mandan
Veitch, Abner Cavalier
Vinje, Ralph Beulah
Vollmer, Frederick . Grand Forks
Weible, Ralph D. Fargo
Williams, M. F Linton
Epidemic Encephalitis in North Dakota and
Minnesota 1941*
Studies on Etiology, Epidemiology and Serum Treatment
Edward C. Rosenow, M.D.f
Hayes W. Caldwell, M.D.j:
Rochester, Minnesota
IN previous studies1,2,3 of epidemic and endemic4
encephalitis and of epidemic encephalomyelitis in
horses,'1 we have isolated consistently, by special meth-
ods,6 alpha or green-producing streptococci that mani-
fested specific affinity for the nervous system of inocu-
lated animals.
Antiserums prepared with streptococci isolated in these
studies were found to be of distinct value in the treat-
ment of epidemic and endemic encephalitis, 2,7,8,9,1° and
epidemic encephalomyelitis in horses.11 Streptococcic vac-
cines were shown to have beneficial action in treatment
of persons who had chronic encephalitis,12,13 and to have
protective action against encephalomyelitis in horses.
The underlying reasons for the occurrence of these
*Presented as part of a symposium on encephalitis at the meeting
of the North Dakota State Medical Association, Jamestown, North
Dakota, May 19, 1942.
t Division of Experimental Bacteriology, Mayo Foundation.
tFellow in Medicine, Mayo Foundation.
epidemics are obscure. Evidence of contact infection in
epidemics previously studied, and in the epidemic which
occurred in North Dakota and Minnesota in 1941, was
slight. Encephalitis of human beings and of horses, in
studies of which the encephalitic type of streptococcus is
demonstrable, not infrequently occurs in winter in the
absence of vectors, such as mosquitoes, flies and ticks.
Changeability or mutability of pneumococci and strepto-
cocci from one type to another, associated with changes
in size and tropism, have been abundantly demonstrated.
14,15 Moreover, streptococci, regardless of original
source, as kept in chick-embryo medium, have been found
to change seasonally16,17 and to acquire specificity cor-
responding to that of the streptococci at hand in persons
and in nature, even in outdoor air, during current epi-
demics of influenza, poliomyelitis and encephalitis. A
suggestion as to at least one of the underlying factors in
248
The Journal-Lancet
nature that might lead to such changes in properties of
micro-organisms was found in a series of experiments in
which streptococci were exposed to high frequency fields.
Arthrotropic types of streptococci became neurotropic,
and vice versa, in cataphoretic velocity, agglutinability
and virulence, depending on the degree of exposure to
this form of radiant energy.18 Thus, it was thought that
some fundamental influence might be operative in caus-
ing comparatively harmless streptococci normally present
in persons, animals and fowl, and in nature, to mutate,
and, in the case of encephalitis, to acquire neurotropic
virulence and to result in the occurrence of encephalitis
in endemic or even epidemic distribution. Since strepto-
cocci have been shown to be airborne,1''1 the infection
may readily be spread over vast areas by this means.
From these and other studies we had come to feel that
flltrability of the inciting agent or virus of encephalitis
did not necessarily imply that it was wholly unrelated to
micro-organisms, such as streptococci. We decided, there-
fore, to study the epidemic as opportunity was afforded,
from both the streptococcic and virus standpoints, in the
hope that knowledge might be forthcoming which would
explain the nature of the infectious process, and which
might lead to methods for specific prevention and treat-
ment of the disease. Since it had been shown that the
sulfonamide drugs have no preventive or curative action
in experimental encephalitis, or in streptococcic infections
due to alpha or green-producing streptococci, we decided
to use the encephalitis antistreptococcic serum in the
treatment.
Methods
The methods used for the isolation and cultivation of
streptococci, for maintenance of specificity, for animal
inoculation, for agglutination, precipitation and cuta-
neous tests, for the preparation of vaccines and anti-
serums and for the demonstration of virus were like
those used in other similar studies.20
The material used for the skin tests was prepared in
the following manner: Nine parts of slightly acidulated
water were added to one part of antiserum in order to
precipitate the euglobulin. The solution then was centri-
fuged. A 10 per cent solution of the sedimented euglob-
ulin was prepared in physiologic salt solution and 0.2 per
cent of phenol was added as a preservative.
The cutaneous tests were made by injecting as super-
ficially as possible into the skin of the forearms of the
patients 0.03 cc. of the solutions of euglobulin from the
encephalitis, poliomyelitis and arthritis antistreptococcic
serums, and normal horse serum diluted 1:10, and noting
the reaction, if any, which occurred in from five to ten
minutes. The size of the maximal flare of erythema was
outlined with pen and ink and then traced on transpar-
ent paper, and from the latter the area of erythema in
square centimeters was determined.
Primary cultures were routinely made in autoclaved
dextrose-brain broth, a medium especially favorable for
the isolation of highly sensitive and highly specific types
of streptococci, and in autoclaved chick-embryo medium
layered with paraffin oil, favorable for the production of
virus and also for isolation of streptococci. Blood-agar
plates were used to determine the type and number of
viable aerobic organisms, but not to isolate pure cultures
for experiments on animals and for other tests. Pure
cultures of the streptococcus were obtained from mix-
tures in contaminated original material and from mixed
primary cultures in dextrose-brain broth by appropriate
inoculation of animals, by making subcultures in rapid
succession in dextrose-brain broth (in which the strepto-
cocci often outgrew contaminants) and by making serial
dilution cultures alternately in tubes of dextrose-brain
broth and dextrose-brain agar.21 If the mediums used
had been prepared a week to ten days previously, they
were first steamed in the autoclave at a pressure of 1 or
2 pounds and cooled, before inoculation.
To obtain material for cultures and other studies, the
nasopharynges of well or ill persons were swabbed
through the mouth with cotton-wrapped aluminum wire
swabs bent to a suitable angle. The adherent material
was washed off in 2 cc. of gelatin (0.2 per cent) Locke
solution. From this suspension, cultures were made, and
the centrifugated clear supernatant fluid was used for
precipitation tests.
Specimens of milk and cream were obtained in a sterile
manner from previously unopened containers. Specimens
of water supplies were obtained from flamed openings of
water faucets or pumps, or after large amounts of water
had been allowed to flow in a steady stream.
The brains of animals that had succumbed to spon-
taneous encephalitis, or that were anesthetized were re-
moved in an aseptic manner and culture were made at
once or after preservation in a 50 per cent solution of
glycerol. Cultures were made, not by planting small
pieces of tissue into ordinary mediums which usually
produces negative results, but by inoculating tubes and
bottles of dextrose-brain broth with varying amounts of
the emulsified tissue (1 gm. or more), made with mortar
and pestle in a nonstacked bacteriologic hood or by shak-
ing pieces of tissue with glass beads and solution of so-
dium chloride in sealed bottles, and of filtrates of emul-
sions of large amounts of brain tissue in physiologic salt
solution. At necropsy of animals that died after inocula-
tion of the streptococcus or virus, cultures were made
routinely by inoculating pipetings of the brain or pieces
of macerated brain tissue into tubes of dextrose-brain
broth.
In making cultures from water and milk or cream,
usually not less than 60 cc. of water and 2 cc. of samples
of pasteurized and raw milk or cream were inocualted
into dextrose-brain broth.
An attempt was made to determine the nature of the
underlying cause of this widespread epidemic. Samplings
of indoor air and stationary and mobile samplings of out-
door air were made in and remote from the region of
the epidemic. Air was drawn through or blown over ex-
posed surfaces of dextrose-brain broth, dextrose broth,
chick-embryo medium and distilled water. Oiled spun
glass and oiled glass beads contained in tubes screened
at both ends were exposed to currents of air on impro-
vised weather vanes for stationary sampling, and on the
front of an automobile, on trains or on an airplane for
mobile sampling. Cultures were made in dextrose-brain
broth and dextrose-brain agar of the material exposed,
August, 1943
249
and precipitation tests were made with the water exposed
to the air (after it had been rendered isotonic) and with
saline washings of the oiled spun glass and glass beads
after exposure.
All inoculated mediums were incubated at 35 C. and
animals were inoculated with young, freshly isolated cul-
tures in dextrose-brain broth, to determine specific viru-
lence, and with old cultures of the streptococci in chick-
embryo medium and with corresponding filtrates to de-
tect the presence of virus. One-tenth of a cubic centi-
meter of culture of the streptococci diluted 1:200 or
1:10,000 or more was routinely inoculated intracerebrally
into rabbits. To demonstrate the presence of virus in
material not badly contaminated, such as an emulsion of
the brain of persons, animals and fowl that had died of
encephalitis, washings of air, water from first rains, lakes,
rivers, wells and supplies, animals, chiefly guinea-pigs
and mice, were inoculated intracerebrally, intralingually
and in the pads, under ether anesthesia. Guinea-pigs
were inoculated with 0.1 cc. intracerebrally, with 0.5 cc.
intralingually and with 0.5 cc. in each of two or four
pads. Mice were inoculated with 0.03 cc. intracerebrally,
with 0.2 cc. intralingually and in the pads, or with 1.2 cc.
intraperitoneally. Monkeys were inoculated intracere-
brally with 2 to 3 cc. of a 5 per cent emulsion or filtrate
of emulsion of the brain of a person, animals or fowl
that had died of epidemic encephalitis, and of the brains
of mice, guinea-pigs and rabbits that had died of experi-
mental encephalitis, and with these amounts of washings
and filtrates of washings of air and dust from air-con-
ditioning filters. The same amounts of appropriate dilu-
tions of cultures were used to inoculate other animals.
Badly contaminated material, such as emulsion of mos-
quitoes and flies, stagnant water, sewage, and suspensions
of filter dust and soil from bottoms of lakes where ducks
and fish were dying was used to inoculate guinea-pigs
and mice intralingually and in the pads. Only rarely
was there swelling or apparent tenderness of pads, and
swelling and tenderness of the tongue never was ob-
served after the inoculation.
The presence of encephalitis in animals that had died
of the spontaneous disease during the epidemic, and in
animals after inoculation of suspected material and ma-
terial known to contain virus was determined by symp-
toms, time of death, congestion of brain tissue with ab-
sence of lesions elsewhere, by reisolation of the strepto-
coccus, and by the presence of characteristic microscopic
lesions in the brain.
Agglutination tests were made almost wholly with sus-
pensions of streptococci that had been freshly isolated in
dextrose-brain broth and then preserved in dense suspen-
sion in glycerol and solution of sodium chloride. The
thoroughly shaken mixtures of serum and streptococci
were kept at 49 to 50° C. for eighteen hours, at which
time readings were made (instead of after being kept
at 37° C. for one or two hours and then in the refrig-
erator over night, as is usually done.) 22 The higher tem-
perature in studies such as these is often necessary to
obtain evidence of specificity of streptococci.
Precipitation tests were made by superimposing cleared
material and serum of persons and animals suspected of
containing antigen on the respective antiserums in small
precipitation tubes. Clouding at the interphase, after in-
cubation for one and a half hours at 35° C. and after
refrigeration over night, was considered as a positive
reaction. Readings were made under the edge of the
shade of a 75 watt electric light in a dark room against
a non-reflecting black velvet background.
Results of Studies on Encephalitis Affecting
Human Beings
The symptoms and findings in cases of encephalitis in
the center of the epidemic were generally severe, and
strikingly similar to those seen during studies of the St.
Louis epidemic. Headache, severe and often uncontrol-
lable, nausea, vomiting and fever were the cardinal
symptoms. Lethargy, delirium associated with loss of
sphincteric control, persistent general weakness, vertigo,
blurred vision, backache, ataxia, occasionally nystagmus
or hemiplegia, localized spasms and even generalized
convulsions occurred. Ocular palsy was not observed and
neurologic findings were minimal, No age group ap-
peared immune. Males, regardless of age, as in cases of
epidemic poliomyelitis, were stricken more often than
were females. At the outskirts of the epidemic, the dis-
ease was usually mild and many cases of the abortive
form of the disease were observed. There was little or
no evidence of contact infection. Cases occurred com-
monly on farms in outlying districts. Polymorphonuclear
leukocytes were present in predominating numbers in the
cerebrospinal fluid at the onset of symptoms, whereas
lymphocytes later predominated in the differential count.
Gram-positive diplococci, sometimes in chains of two or
three, were demonstrated in the sediment of the freshly
drawn cerebrospinal fluid in 50 of 73 cases, and the
streptococci were isolated in dextrose-brain broth in 17
of 49 cases in which cultures were made. There was
great reduction in number and sometimes disappearance
of the cells and diplococci during storage of the cerebro-
spinal fluid, even for a period of twenty-four or forty-
eight hours. Laboratory technicians at the hospitals
before our arrival in the epidemic zone often found dip-
lococci in the properly stained smears of sediment of
freshly drawn cerebrospinal fluid of patients who were
acutely ill.
A Diagnostic Skin Test
In previous studies,23 it was found that intradermal
injection of the euglobulin fraction of the serum of
horses immunized with streptococci was followed imme-
diately (five to ten minutes) by an erythematous-edema-
tous reaction at the site of injection, in cases in which the
infection was due to streptococci, antigenically identical
or similar to the streptococci with which the injected
antibody was prepared. Four groups of patients first test-
ed in this epidemic reacted strongly to the euglobulin
fraction of the serum of horses immunized with the
streptococci isolated in previous epidemics (Table I) .
The degree and incidence of reactions to the encepha-
litis streptococcic euglobulin were greater in the group of
contacts than they were in the group of noncontacts in
the epidemic zone. These findings suggested to us that
a subclinical, but presumably immunizing infection by
the streptococci occurred commonly among contacts and
250
The Journal-Lancet
TABLE I
Cutaneous reaction to euglobulin fraction of serum of horses that had been immunized with streptococci isolated in cases of encephalitis
and with equine encephalitis virus
Reaction to the euglobul
n fraction
of the serum of hor
scs that had been immunized with*:
Streptococci from encephalitis affecting:
Equine
encephalitis virus,
western type
Streptocc
>cci from:
Human beings
Horses
Influenza
Poliomyelitis
Subjects tested
Cases
Average
area,
sq. cm.!
Area of 3
sq. cm.
or more,
pier cent
of cases!
Average
area,
sq. cm.!
Area of 3
sq. cm.
or more,
per cent
of cases!
Average
area,
sq. cm.|
Area of 3
sq. cm.
or more,
per cent
of cases!
Average
area,
sq. cm.!
Area of 3
sq. cm.
or more,
per cent
of cases!
Average
area,
sq. cm.!
Area of 3
sq. cm.
or more,
per cent
of cases!
Encephalitis
Group If
26
5 63
72
2 43
33
1 9
23
■5
Group 2t
19
5 23
77
6.75
74
4 34
60
1 84
33
it
Group 3f
9
4 82
86
5 56
88
5 52
66
2 09
22
d
o
Group 4f
18
5 48
85
5.12
77
4.38
72
3 72
50
1.96
11
<X>
Pi
Poliomyelitis in Minnesota, Illinois and New Jersey
23
3 45
13
0
0
8 63
87
Other diseases in area of epidemic
9
1 14
22
4 04
33
1 40
22
Contacts in epidemic zone
43
3.7
53
2.05
13
0
0
is S.S
Noncontacts in epidemic zone
20
1 61
15
1 25
0
0
0
* Reactions to the euglobulin fraction of arthritis, ulcerative colitis and antistreptococcic serums and to equine antiviral serum were
slight; their average area was less than 1 sq. cm. and in no case was the area 3 sq. cm. or more.
tThese groups have been used to designate cases observed in four different localities in Minnesota and North Dakota in the epidemic
that occurred in 1941.
JThe average area of the reaction and the percentage of cases in which the area was 3 sq. cm. or more were not determined in all cases.
The number of cases in which these data were determined was sufficient to permit, for the sake of brevity, the omission of the number
of cases on which the figures are based.
less often among noncontacts within the epidemic zone.
The high degree and high incidence of reactions to the
poliomyelitis euglobulin among persons having polio-
myelitis, and the low incidence of reactions among per-
sons having encephalitis is a further indication of the
reliability of the skin test.
It occurred to us that, since this simple test appeared
to be a measure of specific antigen and to be of diag-
nostic value in encephalitis as it occurred in human be-
ings, testing patients simultaneously, before and after
therapeutic injection of the antistreptococcic serum, with
the euglobulin of the serum of horses immunized respec-
tively with the streptococci isolated from patients and
horses during attacks, and with equine encephalomyelitis
virus, might throw light on the nature of the relation
between the streptococci and virus. A striking parallelism
in reactions was obtained. The reactions were strongly
positive before (Table I) and mainly negative after
therapeutic injection of the encephalitis antistreptococcic
serum, which indicated antigenic similarity of strepto-
cocci and the virus of equine encephalomyelitis (western
type) •
Eight patients who had had encephalitis for from one
to six days were given parallel intradermal injections of
the three types of euglobulin, before and after receiving
therapeutic intramuscular injections of the encephalitis
antistreptococcic serum prepared with streptococci ob-
tained from persons who had epidemic encephalitis. The
average reaction to the euglobulins from antiserums pre-
pared respectively, with the streptococci obtained from
persons who had encephalitis, with the streptococci ob-
tained from horses that had encephalomyelitis, and with
equine encephalomyelitis virus (western type) was 4.77,
6.49 and 6.54 sq. cm., respectively, before injection of
the antistreptococcic serum; one to eight hours after one
therapeutic injection it was 0.82, 1.57 and 1.52 sq. cm.,
respectively; one to five days after two or more thera-
peutic injections it was 1.54, 0.38 and 0.39 sq. cm., re-
spectively. After ten days — with or without serum sick-
ness— the reactivity of the skin to each of the euglobu-
lins had completely disappeared. Three different brands
of equine encephalomyelitis antiviral serums were used
with comparable results. In contrast, the reactivity of
the skin to the streptococcal euglobulin persisted for two
to four weeks in cases in which the patients were not
treated with the encephalitis antistreptococcic serum.
Serum Treatment
It has been found that the euglobulin prepared from
the encephalitis antistreptococcic serum is diagnostic, and
the whole serum is curative in encephalitis, 2,8,9 regard-
less of type of disease. The clinical results of the use of
the serum in treatment have been reported in abstract in
a preliminary report24 and are set forth in detail in a
paper now in press.2'1 Suffice it to state here that the
mortality in the group of 70 patients treated with the
encephalitis antistreptococcic serum was 4.3 per cent,
whereas in the control, untreated, but otherwise com-
parable group of 27 patients it was 26 per cent. Simi-
larly, Finnigan and Abel,7 in a group of cases observed
during the epidemic of encephalitis in St. Louis, reported
a mortality rate of 13 per cent in 15 cases in which serum
therapy was used in contrast to 35 per cent in 20 control
cases in which serum was not administered.
In agreement with the results of experimental studies,
we found no definite evidence that the sulfonamide
drugs favorably influenced the disease. Fever and strong-
ly positive skin and precipitation reactions were still pres-
ent, and the streptococci were demonstrated in the cere-
brospinal fluid in some cases after the administration of
full doses of one or more of these drugs for as long as
ten days. Clinical response in these and in nearly all
cases, especially when the serum was given early, was
often so prompt and striking as to suggest specific neu-
tralization of toxin or antigen.
251
August, 1943
TABLE II
Isolation in dextrose-brain broth or chick-embryo medium of strep-
tococci from persons, animals and fowl that had symp-
toms of, or that died of encephalitis
Material cultured
Speci-
mens
or
cases
Incidence of
isolation of
streptococci
Number
Percent
Persons having
symptoms of
acute enceph-
alitis
Nasopharnyx
114
114
100
Stool
23
12
52
Cerebrospinal fluid
49
17
35*
Animals or fowl
having symp-
toms and
lesions of
encephalitis
Blood, nares, and brain of horses
18
12
72
Brain of chickens
15
12
80
Brain of wild ducks
15
13
87
Brain of sheep, dog, hog, goose,
pheasant, mink, bat and fish
15
13
87
Feces of ducks and chickens
13
11
85
*Diplococci or streptococci were found in stained films made im-
mediately of the sediment of fresh cerebrospinal fluid in 50 of
73 cases.
V
The intradermal injection of the euglobulin fraction
of the antiviral serum (western type) was found diag-
nostic in cases of encephalitis observed in this epidemic
and in which, according to neutralization tests, the dis-
ease was found to be due to equine encephalomyelitis
virus (western type) . Hence, it is suggested that anti-
viral serums, now available commercially for treatment
of encephalomyelitis in horses, of the type indicated by
the cutaneous test, be used in treatment of persons, in
instances in which the antistreptococcic serum is not
available.
Results of Studies of Affected Persons, Animals
and Fowl on Individual Farms
The symptoms in sheep, a hog, dog and mink con-
sisted mainly of varying degrees of congestion of eyes,
lacrimation, tremors, muscular spasms, ataxia, lethargy
or coma and weakness or paralysis, whereas those in
chickens, turkeys, wild ducks, a goose and pheasant con-
sisted of a progressive weakness of muscles of legs, neck
and wings and of lethargy in the terminal stages, with
minimal evidence of involvement of cerebral cortex. The
illness in the fowl had usually been diagnosed as "limber
neck” or "botulism” and in some instances improvement
occurred with change of water and food.
On farms in the epidemic area in which the disease
affected persons, animals and fowl, cultures in dextrose-
brain broth made of material obtained from patients and
contacts and from affected animals or fowl, and cultures
from flies, from milk obtained in a sterile manner from
cows, and from the respective water supplies usually
yielded the streptococci. The cutaneous test with the
euglobulin of encephalitis antistreptococcic serum was
consistently positive in the case of patients and contacts.
The precipitation test was often positive with the en-
cephalitis antistreptococcic serum and the blood serum
and cleared extracts of nasopharyngeal swabbings of pa-
tients, filtrates of emulsions of flies, and sometimes with
water obtained from epidemic areas.
Control studies made on farms where no cases of en-
cephalitis occurred generally proved negative.
TABLE III
Isolation in dextro-brain-broth or chick-mash medium of streptococci
from air, milk, water, mosquitoes and flies in
relation to epidemic encephalitis, 1941
Incidence of
isolation of
streptococci
Source of material cultured
Samplings
Number
Percent
Air of rooms occupied by persons having acute
encephalitis
51
31
61
Outdoor air within epidemic zone
147
114
78
Outdoor air remote from epidemics
102
54
53
Outdoor air at high levels
(1,000 to 2,000 feet) during
airplane flights
During epidemic
78
60
77
After epidemic
78
34
44
Milk supplies of cities where
cases of encephalitis
occurred
Pasteurized
28
27
96
Raw
26
26
100
Milk obtained from individual
where encephalitis occurred
cows on farms
33
19
58
Water, epidemic zone
Supplies, cities
and farms
48
29
60
Lakes, rivers
and so forth
34
26
76
Water supplies remote from epidemics
33
0
0
Mosquitoes within epidemic zone
9
8
89
Flies within epidemic zone
14
12
86
Isolation, Virulence and Heat Resistance
of the Streptococci
As shown in Tables II and III, streptococci were iso-
lated consistently from the nasopharynx, stools, cerebro-
spinal fluid and brain of patients, from the brains of ani-
mals and fowl and from the feces of ducks and chickens
that died of encephalitis, and from air, raw and pasteur-
ized milk, water, mosquitoes and flies. The streptococci,
regardless of type of material from which they were iso-
lated, produced alpha or green type of hemolysis on
blood-agar, were gram-positive, were much alike morpho-
logically and in cultural characteristics, and usually had
high neurotropic virulence.
It must not be thought that the streptococci were
present in large numbers or that they were readily iso-
lated from material such as cerebrospinal fluid and emul-
sions of brain of persons, animals and fowl that died of
the disease. The methods usually employed by others did
not suffice for their isolation, and prolonged search and
special staining methods were often necessary for their
demonstration.
The mortality rate, incidence of cardinal symptoms,
and the incidence of isolation of streptococci from the
brain of rabbits that died after intracerebral inoculation
are recorded in Table IV. The incidence and type of
symptoms after inoculation with the streptococci and
those after inoculation with emulsions and filtrates of
emulsions of the brains of animals that died of spon-
taneous encephalitis were strikingly similar, but the peri-
od of incubation after inoculation with material contain-
ing virus was longer and the lesions were more typical
than following inoculation with the streptococcus.
In keeping with the relatively common occurrence of
respiratory infections associated with encephalitis affect-
ing human beings, severe congestion of the mucous mem-
brane of the trachea and bronchi and a variable degree
252
The Journal-Lancet
TABLE IV
Symptoms, mortality and isolation of streptococci from brains of rabbits after intracerebral inoculation with streptococci
isolated in studies of encephalitis, 1941
Rabbits
Per cent showing symptoms
Cultures
Circum-
corneal
conges-
tion and
edema
Source of streptococcus
Strains
or
sam-
plings
Inoc-
ulat-
ed
Per
cent
that
died
Trem-
ors
Spasms
Ataxia
Leth-
argy
Paral-
ysis
Num-
ber
Per cent
yielding
strepto-
cocci
Nasopharynx, cerebrospinal fluid and stool of persons with
symptoms of acute encephalitis
50
60
60
55
58
55
40
12
13
41
80
Nares and blood of horses with symptoms of, and brains of
animals and fowl that died of encephalomyelitis
14
42
55
26
48
43
29
19
26
28
46
Emulsions and mosquitoes and flies in epidemic zone
4
11
45
45
64
45
36
36
0
3
67
Water supplies in epidemic zone
14
28
46
43
61
50
50
21
4
12
42
Milk supplies in epidemic zone
44
52
54
38
62
54
48
15
10
34
68
Air of rooms occupied by persons or stalls occupied by horses
having symptoms of acute encephalitis
19
31
65
26
52
35
19
13
10
32
56
Outdoor air in epidemic zone
35
75
41
59
69
51
21
11
9
39
76
Outdoor air remote from epidemics
83
132
23
8
20
8
2
0
2
36
25
Emulsions or filtrates of emulsions of brains of animals that died
of spontaneous encephalitis
21
23
39
22
26
30
22
26
22
8
13
of hemorrhagic edema of lungs were found in rabbits
that died after experimentally produced encephalitis.
The streptococci isolated in these studies also revealed
high neurotropic virulence for mice. The mortality rate
following intracerebral inoculation with the different
groups of strains varied from 45 to 96 per cent, and
after intraperitoneal injection it ranged from 31 to 90
per cent. Altogether, 80 strains were injected intra-
cerebrally into 140 mice, of which 84 (60 per cent) died.
Cultures were made from the brains of 51 mice that
died. The streptococci were obtained in 40 (78 per cent)
of these cultures. One hundred fifty-three strains were
injected intraperitoneally into 340 mice, of which 224
(66 per cent) died. Cultures were made from the brains
of 125 of these mice and the streptococci were obtained
in 60 (48 per cent) of the cultures.
Owing to the high incidence of isolation of strepto-
cocci from samples of pasteurized milk (Table III), in-
dicating high resistance of the streptococci to heat, sam-
ples of pasteurized milk were repasteurized at 63° C.
(145° F.) and 73° C. (163° F.), and suspensions in auto-
claved milk of streptococci freshly isolated from different
sources in the epidemic zone were heated at these tem-
peratures for 30 minutes under carefully controlled con-
ditions. One hundred thirty-eight strains were tested.
Fifty-eight (42 per cent) yielded the encephalitic type of
streptococcus in dextrose-brain broth cultures after being
heated to 63° C. but none yielded streptococci after be-
ing heated to 73° C. The strains that resisted pasteur-
ization in milk had high neurotropic virulence and were
agglutinated specifically by the encephalitis antistrepto-
coccic serum. These experiments indicate that it might
be well to consider whether the present method of pas-
teurization of milk is adequate.
Agglutination of the Streptococcus
As shown in Tables V and VI, there was a consistently
high incidence of specific agglutination by the encepha-
litis antistreptococcic serum of pure cultures of the strep-
tococcus isolated from persons who had encephalitis,
from contacts and from noncontacts at the time of the
epidemic, from animals, fowl and fish that died of en-
cephalitis, and of the streptococci isolated from air,
water, milk, mosquitoes and flies in relation to the epi-
demic. This was not true of streptococci isolated from
nasopharynges of well persons which were reswabbed
nine months later, or of streptococci isolated from out-
door air remote from the epidemic. The agglutinins in
the encephalitis antistreptococcic serum for nearly all
strains, regardless of source, were removed specifically by
absorption tests with the streptococci isolated during
studies of encephalitis.
Agglutinins for the streptococci increased in the serum
of patients during convalescence, as shown by the consis-
tent increase in agglutinating titer of the serums of 88
patients for each of eleven strains of streptococci from
encephalitis, for five of the six strains from encephalitis
contacts, and for only one of nine strains from polio-
myelitis contacts.
Precipitation Reactions with Encephalitis
Antiserums
Extracts of nasopharyngeal swabbings of patients, con-
valescents, contacts and noncontacts within the epidemic
zone, and of noncontacts remote from the epidemic, and
the serum of persons, chickens, ducks and a goose, hog
and dog that had encephalitis were subjected to precipi-
tation tests. As summarized in Table VII, material from
patients uniformly gave a much higher incidence of
clouding at the interphase with the two encephalitis anti-
streptococcic serums and with the antiviral serum (west-
ern type) than with control antistreptococcic serums and
antiviral serum (eastern type) . Interestingly, precipita-
tion did not occur with serums obtained after recovery
or with cleared extracts of nasopharyngeal swabbings ob-
tained from poliomyelitis contacts remote from encepha-
litis, but there was a specific reaction with the polio-
myelitis antistreptococcic serum in the case of the polio-
myelitis contacts. Cleared extracts of nasopharyngeal
August, 1943
253
TABLE V
Agglutination by encephalitis antistreptococcic serum of streptococci
isolated from persons, animals and fowl that were ill with
or that died of epidemic encephalitis, 1941
Percentage incidence of
specific agglutination by:
Streptococcic antiserums*
Source of streptococci
Cases
or
strains
Cul-
tures
tested
En-
ceph-
alitis
Polio-
mye-
litis
Influ-
enza
Arth-
ritis
Nasopharynx of patients
44
98
89
7
3
0
Stool of patients
12
14
71
0
7
0
Cerebrospinal fluid of patients
16
18
89
6
0
0
Nasopharynx, contact nurses at
hospitals during epidemic of en-
cephalitis, 1941
19
24
83
4
0
4
Nasopharynx, noncontact nurses at
same hospitals remote from en-
cephalitis, some having mild res-
piratory infections. May 20, 1942
35
35
14
0
29
0
Blood, nares and brain of horses ill
with or that died of encephalo-
myelitis
8
24
71
13
4
13
Brain of chickens and goose that
died of encephalitis
17
26
69
15
4
0
Brain of sheep, hog, dog, mink, wild
ducks, pheasant, bat and fish that
died of encephalitis
23
58
72
21
3
0
*No agglutination with antiserum of ulcerative colitis, normal horse
serum and antiviral horse serum, western or eastern type.
TABLE VI
Agglutination by encephalitis antistreptococcic serums of strepto-
cocci isolated from air, water, milk, mosquitoes and flies
in relation to epidemic encephalitis (1941)
Percentage incidence of
specific agglutination by:
Streptococcic antiserums*
Streptococci isolated from:
Sam-
plings
Cul-
tures
tested
En-
ceph-
alitis
Polio-
mye-
litis
Influ-
enza
Arth-
ritis
Indoor air, cases of encephalitis
13
13
92
8
0
0
Outdoor air within epidemic zone
63
145
79
14
2
3
Outdoor air remote from epidemics
43
75
16
17
10
17
Outdoor air at high
levels, during air-
plane flights
During
epidemic
11
43
79
9
7
0
After
epidemic
11
23
17
13
13
17
Milk
Individual cows where cases
occurred
12
17
71
6
0
6
Supplies dur-
ing epidemic
Pasteurized
35
50
80
18
0
2
Raw
16
22
82
14
0
0
Water supplies, epidemic zone
15
19 '
74
5
5
5
Mosquitoes, epidemic
zone
7
7
86
0
0
0
Flies,
epidemic zone
11
20
75
10
0
0
*No agglutination with antistreptococcic serum of ulcerative colitis,
equine encephalomyelitis antiviral serum and normal horse serum.
TABLE VII
Precipitation reaction between streptococcic and viral antiserums and extracts of nasopharyngeal swabbings and the serum of persons and
the serum of animals and fowl having symptoms of encephalitis, 1941
Percentage incidence of positive reactions with antiserums*
Streptococcic
Viral equine
encephalo-
myelitis
Encephalitis
Polio-
mye-
litis
Arthri-
tis
Influ-
enza
West-
ern
East-
ern
Antigens
Strains
Human
Horse
Patients having encephalitis
Nasopharynxf
114
78
72
21
5
0
49
9
Serum
67
73
61
25
0
0
34
3
Cerebrospinal fluid
29
69
76
10
3
0
49
0
Serum of persons convalescent from encephalitis
19
11
0
0
0
0
0
0
Nasopharynges.f contact nurses at hospitals during epidemic of encephalitis, 1941
37
65
49
5
8
0
29
5
Nasopharynges.f noncontact nurses at same hospitals remote from encephalitis, some
having mild respiratory infections, May, 1942
41
2
5
5
27
0
0
Nasopharynges.f well noncontacts within epidemic zone
25
52
28
8
0
0
16
0
Nasopharynges.f poliomyelitis contacts within epidemic zone of encephalitis
56
57
22
75
2
0
30
9
Nasopharynges.f poliomyelitis contacts remote from encephalitis
15
13
60
0
0
0
0
Serum of persons convalescent from poliomyelitis
10
10
20
0
0
0
0
Serum of chickens, ducks, goose, hog and dog having symptoms of encephalitis
18
61
39
61
11
0
33
0
*No positive reactions to antiserums of ulcerative colitis and to normal horse serum.
tCleared washings in gelatin Locke solution of nasopharyngeal swabbings.
swabbings of poliomyelitis contacts within the epidemic
zone of encephalitis gave positive reactions to both the
encephalitis and poliomyelitis antiserums.
As shown in Table VIII, washings of indoor and out-
door air, water from supplies, lakes and rivers, and ex-
tracts of emulsions of flies and mosquitoes gave a high
incidence of positive precipitation reactions with encepha-
litis antiserums prepared with streptococci from epidemic
encephalitis in human beings and horses, respectively,
and equine encephalomyelitis virus (western type) . With
only one or two exceptions, this was not the case with
corresponding samplings obtained remote from the epi-
demic.
The finding of specific types of streptococci and strep-
tococcic antigen in the air throughout the epidemic zone
and their absence in air remote from epidemics are new
and of epidemiologic importance.
Encephalitis in Guinea-pigs and Mice Produced
with "Natural” Virus and with Virus
Derived from the Streptococcus
The incidence of deaths from encephalitis in guinea-
pigs and mice after inoculation with emulsions, or with
254
The Journal-Lancet
table VIII
Precipitation reaction between streptococcic and viral antiserums and washings from air and filter dusts, water supplies and filtrates of
emulsions of flies and mosquitoes in relation to epidemic encephalitis, 1941
Percentage incidence of positive reactions with antiserums*
Streptococcic
Viral
Speci-
mens
Encephalitis
Polio-
Arthri-
tis
Equine enceph-
alomyelitis
Source of material used as antigen
Human
Horse
litis
Western
Eastern
Washings in water from
Indoor air within epidemic zone
16
63
75
13
25
50
13
Indoor air remote from epidemics
16
6
0
0
0
0
0
Outdoor air in epidemic zone
165
60
56
22
17
33
7
Outdoor air remote from epidemics
82
9
I
1
11
4
0
Dust from air-conditioning filters in epidemic zone
9
67
56
0
0
22
0
Water supplies
Within epidemic zone
49
55
12
4
35
0
Remote from epidemics
49
12
4
8
4
2
0
Water from lakes, rivers, and so forth
Within epidemic zone
46
67
17
11
43
4
Remote from epidemics
29
0
0
0
4
0
0
Extracts of emulsions of
Flies in epidemic zone
16
81
50
13
0
38
19
Mosquitoes in epidemic zone
14
92
86
29
7
64
21
Mosquitoes remote from epidemics
8
13
0
13
0
0
0
*No positive reactions with antistreptococcic serums of influenza and ulcerative colitis and normal horse serum.
TABLE IX
Encephalitis in guinea-pigs and mice after intracerebral inoculation of emulsions or filtrates of emulsions of brains of a patient, animals
and fowl that died of encephalitis, 1941
Guinea-pigs
Mice
Per cent
that
died of
enceph-
alitis
Cultures from brain
Per cent
that
died of
enceph-
alitis
Cultures from brain
Material inoculated
Patients,
animals
or fowl
Inoc-
ulat-
ed
Num-
ber
Per cent
yielding
strepto-
cocci
Inoc-
ulat-
ed
Num-
ber
Per cent
yielding
strepto-
cocci
Emulsions or filtrates of
emulsions of brain of a
patient, animals* and
fowl* that died of en-
cephalitis
Patient
i
23
61
10
30
44
50
20
40
Horses
3
37
68
18
50
139
64
64
52
Birds, chickens, ducks, goose, pheasant
36
147
42
56
45
181
38
68
39
Hog, dog, sheep, bat, mink
9
51
63
20
55
116
66
37
54
Fish
6
27
42
12
42
38
58
17
24
Total
55
285
52
116
46
518
53
206
45
*Diagnosis confirmed by characteristic lesions in sections of brains.
filtrates of emulsions, of brain material obtained from a
patient, animals and fowl that died of encephalitis, and
the incidence of isolation of streptococci from the brains
of the guinea-pigs and mice that died are summarized in
Table IX.
The experimental production of encephalitis with virus
from the brain of different species of animals and fowl
is in accord with the demonstration by Cox, in this same
epidemic, of equine encephalomyelitis virus (western
type) in the brain of a prairie chicken,21’ ground squirrel
and deer, and of viral neutralizing antibodies in the
serums of persons, geese, turkeys, wild ducks and horses
not known to have been ill.27
As shown in Table X, a relatively high death rate
from encephalitis occurred in guinea-pigs and mice after
inoculation with material from nature which was shown
to contain the streptococci — such as emulsions or filtrates
of emulsions of mosquitoes and flies, water from supplies,
and filtrates of old cultures in chick-embryo medium of
washings of outdoor air — and after inoculation with virus
produced from the streptococci far removed from origi-
nal source.
In these experiments and in the experiments with
emulsions of brain tissue of animals that died of spon-
taneous encephalitis (Table IX), it was not certain
whether the symptoms and lesions produced in the ani-
mals were due to the streptococci, to virus derived from
the streptococci, or to "natural” virus. However, experi-
ments were done to determine whether the effects ob-
tained in guinea-pigs and mice were due to the strepto-
cocci as such, far removed from virus, or to virus derived
from the streptococci. In these experiments the strepto-
cocci were separated from original source by making sub-
cultures in dextrose-brain broth in rapid succession, and
by making serial dilution cultures alternately in dextrose-
brain broth and dextrose-brain agar.21 Original material
from which the streptococci were isolated was diluted
many billion times in all instances.
Encephalitis developed in guinea-pigs and mice after
inoculation with streptococci isolated primarily from
August, 1943
255
TABLE X
Encephalitis in guinea-pigs and mice after inoculation of material from nature and of experimental virus derived from streptococci
far removed from original source
Source and type of material inoculated
Specimens
or
strains
Inoc-
ulat-
ed
Guinea-pigs
M
ce
Per cent
that
died of
enceph-
alitis
Cultures from brain
Inoc-
ulat-
ed
Per cent
that
died of
enceph-
alitis
Cultures from brain
Num-
ber
Per cent
yielding
strepto-
cocci
Num-
ber
Per cent
yielding
strepto-
cocci
Material containing
streptococci and/or virus
Emulsions or filtrates of emulsions of mosquitoes
h
48
48
14
43
43
46
29
38
Emulsions or filtrates of emulsions of flies
5
22
55
10
30
32
63
19
31
Emulsions and filtrates of washings of dust from air-
conditioning filters in epidemic zone
6
28
50
12
8
13
23
Water supplies of persons and horses that had encephalitis
7
45
69
10
60
94
39
16
19
Filtrates of old chick-embryo cultures of washings from
outdoor air containing the streptococcus
10
31
39
6
50
54
28
18
22
Pure cultures of the streptococci, far
removed from original source, from
nasopharynx and cerebrospinal
fluid of patients with encephalitis;
outdoor air; brains of animals that
died of encephalitis; emulsions of
mosquitoes and flies; water supplies
Dextrose-brain broth cul-
tures from nasopharynx
and cerebrospinal fluid
6
17
18
4
0
26
35
11
18
Single colony cultures in
dextrose-brain agar or
dextrose-brain broth
15
43
52
15
40
194
51
125
29
Filtrates of old cultures in
chick-embryo medium
22
66
45
13
15
87
51
26
35
Controls: inert filtrates or emulsions of brains, chick-embryo
medium, and so forth
47
89
0
43
0
234
0
107
2
nasopharynx, from outdoor air, from the brain of one
person and from brains of animals that died of spon-
taneous encephalitis, from mosquitoes and flies, and from
water supplies, and after inoculation of filtrates of old
chick-embryo cultures of the streptococci (Table X) .
In four instances, virus that was highly effective for
guinea-pigs developed in vitro in chick-embryo cultures
from streptococci that were isolated from the brain of a
horse that died of encephalomyelitis, and which — by ex-
tremely high dilution — was separated from original ma-
terial.
Thus, a young dextrose-brain broth culture of the
streptococci that had been subcultured three times, twice
from single colonies, was subjected to a serial dilution
culture. At intervals of about twelve seconds, approxi-
mately 2 cu. mm. of inoculum was transferred from tube
to tube, each of which contained approximately 20 cc.
of medium, with the inoculating wire which was not
heated between transfers. Pure cultures of the strepto-
cocci were obtained from the 136th, 144th, 194th and
198th tubes or dilutions, respectively. Each was inocu-
lated into a tube of chick-embryo medium, in all of
which the virus developed.
The incidence of isolation of the streptococci from the
brains of guinea-pigs and mice that died of encephalitis
after inoculation with virus derived from the streptococci
was similar to that of isolations of streptococci from ani-
mals that died of encephalitis after inoculation with
"natural” virus. Results such as these were not obtained
after inoculation with control material (Table X) .
In order to determine whether the virus phase of the
streptococci might develop in persons, animals and fowl
on breathing or swallowing the streptococci shown to be
in the air in the epidemic zone, young dextrose-brain
broth cultures of the streptococci — also far removed
from original source — which had been isolated from air
at high levels during an airplane flight within the epi-
demic zone, and from cerebrospinal fluid or brain of in-
dividuals having encephalitis, were nebulized into the air
of cages in which mice were kept, and were added to the
running water in which goldfish and rainbow trout were
kept. As a control, sterile dextrose-brain broth was neb-
ulized into cages containing the same number of mice
and was added to running water, in the same amount as
the culture, where the same number of fish were kept.
The details of these experiments will be published else-
where. It is sufficient to state here that the streptococci
invaded the brains of mice and fish and that transmis-
sible encephalitic virus was obtained from the brains of
mice and fish that were made to breathe and perhaps
swallow the streptococci, whereas inoculation with the
brains of control mice and fish proved innocuous, and
cultures of emulsions of their brains remained sterile.
Twelve strains of "natural” encephalitic virus obtained
from the brains of animals that died of encephalitis and
from other material have been passed serially through
guinea-pigs and mice. Three of these virus strains were
isolated from water supplies where cases of encephalitis
occurred, two were obtained from emulsions of flies that
were caught where cases of encephalitis occurred, two
were obtained from emulsions of mosquitoes caught with-
in the epidemic zone, two were obtained from washings
of air in rooms of patients who had encephalitis, and
three were obtained from washings of outdoor air within
the epidemic zone. Thirty-four (45 per cent) of 76 ani-
mals inoculated in the first passage; 33 (59 per cent) of
56 animals inoculated in the second passage; 20 (57 per
cent) of 35 animals in the third and fourth passages,
respectively, and 2 (100 per cent) of 2 animals in the
fifth and sixth passages, respectively, died of encephalitis.
Twelve strains of experimental virus produced from
streptococci far removed from original source have like-
wise been passed serially through guinea-pigs and mice.
One of these strains of streptococci was isolated from the
256
The Journal-Lancet
brain of a patient who died of encephalitis, one repre-
senting five cultures was isolated from the brain of a
horse that died of encephalomyelitis, one was obtained
from flies where a case of encephalitis in man had oc-
curred, and four were obtained from washings of out-
door air within the epidemic zone. Thirty (91 per cent)
of 33 animals inoculated in the first passage; 31 (76 per
cent) of 41 animals inoculated in the second passage;
10 (63 per cent) of 16 animals inoculated in the third
passage; 6 (86 per cent) of 7 animals inoculated in the
fourth passage; 4 (80 per cent) of five animals inocu-
lated in the fifth, and 2 (100 per cent) of 2 animals
inoculated in the sixth passage died of encephalitis.
The incidence of isolation of the streptococci from the
brain of animals that died of encephalitis in these two
groups of passage experiments was approximately the
same and about as that in the case of animals that died
after primary inoculation with material that contained
virus.
The "natural” and experimental virus strains were
found to be approximately equally resistant when the re-
spective brain and cord tissues were preserved in 50 per
cent glycerol.
Encephalitis Induced in Monkeys
Emulsions or filtrates of emulsions of the brain of one
patient and of animals and fowl that died of spontaneous
encephalitis, emulsions or filtrates of brains of rabbits,
guinea-pigs and mice that died of experimental encepha-
litis, and highly diluted suspensions of five strains of
streptococci (far removed from virus) isolated from
them, were injected intracerebrally into 17 monkeys in
forty-one instances. Seven of thirty-seven specimens used
were obtained from outdoor air, three were filtrates of
washings from dust of air-conditioning filters, fifteen
were obtained from spontaneous encephalitis affecting
persons and animals and twelve were obtained from fowl
directly or after several animal passages. Cardinal symp-
toms of encephalitis developed in twenty-five instances
after forty-one inoculations, including each of the five
strains of streptococci, and 9 of the 17 monkeys inocu-
lated died. After death, streptococci were isolated from
the brains of 6, and virus — effective in guinea-pigs and
mice — was obtained from the brains of 5. Reinoculations
were never made until long after the monkeys had re-
covered completely.
Cutaneous tests were made on nine monkeys having
active symptoms of encephalitis, with the euglobulin
from the three typ>es of antisera, together with suitable
controls. All of the monkeys reacted to each of the
three encephalitis euglobulins but not to control euglobu-
lins. The reactivity of the skin to reinjection of each of
the three euglobulins disappeared promptly in four mon-
keys after several daily intramuscular injections of 0.5 cc.
per kilogram of body weight of the encephalitis anti-
streptococcic serum, and all four recovered. Immunity to
reinjection of encephalitis virus was noted in five in-
stances but all of four monkeys that had recovered from
encephalitis died of flaccid paralysis after inoculation
with poliomyelitic virus. Each of these four monkeys
reacted specifically to the encephalitis euglobulin during
attacks of encephalitis, and specifically to the poliomyeli-
tis euglobulin during attacks of poliomyelitis.
Microscopic Lesions
Infiltrative and degenerative lesions associated with
varying degrees of neuronophagocytosis and gliosis, char-
acteristic of encephalitis, were found in the brain of a
patient who died of encephalitis, and in the brains of
all animals and fowl that had symptoms and that died
of encephalitis, or that were anesthetized during the
active stage of the disease. A striking difference was
found; this consisted of the distribution and proportion
of the different typ>es of lesions in the patient and ani-
mals, on the one hand, and in fowl, on the other hand.
In the patient, horse, sheep, hog, dog, mink and fish the
lesions were widely disseminated, sometimes involved the
meninges of sulci and choroid plexus and ependyma in
localized regions, whereas in chickens, wild ducks and
the goose and pheasant, in which paralysis was the out-
standing clinical manifestation, severe degeneration of
ganglion cells, associated often with pronounced neurono-
phagocytosis, was largely limited to the pons and medulla
and there were usually only slight lesions of the cerebral
cortex.
Comment and Conclusions
This report is based on a clinical study of patients
treated with the encephalitis antistreptococcic serum and
on bacteriologic studies of material obtained during the
epidemic of encephalitis in North Dakota and Minne-
sota in 1941. The encephalitis antistreptococcic serum
had beneficial action in treatment, and the euglobulin
fraction of the antistreptococcic and antiviral serums
proved diagnostic and of value in determining the
amount of the antistreptococcic serum to be injected for
best results. _
Alpha, or green-producing, streptococci and virus were
demonstrated consistently in persons, animals, fish and
fowl that had encephalitis, and in a wide range of ma-
terial from nature, including outdoor air. The incidence
of isolation of the streptococcus was especially high from
those materials in which virus was most readily dem-
onstrated. The streptococci and equine encephalomyelitis
virus (western type) are similar antigenically, but are
very different in growth requirements. Special mediums
sufficed for the consistent isolation of the streptococci
but not for the propagation of the virus, as such. For
this, the living cells or other conditions in the tissues of
susceptible animals were necessary, but as symptoms de-
veloped the streptococci also grew in cultivable and de-
monstrable form.
Virus has been produced experimentally from the
streptococci in vivo and in vitro by suitable injections of
the streptococci and of filtrates of old chick-embryo cul-
tures of the streptococci, and by causing mice and fish
to breathe the streptococci.
The results of our studies indicate that epidemic en-
cephalitis is due primarily to a highly specific neurotropic
type of streptococcus, and as such infection occurs a virus
phase of the streptococcus develops.
It is likely that various factors, such as the consump-
tion of contaminated water and milk, and perhaps bites
by mosquitoes and flies, were causative of infection in
August, 1943
257
individual cases, but that more fundamental factors, such
as mutation of the streptococci and virus and their ready
means of spread by air, were responsible for the occur-
rence of this epidemic of encephalitis over such a vast
area.
It would seem that specific vaccination, in addition to
sanitary measures, such as more adequate purification of
water supplies and pasteurization of milk at higher tem-
peratures than now practiced, may be necessary for the
prevention of outbreaks of encephalitis. However, since
from 2,000 to 5,000 persons would need to be immunized
during epidemics to protect one from contracting the dis-
ease, a practical impossibility by present methods, the
use of the diagnostic and therapeutic antistreptococcic
serum in the early stages of the disease is strongly in-
dicated.
References
1. Rosenow, E. C. : Experimental studies in the etiology of epi-
demic encephalitis, epidemic hiccup, spasmodic torticollis and allied
conditions, Northwest Med. 21:329—33 1 (Sept.) 1922.
2. Rosenow, E. C. : The relation of streptococci to the epidemic
of encephalitis in St. Louis: preliminary report, Proc. Staff Meet.,
Mayo Clin. 8:559-563 (Sept. 13) 1 933.
3. Rosenow, E. C., and Jackson, G. H., Jr.: Microscopic dem-
onstration of bacteria in the lesions of epidemic (lethargic) en-
cephalitis, J. Infect. Dis. 32:144—152, 1923.
4. Rosenow, E. C. : Streptococci in relation to etiology of epi-
demic encephalitis; experimental results in 8 1 cases, J. Infect. Dis.
34:329-389, 1924.
5. Rosenow, E. C., and Schlotthauer, C. F.: Studies on the
relation of streptococci to the etiology of equine encephalomyelitis:
preliminary report, Proc. Staff Meet., Mayo Clin. 12:631—636
(Oct. 6) 1937.
6. Rosenow, E. C.: Serologic specificity of streptococci having
elective localizing power as isolated in various diseases of man,
J. Infect. Dis. 45:331-359, 1929.
7. Finnigan, F. R., and Abel, Oliver, Jr.: Personal commu-
nication to the authors.
8. Helmholz, H. F., and Rosenow, E. C.: Three cases of acute
encephalitis treated with specific serum, J.A.M.A. 79:2068—2071
(Dec. 16) 1922.
9. Rosenow, E. C.: Experimental studies on the etiology of
encephalitis; report of findings in one case, J.A.M.A. 79:443—448
(Aug. 5) 1922.
10. Rosenow, E. C.: Specific serum treatment of epidemic
(lethargic) encephalitis; further results, J.A.M.A. 80:1583 — 1 588
( J une 2 ) 1923.
11. Rosenow, E. C., and Schlotthauer, C. F.: Further studies on
the relation of streptococci to epidemic equine encephalomyelitis:
treatment and prophylaxis, Proc. Staff Meet., Mayo Clin. 12:825—
830 (Dec. 29) 1937.
12. Neal, Josephine B., and Bentley, Inez A.: Treatment of
epidemic encephalitis; review of work of the Matheson Commission,
A. Research Nerv. &C Ment. Dis., Proc. 12:302—314, 1932.
13. Rosenow, E. C., and Nickel, A. C.: Results in various dis-
eases from elimination of foci of infection and use of vaccines pre-
pared from streptococci having elective localizing power, J. Lab. &C
Clin. Med. 14:504-512 (Mar.) 1929.
14. Rosenow, E. C. : Transmutations within the streptococcus-
pneumococcus group, J. Infect. Dis. 14:1—32 (Jan.) 1914.
15. Rosenow, E. C.: Elective localization of the streptococcus-
pneumococcus group as a factor in the production of disease, Ann.
Clin. Med. 1:21 1-230 (Jan.) 1923.
16. Rosenow, E. C. : Changes in streptococcus from encephali-
tis, induced experimentally, and their significance in pathogenesis
of epidemic encephalitis and influenza, J. Infect. Dis. 33:53 1—556,
1923.
17. Rosenow, E. C.: Seasonal changes in the cataphoretic veloci-
ty and virulence of streptococci; as isolated from well persons, from
persons having epidemic or other diseases and from raw milk,
J. Infect. Dis. 53:1-1 1, 1933.
18. Sheard, Charles, Pratt, C. B., and Rosenow, E. C. : Sympo-
sium on cataphoresis and localization of streptococci. The high fre-
quency field as an agent in changing the cataphoretic velocity and
the localization of streptococci, Proc. Staff Meet., Mayo Clin.
8:496-504 (Aug. 16) 1933.
19. Rosenow, E. C.: Isolation from the air of streptococci and
streptococcal antigens resembling those associated with certain epi-
demic diseases, (Abstr.) J. Bact. 39:73—74 (Jan.) 1940.
20. Rosenow, E. C. : Unpublished data.
21. Rosenow, E. C.: Isolation of bacteria from virus and phage
by a serial dilution method. Arch. Path. 26:70—76 (July) 1938.
22. Burdon, K. L., Thurston, E. W., Varney, P. L., and Bron-
fenbrenner, J.: Etiologic significance of streptococci in epidemic
encephalitis. I. Incidence of streptococci in cultures from patients
with encephalitis in St. Louis and from normal controls, and char-
acteristics of various strains isolated, Arch. Int. Med. 58:285—308
(Aug.) 1936.
23. Heilman, F. R., and Rosenow, E. C.: Newer methods of
study and treatment of chronic streptococcal disease, Proc. Staff
Meet., Mayo Clin. 12:252-256 (Apr. 21 ) 1937.
24. Rosenow, E. C., and Caldwell, H. W.: Studies on the etiol-
ogy and serum treatment of encephalitis during the epidemic in
North Dakota and Minnesota, 1941, Proc. Staff Meet., Mayo Clin.
16:587-588 (Sept. 10) 1941.
2 5. Rosenow, E. C., and Caldwell, H. W.: Studies on the etiol-
ogy and serum treatment of encepahlitis during the epidemic in
North Dakota and Minnesota, Ann. Int. Med. 17:474—485 (Sept.)
1942.
26. Cox, H. R., Jellison, W. L., and Hughes, L. E.: Isolation
of western equine encephalomyelitis virus from a naturally infected
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27. Cox, H. R.: Personal communication to the authors.
Observations on Selenium Poisoning in South and
North America
Ray E. Lemley, Captain, Medical Corps,
0 ^
Ft. George Wright, Washington
FOLLOWING a description of numerous cases of
selenium poisoning from natural sources,1,2 sev-
eral investigators3 have been observing such cases
and many patients have been referred to the writer’s
clinic for study. Many of these cases were determined
to be due to selenium poisoning. In the selenium areas,
it is thus shown the symptoms of the poisoning can be
recognized by the general practitioner even though the
selenium syndrome is not yet well understood.
The opportunity to make a South American tour to
investigate the disease there was presented to the writer
in 1941. Inasmuch as samples, mostly grains, from vari-
ous parts of the world analyzed for selenium content
•This review has been released for publication by the War De-
partment Manuscript Board, which assumes no responsibility, other
than censorship, for the contents, and permits no published ref-
erence to it.
have shown appreciable amounts, the South American
investigation was considered to be highly interesting. Ar-
gentine wheat samples in shipload lots usually show a
little less than one part per million of selenium, which
would indicate a widespread, low-grade selenium content
of soil, or a few areas of rather high selenium content,
or both.
Selenium Soils in Argentina
Selenium occurs in the United States, Canada, and
Mexico in the upper Cretaceous and lower Tertiary for-
mations and is a great source of damage to animals and
humans. In Argentina the sides of the Andes Moun-
tains present great deposits of Cretaceous strata, mostly
resembling the Niobrara, which in the United States is
the greatest offender, being widespread, highly toxic, and
258
The Journal-Lancet
particularly available to range plants and grasses and
other farm products. The level portion, or Pampas, of
Argentina, extending from the Andes to the sea, is large-
ly covered with loess, originating from the components
of the Andes Mountains. In places this loess probably
reaches a depth of nearly one thousand meters; in other
places, notably along the rivers, it is absent, owing to
erosion to deeper layers of strata which are similar to
those on the sides of the Andes. The stratigraphy of
the South American countries is in a very jumbled state;
geographical studies are extremely difficult and as yet
very incompletely correlated. However, many of the sus-
pected strata contain fossils. In particular the noded
scaphites of the upper Cretaceous are contemporary with
those in the toxic deposits of the Cretaceous in the
United States. A study of all available maps shows that
these deposits, of possible toxicity, are quite widespread
throughout Argentina. On personal tour, there seemed
to be more Cretaceous deposits than the stratigraphical
maps of the country show. As that strata compares to
that of known toxicity in the United States, it was neces-
sary to determine the presence of selenium, and in the
event of its presence, its effect on the animals and hu-
mans in these areas.
Now in the United States, Canada, and Mexico cer-
tain plants grow only in the presence of selenium and
convert it from the inorganic forms of its original state
to the organic forms which may be taken up by other
plants and which may be used for animal and human
food. These plants, the loco weeds, are members of the
Astragalus group and are easily recognized. Also by the
odor of these plants some idea of the selenium content
may be gained. The presence of these plants in the sus-
pected selenium-bearing strata of the Argentine was ev-
erywhere evident, and thus it could be determined that
without doubt, selenium occurred in fair concentration in
various portions of Argentine soils. Any Argentine gau-
cho or estancia owner can show you loco weeds, and
knows the effects of these toxic selenium-bearing plants
on his livestock. Probably the greatest offender in the
Argentine is the Astragalus bergi, which is similar to
Astragalus racemosis of the western United States, ex-
cept that its leaves are slightly broader and the pods are
shaped more like common pea pods. Many other vari-
eties of Astragalus are found in Argentina and nearby
countries of South America, where there are many re-
ports of toxicity to livestock. A fine collection of As-
tragalus are on display in the Botanical Institute, Immi-
grants Hotel, Buenos Aires; Senor Professor Malfino
there can give many interesting facts about livestock
losses from these toxic plants.
After inspection of thousands of cattle in the great
municipal stockyards in Buenos Aires, where many cases
of typical selenium hooves could be observed and obser-
vations made on the regions these cattle came from, it
was very clear that selenium poisoning in Argentina is a
problem similar to that in the United States. In one
area in the southwestern portion along the Patagonian
border, there have been some rather heavy livestock
losses due to acute selenium poisoning, probably caused
by ingestion of Astragalus bergi. Throughout Argentina
descriptions of both acute (loco disease) selenium poi-
soning and chronic (alkali disease) selenium poisoning
are common and coincide closely with descriptions of
western stock men in the United States. As in our
western stock country, many wierd and fantastic treat-
ments of the affected animals have been developed. One
Argentine estancia owner, for example, is certain that by
inclosing the animal’s head in a tent and burning the
loco weed in this tent, beneficial results are obtained. In
another area of the Argentine, all new livestock, particu- ,
larly horses, are caught upon entering the area and their |
mouths and noses thoroughly rubbed with macerated
loco weeds. After this treatment, the Gaucho then be- !
lieves the animals will not eat the weed.
Selenium Soils in Peru
In Chile the writer observed several toxic areas con- j
taining typical toxic Astragalus plants. In Peru a town
of about 17,000 people largely isolated from the rest of
the world by geographical barriers, was particularly ob-
served. This town lies in a basin of Cretaceous deposits. I
Owing to irrigation facilities, most of its foodstuffs are
grown in this localized area and used to a large extent i
by the populace. The strata components of this area
were probably in the upper Cretaceous age and closely
related to the Niobrara deposits in the United States, j I
On investigation and inquiry among the doctors in this I
town, it was enlightening to find that a large majority [
of the populace, and especially newcomers to this area, .
complained of the typical symptoms of selenium poison- i
ing described by the writer’s first two articles on the
subject.1 •- Animals from this area also show signs of ;
chronic selenium poisoning. Throughout the middle pla- j 1
teau of the Andes in Peru, particularly between the re- [
gions of Cuzco and Juliaca, there were many evidences
of selenium-bearing strata, as evidenced by the plants H
and geographical formations. A survey was made in the ]
regions of the properties of the Cerro de Pasco Copper
Corporation and it is the writer’s opinion there is a great
possibility of innoculation of the soil by the volatilized j
selenium from the smelters in addition to selenium nat- I :i
urally present in the soils. Also, Astragalus plants found
in these properties, which undoubtedly contain selenium, fl
are known by the natives to be toxic to animals.
Selenium Poisoning
Further studies on this interesting problem in South
America were halted by the difficulties in shipping sam-
ples obtained, owing to the onset of the present war. As
soon as these samples are available for analysis, further
reports will be made. A conclusion of the writer, made
after seeing selenium poisoning in its various phases
throughout most of North and South America, is that
its economic importance is much greater than heretofore
realized. It is his opinion that the loss to the livestock
industry lies not so much in the stock killed by the
poisoning, but in the subclinical chronic low-grade poi-
sonings which are so common and widespread.
All stockmen know that in certain years feed will be
good but that their cattle will not do well; and the com-
mon expression, "The grass has no strength in it this
year,” is often heard. In the writer’s opinion, a more
August, 1943
259
careful examination will usually show a higher selenium
content that year.
Another well-known fact is that certain areas in the
range countries throughout North and South America,
for example, the Sand Hills region of Nebraska, are
famous for their large, fat beef cattle. The grass and
available food for stock is certainly no better there than
in other areas, but it will be noted that the geology of the
regions indicates no available selenium.
Throughout the huge selenized areas of those coun-
tries which are largely used for livestock raising, the
total loss in weight and growth of cattle alone, produced
by chronic low-grade subclinical selenium poisoning,
must be of tremendous economic importance, hitherto
unrecognized.
It is the writer’s opinion that human selenium poison-
ing is common, widespread, and in certain localities of
importance to the general public heatlh.
References
1. Lemley, R. E.: Journal-Lancet 60:12, 528. (Dec.) 1940.
2. Lemley, R. E.: Journal-Lancet 61:435, (Nov.) 1941.
3. Personal communications to author.
Securing and Retaining Nursing Service During
the War Crisis*
Hospitals, like all employers today, are confronted
with the problem of securing and retaining help at this
time, and, unlike most employers, hospitals must think in
terms of both professional and non-professional help.
Hospitals fortunate enough to have schools of nursing,
now expecting to admit additional students in conform-
ance with our government’s plans for student nurse re-
cruitment, will receive much nursing help, when these
students, of necessity, are called upon to take more and
more nursing responsibility. Under adequate supervision
this will work no hardship.
However, to insure this supervision, to secure and re-
tain a supervisory staff, is another problem. We all know
that our armed forces are absorbing the graduate nurses
in increasing numbers. We know that the best nurses
are needed, as are the best troops, if we are to win this
war. As our army increases in size so must the numbers
of our nurses be augmented to care for this tremendous
military establishment of ours. At the same time the
battle for health on the home front must not be
neglected.
This battle for health going on in hospitals whose
schools form a proving ground for the basic training of
nurses, will be a losing one if we lose sight of the plan
for adequate supervision for the student nurse, and for
the paid non-professional and volunteer non-professional
groups, now in hospital service.
The recognition of head nurses and supervisors who
are responsible for this direct supervision as key people
in the hospitals is of utmost importance. The efficiency
with which they run their respective departments is in
direct proportion to their ability to orient and instruct
new, transferred, and displaced help. We need not enu-
merate the increasing numbers of new people who must
be introduced daily to the hospital situation. Hospitals,
then, must recognize that head nurses and supervisors
need aid in order to direct these "green” helpers as well
as put them to work in the shortest possible time, at the
*This article has been written expressly for publication in the
Journal-Lancet by the War Department Manuscript Board and is
released by E. L. Olrich, District Director of WMP Office for
Emergency Management, through Ellen L. Aird. Associate Train-
ing Specialist.
same time being fully aware of the safety of the patient,
personnel and equipment.
A plan to orient and instruct inexperienced workers
has been used by industry for about twenty years. At
first designed to train a person on the job in industrial
plants, it has recently been adapted to needed hospital
instruction programs by the Training Within Industry
Service, Bureau of Training of the War Manpower Com-
mission.
First introduced in the states of Nebraska, Iowa,
North and South Dakota, and Minnesota, which make
up a field district for T.W.I., under the direction of
E. L. Olrich, the Training Within Industry Service of-
fers to hospitals, at no cost to the institutions, a course
called Job Instruction Training.
The plan, briefly is this: Selected representatives from
various hospitals are given a thirty-two hour Institute,
over a five-day period, in how to instruct a person to do
a job correctly, quickly, and conscientiously. Each key
person attending this institute (chief dietitian, director
of nursing, nursing instructor, administrator, or any other
department head) who has given evidence of interest and
ability is given a certificate of recognition by our govern-
ment.
This certification qualifies him or her to instruct
groups of ten key people by giving ten-hour training
sessions, in his or her own institution.
Much of the best instruction in hospitals today must
of necessity be done on the job. The rapid turnover of
personnel leaves no other alternative. A planned method
of job instruction will help solve a large percentage of
such personnel problems.
The Job Instruction Training method has been used
in leading hospitals of Minnesota, Iowa, Maryland, New
York, Massachusetts, Ohio and many other states, in-
cluding those on the Pacific Coast. The participating
hospitals have written of the profit derived from this
training.
For further information write to your district director,
or to C. R. Dooley, Directpr, Training Within Industry
Service, Bureau of Training, War Manpower Commis-
sion, Washington, D. C.
260
The Journal-Lancet
AMERICAN STUDENT HEALTH ASSOCIATION MONTHLY NEWS-LETTER
HEALTH SERVICE AND THE WAR PROGRAM
The past year has witnessed many changes in health
service duties and policies to adapt them to present needs.
The following monthly report of the Health Service to
the University of Michigan, kindly contributed by its
Director, Dr. Warren E. Forsythe, is illustrative of the
multiple functions of a modern health service.
"The part played by the Health Service of the Uni-
versity war program to July 1, 1943, is summarized here-
with:
1. Training the Medical Corpsmen. During the spring
of 1942, as an early effort at preparing students for
some particular military service, members of the staff
arranged an evening course to give students some idea
of the duties of enlisted men in the medical services.
This was set up under advice of Army Medical Corps
Officers. It was elected by about 25 students during one
semester, but the course was discontinued upon the ad-
vice of the resident Medical Officer.
2. Preliminary Selective Service Examinations to Stu-
dents. At the request of Selective Service Board No. 1
here, preliminary examinations of students were done.
In most instances, these were for students registered else-
where and whose examinations were transferred to Ann
Arbor. The number examined was 441.
3. Enlisted Reserve Corps Examinations. Student ap-
plicants for admission to the Army, Navy, and Marine
Corps were given the very complete final type examina-
tion here at the request of these services. The number
examined was: Army 745, Navy 234 and Marine 47.
4. Assistance to Army Medical Corps Officers. Before
the real outbreak of war activities and since, the depart-
ment has given space and other assistance to the Med-
ical Corps personnel stationed here for duty with the
R.O.T.C. and non-student military matters.
5. Contract Medical Service. During the Spring
Term, about 400 students in the Specialized Training
program were given medical care upon contract with the
Army. This was based upon the service to which reg-
ular students were entitled, with some modifications. Ex-
perience with these groups required about 10 per cent
more hospitalization; otherwise it was about as for other
students.
6. Personal Advice to Students. There were many
services to students in the way of determination of health
conditions in relation to standards for volunteer services
in particular.
7. Service in War Related Organizations. Many mem-
bers of the staff were variously engaged in activities of
Red Cross Emergency Medical Service, and other civilian
organizations.
The Director is Chief of Emergency Medical Service
for Washtenaw County, and the Health Service building
with the entire staff has been organized as a Casualty
Station for service in case of disaster from enemy action.”
PERSONAL ITEMS
The medical staff of Queens College now consists of
Dr. Ruth I. Cudmore and Dr. Nathan A. Goldstein.
Dr. Goldstein is substituting for Dr. Charles M. Rieber
who is in military service.
The new director of Student Health at Long Island
College of Medicine is Dr. Duncan W. Clark, succeed-
ing Dr. Ernest E. Keet, Jr.
Dr. John E. Beck is Acting Director of the Depart-
ment of Student Health at the University of Virginia.
Dr. J. D. Farris, formerly College Physician at East-
ern Kentucky State Teachers College, is now University
Physician at Emory University.
Dr. A. O. Swenson, physician at Duluth State Teach-
ers College, is now on duty in the Navy.
There is a number of attractive positions open in
health services according to inquiries made through the
office of the Secretary-Treasurer.
A.S.H.A. DIGEST OF MEDICAL NEWS
A Safe and Efficient Nasal Vasoconstrictor. Fabricant,
N. D., and Van Alyea, O. E., report in the January
(1943) issue of the Am. J. of Med. Sciences that upon
104 human subjects the use of 0.1 per cent Privine H Cl
as a nasal constrictor was effective and unaccompanied
by unwanted side-actions such as tingling, smarting,
burning, apprehension, insomnia, tremor, palpitation, uri-
nary retention and skin eruptions. A 0.1 per cent solu-
tion of Privine H Cl is isotonic and has a pH of 6.2
which is approximately that of the nasal mucus of a
normal human being. It is not detrimental to ciliary
activity.
Immunizing Potency in Man of a Purified Antigenic
Material Isolated from Eberthella Typhosa. Morgan,
H. R., Favorite, G. O., and Horneff, J. A., in the J. of
Immun., May, 1943, report "A purified antigenic ma-
terial isolated from E. typhosa cultured in a synthetic
medium in total dosage of 0.1 mg., administered by sub-
cutaneous injection in man, has been demonstrated to
produce mouse-protective antibody in greater amounts
than 2.5 ml. of 2 standard vacterial vaccines. This re-
sponse was attained with less local constitutional reactions
than those following the use of the bacterial vaccines.”
Renal Glycosuria in Selectees and Volunteers. In a
study of 45,650 consecutive selectees and volunteers aged
18 to 45 years, the authors found glycosuria in 367 cases
(0.8 per cent). Further study of these 367 cases by re-
peated urine examinations and sugar tolerance tests of
those repeatedly positive, resulted in classification of the
cases into three groups, i. e. (1) 208 cases of diabetes
mellitus; (2) 126 cases of transient glycosuria; (3) 33
cases of renal glycosuria. "The diagnosis of renal glyco-
suria was made when the subject had a normal blood
sugar curve and specimens of urine contained varying
amounts of sugar after the ingestion of 100 mg. of dex-
trose.” There were no symptoms referable to the disease.
Joslin, Fitz, and Wilder are quoted as offering a good
prognosis, a normal life expectancy and no tendency to
August, 1943
261
progress to diabetes mellitus in these cases. (Harry Blot-
ner and Robert W. Hyde, JAMA., June 12, 1943) .
Smallpox Rapidly Disappearing in U . S. The May
(1943) issue of the Statistical Bulletin of the Metropoli-
tan Life Insurance Company reports new low records for
smallpox in this country. For the first time in history,
the number of smallpox cases fell below 1000, and the
smallpox deaths totaled less than 10 for the country as
a whole. It is pointed out that the number of cases in
relation to population is still generally high in the states
west of the Mississippi.
Rose Hips and Evergreens as Source of Vitamin C.
Studies of the fruit of the rose reveal the following
facts: (a) with stalk and flower residues removed, the
weight is approximately 1 gram; (b) an average rose hip
contains about 10 mg. of vitamin C; (c) 3 of these rose
hips contain as much vitamin C as will a good orange;
(d) on the dry basis 4.91 per cent of rose hip material is
ascorbic acid; (e) the rose hip crop of Alberta Province
alone is estimated at half a million tons per year, which
might yield 5000 tons of ascorbic acid (enough to give
140 million people 100 mg. of ascorbic acid daily for a
year) .
The same workers found that there are 103 to 317
mgs. of ascorbic acid in each 100 grams of fresh ever-
green leaves. The vitamin C content of evergreen leaves
is thus only about one tenth that of rose hips, but is
from 3 to 5 times higher than that of orange juice.
Hunter and Tuba, Canad. M. A. J. 48:30, 1943).
Experimental Production of Stones in the Bladder.
Hector Alfonso Davalos, Jr., in the May (1943) issue
of the J. of Urol., reports producing stones in the uri-
nary bladder of rabbits by means of a two-step procedure.
The first step includes instillation of 2 to 5 cc. of a
1:1000 alcoholic solution of salicylic acid daily for four
days into the urinary bladder in order to produce a chem-
ical cystitis. The second stage includes the instillation of
2 to 4 cc. of a 24 hour culture of Proteus bacilli intra-
vesically every fifth day, in order to maintain a chronic
infection in the bladder.
The Proteus culture used was one from a patient with
urinary lithiasis. It was selected because of its ability to
split urea in the urine, liberate ammonia, produce a sud-
den increase in the urinary pH, and favor the precipita-
tion of phosphates and carbonates.
Epidemic of Sonne Type Dysentery Stopped by Sulfa-
guanidine. Lt. J. C. Scott in the J.A.M.A. of June 26,
1943, reports the abrupt stopping of an epidemic of
Sonne type dysentery among a group of mentally handi-
capped children by giving 0.5 gram of sulfaguanidine
three times a day by mouth to all well children, and per-
sonnel exposed. No toxic signs or symptoms were noted.
An Outbreak of Ringworm of the Scalp. The May
(1943) issue of City of New York, Department of
Health Quarterly Bidletin reports an outbreak of ring-
worm of the scalp affecting "several scores” of children
in certain schools in the Borough of Queens. Transmis-
sion is considered to be by means of brushes, combs, hats
and towels. Diagnostic measures recommended are (1)
examination of hairs and scales microscopically of prepa-
rations made in 20 per cent potassium hydroxide (2) ex-
amination of hair for characteristic fluorescence in ultra-
violet light filtered through a Wood filter. (3) culture
of diseased tissues, hairs or scales. Recommended treat-
ment includes (1) topical antiparasitic application (2)
manual epilation (3) x-ray irradiation.
Nail Polish Dermatitis. W. H. Guy and F. M. Jacob
in the June 12 (1943) issue of the J.A.M.A. point out
the frequent occurrence of simple dermatitis with edema
of the eyelids associated with a dermatitis of varying
severity involving the neck. Such cases have been fre-
quently proven by patch tests to have been caused by
allergy to both colored and clear nail polish. All cases
cleared promptly when soothing lotions were used and
the nail polish discontinued.
Required Hygiene Teaching in High School. The
New York State Board of Regents, by new regulations
just distributed, (a) make it the duty of school trustees
and boards of education to provide a satisfactory pro-
gram in health and safety in accordance with the needs
of all pupils from the kindergarten through the high
school; (b) require that in junior and senior high school
grades, health must be taught by teachers with approved
preparation; (c) require that some member of each fac-
ulty with approved preparation must be designated as
health coordinator.
This extension of the teaching health and safety to the
high school will be accompanied by the provision of one
unit of credit for the new program.
Sensitivity to Sulfonamides. Data accumulated by the
Committee on Chemotherapeutic and Other Agents of
the National Research Council indicate that toxic effects
as the result of sulfonamide therapy occur approximately
as follows:
(a) Percentage of sulfonamide-treated patients show-
ing any toxic reaction (including fever, rash, anemia,
leukopenia, acute agranulocytosis, renal complications,
hepatitis) : sulfathiazole, 19%; sulfapyridine, 16%; sulf-
anilamide, 12%q sulfadiazine, 6.5%. (b) Percentage of
sulfonamide-treated patients showing fever or skin erup-
tion only: sulfathiazole, 10%; sulfanilamide, 10%; sulfa-
pyridine, 8%; sulfadiazine, 3 to 4%.
There is at present no simple test for detecting sulf-
onamide sensitivity other than giving a test dose of the
drug.
Use of Sidfadiazine in Controlling an Outbreak of
Scarlet Fever. The Burned News Letter of June 11,
1943, reports that an outbreak of scarlet fever at a
Naval Activity was brought promptly under control by
the prophylactic use of daily doses of 1.0 gram of sulfa-
diazine, over a period of several weeks. The command
was divided into two groups, one group starting the pro-
phylactic sulfadiazine immediately, the other group start-
ing only after a wait of three weeks. The incidence of
new cases of scarlet fever dropped sharply in the first
(treated) group during the first three weeks but con-
tinued high in the second (untreated) group. As soon as
diazine treatment was also instituted in the second group,
the same sharp drop in incidence of new cases occurred
as occurred in group 1. After 12 days treatment of both
groups, a complete remission in the scarlet fever occurred.
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn.
Montana State Medical Assn.
Dr. J. P. Ritchey, Pres.
Dr. M. G. Danskin, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-Treas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Treas.
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres. -Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
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., 1859-193 1 84 South Tenth Street, Minneapolis, Minnesota
W. L. Klein, 1851 1931
Minneapolis, Minnesota, August, 1943
CORONER OR MEDICAL EXAMINER
When the word coroner was first used to designate an
official whose duty it was to investigate cases of sudden
death to determine the cause, little was it known how ap-
propriate that title might appear in this day and age
when so many coroners’ cases are coronary cases. The
term seems to have stemmed from the Latin for crown,
when it was a crown officer’s duty to investigate, appre-
hend and arrest law violators. When the office of coroner
was created, it became his specialty to investigate the
mysterious deaths. In many of the United States now,
a coroner takes over the duty of sheriff on demise of the
latter, indicating a vestigial retention of this earlier and
broader concept of his functions as an officer of the
crown.
In several of the states, the office of coroner has been
replaced by that of " medical examiner,” in evident rec-
ognition of the fact that the office needs the acumen of
a man of medical training. In the majority of our states,
however, no such qualification is actually required by law.
It is our purpose here and now to contend for the neces-
sity of this further change. We can readily see how the
coroner may logically supplant a sheriff in certain med-
ico-forensic cases, but, by no stretch of imagination, can
the reverse be true. A layman is not properly qualified
to investigate the circumstances of a death supposedly
due to any but so-called natural causes. This calls for
more than intuition and " hunch.” It requires a perspi-
cacity that can be attained only through scientific study
and professional experience. There may be a shortage of
physicians, but surely not to the degree that any county
should have to forego the services of a man of medical
training in this important office.
A. E. H.
August, 1943
263
CLIMATIC PHYSIOLOGY, DOG DAYS,
AND LUNACY
Medical literature recently has been greatly taken up
with the dramatic effects of plasma and sulfonamides,
the treatment of military and industrial emergencies, and
with tropical diseases. Because human biological proc-
esses continue to function best under conditions of alter-
nating work and rest, it seems wise at this time to sit
down for a few minutes and think about the weather.
If it is any balm to your driving conscience, you may call
it climatic physiology.
The human body through its capillary system and
sweat glands regulates heat loss and maintains optimum
body temperature very well for a period of about ten
days of excessive heat. Then the cellular combustion rate
| declines. With this decline, there is impairment of effi-
I ciency in vital processes, mental activity, and immunity
to disease. It is after the first ten days of a heat wave
that instances of heat exhaustion are most frequent. Peo-
! pie living continually in tropical climates are retarded in
i growth, development, and fertility. Experimental work
with mice has shown that the minimal lethal dose of
' hemolytic streptococci for animals maintained in a tem-
perature of 91° F. is one-fourth of that for those kept
at 65°. Another thing that one hesitates to mention
above a whisper is that thiamine requirements are found
to be twice as high at 91° as at 65°.
On the other hand, according to C. A. Mills, the en-
ergizing effect of the cooler weather of northern states is
such that there is a high incidence of degenerative dis-
; eases, hypertension, neurasthenia, goitre, etc. Now is a
good time to decide whether you would rather burn out
in a whirlwind of activity or spend your days taking
quinine and fighting vectors under a palm tree.
It is also interesting to note the effect of storm or
cyclonic conditions on the prevalence of acute infections
such as appendicitis, upper respiratory infections, and
rheumatic fever. Comparison of weather charts and
health reports bears out this association in North Amer-
ica and the Philippines where cyclonic conditions are
found. Acute infections in the storm tracks of the Unit-
ed States are four times those of southern hemisphere
countries, such as Australia, where temperatures are the
same but cyclonic disturbances are rare. Interesting
studies of the physiological effects of climate have ap-
peared from time to time in monographs and articles,
but the subject is still full of speculation.
The dog days of late summer are attended by mood
disturbances and irritatibility, but their importance, like
that of the summer moon, is intangible. Nowhere in
readings on climatology does one find any reference to
the moon, but last night it was full and shone beauti-
ful across the hills and fields. It wasn’t a harvest moon
II or a June moon, but it was nevertheless a nostalgic, com-
pelling, heart breaking, vacuum-producing moon for one
person. She left the gay gathering of soldiers and their
friends to go out and sit alone with it. She said she went
out there because it was so beautiful, but she seemed to
be held there by something more. The same moon that
shone last night over the wooded hill was shining over
Guadalcanal, and the moon seemed very near.
That’s another thing that’s affecting us this summer,
but like the weather, there’s not much to do about it.
Unless it is to go back to work. L. M. D.
MILITARY SERVICE OPPORTUNITY
Realizing the civic interest of the medical profession
and reminding that the young manhood of the North-
west— so far as uniformed men are concerned — flows
through Minneapolis, Mrs. F. Peavey Heffelfinger, chair-
man of Women’s Activities, Minneapolis Defense Coun-
cil, asks for assistance for the Military Projects Division.
This division, in response to the invitation of the mili-
tary authorities to install much needed recreation rooms
for the Armed Forces, already has built and equipped
twenty-seven such rooms and fourteen more are in proc-
ess of being furnished.
Sponsorships to date include Navy Mothers Club,
Veterans of Foreign Wars, American Legion Auxiliary,
Jewish War Veterans, Edina Women’s Club, Colonial
Dames, B’nai B’rith and Rotary Club. Many organiza-
tions have donated funds in varying amounts. Contribu-
tions of work and time have been made by labor organi-
zations. Merchants have sent materials and furniture at
much less than cost.
Inasmuch as there are medical detachments assigned
to both arms of the service, and hospitals corps attached
to all units, there is logic in the request to medical
groups that they consider contributing lounge rooms, rec-
reation rooms and day rooms with a touch of home
atmosphere. No money is available from the army and
navy for this phase of morale maintenance. Any med-
ical body desiring to participate should call the Military
Projects Division of the Minneapolis Defense Council
at Main 5275 or visit the office in Citizens Aid Building,
Minneapolis. Meanwhile, doctors are invited to call at
the recreation rooms and/or any of the hundreds of
other service spots (which run from extra-coffee-ration
dispensaries to concrete tennis courts) and acquaint
themselves with the work.
BmU IUvJUws
Physiological Regulations, by E. F. Adolph. Lancaster, Pa.:
Jaques Cattell Press, 502 pages, 46 tables, 186 figures,
1943, price $7.50.
This is primarily an exhaustive and scholarly treatise on the
comparative physiology of water balance and associated phenom-
ena. It begins with a critical but interesting and informative
account of factual data about osmotic phenomena, and ends
with a philosophical, or perhaps theoretical, attempt to integrate
these data into an intelligible whole. Such an undertaking can
never be complete, or completely adequate, but it is clearly
desirable.
Adolph has shown very clearly how inadequate are the naive
attempts to account for physiological regulations in terms of
direct adaptations which have sometimes been suggested in the
past. He has emphasized the interrelations of variables in living
systems. This book is not easy reading, but it will constitute
interesting reading for the physician or biologist who expects to
get no practical instructions for treating patients but is satisfied
with broadening his background of factual knowledge and un-
264
The Journal-Lancet
demanding of physiological processes as they relate in one way
or another to osmotic regulation. A word should be said about
the importance of osmotic regulations. They are so important
to medicine, to physiology and to life itself that they are fre-
quently ignored. This is because when they are upset more
than a very little life is impossible for higher animals. The tre-
mendous importance of the problem is ignored simply because
it is taken for granted. The ingestion of water is harmless even
in relatively large amounts, only because the normal organism
is able to excrete it. And when it cannot be excreted, as in
severe nephritis, the physician does not ordinarily think of the
disturbance as one in osmotic regulation, but as kidney disease.
From a practical viewpoint the kidney disease is of great impor-
tance, to be sure, but it is no more important in guiding treat-
ment than is a thorough knowledge of the principles of water
and salt balance in health and disease. Only by an understand-
ing of the latter can a completely intelligent system of manage-
ment be achieved.
Adolph’s book is not apt to be a popular one, but it is a
very useful one, and represents a type of which there should be
many more in various fields of normal and pathological physiol-
ogy. Medical science today needs such scholarly integrations of
knowledge.
Allergy Anaphylaxis and Immunotherapy, by Bret Rat-
ner, M.D. Baltimore: The Williams & Wilkins Co., 834
pages, 1943, price $8.50.
Twenty years ago an increased interest in the field of im-
munology gave us much new knowledge concerning anaphylaxis
and, soon after this, improved methods of taking care of the
allergic patient were revealed. With time, however, the practice
of allergy began to drift away from the fundamental facts
originally established. In this book, the author makes a great
contribution, for he places the field of allergy anaphylaxis and
immunotherapy on a scientific basis. Many of the laboratory
investigations and much of the clinical research which has con-
tinued but has been more or less ignored by those interested in
allergy are revealed. No longer need the physician carry out
procedures without knowing the principles behind them, even
though they be in the field of anatomy, pathology, physiology,
chemistry, bacteriology or immunology. The gap in medical
literature, namely the absence of a monograph correlating the
up-to-date scientific and practical facts of allergy, has been
filled by this book and for this reason it is highly recommended
for students, investigators, and practicing physicians.
Laugh at the Lawyer Who Cross-Examines You: A Court-
room Antidote, by Charles L. Cusumano. New York: Old
Faithful Publishing Co., 375 pages, 1943, price $3.
This is not a technical book but a compilation of admoni-
tions, cautions and warnings regarding conduct on the witness
stand and the considerations on which that conduct is based.
Thirteen pages are devoted to medical testimony. According to
the author, doctors testify on (1) their qualifications, (2) con-
dition of patient and services rendered, (3) opinions, (4) value
of services. Since most doctors’ appearances in court are as ex-
pert witnesses for plaintiffs in accident cases, the book concen-
trates on such testimony. The first problem of the doctor is to
show the causal relationship between the accident and the
alleged injury to the plaintiff. The next most important question
asked is whether or not a particular injury is a permanent one;
another question may be whether or not a certain condition re-
sulting from an accident may give rise to other conditions not
yet apparent. Other possible lines of inquiry — Was the condi-
tion due to an earlier injury aggravated by this accident or was
it due entirely to the original accident? Was a blow caused by
a sharp or a blunt instrument? In the hands of another or
self-inflicted? (This being testimony of a medical-mechanical
nature the answers, coming from a doctor testifying as an ex-
pert, are admissible.) Can the injury be explained from the
x-ray introduced in evidence?
The author suggests a few guiding principles. If the amount
of the physician’s bill as testified to is made too great, it an-
tagonizes the jury, leading them to suspect a "frame-up” or a
"shake-down”. All questions of an hypothetical nature should
be faced squarely and answered at once with common sense, but
if they involve internal injuries the physician may take time for
investigation and research. If a broken bone will cause perma-
nent limitation of the use of a joint, the doctor should say so
unhesitatingly. Questions regarding prognosis call for study of
other case histories and, if possible, the citing of examples that
are a matter of record. If an injury is complicated, it is ad-
visable to call a specialist, obviating the possibility of a general
practitioner having to admit inexperience with such cases. The
original record or chart, complete, should be brought into court,
excerpts tending to arouse suspicion. Above all, opines the
writer, the physician is not to be intimidated but to "speak up,”
frankly and promptly and in simple terms.
The Inner Ear, including Otoneurology, Otosurgery and Prob-
lems in Modern Warfare, by Joseph Fischer, M.D., Staff
member, Beth Israel Hospital, Boston, and Louis E. Wolf-
son, M.D., instructor in Ear, Nose and Throat, Tufts Med-
ical School. New York: Grune & Stratton, Inc., 421 pages
with 77 figures and 7 tables, 1943, price $5.75.
This is an excellent treatise on the anatomy, general physi-
ology, applied physiology, functional tests and disease of the
labyrinth and its central pathways. Also, there are chapters on
war trauma and the role of the ear in aeronautics. Each chapter
is followed by an extensive list of references. The book can be
highly recommended to all clinicians who are interested in the
ear, whether they be otologists, neurologists or internists.
Principles and Practice of War Surgery, by J. Trueta,
M.D. St. Louis: C. V. Mosby Co., 425 pages, 144 illustra-
tions, 1943, price $6.50.
The essentials of treatment of war wounds, according to five
basic principles (prompt surgical treatment, cleansing of the
wound, excision of the wound, provision of drainage and im-
mobilization in a plaster-of-Paris cast) are elaborately covered.
Dr. Trueta makes no claim to being the first to describe these
principles, but considers his main contribution to be the com-
bining of established principles into a single, logical method of
treatment.
The book includes discussions on wound healing, infections,
shock, transfusions, chemotherapy, skin grafts and other sur-
gical problems, with emphasis on biological methods of treat-
ment. Clear, detailed descriptions and drawings, photographs
and radiographs make understanding easy. The work is a val-
uable aid, not only to the military surgeon, but to the civilian
surgeon and general practitioner as well. It is based chiefly on
experiences in the treatment of 1,073 patients by Dr. Trueta
and his colleagues in Barcelona in the Soanish Republican Armv
during the recent civil war, and more than 200 patients treated
at Wingfield-Morris Orthopaedic Hospital, Oxford, England.
Human Neuro- Anatomy, bv Oliver S. Stong and Adolph
Elwyn. Baltimore: The Williams & Wilkins Company, 422
pages, 1943, price $6.
This is an excellent work on the anatomy of the human nerv-
ous system. It is somewhat unusual, in that the authors have
incorporated some practical physiology and clinical applications
in their discussions of the anatomy. This approach certainly
lends a dynamic pattern to the purely anatomical descriDtions.
There has been no sacrificing of anatomical detail. The illustra-
tions are excellent and numerous. The descriptive style is simple
and easy to follow, and the physiological discussions have been
well summarized and are brief and up to date.
This book should prove most valuable as a textbook for stu-
dents. Though some of the functional and clinical concepts
may be a little advanced for students during their basic years,
the correlated information will be appreciated later when the
student enters his clinical training and has need for a review of
certain neuroanatomical concepts. As a reference book for those
especially interested in the nervous system, this publication
should prove invaluable.
August, 1943
265
Navy Doctors and Hospital Ships
An official release by the Office of War Information
EDITORIAL NOTE: On May 18th, the day on which the news-
papers carried the story of the dastardly sinking of the Australian
hospital ship Centaur by a Japanese submarine, periodicals in the
Northwest received a news bulletin which the United States gov-
ernment, through the Minneapolis regional office of OWI had sent
under the head "97 Per Cent of Navy and Marine Wounded Re-
covery from Injuries."* Of this release the following, having a
navy application, is a liberal excerpt:
The success of a certain hospital ship, which must re-
main unnamed, is one of the navy’s proudest achieve-
ments. She was at Pearl Harbor when the Japs struck,
and hundreds of the wounded were treated aboard her.
The doctors, nurses, and splendid equipment on the ves-
1 sel were responsible for saving many lives. This ship has
a remarkable record — during an extended period begin-
ning with the Solomon islands offensive in August, 1942,
the floating hospital cared for 4,039 patients — men
wounded by machine gun bullets, shell fragments; men
terribly burned, lacerated. Many fell on Guadalcanal,
others in sea engagements and aerial combat. Among
these 4,039 cases, only seven deaths occurred — a mor-
tality rate of 0.18 per cent.
What the mobile surgical units are to land forces,
hospital ships are to our sea fighters. These ships are
staffed by the most expert surgeons and doctors. Their
equipment is the equal of the equipment in the best met-
ropolitan hospital. Each ship has dispersed operating
and dressing rooms so that if one is put out of action
by damage to the ships, others will be available. The
ships carry specialists in surgery, medicine, eye, ear, nose
and throat, dentistry, physiotherapy, urology, and psy-
chiatry. They are used not only by naval forces but by
land forces. Lying close in to shore, wounded are trans-
[ ferred to these ships from field hospitals. Often patients
are aboard the ships a few hours after being hurt. Each
: i such vessel carries below decks a complete field hospital,
with tents, portable operating unit, power plant and am-
bulance. These stations are taken ashore in boats and
can be set up in time to serve any casualties resulting
from shore operation.
Battleships and aircraft carriers have their own hos-
pital units, all complete. Smaller war vessels, however,
may depend on the hospital ship. Radio informs the hos-
pital ship that wounded men are to be transferred. A
boat is sent. Patients are wrapped well in blankets and
transported in the Stokes stretcher — a shallow wire sup-
port, made in the shape of a man’s body with compart-
ments for the legs. These stretchers permit patients to
be moved from ship to ship comfortably.
^Figures are from Pearl Harbor to March 31, 1943.
The navy’s hospital ships today include the Solace and
the Relief, having 500 beds each. Three more have re-
cently been launched to be operated by a naval medical
staff. Another three, to be operated by the navy, but
manned by army doctors, will be completed in the near
future.
Then there are the special boats used by the navy to
rescue men from sinking vessels or aircraft disasters over
water. When an aircraft goes down, fast rescue craft
which skim along shallow creeks to the scene bring sur-
vivors ashore at speeds of 50 or 60 miles an hour.
There are specially constructed one-man packs contain-
ing all necessary equipment for the battalion aid stations,
which can be strapped to the back of the hospital corps-
man permitting him to have both hands free for climb-
ing down the side of hospital ships or debarking from
ambulance boats. For loading stretcher-cases aboard hos-
pital ships, hoists are used which lift a number of wound-
ed at once. As much as two days are saved this way in
getting aboard the casualties for transportation out of
the war area.
Of all navy and marine personnel wounded only 2.6
per cent died subsequently. Fifty-three per cent were
returned to duty. Still under treatment as of March 3 1
were 43.5 per cent. Invalided from service were 0.9 per
cent.
The breakdown of the figures shows: Naval officers
wounded, 61.6 per cent returned to duty; 35.9 per cent
were still under treatment; 0.2 per cent were invalided
from service; only 2.3 per cent died.
Of naval enlisted men wounded, 60.4 per cent re-
turned to duty; 35.4 per cent were still under treatment;
1.4 per cent were invalided from the service; and 2.8 per
cent died.
Of marine officers wounded, 46.8 per cent returned to
duty; 51.6 per cent were still under treatment; and 1.6
per cent died. None was invalided.
Of marine enlisted men wounded, 41.5 per cent re-
turned to duty; 55.9 per cent were still under treatment;
.4 per cent were invalided from service; and 2.2 per cent
died.
The particular problems met by doctors in the navy
are studied at the various naval medical training centers,
the naval hospitals located in many parts of the country.
Navy doctors not only serve on combat ships; they also
serve in amphibious commands, where they must adapt
themselves both to land and sea operations; they serve
with air units and with paratroops.
266
The Journal-Lancet
hews Item*
Dr. Harold A. Reif joins the staff of the Nicollet
Clinic, Minneapolis, August 1st, in the Department of
Urology, succeeding Dr. G. J. Thomas, who has left
for California. Dr. Reif comes from Cleveland General
Hospital and the Western Reserve University. While in
Cleveland, he was associated with Dr. H. R. Trattner,
well known urologist of that city. Previous to his being
in Cleveland, he was associated with Dr. W. M. Copp-
ridge, urologist, Duke University, Durham, North Car-
olina. Dr. Reif’s position with the Western Reserve Uni-
versity was that of Demonstrator in Urology.
Frank J. Hill, M.D., M.P.H., who has been acting
state health officer for North Dakota during the past
eighteen months, has been appointed state health officer
by the North Dakota public health advisory council for
a term of four years. June 21, Dr. Hill conferred with
the commissioners of Burke and Ward counties, looking
toward a union with several adjacent counties to form a
public health district as authorized by the 1943 state
legislature.
Dr. Lunsford D. Fricks tendered the Helena, Mon-
tana, city council his resignation as city-county health
officer to become effective August 31. Dr. Fricks relin-
quishes the position because poor health necessitates a
change of climate.
Dr. Frederick W. Orvedahl has left Preston, South
Dakota, after a residence of five years, to join four other
physicians in a clinic at Winton, Wyoming.
Dr. J no. J. Stratte, of Grand Forks, North Dakota,
having recently completed an internship at Ancker Hos-
pital, St. Paul, will open a general medical practice at
Warren, Minnesota, in which his father, Dr. Jos. I.
Stratte, will assist him in surgery.
Dr. Francis J. Pelant, practicing in New Ulm, Minne-
sota, since 1916, has removed to Owatonna.
Drs. Thomas J. B. Shanley and John R. E. Sievers of
Butte, Montana, attended the meeting of the Inter-
national College of Surgeons in New York City.
Dr. Leonard W. Brewer of Missoula, Montana, has
been appointed to assist in screenings for the selective
service of Missoula county.
Dr. Elvin L. Sederlin, district health officer with head-
quarters at Valley City, North Dakota, has instituted a
series of child-health conferences in Barnes county. Dr.
Sederlin has just returned from taking a course in public
health administration at Johns Hopkins University.
Lt. Comdr. Everett N. Jones, of Boise, Idaho, at one
time on the staff of Holy Rosary Hospital, Miles City,
Montana, and later practicing at Wolf Point, received
an official citation for meritorious service during a South
Pacific naval engagement in which the heavy cruiser on
which he was serving sustained heavy damage from Japa-
nese aircraft, the commander remaining at his station
until certain that all the injured had reached the safety
of the upper decks.
Dr. Robert Spratt of Butte, Montana, lately returned |
from a wedding trip with his bride, the former Helen
Frisbee, daughter of Dr. and Mrs. Jno. B. Frisbee of
Butte, has been commissioned a lieutenant, junior grade,
in the United States Naval Reserve and reported for
active duty at the naval hospital, Seattle, Washington, J
July 10.
Dr. William C. Bernstein, whose practice had been at
New Richland, Minnesota, prior to 1940 and at St. '
Paul since, is one of a group of University of Minnesota
Memorial Hospital doctors called to service July 1, and i
is stationed at Knoxville, Tennessee.
Dr. Myrtle Carney of Sioux Falls and Ft. Pierre,
South Dakota, supervisor of public nursing and the state
child health program for more than five years, is joining
her husband, Dr. Jas. G. Carney, who is physician at the
Dupont defense plant in Pasco, Washington. Other
fields in which Dr. M. Carney practiced are Armour and
Mitchell.
Dr. Henry O. Grangaard of Ryder, North Dakota,
has taken residence at Proctor, Minnesota.
Dr. Russell R. Heim, Hennepin county coroner, de-
livered the address of welcome to the delegates to the
sectional meeting of the National Association of Coro-
ners in Curtis Hotel, Minneapolis, July 9.
Dr. E. T. Bell, chief of the department of Pathology, .
University of Minnesota, was to have read a paper, 1
"The Medical Legal Autopsy from the Standpoint of
the Pathologist” at the conference of coroners, but con-
flict with a speaking date at the 65th annual scientific :
session of the Montana State Medical Association at
Billings caused a postponement of the Minneapolis ap-
pearance until the day following. Dr. Bell was the prin- I
cipal speaker at the Montana association’s banquet.
Dr. James Grassick, Grand Forks, North Dakota, the
dean of the state’s physicians, celebrated his ninety-third
birthday on June 30. He began his practice in Buxton
in 1885.
Service transfers involving northwestern physicians in-
clude removal of Capt. J. G. Sawyer of Mobridge, South
Dakota, from O’Reilly General Hospital at Springfield,
Missouri, to 45th Evacuation Hospital at Camp Gordon,
Georgia; of Lt. Col. D. N. Monseratte of Helena, Mon-
tana, from the station hospital at Camp Beale, Califor-
nia, to San Anselmo; of Capt. A. R. Gilsdorf of Dickin-
son, North Dakota, from the station hospital at Raine
Field, Washington, to March Field, Riverside, Califor-
nia; of Maj. Louis Sperling from Philadelphia to Ken-
nedy Hospital, Memphis, Tennessee; Dr. R. F. Hubner
of Yankton, South Dakota, from Station Hospital at
MacDill Field, Tampa, Florida, to Ardmore, Oklahoma;
Dr. T. W. Ferris of Chamberlain, South Dakota, from
the naval recruiting station at Salt Lake City, Utah, to
that of San Francisco, California. Major Mortimer A.
Lasky of Brooklyn is executive officer of the army air
base surgeon’s office at Great Falls, Montana. Dr. M.
Greengard, formerly of Rolla, North Dakota, is now at
the station dispensary, Ft. Barry, California.
August, 1943
267
The Montana State Medical Association annual meet-
ing was held July 7 and 8. It was preceded directly by
the semi-annual midsummer meeting of the Montana
Academy of Oto-ophthalmology, Dr. W. R. Morrison,
president. In conjunction with the state society’s meet-
ing, the women’s auxiliary of the State Medical Associa-
tion assembled, with Mrs. Eben J. Carey of Wauwatosa,
Wisconsin, president of the women’s national body, as
honor guest.
Dr. Arild Hanson of the department of pediatrics,
University of Minnesota school of medicine, spoke on
nutrition and rheumatic fever when the South Dakota
state health department’s division of maternal and child
health conducted its second annual institute in pediatric
dentistry the week of June 21. A series of one-day meet-
ings was held in Aberdeen, Huron, Rapid City, Yank-
ton and Sioux Falls.
The sanitary engineering division of the South Dakota
state board of health, in addition to the board’s "Health
Highlights,” now in its third issue as a monthly, has be-
gun to publish a Milk Plant News Letter in the opening
number of which it warns milk plant operators, city milk
inspectors and local health officers that less than 15 per
cent of the state’s milk plants have the equipment for
properly carrying out pasteurizing. It is the purpose of
the department to assist the plant operators to increase
their knowledge of sanitary procedures.
The National Foundation for Infantile Paralysis set
up at the University of Minnesota a special unit to study
exactly what happens in the human body when infantile
paralysis strikes, and the methods of treating the disease.
The Foundation has approved a grant of $175,000 for
the five-year period July 1, 1943, to June 30, 1948.
Building space and basic laboratory facilities are
already available. The unit will be under the general
direction of a committee composed of members of the
departments of physiology, neuropsychiatry and pediat-
rics in the Medical School of the University. Dr. Mau-
rice B. Visscher, head of the department of physiology,
will be in charge of administration.
Much progress has already been made at the Univer-
sity of Minnesota in the treatment of infantile paralysis.
It is a logical place for the further development of
studies of the physiological problems involved in the dis-
ease and the methods of its treatment.
These problems will require the coordinated efforts of
physiologists, biochemists, pharmacologists, pathologists,
anatomists, neurologists, pediatrists, orthopedists and
physical therapists. Ample funds have been provided
to secure technical assistance to conduct clinical investi-
gations.
The different departments of the Medical School will
set up a coordinated program which will investigate the
mechanics involved in the effects of various treatment
procedures, the disturbances in the nervous system which
produce the many different kinds of symptoms found in
infantile paralysis, the nature of the chemical changes
produced in the cells by the infantile paralysis virus, and
other related problems.
The funds which make this and other research pro-
grams of the National Foundation possible are raised
annually in January through the celebration of President
Roosevelt’s birthday.
A complete bibliography of all scientific literature that
ever has been published pertaining to infantile paralysis
is being compiled by the National Foundation for Infan-
tile Paralysis and is expected to be ready for publication
in book form in the early part of 1944.
The Association of Military Surgeons of the United
States will hold its fifty-first annual convention in Phila-
delphia at the Bellevue-Stratford Hotel, October 21-23.
The convention will assemble doctors from all the cur-
rent war fronts where United States armed forces are
fighting and from the great base hospitals where re-
habilitation of the wounded is in progress.
Physicians attending will have an opportunity to study
army and navy treatments of casualties at two of the
nation’s leading military hospitals, the U. S. Naval Hos-
pital, Philadelphia, and the U. S. Army Hospital at
Valley Forge, near the site of George Washington’s win-
ter headquarters in the bitter season of 1777-78.
The Medical Division of the Office of Civilian De-
fense recommends that hospitals throughout the United
States should make complete plans for the immediate
establishment, when needed, of gas cleansing stations for
the care of injured persons who have been exposed to
war gases. The local chief of emergency medical service
is responsible for the development of such stations, with
the advice of the senior gas officer of the community.
The primary purpose is the protection of hospital staffs
and patients from contamination by injured persons who
have been exposed to vesicant agents. Contaminated per-
sons who are not disabled are expected to cleanse them-
selves in the nearest private home or in other local facili-
ties.
Midwest Leads in Hospital Comfort Items Made
for Army and Navy by Red Cross Volunteers
American Red Cross volunteers have produced the
staggering total of 3,102,072 articles for the use of the
United States Army and Navy hospitals and the able-
bodied men in the armed forces within the past eight
months.
Exceptions to military regulations were the comfort
articles distributed to the men in hospitals: bathrobes,
hot water bag covers, pajamas, pneumonia jackets, sleeve-
less sweaters, afghans, bedroom slippers, bed shirts, bed-
side bags, pillows, pillow covers, quilts and socks.
Predominant on the list for Army were: wristlets,
turtle-neck sweaters, rifle mitts, cap-mufflers and other
warm apparel.
Navy needs were met with watch caps, "Iceland”
sweaters, helmets, sea boot stockings and scarves.
The Midwestern Area contributed the greatest amount
of hospital equipment with a total of 221,781 articles. In
the majority of cases, every area either equalled or ex-
ceeded its quota.
268
VUcAolOQty
Dr. William Crozier Fawcett, 65, of Starkweather,
North Dakota, died June 21 at his home. He settled in
North Dakota 42 years ago, practiced first at Drayton
and arrived in Starkweather the same day the first train
arrived. He was a charter member of the Devils Lake
district medical society and served two terms, 1924 and
1935, as president of the state association. He was also
a member of the state medical examining board, serving
as its president for five years of a seven-year tenure.
Four sons are doctors, Donald W., Newton W. and
John C. of Devils Lake, and Lt. Robert M. who left
five days before his father’s death to join an army med-
ical unit training at Carlisle Barracks, Pennsylvania.
Dr. Frank Eugene Towers, 92, of Minneapolis where
he practiced medicine for fifty-six years, died June 1 at
Minneapolis after an illness of three months. He was
former president of Hennepin County Medical Society
and, a generation ago, county coroner. His wife, who
preceded him in death by sixteen years, was a widely
known woman physician of Minneapolis.
Dr. George P. Connolly, 84, of Minneapolis, died
June 5 at Franklin Hospital. He had practiced medicine
in the state 45 years, including 23 years in his native
city, Minneapolis, prior to his retirement thirteen years
ago.
Dr. Joseph P. LaPointe, 52, Harvey, North Dakota,
died June 25 at Harvey, where he had practiced for 13
years. He was a native of Montreal, Quebec.
Dr. Edward W. Jones, 64, Mitchell, South Dakota,
died suddenly in bed at Mitchell of a heart attack July 6.
He was a 1906 graduate of Northwestern University
Medical School, Fellow of the American College of Sur-
geons, long examining physician for the Milwaukee rail-
road, past president of the South Dakota State Medical
Association and of the Mitchell District Medical Society.
In World War I he served overseas in the medical corps,
rising to a captaincy. His son, Dr. John Paul Jones, is
with the Armed Forces.
Dr. Homer Augustus Davis, 85, of Missoula, Mon-
tana, died at his home, June 27. He was a graduate of
Dartmouth Medical college, entering in 1890 and taking
up practice on graduation. He retired in 1928 after 36
years of continuous practice, during which time he was
never ill in bed. After his retirement he lived at Rapid
City, removing to Casper, Wyoming, in 1934, thence to
Arlee, Montana, a year later, and having come to Mis-
soula in September, 1942.
Dr. John L. Rothrock, 80, St. Paul, died July 5 at
Miller Hospital after an illness of four months. For
three years, beginning in 1896, he was assistant health
commissioner of St. Paul, and for some years he was an
associate professor of obstetrics and gynecology at the
University of Minnesota medical school.
The Journal-Lancet I
Dr. Frederick L. Ecker, 70, of Parker’s Prairie and
Bertha, Minnesota, died suddenly May 3 at Dalton,
Georgia. He was born in Byron, Minnesota, practiced
at one time in Benton Harbor, Michigan, and spent sum-
mers in Bertha.
Dr. Carl Abraham Fjelstad, 71, formerly of Minne-
apolis and for three years house physician at Mudbaden, ;
Minnesota, died May 16 at Spokane, Washington.
RED CROSS SCHOLARSHIPS IN SOCIAL
WORK OFFERED
Seventy-five Red Cross scholarships are available to I
selected persons eligible for training in approved schools |
of social work, Red Cross Home Service announced to- J
day. These are being made available to provide the or- |
ganization with a larger number of home service workers. |
The need for trained personnel in home service activi-
ties has increased with the rapid rise in requests for Red
Cross assistance from servicemen and their families, it
was pointed out. Requests for financial assistance, help
in filing claims for Government benefits as well as for
other special Red Cross services have jumped from a na-
tional average of 500 daily before Pearl Harbor to more
than 4,000 per day, according to nation-wide report from '
home service chairmen.
The scholarship plan is expected to help relieve the
shortage of trained personnel required by the Red Cross (
in fulfilling its obligations to the men of the armed
forces and their families. Upon completion of the schol- j
arship, students will be assigned to home service positions ;
as executive secretaries, supervisors, and case workers in
local chapters, and to area home service positions as
field representatives.
Candidates for scholarships must be between the ages |
of 22 and 40 years. They must be graduates of an
accredited college and acceptable for admission to schools
of social work accredited by the American Association of
Schools of Social Work.
Scholarships provide full tuition and an allowance of
$65 a month toward maintenance for a period of one
academic year.
The scholarship plan is under the immediate super-
vision of the home service directors in each of the four
Red Cross area offices: Eastern Area, 615 North St.
Asaph Street, Alexandria, Virginia; North Atlantic Area,
300 Fourth Avenue, New York City; Midwestern Area,
1709 Washington Avenue, St. Louis, Missouri; Pacific
Area, Civic Auditorium, Larkin and Grove Streets, San
Francisco, California.
Dr. H. W. Sybilrud, for twenty years physician and
surgeon at Bricelyn, Minnesota, has been stationed with
the U. S. Marine Corps in the South Pacific area for
some time. He volunteered on February 4, 1941, and
for a year and a half beginning October was at San
Diego, California. July, 1942, he was promoted from
lieutenant commander to commander. Mrs. Sybilrud is
at Blue Earth, Minnesota.
Minneapolis, Minnesota
September, 1943
Transactions of the Montana State Medical
Association
Sixty-fifth Annual Session
Billings, Montana
July 7 and 8, 1943
OFFICERS, 1943-44
J. P. RITCHEY, M.D., Missoula President
E. D. HITCHCOCK, M.D., Great Falls Past President
J. C. SHIELDS, M.D., Butte President-Elect
M. G. DANSKIN, M.D., Glendive Vice President
T. F. WALKER, M.D., Great Falls Scretary-Treasurer
J. H. IRWIN, M.D., Great Falls Delegate to A. M.A.
E. M. GANS, M.D., Harlowtown Alternate Delegate
COUNCILLORS
R. D. KNAPP, M.D. _ ... District No. 1 (1946)
CHARLES HOUTZ, M.D. . ... District No. 2 (1946)
J. H. GARBERSON, M.D. District No. 3 (1945)
L. W. ALLARD, M.D. .... District No. 4 (1945)
A. D. BREWER, M.D. District No. 5 (1944)
E. A. WELDEN, M.D. District No. 6 (1945)
F. B. ROSS, M.D. _ ...... District No. 7 (1946)
J. H. IRWIN, M.D. ... . District No. 8 (1945)
H. W. GREGG, M.D. District No. 9 (1944)
A. C. KNIGHT, M.D. District No. 10 (1946)
S. A. COONEY, M.D. District No. 11 (1944)
A. R. FOSS, M.D. District No. 12 (1944)
COMMITTEES
LEGISLATIVE COMMITTEE
HOSPITAL COMMITTEE
(3 years)
R. L. TOWNE, M.D. (1945) Kalispell
R. W. MORRIS, M.D. (1946) .. Helena
F. K. WANIATA, M.D. (1944) Great Falls
PUBLIC INSTRUCTION AND HEALTH COMMITTEE
AND PUBLIC RELATIONS COMMITTEE
(1 year)
M. A. SHILLINGTON, M.D. (1944).. .. Glendive
L. W. BREWER, M.D. (1944)... ... Missoula
R. G. LEMON, M.D. (1944) Glendive
CANCER COMMITTEE
(1 year)
J. H. GARBERSON, M.D. (1944) Miles City
R. F. PETERSON, M.D. (1944) Butte
J. H. BRIDENBAUGH, M.D. (1944) Billings
J. M. NELSON, M.D. (1944) Missoula
L. G. DUNLAP, M.D. (1944) Anaconda
HISTORY OF MEDICINE COMMITTEE
(1 year)
E. D. HITCHCOCK, M.D. (1944) Great Falls
T. F. WALKER, M.D. (1944) Great Falls
J. H. IRWIN, M.D. (1944) Great Falls
ORTHOPEDIC COMMITTEE AND ADVISORY COMMITTEE TO
STATE BOARD OF HEALTH
(1 year)
L. W. ALLARD, M.D. (1944) Billings
A. D. BREWER, M.D. (1944) Bozeman
J. K. COLMAN, M.D. (1944) Butte
F. R. SCHEMM, M.D. (1944) _ Great Falls
W. E. LONG, M.D. (1944) Anaconda
DENTISTS, PHARMACISTS AND NURSES COMMITTEE
( 1 year)
B. K. KILBOURNE, M.D. (1944) Helena
B. R. TARBOX, M.D. (1944) .. Forsyth
F. K. WANIATA, M.D. (1944) Great Falls
PROGRAM COMMITTEE
(3 years)
T. F. WALKER, M.D. (1945) Great Falls
M. A. SHILLINGTON, M.D. (1945) Glendive
H. W. GREGG, M.D. (1944) Butte
MEDICAL INSURANCE AND LEGAL AFFAIRS COMMITTEE
(2 each year, 4-year term)
P. E. KANE, M.D. (1946) Butte
J. C. MacGREGOR, M.D. (1947) Great Falls
GEORGE JESTRAB, M.D. (1946) . Havre
F. B. ROSS, M.D. (1946) Kalispell
J. H. BRIDENBAUGH, M.D. (1947) Billings
E. R. GRIGG, M.D. (1947) Bozeman
A. T. HAAS, M.D. (1947) Missoula
270
The Journal-Lancet
MEDICAL PUBLICATIONS COMMITTEE
(1 year)
A. R. FOSS, M.D. (1944) Missoula
A. J. KARSTED, M.D. (1944) Butte
S. A. COONEY, M.D. (1944) Helena
MEDICAL ECONOMICS COMMITTEE
(3 years)
J. C. SHIELDS, M.D. (1944) Butte
J. H. GARBERSON, M.D. (1944) Miles City
F. F. ATTIX, M.D. (1946) Lewistown
M. A. SHILLINGTON, M.D. (1946) Glendive
R. B. DURNIN, M.D. (1946) Great Falls
POSTGRADUATE COMMITTEE
(1 year)
A. R. FOSS, M.D. (1944) Missoula
S. V. WILKING, M.D. (1944) - Butte
A. R. KINTNER, M.D. (1944) Missoula
FRACTURES COMMITTEE
(1 year)
H. H. JAMES, M.D. (1944) Butte
T. B. MOORE, JR., M.D. (1944) Kalispell
I. A. ALLRED, M.D. (1944) Great Falls
H. J. HALL, M.D. (1944) Missoula
D. J. COOPER, M.D. (1944) Big Sandy
TUBERCULOSIS COMMITTEE
(1 year)
F. I. TERRILL, M.D. (1944) Galen
P. L. ENEBOE, M.D. (1944) Bozeman
E. M. LARSON, M.D. (1944) .... Great Falls
J. L. MONDLOCH, M.D. (1944) _ Butte
W. GORDON, M.D. (1944) Billings
ADVISORY BOARD, WOMEN’S AUXILIARY
(3 years)
J. P. RITCHEY, M.D. Missoula
E. D. HITCHCOCK, M.D Great Falls
J. C. SHIELDS, M.D Butte
C. H. NELSON, M.D Billings
D. T. BERG, M.D. Helena
EXECUTIVE COMMITTEE
J. P. RITCHEY, M.D Missoula
E. D. HITCHCOCK, M.D. _ Great Falls
W. E. LONG, M.D. Anaconda
T. F. WALKER, M.D. Great Falls
J. C. SHIELDS, M.D. Butte
INDUSTRIAL HYGIENE COMMITTEE
(3 years)
A. T. HAAS, M.D. (1946) Missoula
HAROLD SCHWARTZ, M.D. (1946) Butte
J. B. FRISBEE, M.D. (1946) Butte
L. M. FARNER, M.D. (1946) Helena
MEDICAL MILITARY PREPAREDNESS AND DEFENSE ACTIVITY
committee (1 year)
F. L. ANDREWS, M.D. (1944) Great Falls
R. V. MORLEDGE, M.D. (1944) .... Billings
W. A. LACEY, M.D. (1944) Havre
F. L. UNMACK, M.D. (1944) Deer Lodge
J. G. LAPIERRE, M.D. (1944) Butte
ROCKY MOUNTAIN CONFERENCE COMMITTEE
(1 appointed each year, 5-year term)
T. F. WALKER, M.D. (1945) _... Great Falls
T. L. HAWKINS, M.D. (1944) Helena
H. W. GREGG, M.D. (1948) Butte
C. H. NELSON, M.D. (1946) Billings
J. R. SOLTERO, M.D. (1947) Lewistown
NOMINATING COMMITTEE
F. F. ATTIX, M.D. (1944) Lewistown
L. G. DUNLAP, M.D. (1944) Anaconda
H. T. CARAWAY, M.D. (1944) Billings
MATERNAL AND CHILD WELFARE COMMITTEE
(3 years)
F. L. McPHAIL, M.D. (1944) Great Falls
D. L. GILLESPIE, M.D. (1944) Butte
G. A. CARMICHAEL, M.D. (1946) Butte
T. L. HAWKINS, M.D. (1944) Helena
L. W. BREWER, M.D. (1946) Missoula
P. L. ENEBOE, M.D. (1946) Bozeman
E. A. HAGMANN, M.D. (1944) Billings
R. L. TOWNE, M.D. (1944) _ Kalispell
W. A. MEADOWS, M.D. (1946) Sunburst
A. L. GLEASON, M.D. (1946) Great Falls
B. C. FARRAND, M.D. (1946) Jordan
E. A. WELDEN, M.D. (1946) Lewistown
J. DIMON, M.D. (1946) Poison
MAUDE GERDES, M.D. (1945) .. Billings
STATE INSTITUTIONS COMMITTEE
HAROLD GREGG, M.D. (1944) Butte
W. E. LONG, M.D. (1944) Anaconda
J. 1. WERNHAM, M.D. (1944 Billings
ANNUAL MEETING OF THE COUNCIL OF THE
MONTANA STATE MEDICAL ASSOCIATION
July 7, 1943
The meeting of the Council of the Montana State Medical
Association was called to order by President E. D. Hitchcock at
the Northern Hotel in Billings, Wednesday, July 7, at 8:30
P. M. The following councillors were present: Doctors J. H.
Garberson, E. A. Welden, H. W. Gregg, A. R. Foss, A. D.
Brewer, L. W. Allard, J. H. Irwin, L. G. Dunlap, and S. A.
Cooney.
The Council chose Dr. E. D. Hitchcock as Chairman. Min-
utes of the last meeting were read and approved. The Secre-
tary made his annual report, a copy of which is included in
these minutes. Upon motion regularly made, duly seconded,
and unanimously carried, the report was accepted.
Dr. Hitchcock appointed Dr. Allan Foss and Dr. Harold
Gregg as an auditing committee to audit the books of the
Association.
It was moved by Dr. Dunlap, seconded by Dr. Gregg, and
unanimously carried, that Mr. Toomey be retained as attorney
for the Association for the ensuing year at a fee of $300.
Dr. E. D. Hitchcock requested that the Council recommend
to the House of Delegates that $200 be made available for
stenographic work in connection with the work of the Historical
Committee, The Pioneer Physician. It was moved by Dr.
Irwin, seconded by Dr. Gregg, and unanimously carried, that
the Council recommend to the House of Delegates that $200 be
made available for the above mentioned purpose.
It was moved by Dr. Dunlap, seconded by Dr. Gregg, that
the Council recommend to each society that the secretary of
the society be asked to keep the history of the society from
1900 on.
The Councillors present reported upon conditions in their
respective districts, each of them calling attention to the fact
that in their district, peace and harmony prevailed; that regular
meetings were held; and scientific programs were a regular fea-
ture of their meetings.
Dr. Gregg of District No. 9 reported that he had received a
complaint from Dr. Farnsworth of Virginia City, that certain
physicians were consulting with osteopaths. Dr. Gregg read a
letter from Dr. Farnsworth which he submitted to the Council.
After a general discussion, the Council decided to follow Dr.
Allard’s suggestion that those doctors mentioned in Dr. Farns-
worth’s letter be talked to by the Councillor from their district,
who should call their attention to the fact that such consulta-
tions were considered unethical.
Dr. Dunlap called attention to the marked shortage of physi-
cians in the State Hospital at Warm Springs, and the lack of
funds to efficiently carry on the work of this institution. He
likewise called attention to the shortage of physicians in the
State Tuberculosis Sanatorium at Galen, as well as the extra
burden carried by the doctors in Anaconda, brought about by
the increase in employees of the Anaconda Copper Mining
plant there.
Dr. Garberson read a letter from Dr. Smith of Glasgow in
which Dr. Smith brought up the constitutionality of the
Thompson law and expressed his opposition to the provision of
this law. It was regularly moved, seconded, and unanimously
carried that the Secretary be instructed to get the opinion of
our counsel, Mr. Toomey, as to the constitutionality of this law.
Dr. Allan Foss read a letter from Dr. Klein, Secretary of the
State Board of Medical Examiners, in which Dr. Klein called
attention to the fact that Attorney Paul Keller of Helena had
September, 1943
271
rendered valuable service during the session of the Legislature
in securing the passage of the new Medical Practice Act, and
brought out that the Board of Examiners had no legal right
to pay Mr. Keller for his services. It was moved by Dr. Dun-
lap, seconded by Dr. Cooney, that the Association pay Mr. Paul
Keller $200 for legal services rendered in securing the passage
of the new Medical Practice Act. Motion was unanimously
carried.
Likewise, Dr. Klein requested the Council to inform him as
to their wishes regarding the amount of the annual re-registra-
tion fee. It was moved by Dr. Irwin, seconded by Dr. Gregg,
and unanimously carried that the Council recommend to the
House of Delegates that it recommend to the Board of Exam-
iners that the annual re-registration fee be $5.00.
There being no further business, the meeting adjourned.
Secretary’s Report to the Council
The past year has been rather a quiet one in so far as activi-
ties coming under the jurisdiction of the Council are concerned.
There have been no new county societies established in the
state, nor have any of our county societies gone out of exist-
■ ence.
The membership in the Association was four hundred sixty-
four (464) as of June 1st. This includes those members who
are in the armed services and are, therefore, exempt from pay-
ing dues. As you are aware, the dues at the last meeting were
increased from $8.00 to $10.00 per year. In so far as we can
determine, this has not resulted in the loss of any members,
although total receipts for the past year are about $475.00 less
than during a similar period of the preceding year.
Expenditures to date have been $99.00 less than during the
same period last year.
I am herewith submitting an audit report of the Medical
Association for the period June 15, 1941, to June 22, 1943,
i inclusive. This report was prepared by Mr. William B. Finlay,
Certified Public Accountant, of Great Falls, Montana, and I
respectfully request that the same be made a part of this report
and incorporated in the minutes.
The matter of a state journal need not be discussed at this
meeting since, agreeable to the instructions of the Council and
the House of Delegates at the last meeting, a contract was en-
tered into with the Journal-Lancet for five years.
Mr. E. G. Toomey, our counsel, was of great service to the
Association during the last session of the Legislature. Many
requests for his opinions were made by the officers of the Asso-
ciation, and his advice and assistance in Legislative matters were
found to be most valuable. It is urgently recommended that
his services be retained for another year.
Thomas F. Walker, M.D., Secretary.
FINANCIAL REPORT
June 15, 1941, to June 22, 1943, inclusive
RECEIPTS
June 15, 1941, Balance of cash on deposit in
Great Falls National Bank
6-15-41 6-15-42
to to
6-14-42 6-22-43
Blaine County Medical Society $ $ 8.00
Cascade County Med. Soc. 376.00 438.00
Chouteau County Med. Soc. 32.20 40.00
Fergus County Med. Soc. 88.00
Flathead County Med. Soc. 160.00 246.00
Gallatin County Med. Soc 144.00 180.00
Hill County Med. Soc. 80.00 70.00
Lake County Med. Soc. 56.00 10.00
Lewis St Clark County Med. Soc. 308.00 206.00
Madison County Med. Soc. 72.00 50.00
Mount Powell Med. Soc. 168.00 168.00
Musselshell County Med. Soc. .... 40.00 50.00
Northcentral Montana Med. Soc. 142.00 106.05
Northeastern Montana Med. Soc. 224.00 70.00
Park-Sweetgrass Med. Soc 80.00 90.00
Silver Bow County Med. Soc 400.00 426.00
Southeastern Montana Med. Soc. 264.00 290.00
Western Montana Med. Soc. 424.00 274.00
$1,228.11
Yellowstone Valley Med. Soc.
416.00
446.00
Interest on Government bonds
150.00
Loan, Great Falls National Bank
: 1,000.00
Sundry — Schedule No. 1
487.66
465.47
Total Receipts
$5,111.86 $3,633.52 8,745.38
Total to be accounted for
$9,973.49
DISBURSEMENTS
6-15-41
6-15-42
to
to
6-14-42
6-22-43
Interest Paid, Great Falls Na-
tional Bank
$ 21.00 $
41.67
Secretary’s salary
600.00
550.00
Telephone and telegraph
89.81
277.15
Supplies and expense
85.75
188.35
Traveling expense
83.14
85.00
Bank charges
6.67
4.32
Postage
41.95
27.96
Flowers
26.20
41.00
Medical Economics Committee .
27.51
14.77
Delegate to A.M.A.
160.95
219.00
Officer’s meeting
166.50
72.20
1941 Annual Convention
986.85
Procurement and Assignment
Committee
120.04
74.65
Cancer Control Committee
29.15
Loan, Hospital Service Assn. _
1,000.00
Attorney’s retainer, Toomey, Me-
Farland and Chapman
300.00
300.00
Subscriptions, Journal-Lancet.
490.00
Auditing expense
115.00
Secretary’s bond
20.00
20.00
Safety deposit box
3.33
3.60
Dr. T. F. Walker (see Schedule
No. 1)
121.82
Refund of dues
10.00
1942 Annual Convention
11.00
1,231.68
Equipment, viewing box
81.64
1943 Legislature expense
175.27
Executive Committee
8.44
$4,516.67 $3,416.70
Total Disbursements
$7,933.37
Balance of cash on deposit in Great Falls
National Bank, June 22, 1943
2,040.12
Total accounted for
$9,973.49
Schedule No. 1
6-15-41
to
6-14-42
Refund, Thos. F. Walker, M.D. $121.82
Traveling expense refund (Western Airlines) 2.31
General Electric X-ray Corporation 25.00
Borden’s Milk Co. 50.00
Sego Milk Co 50.00
Mead Johnson St Co. 50.00
Lederle Laboratories 50.00
Refund, Procurement & Assignment Com 13.53
Sandos Chemical Works, Inc. 25.00
Riggs Optical Co. 50.00
American Optical Co. 50.00
Physicians St Hospitals Supply Co., Inc.
E. R. Squibb St Sons
Eli Lilly St Co.
Schadell Sanitorium
Upjohn Co
Cutter Laboratories
Phillip Morris Co
Morning Milk
Refund, traveling expenses (Dr. T. F.
Walker) .
6-15-42
to
6-22-43
$50.00
50.00
50.00
50.00
25.00
50.00
50.00
50.00
38.47
272
The Journal-Lancet
John Wyeth & Bro. 50.00
Error in posting by Great Falls Natl. Bank 2.00
Total . #487.66 #465.47
RECONCILIATION OF ACCOUNT WITH THE
GREAT FALLS NATIONAL BANK
June 22, 1943
Balance as per bank statement, June 22, 1943 #2,112.32
Less: Outstanding Checks, viz.:
June 16, 1943 —
To Dr. E. D. Hitchcock, Ck. No. 269, #34.97
June 21, 1943 —
To Dr. J. P. Ritchey, Ck. No. 270, 37.23 72.20
Balance as per Cash Book, June 22, 1943 #2,040.12
INVESTMENT ACCOUNT
Negotiable Promissory Notes — Hospital Service Asso-
ciation of Montana, dated July 24, 1941, due on
demand with interest at 6% #1,000.00
U. S. Treasury Bond, No. 16127H #5,000.00
(Held as security by Great Falls National Bank on
loan of #1,000.00.)
Equipment: Viewing Box (purchased July 13, 1942).# 81.64
secretary-treasurer’s fidelity bond
Thomas F. Walker, M.D. #4,000.00
Thomas F. Walker, M.D., Secy.-Treas.
PROCEEDINGS
of the
HOUSE OF DELEGATES
SIXTY-FIFTH ANNUAL MEETING
of the
MONTANA STATE MEDICAL ASSOCIATION
First Session, Wednesday, July 7, 1943
The session of the House of Delegates was held in the
Northern Hotel in Billings, Montana, July 7 and 8, 1943. The
session was called to order at 9:00 A. M. Wednesday, July 7,
by the President, Dr. E. D. Hitchcock. A roll call of delegates
showed present the following delegates:
Chouteau County — None.
Cascade County — Drs. J. H. Irwin, F. L. Andrews, F. D.
Hurd, R. J. McGregor.
Gallatin County — Drs. R. E. Sigler, A. D. Brewer.
Hill County — None.
Fergus County — Drs. F. F. Attix, J. R. Soltero.
Flathead County — None.
Lake County — None.
Mt. Powell — Drs. F. I. Terrill, L. G. Dunlap.
Northcentral — Dr. H. F. Schraeder.
Northeastern — Dr. H. B. Cloud.
Park-Sweetgrass — None.
Silver Bow County — Drs. H. W. Gregg, R. F. Peterson, R.
C. Monahan, J. C. Shields.
Southeastern — Drs. M. G. Danskin, B. C. Farrand.
Madison — Dr. R. B. Farnsworth.
Lewis and Clark County — Drs. D. T. Berg, R. W. Morris.
Western Montana — Drs. W. J. Marshall, C. A. Farabough,
A. M. Blegen, A. D. Brewer.
Yellowstone — Drs. L. W. Allard, R. V. Morledge, J. H.
Bridenbaugh, J. I. Wernham, C. H. Nelson, H. T. Car-
away, Wayne Gordon.
A majority of the delegates being present, the House of Dele-
gates proceeded with the business of the Association. It was
moved, seconded, and unanimously carried that the reading of
the 1942 minutes be dispensed with, since they had been pub-
lished in the official journal of the Association. The Secretary
read his report to the House of Delegates. It is incorporated
with and constitutes a part of these minutes.
REPORT OF SECRETARY
Aside from routine matters, the problems brought about by
a session of the legislature have required the most attention of
your officers and committees.
As you doubtless know, there were introduced in the Senate
three measures by the chiropractors. It was the opinion of the !
Executive and Legislative committees that the passage of such
measures would result in grievous harm to the citizens of our i
state. Therefore, strenuous efforts to secure the defeat of these
measures were made by the above mentioned committees.
Owing to the fact that the chairman of the Legislative Com-
mittee was away, the above mentioned measures had been ap-
proved by the Judiciary Committee of the Senate, before your j
officers and members of the Legislative Committee got busy.
However, we were able to have these measures recalled by the
Judiciary Committe. At a hearing before this committee your ;
officers and members of the Legislative Committee gave evidence
which resulted in the committee turning in an adverse report
on two of these measures. After much delay the report of the i
committee was adopted and the measures definitely killed. One
bill introduced by the chiropractors was passed. This, however,
had to do only with penalties invoked for violation of the Chi- i
ropractic Act. Since it was no concern of ours, we did not
oppose this bill which was passed.
At a meeting of the Executive and Legislative committees
held at the Montana Club early in the session, the committees
went on record as unanimously endorsing the new Medical Prac-
tice Act which had been introduced by the State Board of Med-
ical Examiners. Members of the Executive and Legislative com-
mittees appeared before the the committee of the House to
whom the new Medical Practice Act had been referred. These
members were successful in combating an amendment asked j
for by the chiropractors, which would have taken all the teeth
' out of the bill insofar as the chiropractors were concerned.
After considerable delay the new Medical Practice Act was
passed by both houses without any amendments whatsoever.
In order to kill the chiropractic bills and secure the passage
of the new Medical Practice Act it became necessary, in the
opinion of the officers and members of the Legislative Com- !
mittee on the job, to withdraw opposition to the Board of
Health Bill. This bill had behind it one of the strongest lobbies
of the session. We had opposed this bill before the committee I
in the Senate to which it had been referred and had their prom-
ise to turn in an adverse report, although the bill had passed
the House without a dissenting vote. However, when it became
quite evident that the final killing of the chiropractic bills and
the passage of the Medical Practice Act to the House were
tied up because of our opposition to the Board of Health bill,
we decided to withdraw such opposition after having consulted
with Mr. Toomey.
We did, however, secure an amendment to this bill. As
originally introduced, it provided that the Board of Health
should consist of three doctors, President of the Food Control
Board, and the President of the State Board of Pharmacy. We
withdrew our opposition to the bill only after the sponsors had
consented to amend it so that five doctors would be on the
Board, together with the other two above mentioned members.
We were somewhat handicapped in our opposition to the bill by
the fact that the State Board of Health had expressed no offi-
cial opinion regarding this bill.
Your Secretary greatly regrets that the pressure of other mat-
ters made it impossible for him to accompany the other officers
on their annual trip which was this year considerably shortened
due to the need to conserve rubber and gasoline.
Thomas F. Walker, M.D., Secretary.
It was regularly moved, seconded, and unanimously carried
that the report be adopted as read.
The Secretary, Dr. Thomas F. Walker, then read the follow-
ing report of the Council to the House of Delegates:
The Council of the Montana State Medical Association in
regular session at Billings, Montana, July 6, 1943, recommends
to the House of Delegates:
1st. That the House of Delegates make available to the
Medical History Committee the sum of #200 for stenographic
work in connection with the work on The Pioneer Physician.
September, 1943
273
2nd. That the House of Delegates make available #200 to
pay Attorney Paul Keller for his efforts during the session of
the Legislature in securing the passage of the new Medical
Practice Act introduced by the State Board of Medical Ex-
aminers.
3rd. That Mr. E. G. Toomey be retained as counsel for the
Montana State Medical Association for the calendar year 1944
at a fee of #300.
4th. That the House of Delegates recommend to the State
Board of Medical Examiners that the annual re-registration fee
be #5.00.
Respectfully submitted,
E. D. Hitchcock, M.D., President of Council.
The House of Delegates proceeded to ballot upon the vari-
ous recommendations made by the Council. It was regularly
moved, seconded, and unanimously carried:
1st, That Mr. Paul Keller be paid #200;
2nd, That #200 be made available to the Historical Com-
mittee;
3rd, That Mr. E. G. Toomey be retained as Counsel for the
Montana State Medical Association for the calendar year
of 1944 at a fee of #300;
4th, That it be recommended to the State Board of Medical
Examiners that the annual re-registration fee be #5.00.
Dr. E. D. Hitchcock appointed the following committees:
Necrology, Drs. M. A. Shillington, L. W. Brewer; Resolutions,
Drs. J. C. Shields, J. H. Bridenbaugh.
Dr. Allen Foss reported for the Auditing Committee that
the Secretary’s books were found to be in order as shown by the
audit of Mr. William B. Finlay, Certified Public Accountant,
of Great Falls, Montana. It was regularly moved, duly second-
ed, and unanimously carried that the report of the Auditing
i Committee be accepted.
REPORTS OF STANDING COMMITTEES
The following committees made their reports which are in-
corporated in and become a part of these minutes:
Child Welfare and Maternal Health
Dr. G. A. Carmichael, Chairman
The 1941 report of the U. S. Bureau of Census credits Mon-
tana with the lowest maternal mortality rate ever recorded for
any state in the Union — 16 maternal deaths per 10,000 live
births. The U. S. rate for the same year is 32 deaths per 10,-
000 live births. The maternal death rate has steadily declined
for the past 10 years. In 1932 the rate was 66; in 1936 — 55;
in 1940—31; and in 1941 — 16.
The provisional rate for 1942 is 23. In this year there were
27 maternal deaths and 6 deaths associated with pregnancy.
Infection, toxemia and hemorrhage together caused 78 per cent
of all maternal deaths. The separate percentages are given
below:
Infection 10 deaths, or 37.0%
Hemorrhage 6 deaths, or 22.2%
Toxemia 5 deaths, or 18.5%
The remaining puerperal deaths (6, or 22%) were assigned
to a variety of causes.
If Montana rates are to be further reduced, greater attention
must be given to these three large factors: infection, hemor-
rhage, and toxemia. Infection in obstetrics can be decreased by
a return to more conservative methods of delivery; by less fre-
quent vaginal manipulation; by more early consultations (before
the optimum time for radical delivery has passed) , and by more
frequent early blood transfusion. Regarding hemorrhage it may
be said that, among these 27 maternal deaths reported for 1942,
there were 12 patients whose death questionnaire showed some
type of hemorrhage during the natal or postnatal period. For
only 2 of these 12 patients was blood transfusion reported as
part of the therapy and blood plasma was given in one other
case. None of the six patients whose deaths were considered
due to hemorrhage, received a blood transfusion according to
reports given.
Three patients in 1942 died following abortion. Deaths from
abortion, induced, spontaneous, or therapeutic, can be reduced
to a minimum by conservative methods of treatment. No pa-
tient who has missed a menstrual period and is bleeding va-
ginally should be examined vaginally without taking strict sterile
precautions. All patients with abortions who show fever should
for purposes of management be considered infected, as they
were probably induced by self or by another person, regardless
of a negative history. There should be no intra-uterine manipu-
lations such as dilatation and curettage, uterine irrigations, or
uterine packings in any febrile patient who is even suspected of
having an abortion, unless uterine bleeding is so severe that
such intervention is absolutely necessary. Even then, the uterus
should not be violently or roughly curetted, but loose tissue
should be gently removed with ring forceps and, if bleeding
continues, packing may be necessary. Blood which is lost during
the abortion must be replaced if the patient’s resistance is to be
maintained. Plasma should be always available for the early
treatment of severe bleeders.
Deaths from toxemia will decrease when our prenatal care im-
proves and when patients are given better attention during labor,
delivery, and postpartum.
Three of the 27 maternal deaths followed ectopic pregnancy.
Here again, blood transfusion or plasma must be used in pre-
paring patients for operation and during operation itself, if mor-
tality rates are to be reduced. More attention must be given to
diagnosis. Every woman in the child-bearing age with a history
of irregular vaginal bleeding must be suspected of the possi-
bility of an ectopic gestation. Two of the three patients with
ectopic pregnancy in 1942 died before operation.
Nine, or 33.3 per cent, of the 27 maternal deaths were pre-
ceded by some type of operative procedure. The nine operations
are listed below:
Cesarean section . 2
Mid forceps . — 2
High forceps 1
Low forceps 1
Laparotomy for tubal pregnancy 1
Manual dilatation of the cervix 1
Dilatation and curettage 1 1
Selection of necessary obstetrical operations requires expert
consideration of all the aspects of each particular case, by per-
sons who are qualified by experience and training. Expert skill
and judgment is essential to the successful execution of the op-
eration chosen. Anything less will result in unnecessary ma-
nipulations and a higher maternal and fetal death rate. It is
highly recommended, therefore, that consultation be obtained
before all obstetrical operative procedures excepting simple out-
let forceps.
Of the six deaths associated with pregnancy, three followed
pneumonia, two followed nephritis and one followed an auto
accident in which the patient suffered complete severance of
the spinal cord. None of these deaths were included in the esti-
mation of the maternal death rate for 1942.
The physicians of Montana can take pride in the record of
recent years. Our goal should be to maintain this record and
not let it be a happy accident for one or two years. The Com-
mittee expresses appreciation of your cooperation given in mak-
ing this study, through the return of questionnaires on mater-
nal deaths. Interest is evidenced by more complete notations
which give data necessary to interpret true cause of death. The
questionnaire in itself is of limited value without additional
notes, and we urge that every physician receiving a question-
naire endeavor to give all pertinent factors influencing the case.
Attention is also called to the importance of assigning the
proper cause for death on the death certificates, filing a birth
certificate for every live or still-born infant, and completing the
data requested on the birth certificate in full. These records
form the only basis for accurate study of our problems.
INFANT MORTALITY
In 1941 the U. S. Bureau of Census reported the infant mor-
tality rate for Montana as 37 infant deaths per 1000 live births
as compared with a rate of 47 in 1940, and 30 for the U. S.
in 1941. There were still 16 states with rates lower than the
Montana rate in 1941. The provisional 1942 rate shows fur-
ther reduction with a rate of 34 per 1000 live births, but fig-
ures for the first five months in 1943 show an upward trend.
The basic problem remains the same. Sixty per cent of these
infant deaths occur during the neonatal period and approxi-
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mately half of these are premature or immature infants. It is
recognized that infants weighing 1000 grams or less have prac-
tically no chance of survival regardless of care, but approxi-
mately one-third of the infants weighing 1000 to 2000 grams
may be saved if given the full benefits of modern nursing and
medical care, and 90 per cent of the infants weighing 2000
grams or more may be saved.
There are now facilities for premature care in practically every
center in the state. The incubators which were built by the
Montana State Board of Health have proved to be most effi-
cient. Demands for more of these incubators have been made
in a number of areas, but war conditions have precluded the
probability of building these at present. But incubators alone
cannot save these infants. The Nursing Consultant in the Ma-
ternal & Child Health Division of the Montana State Board of
Health, who is trained in care of premature infants, has dem-
onstrated the use of the incubator and nursing technics to nurs-
ing staffs in hospitals and discussed procedures with physicians
in these areas. Observations during the past year emphasize the
need for better nursing technics not only for care of premature
infants but for normal newborn as well. Physicians must give
closer supervision if these infants are to be given better chances
for life and well being. Standards for care must be developed
and carried out. With limited nursing personnel and limited
qualifications of many now serving in the hospitals, eternal vigi-
lance is imperative if we are to avoid such hazards as epidemic
diarrhea in our nurseries, which has occurred elsewhere.
Too many infants are placed on artificial feeding before dis-
charge from the hospital without any attempt to establish lacta-
tion or teach the mother technic of breast feeding.
Too few hospitals and physicians have availed themselves of
the services offered through the State Board of Health in this
program, when there are premature infants in the nursery to
serve as teaching material for demonstration of technics by
trained nursing consultant.
The infant mortality rate in Montana can and should be
lowered, but there will be no appreciable change until we take
concerted action regarding care of the infant during the neo-
natal period — especially in the first day and first week of life.
The stillborn rate remains practically the same and this pro-
gram, of course, is primarily related to prenatal and natal care.
Attention is called to the fact that as of July 1, all infants
born dead after 20 weeks of gestation, must be registered as
still births instead of after 24 weeks, as heretofore.
PREMATURE PROGRAM
The general aspect of this program has already been men-
tioned from the state-wide point of view. Detailed outlines of
technics have been prepared for use in hospitals. In addition,
a more intensive program was initiated in Great Falls, in co-
operation with the Deaconess and Columbus hospitals and in
conjunction with the Cascade City-County Health Unit. A
qualified supervisor was appointed from the state staff to set up
and carry on a premature care demonstration. It was the plan
to have premature nurseries in each hospital, training not only
nursing personnel of these hospitals but also graduate nurses
from other hospitals and private duty nurses. It has not been
possible to date to carry out the plans as originally outlined,
primarily because of limited nursing personnel. However, this
supervisor, in addition to assuming responsibility for the pre-
mature care in each hospital as requested, has worked with
supervisors of obstetric services and the newborn nursery to
study and improve technics of nursing care. It is hoped that,
with modifications, it will be possible to carry out the original
plan for a premature center as a demonstration of how this
problem may be met and to provide facilities for training of
other nursing personnel.
MATERNITY HOSPITAL LICENSING
Rules and regulations for maternity hospitals and homes have
been formulated by the Division of Maternal and Child Health
of the Montana State Board of Health in cooperation with your
committee. These have been distributed to all the institutions
taking obstetrical cases in the state, as well as to all the physi-
cians.
It is the intention of the proper authorities to conduct four
types of inspection of all institutions applying for license —
namely, medical inspection, nursing inspection, sanitary inspec-
tion, and fire inspection. Thus far, about 60 medical, 120 nurs-
ing, and 50 sanitary inspections have been completed. Licenses
will not be granted until all four inspections are accomplished
and the institution has been found to come up to at least the
minimum standards of its particular class.
A survey of the inspections already made indicates that the
same difficulties are being encountered in a large number of
different institutions. The following factors are important from
the medical standpoint:
(a) Hospital superintendents state that they have great diffi-
culty in getting physicians to complete their obstetrical records.
(b) Hospital authorities again complain of the physicians’
failure to cooperate in observing the rules of the obstetrical and
newborn departments. Physicians still enter nurseries, delivery
rooms and operating rooms without caps, masks, and gowns.
(c) Consultation on all operative obstetrical cases is not yet
routine among the various hosptials.
(d) Too often, no examination of the newborn is made by
the physician and care of these infants is relegated to the nurs-
ing staff without adequate medical supervision.
(e) Breast nursing is not being stressed and urged sufficiently
during the hospital stay. This requires unnecessary artificial
feeding and creates additional nursing problems.
The physicians of Montana are respectfully and earnestly
asked to cooperate in correcting the above factors. The work of
nurses in the hospitals can be greatly lessened if the physicians
will meet and establish common technics and procedures for
obstetric and new-born care. The rule of consultation before
operation must be the result of a concerted action on the part
of the hospital medical staff. The various staffs are hereby
asked to meet and see that such regulations concerning consul-
tation are passed and become hospital routine.
It is further recommended that the medical staff be thor-
oughly familiar with the rules and regulations governing ma-
ternity hospitals and the standards recommended, so that re-
sponsibility for meeting these standards will be shared with hos-
pital administrators and nursing personnel. The medical staff
should be fully cognizant of the technics being used and condi-
tions under which care is given to patients hospitalized by them
and should assume full responsibility for bringing standards of
care to optimal level. This becomes increasingly more impor-
tant under present conditions, when nursing personnel is being
depleted and is often inadequate. The procedures must be
studied and modified to meet existing conditions if patients are
to be protected.
POSTGRADUATE EDUCATION
Postgraduate courses in obstetrics and pediatrics were not
planned this year because of national conditions. However, a
number of men have signified their desire for continuation of
this program and indicate that they feel this type of instruc-
tion is more than ever necessary.
Many physicians are now doing obstetrics and pediatrics who
have not engaged in this practice to any extent for a number of
years. The so-called "refresher” courses, therefore, have increas-
ing value at this time. Under present conditions many physi-
cians cannot avail themselves of postgraduate opportunities in
more distant centers and with heavy case loads have limited
time for reading. The postgraduate sessions offer an oppor-
tunity for reviewing normal obstetrics and pediatrics and recent
developments in modern methods and technics.
Local medical societies should meet regularly and offer a
planned program for medical discussions including problems of
obstetrics and pediatrics. The Assistant Director of the M-C-H
Division is a qualified obstetrician, and his services are available
for local meetings. Discussion of the maternal mortality study
were presented by him to the Cascade County Society and the
Southeastern Medical Society during the past year. When in
the area, he is also in a position to discuss individual case prob-
lems with physicians who may desire his consultation on such
cases.
EMERGENCY MATERNITY AND INFANT CARE PROGRAM
This program was initiated in Montana the latter part of
April, at which time all physicians and hospitals of the state
were advised of the plan and procedures to be followed in order
September, 1943
275
to make application for medical and hospital care of wives of
enlisted men of the fourth to seventh payroll grades. Federal
funds for this program were requested by the State Board of
Health only after physicians and hospitals were canvassed to
determine whether a sufficient number wished to participate in
this program. In making this special appropriation, the gov-
ernment has recognized that the allowance for these wives is not
adequate to pay for medical and hospital care, and the wives of
men who are serving in the armed forces should not be obliged
to turn to charity for care, or be considered indigents. Physi-
cians, as a whole, have also recognized their obligations to the
men who are in service, as these men must be assured that in
their absence their wives and families will receive adequate care.
The details of this program are known to you, but the com-
mittee wishes to call attention to some of the problems encoun-
tered in setting up the administrative details and in the admin-
istration of the program. This program is on a nation-wide
basis under the administration of the U. S. Children’s Bureau.
Your committee met with the staff of the Montana State Board
of Health, which is responsible for the administration of the
program in Montana, to advise regarding the modifications nec-
essary to meet conditions in this state, which would also be
acceptable to the U. S. Children’s Bureau. Your committee can
report that every effort was made to formulate a plan that
would be acceptable to the medical profession in the state, and
every effort was made to administer this program with the min-
imum of "red tape’” and clerical work. All of the funds must
be used for medical and hospital care and cannot be used to
cover administrative costs. Your cooperation is sought with
regard to the following difficulties:
(1) While applications were accepted on a retroactive basis
in the initiation of the program, so that the patients would not
be deprived of the benefits, it is absolutely necessary for physi-
cians to file applications without delay. Funds are allotted on
the basis of applications on file at the beginning of each month.
Authorization must be forwarded to hospitals so they may
know the basis on which a patient is admitted, as the plan does
not permit use of private room facilities. All payments must be
made to the hospital or to the physician, no payment can be
made to the patient. If the hospital has not received authoriza-
tion, payments ma" be accepted in advance and difficulties en-
countered. Privilege of phone or wire to the State Board of
Health in an emergency is allowed, with cost of payment of
same, so there is no excuse for retroactive applications.
(2) While initial authorization for hospital care is given for
14 days to eliminate additional applications, in some cases it is
believed that 10 days of hospital care should be adequate for
a normal obstetric case; and your cooperation is sought to keep
costs at a minimum by arranging for discharge at the end of
the 10 day period.
(3) There has been a considerable amount of unnecessary
correspondence due to the failure of physicians to inform them-
selves of the procedures and to file application blanks correctly.
Application blanks have been distributed to physicians only.
The patient has free choice of physicians; and no physician is
required to participate in the program if he does not wish to
do so.
(4) Physicians should advise their patients who may be eligi-
ble of the plan, as there is some question of distrust on the
part of the public and the patient if this is not done. All men
in the armed forces are informed of the program so that their
wives will be advised. The law includes all wives and infants
of enlisted men in the fourth to seventh grade payroll without
regard to economic need and without investigation (there are a
limited number of wives with more than the $50 a month
allowance) . If the patient is in good economic circumstances,
she should be advised that it is hoped the money will be ade-
quate to care for those in need, and in all probability she will
want private room facilities which will exclude her from bene-
fits. Application must be made for both hospital and medical
care (except in home deliveries) . The patient cannot assume
responsibility for one and expect to have the other paid by the
State Board of Health.
(5) Physicians must assume full responsibility for verification
of the serial number from the allowance card shown by the
patient, otherwise ineligible cases may be accepted. If the
patient does not have the card, the number must be obtained
by the State Board of Health before authorization is made.
(6) The one matter of most serious consideration is the
complaint made by several applicants that the physician has ad-
vised them that there would be additional fees, as the fee
allowed by the state was not sufficient to cover his charges. In
filing the request for authorization, the physician signs an agree-
ment that he will not accept any supplementary fees from the
patient or family. The patient also signs an agreement that
she understands that she is not to make any payments to physi-
cians or hospital. Since federal funds are used for this service,
the State Board of Health is responsible for administering these
funds in accordance with the written agreements with the U. S.
Children’s Bureau. Violations of these agreements would con-
stitute misuse of federal funds. Your Committee recommends
that the Montana State Medical Association go on record as
approving disqualification for participation in the plan of any
physician known to violate the agreement regarding supplemen-
tary fees.
(7) The regulations under which the plan is administered re-
quire that a summary of medical record be submitted by the
physician, and a summary of hospital record by the hospital,
before claim vouchers are approved for payment. These records
are brief summaries and your Committee urges full cooperation
in preparation of these reports.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Legal Affairs Committee
Dr. P. E. Kane, Chairman
Tuberculosis Committee
Dr. F. I. Terrill, Chairman
The war will, without question, result in an increase in the
tuberculosis rate. This is, and will be, caused by conditions that
result from the over-crowding, poor housing, and general war
strain that is occurring in most of our industrial cities. This
problem is not only present in the large cities; it is also present
in some of our own Montana communities.
The Medical Research Council in England has already shown
the rapid rate of increase in tuberculosis that has resulted since
the beginning of the war. The postwar problem of tuberculosis
control must and will be met in this country. It is necessary
that we in Montana be prepared, when this conflict is over, to
keep abreast of the rest of the nation. We have all the tools
necessary to control tuberculosis, but intelligent education of
the people, and, I might add, of the physicians, is necessary. It
is a medical problem and one that must be solved by this group.
If it were possible to skin test every man, woman, and child
in this state and then x-ray the positive reactors, we would have
an accurate knowledge of the open cases that exist; we would
know who were contacts and would be able to more accurately
observe them for evidence of an activation. Then, if the active
cases could be isolated in an institution and kept there until
they were no longer a source of infection, the problem would
be solved. It would be necessary, for a period of time, to con-
tinue the checks so that new cases would be discovered.
At the present time, such a plan is possible; and I can assure
you that it will come, if not initiated by the physicians, then
by the federal government.
So far, most of the tuberculosis control has been through lay
organizations such as the State Tuberculosis Association. Or-
ganizations of this kind have supplied a very worthwhile begin-
ning to tuberculosis eradication, but they have gone as far as
it is possible for lay persons to go, and it is necessary that this
work be taken over by professional workers.
It is the hope of this committee that a full discussion of the
problem take place at this meeting and, if possible, that rec-
ommendations be made to the committee as to what course
should be followed for a future policy of the State Medical
Society.
The committee first feels that there should be a tuberculosis
control officer in the state. This individual should be a physi-
cian especially trained in the prevention of tuberculosis. In the
past, this work has been carried on by public health nurses, and
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in the future much of the work will of necessity be done by
this group. There should be, however, a supervisor of the pro-
gram and a field worker who is a well-trained physician.
Into what department this work would be placed is a prob-
lem and one that must be decided either now or at the next
meeting. The most logical organization to control this work
would be the State Board of Health. The only objection to
this would be that indirectly, in the future, the program might
be dominated by the federal government. It is, however, the
opinion of the committee that a Tuberculosis Medical Control
Officer should be added to the State Board of Health. It
would be the duty of this officer to carry out tuberculosis find-
ing surveys and to follow up all known cases of the disease.
During the last few years, advances have been made in the
method of taking x-rays for mass surveys. The development of
the miniature film (4"x7") and of the 35 mm. film has so re-
duced the cost of a chest x-ray that large groups can be studied
at a minimum cost. In fact, whole nations, notably Sweden,
have been x-rayed. It is within the realm of possibility and
should be one of our aims to x-ray every individual in this state.
Such a program could be carried out under the direction of
a Tuberculosis Control Officer by using either a miniature x-ray
unit or a 35 mm. unit installed on a truck. These complete
units were being manufactured before the war and will be avail-
able after the war is ended.
It is anticipated that such a program might not have the
approval of individuals owning large x-ray units, but it is more
likely that such a program would stimulate interest in health
and would result in more x-rays being taken by private physi-
cians.
This question should be discussed at this time because it is
felt that a tuberculosis case finding program will sooner or later
be initiated, if not one sponsored by the medical organization,
then one by the government.
To finance a permanent tuberculosis control unit would re-
quire appropriation from the State Legislature, and if such a
program is sponsored by this organization, then at the next
legislative assembly the plan should be submitted to the State
Appropriation Committee, probably by a combined committee
of the Medical Tuberculosis Committee and the Medical Legis-
lative Committee.
It is requested by the State Tuberculosis Committee that Tu-
berculosis Committees be appointed in each local society. These
committees would approve any local program that was under-
taken. In this way it would be possible to keep programs un-
der control by the medical men, instead of having a govern-
ment-dominated program.
After a general discussion of this report it was, upon motion
duly made, regularly seconded, and unanimously carried,
adopted.
Dr. Caraway then moved that the Association go on record
as favoring the State Board of Health creating a Division of
Tuberculosis with a State Control Officer. Motion was second-
ed by Dr. Gregg, and, upon ballot, was unanimously carried.
There being no further business to come before the meeting
of the House of Delegates, upon motion regularly made, duly
seconded, and unanimously carried, the House adjourned.
Cancer Committee
Dr. J. H. Garberson, Chairman
Your Cancer Committee has functioned through the year to
a great extent in cooperation with the Women’s Field Army.
A meeting was held at the Florence Hotel on the last day of
the 1942 meeting, in conjunction with the meeting of the Wom-
en’s Field Army Committee. Since that time, cooperation has
been extended to the Women’s Field Army in their program
of placing educational literature in the schools and in conjunc-
tion with their publicity campaign.
It is recognized that there is a definite need for further edu-
cation as to the early diagnosis and treatment of cancer among
the medical profession. Until such education has been accom-
plished, the educational work among the laity can be only par-
tially successful. However, there is a question as to, whether
this work can be carried on among the members of the medical
profession to the best advantage during the period when our
members are already overtaxed due to war conditions.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Dentists, Pharmacists and Nurses Committee
Dr. B. K. Kilbourne, Chairman
The Dental Society reports that 50 dentists from Montana
are now in the armed forces. This means much additional work
for the remaining group in order to meet the demands from the
public for services. The annual meeting was held in Helena in
May, and registration was in excess of the number expected.
The Director of Public Health Dentistry for the State of Utah
addressed this meeting of the dentists and also the meeting of
the Montana Public Health Association, which was held at
Bozeman on June 7 and 8. The Dental Association sponsored
the bill which is included in the Session Laws of Montana as
Chapter 125 of the Session Laws of 1943. This bill provides
for the establishment of a Division of Dental Health in the
State Board of Health. The bill was passed, signed by the
Governor, and becomes effective July 1, 1943. It is hoped that,
through the activities of this Division, the dental health needs
of the people of the state of Montana will be more adequately
appreciated and provided for.
The State Board of Pharmacy held only a one day annual
meeting in June. This Board supported a bill passed by the
1943 Legislature and included in the Session Laws of Mon-
tana as Chapter 225 of the Session Laws of 1943. This pro-
vides that the President of the State Board of Pharmacy and
the President of the State Board of Food Distributors be ap-
pointed by the Governor as members of the State Board of
Health. The Board of Pharmacy wished to call to the atten-
tion of the medical profession that much confusion could be
prevented, if the medical men, in writing prescriptions for nar-
cotics, barbiturates, or any sulfa compounds would specify on
the original prescription whether or not it should be refilled, in
order that the druggist may comply with the federal law. The
federal law requires that such prescriptions cannot be refilled
without direct authorization from the physician. So far, the
pharmacists have experienced very little difficulty in obtaining
necessary drugs, with the exception of some of the arsenicals,
for the Army has first priority on the supply of arsenicals.
Since a discussion of the supply of and demand for nursing
service is to be presented by the President of the State Nurses
Association to this body, no resume will be given of the nursing
activities and situation by this committee.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Executive Committee
Dr. E. D. Hitchcock, Chairman
The Executive Committee of your State Association met on
two occasions during the past year.
A meeting was called during the Legislative session and met i
with the Legislative Committee. This meeting was very helpful
in formulating procedures to combat the chiropractic bills intro-
duced in the Senate. The State Board of Health Bill came in
for consideration as well as the Medical Practice Bill introduced
by the Board of Medical Examiners. A second meeting was
called in Helena, to consider the appointment made to the State
Board of Health, and the position of the State Medical Asso-
ciation in relationship to the proposed referendum on the State
Board of Health Bill.
I deeply appreciate the help and wholehearted cooperation of
each member of this committee.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
History-of-Medicine Committee
Dr. E. D. Hitchcock, Chairman
Your Committee on the History of Medicine wishes to make
the following report: We have met on several occasions to re-
view the material gathered on The Pioneer Physician. The ma-
terial is fairly complete, but there is considerable reviewing to
September, 1943
111
be done to place it in proper shape. Recently we placed this
material in the hands of Judge Lew Callaway who is a noted
Montana historical authority and who is now working in his
spare time on the book. The only expense to be incurred is for
stenographic work, and we respectfully request an appropriation
of $200.00 for the coming year.
It is quite impossible to set a time for publication and this
must await the conclusion of the war and the return of normal
times.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Medical Economics Committee
Dr. J. C. Shields, Chairman
A meeting of the Medical Economics Committee was called
to order July 7, 1943, by Dr. Shields, chairman.
A request from the Committee on Maternal Health and
Child Welfare was received, to the effect that they would like
the section on minimum fees amended to read: "Except in the
case of a child one year of age or under in which the minimum
fee shall be $10.00.” A motion recommending to the House
of Delegates that this change be made, as above, was adopted,
with the provision, however, that it apply only to cases coming
under the plan for federal benefits, that is, cases involving sol-
diers’ families.
The following recommendation to the House of Delegates
was also adopted: "The orthopedic rehabilitation fee as acted on
by the Orthopedic Commission allows $100.00 for reduction of
! dislocation of hip, of which $50.00 is to be paid at the time of
! operation and the remaining $50.00 is to be paid in installments
of $25.00 over a period of months. This fee schedule will be
j applicable to cases coming under the orthopedic commission.”
Heeding the advice of our President, the Economics Com-
mittee will study the Wagner-Murray-Dingell Act for the en-
largement of social security benefits and sick benefits, and for
the payment of the the costs of hospital, surgical, and medical
services.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Medical Publications Committee
Dr. A. R. Foss, Chairman
The Medical Publication Committee wishes to advise that our
i contract with the Journal-Lancet as official publication for
our society will not terminate during the coming year. The
Journal-Lancet has been very satisfactory and no change is
necessary at the present time.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Postgraduate Committee
Dr. A. R. Foss, Chairman
The Postgraduate Committee of your Society has not func-
tioned during the year 1942-43, and, therefore, has no report
to make.
Public Instruction and Health Committee
and Public Relations Committee
Dr. Leonard W. Brewer, Chairman
The Committee on Public Relations and on Public Instruc-
tion and Health, which, by appointment of Dr. Hitchcock is
' this year a combined committee, wishes to report for the year
that it has been entirely inactive.
I Committee on State Institutions
Dr. H. W. Gregg, Chairman
I beg to submit the following report from the Committee on
State Institutions. Unfortunately, the Committee has not been
: as active as it should have been during this year of extreme
stress.
Dr. Pampel had his difficulties in this legislative year, and I
believe that he may personally report some of his suggestions.
He wishes that the delegates may understand certain present
conditions at the State Hospital. Dr. Pampel has only four
doctors who are registered in the state, including himself. He
was unable to get more and has taken a graduate of a grade B
school as an intern; a man 35 years old, of pleasant personality
and appearance, very capable, who cannot register in Montana
because of his training. Dr. Pampel regrets that he is unable
to get more registered men, but the exigencies of the situation
have made this alternative necessary. Dr. Pampel believes that,
in this non-election year, any attempt on the part of the Med-
ical Society to influence any appropriations for the next legisla-
tive year would be untimely.
Dr. Terrill from the State Hospital for Tuberculosis tells me
that he has nothing of importance to report to the delegates
at this time.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Advisory Board Women’s Auxiliary
Dr. J. I. Wernhan, Chairman
Your Advisory Board of the Women’s Auxiliary begs to
report as follows:
The formation of the Women’s Medical Auxiliary was first
discussed by the Medical Association at the annual meeting in
Great Falls in 1929. At that time, approval was given for the
formation of a State Auxiliary but the following years interest
subsided. However, there was one unit formed in Western
Montana centering around Missoula. This unit has been suc-
cessful and active.
This pioneer unit has been an incentive for the formation of
other units, as has been done in Lewis & Clark county and in
Cascade county. This year Flathead and Yellowstone counties
have organized.
The summation at the present date is that there are five
units formed and active, covering thirteen counties. A state-
wide organization will be formed as soon as there are a few
more units organized.
The object of the Auxiliary is to assist the medical profes-
sion and the doctors in their chosen profession, in the educa-
tion of the public along medical lines, and to assist in any
possible way.
Your Committee recommends that the Association lend its
support and good will to the Women’s Auxiliary of the Mon-
tana State Medical Society.
Upon motion duly made, regularly seconded, and unani-
mously carried, this report was adopted.
Nominating Committee
Dr. F. F. Attix, Chairman
Your Nominating Committe respectfully submits the follow-
ing names in nomination for election for state officers of the
Montana State Medical Association:
President — Dr. J. C. Shields, Butte, Montana; Dr. S. A.
Cooney, Helena, Montana.
Vice President — Dr. M. G. Danskin, Glendive, Montana;
Dr. P. E. Logan, Great Falls, Montana.
Secretary-Treasurer — Dr. T. F. Walker, Great Falls, Mon-
tana; Dr. M. A. Shillington, Glendive, Montana.
Delegate to A M. A. — Dr. J. H. Irwin, Great Falls, Mon-
tana; Dr. Alfred Karsted, Butte, Montana.
Alternate Delegate to A.M.A. — Dr. E. M. Gans, Harlowton,
Montana; Dr. W. H. Stephan, Dillon Montana.
Councillors — Dr. R. D. Knapo. Wolf Point (incumbent) ;
Dr. O. G. Benson, Plentywood; Dr. Charles Houtz, Havre (in-
cumbent) ; Dr. D. J. Almas, Chinook; Dr. F. B. Ross, Kalis-
pell (incumbent) ; Dr. W. W. Taylor, Whitefish; Dr. L. G.
Dunlap, Anaconda (incumbent) ; Dr. A. D. Knight, Philips-
burg.
Names available to Governor Ford for appointment to State
Board of Health — Dr. C. J. Bresee, Great Falls; Dr. R. L.
Towne, Kalispell; Dr. M. D. Winter, Miles City; Dr. M. A.
Shillington, Glendive; Dr. J. W. Craig, Circle; Dr. F. L. Un-
mack, Deer Lodge; Dr. E. M. Gans, Harlowton; Dr. C. R.
Monahan, Butte; Dr. A. T. Haas, Missoula; Dt. C. C. Seerley,
Bozeman.
278
Fracture Committee
Dr. R. B. Richardson, Chairman
No report received.
Medical Military Preparedness and Defense Activity
Dr. F. L. Andrews, Chairman
Dr. F. L. Andrews, chairman, gave a verbal report saying
that no meetings had been held by the committee during the
year. He gave a brief report of the activities of the O.C.D.
in Great Falls.
Rocky Mountain Conference
Dr. T. F. Walker, Chairman
Dr. Walker reported that no meetings of the Rocky Moun-
tain conference would be held this year and probably not for
the duration.
Orthopedic Committee
Louis W. Allard, M.D., Chairman
As chairman of the Orthopedic Committee of the Montana
State Medical Association, I present for your committee the
following report of our activities during the past years. Due to
the fact that the other members of the committee are not pres-
ent at this conference, the responsibility of this report must be
assumed entirely by the chairman.
Our committee has been reduced to two active members pres-
ent in this state, Dr. Colman and Dr. Allard.
With sadness and regret we report the death of one of the
oldest members practicing orthopedics in this state, Dr. E. M.
Porter, Great Falls; and with solicitation we report the illness
of another esteemed member of our committee, Dr. E. S.
Porter of Lewistown. We understand Dr. Porter is gradually
improving and we hope he will soon be back to active duty.
Dr. John R. Vasco of Great Falls is serving with the Armed
Forces for the duration.
Dr. Colman of Butte sent word he will be unable to be at
this meeting because of urgent duties at home.
During the past year Dr. J. K. Colman and myself have
been in conference with either Dr. Margaret Smith or Dr.
Thomas M. Leonard of the Crippled Children Division of the
State Board of Health. Due to ill health, Dr. Smith resigned
from the State Board in 1942 and her duties have been carried
on by Dr. Thomas Leonard.
Our relations as Orthopedic Surgeons and as members of
this committee with the State Board of Health have been
pleasant. Together we have worked in the interests of the
crippled children in Montana.
Before Dr. Smith resigned from the State Board of Health,
there was presented for our consideration certain changes in
the fee schedule which was intended to place the fee schedule
on a more equitable and satisfactory basis.
These changes are as follows:
1. When a physician has left our service previous to July 1,
1942, patients of that surgeon, for whom the maximum fee has
been paid, will be eligible for care under another surgeon of
the staff at 50 per cent of the original operative fee scale. This
replaces the old ruling that when the maximum fee scale has
been paid, no charge may be made, irrespective of the number
of surgeons employed.
2. In order to obviate further occurrence of having a large
number of patients left without funds for further treatment,
hereafter, when two or more major operations are necessary in
the total treatment of one patient, such operations requiring
more than one operative period, not more than 50 per cent of
the operating fee will be paid until the case is discharged as
maximum correction. If the maximum fee has been paid before
July 1, 1942, and the attending surgeon leaves our service,
Number One comes into effect.
3. When a maximum fee has been reached and a period of
two years or more has elapsed since the last payment, and
more surgery is necessary, up to 50 per cent of the maximum
fee will be allowed for this additional care.
4. The maximum fee for osteomyelitis or tuberculosis of the
bone will be limited to #100 for a period of one year; aspira-
tion of abscess, #10.
5. In the treatment of nonoperative club-foot, #50 will be
allowed for the first six months’ care; #25 for the subsequent
The Journal-Lancet
three months; with a maximum of #75 for one foot and #100
for two.
6. #50 will be allowed for the repair of soft palate cleft. In
complete cleft, #50 will be allowed for first operation if tandem,
but #100 may be charged if complete closure is obtained in one
operation; #50 may be charged for each succeeding operation,
with a maximum of #200. The fee for lip repair is #50.
7. On closed reduction of congenital hip, #50 will be allowed
for the first six months, #25 for each subsequent three months,
with a maximum of #100 for single hip and #125 for double.
Open reduction: #75 for single hip, #150 for double. Shelf
operation: #100 per hip.
After considerable correspondence and discussion, Dr. Col-
man and I agreed to the changes, provided they were acceptable
to the House of Delegates Committee of the State Medical
Society.
SECOND SESSION OF THE HOUSE OF
DELEGATES
Thursday, July 8, 1943
The adjourned meeting of the House of Delegates convened
at 9:00 A. M., Thursday, July 8th.
Report of the Delegate to the American Medical
Association
Dr. J. H. Irwin, delegate to the American Medical Associa-
tion, gave the following report: Cold rainy trip — still cold in
Chicago on arrival. Stood in line thirty minutes to register at
the Palmer House and then had to wait four hours for a room
engaged four months ago. Met a goodly number of delegates
who had already arrived, and had a pleasant time renewing
acquaintances.
Meeting opened at 10 A. M. Monday with nearly all dele-
gates present and, before the day was ended, every state in the
Union had its entire delegation present, the only absent dele-
gates being Porto Rico, Panama Canal, Alaska, Hawaii, and
the Philippine. There has not been a full showing of states
before during my tenure of office.
Following the usual opening procedures, the first order of
business is always election of Distinguished Service medal, and
Dr. Joslyn of Boston received this honor which, I am sure you
all agree, is well deserved.
We then listened to addresses by the Speaker of the House,
President and President-Elect. All these are printed in full in
the Journal of the A.M.A., and I urge you to read them, for
they present the ideas and thoughts of most doctors in the
United States today.
The business of the House of Delegates is conducted largely
through reference committees, and under the order of new busi-
ness, numerous resolutions were offered — some by individual
delegates, but mostly resolutions passed at various state asso-
ciations and asking the support of the A.M.A. These are reg-
ular reference committees and, as each resolution is introduced
and read, it is referred to one of these committees. The after-
noon of the opening day is devoted entirely to these commit-
tees; and all members are urged to appear before any of them
to present any ideas they may have, to question, and to argue
either pro or con. These reference committees remain in session
until all are heard and then make up a report of their conclu-
sions to present to the House of Delegates. In the majority of
cases, the reports and conclusions of the committees are adopted
by the House of Delegates, but if any member of the House of
Delegates does not agree with the report, he may then present
his case and, at times, I can assure you a very spirited debate
develops.
First quote — Journal A.M.A., June 19, by the President,
Brigadier General Fred W. Rankin, "In the national fulfillment
of our altruistic objectives it must be recognized that two essen-
tial provisions are required, namely; professional and financial
facilities. It must also be recognized that the successful attain-
ment of these objectives cannot be accomplished if, in the im-
plementations of any plan or proposal, the professional facili-
ties are subjugated to the authoritative management, tradi-
tionally dictated by political whimsy, of some legislative council
controlling the financial provision. These two provisions are
September, 1943
279
interdependent and cannot be distinctly separated in approach-
ing our objectives. The successful application of the former
requires certain facilities supplied by the latter, which in turn
can be guided intelligently only by professional knowledge.
These vastly significant facts must be sincerely appreciated by
all parties, both medical and non-medical, concerned with this
problem, in their approach to its solution.”
Second quote — President-elect James E. Paullin: "It is rec-
ommended that the House of Delegates approve the action of
the Board of Trustees in making plans to meet these problems
and authorize the development of a permanent Committee on
Planning of Postwar Medical Services to cooperate and collab-
orate with other agencies concerned with these problems.”
Surgeon General Norman T. Kirk of the U. S. Army was
introduced and gave a very interesting talk on his experiences
in Tunisia. He was fortunate enough to be there at the climax,
and his talk is printed in full on page 552 of the Journal of
the A.M.A. for June 19.
George M. Morris, President of the American Bar Associa-
tion, was introduced and I here quote part of his speech: "I
happen to be a member of the committee which reorganized the
American Bar Association in 1936. At that time, the Ameri-
can Bar Association instituted a House of Delegates, almost a
direct adoption of the House of Delegates which has been so
successfully conducted by the American Medical Association. I
made a study, not only of the constitutional background of this
organization, but of its regulatory background, and here I am
today a good deal like a boy who has read about a famous man,
never thinking he would meet him, and suddenly stepping
around the corner, meets the famous man whom he knows all
about.
"In connection with the formulation of our procedure and
fundamental concepts in the American Bar Association, the ex-
perience of the American Medical Association was an invaluable
aid. It always seems an anachronism to me, but nevertheless it
was true, that here were the lawyers who would be expected
to be the pioneers in a legislative group like this, taking their
lessons from their brother professionals, the medics, on how to
do the job that the lawyers themselves ought to know how
to do.”
A report of the Board of Trustees on Hospital Corporations
engaging in the practice of medicine and a report of the joint
meeting of the Board of Trustees and the National Hospital
l Association is given in full and I urge all pathologists and radi-
ologists to read and study this on pages 528-534 in the Journal
i of the A.M.A. of June 19th.
Numerous resolutions were introduced and, following the
usual procedure, were referred to committee for consideration.
The afternoon of Monday was given over to committee meet-
ings. These resolutions are printed in full in the June 19th
Journal and the reports of committees on same are printed in
the June 26th Journal.
Six or seven of these resolutions bear on the same line of
thought: better informing of M.D.’s in general regarding med-
icine and medical matters; better information to the public re-
garding medical affairs, and especially new procedures, new do-
ings and appliances, with as true an idea as possible of their
worth and limitations; better contact with Congress, in order
that the medical profession may rightly be heard and her side
of questions up for legislation be presented. The ultimate out-
come of three sessions discussing this question was the creation
of a Council on Medical Service and Public Relations, com-
posed of six members geographically distributed in the United
States, President, Past-President, and Secretary, and a member
of the Board of Trustees. The duties of the Council shall be
— (I quote): "(a) To make available facts, data, and medical
opinions with respect to timely and adequate rendition of med-
ical care to the American people; (b) To inform the constitu-
ent associations and component societies of proposed changes
affecting medical care in the nation; (c) To inform constituent
associations and component societies regarding the activities of
the Council; (d) To investigate matters pertaining to the eco-
nomic, social and similar aspects of medical care for all the peo-
ple; (e) To study and suggest means for the distribution of
medical services to the public, consistent with the principles
adopted by the House of Delegates, and (f) To develop and
assist committees on medical service and public relations origi-
nating within the constituent associations and component so-
cieties of the American Medical Association.
In the exercise of its functions, this Council, with the co-
operation of the Board of Trustees, shall utilize the functions
and personnel of the Bureau of Legal Medicine and Legislation,
the Bureau of Medical Economics, and the Department of
Public Relations in the headquarters office.
Dr. Herman L. Kretschmer of Chicago was elected President-
elect; Dr. John W. Amesse of Denver elected Vice President;
Olin West, Secretary; Dr. Josiah J. Moore, of Chicago, Treas-
urer; H. A. Shoulders, Speaker of the House; R. W. Fouts,
Vice Speaker.
San Francisco was chosen as the meeting place in 1946.
Election of Officers
The next order of business was the election of officers. No
names in addition to those submitted by the Nominating Com-
mittee having been submitted, the House of Delegates proceed-
ed with the ballot.
Dr. S. A. Cooney withdrew his name as a candidate for
President-elect, and upon motion regularly made, duly seconded,
and unanimously carried, the Secretary cast a ballot of the
House of Delegates for Dr. J. C. Shields of Butte.
Dr. P. E. Logan withdrew his name as candidate for Vice
President, and upon motion regularly made, duly seconded, and
unanimously carried, the Secretary cast a ballot of the House
of Delegates for Dr. M. G. Danskin of Glendive.
Dr. M. A. Shillington of Glendive withdrew his name as a
candidate for Secretary, and upon motion regularly made, duly
seconded, and carried, the Secretary cast a ballot of the House
of Delegates for Dr. Thomas F. Walker of Great Falls. The
ballot was then distributed for the election of the officers with
the following results:
Delegate to A.M.A.:
Dr. J. H. Irwin, Great Falls . 20 votes
Dr. Alfred Karsted, Butte 8 votes
Alternate Delegate to A.M.A.:
Dr. E. M. Gans, Harlowton 20 votes
Dr. W. H. Stephan, Dillon _ 7 votes
District No. 1 — Dr. R. D. Knapp 21 votes
Dr. O. G. Benson 4 votes
District No. 2 — Dr. Chas. Houtz 18 votes
Dr. D. J. Almas 5 votes
District No. 7 — Dr. F. B. Ross 18 votes
Dr. W. W. Taylor _ 6 votes
District No. 10 — Dr. L. G. Dunlap 12 votes
Dr. A. C. Knight 12 votes
Since Dr. Dunlap and Dr. Knight received the same number
of votes for Councillor of District No. 10, the ballot was again
spread and the vote taken for Councillor in <this District. Upon
this ballot Dr. A. C. Knight received 21 votes and Dr. Dunlap
12 votes.
The House of Delegates unanimously chose the following
doctors whose names should be submitted to the Governor for
selection of two physicians to fill the existing vacancies on the
State Board of Fdealth:
Dr. C. J. Bresee, Great Falls.
Dr. R. L. Towne, Kalispell.
Dr. M. D. Winter, Miles City.
Dr. M. A. Shillington, Glendive.
Dr. J. W. Craig, Circle.
Dr. F. L. Unmack, Deer Lodge.
Dr. E. M. Gans, Harlowton.
Dr. C. R. Monahan, Butte.
Dr. A. T. Haas, Missoula.
Dr. C. C. Seerley, Bozeman.
Miss McCoy of the Red Cross briefly reviewed the activities
of the Red Cross in recruiting nurses for the armed forces of
the United States.
Mrs. Frances McDonald, President of the Montana Nurses
Association, addressed the House of Delegates, asking for their
aid and assistance in recruiting nutses to carry on nursing serv-
280
The Journal-Lancet
ices for the civilian population in Montana, emphasizing the
great shortage of nurses.
The President declared the next order of business the selec-
tion of place for the 1944 session of the Montana State Med-
ical Association. An invitation was extended to the Association
by the Silver Bow County Medical Society to hold its next
annual session in Butte. Upon motion duly made, regularly
seconded, and unanimously carried, it was resolved to accept
the invitation of the Silver Bow County Medical Society.
There being no further old or unfinished business to come
before the House of Delegates, the President asked for any
new business to be presented.
Dr. Sid Cooney of the Lewis & Clark County Medical So-
ciety proposed that the association permit him to go ahead and
secure petitions to refer the Board of Health bill passed at the
last session of the Legislature to the voters at the next general
election.
After a general discussion it was moved by Dr. Gregg, sec-
onded by Dr. Caraway, that the question of the referendum on
the Board of Health bill be referred to the Legislative Com-
mittee, with power to act after consulting with the State Board
of Health. By standing vote, this motion was carried by a vote
of 13 for and 11 against. The Legislative Committee subse-
quently reported that it was their opinion that no action should
be taken toward securing petitions for a referendum.
There being no further business to come before the House
of Delegates, upon motion regularly made, duly seconded, and
unanimously carried, the House adjourned.
SCIENTIFIC SESSION
Wednesday, July 7, 1943
The Sixty-fifth Annual Scientific Session of the Montana
State Medical Association was called to order by President E.
D. Hitchcock at the Northern Hotel in Billings, Montana, at
11:00 A. M., Wednesday, July 7th.
Dr. Hitchcock introduced President Cedric H. Nelson of the
Yellowstone Valley Medical Society, who welcomed the mem-
bers of the Montana State Medical Association to Billings.
Dr. Nelson’s address of welcome was followed by the in-
stallation of Dr. J. P. Ritchey as President of the Association.
Dr. Ritchey then gave the Presidential Address, which is
incorporated as a part of these minutes.
PRESIDENTIAL ADDRESS
J. P. Ritchey, M.D.
Missoula, Montana
I am grateful indeed for the high honor you paid me
in naming me your president-elect. Your action in so
doing caused me a good deal of self-searching; it made
me feel humble; and it made me desire to meet the re-
sponsibilities of the office of president in a manner
worthy of your confidence and esteem.
I have lately visited a number of the component so-
cieties of this association in company with Dr. Hitch-
cock, your president, and part of the time with Dr. Car-
away, State Procurement and Assignment Officer, and
Dr. Cogswell, State Health Officer. The courtesy and
friendliness with which we were met made a deep impres-
sion upon me. A wide diversity of viewpoints was ex-
pressed, and such expression was received with tolerance
and good feeling by everyone; but the essential unity and
singleness of purpose of the profession of this state was
evident. The vast extent of territory and of human need
served was brought home to us. I believe that such visits
are a highly useful activity on the part of the state offi-
cers and I hope the custom may be continued.
The year now closing has been marked by tragedy, by
whirlwind changes and adjustments, by toil, labor and
suffering beyond human imagining. As regards our state
association, the year has seen the number of physicians
who have obtained commissions in the armed services I
reach a total of 122, or about 25 per cent of our mem- I
bership, and some of these have already given their lives.
It has seen the physicians at home adjust themselves to
their increased burden and extend themselves to give a
still adequate medical service to our people. It has seen
the Women’s Auxiliary to the Medical Association of
Montana grow in strength, by the addition to it of sev-
eral new local Auxiliaries. For this we are glad, not only
because the Auxiliary is an added source of strength to
us, but also because it increases good feeling and unity
among its members and among ourselves. The year has
seen the state legislature show a considerable measure of
confidence in our state association, in its integrity of pur- j
pose and in the soundness of its advice. Nationally, it
has seen a demonstration of the indispensability of the
medical profession. Nationally, also, it has seen Wash- '
ington court decisions characterize group medical service
as a business and the attempt of organized medicine to
maintain its standards of practice as being in restraint
of trade; but up to date our profession is still unham-
pered by legal enactments creating a country-wide system
of government-controlled medical practice. It has seen
a recent meeting of the house of delegates of the Ameri-
can Medical Association at which, if I read the published
proceedings correctly, there was manifested a sense of
change, a feeling of urgency, a taking counsel together
and a getting ready for new and extended action.
As regards the immediate future, one purpose, to win ,
this war, dominates all other purposes and draws them
into itself. Still more of our members will be entering I
service; still fewer will remain at home to serve essential j
civilian needs. The 42,000 American physicians in serv- |
ice at the end of 1942 will be augmented, it is said, to j
53,000 by the end of 1943. Almost 6,000 persons are i
being graduated as physicians each year. Forty-five hun- i
dred of these will enter the medical corps. The other ;
1200, men not physically qualified for service, and worn- j
en, will be available for civilian practice. These will par-
tially offset the loss of 2500 physicians by death each
year.
Civilian physicians will continue to have the same need
of postgraduate study, including refresher courses. As
present limitations make extended travel difficult or im- i
possible, all national meetings are discontinued. We fall
back, then, upon local, state and interstate meetings and
study courses, with military medical personnel participat-
ing and cooperating. Some such meetings have already
been held, and more are to follow.
In these times we have a special duty, that of being
on guard against epidemic disease and of cooperating
with health departments to this end. We have also to
cooperate with and advise lay agencies concerned with the
maintenance of health. In industry, we are concerned
with guarding the older men against becoming unneces- j
sarily incapacitated and from loss from unaccustomed
overloading and overstrain.
One might say that with this matter of winning the
war our hands are full, and that we may let the postwar
future take thought for itself. But, as we look about us
September, 1943
281
and ahead, we see vast upheavals. We perceive that pro-
digious forces are loosed. We see our country profound-
ly disturbed and changing. As physicians, we should be
blind indeed to believe that our ways will continue to
remain, in all respects, the ways to which we have been
so long accustomed. Neither the inertia of a long estab-
lished system of practice, nor the desire to choose one’s
own physician, nor the recognition by government and
people of the value of the services furnished by the med-
ical profession in and out of the armed forces will suffice
to stay the hand of change. The members of this associa-
tion are therefore thinking seriously of postwar problems.
I’d like to mention two of these.
The first is the delicate and difficult one of the re-
assimilation into practice of returning medical officers.
It is expected that demobilization will be slow. Many
medical officers are likely to be needed for use in rehabili-
tating foreign lands laid waste by the war. Many offi-
cers may even prefer to remain in the service more or
less indefinitely, as they have become more at home in it
and the readjustments to private practice become in their
eyes more formidable with the lapse of time. For others,
the return to private practice will be a welcome escape
from a regimented existence endured for the sake of
duty. The desires and the choices of the young men who
have never had the experience of private practice, but
who entered the service directly from college, are some-
what unpredictable. The enormous increase in the num-
ber of veterans, all of whom will have access to the med-
ical care of the Veterans’ Administration, further com-
plicates the picture.
The task, however, remains. Some observers expect
that in communities, such as our larger Montana cities,
the total number of men desiring to practice will ap-
proach a number double that of prewar days. If this be
even partially true, and in any case, the task will call for
all the wisdom, patriotism, sense of justice and unselfish-
ness we have. It is a job for the component societies and
for every one of us individually. But it is particularly a
job for the state association, in that it must assume lead-
ership both in planning and execution. And it is a job
that will not be bungled. A fitting welcome to these men,
a happy and harmonious solution of this situation, result-
ing in continued unity and good will within our ranks,
will also redound to our credit with the public and add
weight to our counsel in all other postwar socio-medical
affairs.
The other problem of the postwar period is still more
grave. It is the future status and form of medical prac-
tice. Thus far we have not been the object of legislation
regimenting our activities as has the profession in Eng-
land and other European countries. But the expectation
of such legislation is upon us, as is also the necessity of
reacting to that expectation wisely and with maximum
effect.
In difficult times like this, it is well to take a look at
basic considerations or principles. As they appear to me,
these are four:
The very first consideration, I take it, is that we exist
as physicians for just one purpose, to heal the sick and
to keep people well.
A second consideration is that what is good for the
health of the people is good for us, and, vice versa, what
is good for us professionally is good for the people and
for their health.
A third consideration is the fact that in our hands,
only, are the medical knowledge, judgment, science and
skill without which our civilization as it is could not exist;
without these, this war could not be fought and won, and
our vast military forces could not even be kept in the
field.
The fourth consideration follows naturally: That while
we are not economists nor sociologists, the medical pro-
fession and its organizations ought to be constantly and
freely consulted and advised with in all matters of public
policy and legislation affecting the care of the sick and
the maintenance of health, if such public policy and
legislation are to be at bottom sound, because any result-
ing plan must function primarily medically, as well as
financially and socially. If these considerations be valid
they would seem to point the direction in which we ought
to move.
Deserving of reference in this connection is the state-
ment made by Justice Miller of the United States Court
of Appeals of the District of Columbia, in which he said
that the failure of the professional groups to insist upon
and to secure the legislative recognition of the distinction
between professional practices and the generally accepted
methods of trade and business may perhaps have been
responsible for the action of Congress in including the
practice of medicine in the activities governed by the
Sherman Antitrust Law.
It may be said, however, that, as a state association, we
must follow the example and leadership of the American
Medical Association. This is indeed true, and it may be
that the American Medical Association is about to en-
large greatly its public activities, in which case it will
point the goal and lay down the pattern of our own en-
deavors. It is fair to say, however, that our state associa-
tion, as a constituent association of the American Med-
ical Association, is responsible in some measure, however
small, for the policies and actions of the American Med-
ical Association. It is also fair to say that the American
Medical Association cannot do for us what we must do
for ourselves. It is only our state association that is
chiefly and immediately concerned with the voters of
Montana, with our state legislature and state administra-
tion, and with our two representatives and our two sena-
tors in Washington.
It is probably not practicable for this association to put
on an intensive and extensive publicity campaign to in-
form the public as to these matters. But this fact is no
proper cause for discouragement. It points merely to
another fact: That it will be more fruitful for us to
think, not in terms of the great things we might accom-
plish had we more leisure, more means and more oppor-
tunity, but rather in terms of what, at the least, is within
our power to accomplish, given a sense of urgency suit-
able to the situation in which we find ourselves. If it be
asked, "What things are these?” I will say:
It is within our power to inform ourselves thoroughly,
through appropriate committees of this association, and
282
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also individually, regarding all pending legislation.
It is within our power to use our best endeavor to in-
form the public in ways actually available to us; and it is
not unlikely that the American Medical Association will
be able to add to the ways available to us.
It is within our power to bring home to the representa-
tives and senators from Montana a full realization of our
vital interest in this legislation and of our determination
that, to the best of our ability, such legislation shall pre-
serve for the people what is essential for first-class med-
ical service, and for ourselves what is essential for our
best functioning as physicians; and we can earnestly and
persistently persuade them that our views are sane, wise,
and conceived in the best interests of all.
It is within our power fully to cooperate with and help
strengthen the hands of the American Medical Associa-
tion and other national organizations that are working
to achieve the same ends.
It is within our power more fully to cooperate with,
and furnish leadership for, all other agencies, public and
private, lay and professional, that are concerned with the
health of the people.
And finally, every one of us may constitute himself a
committee of one on public relations, to uphold the credit
and honor of our state association, and, in his contacts,
to help establish in the minds of our fellow citizens a con-
viction of the good faith and unselfish aims of the med-
ical profession.
Mrs. Eben J. Carey, President of the Women’s Auxiliary of
the American Medical Association, was introduced by Dr. E. D.
Hitchcock, and was kind enough to favor the Association with
a few remarks.
Dr. Earl Wheeden, President of the Wyoming State Medical
Association, was also presented by Dr. Hitchcock.
Dr. Hitchcock then declared the meeting adjourned until
2:00 P. M.
The official program follows:
Wednesday, July 7th
9 to 1 1 A. M. — Assembly Room — Meeting of the House of
Delegates.
11:15 — Ballroom — Call to Order by President E. D. Hitch-
cock, M.D. Address of Welcome by Cedric H. Nelson, M.D.,
Billings. Installation of J. P. Ritchey, M.D., as President. Pres-
idential Address by J. P. Ritchey, M.D., Missoula.
12:15 — Luncheon Meetings — (1) Presidents and secretaries
of county societies. (2) Alumni groups.
2:00 P. M. — Ballroom — "A Treatment of Eye Diseases by
the General Practitioner,” William M. Bane, M.D., Denver,
Colorado.
3:00 — "Hematuria and its Significance,” L. W. Howard,
M.D., Great Falls, Montana.
3:30 — "The Management of Breech Presentation,” G. A.
Carmichael, M.D., Butte, Montana.
4:00 — "A Discussion of Some of the Newer Drugs,” I. J.
Bridenstine, M.D., Terry, Montana.
7:00 — Banquet. The annual banquet was held in the ball-
room of the Northern Hotel at 7:00 P. M., Dr. Allard acting
as toastmaster. Lt. Col. E. S. Murphy of the Surgeon General’s
Office addressed the Association on "Contributions of Medicine
in the Present War,” and read a fable, "Isadore, the Indian.”
Dr. E. T. Bell, Professor of Pathology, University of Minne-
sota, gave an address on "Diseases of the Kidney.”
Thursday, July 8th
9 to 11 A. M. — Assembly Room — Meeting of the House of
Delegates.
11:15 — Ballroom — "Symptoms Associated with Chronic Gas-
tritis,” Wayne Gordon, M.D., Billings, Montana.
12:15 — Assembly Room — Panel Discussion Luncheon. Panel
Discussion — Dr. E. T. Bell, Professor of Pathology, University
of Minnesota, "Carcinoma of the Breast.”
2:00 — Ballroom — "The War-Time Spread of Communicable
Diseases,” Major A. P. Ormond, M.D., Great Falls, Montana.
3:00 — Reports of Women’s Auxiliaries of the Montana State
Medical Association and by Women’s Field Army for the Con-
trol of Cancer.
Mrs. H. W. Peterson of the Women’s Field Army for the
Control of Cancer, briefly addressed the Association. Mrs.
Eben J. Carey, President of the Women’s Auxiliary of the
American Medical Association addressed the Association.
Mrs. Frances McDonald, President of the Montana State
Nurses Association, spoke regarding the part the Medical Asso-
ciation could play in cooperating with the Nurses Association
to maintain adequate nursing facilities for the civilian popula-
tion during the war.
3:30 P. M. — "The Sex Hormones and Their Relationship,”
H. O. Drew, M.D., Billings, Montana.
4:00 — "Gastro-colic Fistula,” H. M. Blegen, M.D., Missoula,
Montana.
Necrology Committee
Dr. M. A. Shillington, Chairman
Since our last meeting, death has come to nine members of
the Montana State Medical Association. Two of these men
gave their lives while in the Armed Forces. These two were
Dr. Leo P. Martin of Missoula, and Dr. Harold Malee of
Butte. The remainder completed years of service in the practice
of their profession and succumbed to illnesses of varied nature.
Cascade County — DR. E. M. PORTER died early in 1943
after an extended illness, at the age of 65. Dr. Porter was one
of the founders of the Great Falls Clinic in Great Falls and was
one of the most talented and dexterous surgeons in the North-
west. His interest during the latter years of his life was cen-
tered upon orthopedic surgery. He was an active participant in
the Crippled Children’s program in the state, and for many
years was a member of the State Board of Health. Dr. Porter
was a member of numerous national scientific societies and was
well known throughout the state of Montana. His death is
deeply mourned by his associates and his many friends through-
out the Northwest.
Fergus County — DR. A. W. DEAL died early in 1943 of
multiple sclerosis, after several years of invalidism. He is sur-
vived by his wife and three daughters, one of whom is in the
WACS.
DR. J. C. DUNN died after an operation late in 1942, after
having practiced from 1911 to 1936 and subsequently having
been appointed to the post of Superintendent at the Asylum at i
Warm Springs.
DR. CHAS. WALLIN died January 1943 of acute leukemia. !
Dr. Wallin started practice in 1908 at White Sulphur Springs
and subsequently had been at Lewistown. For the last three j
years of his life he was full-time Health Officer.
Missoula County — DR. LEO P. MARTIN was killed in an
airplane crash by burning at the Walla Walla Air Base shortly
after entering the Air Corps Medical Service. Dr. Martin had
begun his practice in Nebraska and subsequently had lived in
Philipsburg, Montana, and Missoula, for the three years before
his death. He had been well known in recent years for his
work as Parachuting Physician for the Forest Service, having
gone to the help of various persons in medical need in isolated
forest areas.
DR. W. T. THORNTON died in 1943 after two years of
invalidism due to myeloma. Dr. Thornton graduated in medi-
cine in 1902. He practiced in Western Montana for 38 years.
He first built a hospital at Stevensville, and ten years later
moved to Missoula where, with his brother, he built the pres-
ent Thornton Hospital. His life was devoted, nearly exclusively,
to surgery, leaving a record of 15,000 operative cases.
Silver Bow County — DR. HAROLD MALEE died of illness
while serving in the Army Medical Corps early in 1943. He
had been in practice in Butte for about six years and interned
at the Murray Hospital, having been associated with the Clinic
later. He is survived by his widow and two children.
September, 1943
283
Yellowstone County — DR. ANDREW CLARK died at the
age of 78 in Billings, of old age, early in 1943. He was grad-
uated in medicine at a Canadian medical school in 1892. Mrs.
Clark, who was also an M.D., preceded him in death by a few
years. He is survived by two daughters.
DR. H. A. HANLEY graduated from Creighton Medical
School. He died in Billings following a coronary thrombosis.
He had been in general practice in Billings since 1916. He is
survived by his widow and three children.
Resolutions Committee
Dr. J. C. Shields, Chairman
The committee submitted the following report, which, upon
motion regularly made, duly seconded, and unanimously car-
ried, was adopted:
The House of Delegates of the Montana State Medical So-
ciety desires to express to their guest speakers, Dr. E. T. Bell,
Dr. William M. Bane, and Major A. P. Ormond, the local
Medical Society, the local Nurses’ Association, the Northern
Hotel, and the press, their appreciation for their invaluable con-
tribution toward the success of our Annual State Meeting.
There being no further business to come before the Scientific
Session, President E. D. Hitchcock declared the Sixty-fifth An-
nual Session of the Montana State Medical Association ad-
journed.
EXHIBITS
No commercial exhibits were displayed this year owing to
difficulties arising because of war conditions.
SCIENTIFIC EXHIBITS AND HOBBY SHOW
The Scientific Exhibits and Hobby Show were arranged by
Dr. M. A. Shillington of Glendive. A list of the exhibits and
hobbies shown follows:
Scientific Exhibits
Dr. E. D. Hitchcock, Great Falls — Bone sarcomata x-rays and
specimens.
Dr. J. H. Bridenbaugh, Billings — Results of Roentgen ther-
apy on bone tumors.
Dr. S. A. Olson, Glendive — Fractures treated by Boehler
technic.
Dr. David T. Berg, Helena — Plaster models of normal and
pathological specimens.
Hobby Exhibits
Dr. Faus P. Silvernale (deceased), Great Falls — Wood work
(courtesy of Mrs. Silvernale) .
Dr. I. J. Bridenstine, Terry — Wood work.
Dr. J. H. Garberson, Miles City — Bows and arrows.
Dr. J. C. Powers, Billings — Stamp collection.
Dr. R. G. Brogan, Roundup — Marquetry, oil paintings, and
lathe work.
Dr. Henry O. Drew, Billings — Clay models and sculptured
pieces.
Membership as of August 3, 1943
Total In
Society Members Army
Cascade County Medical Society 52 10
Chouteau County Medical Society 4 0
Fergus County Medical Society 16 4
Flathead County Medical Society 27 4
Gallatin County Medical Society 19 0
Hill County Medical Society 13 3
Lake County Medical Society 10 3
Lewis & Clark County Medical Society 28 10
Madison County Medical Society 6 1
Mt. Powell Medical Society 24 2
Musselshell County Medical Society 6 1
Northcentral Montana Medical Society 16 3
Northeastern Montana Medical Society 15 1
Park-Sweetgrass Medical Society 13 4
Silver Bow Medical Society 55 11
Southeastern Montana Medical Society 33 2
Western Montana Medical Society 56 18
Yellowstone Valley Medical Society 67 20
459 97
REPORT OF THE SECOND ANNUAL MEETING
OF THE WOMAN’S AUXILIARY TO THE
MONTANA STATE MEDICAL ASSOCIATION
The second annual convention of the Woman’s Auxiliary to
the Montana State Medical Association was called to order by
the president, Mrs. David T. Berg, in the Northern Hotel,
Billings, Thursday, July 8, 1943, at 11:00 A. M.
The president introduced Mrs. Roy V. Moreledge, member
of the newly organized hostess auxiliary of Billings, who deliv-
ered the address of welcome.
Mrs. E. L. Hitchcock, Great Falls, responded as representa-
tive of the state auxiliary.
Dr. Hitchcock, Great Falls, president of the Montana State
Medical Association, spoke on the importance of the auxiliary
to the state association, discussed certain pending legislation
that has to do with public health and public welfare, and de-
clared the goal for the coming year a complete organization of
auxiliaries to every medical society in the state.
The president introduced Mrs. Eben J. Carey of Wauwatosa,
Wisconsin, president of the Woman’s Auxiliary to the Ameri-
can Medical Association, Mrs. P. E. Logan, Great Falls, presi-
dent-elect of the state auxiliary, Mrs. Wernham, chairman of
convention, and her committee, and Mrs. P. E. Griffin, presi-
dent of the hostess auxiliary.
Mrs. T. L. Hawkins, chairman of credentials, gave the fol-
lowing report:
Number of state board members 2
Number of state officers _ 4
Number of national officers 2
Number of members 31
Number of guests — 21
Total number present 52
The secretary read the minutes which were approved without
correction.
The treasurer’s report showed a balance of $101.95 on June
I, 1943. The report was filed with the secretary without ques-
tion.
The president called for reports of the state officers, of the
chairmen of standing committees, and of county presidents as
follows:
State — President, Mrs. David T. Berg; vice president, Mrs.
J. M. Nelson; corresponding secretary, Mrs. T. L. Hawkins;
program and public relations, Mrs. J. P. Ritchey; legislation and
archives, Mrs. L. F. Hall; Hygeia, Mrs. Leonard Brewer; press
and publicity, Mrs. T. L. Hawkins.
County Presidents — -Western Montana, Mrs. J. M. Nelson;
Lewis & Clark, Mrs. T. L. Hawkins; Cascade, Mrs. Robert
Holzberger; Flathead, Mrs. F. B. Ross; Yellowstone Valley,
Mrs. P. E. Griffin.
The following recommendations were approved by the 1943
annual meeting of the Woman’s Auxiliary to the Montana
State Medical Association.
I. That each county auxiliary amend its constitution to read:
(a) that the fiscal year shall be from May 1st to May 1st;
(b) that county, state and national dues become payable to the
county treasurer on October 1st, and dues become delinquent if
not paid by November 30; (c) that associate members be re-
quired to pay county, state and national dues, and that they
serve on committees.
II. That article I under By-Laws in the State Constitution
be changed to read: The president, president-elect, vice presi-
dent, secretary, treasurer, the four directors, the chairmen of
standing committees, and the county presidents shall constitute
an Executive Council to conduct all necessary business of the
auxiliary between annual meetings. Such business may be con-
ducted by mail.
III. That the president, vice president and treasurer work out
a financial plan for the expenses of the state auxiliary to be
presented at the midyear board meeting.
IV. That the recommendations for program and public rela-
tions made by Mrs. J. P. Ritchey, Missoula, be recommended
to the state chairmen of these same committees, to be incor-
porated to as great extent as possible in their plans for 1943-
1944. These recommendations are as follows:
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The Journal-Lancet
1. An informational course covering all state institutions hav-
ing to do with the care of the sick: (a) Hospital for the In-
sane— Warm Springs; Dr. Holmes of War Springs suggested
as speaker. (b) Tuberculosis Sanitarium — Galen; "Fighting
Tuberculosis in the Rockies,” by Esther G. Price, published by
the Montana Tuberculosis Association. (c) School for the
Blind — Great Falls, (d) School for the Feebleminded — Boul-
der. (e) Hamilton Laboratory; there are movies showing life
cycle of the tick — probably showing could be arranged, (f)
State Board of Health, its departments and workings: (1)
Bureau of Vital Statistics, (2) Hygienic Laboratory, (3) Divi-
sion of Foods and Drugs, (4) Division of water and sewage,
(5) Division of maternal and child welfare, (6) Division of
Communicable Diseases, (7) Administration, (8) Division of
Industrial Hygiene, (9) Division of Services for Crippled Chil-
dren— to include hospitals for same.
2. Biographies and other books of historic value in medicine:
As l Remember Him (Hans Zinnser) , Life of Sir William
Osier (Harvey Cushing), Fatal Partners — War and Disease
Ralph Major, M.D., Madame Curie (Eve Curie), An Ameri-
can Doctor’s Odyssey (Victor Heiser) , Papers and Speeches
(John Chalmers De Costa), Medicine at the Crossroads (Ber-
tram M. Bernheim),/! Family Doctor’s Notebook (I. J. Wolfe,
M.D.), For Daughters and Mothers (Valeria H. Parker, M.D.),
The Doctor’s Wife (Dr. Rock Sleyster) , Triumph Over Pain
(Rene Fiilop-Miller) , Medicine Marches On (Edward Podolsky,
M.D.), A Surgeon’s Life — the Autobiography of J. M. T.
Finney (of Johns Hopkins group, and the growth of the insti-
tution and its personnel), Life of Edward Jenner, and A Sur-
geon’s Autobiography (Hugh Young).
3. (a) Build up group consciousness and loyalty to each
other; (b) Build up consciousness of the Auxiliary as a work-
ing unit in the community — identify Auxiliary with the com-
mercial club as a city organization to be of service to commu-
nity.
4. Plan one meeting with special speaker on some phase of
medicine, health or public health, and invite the Woman’s Club
or other groups to attend.
5. Don’t forget the social function in the Auxiliary.
The chairman of the nominating committee presented the
following slate:
President-Elect — Mrs. J. M. Nelson, Missoula.
Vice President — Mrs. P. E. Griffin, Billings.
Treasurer — Mrs. A. A. Dodge, Kalispell.
Directors — Mrs. Pat Murphy, Missoula, and Mrs. David
T. Berg, Helena.
The meeting recessed for luncheon. Miss McCoy of the Red
Cross spoke briefly on the need for more nurses to serve the
armed forces. Mrs. Ralph Spitzer sang two solos accompanied
by Mrs. W. J. Jameson on the piano.
The session reconvened at 2:15. The president introduced
Mrs. E. J. Carey, who spoke on the aims of the Auxiliary, ideas
for program and public relations, service to community, accom-
plishments of the Doctors’ Aide Corps in other states, and
ways of helping in the defense effort. Mrs. Carey asked the
assembly to take the Auxiliary pledge by repeating it in unison.
The president asked for nominations from the floor. Since
there were no further nominations, the candidates were unani-
mously elected and were introduced to the assembly.
Mrs. J. P. Ritchey, Missoula, having been introduced by
Mrs. J. M. Nelson of Missoula, expressed the appreciation of
the Auxiliary and asked for a rising vote of thanks to Mrs. D.
T. Berg.
The second annual convention was declared adjourned.
Mrs. T. L. Hawkins, Secretary.
Mrs. David T. Berg, President.
MONTANA STATE MEDICAL ASSOCIATION
ROSTER-- 1943
MEMBERSHIP BY DISTRICTS
CASCADE COUNTY MEDICAL SOCIETY
Dr. L. L. Howard, Pres. Great Falls
Dr. R. C. Davis, V.-Pres. Great Falls
Dr. Earl L. Hall, Sec.-Treas.
Great Falls
Allred, I. A. Great Falls
Anderson, C. E. Great Falls
Andrews, F. L. Great Falls
Bateman, H. W. Choteau
Blankenhorn, C. E Great Falls
Bresee, C. J. Great Falls
★Craigo, F. H. Great Falls
Crary, L. S. Fairfield
Davis, R. C Great Falls
Durnin, R. B. Great Falls
Fuller, H. W Great Falls
★Gibson, H. V. .... Great Falls
Gleason, A. L. Great Falls
Greaves, J. P. Great Falls
Dr. C. W. Wilder, Pres Lewistown
Dr. J. J. Elliott, V.-Pres Lewistown
Dr. F. F. Attix, Sec.-Treas. Lewistown
Alexander, J. L. Winnett
Attix, F. F. Lewistown
Deal, A. W. Lewistown
★Hall, Cecil M Great Falls
Hall, E. L. Great Falls
Hitchcock, E. D. Great Falls
Holzberger, R. Great Falls
Howard, L. L. Great Falls
Hurd, F. D. Great Falls
Irwin, J. H. Great Falls
★Johnson, A. C. Great Falls
Keenan, F. E Great Falls
Larson, E. M. Great Falls
Layne, J. A Great Falls
Little, C. F Great Falls
Logan, P. E. Great Falls
Lord, B. E. Great Falls
MacGregor, J. C Great Falls
★Magner, Chas Great Falls
Mayland, L. L. Great Falls
McBurney, L. R. Great Falls
McGregor, H. J Great Falls
★ Dismore, A. B. Stanford
★Eck, Raymond Lewistown
Elliott, J. J. Lewistown
Freed, Hazel Stanford
Gans, E. M Harlowton
★Gans, E. W. Harlowton
★Gans, Paul J. Lewistown
★McGregor, J. F. Great Falls
McGregor, R. J. Great Falls
★McPhail, Malcolm Great Falls
★Nagel, Chas. E. Great Falls
★Peterson, C. H. Great Falls
Richardson, R. B. Great Falls
Russell, R. Fort Shaw
Schemm, F. R. Great Falls
Setzer, Geo. W. Malta
Shephard, H. C. Hughesville
Strain, Earle Great Falls
Templeton, C. V. Great Falls
★Vasco, John R. Great Falls
Walker, Dora Great Falls
Walker, T. F. Great Falls
Waniata, F. K. Great Falls
Weisgerber, A. L. Great Falls
Williams, W. T Malta
Bassow, C. F. Fort Benton
Cooper, D. J. Big Sandy
Worsted, Gaylord Fort Benton
Herring, J. H. Lewistown
Johnson, R. G Harlowton
Porter, E. S Lewistown
Soltero, J. R. Lewistown
Welden, E. A. Lewistown
Wilder, Curtis W Lewistown
CHOUTEAU COUNTY MEDICAL SOCIETY
Dr. C. F. Bassow, Pres. Ft. Benton Dr. E. L. Anderson, Sec.-Treas
Dr. D. J. Cooper, V.-Pres Big Sandy Ft. Benton
Anderson, E. L Fort Benton
FERGUS COUNTY MEDICAL SOCIETY
September, 1943
285
FLATHEAD COUNTY MEDICAL SOCIETY
Dr. F. B. Ross, Pres.
Kalispell
Cockrell, E. P.
Kalispell
Martin, Chas. J.
Libby
Dr. M. O. Burns, V.-Pres.
Kalispell
Conway, W. Q.
Kalispell
Moore, T. B., fr.
Kalispell
Dr. A. A Dodge, Sec.
. Kalispell
★ Delaney, J. R
Kalispell
Munro, A. T. ....
Kalispell
Dr. J. Arthur Lamb, Treas.
.Kalispell
Dodge, A. A.
... Kalispell
Ross, F. B.
Kalispell
Griffis, L. G.
Kalispell
Simons, John B.
Whitefish
★ Borkow, M. .... .
Whitefish
★Holcomb, M. D. ....
Whitefish
Stewart, Robt. M.
Whitefish
Brassett, A. J.
Kalispell
Huggins, H. D.
Kalispell
Taylor, W. W.
Whitefish
Brown, J . W.
Whitefish
Kell, W. L..
Columbia Falls
Towne, P. L
Kalispell
Burns, M. O.
Kalispell
Lamb, J. A. _
★ Weed, V. A.
Kalispell
Cairns, J. M.
Libby
Lees, A. T.
Wright, G. B.
Kalispell
Clark, C. A.
... Eureka
Liest, J.
Big Fork
GALLATIN COUNTY MEDICAL SOCIETY
Dr. R. A. Williams, Pres.
Manhattan
Eneboe, Paul L. ..
Bozeman
Scherer, R. G
Bozeman
Dr. A. D. Brewer, V.-Pres.
Bozeman
Grigg, E. Roy
Bozeman
Seerley, C. C.
Bozeman
Dr. E. J Kearns, Sec. -Treas
>. Bozeman
Heetderks, B. J
Bozeman
Seitz, R. E.
Bozeman
Kearns, E. T
Bozeman
Sigler, R R.
Bozeman
Bole, W. S.
Bozeman
Keeton, R. G.
Bozeman
Smith, C. S.
Bozeman
Bradbury, J. T Willow Creek
Maillet, L. L. ..
... Three Forks
Whitehead, C. E.
Bozeman
Brewer, A. D. ....
Bozeman
Phillips, J. H.
Bozeman
Williams, R. A. .... .
Bozeman
Craft, Chas. B. ... _
Bozeman
Sabo, F. I.
Bozeman
HILL COUNTY MEDICAL SOCIETY
Dr. Chas. Houtz, Pres.
Havre
Benke, R. A.
Chester
Lacey, Wm. A.
Havre
Dr. W. F. Hamilton, V.-Pres. Havre
Forester, W. L. ....
Havre
★Mackenzie, D. S., Jr.
Havre
Dr. Geo. Jestrab, Sec. -Treas. Havre
Hamilton, W. F.
Havre
MacKenzie, D. S.
.... Havre
Hoon, A. S.
Chinook
McCannel, W. A
Harlem
Almas, D. I
Chinook
Houtz, C. S.
Havre
★Sussex, L. T.
Havre
★Aubin, F. W.
Havre
Jestrab, G. A.
Havre
LAKE COUNTY MEDICAL SOCIETY
Dr. G. E. Armour, Pres. 1
St. Ignatius
Dimon, J.
Poison
Mathews, T. A.
. St. Ignatius
Dr. I. E. Law. Sec. -Treas.
Poison
French, E. J.
★Tanglin, W. G. ..
Poison
Armour, G. E. St. Ignatius
Koehler, H. L.
Poison
Teel', H M.
Poison
★ Brooke, J. M.
Ronan
★Lipow, E. G.
... Dixon
Venneman, F. W. ....
St. Ignatius
LEWIS & CLARK COUNTY
MEDICAL SOCIETY
Dr. David Berg, Pres
Helena
Flinn, J. M.
Helena
★McCabe, James
Helena
Dr. E. L. Gallivan, V.-Pres
Helena
Fricks, 1 D.
Helena
McElwee, Wm. R.
Dr. Edythe Hershey, Sec. -Treas.
Gallivan, E. L.
Helena
White Sulphur Springs
Helena
Hall, L. F.
Helena
★Mears, Claude
Helena
Bayles, R. G. ....
Townsend
★Hawkins, Thos. L._.
Helena
★Monserrate, D. N. ...
Helena
Berg, David T.
... Helena
Hershey, Edythe .. .
Helena
Moore, O. M.
Helena
★Campbell, Robt.
Helena
★Jump, C. F.
Morris, R. W.
Helena
Cashmore, W. F.
... Helena
Kilbourne, B. K. ....
Helena
Nash, F.
Townsend
Cooney, S. A.
... Helena
Klein, O. G.
Helena
★Shearer, Beryl C.
Helena
Copenhaver, Wm. M. ....
Helena
Leonard, T. M.
Helena
Thompson, J. G.
Helena
★l amer. 1 M.
Helena
★Lindstrom, E. H. ...
Helena
★Whitlinghill, I. A. ...
~
MADISON COUNTY MEDICAL SOCIETY
Dr. L. R. Packard, Pres
Whitehall
Burns, W. J.
Sheridan
Dyer, R. H.
Sheridan
Clancy, D. F.
Ennis
Farnsworth, F. B
Virginia City
Ur. K. H. Uyer, bee.- 1 reas. Sheridan
★Clancy, John
Ennis
Packard, L. R.
Whitehall
MOUNT POWELL MEDICAL SOCIETY
Dr. M. R. Snodgrass, Pres.
Anaconda
Downey, R. E.
Warm Springs
Malee, J . J .
— Anaconda
Dr. J. L. O’Rourke, V.-Pres
Anaconda
Dr. L. G. Dunlap, Sec Anaconda
Dr. Gladys Holmes, Treas.
Warm Springs
Anderson, G. A. Deer Lodge
Bolton, LeRoy ... Deer Lodge
Crowley, L. S. Warm Springs
Dunlap, L. G. Anaconda
Getty, R. W. Galen
★Grossboll, A. N. Philipsburg
★Harpo, D. T. Deer Lodge
Holmes, G. V Warm Springs
Kargacin, Tom J. Anaconda
Knight, A. C. Philipsburg
Larson, Eloise Livingston
Noonan, J. H. Anaconda
O’Rourke, Leo J. Anaconda
Pampel, B. L. Warm Springs
Place, B. A. Warm Springs
Scanlon, J. J. Deer Lodge
Snodgrass, M. R. Anaconda
Terrill, F. I. Galen
Unmack, F. L. Deer Lodge
Willits, A. J. Anaconda
Long, W. E. Anaconda
MUSSELSHELL COUNTY MEDICAL SOCIETY
Dr. R. E. Brogan, Pres Roundup ★Bennett, A. A. Roundup Fouts, E. R. Ryegate
Dr. E. R. Fouts, V.-Pres Ryegate Brogan, R. E. Roundup Lewis, G. A. Roundup
Dr. G. A. Lewis, Sec. -Treas. Roundup Crouse, S. A. Roundup O’Neill, R. T. Roundup
NORTHCENTRAL MONTANA MEDICAL SOCIETY
Dr. L. L. Elliott, Pres Cut Bank
Dr. W. C. Robinson, V.-Pres. Shelby
Dr. W. L. DuBois, Sec. -Treas. Conrad
Bosshardt, O. A Ontario, Calif.
Cannon, P. S. Conrad
DuBois, W. L. Conrad
Elliott, L. L. Cut Bank
Meadows, W. A. Sunburst
Neraal, P. O. Cut Bank
Olsen, N. A. Cut Bank
Paterson, W. F. Conrad
★Peterson, W. M. Plentywood
Powell, C. D. Vancouver, Wash.
Power, H. W. Conrad
Robinson, W. C. Shelby
Rogers, R. V. ... Browning
Schraeder, H. F Browning
★Spatz, J. M. Cut Bank
Whetstone, S. D Cut Bank
286
The Journal-Lancet
NORTHEASTERN MONTANA MEDICAL SOCIETY
Dr. O. G. Benson, Pres. Plentywood
Dr. H. B. Cloud, V.-Pres. Wolf Point
Dr. R. E. Ryde, Sec.-Treas. Glasgow
Agneberg, N. O. Glasgow
Benson, O. G. Plentywood
Cloud, H. B Wolf Point
Cockrell, T. L Hinsdale
Habel, Wm. P. H Wolf Point
Knapp. R. D. Wolf Point
Knierim, F. M. Glasgow
Krogstad, L. T Wolf Point
Larson, C. B Glasgow
Mittleman, Edw. J Wolf Point
Munch, C. J Culbertson
Ryde, R. E Glasgow
★Schweizer, H. W. Ft. Worden, Wash.
Smith, A. N Glasgow
Studer, D. J Faribault, Minn.
PARK-SWEETGRASS MEDICAL SOCIETY
Dr. A. M. Lueck, Pres. Livingston
Dr. Paul L. Greene, V.-Pres. Livingston
Dr. Dan R. Bennett, Sec.-Treas.
Livingston
Baskett, L. W. Big Timber
Bennett, Dan R. Livingston
Claiborn, D. R. Big Timber
Cogswell, W. F. Helena
Greene, P. L. Livingston
★ Harris, W. E Livingston
Leard, S. E. Livingston
Lueck, A. M Livingston
★ Paul, F. W Big Timber
★ Pearson, J. A. ... Livingston
Townsend, G. A. Livingston
★Walker, R. E. Livingston
Windsor, G. A. Livingston
SILVER BOW COUNTY MEDICAL SOCIETY
Dr. R. F. Peterson, Pres. Butte
Dr. J. E. Garvey, V.-Pres Butte
Dr. S. V. Wilking, Sec Butte
Dr. C. R. Canty, Treas Butte
Atkins, D. A. Butte
Brody, John Butte
★ Bush, T. F. Butte
Canty, Chas. R Butte
Carmichael, G. A. Butte
Casebeer, H. L __ Butte
★Casebeer, R. L. Butte
Coleman, J. K. Butte
★Donich, G. M Butte
Floyd, J. S Butte
Frisbee, J. B. Butte
Garvey, J. E. Butte
Gillispie, D. L Butte
Gregg, H. W. Butte
★Hale, D. E. Butte
Hill, R. J Whitehall
Horst, C. H. Butte
James, H. H. Butte
Joesting, H. C Butte
Kane, P. E Butte
★Kane, R. C. „ Butte
Karsted, A. Butte
★Kroeze, R. Butte
Lapierre, J. C Butte
Lhotka, J. F. Butte
MacPherson, G. T. Butte
McGill, Caroline Butte
McMahon, E. S .. Butte
★Monahan, R. C. Butte
Mondloch, J. L. Butte
★Morgan, R. N Butte
O’Keife, N. J. Butte
★Pemberton, C. W. Butte
Peterson, R. F. Butte
Poindexter, F. M Dillon
Rodes, C. B.
Butte
★ Routledge, Geo. L.
Dillon
Saam, S. F
— . Butte
Saam, T. W.
.... Butte
Schwartz, Harold
Butte
Schwartz, S. E.
Butte
Shanley, T. J. B.
Butte
Shields, J. C.
Butte
★Sievers, A. R.
Butte
Sievers, J. R. E. ....
... Butte
Smetters, McCormick
— . Butte
Smith, L. W
.... Butte
Spurck, P. T
Butte
Stanchfield, H.
Dillon
Steinberg, S. S
Butte
Stephan, W. H.
Dillon
Thorkelson, Jacob
.... Butte
Ungherini, V. O.
Butte
Wilking, S. V.
.... Butte
Williams, Frank
— . Butte
SOUTHEASTERN MONTANA MEDICAL SOCIETY
Dr. R. D. Benson, Pres. Sidney
Dr. B. R. Tarbox, V.-Pres Forsyth
Dr. R. G. Lemon, Sec.-Treas. .Glendive
Beagle, J. S. Sidney
Benson, R. D. Sidney
Blakemore, W. H Baker
Bridenstine, I. J Terry
Craig, J. W. Circle
★ Dale, E. Wibaux
Danskin, M. G. Glendive
Denman, H Baker
Farrand, B. C Jordon
Garberson, J. H.
Harper, R. D.
Haywood, Guy T -
Hogebohm, C. F.
Miles City
Sidney
... Forsyth
Baker
Howard, E. M.
Miles City
Forsyth
Hunt, J. H. ..
„ Glendive
★Lemon, R. G.
Lindeberg, S. B.
Morrill, R. A
Noonan, E. F.
Olson, S. A.
Glendive
Miles City
Sidney
... Wibaux
.. Glendive
Parke, Geo. F. Glendive
Pratt, S. C. - Miles City
Randall, R. R - Miles City
Rowen, E. H. Miles City
Rundle, B. S. Circle
Sandy, B. B Ekalaka
Shillington, M. A. „ Glendive
Tarbox, B. R Forsyth
Thompson, J. R Miles City
Varco, A. R. _• Miles City
Weeks, S. A Baker
Winter, M. D Miles City
WESTERN MONTANA MEDICAL SOCIETY
Dr. Leonard Brewer, Pres Missoula
Dr. A. T. Haas, V.-Pres Missoula
Dr. Wm. E. Harris, Sec.-Treas
Livingston
Alderson, L. R Missoula
Blegen, H. M Missoula
Bourdeau, C. L Missoula
Bourdeau, E. J. Missoula
Brewer, L. W Missoula
★ Bussabarger, R. A Missoula
★Cummings, I. K. Missoula
Doyle, W Superior
★Duffalo, J. A __ Missoula
Farabaugh, C. L. Missoula
★Fattic, G. F Hot Springs
J. W. Fennell Missoula
Ferret, A Missoula
Flynn, J. J Missoula
Foss, A. R. Missoula
★Fredrickson, C. H. Missoula
Frogner, G. S Thompson Falls
George, E. K. Missoula
★Gordon, Donald A. Hamilton
Haas, A. T. Missoula
Hall, H. J Missoula
Harris, W. E Missoula
Hayward, Herbert Hamilton
★Hesdorffer, M. B Missoula
Hiemstra, W. Missoula
Holmes, J. L. Missoula
★Honeycutt, C. F Missoula
★Keys, R. W. Missoula
King, W. N. Missoula
Kinter, A. R. Missoula
Koessler, H. H Missoula
Lowe, F. H. Missoula
Marshall, Wm. J. Missoula
★Martin, L. P. Missoula
McPhail, W. N. Missoula
★Morrison, W. F. Missoula
★Murphy, E. S. Missoula
★ Murphy, J. E. Missoula
Nelson, J. M Missoula
★Noble, P. C. Poison
★Ohlmack, J. P. Missoula
Pease, F. D Missoula
Peterson, R. L Hamilton
Preston, S. N Missoula
Rennick, P. S. Stevensville
Rew, A. W Thompson Falls
Richards, J. L. Poison
Ritchey, J. P Missoula
★Sale, G. G Missoula
★Stephan, Louis B. Missoula
Svore, C. R. Somers
Tefft, C. C Hamilton
Thornton, C. R. Missoula
Trenouth, S. M Missoula
Turman, G. F. Missoula
★Weber, R. D Missoula
Wirth, R. E Missoula
September, 1943
287
YELLOWSTONE VALLEY MEDICAL SOCIETY
Dr. Cedric H. Nelson, Pres. Billings
Dr. Phillip E. Griffin, V.-Pres
Billings
Dr. H. T. Caraway, Sec Billings
Dr. Albert E. Stripp, Treas. Billings
Adams, E. M. Red Lodge
Allard, L. W.
★Anderson, M. O.
Appleman, R. W. ...
Billings
Hardin
Beltzer, Chas. E.
Benson, Theo. J. ....
★ Biehn, R. H.
Washoe
Fromberg
Blackstone, A. V. ...
Bridenbaugh, J. H.
★Brunkow, B. H. ....
Burdick, M. S.
Caraway, H. T. .
Carey, W. R.
★Chappie, R. R.
Clark, A. E. ...
Culbertson, H. H. .
Absarokee
Billings
Billings
Crow Agency
Billings
. Crow Agency
Billings
Billings
★Currie, Robt. W. ..
DeCanio, John
DeMers, J. J.
Billings
Crow Agency
Huntley
Drew, H. O. Billings
Dunkle, Frank Billings
Farr, E. M. Billings
Ferree, V. D. .... Bridger
Fisher, M. L. Hardin
Gerdes, Maude M. Billings
Gordon, Wayne Billings
★ Graham, J. H. Billings
Griffin, P. E. Billings
★Hagmann, E. A. Billings
Hall, E. C .... Laurel
Hamerick, Fred Crow Agency
Hammerel, A. L. Billings
★ Hammerel, J. J. Billings
★Hayes, J. D. Mammoth Hot Springs
★ Hodges, D. E. Billings
★Hynes, John E. Billings
★Knese, L. A. .Yellowstone County
Kronmiller, L. H. Billings
Labbitt, L. H. ... Hardin
Leeper, D. D. Laurel
★Levitt, Louie Worden
MacDonald, D. J. Billings
★McHeffy, Geo. J. Billings
★McIntyre, H. E Billings
Morgan, H. G Red Lodge
Morledge, R. V. Billings
★Morrison, J. D. . Billings
Morrison, W. R. Billings
Movius, A. J., Jr Billings
Movius, A. J., Sr. Billings
Nelson, C. H Billings
Neville, J. Vernon Columbus
Olemik, John M. Red Lodge
Power, J. C. Billings
★ Rathman, Omer C. Billings
Richards, W. G. Billings
★ Russell, Leland Billings
Schubert, J. W Hardin
★Shaw, John A Billings
★Smith, W. P. Columbus
Souders, S. M. Red Lodge
Stripp, A. E. Billings
Unsell, David H. Billings
Vye, T. R. Laurel
Weedman, W. E. Billings
Werner, S. L. Billings
Wernham, J„ I Billings
★ Member in the Armed Forces of the United States.
ROSTER
Montana State Medical Association-" 1943
Adams, E. M. Red Lodge
Agneberg, N. O. Glasgow
Alderson, L, R. Missoula
Alexander, J. Winnett
Allard, L. W. Billings
Allred, I. A. Great Falls
Almas, D. J. Chinook
Anderson, C. E Great Falls
Anderson, E. L Fort Benton
Anderson, G. A Deer Lodge
★Anderson, M. O. Hardin
Andrews, F. L. Great Falls
Appleman, R. W Worden
Armour, G. E. St. Ignatius
Atkins, D. A Butte
Attix, F. F. Lewistown
★Aubin, F. W. Havre
Baskett, L. W. Big Timber
Bassow, C. F. Fort Benton
Bateman, H. W. Chouteau
Bayles, R. G. Townsend
Beagle, J. S. Sidney
Beltzer, C. E. Washoe
Benke, R. A. Chester
★Bennett, A. A. Roundup
Bennett, Dan R. Livingston
Benson, O. G. Plentywood
Benson, R. D Sidney
Benson, T. J. Fromberg
Berg, D. T Helena
★Biehn, R. H. Billings
Blackstone, A. V Absarokee
Blakemore, W. H. Baker
Blankenhorn, C. E Great Falls
Blegen, A. M. Missoula
Bole, W. S. Bozeman
i Bolton, L. R. Deer Lodge
★Borkow, M. Whitefish
Bosshardt, A. O. Ontario, Calif.
Bourdeau, C. L Missoula
■
Bourdeau, E. J. __ . Missoula
Bradbury, J. T. Willow Creek
Brassett, A. J. Kalispell
Bresee, C. J. Great Falls
Brewer, A. D. Bozeman
Brewer, L. W. Missoula
Bridenbaugh, J. H. Billings
Bridenstine, I. J Terry
Brody, John .... ... Butte
Brogan, R. E. Roundup
★Brooke, J. M Ronan
Brown, J. W. Whitefish
★ Brunkow, B. H. Billings
Burdick, M. S Crow Agency
Burns, M. O. KalispeLl
Burns, W. J. Sheridan
★ Bush, T. F. Butte
★ Bussabarger, R. A. Missoula
Cairns, J. M Libby
★Campbell, Robt. Helena
★Cannon, P. S. Conrad
Canty, C. R. Butte
Caraway, H. T. Billings
Carey, W. R. Crow Agency
Carmichael, G. A. Butte
Casebeer, H. L Butte
★Casebeer, R. L. Butte
Cashmore, W. F. Helena
★Chappie, R. R. .... Billings
Claiborn, D. R. .. Big Timber
Clancy, D. F. Ennis
★Clancy, John Ennis
Clark, A. E. Billings
Clark, C. A. Eureka
Cloud, H. B. ... Wolf Point
Cockrell, E. P. Kalispell
Cockrell, T. L Hinsdale
Cogswell, W. F. Helena
Colman, J. K. Butte
Conway, W. Q. Kalispell
Cooney, S. A Helena
Cooper, D. J Big Sandy
Copenhaver, W. M. Helena
Craft, C. B Bozeman
Craig, J. W Circle
★Craigo, F. H. Great Falls
Crary, L. S. Fairfield
Crouse, S. A. Roundup
Crowley, L. G. Warm Springs
Culbertson, H. H. Creston
★Cummings, I. K. Missoula
★Currie, R. W. Billings
Danskin, M. G Glendive
★Dale, E. Wibaux
Davis, R. C Great Falls
Deal, A. W. Lewistown
DeCanio, J. Crow Agency
★ Delaney, J. R. Kalispell
DeMers, J. J. Huntley
Denman, H. Baker
Dimon, J. Poison
★ Dismore, A. B. Stanford
Dodge, A. A Kalispell
★Donich, G. M. Butte
Downey, D. E. Warm Springs
Doyle, W. J. — Superior
Drew, H. O. Billings
DuBois, W. L. Conrad
★ Duffalo, J. A Missoula
Dunkle, F. Billings
Dunlap, L. G. Anaconda
Durnin, R. B. Great Falls
Dyer, R. H. Sheridan
★ Eck, Raymond Lewistown
Elliott, J. J. Lewistown
Elliott, L. L Cut Bank
Eneboe, P. L Bozeman
Farabough, C. A. Missoula
★Farner, L. M. Helena
Farnsworth, R. B. Virginia City
288
The Journal-Lancet
Farr, E. M. Billings
Farrand, B. C. Jordan
★Fattic, G. R. Hot Springs
Fennell, J. W. Missoula
Ferree, V. D Bridger
Ferrett, A. ... Missoula
Fisher, M. L. Hardin
Flinn, J. M. Helena
Floyd, J. S. Butte
Flynn, J. J. Missoula
Forster, W. L. Havre
Foss, A. R .... Missoula
Fouts, E. R. Ryegate
★Fredrickson, C. H. Missoula
Freed, H. Stanford
French, E. J Ronan
Fricks, L. D. Helena
Frisbee, J. B. Butte
Frogner, G. S. .... Thompson Falls
Fuller, H. W. Great Falls
Gallivan, E. L. Helena
Gans, E. M. Harlowton
★Gans, E. W. Harlowton
★ Gans, P. J. Lewistown
Garberson, J. H. Miles City
Garvey, J. E. Butte
George, E. K. .... Missoula
Gerdes, Maude M. Billings
Getty, R. W. Galen
★ Gibson, H. V. Great Falls
Gillespie, D. L. Butte
Gleason, A. L. Great Falls
★Gordon, D. A. __ Hamilton
Gordon, Wayne Billings
★Graham, J. H. Billings
Greaves, J. P Great Falls
Greene, P. L. Livingston
Gregg, H. W. Butte
Griffin, P. E Billings
Griffis, L. G Kalispell
Grigg, E. R. Bozeman
★Grosboll, A. N. Philipsburg
Haas, A. T. Missoula
Habel, W. P. Wolf Point
★ Hagmann, E. A. Billings
★Hale, D. E. Butte
★Hall, C. M. Great Falls
Hall, E. C. Laurel
Hall, E. L. Great Falls
Hall, H. J. Missoula
Hall, L. F. Helena
Hamernick, F. Crow Agency
Hamilton, W. F. Havre
Hammerel, A. L. Billings
★Hammered, J. J. Billings
Harper, R. D. Sidney
★Harpo, D. T. Deer Lodge
★Harris, W. E. Livingston
Harris, W. E. Missoula
★ Hawkins, T. L. Helena
★Hayes, J. D. Mammoth Hot Springs
Hayward, H. C. Hamilton
Heetderks, B. J. Bozeman
Herring, J. H. Lewistown
Hershey, E. Helena
★Hesdorffer, M. B. Missoula
Heywood, Guy Forsyth
Hiemstra, W. Missoula
Hill, R. J. Whitehall
Hitchcock, E. D. Great Falls
Hogebohm, C. F. Baker
★ Hodges, D. E. Billings
★Holcomb, M. D. Whitefish
Hoi mes, G. V. Warm Springs
Holmes, J. T. Missoula
Holzberger, R. J. Great Falls
★Honeycutt, C. F. Missoula
Hoon, A. S. Chinook
Horst, C. H. Butte
Houtz, C. S. Havre
Howard, E. M. Miles City
Howard, L. L. Great Falls
Huene, H. J. ... Forsyth
Huggins, H. D. Kalispell
Hunt, J. H Glendive
Hurd, F. D. Great Falls
★Hynes, J. E. .. .. Billings
Irwin, J. H. Great Falls
James, H. H Butte
Jestrab, G. A. Havre
Joesting, H. D. Butte
*J ohnson, A. C. Great Falls
Johnson, R. G. Harlowton
★Jump, C. F Helena
Kane, P. E. .. Butte
★ Kane, R. C. Butte
Kargacin, T. J. Anaconda
Karsted, A. J. Butte
Kearns, E. J. .... Bozeman
Keenan, F. E. Great Falls
Keeton, R. G. Bozeman
Kell, W. L. Columbia Falls
★Key, R. W. .... Missoula
Kilbourne, B. K. Helena
King, W. N. _ Missoula
Kintner, A. R. ... Missoula
Klein, O. G. . Helena
Knapp, R. D. .... Wolf Point
★Knese, L. A. Yellowstone County
Knierim, F. M. Glasgow
Knight, A. C. Philinsburg
Koehler, T. L. ... Poison
Koessler. H. H. — ... Missoula
★K roeze, R. Butte
Krogstad, L. T. Wolf Point
Kronmiller, L. H Billings
Labbitt. L. H. .... Hardin
Lacey, W. A. Havre
Lamb, J. A. Kalispell
Lapierre. T. C. .... Butte
Larson, Eloise Great Falls
Larson, C. B. Glasgow
Larson, E. M. Great Falls
Layne, T. A. Great Falls
Leard, S. E. Livingston
Leonard. T. M. Helena
Leeper, D. D. Laurel
Lees, A. T Whitefish
★Lemon, R. G. Glendive
★ Levitt, L. Worden
Lewis, G. A. Roundup
Lhotka, J. F. Butte
Liest, J. Big Fork
Lindeberg, S. B. Miles City
★ Lindstrom. E. H. Helena
Little, C. F. Great Falls
★Li pow, E. G. Ronan
Logan. P. E. Great Falls
Long, W. E. Anaconda
Lord, B. E. Great Falls
Lowe, F. H. Missoula
Lueck, A. M. ... Livingston
MacDonald, D. J. Billings
MacGregor, T. C. Great Falls
★MacIntyre, H. E. Billings
★MacKenzie, D. S., Jr Havre
MacKenzie, D. S. Havre
MacPherson, G. T. Butte
★Magner, Chas. Great Falls
Maillet, L. L. Great Falls
Malee, J. J. Anaconda
Marshall, W. J. Missoula
Martin, C. J.
Libby
★Martin, L. P.
Missoula
Mathews, T. A.
St. Ignatius
Mayland, L. L.
Great Falls
McBurney, L. R.
Great Falls
★McCabe, J. J.
Helena
McCannel, W. A.
Harlem
McElwee, Wm. R.
White Sulphur Springs
McGill, Caroline
Butte
McGregor, H. J.
Great Falls
★McGregor, J. F.
Great Falls
McGregor, R. J.
Great Falls
★McHeffy, G. J.
Billings
McMahon, E. S. ...
Butte
★McPhail, F. L.
Great Falls
McPhail, Malcolm
Great Falls
McPhail, W. N. ....
Missoula
Meadows, W. A.
Sunburst
★Mears, Claude
Helena
Mittleman, E, J.
Wolf Point
★Monahan, R. C. .
Butte
Mondloch, J. L. ....
Butte
★Monserrate, D. N.
Helena
Moore, O. M.
Helena
Moore, T. B., Jr
Kalispell
Morgan, H. G.
Red Lodge
★Morgan, R. N.
Butte
Morledge, R. V. ....
Billings
Morrill, R. A.
. Sidney
Morris, R. W.
Helena
★Morrison, J. D. ....
Billings
★ Morrison, W. F. ....
Missoula
Morrison, W. R.
Billings
Movius, A. J., Jr. ..
Billings
Movius, A. J.
Billings
Munch, C. J.
Culbertson
Munro, A. T.
Kalispell
★Murphy, E. S.
Missoula
★Murphy, J. E.
Whitefish
★ Nagel, C. E
Great Falls
Nash, F.
Townsend
Nelson, C. H. .... ...
Billings
Nelson, J. M.
Missoula
Neraal, P. O.
Cut Bank
Neville, J. V.
Columbus
★Noble, P. G.
Poison
Noonan, E. F.
Wibaux
Noonan, J. H.
Anaconda
★Ohlmach, J. P.
Missoula
O'Keefe, N. J.
Butte
Oleinek, John M. ..
Red Lodge
Olson, N. A.
Cut Bank
Olson, S. A.
Glendive
O'Neill, R. T.
Roundup
O’Rourke, J. L.
Anaconda
Packard, L. R.
Whitehall
Pampel, B. L.
Warm Springs
Parke, Geo. F
Glendive
Paterson, W. F.
Conrad
★Paul, F. W.
Big Timber
★Pearson, J. A.
Livingston
Pease, F. D.
Missoula
★Pemberton, C. W. .
. .... Butte
★Peterson, C. H.
Great Falls
Peterson, R. L.
Hamilton
Peterson, R. F.
Butte
★Peterson, W. M.
Plentywood
Phillips, J. H.
Bozeman
Place, B. A.
Warm Springs
Poindexter, F. M. ...
Dillon
Porter, E. S.
Lewistown
Powell, C. D. Vancouver, Wash.
Power, H. W.
.... Conrad
Powers, J. C. .
_. Billings
Pratt, S. C.
Miles City
September, 1943
289
Preston, S. M. Missoula
Randall, R. R. Miles City
★ Rathman, O. C. Billings
Rennick, P. S. Stevensville
Rew, A. W. Thompson Falls
Richards, J. L. Poison
Richards, W. G. Billings
Richardson, R. B. Great Falls
Ritchey, J. P. Missoula
Robinson, W. C. .... Shelby
Rodes, C. B. Butte
Rogers, R. V. Browning
Ross, F. B. Kalispell
★ Routledge, Geo. L. Dillon
Rowen, E H. Miles City
Rundle, B. S. Circle
★ Russell, L. G. __ Billings
Russell, R. . Fort Shaw
Ryde, R. E. Glasgow
Saam, S. F. Butte
Saam, T. W. Butte
Sabo, F. I. .... Bozeman
I ★Sale, G. G. Missoula
Sandy, B. B. Ekalaka
Scanlon, J. J. Deer Lodge
★Schearer, B. C. Helena
Schemm, F. R. Great Falls
Scherer, R. G Bozeman
Schraeder, H. F. .... Browning
Schubert, J. W.
Schwartz, H. ....
Schwartz, S. E. ..
★Schweizer, H. M.
Seerley, C. C.
Seitz, R. E.
★Seivers, A. R.
Seivers, R. E.
Setzer, G. W.
★
Shanley, T. J. B. Butte
★Shaw, J. A. Billings
Shephard, H. C. Hughesville
Shields, J. C. ... ... Butte
Shillington, M. A. Glendive
Sigler, R. E. Bozeman
Simons, J. B Whitefish
Smetters, M. _ . Butte
Smith, A. N. Glasgow
Smith, C. S. Bozeman
Smith, L. W. Butte
★Smith, W. P. Columbus
Snodgrass, M. R. Anaconda
Soltero, J. R. Lewistown
Souders, S. M. Red Lodge
★Spatz, J. M. .... Cut Bank
Spurck, P. T. Butte
Stanchfield. H. Dillon
Steinberg, S. S. .... ... ... Butte
Stephan, W. H. Dillon
★Stephan, L. B. ... Missoula
Stewart, R. M. Whitefish
Strain, E. Great Falls
Stripp, A. E. Billings
Studer, D. J Faribault, Minn.
★S ussex, L. T. Havre
Svore, C. R. Somers
★Tanglin, W. G. Poison
Tarbox, B. R. Forsyth
Taylor, W. W. Whitefish
Teel, H. M. Poison
Tefft, C. C. Hamilton
Templeton, C. V. Great Falls
Terrill, F. I. Galen
Thompson, J. G. Helena
Thompson, J. R. Miles City
Thorkelson, J. ..... Butte
Thornton, C. R. Missoula
Towne, R. L. .... Kalispell
Townsend, G. A. Livingston
Trenouth, S. M. . Missoula
Turman, C. F. Missoula
Tyler, K. A. Galen
Ungherini, V. O. Butte
Unmack, F. L. Deer Lodge
Unsell, David H. Billings
Varco, A. R. .. . Miles City
★Vasko, J. R. Great Falls
Vennemann, S. W St. Ignatius
Vye, T. R. Laurel
Walker, Dora V. H Great Falls
★ Walker, R. E. Livingston
Walker, T. F. Great Falls
Waniata, F. K. Great Falls
★Weber, R. D. __ Missoula
★Weed, V. A. Kalispell
Weedman, W. F. Billings
Weeks, S. A. Baker
Weisgerber, A. L. Great Falls
Welden, E. A. Lewistown
Werner, S. L. Billings
Wernham, J. I. Billings
Whetstone, S. D. Cut Bank
Whitehead, C. E. Bozeman
★ Whitlinghill, I.A. ..
Wilder, C. W. Lewistown
Wilking, S. V. Butte
Williams, Frank Butte
Williams, R. A. Manhattan
Williams, W. T. Malta
Willits, A. J. Anaconda
Windsor, G. A. Livingston
Winter, M. D. Miles City
Wirth, R. E. Missoula
Worsted, G. Big Sandy
Wright, G. B. Kalispell
Hardin
Butte
Butte
Poplar
Bozeman
Bozeman
Butte
... Butte
Malta
Member in the Armed Forces of the United States.
South Dakota Public Health Association Meeting
The annual meeting of the South Dakota State Public Health
Association will be held in the Marvin Hughitt Hotel, Huron,
South Dakota, on Tuesday, September 21, 1943, at ten o’clock
A. M., with George L. Hickman, M.D., Bryant, South Da-
kota, president, in the chair. The following program will be
presented:
"Problems of the Public Health Officer” — A. Triolo, M.D.,
Director of the Division of Maternal and Child Health and
Crippled Children, South Dakota State Board of Health.
"Vital Statistics and Public Health Education” — Mr. I. R.
Vaughn, Director, Division of Public Health Education and
Assistant Director of Department of Vital Statistics, South Da-
kota State Board of Health, Pierre, South Dakota.
"Tropical Diseases” (motion pictures and comments) — M.
Fernan-Nunez, M.D., F.A.C.P., since 1927 Professor of Path-
ology and Tropical Medicine, Marquette University School of
Medicine, Milwaukee, Wisconsin, whose formal address on the
same subject will be given at 8:00 P. M.
(With the return of members of the armed forces from serv-
ice in tropical and semi-tropical countries, a new public health
problem has arisen. While the general health of the troops has
been exceptionally good and the diseases which can be prevented
by immunization have been notably low in incidence, the fact
remains that through unavoidable exposure to the bites of in-
sects and other modes of transmission, many individuals have
contracted diseases which hitherto have been almost entirely con-
fined to areas other than those in the northern latitude of the
United States.
Our problem is to be able to recognize and treat these dis-
eases when they are brought back here, for they constitute a
disability to the person who suffers with them, and a source of
danger to the community in which he lives. We must become
familiar with these tropical diseases, in order to know and treat
them, but more important yet, to be able to keep them from
being transmitted to others.
Fully realizing the importance of this problem, the services of
an outstanding specialist in tropical medicine have been secured
by the State Board of Health and United States Public Health
Service for talks in various centers in the state under the aus-
pices of the local district medical societies. The other places
and dates are: Aberdeen, Alonzo Ward Hotel, Monday, Sep-
tember 20; Sioux Falls, City Hall, Wednesday, September 22;
Pierre, Jr. High School Auditorium, Thursday, September 23;
Rapid City, St. John’s Hospital, Friday, September 24.
All licensed physicians, registered nurses, hospital personnel,
(including senior students) and public health workers, also
army, navy, Indian Service, and veteran administration physi-
cians, and nurses are cordially invited to attend these meetings
at whichever place is most convenient. There is no charge for
admission.
Dr. Fernan-Nunez, a native of the United States, is a grad-
uate of the University of Madrid, the London School of Trop-
ical Medicine, and the Universities of Paris and Edinburgh. He
is an accomplished and interesting speaker.)
"Follow-up Technic in Tuberculosis” — W. L. Meyer, M.D.,
Superintendent, South Dakota State Sanatorium for Tubercu-
losis, Sanator, South Dakota.
"Public Health in South Dakota” — Gilbert Cottam, M.D.,
Superintendent.
All persons interested in public health matters are invited and
urged to attend this meeting without any obligation to join the
organization.
G. L. Hickman, M.D., President.
J. D. Curtis, M.D., Vice President.
Gilbert Cottam, M.D., Acting Sec.-Treas.
290
The Journal-Lancet j
Induction and Stimulation of Labor with Ergot"
Claude J. Ehrenberg, M.D., Minneapolis, Minnesota
Lt. Com. U.S.N. John A. Haugen, M.C., El Toro, Cal.
ONE hundred years ago, ergot was called " pulvis
parturiens,” because of its wide use in the stimu-
lation of labor. Subsequently, because of acci-
dents the use of ergot was discouraged. Presently, for a
number of reasons, it may be a propitious time to revalue
the oxytocic properties of this complex drug, both before
and during labor. First, recent improvements in the meth-
ods of extraction,1 and, more recently, the isolation of the
principle therapeutic oxytocic alkaloid2,3,4,5 (ergonovine)
permit of accurate standardization for the first time in
the long history of ergot. Second, moisture and other
factors responsible for the deterioration of ergot prepara-
tions have been determined and may be avoided/’ In the
third place, side effects, such as the pressor action of pos-
terior pituitary extract on the blood pressure, and such as
the hemolytic effect of quinine are absent with ergot.
These are important considerations in certain conditions,
such as the toxemias or the anemias of pregnancy.
Our experience with ergot for inducing labor began
eight years ago and for stimulating lagging labor, some
months after. Continued use of this medication has
changed in no way an opinion expressed in 1939,' that,
"contrary to obstetrical opinion, small doses of ergot are
tolerated by the pregnant woman with no ill-effect, and
selected doses of carefully standardized powdered ergot
are safe and effective in inducing labor.” To this state-
ment, we would append, " and for stimulating labor.”
Ergot is a complex substance. s At least ten alkaloids
have been isolated from it, in addition to histamine,
tyramine, iso-amylamine, choline, acetylcholine, ergos-
terol, and a number of amino acids. Of these substances,
three of the alkaloids are important therapeutically: ergo-
toxine, ergotamine (gynergen), and ergonovine. These
alkaloids are smooth muscle stimulants, particularly of
the uterus, and, more particularly, of the gravid uterus.
It has been pointed out that there is little or no essential
difference in the action of the three alkaloids so far as
the uterus itself is concerned, but because ergotoxine and
ergotamine are not readily absorbed from the gastro-
intestinal tract while ergonovine is, the latter has become
the most important, therapeutically. It has also been sug-
gested that the same differences apply when the drugs
are used intramuscularly.
It is known that ergot from different places in the
world varies widely as to the alkaloid content. However,
it has been shown that the proportion of alkaloids to
each other in various samples of ergot deviate but slight-
ly.9,10 Therapeutic reliability, then, may be expected with
any ergot that has been standardized for one or two of
the alkaloids, such as ergotoxine and ergonovine, if the
extraction process has been complete and if deterioration
is prevented. Thompson has shown that the factor re-
sponsible for deterioration is moisture and maintains that
dry powdered ergot in the presence of less than 5 per
cent of moisture will remain stable indefinitely. This pre-
•Originally presented at the University of Minnesota Center for
Continuation Study Course in Obstetrics, May 5, 1943.
eludes, immediately, any liquid preparation of ergot for
therapeutic purposes.
The question may well be asked — if ergonovine con-
tains approximately all of the therapeutically oxytocic
activity in ergot, and can be administered orally, and
does not deteriorate, why would its employment not be
preferable to the whole ergot? Burn,11 Rothlin,12 and
recently Bickers,13 have demonstrated that the oxytocic
activity of ergonovine is prolonged by the presence of I
the other component alkaloids of ergot. On the other
hand, little is known of the possible synergistic, antago- i
nistic or additive effects of the other components of
whole ergot, which might be desirable or undesirable in j
its therapeutic employment.
We have continued to use whole ergot for two rea-
sons: (1) because isolated active principles generally have
shown no superiority to the parent substance, and (2)
because, in the development of natural history, it might
seem philosophically correct to use whole substances as
found in nature.
The product used by us during this time has been
dried, powdered ergot, standardized according to the
United States Pharmacopoeia No. XI,14 after extraction
to exhaustion as recommended by Thompson. This prep-
aration, known as U.S.P. Ergota Preparata, is defatted
and is standardized to possess the equivalent of 0.5 mg.
(1 128 gr.) ergotoxine ethanesulphonate per gram. The
capsules furnished usj are of two sizes, the 12 grain
ergot equivalent capsule used for labor induction, and the
6 grain ergot equivalent capsule used for stimulation.
The 12 grain ergot equivalent capsule contains 0.4 mg.
(1 160 grain) total ergot alkaloids, calculated as ergo-
toxine ethanesulphonate, in which is present ergonovine
(Hampshire-Page assay) 0.11 mg. (1/600 grain). The
6 grain ergot equivalent capsule contains one-half of the
above amounts.
Further experience with the prepartum and intrapar-
tum use of ergot reaffirms our earlier observations, that,
in the dosages used, it possesses no pressor and anti-
diuretic action as is the case with posterior pituitary ex-
tract. This fact is obviously of extreme importance in
handling the patient with toxemia of pregnancy, when
induction of labor may become a necessity and when
stimulation may be desirable. Moreover, ergot does not
exert the intravascular hemolytic effect that is produced
with quinine. Failure to appreciate this fact led, in one
case, to a fatal issue for both the mother and the baby.
Two technics, generally, have been employed in the
induction of labor cases. First, the medical induction,
which pertains to the patient while still at home. One
ounce of castor oil in one-half glass of root beer is taken
before breakfast. A light breakfast is eaten and, im-
mediately after breakfast, a grain XII ergot equivalent
capsule is taken. If no painful contractions are present
in two hours, a second capsule of ergot is taken. Labor
^Capsules Ergot (Upsher Smith) furnished through the courtesy
of the Upsher Smith Company, Minneapolis, Minnesota.
September, 1943
291
SECOND SERIES
FIRST SERIES
TOTALS
84
142
226
20
25
45
56
26
82
2
2
4
59 (70%)
25 (29%)
111 (78%)
31 (22%)
170 (75.2%)
56 (24.8%)
16 (80%)
4 (20%)
17 (68%)
8 (32%)
33 (73%)
12 (27%)
10 minutes
5 days
2 hrs. 3 5 min.
(excluding long case)
40 minutes
24 hours
4 hrs. 45 min.
0
0
0
3
(all proven prepartum
intrauterine deaths)
3
( 1 intrauterine death,
2 operative delivery)
2 (corrected)
Ergot and Castor Oil — -
Ergot and castor oil plus posterior pituitary extracts
Ergot and rupture of membranes -
Ergot and bag or bougie - -
Ergot and castor oil:
Successful
Unsuccessful
Ergot and castor oil plus posterior pituitary extracts:
Successful
Unsuccessful
Ergot and rupture of membranes:
shortest latent period
Longest latent period —
Average latent period
i Maternal mortality „ -
i Infant mortality -
is considered to have been induced, if it begins within
twenty hours of the ingestion of castor oil. Second, the
surgical induction, which pertains only to the hospitalized
patient and which is merely a modification of or addi-
tion to the technic of rupturing and draining the bag of
waters. The patient is prepared surgically, is given a
cleansing enema, and is given a 12 grain ergot equiva-
lent capsule. In one hour, the membranes are ruptured
with a membrane hook inserted through a vaginal spec-
ulum.
We believe that the addition of ergot shortens the
latent period. With either type of induction, if labor is
slow and lingering, stimulating doses of ergot — as pres-
ently to be described — are used after four hours. Further
additions have sometimes been made to the therapy, in
the form of pituitrin, either hypodermically or intra-
nasally if toxemia of pregnancy is absent.
The results obtained in the second series of cases is
shown with those reported previously:
The first attempts to stimulate labor with ergot were
made with gr. XII ergot equivalent capsules. Although
the results were generally satisfactory, a few patients de-
veloped tumultuous contractions. It was then decided to
reduce the dosage for stimulation to grain VI ergot
equivalent, after which this undesirable feature has not
occurred. Undoubtedly, higher proportions of the stim-
ulated cases would have been successful with the larger
dosage, but it was felt that the employment of ergot in
these circumstances must always remain within the limits
of ascertained safety. On the other hand, the ergot has
been repeated after a four-hour interval for as many as
four doses, and its administration has not been consid-
ered a contraindication to the employment of posterior
pituitary extract or the employment of intravenous cal-
cium and parathormone. Cases in which other oxytocics
were used have been considered unsatisfactory. The re-
sult in those labors stimulated with ergot are as follows:
Total cases receiving ergot stimulation 192
Total cases receiving ergot and other oxytocic
stimulation 28
Total cases receiving ergot and intravenous calcium
levulinate with parathyroid extract 1 1
Total cases receiving two or more doses of ergot 36
Maternal mortality 0
Infant mortality (all operative deliveries) 3
A discussion of the indications for induction of labor
would serve no purpose in this report. However, some
mention of primary uterine inertia would seem necessary.
Of the three major factors in labor — the passages, the
passengers, and the powers — almost nothing is known of
the last. No instrument or method has as yet been de-
vised, which records adequately or objectively the inten-
sity of the uterine contraction during labor. Lagging
labor, then, was diagnosed purely on the basis of clinical
judgment, a quality which is recognized at once as being
widely variable among individuals. Neither time limits,
according to arbitrary standards placed on the interval or
length of the uterine contractions, nor subjective pain
sensation of the patient have been considered the index
to uterine inertia. Rather, it has been these, plus those
indefinable objectivities ascertained through repeated ex-
periences of examination and observation, which have
been used as the guide for stimulating a particular labor.
Secondary uterine inertia due to fatigue, or dystocia
due to cephalopelvic disproportion must be considered as
definite contraindications to uterine stimulation with
ergot.
Summary
Ergot may be accurately standardized in the light of
recent contributions to the knowledge of ergot. Used in
small dosages, it is safe and effective for inducing labor
and for stimulating a lagging labor.
References
1. Thompson, Marvin R.: J. Am. Pharm. A. 22:736, 1933.
2. Dudley, H. W., and Moir, C.: Brit. M. J. 1:520, 1935.
3. Karasch, M. S., and Regault, R. R.: J. Am. Chem. Soc.
57:956, 1935.
4. Thompson, Marvin R.: J. Am. Pharm. A. 24:185, 1935.
5. Stoll, H., and Burckhardt, E.: Compt. Rend. Soc. de Biol.
200:1680, 1935.
6. Thompson, Marvin R.: J. Am. Pharm. A. 22:736, 1933.
7. Ehrenberg, C. J., Robbins, O. F., and Haugen, J. A.:
Am. J. Obst. Qc Gynec. 39:653, 1940.
8. Nelson, E. E.: Internat. M. Digest 38:180, 1941.
9. Allport, N. L., and Porter, G. V.: Quart. J. Pharm. dC
Pharmacol. 2:96, 1938.
10. Hampshire, C. H., and Page, G. R.: Idem. 9:60, 1936.
11. Burn, J. H.: Pharm. J. 134:357, 1935.
12. Rothlin, E.: Schweiz, med. Wchnschr. 65:947, 1935.
13. Bickers, W.: Am. J. Obst. 6c Gynec. 46:238, 1943.
14. United States Pharmacopoeia No. XI.
292
The Journal-Lancet
The Minnesota Multiphasic Personality Inventory
Burtrum C. Schiele, M.D.
A. B. Baker, M.D., Ph.D.
Starke R. Hathaway, Ph.D.
Minneapolis, Minnesota
IN psychiatry, as in other fields of medicine, increas-
ing need is being felt for the development of objec-
tive measurement devices. A signal accomplishment
in this respect has been the tests for intelligence the value
of which is no longer a matter for dispute. In the more
involved field of personality traits, however, the need has
become especially apparent, particularly for scales with
known limits of error designed to measure abnormal
components of personality.
It is impossible, except grossly or in special cases, to
reduce human traits to such physical measurements as
space, weight, temperature, time and the like. But it is
possible to arrive at certain kinds of measures of behav-
ioral reactions of individuals, in comparison with those of
groups of people selected for their common possession of
one or another trait. Examples of such behavioral re-
actions would be the response to an association word, a
problem in algebra, or to individual inquiries about atti-
tudes towards religion, sex, health and the like. Indeed,
the subjective evaluations we all make of those about us
are really so determined. We see a person who has an
opportunity to spend money for a purpose which appeals
to most others, but he refuses to do so; this is one unit
in our minds by which he is denoted to be stingy. If,
then, he subsequently reacts more times in a similar way,
we judge him as stingy in proportion to the number of
such times and to the importance of the individual times
he has so reacted.
To a considerable extent, diagnostic judgment in psy-
chiatry proceeds likewise; the patient is observed and his
behavior assorted. For example, he posturizes, he appears
to listen, he says irrelevant things, he smiles enigmatically.
These are heavily weighted behavior items or signs of
schizophrenia and, if all are present, it is pretty safe to
assume him to be schizophrenic. Final decision cannot be
made, however, until he is shown not to score heavily on
other behavior points, indicating other diagnoses or neg-
ating the significance of the first observations.
There are several ways of observing the symptoms or
bits of behavior that one uses to form a psychiatric judg-
ment. One may passively observe a patient as he moves
and speaks or one may actively interfere with the patient
by bodily manipulation or by social restriction, mean-
while observing the results. The most common and use-
ful manner of discovering significant points in a coopera-
tive patient, however, is to ask specific questions or make
specific statements and note the response. For each re-
sponse, a judgment is made as to whether it is common
and normal or symptomatic. The latter approach is also
that most widely used in psychometric evaluation.
*From the Departments of Neuropsychiatry and of Psychology,
University of Minnesota Medical School. Supported in part by a
grant from the Graduate School, University of Minnesota.
Objective measurement must, in the first instance,
eliminate the examiner’s variability in manner of pre-
senting the statement or question to the patient. This
does not assume that a particular examiner is incapable
of reliable presentation, but it is a recognition of the fact
that not all examiners are reliable and unbiased. The
most common way of removing the influence of an exam-
iner is to print the question or statement, present it to
the patient without comment, and permit him to react.
It is essential to note that neither the personal nor the
printed examination guarantees truth or candor on the
patient’s part. Both methods must rely on what a patient
does. It is true that a subjective personal examination
permits the examiner to intuitively follow certain leads
but, in the objective examination, many more and care-
fully prepared items can be presented. The essential
truths about the patient may be subtly discovered through
the patient’s inability to mislead consistently through a
maze of items cunningly designed to bring out the truth.
There have been a number of reasons for failure to
evolve a clinical scale. A chief point was that the psy-
chologists working on scale developments were in greater
part academic teachers and naturally tended to adapt
their instruments to the school student. Furthermore,
adequate validity and flexibility needed the cooperative
efforts of psychiatrists and psychologists working in a
psychiatric clinic treating a wide variety of borderline
cases.
With the completion of the housing and staff of the
Psychopathic Unit of the University Hospitals, an un-
usual opportunity was provided for such research and the
Minnesota Multiphasic Personality Inventory was begun.1
The basic principles of the approach to the problem were
similar to those established twenty years before by Wood-
worth." Details differed, however. More items were used,
simple wording was stressed, the question was changed
to a positive statement, usually in the first person. Also,
instead of a forced restriction of the patient to two an-
swers, he was permitted to answer that he did not know.
From more than a thousand items initially selected, five
hundred and fifty have been retained for the final in-
ventory. Each of the five hundred and fifty items is
printed on a separate card and the whole collected into
a box with three index cards marked "True,” "False,”
and "Cannot Say.” The patient takes the cards one at
a time and places them behind the index card that he
feels most nearly represents his attitude toward the state-
ment. Sample statements are: (1) "Often I feel as if
there were a tight band about my head,” (2) "It is
always a good thing to be frank,” (3) "The future
seems hopeless to me.” A classification of the five hun-
September, 1943
293
dred and fifty items follows:
1. General health (9 items)
2. General neurologic (19 items)
3. Cranial nerves (11 items)
4. Motility and coordination (6 items)
5. Sensibility (5 items)
6. Vasomotor, trophic, speech, secretory ( 10 items)
7. Cardiorespiratory system (5 items)
8. Gastrointestinal system (11 items)
9. Genitourinary system (5 items)
10. Habits (19 items)
11. Family and marital (26 items)
12. Occupational (18 items)
13. Educational (12 items)
14. Sexual attitudes (16 items)
15. Religious attitudes (19 items)
16. Political attitudes — law and order (46 items)
17. Social attitudes (72 items)
18. Affect, depressive (32 items)
19. Affect, manic (24 items)
20. Obsessive and compulsive states (15 items)
21. Delusions, hallucinations, illusions, ideas of ref-
erence (31 items)
22. Phobias (29 items)
23. Sadistic, masochistic trends (7 items)
24. Morale (33 items)
25. Items primarily related to masculinity-femininity
(55 items)
26. Items to indicate whether the individual is trying
to place himself in an improbably acceptable light
(15 items) .
The Minnesota Multiphasic Personality Inventory is
the first inventory measuring common specific clinical
syndromes, in contrast to the earlier schedules designed
for either the more general concept of "neuroticism” or
special states like "inferiority”. The scales now available
for scoring in the Minnesota Multiphasic Personality In-
ventory are Hypochondriasis, Depression, Hysteria, Psy-
copathic Personality, Paranoia, Psychasthenia, Masculin-
ity-Femininity of Interests, Schizophrenia, and Hypo-
manic Trends.3 Some of these are in a more advanced
stage of development than are others.
These scales have been compiled by comparing the re-
sponses of clinically diagnosed patients with those of per-
sons not under the care of a doctor. It is important to
note that the particular items characterizing a symptom
complex are identified by the contrasting tendency for
normal and abnormal patients to respond "True” or
"False”, without regard to the verbal content of the
item. This procedure assures that the given abnormal
group differs from normals in the way the item is re-
sponded to, and for scoring, no assumption is made or
needs to be made regarding the import of the item.
Three tests to indicate whether or not the cards are care-
fully and reliably sorted are provided. These validating
scores help to eliminate cases where the patient does not
understand the items, tries to place himself in too favor-
able a light or is not cooperative.
For final interpretation, the various responses are trans-
lated into a standard scale system. On this, the average
value is always 50 and a value high enough to be safely
called borderline is 70. All the scores are arranged so
that a score higher than 50 is in the direction usually
regarded as abnormal, although scores below 50 may
have some significance. A typical result is given in
figure 1.
Fig. l.
This is an essentially normal profile. No score is as
high as the borderline. The three scores at the left are
the validating scores, and, being within average range,
they may be disregarded. The key to the remaining
symbols is as follows:
H-Ch
Hypochondriasis
Pa Paranoia
D
Depression
Pt Psychasthenia
Hy
Hysteria
Sc Schizophrenia
Pd
Psychopathic deviate
(Psychopathic personality)
Although none of these scores is as high as the bor-
derline in the example given, the highest point is hys-
teria; this is frequently seen in young intelligent persons.
Even in these normal cases, where the hysteria score is
the highest point, a careful review of the person’s history
will usually elicit examples of personal problems being
solved by physical symptoms. Also, if this person could
be placed under sufficient strain to produce a neurosis,
his most probable reaction type would be hysteria.
Examples of abnormal curves will be given below.
Such curves may be high in one or nearly all components
according to the complexity of the psychological system.
It must be repeatedly stressed that persons called normal
by default of critical examination are common among us.
Thus, abnormal curves may be discovered among per-
sons who for one reason or another have shown no dis-
ablement. Similarly, some who are psychologically dis-
abled have relatively normal curves. A few of these may
have abnormalities not yet measured on the profile, but
more often they are persons who have been placed under
unusual environmental stress.
To illustrate the use of the Multiphasic Personality
Inventory in the matching of groups, a series of 100
cases of psychopathic personality is available. These rec-
ords were obtained at the Federal Reformatory, El Reno,
Oklahoma, by H. D. Remple, psychologist, and released
to us for study through the courtesy of Dr. John W.
Cronin and the United States Public Health Service.
294
The Journal-Lancet
All the cases were diagnosed by the reformatory staff
as Constitutional Psychopathic Inferior. This diagnostic
class has been known to include a heterogeneous group
of personalities. It thus becomes of interest to study the
Oklahoma cases with regard to consistency of the per-
sonality profiles.
Fig. 2.
For the diagnosis, Constitutional Psychopathic In-
ferior, (or in more recent terminology, Psychopathic
Personality) the profile in figure 2 is typical. The his-
tory given with this case is summarized as follows:
This is an 18-year-old single white male serving 2 years
and 11 months under the Dyer Act. He has served
terms in the Boys Industrial School and the State Re-
formatory where his record was poor. While acting as
a trusty, he and two other youths became intoxicated,
slugged a man, took his car and escaped from the insti-
tution. He was considered to be inefficient, lazy, indif-
ferent, untrustworthy and an agitator. He had an eighth
grade education and has been employed chiefly as a farm
worker. His father is a law-abiding farmer. His mother
died when he was 2 years of age, and the father later
remarried.
The neurological examination was negative. Mental
tests revealed normal intelligence: Army Alpha mental
age 14-3, I.Q. 103, superior to 55 per cent. It was the
reformatory psychiatrist’s opinion that he was an alert
but unstable and irresponsible youth, lacking in definite
vocational interestss and with no evidence of a frank
psychosis. He was diagnosed as a Constitutional Psycho-
pathic Inferior. It was felt that he was a definite cus-
todial risk and a source of disciplinary difficulties.
The outstanding high point of the profile is at Pd
(psychopathic personality). In this case there are no
other high points that seriously confuse the diagnosis.
If other high points occur in these cases, the tendency
is for them to be at Pa or Sc (paranoia or schizophre-
nia) . From psychiatric experience, this is an expected
finding and is illustrated on the composite curve made
from the average scores for the whole group of 100 pris-
oners (%• 3).
If these persons are measured soon after being caught,
D is likely to be high. This depression is apparently dy-
namically related to the revulsion of feeling coming with
the discovery of the acts leading to the patient’s diffi-
culty.
Although from 55 to 65 per cent of the 100 cases had
profiles clearly enough similar to figure 2 to warrant the
diagnosis, some were definitely of other types. Figure 4
will serve to illustrate the point. The following is a sum-
mary of the case report:
This is a 20-year-old single white male serving five
years under the Dyer Act after parole violation. He com-
pleted the tenth grade in school but never made a satis-
factory adjustment during this itme. He was a chronic
truant and showed nomadic tendencies. He has been em-
ployed as a service station operator and garage man. His
father, a successful real-estate agent, was recently killed
in an automobile accident. His mother is employed by
a doctor. The parents were separated at the time of the
father’s death.
? L F H-Ch D Hy Pd Pa Pf Sc
Fig. 4.
Neurologic examination was essentially negative except
for slightly hyperactive deep reflexes. Psychologic tests
showed superior intelligence: Army Alpha mental age
18-4, I.Q. 132, superior to 94 per cent.
It was the opinion of the reformatory psychiatrist that
he was an unstable, irresponsible individual, lacking in
vocational interests and with possible latent homosexual
characteristics. There was no evidence of a frank psy-
chosis. Diagnosis was made of a Constitutional Psycho-
September, 1943
295
pathic Inferior. It was thought that he would have diffi-
culty making a satisfactory institutional adjustment and
that he should be guarded against homosexual assault.
This case appears to belong more to the schizoid than
to the predominantly psychopathic personality type. Cases
with significant abnormality other than P<fl made up the
majority of the records not clearly belonging to the main
type. Only about 10 per cent of the records could be
confused with clearly normal records.
This brief summary of a sample group from another
institution shows the progress that has been made in the
establishment of an objective method of group evalua-
tion. The chief scale in the above evaluation was still in
preliminary form. A new and more reliable P<fl scale
has now been developed which accentuates the above
findings. Other scales as they are evolved will afford
more inclusive personality evaluations for general pur-
poses of group comparison and individual analysis.
University of Minnesota Cases
A 50-year-old housewife described a variety of "nerv-
ous spells” which occurred several times daily. In some
of these she would shake so severely that she was unable
to walk or stand; in others one side of her body would
become numb, she would lose her voice and "almost
pass out.” This latter type of spell was very frightening
to her. In addition, she complained of marked fatigue,
loss of weight, constant headache, poor vision, dizzy
spells, ringing of the ears, night sweats, hot flashes, and
vague pains in the extremities.
During the past six years, because of increasing nerv-
ousness, she made frequent visits to the family physician
who blamed her trouble onto the "change of life.” In
December, 1940, another physician found that she had
syphilis. The patient was acutely distressed at this dis-
covery and soon thereafter began to have the above de-
scribed nervous spells. Though she received fairly ade-
quate antiluetic therapy, the symptoms continued to pro-
gress; she was referred to the University Hospitals for
study on September 23, 1942.
The past history gave no evidence of previous psychi-
atric breakdown or of other serious physical diseases.
However, the patient had numerous and scattered com-
plaints. The history indicated that the patient had been
"nervous and fidgety” from childhood. For years she
had exhibited neurotic tendencies in the form of fear of
high places and fear of automobiles. She blamed this
temperamental handicap on an unhappy childhood. She
had very little schooling. Her father was an improvident
drunkard. She and her mother lived in various mining
camps of the west until she married at the age of 18.
Her married life was uneventful, except that her hus-
band developed arthritis ten years ago. Now he is severely
handicapped and thus a burden and worry to her.
The general physical examination was negative. The
positive neurologic findings of unequal fixed pupils, par-
tial loss of deep sensibility in the lower extremities and
slurred speech suggested a diagnosis of early taboparesis.
This was supported by the spinal fluid findings: Kline
and Kolmer 4+; colloidal gold curve 5555531000. The
mental examination revealed no evidence of psychosis.
Her memory and orientation were intact.
The nervous spells described in the history were fre-
quently observed in the hospital; they were lessened by
the use of phenobarbital and further decreased by re-
assurance. The patient had been convinced that her con-
dition was hopeless and she was anxious over the con-
sequences of the "dread disease” from which she suf-
fered.
Fig. 5.
Figure 5 shows the test profile of the Minnesota Mul-
tiphasic Personality Inventory taken on admission. It
illustrates the mixed type of neurotic reaction commonly
seen in this hospital. The hypochondriacal score of 89
fits perfectly with her long list of complaints and her evi-
dent concern over her health. Consistent with the hys-
terical score of 82 are the shaking attacks, numb spells
and aphonia which almost certainly are hysterical in
origin. The depressive score (71) is also somewhat high.
If it stood alone we would be inclined to interpret it as
evidence of a predominantly depressive reaction. But in
combination with higher hypochondriasis and hysteria
scores we have found it to be a characteristic accompani-
ment of severe neuroses.
The indication in a test result of this type obtained on
any patient is emphatically that the patient should not
be regarded and treated exclusively as a neurotic patient.
Rather, such a patient must be clinically evaluated, mak-
ing due allowance for her neurotic temperament and its
effect on any somatic symptoms that may be present.
Conversely, a careful evaluation of the role the somatic
problem plays in the neurotic complex must also be made.
In other words, a neurotic score indicates the presence
of a neurotic temperament but does not prove the ab-
sence of organic disease. Conversely, we have already
shown that stable persons, even though suffering from
widespread organic disease, score little higher on hypo-
chondriasis and hysteria than do the normal.
In this case, concurrent therapies were instituted for
the somatic and the psychic components. Either one
alone might leave the patient incapacitated. The prog-
nosis, like the diagnostic formulations, is dependent upon
a combination of the separate futures for the two condi-
tions as well as their interrelation.
A 58-year-old male came to the hospital for psychiatric
study because of nervousness, anxiety, loss of confidence,
296
The Journal-Lancet
inability to concentrate, inability to work, occasional mild
headaches and a morbid desire to pull out his hair (tricho-
tillomania) . Although he had been partially incapacitated
for many years, psychiatric consultation was not previous-
ly considered necessary by the patient or his relatives.
The present illness began five years previously when
the drug company for which the patient was working
changed hands, and the nature of the patient’s work was
changed from the purchasing to the adjustment depart-
ment. Although he was unable to cite any tangible rea-
son, he became afraid that he would lose his position.
Shortly thereafter, the company’s business increased in
volume with a resultant increase in the patient’s work
and duties. He then became concerned over his lack of
ability to complete his work and soon found that it was
difficult for him to concentrate on mental tasks. He,
therefore, requested and was granted a leave of absence.
He returned to work after two months but was still un-
able to function at his job. Rather than be discharged
he resigned and moved to another city. After spending
the summer at a lake cottage he improved remarkably.
He then worked for a period of time in a relative’s toy
factory, but was restless and inefficient. He later returned
to his former place of residence but he was unsuccessful
in finding work. As a result of this disappointment, he
developed a complete recurrence of his nervousness,
anxiety, inability to concentrate and trichotillomania. He
lost interest in his surroundings and would sit around the
home wringing his hands. Only occasionally did he com-
plain of headache or insomnia. It was because of these
persisting complaints that he presented himself for psy-
chiatric care.
His past history was essentially negative. As he was a
member of a large family he had been forced to go to
work after finishing the eighth grade. He had received
a series of increases in pay at his various jobs and had
worked 17 years for his last employer. He was happily
married and took a mild but normal interest in various
social activities and had been active in several fraternal
organizations. His only disappointment occurred shortly
after he was married; at this time he wanted to return to
school to study pharmacy but was financially unable to
do so.
The general physical and neurological examinations
were essentially negative as were also the laboratory
studies. At the first interview the patient appeared some-
what tense and moderately agitated. He moved his hands
about constantly and picked at his scalp until it had be-
come almost bald. Other than this he disolaved no signs
of severe emotional fluctuations. At times he appeared
almost apathetic. He denied any profound depression or
suicidal desire. His answers to questions, although brief,
were adequate and to the point. He was unable to offer
any explanation for the development of his symptoms.
In fact, he stated that this question had bothered him
a great deal. There was no pronounced intellectual dis-
turbance.
In spite of the above symptoms, the patient did not
appear to be depressed, so that the diagnosis was not
clear at first. Although the patient was severely mal-
adjusted and somewhat incapacitated by his apparent
? L F H-Ch D Hy Pd Pa Pt Sc
Fig. 6.
anxiety reactions, he did not seem to be psychotic. There-
fore, his condition was temporarily regarded as a severe
anxiety state. The Minnesota Multiphasic Personality
profile (Fig. 6) , to the surprise of the staff, revealed an
exceedingly high score for depression, 125. The case was
further shown to be an involved one, in that the hypo-
chondriacal and psychasthenic scores were also definitely
in the abnormal levels. In view of this new information,
the patient was interviewed more thoroughly in respect
to his emotional depression and now much new and sig-
nificant information was forthcoming. It was discovered
that he was and had been much more depressed than he
appeared to be on casual examination. He stated that
for many years he had felt very unhappy and extremely
unworthy of his wife and family. The future to him
had become quite hopeless. He often felt that his pres-
ence was not desired by others and he therefore refused
to accompany his family on any social functions. Dur-
ing the past year he had also noticed a marked diffi-
culty in thinking, which had become progressively worse.
The findings obtained from the subsequent interviews
necessitated a change in our diagnosis from that of
anxiety state to one of agitated depression. The condi-
tion thus seems much more serious than was first appre-
ciated. The patient has been receiving rather intensive
therapy including reassurance, re-education, hydrothera-
py and mild sedation with the result that he has become
much less agitated. His speech defect has vanished and he
has started to take at least a minimal interest in the ward
activities. The trichotillomania has also disappeared and
his hair has begun to return. However, he still remains
profoundly depressed, although his appearance and ward
behavior might lead one to become falesly optimistic
about his progress.
Comment
The Minnesota Multiphasic Personality Inventory, in
the role of a clinical aid, applies not alone to the case
obviously needing neuropsychiatric consultation, but also
to any clinical problem in which psychic factors could
play a part in diagnosis or therapy.
September, 1943
297
The negative or normal profile obtained on such a
case is a reassurance to the clinician, which relieves him
in part from disturbing concern with psychological fac-
tors. An abnormal profile, especially if several scales are
above the borderline, indicates in all cases the advisability
of psychiatric referral.
To further illustrate, a recent medical patient showed
lack of reasonable cooperation and concern, when his
symptoms suggested a bleeding gastric ulcer. Ordinarily,
such a case would not be likely to receive prompt psy-
chiatric attention. In this case, the multiphasic profile,
which was obtained by clerical help alone, gave strong
evidence of a probable psychiatric disorder. The result
was a profile with moderate depression and definite psy-
chopathic personality. With this cue, the patient was in-
terviewed and after considerable resistance admitted to
quasi-malingering in order to obtain drugs. It became
clear, as the history developed, that the addiction was
on the basis of psychopathic personality and the ulcer
problem became a minor one. As in the case of most
patients with psychopathic personality, psychotherapy was
not effective and shortly after discharge the patient com-
mitted suicide by overdosage with a barbiturate.
These cases serve to show the objective complexity of
the personalities with which we are dealing in the psy-
chiatric field. In psychiatry, as in other fields of medi-
cine, rapid progress can not be made in therapeutic effort
and in research until the clinician is relieved of the labor
and prolonged procedures necessary for diagnosis. In a
proportionate degree, as direct and reliable diagnostic
technics are developed, the present overemphasis of psy-
chiatric time spent on the diagnostic formulation will be
relieved in favor of more constructively active time on
therapy and management.
A REPORT ON THE HEART PROGRAM OF
THE BUREAU FOR CRIPPLED CHILDREN
MEDICAL UNIT (Abridged)
Division of Social Welfare
February 16, 1942, to February 15, 1943
Malvin J. Nydahl, M.D.f
The Social Security Act passed in 1935 authorized the
appropriation of Federal funds for services for crippled
children.
The child with rheumatic fever or heart disease may
be included in the definition of a crippled child.
The child must reside in the limited area which is
served, but legal residence is not required. This area in-
cludes Scott, Dakota, Carver, McLeod, rural Ramsey,
and rural Hennepin counties. Minneapolis and St. Paul
residents are not accepted. The area had to be limited
because of lack of funds, and because the Children’s
Bureau has advised the state agencies to start the pro-
grams in limited areas, and do intensive work in these
areas until funds are available to expand the program.
Emphasis is given to the care of children with rheu-
matic fever or rheumatic heart disease. However, chil-
tHead, Bureau for Crippled Children, Dept, of Social Security,
Division of Social Welfare, State of Minnesota.
In the foregoing description of the development of the
Minnesota Multiphasic Personality Inventory there is no
intention of minimizing the imperfection of the partic-
ular device. From the outset, we have recognized that
this whole approach might be inadequate. The results
have gratifyingly vindicated the method and promise
fruitful future development.
With the Minnesota Multiphasic Personality Inventory
in its present form, a few cases still show abnormal test
records in the absence of symptoms or disability brought
out by other types of examination. A somewhat larger
number of patients has easily observable disabilities but
relatively normal test profiles. Whether these latter are
successfully dissembling, inadequately questioned by the
test, or have traits not yet measured has not been deter-
mined. It is likely that several sources of error exist.
Nevertheless, making cautious allowance for present
imperfections, the validity of the scales is surprising.
One should hardly expect to assay an individual’s per-
sonality accurately and completely in a single behavior
test session of an hour or two. If does not seem likely
that an individual’s personality could be more simply
and quickly surveyed than could his physical system, —
a complete physical evaluation being hardly possible in
several times the test period employed for the Inventory.4
References
1 Hathaway, S. R., and McKinley, J. C. : A Multiphasic Per-
sonality Schedule (Minnesota): I. Construction of the Schedule,
J. Psychol. 10:249-254, 1940.
2. Woodworth, R. S. ; quoted from Franz, S. I : Handbook on
Mental Examination Methods, The Macmillan Company, New
York, 1919.
3 Hathaway, S. R., and McKinley, J. C. : The Minnesota Mul-
tiphasic Personality Inventory, Manual and Test Materials, The
Minnesota Press, 1942.
4. Sets of test materials for the Minnesota Multiphasic Person-
ality Inventory are manufactured and sold by the University of
Minnesota Press, Minneapolis. Recording sheets for fifty patients
are included. The cost is #15.00.
dren with other types of heart disease which offer a rea-
sonable expectation of improvement from treatment are
also eligible for care.
Diagnostic services are available to all children living
in the designated area. Treatment is given only when
the family is unable to provide adequate private care.
The approval of the family physician must be obtained
before the child is referred to the heart clinic.
A clinic is held each Friday morning at the Children’s
Hospital, St. Paul, to provide diagnostic services and
follow-up care. Hospital care is provided for the chil-
dren during acute illness, at Children’s Hospital, St.
Paul, under the direct supervision of the heart clinician
of the Bureau for Crippled Children. Convalescent care
is also given at the Children’s Hospital under the same
supervision as hospital care.
As seen from the table below, from February 16, 1942,
to February 15, 1943, there were 52 hospital admissions
of 36 hospital patients, and 133 visits were made to the
weekly heart clinics by 47 clinic patients.
Ten
cases
were
in the hospital on February 15,
1943.
Total number of cases
83
1942
1943
Total
Number of Hospital Patients
31
5
36
Number of Hospital Admissions
45
7
52
Number of Hospital Discharges
39
9
48
Number of Clinic Patients
44
3
47
Number of Hospital Visits
112
21
133
298
News-Letter
of the American Student Health Association
The Journal-Lancet
PLANS FOR THE HARD OF HEARING
Edward King, M.D.
Cincinnati, Ohio
The return of the men from the war will offer new
problems to those who are interested in the prevention
and amelioration of deafness. How great these problems
will be is difficult to estimate at the present time, but we
must be prepared to do all in our power to classify these
men properly and to aid them in fitting themselves into
the civilian life which awaits them.
The medical departments of the Army, Navy and Air
Corps are aware of the dangers to the hearing from high
explosives, continuous exposure to noise, such as airplane
engines, as well as the diseases which produce ear disa-
bilities, and they are doing everything possible to prevent
deafness. The otologist will be called upon to diagnose
and decide the amount of disability.
The American Society for the Hard of Hearing,
through its many branches located in all the principal
cities in the country, is laying plans for the care of those
who are disabled. Through this organization, with its
thirty years of experience in the prevention and ameliora-
tion of deafness, the proper handling of the hard of
hearing problem is assured. This organization has the
personnel, the experience and the vocation to carry on
a great work and deserves our utmost confidence and
support.
The problem must be faced by Student Health Serv-
ices as well as others. Nearby branches of the American
Society for the Hard of Hearing can be of great service
in developing the programs.
ASHA DIGEST OF MEDICAL NEWS
Poliomyelitis. In the July 10 (1943) issue of the
Journal of the American Medical Association, Dr. P. M.
Stimson summarized our present-day knowledge in re-
gard to the prevention of poliomyelitis in the following
instructions:
"In the presence of the disease in a community:
1. Avoid the use of any water that is possibly contam-
inated with sewage, either for drinking, swimming or
washing utensils. We know that sewage can carry the
virus considerable distances and for an appreciable time.
2. Avoid exhaustion from exertion or chilling. We
know that overexertion and chilling during the incuba-
tion period tend to augment the oncoming disease.
3. Avoid injury to the mucous membranes of the nose
and throat, such as that resulting from a tonsil opera-
tion. We know that poliomyelitis exposures in the early
posttonsillectomy period are liable to result in severe —
even fatal — infections, usually of the bulbar type.
4. Treat every minor illness as a possible case of polio-
myelitis, particularly if there is fever, headache and some
spasm of the neck, spine and hamstrings. We know that
very mild cases of poliomyelitis without recognizable
paralysis are much more numerous than paralytic cases.
Suspected patients should be kept quiet in bed for sev-
eral days, and until passed as well by a competent ex-
aminer.
5. Strive for proper sanitary conditions and, in par-
ticular, destroy flies and their breeding places. We know
that flies can carry the causative virus of poliomyelitis,
although it has not yet been proved that they can carry
enough to infect human beings.
6. Avoid unnecessary physical contacts with other peo-
ple, wash hands carefully before eating, and don’t put un-
clean objects in the mouth. We know that many healthy
people carry the virus in their intestines and that for
some cases, perhaps most, the port of entry of the in-
fection is the mouth.
7. Don’t prescribe or take drugs or chemicals that are
intended to protect against the disease. As yet we know
of none that will do this.”
Though poliomyelitis is occurring in California and
Texas in much larger numbers than is usual, the tend-
ency for this disease to increase through June, July and
August and reach its peak late in September should be
recognized.
The State of the Salmonella Problem. S. Bernstein in
the June (1943) issue of the Journal of Immunology
makes the following points regarding the Salmonella
group of bacilli:
(a) Salmonelli bacilli may produce three quite differ-
ent clinical pictures in the human, i. e., Salmonella fever,
Salmonella septicemia and Salmonella gastroenteritis.
(b) In Salmonella fever, the fever and malaise are the
dominating symptoms and usually last from one to three
weeks; leukopenia occurs in some cases and the disap-
pearance of eosinophiles is common; blood cultures are
often positive early in the disease; Salmonella organisms
are occasionally found both in the urine and in the spu-
tum; bronchitis and bronchopneumonia are not infre-
quent complications.
(c) In Salmonella septicemia, the history may reveal
an attack of diarrhea preceding the onset by a few
weeks; there is a high remittant fever and positive blood
culture.
(d) In Salmonella gastroenteritis, there is an incuba-
tion period of eight hours to more than twenty-four
hours between the consumption of the contaminated food
and the first symptoms. Vomiting is usually the first
symptom; diarrhea is less severe than in dysentery and
not characterized by bloody stools or tenesmus. The fever
usually subsides after three or four days and recovery is
complete in less than a week, as a rule.
(e) In all Salmonella infections, sulfaguanidine is con-
sidered useful, particularly in infections with S. cholerae
suis and S. paratyphoid A.
(f) Smoked fish has been found responsible for sev-
eral outbreaks; fish have been shown to be contaminated
by sewage.
(g) There is some evidenec that rat excreta have con-
taminated food.
September, 1943
299
(h) The hands of human carriers are an important
source from which food material may become contam-
inated.
(i) Salmonella have been found in Chinese egg prepa-
rations.
(j) Salmonella multiply rapidly in the cream filling
of pastries but do not survive in pure fruit fillings of pies.
(k) Salmonella bacilli are resistant to low tempera-
tures and, as a result, outbreaks of infection related to
ice cream have repeatedly occurred.
Aqueous Base Yellow Fever Vaccine. In the March
26 (1943) issue of Public Health Reports, Hargett, Bur-
russ and Donovan state (a) that the earlier used yellow
fever vaccine contained 10 to 40 per cent embryo extract
(extract of 10 to 11 day old chick embryos infected with
the attenuated 17D strain of yellow fever virus) in a
human blood serum diluent; (b) the new U.S.P.H.S.
vaccine is an aqueous extract (75 per cent rather than
10 to 40) and contains no serum diluent; (c) that more
than 600,000 doses of this more potent, serum free, aque-
ous extract vaccine have been released for general use
without encountering unfavorable reactions.
Sulfathiazole Powder in Pharyngeal Infections. In the
April (1943) issue of Archives of Otolaryngology, M. S.
Freeman recommends the use of 1 to 2 grams of sulfa-
thiazole powder in cases of acute pharyngitis. The pow-
der is applied with a compressed air powder syringe until
it thickly cakes the pharyngeal mucosa. Eating and
drinking is forbidden for two hours following treatment.
From one to four treatments at twenty-four hour inter-
vals were required.
Infections of Nose and Throat in Young Adults.
Rhoads and Afremow in the April (1943) issue of the
Archives of Internal Medicine report that hemolytic
streptococci were found responsible for about two-thirds
of the attacks of tonsillitis, pharyngitis, laryngitis and
sinusitis in young adults.
Radiation Therapy of Acute Subdeltoid Bursitis. Brew-
er and Zink in the July 17 (1943) issue of the Journal
of the American Medical Association state "that the
treatment of choice for acute subdeltoid bursitis is (roent-
gen) irradiation.” If there is no improvement within
forty-eight hours, such treatment may be considered a
failure and more radical procedures undertaken. Im-
mediately following treatment and for eight to twenty-
four hours, there may be an aggravation of symptoms,
but in 11 of the last 14 cases treated by the authors, re-
sumption of duty was possible within forty-eight hours.
In chronic bursitis, only 30 per cent show any improve-
ment under roentgen treatment and only an occasional
patient is actually cured. If definite symptomatic relief
does not occur within ten days after treatment, the meth-
od must be considered a failure.
Thyroid Extract in Furunculosis. Barnes reports in the
April (1943) issue of the Journal of Clinical Endocrin-
ology the following observations on 16 college students
17 to 25 years of age, who were suffering from fur-
unculosis:
(a) The basal metabolic rate or basal temperature was
below normal in each case, (b) Thyroid 1 grain a day
was given and further boils did not develop during the
period of this therapy. The theory of the treatment is
as follows: In myxedema, the blood flow per minute and
the skin temperature are reduced but are restored to
normal by proper thyroid medication. In these cases of
poor peripheral circulation, thyroid medication should im-
prove the circulation in the skin and thus aid in the
healing process of the furunculosis.
The Terminology of Malaria. The American Journal
of Public Health announced in an editorial in the July
(1943) issue that it had adopted a terminology based
upon etiology. It will use the term Vivax malaria to des-
ignate Benign tertian, Falciparum malaria to designate
Malignant tertian (Aestivo-Autumnal) , Malariae ma-
laria to designate Quartan, and Ovale malaria to desig-
nate that associated with the presence of the Plasmodium
ovale. The 1942 edition of the Standard Nomenclature
of Disease and Operations has also adopted an etiological
classification for malaria.
Sore and Bleeding Gums in Naval Personnel. C. C.
Ungley and J. S. F. Horton reported in the Lancet of
March 27 (1943) their findings on 51 patients with sore
and bleeding gums as follows: (a) The daily intake of
ascorbic acid estimated from dietaries ranged from 16 to
80 mg. with an average of 37 mg. (b) Clinical evidence
of scurvy or "subscurvy” was lacking, (c) Though the
patients were "unsaturated” with ascorbic acid they were
no more so than healthy controls, (d) About 85 per cent
of the patients had Vincent’s stomatitis, (e) Local
causes, infections, calculus, etc., were apparently suffi-
cient to account for the condition in all cases, (f) Ascor-
bic acid was therapeutically ineffective, (g) No relation
to nicotinic acid deficiency could be demonstrated.
Efficacy of Vaccination Against Influenza Type A.
In this experiment, 44 persons received allantoic fluid
vaccine and 28 persons were followed as controls. All in-
haled a recently isolated Type A influenza virus. Of the
28 controls, 10 came down with clinical influenza; of the
44 vaccinated persons (27 of whom had been vaccinated
four months prior to the inhalation exposure) only one
came down with clinical influenza. — W. Henle, A. Hen-
le, and J. Stokes, Jr., March (1943) Journal of Im-
munology.
Transmission of Jaundice by Intranasal Instillation.
G. M. Findlay and N. H. Martin in the May 29 (1943)
Lancet report producing jaundice in three human volun-
teers by instilling into the nose nasal washings in saline
from three patients who were in the preicteric or early
icteric stages of jaundice, following injections of icteric
strains of yellow fever vaccine. The incubation period
was 28 days, 30 days, and 50 days.
Treatment for Epidemic Keratoconjunctivitis. H. S.
Gradle and G. H. Harrison report in the July 10 (1943)
issue of the J.A.M.A. that sodium sulfathiazole desoxy-
ephedrine used as eye drops reduced the acute conjunc-
tivitis stage of this disease in 50 cases to 3 to 7 days. The
solution contains 1 per cent sodium sulfathiazole, stabil-
ized by 0.8 per cent of sodium sulfite to which has been
added 0.1 per cent of desoxyephedrine. It is stable, non-
irritating and buffered to a pH of 9.0.
300 The Journal-Lancet
LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS
ON APRIL 10, 1943, BY EXAMINATION MARCH 22, 23, 24
Name
Anderson, David Mahlon
Anderson, Harold Clifford
Anderson, Horace Alfred
Anderson, Richard William
Anderson, Warren Rouvel
Anderson, William Theodore
Batdorf, B. Niles _
Bennett, James Gordon
Blake, Paul Swenson
Carlisle, Joseph Dyer
School
U. of Minn., MB. 1943
U. of Minn., MB. 1943
U. of Kansas, M.D. 1941
U. of Minn., MB. 1943
U. of Minn., M.B. 1942
U. of Minn., MB. 1943
U. of Minn., M B. 1942
Harvard U., M.D., 1939 _
U. of Minn., MB. 1943
U. of Minn., M.B. 1942
Carlson, Catherine Dorothy ... U. of Minn., MB. 1943
Chadbourn, Wayne Alfred U. of Minn., MB. 1943
Christensen, Llewellyn Eckhoff U. of Minn., MB. 1943 Detroit Receiving Hosp., Detroit, Mich
Cohen, Ellis Nahum — U. of Minn., MB. 1943 Detroit Receiving Hosp., Detroit, Mich.
Address
San Francisco City & Co. Hosp., San Francisco
New Haven Hospital, New Haven, Conn.
Mayo Clinic, Rochester, Minn.
U. S. Marine Hospital, Seattle, Wash.
Cambridge, Minn.
St. Luke’s Hospital, Duluth, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
University Hospital, Minneapolis, Minn.
32 Queen Ave. S., Minneapolis, Minn.
Infirmary for Women & Children, N. Y. C.
U. S. Navy Hospital, Seattle, Wash.
Cooper, John P. U. of Minn., MB. 1943
Corman, Morris D. U. of Minn., M.B. 1941, M.D
Davis, George Richard U. of Minn., MB. 1943- ...
Delmore, Robert Joseph -U. of Minn., MB. 1943
Devney, James William -U. of Minn., MB. 1943
Dixon, Frank James, Jr U. of Minn., MB. 1943
Edwards, Lloyd Gideon U. of Minn., MB.
Eilert, Mary Louise U. of Minn., MB.
Englund, Elvin Frederick . U. of Minn., M.B.
Felion, Arthur Joseph, Jr U. of Minn., MB.
Ferguson, Wilson Joseph Washington U., M.D. 1941
Frey, William Burton U. of Minn., MB
Frykman, Howard Martin U. of Minn., MB
1942
1943
Gilinsky, Irvin Lloyd .
Godwin, Bernard Eugene U. of Minn., MB.
Gridley, John Willis U. of Minn., MB.
Grogan, John Melby U. of Minn., MB.
Hestenes, Erling Gerhard U. of Minn., MB.
Johnson, Georgia L. U. of Minn., MB.
Jorgens, Joseph U. of Minn., MB.
Kaster, John David U. of Minn., MB.
Knutson, Julian Roland Borck U. of Minn., MB. 1943
Larson, Kenneth R U. of Minn., MB. 1943
Lytle, Francis Theodore U. of Minn., MB. 1943.
McGauvran, Theodore Edgar U. of Manitoba, M.D. 1925 —
Magraw, Richard Mueller U. of Minn., MB. 1943
Moe, Allan Eugene U. of Minn., MB. 1943
Morgan, Loran Brown U. of Minn., MB. 1943
Moyer, John Burroughs U. of Minn., MB. 1943
Nachtigal, Beatrice Kelber U. of Minn., M.B. 1942
Navratil, Donald Raymond U. of Minn., M.B. 1942
Nelson, Bernette Genevieve U. of Minn., MB. 1943
Nelson, Bernice Antoinette U. of Minn., MB. 1943
Nelson, Carl Gilbert U. of Minn., M.B. 1942
Neuenschwander, Harold Lawrence U. of Minn., MB. 1943
Nolte, Mark Edward - U. of Minn., MB. 1943
O’Malley, Valentine U. of Minn., MB. 1943
Olson, Albert Jarl U. of Minn., MB. 1943
Olson, Carlton Kent U. of Minn., MB. 1943
Pennington, Mary Helen U. of Minn., MB. 1943
Peterson, Elroy Russell U. of Minn., MB. 1943
Pulford, James Hartman U. of Minn., MB. 1943
Quist, Henry William, Jr. U. of Minn., MB. 1943
Good Samaritan Hosp., Los Angeles, Cal.
317 - 14th Ave. S. E., Minneapolis, Minn.
Ancker Hospital, St. Paul, Minn.
St. Francis Hospital, Pittsburgh, Pa.
Cine. General Hospital, Cincinnati, Ohio.
U. S. Navy Hospital, Great Lakes, 111.
St. Joseph’s Hospital, St. Paul, Minn.
U. of Chicago Clinics, Chicago, 111.
Mpls. General Hospital, Minneapolis, Minn.
Wm. J. Seymour Hospital, Eloise, Mich.
Mayo Clinic, Rochester, Minn.
1943 Milwaukee Hospital, Milwaukee, Wis.
1943 St. Mary’s Hospital, Duluth, Minn.
1943....
1943 ...
1942
1943
U. of Minn., MB. 1943 San Diego Co. Hospital, San Diego, Cal.
1943- St. Elizabeth’s Hospital, Washington, D. C.
1943 Miller Hospital, St. Paul, Minn.
1943 Kansas City General Hosp., Kansas City, Mo.
1943- Ancker Hospital, St. Paul, Minn.
1943 Milwaukee Co. Hospital, Wauwatosa, Wis.
1943 Mpls. General Hospital, Minneapolis, Minn.
Raths, Otto Nicholas, Jr. St. Louis U., M.D. 1942 1171 Summit Ave., St
Reid, James Wilson U. of Minn., MB. 1943 Miller Hospital, St. Paul
Milwaukee Co. Hospital, Wauwatosa, Wis.
University Hospital, Minneapolis, Minn.
St. Joseph’s Hospital, St. Paul, Minn.
Presbyterian Hospital, Chicago, 111.
Marshall, Minn.
Ancker Hospital, St. Paul, Minn.
University Hospital, Minneapolis, Minn.
St. Luke’s Hospital, Denver, Colo.
Wm. J. Seymour Hospital, Eloise, Mich.
63-50 Wetherole St., Rego Pk., Queens, N.Y.C.
- 520 Wash. Ave. S. E., Minneapolis, Minn.
Mpls. General Hospital, Minneapolis, Minn.
Mpls. General Hospital, Minneapolis, Minn.
.Mpls. General Hospital, Minneapolis, Minn.
Wm. J. Seymour Hospital, Eloise, Mich.
U. S. Navy Hospital, Seattle, Wash.
- Milwaukee Co. Hospital, Wauwatosa, Wis.
San Francisco Co. Hosp., San Francisco, Cal.
Mpls. Gen. Hospital, Minneapolis, Minn.
- Detroit Receiving Hospital, Detroit, Mich.
New Haven Hospital, New Haven, Conn.
Detroit Receiving Hospital, Detroit, Mich.
Mpls. General Hospital, Minneapolis, Minn.
Paul, Minn.
Minn.
Rice, Roberta Geraldine U. of Minn., MB. 1943 U. of 111. Res. & Ed. Hosp., Chicago, 111.
Riegel, Gordon Stannard U. of Minn., MB. 1 943 Rochester Gen. Hospital, Rochester, N. Y.
Schoeneberger, Paul Bernard U. of Minn., MB. 1943 Wm. J. Seymour Hospital, Eloise, Mich.
Skinner, Abbott -Harvard U., M.D. 1942 1501 Summit Ave., St. Paul, Minn.
Skubi, Kazimer B. Rush Med. Col., M.D. 1940 University Hospital, Minneapolis, Minn.
Smith, Paul McClay U. of Minn., MB. 1943 Wilkes-Barre Gen. Hosp., Wilkes-Barre, Pa.
Sterner, Donald Carl U. of Minn., MB. 1 943 Bethesda Hospital, St. Paul, Minn.
Ulvestad, Harold Sigurd U. of Minn., M.B. 1943 Ancker Hospital, St. Paul, Minn.
BY RECIPROCITY
Donoghue, Francis Edmund . Columbia U., M.D. 1940 Mayo Clinic, Rochester, Minn.
Garner, Fay Lorenzo U. of Neb., M.D. 1942 Miller Hospital, St. Paul, Minn.
NATIONAL BOARD OF MEDICAL EXAMINERS
Dumais, Alcide Fernand Boston U., M.D. 1940 Mayo Clinic, Rochester, Minn.
Hurley, Joseph Patrick Tufts Col., M.D. 1940 Mayo Clinic, Rochester, Minn.
September, 1943
301
i
i
Name
Anderson, Franklin Carl
Bianco, John James
Christensen, Norman Anton
Cluxton, Harley Ernest, Jr.
Ellison, Adam Brown Curry
Fortner, Lucille Lanier
Giebink, Robert Rodger
Hamm, Robert Snyder
Haugseth, Ellsworth Kenneth
Hohm, Theodore Arthur
Johnson, Frank Waters
Kemper, Clarence McDaniel
Larson, Keith Delmar
Lobitz, Walter Charles, Jr.
Mason, Eugene Edgar
Multhauf, Cyril Joseph
Murphy, Jack Tullus
Notier, Victor Anthony
Quattlebaum, Frank Walter
Rogers, James Del
Rosenblatt, Henry Dennis
Snider, Gordon Gaskill
Stratte, John Joseph ....
Taylor, Douglas Hamilton ...
Thornes, Arthur Boyd
Tinkham, Robert Grey
Tongen, Lyle Aaron
Watson, Theodore
Calmenson, Marvin
Johnson, Aldridge Francis
Levin, Jules Darrell
Murdoch, James William, Jr.
ON MAY 7, 1943, BY EXAMINATION APRIL 20, 21, 22
School
U. of Minn., M.B. 1942 ...
Temple U., M.D. 1941
Rush Med. Col., M.D. 1941
Johns Hopkins, M.D. 1941
Rush Med. Col., M.D. 1941
_U. of Ore., M.D. 1940
U. of Minn., M.B. 1942
Ohio State LI., M.D. 1940
U. of Minn., M.B. 1943
U. of Chicago, M.D. 1941
Rush Med. Col., M.D. 1942
LI. of Colo., M.D. 1941 .... ..
Northwestern, M.B. 1940, M.D. 1941 ...
U. of Cincinnati, M.B. 1940, M.D. 1941
Baylor U., M.D. 1940
Marquette 11., M.D. 1941
Northwestern, M.D. 1942
Rush Med. Col., M.D. 1941
U. of Georgia, M.D. 1939
Northwestern, M.B. 1941, M.D. 1942....
1 1. of Minn., M.B. 1942
U. of 111., M.D. 1941
Rush Med. Col., M.D. 1942
LJ. of Ore., M.D. 1942
U. of Minn., M.B. 1942
U. of Minn., M.B. 1942
Washington U., Mo., M.D. 1942
U. of Minn., M.B. 1943
BY RECIPROCITY
Rush Med. Col., M.D. 1938
U. of Ark., M.D. 1942 .
U. of Wis, M.D. 1938
Address
115 Third St., Cloquet, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
4404 Harriet Ave., Minneapolis, Minn.
Mayo Clinic, Rochester, Minn.
Twin Valley, Minn.
Huron, S. D.
5610 Dorchester Ave., Chicago, 111.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
809 Portland Ave., St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Warren, Minn.
Mpls. General Hospital, Minneapolis, Minn
University Hospital, Minneapolis, Minn.
25 Seymour Ave. S. E., Minneapolis, Minn.
Walhalla, N. D.
Miller Hospital, St. Paul, Minn.
Mayo Clinic, Rochester, Minn.
Greenwood, Ark.
University Hospital, Minneapolis, Minn.
826 S. 36th, Lincoln, Neb.
U. of Neb., M.D. 1942
NATIONAL BOARD OF MEDICAL EXAMINERS
Tice, Arnold U. of Iowa, M.D. 1941 Mayo Clinic, Rochester, Minn.
ON JULY 17, 1943, BY EXAMINATION JUNE 15, 16, 17
Booren, Jack Carleton U. of Minn., M.B. 1943 St. Mary’s Hospital, Duluth, Minn.
1943 1000 Univ. Ave. S. E., Minneapolis, Minn
1923 2343 Carter Ave., St. Paul, Minn.
1943 Watertown, S. D.
1943 Lamberton, Minn.
2117 - 6th Ave. E., Hibbing, Minn.
1943 718 - 5th St. S. W., Rochester, Minn.
1943 1910 Franklin Ave. S. E., Minneapolis, Minn
1943 Hamel, Minn.
Burklund, Edwin Carl Northwestern, M.B. 1942, M.D
Colberg, Arthur J. U. of Minn., M.B. 1922, M.D.
Conley, Robert Hanten U. of Minn., M.B. 1942, M.D.
Coulter, Harold Eugene U. of Minn., M.B. 1942, M.D.
Flynn, Bernard Francis Loyola U., M.D. 1943
Gaarde, Frederic William, Jr. U. of Minn., M.B. 1942, M.D.
Galligan, Margaret Mary Durkin ... U. of Minn., M.B. 1942, M.D.
Geurs, Benjamin R. U. of Minn., M.B. 1942, M.D.
Horns, Richard Coburn _U. of Minn., M.B. 1942 University Hospital, Minneapolis, Minn
Ide, Arthur Wheaton, Jr. U. of Mich., M.D. 1943 ...... .Ancker Hospital, St. Paul, Minn.
Kaplan, Harold Arthur U. of Minn., M.B. 1943 Ancker Hospital, St. Paul, Minn.
Kern, Carroll E. Indiana U., M.D. 1940 Mayo Clinic, Rochester, Minn.
Kirklin, John Webster Harvard U., M.D. 1942 1104 - 7th St. S. W., Rochester, Minn.
Lick, William Joseph, Jr. U. of Minn., M.B. 1942 587 Dayton Ave., St. Paul, Minn.
Lofgren, Karl Adolph Harvard U., M.D. 1941 Mayo Clinic, Rochester, Minn.
Luckemeyer, Carl Joseph Marquette U., M.D. 1943 ...St, Mary’s Hospital, Duluth, Minn.
Lund, Curtis Joseph U. of Wis., M.D. 1935 University Hospital, Minneapolis, Minn.
McCarthy, Austin Michael U. of Minn., M.B. 1942 Mpls. General Hospital, Minneapolis, Minn.
Michels, Roger P. U. of Minn., M.B. 1942, M.D. 1943 801 Becker Ave. W., Willmar, Minn.
Milnar, Frank Joseph Marquette U., M.D. 1942 412 Otis Ave., St. Paul, Minn.
Neander, John Frederick U. of Minn., M.B. 1943 1242 Earl St., St. Paul, Minn.
Padgett, Harold Owen Baylor U., M.D. 1939 Mayo Clinic, Rochester, Minn.
Poore, Thomas Nelson U. of Minn., M.B. 1943 St. Mary’s Hospital, Duluth, Minn.
Rinehart, Robert Earl U. of Oregon, M.D. 1942 Mayo Clinic, Rochester, Minn.
Rives, Hugh Farrar U. of Arkansas, M.D. 1938 Mayo Clinic, Rochester, Minn.
Roth, Robert Russell U. of Illinois, M.D. 1941 Mayo Clinic, Rochester, Minn.
Schulze, John William U. of Minn., M.B. 1942, M.D. 1943 Hutchinson, Minn.
Shonyo, Elwyn S. Rush Med. Col., M.D. 1937 Mayo Clinic, Rochester, Minn.
Troxil, Elizabeth B. U. of Minn., M.D. 1943 Mpls. General Hospital, Minneapolis, Minn
Vigeland, George Norman Northwestern U., M.B. 1941, M.D. 1942 .... 628 Grand Ave., St. Paul, Minn.
Whelan, Joseph L. U. of Minn., M.B. 1942, M.D. 1943 20 First St. S. W., Chisholm, Minn.
Whitlock, Gerald Frederick Washington U., Mo., M.D. 1941 .... Mayo Clinic, Rochester, Minn.
BY RECIPROCITY
Baird, Joe William U. of Neb., M.D. 1930 Mayo Clinic, Rochester, Minn.
Westphal, Kean F. Northwestern U., M.B. 1937, M.D. 1938 .... .1947 Grand Ave., St. Paul, Minn.
NATIONAL BOARD OF MEDICAL EXAMINERS
Baker, Milton Ernest Northwestern U., M.B. 1942, M.D. 1943 2284 W. Lake of Isles Blvd., Mpls., Minn.
Christopherson, Joseph Elmer .. U. of Minn., M.B. 1942, M.D. 1943 812 - 5th Ave. S., Virginia, Minn.
Serves the A Medical Profession of
MINNESOTA, NORTH DAKOTA V SOUTH DAKOTA and MONTANA
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn.
Montana State Medical Assn.
Dr. J. P. Ritchey, Pres.
Dr. M. G. Danskin, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres.-Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, T reas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
Dr. J. O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J . C. McKinley
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
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 84 South Tenth Street, Minneapolis, Minnesota
W. L. Klein, 1851-1931
Minneapolis, Minnesota, September, 1943
UNDULANT FEVER
Under the caption " Look for Malta Fever ” we dis-
cussed the increasing prevalence of this disease in an edi-
torial, January first, 1934. Since that time we have been
conscious of its increasing spread in the United States.
In the year preceding that editorial there were 72 cases
of undulant fever in Minnesota and no deaths. Last
year, there were 257 cases, 206 males with one death and
51 females with no deaths. The last seven years, partic-
ularly, have seen a steady and alarming climb in these
figures. During the years 1932 to 1942, inclusive, the
records show a grand total of 1264 cases with 22 deaths.
These figures are authentic, having been compiled at our
request, through the kindness of Dr. Orianna Mc-
Daniel, director of the division of preventable diseases,
and Dr. A. J. Chesley, executive secretary of the Minne-
sota department of health. They also have statistics on
the occupational hazards, with milk and meat handlers
naturally leading the list, but many cases represent em-
ployments apparently unrelated to any known source,
including 142 children and students.
When our valiant soldiers return from the battle
fronts of the world, those who served in the medical
corps around the Mediterranean area may bring us some
first hand information that will help to combat this ris-
ing affliction here at home. If they bring back with them,
however, a mascot in the shape of a brucella melitensis
infested goat, we hope their delight at seeing the Statue
of Liberty will prompt them, forthwith, to give it up as
a suitable burnt offering on Quarantine Island at the joy
of their safe deliverance.
A. E. H.
September, 1943
303
THE SUNSET SLOPE
Geriatric medicine has been the subject of many excel-
lent articles appearing in the past two years. The care of
the aged has always been accepted as a part of every doc-
tor’s work but it is now becoming more and more a spe-
cialty and, therefore, arouses our interest. The reasons
!j for such a designation and allocation are several. In the
' first place, those doctors who were adept at caring for
the aged and who studied the problem found themselves
j faced by the fact that there are now more septagenarians
1 on the hoof than there used to be. Furthermore, they
found that these needed different and special care, and
had different and special problems from children and
young adults. There are two important sides to geriatric
care; the diagnosis and treatment of organic changes and
disease particular to senescence, and the mental care and
prevention of those psychic changes of involution which
characterize many old people.
Physically, one is dealing with a body in which there
is a degree of dehydration, shrinking, sclerosis, inelas-
ticity, loss of strength and tone, and changes in colloidal
structure. There are also atrophies, postural changes, and
functional weaknesses dependent on the foregoing factors
and on lowered metabolism. The involution of the circu-
latory system alone may account for senescent changes
such as drying and hardening of the skin from an im-
poverished blood supply. The senile dermis fails to some
extent in its important function as a heat regulator and
thus we find that older people do not tolerate tempera-
ture extremes. It is the old folks who are apt to have
heat strokes and who must draw a shawl over their shoul-
ders when they sit in front of the fire on a winter eve-
ning. The physiologist and biochemist recognize these
changes but do not shed much light on them. Accord-
ing to Dr. A. J. Carlson of Chicago, more time should
be spent on their study and less on their enumeration.
And speaking of senescent vascular changes, one writer
has paraphrased an easily recognized quotation, saying,
a man is as old as his ability to disperse cholesterol.
Of course there is no definite time when old age sets in,
but the aging process starts early. One writer, Dr. G. M.
Davidson, remarks in a lecture on "Passing the Meri-
dian of Life” that grace and agility of movement begin
to dwindle in the early thirties. That, you say, may be
true of some people, but not of you. Well — good for
you! It must be admitted, however, that as far as others
are concerned, there comes a time when mental processes
begin to deteriorate. Concentration is poor, memory
flags, there is less externalization of ideas, and a period
of psychological crystallization approaches.
Let it be remarked here as a hopeful note that mental
senescence does not come to everyone. Hundreds of
mentally alert octogenarians who are doing active and
even brilliant work can be named. Dr. E. B. Allen in a
paper read at the organization meeting of the American
Geriatrics Society is convinced that prophylactic mea-
sures taken before the onset of psychological involution
could do a great deal to increase the happiness and use-
fulness of those whose old age finds some degree of phys-
ical retirement necessary. According to Dr. Starke Hath-
away of Minnesota, salients in the personality profile as
demonstrated by the Minnesota Multiphasic Personality
Inventory would give definite leads for the prophylactic
psychotherapy in pre-senescence. It is in this field that
geriatrics has its greatest appeal.
L. M. D.
Book Reviews
Outline of Roentgen Diagnosis, an Orientation in the Basic
Principles of Diagnosis by the Roentgen Method, by Leo G.
Rigler, M.D. Philadelphia: J. B. Lippincott Co., 196 pages
with index and pictorial atlas of 254 illustrations, price $6.50.
Although Dr. Rigler offers the second edition of his book on
the same basis as the first one in 1938, as an outline for the
teaching of roentgen diagnosis, the work has always been more
than that. It is a convenient reference for any physician doing
all or part of his own roentgenographic work in regard to
doubtful diagnostic matters and points of technic. The outline
form compels brevity and conciseness, and the author has mas-
tered this particular method of presentation, avoiding the sem-
blance of dogmatism inherent in such a technic.
Information concerning the new procedures of roentgen-
kymography, body section roentgenography, and myelography
for investigation of defects of the spinal canal is given in the
second edition, and discussion of older, standard methods has
been augmented by addition of proved and useful data.
The advantages of fluoroscopy have been presented and elab-
orated— a subject which needs intelligent stimulation. The dan-
gers to be avoided, particularly by those not specializing in
roentgen work and who often, out of ignorance, endure need-
less exposure, are rightfully stressed.
Those who have not become acquainted with the first edition
should hasten to read the second; those who have learned to
depend upon the first edition, should obtain this rewritten text.
A Manual of Allergy, by Milton B. Cohen, M.D. New
York: Paul B. Hoeber, Inc., 156 pp., 1942, $2.
This is a short, rather concise book intended to summarize
for the busy practitioner the important features to study in
allergic patients. Much attention is given to the type of history-
taking which is necessary in determining allergic conditions.
This book cannot be considered a textbook of allergy, but is
merely a compendium which lights the high spots on this par-
ticular field. It is of value, of course, because of its concise-
ness, especially for the family physician who has most of these
problems to consider.
Nutritional Deficiencies, by Jno. B. Youmans, A.B., M.S.,
M.D. Philadelphia: J. B. Lippincott Co., 385 pp., 1941, $5.
Exploration for a better world today calls for international
food conferences and the compilation of literature looking
toward a full understanding of nutrition. More and more phy-
sicians will be asked to give advice on nutritional problems.
Clinical observations and scientific investigations of the past and
present are expected to disclose the answers to questions that are
confronting all countries. Much has been written. True and
false claims have been made. This leads to confusion. The phy-
sician can expect to be called upon to say how much vitamins
influence our lives, what protein does, where calcium, iron and
iodine fit in. Failure to clarify the situation might easily discon-
cert and discourage great groups on whose cooperation and un-
derstanding governments depend, and retard advances in the
study of nutrition. This new book goes a long way toward
straightening out the diagnosis and treatment of nutritional de-
ficiencies. It is therefore most timely and should be read by
practising physicians who have a concern for this generation and
for those who will want food knowledge in the years to come.
304
The Journal-Lancet
A Guide to Practical Nutrition, a series of articles, sponsored
by the Philadelphia County Medical Society, edited by
Michael G. Wohl, M.D., and Jno. H. Willard, M.D.
Reprinted from Philadelphia Medicine, 1941-1942. Publica-
tion and distribution made possible through a grant-in-aid
from Jno. Wyeth & Bro., Inc.; 6/4x9%, bound in heavy
gray paper, 100 pp., 1943. Sent with the compliments of the
Society.
Food shortages, lack of buying power, or ignorance may be
the cause of poor nutrition but in this country, the greatest of
these is ignorance. Public illumination is not a simple problem
but one which will require diligent attack from all possible
angles before solution is approached. This book is an excellent
contribution to the educational campaign now being carried on
by many interested agencies.
Twelve authors, all distinguished in their own fields, have
written chapters on the different normal food requirements and
on the special needs for childhood, pregnancy, and old age.
Complete food tables, vitamin and mineral charts, and a cross-
index make this a good reference book for the physician who
should take a leading part in the dietary education of the public.
Rehabilitation of the War Injured, a Symposium edited by
William Brown Doherty, M.D., and Dagobert D. Runes,
M.D.; New York, Philosophical Library; 684 pages, numer-
ous black and white illustrations; 1943; price $10.
This symposium includes over fifty articles by leading Eng-
lish, American and Russian authors, presenting sections on neur-
ology and psychiatry, reconstructive and plastic surgery, ortho-
pedics, physiotherapy, occupational therapy and vocational guid-
ance, the legal aspects of rehabilitation, and neurologic lesions in
survivors of shipwreck. Most of the material has been pub-
lished previously in prominent medical journals and books. The
papers are concise, each concerning itself essentially with only
the one phase of the subject which presents the most difficulty
in rehabilitation. The book is well illustrated with photographs
and drawings and the inclusion of lists of references adds to
its value.
Eye Hazards in Industry, Extent, Cause and Means of Pre-
vention, by Louis Resnick. Published for the National So-
ciety for the Prevention of Blindness, by Columbia Univer-
sity Press, 321 pages. New York, 1941. Cloth, price $3.50.
This book contains information concerning the eye accidents
which may affect the industrial worker, and points out the bene-
fits, both to the worker and his employer, to be obtained by
better eye protection.
The author’s conclusions are, that the only safe method of
preventing eye injuries, in industry, is for all employees as well
as visitors to wear goggles during the entire time they are in
the plant. He quotes the results in certain plants where this
rule has been in effect. Anyone interested in this subject will
find this book of great service.
The 1942 Year Book of General Medicine, edited by Geo.
F. Dick, M.D., J. Burns Amberson, Jr., M.D., Geo. R.
Minot, M.D., Wm. B. Castle, M.D., Wm. D. Stroud,
M.D., and Geo. B. Eusterman, M.D. Chicago: Year Book
Publishers, Inc., 848 pages with index, 1942, $3.
The Year Book of General Medicine maintains the high
standard of excellence set by the previous publications. The out-
standing articles from recent medical literature, noting salient
observation in the fields of infectious diseases, pulmonary con-
ditions, blood dysaemias, kidney, heart and vascular disorders
and disturbances of the digestive system and metabolism have
been ably abstracted by the six recognized clinical leaders who
have compiled this volume. The emphasis has been properly
placed upon matters of practical application by the non-special-
izing practitioner. No better compendium of postgraduate edu-
cation could be desired by the busy medical man than that com-
prised in this handy, compact, well documented and indexed
book.
Views Items
Dr. Robt. G. White, formerly of Valley City, North
Dakota, and Bismarck, at which latter point he has
served as director of maternal and child hygiene for the
state department of health, became director of the
Burke-Minot-Ward district public health unit, with of-
fices at Minot, August 1, succeeding the late Dr. Olaf
Haraldson.
Dr. George F. Campana, formerly of New Rochelle,
New York, recently licensed to practice medicine in
North Dakota, has been appointed state epidemiologist
and director of the division of preventable diseases by
North Dakota state health officer, Dr. F. J. Hill.
On July 29, the Watertown, South Dakota, Public
Opinion published the picture of a bacteriologist in the
laboratories of E. R. Squibb & Company examining the
penicillium mold from which is extracted the potent
germ fighter, penicillin.
The farthest advanced general hospital set up by the
American army up to May, 1943, was established near
the Tunisian front by the University of Minnesota unit
and was put together in less than three weeks time partly
out of salvage from army junk piles. The Red Cross
credits the University of Minnesota men with accom-
plishing miracles with gasoline drums, bits of glass, wire,
and iron from salvage dumps. The hospital was almost
entirely under canvas.
Dr. T. E. McGauvran, a practitioner formerly of
Velva, North Dakota, and Marshall, Minnesota, has
taken up the practice of Dr. Roy W. Pence, Minot,
North Dakota, whose ill health causes him to move to
southern Texas.
Changes in the Montana State Board of Health per-
sonnel find Dr. Charles J. Bresee of Great Falls, succeed-
ing Dr. George F. Turman of Missoula, resigned, and
Dr. R. C. Monahan of Butte filling the post of Dr.
Enoch M. Porter, of Great Falls, deceased.
Dr. Howard R. Wold of Grafton, North Dakota, has
taken over the practice of Dr. David H. McKeague at
Maddock, North Dakota.
Dr. Gilbert Cottam, superintendent of the South Da-
kota State Board of Health, announced the opening of
a branch laboratory at Rapid City, South Dakota, during
July.
Dr. Vincent S. Irvine, formerly of Grafton, Lankin
and Park River, North Dakota, has succeeded to the
practice of Dr. Ernst G. Sasse of Lidgerwood. He prac-
ticed at Park River for twenty years.
Drs. J. C. McKinley and S. R. Hathaway of the de-
partment of neurology and psychiatry of the University
of Minnesota medical school discussed a technic for the
easy characterization of abnormal mental traits at the
annual meeting of the Southern Minnesota Medical
Association, August 23, at Austin, Minnesota.
September, 1943
305
Dr. Fredk. W. Freyberg of Conde, South Dakota, has
removed to Mitchell, where he began his medical career
many years ago.
Dr. Walter F. Ramsey, Children’s Hospital, St. Paul,
toured the North Shore of Lake Superior for three
weeks in behalf of the Medical and Surgical Relief Com-
mittee seeking donations of instruments for army, navy,
and coast guard stations. He was accompanied by Mrs.
Ramsey and made his headquarters at Lutsen, Minnesota.
Dr. L. D. Fricks, city-county health commissioner for
Helena, Montana, from September, 1942, until May,
1943, has been succeeded by Dr. R. J. Shale, lately of
Tampa, Florida, and at one time health officer at On-
tonagon, Michigan.
Dr. George H. Stidworthy of Deerfield, South Da-
kota, was tendered a birthday party by his friends on his
82nd birthday. He practiced at Viborg for 50 years.
Among the guests present was the first baby delivered by
Dr. Stidworthy.
Captain Sidney C. Stenerodden of Grand Forks,
North Dakota, is attached to an American portable hos-
pital in mandated New Guinea, near Morobe. Captain
Stenerodden is a graduate of the University of North
Dakota school of medicine. He has been in the service
since June, 1942, and in the South Pacific since Sep-
tember.
Dr. Bernard I. Saliterman, formerly of Janesville,
Minnesota, and lately practicing in Minneapolis, has
joined the army with the rank of captain and has been
assigned to the hospital base at the Presidio, San Fran-
cisco.
Dr. Leonard L. Kallestad, Hutchinson, Minnesota, has
received a war department appointment as orthopedic
surgeon in the unit of ten specialists formed by Dr.
Charles Rea of St. Paul. Dr. Kallestad’s station is Knox-
ville, Tennessee. Dr. Gerhard F. Knutson of Belview,
Minnesota, has received a similar appointment from the
war department and has left for the Smokey Mountains
of Tennessee.
Dr. Martin G. Ericsson, formerly of Long Prairie,
Minnesota, who for the past several years has been in
Cedar Falls, Iowa, reported to Carlisle Barracks, Penn-
sylvania, August 25, for preliminary training, entering
the service with rank of captain.
Captain John J. Scanlon of the U. S. Army medical
corps paid a visit to his home city, Anaconda, Montana,
accompanied by his wife and small son while on leave
from his post at San Antonio, Texas.
Dr. Roger P. Hentz, manager of the veteran’s admin-
istration facility at St. Cloud, Minnesota, will be trans-
ferred to Fort Custer, Michigan, on September 1, and
will be succeeded by Dr. J. A. Pringle, now assistant
medical director of the neuropsychiatric division of the
veteran’s administration medical center in Washington,
D. C.
Lt. Desmond M. Thysell of Minneapolis, is at the
Naval Base Hospital in Waukegan, Illinois.
Dr. Frank W. Bilger, who practiced medicine 34 years
in and near Hot Springs, South Dakota, has been ap-
pointed contract surgeon with the rank of first lieuten-
ant in the U. S. Army medical service and, after training
at Fort Robinson, Nebraska, will be asigned to duty at
the Black Hills Ordnance Depot at Provo.
Captain B. L. Sinner, M.C., of Fargo, North Dakota,
has been transferred from Station Hospital at Camp
Crowder, Missouri, to the Fourth Auxiliary Surgical
Group, at Lawson General Hospital, Atlanta, Georgia.
Major R. D. Nierling, M.C., of Jamestown, North
Dakota, has left the Station Hospital at Camp Carson,
Colorado, for Camp Barry at Banning, California.
Captain Alvin J. Swingle, M.C., of Mandan, North
Dakota, has left Camp Barry, California, and is with the
58th General Hospital which was shipped from an east-
ern seaport early in August.
Captain Loren F. Wasson, M.C., of Alexandria, Min-
nesota, is attached to the 309th Fighter Control Squad-
ron at Bradley Field, Connecticut.
Dr. Rudy E. Hultkrans has left Minneapolis to enter
the army medical corps with the rank of captain. He has
been assigned to the staff of the Army and Navy hos-
pital at Hot Springs, Arkansas.
The British Information Services, with an office at
360 North Michigan Avenue, Chicago, has issued a
booklet on British health services in wartime, which con-
tains many chapters of interest to the medical profession.
Dr. Caroline F. Helmick of the division of maternal
and child hygiene of the North Dakota State Board of
Health, held a series of meetings for the examination of
pre-school children throughout the Devils Lake area, the
first 18 days of August.
Dr. Chas. F. Culver, for 40 years a general practi-
tioner at Sioux Falls, South Dakota, has removed to the
Rio Grande Valley district of Texas, where he will take
residence in September after a short stay in Minnesota.
Dr. R. S. Madland, Fairfax, Minnesota, received his
appointment in the Medical Corps of the Army, with
the rank of Captain. He was at Carlisle Barracks, Penn-
sylvania, for a six weeks training period, then went to the
Springfield, Missouri, O’Reilly General army hospital.
The Annals of Allergy, which is to be published once
every two months by the American College of Allergists,
took its place in the field of medical literature last month.
In its editorial pages it introduces itself and gives an in-
teresting account of the incorporation of the College.
The first number contains an article on army allergy,
reporting the experience with allergy clinics in the Fourth
Army Command. Dr. Duttin of El Paso discusses allergy
as etiological factor in some cases of appendicitis. De-
allergization versus Hyposensitization is the subject of a
paper by Drs. Urbach and Gottlieb of Philadelphia.
Titles of other articles appearing in this issue are "Some
of the Factors to be considered in the etiology of Bron-
chial Asthma,” "Vernal Conjunctivitis,” "Ragweed Pollen
Extract,” and "Molds and their Relation to Allergy.”
The last is a report of a committee of allergists for the
study of unknown causes of hay fever and asthma.
306
The Journal-Lancet
VUtMloW
Dr. Alfred J. Willits, 69, of Anaconda, Montana,
died July 26, at his home, following an extended illness.
Dr. Willits practiced in Anaconda for 30 years, 23 years
of which he was chief of staff of St. Ann Hospital. He
was a past president of the Mount Powell Medical So-
ciety and at one time was on the faculty of the North-
western University School of Medicine.
Dr. George J. Gordon, 69, of Minneapolis, died July
25, of a heart ailment which had forced his retirement
two years ago. He was a graduate of Jefferson Medical
College, Philadelphia, and had practiced in Minneapolis
for more than 40 years.
Dr. Lawrence F. Dugan, 45, of Faribault, Minnesota,
died in Faribault, July 17, after 13 years residence there.
Dr. Cephas Swanson, 67, of Minneapolis, a native of
Carver, Minnesota, died at Minneapolis July 20. He
was the head physician of the Scandinavian-American
fraternity.
Dr. William D. Wagar, 68, Michigan, North Dakota,
died July 25 at Michigan. He was a graduate of the
University of Minnesota Medical School, class of 1898.
Dr. A. R. Johnson, 44, Isanti, Minnesota, died July 25
at Asbury Hospital, Minneapolis, following an appen-
dectomy. He was a graduate of University of Minne-
sota Medical School, class of 1929.
Dr. Charles P. Arzt, 73, St. Paul, a native of Ger-
many and an 1895 graduate of the University of Minne-
sota, died July 29th at his home in St. Paul.
Dr. Manley H. Haynes, 54, Menahga, Minnesota,
died August 8, at Menahga. He was a graduate of the
University of Minnesota.
Tutuie- Iflceii
The Omaha Mid-West Clinical Society will hold its
annual session in Omaha October 25-29. Among the
speakers scheduled are Dr. Jennings C. Litzenberg, of
Minneapolis, and Dr. Eben J. Carey, Dean of the School
of Medicine, Marquette University, Milwaukee. Dr.
J. D. McCarthy, Medical Arts Building, Omaha, is sec-
retary and director of clinics.
The Mississippi Valley Medical Society will convene
September 29 and 30 at Quincy, Illinois. Dr. Samuel F.
Haines of the University of Minnesota will speak on
treatment of parathyroid insufficiency.
Medicine’s methods of meeting the new and compli-
cating factors brought on by mechanized modern war-
fare will highlight the sessions of the three-day conven-
tion of the Association of Military Surgeons of the
United States at the Bellevue-Stratford Hotel, Phila-
delphia, October 21, 22, 23.
Classified AdverUse^ne^is
POSITION WANTED
Medical secretary, — ten years experience, — available.
Member of the Medical Record Librarians Association.
Medical secretarial position wanted. Gladis Damschen,
19 Shirley Court, Minot, North Dakota.
PHYSICIAN WANTED
Wanted, physician First Aid Department Morrell Pack-
ing Company, Sioux Falls, South Dakota. Apply Dr. S.
A. Donahoe, Sioux Falls, South Dakota.
FOR SALE
Clinic equipment, the doctors of which are in the
Armed Forces. Complete 200 M.A. x-ray unit, Sanborn
cardiette, Birtcher portable shortwave diathermy, 3-piece
Dictaphone unit, Collins-motorless metabolator. Address
Box 757, care of this office.
EXCEPTIONAL OPPORTUNITY
for beginning or established physician to share suite of
offices with another physician or dentist. Individual treat-
ment room or laboratory, in new office building located
in very best residential retail section. Address Box 653,
care of this office.
Advertises' s AttMUHtetnewks
SCHERING AWARD COMPETITION WINNERS
The subject in the second competition of the Schering Award
was "Endocrinology in War Medicine” or certain approved alter-
nate subjects. The Committee of Judges announces these results:
1st prize: One full year’s scholarship to Elizabeth L. Brown,
Class of 1943, New York Medical College, "Endocrines in the
Nervous System,” (Miss Brown was the 3rd prize winner in the
Schering Award Competition of 1941). 2nd prize: One-half
year’s scholarship to Eugene B. Brody, Class of 1944, Harvard
Medical School, "Hormone Factors in Personality.” 3rd prize:
$100.00 to Roslyn Wiener, Class of 1945, University of Michi-
gan Medical School, "Role of Hormones in Pregnancy and
Parturition.”
The Schering Award Competition is offered annually by the
Schering Corporation and is sponsored and administered by a
special committee of the Association of Internes and Medical
Students. The competition is now in its third year. A large
number of excellent manuscripts were submitted. The following
students have warranted honorable mention: N. G. Demy,
Marquette University; N. Josephson, Yale Medical School;
S. Kafka, Middelsex University; G. V. Mann, Johns-Hopkins;
L. W. Pratt, Johns-Hopkins; A. Segaloff, Wayne University;
A. J. Sawyer, University of Vermont; G. Turtletaub, Middel-
sex University; E. W. Amyes, College of Medical Evangelists;
C. Cohen, Loyola University; and A. P. Rosen, Long Island
College of Medicine.
The Committee of Judges comprised these outstanding Amer-
ican investigators in the fields of endocrinology, medicine and
chemistry:
R. G. Hoskins, Director of Memorial Foundation for Neuro-
Endocrine Research, Harvard Medical School; E. P. McCulIagh,
Section of Endocrinology and Metabolism, the Cleveland Clinic;
E. C. Hamblen, Associate Professor and Chief of the Endocrine
Division, Department of Obstetrics and Gynecology, Duke Uni-
versity School of Medicine; E. Novak, Associate Professor of
Obstetrics, University of Maryland School of Medicine and Col-
lege of Physicians and Surgeons; H. M. Evans, Institute of
Experimental Biology, University of California; F. C. Koch,
— " - ° ~ " — ' - J
Chairman of the Department of Biochemistry, University of
Chicago; E. L. Sevringhaus, Professor of Medicine, University
of Wisconsin Medical School; E. Shorr, Assistant Professor of
Medicine, Cornell University Medical College, and the New
York Hospital.
At the present time, plans for the Schering Award Competi-
tion of 1943 are being formulated.
TETANUS IMMUNIZATION OF MILITARY
PERSONNEL
All military personnel, on induction, are being immunized
against tetanus either, as in the Army, by three injections of
fluid toxoid, or as in the Navy and Marine Corps, by two in-
jections of alum precipitated toxoid (New Eng. J. Med.
227:162, 1942). In addition, a small or stimulating dose is in-
jected prior to departure for a theater of operations and an
emergency dose is given to those wounded or burned in battle
or incurring other wounds likely to be contaminated with
Clostridium tetani. According to recent report (Am. J. Pub.
Health 33:53, 1943), since June, 1941, when the present tetanus
immunization program was adopted, there have been but four
cases reported from the entire Army, and none of these were in
immunized individuals. Although perhaps too early in the pres-
ent war to draw any conclusions, it is of particular interest that
no cases of tetanus have been reported from battle casualties.
For civilian use, especially in children, it is of decided advan-
tage to accomplish simultaneous immunization against tetanus
and diphtheria. Combined Diphtheria Toxoid-Tetanus Toxid,
Alum Precipitated, Lilly, is designed for prophylaxis only,
affords effective immunity against both diseases, and avoids risk
of serum sensitization which may follow use of an antitoxin.
CHANGE IN CASEC MEASUREMENTS
Casec now measures six packed level tablespoonfuls instead of
12 level tablespoonfuls, as formerly, so that directions to the
patient should be amended accordingly. Casec is indicated in
colic and loose stools in breast-fed infants, and in fermentative
diarrhea, malnutrition, celiac disease and for premature infants.
Mead Johnson & Company, Evansville, Indiana, U.S.A.
SQUIBB VITAMIN K CONCENTRATE
If the patient cannot retain material when given by mouth, or
if the prothrombin time shows no improvement, a duodenal tube
or T tube may be used for administration. (The solution
should not be given by injection) . In this case, 2 cc. to 4 cc.
Solution Vitamin K Concentrate Squibb are mixed with or fol-
lowed by a solution of bile salts or acids (3 to 6 Procholon Tab-
lets may be used) in 200 cc. of warm water. One or two such
treatments are usually sufficient.
For curative treatment in cases of severe hemorrhage charac-
terized by low prothrombin content of the blood, 4 to 8 capsules
or 2 cc. to 4 cc. of the solution may be administered with bile
salts or acids (Procholon Tablets) for one to three days. If the
patient cannot retain the material, the solution should be admin-
istered by duodenal tube.
Squibb Vitamin K Concentrate is biologically standardized on
vitamin K deficient chicks and its activity expressed in Ans-
bacher (Squibb Institute for Medical Research) units. One
Ansbacher unit is the amount of anti-hemorrhagic factor nec-
essary to reduce the blood-clotting time of the K-deficient chick
to normal within six hours after administration.
VETERINARY SULFAGUANIDINE HAS
WAR IMPORTANCE
Veterinary application of the sulfa drugs advanced substan-
tially during the year 1942. Sulfaguanidine (an exclusive Le-
derle veterinary product) particularly, has proved effective in
treating the infections known as coccidiosis in the digestive
tracts of animals and fowls. This is the first time diseases of
this type could be successfully treated. Calf scours, which causes
high mortality among young calves, can be successfully treated
with sulfaguanidine with important savings to cattle raisers.
This development is vital to maintaining the nation’s meat
supply in war.
When you prescribe beer, the rich
flavor and mellowness of Gluek’s will
make its use a delightful experience.
And remember, Gluek’s is brewed and
bottled under ultraviolet-ray Steri-
lamps — an extra precaution to pro-
tect its purity.
GLUEK’S
BEER
Gluek Brewing Company
Minneapolis
Warrior
THE military doctor of World War II — unarmed yet
unafraid — moves up shoulder to shoulder with the
combat troops. Bayonet charge . . . parachute landing . . .
beach-storming from raiding barges . . . constantly, the
medical officer proves that he is every inch a fighting man.
More than likely, he’s a Camel smoker, too, for Camel’s
mellow mildness and smooth, comforting flavor quickly
won it first choice in the armed forces.*
f
Planning a gift for someone in service ? Make it Camels
... a carton . . . the thoughtful remembrance.
Camel _
Studies on Conditioned Reactions and their Clinical
Implications*
E. Gellhorn, M.D., Ph.D.f
Chicago, Illinois
EARLIER investigations from this laboratory at-
tempted an analysis of the effects of insulin hypo-
glycemia and other forms of "shock therapy” in-
volving different types of convulsions, by the study of
the effects of these procedures on autonomic centers.
It was found that insulin hypoglycemia,1 metrazol2 and
picrotoxin convulsions,3 as well as convulsions induced
electrically4'5 by application of a current to the brain,
lead to a greatly increased excitability of the sympathetic
centers located in the medulla oblongata and in the hypo-
thalamus. Studies on the action of metrazol on the sym-
pathetically innervated nictitating membrane of the cat
indicated that the period of increased sympathetic ex-
citability was by no means restricted to the time when
convulsions occurred, but was evident even hours after
the convulsions had ceased. These observations made it
seem probable that the various forms of shock therapy
may exert chronic functional effects which may last
longer than the acute effects on the sympathetic nervous
system, thus far studied. It is not unlikely that such
chronic functional action on the brain is responsible for,
or involved in, the reported improvement of mental pa-
tients subjected to these procedures.
The work described in this paper is an attempt to
study the chronic physiological effects of various forms
of "shock therapy” on normal animals. The ideal meth-
od for studying the chronic effect of insulin hypogly-
♦Third annual Journal-Lancet lecture given on May 19, 1943, at
the University of Minnesota.
t Department of Physiology, University of Illinois College of
Medicine. (Aided by grants from the John and Mary R. Markle
and the Josiah Macy, Jr., Foundations.)
cemia and experimentally induced convulsions would be
a complete analysis of the behavior of the animal before
and after these procedures have been applied. The study
of some forms of conditioned behavior is a simplified,
but apparently adequate, procedure. Instead of using the
conditioned reflex of Pavlov, a more natural escape re-
action was selected.
The experiments were performed on rats which were
placed in an apparatus consisting of two compartments,
A and B, separated by a low partition. The bottom of
these compartments consisted of a grid which could be
charged through a General Electric variac. At first, the
unconditioned response was established through applica-
tion of a few shocks. It consisted of two integrated
movements: one in which the rat in response to the elec-
trical stimulus jumped from compartment A to com-
partment B; the other in which the animal turned back.
Then the conditioning process was begun by sounding a
bell two seconds before the electrical stimulus was ap-
plied. The sound continued to the end of the electrical
stimulation. As a rule not more than 20 to 30 stimuli
were applied in one session. The experiments were per-
formed daily or on alternate days until a conditioned re-
sponse of 80 to 100 per cent was established. This re-
sponse was then maintained for three successive days, to
insure a thorough retention of the conditioned response.
This was accomplished by subjecting the animals to seven
to twelve conditioned stimuli (bell) reenforced by un-
conditioned stimuli (shock) before applying the test
series of ten non-reenforced conditioned stimuli.
308
The Journal-Lancet
Fig. 1. The influence of electrically induced convulsions on the recovery of inhibited
conditioned responses. Experiments on rat 21 illustrates the effect of electroshock in-
dicated by arrow. Experiment on rat 12 shows that, after three ineffective convulsive
shocks, two convulsions elecited by metrazol resulted in recovery of the conditioned
response. The large interrupted arrow indicates inhibition of the conditioned response
by lack of reenforcement.
Thereafter, the conditioned response was inhibited by
the daily application of ten unreenforced conditioned
stimuli (inhibition by lack of reenforcement in the sense
of Pavlov) . However, this test was always preceded by
one or, in the majority of the experiments, two re-
enforced stimuli. In the latter case, one was applied
while the animal was in compartment A, and the other
while in compartment B in order to avoid the formation
of positional habits.
This procedure led with great regularity to a loss of
80 to 90 per cent of the conditioned responses in about
three to four days. After this level had been established
for at least six days, the rats were subjected to electro-
shock, metrazol, insulin hypoglycemia, anoxia and vari-
ous control experiments.
Results
Figure 1 shows the effect of electroshock on the re-
establishment of inhibited conditioned reactions. It is
evident from this figure that after the application of
several electroshocks the behavior of the rat was altered.
It was no fonger in the inhibited state, but responded to
the conditioned stimulus. The effect was temporary and
had completely disappeared a few days later. After a
period of about twenty days had passed, during which
the conditioned reaction was absent, the electroshock
treatment was repeated and again led to a restitution of
the conditioned reaction for a number of days.
A similar effect was obtained by the use of metrazol as
a convulsant, as is indicated in Figure 2. Here again the
conditioned reaction rises from an insignificant level to
as high as 60 per cent but falls gradually after a few
days to the original level. The second graph of Figure 1
is particularly interesting since it shows that in one case
in which three electroshocks were inadequate to restore
the conditioned reaction, the administration of metrazol
produced a very marked effect since the conditioned re-
action was restored to 80 per cent.6
An extensive series of experiments was carried out with
insulin hypoglycemia under similar conditions.7 Here
again, insulin was injected after the conditioned reaction
had been inhibited and had remained either completely
or almost completely inhibited for some time. Figure 3
shows that insulin coma may restore
the conditioned reaction in a manner
similar to that described for electro-
shock and metrazol. In addition, Fig-
ure 3 shows that repeated comas prop-
erly timed cause a cumulative effect
and may maintain the conditioned re-
action for longer periods of time. This
phenomenon is clearly shown in Fig-
ure 4 in which at first insulin coma
produced only a temporary recovery
of the conditioned reactions. However,
several comas effected a permanent re-
covery of the conditioned reaction and,
as indicated in the insert of Figure 4,
this complete recovery persisted even
after the interruption of the testing
for 30 days. Similar results were ob-
tained in several other animals.
Figure 4 is interesting from still another point of view,
inasmuch as it shows that the restitution of inhibited
conditioned responses by insulin depends on the syndrome
observed in hypoglycemia. Depending on the dose of in-
sulin used and the duration of hypoglycemia, insulin may
lead either to a depression, a coma, or convulsions in rats.
The depression is characterized by the absence of spon-
taneous movements, diminished tone of extremities, slow
righting reflexes and salivation. At this stage a rat reacts
to pain but not to slight pressure. We speak of insulin
coma when the righting reflexes and the reaction of pain-
ful stimuli were abolished. Insulin convulsions are char-
acterized by clonic-tonic-discharges. In general, these
three stages follow each other gradually, but occasionally
an animal will convulse without having shown a distinct
comatose phase.
The investigation showed clearly that insulin depres-
sion is, in general, ineffective to bring about a restoration
of inhibited conditioned reactions. Insulin coma main-
tained for about seven minutes was the most effective
"therapeutic” procedure, and convulsions were in general
little effective as demonstrated in Figure 5.
From the above it follows that metrazol and elec-
trically induced convulsions as well as insulin coma will
result in a definite change in behavior of rats, inasmuch
as these procedures restore inhibited conditioned re-
actions. That this interpretation of the data is correct is
indicated by several series of control experiments. First,
it was shown that rats which had been conditioned and
then inhibited never showed a spontaneous recovery of
the inhibited reaction. This is illustrated by Figure 1
in which the second shock was applied many days after
the first, but no recovery resulted after the temporary
effect of the first shock had passed off. Secondly, the
restitution of the response to the conditioned stimulus
was specific. If, for instance, a rat had been conditioned
to the sound of a door bell and was then inhibited by
lack of reenforcement, the recovery of this reaction by
insulin coma, metrazol, or electroshock was specific to
the stimulus of the door bell, since this rat failed to re-
act to another acoustic stimulus or to a light. Thirdly,
October, 1943
309
Effect of metrazol on conditioned reflexes
Fig. 2. The arrows indicate that convulsions
of 5 5 mg. /kg. metrazol subcutaneously.
had been induced by injection
it was found that if animals were subjected to insulin
coma prior to the conditioning, the conditioned stimuli
failed to produce any effects. Therefore, it seems to fol-
low from these experiments that the various forms of
shock treatment mentioned will restore inhibited condi-
tioned reactions in rats. This restoration is temporary
after one or two comas or convulsions. It may be per-
manent if a coma is administered repeatedly at proper
intervals.
The experiments reported in this paper are of interest
for a functional understanding of "shock therapy” of
mental diseases. The fact that excessive insulin comas in
animal experiments8 lead to hemorrhage and other ana-
tomical changes in the central nervous system does by no
means indicate that these procedures act through the
damage which they inflict on the central nervous system
under rather excessive conditions. Our observation, that
often a single coma may restore inhibited conditioned re-
actions, as well as the reversibility of this effect, suggest
that insulin coma causes functional intracerebral changes.
The "permanent recovery” after repeated comas is of
particular interest. Not only have such animals restored
specifically their previously inhibited conditioned re-
actions, but they display also fundamental changes in
personality. Placed in the apparatus they show signs of
great alertness. They react to the conditioned stimulus
with even greater promptness than was displayed by them
at the end of the period of conditioning. Moreover, the
repeated application of conditioned stimuli over many
days causes, in spite of the complete absence of reenforc-
ing unconditioned stimuli, no weakening in the condi-
tioned response.
The application of experimental physiological observa-
tions to human pathology is always a hazardous under-
taking. This holds particularly true for the problem of
mental disease. It seems, however, to be justified to as-
sume that insulin coma and other procedures of "shock
therapy” will influence acquired conditioned processes in
the human brain in a manner similar to that demon-
strated in the experiments described in this paper. Since
the role of conditioned reactions for behavior is undis-
puted, no fundamental objection seems to exist to inter-
pret the changes in personality seen after successful
shock therapy on a physiological basis.
The experiments described thus far raise the question
whether or not the various procedures used in our experi-
ments have a specific influence solely on inhibitory intra-
cerebral processes, or whether excitatory
processes are likewise influenced. In order to
study this problem the effect of insulin coma
on the rate of conditioning was investigated.
It was found that rats, when only partially
conditioned and then subjected to two in-
sulin comas, show a much higher degree of
conditioning than similarly treated control
animals which were given injections of so-
dium chloride instead of insulin. Apparently,
insulin coma influences not only inhibitory
but also excitatory processes involved in con-
ditioning (Table).
It was stated repeatedly that insulin coma
and convulsions induced by metrazol and electrick shock
cause an increased excitability of sympathetic centers.
This action was thought to be responsible for the im-
provement observed in mental patients subject to the so-
called "shock treatment,” as well as for the recovery of
inhibited conditioned reactions. It is now of interest to
point out that not all rats in which conditioned reactions
had been inhibited by lack of reenforcement will show a
restitution of these reactions when subjected to insulin
coma or experimental convulsions. Figure 6 is a case in
point. It shows that in this animal neither insulin coma,
nor two periods of anoxia, nor a combination of insulin
coma and electric shock produces a significant increase in
the conditioned response. Three further electric shocks
were likewise ineffective. It was then thought that it
might be possible to increase the responsiveness of the
sympathetic centers by the administration of thyroxin,
sympathetic centers by the administration of thyroxin. A
total number of eight injections was given which resulted
in some increase in general excitability of the animal.
Toward the end of the period of thyroxin administra-
tion two electroshocks were administered. As the graph
shows, this procedure resulted in a considerable restora-
tion of the conditioned response. In another animal
which was likewise unresponsive to insulin coma and
electroshock, the administration of thyroxin alone with-
out any further "shock treatment” resulted in the resti-
tution of the previously inhibited conditioned reaction.
These experiments strongly support the hypothesis, that
the restitution of inhibited conditioned reactions, is a re-
sult of increased excitability of sympathetic centers. It is
of interest to point out that the central action of thyroxin
has been clearly established by the work of Gellhorn and
Feldman,8* who showed that the sympathetico-adrenal
response to metrazol and electroshock is greatly increased
after the administration of thyroxin. Since this effect
was observed under conditions in which the peripheral
action of adrenalin was not potentiated by thyroxin, it
was clearly proven that thyroxin administered in rela-
tively small doses increases the reactivity of the centers
of the sympathetico-adrenal system.
It will be the task of further investigations to show
how the increased excitability of sympathetic brain cen-
ters alters intracerebral processes involved in the forma-
tion of conditioned responses, as well as in the removal
of inhibited conditioned reactions, but it may be said that
the profound influence exerted by the hypothalamus on
310
The Journal-Lancet
Fig. 3. Effect of insulin hypoglycemia on the restoration of previously inhibited conditioned reactions. Ver-
tical lines at the beginning of the graph show the number of reenforced conditioned stimuli (bell plus shock)
which established the conditioned response. It was maintained for three days at 70 to 80 per cent and then
inhibited by lack of reenforcement. On the 12th day 4 units/kg. of insulin were given intraperitoneally , on th ?
other days marked by an arrow 5 units /kg. were administered. The experiment showed that hypoglycemic
"depressions” were unable to restore the conditioned reaction, but coma caused recovery. Note the cumulative
effect of three comas given between the 3 0th and 40th day.
cortical processes is well established on the basis of ex-
perimental as well as clinical investigations.9'10
The close relationship of anoxia to hypoglycemia as
far as brain metabolism is concerned, as well as the fact
that anoxia likewise leads to an excitation of sympathetic
centers, was the basis for a study of the effects of anoxia
on inhibited rats. Here again, the rats were first condi-
tioned to the bell and then inhibited. After the inhibi-
tion had lasted for at least six or eight days, the rats were
subjected to anoxia by exposure to lowered barometric
pressure. In the majority of the experiments, the baro-
metric pressure was gradually lowered to 280 mm. Hg.
and the rats stayed at that level for five minutes. This
procedure was not as regularly effective as was insulin
coma. However, in a number of instances, a recovery
was obtained which was very considerable not only in
degree but also in duration.
It was mentioned in the introduction that the various
procedures used in shock therapy had in common the
excitatory effect on central structures of the sympathetic
system, and it was implied that this action is largely re-
sponsible for the restoration of inhibited conditioned re-
actions. A number of experiments seemed to confirm
this interpretation, since drugs such as adrenalin and
atropin which act largely on the peripheral structures of
the autonomic system did not lead to a restitution of the
previously inhibited conditioned reactions. Rats in which
conditioned reactions had been inhibited were injected
repeatedly with atropine and also with adrenalin. Neither
of the two drugs was effective, although in the same ani-
mals insulin hypoglycemia, electroshock, or metrazol re-
stored the conditioned reactions for various periods of
time.J;
In order to obtain a further insight into the factors re-
sponsible for the restoration of inhibited conditioned re-
actions, experiments were performed with pentothal and
alcohol. It had been claimed by several authors that the
JLarge doses of atropine which increase the blood sugar have
been found effective in two instances in restoring inhibited condi-
tioned reactions. This fact is being investigated at the present time.
action of insulin hypoglycemia and metrazol was due to
a reduction in brain metabolism. However, neither alco-
hol nor pentothal had any effect on the conditioned re-
action of our rats, although insulin coma produced the
typical effects on them. Since both narcotics and alcohol
reduce the metabolism of the brain, it seems likely that
the action of insulin coma and other shock procedures
as studied in rats with inhibited conditioned reactions is
not due to their metabolic effects on the brain.
Rosen and Gantt11 reported recently that metrazol
convulsions altered conditioned reflexes in dogs. They
observed that ten metrazol convulsions lead to an im-
pairment of the differentiating ability of the animals, as
shown by the study of positive and negative conditioned
reflexes which had been previously established. In order
to ascertain whether this result would hold true for the
experimental arrangement used in our studies, experi-
ments were performed in which two or three conditioned
reactions were successively established.12 Of these con-
ditioned reactions, one or two were inhibited by lack of
reenforcement, whereas one reaction was not inhibited
and was maintained at approximately 100 per cent.
When electroshocks or insulin comas were administered
to these animals, it was found invariably, as illustrated by
Figure 7, that the positive conditioned reaction remained
unaltered, whereas the inhibited (negative) conditioned
reaction rose to a high positive level. Thus, it is seen in
Figure 7, that following insulin convulsions, the condi-
tioned reaction to light rose from 0 per cent to 70 per
cent; the reaction to the sound which had been varying
between 0 per cent and 20 per cent prior to the insulin
convulsions rose to 100 per cent. The positively condi-
tioned reaction to the bell, however, which showed a
variation between 90 per cent and 100 per cent prior to
the insulin coma remained at 100 per cent during the
period when the inhibited conditioned reactions rose con-
siderably. Moreover, the positively conditioned reaction
to the bell did not fall to a lower level than 80 per cent
when the inhibited conditioned reactions to sound and
October, 1943
311
light fell again to the preconvulsive level of 0 per cent.
In other experiments in which two conditioned reactions
were employed, one of which was completely inhibited so
that the response to the conditioned stimulus was 0 per
cent whereas the other was maintained at approximately
50 per cent, it was observed that, here again, both inhib-
ited reactions became more positive after administration
of insulin coma, and that the partially inhibited reaction
was more fully restored than the completely inhibited
reaction. A dedifferentiation, as Rosen and Gantt have
observed, would lead one to expect not only an increase
in the response of previously inhibited reactions but also
a diminution in the response of positively established con-
ditioned reactions. The fact that this diminution was
never seen in our observations, as well as the previously
reported results that insulin coma enhances the estab-
lishment of conditioned reactions, suggests that insulin
coma as well as other forms of shock therapy diminish
intracerebral inhibitory processes and enhance those ex-
citatory associative processes which are the basis of learn-
ing. The dedifferentiation observed by Rosen and Gantt
is undoubtedly a sign of impaired brain activity. It ap-
pears, however, from our own results that this is not
necessarily a characteristic of the action of metrazol or
insulin on the brain but rather the result of so frequently
repeated convulsions or comas that brain damage actually
occurs.
Numerous clinical questions as well as problems of an
experimental nature are raised by the investigations re-
ported in this paper which cannot yet be answered ade-
quately. Suffice it to say, that our studies have given
ground for the assumption that the conditioned reflex
method is a useful tool for an analytical study of the
procedures commonly applied at the present time in the
therapy of mental diseases.§
Summary
An escape reaction produced by application of an elec-
trical stimulus to the grid on which the animal stands
was conditioned in rats by using various sensory stimuli
(the sound of a door bell, a sound of 250 vibrations per
second, and a light) as conditioned stimuli. After the
conditioned reactions had been established, they were
inhibited by lack of reenforcement. Spontaneous recov-
ery of inhibited conditioned reactions was never observed.
It was, however, found that various forms of "shock
§A fuller evaluation of the physiological basis of shock therapy is
given in the last chapter of my book on "Autonomic Regulations,"
New York, 1943.
therapy” lead to either a temporary or permanent recov-
ery of previously inhibited conditioned reactions. When
insulin is given, insulin coma is far more effective than
either a precomatose insulin hypoglycemia or insulin
convulsions. Anoxia induced by exposure to a low baro-
metric pressure of 280 mm. Hg. produces similar effects
which, however, are far less regular than those obtained
by insulin coma, electroshock, or metrazol convulsions.
It is assumed that the effect of these procedures is linked
up with a stimulation of sympathetic centers in the
brain, which in turn alter fundamentally those intra-
cerebral processes which are the basis of the conditioned
reactions. In support of this assumption, it is shown that
drugs acting on the peripheral autonomic structures have
no effect on restitution of inhibited conditioned reactions.
TABLE
Effect of Insulin Hypoglycemia on Partially Conditioned Rats
(A) CONTROLS
Animals
No. of Bell
Shock
Applied
for Partial
Condi-
tioning
Amount
Saline
Injected
No. of
Bell +
Shock
Applied
after 2nd
Saline
Inj.
Total No.
Bell -f
Shock
Applied
Condi-
tioned
Response
on
Testing
Average
of 8
animals
75
0.5 cc.
20
95
20%
(B) INSULIN-INJECTED
RATS
Animals
No. of Bell
-f- Shock
Applied
for Partial
Condi-
tioning
Amount
Insulin
Injected
in u /kilo
Wt.
No. of
Bell +
Shock
Applied
after insu-
lin Coma
Total No.
Bell +
Shock
Applied
Condi-
tioned
Response
on
Testing
Average
of 8
Animals
75
4 to 10
u/kilo
15
90
*82.5 %
That the action of hypoglycemia is not due to a depres-
sion of the brain metabolism, as such, is suggested by
the fact that alcohol and narcotics, such as pentathol,
which depress oxidative brain metabolism are ineffective
as far as the restitution of inhibited conditioned reactions
is concerned. In further support of the hypothesis is the
fact that animals which are refractory to insulin coma
and electroshock treatment may show clear-cut positive
effects after a "treatment” with thyroxin, which increases
the excitability of sympathetic centers in the brain. The
investigations reported in this paper seem to indicate that
the study of conditioned reactions is a useful tool for the
analysis of the actions of procedures used in the treat-
ment of functional mental diseases.
312
The Journal-Lancet
100-
90
Fl£.5.
80
70-
^60
U
> 50
o
u
p 40
»
o
u 20
10-
f
Insulin oonv.
0 J
Depression
Coma
Convulsions
Fig. 5. Relative efficiency of insulin ’'depression”, coma, and
convulsions on the restitution of previously inhibited conditioned t
responses. The ordinate refers to the increase in the percentage of
the conditioned response following administration of insulin.
7174 76 78 79 61 63
Number of days
Fig. 7. Effect of insulin convulsions
on positively and negatively conditioned
reactions. The inhibited reactions are
temporarily restored, but the positively
established reaction to the bell remains
unchanged.
KDO
V)
8.80-
Bel I
Fig. 6. This graph demonstrates that in a rat in which insulin coma,
anoxia, electroshock, and a combination of electroshocks with insulin coma
were unable to restore inhibited conditioned reactions, electroshock becomes
effective after thyroxin administration.
T)
References
1. Gellhorn, E.: Effects of hypoglycemia and anoxia on the
central nervous system, Arch. Neurol. 6C Psychiat. 40:125—146,
1938. — Gellhorn, E.: The influence of variations in the blood
sugar on the functions of the brain, Am. J. Psychiat. 97:1204—
1217, 1941. — Gellhorn, E., Ingraham, R. C., and Moldavsky, L.:
The influence of hypoglycemia on the sensitivity of the central
nervous system to oxygen want, J. Neurophysiol. 1:301—312, 1938.
2. Gellhorn, E., and Darrow, C. W.: The action of metrazol
on the autonomic nervous system. Arch, internat. de pharmacodyn.
et de therap. 62:114—128, 1939.
3. Gellhorn, E.: Autonomic Regulations, Interscience Publish-
ers, Inc., New York, 1943.
4. Kessler, M., and Gellhorn, E.: The effect of electrically in-
duced convulsions on the vago-insulin and sympathetico-adrenal
system, Proc. Soc. Exp. Biol. 6c Med. 46:64—66, 1941.
5. Gellhorn, E., and Kessler, M.: Experimental investigations
on the interaction of electroshock and insulin hypoglycemia, Arch.
Neurol. Psychiatry, 1943. In Press.
6. Kessler, M., and Gellhorn, E.: The effect of electrically
and chemically induced convulsions on conditioned reflexes, Amer.
J. of Psychiat. 99:5:687-691, 1943.
7. Gellhorn, E., and Minatoya, J.: The effect of insulin hypo-
glycemia on conditioned reflexes, J. Neurophysiol., 1943. In Press.
8. Weil, A., Liebert, E., and Heilbrunn, G.: Histopathological
changes in the brain in experimental hyperinsulinism, Arch. Neurol.
Psychiat. 39:467, 1938.
8a. Gellhorn, E., and Feldman, J.: The influence of the thyroid
on the vagoinsulin and sympathetico-adrenal systems, Endocrin-
ology 29:467-474, 1941.
9. Obrador, S.: Effect of hypothalamic lesions on electrical
activity of cerebral cortex, J. Neurophysiol. 6:81—84, 1943.
10. Walter, W. G., Griffiths, G. M., and Nevin, S.: The elec-
tro-encephalogram in a case of pathological sleep due to hypo-
thalamic tumor, Brit. Med. J. 1:107—109, 1939.
11. Rosen, V. H., and Gantt, W. H.: The acute and chronic
effects of metrazol convulsions on conditioned reflexes in the dog,
Trans. Amer. Neurol. Assoc., 1942, pp. 41—45.
12. Gellhorn, E., and See se, K.: The effect of insulin coma on
differentiated conditioned reactions of the rat, Federation Proc.
2:15, 1943.
October, 1943
313
Wagner-Murray-Dingle Social Security Plan
S. 1161 H. R. 2861
Analysis of Bill by
J. C. Shields, M.D.f
Butte, Montana
This Bill was introduced into the Senate and into the
House of Representatives, June 3, 1943, and has had two
readings. It is designated as amending the Social Security
Act, and is of great importance to all taxpayers.
The system proposed to be created will be financed in
general from a trust fund established by a 6 per cent
withholding tax from the employee, and a 6 per cent
contribution from the employer on all wages and salaries
up to the first $3,000 paid or received after December
31, 1943.
Included in this proposed bill will be a system of pub-
lic employment offices, increased old age and surviving
insurance, temporary and permanent disability insurance,
protection to individuals in the military service, and in-
creased unemployment benefits under a federalized un-
employment system. It is estimated that these provisions
of the Bill would add approximately 25 million persons
to the 37 million now carrying cards.
The Bill provides that — (a) Sec. 960 — Every employer
shall pay a tax of 6 per cent up to $3,000 on wages paid
to individuals, and, (b) Sec. 961 — Every employee shall
pay a tax of 6 per cent, deducted from wages on earned
I income, up to $3,000 per year. Total from payrolls, 12
per cent, (c) Sec. 963— Every self-employed individual
shall pay a tax of 7 per cent, up to $3,000, on the market
value of his services per year, (d) Sec. 962 — Federal,
state, and municipal employees (under certain conditions)
shall pay a tax of 3% per cent. The estimated total
annual revenue from this Bill would be $12,000,000,000.
The Bill provides (Sec. 969): The establishment of a
Trust Fund, known as "Federal Social Insurance Trust
Fund.” Into this fund, all Social Security Taxes will be
paid, $12,000,000,000 annually.
Medical
total coverage of 30 days of hospitalization in any one
year. This may be increased to 90 days each year, if
funds are available.
Administration
The Bill provides (Sec. 903): (a) The Surgeon Gen-
eral of the Public Health Service is hereby authorized
and directed to take all necessary and practical steps to
arrange for the availability of the benefits provided under
this title, (b) In carrying out the duties imposed upon
him by subsection (a) of this section, the Surgeon Gen-
eral is hereby authorized to negotiate and periodically to
re-negotiate agreements or cooperative working arrange-
ments with appropriate agencies of the United States, or
of any state or political sub-division thereof, and with
other appropriate agencies, and with private persons or
groups of persons to utilize their services and facilities,
and to pay fair, reasonable, and equitable compensation.
The Bill provides (Sec. 904): There is hereby estab-
lished a National Advisory Medical and Hospital Coun-
cil to consist of the Surgeon General and sixteen mem-
bers appointed by him.
This council has no authority. All authority and power
are vested in the Surgeon General.
The Bill provides (Sec. 905): (1) Any physician
qualified by a state can furnish medical services in accord-
ance with such rules and regulations as may be prescribed
by the Surgeon General. (2) Every individual shall be
permitted to select or to change physicians in accordance
with rules and regulations as may be prescribed by the
Surgeon General. (3) Services which are deemed to be
special services shall be those designated by the Surgeon
General. (4) Payments to physicians may be made on a
fee schedule approved by the Surgeon General, on a per
capita basis, on a salary basis, or a combination or modifi-
cation of all these bases, as approved by the Surgeon
General. (5) The Surgeon General may prescribe the
maximum number of individuals for whom any physician
may provide services. (6) The Surgeon General may
distribute the available patients among the available doc-
tors on a pro rata basis.
The Bill provides (Sec. 907): (a) The Surgeon Gen-
eral shall publish a list of institutions found by him to be
suitable for hospitalization, (b) Hospitalization benefit
means an amount determined by the Surgeon General
after consultation with the Council, and after approval
by the Social Security Board; not less than $3.00, and
not more than $6.00 for each day of hospitalization not
in excess of 30 days, and not less than $1.50 and not
more than $4.00 for each day of hospitalization in excess
of 30 days in a period of hospitalization; and not less
than $1.50 and not more than $3.00 for each day of care
in an institution for the care of the chronic sick.
The Bill provides (Sec. 913): (a) There is hereby
established within the Trust Fund a separate account to
be known as the "Medical Care and Hospitalization
Account.” The managing Trustees shall credit to this
account (1) one-fourth of the Social Security Taxes for
medical, laboratory, and hospitalization benefits, and (2)
three-sevenths of the self-employed service taxes.
In other words, on the basis of the above estimates, a
minimum of $3,000,000,000 would be transferred each
year from the Trust Fund to the Medical Care and Hos-
pitalization Account.
The Bill provides (Sec. 901): (a) Every insured indi-
vidual, and (b) every dependent entitled to benefits shall
be entitled to receive general medical, special medical,
laboratory and hospitalization benefits. This provides a
fChairman, Committee on Medical Economics, Montana State
Medical Association. (Presented for him at meeting of Western
Montana Medical Society with Senator Murray, at Missoula, August
24, 1943.)
314
Summary
This is the method and manner for the medical care
and hospitalization of more than 1 10,000,000 people,
and is placed upon the shoulders of one man, the Sur-
geon General of the Public Health Service.
This is the machinery to place in the hands of one man,
the Surgeon General of the Public Health Service, the
expenditure of $3,000,000,000 annually.
Financial Aspects
What is $3,000,000,000? If you were to drop three
silver dollars into a great vault each minute since the
year 1, A.D., to the present time, 1943, you would have
approximately $3,000,000,000.
What can be done with $3,000,000,000, one-fourth, or
25 per cent of the tax to be levied as a withholding tax
in this Wagner-Murray Bill?
What can be accomplished?
We can understand this only by comparisons.
For the ten year period from 1924 to 1933, both years
inclusive, the total revenue of the government of the
United States from all sources was $35,412,944,412, or
a yearly average of $3,541,294,441.
For the five year period beginning April 1, 1931, to
March 31, 1935, the total revenue of the German gov-
ernment was $15,725,840,000. This represents an average
income rate of $3,145,168,000 per year.
In 1938, the total expenses of the pre-war government
of France, for all purposes, were $3,130,777,635.
In 1940, the total expenses of the Japanese Empire
were $1,999,773,180.
The Wagner-Murray-Dingle Bill provides for placing
in the hands of one man a sum of money three times the
amount of the normal non-war expenses of Japan, ap-
proximately equal to the pre-war expenses of the Govern-
ment of France, and approximately the average annual
national income and expenditures of the United States
Government from 1924 to 1933.
What could the Surgeon General do? It is estimated
that at the present time there are available in the United
States for civilian practice 120,000 physicians. The Sur-
geon General could —
(a) Allocate 20 per cent for administration costs —
$600,000,000;
(b) Hire all of the 120,000 physicians at an average
salary of $5,000 a year — $600,000,000;
(c) Hire all hospital beds not owned by the govern-
ment, for 365 days each year at $5.00 per day —
$671,683,950;
(d) Pay $2.50 per day for every government-owned
hospital bed for 365 days each year — $959,750,-
162.50;
(e) Spend for drugs and medicines $168,565,887.50.
Total— $3,000,000,000.
The Bill provides (Sec. 1111): For the purpose of
encouraging and aiding the advancement and dissemina-
tion of knowledge and skill in providing benefits under
this Act, and in preventing illness, disability, and prema-
ture death, the Surgeon General is hereby authorized and
directed to administer grants-in-aid to non-profit institu-
tions and agencies engaging in research or in undergrad-
uate or postgraduate professional education.
The Journal-Lancet
The amount of money for this purpose shall be 1 pier
cent of the total amount expanded for benefits from the
Trust Fund, exclusive of unemployment insurance bene-
fits, or 2 pier cent of the amount expanded for benefits
under Title IX.
Assuming that out of $3,000,000,000, $600,000,000 is
spient for administration, and $2,400,000,000 is paid out
in benefits, the Surgeon General would have 2 pier cent
of this sum, or $48,000,000 each year to spend for med-
ical education and medical research. What could be
done? —
(a) Assume the total costs of operating the sixty-six
accredited medical colleges in the United States —
$21,491,248;
(b) Subsidize 22,000 medical students to the extent of
$700 pier year for a period of four years — $15,-
400,000;
(c) Spend for other educational research each year,
$11,180,752.
Total— $48,000,000.
OR:
(a) Duplicate all existing medical facilities — $22,-
000,000;
(b) Pay 20,000 additional medical students $700 pier
year during a period of four years — $14,000,000;
(c) Spiend on other research, $12,000,000.
Total— $48,000,000.
The Bill provides (Sec. 912): That the Surgeon Gen-
eral and the Social Security Board shall study and make
recommendations for providing dental, nursing, and
other needed benefits; and for determining the costs, the
division of costs, and the manner in which the money
should be raised in payment for these benefits.
Conclusion
Under this system, every physician would become a
Federal officer, just as truly as our Federal judges and
Federal marshals.
The expenditure of $3,000,000,000 annually, and the
medical and surgical care of 110,000,000 people is placed
solely and absolutely in the hands of the Surgeon Gen-
eral of the Public Health Service.
This outline briefly analyzes the medical and hospital
services provided under this Bill, into which goes only
$3,000,000,000, or one-fourth of the proposed amount to
be raised, $12,000,000,000, by the Wagner-Murray Bill.
If this Bill becomes a law, there will be an added 12
per cent tax on the amount of the payroll of all employed
persons over and above the 20 per cent now being deduct-
ed from our monthly paychecks.
Do we wish an added 12 per cent tax? Do we wish all
medical, surgical and hospital services directed by one
man from a bureau in Washington?
Our attitude heretofore has been that any money ob-
tained from the Federal Government in Washington did
not come from our own pxickets. With the increased rate
of Income Tax, particularly the monthly deduction of the
payroll, we now realize where the Government obtains
the money which it spiends.
We expect changes, not only in government and laws,
but also in the individual. It is one of the laws of nature,
and, while it is true, and also desirable, it is your duty
and mine to control and to direct these changes.
October, 1943
315
REMARKS ON SENATE BILL 1161*
J. P. Ritchey, M.D.,
President, Montana State Medical Association,
Missoula, Montana
I submit that the present 20 per cent withholding tax
on payrolls, necessary as it is, is a tremendous burden for
the taxpayers to carry, in addition to state, municipal
and the numerous special taxes in force, and that the
burden of it far exceeds any tax burden that the people
of this country have ever previously assumed.
I submit further that to add to this incredible burden
at this time a further tax of 12 per cent (12 billion
dollars each year) upon the amount of all payrolls is an
undertaking both critical and serious.
I submit further that this would be war-time legisla-
tion, and that war-time, with its intense preoccupations
i with the conduct of the war, and with a great part of
the country’s voting population under arms, is scarcely
1 the time to place upon the country a permanent arrange-
ment with such far-reaching consequences. As the one
outstanding example of war-time legislation, as such, we
think of the Prohibition Amendment of 1918, of its sorry
course, and of its final repudiation.
I submit further that this proposed legislation, particu-
larly as it applies to the medical care of our people, is
revolutionary legislation, seeking to accomplish at a stroke
what can only be accomplished by day to day changes
and adjustments over an extended period of time. Such
changes and adjustments have constantly been made over
the past many years, and are proceeding at the present
time at an accelerated pace, with the medical profession
1 cooperating with all other agencies, public and private,
lay and professional, that are concerned with the health
of our people. These progressive changes and adjust-
ments are steadily raising the standards of medical care,
increasing the amount of such care available, and decreas-
ing, well toward the vanishing point, the minute propor-
tion of our population not receiving such care.
The medical profession has always accepted its respon-
: sibility for the care of the sick and the maintenance of
the health of the people. It has acted upon its own initia-
tive. It has been essentially self-governing. It has accept-
ed over the years the necessity of an increasing degree of
socialization of medical care. And by socialization in this
talk, I mean simply and solely making accessible to every
person, regardless of his ability to pay, the best in med-
ical and hospital care according to his need. This social-
ization has been voluntary on the part of all concerned.
It has worked. It will attain a high degree of perfection
in operation if allowed to develop naturally and grad-
ually, and if allowed to remain voluntary and cooperative.
Under this proposed legislation all this would be
changed. The medical profession would no longer be
primarily responsible for the care of the sick and the
maintenance of the health of our people. By the specific
terms of this bill, this responsibility would be placed on
one man, the Surgeon General of the Public Health
Service, and on him alone. The medical profession would
have no initiative; the Surgeon General would furnish
the initiative. The medical profession would not be self-
•Presented at a meeting of the Western Montana Medical Society
with Senator Murray, August 24, 1943.
governing: the Surgeon General would have absolute,
autocratic power to dictate each doctor’s conduct of his
practice in each and every particular as he might see fit.
The socializing trend of medical care would no longer be
voluntary: it would be compulsory. The practice of medi-
cine in all its aspects, including medical education, would
become State Medicine indeed.
It may be of comparatively minor importance, what
may happen to the 120,000 physicians as such, in this
country, to their way of life and to their method of
practice. But is it not of the greatest importance to the
130,000,000 citizens, what happens to their medical care?
Is it a good thing for these 130,000,000 that the primary
responsibility for their medical care be removed from the
physicians and be placed on the shoulders of one man,
the Surgeon General? Is it a good thing for our people
that the medical profession be deprived of their primary
initiative and that this initiative be given to one man?
Is it a good thing for our people that the doctors no
longer govern themselves but become hired men subject
to the orders of one man, the Surgeon General? Is it a
good thing for our people, a democratically governed
people like unto no other people on earth, that the vol-
untary democratic process be removed, root and branch,
from so large a segment of their daily life as is included
in their medical care, and be replaced by a bureaucratic
administration from above, under the absolute dictator-
ship of one man, the Surgeon General? Is it a good
thing for our people to put all their funds for medical
and hospital care, and all their funds for the education
of future physicians, three billion dollars annually, into
the hands of any one man to dispense as he may see fit?
Is it a good thing for our people that from 20c up, out of every
dollar they pay out in taxes for the purchase of medical and
hospital care, be spent instead for salaries of an army of perhaps
four or five hundred thousand lay administrators and for office
room for them? Is it a good thing for our people that their
physicians, who have up to this time attained recognition, each
according to his ability in diagnosing and curing diseases, should
now have their way smoothed for them, each in the degree to
which he may care to and be able to build up political influence?
Soberly and in all good faith, I do not believe that political in-
fluence and political pressure can be dissociated from the work-
ings of the kind of State Medicine which this bill stands for,
regardless of the good intentions of its sponsors. And would it
be remarkable if, under such influences, the incentive for inten-
sive postgraduate study and training should be lessened for many
physicians?
In closing, may I address you, Senator Murray, as follows?
As a member of a learned profession, the profession of law, you
are in a position to appreciate, and do appreciate, the distinction
between professional attitudes and practices, on the one hand,
and the commonly accepted methods of trade and business on
the other. May I say to you then, that the main preoccupation,
by and large, of the members of the medical profession is and
always has been the ultimate good of their patients? That this is
the case is abundantly proved in many ways, not the least of
which are the way in which physicians have conquered disease
after disease, and the way in which physicians have consistently
raised the standards of medical education and practice. It is in
the perspective of this preoccupation with the good of our pa-
tients that we have studied and judged Senate Bill 1161. It may
matter little what happens to us physicians as individuals; but it
matters tremendously what happens to us as the medical shep-
herds of 130,000,000 patients. You, Senator Murray, must do
as you must. What we, as guardians of the good of our people,
would like to see you do is to withdraw your sponsorship of this
proposed legislation.
316
The Journal-Lancet
The Medical Aspects of Civilian Defense"
Fred T. Foard, M.D.,
Regional Medical Officer,
Office of Civilian Defense, 9th Civilian Defense Region.
PUBLIC health workers and members of the med-
ical profession have been most cooperative in de-
veloping an operable plan of medical care which
we hope will never be used, but which will be urgently
needed if our country should be attacked.
The U. S. Office of Civilian Defense was created by
Executive Order No. 8757 on May 20, 1941. It is prin-
cipally a planning agency and was created to assist state
and local government agencies in perfecting plans for
combatting enemy action. The plan involves the creation
of Auxiliary Fire Service; Auxiliary Police Service; the
organization of an Emergency Medical Service, which in-
cludes among its specific functions the setting up of a
system of Base Hospitals, provisions of medical equip-
ment, provision of plasma, protection of water supplies
against sabotage and providing, where possible to do so,
for alternate water supplies; the establishment of medical
care and facilities in state and local evacuation programs
and other important services. The task of organizing the
several protective services for civilian protection has been
difficult. It has required the tireless effort of a nucleus of
paid workers on Federal, state, and local levels, and an
army of volunteer civilian workers approximately equal-
ling in number the total personnel of our military forces.
There are approximately 6,000,000 civilians who are
actively participating in Civilian Defense work as en-
rolled members of state and local Civilian Defense or-
ganizations. Next to the Army and Navy these workers
constitute the third line of defense, and upon them we
must depend for such protective measures as will be
available to the entire civilian population of the country.
And of the entire population more than 68,000,000 peo-
ple reside within 350 miles or easy bombing distance of
our Atlantic, Pacific or Gulf Coasts.
With this background of the overall Civilian Defense
Program, I shall now refer specifically to the Division of
Emergency Medical Service and some of the several
functions for which, from an organizational standpoint
at least, it is responsible.
Base Hospitals
Usually hospitals are large buildings and are excellent
targets for bombs. In London, for instance, about 80 per
cent of all hospitals existing before the war have been
partially or completely abandoned because of the effect
of incendiary or high explosive bombs. It has been neces-
sary, therefore, to provide base hospital facilities for all
patients needing hospitalization, including casualties re-
sulting from enemy action. In anticipation of possible
enemy action on the Pacific Coast, and in view of the
fact that the hospitals of the Pacific Coast are filled to
about 90 per cent of capacity at the present time, we are
profiting by experiences met within English cities and,
applying the plan found effective in England, have made
arrangements with hospitals located in the interior for
•Read before the Montana Public Health Association, June 8,
1943.
the hospitalization of patients whom it may be necessary
to evacuate from coastal cities. These base hospitals in-
clude county hospitals, privately owned hospitals, state
institutions, and, in a few instances, reconditioned C.C.C.
Camps or other buildings which could at least house the
chronically ill or custodial patients who may have to be
evacuated from coastal areas. Bed space for about 12,-
000 emergency patients has been provided in the Sacra-
mento and San Joaquin Valleys and in already existing
hospitals or other suitable buildings located in Southern
California at considerable distances from the larger cities
and industrial centers. To meet this emergency more
than 7,000 Government owned hospital beds with mat-
tresses are now stored in California ready for immediate
use if and when they are needed. Base Hospital facilities
to accommodate as many as 3,000 persons have been pro-
vided, if the evacuation of patients should be necessary
from west of the Cascade Mountains in Oregon and
Washington to safer areas on the interior. This plan in-
cludes base hospital beds as far east as Boise, in Idaho,
and Butte, Helena and Great Falls, in Montana. The
plan for moving patients by ambulance, railway and, if
necessary, by water, has been worked out for most of the
cities along the coast and could be placed into operation
within a few hours.
Affiliated Base Hospital Units
Because so many physicians have gone into military
service, there is already a shortage of medical personnel
to care for civilian populations; yet it is essential that
we be in position to give proper medical care to persons
who may be injured as a result of enemy action, as well
as to patients who may have to be removed from Casual-
ty Receiving Hospitals along the coast. To provide for
this emergency we are now in the process of recruiting
medical personnel to form Affiliated Base Hospital Units,
each of which will be made up of fifteen members to
include a Chief and Assistant Chief of Medical Services,
two general internists, a Chief and Assistant Chief of
Surgical Services, four general surgeons, two orthopedic
surgeons, one dental surgeon, one Pathologist and one
Radiologist. These units will be formed from the staffs
of hospitals approved by the American Hospital Associa-
tion. This program has been approved by the Surgeons
General of the Army and the U. S. Public Health Serv-
ice, and the Governing Board of the Procurement and
Assignment Service. Medical personnel chosen to make
up these units will include only physicians who are above
military age and therefore are not eligible for military
service; women physicians, physicians within military
age who have been rejected for military service because
of physical defects, and physicians who have been de-
clared essential by Procurement and Assignment and are
temporarily exempt from military service. Physicians who
accept invitations to join Affiliated Hospital Units will
be commissioned in the Reserve Corps of the U. S. Pub-
October, 1943
317
lie Health Service with ranks varying from P.A. Sur-
geon, corresponding to Captain in the Army, to Senior
Surgeon, which corresponds to Lieutenant Colonel in the
Army. They will remain on inactive duty until such time
as an acute emergency arises and will then be called to
active duty by the Surgeon General, USPHS. If called
to active duty they will remain on active status only
until the acute emergency is over, when they will return
to private practice. Members of units who may wish to
enter military service will be permitted to resign from the
Reserve Corps of the Public Health Service. At the
present time 195 of the leading hospitals in the country
have been invited to form these units, and of this num-
ber 49 are in the Ninth Civilian Defense Region, with
27 located in California, 6 in Oregon, 13 in Washing-
ton, and 3 in Utah. Invitations for the formation of
■ units will be forwarded in the near future to one or more
hospitals located in Phoenix and Tucson, in Arizona;
Reno, Nevada; Boise, Idaho; and Great Falls, Montana.
By organizing these Units in each of the principal cities
of the Western States it is expected that even though an
1 emergency should occur necessitating the evacuation of
patients from the coast to the interior, it will not be nec-
| essary to remove physicians very far from their home
i town. If they should be moved from their usual resi-
dence, it will be to care for patients who may be evac-
uated to Base Hospitals in the interior. They will not
be called to active duty in any capacity other than for
the care of military or civilian casualties.
Blood Plasma
Military authorities are agreed that the four principal
factors responsible for the great reduction in the death
rate among military casualties in this war as compared to
the death rate in World War I, are:
1. The use of sulfa drugs in the prevention and con-
trol of infection;
2. Placement of medical field hospitals directly behind
the front lines;
3. The rapid transportation of casualties to hospitals
where proper treatment facilities are available, and
4. The prompt use of blood plasma in the treatment
of shock.
Through the organization of Emergency Medical
teams to work out of hospitals and well equipped Cas-
ualty Stations in all target area cities, it is expected that
any casualties that may occur as a result of enemy action
will be quickly transferred to Receiving Hospitals for
prompt medical attention. To assist in the treatment of
these patients, or in the treatment of casualties which may
occur from natural disasters such as the Cocoanut Grove
Fire in Boston, the U. S. Public Health Service and the
Office of Civilian Defense have accumulated blood plas-
ma reserves, along the Pacific Coast, either through out-
right purchase or through grants to hospitals for the de-
velopment of blood banks, in the amount of about 24,-
000 units. This plasma can be immediately made avail-
able to any part of the Region where it may be needed.
It is stored in hospitals from San Diego, Calif., to Se-
attle, Wash. To meet any need for plasma over and
above the amount available in any city or community,
authority has been granted to use the Civil Air Patrol
to immediately transport plasma by air to any point in
the Region.
Emergency Medical Service
This is concerned with the organization of physicians,
nurses, nurses aides, and other auxiliaries to work with
Local Chiefs of Emergency Medical Service. Teams are
composed of a physician, one nurse, and two auxiliaries,
and serve as mobile field units to work out of hospitals
or improvised emergency centers known as Casualty Sta-
tions. The duties of these teams are to render first aid
at the scene of the incident and to segregate casualties
having minor injuries from those having serious injuries
who should be sent directly to hospitals.
Every hospital of a community is considered to be a
Receiving Hospital for casualties, and every hospital
should form one or more medical teams, preferably from
members of its resident staff, who may be dispatched on
immediate notice to points of incidents. These emergency
medical teams have been organized in all of the leading
hospitals along the Pacific Coast and from time to time
are called upon to participate in practice drills with the
view of perfecting their method of operation. Because
of the serious nature of high explosive bombs and the
urgent need to get many of these patients to hospitals
for immediate care, the Emergency Medical Team, after
the fire services, is the most important field unit of the
entire Civilian Defense Organization. The lives of many
people depend upon the rapidity with which these teams
can respond to calls and upon their skill in handling and
dispatching casualties.
Medical Equipment and Supplies
Early in the Civilian Defense program it was antici-
pated that medical equipment and supplies would be
needed by local communities for use by Mobile Medical
Teams and in Casualty Stations in Target Areas. Funds
were allotted the O.C.D. for the purchase of this equip-
ment and orders were placed through the Army Procure-
ment Service for instruments, dressings, hospital beds,
cots, stretchers, First Aid pouches, etc. However, the
needs of the Army and Navy had to be supplied first,
and many months passed before equipment for Civilian
Defense activities could be furnished. Within the past
sixty days, however, medical equipment has been or is
now in the process of being shipped to approximately
180 priority towns and cities along the Pacific Coast.
Distribution of Narcotics
For the immediate care of bomb victims in England
the use of morphine was found to be indispensable. Early
in the war local supplies were inadequate and the prob-
lem of relieving pain, particularly of casualties in the
field who were seriously injured or trapped in demolished
buildings became acute. To forego such an emergency
in this country, a plan has been worked out with the
U. S. Commissioner of Narcotics whereby supplemental
supplies of morphine are now being issued to priority
cities in proportion to the amount of medical equipment
allotted these cities. This morphine will be deposited
with all Casualty Receiving Hospitals out of which Mo-
bile Medical Teams will operate, with local Chiefs of
318
The Journal-Lancet I
E.M.S., and with a few private physicians who are mem-
bers of Mobile Medical Teams operating out of Cas-
ualty Stations located in isolated places where hospitals
are not available. Only hospitals and physicians holding
narcotic licenses will be furnished morphine. The hos-
pital or the physician, as the case may be, will be respon-
sible to the Commissioner of Narcotics for morphine is-
sued to them.
Protection Against the Use of War Gases
To be prepared for the possible use of war gases by
the enemy, every effort is being made to educate the
public as to what to do in a gas attack. Programs are
also being held in order to instruct physicians as to meth-
ods of treating persons affected by war gases. The
O.C.D. plan for protection against war gases provides
for the appointment of an experienced chemist, as Gas
Consultant, on the state level in each state. This State
Gas Consultant is responsible for the development of gas
protective programs on the local level in all cities and
towns in target areas. The Chemical Warfare Service of
the U. S. Army has, for the past year, been conducting
Gas Specialist Schools at Occidental College in Los An-
geles, Stanford University at Palo Alto, and the Univer-
sity of Washington in Seattle. These special courses are
designed to instruct local gas officers in methods of iden-
tifying the various war gases, methods of decontaminat-
ing areas affected by gas, in the instruction of the pub-
lic against contamination, in methods of cleansing per-
sons who are gassed and also wounded. Several hundred
lay gas officers have completed the five day course given
at these Civilian Protection Schools.
For training the medical profession, a special course
for physicians was recently conducted in cooperation with
Stanford University Medical School in San Francisco.
Participating in this course of instruction were Medical
Specialists in Chemical Warfare whose services were
made available to the Office of Civilian Defense from
the National Research Council. The six medical schools
in the Region were invited to send representatives from
their faculties to this school with the understanding that
those taking the course would return to their respective
schools and conduct a similar course of instruction for
medical students, for other faculty members of the
schools they represented, and to deliver special lectures
on the treatment of gas casualties before local medical
societies. This course of instruction, designed primarily
for the medical profession and planned to eventually
reach a majority of the practicing physicians of the re-
gion, was very well received. Faculty members were pres-
ent from the medical schools at the Universities of Utah,
Oregon, California, Stanford, Southern California, and
the School of Medical Evangelists in Los Angeles. Also
attending were Chiefs of Emergency Medical Service
from five states, and Chiefs of Emergency Medical Serv-
ice in target area cities. Army Medical Officers also
attended.
Too much stress cannot be placed upon the importance
of educating the general public as to what to do in a gas
attack to protect themselves, and of making it possible
for every physician to know how to properly treat gas
casualties. War gases have already been used by the
Japanese against civilian populations in China, and there
would be no hesitancy on the part of the Japanese to use i
war gases against military or civilian populations of this j
country if by doing so they would strengthen their
chances of winning the war. In any event, we should be
just as well prepared against the possible use of gas as
we are against attacks by high explosives or incendiary
bombs.
Nurses and Nurses Aides
Because of the continued great demand for graduate
nurses for the military services, the country is rapidly
approaching a crisis in the nursing field. Particularly is
this so in our industrial cities to which many thousands
of industrial workers with their families have migrated
and where there is now a very definite shortage of both
experienced Public Health nurses and registered nurses
for hospital or private duty. Special nursing in some
localities is a service which is gone for the duration. Ex-
cept in extreme cases of severe illnesses special nursing
should not be requested or permitted, as there is too great
a demand for nursing service from other sources. In line
of importance, our first responsibility is to provide nurs-
ing service for our military forces. Secondly, we must
have graduate nurses to work in teaching and supervisory
positions in our training schools and private hospitals. Of
equal importance is the necessity for providing experi-
enced Public Health nurses for our official Public Health
agencies, including city, county, and state departments
of health. In the Public Health field, I do not feel that
we have made the adjustments that should be made. I
refer particularly to the widespread use of school nurses,
many of whom are well trained and thoroughly experi-
enced in Public Health nursing yet are devoting their
entire time to school nursing work and in some instances
are employed for only nine to ten months of the year.
For the duration of the war at least there should be no
such thing as a specialized school nursing position in
areas where there is a shortage of Public Health nurses j
for general duty. School nurses should be integrated into :
the general nursing program of the official Public Health '
agency operating in the community in which they are em-
ployed. If this were done and there should be a surplus
of nursing personnel for general duty, those not needed
should be given leave of absence by their employers for
the duration of the war and be released for duty in the
armed forces or for Public Health nursing positions in
areas where they are more urgently needed.
Additional Training Facilities
To facilitate the training of more nurses a plan is now
being considered, and is in the process of being worked
out, whereby at least one-third more nurses might be 1
trained by approved training schools without altering the
quality of instruction to be given. Briefly, this plan in-
volves the inclusion of all intramural training within two,
rather than three, years. During the third year of in-
struction senior student nurses would be housed outside
of the nursing quarters but would return daily for prac-
tical instructional work on wards and in special services
under supervision, or would be assigned for their third
October, 1943
319
year of training either to approved private hospitals hav-
ing no training schools or to Army or Navy hospitals
approved by the training school for third year instruc-
tional work. Nurses enrolling under this plan and agree-
ing to serve with the military forces after graduation
would have tuition paid by the Government and a rea-
sonable monthly stipend for laundry, etc., (about $15.00
per month) during their training period. A larger
monthly stipend would be provided for those living away
from the hospital in which they were receiving their
third or senior year of training. Such a plan, in that it
would vacate quarters ordinarily occupied by student
nurses after the second year, would make possible the
enrollment of one-third more nurses than could other-
wise be accepted by training schools. It would also make
available to military hospitals a great many senior student
nurses who would relieve graduate nurses in the military
services for foreign or other duty.
Nurses Aides
Too much praise cannot be given to the many thou-
sands of women who are volunteering for training as
nurses aides. The course itself, which requires about 150
hcurs to receive the certificate, is the longest and one of
the most exacting of all the special courses given in con-
nection with the war program. With respect to the num-
ber of persons involved, there is more service and less
glamour connected with this program than with any of
the many voluntary services of the Civilian Defense or-
ganization.
The latest report has not been received, but as of
April 1st there were 89,104 volunteer nurses aides trained
or in training in the United States. In the Ninth Region
as of Aor'l 1st there were a total of 7,824 nurses aides,
divided by states as follows: Arizona 315, California
5,268, Idaho 199, Montana 81, Nevada 76, Oregon 414,
Utah 360, and Washington 1,192. These women are
making it possible for many hospitals to operate effi-
ciently, which otherwise would be greatly handicapped
for nursing service, or would be turning patients away.
The American Red Cross is doing a marvelous job in re-
cruiting nurses aides, and the nurses aides themselves are
contributing a service which, during this time of war, is
almost indisoensable. The recruiting program is by no
means complete. We need graduate nurses for our mili-
tary forces, for our training schools and for supervisory
positions in our private hospitals, for our Public Health
agencies and for industry. It is only through the Nurses
Aide program that graduate nurses may be made avail-
able to fill these key positions.
War Security Aid
In February of 1942 the President made available
from his Emergency Fund, the sum of $5,000,000 to the
Administrator of the Federal Security Agency for pro-
viding temporary aid to civilians injured by enemy action.
This fund is also available for providing medical and
hospital care and benefits to dependents of persons in-
jured while in the performance of their duties as Civilian
Defense workers. The requirements are that the indi-
vidual, to receive protection, must be a member of the
Citizens Defense Corps. If the worker is injured either
in the process of receiving prescribed training, in prac-
tice drills, or in the performance of actual duties during
blackouts, he will be eligible for full medical and hos-
pital care on the same basis as provided under the Work-
man’s Compensation Act, of the state in which the in-
jury occurred. This program covers all persons assigned
to Emergency Medical Teams including physicians,
nurses, nurses aides, auxiliary workers, First Aid workers,
ambulance drivers, etc. Also, it covers Auxiliary Fire-
men, Auxiliary Police, Air Raid Wardens, and others
who are registered members of the protective services.
It is absolutely essential, however, that every Citizens
Defense worker, for protection, must conform to the
above mentioned requirements. Therefore, from the
standpoint of protecting its workers, the most important
officer of a Citizens Defense Corps is the Personnel Offi-
cer who has the responsibility of knowing that all Civil-
ian Defense workers are properly registered in the Citi-
zens Defense Corps.
In conclusion, may I again emphasize that the task of
organizing the Emergency Medical Service has been, and
is still, a difficult one. Probably equally difficult has been
the organization and training of Auxiliary Fire and Po-
lice Services, Wardens, Public Utility Squads, and others
of the protective services who are expected to serve effi-
ciently in time of emergencies. And once organized as
individual units, much will depend upon how well these
services are coordinated, each with the other.
Speaking for the Medical Service only, I feel that
much progress has been made in the development of a
workable program in many of our cities, yet there is still
much to do to bring these programs to the degree of per-
fection at which they should be able to work. Improve-
ment can be made only by practice drills repeated over
and over again and every person who has volunteered his
services as a member of the protective services, whether
it be Emergency Med’cal, Fire Protection, Police Protec-
tion, or other, should realize the responsibility which he
has assumed. By volunteering their services to act in an
emergency, they have assumed an obligation to be pre-
pared, and being prepared means to act on a team and
in unison as a team. Every member should know his
place and exactly what he is to do. Such team work can
be acquired only by practice. That the United States
will be attacked from the air is the belief and the predic-
tion of many of our higher military authorities. The
threat to bomb our Pacific Coast has been made by the
highest Japanese military authority, and we should be
ready to meet any emergency which may result from the
fulfillment of his promise.
320
The Journal-Lancet
The Emergency Maternity and Infant Care Program*
Administered by State Health Departments
Edith P. Sappington, M.D.f
San Francisco, California
AS the size of the armed forces increases, the secur-
ity of an even greater group of women and chil-
^ dren is dislocated. Most of the women are young
and not yet financially stable; many are pregnant. They
try to follow their husbands to training areas in spite of
overcrowded living quarters and insufficient funds. Their
physical care is an ever increasing problem to the already
strained medical and hospital facilities of these areas.
In response to this problem, the Children’s Bureau,
United States Department of Labor, in March 1942,
announced the availability of limited funds for the med-
ical and hospital obstetric and pediatric care for wives
and infants of servicemen. A program for such services
has been operating in the state of Washington in a lim-
ited area since 1941.
Reports from 36 states show that medical and hospital
obstetric care was provided for over 16,000 mothers. As
of March 6, 1943, almost 5(650,000 of the Social Secur-
ity grants-in-aid for maternal and child health services
had been expended for the operation of these programs
in some 30 states in this country, providing maternity
care for approximately 10,000 wives of enlisted men.
Congress, recognizing the great need for continuing
these services and extending them into all states, includ-
ed in the First Deficiency Appropriation Act, 1943,
which was approved on March 18, 1943, an appropria-
tion of $1,200,000 for the period ending June 30, 1943,
"for grants to states, including Alaska, Hawaii, Puerto
Rico, and the District of Columbia, to provide, in addi-
tion to similar services otherwise available, medical, nurs-
ing, and hospital maternity and infant care for wives and
infants of enlisted men in the armed forces of the Unit-
ed States of the fourth, fifth, sixth, or seventh grades,
under allotments by the Secretary of Labor and plans
developed and administered by state health agencies and
approved by the Chief of the Children’s Bureau.’’^:
Congress has recently appropriated $4,400,000 more
for the continuation of the programs during the fiscal
year ending June 30, 1944.
Under this plan how long the wife has lived in the
state does not matter. How much money the family has
does not matter. Race or color does not matter.
Forms for requesting care are made available to the
wives of enlisted men by the state health departments
through local health and welfare agencies, local Ameri-
can Red Cross chapters, prenatal clinics, military posts,
and through local practicing doctors of medicine.
The wife fills out and signs her part of the applica-
tion, including her husband’s serial number. Her doctor
•Presented at the annual convention of the Montana Public
Health Association, at Bozeman. June 7, 1943.
t District Medical Director, Children's Bureau, U. S. Department
of Labor, San Francisco Regional Office.
JThis excludes the families of commissioned officers; of master,
first, technical, platoon, and staff sergeants; and of chief, first, and
second-class petty officers.
completes and signs the application and forwards it to
the state director of maternal and child health or his
authorized deputy. The form includes a statement by
the doctor (or hospital) that the services authorized will
be rendered for the amount paid by the state health de-
partment without payment from the patient or the
family.
In an emergency, medical or hospital care may be
given before an application is sent in. The application, ,
however, should be completed as soon as possible and
forwarded to the state health agency.
The state director of maternal and child health
promptly notifies the patient and attending physician, or i
clinic, and the hospital (if the patient is going to a hos-
pital) whether or not the care is authorized.
In states providing these services, the patient can ex- |
pect the following:
Complete medical service for maternity patients during j
the prenatal period, childbirth, and six weeks thereafter ;
— including care of complications, operations, and post-
partum examination — and for the newborn infant.
Health supervision for infants usually provided in !
child-health conferences.
Nursing care in the home through the local health de- :
partment — including whatever bedside nursing care is j
ncessary — for the mother, before, during, and after child- :
birth and for the baby during the first year of life.
Hospital care in wards or at ward rates for maternity |
patients and infants. The funds cannot be used in part
payment for more expensive hospital accommodations. A
minimum stay in the hospital of ten days after childbirth i
is arranged if possible. Hospital care may be authorized
in any hospital, including Army and Navy hospitals, in
which the maternity and pediatric services have been
approved by the state health agency.
Referrals for social services by the medical-social-serv- ;
ice staff of the state agency to cooperating state and local ;
departments of welfare and other public and private
agencies for help in meeting individual problems that
interfere with medical care, such as unsatisfactory living
conditions, separation from husband and family, inade-
quate income and lack of proper food.
As of June 30, 1943, thirty-eight states have approved
plans in operation and approval of other state plans is \
pending. All sections of the country are represented. All
plans now provide services on a state-wide basis.
Difficulties (though surprisingly few of them) have
been encountered by most states. When physicians have
understood that the plan is a temporary war expedient
and that they are free to refuse to participate if the stip-
ulated terms are not agreeable to them, most misunder-
standing has been cleared. Most, if not all, physicians
practicing obstetrics are fully cooperating with the state
health agencies in making these services available.
October, 1943
321
Adherence to the flat case rates has obviated fee diffi-
culties in almost all regions. There has been some quib-
bling about fees, but it has been very little. A profes-
sional failing — procrastination in securing authorization
for cases — has occurred rather frequently but, on the
whole, the simpler the setup the more smoothly and sat-
isfactorily it has functioned.
Hospitalization has been the major problem. The
facilities even in normal times have been inadequate in
quantity and often in quality in places in which they are
most needed, and now loss of both professional and un-
skilled personnel, complicated by a capacity census, pre-
sents nearly insurmountable obstacles. In many instances,
it has been impossible to find an institution able even to
approximate the standards required for participation. In
cases in which the state department of health can main-
tain a friendly consultation service to the available hos-
pitals, much can be done to mitigate hazards to mothers
and infants, even without many physical changes.
The administration of the plan has been the respon-
sibility of the maternal and child-health divisions of the
various states, and has demanded much time and per-
sonal direction.
The state health agencies and the Children’s Bureau
have on file hundred of case histories and personal appeal
letters demonstrating the needs of wives of servicemen,
which it is hoped will be taken care of fully in the near
future, through the extension of the program for emer-
gency maternity and infant care into the few states that
have been unable to establish these services up to the
present time.
TRANSACTIONS OF
THE MINNEAPOLIS ACADEMY OF MEDICINE
Founded January 17, 1920
Stated Meeting Held at the Minneapolis Club, December, 1942
Dr. Roy E. Swanson in the Chair
THE USE OF
SULPHOCYANATE IN HYPERTENSION
Inaugural Thesis
L. Raymond Scherer, M.D.
In 1903, Pauli began some experiments with the sulphocya-
nate ions. He reported his results in 35 cases, each of which
received 15 grains daily of the sodium sulphocyanate. He stated
that the drug exerted a satisfactory sedative action and included
headache, vertigo, and tabetic pain among the phenomena that
seemed to be controlled by it. He also reported a marked reduc-
tion of blood pressure and the disappearance of symptoms asso-
ciated with hypertension.
Nichols in 1925 made quite a detailed study of the sulpho-
cvanates, from both pharmacologic and therapeutic standpoints.
He noted that solutions containing sulphocyanate are turned a
dark red color on the addition of a drop or two of ferric chlor-
ide and decolorized by the addition of mercuric chloride. These
color reactions were not obtained if the solutions were markedly
alkaline. Sulphocyanates were found to be normal constituents
of the saliva, tears and gastric juice. The estimated amount in
the saliva was about .01 per cent. The drug when given was ex-
creted unchanged through the kidney. Pollock was able to ob-
tain from the urine the same amount that was ingested.
Experiments with guinea pigs (Nichols) revealed that lethal
doses of sulohocyanate varied from 200 to 300 mgs. per kilo-
gram of body weight when given intraperitoneallv. The ani-
mals became sluggish, developed diarrhea, occasional hemorrhage
from the anus, and later, evidence of spinal irritation and finally
coma — death usually occurring within two or three days.
Bernard stated that sulphocyanate acted as a direct muscle
poison, abolishing muscular activity. In dogs, Lodholz found
that 100 mgs. per kilo of body weight injected intravenously
usually caused immediate and permanent cardiac arrest; in those
dogs not dying immediately, a marked rise in blood pressure
was noted.
With the first general use of this drug following the prelim-
inary favorable reports, many severe toxic manifestations were
obtained. These included profound weakness, disturbance of the
gastrointestinal tract, dermatitis and nervous phenomena, includ-
ing psychosis. The drug, as a result, fell into disrepute and was
largely discarded and considered unsafe.
Barker in 1936 aroused further interest in sulphocyanate by
describing a technic (a modification of Schriber’s) for deter-
mining the amount of sulphocyanate in the blood. His original
observations were made on 45 patients; 35 of this group showed
a fall in systolic and diastolic blood pressures when blood levels
above 5 or 10 mgs. /per cent were obtained. Slight toxic mani-
festations were noted in many of these but did not become dis-
turbing until they were raised above 10 to 15 mgs. /per cent.
These manifestations became more marked, Barker stated, in
levels above 20, but none were serious until concentrations of
from 35 to 50 mgs. /per cent were obtained. The dosage for
maintaining levels of from 6 to 10 mgs./per cent varied from 60
to 720 mgs. daily.
Further observations on the pathologic effect of sulphocyanates
were reported in 1941 by Lindberg, Wald and Barker. They
determined blood cholesterol, serum proteins, erythrocyte counts
and hematocrit readings on 12 normal dogs, each receiving 5
grains daily. When toxic levels were maintained, there was a
significant fall in cholesterol and in serum proteins.
Cholesterol, 170 - 120 - 100.
Serum protein, 7 - 4.5 - 4.1.
Hematocrit, 37 - 24 55 - 32 47 - 18.
Red blood cells, 5.3 - 3.48 6.3 - 4.8 5.95 - 2.97.
There was a reduction in the erythrocyte count and an increase
in the sedimentation rate of the red cells. They stated that such
phenomena did not occur with the therapeutic doses given to
humans, although a secondary type of anemia is not uncommon
in long continued use of this drug. Tissue studies made on
these dogs showed that KSCn permeates all tissues in essentially
the same concentration. There were significant liver and bone
marrow changes. In the less toxic cases Lindberg found that the
normal matrix was replaced by fat. In the more severe toxic
states he demonstrated that the fatty marrow was replaced by
a clear eosin staining gelatinous material, not unlike that found
in benzol poisoning. Examination of the liver showed diffuse
intracellular fatty vacuolization of marked degree with little
tendency to regeneration. The icterus index remained normal.
Other organs showed no gross or microscopic change. The ad-
renals were entirely normal. Blood chemistry studies were all
within normal limits. They concluded that there was nothing
in their studies to indicate how the cyanates function in reduc-
ing blood pressure.
322
The Journal-Lancet
Caviness, ct al. (1942), inserted a unique idea as to the func-
tion of sulphocyanates. They studied 241 persons to whom the
drug had never been administered and found their blood con-
centrations of sulphocyanate ranged from .31 to 2.55 mgs. /per
cent. They found individuals with normal blood pressure gen-
erally had a concentration of 1.2 mgs. /per cent. They repeated
these determinations and found quite a constancy in this level
from week to week. They stated that hypertensive individuals
seem to have the lowest figures, and that the hypotensive indi-
viduals had the higher concentrations. They concluded that this
drug acts as a depressor substance, which conclusion accounts for
the therapeutic use of the drug which heretofore has been used
empirically.
I, personally, have made only a few determinations on normal
individuals and have found only traces of the sulphocyanate — -
too small to measure by the modification of Schrieber’s technic
as described by Barker. Caviness’ determinations were made by
the use of an Evelyn photoelectric colorimeter, using blood
serum. In a personal communication, Dr. Binger of the Mayo
Clinic stated that they have made no determinations on normal
individuals, but Dr. Osterberg was going to do so.
I have made use of KSCn. for approximately four years,
both in private practice and more recently at the Heart Clinic at
the University of Minnesota. In this report I wish to present
my own observations on the effect of KSCn. upon 60 individ-
uals with hypertension.
Table 1: Grouping into decades and result. 41 showed mod-
erate to marked improvement objectively, 19 showed slight or
no improvement in blood pressure reading, 37 showed moderate
to marked subjective improvement, 10 showed slight or no relief
of symptoms, 13 were asymptomatic.
TABLE I
Result of Sulphocyanate Therapy
Decades
No. of
Cases
Subjective
Imorovement
Objective
Improvement
Toxic
20 to 30
3
2 Marked
1 Asymptomatic
1 Marked
1 Moderate
1 None
0
30 to 40
6
5 Marked
1 Moderate
1 Marked
5 Moderate
0
40 to 50
16
6 Marked
5 Moderate
2 Slight
3 Asymptomatic
3 Marked
8 Moderate
3 Slight
2 None
2
50 to 60
17
8 Marked
3 Moderate
5 Slight
1 Asymptomatic
7 Marked
3 Moderate
4 Slight
3 None
2
60 to 70
13
5 Marked
1 Moderate
2 Slight
5 Asymptomatic
4 Marked
3 Moderate
4 Slight
2 None
4
70 to 80
4
1 Moderate
1 Slight
2 Asymptomatic
1 Marked
3 Moderate
2
80 to 90
1
1 Asymptomatic
1 Moderate
1
Totals
60
60
60
11
The average systolic fall in blood pressure was 37 mm. The
average diastolic fall in blood pressure was 17.5 mm. The maxi-
mum systolic fall in blood pressure was 80 mm. The maximum
diastolic fall in blood pressure was 45 mm. The minimum for
both was 0.
Seven of this group had decompensated and were digitalized
before cyanates were commenced. In this small group, the
KSCn. worked equally as well in reducing hypertension as in
the non-decompensated group.
Fifty-one out of the 60 had electrocardiographic studies and
23 of these tracings showed myocardial damage, not including
left axis deviation or those showing depressed RT interval in
lead 1 with left axis deviation.
In consideration of the hereditary tendencies in hypertension,
a positive family history was noted in 30 patients. In 9 it was
TABLE II
Toxic Phenomena
Case
No.
i Age
Symptoms
Dose in
Grains
KSCn.
Level
12
53
Nausea, Anorexia,
Weakness
6
7
13
81
Confused, Anorexia
6
8
14
68
Weakness, Anorexia
6
3.2
17
47
Dermatitis, Nausea,
Vomiting
5
20.6
20
60
Confusion. Patient had
cerebral vascular accident
6
13.5
28
62
Weakness. Unsteady gait
2.5
6.4
29
55
Confusion, Weakness,
Anorexia, Persistent
Depression
10
5
14.4
38
75
Dermatitis
4.5
7.9
45
62
Weakness
4
10
46
46
Severe Dermatitis on ex-
posed parts
3
20
53
74
Nausea, Confusion,
Staggering eait
3
4.2
negative. In 21 it was not stated.
Thirty-four patients complained of headaches — 31 received
complete relief, 1 was improved and 2 received no relief.
Forty-one in the series had notes on fundus examinations.
Thirty of these had retinal vessel narrowing (grades 1 to 3)
and 7 of these also had retinitis. The response to the drug was
not necessarily related to the degree of retinitis.
In the group of 11 having toxic phenomena, as shown in
Table II, 6 demonstrated decreased renal function by either the
P.S.P. test or urea nitrogen determination.
CASE HISTORIES
Mrs. J. (No. 17). Age 47. Examined Feb. 5, 1941. Known
hypertension since 1925. Recent examination elsewhere with
diagnosis, grade 4 hypertension with retinitis and beginning
renal insufficiency. Patient complained of severe headaches, nerv- j
ousness and fatigue, also insomnia. She had peculiar attacks of
localized paresthesia. B.P. 254/155 on Feb. 19. KSCn started, I
5 grains daily. March 4, 1941, KSCn level 20.6 mg. /per cent. L
B.P. remained unchanged. No toxic phenomena. Drug reduced
to 2 grains daily.
March 17, 1941. Patient reported by telephone that she had
nausea, vomiting and diffuse rash on neck and arms. The drug
was discontinued.
March 27, 1941. KSCn. level still 17.2 mg. /per cent. Same
rash present. No other toxic phenomena. Patient reports no ■
headaches, comfortable and sleeping well.
Aoril 10, 1941. Having received no cyanates for three weeks, ,
her KSCn. level is 12.9 mg./per cent — still some dermatitis.
Patient feels well. B.P. 240/140.
On April 20, 1941, patient had cerebrovascular accident and i
expired.
* ♦ ^ dp s)c
Mr. G. (No. 29). Age 55. Salesman. Negative hypertensive
family history. Known hyertension since 1931. Severe anginal
attack in May, 1939. Occasional occipital headaches.
Examination. Sept. 22, 1939. B.P. 220/150. Retinal vessels
narrowed grade 2 to 3. No retinitis. The heart quite markedly
enlarged to the left. E.K.G. shows left axis deviation with T
negativity in leads 1, 2 and 4. P.S.P., 32 per cent in 1 hr.
Urea Nit., 14.7 per cent.
October, 1943
323
Treatment : KSCn. started Sept. 22, 1939 — 5 grains b.i.d.
for four days, then 5 grains a day. Patient returned home.
Oct. 7, 1939, local physician sent in specimen of blood and
stated B. P. was 210/140. KSCn level 6.7 mg. /per cent. Patient
was instructed to take 10 grains for three days, then return to
3 grains. Oct. 20, 1939, patient re-examined. B.P. 185/105.
KSCn level 14.4 mg. /per cent. Patient was drowsy and seemed
somewhat confused — complained of marked fatigue and anor-
exia. Personality change present. Drug discontinued.
Jan. 31, 1940, patient re-examined. Still somewhat depressed
and wife stated change of personality is persisting. B.P. 230/120.
Mr. Z. (No. 42). Aged 60. Seen April 1941. Known hyper-
tension since 1918. Symptoms : Asymptomatic except for occa-
sional abdominal pain referred into left arm. Recent examination
elsewhere showed B.P. 210/110, 240/155. Retina showed mod-
erate narrowing of vessels. Urine and blood urea normal.
E.K.G. negative.
Treatment-. Phenobarbital, gr. Vi t.i.d. for three weeks. B.P.
200/120, 220/130. May 26, 1941— KSCn 3 gr. b.i.d. June 12,
1941 — B.P. 200/130, 210/140. KSCn level 10.8 mg./per cent.
Patient complained of frequent anginal attacks not related to
effort. Drug discontinued. Later this patient had a coronary
thrombosis.
sje s|e :{c sjs :je
Miss L. (No. 59). Examined Nov. 12, 1942. Known hyper-
tension for 10 years (insurance examination). Frontal and oc-
cipital headaches began two months ago and awakened her in
the morning. Complained of cold lower extremities.
Examination: B.P. 210/130. Urine — negative. P.S.P., 67
per cent in 1 hour. Urea N. 17.5 mg./per cent. E.K.G. shows
deeply negative TV Fundus examination shows grade 2 sclerosis
of the retinal vessels with moderate edema. The brachial vessels
were thickened but normal in pulsation. No pulsation was pres-
ent in femoral, posterior tibial, and dorsal pedal vessels. B.P.
in lower extremities could not be obtained. Intravenous urogram
was negative. Chest x-ray revealed the heart to measure 11.2
cm. in transverse diameter. Transverse diameter of chest was
22.0 cm. "The aortic arch is small. In the oblique view, the
distal part of the arch and the descending aorta are not vis-
ualized. There is slight scalloping of the posterior part of sev-
eral of the ribs.” A diagnosis of coarctation of the thoracic
aorta with secondary severe hypertension was made.
Nov. 30, 1942. B.P. 210/130. KSCn. level 4.3 mg./per
cent. Headaches completely relieved.
Dec. 7, 1942. KSCn. level 10.8 mg./per cent. B.P. 210/130.
sje sjc sjc s|e sje 4:
Mrs. A. (No. 11). Age 50. Positive hypertensive family his-
tory. Known hypertension 13 years. Toxemia with three preg-
nancies. Ca. of sigmoid removed in 1927.
Symptoms: Severe occipital headaches in morning for four
years. Retrosternal pain and dyspnea with effort for two years.
Fatigue prominent for three years. Unable to carry on any
activity.
Examination: Retinal vessels showed grade 2 sclerosis, no
retinitis. B.P. 205/128 after use of phenobarbital. E.K.G.
shows left axis deviation. P.S.P., 62 per cent one hour.
Treatment: KSCn. started Feb. 23, 1940 — 3 grains b.i.d.
March 6, 1940, B.P. 160/105; KSCn. level 7.8 mg./per cent.
Headaches relieved. April 8, 1940, B.P. 150/100; KSCn. level
7 mg./per cent. May 6, 1940, B.P. 140/90; KSCn. level 7
mg./per cent. This continued throughout 1941.
October 13, 1942, B.P. 170/110; KSCn. level 5.2 mg./per
cent. Occasional morning headaches. Cyanates increased to 3
grains t.i.d. Dec. 7, 1942, B.P. 150/100. Patient able to carry
on active secretarial work for the past two years.
SUMMARY AND CONCLUSIONS
1. Out of 60 hypertensive individuals treated with KSCn.,
41 obtained significant lowering of the systolic and diastolic
blood pressures.
2. Thirty-seven having subjective symptoms were completely
relieved of these. Ten had slight or no relief.
3. Toxic phenomena appeared in 11, one of which was rather
severe. These tended to appear at lower concentrations than
usually described.
4. KSCn. very definitely should not be used unless careful
clinical and laboratory observations can be made at frequent in-
tervals.
5. Further studies should be carried on, particularly in
attempting to determine the basis for the action of the drug.
BIBLIOGRAPHY
Pauli, Wolfgang: Munchen. med. Wchnschr. 1903, p. 50, 153.
Zentralbl. f. d. ges. Therap. 1904, p. 22, 19. Physical Chemistry
in the Service of Medicine (translated by M. H. Fischer) New
York, 1907, p. 71.
Nichols, John Benjamin: The pharmacologic and therapeutic
properties of the sulphocyanates, Am. J. M. Sc. 170:735-747.
Pollock, L.: Beitr. z. Chem. Phys. u. Path. 1902, p. 2, 430.
Bernard, Claude: Lecons sur les effeats des substances toxique et
medicamentenses, Paris, 1857, p. 354, 385.
Lodholz, E.: Univ. Penn. M. Bull. 1905, p. 18, 279.
Barker, M. Herbert: The blood cyanates in the treatment of
hypertension, J.A.M.A. 106:762-767.
Lindberg, Howard A.. Wald, Maurice H., and Barker, M. Her-
bert: Observations on the pathologic effects of thiocyanate, Am.
Heart J. 21:605-616.
Caviness, Verne S., Umphlet, Thos. L., Royster, Chauncey L. :
Blood pressure and sulphocyanates. Am. J. M. Sc. (Nov. 19) 1942.
p. 688-703.
Discussion
Dr. C. A. McKinlay: We are indebted to Dr. Scherer for
the study of these cases. Personally, I am impressed by the fact
that 18 per cent of the cases reported had some toxic manifesta-
tions, and that it is the kind of treatment which may carry
quite a wallop. Undoubtedly, some cases show marked reduc-
tion of blood pressure, but I am unable to speak from much
experience with the use of this drug.
Dr. Reuben A. Johnson: I believe that Dr. Rudolph Loge-
feil was the first local physician to use potassium thiocyanate
here in Minneapolis in the treatment of hypertension, which
may be of interest to the members of this society. He used a
German proprietary called Rhodan. This was before the appear-
ance of the article by Dr. M. Herbert Barker, of Chicago, in
the Journal of the American Medical Association , several years
ago, in which the importance of chemical control of the blood
level of the drug for satisfactory results was emphasized. Dr.
Logefeil reported some brilliant but variable results. This drug
is undoubtedly one of our most effective agents for the contin-
ued control of hypertension in selected cases.
The treatment of hypertension was the subject of a round
table discussion at the Boston meeting of the American College
of Physicians in the spring of 1941. Dr. O’Hare of Boston dis-
cussed the use of thiocyanate, and the criteria which he uses for
selection of cases appealed to me, and I have followed his rules
in this matter since that time. He restricts the use of this drug
to patients under the age of 60, and to individuals who show
no important involvement of the cerebral or heart circulation, or
kidney insufficiency. There must also be a real hypertension
present, and when he was pinned down as to what he considered
a real hypertension, he had levels of 200 systolic, and 120 dias-
tolic and above in mind. I feel sure that in one of my patients
two attacks of coronary thrombosis were precipitated by the use
of this drug. Her systolic blood-pressure ranged at about 220
and 230 mm. of mercury, and she was anxious to have some-
thing done. Within two weeks after starting the drug, when
the systolic blood-pressure was around 170, she had an attack of
coronary thrombosis. She made a complete recovery. Later on
she wanted to try it again, and again she had a similar vascular
accident with fortunately a good recovery; she is still living in
reasonably good health.
One wonders whether the application of this drug earlier in
the disease might not be advantageous. Perhaps the life ex-
pectancy of individuals destined to become severe hypertensives
would be extended if the drug were used earlier in the course
of the disease. Possibly broken courses might be advantageous.
It is most interesting to learn of the extreme variability in the
rate of excretion of this drug shown by individuals. Dr. Scherer
mentioned a tenfold variation in the rate of excretion, and Dr.
O’Hare noted a sixfold variation. This variability in the rate
of excretion is manifested by other drugs. For example, I had
in the office on the same day, two individuals of about the same
age, with approximately the same type of cardiac disease, both
fibrilladng; one requiring two cat units a day for complete digi-
talis control, and the other requiring only one cat unit in five
days for an equal effect. Recently Hines and Eaton of the Mayo
324
Clinic have been using potassium thiocyanate in the treatment
of migraine, and the preliminary report on their results seems
convincing, that this drug has a distinctly beneficial action in
the control of migraine.
Dr. A. E. Cardle: Did you notice any change in the electro-
cardiogram after giving the drug?
Dr. L. Raymond Scherer: This was not routinely checked,
but on the few cases that it was, there was no change in the
electrocardiogram.
In considering Dr. Johnson’s remarks I do not believe that
renal insufficiency should be a definite contraindication, but the
drug should be used much more cautiously, as the concentra-
tion of the drug in the serum tends to increase much more
rapidly in these cases. I am not convinced, also, that elderly
individuals should not be given a careful trial on the drug, as
I have had several past 70 receive marked symptomatic and
objective improvement without toxic effects. I am sure some in-
dividuals have idiosyncrasies to the drug which are not related
to the usual toxic effects seen.
Dr. Jay C. Davis: Do you know whether or not Dr. Barker
The Journal-Lancet
has run the thiocyanate blood levels on people without hyper-
tension?
Dr. L. Raymond Scherer: No, I do not know. I wrote to
Dr. Barker about this but he did not reply. I wrote to Dr.
Binger at the Mayo Clinic, and he replied that they had made
no such studies, but Dr. Osterberg had planned on doing so.
Dr. Reuben Johnson: In evaluating the toxic symptoms of
potassium thiocyanate, one must bear in mind that we are deal-
ing with a particular group of cases where circulatory disturb-
ances may produce such symptoms as dizziness, headaches,
nausea, etc., and these may occur as a part of the disease pic-
ture independent of action of any drug, and it is therefore diffi-
cult to know always that the drug is responsible for the symp-
toms.
Dr. Jay C. Davis: Some might have had personality changes
without any drug at all due to cerebral arteriosclerosis.
Dr. L. Raymond Scherer: I agree with Dr. Davis that this
group of individuals may have personality changes on a vas-
cular basis, but I have felt it wise to discontinue the drug if any
unusual change in personality made its appearance.
Stated Meeting, Held at the Minneapolis Club, January, 1943
Dr. Roy E. Swanson in the Chair
BRONCHIAL ADENOMA
Inaugural Thesis
Thomas Lowry, M.D.
Benign adenoma of the bronchus is a disease relatively new to
clinical medicine. With the exception of a few case reports, the
now considerable literature of the condition has all appeared
during the past eleven years. Within that period, the more gen-
eral use of bronchoscopy has been largely responsible for the in-
creasing frequency with which bronchial adenoma is recognized;
and the rapid advance of thoracic surgery has made possible (at
least in many instances) effective treatment of what was for-
merly only a pathological curiosity. My purpose, after review-
ing briefly the earlier work on the subject, is to present four of
our own cases, all of which have so far been treated broncho-
scopically by local removal, and to outline the difficulties con-
fronting us at present in the diagnosis and management of this
tumor.
Historical : Prior to 1932, adenoma of the bronchus was not
clearly distinguished as an entity. Occasional cases were discov-
ered at necropsy. As bronchoscopy became more frequently em-
ployed (at first, in this country, through the influence of Jack-
son and his school), these tumors were found during life and a
few were locally removed through the bronchoscope. Some were
considered to be carcinomata; and, indeed, because of their
peculiar cytological features, many adenomata continue to be
difficult of microscopic identification even by pathologists famil-
iar with them. Others were called "vascular adenoma,” "adenom-
atous polyp,” or were thought to be inflammatory polypi with
epithelial metaplasia.
In 1932, Wessler and Rabin established adenoma of the
bronchus as an entity, by their review of 12 cases with analysis
of the clinical and pathologic characteristics of the disease. They
felt that these tumors were benign, but that malignant degen-
eration could and probably did occur. The general experience
since the appearance of their report has indicated that distant
metastasis occurs extremely rarely, if ever, in proven cases.
About 150 instances of bronchial adenoma have been recorded
in the literature since 1932, and it is now well recognized as a
clinical entity having several distinctive characteristics.
I should like now to present some illustrative cases. These
patients were observed at the University Hospitals, and I should
like especially to express my appreciation to Dr. Leo Rigler for
his permission to use the roentgenological material in connec-
tion with them.
CASE REPORTS
Case 1. The first patient, a 36 year old American housewife,
was seen in the Out-Patient Clinic in August 1940. She pre-
sented a history of cough for two years, productive of thick
purulent sputum, varying in amount from 1 ounce to 54 cup
in twenty-four hours. This had not been foul, but there had
been hemoptysis of 2 ounces or so of bright red blood on four
or five occasions during the two-year period. She had not lost
weight and had had no fever as far as she knew. Examination
of the chest showed slightly diminished expansion of the right
side of the thorax. There were decreased breath and voice
sounds over the lower third of the right lung posteriorly. No
rales were heard and there was no impairment of resonance on
percussion. The remainder of the examination was negative.
Routine urine and blood examinations showed no abnormalities.
Her x-ray revealed increased density in the medial portion of
the lower right lung field. This was interpreted as probably in-
dicating an area of atelectasis or "drowned lung” in the medial
segment of the right lower lobe. A bronchogram was made and
showed obstruction of a branch of the right lower lobe bronchus
with a rounded filling defect in the lipiodol shadow. At bron-
choscopy, done by Drs. Robert Priest and L. R. Boies, a ped-
unculated, polyp-like mass was seen. This was smooth, movable
and covered by glistening mucous membrane. Biopsy revealed
adenoma of the bronchus, and, at a subsequent bronchoscopy,
the mass was removed in toto. It was attached by a long pedicle.
Three months later, the patient had gained 7 pounds and was
coughing much less, but still raised 14 ounce or so of purulent
sputum per day. A bronchogram in April 1941 showed filling
of several saccular bronchiectatic pockets distal to the point of
obstruction which were not reached by lipiodol injection before
removal of the adenoma.
This patient went through a normal pregnancy and was de-
livered in July 1941. Since then her symptoms have continued
to be mild, consisting of a slight cough with less than 5 cc. of
purulent sputum daily and no hemorrhages. Bronchoscopy in
April 1942 showed recurrence of the adenoma in the right lower
lobe bronchus. Lobectomy was refused and therefore tissue was
again removed locally.
When last seen, in November 1942, the patient was in good
health, had maintained her weight, and her symptoms were
still in abeyance.
* * * * * *
Case 2. The second case was studied in more detail. It pre-
sented a more difficult problem. The patient was a 29 year old,
single waitress, admitted to the University Hospital in May,
1940. She had had a febrile illness three months earlier, said
to be pneumonia involving the left lower lobe. At that time
she was hospitalized for three weeks. Following this, she had
felt well, but a dry cough had persisted, and during the month
prior to admission she had noted anorexia and daily afternoon
fever with a weight loss of over 20 pounds. The week before
October, 1943
325
entry she had a small hemoptysis. There was no history sug-
gesting aspiration of a foreign body. On examination we found
an acutely ill young woman, with a fever of 101.6°, pulse
140, respirations 24. There was evidence of obstruction of the
left main bronchus, with dulness, diminished expansion and
diminished breath sounds over the whole left lung. The me-
diastinum was displaced to the left. The significant laboratory
finding was leucocytosis of 23,000 with 88 per cent polymorpho-
nuclears. The diagnosis was obstruction of the left bronchus
with atelectasis and infection of the distal lung. X-ray showed
density through the lower half of the left lung and, as you see,
the planigram established the nature of the obstruction with
virtual certainty.
Bronchoscopy was done by Dr. Logan Leven and the tumor
was visualized as a smooth round pink mass in the left main
bronchus. Following gentle instrumentation, it bled freely and
seemed to disappear from view, so that no tissue could be ob-
tained. Following the procedure, the entire left bronchial tree
became occluded by blood clot and a "drowned lung ’ resulted.
The patient became very ill, with temperature of 105°. Bron-
choscopy was repeated for removal of the clot, but this only
started fresh bleeding and the attempt was abandoned. As the
clot absorbed, she improved gradually and the lung cleared. She
left the hospital about five weeks after admission. At that
time, the tumor was much smaller and the obstruction corres-
pondingly relieved.
The patient gained weight rapidly after leaving the hospital
and had very little cough. Only occasionally was there a small
amount of purulent sputum. The only symptom was dyspnea
on moderate exertion. She was followed in the Out-Patient De-
partment until February 1941. The situation did not change
appreciably. It was felt that the tumor should be removed, if
possible, before it grew sufficiently to occlude the bronchus again.
Accordingly, the patient was re-admitted, and at this time the
bronchial mass was removed through the bronchoscope by Dr.
Leven. Only slight bleeding and no untoward reaction occurred.
In this patient, there is undoubtedly much permanent lung dam-
age in the form of bronchiectasis and fibrosis. At present, rales
are audible throughout her left lung. Further observation will
be necessary to decide whether radical surgical methods will be
required to manage this residual bronchiectasis. However, at
present she has no cough and very little sputum and has gone
through two winters without difficulty. Therefore, at present
the symptoms hardly justify a pneumonectomy.
s|c 3]e ijc ijc :je
Case 3. This was a 32 year old married white garage me-
chanic, admitted in August 1941. He had had pneumonia four
times between the ages of 10 and 31. For one year, a cough
had been present, productive of one cupful daily of purulent
sputum which was sometimes blood -streaked and slightly fetid.
Examination showed a well-developed and well-nourished man.
There was reduced expansion of the right hemithorax. On per-
cussion, dulness was elicited over the lower half of the right
lung posteriorly, with diminished breath sounds, a few coarse
rales and a transient expiratory wheeze in this area. Examina-
tion was otherwise normal. The laboratory findings were within
normal limits.
X-ray of the chest showed consolidation in the right lower
lobe with some evidence of atelectasis. Bronchoscopy revealed a
smooth rounded pink mass obstructing the right lower lobe
bronchus, which bled easily and proved to be an adenoma. It
was removed locally and subsequent bronchography showed ex-
tensive bronchiectasis in the previously obstructed area.
The patient’s symptoms disappeared in one month. He has
been seen periodically since and his cough has not recurred.
A checkup bronchoscopy in April 1942, eight months after
removal of the growth, showed no recurrence and a lipiodol
study done over a year after the procedure showed the bronchus
to be unobstructed. Ordinary roentgenograms of the lung have
remained practically clear, but persistent rales in the right lower
lobe testify to the presence of the bronchiectasis shown by bron-
chography. The patient’s improvement was so striking that the
surgical staff decided to defer the lobectomy which had been
planned to follow bronchoscopic extirpation of the adenoma.
Case 4. The last case is that of a 39 year old housewife ad-
mitted in June 1942. Thirteen years previously she had been
told she had a "spot” on her right lung. However, she remained
free of symptoms until 1933 when she developed a chronic
cough. This persisted with some intermissions and was asso-
ciated with frequent small hemoptyses which were apt to occur
at the time of her menstrual periods. For two years there had
been increasing dyspnea and a feeling of substernal pressure.
Examination showed a well-developed, well-nourished woman.
There was marked restriction of motion of the right thorax,
with an inspiratory thrill and harsh breath sounds, suggesting
almost complete obstruction of the right bronchus.
X-rays showed what appeared to be an upper mediastinal
mass, but on bronchoscopy a typical adenoma was found in the
right main bronchus just below the bifurcation. It now appears
that the mediastinal mass is merely the extrabronchial portion
of this neoplasm.
The proximity of the lesion to the carina precluded lobectomy
or pneumonectomy in this case and, therefore, local extirpation
was performed by Dr. Leven, part of the tumor being removed
in June 1942 and a further portion in November 1942. Bron-
choscopy January 14, 1943, showed the bronchus to be open.
No further growth of the tumor could be noted, although only
tv/o months had elapsed and this patient will be closely followed.
Since the first partial removal of this neoplasm seven months
ago, the patient has had no cough, wheeze or dyspnea. At long
intervals she raises 1 or 2 cc. of blood-streaked sputum. She
has gained a small amount of weight and feels entirely well.
INCIDENCE
Bronchial adenoma is not a common tumor, but its incidence
is probably greater than has been supposed, amounting to
between 6 and 10 per cent of all primary bronchial neoplasms.
However, since the majority of bronchogenic carcinomata ad-
vance beyond the operable stage before a diagnosis is made,
adenomata make up a considerably greater percentage of the
curable tumors. Churchill recently stated that 25 per cent of
resectable bronchial growths belonged to this group.
The age and sex incidence of adenoma are in sharp contrast
to those of carcinoma of the bronchus, as shown in Table I.
These facts, together with the clinical features to be discussed,
are strongly in favor of the view that the two are essentially
different tumors.
PATHOGENESIS
There has been a good deal of dispute about the origin of
bronchial adenoma. Some of the earlier workers believed that
stasis of bronchial secretions might cause inflammatory polypi,
TABLE I
Bronchial Neoplasms
Adenoma
Carcinoma
Age
80% under 40
90% over 40
Sex
70% female
85% males
Appearance
Smooth, pink, oval or
lobulated; often ped-
unculated. Bronchus
not fixed. Troublesome
bleeding on biopsy.
Irregular, yellowish or
grey; often ulcerated;
bronchus infiltrated and
fixed. Bleed readily but
not profusely.
Clinical
Attacks of suppuration
intermittent with long
healthy intervals.
Suppuration or atelecta-
sis usually progressive.
Steady downhill course.
Bronchiectasis
Frequent, due to
chronicity of course.
Infrequent; course
usually too rapidly
progressive.
Type of
Hemoptysis
Often profuse, with
sudden onset and
abrupt cessation.
Usually only streaking,
which is often
continuous.
326
The Journal-Lancet
and that epithelial metaplasia then occurred and produced the
final pathologic picture. This concept has been generally aban-
doned, and it is now agreed that the adenoma is a true tumor,
inflammatory changes in the lung being secondary to it rather
than responsible for it. We have no good evidence as to the
cell type giving rise to these neoplasms, but the most commonly
.accepted view is that they originate from the duct epithelium
of the bronchial glands. The fact that these ducts traverse the
bronchial wall beyond the cartilaginous rings is given as one
reason for the frequent extrabronchial extension of these
growths.
PATHOLOGY
Bronchial adenomata occur in the larger bronchi. It has been
said that they do not arise in branches of less than 10 mm.
diameter, but such a sharp limit can probably not be applied
to all cases.
Grossly, the adenoma is a smooth, round or oval, pinkish
tumor. The intrabronchial portion most frequently is polypoid
and may be pedunculated. In some instances, however, it is
relatively flat and attached by a broad base. There is often
extension through the bronchial wall with the formation of an
extrabronchial mass which may be larger than the intrabronchial
portion. A recent article reviewed 19 cases, in 90 per cent of
which extrabronchial growth was present.
Microscopically, the adenoma is usually covered by epithelium
which frequently undergoes metaplasia to the squamous cell
type. Beneath the epithelium is a layer of loose connective tis-
sue. This is often very vascular and is the origin of the profuse
bleeding so commonly encountered in the condition. The neo-
plastic cells are rather small, cuboidal or polygonal in shape and
uniform in size. They usually grow in sheets or cords and look
rather undifferentiated. However, their nuclei are very uniform
and mitotic figures are uncommon.
There is still a good deal of argument as to whether these
lesions are benign or of low-grade malignancy. They are locally
invasive and frequently recur after local removal. One recent
paper reported two cases in which distant metastasis was said to
have occurred, but the report is not very convincing. At pres-
ent, the consensus is that the bronchial adenoma is not malig-
nant in the clinical sense. No case is on record in which a
patient has died of metastasis, even though some of these
tumors have been known to exist for 25 years and more. They
grow very slowly, and the symptoms and signs to which they
give rise are largely produced by the complications of a long-
standing and slowly progressive bronchial obstruction.
CLINICAL FEATURES
The clinical history in bronchial adenoma is of great impor-
tance. Usually there have been recurrent episodes of pulmonary
infection characterized by cough, purulent sputum, fever, often
pain (when pneumonia with pleural involvement has occurred) .
Hemoptysis is a prominent symptom, being encountered in about
two-thirds of the cases. The bleeding is often profuse and re-
peated. It tends to start and stop abruptly. In women, hem-
orrhage from the adenoma often accompanies a menstrual
period. The patient ordinarily has a cough and this may or
may not be productive, depending on the stage of the disease
and extent of bronchiectasis or pneumonitis present. Wheezing,
due to partial bronchial stenosis, is often a complaint and if the
obstruction is marked and involves a large bronchus, dyspnea
may be severe.
The physical signs vary, depending on the degree of bronchial
occlusion and the amount of pulmonary suppuration. Table II
summarizes these changes. An early lesion may give no phys-
ical signs or there may be a localized coarse rhonchus over the
lobe whose bronchus is involved. If pneumonitis is present,
dulness, rales, and tubular breath sounds may be found. (The
latter are usually reduced in intensity because of obstruction of
the airway) . In the late stages the signs are those of total
atelectasis. A few cases may at some stage exhibit obstructive
emphysema. Most of them develop bronchiectasis, which is of
a severe grade in the more advanced cases.
ROENTGENOLOGIC FEATURES
Until fairly recently, the x-ray gave us chiefly circumstantial
evidence about these tumors. That is to say, a patient exhibiting
recurrent pneumonia in the same lobe with intermittent atelecta-
TABLE II
Mechanical Effects of Bronchial Tumors
Stage
Effect on Bronchus
Manifestation
Early
No obstruction
Irritation of mucosa
Cough
Erosion of mucosa
Hemoptysis
Moderately
Partial obstruction
Dyspnea. Wheeze, often
localized. Impaired
bronchial drainage:
Pneumonitis. Fever, pur-
ulent sputum. Later —
bronchiectasis.
Obstruction partial in
inspiration, but total
in expiration.
Obstructive emphysema.
Far advanced
Total obstruction
Total atelectasis, usually
with suppuration.
sis and some bronchiectasis was suspected of having a bronchial
adenoma. Lipiodol studies were then our best roentgenologic
means of diagnosing the disease. An occluded bronchus at the
end of which a smooth rounded filling defect appeared in the
lipiodol shadow was often very suggestive evidence of adenoma.
In the past three years or slightly more, the use of body sec-
tion roentgenography has been very helpful in identifying and
following these cases, since films made with this technic often
may outline clearly both the intra- and extrabronchial portions
of the growth.
BRONCHOSCOPY
Final diagnosis is ordinarily accomplished by bronchoscopic
visualization of the adenoma. Its gross features, the lack of in-
filtration and fixation of the bronchial wall so common in car-
cinoma, are extremely important in reaching a correct conclusion
as to the nature of the tumor. Biopsy is frequently helpful and
incidentally is often accompanied by free bleeding. Because of
the difficulty of identifying these neoplasms microscopically from
the small amount of tissue obtained in a biopsy, we have often
had conflicting reports from the pathologist. It may be difficult
or impossible for him to exclude carcinoma. It is our feeling,
therefore, that a diagnosis of bronchial adenoma must be based
on the entire clinical picture, including the x-ray and gross
bronchoscopic findings, and that, if all these features are in
accord, a report of microscopic malignancy from a biopsy should
not be accepted as proof of cancer.
CLINICAL COURSE AND TREATMENT
The natural history of these tumors is that of a slowly pro-
gressive bronchial obstruction and often extends over many
years. One case is on record in which symptoms due to a bron-
chial adenoma apparently were present for 53 years. As has
been stated, all, or certainly nearly all, these lesions are benign
as far as metastasis is concerned. However, their effects upon
the lung may be extremely damaging or even fatal. Severe
grades of bronchiectasis, suppurative pneumonitis, lung abscess,
and empyema are common sequelae. It is obviously important,
since the tumor itself is benign, to recognize and treat it, if
possible, before fatal or permanently incapacitating damage has
been produced.
Attempts at treatment have been in three general directions:
1. Local bronchoscopic removal. This has been done in all
our cases and there seems to be reason to believe that the meth-
od has advantages under certain circumstances. Early cases, in
which damage to the lung is not extensive and the patient can
be carefully watched for recurrences, are suitable. Patients who
refuse pulmonary resection or in whom the position of the
growth makes this impossible (e. g. case 4) also will fall in this
group. All patients who are to have lobectomy or pneumonecto-
my should be subjected to local removal first, if it is feasible,
to permit good preoperative drainage of the diseased lobe and
thus reduce the operative risk.
Most authors now feel that the majority of cases, because of
the high incidence of local recurrence and extrabronchial exten-
sion, will require pulmonary resection. A recent article stated
October, 1943
327
that this was the method of choice in 90 per cent of cases. In
my opinion, this has still to be proved. There has as yet been
no report of a careful follow-up study of cases such as ours
without resection over a period of years, with repeated local
removal when indicated.
2. Radiation. This method has been given a limited trial.
Results in general have not been satisfactory as these tumors
are apparently not especially radio-sensitive.
3. Pulmonary Resection. Lobectomy or pneumonectomy will
undoubtedly be necessary in a large number of cases, particu-
larly where local removal is not feasible or is unable to relieve
the symptoms of secondary bronchiectasis. Most authors now
feel that, in carrying out resection, the tumor should be regard-
ed as benign and the procedure therefore limited to lobectomy,
if possible, in order to reduce the operative risk. A recent report
records 19 bronchial adenomata, of which 7 had been treated by
resection: 3 pneumonectomies with 1 death, 4 lobectomies with
no deaths. AH the living patients secured satisfactory results.
CONCLUSIONS
1. Early diagnosis is important, for if these tumors are re-
moved early, the pulmonary suppuration seen later will not de-
velop. Unexplained hemoptysis and recurrent pneumonia or
atelectasis in the same part of a lung demand investigation.
2. Clinical evidence supports the concept that the so-called
"bronchial adenoma” is an entity distinct of carcinoma from the
bronchus.
3. Treatment cannot be guided by general rules. Each case
is an individual problem.
4. Pulmonary resections (lobectomy or pneumonectomy) will
be indicated in many instances. However, the patients who re-
fuse radical surgery, or are not suitable for it, may often be
kept in good health over considerable periods by more conserva-
tive measures.
REFERENCES
1. Wessler, H., and Rabin, C. B. : Benign tumors of the
bronchus. Am. J. Med. Sc. 183:164, 1932.
2. Peterson, H. O.: Benign adenoma of the bronchus, Am. J.
Roentgenol. 36:836, 1936.
3. Phelps, K. A.: Benign adenoma of bronchus, Minnesota
Med. 23:375, 1940.
4- Tchertkoff, I. G., and Kiosk, E.: Adenoma of bronchus,
Q. Bull. Sea View Hosp. 4:202, 1939.
5. Brunn, H.: Bronchial adenoma, Leahy Birthday Vol. 1940
pp. 99-108.
6. Brunn, EL, and Goldman, A.: The differentiation of benign
from malignant polypoid bronchial tumors, Surg. Gynec. & Obst
71:703, 1940.
7. Goldman, A., and Stephens, H. B.: Polypoid bronchial
tumors, J. Thoracic Surg. 10:327, 1941.
8. Adams, W. E., et al.: Malignant adenoma of the lung.
Surgery 1 1:503, 1942.
9. Brunn, H., and Goldman, A.: Bronchial adenoma. Am. J
Surg. 54:179, 1941.
10. Foster-Carter, A. F.: Bronchial adenoma. Quart. J. Med.
10:1 39, 1941.
Discussion
Dr. L. Raymond Scherer: I enjoyed Dr. Lowry’s paper
very much. I particularly appreciated his clear development of
the clinical aspects of this syndrome. We are too prone — at
least I am — to group chronic obstructive bronchial disorders
under one heading, i. e., that of malignancy.
Dr. Kenneth A. Phelps: I want to congratulate Dr. Lowry
on this paper. It is a very nice discussion of a subject which
still has many aspects which have not been settled. The Minne-
apolis Academy of Medicine should also be congratulated on
having a new member who can give such a splendid report.
The subject of bronchial adenoma is interesting to the bron-
choscopists, because we feel we have contributed something to
both treatment and diagnosis. The subject has been so com-
pletely covered that I can add nothing except a few technical
points.
Sometimes, if the adenoma is really a large mass, it can be
cored out by using the bronchoscope itself. The end is dull and
the hemorrhage is comparatively little. Also, the electrocoagu-
lator can be used to help control bleeding. If necessary, the
bronchus can be packed through the bronchoscope. It should
first be determined whether or not all of the adenoma is endo-
bronchial, or if it extends beyond the bronchial wall. The 1am-
inogram is of great aid in this respect. If the adenoma is with-
in the bronchus, it seems logical to try to remove it by means
of the bronchoscope or some instrument through the broncho-
scope.
Usually the symptoms of bronchiectasis disappear when the
tumor is removed, so quite often the patient is symptom-free.
Clinically they are well.
Although the tumor is benign from the standpoint of meta-
stasis, it does recur, and we might say it is locally malignant.
We usually send the pathologist a small biopsy, obtained
from the bronchus, and ask him to tell us what it is. This is
not giving the pathologist a square deal. It must be that often
these tumors have a varying pathological picture. It is some-
times quite easy for him to make a diagnosis, but at other
times he seems to have considerable trouble.
Dr. Malcolm Hanson: These are very interesting tumors
and I think these roentgenograms are somewhat self-explanatory.
One secondary x-ray finding seen sometimes in this type of
tumor is an obstructive emphysema.
Dr. James S. McCartney: I had already read Dr. Lowry’s
paper and enjoyed it very much, but gained a great deal from
seeing the pictures tonight. As Dr. Phelps just told you, the
bronchoscopists frequently give us a small bite of tissue. Usually
about all the information there is regarding the tissue is, "Here
is a bit of bronchus. What is it?” There is usually nothing
about the sex of the individual, nor any hint as to the duration
of the process, in fact, not much of anything is given.
Ever since we have been getting these biopsies, we, in our
department, have been passing them around, so that everyone
has a chance to say what they are. I think my batting average
is not very good, but I don’t believe anyone else in the depart-
ment is much better. We are pretty much divided in our opin-
ion as to whether they are benign or malignant. I recall one
case where there was a rather sharp division of opinion. The
majority thought it was benign, but one or two thought it was
malignant. Within a short time the patient had a pneumo-
thorax, and well-defined but atypical glands were present in it.
You can ask, and I cannot answer why these are called bron-
chial adenoma, because the ordinary conception of an adenoma
is that it is a proliferation of glands which has a tendency to
fairly closely reduplicate the structure from which it arises,
whether in the thyroid, parathyroid, adrenal, or prostate, etc.
This does not in any way reduplicate the appearance of the nor-
mal glands in the bronchial tree. They are solid cords of epi-
thelial cells, but nothing on which one can base one’s opinion
that it is bronchial epithelium.
As we commonly see, the malignant tumor is one which does
not attempt to duplicate the structure from which it arises. We
recognize the bronchial adenoma then for what they are. We
have a tumor that is composed pretty much of solid cords of
cells. These cells differ from malignant cells in the fact that
there is rather marked uniformity in the size and depth of
staining. There are no mitotic figures, but cells which are ir-
regular and atypical in arrangement, yet tend to be fairly uni-
form in size and depth of staining. Yet, in the case I cited,
these cells appeared to be ones which were not growing actively.
However, in the material obtained from the pleural space, well-
defined glands were present, and those cells showed considerable
more evidence of active growth than was true in the primary
lesion.
Personally, I am rather on the fence as to how to really make
a diagnosis from the bronchial biopsy. I saw a bronchial biopsy
a few weeks ago which I called a carcinoma. If I had seen it
a while back, I think I would have called it an adenoma. I
believe we are now inclined to call these biopsies carcinomas
rather than adenomas.
Dr. Thomas J. Kinsella: I have enjoved this presentation
by Dr. Lowry and wish to congratulate him on this excellent
thesis. He has been perfectly fair in evaluating the various
phases of the subject. In making a diagnosis of benign bronchial
adenoma it is necessary that all phases of the picture be taken
into consideration, for the diagnosis may be a tricky one.
In the first place, I do not believe that we are always fair to
the pathologist when we give him a piece of tissue the size of
a pinhead, considerably crushed and probably altered by sec-
ondary infection, and then expect an accurate diagnosis. We
have seen much confusion in this field, with benign tumors
called malignant and vice versa.
328
The Journal-Lancet
Local removal alone becomes the more hazardous in direct
proportion to the uncertainties of diagnosis, for delay in treat-
ment of a malignant lesion may mean the loss of all chance
of cure.
The bronchoscopist often has a better chance than the clini-
cian or pathologist to recognize this condition. The distant
view may be more characteristic than that at close range. The
typical adenoma is a smooth, rounded, pinkish mass often with
small blood vessels crossing its surface, attached to the bronchial
wall by a small or broad base. Secondary infection or ulceration
may change its appearance. Bleeding occurs readily following
any trauma. This local picture, considered with the history and
age of the patient may establish the diagnosis without micro-
scopic section.
Another suggested surgical procedure, in addition to those
already mentioned, is bronchostomy with local excision of the
tumor and reconstruction of the bronchial wall. This may be
possible in some instances, yet narrowing of the bronchus from
this procedure may well cause as much damage to the lung as
the original tumor itself.
From the pathological standpoint, I should like to ask Dr.
McCartney for his reaction to the ideas of Womack and Gra-
ham of St. Louis, that these tumors are mixed tumors, and also
the suggestion that they represent fetal lung buds which have
undergone a late new growth.
Dr. James S. McCartney: I am inclined to agree with the
latter point of view. I haven’t seen any in which I thought there
was a possibility of its being a mixed tumor. It doesn’t look
like tumor stroma, but it looks like ordinary connective tissue or
trabeculated supporting tissue.
Dr. Thomas Lowry: I have nothing to add, except that I
want to thank the discussors for their remarks. I, also, wish to
emphasize again the fact that I think the diagnosis has to be
based on the entire picture, history, gross appearance of the
tumor, and its clinical course as well. It is not fair to ask the
pathologist to decide upon a diagnosis without benefit of these
other factors.
CASE REPORT AND REVIEW OF CHOLECYST-
ELECTROCOAGULECTOMY (Thorek)
Stanley R. Maxeiner, M.D., F.A.C.S.
I beg your indulgence to report this case, not because it is
unusual, but because it was treated by a type of surgery not
commonly used nor understood.
The patient was a white female, 50 years of age, who entered
the hospital in February, 1942. Seven days previous to admis-
sion, she developed pains which were more marked in the right
upper quadrant and at times became severe. The patient tried
simple remedies without relief. The onset occurred following a
heavy meal which included fried meat and pastry. She had had
no previous attacks, no jaundice, and no dark colored urine. Her
past history had been essentially negative and her family history
was irrelevant.
Physical examination revealed a well nourished individual. Her
blood pressure was normal. There was considerable abdominal
distention, and palpation revealed marked tenderness in the
right upper quadrant with muscle spasm, and gave the impres-
sion of a well defined, firm, tender mass extending three fingers’
breadth beneath the right costal margin. The balance of our ex-
amination was essentially negative. White blood count was
18,000 and bleeding and clotting time were normal. Icteric
index was 6.4.
The day following admission to the hospital, the patient had
a chill with an elevation of temperature to 101°. On each of
the following days she had at least one chill with an elevation
of temperature to 102.5°. All during the first week, the patient
had a continuous temperature with elevated pulse. Because of
her vomiting, feedings were given intravenously. A flat film
made of the abdomen showed two or three calcified shadows,
which had the appearance of large biliary calculi. The patient
remained in the hospital for eleven days preoperatively, during
the last five of which she became temperature-free.
At that time she was operated upon, and the gallbladder was
found to be very tense and completely buried in adhesions.
Stones were palpable in the gallbladder as well as in the cystic
duct. On opening the gallbladder, it was found to contain a
purulent fluid, cultures of which showed gram-positive cocci,
gram-positive rods and some gram-negative rods. A resection of
the gallbladder with removal of the stones was carried out after
the manner of Max Thorek. Seven grams of sulfanilamide
were placed in the peritoneal cavity, and the abdomen was
drained by two split tubes. The abdominal wall was closed with
stainless steel wire, and the patient made a very satisfactory and
unusually uneventful recovery.
The postoperative diagnosis was acute empyema of the gall-
bladder with cholelithiasis.
Discussion and Description of Thorek1
Operation
Pribram1 noted no operative death in a series of 200 consecu-
tive cases of biliary disease which comprised complicated and in-
fected cases. He attributed these results to an isolated destruc-
tion of the mucous membrane of the gallbladder with thermal
cautery after dividing the cystic duct. The technic of Pribram
is termed carbonization by Thorek who substitutes electrocoagu-
lation. This is accomplished by the use of a large electrode held
in contact with the tissues for several seconds, until they have
become white and coagulated but not charred or carbonized. The
chief object of the coagulation is to obtain a dry operative field,
which permits closure without drainage. The coagulation pre-
vents the oozing of bile and blood from the denuded surface of
the liver and, likewise, prevents absorption of septic material
directly into the lymphatics.
Technic5
Through an appropriate abdominal incision, the gallbladder
is exposed and the biliary passages and adjacent viscera exam-
ined. He does not attempt to eviscerate the liver. The field of
operation is isolated with moist, warm sponges. The cystic duct
and cystic artery are isolated and cut between ligatures. The
gallbladder is then aspirated of its liquid content. It is opened
widely and the stones removed. Next, the redundant convex
portion of the gallbladder is removed, and the remaining por-
tion of the gallbladder is coagulated electrically without, in any
manner, disturbing the gallbladder bed.
After all of the mucosa has been destroyed, a running catgut
suture approximates the two lateral cut edges of the gallbladder.
The falciform ligament is detached from the abdominal wall an-
teriorly and folded laterally across the gallbladder remnant. The
abdominal incision is closed by Thorek without drainage.
We have now operated upon approximately twelve very bad
gallbladders, some of which were grossly infected, as in the case
reported. Up to this time, we have not been able to make our-
selves close the abdomen without drainage, and, as a result, one
or two split tube drains have been introduced. Recently, at the
meeting of the International College of Surgeons in Denver,
I had an opportunity to confer personally with Doctor Thorek,
and he presented a strong argument in favor of the complete
absence of drainage. In a personal communication from Doctor
Thorek3 under date of February 10, 1943, he states, "Up to the
present time we have done 1940 cases. The mortality is one-
fifth of one per cent, and this mortality was in my own cases,
a rather brilliant series for so large a number of unselected
cases with empyemas, gangrenous gallbladders and other com-
plicating conditions. Please remember that the global mortality
in unselected cases is still about 9.6 per cent.”
In an article entitled "Electrosurgical Obliteration of the
Gallbladder Without Drainage,” Bailey and Love,2 of the Royal
Northern Hospital, report 129 consecutive cases without mor-
tality.
Conclusions
The purpose of this discussion is not to "sell” the Thorek op-
eration but to call to your attention and perhaps add to your
armamentarium a surgical procedure which has been used about
twelve times in our very worst gallbladder risks without mor-
tality, and has been used 1940 times by a number of other sur-
geons with a mortality of one-fifth of one per cent in unselected
cases.
Bibliography
1. Pribram, B. O.: Fortschritte in der chirurgischen Behandlung
des Gallensteinleidens, Med. Klin. 24:1187 (Aug. 3} 1928.
2. Bailey, Hamilton, and Love, R. J. McNeill: Electrosurgical
obliteration of the gallbladder without drainage, Brit. M. J. 2:682
(Sept.) 1939.
October, 1943
329
3. Thorek, Max: Personal communication.
4. Thor?k, Max: Cholecystelectrocoagulectomy without drain-
age in the treatment of gallbladder disease, Illinois M. J. (Nov.)
1933.
5. Thorek, Max: Electrosurgical obliteration of the gallbladder
without drainage, Tr. Internat. Coll. Surgeons 1:2:173-184.
LUXATION AND AVULSION OF THE EYE BALL
Kenneth A. Phelps, M.D.
The eye ball lies in the anterior part of the orbit, nearer the
roof than the floor and nearer the outer wall than the inner.
It is supported by orbital fat which is surrounded by the thin
orbital fascia, through which the fat may at times easily her-
niate. The ocular muscles are attached to the globe at one end
and to the posterior portion of the orbit at the other. This ar-
rangement is admirable to make the globe freely movable, but
it does not offer much resistance to external pressure.
The eye ball is dependent upon the bony orbital walls of the
eye lids for protection against external violence. A line from the
superior to the inferior orbital margin would pass through the
cornea, and a line between the lateral margins would leave one-
third of the globe anterior to it. The lateral wall offers the least
protection. The globe tends to rotate since the axis of the orbit
is divergent and the globe in a direct ahead axis, so that its
posterior pole is not much behind the anterior margin of the
lateral orbital wall.
When strong pressure is applied, pushing the globe forward,
there is not much to hold it in the orbit.
Luxation is dislocation of the eyeball so the eyelids close be-
hind it. The optic nerve and the ocular muscles are stretched
but still attached. Such eyes can frequently be replaced within
the orbit without any resulting impairment of vision.
Causes
(1) Deliberate Trauma : (a) Some people can dislocate their
eye ball by a little pressure with their finger, (b) The surgeon
dislocates the globe with the speculum as a part of the opera-
tion to remove an eye. (c) In the old days, robbers were quite
apt to gouge out the eyes of their victims and, in some coun-
tries, one eye was gouged out of all slaves, as a mark of slavery,
(d) Lunatics may gouge out their own eyes, sometimes quoting
Scriptures, "if thine eye offend thee pluck it out." The pro-
cedure of gouging out an eye is described as being done with
the thumb entering the temporal part of the orbit and the fin-
gers on the nose as a support or fulcrum.
(2) Accidental Trauma : Birth injury — usually from forceps.
There are numerous cases on record of an eye ball being dis-
located at birth and being replaced, with good vision resulting.
Other forms of trauma:
Case G. P .: January 12, 1933, a boy was sliding down hill
"belly flop” and the runner of the sled ahead of him in some
way penetrated his left orbit on the nasal side. A passerby
picked him up and stated that he put the boy’s eye back into its
socket. He was brought to Abbott hospital at once. A wound
was present at the left inner canthus involving both eye lids and
the caruncle. There seemed to be some retrobulbar hemorrhage,
as the edges of the lid wounds could hardly be sewed together.
The child stated that he had no perception of light, though the
optic disc and retina seemed to be healthy. This eye remained
blind (a primary optic atrophy developed), never moved well,
and now has a cataractous dislocated lens, retinal detachment
and other signs of degeneration. He is anxious to have the eye
removed for cosmetic reasons, and is to have this done next
week.
(3) Pressure from behind: Exophthalmic goitre, pulsating
exophthalmia, tumor of the orbit, hemorrhage of the orbit
(especially gunshot wounds) , air from blowing the nose, when
a fracture of the naso-orbital wall is present.
(4) Shallow orbit and prominent eye ball. Case L. B.: First
examined at 1 1 months of age, eyes very prominent and ques-
tion of intracranial pressure. The fundi essentially negative.
At the age of four, still prominent eyes and shallow orbits. He
woke up at 5 o’clock one morning with one eye dislocated
and the lids closed behind it. He was taken to Abbott hospital
and, under anesthesia, the eye was replaced. No visual loss
resulted. Three months later the other eye luxated, but went
back spontaneously. An operation was attempted by a neuro-
logic surgeon to enlarge the orbits, but the child did not survive.
Avulsion of the eye ball is a dislocation, plus a tearing of
some or all of the muscles and nerves, so they are not attached
to the eye ball. Cause: Always trauma and usually severe. In
most such cases the eye can not be saved. Some cases of lost
eyes are recorded where the eye was found in the apex of the
orbit, the nose, ethmoids, or antrum.
Case F. ].: A man working on a concrete job fell back-
wards, striking an iron rod which penetrated the left lateral
orbital wall after fracturing and dislocating the malar bone and
pushing the eye out onto the cheek. He was brought to Abbott
hospital within an hour. There was considerable bleeding from
the wound as well as from the nose. This was controlled and
sulfadiazine used locally and by mouth. No evidence of menin-
gitis or local infection developed, and an attempt was made to
replace the globe into the orbit, after reducing the fractured
orbital walls. Not successful, so enucleation was required.
Conclusion
The eye can not stand much pressure from behind, as it is
not very solidly anchored in the orbit.
Luxation or avulsion may occur from many causes, the former
not usually causing the loss of the eye and the latter practically
always.
ENGLISH BUY X-RAY UNITS FOR RUSSIAN ARMY
Thirteen mobile trailer units, each compactly fitted with portable x-ray equipment that
can be set up during battle or air raids in 20 minutes, have been purchased in this country
by English donors for the Russian army.
Designed for use on the fighting fronts and in civilian emergency areas, each trailer carries
complete facilities for fluoroscopy and radiography. Spanish refugees in England donated two
of the units and various English organizations the others. Two units will be shipped first to
England for acceptance ceremonies featuring Mrs. Ivan Maisky, wife of the Russian ambassa-
dor to England.
330
News-Letter
of the American Student Health Association
The Journal-Lancet
MEDICAL COVERAGE FOR ARMY TRAINEES
Max L. Durfee, M.D.,
Student Health Director, Iowa State Teachers’ College,
Cedar Falls, Iowa
(In schools not associated with a medical department
various plans have been worked out to provide complete
medical coverage. The following report, quoted from a
letter from Dr. Durfee, outlines a working plan in a
school training both Army and Navy groups.)
I. Upon arrival of contingent of Soldier-Students
A. Sick call shortly after arrival.
B. Physical inspection of entire new group, usually
day after arrival.
1. Advised concerning daily sick call at 0700 in
a brief talk on personal hygiene.
II. Sick Call Daily at 0700, Sunday at 1000.
A. Soldiers desiring medical consultation requested
to enter names on "Sick Book” after they
arise at 0500. These men brought to Student
Health Service from command headquarters
by one of non-commissioned officers on med-
ical staff. Each is disposed of in one of the
following ways.
(1) Any soldier with a temperature above 98.6,
with occasional exception, is admitted to
College hospital for observation, further ex-
amination, diagnosis and care as needed.
We have never regretted following this
rule. Other cases requiring hospitalization
are also sent directly from sick call.
(2) Minor treatments carried out by enlisted staff,
under supervision of Health Director.
(3) Arrangements made for appointment with
local specialists, mainly EENT, and for
necessary dental work.
(4) Recommendations made by Health Director
for limited duty when indicated. Most
Health Service workers will recognize in
this a similarity to civilian student’s requests
for excuse from physical education. The
Army calls it "Gold Bricking.”
(5) Occasional student sent to room for rest, or,
as the Army says, is put in Quarters.
B. Soldiers required to report illnesses at sick call
whenever possible, but obviously, since illness
does not strike by the clock, provision must
be made for medical consultation at other
times. Except in emergency, all soldiers must
enter their names on the Sick Book before
coming to the Health Service for attention.
Their schedule is such that they do not inter-
fere with the Student Health Service program
when they are really in need of medical care
at odd times. The services of the Director
are available 24 hours daily. Medical care for
the soldiers is simplified by the fact that the
dormitories in which they live, the Health
Service office and the hospitals are in directly
adjacent buildings, so close they almost touch
each other.
III. Hospitalization
A. Complete hospital care, within the limits of phys- i
ical plant and personnel, especially for acute I
medical conditions.
1. Acute surgical emergencies.
a. We have not even had an acute appendix
up to the time this is written (4/2
months). If one occurs, it would be
transferred to local City hospital and
operated with the help of Navy sur-
geons, resident on this campus.
b. We have been able so far to take care of
all fractures and minor surgery that we
have encountered.
2. Elective surgery.
a. When some defect interferes with a sol-
dier’s efficiency, and surgery is indicated,
he is transferred to one of the Army
hospitals in this area, usually Schick
General Hospital in Clinton, Iowa.
3. Medical conditions requiring long hospitaliza-
tion, when able to be moved, also trans- I
ferred to Army hospital.
4. Laboratory.
a. There has never been a satisfactory labora- I
tory for our Student Health Service.
We had a good microscope. The Navy I
had none. As a result, because they are j
well staffed, they do our laboratory work !
in return for the use of our microscope, i
the use of our sterilizer facilities and 1
our x-ray darkroom. The Army and '
Navy really cooperate on this campus.
B. It has been necessary to increase our permanent I
bed capacity from 11 which was adequate for
the college students, to 28. This was done by 1
remodeling one of the three buildings in our
Health Service group (hospital, health serv- !
ice, isolation hospital) that had been infre-
quently used in the past for isolation. Our
permanent nursing staff was increased from 1
three to six.
IV. Miscellaneous
A. Reports
1. All paper work is done by two soldiers, a Cor-
poral and a First Class Private, sent here j
on detached service to constitute the Med- 1
ical Staff. All reports must be checked and
signed by the Health Director. They in- !
elude the following.
a. Weekly — Strength of Command and com-
municable disease report.
b. Monthly — Sanitary report; venereal disease
report; Form 52, a copy in duplicate of
October, 1943
331
which is made out for each hospital ad-
mission, each soldier put in quarters and
every medical transfer to another hos-
pital. This has the soldier’s identifica-
tion and diagnosis and is signed by the
Health Director.
2. Form 52A. This is similar to the dispensary
record kept on each student coming to the
average Health Service for medical atten-
tion. On this form are recorded all the
pertinent findings of each visit of the sol-
dier to the dispensary, usually at sick call.
B. Physical Examinations and Inspections
1. Physical inspections are made on each group
of soldiers shortly after their arrival at the
station. This inspection is somewhat more
than casual but much less than a complete
physical examination. Its purpose seems to
be to detect cases of venereal disease, dis-
orders having skin manifestations, and give
the physician a chance to estimate the per-
sonal cleanliness of the group. Each group
of departing soldiers is also subjected to
an inspection.
a. Monthly inspection of entire command, ex-
cept commissioned officers.
b. 1617 inspected during the first 3 months
of program.
2. Physical examinations, done at request of
Commanding Officer for the following rea-
sons. ( 1 ) Soldiers being transferred to an-
other branch of service because of being
mal-adapted to the demands of this pro-
gram. (2) Non-commissioned officers
scheduled for or desiring advancement in
rank. (3) Soldiers being released from
Army. Agricultural discharge is an ex-
ample.
C. Immunization procedures.
1. Most of the soldiers coming to this station
have been in the Army too short a time
to have completed their typhoid and teta-
nus series. Others have been in long
enough for their immunizations to be out-
dated so require repetition or "booster
shots.” 1517 injections given during first
three months of program.
D. Supervision of Sanitation of Environment.
1. All campus food handlers examined. The size
of this force may be realized when it is
understood that 6,000 meals are served
daily in the College Food Service. Tuber-
culin testing, x-ray of positive reactors, an-
nual retesting of negative and re-raying of
positive reactors, blood tests and vaccina-
tions are done on these people.
2. Supervision of swimming pool and shower
room sanitation.
3. Establishing of quarantine and inspection of
contacts of communicable disease.
V. Finance.
A. This is handled entirely through the business
office of the college and is determined by the
President of the college and the Army con-
tracting party.
PERSONAL ITEMS
Dr. Jerome E. Andes, formerly director of Health
Service at the University of Arizona, who for the past
year has been medical director of the Sunflower Ord-
nance Works, has recently accepted an appointment at
the University of West Virginia at Morgantown. Dr.
Andes will direct the Health Service and in addition will
do some teaching.
ASHA DIGEST OF MEDICAL NEWS
The BuMed News Letter of August 20, 1943, sum-
marizes our present knowledge regarding the isolation
periods necessary for the ordinary communicable dis-
eases as follows:
"In combating the spread of communicable diseases,
the isolation of the case throughout the period of marked
infectivity is of considerable importance. At best, how-
ever, this can be only partially accomplished, for the
period of infectivity so often begins hours or days before
symptoms sufficiently manifest themselves to make pos-
sible a diagnosis. Mild subclinical infections go undiag-
nosed, yet serve to spread infection to others. Obviously,
with such initial gaps in isolation procedure, we can hope
to gain but little by being hyper-meticulous in carrying
out the latter part of the isolation process. The effort
should be two-fold: (a) to prevent, as far as practicable,
the spread of infection to others; (b) to keep the time
lost by the case in isolation at a minimum.
With this double objective in mind, we should avoid
on the one hand, such lax regulations as would permit
German measles cases to carry on their regular duties
and contacts in the obvious presence of rash and swollen
post-cervical lymph nodes, and on the other hand, such
strict regulations as would keep scarlet fever patients
routinely under isolation for six weeks or more. A well
balanced communicable disease control program will en-
deavor to isolate suspected cases promptly and freely;
will release them just as promptly when observation
shows the suspicion unfounded; and will extend the iso-
lation only through the definitely and dangerously in-
fective period.
Recommended isolation periods for the more common
communicable diseases are as follows:
Measles. Communicable from the onset of the catar-
rhal symptoms (usually at least three days before the
appearance of the rash) until the catarrhal symptoms
have ceased (usually shortly after the return of the
temperature to normal and well before the rash has com-
pletely disappeared) . In a case without complications or
abnormal discharges, release from isolation is usually
safe any time after the fifth day following the appear-
ance of the rash, provided the catarrhal symptoms have
ceased.
(Continued on page 336)
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
South Dakota State Medical Assn
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn
Montana State Medical Assn.
Dr. J. P. Ritchey, Pres.
Dr. M. G. Danskin, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Treas.
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
BOARD OF EDITORS
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres.-Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
Dr. J. A. Myers, Chairman
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
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 84 South Tenth Street, Minneapolis, Minnesota Klein, 1851-1931
Minneapolis, Minnesota, October, 1943
PEDIATRICS COMING BACK
On a trip to a medical meeting in Wisconsin about
three years ago, a prominent St. Paul pediatrician made
the startling statement "Pediatrics is a vanishing spe-
cialty.” Naturally it became necessary for him to sub-
stantiate the basis for his conviction, and this he pro-
ceeded to do by relating that the Children’s Bureau,
United States Department of Labor, published pam-
phlets on child management in health and disease. These
rather complete booklets, edited by eminent authorities
on infant care, are distributed free of charge to all who
may apply. No one can find any fault with this because
its laudable purpose is to supply enlightenment to every
home in an effort to improve the race. Then he referred
to infant feeding, which formerly consumed so much of
the pediatrician’s time, being served more and more by
baby food manufacturers in supplying tables and for-
mulas the directions and appropriate modifications of
which the general practitioner or intelligent mother can
understand and follow. Finally he cited the reduction in
children’s diseases due, not only to the above mentioned
publicity, but, in a large measure, to vaccines and sera
whose administration require no special skill.
He seemed to have proven his contention but if he j
were alive today it would be a pleasure to call his atten-
tion to certain changes that have taken place since then
to increase pediatric practice. Basically because there are
more babies in our midst. We would not infer that the
drafting of fathers has had anything to do with it;
rather let us assume that the increased birthrate that our
country has experienced is somehow more of a patriotic
urge. "Birth control,” to some an ominous portent a few
October, 1943
333
years ago, seems to have been discarded for planned par-
enthood, judging by our crowded maternity wards, and
this should give heart to disconsolate pediatricians. Ob-
stetricians are having their inning now but this bids well
for a pediatric boom.
A.E.H.
PRESSURE AND THE PRESS
Some time ago we were apprised of the fact that Oc-
tober with its other bounties would bring out National
Newspaper Week, devoted to freedom of the press.
Perhaps by the time this reaches you it will be taken care
of and over with but, even so, there is no harm in mis-
interpreting the banner enough to do a little mild grum-
bling about the undesirable liberties of the press as they
affect the doctor.
We refer especially to the premature, irresponsible,
and often incorrect news reports of medical discoveries
and "cures”. Every medical meeting of any size seems
to be followed by a plague of them. Someone reports
work in progress on the treatment of asthma, for exam-
ple, and by the time the home town papers pick it up
the unsuspecting medical essayist has caused a disruption
in economics, transportation, and housing. He has to
spend all his time explaining, move out of town, or enjoy
a brief but insecure period of big business until the sound
and the fury dies.
No matter how carefully a medical news article is
worded it seems to be pounced on as a sure cure by the
public. Then come the phone calls to the doctor to see
if it’s true what they say in the paper about arthritis,
blood pressure, or cancer.
There was once an advertiser who had a voice boom
out at intervals on the radio: "Many people are using
such-and-such for hay-fever.” That was true — many mis-
guided sufferers were trying it at somebodies’ suggestion
— and it was doing them no harm. But the public’s amaz-
ing ability to interpret the news to suit their own fancy
is something from which they should be more carefully
guarded. But that is getting away from the freedom of
the press and into a more questionable field. All that is
intended here is to remark that the fourth estate, like
the first profession, is often guilty of taking advantage
of a well known public weakness.
There have also appeared in recent years many things
to indicate that the medical profession is not always one
hundred per cent perfect.
L.M.D.
WORLD IS WARNED ON TUBERCULOSIS
Dr. Esmond R. Long of the Henry Phipps Institute
of the University of Pennsylvania and Dr. Robt. E.
Plunkett of New York State Department of Health are
quoted thus in a recent issue of Consumer Reports,
published by Consumers Union: "A grave menace exists
of another world-wide recrudescence of tuberculosis. Its
prevention will require vigorous effort against the spread
of infection and all measures possible to maintain a high
level of resistance to disease.”
BmU Timms
Nephritis, by Leopold Lichtwitz, M.D. Cloth. New York:
Grune and Stratton, Inc., 1942, 328 pages with 120 tables
and illustrations, price $5.50.
This monograph represents a compilation of the author’s life-
time observation of nephritis and allied renal diseases. It pre-
sents some unique viewpoints which will be useful to the stu-
dents of nephritis both from the academic and practical aspects.
Upon first reading, some of the author’s concepts appear to be
in direct disagreement with theories which the student may
have acquired from other schools of nephritis research. How-
ever, the methods of treatment which are summarized give the
physician a practical approach to dealing with all types of renal
disease. The author includes sections on disorders of the kid-
ney in pregnancy, the central nervous system and endocrine in-
fluences on renal disease, and has an excellent review of the
allergic mechanism in the nephritic syndrome.
The Blood Bank and the Technique and Therapeutics of
Transfusions, by Robt. A. Kilduffe, A.B., M.D., F.A.C.S.,
and Michael De Bakey, B.S., M.D., F.A.C.S. 558 pp., 214
illustrations and 1 color plate. St. Louis: C. V. Mosby,
1942. $7.50.
The book presents an amazingly complete and comprehensive
review of the literature on all aspects of the blood transfusion
problem. An outstanding feature is the excellent extensive bib-
liography at the end of each chapter. The illustrations and lab-
oratory methods described are simple but adequate both for the
doctor who gives an occasional transfusion and the technician in
an active hospital blood bank.
This book makes an easily accessible reference for the gen-
eral practitioner to review known facts on blood groups and
typing, and also makes available in a condensed form the latest
literature on tests for blood incompatibility, changes in stored
blood, and nature of transfusion reactions.
On Your Own: How to Take Care of Yourself in Wild
Country, by S. A. Graham and E. C. O’Roke. Minneapo-
lis: University of Minnesota Press, 150 pages, 1943, price
$2 (trade), $1.50 (text).
On Your Own was undoubtedly stimulated by the war. The
need for advice on matters essential for self-preservation under
geographical and climatic conditions unusual for the ordinary
urban civilian, motivated Professors Graham and O’Roke to com-
pile a manual useful for anyone stranded in tropical jungles or
Arctic regions. In a small manual of 150 pages, these experi-
enced and widely traveled woodsmen have compressed informa-
tion suitable for any situation from blisters to bedbugs.
By eliminating all data already available concerning first aid,
camping, venereal disease and other matters which every Boy
Scout should have learned, the authors have given valuable help
on such practical considerations as to what edible plants and
animals may be obtained in particular localities, how to avoid
submersion in quags and bogs, what to do when lost, and many
other important details esoteric to undisturbed city folks but
vital when these protected persons are projected into foreign and
strange situations.
This small, compact volume would be a valuable addition to
the impedimenta of anyone going to foreign lands. It should be
a complement to whatever official bulletins are included in the
kits of soldiers, sailors and marines destined for foreign service.
334
The Journal-Lancet
Views Items
Dr. Ernst Gellhorn of the department of physiology,
University of Illinois College of Medicine, author of
"Studies on Conditioned Reactions and their Clinical
Implications,” leading this number, which constituted
the third annual Journal-Lancet Lecture given on
May 19 at the University of Minnesota, has joined the
staff of the latter institution. He has accepted a profes-
sorship in the department of physiology and removed to
Minneapolis. He will head the special unit in neuro-
physiology for the study of infantile paralysis that the
National Foundation is setting up at Minnesota. The
conditions of the grant by the Foundation were reported
at length in these columns in the August issue.
Mike Mansfield, representative to Congress from the
western Montana district, states that many Montana
dude ranches and lodges have opened their property to
the government for the rehabilitation of returned service
men who require psychiatric treatment. He urges the
utilization of the greatest possible number of them and
increased use of the hospital for the veterans’ facility at
Fort Harrison.
Lieutenant Colonel Edwin S. Murphy, physician of
Missoula, Montana, now is director of the office of med-
ical information in the surgeon general’s office at Wash-
ington, D. C.
It is reported in the newspapers of the state that it was
at the instance of the North Dakota State Medical As-
sociation, which found that insufficient medical service
was available currently in McKenzie county, that Dr.
Jesse W. Moreland, a former Ward county health officer
and a physician at Carpio for many years, removed to
Watford City, McKenzie county.
Through the efforts of the Red Cross chapter of High-
more, South Dakota, the community has secured the
professional services of Dr. E. A. Wilkinson, formerly
at Haiti, a physician of 38 years’ experience.
Drs. Geo. H. Williamson, Grand Forks, Archie D.
McCannell, Minot, and Willard A. Wright, Williston,
have been reappointed to the state board of medical ex-
aminers by Governor John Moses.
An auxiliary unit to the Silver Bow County Medical
Association has been organized at Butte, Montana. Mrs.
R. C. Monahan is acting as temporary chairman and
nominations for permanent officers are to be submitted
at the next meeting by a committee composed of Mmes.
C. B. Rodes, J. C. Shields, T. J. B. Shanley, Sami. E.
Schwartz, R. F. Peterson, D. L. Gillespie, Jno. S. Floyd
and Chas. R. Canty. The organization meeting was pre-
sided over by Mrs. P. E. Logan, Great Falls, president of
the state auxiliary, with Mrs. L. F. Hall, Helena, past
state president, Mrs. A. L. Gleason, Great Falls, state
secretary, and Mrs. D. T. Berg, Helena, national re-
cording secretary, in attendance.
Mrs. Margaret N. Wolfe, secretary of the central of-
fice of the Woman’s Auxiliary to the American Medical
Association, has succeeded Mrs. George H. Ewell of
Madison, Wisconsin, in the work of the office of chair-
man of press and publicity.
The officers and councillors of the South Dakota State
Medical Association held a business meeting at Huron,
Saturday, September 11, all officers and all councillors
except one being present. Routine business matters were
disposed of and a decision reached to hold the 1944
annual meeting of the Association with a scientific session
at Huron in May.
Dr. Owen H. Wangensteen, director of the depart-
ment of surgery, University of Minnesota Medical
School, announces that the eleventh E. Starr Judd lec-
ture will be given by Major General Norman T. Kirk,
Surgeon General, United States Army, War Depart-
ment, at the University of Minnesota, Monday evening,
December 6, at 8:15 o’clock in the Museum of Natural
History auditorium. The subject is "Surgery in War.”
Dr. E. Martin Larson, Great Falls, Montana, presi-
dent of the state tuberculosis association, delivered an
address "The General Practitioner’s Role in the Work
of Offsetting a Threatened War Time Rise in Tubercu-
losis” at the annual meeting of the association in Helena,
September 11th. Dr. Thomas F. Walker, Great Falls,
presented a report on that city’s tuberculosis program.
Miss Mary Dempsey, statistician for the National Tuber-
culosis Association, spoke on sanatorium problems. Drs.
Herman F. Schrader of Browning and John DeCanio of
Crow agency reported on health problems among the
Blackfeet and Crow Indians and a group of Blackfeet
Indians performed an Indian dance.
Mrs. P. C. Gaines, Bozeman, president of the Gallatin
County Tuberculosis Association, reported on the tuber-
culosis case-finding program among Montana State col-
lege students. Lucien Benepe of the state board of
health submitted a summary on 1942 tuberculosis mor-
tality rates in the state and Lief Fredericks of the state
bureau of vocational rehabilitation recounted the work
of the bureau with tuberculous patients. A symposium
on tuberculosis control among special groups was led by
Drs. Jos. L. Mondloch, Butte, James M. Flinn, Helena,
and Marion S. Lombard, Spokane, Washington.
Lt. George A. Gray has taken over the duties of base
surgeon at the Mitchell, South Dakota, Army Air Base,
filling the vacancy left by the transfer of Lt. Thomas E.
Crowell. Lt. Gray formerly was stationed at Sioux City,
Iowa, and brings Mrs. Gray and baby son to Mitchell.
Dr. Bernard S. Clark, who practiced at Manchester,
Missouri, has taken residence at Spearfish, South Dakota.
Dr. C. B. Darner of Fargo, North Dakota, has joined
the personnel of the Medical Corps station at Mojave,
California.
Dr. L. J. Nessa, who has been at the Black Hills ord-
nance depot at Provo, South Dakota, has been trans-
ferred to the St. Louis, Missouri, ordnance depot of
infirmary.
SHAFT OF LIGH T — Prostigmin ‘Roche’ is undoubtedly one of the most outstanding
achievements of the past decade. In clinical research Prostigmin is proving a shaft of light, helping
the profession to combat successfully a number of disorders, the treatment of which has hitherto
been a groping in the dark. Surgeons everywhere use it as a routine measure in preventing abdominal
distention and urinary retention — and to the myasthenia gravis patient Prostigmin has indeed come
as a shaft of light in his dark world of suffering and disability . . . Hoffmann - La Roche, Inc.,
Roche Park, Nutley, New Jersey — Makers of Medicines of Rare Quality
PROSTIGMIN ‘ROCHE’
336
The Journal-Lancet
Major John R. Vasko, M.C., of Great Falls, Montana,
has been at the Fresno, California, Station for the past
five and a half months.
Captain Paul T. Cook, M.C., of Valley City, North
Dakota, after eight months at the Army Air Corps gun-
nery school at McCarran Field, Las Vegas, Nevada, has
been transferred to the field at Stockton, California.
Dr. Erhart E. Zemke, physician and surgeon who en-
listed from Fairmont, Minnesota, has been promoted to
a captaincy.
Dr. J. M. Spatz of Cut Bank, Montana, is serving
with the field artillery command at Ft. Leonard Wood,
Missouri.
Dr. William A. O’Brien, director of postgraduate
medical education at the University of Minnesota, was
honored by the award of a fellowship by the American
College of Fdospital Administrators at the annual meet-
ing of that organization at Buffalo, New York. Ffe was
cited for his "profound interest in problems of the Hos-
pital Administrator, manifested by outstanding service
as director of seven institutes for hospital administrators
at the center for continuation study, University of Min-
nesota.”
yiw&toQij-
Dr. Philip A. Delavan, 44, St. Paul, died September 6
at St. Joseph’s Fdospital after an illness of 11 days. Fde
had practiced in St. Paul for 14 years. Fde was resident
physician at Ancker hospital for eye, ear, nose and throat
ailments, was on the staff at St. Joseph’s and Children’s
Fdospitals as well as on the staff of the University of
Minnesota Student Fdealth Service.
Dr. Wilfred F. Lowe, 40, former Grand Forks resi-
dent, lately residing at Jackson, California, died at the
latter place September 11. Fde had practiced in Jackson
for fifteen years after graduating from the University
of North Dakota and completing his medical training
at Rush Medical School, Chicago.
Dr. Andrew J. Gifford, 62, for 42 years a practicing
physician of Alexandria, South Dakota, suffered a stroke
September 14th and died suddenly at his home in Al-
exandria.
Dr. Ernest G. Sasse, 73, Richland County physician
and surgeon for 39 years, died Wednesday, September
15th, at his home in Lidgerwood, North Dakota. Fde
was born in Minnesota and had practiced in Bridger and
Bear Creek, Montana, as well as in North Dakota.
Dr. John Butler, 67, former University of Minnesota
medical school professor, and one time assistant city phy-
sician, died September 17th, at his home in Minneapolis
after an illness of several weeks. Dr. Butler was the
author of several medical books, had served with distinc-
tion to his profession in the last war, and was a member
of county and state medical bodies, the American Uro-
logical Association and the American Dermatological
Association.
ASHA NEWS-LETTER
(Continued from page 331)
Mumps. Communicable from 24 hours preceding the
appearance of symptoms until the subsidence of all swell-
ing in salivary glands or involved testicles. Release from
isolation is usually safe 24 hours after all swellings of
salivary glands or testicles have subsided. (It should be
remembered, however, that with adult males the chance
of orchitis persists for about one week after the sub-
sidence of the parotitis.)
Rubella. Apparently communicable from 24 hours pre- i
ceding the appearance of the rash until the subsidence of
the rash. Release from isolation is usually safe 24 hours i
after the disappearance of the rash.
Scarlet fever, Streptococcic pharyngitis, Streptococcic
tonsillitis. Most communicable in the first two weeks of
the illness, communicable in the third week in approxi-
mately 25 per cent of cases, communicable in the fourth
week in approximately 5 per cent of cases, communicable
after the fourth week in approximately 1 per cent of
cases. Release from isolation is usually safe 21 days ■
after the onset of the disease, provided there are no com-
plications or discharges. For another three weeks after
release from isolation the patient should consider his nose
and throat secretions still possibly dangerous to others.
Desquamation has no relation to communicability.
Chickenpox. Infectious from 24 hours preceding the
appearance of the eruption until there are no longer any
actual pustules. Release from isolation is usually safe '
when all pustules are gone (usually about seven days
from onset) , and the patient has taken a thorough bath
and shampoo. The dry scabs apparently bear no relation
to communicability.
Meningococcus meningitis. Probably communicable
throughout the course of the disease and until the men-
ingococci have disappeared from the secretions of the
nose and throat. Release from isolation is usually safe
when 14 days have elapsed since the onset and the fever
has subsided.
Poliomyelitis. Apparently communicable the last one
or two days of the incubation period, and for the first .
seven to ten days of the disease (virus may be found in
the stools even much later in the disease) . Isolation is
necessary only during the first 14 days following onset.
Smallpox. This disease is apparently the most com-
municable of all diseases. It is communicable from the
inception of the first signs or symptoms until the com-
plete disappearance of all crusts and scabs. There is
some evidence that the disease is communicable in the i.
last one or two days of the incubation period. Isolation j
in screened quarters, free from vermin, is necessary until j
recovery is complete and all crusts and scabs have dis-
appeared.
Diphtheria. Communicable from 24 hours before the
onset of symptoms until the diphtheria bacilli have dis-
appeared from the nose, throat or other site of infection.
Isolation should be continued until symptoms and dis-
charges have ceased and two successive nose and throat ,
cultures, taken no less than 24 hours apart, are negative.”
Introduction to the Symposium on Vitamins
Ancel Keys, Ph.D.f
Minneapolis, Minnesota
THE subject of the vitamins has acquired both sci-
entific importance and public interest which could
scarcely have been imagined a dozen years ago
although at that time the major vitamin deficiency dis-
eases were by no means terra incognita, and inspired sug-
gestions as to their manner of action had foreshadowed
modern work on the behavior of some of them as en-
zymes. The progress of research has been so rapid that
the significance of many findings has not yet been eval-
uated properly. As in some other fields, the most ob-
viously difficult transition is that from chemistry to exact
clinical application. In the case of the vitamins there has
been a tendency by clinicians to obviate the problem by
adopting the "conservative” policy of prescribing vita-
mins in case of doubt since, with the exception of vita-
min D, they are almost completely non-toxic. Most in-
ternists realize that, as a result of popular "education”
and commercial propaganda, vitamin administration may
confer important psychological benefits quite apart from
direct effects on intermediary metabolism.
The complexity of the problem of vitamin require-
ments of man is amply illustrated in the papers in this
symposium. "Subclinical” deficiencies pose a most diffi-
cult problem. Until recent years it was considered that
for each vitamin there is a general level of intake below
which a frank deficiency disease would develop and above
which there is no effect. With the realization of the in-
adequacy of this view the idea has developed that there
might be a more or less direct quantitative relation be-
tween the amount of the intake of some of the vitamins
and the general health and vigor. The truth of the mat-
ter is probably between those extremes but we are far
from having precise answers as yet. Unfortunately there
t Laboratory of Physiological Hygiene, University of Minnesota.
undoubtedly are important individual variations, especial-
ly in the presence of other disease. Clinical experience
with patients suffering from deficiency diseases may lead
to erroneous conclusions about the public at large. The
limited number of controlled studies on normal persons
may not apply to those who are not so "normal”. Modi-
fying factors may exist in other elements of the diet, in
the nutritional history and even in the climate or occu-
pation.
In the past few years there have been many reports on
the prevalence of vitamin deficiencies in the United
States and Canada. In general these reports show that
diets which do not conform to certain "recommenda-
tions” are very common and that one or more signs or
symptoms which may occur in cases of true vitamin de-
ficiency are so frequent as to be almost universal. The
alarming conclusions that are frequently drawn from
such studies depend on the acceptance of standards and
criteria that are necessarily arbitrary. The recommenda-
tions of the National Research Council (1941) may be
defended on the ground that the vitamin intakes thus
provided would safely cover all reasonable contingencies
with a generous margin. On the basis of present knowl-
edge, however, it is not justifiable to conclude that health
and vigor are jeopardized if these recommendations are
not met.
Dietary surveys have provided much useful informa-
tion.17’28’34’35'40 The utility of such surveys is strictly
limited by the present fragmentary state of knowledge
as to real human requirements. Another type of survey
provides data on the frequency of signs and symptoms
which may be related to the vitamin adequacy of the
diet.3’4-23’36 We can agree with Mackie (1942) that:
"Investigators working in different areas are not in agree-
338
The Journal-Lancet
ment concerning the incidence or exact significance of
particular symptoms and particular physical signs,” (p.
276), and, "It must be emphasized, however, that no
symptom or sign can be accepted as diagnostic unless
supported by other evidence,” (p. 277). By and large
adequate "other evidence” is lacking in reports which
purport to show that vitamin deficiency is exceedingly
common in school children, W.P.A. personnel, factory
workers and so on.
It is easy to criticize reports which rely on symptoms
like "lack of appetite,” "lassitude,” "muscle pains,” and
"irritability,” or on signs such as "poor muscle tone,”
"unexplained dermatitis,” "fatigue of accommodation,”
and so on. Acceptance of such criteria means that every
neurasthenic and every biologically inferior person would
be counted as a case of vitamin deficiency. Even more
definite observations are less specific than commonly sup-
posed. For example, the correlation between night blind-
ness and vitamin A is not close except under some highly
artificial experimental conditions.12,27,32,38,39
The case of corneal vascularity and of other ocular
manifestations emphasized for the diagnosis of aribofla-
vinosis15,28’29 is instructive. Vascularity of the cornea
develops in rats deprived of riboflavin2,8 and in some
cases ocular lesions in man have responded to treatment
with this vitamin.25,26 On this basis some investigators
diagnose ariboflavinosis from corneal vascularity alone.36
The application of this criterion to 1171 aircraft workers
results in the conclusion that "every subject, regardless
of age or economic status must be considered deficient in
riboflavin” (Borsook, Alpert and Keighley, 1943, p. 133).
It is interesting that "no correlation was found between
ocular complaints, the incidence of cheilosis and corneal
vascularity” (ibid.). Study of the diet of the same air-
craft workers showed that 29.2 per cent of them had a
regular daily intake of 2.7 mg. or more of riboflavin.35
Only one of 198 Canadian aviators was free from vascu-
larity of the cornea (Tisdall, 1943). However, in con-
trolled experiments corneal vascularity does not develop
with a daily intake of 0.5 to 1 mg. of riboflavin contin-
ued for many months.14,24,37 On the other hand, appli-
cation of intensive riboflavin supplementation to aviators
with corneal vascularity resulted in improvement in most
of them in two months.31
The argument of the prevalence of corneal vascularity
undoubtedly has been an important factor in estimating
a high incidence of ariboflavinosis in the United States.
The present indications are that, except for this argu-
ment, a riboflavin intake of about 1.5 mg. per day could
be accepted as fulfilling all requirements. If riboflavin is
needed to prevent corneal vascularity then possibly much
more than the N.R.C. recommendation of 2.7 mg. would
be required.
It is tempting to draw important practical conclusions
from surveys of the amount of certain vitamins in the
blood or urine but the proper interpretation of these
surveys is uncertain. For example, it is frequently as-
sumed that a level in the blood plasma of less than 0.5
mg., or even 0.75 mg., per cent of ascorbic acid is in-
dicative of dangerous deficiency of vitamin C. A daily
intake of 75 mg. or more of ascorbic acid would be
needed to maintain the plasma concentration above these
levels. But plasma C of 0.5 mg. per cent is common in
persons who show no other signs or symptcms of de-
ficiency. Rinehart, et al., 22 found 26.6 per cent of 120
"normal” healthy medical students with plasma values
less than 0.5 mg. p>er cent. Dagulf7 found only 7 cases
of clinical deficiency of ascorbic acid in 20,000 persons
but a study of 326 representative persons showed that in
the spring only 6 per cent of these had plasma ascorbic
acid concentrations as high as 0.5 mg. per cent and even
at the time of the peak vitamin C intake (summer) 11.5
per cent were below this level. Lower levels prevailed in
255 tubercular patients and extra ascorbic acid given to
these persons for up to 6 months had no effect on any
aspect of health. In another group of 125 patients with
plasma ascorbic acid lower than 0.5 mg. per cent there
were no signs or symptoms referable to the vitamin C
nutrition.1 In a group of 60 children studied at intervals
from May through the following March more than 50
per cent had plasma levels below 0.5 mg. per cent for the
entire period yet weight, growth, gums, teeth, and so on
were normal and there was no difference in the general
health of children who characteristically had a low plas-
ma ascorbic acid level and those who regularly had high
levels.11 In studies of industrial workers about half the
men showed plasma ascorbic acid values below 0.5 mg.
per cent (78 men23, 1160 men3), yet no other signs or
symptoms of ascorbic acid deficiency were seen. The be-
lief that plasma ascorbic acid values reflect only relatively
recent dietary history10 does not improve the argument
that the frequency of values below 0.5 indicates a de-
plorable state of vitamin C nutrition. Skepticism, based
on reasonable arguments, about setting ascorbic acid re-
quirements as high as 60 or 75 or more mg. daily has
been expressed by Rietschel, 19,20 Fox and Dangerfield,9
and others.
The state of fomented alarm about vitamin deficiencies
in this country has been sharply criticized by Clendening4
who cites many facts that are difficult to reconcile with
statements popularized in nutrition campaigns and com-
mercial advertising. It would seem fair to conclude that
even if "subclinical vitamin deficiency” is frequent — and
this is not proved — it is extraordinarily benign and scarce-
ly warrants heroic efforts to correct in the midst of the
crisis of war. From the scientific viewpoint one could
wish for much more controlled research and far less
propaganda on the subject.
Intakes of vitamin A, thiamine, riboflavin and ascorbic
acid at levels much below the average American dietary
produce no real deterioration for months and very spe-
cial diets are required to produce true deficiency disease,
even in the mildest form, in normal adults within half
a year.5,6,13,14,21,33 It may be that vitamin requirements
of man are very different for 20 years than they are for
a year. The ultimate effects of subsistence of man at
moderately low levels of vitamin intake for very long
periods are not known.
Vitamin requirements have become more than a diffi-
cult scientific and medical question; already they have
great sociological implications and tend to become a sym-
bol of demands for economic equalization. This develop-
November, 1943
339
ment is most marked in the United States but it is rec-
ognized in England and elsewhere. The responsibility of
the scientist and the physician in all this is arguable. For
both it is probably desirable to extend their sociological
consciousness beyond the ordinary horizons of their daily
activity. But for both the primary responsibility remains
the most honest performance in their chosen sphere of
personal work. If that work touches on the vitamins
then symposia like the present should serve a useful pur-
pose. Even though there is a tendency at present to reg-
ulate nutrition by government it may be expected that
the individual physician will still have some latitude in
which to exercise sound judgment based on scientific
knowledge.
Bibliography
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11 1:1, 1940.
2. Bessey, O. A., and Wolbach, S. B. : J. Exp. Med. 69:1,
1939.
3. Borsook, H., Alpert, E., and Keighley, G. L.: Milbank
Mem. Fund Quart. 21:1 15, 1943.
4. Clendening, L.: J.A.M.A. 1 17:1035, 1941.
5. Crandon, J. H.. and Lund, C. C. : New England J. Med.
222:748, 1940.
6. Crandon, J. H., Lund, C. C., and Dill, D. B.: New Eng-
land J. Med. 223:353, 1940.
7. Dagulf, H.: Klin. Wchnschr. 18:669, 1939.
8. Eckardt, R. E., and Johnson, L. V.: Arch. Ophth. 21:3 15,
1939.
9. Fox, F. W., and Dangerfield, L. F.: Proc. Transvaal Mine
Med. Off. A. 19:19, 1940.
10. Greenberg, L. D., Rinehart, J. F., and Phatak, N. M.: Proc.
Soc. Exp. Biol. Qc Med. 35:1 35, 1936.
11. Holmes, F. E., Cullen, G. E., and Nelson, W. E.: J. Pediat.
18:300, 1941.
12. Keys, A.: Federation Proc. 2:164, 1943.
13. Keys, A., Henschel, A. F., Mickelsen, O., and Brozek, J.:
J. Nutr. in press, 1943.
14. Keys, A., Henschel, A., Mickelsen, O., Brozek, J., and
Crawford, J. H.: In press, 1943.
15. Kruse, H. D., Sydenstricker, V. P., Sebrell, W. H., Jr., and
Cleckley, H. M.: U. S. Public Health Rep. 55:1 57, 1 940.
16. Mackie, T. T.: Clinics 1:271, 1942.
17. McHenry, E. W.: Canad. Pub. Health J. 30:4. 1939.
18. National Research Council: Committee on Food and Nutri-
tion: Recommended Dietary Allowances, distrib. by Fed. Security
Agency, Washington, D. C., 1941. (Also, J. Am. Diet. A. 17:565,
1941.)
19. Rietschel, H.: Deutsche med. Wchnschr. 64:1 382, 1938.
20. Rietschel, H.: Deutsche mil. Arzt. 4:1, 1939.
21. Rietschel, H., and Mensching, J.: Klin. Wchnschr. 18:273,
1939.
22. Rinehart, J. F., Greenberg, L. D., Baker, F., Mettier, S. K.,
Bruckman, F., and Choy, F.: Arch. Int. Med. 61:537, 1938.
23. Schnedorf, J. G., Weber, C. J., and Clendening, L.: Am. J.
Digest. Dis. & Nutrition 9:188, 1942.
24. Sebrell, W. H., Jr., Butler, R. E., Wooley, J. G., and
Isbell, H.: U. S. Public Health Rept. 56:510, 1941.
25. Spies, T. D., Bean, W. B., and Ashe, W. F.: Ann. Int.
Med. 12:1830, 1939.
26. Spies, T. D., Vilter, R. W., and Ashe, W. F.: J.A.M.A.
1 13:931, 1939.
27. Steven, D., and Wald, G.: J. Nutr. 21:461, 1941.
28. Stiebeling, H. K., and Phipard, E. F.: U. S. Dept. Agric.
Circular No. 507, U. S. Govt. Printing Office, 140 pp. 1939.
29. Sydenstricker, V. P.: Am. J. Pub. Health 31:344, 1941.
30. Sydenstricker, V. P., Geeslin, L. E., Templeton, C. M., and
Weaver, J. W.: J.A.M.A. 1 1 3:1697, 1939.
31. Tisdall, F. F., McCreary, J. F., Pearce. H.: Canad. M. A.
J. 49:5, 1943.
32. Wald, G.: Biol. Sympos. 7:43, 1942.
3 3. Wald, G., Brouha, L., and Johnson, R. E. : Am. J. Physiol.
137:551, 1942.
34. Wiehl, D. G.: Milbank Mem. Fund. Quart. 20:61, 1942. A.
35. Wiehl, D. G.: Milbank Mem. Fund Quart. 20:329, 1942. B
36. Wiehl, D. G., and Kruse, H. D.: Milbank Mem. Fund
Quart. 19:241, 1941.
37. Williams, R. D., Mason, H. L., Cusick, P. L., and Wilder,
R. M.: J. Nutr. 25:361, 1943.
38. Wittkower, E., and Rodger, T. F. : Brit. M. J. 1941 (2), 607.
39. Youmans, J. B., and Patton, E. W.: Clinics 1:303, 1942
40. Young, E. G.: Canad. Pub. Health J. 32:236, 1941.
Newer Members of the Vitamin B Complex
C. A. Elvehjem, Ph.D.f
Madison, Wisconsin
THE three best known and most widely used mem-
bers of the B complex have been discussed in other
papers in this symposium. The deficiency diseases
resulting from a lack of thiamine, riboflavin or nicotinic
acid were known before the individual vitamins were
isolated and synthesized. The existence of the remaining
members of the B complex is based largely upon work
with animals and the use of these factors in practical
nutrition is not too clearly understood. This does not
mean that these newer factors are not essential in the
metabolism within the body, but the corresponding de-
ficiency diseases are not so apparent. This situation may
be due to several factors: first, the recognition of the
additional B vitamins is so recent that extensive clinical
studies have not been made; second, these factors are so
widely distributed in a variety of foods that a serious
deficiency is less likely to occur; and third, some of them
at least are produced in the intestinal tract by bacteria.
Two additional compounds, namely, pyridoxine and
pantothenic acid, were added to the B complex between
1938 and 1940. Pyridoxine (vitamin Be) was recognized
through its ability to prevent a dermatitis in rats, which
was observed during attempts to produce experimental
pellagra in rats. It was first obtained in crystalline form
in 1938 and its synthesis was described by Harris and
t Department of Biochemistry, University of Wisconsin.
Folkers1 shortly thereafter. Pyridoxine hydrochloride is
a white crystalline powder, slightly bitter in taste and
odorless, possessing the following formula:
CH.OH
C
HOC CCH.OH
II I
CHmC ch
N
H Cl
Pyridoxine deficiency in the rat has always been asso-
ciated with a specific dermatitis called acrodynia by
Gyorgy,2 although it has been demonstrated3 that a lack
of this vitamin may cause retarded growth without the
dermatitis, if ample fat is supplied in the diet. It ap-
pears4 that linoleic acid, pyridoxine and pantothenic acid
are together concerned in the prevention of dermatitis.
Chick and coworkers5 reported convulsions in pyridoxine
deficient rats and pigs resembling epileptic fits in the
human. Convulsions in dogs were observed by Fouts
et ah, 6 and Wintrobe7 has recently described convulsions
in pigs on pyridoxine low diets.
A microcytic hypochromic anemia also results from a
340
The Journal-Lancet
chronic pyridoxine deficiency in dogs8 and pigs.7 The
hemoglobin and the red cells decrease progressively, the
hemoglobin relatively faster than the red cells. Addition
of pyridoxine causes a large reticulocyte response with
rapid increase in hemoglobin and red cells until the nor-
mal level is attained. Rats,9 pigs10 and to some extent
dogs11 excrete in the urine a green pigment when on
diets low in pyridoxine. Lepkovsky, et al.12 have now
identified this compound as xanthurenic acid and have
shown the compound to originate from dietary trypto-
phane. These and other results indicate that pyridoxine
may be closely related to protein metabolism.
No clear cut symptoms resulting from pyridoxine de-
ficiency have been described in man. Spies, Bean and
Ashe1'1 have reported an additional improvement in pel-
lagrins when given pyridoxine after treatment with nico-
tinic acid, riboflavin and thiamine. Smith and Martin14
observed a rapid and satisfactory healing of the typical
lesions of cheilitis with vitamin Br therapy. Although
clinical treatment of such conditions as Parkinson’s dis-
ease, muscular dystrophy and paralysis agitans has been
studied, the results are not definite enough to permit pos-
tulation of the action of the vitamin or to associate any
one of these syndromes with specific lack of pyridoxine
in the diet. Pyridoxine administration has been used with
some success in reduction in the oiliness of the skin in
cases of acne.16
The human requirement is unknown, but animal ex-
periments indicate that it may be about the same as that
for thiamine, namely, 1 to 2 mg. per day. In fact, the
vitamin Be requirement of chicks is higher than that for
thiamine, 300 7 per 100 grams ration. There appears to
be no difficulty in meeting this requirement because of
the wide distribution in foods. Swaminathan16 found
diets consumed in India to supply 3.5 to 5.0 mg. per
day. Chemical methods have been used for the estima-
tion of vitamin B(; but the rat growth method is still the
most reliable. The yeast method17 has been found to give
results comparable to those obtained with rats. When
bacterial methods are used, tissues have been found to
contain a substance called pseudopyridoxine,18 which is a
thousand times more active than pyridoxine hydrochlor-
ide. Recent work in the author’s laboratory has shown
that this substance shows no greater activity for the rat.
Among the best sources of vitamin Be are rice, bran, liver,
yeast, cereals, legumes, and milk. Whole wheat contains
about 0.46 mg. per 100 grams, most meats 0.4 to 0.7 mg.
per 100 grams on the fresh basis, and fresh vegetables
about 0.1 mg. per 100 gm.
Pantothenic acid in the form of calcium pantothenate
became available in 1940. The term, filtrate factor, was
used for several years to designate that member of the
B complex which prevented dermatitis in chicks. Although
the so-called filtrate fractions from liver extract were
effective in the prevention of black tongue in dogs, pel-
lagra in humans and dermatitis in chicks, it was recog-
nized as soon as nicotinic acid was accepted as the anti-
pellagra factor that the activity of these fractions for the
chick was not due to the nicotinic acid present but to a
separate and distinct vitamin. Woolley, Waisman and
Elvehjem19 and Jukes20 independently demonstrated that
pantothenic acid, which Williams21 had shown to be a
growth factor for yeast as early as 1933, was similar to
the chick antidermatitis factor. The complete synthesis
of calcium pantothenate which has the empirical formula
(Q,H10NOn)2Ca was achieved by Stiller et al.22 The
free acid has the following structure:
H
H
O
CH;i
1
n o
1
n
H
H
HC-
-C
— N C
- C — COOH
H
H
H
H
Rats placed on diets low in pantothenic acid grow very
poorly and develop in a few weeks necrosis of the ad-
renal cortex, a condition first described by Daft and
Sebrell.23 When black or piebald rats are used, signifi-
cant changes in hair pigmentation (graying) can be ob-
served. Unna et al.24 have published photographs of
these fur changes in nutritional achromotrichia. Ralli
and Graef2,1 have shown that adrenalectomy will cause
an increase in the deposition of melanin in the hair bulbs
and follicles of rats showing graying due to filtrate factor
deficiency.
Acute pantothenic acid deficiencies in dogs26 are char-
acterized by sudden collapse associated with decreased
blood dextrose, increased non-protein nitrogen and low-
ered blood chlorides. Severe intussusception in the intes-
tinal tract and fatty livers have also been observed. Scudi
and Hamlin27 found that a lowering of blood lipids
accompanied the production of fatty livers. Hughes28
and Wintrobe et al29 have described the following symp-
toms: slow growth, rough coat, loss of hair, ulcers in the
intestinal tract, and a "goose stepping gait” as a result
of pantothenic acid deficiency in pigs. Phillips and En-
gel30 found specific neuropathologic changes in the spinal
cord of chicks suffering from pantothenic acid deficiency,
and Wintrobe29 has described sensory neuron degenera-
tion.
In spite of these interesting symptoms in experimental
animals, little is known about the importance of this vita-
min in human nutrition. Spies and his coworkers30 con-
cluded from studies based largely on blood pantothenic
acid values that it is essential in human nutrition. Gor-
don31 found the average daily excretion for 40 subjects
to be 3.5 mg. The daily human requirement may fall
within 5 to 10 mg. per day.
The pantothenic acid content of foods may be mea-
sured by growth experiments with chicks, but the micro-
biological methods32 are now in more general use. Liver
is one of the richest sources, containing about 5 mg. per
100 grams fresh liver. Meats, cereals, and milk are also
reliable sources. The administration of pantothenic acid
has produced some improvement in cases of peripheral
neuritis, Korsakoff’s syndrome and delirium tremens.3'1
Brandaleone, et al34 have recently reported that in a
group of 19 elderly individuals with gray hair, a signifi-
cant hair color change was noted in only 2 individuals
during intensive therapy with calcium pantothenate, para-
aminobenzoic acid, and brewer’s yeast.
Although there may be some question about the inclu-
sion of choline in the B complex, the fact that it is now
added to most of the purified diets used in vitamin
November, 1943
341
studies suggests that it is logical to discuss its nutritional
significance along with this group of compounds. Choline
has been recognized for many years as a component part
of the phospholipid lecithin, but its possible need in the
diet was not apparent until Best demonstrated its role in
the prevention of fatty livers in depancreatized dogs.3”
The function of choline is related to the mobilization of
fatty acids in the body, since in its absence liver fat
accumulates rapidly. Fatty livers in rats, induced by feed-
ing high cholesterol diets, do not respond to choline treat-
ment. The observations of du Vigneaud and his collab-
orators36 that the methyl groups of choline as well as
those of methionine and betaine are transferable in the
animal organism have led to the conclusion that one of
the functions of choline is to supply labile methyl groups.
McHenry3'’ states that there is evidence now that choline
may function in at least three ways: to stimulate the for-
mation of phospholipids, to make possible the production
of acetyl choline, or to supply labile methyl groups.
Jukes37 has shown that choline is one of the factors
required in addition to adequate manganese to prevent
slipped tendons or perosis in young turkeys. Depression
of the growth rate when choline is omitted from the diet
has been observed in the case of the rat by Richardson
et al., 38 in the chick by Hegsted et al.39 and in the dog
by Schaefer et al.40
The high requirement of the young rat for choline
has been stressed by Griffith,41 who previously reported
fatty degeneration of the liver, hemorrhagic renal lesions,
ocular hemorrhages and regression of the thymus within
ten days after the rats had been placed on a low choline
but otherwise adequate diet. Cirrhosis of the liver in rats
fed diets low in choline and protein has been reported by
Gyorgy and Goldblatt,42 Blumberg and McCollum,43
Webster44 and Lowry et al.4° The results of these
studies have been summarized in Nutrition Reviews , vol.
1, p. 88, Jan. 1943, as follows:
1. Rats fed a diet low in protein but high in fat de-
velop hepatic change characterized by (a) enlargement
of the liver with a roughened, hob-nail like surface, (b)
central or midzonal areas of necrosis and hemorrhage in
the liver lobule, and (c) periportal increase in fibrous
tissue. At times there is lymphocytic infiltration in the
periportal areas and prominence of bile ducts. In some of
these experiments the changes were similar to those seen
in the livers of patients with portal cirrhosis.
2. The experimentally produced hepatic damage can
be prevented either by increasing the protein content of
the diets or by adding yeast.
3. Cystine aggravates the development of the cirrhotic
process.
4. Choline and methionine (a choline precursor) pro-
vide at least partial protection against the development
of cirrhosis.
Fouts46 has described fatty cirrhotic livers in dogs re-
ceiving the B vitamins in synthetic form without choline.
Partial clinical improvement followed the administration
of large amounts of choline, but combined administra-
tion of choline and liver extract produced more rapid im-
provement although fibrosis of the liver still persisted.
Some success has been reported with choline in the treat-
ment of portal cirrhosis in man (Brown and Muether4’
and Fleming and Snell48) , but the workers suggest that
improvement is possible only when hepatic damage is not
too far advanced. With the present necessary modifica-
tions in the protein and fat sources in the human diet
it would be well to pay some attention to the choline in-
take. Meats, cereals, vegetables and eggs are good sources
of choline. The choline content of a number of animal
and plant products has recently been tabulated by
Engel.49
Although biotin has been recognized as necessary for
the growth of microorganisms for some time, its signifi-
cance in the nutrition of animals has been elucidated
only within the past year or so. Biotin was first isolated
in 1936 by Kogl and Tonnis,50 but its complex nature
and its minute concentration in natural products delayed
identification of its structure. Du Vigneaud and co-
workers’1 have recently shown that biotin has the follow-
ing molecular structure.
O
c
/ \
HN NH
HC — CH
H-.C CH — (CHo)4COOH
\ /
s
Biotin is a stable compound, resisting autoclaving with
strong mineral acids, and in the form found in natural
products is but slowly inactivated with strong alkali. It is
readily destroyed by oxidizing agents.
It has been known for several years that a characteris-
tic syndrome can be produced in rats fed diets contain-
ing high amounts of raw egg white. Lease, Parsons and
Kelly52 found that the rabbit and the monkey also exhib-
ited a typical dermatitis when fed rations containing egg
whites. As early as 1933 Parsons03 concluded that the
injury involved an interrelation between a positive toxicity
and a relative absence of a protective factor, and a little
later Gyorgy named this factor vitamin H. Birch and
Gyorgy ’4 obtained highly potent concentrates of the fac-
tor, and in 1940 du Vigneaud, Melville, Gyorgy and
Rose55 suggested the identity of biotin and vitamin H.
Gyorgy, Rose, Eakin, Snell and Williams06 have now
established the presence of "avidin” (an albumin) as the
biotin inactivating factor in egg white. Thus, it becomes
apparent that egg white injury is due to the unavaila-
bility of biotin by virtue of being tied up with avidin, in
which complex biotin cannot be absorbed from the intes-
tine and is excreted in the feces. Nielsen and Elvehjem,57
using a more complete ration than had been used in the
early work, were able to demonstrate a biotin deficiency
in the rat fed 10 per cent levels of egg white. Typical
symptoms of "spectacled eye” progressing to general alo-
pecia and in the later stages to the onset of a spasticity
and to final death of the animal were recorded. Even the
severe symptoms of spasticity were cured when excess bio-
tin (in excess of that which unites with the avidin) was
342
The Journal-Lancet
added to the diet. On the synthetic diet without the egg
white these workers were unable to demonstrate any signs
of biotin deficiency, and it seems probable that under most
conditions the rat can synthesize, through the medium of
bacteria in the intestine, sufficient biotin for its require-
ment. Biotin deficiency has been reported in the chick
without resorting to egg white diets, which seems to indi-
cate that very limited synthesis of biotin in the intestinal
tract must prevail. A typical dermatitis involving the feet
was found by Hegsted et al'8 to be characteristic of the
deficiency in the chick, and Patrick et al.,59 also have
noted similar dermatitis with turkeys on biotin deficient
rations.
Rather definite information is available regarding the
importance of biotin in human nutrition. Sydenstricker
and coworkers90 produced a deficiency in man by feeding
egg white at a level which supplied 30 per cent of the
calories. Symptoms of dermatitis developed as early as
the third and fourth weeks and other symptoms similar
to those seen in thiamine deficiency were observed. All
symptoms were cured by the parenteral administration of
150 to 300 7 of biotin per day. Oppel61 has shown that
the biotin content of the urine is influenced by the
amount in the diet. Most of the normal subjects excreted
20 to 50 7 per twenty-four hours, and he was unable to
find a single patient who did not excrete biotin. Syden-
stricker’s patients receiving egg white showed levels as
low as 3.5 7 per day. Oppel also reported that diets of
average composition contained 30 to 40 7 per day, or
10 to 16 7 per 100 gram of dry food. The latter value is
interesting because the biotin requirement of chicks is 7
to 10 7 per 100 gram of ration. ’8 When the biotin con-
tent of the feces was also determined it was found that
the total biotin output was three to six times as great as
the intake from the diet. Thus there is apparently intes-
tinal synthesis of biotin in the human as well as in the
rat. The intake of biotin in the diet may not be impor-
tant except in special cases. It should be kept in mind,
however, that a lack of some of the other B vitamins
may cause deficiencies due to reduced synthesis of biotin
as well as a deficiency due to a direct lack of the vitamin
in the body tissues.
The significance of inositol in animal nutrition was
first recognized through the use of the mouse. Eastcott
showed as early as 1928 that inositol would stimulate the
growth of yeast. In 1940 Norris and Hauschildt62 found
that mice failed to grow on a synthetic diet containing
the known members of the B complex. In addition to
lack of growth, the animals showed loss of hair and scaly
dandruff. Liver and yeast supplements produced normal
animals. Woolley63 described a similar condition and
identified the factor in the yeast and liver as inositol.
Further studies64 indicated that some of the animals
without inositol showed spontaneous cures. Cultures from
the intestinal tract of the mice showing the spontaneous
recovery yielded organisms which would synthesize much
more inositol than cultures taken from the tract of mice
that remained hairless. This synthesis was not observed
when pantothenic acid was absent from the diet. Since no
one has been able to demonstrate the need for inositol in
the diet of growing rats, there is apparently sufficient
synthesis by the bacteria to meet the requirement.
Whether this is true in humans remains to be determined.
p-Aminobenzoic acid was first described as a bacterial
growth factor by Rubbo and Gillespie,6'1 and Ansbacher66
concluded it was a vitamin in 1941. Sieve'" has used it
as an achromotrichia factor. The fact that this com-
pound is widely distributed in nature suggests that it may
be an important vitamin, but we have been unable in our
laboratory to demonstrate any definite effect of this com-
pound in the rat except its counteracting effect on sulfa-
guanidine. In the chick it can partially compensate for
the lack of liver extract factors when fed at high levels.
Thus it may have an indirect effect by altering the syn-
thesis of other factors in the tract. Martin68 has reported
similar results in the rat and suggests that it may have
such an effect in humans.
In order to study still other possible members of the
B complex, it has been necessary to use rats receiving
sulfaguanidine or succinyl sulfathiazole, or chicks and
monkeys on synthetic diets containing the nine B vita-
mins mentioned so far.
If 0.5 per cent sulfaguanidine or succinyl sulfathiazole
is added to a synthetic diet containing thiamine, ribo-
flavin, nicotinic acid, pyridoxine, pantothenic acid and
choline and fed to rats, the rate of growth is greatly re-
duced and the prothrombin time of the blood is increased.
The addition of liver extract to this ration gives ootimum
growth and normal clotting time of the blood.69 The
liver extract can be replaced by a folic acid concentrate
and biotin.'" Thus, the rat requires biotin and one or
more factors in the folic acid concentrate, but under nor-
mal conditions these factors are produced by the intes-
tinal bacteria. Gant et al.'1 have shown a reduction in
the coliform organisms in the tract of rats fed upon suc-
cinyl sulfathiazole. Spicer, Daft, Sebrell and Ashburn'2
have reported a consistent development of a leucopenia
and an agranulocytosis in rats receiving sulfaguanidine or
succinyl sulfathiazole, in synthetic rations. The total
number of leucocytes dropped from a normal of 10,000
to less than 1,000 in severe cases. These results have been
verified in the author’s laboratory and folic acid concen-
trates have been shown to be effective in preventing the
leucopenia.
Chicks fed a modified synthetic diet plus the synthetic
B vitamins including biotin and inositol, not only fail to
grow but show very poor feathering and a rather exten-
sive anemia.73 All three deficiencies can be counteracted
by adding 2 per cent liver extract or 5 per cent yeast to
the diet and all the activity can be concentrated in crude
folic acid preparations from these foods. Similarly, mon-
keys fail on synthetic diets but live and develop normally
if liver extract, grass juice powder or a crude folic acid
preparation is used.'4 The monkeys on the synthetic diet
also show a leucopenia similar to that described by Day
and coworkers75 in monkeys fed a modified Goldberger
diet. They found that yeast and liver were effective, and
they named the active factor vitamin M.
It is evident, therefore, that the remaining members of
the B complex can be concentrated in a crude folic acid
concentrate. Most of these preparations have been made
according to the procedure described by Hutchings, Bo-
November, 1943
343
honos and Peterson.76 These workers used the Lacto-
bacillus easel for the assay of the activity. Mitchell, Snell
and Williams' 7 used spinach as the source of their factor
and the Stept Lactic R as the test organism. They named
the factor folic acid and found a rather pure concentrate
to stimulate the growth of L. casei as well as S. lactis.
For some time the two factors were considered to be the
same, but very recently Keresztesy, Rickes and Stokes78 isolated
a pure substance which is effective for S. lactis but is inactive
for L. casei and they suggest that it is not folic acid. Pfiffner
et al.79 have obtained from liver a compound in pure form
which is active in preventing anemia80 in chicks on purified
diets. These workers have retained the term Be for this com-
pound and they suggest that it may be identical with both the
L. casei and S. lactis factors. In light of the above report this
is not possible. The question which remains, therefore, is: are
the two bacterial growth factors related to the factors needed by
the rat, chicken and monkey. Briggs et al.81 have clearly dem-
onstrated that the chick requires two factors which are separate
and distinct from the 5. lactis factor. These two factors have
been temporarily called Bio and Bn. It is more likely that the
factor needed by rats fed the sulfonamides and by monkeys fed
synthetic diets is related to the L. casei factor, especially since
the factor corrects an anemia in chicks. The final isolation of
these factors will do much to give us a complete picture of the
remaining B vitamins.
We can only speculate as to the importance of these newer
factors in human nutrition, but some of the possibilities are
most intriguing since some of the conditions observed in the ex-
perimental an mals certainly occur in humans. Thus, with fur-
ther information some of the deficiency diseases which are un-
controllable today may be handled as readily as scurvy, rickets
and pellagra are now controlled.
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344
The Journal-Lancet
Vitamin D
Genevieve Stearns, Ph.D. j
Iowa City, Iowa
THE D vitamins are chemically classified as sterols,
and belong to the fat-soluble group of vitamins,
a highly artificial, though useful, classification.
These vitamins can be produced from sterols commonly
occurring in plant and animal life, by ultraviolet irradia-
tion or by activation with low velocity electrons. Al-
though several related sterols have vitamin D activity,
only two are of clinical importance. The plant sterol er-
gosterol, when treated with ultraviolet irradiation gives
rise to several products, one of which, calciferol, or vita-
min Du, has marked vitamin D activity. Commercial
viosterol is an oily solution of activated ergosterol, having
calciferol as its chief component. Ergosterol occurs in
yeasts and irradiation of the yeast cells produces cal-
ciferol. Activated 7-dehydro cholesterol, or D.j, is the
form of vitamin D produced in the human body by
action of ultraviolet rays on the skin. It is also the form
found in the liver oils of cod and many other species of
fish. Some fish liver oils, however, contain both vitamins
Du and D3. In general, vitamin D3 predominates in
naturally occurring vitamin D.1,0
Whereas fish liver oils and the body oils of a few fish,
like salmon, are relatively rich in vitamin D, most foods
normally contain little or none of this vitamin. Bovine
and human milk contain from 3 to 40 U.S.P. units to
the quart.11 Egg yolks contain variable amounts, depend-
ing on the food of the hen. The chief source of vitamin
D for primitive peoples living inland is through the ac-
tivation of body cholesterol by the ultraviolet rays from
the sun. Modern civilization has reduced the effective-
ness of this source. Irradiation of foodstuffs containing
7-dehydro cholesterol or ergosterol results in the forma-
tion of vitamin D in the food. Vitamin D from other
sources is easily added to such foods as milk. Milk and
bread are the only foods for human use now recognized
by authoritative bodies as carriers for vitamin D, because
unregulated irradiation of or addition of vitamin D to
foodstuffs would result in overdosage of this vitamin
among the general population. (Irradiated yeast is much
used as a cheap and effective source of D for animals’
feed other than for chickens. The milk of cows fed irra-
diated yeast contains increased amounts of vitamin D,
as does the milk of human mothers who are ingesting
vitamin D.)
Vitamin D in foods or in oily solution is stable as long
as the oil does not become rancid. Rancidity in the carry-
ing oil is accompanied by destruction of the vitamin.
Exposure to heat and light is to be avoided because it
increases the development of rancidity.
Vitamin D is absorbed from the intestine along with
the fats in which it is carried. Adequate amounts of bile
salts must be present in the intestine to provide for its
absorption. Any condition which prevents absorption of
fat will decrease the absorption of the fat soluble vita-
t Department of Pediatrics, College of Medicine, State Univer-
sity of Iowa.
mins, including vitamin D. The absorbed vitamin, and
that manufactured in the skin by the action of ultraviolet
rays, are transported to the liver, which appears to be
the chief storage place for the vitamin, though some may
be stored also in other tissues. The stored vitamin D is
released slowly for use, so that its effect may be appar-
ent for a considerable period after the vitamin is with-
drawn from the diet.
The functions of vitamin D in the animal body all
relate to the metabolism of calcium and phosphorus.2,7,8-9
The chief function is to increase the amounts of these
substances absorbed and retained in the body. Usually
some increase in urinary excretion of calcium and some
decrease in urinary phosphorus also are observed, espe-
cially during recovery from avitaminosis D. Experiments
on dogs depleted of vitamin D show that administration
of large amounts of this vitamin decreases urinary phos-
phorus by increasing the reabsorption from the kidney
tubules.12 In addition to the above functions it has been
postulated also that vitamin D plays a specific role at the
site of deposition of mineral in bone. Also, because of its
effect in increasing the amount of calcium and phospho-
rus available for mineralization of bone, vitamin D is
effective in regulating the rate of skeletal growth, an
effect particularly noticeable in infancy, when skeletal
growth normally is rapid.13 The effects of overdosage
differ markedly from the effect observed after adminis-
tration of prophylactic or therapeutic amounts of the
vitamin, and will be discussed under hypervitaminosis.
Calcium and Phosphorus Metabolism
The functions of vitamin D are associated intimately
with calcium and phosphorus metabolism. About 98 per
cent of the calcium and 90 per cent of the phosphorus of
the body are found in bone. Both calcium and phosphate
are simultaneously deposited in, or withdrawn from bone.
In this country, the phosphorus intake is usually ample
unless the diet is deficient in many respects; the intake
of calcium is often grossly inadequate and so becomes
the limiting factor.
The greatest need for calcium and phosphorus is dur-
ing the period of skeletal growth. However, even in
adults, bone is not an inert tissue. Studies using radio-
active phosphorus as "tracer” show that phosphorus (and
therefore calcium) once deposited in bone, does not re-
main there for the life of the individual but only for a
space of a few weeks or months.7'8-9 The trabeculae of
bone can be rapidly built up and destroyed, thus forming |
a reservoir of readily available calcium and phosphorus.14
The rate of exchange of radioactive phosphorus in enamel
of teeth is so slow as to be negligible.9
Measurement of the amount of calcium and phos-
phorus absorbed from the gastrointestinal tract is compli-
cated by the fact that both of these substances are also
secreted or excreted into the intestine. It has been esti-
mated that from 0.3 to 0.8 grams of calcium are secreted
November, 1945
into the gastrointestinal tract daily, in the various diges-
tive juices.1 Study of phosphorus excretion made by use
of the radioactive isotope showed that about one-eighth
of the phosphorus absorbed into the circulation of human
subjects was excreted through the intestine.5' Thus the
term "net absorption,” meaning the difference between
ingested and fecally excreted calcium and phosphorus,
has come into use.
The calcium phosphates are not very soluble except in
acid solutions. The chief absorption of these substances
then, must occur high up in the tract, before the con-
tents become alkaline. It follows that any factors tend-
ing to increase the acidity of the tract will facilitate ab-
sorption and, conversely, any decrease in acidity will less-
en absorption. The solubility of calcium phosphate in
the intestinal fluids is decreased also when a marked pre-
ponderance of phosphate over calcium ion occurs. The
reverse would also be true, but is found less commonly.
Calcium forms insoluble soaps with fatty acids, which are
hydrolyzed from food fats by the action of intestinal
juices. The formation of calcium soaps occurs whenever
the absorption of fats is unduly slow. The decrease in
fat utilization does not need to be of such magnitude as
to cause steatorrhea in order to reduce effectively the
calcium absorption. In illness, with consequent disturb-
ance of gastrointestinal function, the rate of calcium and
phosphorus absorption may be sharply decreased, espe-
cially in infants and younger children. The absorption of
fat and of vitamin D is often also decreased in these
circumstances.
The efficiency of absorption for calcium and phos-
phorus varies widely among various species. The rat is
extremely efficient, absorbing over 90 per cent of the in-
take. The human is relatively inefficient, usually absorb-
ing well under 50 per cent of intake even with the aid
of vitamin D, and often absorbing none without the aid
of the vitamin. For this reason the results of experi-
ments on rats and other species can be applied to humans
only with reservations.
The quantity of calcium and phosphorus excreted in
the urine varies with the intake, the age of the subject,
the acid-base regulation of the body, the efficiency of the
kidney tubules, the endocrine balance of the individual,
and the amount of vitamin D available. In the non-
rachitic child, the ingestion of moderate amounts of vita-
min D does not appear to increase the urinary excretion
of calcium, though the absorption and retention of this
element may be sharply increased.15 In the avitaminotic
person, urinary excretion of calcium is reduced below the
normal and is increased with the administration of vita-
min D.16 Excessive amounts of the vitamin increase the
urinary calcium above the normal limits. The urinary ex-
cretion of phosphorus, on the other hand, is increased
during avitaminosis D, and administration of the vita-
min decreases the amount so excreted, thereby increasing
the amount of phosphorus retained in the body.12-16
Some calcium and phosphorus are always excreted
from the body. If the intake is very little, loss of min-
eral from the body is inevitable even though vitamin D
is ingested. However, without vitamin D, ingestion of
345
ample amounts of calcium and phosphorus may still re-
sult in loss of both minerals from the body.
The Vitamin D Requirement of Normal
Persons
The vitamin D requirements of persons of various ages
have been stated by the National Research Council, on
the basis of present evidence, as 400 to 800 units daily
for infants, children and pregnant and lactating women.
No requirement is stated for adults.1 1 Supplementary dis-
cussion of these requirements is perhaps desirable.
Infdntf. The calcium and phosphorus intake of a full
term breast-fed infant is just adequate to provide for
good growth and development. Though the intake is
minimum, the proportions of minerals, carbohydrate, and
protein provide for optimum absorption. In addition, the
breast-fed infant may receive as much as 50 to 100
U.S.P. units of vitamin D in the milk, if the mother
ingests vitamin D, or is exposed to considerable sunshine.
These factors probably account for the decreased inci-
dence of rickets in the breast-fed infant, even when no
additional vitamin D is given. Nevertheless, the baby
fed human milk almost always retains more calcium and
phosphorus when vitamin D is also given. The daily
vitamin D requirement is certainly no more and may be
less than that of the infant fed cow’s milk.
The premature infant has a much smaller gastric ca-
pacity and a much greater rate of growth than the full
term infant. Such an infant cannot get enough calcium
and phosphorus from human milk to provide for bone
deposition, even if vitamin D is also given.10,18 Thus
these infants need both vitamin D and additional min-
eral. The latter is easily provided by adding dried skim-
med milk to the human milk. When sufficient mineral
is provided, the vitamin D requirement, though not
known with certainty, is probably not above the maxi-
mum given for infancy, or 800 units daily.
Infants fed cow’s milk have an ample intake of min-
eral, but the proportions of the other constituents of
milk tend toward the production of alkalinity in the up-
per intestine, and the absorption of calcium and phos-
phorus is poor unless vitamin D is also given. Very
small amounts of vitamin D are sufficient to improve the
absorption greatly. Infants given no vitamin D retain
an average of only 10 per cent of the calcium intake;
when 90 to 100 units (the average daily intake from 135
unit vitamin D milk) are taken daily, the retention is
increased to between 25 and 30 per cent of the intake.
When whole milk modifications are fed, the amount of
calcium and phosphorus retained is sufficient to prevent
the development of rickets.3-3 When 300 to 400 units
of vitamin D are taken daily as codliver oil or vitamin D
milk, the retention of calcium is increased to between 35
and 40 per cent of the intake. The additional retention
appears to provide sufficient mineral for somewhat accel-
erated growth of bone, as these infants grow at a sig-
nificantly greater rate than do those given 100 units of
D daily. The rate of growth of the latter is, in turn,
greater than the average growth of infants recorded be-
fore vitamin D was given prophylactically.13*
Infants fed the same cow’s milk formulas but given
2,000 or more units of vitamin D retained nearly 40 per
346
The Journal-Lancet
cent of the calcium intake, but by five months of age
showed an alarming lack of appetite. Skeletal growth
slowed and even ceased entirely for several weeks; when
resumed, growth in length proceeded at less than average
rate.13b It was concluded that vitamin D in amounts of
2,000 U.S.P. units or more daily produced a chronic
mild hypervitaminosis, affecting appetite and, secondarily,
growth, because of decreased intake.
From time to time, the relative efficacy for infants of
vitamins D2 and D:{ has been questioned. The question
is still unsettled, but from the evidence at hand, it ap-
pears probable that the difference in effective unitage for
the baby is not large and may be zero. Some evidence
has been obtained indicating that concentrated oily forms
of either type of vitamin D are not so effective for in-
fants as the more dilute sources, and that if concentrated
sources are used, the dosage should be approximately
doubled.10 However, the range of dosage given by the
National Research Council, 400 to 800 units daily, covers
the requirements for both forms of administration.
Recently, the use of the so-called "shock treatment” or
administration of one massive dose of D2 or D2, has been
advocated in this country.20 This treatment was first
used in Germany as an automatic prevention of rickets
in infants. It is reported that no toxic effects have been
observed, even though dosages as high as 600,000 to a
million units have been given orally or parenterally. How-
ever, death occurred suddenly to two infants given large
amounts of vitamin D orally, after a total of about 3
million units had been given. In each case extensive meta-
static calcification was found at autopsy.21,22 In general,
because of the possibility of permanent damage which
may not be evident within a few days or months, this
type of prophylaxis seems to have few advocates in this
country.
Any discussion of vitamin D prophylaxis, particularly
during the period of infancy, is incomplete without com-
ment on the psychology of vitamin D administration.
Mothers who object strongly to the taste or odor of fish
liver oils are apt to impart this dislike, consciously or
subconsciously, to their offspring. Also, in general, the
greater the effort needed to administer the dosage, the
greater the likelihood of total failure in administration.
For this reason primarily, the use of concentrates, admin-
istered in drop doses, and the use of vitamin D milks
have become popular with mothers. The physician, on
the other hand, is more apt to be concerned about the
fallibility of mothers, and prescribe two or three times
the dosage desired, in the hope that at least the desired
dosage will be administered. The logic back of such a
prescription is open to serious question as is evidenced by
the outpatient study of Drake, Tisdall, and Brown in
1934. 2-1 Codliver oil was prescribed for three groups of
infants in amounts of 1, 2, and 3 teaspoonfuls daily, re-
spectively. No infant getting 1 teaspoonful of codliver
oil developed clinical rickets; one of the group getting
2 teaspoonfuls and two of the group getting 3 teaspoon-
fuls of codliver oil daily developed rickets of moderate
to marked severity. Thus the greater the dosage, the
more rickets was observed; or to state the matter more
correctly, the less the effort required of the mother, the
greater the certainty that directions would be followed.
The increase in rickets observed meant merely that to
give codliver oil several times daily involved too much
effort for a certain proportion of the mothers, who dis-
carded the whole idea instead of carrying through any
part of it. From these and similar observations, it seems
wiser to adjust the dosage so that it may be given no
more than once daily, or automatically in the milk
feeding.
Children. After the period of infancy, dietary habits
are so varied that the intake level of calcium is often as
much at fault as the intake of vitamin D. It appears
probable that the amount of calcium and phosphorus
needed yearly depends on the normal rate of growth for
that year. Skeletal growth slows definitely from about
one to three years of age, remains fairly constant during
midchildhood and becomes more rapid preceding ado-
lescence. The retention of calcium and of phosphorus in
children one to fourteen years of age has been studied
in our laboratory.24 At each age, and regardless of min-
eral intake, some children have been unable to retain
amounts of calcium and phosphorus adequate for bone
growth unless vitamin D was also ingested. Usually,
however, retention increased with intake, and the inges-
tion of vitamin D increased the retention at each level
of intake. Results of studies from other laboratories per-
mit somewhat similar conclusions. An adequate intake
of minerals (a pint of milk daily at the age of slowest
growth, more as growth increases, up to at least a quart
daily during the prepuberal growth spurt) , and daily in-
take of vitamin D equal to that of infancy, 400 units,
appear to permit good growth and mineralization of
bone.
Some evidence has been brought forward to show that
greater amounts of vitamin D are needed for prevention
of dental caries than for skeletal growth and mineraliza-
tion and one study indicates that, as measured by caries
prevention rate, vitamin D2 is more effective than vita-
min D2.2:> The present confusion as to the relative im-
portance of various factors that influence dental caries
makes it appear best to hold conclusions in abeyance un-
til these experiments can be repeated with all factors pos-
sibly influencing the results carefully controlled.20
Adolescence. The period of adolescence and the two
years immediately preceding puberty are again periods of
rapid skeletal growth. They are also periods of readjust-
ment of many metabolic functions and it appears that,
particularly in girls, depression of retention of calcium
and phosphorus may be marked. Johnston'7 has ob-
served that at about the time of puberty, girls exhibit a
marked lowering of calcium and phosphorus retention
from a given intake, even when the amount of vitamin D
provided is far in excess of the requirement as stated by
the National Research Council. Osteoporosis is common
in adolescence3 and dental caries is so common as to be
almost universal. Much more study of the calcium and
vitamin D requirements of this age group is needed.
Adults. All studies of calcium and phosphorus reten-
tion in pregnant and lactating women show that vitamin
D is needed at these periods, together with an increased
intake of calcium and phosphorus to meet the increased
November, 1943
347
demands on the maternal organism. It appears that lacta-
tion is more of a strain than pregnancy and an intake of
milk up to 1 Zi quarts daily, together with 400 to 800
units of vitamin D, is needed to prevent depletion of
the mother’s calcium and phosphorus stores/
Attempts to determine the vitamin D need of "non-
encumbered” adults have as yet been unsuccessful. It
seems established, however, that vitamin D does not de-
crease the minimum requirement for calcium and phos-
phorus, and that the average adult is more likely to need
additional mineral, rather than vitamin D. Observations
on college women28 show that adequacy of the remainder
of the diet is at least as important in determining the re-
quirement of calcium and phosphorus as is added vita-
min D. However, it appears reasonable to suggest that
a moderate ingestion of vitamin D may be wise for night
workers, miners, the aged and infirm, and others exposed
to little or no direct sunshine. The need for adults is
certainly no greater than 400 units daily and possibly is
much less. The minimum requirement of calcium is met
by a pint of milk or its equivalent in cheese, ice cream or
other milk containing foods.
Severe osteoporosis at menopause is an all too common
finding today. Most women at this time have ingested
diets deficient in many factors besides vitamin D and
calcium throughout their entire reproductive cycle and
arrive at menopause nutritionally exhausted. Unpublished
studies in this laboratory show that lowered gastric acidity
and decreased absorption of fat are common; both of
these decrease the absorption of calcium and aggravate
the effects of a poor intake. Such women have usually
lost all teeth long before menopause and depletion of
bone mineral is marked. Recovery is slow because of the
general lowering of nutritional status. It has been ob-
served that diets rich in calcium and phosphorus, and
low in fat, together with vitamins A and D may need
to be supplemented with bile salt therapy to insure ab-
sorption of the fat soluble vitamins. In any event, recov-
ery appears to be slower at this age than in younger per-
sons. It will be interesting to watch whether menopausal
osteoporosis will disappear, with better nutrition of adults,
as has the chlorosis so common at puberty a generation
or two ago.
Vitamin D Therapy
Rickets. The primary use of vitamin D was in the
cure of infantile rickets. Without ingested vitamin D,
rickets was exceedingly common in infants fed cow’s
milk, the peak incidence occurring toward the end of
the winter season. While less common in breast-fed in-
fants, rickets was by no means uncommon. Since vita-
min D prophylaxis has become common, infantile rickets
of clinical importance has become an uncommon disease
in many parts of the country. Rickets of a degree dis-
cernible only by roentgenogram is still fairly common.
Histological evidence of rickets was found in 46.5 per
cent of 230 children from two to fourteen years of age,
examined in consecutive autopsies.29 Only 5 per cent of
these cases could have been recognized by roentgenogram.
Late rickets of clinical degree due only to avitaminosis D
is rare in this country. Late rickets due to avitaminosis D
and deficiency of calcium and phosphorus was common
in Europe after the last war and probably is again found
there. Osteomalacia due chiefly to mineral deficiency,
has always been common in some sections of China. In
India avitaminosis D is common among girls following
the custom of purdah, or confinement indoors from pu-
berty to marriage.
Avitaminosis D is characterized by normal or si ightly
lowered serum calcium, lowered serum inorganic phos-
phorus, increased phosphatase, poor or no absorption of
calcium and phosphorus from the intestine, a very low
urinary excretion of calcium and often an increased uri-
nary phosphorus excretion. When sufficient vitamin D is
given, absorption of both calcium and phosphorus from
the intestine is rapid and may amount to well over 50
per cent of the intake during the recovery period. The
urinary calcium is somewhat increased, indicating pos-
sibly that absorption is more rapid than deposition. Uri-
nary phosphorus is decreased and the serum phosphorus
increases rapidly to normal levels. The plasma phospha-
tasetase decreases, at first rapidly, then more slowly. De-
position of mineral in bone can be discerned by roent-
genogram within a week to ten days.
In avitaminosis, it appears that in general the greater
the dosage, the more rapid the recovery. A dosage about
ten times the prophylactic amount, or about 4000 units
daily, permits rapid recovery from rickets in the infant.
Single massive doses of from 600,000 to 1,000,000 units
have been given for therapy of infantile rickets and may
be desirable when circumstances render ingestion of a
daily dosage improbable. Ordinarily such drastic therapy
seems unnecessary and healing appears to be no more
rapid with these dosages than with more moderate dos-
age. As soon as healing is complete, the dosage of vita-
min D should be decreased to the customary prophylac-
tic dose in order to prevent hypervitaminosis. In adult
women with osteomalacia, daily ingestion of less than
500 units of vitamin D resulted in a marked increase in
the amounts of calcium and phosphorus retained. High-
er dosages of vitamin D caused further increases in min-
eral retention.18
In late rickets of the "refractory” type, blood, urine
and bone findings are similar to those of infantile rickets,
but healing does not occur until the dosage of vitamin D
is increased to from 10,000 to 50,000 or more units daily.
The underlying cause of this type of rickets is not clear.
It has been shown that vitamin D is present in ample
amount in the blood serum of children with this type of
rickets when no evidence of healing can be observed in
bone. If the intake of vitamin D is sufficiently raised,
healing occurs. With such children one steers a difficult
course between the Scylla of insufficient dosage and the
Charybdis of overdosage with resulting toxic effects. We
have observed that a dosage just sufficient to maintain
normal blood values becomes a toxic dosage after osteot-
omy and immobilization of considerable part of the skele-
ton. These children need careful watching at all times.
Parents should be warned that loss of appetite, nausea
and vomiting on the part of the child are signs of acute
toxicity with vitamin D and all vitamin D therapy should
be discontinued until a week or ten days after all symp-
toms disappear.
348
The Journal-Lancet
In the late rickets associated with chronic acidosis or
with kidney lesions, the primary cause of rickets is loss
of calcium because of its use to neutralize excessive body
acidity. The primary need of children with this type of
rickets is for base rather than for vitamin D and the
dosage of the latter usually need be no greater than for
infantile rickets.
In osteomalacia, the treatment follows the lines advo-
cated for rickets. Here again, supplementary factors,
the utilization of fat and the gastric acidity, should be
checked. High dosage of vitamin D starts rapid healing
but the vitamin intake must be reduced as soon as heal-
ing occurs, to prevent symptoms of overdosage.
Very high dosages of vitamin D have been recom-
mended for diseases other than those of bone, especially
in arthritis, allergic disorders and psoriasis. The efficacy
of vitamin D as a therapeutic agent for these conditions
has not been borne out by the clinical evidence,30 and
the danger of hypervitaminosis is very real.
Hypervitaminosis D
Vitamin D in excessive amounts causes effects similar
in many respects to those of hyperparathyroidism. The
serum calcium is elevated above normal levels and cal-
cium is rapidly lost from the body by excretion in the
urine. Deposition of calcium phosphate occurs in many
soft tissues, particularly the arteries. Collapse and death
may occur suddenly in acute vitamin D toxicity.
The first symptoms of acute toxicity are often anorexia
and lassitude; nausea, headache, diarrhea and urinary
frequency may occur if the dosage is not decreased
promptly. The exact dosage at which these symptoms
occur varies with different persons. Some adults may
show symptoms of toxicity with a daily dosage of 150,-
000 U.S.P. units; other adults seemingly can ingest
double this dosage for a period of several weeks without
apparent damage.
It seems often to be assumed that if symptoms of
acute toxicity are absent, hypervitaminosis does not occur
and no damage can result from long continued dosage
with high levels of vitamin D. It appears more reason-
able to assume that for a considerable range below the
dosage causing symptoms of acute toxicity some damage
may occur. Vitamin D is stored in the body and the
effects of long continued excessive dosage may be expect-
ed to be cumulative. In fact it appears logical to assume
five states of the body with reference to vitamin D;
avitaminosis or severe hypovitaminosis, subclinical hypo-
vitaminosis, normal zone, subclinical hypervitaminosis,
and clinical hypervitaminosis. Four of these five zones
have been observed in the study of the effect of vitamin
D dosage on the skeletal growth of infants. In avita-
minosis, rickets occurs, with its pathological changes in
the skeleton. With 100 units of vitamin D daily, rickets
is prevented but the growth and development of the in-
fant are only fair. When the daily vitamin D intake is
increased to 300-40Q units daily, the physical develop-
ment of the infant is excellent. If the vitamin D intake
is increased to 2000 units or more daily anorexia occurs
and skeletal growth slows. Further marked increase in
vitamin D intake would result in symptoms of acute
toxicity.
It appears that until much more knowledge is gained
concerning subclinical hypervitaminosis, the use of ex-
cessive levels of this vitamin, either in therapy or in pro-
phylaxis, should be attended with caution.
References
General and Review Articles:
1. Bills, C. E.: The chemistry of vitamin D, chapter 23, The
Vitamins, J A M. A., 1939.
2. Shohl, A. T.: Physiology and pathology of vitamin D,
chapter 24, ibid.
3. Jeans, P. C., and Stearns, G.: The human requirement of
vitamin D, chapter 26, ibid.
4. Park, E. A.: The uce of vitamin D preparations in the pre-
vention and treatment of disease, chapter 27, ibid.
5. Jeans, P. C.: Vitamin D milk, J.A.M.A. 106:2066, 2150,
1936.
6. McCune, D. J.: Recent advances in the clinical use of vita-
min D and related compounds, M. Clin. North America 24:759,
1940.
7. Cohn, W. E., Cohn, E. T., and Aub, J. C.: Calc:um and
phosphorus metabolism; clinical aspects, Annual Rev. Biochem.
1 1:415, 1942.
8. McLean. F. C.: The economy of phosphorus in the an;mal
organism, in The Biological Action of the Vitamins, Univ. of Chi-
cago Press, Chicago, 1942.
9. Hevesy, G.: The application of radioactive indicators in
biology, Annual Rev. Biochem. 9:641, 1940.
10. Stearns, G.: The mineral metabolism of normal infants,
Physiol, Rev. 19:415, 1939.
Other References:
11. Drummond, J. C., Gray. C. H.. and R:chardson. N. E. G.:
Brit. M. J. 2:757, 1939. — Harris, R, S. and Bunker, J. W.:
Am. J. Pub. Health 29:744. 1939 — Bechtel, H. E., and Hop-
pert, C. A.: J. Nutrition 1 1:537, 1939.
12. Harrison, H. E., and Harrison, H. C.: J. Clin. Investiga-
tion 20:47, 1941.
13-a. Stearns, G., Jeans. P. C., and Vandecar, V.: J. Pediat.
9:1, 1936. — 13-b. Jeans, P. C., and Stearns, G.: J. Pediat. 13:730,
1938.
14. Bauer, W., Aub, J. C., and Albright, F.: J. Exper. Med.
49:145, 1929.
15. Knapo, E, : Thes;s. Factors affecting the urinary excretion
of calcium, State Univ. Iowa, 1943.
16. Liu. S. H., Chu, H. I., Su, C C.. Yu. T. F . and Chen-.
T. Y.: J. Clin. Investigation 9:3^7, 1940. Chu H I , Liu. S.
H., Yu, T. F., Hsu, H. C., Cheng, T. Y., and Chao, H. C.:
ibid. 19:349, 1940.
17. Recommended D:etary Allowances Nat'onal Resea-rh Coun-
cil Reprint and Circular Series No. 115, Washington, D. C. (Jan.)
1943.
18. Benjamin, H, R.. Gordon, H. H , and Marp’es, E : Am J.
Dis. Chi’d. 65:412. 1943.
19. Jeans, P. C., and Stearns, G.: Unpubl shed data.
20. Vollmer, H.: J. P3d:at. 14:491, 1939; 16:419. 1940.
21. Ross, S. G., and Williams, W. E.: Am. J. Dis. Child.
58:1 1 37, 1939.
22. Wolf, I. J.: J. Pediat. 22:707, 1943.
23. Drake, T. G. H., Tisdall, F. F., and Brown, A.: Canad.
M. A. J. 31:368, 1934.
24. Jeans, P. C., Stearns, G., and others: Unpublished data.
25. McBeath, E. C., and Verlin. W. A.: J. Am. Dent. A.
29:1 393, 1942. — Livermore, A. R : Dental Survey 18:1 169, 1 942.
Brodcky, R. H., Shick, B., and Vollmer, H.: Am. J. Dis. Child.
62:1 183, 1941.
26. Anonymous: Nutrition Rev. 1:5, 1942.
27. Johnston, J. A.: Am. J. Dis. Child. 59:287, 1940;
62:708, 1941.
28. McKay, H., Patton, MB. and others: J. Nutrt'on 24 367,
1942. — McKay, H., Patton, M. B., and others: ibid. 26:153, 1943.
29. Follis, R. H.. Jackson, D., Eliot, M. M., and Park, E. A.:
Am. J. Dis. Child. 66:1, 1943.
30. New and Non-official Remedies, p. 584, American Medical
Association, Chicago, 1943.
November, 1943
349
Ascorbic Acid Intake and the Appearance of
Vitamin C Deficiency
F. W. Fox, D.Sc.f
Johannesburg, Union of South Africa
IN normal times the quantitative aspects of ascorbic
acid metabolism, though of much academic interest,
are of less practical importance since this vitamin
occurs in many accessible and popular foodstulfs. In
times of emergency and restricted diets such as the pres-
ent, however, there are all too many occasions when a
generous supply may be difficult or even impossible to
ensure. Hence the quantitative aspect assumes some im-
portance. In what follows we have attempted to discuss
this subject in the light of recent investigations.
As the issues are somewhat confused it is helpful to
keep the following four points constantly in mind:
(a) In everyday life vitamin deficiencies seldom occur
singly; hence some of the symptoms noted, for example
in scurvy, may be due to associated deficiencies, e. g.,
iron, protein, or perhaps another vitamin, such as the
much debated "vitamin P”.
(b) One may expect to encounter manifestations, fol-
lowing a short but acute deprivation of the vitamin, dif-
ferent from those arising after a prolonged but more
moderate deficiency.
(c) Individuals evidently show a wide variation in
their susceptibility to hypovitaminosis C.
(d) Inability to absorb the vitamin efficiently or even
at all may undoubtedly occur, while an abnormal metab-
olism cannot altogether be excluded. Thus both in Eng-
land and Austria it has recently been claimed that scurvy
was encountered even in dogs, who are normally able
to synthesize ascorbic acid.1
Effect of a Diet Solely Deficient in
Ascorbic Acid
Just as Williams and his associates have advanced the
study of thiamin deficiencies by carrying out experiments
on human subjects in whose diet this was the sole known
constituent lacking, so Crandon, et al., 2 have done the
same for vitamin C. This work was so carefully per-
formed, was so prolonged and so elaborately studied
from many angles that, in our opinion, it represents as
important an advance as that made in 1906 by Holst
and Frolich when they found they could produce scurvy
in guinea pigs, for it demonstrates clearly the sequence
of events as the gradual onset of scurvy is achieved.
Crandon submitted himself to a diet totally devoid of
ascorbic acid for a period of six months. Among other
observations it was noted that (a) the first abnormal
sign — hyperkeratotic papules — took 132 days to appear,
(b) 91 days before this, the plasma ascorbic acid had
fallen to zero, (c) adequate wound healing occurred
after such zero values had existed for 44 days, (d) there
was no subjective weakness until the beginning of the
third month, (e) no gross changes of the gums took
place, (f) there was no anemia, (g) capillary fragility
tSouth African Institute fof Medical Research.
was not increased, (h) the blood complement titre re-
mained normal throughout, and (i) no evidence of low-
ered resistance to infection was obtained.
Had other equally heroic volunteers been forthcoming
to endure this ordeal, there would doubtless have been
instructive variations in the results obtained, but restrict-
ed as the results are, they help to explain much that was
formerly obscure. They have at any rate thrown a flood
of light on certain aspects of the problem as we see it
under South African conditions. Moreover, Crandon’s
unexpected findings gain direct support from the work of
several other investigators. For instance, Rietschel and
Schick'1 have recorded almost identical results from
equally drastic though far less elaborately controlled ex-
periments carried out on themselves over 160 days. We
reported4 the case of a Native prisoner whose natural
aversion to vegetables and fruit was made use of during
a period of ten months under very strict supervision. To
our amazement he remained free from all clinical signs
of scurvy and lived apparently in good health, gums in-
cluded, on a diet containing exceedingly little ascorbic
acid, derived from a well-cooked but small ration of
meat. For days he excreted no measurable reducible sub-
stance in the urine *sec also 5-6'7)- The whole trend of
our observations on the 950 Native mine labourers in our
orange juice experiment supports Crandon’s work. The
precarious nature of their vitamin supplies may be judged
by the fact that twelve cases of obvious scurvy occurred
during the seven months, yet several of these cases
showed no increased capillary fragility, no clinically un-
healthy gums and no anemia. Repeated blood tests indi-
cated how very low their "reserves” must have been, yet
the overwhelming majority remained remarkably healthy,
worked hard and were fully able to repair such wounds
as arose from accidents.
It is also well to remember the extraordinary observa-
tion recorded by Hess,8 which can be fully substantiated
from experience here, that complete and apparently last-
ing recovery from scurvy may be achieved by the giving
of trivial amounts of the vitamin (also noted in experi-
mental animals by Wolbach.9)
Combining all these observations, as well as others that
space forbids us to mention, we have been driven to the
conclusion that a healthy adult is capable of living, at
least for a considerable period, on an extremely small
daily intake of this particular vitamin without suffering
any demonstrable impairment of health, vigour or loss of
resistance to infection. The minimal requirement is not
clear, but it must be not more than 15 mgm. and quite
possibly less. It seems, too, that we are now in a position
to distinguish between the inevitable results of prolonged
ascorbic acid deprivation, such as interference with
wound healing and eventual death, and those commonly
350
The Journal-Lancet
associated disturbances such as increased capillary fragil-
ity, gum lesions and anemia, which may depend either
on individual susceptibilities or on some as yet unidenti-
fied vitamin presumably closely associated with ascorbic
acid in natural foodstuffs.
If we want to understand the functions and behaviour
of vitamin C it seems to us that such considerations have
their importance, but we fully admit that the nutritionist
must never rest satisfied with supplying minimal require-
ments, which as our own evidence shows are but a pre-
carious protection, even against scurvy.
What we need to know is whether a larger daily in-
take confers a superior degree of health, apart from its
insurance value against contracting scurvy. In fact, as
Bourne10 remarks, we need to know the effects upon
health of a low intake continued for say 30 or 40 years.
Since it is most unlikely that this aspect will be settled
by experiments like those of Crandon carried out for
very long periods, we must fall back on less direct evi-
dence to be gained (a) from observations on persons or
groups living on limited amounts of the vitamin, (b) the
effects produced when more generous supplies are pro-
vided for such groups, (c) what happens when patients
suffering from various complaints are treated solely with
ascorbic acid.
A. Effects of sub-optimal supplies. An outstanding
question is whether the capacity for sustained manual
labour is diminished on sub-optimal vitamin C intakes.
We have discussed the theoretical aspects in a later
section.
Since our 950 Native mine labourers were all living
on a diet so low in vitamin C that no less than twelve
actually developed scurvy, it may be assumed that they
must have all been in a state of gross hypovitaminosis C;
indeed, it would be more usual to regard them as "suf-
fering” from latent scurvy. Perhaps they were, but those
in close contact with them could only marvel at the high
level of general health and the high spirits they main-
tained. We wish that it had been possible to apply the
many tests that Crandon used, but so far as the evidence
goes — and we are not aware that any similar large scale
study is available — it would seem that it is possible to
live actively and healthily right up to the very edge of
this particular nutritional precipice. We need not add
that we are wholeheartedly against the existence of such
precipices, but according to our experience there is as yet
no infallible clinical sign to warn us before the brink is
reached, which only makes the situation more dangerous.
It may be added that there is a good deal of negative
evidence in this country among Europeans and non-Euro-
peans, as well as elsewhere, that large numbers of people
do in fact live for long periods on extremely low daily
intakes of ascorbic acid without showing signs of dis-
turbed health that can as yet be attributed to this cause.
B. Improved health on larger intake. Obviously the
foregoing does not get us very far and we pass on to
consider the few studies in which a larger intake has been
correlated with some aspects of health. For obvious rea-
sons it is not easy to carry out experiments on human be-
ings in which the amount of ascorbic acid available is
the sole variant. Cowan, et al.,11 and Glazebrook and
Thomson12 attempted to do this. They report that pro-
longed dosing with large amounts of vitamin C had no
important effect either on the number or severity of in-
fections of the upper respiratory tract when adminis-
tered to fair-sized groups of young adults. In the latter
study the daily intake of the control group was estimated
and found to be from 10 to 15 mgm. On the other hand
these workers noted that, although the incidence of ton-
sillitis was not increased, the duration was almost a week
longer in the untreated group. Moreover, there were no
less than 17 cases of pneumonia and 16 cases of acute
rheumatism among the controls, though none occurred
among those treated with the vitamin. When consider-
ing this remarkable finding it is important to read Glaze-
brook’s later commentary0 in which he emphasizes what
he calls "the other side of the picture,” i. e., that many of
the control group achieved a high degree of immunity
without ever falling ill.
A somewhat startling report emanates from Ger-
many1,1 where a confection containing 50 mgm. ascorbic
acid was given to one and a half million boys and girls
aged ten to fourteen years, for a period of two months.
The resistance of the children to infection was said to be
increased and their physical development accelerated. It
is somewhat difficult to reconcile this finding with those
obtained in England, where, although numerous studies
have demonstrated a decreased intake or lower state of
the vitamin C reserves, there seems to have been little
evidence of any deterioration of health.1 4,1 r,,r>
C. Curative properties. As far as we are aware very
few studies have been carried out in which a low level of
health suspected to be due solely to a defective intake of
vitamin C was treated only with ascorbic acid. Some of
the twenty-seven cases reported on by Rinehart and
Greenberg11' fall into this category, though others were
also suffering from rheumatoid arthritis. In 17 of the
22 cases that were followed, definite clinical improvement
was noted, apparently due solely to the administration
of ascorbic acid (amounts not stated) .
It is most desirable that close attention should be paid
to this aspect of the subject in order that the signifi-
cance of terms such as "hypovitaminosis C”, "sub-clin-
ical scurvy”, etc., can be ascertained.
How does ascorbic acid function in the body? Pre-
sumably we should be in a better position to estimate our
daily requirements more accurately and detect defects
arising from sub-optimal supplies of this vitamin if we
were more clear as to its functions in the body. Although
ten years have passed since its chemical nature was estab-
lished it will probably be agreed that the advances made
in this field have been somewhat disappointing, at any
rate they compare unfavourably with the progress made
since the function of thiamin in relation to carbohydrate
metabolism was recognized.
(a) Carbohydrate metabolism. When the ease with
which ascorbic acid can be reversibly oxidized and re-
duced was discovered it was naturally thought that it
might play a most important role in cell chemistry. It
provided a simple explanation for the fact observed in
the field that scurvy frequently appeared when hard
work was undertaken.
November, 1943
351
The evidence already quoted does not lend much sup-
port for this latter hypothesis, though the inability to
perform aerobic work which gradually appeared in Cran-
don’s case is certainly highly suggestive, as are the re-
sults reported by Yakovlev.44 We were able to trace the
histories of over one thousand Native mine labourers
who contracted scurvy and we came to the conclusion
that it had developed neither more often nor more rap-
idly in those engaged in strenuous work than among
those whose metabolic resources were less severely taxed.
While we do not doubt that this phenomenon sometimes
occurs we strongly suspect that it is due to an associated
deficiency of thiamin and this is supported by the symp-
toms formerly observed here — the so-called "Rand
Scurvy.”
According to Keys and Henschel46 muscular ability,
endurance, resistance to fatigue or recovery from exer-
tion remained unaffected, both in brief extreme exercise
and prolonged severe exercise, when a diet containing 70
mgm. ascorbic acid was supplemented by 100 or 200
mgm.
Studying this question experimentally Stotz, et al., 17
while not doubting that ascorbic acid plays an important
role in the metabolism of animals, remark that "at the
present time there is considerable evidence against, and
very little for, the function of ascorbic acid as a major
respiratory agent in animal tissues, at least in the sense
of being comparable to cytochrome or 'yeH°w enzyme’.”
In the same year Barron, et ah, 18 concluded that "Ascor-
bic acid, a sluggish oxidation-reduction system, protected
in the body from oxidation by the ordinary oxidation
catalysts, seems to act as a promotor or catalyst of syn-
thetic reactions (reductions, polymerisations), thus tak-
ing part in the building up of cellular and intercellular
structures.”
(b) Possible relation to melanin. Another clue lies in
the disturbed metabolism of the aromatic amino-acids
(phenyl alanine and tyrosine) which is said to occur in
the absence of ascorbic acid (e. g., see Levine, et ah,19)
and in the effect this may have on the production of
melanin.20
(c) Production of intercellular substances. As a result
of his prolonged studies Wolbach9 writes, "Scurvy rep-
resents the inability of the supporting tissues to produce
and maintain intercellular substances. The effect is there-
fore on cells of mesenchymal origin in contrast to the
ectodermal and endodermal effects of vitamin A ... .
the intercellular substances concerned in vitamin C de-
ficiency are the collagen of all fibrous tissue structures,
the matrices of bone, dentin and cartilage and all non-
epithelial cement substances, including that of the vas-
cular endothelium.” This function of ascorbic acid is
obviously of the very greatest importance because of its
bearing on the healing of wounds. The history of the
discoveries in this field has recently been discussed by
Hartzell, et al.,21 and Bourne.10 The reality of the part
played by the vitamin in the case of human wounds was
dramatically proved by Crandon on his own body. In a
later paper Lund and Crandon22 discuss the significance
of various degrees of deficiency in relation to everyday
hospital problems.
In spite of the frequent and severe deficiencies of this
vitamin observed among our Native population, South
African hospital experience would seem fully to support
the conclusion reached by these workers and summarized
by the American Medical Association23 that "under
usual conditions of diet and absorption the average per-
son possesses a high enough ascorbic acid content in his
tissues for normal wound healing.” That very small
amounts bring about prompt repair for animals had pre-
viously been noted by Wolbach.
Nevertheless the tissues are so vital that a supplemen-
tary supply should be administered either before or after
operation wherever the least doubt arises. Lund and Cran-
don emphasize that a history of prolonged deprivation,
diarrhea, gastric or duodenal ulcers, fevers, etc., are good
examples of where such precautionary measures ought
to be taken.
(d) Capillary fragility. It seems no longer possible to
attribute to ascorbic acid the sole responsibility for main-
taining "normal” capillary resistance, not only because
acute scurvy may occur without such increase in fragil-
ity,2,4,10 but also because this substance does not neces-
sarily relieve the condition when it occurs, while a sub-
stance (or substances) obtainable from foodstuffs can
apparently do so.24 ^See also review 4,>4 In view of the ex-
perience gained from the study of other vitamins such
observations should make us very guarded in attributing
all the conditions that can be observed in clinical scurvy
to a deficiency of a single substance.
(e) Resistance to infection. Long ago Hess concluded
that "infection is the most important condition that may
suddenly and precipitously induce scurvy.” Many others
besides ourselves must have been impressed with the sud-
den transformation that can take place, and the simile
of a precipice again suggests itself. On the other hand
there seems as yet to be no conclusive evidence that the
reverse holds good; that a diet deficient in this constitu-
ent renders the consumer more liable to infection.2,11,12,
14,22,25,26,27
It has of course been repeatedly demonstrated that dis-
turbances of the vitamin C situation are likely to take
place in a variety of illnesses especially when of a febrile
type. The difficulty is to assess their significance. An
increased requirement is usually assumed though the ef-
fects noticed might be due either to some interference
with appetite, absorption, abnormal excretion or a de-
struction merely incidental to the disordered metabolism.
Abt, et al.,26 do not accept the view that a rise in tem-
perature per se increases requirements. Whatever the ex-
planation for the "disappearance” of vitamin C that evi-
dently occurs, it must be admitted that the beneficial
effects following treatment with ascorbic acid in such
conditions is, to say the least, disappointing. Abt’s nega-
tive findings with 145 young children suffering from
scarlet fever, diphtheria and rheumatic infections are par-
ticularly significant. ^See aIso 274 Similarly disappointing
results have been recorded even in tuberculosis where,
since the healing process is characterized largely by the
formation of connective tissue, it might have been
thought that treatment with ascorbic acid had its most
logical basis.28,29,30
352
The Journal-Lancet
Nor has better success attended laboratory investigation of
the mechanisms concerned with resistance to infection. Thus
although much has been written proving or disproving the ex-
istence of a relationship between vitamin C and complement, it
is significant that in Crandon’s case normal values were obtained
even after clinical scurvy had been apparent for three weeks.
The tests made by Agnew, et al., 31 were also negative, nor
could they obtain any evidence that the amount of ascorbic acid
present affects the anti-bactericidal activity of human blood.
Feller, et al.,2;l also report various negative immunological find-
ings.
(f) Anemia. Anemia is frequently, but by no means invar-
iably, present in severe scurvy. However, Crandon showed no
anemia, though no less than 6,000 cc. of blood was withdrawn
during his experiment. (See also 0,8.) According to Israels32
"the effect of ascorbic acid deficiency seems to be more a de-
pression of erythropoiesis than a failure of maturation at any
particular stage.” (See also 83.)
(g) Protection against toxic substances. Judging by the work
of Beyer,34 Bundesen, et al.,33 Hagen36 and Holmes,37 ascorbic
acid is able to prevent or cure the toxic effects produced by sub-
stances such as hepatoxin hydrazine, neoarsphenamine, benzene
or trinitrotoluene. Somewhat similar claims have been made both
in America and England in relation to lead poisoning, but they
are not supported by the study of Evans, et al.38 The danger
of any false sense of security, or of slackness in maintaining
well-established precautions, arising because of such claims has
been rightly emphasized.3®
(h) Anti-toxic properties. The fact that ascorbic acid is non-
toxic even when taken in large amounts, provides us with a
means of utilizing its remarkable ability to undergo reversible
oxidation and reduction. Dr. L. Golberg of this Institute has
suggested that some of the unexpected effects now being claimed
for vitamin C, when operating in high concentrations, may well
be attributed to these properties in contradistinction to its phys-
iological functions as a vitamin. For instance, this might explain
the foregoing anti-toxic properties, the benefits claimed in cases
of hay-fever46 and particularly its value in the treatment of
methaemoglobinemia.44
D. Effects of high temperature. Claims have been made that
the requirement for ascorbic acid is increased in hot environ-
ments, especially in hard physical work. These have been dis-
cussed by Henschel, et al., 47 who have shown that, in the crit-
ical period of a few days when heat exhaustion and collapse are
most imminent, administration of ascorbic acid (500 mg. daily)
has no effect. The argument for increased vitamin C need in
the heat seems to have originated from reports that ascorbic acid
is lost in the sweat. It now is clear that sweat contains little or
no ascorbic acid so the theoretical justification for using this
vitamin in prophylaxis or therapy for heat exhaustion48.46 dis-
appears.
Need for Efficient Use of Available Resources
of Vitamin C
Whether we require larger or smaller amounts for optimal
health there is no more important aspect of our subject than the
need for a greater appreciation of the ways whereby the available
supplies of ascorbic acid can be most efficiently utilized. Even
before the war there was much room for improvement, but in
these days of famine or restricted supplies of food and medical
supplies it becomes of far greater urgency.
Many humble but most valuable natural sources of vitamin C,
such as pine-needles, alfalfa, rose hips, etc., are now attracting
attention. The high concentration to be found in black currants
and in guavas has also been turned to good account. But what
is still so often overlooked is the alarming amount of vitamin C
destruction which may take place before actual consumption.
Quite apart from the reduction in intake that may arise from
growing inferior crops or from harvesting them at an unsuitable
stage, we would stress particularly the great losses that contin-
ually arise (a) from delay between picking and cooking, (b)
from wasteful or unduly prolonged cooking (for example, boil-
ing extracts much vitamin from peeled potatoes, cabbage, etc.,
so that whenever possible potatoes should be cooked in their
jackets, or the cooking water also used), (c) from bringing vege-
tables slowly to the boiling point, which greatly increases enzy-
matic destruction, (d) from delay between the completion of
cooking and the serving, which may, after 15 minutes, reduce
the remaining amount by as much as 25 per cent for cabbage
and 40 per cent for potatoes. Harris42 discusses many of these
points and rightly emphasizes the unique importance of the po-
tato as the cheapest, most widely available and best-liked anti-
scorbutic foodstuff that is likely to be eaten in significant quan-
tities. Raw vegetables and fruit, though very valuable where
they are readily available and popular, are broadly speaking of
less widespread importance, because they are eaten in less signifi-
cant amounts and are less adequately digested and absorbed.
There is abundant evidence to show that a great deal of pre-
ventable waste arises from lack of persistent attention to these
apparently trivial details. In fact, many responsible persons
would be astonished if they discovered that they were ignoring
available sources of this vitamin and if they realized the dis-
crepancies between the amounts supplied by a given diet on pa-
per and those which are actually consumed by the persons under
their charge. How low the net daily intake may fall, even where
some attention may be assumed to have been given to dietary
matters, has been shown by several recent investigations,3.42.43
Finally, medical men are undoubtedly responsible for much
thoughtless waste when they prescribe pure ascorbic acid where
natural sources could just as well be employed. The value of
using natural foodstuffs to cure disease should be more appre-
ciated, for in this way large stocks of the synthetic product
could be built up for emergency use overseas.
Conclusion
At present it is much easier to detect and measure the degree
of saturation of an individual in respect to vitamin C than to
assess its clinical significance. A healthy person is evidently
capable of maintaining himself for a considerable period on a
remarkably small daily intake, while so far it has not been found
possible to establish with any degree of certainty that health or
resistance to infection is thereby impaired. Nor is there convinc-
ing evidence that this vitamin exerts any beneficial effect upon
the course of various common diseases.
In our present abnormal circumstances there are likely to be
situations where this conclusion may be of practical value, or at
least bring some assurance. Obviously, however, such ? restrict-
ed intake offers no margin of safety and must be regarded as a
precarious basis that should never be accepted with complacency.
Since vitamin C is widely distributed and usually obtainable in
cheap and popular foodstuffs there is seldom any valid excuse
for such minimal intakes. Moreover, a generous supply is all
the more desirable when it is remembered that not a few indi-
viduals exhibit certain abnormalities when dealing with this sub-
stance. Above all, it must be remembered that extreme pro-
longed depletion may interfere with the efficient healing of
wounds.
There are some grounds for believing that ascorbic acid can
be utilized by the body in ways which are quite apart from its
specific activity as a vitamin.
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148:359, 1943.
Medical Aspects of Vitamin K
Henrik Dam, M.D., Ph.D.f
Rochester, New York
THE criterion for vitamin K deficiency is lowered
prothrombin which can be raised by suitable ad-
ministration of vitamin K. Hemorrhages need not
be present but a bleeding tendency exists when the pro-
thrombin is lower than about 30 per cent of the normal
value.
Clinical methods for the determination of blood pro-
thrombin are mostly variations of Quick’s method. Two
modifications of this method, which ensure a good differ-
entiation between the prothrombin values and which have
been studied with regard to nearly every detail, are de-
scribed by Larsen and Plum (1941).
The richest sources of vitamin K among food stuffs
are green leaves of any kind, tomatoes, hog liver and
some cheeses. Meat and milk are poor sources and po-
tatoes, beets, carrots, etc., are very poor in vitamin K.
The intestinal bacteria produce vitamin K. The putrefac-
tion organisms produce more than the lactic acid bac-
teria.:}:
It is not known exactly how much vitamin K an adult
t University of Rochester, School of Medicine and Dentistry.
{Vitamin K isolated from green leaves (designated Kt) is
2-methyl-3-phytyl- 1 ,4-naphtoquinone, whereas vitamin K isolated
from putrefied material (designated K») has a longer side chain in-
stead of the phytyl group. Vitamins Ki and K2 are both fat soluble
and their biological activity is quantitatively much the same, Ki
being slightly more potent per weight unit than K>. Green leaves
may contain as much at 30 to 40 micrograms of K] per gm. dry
matter. Dried b. coli has an activity corresponding to 100 micro-
grams of Ki or more, probably in the form of K2. The artificial
vitamin K substitutes which are commonly used for therapeutic pur-
poses are derivatives of 2-methyl- 1 ,4-naphtoquinone (Menadione
U.S.P. XII) or this compound itself. Certain of the esters (di-
phosphate, disuccinate, disulphate) of the hydroquinone which cor-
responds to menadione and a few other derivatives such as 2-methyl-
4-amino- 1 -naphthol hydrochloride and menadione-bisulfite are water-
soluble or form water-soluble alkali salts and are therefore useful
for intravenous injection. Menadione itself has a strong burning
taste and irritates the mucosa of the stomach if given in excessive
quantity. The reviewer and his associates have had experience with
all the aforementioned substances but have mostly used the water-
soluble tetra-sodium salt of 2-methyl- 1 ,4-naphtohydroquinone-di-
phosphoric acid or the corresponding disuccinate ( "Synkavite”,
Roche).
person requires per day but alimentary vitamin K defi-
ciency in adults is rare. If the supply of vitamin K from
the food is low, the normal putrefaction in the large in-
testine will furnish enough of the vitamin to prevent a
substantial fall in prothrombin. Cases of mild alimentary
vitamin K deficiency were reported by Kark and Lozner
(1939). (See also Scarborough 1940). Aggeler et al.
(1942) have observed the disease in a more severe degree
in a patient with anorexia nervosa and diarrhea. Drastic
dietary vitamin K deficiency may be expected when the
food is low in vitamin K or when no food is given and,
at the same time, the intestinal flora is depressed, such as
may be the case in sulfa-drug treatment.
All conditions which reduce the absorbability of fatty sub-
stances, including vitamin K, may lead to vitamin K deficiency.
The most important condition of this kind is the absence of
bile from the intestine in obstructive jaundice; and the cholemic
bleeding tendency was, in fact, the first instance of vitamin K
deficiency to be recognized in humans (Warner, Brinkhous and
Smith 1938, Butt, Snell and Osterberg 1938, Dam and Glavind
1938). This complication, which previously constituted a seri-
ous danger in the surgical treatment of patients with obstructive
jaundice, is now brought under control by the administration
of a few milligrams of one of the water-soluble vitamin K sub-
stitutes, orally or parenterally, one day before the operation and
daily or every other day for as long a time after as is required
for the establishment of the flow of normal bile into the intes-
tine (usually a couple of weeks).
Sprue and certain other intestinal diseases, such as ulcerative
colitis, which result in profuse diarrhea and abnormal changes
of the intestinal mucosa may also lead to lowered absorption of
vitamin K and to a bleeding tendency (Hult 1939, Clark Dixon,
Butt and Snell 1939, cf. also the monograph of Fanconi 1941).
From experiments with animals it may be expected that in-
sufficient secretion of pancreatice juice (Sproul and Sanders
1941) may, at least to some extent, lead to vitamin K deficiency
due to faulty absorption, even if perhaps not to such severe
manifestations as under the conditions mentioned above.
An important manifestation of vitamin K deficiency is the
hypoprothrombinemia of the newborn (Waddell et al. 1939,
354
Nygaard 1939, Dam, Tage-Hansen and Plum 1939, Quick and
Grossman 1939). The prothrombin of the baby is usually more
or less subnormal at birth and decreases further during the first
few days of extrauterine life. After the third day the prothrom-
bin usually increases so that in most cases the baby is out of
danger of bleeding at the end of the first week. At the age of
two to three months the prothrombin is the same as for normal
adults. The percentage of babies with actual bleeding in the
first week is about 1 per cent. One single large dose of vita-
min K given immediately after birth (5 milligrams of "Synka-
vite,” for instance) will not only raise the prothrombin to about
normal in one day but will also prevent the fall in prothrombin
during the first week. The same result can be obtained by
treatment of the mothers with vitamin K prior to delivery. The
same or a somewhat higher dose (say 20 mg.) can be used with
mothers, but should be given every day during the last two
weeks before parturition is expected, the essential point being
that one dose is given between twenty-four and two hours before
delivery.
It is of interest that the prothrombin of the pregnant woman
is normally increased by 50 to 100 per cent at the time of de-
livery and some time before (E. Tage-Hansen 1940 and O.
Thordarson 1940) . This, together with the observations men-
tioned below, makes it seem likely that there is a certain resist-
ance to the transfer of vitamin K through the placenta, so that
an excess of the vitamin must be given to the mother in order
to supply the fetus with the optimal amount.
The daily requirement of vitamin K is astonishingly low in
babies, namely only a few micrograms of one of the artificial
vitamin K substitutes. (Sells, Walker and Owen 1941, Hj.
Larsen 1942). The prothrombin will, therefore, increase when
the supply of vitamin K from the developing intestinal flora
begins, and perhaps even the low content of vitamin K in the
milk will contribute to the rise in prothrombin after the third
day. The initial fall during the first few days must be explained
by the absence of vitamin K due to the sterility of the intestine
immediately after birth and to the negligible intake of milk.
Other causes, such as low ability to absorb fat, low production
of bile acids or inability of the liver to form prothrombin, have
been ruled out as important factors (Plum and UIdall 1942,
Venndt and Plum 1942, Glavind, Larsen and Plum 1942).
Differences in the functioning of the liver may account for the
fact that the normal value of the prothrombin is slightly lower
in the first few weeks than two to three months later, but do not
account for the low prothrombin in the first week.
Hemorrhages in the newborn with low prothrombin may oc-
cur in the intestinal tract (melaena), the skin, the cranium, the
umbilicus and the retina. The question whether suitable vita-
min K treatment actually can reduce the incidence of hemor-
rhage in the newborn has been answered in the affirmative by
many investigators.
Series of several thousand newborn have been examined by
Beck et al. (1941), Heilman and Shettles (1941) and Plum and
co-workers (1942). A considerable decrease in the number of
cases with bleeding was found in the treated series, and even a
substantial drop in the number of early deaths and still births
(the latter when the mothers were treated) . Hemorrhages which
are due to the rupture of larger vessels can, of course, not be
prevented by vitamin K treatment. In contrast to the above-men-
tioned series, Sanford et al. (1942) reported that vitamin K
treatment, even if it raised the prothrombin failed to prevent
hemorrhages. Sanford’s view was criticized by Quick (1942),
Kugelmaas (1942) and Waddell (1942), and is, in fact, diffi-
cult to understand, since sufficiently lowered prothrombin always
will dispose to bleeding.
There is a seasonal variation in the frequency and severity of
the hypoprothrombinemia of the newborn (Waddell and Law-
son, 1940, and others) and it is likely that the diet of the preg-
nant woman may influence the prothrombin of the baby even if
her own prothrombin is not altered by changes in the diet with-
in normal limits. (MacPherson 1942).
Experiments carried out with rabbits (Moore et al. 1942)
have shown that vitamin K deficiency may lead to retroplacental
hemorrhage and abortion.
Vitamin K deficiency has been observed in connection with
icterus gravis (Dam, Tage-Hansen and Plum 1939).
The Journal-Lancet
Vitamin K can act only when the liver has maintained its
ability to form prothrombin, and is ineffective against the hypo-
prothrombinemia which is found in certain liver diseases. Sev-
eral authors have, therefore, suggested prothrombin determina-
tion and ingestion of vitamin K as a test for liver function.
(Lord and Andrus 1941).
Warner (1941) has found a decrease in prothrombin in per-
nicious anemia which could be eliminated by liver extract but
not by vitamin K.
Hemorrhagic diseases which are due to factors other than low
prothrombin are not affected by vitamin K. This holds for
hemophilia, thrombocytopenia, fibrinopenia and scurvy. Bleeding
from gastric ulcers has no general relation to vitamin K defi-
ciency (Lebel and Dam 1940). The author is also of the opin-
ion that the same holds for hemoptysis in patients with pulmo-
nary tuberculosis, even though some reports to the contrary have
appeared (Sheely 1941, Levy 1942). Gyntelberg and Dam
(1940) found no change in prothrombin in a series of patients
with hemoptysis, and the same was found by Plum and Poulsen
(1942) in a much larger series. The last mentioned authors also
tried treatment with vitamin K but with negative result.
A new and somewhat surprising use of vitamin K in the form
of menadione has been suggested by Fosdick et al. (1942). They
reported that menadione given by mouth prevents the formation
of lactic acid in saliva and thereby might counteract dental caries.
The inhibitory effect on lactic acid formation is not specific for
vitamin K, since other quinones may act similarly (Armstrong
and Knutson 1943). The practical value of this observation has
not yet been established.
Bibliography
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W. D. Armstrong and J. W. Knutson: Proc. Soc. Exper. Biol.
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November, 1943
355
Vitamins and Physical Performance
Austin F. Henschel, Ph.D.f
Minneapolis, Minnesota
WAR by its demands for increased physical out-
put and its restrictions on availability and
choice of foods has made mandatory a crit-
ical analysis of the factors that influence the work capacity
of man. The general problem of the relation of diet to
physical performance has recently been reviewed. 2|-18
Frank vitamin deficiencies may produce profound dis-
turbances in general bodily functions and as a result de-
crease the ability to do work. It is then by inference
often assumed that "suboptimal” vitamin intakes should
produce some decrease in physical performance. If from
25 to 50 per cent of the population are on diets contain-
ing "suboptimal” amounts of vitamins, °'39,41 the impli-
cations are alarming. However, before wholesale vitamin '
supplementation is justified it must be proved that more
than minimal vitamin intakes are a real value in increas-
ing the general level of health and physical vigor.
In the present discussion emphasis will be placed upon
vitamin A, the B complex vitamins (particularly thia-
mine, riboflavin and niacin) and ascorbic acid. The
purely clinical manifestations of vitamin deficiencies will
be included only as they bear upon the specific problem
of physical ability.
Vitamin A
Observations on the effect of low vitamin A intakes
on physical ability have been chiefly incidental to other
studies. Rats on diets supplemented with vitamin A were
more active than the controls1,1 but dogs remained active
and in good health on low vitamin A diets for nearly a
year after vitamin A disappeared from the blood.30 Dri-
galski8 reported psychic disturbances, easy fatigability
and muscular cramps in a young man on a vitamin A
deficient diet for two months. Controls and objective
measurements were lacking.
The effects of low vitamin A intakes on the ability of
five men to do moderate and exhausting exercise have
been studied by Wald, Brouha and Johnson.42 For six
months the diet contained about 100 I.U. of vitamin A
per day but was adequate otherwise. This period was
followed by six weeks on a normal diet supplemented
with vitamin A. Measurements were made on heart rate
during and after work, blood pressure, ventilation, oxy-
gen consumption, respiratory quotient and blood lactate
after both moderate and exhausting exercise. Work and
recovery indexes were calculated. None of the physio-
logical variables were significantly changed by the defi-
cient diet. One subject reported abnormal fatigue and
lassitude while on the deficient diet even though objec-
tive tests showed no decline in ability. All the subjects
thought they felt better and could do the work more
easily on the normal diet. Subjective impressions are
apparently of little value in establishing the true phys-
ical state of subjects.
t Laboratory of Physiological Hygiene, University of Minnesota.
Harper, Mackay, Raper and Cann17 observed an in-
crease in vital capacity, breath-holding time and the time
a column of mercury could be maintained at 40 mm. by
a steady exerted expiration in a group of 69 young men
when vitamins A, D, and C were added to a diet of un-
known vitamin content. The resting heart rate was, how-
ever, lower when the supplements were not given. It is
doubtful that the tests used were true measures of phys-
ical fitness.
Vitamins of the B Complex
Vitamins of the B complex have been claimed to have
profound influences on physical performance, even in the
absence of clear symptoms or signs of clinical deficiency.
In the case of thiamine, riboflavin and niacin such claims
are bolstered by the undoubted importance of these vita-
mins in energy systems fundamental to carbohydrate
metabolism and, presumably, to muscular contraction.
Physical deterioration may be striking in beri-beri and
pellagra, of course, but the important questions are: (1)
Can physical performance be improved by the addition
of these vitamins to a diet which would otherwise be con-
sidered adequate? (2) Is physical performance depressed
in the absence of other objective signs of deficiency?
(3) How rapidly does physical deterioration occur in
an individual on a diet which eventually may produce
definite signs of deficiency in these vitamins?
Supplementation of an Adequate Intake
with B Complex Vitamins
The supplementation of a normal diet with B complex
vitamins has no influence on work capacity in properly
controlled experiments. Csik and Bencsik1 thought they
observed an increased strength and ability to work in two
subjects that were given a B complex preparation. They
had no controls and the increased ability appears to be
purely a training effect. Large daily supplements of the
B vitamins to soldiers subsisting on the regular U. S.
Army Garrison rations have in this laboratory proved
negative.20 The experiments were carefully standardized
and controlled. Ability to perform brief exhausting work
and sustained hard work, psychomotor functions, and
biochemical blood and urine details of metabolism failed
to indicate any advantage derived from the large B com-
plex supplementation. Failure of extra vitamins of the
B complex to increase physical performance has been
confirmed.40 The rate of recovery from muscular fatigue
is also not influenced by supplementing an "adequate”
diet with intravenous injections of the B vitamins.12
Supplementation of a Restricted Intake
with B Complex Vitamins
A decrease in physical performance has recently been
reported to occur rapidly when normal men are placed
on diets presumably very deficient in all the B vitamins.
Within four weeks sedentary men reported some vague
356
The Journal-Lancet
subjective symptoms of easy fatigue, loss of ambition
and loss of efficiency in doing their normal routine
work.10 A moderate deterioration in ability to do brief
exhausting exercise (Harvard Physical Fitness Test) was
also noted. Other objective measurements were gener-
ally negative. All symptoms were cleared up by the ad-
ministration of brewers’ yeast. When subjects were forced
to do hard work (4,000 to 5,000 calories per day) on a
similar deficient diet a marked progressive physical de-
terioration occurred during the first week."0 At the end
of one week brewers’ yeast was added to the diet. "Phys-
ical fitness” increased. No analyses of the diets were
made, caloric intake and output were not regulated nor
were control subjects used. The results can be further
seriously criticized because the subjects suddenly started
on a program of severe muscular work without any train-
ing. Psychological factors were not controlled; it is in-
conceivable that the subjects (some of whom were doc-
tors) did not realize when the 18 gms. of yeast were
added to their diet.
Barborka, et al.,1 reported a decrease in work output
shortly after their subjects were put on a vitamin B defi-
cient diet even though there was no other objective evi-
dence of deficiency. The usual subjective symptoms of
easy fatigue, lack of pep and muscle pains which often
accompany a monotonous diet were noted. The work
output for the one subject reported in detail was pro-
gressively decreasing for months before the introduction
of the deficient diet. It should be noted that the type
of work measured is easily influenced by motivation. The
problem of the effect of low B vitamin intakes on phys-
ical performance during hard work has been subjected
to carefully controlled experiments in this laboratory.27
Details of the results will be published elsewhere. Diets
containing from one-fourth to one-third the amount of
B vitamins recommended by the National Research
Council proved to be ample for men doing 4,500 to
5,000 calories of work per day for periods of at least
two weeks. When properly controlled, the objective mea-
surements of physiological, psychomotor, psychological
and biochemical variables in rest, in different types of
work and in recovery refute the claims that physical per-
formance rapidly decreases when men work hard while
on a diet restricted in the B vitamins.
Thiamine
The addition of 5 to 15 mgs. of thiamine daily to a
diet containing sufficient thiamine to prevent deficiency
symptoms has been reported to increase work capacity
in uncontrolled experiments.9,14,32 Such tests are greatly
affected by psychological factors and are not true mea-
sures of muscular endurance. Bpje3 found extra thiamine
of no value in increasing the performance of trained
athletes. In controlled experiments thiamine did not in-
crease breath-holding and arm-holding ability.23 Objec-
tive measurements have demonstrated that large thiamine
supplementation of a normal diet does not increase phys-
ical performance.26
Subjects on a very low thiamine diet have been report-
ed to develop, in the course of a few weeks to months,
clinical deficiency symptoms which include muscle sore-
ness, weakness, fatigability, and decreased ability to do
physical work.11,22,33,44 The acceptable evidence indicates
that cl nical thiamine deficiencies are slow in developing
even when the thiamine intake is extremely low. Of par-
ticular concern is the fundamental problem of whether
physical performance is enhanced by a thiamine intake
greater than that required to prevent frank symptoms of
deficiency.
The results from experimentally induced thiamine de-
ficiency in female patients in an insane asylum have led
Williams, et al.,44,4;>,4(i’47 to believe that there is a dif-
ference between minimal and optimal thiamine require-
ments. Emphasis was placed on clinical and indirect bio-
chemical observations rather than on physical perform-
ance. They concluded that 0.40 mgs. per 1,000 calories
was the absolute minimum daily requirement to prevent
thiamine deficiency symptoms and that from 0.60 to 1.0
mg. per 1,000 calories is necessary for the maintenance
of maximum physical efficiency. They infer that the op-
timal intake is greater than the minimal requirements.
In this laboratory28 normal male subjects have been kept
on restricted thiamine intakes with a carefully controlled
regime of diet, work, and observations. The results in-
dicate that for at least ten weeks no benefit of any kind
was derived from thiamine intakes greater than 0.23 mg.
per 1,000 calories. Muscular, neuromuscular, cardiovas-
cular, psychomotor and metabolic functions were not lim-
ited by the thiamine intake. Clinical signs, subjective im-
pressions, mood and behavior were not influenced. Wang
and Yudkins’ 43 subjects on a very low thiamine intake
developed no symptoms except lack of appetite, general
fatigue and lassitude. The symptoms persisted as long
as the special diet was eaten even after the addition of
1.8 mgs. of thiamine per day and probably were psycho-
logical reactions to the monotonous diet.
Riboflavin
Clinical ariboflavinosis is not notably associated with
muscular weakness or reduced work capacity and restric-
tion of the riboflavin intake of man for many months
has failed to demonstrate any physical deterioration29,48
Levels of riboflavin intake as low as 0.3 mg. per 1,000
calories maintained for five months permit maximum ex-
ertion and efficiency in neuromuscular, cardiovascular and
psychomotor performance (op. cit.) It should be noted
that in the United States an intake of less than 1 mg.
of riboflavin on a 3,000-calorie diet is achieved only by
considerable effort and special precautions. Accordingly
it would appear that under ordinary circumstances in
this country limitation of physical performance by a de-
ficiency of riboflavin must be extremely rare.
Niacin
Weakness and inability to work effectively are prom-
inent in pellagra and, in view of the reported high inci-
dence of this condition, we might surmise that many
thousands of people are limited in physical performance
by deficiency of niacin in the diet. However, there is
little that can be said as to quantitative relations. The
requirement for niacin to prevent frank pellagra is un-
known and criteria for estimating the state of niacin nu-
trition are unsatisfactory.34,37,49 Accordingly, it cannot
be stated what level of intake of the vitamin is needed
November, 1943
357
to guarantee maximum capacity for work performance
nor whether neuromuscular deterioration proceeds ap-
preciably at levels of restriction where cutaneous and
other signs do not appear. Controlled studies on phys-
ical fitness and work output are lacking. It does appear
that physical performance is not improved by the addi-
tion of large niacin supplements to ordniary diets which
are considered adequate for the prevention of frank de-
ficiency states. 20,40
Ascorbic Acid
Ascorbic acid has not been neglected as a factor in-
fluencing physical performance. Claims have been made
that the vitamin C requ’rement is increased during hard
work and that vitamin C supplementation enhances work
capacity even in the abscence of deficiency symptoms
2,4,16,31,38. evidence Up0n which the claims are
made is by no means unquestionable. Data collected
from South African mine workers who were on a low
vitamin C intake demonstrated that work capacity and
performance in athletic events were not influenced by
ascorbid acid supplementation.5,13'21,30 It was shown
that the work output of the miners was the same wheth-
er the men were receiving 15 to 25 mgs. or more than
50 mgs. of ascorbic acid per day. The addition of 200
mgs. of ascorbic acid daily to diets containing 70 mgs.
had no effect on the ability of U. S. Army soldiers to
do hard work.20
Vitamin E
The present state of knowledge of the role of vita-
min E in muscle metabolism and muscular disorders has
been reviewed by Keys25 and Pappenheimer.35 Animal
experiments demonstrate that lack of vitamin E is asso-
ciated with profound muscular changes.19,24 No con-
trolled observations have been made on the physical abil-
ity of men on low vitamin E diets and it is probably
safe to assume that the average diet contains sufficient
vitamin E to fill most human needs.
Conclusions
All acceptable evidence agrees that the supplementa-
tion of an "adequate” diet with any or all of the vita-
mins known to be required by humans does not increase
physical performance, work output or recovery from
fat’guing work.
Hard physxal work can be performed without phys-
ical deterioration for months on diets that contain about
one-half the recommended daily intake of B complex vi-
tamins. Hard physical work apparently does not greatly
increase B complex vitamin requirements beyond those
due to the increased caloric output.
In the normal young man 0.30 mg. of thiamine per
1,000 calories is sufficient for at least some months to
prevent deficiency symptoms and to allow maximum
physical performance. Larger thiamine intakes have no
effect on work capacity.
The riboflavin requirement for maximum physical effi-
ciency is probably not appreciably more than 1 mg. daily.
Available information does not allow a precise estima-
tion of the niacin requirements for maximum physical
performance. However, 15 to 20 mgs. per day will prob-
ably prove sufficient.
Daily intakes of 25 mgs. of ascorbic acid over long
periods of time have not been accompanied by signs of
scurvy or by physical deterioration.
Claims about the possible reduction in work output by
the current vitamin levels in the American diet are not
justified from the present state of knowledge.
Bibliography
1. Barborka, C. J., Foltz, E. E., and Ivy, A. C.: J.A.M.A.
122:717-720, 1943.
2. Basu, N. M., and Ray, G. K.: Indian J. M. Res. 28:419-
426, 1940.
3. Bpje, O.: Bull. Health Organ., League of Nations 8:439-
469, 1939.
4. Brunner, H.: Schweiz, med. Wchnschr. 71:715-716, 1941.
5. Cluver, E. H.: Bull. Health Organ., League of Nations
9:327-341, 1940.
6. Cowgill, G. R.: J.A.M.A. 1 13:2146, 1939.
7. Csik, L., and Bencsik, J.: Klin. Wchnschr. 6:2275-2278,
1927.
8. Drigalski, W.: Ztschr. f. Vitaminforsch. 9:325-330, 1939.
9. Droese, W.: Miinchen. med. Wchnschr. 88:909-910, 1941.
10. Egana, E., Johnson, R. E., Bloomfield, R., Brouha, L.,
Meiklejohn, A. P., Whittenberger, J., Darling, R. C., Heath, C.,
Graybiel, A., and Consolazio, F.: Am. J. Physiol. 137:731-741,
1942.
11. Elsom, K. O., Reinhold, J. G., bjicholson, J. F., and Chor-
mack, C.: Am. J. M. Sc. 203:569-577, 1942.
12. Foltz, E. E., Ivy, A. C., and Barborka, C. J.: J. Lab. and
Clin. Med. 27:1 396-1399, 1942.
13. Fox, F. W., and Dangerfield, L. F.: Proc. Transvaal Mine
Med. Off. Assoc. 19:19-40, 1940.
14. Gounelle, H.: Bull, et mem. Soc. med. d.hop. de Paris
56:255-257, 1940.
15. Guerrant, N. B., Dutcher, R. A., and Chornock, F.: J.
Nutrition 17:473-484, 1940.
16. Hamel, P.: Klin. Wchnschr. 16:1 105-1 1 10. 1937.
17. Harper, A. A., Mackay, I. F. S., Raper, H. S., and Camm,
G. L.: Brit. M. J. 1:243-245, 1943.
18. Henschel, A. F.: Minnesota Med. 25:974-976, 1942.
19. Hines, H. M., Lazere, B., Thompson, J. D., and Cretz-
meyer, C. H.: Am. J. Physiol. 139:183-187, 1943.
20. Johnson, R. E., Darling, R. C., Forbes, W. H., Brouha, L.,
Egana, E., and Graybiel, A.: J. Nutrition 24:585-596, 1942.
21. Jokl, E., and Suzman, H.: Proc. M*ne Med. Off. Assoc.
(South Africa) (March) 1940 (cited by Steinhaus: Ann. Rev.
Physiol. 3:710, 1941).
22. Jolliffe, N., Goodhart, R., Gennis, J., and Cline, J. K.:
Am. J. M. Sc. 198:198-21 1, 1939.
23. Karpovich, P. V., and Millman, N.: New England J. Med.
226:881-882, 1942.
24. Kaunitz, H., and Pappenheimer, A. M.: Am. J. Physiol.
1 38:328-339, 1943.
25. Keys, A.: Federation Proc. 2:164-187, 1943.
26. Keys, A., and Henschel, A.: J. Nutrition 23:259-269, 1942.
27. Keys, A., Henschel, A. F., Taylor, H. L., Mickelsen, O.,
and Brozek, J. M.: To be publ:shed. 1943.
28. Keys, A., Henschel, A. F., Mickelson, O., and Brozek, J.
M.: J. Nutrition (in press) 1943.
29. Keys, A., Henschel, A. F., Mickelcen, O., Brozek, J. M.,
and Crawford, J. H.: To be published. 1943.
30. Leong, P. C: Biochem. J. 35:806-81 2. 1941.
31. Mathews, S.: Ztschr. f. Untersuch. d. Lebensmitt. 81:53-54,
1941.
32. McCormick, W. J.: M. Rec. 1 52:439-442, 1940.
33. Melnick, D., Field, H., and Robinson, W. D.: J. Nutrition
18:593-610, 1939.
34. Mickelsen, O.: Journal-Lancet (this issue) 1 943.
35. Pappenheimer, A. M.: Physiol. Rev. 23:37-50. 1943.
36. Reitschel, H., and Mensching, J.: Klin. Wchnschr. 18:273-
278, 1939.
37. Salter, W. T.: New England J. Med. 226:649, 1942.
38. Schroll, W.: Pfliigers Arch. f. d. ges. Physiol. 240:642-
646, 1938.
39. Sebrell, W. H.: Am. J. Pub. Health 32:15, 1942.
40. Simonson, E., and Enzer, N.: J. Indust. Hyg. and Toxicol*
24:83-90, 1942.
41. Stiebeling, H. K., and Phioard, E. F.: Circular 407, U. S.
Dept. Agriculture, Washington, D. C., 1939.
42. Wald, G., Brouha, L., and Johnson, R. E.: Am. J. Physiol.
1 37:551-556, 1942.
43. Wang, Y. L., and Yudkins, L.: Biochem. J. 34:343-352,
1940.
44. Williams, R. D„ Ma-on, H. L.. Wilder, R. M., and Smith,
B. F.: Arch. Int. Med. 66:785-799, 1940.
45. Williams, R. D., Mason, H. L., Smith, B. F., and Wilder,
R. M.: Arch. Int. Med. 69:721-738, 1942.
46. Williams, R. D., Mason, H. L., Power, M. H., and Wilder,
R. M.: Arch. Int. Med. 71:38-53, 1943.
47. Williams, R. D., Mason, H. L.. and Wilder, R. M.: J. Nu-
trition 25:71-97, 1943.
48. Williams, R. D., Mason, H. L., Cusick, P. L., and Wilder,
R. M.: J. Nutrition 25:361-377, 1943.
49. Youmans, J. B., and Patton, E. W.: Clinics 1:303-345,
1942.
358
The Journal-Lancet
Climate and Vitamin Requirements
Henry Longstreet Taylor, Ph.D.f
Minneapolis, Minnesota
TROPICAL or semi-tropical conditions have long
been associated with diseases caused by deficiency
of the various vitamins, particularly those vitamins
of the B complex. It is of interest, then, to inquire what
effect climate may have on vitamin requirements of man.
Van Veen' has pointed out that this problem is compli-
cated by the fact that poor social and economic conditions
co-exist with tropical conditions in the Far East; this is
also true in other tropical areas. The high incidence of
parasitic infection in such regions is another complicating
circumstance. Thus, factors other than climate per se
are operative in the tropical and sub-tropical areas where
nutritional deficiency diseases are endemic. To obtain
reliable information on the question of the influence of
climate on the vitamin requirements of man, it would be
necessary to set up rigidly controlled experiments to test
the effects of light, humidity and temperature. These
questions are of particular importance when so many
members of the Armed Forces are taking up residence
under rigorous conditions in many parts of the globe
where the climate is of an extreme nature.
The influence of light on the requirements for vitamin
D in children requires no comment here. The possible
effect of light on the requirement of riboflavin necessary
to prevent damage to the cornea is currently being stud-
ied in several laboratories, but the results of these investi-
gations are not available as yet. There have been no sug-
gestions that very low temperatures have any effect on
vitamin requirements other than those due to increased
consumption of calories. Accordingly, the present dis-
cussion will be confined to the effects of high tempera-
tures.
In the desert and tropics sweat production may be ex-
tremely high. Bock and Dill2 have shown that a seven-
hour walk in hot desert conditions may lead to a loss of
9 liters of sweat. In this laboratory3 losses of 5 to 8 liters
have been regularly observed under such conditions.
Early studies on the concentration of both thiamine and
ascorbic acid in sweat suggested that important losses of
these vitamins might occur in this way. Hardt and Still4
reported 1.5 micrograms of thiamine in a pooled sample
from four subjects at rest. In work, these authors re-
ported 90 micrograms of thiamine per liter of sweat and
as much as 4,540 micrograms per liter of sweat collected
from men who had ingested 50 mg. of thiamine orally.
The ascorbic acid content of sweat has been reported to
be as high as 0.64 mg. per 100 ml. (Cornbleet, Klein and
Pace6), or even 1 mg. per 100 cc. (Bernstein1). It now
appears that these high values for the concentrations of
thiamine and ascorbic acid were the results of technical
errors. Carefully controlled work in this laboratory1 has
shown that the average ccncentration of ascorbic acid in
sweat is not more than 0.06 mg. per 100 ml., a figure
which would indicate a loss in the most extreme condi-
t Laboratory of Physiological Hygiene, University of Minnesota.
tions of less that one-tenth of the N.R.C. recommended
daily allowance. Tennent and Silber8 have reported find-
ing no ascorbic acid in sweat and only minimal amounts
of dehydro-ascorbic acid. Thiamine concentrations of the
order of 0.15 micrograms per 100 ml. were found.7 This
might lead to a maximal loss of 50 micrograms per day,
less than one-thirtieth of the estimated daily requirement.
Unpublished results from other laboratories confirm
these negligible losses of thiamine and ascorbic acid in
sweat.
Riboflavin occurs in sweat in such small amounts that
it was necessary to concentrate pooled samples by low
temperature vacuum evaporation to obtain a reliable
analysis. The concentration of riboflavin was estimated
at 0.5 micrograms per 100 ml.‘ which represents a pos-
sible loss under extreme conditions of less than 2.5 per
cent of the daily estimated requirement.
Preliminary estimates of the nicotinic acid content of
sweat indicate that some nicotinic acid may be lost under
conditions of maximal sweating. The concentration of
nicotinic acid in sweat has been estimated to be as high
as 0.1 mgm. per 100 ml. by both the chemical and micro-
biological methods. These are preliminary estimates; fur-
ther work is necessary before it is established that the
nicotinic acid requirement in hot climates is increased sig-
nificantly by losses through sweating.
Recently claims have been made for increased require-
ments of both thiamine and ascorbic acid in hot environ-
ments due to causes other than losses through sweating.
Mills9,10 has recently reported that growing rats require
twice as much thiamine at 90° F. as at 60° F. His results
are striking and leave no doubt as to the effect of tem-
perature on the thiamine requirement of the rat. How-
ever, it is doubtful whether these results can be applied
to man as Mills has recently suggested.11 The rectal tem-
perature of adult rats in an environment of 90° F. is 2.5°
F. higher than in a 68° F. temperature;12 young rats are
even more poikilothermic. This is in sharp contrast to
the drop of 0.5° F. rectal temperature which usually
occurs in men entering the tropics.13
Data relating to the effect of temperature on the thia-
mine requirement of man is at best fragmentary. Pre-
liminary studies14 in this laboratory indicate that supple-
mentation of a normal diet with 5 mgs. of thiamine, 10
mgs. of riboflavin and 100 mgs. of nicotinamide does not
influence the ability of men to perform work during the
critical3 period of adaptation to high temperature. Holt15 \
has concluded from studies of the urinary excretion of
thiamine of subjects cn controlled diets that the thiamine
requirement of man during periods of increased tempera-
ture is less than it is during cool spells. This conclusion
is in agreement with the report of Williams, et al.16 that
4 patients on 0.15 mg. thiamine a day tolerated the diet
for 88 days in the winter, while another group on the
same diet was able to continue 147 days during the sum-
November, 1943
359
mer. However, the lack of objective criteria in the sum-
mer experiment17 and the high dependence in both ex-
periments on vague clinical symptoms of subjects who
had been previously classed as psychotics do not lend as
much support to the validity of this observation as might
be desirable. The answer to this question will come only
when long-term experiments (four to six months) similar
to that of Keys, et al.18 or Williams, et al.19 are carried
out under the desired climatic conditions.
Claims for supplementation with ascorbic acid in hot
weather have been based on trials of this vitamin for the
prevention of heat exhaustion at a large industrial con-
cern.20,21 The problem of the prevention and treatment
of heat exhaustion in desert and tropical areas is one
that is important to the armed forces as well as to in-
dustry. The question has been carefully studied in this
laboratory.22 Cardiovascular functions, the performance
of standard physical tasks, psychomotor functions, ascor-
bic acid in sweat, blood plasma and urine and the inci-
dence of heat exhaustion were studied intensively in 44
normal young men living in the laboratory’s air-condi-
tioned suite under rigidly controlled conditions of diet,
physical work and environment. Air temperatures during
the day were 120° F. and at night 85 to 90° F. The resi-
dence in the hot suite varied from four hours to six days.
The effects of ascorbic acid intake of 20 to 40 and 520
to 540 mg. a day were carefully compared. Pulse rates
in rest and work, rectal temperatures, vasomotor stability
tests, rates of sweating, general observations and subjec-
tive reports all failed to demonstrate any significant ad-
vantage for the men receiving supplements of ascorbic
acid. Heat exhaustion, characterized by nausea, vomit-
ing, tachycardia, hypotension, vertigo, dehydration and
collapse occurred with equal frequency in the vitamin C
restricted and supplemented groups. This investigation
seems to have ruled cut any specific curative or prophy-
lactic effect of ascorbic acid on the treatment or preven-
tion of heat exhaustion. Sodium chloride still seems to
be the most effective agent for the prevention and cure
of both heat cramps23 and heat exhaustion.24
It should be remembered that the long-term effects of
hot climates on the ascorbic acid requirement have not
been ruled out. However, the ascorbic acid requirement
of man in temperate climates is still very much in dis-
pute.20 Adequate criteria for the determination of the
normal vitamin C requirement will have to be developed
before differences in requirements due to climatic condi-
tions can be properly evaluated. The same statements
apply to the other vitamins.
Conclusions
Vitamin losses in the sweat are negligible and do not
contribute in any significant degree to the development
of deficiency diseases in hot climates. A possible excep-
tion to this may be nicotinic acid.
Ascorbic acid does not improve the ability of men to
perform work in the heat and does not appear to have
any effect on the prevention or cure of heat exhaustion.
There is at present no acceptable evidence that vitamin
requirements of man are increased by tropical or desert
conditions. However, it has not been proved that require-
ments are not ultimately affected under these conditions.
The answer to these questions awaits long-term objective
experiments on man under these particular climatic con-
ditions.
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Staff Meet., Mayo Clin. 14:787, 1939.
18. Keys, A., Henschel, A. F., Mickelsen, O., and Brozek, J.
M.: J. Nutr., in press, 1943.
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R. M.: J. Nutr. 25:361, 1943.
20. Anonymous: Science Suppl. 95:12, 1942.
21. Holmes, H. N.: Science 96:384, 1942.
22. Henschel, A., Taylor, H. L., Brozek, J., Mickelsen, O.,
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23. Talbott, J. H.: Medicine 14:323, 1935.
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To be published, 1943.
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Med. Off. A. 19:19, 1940.
360
The Journal-Lancet
Laboratory Methods of Evaluating Vitamin
Nutritional Status
Olaf Mickelsen, Ph.D.f
Minneapolis, Minnesota
AT present there is good evidence that human be-
ings require thiamin, riboflavin, niacin, vitamins
LA, D, C and K. Many methods have been pro-
posed by which it was hoped to determine whether an
individual is deficient in these vitamins. These tests have
involved physiological, neurological, psychological and
biochemical measurements. This review will be limited
to an evaluation of the chemical methods suggested for
these measurements. There are a number of good sur-
veys of the methods used in the study of vitamins D
60,115 ancj K, 15,24 consequently these vitamins will not
be considered further.
Vitamin A
Methods of Analysis. Considerable research is still
being done on the methods for the determination of vita-
min A. The present methods of analysis have been re-
viewed by Hickman.56 There are a number of modifi-
cations of the Carr-Price reaction which have been used
extensively in the work to be reported. 71,76 These meth-
ods depend upon the extraction of vitamin A by means
of an organic solvent (or mixture of solvents) , evapora-
tion of solvent, solution of residue in dry chloroform and
formation of a blue color upon the addition of a chloro-
form solution of antimony trichloride. This procedure
determines both carotene and vitamin A. The carotene
can be measured separately by comparing the yellow
color of the first extract with a standardized solution of
potassium dichromate.
Blood Levels. Many reports have purported to show a
correlation between the level of vitamin A in the plasma
and the individual’s reserves of this vitamin. Most of
these reports have been studies of subjects from various
economic levels.70,84,85’88 The assumption has been made
that the people with the higher income have the larger
intake of vitamin A. This is probably true for large
groups, but in individual cases and in small series it may
give a false impression of the vitamin status. Even if the
assumption were valid' the results of the plasma vita-
min A analyses show considerable overlapping. In spite
of these limitations, the above workers suggest plasma
levels of 40 to 49 I. U. per 100 cc. serum as borderline
for children.
There is some experimental evidence that the vita-
min A in the plasma decreases when the intake is re-
duced,130 but no indication of the lower level compatible
with health was secured. Surveys of adults from differ-
ent economic levels have been made similar to those
among children.1,148,150 In one of these studies1 the
lower limit for normal plasma concentration of vitamin A
was set at 80 I.U. per 100 cc., yet 77 per cent of the
male subjects from a "low socio-economic stratum” had
t Laboratory of Physiological Hygiene, University of Minnesota.
more than this. Such a finding is inconsistent with the
hypothesis that people with small incomes are malnour-
ished, or else the plasma level does not accurately reflect
vitamin A nutrition.
Other investigators have assumed that their modifica-
tions of the visual tests for vitamin A sufficiency are valid
indications of nutritional status and on this basis have
attempted to set up normal blood levels.86,104 There is
still too much controversy as to the influence of vita-
min A on dark adaptation to permit the use of this tech-
nic in establishing normal plasma levels.
In general, it seems as though a low vitamin A intake
is associated with a low level in the blood. As yet there
has been no agreement on the lower levels of normalcy.
Even if one were to accept the lowest level given by the
above workers (30 to 60 suggested by Wolff), one can
still find such great variations that the validity of the
basic assumption is questioned. For instance, de Haas
and Meulemans49 found 3 of 16 children showing signs
of vitamin A deficiency (blindness, xerosis or Bitot’s
spots) who had some vitamin A in their serum, in one
case as much as 38 I.U. per 100 cc. On the other hand,
if one accepts the higher limits, there are many persons
who, on this basis, would have to be considered deficient,
but who show no other signs of deficiency than the low
plasma level. This matter cannot be definitely settled
until a controlled dietary study at various levels of vita-
min A has been made. These tests will have to consider
the possible destruction of this vitamin in the diet and
the gastrointestinal tract.19,56
Most emphasis has been placed on the amount of vita-
min A in the plasma because the carotent level "seems
to be a measure of the difference between the rate of
absorption from the intestines and the rate of absorption
by the tissue and not an index of nutritional reserves or
intake.” 13
The liver is the main storage depot for vitamin A
34,94,107. amount in the rest of the body is only a
small fraction of that normally occurring in the liver. A
number of attempts have been made to correlate the vita-
min A in the liver of experimental animals with that
present in the plasma. So far most of these experiments
have shown that when the level of vitamin in the liver
is high, the blood level is also high but in none of these
is the correlation very good in the lower ranges where it
is most important for the differentiation of "subclinical
avitaminosis.” 61,68,82,83,148 A similar conclusion was
reached by Meyer, et al.,91 who studied the vitamin A
in human liver biopsy samples and compared the values
with the plasma levels.
The ingestion of a meal has no perceptible influence
on the amount of vitamin A in the blood.76 The inges-
November, 1943
361
tion of fairly large amounts of alcohol increases the
plasma level, largely because of the appearance of an
esterified form of the vitamin.27 This test has been sug-
gested as a means of measuring the vitamin A stores26
but so far nothing has been done to evaluate it.
Josephs69 claims on the basis of experiments with rats
that the first manifestation of a vitamin A deficiency is
a decrease in the total blood lipids. However, his own
results with human beings70 indicate that there is no very
great difference in the total blood lipids of individuals
of different vitamin A status.
Ralli, et al.,110 found that when normal subjects are
given a dose of 100,000 I.U. vitamin A in the form of
a codliver oil concentrate, the increase in the plasma level
was much greater than that in patients with cirrhosis of
the liver. They had previously shown that the stores of
vitamin A in the livers of patients with cirrhosis were
less than those in normal individuals.109 The fasting
blood levels in all of their normal subjects were much
higher than those reported by other workers. Further-
more, two of their patients with cirrhosis showed fasting
levels between 70 and 75 I.U. per 100 cc., which accord-
ing to other workers is normal.
Excretion tests cannot be performed on human beings
because normally there is no excretion in the urine of
vitamin A or carotene. 79,117,135
Conclusion. At present there is no reliable laboratory
test for vitamin A sufficiency. Further work under more
controlled conditions will have to be done in order to
establish whether the plasma vitamin A level adequately
reflects one’s nutritional status.
Vitamin Bi
Methods of Analysis. At present there are a number
of methods for the determination of small amounts of
thiamine. These methods have been reviewed by de
Jong.67
Bisulfite Binding Substances. In an effort to find some
biochemical difference between people securing an ade-
quate thiamine intake and those on a deficient intake,
early investigation was directed toward a study of the
amount of keto-compounds in the blood under different
dietary conditions. Peters and his group at Oxford65'3,
103 showed that a deficiency of vitamin Bi in rats pro-
duced an increase in pyruvic acid. Since then many at-
tempts have been made to determine whether the amount
of aldehydes and ketones (bisulfite binding substances)
in the blood reflects the thiamine nutritional status. The
increase in these compounds in the blood of animals
maintained on varying levels of vitamin Bi has been
questioned. Thompson and Johnson134 maintained that
there was a marked increase in the bisulfite binding sub-
stances (B.B.S.) in the blood of polyneuritic pigeons and
that most of this increase was due to the presence of
pyruvic acid. De Jong66 followed the B.B.S. in the
blood of pigeons from the start of an experimental defi-
ciency and found that some birds developed opisthotonus
before there was any increase in the B.B.S.
Some of the earlier clinical results indicated an in-
crease in the B.B.S. in the blood of Orientals with beri-
beri and a decrease following yeast supplementation.105
The studies on pyruvic acid in the blood during this con-
dition showed a considerable overlapping of the various
groups.9,17,106 In all of the cases so far studied, there
has been no careful study of the diet other than that
secured by case histories. Most of the deficient persons
studied had various diseases which might have decreased
their thiamine intake, but the independent influence of
these diseases on the B.B.S. in the blood was not con-
sidered.
Recent work indicates that there is no close relation
between the blood B.B.S. and the urinary excretion of
thiamine. This was shown in the experiment of Robin-
son, et al.,113 in which a subject was maintained on a low
thiamine diet for one month. During this time there
was a progressive decrease in the blood B.B.S. Even after
prolonged exercise, while the subject was on this diet,
there was no increase of total keto-compounds in the
blood. It had previously been reported87 that after mild
exercise the blood pyruvic acid increased to a greater ex-
tent in subjects with a poor intake of thiamine than in
their controls. Diseases not associated with a thiamine
deficiency may also increase the level of B.B.S. in the
blood and cerebrospinal fluid.146,149
Shils, et al.,125 have shown further that when persons
are kept on a very low intake of thiamine for 37 days,
the excretion of B.B.S. in the urine shows no change even
though the excretion of thiamine in the urine ceases.
So far no one has studied the rate at which pyruvic
acid injected into human beings is removed from the
blood stream in relation to thiamine deficiency. Sherman
and Elvehjem124 found that normal chicks showed prac-
tically no increase in the blood pyruvic acid under these
conditions whereas polyneuritic chicks showed a high
peak which was maintained for some time. Bueding,
et al.,18 claim that following the ingestion of glucose the
pyruvic acid increases to much higher levels in the blood
of subjects with a deficiency of thiamine than in the
blood of their normal subjects. They give no indication
of the thiamine intakes of their subjects.
Urinary Excretion. As soon as the tests for thiamine
became sufficiently sensitive, studies on the excretion of
this compound were initiated. Harris, et al.,51 used the
bradycardia assay technic with rats and found in normal
persons an excretion of 0.39 mg. per day. Seven cases of
beriberi excreted less than 0.01 mg. per day. They con-
cluded that symptoms of polyneuritis were associated with
an excretion of less than 0.023 mg. per day. Other Euro-
pean and Asiatic reports62,136,144 list the minimal thia-
mine excretion by normals near the same level. Ameri-
can reports89 have tended to place the minimal level
much higher. Most of the suggested minimal levels for
this country have been 0.09 mg. for males and 0.06 mg.
for females per twenty-four hours.
Before examining various modifications of the excre-
tion assay, it is necessary to consider the standards of
normalcy so far proposed. Most of the reports in the lit-
erature can be criticized because the vitamin intake has
been unknown and the deficiency cases have been sub-
jects who had some other complicating disease. In our
362
The Journal-Lancet
laboratory we have had normal men on a known amount
of thiamine.73 These men excreted over a period of six
months less than the amounts of thiamine suggested by
American investigators as being indicative of a deficiency.
During this time there was no change in their physical or
psychological performance. At present we have another
group of normal men on a still lower thiamine intake.
Over an extended period their thiamine excretion has
been close to zero without any physiological change.75
Holt59 has also questioned the validity of the urinary
thiamine levels so far proposed for adequacy. According
to him the excretion of any thiamine (or for that matter
any other vitamin) in the urine indicates that the body
has a surplus available for excretion. This and similar
evidence make it necessary to re-evaluate the criteria pro-
posed both for the estimation of the nutritional status
on the basis of urinary excretion as well as for the min-
imal requirement for these vitamins in so far as the esti-
mates have been based on urinary excretion.
A number of saturation tests have been proposed in
an effort to overcome the disadvantages of the basal
twenty-four-hour excretion. The test doses have varied
from 1 to 100 mg. when given orally and from 1 to 50
mg. when given by injection. These tests have been de-
scribed and discussed by de Jong.67 Nothing very defi-
nite can be said about the standards for normalcy until
some agreement can be reached on the technic to be used
for this test.
There are certain factors that may influence an excre-
tion test, de Jong67 found that even when the thiamine
intake of normal men was constant the excretion varied
by as much as 375 per cent from day to day, especially
at the lower levels of excretion. If a twenty-four-hour
basal urine collection were made on the day of the low
excretion and the urine following the saturation test dose
were collected on the day of the high excretion, a falsely
high value would be obtained. The unexplained varia-
tion in the urinary thiamine is much more important at
the lower levels of excretion where it may give a fairly
high percentage excretion of the saturation test dose one
time and a negative value the next.92 Another factor of
importance is the presence of concomitant deficiencies
which may produce a high excretion of the test dose even
though there are symptoms of thiamine avitaminosis.96
Intestinal absorption and renal excretion are other fac-
tors which may influence the excretion of the test dose.
Blood Levels. Many reports have appeared on the
amount of thiamine in whole blood and the possible use
of this criterion in evaluating the nutritional status.45,145
Most of the early work indicated that normal values
varied from 0.004 to 0.018 mg. per 100 cc. whole blood.
Cases with signs of clinical thiamine deficiency had small-
er amounts than this. More recent reports120,151 have
shown a great variation in the day-to-day level of thia-
mine in the blood. Further doubt is cast on the relia-
bility of this method by the finding that some Batavians
with severe beriberi had normal blood levels.101 The dis-
tribution of thiamine in the blood has shown that the
white cells contain an average of 0.07 mg. per 100 cc.,
the red cells 0.086 mg. and the plasma almost none.48
The amount of B] in the white cells has been proposed
as an index of thiamine saturation but as yet there has
been nothing more than the suggestion.48
Conclusion. Of the methods so far proposed for the
evaluation of the state of thiamine nutrition, the best one
appears to be the twenty-four-hour urinary excretion
while the subject remains on his usual diet. If a large
amount of vitamin Bj (0.1 mg. or more) is excreted in
such a sample, that person is in no danger of being de-
ficient. At the lower levels (0.05 mg. or less) it may be
necessary to repeat the determination and if there is still
some thiamine in the urine, it seems safe to consider that
individual as receiving a low but sufficient amount of the
vitamin.
Riboflavin
Methods of Analysis. There are a number of chemical
tests for riboflavin which depend on the measurement of
the characteristic yellowish fluorescence of this compound
when ultraviolet light is passed through a solution of it.
In our laboratory we have found that the method of
Connor and Straub28 is the best one for urinary analyses.
It may be advantageous to run blanks on these samples
after irradiating them to destroy the flavin because there
are some non-vitamin substances present in urine which
fluoresce under the conditions of the test. The micro-
biological assay of Snell and Strong127 has been found
admirable for other analyses providing certain precau-
tions are observed.2,10
Blood Levels. A few reports have appeared on the
concentration of riboflavin in the blood as determined by
the microbiological procedure.5,133 The work at Hill-
man Hospital showed that there was no apparent dif-
ference in the amount of riboflavin in the blood of nor-
mal people and in that of persons showing clinical signs
of ariboflavinosis. Shortly thereafter Eckardt, et al.35
showed that there was something in blood which inter-
fered with the microbiological determination. So far no
report has appeared in which this difficulty has been over-
come. The interfering substance has been concentrated
by continuous ether extraction but a large part of the
material still remains in the blood.40 At present it is
hard to determine whether the riboflavin level in blood
offers any index of nutritional status because the concen-
tration of the stimulatory substance varies from sample
to sample.35
Urinary Excretion. The amount of riboflavin excreted
in the urine appears to be related to the dietary intake.
A measurement of the urinary excretion as an index of
nutrition is subject to the same limitations as discussed
under thiamine. A number of isolated studies on normal
individuals have led some investigators to put the "nor-
mal level of excretion” at over 0.5 mg. per day.41,133
Axelrod, et ah, 4 state that the normal excretion is above
0.2 mg. per day while levels below 0.05 are indicative of
ariboflavinosis.
Najjar and Holt97 have claimed that their modifica-
tion of the saturation test distinguishes between normal
subjects and those with mild clinical symptoms of flavin
deficiency. This, however, has not been the experience
November, 1943
363
of Axelrod, et al.,4 who found no relation between the
excretion of a test dose and the previous daily excretion
of riboflavin. The results of the group at the Mayo
Clinic147 tend to confirm the fact that the test dose
method offers no better guide to the nutritional status
than can be secured from the ordinary twenty-four-hour
urine excretion. Our own experience72 has been very
similar to this and more recently we have occasionally
found an apparently complete retention of the test dose
by normal individuals.74
Conclusions. The twenty-four-hour urinary excretion
offers the best available index of riboflavin nutrition. The
interpretation of these results is similar to that discussed
under thiamine.
Nicotinic Acid
Methods of Analysis. There are a number of methods
available for the determination of nicotinic acid and its
derivatives. The chemical methods have been reviewed
by Bandier.7 Most of these methods involve the splitting
of the pyridine ring by means of cyanogen bromide fol-
lowed by coupling of the liberated compound with an
aromatic amine to produce a yellowish color. There are
pigments present in most biological materials which in-
terfere with the final colorimetric estimation. This has
resulted in a number of modifications which attempt to
overcome the difficulty.1 43 A microbiological procedure
has been developed by Snell and Wright128 which over-
comes many of the disadvantages of the chemical meth-
ods but suffers from the fact that it requires a number
of days before the results are available. For most pur-
poses where time is not an important factor, this is prob-
ably the best procedure to use.
Blood Levels. As soon as it became evident that nico-
tinic acid was a cure for pellagra, attempts were made to
determine whether there was any relation between the
nutritional status of an individual and the level of nico-
tinic acid in the blood. A number of early reports8,141
stated that the level of nicotinic acid in the blood of pel-
lagrins was lower than that in normal blood. More re-
cent work has definitely shown that there is no decrease
in the level of nicotinic acid in the blood of persons suf-
fering from an acute deficiency of this vitamin. Most of
the nicotinic acid in the blood is present in the corpuscles
where it occurs as coenzymes I and II; very little is pres-
ent in the plasma and all of that is in the free state.37
Porphyrin Excretion. Ellinger and coworkers reported
an increased excretion of porphyrin in pellagrins.1 1,36,129
They used a method which according to Watson90,139
measured either urorosin or indirubin. More exact tests
for porphyrins indicate that pellagrins and normal sub-
jects excrete the same amount.
Urinary Excretion. Studies on the excretion of nico-
tinic acid in the urine have been complicated by the fact
that most of it is excreted as trigonelline and only a small
part as nicotinuric acid.90 Vilter and coworkers report-
ed139 that no nicotinic acid or any of its derivatives are
excreted by pellagrins. The method used by these work-
ers has been criticized as being unreliable and only semi-
quantitative.142 Rosenblum and Jolliffee116 claim that
cases of alcoholic pellagra excrete less nicotinic acid than
normal persons but their procedure also measures a cer-
tain amount of trigonelline.42 The end products of nico-
tinic acid metabolism appear to be the same in dog and
in man.118 No change occurs in the excretion of nico-
tinic acid in dogs even up to the development of black
tongue, but there is a marked decrease in the excretion
of trigonelline during this time.118 A similar decrease in
trigonelline excretion has been observed in humans main-
tained on a restricted nicotinic acid intake.42,46 A fairly
simple method is available for the determination of trigo-
nelline44 but the interpretation of the analytical results
is difficult because the diet may add considerably to the
excretion. When the dietary intake of trigonelline is kept
as low as possible, the excretion of trigonelline plus nico-
tinic acid derivatives ranged from 4.3 to 15.0 mg. per
day (average 8.7) in persons showing signs of vitamin
deficiency and from 12.3 to 22.1 (average 16.1) in nor-
mal persons.46
Two saturation tests have been proposed for evaluating
the nicotinic acid status of a subject.46,102 Both of these
tests involve a basal twenty-four-hour urine excretion fol-
lowed by another twenty-four-hour urine collection after
a test dose of 300 or 500 mg. of nicotinic acid has been
given. The authors claim that the per cent of the test
dose excreted is related to the previous nicotinic acid in-
take. Most of the increased excretion was due to the
presence of trigonellin.
In man the largest part of the excreted nicotinic acid is
accounted for in the form of some compound (or com-
pounds) other than the three that have so far been stud-
ied (trigonelline, nicotinic and nicotinuric acids). When
Sarett, et al.,119 gave 500 mg. of nicotinamide per day
to six normal students, they were able to account for
only 36 per cent of the ingested vitamin on the basis of
urinary excretion on the last day. In dogs a somewhat
similar experiment1 18 showed an excretion of 90 to 100
per cent of the ingested vitamin on the last day of the
saturation test.
Najjar and coworkers95,98,99 have reported that when
a person on a normal diet changes to one restricted in
nicotinic acid, the excretion of a fluorescent compound
(Fo) decreases. As the excretion of this compound de-
creases and as the nicotinic acid deficiency progresses,
another fluorescent compound (Fi) appears in the urine.
Under normal conditions the urine contains mostly the
F2 compound whereas in pellagra nothing but Fi is ex-
creted. A number of recent reports have attempted to
identify Fa with thiochrome29 and with N-methyl nico-
tinamide chloride.63 These claims have been refuted100
by Najjar and his group who maintain that it is one of
the dihydro-N-methyl nicotinamides. At present there
have been no other reports than those from Johns Fdop-
kins on the use of this technic.
Conclusion. At present there is no wholly acceptable
method for the evaluation of the nicotinic acid status
of a subject.
Vitamin C
Methods of Analysis. The oldest and the most com-
monly used method for the determination of vitamin C
in biological materials depends upon its reduction of the
364
The Journal-Lancet
dye 2, 6-dichlorophenolindophenol. Under ideal condi-
tions the dye is decolorized instantaneously by ascorbic
acid. There are some other compounds present in urine
and blood such as thiosulfates, ergothioniene and disul-
fides which decolorize the dye more or less slowly. The
various modifications of this technic which have been
proposed with the hopes of making the method more
specific have been reviewed by Bessey.12 A more precise
technic has been described recently57 in which the influ-
ence of the non-vitamin reducing substances has been re-
duced to a minimum. This method is probably the best
one to use for urine samples whereas the Mindlin-Butler
procedure has proved satisfactory for plasma analyses.93
These procedures involve the use of a photoelectric
colorimeter in making the final determination. A number
of methods have been described39,52 whereby the amount
of vitamin C is determined by titration. Most of these
methods include a larger amount of the interfering sub-
stances than do the procedures which depend upon the
photoelectric colorimeter. A procedure which depends
upon the formation of a hydrazone with dehydroascorbic
acid has been described114 but as yet no other laboratory
has commented on it.
Blood Levels. The determination of the fasting plas-
ma level of vitamin C has long been used as a method of
determining whether a subject is receiving a sufficient
amount of the vitamin. Many American and European
workers126,148 have set up the following criteria to aid
in their interpretation of the chemical results: above 1.2
mg. per cent "saturated”, 0.6 to 1.2 mg. per cent "satis-
factory”, 0.3 to 0.6 "prescorbutic”, below 0.3 mg. per
cent "scurvy level”. It was originally thought that the
fasting plasma value was a reflection of the immediate
preceding dietary intake16,38 and that if there had been
no marked change in the ascorbic acid intake the plasma
level indicated roughly the amount of vitamin C in the
body. Some workers have put so much faith in this
method that they have proposed tables showing the extra
amounts of vitamin C that would be required to raise the
plasma level from one value to another.137 The above
work implies that all subjects receiving the same intake
of vitamin C will show the same plasma level. Recent
work indicates, at least as far as women are concerned,
that this is not so and that there may be a considerable
variation in the day-to-day plasma levels when the dietary
intake is maintained constant for a period of three weeks
or more.131 A similar finding has been reported for chil-
dren living in a "well managed orphanage” over a period
of ten months.58 Here in a group of 60 children getting
the same food the plasma vitamin C level ranged from
below 0.25 to 1.2 mg. per cent.
These examples make one wonder, first, whether the
plasma level reflects the previous dietary intake as ac-
curately as some workers have claimed and, second,
whether the low levels classified as "prescorbutic” are
actually indicative of latent scurvy. Dagulf32 showed
that in Sweden the levels of plasma ascorbic acid in the
spring averaged 0.22 mg. per cent for 326 healthy indi-
viduals. These levels are maintained through most of
the year except during the summer months and, in spite
of this condition, the general health and well-being of
the Swedes have steadily improved. In the last few years
a number of workers20,23,3 1,43,71 a'1 1 1 have questioned
the reliability of the plasma level as an index of vita-
min C nutrition.
Butler and Cushman21,22 showed that the white cells
contain a very high concentration of vitamin C. In a
study on a human subject30 the white cells still had their
normal concentration of ascorbic acid long after the plas-
ma was free from it. These workers have suggested that
the white cells would offer a better index of vitamin C
nutrition than the plasma level but as yet there have been
no other reports on such a study. Heinemann55 has pro-
posed the determination of the vitamin C in whole blood
to replace the plasma levels. The determination of ascor-
bic acid in both white cells and whole blood presents
more analytical difficulties than the plasma procedure
since special precautions have to be taken in order to
overcome the oxidative action of the oxygen liberated
from oxyhemoglobin during the laking of cells.81
A high concentration of vitamin C in the plasma is
a good indication that the individual is receiving suffi-
cient vitamin. The interpretation of low levels has be-
come more difficult than was originally anticipated. Until
more definite evidence has been produced it is unwar-
ranted to speak of plasma levels below 0.5 mg. per cent
as "subclinical scurvy” or "prescorbutic”.
Many attempts have been made to surmount the short-
comings of the plasma vitamin C determination by the
use of "saturation tests”108,132 in which the increase in
the plasma level after a test dose of vitamin C is mea-
sured, but each worker has used his own procedure and
criteria so no valid comparison or evaluation of this tech-
nic can be made.
Urinary Excretion. The ease with which vitamin C is
destroyed has prompted a considerable amount of work
on methods of preserving this compound in the urine
during collection periods. Vitamin C can be preserved in
brown bottles at room temperature for twenty-four hours
when 8-hydroxy-quinoline is used as a preservative as rec-
ommended by Sendroy and Miller.121 Another equally
satisfactory method is to use solid metaphosphoric acid
as a preservative in such an amount that the final con-
centration in the urine sample is about 3 per cent.
In the early work on the urinary excretion of vitamin
C, the daily excretion was used as a measure of the ade-
quacy of the diet. The minimal level of excretion which
indicated an adequate intake was set at 13.8 mg. per
day.50 It was soon shown that the excretion of reducing
substances was influenced by things in the diet other than
vitamin C.53 These substances are apparently thiosul-
fates, disulfides and other substances which can be re-
moved by precipitation with barium acetate.138 Various
reports have indicated that some patients with clinical
scurvy still continued to excrete considerable amounts of
reducing substance as determined by the indophenol titra-
tion technic.123 How much of this is actually non-vita-
min-C reducing substances has never been investigated.
These considerations have led most investigators to rely
November, 1943
365
on various modifications of the "saturation” test as an
index of vitamin C nutrition.
Practically each worker has used his own modification
of the "saturation” test with the result that the dose has
ranged from 25 to 1,000 mg. The method of adminis-
tering the test dose has included oral, intravenous and
subcutaneous routes. When a test dose is given in addi-
tion to the usual intake, the greatest part of the extra
excretion (if there is any) occurs during the following
six hours.64 If the test dose is taken with a meal, the
amount excreted is larger than if the dose is given in the
fasting state.54 Most workers are agreed that the excre-
tion of at least 50 per cent of a test dose of vitamin C
during the following twenty-four hours indicates that
the individual is "saturated” with the vitamin.126 Again
it is difficult to interpret the values below 50 per cent
since most workers consider anyone who is not "satur-
ated” as deficient to a certain extent. Zilva152 has ably
questioned tue validity of such reasoning and suggests
a revis’on of the present theories that a person must be
flooded with vitamins in order to maintain a salubrious
condition. The establishment of the lowest percentage
excretion of the test dose compatible with normal health
will have to await further investigation.
Conclusion. If the amount of vitamin C in the plasma
or in the urine is high enough, there is no doubt that the
subject is receiving a sufficient amount of ascorbic acid.
When the plasma level falls below 0.5 mg. per cent and
the urinary excretion drops under 14 mg. per day, the
interpretation thereof is uncertain at the present time.
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The Clinical Diagnosis of Deficiencies of Thiamine,
Riboflavin and Niacin
L. Emmett Holt, Jr., M.D.
Victor A. Najjar, M.D.J
Baltimore, Maryland
THE task of attempting to throw light on this
much confused subject is one which we have un-
dertaken with some hesitation. Our own experi-
ence does not stem from regions where manifest B defi-
ciencies are endemic. Our work has been in an area —
perhaps more typical of the country as a whole — in which
frank deficiencies of the B complex are rare and where
the chief problem is the recognition of the latent or
"subclinical” deficiency. The frequency of these sub-
clinical deficiencies, the criteria for establishing the diag-
nosis and applying vitamin therapy are burning ques-
tions at the present time. Let us begin by considering
the recognized clinical manifestations of these three de-
ficiency states.
Thiamine Deficiency
The recognized manifestations of frank thiamine de-
ficiency are: polyneuritis, myocardial failure, edema, an-
orexia, and psychic changes. We have seen all of them
tFrom the Harriet Lane Home, Johns Hopkins Hospital, Bal-
timore.
in sporadic cases that have come under our observation.
The neuritis affects the legs with the greatest frequency,
next the arms; the cranial nerves are involved excep-
tionally in the adult, a third nerve palsy being the most
frequent manifestation. Observers from the Orient re-
port that in infants the recurrent laryngeal nerve is often
singled out, aphonia being an early and prominent symp-
tom. No better description of the signs of early thiamine
neuritis in the lower extremities has been given than that
of Jolliffe,1 who emphasizes the fact that the process is
always a symmetrical one, that the sensory and reflex
changes precede the motor ones and that there is a reg-
ular pattern of extension — the plantar area, sock area
and calf area being successively involved. According to
Jolliffe evidences of neural involvement occur in the fol-
lowing sequence: muscle hyperesthesia, loss of vibratory
sense, loss of reflexes, loss of position sense, motor weak-
ness. Abnormality of gait, may, however, develop before
there is definite motor atrophy because of the hyper-
esthesia. Our own experience, based on a number of cases
November, 1943
367
that have developed under close observation, is not en-
tirely in accord with this. We can affirm the symmetrical
character of the neuritis and the fact that involvement of
the legs usually, though not invariably, precedes that of
the arms. The progressive involvement of the plantar,
sock and calf region has not been characteristic of our
cases, which have usually shown tenderness of calves and
thighs simultaneously as the first signs of sensory involve-
ment. In cur experience motor weakness and hyper-
esthesia have developed early and almost simultaneously,
followed shortly by loss of reflexes; other sensory func-
tions— vibratory, position and temperature sense — have
not been noticeably affected at the onset. The first ob-
jective sign is an ataxic gait due to weakness. It may be
difficult to evaluate motor weakness in the presence of
i muscle hyperesthesia, but we have seen weakness develop
with little or no hyperesthesia to account for it.
The cardiac manifestations of thiamine deficiency may
precede or follow the neuritis. Whether the heart is
affected early appears to depend on the physical activity
of the subject; individuals leading sedentary lives usually
develop neuritis before there is any evidence of cardiac
failure, the reverse being true of those who are more
active. It is now clear that there is nothing characteristic
about cardiac failure resulting from thiamine deficiency.
Earlier reports indicating the right heart to be particu-
larly affected have not been confirmed by recent observa-
tions. A rapid pulse, symmetrical enlargement of the
heart and all the signs of congestive failure may be
present. The electrocardiagram shows changes, but none
that differentiate this condition from other forms of
myocarditis.
Edema in thiamine deficiency may result from cardiac
insufficiency or may occur quite independently of it.
Such edema has often been attributed to low serum pro-
teins due to a concomitant deficiency of protein in the
diet, but it is now clearly established that thiamine de-
ficiency per se can produce edema which is not explained
by cardiac failure or by a reduction in serum proteins.
The mechanism of its production is obscure but the re-
sponse to therapy is rapid, rarely requiring more than
twenty-four to forty-eight hours.
Anorexia is usually listed as an early symptom; in our
experience, too, it has usually been the first manifesta-
tion to appear.
Vomiting is likely to occur only when food is forced
in the face of a poor appetite. Failure to gain weight or
loss of weight does not in our experience occur in the
absence of gastrointestinal symptoms.
Psychic Changes. Claims have been made that delir-
ium and coma may result from acute thiamine deficien-
cy.2 Even more difficult to evaluate are reports of various
neurasthenic manifestations that may occur in chronic
thiamine deficiency. In addition to aches and pains, fa-
tigability and insomnia, emotional tension and irritability
have been particularly noted3 as well as lack of concen-
tration. We have observed evidences of irritability asso-
ciated with the development of thiamine deficiency but
only exceptionally. As a rule the psyche has not been
affected in our experience.
On what criteria can the diagnosis of thiamine defi-
ciency be based? None of the symptoms mentioned above
are pathognomonic of this condition. When any one of
the major objective symptoms, such as polyneuritis, edema,
or cardiac insufficiency is present without other explana-
tion it is proper to think of thiamine deficiency, and
when several of these symptoms coexist the probability
of their being due to lack of thiamine is correspondingly
increased. Nevertheless, it is always hazardous to make
such a diagnosis unless, (a) some factor known to pre-
dispose to thiamine deficiency is present or, (b) definite
laboratory evidence of thiamine deficiency can be ob-
tained.
In the absence of any of the major objective symp-
toms, when the only evidences of deficiency are vague
and highly non-specific, such as poor appetite, lassitude,
vague pains, poor sleep, emotional irritability, etc., the
diagnosis of thiamine deficiency becomes even more ten-
uous. Yet it is on precisely such grounds that thiamine
is being prescribed or is being self-administered to our
population on an appalling scale. The propaganda comes
from places high and low, from those commercially mind-
ed and those with altogether altruistic motives. We are
confronted by dietary surveys made by reputable indi-
viduals which report that millions of Americans ingest
subnormal amounts of thiamine. Reputable medical men
support this view. Advertising of vitamins and of re-
inforced foods is permitted, which gives the impression
that the government itself shares the view that Ameri-
can diets are generally thiamine deficient and that the
ingestion of vitamin pills or reinforced foods will abolish
fatigue, crankiness, loss of sleep, the war jitters and
what not and will substitute vim and vigor. The con-
servative medical man can hardly be blamed if he fails
to resist the current and permits himself to prescribe
B vitamins, and thiamine in particular, for symptoms
which are common to the great majority of diseases he
has to treat.
In the interest of correct thinking the present writers
would like to point out, (1) that the existence of thia-
mine deficiency on a wide scale in this country has never
been demonstrated by medical surveys employing accu-
rate laboratory criteria; (2) the surveys made have been
dietary surveys based on values for thiamine "require-
ments” that have never been accurately determined and
that have for this very reason been set at a high level.
What then justifies the physician in making a diag-
nosis of thiamine deficiency and in prescribing thiamine?
It is our opinion that although any of the vague as well
as the definite symptoms should make one think of such
deficiency, a diagnosis should not be made unless there
is evidence from the history of some factor predisposing
to B avitaminosis or some laboratory evidence for the
same. The factors known to predispose to B avitaminosis
are as follows:
1. An unbalanced diet — predominantly of refined car-
bohydrates— which adds to the B requirements and also
diminishes the supply of these factors. Patients nour-
ished by intravenous glucose alcne may be included in
this group.
368
The Journal-Lancet
2. Disturbances of digestion or absorption which in-
terfere with the assimilation of these factors.
3. Circulatory disturbances, such as post-hemorrhagic
shock, which may interfere with the adequate distribution
of B factors.
4. Conditions which increase the demand for B fac-
tors— fever, hyperthyroidism, exercise, pregnancy, lacta-
tion, an overactive heart.
Only when such evidence is at hand, pointing to a
reasonable possibility of B vitamin deficiency, are we jus-
tified in advocating vitamins beyond those contained in
a normal balanced diet.
Is there any harm in giving B vitamins? Aside from
the drain on the pocketbook, the contents of which might
better be used for nourishing foods, there seems to be
little danger in giving B complex as a whole. Toxicity
studies with individual members of the complex indicate
that enormous doses must be given before symptoms are
encountered. On the other hand, if an unbalanced in-
take of B factors is taken the possibility of producing
harm is not so remote, and it may be worthwhile to re-
view the evidence on this point. The administration of
thiamine to patients with polyneuritis4,5,6 has been fol-
lowed by symptoms of pellagra. There is laboratory evi-
dence' that both thiamine and riboflavin will, in excessive
amounts, cause an increased demand for niacin. Analo-
gous effects have been observed from the administration
of niacin alone; pellagrins so treated have developed ribo-
flavin deficiency8 or beriberi.9 It is clear that correction
of a single deficiency may precipitate seme other defi-
ciency that was already present in a latent form. It does
not follow that the normal individual is harmed by the
administration of single vitamins, but there are reasons
for conservatism even here. Vitamins taken in excess are
disposed of in large part by unknown mechanisms, some
of which may involve the use of other vitamins, creating
an abnormal demand for the latter. For example, Hand-
ler and Dann10 showed that an excess of nicotinamide
will interfere with rat growth and cause fatty liver, an
effect preventable by adding choline or methionine to the
diet. Apparently the unneeded nicotinamide is methyl-
ated, causing a drain on the body’s methylating agents —
methionine and choline. In the case of thiamine there is
evidence that, taken in excess, it may deplete the available
supply of niacin, perhaps because a niacin-containing en-
zyme is concerned in its phosphorylation, as Lipton and
Elvehjem11 have shown. The practical conclusion to be
drawn from these facts seems clear enough: therapy
with pure B vitamins should always be combined with
some B complex preparation.
Before taking up the laboratory diagnosis of the three
major B deficiencies, which can conveniently be discussed
together, let us review the situation for the clinical diag-
nosis of riboflavin and niacin deficiency.
Riboflavin Deficiency
The cardinal symptoms of this deficiency are: an
atrophic glossitis, in which the tongue is said to be cy-
anotic in color rather than angry red, as in pellagra;
cheilitis, involving the lips as a whole; angular stomatitis
("perleche”), in which exudative lesions occur at the cor-
ners of the lips, often with cracking; seborrheic lesions
about the nose and eyes and occasionally elsewhere;
"rosacea keratitis,” a vascularizing lesion of the cornea
beginning at the margin and extending centripetally. We
have had an opportunity to see this picture in a number
of experimental subjects studied by Sebrell and Butler,
and have encountered it in characteristic form in at least
two or three cases in Baltimore. The picture, when well
developed, is clear enough, and the evidence of its rela-
tion to riboflavin deficiency is impressive. On the other
hand, a number of observations have recently come to
light which make the diagnosis difficult. The glossitis
may be indistinguishable from that of pellagra. An an-
gular stomatitis indistinguishable from that described
may respond to pyridoxin therapy, and furthermore le-
sions of the angles of the mouth are often traumatic,
having no relation to avitaminosis.12 The most specific
feature of the syndrome, the corneal lesion, can no longer
be regarded as specific13 for it has been produced in a
number of experimental deficiencies and has been ob-
served in thallium poisoning and in association with vari-
ous infectious diseases, notably measles.14 During the
past two years thirty-two patients with the clinical diag-
nosis of simple rosacea keratitis have been referred to us
for study from the Wilmer Ophthalmological Institute.
In two of these we have found definite evidence of ribo-
flavin deficiency by means of the urinary excretion test
described below. In both these patients the condition
responded dramatically to riboflavin therapy. The re-
maining patients showed normal riboflavin excretion fig-
ures and failed to respond to therapy.
It is our present impression that riboflavin deficiency
is a decided rarity, apart from areas where it is reported
to be endemic. The criteria for trying specific therapy
would appear to be any of the specific lesions described,
bearing in mind that such lesions are not necessarily
specific.
Niacin Deficiency (Pellagra)
The cardinal symptoms of pellagra are described in
most textbooks of medicine and will not be taken up in
detail here. The characteristic symmetrical lesions of the
skin, erythematous at first and subsequently pigmented
and scaly, and their symmetrical distribution on exposed
parts of the body are highly characteristic. A fiery red
glossitis, diarrhea and mental changes highly variable in
character constitute the rest of the picture.
We shall confine ourselves to calling attention to some
recent additions to the picture — notably to the syndrome
of acute encephalopathy described by Jolliffe et ah, 14 and
by Cleckley et al.10 This syndrome is characterized by an
acute stuporous condition, sometimes with extrapyramidal
symptoms, and is said to respond dramatically to specific
therapy. It is regarded as an extremely acute form of
niacin deficiency in contrast to the more chronic states
giving rise to the cutaneous, oral and enteric lesions.
Our experience with frank pellagra in Baltimore is
very limited. We should, however, like to mention an
interesting recent observation — a patient who developed
pellagra on the wards of the Harriet Lane Home while
receiving a supposedly adequate B complex preparation.
November, 1943
369
EXCRETION OF THIAMINE. IN URINE
AT .DIFFERENT LEVELS OF INTAKE
EXCRETION OF RIBOFLAVIN IN URINE
AT -DIFFERENT LEVELS OF INTAKE
EXCRETION OF Fj IN URiNE.
after ingestion of nicotinamide:
The patient, a 12 year old girl, was suffering from what
was apparently a very low grade ulcerative colitis. Yet
despite almost negligible gastrointestinal symptoms, un-
mistakable pellagra developed. Assay of the B complex
preparation used showed that it was very high in thia-
mine and relatively low in niacin; it seems possible that
the excess of thiamine administered may have contrib-
uted to the pellagra.
The belief that subclinical niacin deficiency states are
of frequent occurrence has been expressed by a number
of observers, but it must be admitted that conclusive evi-
dence for this has yet to be presented. The failure of any
satisfactory laboratory test has until recently made it
very difficult to assess the situation. This state of affairs
no longer holds since the discovery in urine by Najjar
and Wood16 of a fluorescent substance which we believe
accurately reflects the state of the body stores with re-
spect to niacin.17
The Laboratory Diagnosis of Early
B Deficiencies
It is not possible in this brief space to discuss ade-
quately the various methods employed by different work-
ers. This topic is, moreover, the subject of another con-
tribution to this symposium. We should, however, like
to call attention to simple procedures, developed in our
laboratory, which permit one to determine by the analy-
sis of a single specimen of urine, collected under appro-
priate conditions, whether or not the body stores of thia-
mine, riboflavin or niacin are deficient and whether the
patient in question is in need of specific vitamin therapy.
The body reserves of thiamine and riboflavin are reflected
in the urinary excretion of these substances, the vitamins
failing to appear in appreciable quantity when the body
is deficient. In the case of niacin we do not measure the
excretion of the vitamin itself but that of its fluorescent
derivative F2; the latter disappears from the urine in
deficient states.
The measurements are made by fluorescence technics.
Thiamine is readily converted into the fluorescent sub-
stance thiochrome which gives a brilliant violet fluores-
cence in ultraviolet light. Riboflavin itself is easily ex-
tracted from urine and gives a yellow-green fluorescence.
F2, the fluorescent derivative of niacin, gives a pale blue
fluorescence. By means of a fluorophotometer highly ac-
curate quantitative measurements of these factors in the
urine can be made, but expensive electrical equipment is
not necessary. The significant information — the pres-
ence or absence of appreciable quantities of one or the
other of these factors in the urine — can be obtained, after
appropriate treatment of the specimen,18 by examining
the fluorescence in a dark box in which an ultraviolet
lamp has been installed.^ If, for example, appreciable
amounts of thiochrome fluorescence can be detected, one
can conclude that the patient does not need thiamine
therapy; and if riboflavin or F2 is demonstrable in the
urine, the conclusion can be drawn that the patient is
not suffering from riboflavin or nicotinic acid deficiency.
These statements must be qualified in one respect; the
tA simple and inexpensive apparatus of this type is manufac
tured by W. A. Taylor and Company, 7300 York Road, Bal-
timore.
370
The Journal-Lancet
urine specimen to be analyzed must be collected under
appropriate conditions. A casual specimen, or a twenty-
four hour specimen is of relatively little value, since the
vitamins (or vitamin derivative in the case of niacin)
may appear in the urine even in markedly deficient sub-
jects as a result of a single vitamin-containing meal. In
order to avoid this difficulty it is necessary to allow suffi-
cient time to elapse after the last meal to permit the ex-
cretion of the excess of unstored vitamin ingested with
the meal. A twelve-hour overnight fast is sufficient for
this purpose, for we have shown that the excess of un-
ut lizable vitamin ingested with a meal is usually excreted
in the urine within eight hours.
The course of vitamin excretion after a vitamin-con-
taining meal is illustrated by the accompanying graphs
(Figs. 1, 2, and 3) which show the excretion of these
factors in two-hour periods following an evening meal
supplying one or another of these vitamins at different
levels of intake. It will be noted that following the in-
gestion of vitamins there is a marked increase in the ex-
cretion of vitamin (or vitamin derivative, in the case of
niacin) . In the course of some eight hours the rate of
excretion falls to almost a constant level, a level which is
determined by the stores of this vitamin in the body. If
the excretion is measured during an arbitrary period, as,
for example, the thirteenth hour after a meal, this value
serves as an accurate guide to the body stores of vitamin.
In practice, this "fasting hour excretion test,” as we
have called it, is conveniently carried out as follows:
7 P. M. — The subject is allowed to eat his evening
meal as usual.
7 A. M.— On arising he voids and discards the speci-
men. He then drinks a glass of water.
8 A. M. — He voids again. This specimen is used for
analysis. Breakfast is permitted only after the second
voiding is obtained. If, by any chance, the subject is
unable to void the second specimen one hour after the
first, breakfast is withheld until it has been voided. The
time interval is then noted (one and one-half or two
hours as the case may be) and the excretion is calculated
on a one-hour basis from this.
The urine specmen is analyzed for thiamine, riboflavin,
and for F2 (this last to measure niacin body stores).
Interpretation of the test. The quantity of thiamine,
riboflavin, or F2 found in the test specimen indicates the
extent of the body reserves of thiamine, riboflavin, and
niacin respectively. As long as any appreciable amount
of vitamin (or vitamin derivative, in the case of F2) is
found in the test specimen, this indicates that the body
has a surplus available for excretion, and that deficiency
of that particular vitamin is not to be feared. But if no
appreciable quantity of the vitamin is demonstrable§ in
the fasting hour test, it indicates that no surplus is then
available for excretion; such an individual is potentially
deficient and should be given additional vitamin in his
diet.
The validity of this interpretation is based on extensive
data which we have obtained in the case of thiamine;
§By highly sensitive instruments and unusually delicate methods,
it can be shown that even under deficiency conditions, minute
amounts of vitamin are excreted. Such quantities are not detectable
in the test as ordinarily used.
limited data in the case of riboflavin and niacin indicate
that the interpretation given above is valid for these two
vitamins also.
Advantages of this test procedure. The advantage of
this procedure over the twenty-four hour excretion mea-
surement has already been pointed out. This test avoids
the interfering effect of vitamins given in the immediate
diet.
The test also has distinct advantages over the so-called
"load tests” in which excretion is measured after a test
dose of vitamin, the deficient individual retaining more
of the test dose than the nondeficient one. Such load
tests, when given orally, are greatly affected by conditions
which impair intestinal absorption. When given paren-
terally, the renal threshold for vitamin excretion may be
exceeded under conditions of impaired renal function.
Load tests are, furthermore, annoying because of the in-
jection, the necessary omission of breakfast and the need
of collecting urine for several hours after the test dose,
inconveniences which are avoided in our procedure.
Disadvantage of the Fasting Hour Excretion Test.
The test has one disadvantage. It does not permit one to
evaluate degrees of deficiency more severe than those
which give negligible values in the fasting hour. In other
words, it permits one to say only whether or not adequate
stores of vitamin are present. The more severe degrees
of deficiency must still be defined by other tests, such as
the various load tests.
It should be pointed out that our procedure, like all
other tests which measure chemical deficiency, is subject
to the limitation that it fails to reveal the cause of ana-
tomical lesions that may remain after a chemical defi-
ciency has been corrected. It must therefore be applied
before a corrective diet or vitamin therapy is instituted.
The frequency of B deficiencies. What has been our
experience in using these tests? In other words, how fre-
quent is so-called "subclinical” B vitamin deficiency? We
would like to be able to answer that question, but we
are not in a position to do so at the present time. No
extensive surveys are yet available. Our experience with
these tests in Baltimore can be measured only in months
and we shall have to have more time. But we can say
this. Evidence of subnormal thiamine stores has been
found in n:ne out of ten cases of diarrhea in children.
That is our most impressive positive finding. We have
also encountered among many suspects one or two in-
stances of thiamine deficiency as well as riboflavin and
niacin deficiency in badly neglected underfed children
living mostly on refined carbohydrates. Our impression
is that the frequency of thiamine deficiency is greatly
overestimated at the present time.
It seemed possible to the writers that the human re-
quirements for thiamine had been overestimated by those
who have attempted to study this problem. It is difficult
to control thiamine intake accurately when natural foods
are given, for their content is at best highly variable. An
accurate determination of thiamine requirements can be
made only if the level of intake can be accurately con-
trolled, as may be done in the synthetic diets given to
experimental animals. We have attempted to determine
the thiamine requirement of man by the use of just such
November, 1943
371
a diet. A group of human volunteers was placed on an
experimental diet consisting of vitamin-free casein, "cris-
co,” a malt-dextrin sugar mixture, a mineral mixture and
a mixture of pure vitamins. This last was the only source
of vitamins provided; all the ingredients were kept con-
stant with the exception of thiamine, which was varied.
It was our plan to reduce the thiamine intake to the
bare minimum needed to prevent symptoms and chem-
ical changes of thiamine deficiency. The results of this
experiment, which has now continued for more than a
year, are very illuminating. It was found that the daily
intake of thiamine could be reduced to one-tenth of the
recommended daily allowance of the National Research
Council (in other words to 0.15 mg. per day for a seden-
tary adult male) and kept at this level for months with-
out any evidence of deficiency developing. We then re-
duced the thiamine intake to zero, fully anticipating that
within a few weeks all subjects would exhibit thiamine
deficiency. Four of the nine developed symptoms in the
course of the first month and the remaining five have
continued to thrive for a period now approximately seven
weeks. Since stores of thiamine are believed to be very
limited, this observation puzzled us and we sought for
the reason why these individuals could remain healthy
without ingesting thiamine. Briefly, it was found that
their intestinal bacteria were manufacturing thiamine
and that there was an abundance of free thiamine in the
stools. When the intestinal bacteria were suppressed by
the administration of sulfasuxidine, the thiamine disap-
peared from the stools. The synthesis of thiamine by
microorganisms in the gastrointestinal tract has been ob-
served in the rat and in the rumen of certain ruminant
animals, but has not hitherto been observed in man. The
phenomenon requires much further study. We do not
know as yet what organisms are responsible for the syn-
thesis or what dietary conditions enable them to flourish;
studies of these aspects are now in progress. But it is at
least clear that a new protective mechanism against avita-
minosis in man has been demonstrated. We may note,
in passing, that this protective mechanism is interfered
with by sulfa drugs, a fact which has obvious clinical
implications.
Conclusions
1. The incidence of B deficiencies in the United
States appears to be greatly overestimated.
2. The biosynthesis of B vitamins in the human in-
testine, demonstrated by the authors for thiamine, is a
protective factor against deficiency that has not hitherto
been considered adequately.
3. Indiscriminate vitamin medication is not without
possibilities of harm and should be condemned.
4. Laboratory tests are now available which make it
possible to determine with accuracy who needs B vitamins
and who does not.
Bibliography
1. Jollifle, N.: In ''The Biological Action of the Vitamins,”
edited by E. A. Evans, Jr., Univ. of Chicago Press, 1942.
2. Wortis, H., Bueding, E., Stein, M. H., and Joliffe, N.:
Arch. Neurol, and Psych. 47:215, 1942.
3. Williams, R. D., Mason, H. L., Smith, B. F., and Wilder,
R. L.: Arch. Int. Med. 69:721, 1942.
4. Lehmann, J., and Nielson, H. E.: Act. med. Scandinav.
99:577, 1939.
5. Salvesen, O.: Nord. med. Tidskr. 5:279, 1940.
6. Braendstrup, P.: Ugeskr. F. Laeger. 102:95, 1940.
7. Najjar, V. A., and Holt, L. E., Jr.: Unpublished observa-
tions.
8. Sydenstricker, V. P.: Ann. Int. Med. 15:45, 1941.
9. Spies, T. D., Vilter, R. W., and Ashe, W. F.: Pellagra,
J .AM. A. 1 1 3:931, 1939.
10. Handler, P., and Dann, W. J.: J. Biol. Chem. 146:357,
1942.
11. Lipton, M. A., and Elvehjem, C. A.: Cold Spring Harbor
Symposia on Quantitative Biology 7:184, 1939.
12. Ellenberg, M., and Pollack, H.: J.A.M.A. 1 19:790, 1942.
13. Corneal Vascularization as a Sign of Ariboflavinosis, Nutr.
Rev. 1:194, 1943. — Specificity of the Ariboflavinosis Syndrome
in Man, Nutr. Rev. 1:327, 1943.
14. Jolliffe, N., Bowman, K. M., Rosenblum, L. A., and Fein,
H D.: J.A.M.A. 1 14:307, 1940.
15. Cleckley, H. M., Sydenstricker, V. P., and Geeslin, L. E.:
J.A.M.A 1 12:2107, 1939.
16. Najjar, V. A., and Wood. R. W.: Proc. Soc. Exp. Biol. 6d
Med. 44:386, 1940.
17. Najjar, V. A., and Holt, L. E., Jr.: Sci. 93:20, 1941. —
Najjar, V. A.. Stem, H. J., Holt, L. E., Jr., Kabler, C. V.: J. Clin.
Investigation 21:263, 1942.
18. A brochure of Methods in Use in our Laboratory, in part
unpublished, is available for distribution.
The Growth of Scientific Knowledge on the
Vitamin Needs of Man
A. J. Carlson, M.D.f
Chicago,
THE coining of the term "vitamin”, the chemical
and biological identification of some of the vita-
mins, the synthesis of some of the vitamins, and
the scientific proof of the causal relation between specific
vitamins and some specific diseases are all achievements
of the last fifty years. But deficiency diseases are ancient.
And some of our forebears of hundreds if not thousands
of years ago must have surmised, however vaguely, that
scurvy at least was related to a dietary deficiency, for the
successful therapy of this malady with fresh fruits, fresh
vegetables, and fresh extracts of green leaves (pine
needles) goes back several hundred years, and appears to
tUniversity of Chicago Medical School, Chicago, Illinois.
Illinois
have been independently discovered in Europe and in
America (by some of our Indian tribes) .
The known story of the occurrence and the therapy of
scurvy, rickets, pellagra, beri-beri or polyneuritis, dis-
eases now known to be due in whole or in part to defi-
ciency of specific vitamins in the diet, is quickly told, at
least so far as this story bears on today’s problems of diet
and disease. Vitamin deficiency diseases undoubtedly
antedate recorded human history, for they can be brought
on by food scarcity alone, quite apart from the processes
of storing, salting, drying, cooking, and refining foods.
Although man, even way back, appears to have been, by
necessity or by preference, fairly omnivorous, occasional
372
The Journal-Lancet
or chronic food scarcity sufficient to produce disease un-
doubtedly occurred, for these diseases are even older than
homo sapiens. We may assume that our earliest human
forebears met these food deficiency diseases in the same
way as does the wild animal today, that is, by eating more
and by eating a greater variety of natural foods, when
these were available and restored health, without any
clear conception of cause and effect. This simple "trial
and error” method is also older than man. Our 20th
century contribution to this method of learning the
causes and cures of vitamin deficiency diseases is mainly
this: more people now see more clearly that only by well
controlled trials on mice and men will we ever eliminate
the errors. This is the essential of our science in modern
biology and medicine. This could and would have made
even our own day bright, and our path fairly clear as to
causes, cures, and preventions of the vitamin deficiency
diseases, had not the inertia of habit, the fog of lay ig-
norance, the wishful thinking of some workers in biology
and medicine, the chronic clouds of quackery, and the
ever clever vortices in the dust of commercial venality
still befuddled the minds of investigators, physicians,
and patients.
Inadequate intake of vitamin A brings on no readily
recognized or specific symptoms, unless the lack is ex-
treme and chronic. And even then the lesions in the
cornea and conjunctiva may be confused with local infec-
tions, the impairment of growth in the young may be
due to many other factors, and not all forms of night
blindness stem from deficiency of vitamin A. There can
be little doubt but that at times sufficient lack of vita-
min A in man’s diet has occurred way back, sufficient
lack to bring on some of the above symptoms. But no
vitamin A deficiency disease as definite as scurvy, rickets,
or beri-beri, appears in human records prior to the pres-
ent century. To be sure, something interpreted as night-
blindness is referred to in Papyrus Ebers (1500 B.C.),
and even liver therapy of the condition may be hinted at
in that document. But that medical document is largely
a collection of incantations and other forms of supersti-
tion and ignorance. And let us not forget that the liver
was a potent tool of the soothsayers of those days.
Towards the close of the last century two investigators
(Luin, 1881; Pekelharing, 1905) showed by controlled
experiments on animals that when all the then known
constituents of cow’s milk were purified, recombined and
fed to animals, growth was retarded and the final issue
was early death. But growth is impaired by prolonged
and serious deficiencies in any one of the essential factors
of the diet (protein, calories, inorganic salts, and vita-
mins A, C, thiamine, riboflavin, and niacin) . Vitamin D
deficiency to the point of definite development of rickets
may not be accompanied by definite retardation of body
growth. Therefore, measurement of growth of the
young is not a criterion of vitamin A adequacy or inade-
quacy of the diet, unless all the other known factors are
present in abundance. An experiment along this line was
reported by the English biochemist, Dr. F. Gowland
Hopkins in 1906. That experiment blazed the trail for
the discovery of vitamins A and D.
Rickets is an old disease, probably antedating man.
The symptoms of rickets were clearly described by the
English physician Gilson four hundred years ago, but the
relation of rickets to vitamin D, to the ultraviolet rays
from the sun, to the calcium and the phosphorus in the
diet, and to the absorption of these substances from the
intestine, as well as the relation of the parathyroid hor-
mone to the deposition and release of calcium in the
bones, was not understood till the present century. In the
nineteenth century rickets was probably the most com-
mon vitamin deficiency disease in the temperate regions
of the world, including the United States. For our cloth-
ing interferes with the production of vitamin D in the
human body, by the ultraviolet sun rays.
This vitamin deficiency disease is an illustration of the
complex factors involved in the genesis and the therapy
of at least some of the dietary deficiency diseases. Rickets
is still a problem in our land, for recent studies at Johns
Hopkins hospital indicate that sub-clinical rickets in chil-
dren is much more prevalent than we would expect from
the incidence of this malady recognizable by clinical tests
on the living child now at our disposal. It is now very
clear that in the preventive and curative therapy of rick-
ets we must reckon with many factors other than the
abundance of vitamin D in the diet of the growing child.
Beri-beri, according to R. R. Williams and T. Spies,
was recognized as a specific disease by the Chinese nearly
3000 B. C. The first important step to prove that beri-
beri is a dietary deficiency disease was taken in 1885 by
the Japanese. By the substitution of barley, fish, etc., for
a considerable part of the polished rice in the ration of
the Japanese sailors, the incidence of beri-beri among
these sailors was greatly reduced. This demonstration ap-
pears to have made scant impression on contemporary
medical men, either in the Orient or in Europe and
America. They were still under the teaching that pro-
teins, calories, and inorganic salts were the only dietary
essentials, despite the known etiology and therapy of
scurvy. The next great step was taken by the Dutch phy-
sician Eijkman, working in Java, who in 1897 produced
in chickens the nervous disturbances of human beri-beri
by feeding initially healthy chickens the prevailing hu-
man diet in the Orient: polished rice. Feeding chickens
unpolished rice did not produce the disease. Therefore,
the missing factor or factors must have been in the part
of rice removed by the polishing process. But Dr. Eijk-
man did not at once draw this seemingly obvious conclu-
sion. But this was soon proved to be the fact and opened
the door to a veritable wonderland: the vitamin B com-
plex, a land still not fully mapped.
Pellagra is to a certain extent the occidental counter-
part of the oriental beri-beri. Some of the pathologic
physiology of these two diseases overlaps. Naturally,
both these maladies may at times be complicated by other
diseases, such as infections, which confused the earlier
observers. Pellagra prevails in countries or sections where
Indian corn (maize) makes up a considerable part of the
daily diet (Russia, Egypt, Italy, United States). Since
the disease appeared to be more prevalent in years when
climatic conditions increased the spoilage of corn by
moulds, there was a possibility that pellagra was a form
of chronic food poisoning, and was not due to a food de-
November, 1943
373
ficicncy. This possibility was largely discounted but not
disproved by the classic work of Goldberger in 1915,
who produced pellagra in healthy persons on diets now
known to be low in the water soluble vitamins, especially
niacin. The next big step was the production and the
cure of pellagra (black tongue) as this disease appears in
dogs, by the type of diets inducing and curing pellagra
in man. But even after the studies by Goldberger be-
came known and were accepted, the possibility that food
poisons, as well as infections, played a role in the genesis
of this disease was still entertained by not a few com-
petent men. While the dietary deficiency inducing pel-
lagra is primarily in niacin and in others in the B group,
protein deficiency and chronic infections frequently com-
plicate the picture.
Scurvy. The successful therapy of scurvy by extracts
of fresh pine needles, as well as by eating fresh vegeta-
bles and fruits, dates back at least 400 years. But the
experimental production of true scurvy in the guinea pig
by Holst and Froelich did not come till the early part of
this century (1912). The isolation, identification, and
synthesis of the C vitamin (ascorbic acid) are all achieve-
ments of the past two decades. Frank or advanced scur-
vy is now almost non-existent in our country, but impair-
ments of health (such as capillary fragility, decreased re-
sistance of the liver to specific poisons, etc.) , by chronic
low intake of the C vitamins, may not be so rare, accord-
ing to recent studies on man and animals. The C vita-
min is less resistant than some other vitamins to storage,
drying, and cooking of foods, but Vilhjalmur Stefansson
showed that there is enough C vitamin in fresh meat
(when eaten raw) to prevent and cure scurvy. In addi-
tion to storage of this vitamin in animal tissues, it is
widely distributed in fresh foods of plant origin. And
on a reasonably abundant and omnivorous diet, there is
certainly sufficient storage of C in the tissues of man and
other animals to carry them in fair health for months on
winter foods, or on no food at all (hibernation). So it
is not true that we must have orange juice every day in
order to maintain the abundant life.
What Are the Optimum Vitamin Needs
of Man?
Here even the most competent and conscientious phy-
sician is in a dilemma. Clinically recognizable vitamin de-
ficiency diseases are now rare in our country, except for
pellagra in the South. Laboratory and clinical tests de-
tecting incipient vitamin deficiencies are as yet largely in
the experimental stage.
The blood plasma concentration of vitamin C and the
daily urinary excretion of vitamin C, in the absence of
definite and specific physiological and clinical symptoms
of vitamin C deficiency, apparently have not yet helped
us to fix either the minimum or the optimum quantity
of vitamin C in the diet. ( Nutrition Reviews, 1:142,
1943.) But some clinical writers claim that bleeding
gums, spring fatigue, gastrointestinal and respiratory in-
fections, capillary hemorrhages, dental caries, pyuria,
(and, on the basis of therapy, hemophilia!) are caused
by or aggravated by subminimal intake of vitamin C.
According to Drs. Holt and Najjar, fasting (12 hours
after the meal) urine may show no thiamine, without the
subject or patient revealing any other recognizable thia-
mine deficiency symptoms. But time, rate of physical
work, and the numerous other factors in health prevent
us from drawing too dogmatic conclusions from these
experiments. However, the authors seem justified in
pointing out that the National Research Council’s rec-
ommendation of 1.5 mg. of thiamine as the daily require-
ment of the average adult is too high by 100 per cent.
According to Dr. H. R. Sanstead (U. S. Public Health
service) , the common capillary invasion of the cornea be-
yond the limbus is not a specific sign of riboflavin de-
ficiency, and is not influenced by riboflavin therapy.
Cheilosis, vascularizing keratitis, and magenta colored
tongue with flattened papillae are clearly not specific for
riboflavin deficiency and may not respond to riboflavin
therapy even when this is accompanied by the eating of
a greater quantity of better foods ( Nutrition Reviews
1:327, 335, 1943). And prolonged subsistence on diets
below the daily intake of this vitamin recommended by
the National Research Council does not usually bring on
distinct symptoms of deficiency, even when by the tissue
saturation tests the tissue reserves of this vitamin are
gradually decreased. The concentration of niacin and
riboflavin in the tissues seems to depend on the level of
the protein in the diet, irrespective of the levels of intake
of these vitamins (Sarett and Perlzweig, J. of Nutrition
25:173, 1943).
It is most unfortunate that the prolonged and, appar-
ently, well-controlled tests on low (about 0.5 mg. per
day) thiamine ingestion by Williams, Mason, Smith and
Wilder (Arch. Int. Med. 69:721, 1942), were made on
psychiatric patients committed to a state hospital, since
the most definite symptoms of deficient intake of this
vitamin in man are related, directly or indirectly, to dis-
turbances in the nervous system. We cannot get reliable
data on the thiamine needs of a person with an average
normal brain from studies on the population of a hos-
pital for the insane. At any rate, Drs. Holt and Najjar
of Johns Hopkins Hospital discovered no deficiency
symptoms in 12 male subjects after months on a diet
containing 0.375 to 0.625 mg. thiamine per day, that is
about the same or lower thiamine intake as in the Mayo
Clinic experiment on psychiatric patients.
Fatigue, or increased susceptibility to fatigue from
physical work, is probably a sequel to all chronic dietary
deficiencies (calories, proteins, vitamins, inorganic salts) .
Such increased fatigability is indicated on prolonged sub-
minimal intake of thiamine (Ivy, et al., Proc. Central
Soc. Cl. Res. 15:20, 1942). But the quantitative deter-
mination of fatigability is full of pitfalls, especially in
uncontrollable psychological factors, and calls for so
much time both on the part of the patient and the phy-
sician that this method is virtually out of the question,
even in the strongest clinics and hospitals. And merely
the record of the patient’s opinion or the report on this
point on the patient’s history sheets gives no reliable data
for the doctor and contributes little or nothing to med-
ical advance, especially in an era, like the present, when
the daily press and the hourly radio promise supreme pep
and power from vitamin pills. To be sure, it is reported
that, if hard physical work is performed daily on a diet
374
otherwise adequate but almost devoid of the vitamin B
complex, increased fatigability may be demonstrated with-
in a week (Johnson et ah, Jour, of Nutr. 24:586, 1942).
This would seem to prove a very rapid depletion of the
tissue stores of these vitamins under these conditions.
However, giving daily the vitamin B complex in excess
of the amount recommended by the National Research
Council (1.5 mg.) and provided by our Army ration
does not give added power to perform physical work
without incurring fatigue (Keys and Henschel, J. Nutri-
tion 23:259, 1942). In later experiments (in press, J.
Nutrition) the same authors, using healthy young men,
over a period of three months, found no increase in fatig-
ability, or any other evidence of thiamine deficiency,
when the daily intake of this vitamin was cut to about
one-half that recommended by the National Research
Council, that is, to 0.25 mg. per 1000 calories, instead of
0.6 mg. per 1000 calories.
We have travelled far since the classic experiment of
Gowland Hopkins in 1906, but not far enough to put all
our dietary health insurance on the 1943 synthetic vita-
min pills. According to Waisman, Rasmussen, Elvehjem
and Clark, the rhesus monkey cannot live on a purified
diet of sucrose, casein, salts, corn oil, vitamin C, and all
eight of the now known vitamins in the B group, but
when liver in the amount of 3 per cent is added to this
synthetic diet nutritional adequacy appears to be attained
(J. Nutrition 26:205, 1943). This brings us almost
back to 1906. The natural foods are still on top.
The public has been rendered "vitamin conscious” by
the press, the radio, and by the less critical laboratory and
clin cal workers in nutrition. The detail man is eloquent
and persuasive. So, lest we overlook a bet, we join the
vitamin band wagon. Even our Councils of Pharmacy
and Chemistry and of Foods and Nutrition have given
provisional approval of the old "shotgun” therapy in the
form of commercial vitamin mixtures (J. A. M. A.
119:948, 1942). Another straw pointing to the strength
and direction of this monsoon is the following assertion
in Nutrition Reviews (1:36, 1942): "Everyone now rec-
ognizes the indispensability of vitamin C and vitamin D
additions to the diet of the normal infant. Every infant
whether breast or bottle fed should be given early and
regularly a generous supply of codliver oil or some other
source of vitamin D. — When formula fed, orange juice
or some other source of vitamin C should be supplied.”
I readily admit that adding codliver oil and orange juice
to the infant’s diet is an insurance against rickets and
scurvy, but to imply or assert that without this insurance
rickets and scurvy are inevitable goes contrary to present
knowledge, contrary to present and past human experi-
ence. The writer (now 69) was breast fed, but never
had codliver oil in infancy or childhood. He had not
seen or tasted citrus fruit or tomatoes till he was 16
years old. He is 5 feet 11, has 28 of his "permanent”
teeth still workable and no x-ray evidence or other se-
quelae of childhood rickets and scurvy. Dr. A. H. Sie-
brell stated recently, "It is significant that almost all
practicing physicians are prescribing vitamin preparations
for more and more of their patients.” Significant of
what? Commercial advertisers and detail men of the
vitamin pill industry prescribe even more vitamin pills on
The Journal-Lancet
laymen’s self diagnosis. Neither fact proves an increasing
need of vitamin pills for the abundant health of the peo-
ple. There was a time when the practicing physician pre-
scribed more and more phlebotomy, more and more
leeches. The only significance of that fact was ignorance
and wishful thinking on the part of that generation of
physicians. Dr. Norman Jolliffe lists "constipation, irri-
tability, and fatigue” as nutritional deficiency diseases.
On that medical dictum it should not be difficult for the
vitamin pill salesman to foist his wares on almost every-
body on some occasion, except for the equally rosy prom-
ises from chewing gum, cigarettes, and Carter’s Little
Liver Pills.
We are told by a colleague in chemistry: "It is recog-
nized already that one vitamin can and does cure mental
derangements.” This is stated without qualifications,
while as a matter of fact mental derangements are due
to a great diversity of factors, including heredity, me-
chanical and chemical trauma and cerebral ischemia. The
value of the vitamin B complex in mental derangements
seems to be largely limited to those accompanying ad-
vanced pellagra and chronic alcoholism. The 1942 faith
and hope in universal health miracles from synthetic vita-
min pills seem premature, if not immature. When I see
our institutions for the feeble-minded and the insane
evacuated and closed by giving any or all of our 1943
variety of vitamin pills to these unfortunate fellow citi-
zens I, too, will sing "Hosanna to the Highest.” This
scientist goes on to say: "Good diets, which mean an
abundant supply of vitamins, promote intellectual keen-
ness. . . . There can be no doubt that much dullness
on the part of school children . . . can be traced in
part to lack of the proper kind of food and especially
lack of enough vitamins.” These are broad and impor-
tant generalizations. But I know of no evidence that an
ample ingestion of vitamin pills will materially improve
the scholastic record of millions of children and young
adults in our schools. These assertions are just too good
to be true. Human biology is not that simple.
Another colleague in chemistry tells us that the Ger-
mans "have enjoyed a more generous supply of thiamine
and other vitamins which grains provide than have the
people of Scandinavia, the Low Countries, France, Spain,
Italy or the British Isles. Perhaps pacifism is a product
of malnutrition.” Yes, the god Mars is traditionally pic-
tured as a well-nourished specimen, and if good nutrition
leads to war, and malnutrition to the striving for peace,
what kind of diet has enabled men to discover the scien-
tific method, to develop a sense of justice, a spirit of fair
play, a love, respect and preference for truth and indi-
vidual honesty? Are modern science and modern educa-
tion sequelae of malnutrition?
Recently a subcommittee on medical nutrition of the
National Research Council presented a report on malnu-
trition, under the heading, "Recognition of Early Nutri-
tional Failure,” and with two tables of signs and symp-
toms. I fully agree with this committee when it says:
". . . there is imperative need for (a) determination of
the actual incidence of early deficiencies among the gen-
eral population and for (b) the establishment of satis-
factory diagnostic criteria for the recognition of such
conditions.” But after tabulating no less than twenty-
375
November, 1943
nine alleged signs and symptoms of early or incipient
dietary deficiencies that even laymen might observe and
diagnose, the committee seems to wipe out its entire tab-
ulation and report by this statement: "Implicit in the
definition of the problem and in the foregoing statements
is the fact that no symptoms or physical signs can be
accepted as diagnostic of early nutritional failure. Cer-
tain symptoms and physical signs, however, when verified
by a competent physician and when other possible causes
have been ruled out, should be considered as significant
indications.” If this latter statement is true, and I sub-
scribe to it, their tabulation is misleading, if not false
in toto, in so far as present known facts of incipient di-
etary deficiencies are concerned.
The committee lists lack of appetite as a sign of in-
cipient malnutrition. This is contrary to my experience,
both in man and in animals. I saw thousands of under-
nourished people on the continent of Europe in the win-
ter of 1919, but, unless moribund, these people were
eager for good foods. They ate the most unappetizing
foods. At the end of over forty days of complete starva-
tion a person, otherwise normal, has an appetite for food
keener than at the start of the fast. I have had dogs,
for various research purposes, fast much longer than
forty days. At the end or towards the end of these long
fasts, these doqs grabbed food eagerly. To be sure, the
rat on a diet deficient in vitamin B complex will after a
while eat less and less of this ration. But it will, unless
moribund, eat a better ration. So appetite is not lacking.
But it is clear that appetite for food being impaired by
any cause will ultimately lead to malnutrition.
The alarming claim ( 100,000,000 Americans do not
have a good diet) for national malnutrition in our land
appears to be based primarily upon a series of surveys
conduced by the Bureau of Home Economics of our
Federal Department of Agriculture. These surveys em-
braced some 4,000 urban and village families of various
levels of income and some 2,000 rural families of vary-
ing levels of income, selected from representative regions
of our country. The surveys consist in reports from
these families as to how much money they spent for food
and what kinds of food were bought and, in the case of
rural families, how much and what kind of food they
consumed from the crops on their own farms. The field
investigators had to take, or did take, the people’s word
for all these alleged facts. It is impossible to determine
the degree of accuracy as to memory of whatever mem-
bers of these families gave the facts or alleged facts to
the enumerators. The precarious character of such data
should have been apparent to any scientist who is free to
work and think.
On the basis of the kind and quantity of the food
bought or grown on the farms, the Bureau of Home
Economics estimated the diets of these families as "ex-
cellent”, "good”, "fair” or "poor”. No physical or med-
ical examination was made of the members of these fam-
ilies. Not even such a simple physical fact as the deter-
mination of the body weights of the people involved
seems to have been undertaken. The necessity of such
checks should also have been evident. The value of these
statistics must largely be left up in the air as regards evi-
dence for good or bad nutrition in our country because
of the neglect of such an obvious factor as medical evi-
dence of the health status of the people concerned. Cri-
teria and standards for the estimation of the quality of
diets are still largely arbitrary and matters of definition.
How does Dr. Parran’s interpretation of these statis-
tical studies by the U. S. Bureau of Home Economics
check with data from other sources? Hospital statistics
(admission, mortality rate) do not reveal significant na-
tional malnutrition in the United States, except for pel-
lagra in the South. Of course, the mortality statistics
reveal only terminal malnutrition, and admission statis-
tics tell us only of malnutrition recognizable by present
tests. Chronic malnutrition shortens the life span, but
last year the average length of life of our citizens reached
an all-time high of 63.42 years. There is some statistical
evidence that our children are growing faster and taller
than in the past, that college freshmen are taller than
they were a decade or more ago. Children and youths do
not grow faster or taller on inadequate diets. We admit
freely that these statistics do not cover our entire popu-
lation. They are, however, indices. Malnutrition on a
national scale does not lead to obesity, quite the reverse.
This is certainly true of the experimental animals and
that was my observation in the war-devastated countries
in Europe at the conclusicn of World War I. Recent
studies by the Life Extension Examiners show that 10
per cent or more overweight is nearly three times more
prevalent (28 per cent) in the United States than 10
per cent or more underweight (12.8 per cent). It is a
curious coincidence that the percentage of obesity in our
people should come so clase to Dr. Parran’s estimate of
the people having a good diet (25 per cent). The obese
may enjoy a good diet, but they do not use it wisely.
Apart from pellagra, perhaps obesity is the most serious
aspect of malnutrition in our country.
If 100,000,000 Americans, in times of peace and food pleth-
ora, had poor diets, that condition should have been revealed on
medical examination of our millions of young men for our Army
and Navy. All these data are not yet assembled and analyzed,
but according to Dr. Rowntree, the first 800,000 men, age 21
to 35, examined in the 1941 U. S. Army draft had an average
height of 67.5 inches, or exactly the same average height as our
drafted men in World War I. But the 1941 men were on the
average eight pounds heavier than the Army men of 1917-1918.
We do not know whether these eight pounds represent muscle,
bone or fat. These data on the 1941 draftees do not point
towards an overwhelming malnutrition in our country. This
should give us some assurance and some happiness. But we
should not be content, we should not rest on the oar until we
have discovered more adequate tests of incipient malnutrition,
until we have cleared our land of myopic food practices, until
we see the dawn of understanding dispelling our fog of ignor-
ance as to the nature of health and the nature and role of foods,
until we have reached first base, at least, in driving pellagra
from the American home.
The growth of our understanding of the vitamin needs of
man is a record of much blundering ignorance, some wishful
thinking and a slow progress through controlled observation and
experiments on man and other beasts. Blundering ignorance as
to food composition and man’s dietary needs brought on us the
classic vitamin deficiency diseases (rickets, scurvy, beri-beri, pel-
lagra) . The striking results of good food therapy in these dis-
eases have engendered in our generation the utopian hope that
a greater abundance of vitamins will rid man of nearly all real
and imaginary ills. But more and better controlled observations
and experiments will restore sense and scientific sanity, will re-
mind us again that life is just not that simple.
376
News-Letter
of the American Student Health Association
The Journal-Lancet
STUDENT HEALTH CENTERS
Warren E. Forsythe, M.D.
Director, University Health Service,
University of Michigan
Public health work clearly has made good in those dis-
eases which are subject to attack by environmental, law
enforcement, or other methods applicable to masses of
people. Other diseases appear to require personal, active,
popular participation in control methods. This has intro-
duced the clinical approach to public health.
Decentralized public health organization has intro-
duced the term "Health Center.” This means estab-
lished building centers for local areas where local health
officers and their workers may carry out modern public
health work either as official or voluntary agencies or
both. The centers have been faced with the establish-
ment of clinics of various types, in their attack upon dis-
ease which does not respond to methods of sanitation.
Over a period of three decades such centers have de-
veloped in great variety at our American colleges and
universities. Under all sorts of names, and with great
variation in programs, most institutions of higher educa-
tion have some such centers under their control to meet
the general problem of student health and related instruc-
tion. These centers usually assume a considerable degree
of responsibility for public health practices for the col-
lege population. This has resulted in the establishment
of clinics of the types required in official public health
practice and, because of the peculiar college and student
situation, the college often is forced to establish clinical
facilities or supervision traditionally associated with the
private practice of medicine.
It would appear that by public health centers which
probably will be established widely in the future, the col-
leges have an opportunity to work out many problems of
the relation of public and private interests.
PERSONAL NEWS
The Council voted against calling a general meeting
in New York City to coincide with meetings of the
American Public Health Association October 12-14.
Because of an urgent request to organizations from the
Office of Defense Transportation to limit civilian travel
and because of the difficulty of health service staffs to
leave their work at this busy time in the fall it seemed
advisable to forego a general meeting in October. In
accordance with tentative plans made last March, an
annual meeting is contemplated for late in the winter.
The dates of the meeting will have to conform, as much
as possible, with end of term breaks in the school year.
Members will be doing a service if they will write,
expressing their opinions on the need for the general
meeting in the face of congested travel conditions, the
dates when most staffs can send representatives, and their
preference for discussion topics.
Dr. Charles E. Shepard is now stationed in Washing-
ton, D. C., with the title of Director, Personnel Training
Program with the Coordinator of Inter-American Affairs
in the Office for Emergency Management.
After four years as physician and director of Student
Health at Texas State Teachers College for Women at
Denton, Dr. E. A. Taylor has resigned to join the staff
of the Terrell Laboratories and Clinic in Fort Worth,
she is succeeded by the former incumbent of the North
Texas State Teachers College post.
Chronic Granuloma Following Typhoid Booster Dose.
Tilden and Arnold, in the July (1943) issue of Archives
of Pathology, describe a granulomatous reaction which
occurred in 6 of 4,500 persons who received intradermal
injection of triple typhoid vaccine. The vaccine was pre-
pared by the U. S. Army, using the Boxill strain. The
reaction, so far as is known, is of cosmetic importance
only.
Immune Rabbit Serum in Rocky Mountain Spotted
Fever. Topping, in Public Health Reports of May 14,
1943, reported treating 52 patients with Rocky Mountain
Spotted Fever Immune Rabbit Serum. Only 2 of the 52
patients died, a fatality rate of 3.8 per cent, as compared
with an expected rate of approximately 18.8 per cent.
The 2 patients who died were men, aged 66 and 72
years.
Another Penicillin-like Antibacterial Substance. Bush
and Goth, in the June (1943) issue of the Journal of
Pharmacy and Experimental Therapy, report another
powerful bacterial substance somewhat comparable to
penicillin. This substance, called "Flavicin”, is produced
by a mold belonging to the Aspergillus flavus group.
Flavicin appears to be more active against the Brucella
abortus, the Staphylococcus albus, the Bacillus anthracis
and the Cory neb acterium diphtheriae than is penicillin.
Toxicity studies on Flavicin have not yet been reported.
The Results of Sulfonamides in Pneumonia. In a sta-
tistical study of a large group of insurees with the Equita-
ble Life Assurance Society, Ungerleider, Steinhaus and
Gubner found (American Journal of Public Health,
Seotember 1943) that since the advent of the sulfona-
mides:
(1) The case fatal'ty rate from pneumonia had fallen
from an average of 20.8 per cent to 3.9 per cent.
(2) The total duration of illness in pneumonia had
decreased from the modal period of 38 days in 1935
to 27 days in 1941.
(3) The incidence of pneumonia had increased from
an average of 2.6 per 1,000 annually to 3.0 per 1,000.
They calculate that sulfonamide therapy now saves
the lives of 25,000 industrial workers annually, as well
as reducing lost time due to illness in industry by 1,000,-
000 working days.
Activated Sludge Renders Polio Virus Non-inf ective.
Carlson, Ridenour and McKhann, in the September
(1943) issue of the American Journal of Public Health,
report that activated sludge in amounts as low as 1,100
November, 1943
377
parts per million, with 6 hours aeration, will remove or
inactivate a mouse-adapted strain of poliomyelitis virus
to a sufficient extent to reduce, greatly, infectivity for
mice injected intracerebrally. "Heavier concentrations of
sludge with longer aeration periods largely eliminate in-
fectivity.”
Active Immunization with Tetanus Toxoid. Fraser,
MacLean, Plummer and Wishart, in the September
(1943) issue of the American Journal of Public Health,
report as follows on their studies of immunization with
tetanus toxoid:
(1) The response in antitoxin in persons given three
doses of toxoid is better than in persons given only two
doses.
(2) A combined antigen, made up of typhoid, para-
typhoid A and B vaccine, suspended in tetanus toxoid
(T.A.B.T.) given in three 1 ml. doses, three weeks apart,
stimulated the production of at least 0.02 unit of anti-
toxin in 99 per cent of 79 persons, and at least 0.1 unit
in 87 per cent.
(3) Results suggest that tetanus toxoid with the ty-
phoid element added is more effective than without.
(4) The antitoxin response to a "recall dose” is less
in persons with low levels of antitoxin than in persons
with relatively higher levels.
They recommend "that the first recall dose of
T.A.B.T (4th dose) be given not less than three and
not more than six months after the primary series of in-
jections.”
Effect of Intramuscular Injection of Atabrine. In the
August 14 (1943) issue of the British Medical Journal,
Frank Hawking, D.M., reported that histological exam-
ination of the tissues of rats and rabbits, after subcu-
taneous and intramuscular injection of atabrine musonate,
always showed a certain amount of necrosis at the site of
injection. The damage produced by the atabrine is simi-
lar in character to that caused by the injection of quinine,
but less than one-third as extensive. The author con-
cludes that, though these findings do not contraindicate
the parenteral use of atabrine in patients who cannot
take it by mouth, they should be borne in mind when
choosing between the intramuscular and the intravenous
routes.
Atypical Pneumonia due to Streptococcus Viridans.
In the June (1943) issue of the American Journal of
Medical Sciences, Solomon and Kalkstein describe 5 cases
of atypical pneumonia in which the etiologic agent ap-
peared to be the Streptococcus viridans, since this organ-
ism was recovered from the blood or pleural fluid as well
as the sputum. These cases exhibited (a) a prolonged
severe course with high mortality; (b) severe pleuritic
reaction with serous effusion; (c) failure to respond to
sulfonamide therapy.
Immunity Produced by Clostridium Welchii Toxoid.
Sarah E. Stewart, Bacteriologist, U.S.P.H.S., in the Jan-
nuary (1942) issue of War Medicine, reported that she
had succeeded in immunizing guinea pigs with Clostri-
dium Welchii toxoid so that they are resistant to many
lethal doses of toxin or to viable culture injected either
intraperitoneally or intramuscularly.
More recently, she compared protection against viable
culture vs. protection against toxin and found that guinea
pigs immunized with this toxoid alone were more resistant
to massive doses of viable culture than to equivalent
"minimal lethal doses” of toxin.
Now, in the Public Health Reports of August 20,
1943, the same worker reports a study of the mechanism
by which this somewhat unexpected phenomenon is
brought about. The answer is that the antitoxin "renders
the toxicogenic bacteria nontoxic and susceptible to the
action of phagocytic cells.”
British Experience with Bacillary Dysentery. A recent
report of the July (1943) meeting of the Army Path-
ology Advisory Committee (British) brought out the
following points with regard to bacillary dysentery:
(1) Most Shiga and Flexner infections yield promptly
to adequate dosage with sulfaguanidine or succinyl-sulfa-
thiazole and stools become regularly negative for these
organisms at an early stage.
(2) Sonne infections do not respond as well to these
sulfa drugs, and tend to persist in the stools for long
periods even if the clinical symptoms have cleared.
(3) When dysentery cases are not bacteriologically
clear in 14 days on sulfa medications by mouth, a two-
ounce retention enema of 10 per cent sulfaguanadine in
normal saline, if given at daily intervals, will usually ren-
der the patient non-infective in a maximum of 28 days.
(4) Sonne infections are infrequent in the Middle
East, frequent in England.
British Treatment of Malaria in Returned Service
Men. Clark, in Vol. II, No. 1 (1943) issue of the Jour-
nal of the National Malaria Society, states that the stand-
ard treatment, in the British Army, of malaria occurring
in individuals returning from service in malarious areas
is as follows:
Days 1 and 2 — Quinine bisulphate or quinine hydro-
chloride, grains 10 in solution, in one fluid ounce of wa-
ter, by mouth, three times in 24 hours.
Days 3, 4, 5, 6, 7 — Nepacrine hydrochloride (equiva-
lent of our atabrine), 0.1 gram tablet, three times a day,
swallowed whole with a draught of water, after food.
Days 8 and 9 — No antimalarial drug treatment.
Days 10, 11, 12, 13, 14 — Pamaquin (equivalent of our
plasmoquine) , 0.01 gram tablet, three times a day, after
food.
Roentgenological Chest Surveys of Recruits. Richards,
in the American Journal of Roentgenology of January,
1942, stated that as the result of x-ray examination of
328,325 recruits for the Canadian Army (using 14x17
inch film), 1.6 per cent were rejected. Of the 5,273 re-
jected, 3,076 were rejected for tuberculosis, 1,088 for
non-tuberculous pulmonary disease, the remainder for
cardiac or other conditions. He estimates that investing
$600,000 in this survey saved the Canadian government
over $20,000,000 (the cost of each such case to the gov-
ernment, if it had not been discovered before induction,
being estimated at $4,000) .
Sulfathiazole in Vincent’s Infections. Hirsch and
Spingarn, in the September (1943) issue of the Military
Surgeon, report success in treating Vincent’s (fuso-spiro-
chetal infection of the gums and throat with sulfathia-
zole. The dose used was 4 grams daily for 2 to 6 days.
Serves the
MINNESOTA, NORTH DAKOTA
Medical Profession of
SOUTH DAKOTA and MONTANA
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
Montana State Medical Assn.
Dr. J. P. Ritchey, Pres.
Dr. M. G. Danskin, Vice Pres.
Dr. Thos. F. Walker, Secy.-Treas.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T teas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, T teas.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
ADVISORY COUNCIL
[ 22 .
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons’ Assn.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres.-Elect
Dr. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy.-Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R. C. Webb, Secy.-Treas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy.-Treas.
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. J. O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cotta m
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H Long
Dr. O. J . Mabee
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. J. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr J.C. Shirley
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr. J . H. Simons
Dr. S. A. Slater
Dr. W. P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. T uohy
Dr. M. B. Visscher
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 84 South Tenth Street, Minneapolis, Minnesota
W. L. Klein, 1851-1931
Minneapolis, Minnesota, November, 1943
VITAMINS
Nothing since the dawn of time, since the creation of
Adam and Eve, or, shall we be content to say, since the
very first page of medical history, has caused such wide-
spread interest as the development of the appreciation of
vitamins.
With every new discovery, vitamins are found to have
more and more general application. Men of science de-
scribe, in terms that the laity does not always under-
stand, how this or that avitaminosis has been corrected,
thereby overcoming some obscure disease that previously
baffled conscientious endeavor on the part of the medical
profession. The story of these accomplishments is hailed
by an eager world. Newspapers and magazines play it
up and the appeal to the laity is natural. The «word itself
bespeaks life. Vitamins are useful in sickness and in
health. And where is the man, pray tell, who even in
health does not wish to be stronger and have health more
abundant? Promise of "vim, vigor and vitality” was the
chief attraction in the days of medicine shows, and now
every mother’s son who makes or sells foodstuffs of any
kind must give assurances that his product has been en-
riched to supply these very requirements. The govern-
ment is faithfully providing vitamins for our fighting
forces and radio programs urge a maintenance dose from
this day until death. The resultant popularity has called
forth mirth-provoking comments that do no good. The
so-called vitamin craze should not be ridiculed. In ethical
hands it isn’t a racket; it is something very wonderful.
Therefore it behooves the medical profession to so master
the subject of vitamins that the natural procedure is for
the patient to advise with his doctor rather than attempt
viamin 9elf-medication.
A. E. H.
November, 1943
3 79
HOW TO PREVENT COLDS
In 1908 my father built a sleeping porch on our house.
We would all sleep out there in the winter, if it got cold
enough, he said, and we wouldn’t have any more colds.
So we all slept out on the sleeping porch. All I can re-
member about it now is that we had fun out there but
I was tired all the time and was glad to get to school
where I could sleep.
Then we started taking cold baths. My father rigged
up a rubber shower contraption so that everybody could
get up and have an ice-water shower first thing in the
morning. That was so that we wouldn’t have any more
colds. Cold showers went on for quite a while and were
very jolly. Everybody slapped and snorted and shrieked
in his turn and then waited to hear the next victim. We
caught father using some warm water one morning, so
the whole system broke down. I don’t remember having
any colds in those days but that was forty years ago.
When I got older and left home, I didn’t do any-
thing about colds except carry a handkerchief. Those
were busy, exciting days in which I don’t remember about
colds. Otherwise occupied.
Now, in the year 1943, my wife says we should do
something so the children won’t have colds. She turns
to me because I am a doctor and she doesn’t know any
better. Well, let’s see, there have been quite a few fads
about colds. Sunlamps, codliver oil, vaccines, and now
we sleep with the windows closed. I think maybe the best
thing would be to build a sleeping porch where the kids
can take up the family pillow fights where they left off
in 1910. I don’t remember any colds then — or much of
anything else. L. M. D.
EMERGENCY MATERNITY AND INFANT
CARE IN NORTH DAKOTA*
The House of Delegates of the North Dakota State
Medical Association, at its annual meeting in Bismarck
last May, rejected the plan proposed by the United
States Children’s Bureau for the emergency maternity
and infant care of service men’s wives and infants. Our
association has been subjected to considerable adverse
comment since that time. The latest reports indicate
that North Dakota and Louisiana are the only states in
which a plan is not in operation. Attempts were made,
since last May, to adopt a plan whereby the hospitals in
the state would provide free hospitalization for the indi-
viduals covered by the act. However, the hospital plan
carried a proviso that the physician attending the wife
or infant would be required to sign a statement that he
was not charging a fee for his services. Obviously this
proviso was objectionable to the hospital administrators,
as well as to the medical profession, so the hospital plan
was rejected. A joint committee consisting of representa-
tives of the state hospital and medical associations was
recommended to study the problem. This committee met
in Fargo on September 12, 1943, and adopted a plan t'o
be submitted to the respective associations for considera-
tion. A special meeting of the Council of the North
Dakota State Medical Association was then called. The
Council met in Fargo on October 3, and adopted the
plan recommended by the joint committee. The plan
is as follows:
Emergency Maternity and Infant Care Program
(E.M.I.C.)
1. It is proposed by the North Dakota State Medical Asso-
ciation that such funds as may be allocated by the Children’s
Bureau under Title V, Part 1, E.M.I.C., Fund E, be adminis-
tered as follows:
1 . A stated allotment for maternity and infant care, similar
to the allotments already provided for the maintenance of
dependents of men in the Armed Forces of the fourth,
fifth, sixth, or seventh grades, be made, leaving the actual
arrangement as to the amount of fees to be fixed by mu-
tual agreement with the wife and the physician of her
choice.
2. This allotment shall be $50 for medical maternity care
and not to exceed $10 per week for medical infant care
for a total of not over five weeks in any one illness.
3. Upon completion of the maternity care, the wife of the
service man shall make application to the state director of
the Maternal and Child Hygiene Division of the North
Dakota State Department of Health for her allotment or,
similarly, in the case of illness of the infant under one
year of age, for the allotment to which she is entitled at
the termination of that infant’s illness, and shall supply,
at the same time, the necessary documentary evidence of
her husband’s military status.
4. When adequate proof of claim for the allotment has been
submitted, the director of the Maternal and Child Hy-
giene Division of the North Dakota State Department of
Health shall prepare the proper voucher for the woman’s
signature and, after proper certification, this voucher shall
be submitted to the North Dakota state auditor for pay-
ment from the state’s share of Fund E, allocated for this
purpose.
5. Recognizing the need for consultation service, it is recom-
mended that a plan for consultation service be developed
by the state health department in cooperation with the
state medical association.
A detailed plan, based on the above plan, is being sub-
mitted by the North Dakota State Health Department
to the Children’s Bureau. It will be interesting to note
the attitude of the Children’s Bureau toward this pro-
posal. The Council felt that the wives of service men
should not only have the right to choose their own physi-
cian, but also to make whatever financial arrangements
are necessary. If a stated allotment for this service is not
permissible under the terms of the act, attempts should
be made at once to amend the act. L. W. L.
*For detailed presentation of plan as administered by state
health departments, see October issue; paper by Edith M. Sap-
pington, M.D.
Book ileviews
Your Own Story, Human Reproduction simply explained, by
Marion L. Faegre, Minneapolis; Minnesota State Depart-
ment of Health, 64 pages, pamphlet, mailed free to citizens
of the state on request.
"An attempt to provide answers to some of the questions
young children ask,” something over two-thirds of the booklet
being devoted to replying to the child directly, in language that
he can understand, and the remainder being addressed to par-
ents. This is another in the series by Dr. Faegre, as a member
of the faculty of the University of Minnesota. A foreword has
been written by Dr. Haven Emerson. The text has been pre-
pared for and published by The Minnesota Department of
Health, Division of Child Welfare, and copies may be secured
from that office.
380
The Journal-Lancet
Neurosurgery and Thoracic Surgery: Volume VI of Mili-
tary Surgical Manuals: prepared and edited by the Subcom-
mittee on Neurosurgery and Thoracic Surgery of the Com-
mittee on Surgery of the Division of Medical Sciences of the
National Research Council; Philadelphia, W. B. Saunders
Co., 310 pages, 1943, price #2.50.
The high mortality rates of central nervous system and tho-
racic injuries in modern warfare and the special nature of these
injuries emphasize the need for this clear, concise text on the
subjects. It is written by authorities in these fields and under
the auspices of the respective sub-committees of the Committee
on Surgery.
Much of the information on neurosurgery is based on ex-
periences in the war of 1914-1918 with additional reports from
the present war. The section on thoracic surgery includes infor-
mation dealing only with the special problems encountered, prac-
tical diagnosis and applied therapy, and makes no attempt to
completely cover the subject. References and 103 photographs
and anatomical drawings supplement the written text.
Gastro-enterology (in three volumes) by Henry L. Bockus,
M.D., Professor of Gastro-enterology, University of Penn-
sylvania Graduate School of Medicine. Separate index vol-
ume. Three volumes total about 2,700 pages, fully illustrated.
Philadelphia, W. B. Saunders Co., 1943, price #35.00.
Volume I: Gastro-Enterology. With the publication of the
first volume of a projected three-volume work, Dr. Bockus has
begun to fill the need, long apparent, for a compendium of in-
formation concerning gastro-enterology. Single volumes, under
single authorities, and other edited collections of several authors,
have appeared in recent years; outlines for students and mono-
graphs on particular diseases have been presented. Many of
these have been important and useful; but there was a lack of
a dfinite, authoritative and interpretative treatise covering the
total field of gastro-enterology. This gap in medical literature
has now been adequately filled by Gastro-Enterology.
The first volume, dealing with the esophagus and stomach,
is now at hand. Written by one with broad experience in the
field, the content is encyclopedic, but at the same time pointed
with personal opinions and sound conclusions. A fair presenta-
tion of all worthwhile ideas on controversial subjects, such as
the etiology of peptic ulcer, is given, emphasized by the forth-
right judgment of a practitioner and experimenter. For integra-
tion and coherence, the writing reminds one of Osier; the ad-
vantage of single authorship of a medical text is amply proved.
The references are to the most recent work in gastro-enter-
ology, buttressed by sufficient, but not burdensome, historical
background source material.
In the discussion of diagnosis, stress is properly placed upon
a carefully taken and intelligently interpreted history. In out-
lining treatment, particularly for peptic ulcer, individualization
is accented as against rigid standardization.
From the promise offered by this first section, Volume II
on the small and large intestine and peritoneum, and Volume
III on the liver, biliary tract and pancreas and secondary gastro-
intestinal disorders, will be eagerly anticipated.
Practical Survey of Chemistry and Metabolism of the
Skin, by Morris Markowitz, M.D.; Philadelphia, the Blakis-
ton Company, 1942, blue fabricoid, gold-stamped, 196 pages,
plus appendix of 4 pages and index of 11 pages. Price #3.50.
The author has written a very concise outline of the essential
facts, as the title indicates. The subject matter is divided into
four parts: Part I, Chemistry of the Skin, discusses metabolism
of the skin as well. Part II, Hematology, covers the hemato-
poietic changes related to cutaneous diseases. Part III, Blood
Chemistry, a practical section, and Part IV, Vitamins in Der-
matoses, which includes a table. Each part is well organized
and outlined and is followed by a complete bibliography on the
subject matter. Considering the brevity of the book, it contains
a world of information. It clearly shows the modification of the
chemical composition of the skin following pathologic processes.
It is recommended to all physicians whether engaged in research
or clinical practice and especially to those interested in skin
diseases.
Views Items
REPORT OF JOINT PROJECT
BY SOUTH DAKOTA STATE BOARD OF
HEALTH AND UNITED STATES
PUBLIC HEALTH SERVICE
A Series of Lectures to Physicians and Health
Workers on Tropical Diseases
Exotic diseases having become a problem in northern
latitudes due to the return of service men from tropical
lands and of tourists from the southern states and
Mexico. South Dakota, the first northern state to under-
take such a program, arranged a series of talks at official
meetings of district medical societies. These talks, given
by Marcos Fernan-Nunez, M.D., professor of pathology
and tropical medicine at Marquette University for six-
teen years, have been thus reported to Dr. Eben J. Carey,
dean of Marquette University medical school:
"Illustration was by lantern slides and motion pictures
and covered the general field of tropical medicine with
special reference to the diagnosis and management of
chronic cases which are the usual types seen in the north.
(Several cases of tropical diseases have appeard in South
Dakota.) The itinerary follows.
September 20 — Aberdeen, South Dakota. A dinner
was given by the Aberdeen District Medical Society. The
meeting was held at St. Luke’s Hospital and was exceed-
ingly well attended by the physicians, sisters and nurses
of the hospital, health workers and scientific people gen-
erally. Total, about 130.
September 21 — Huron. Appearance on the afternoon
program of the meeting of the South Dakota Public
Health Association, a very live organization, and formal
presentation which constituted the evening program. At-
tendance at both meetings, about 250.
September 22 — Sioux Falls. Evening meeting held at
the city hall was attended by the district medical society,
army medical officers from the air forces technical
school, sisters and nurses from the Sioux Valley Hos-
pital and McKennan Hospital, Dr. J. C. Ohlmacher,
Dean of the South Dakota University Medical School,
health workers and scientists generally. Attendance,
about 300.
September 23 — Pierre. A dinner was given by the dis-
trict medical society. The talk was at the high school
auditorium and attended by the physicians, sisters and
nurses of St. Mary’s Hospital, science teachers, health
workers, and physicians wives, total around 150. Follow-
ing the meeting, a reception was held at the home of
Dr. Triolo. While in Pierre Governor Sharpe was vis-
ited. He invited Dr. Fernan-Nunez to his press confer-
ence and the lecturer attended.
September 24 — Rapid City. The meeting was held in
the high school auditorium and attended by the district
medical society members, medical officers of the army
bombing school, sisters and nurses of St. John’s Hospital,
health workers, scientific people, high school students,
and others. Total, about 130.
X-
ANNOU.I
mm
Each Daily Dose
(3 tablets)
PROVIDES
Vitamin A 5000 U.S.P. units
The minimum daily adult
requirement is 4000 U.S.P.
units.
Vitamin Bt 2 mg
1.8 mg is the recommended
daily requirement.
Vitamin B2 2 mg
Equivalent to the minimum
daily adult requirement.
Vitamin B6 0.5 mg
Daily requirement not yet
established.
Vitamin C 50 mg
Exceeds the recommended
allowance of 30 mg.
Vitamin D 500 U.S.P. units
Exceeds the 400 U.S.P.
units advocated as the
minimum daily require-
ment.
Vitamin i 3 mg
Requirement not yet es-
tablished.
Calcium Pantothenate 3 mg
Requirement not yet es-
tablished.
Niacinamide 15 mg
While 10 mg is regarded
as the minimum daily adult
requirement, daily intake
of 15 mg is advocated.
Iron 10 mg
Exceeds the 8 mg esti-
mated as minimum daily
adult requirement.
Calcium 200 mg
A generous contribution
toward the daily require-
ment.
Phosphorus 175 mg
Effectively supplements
normal intake.
Manganese 0.5 mg
Exact needs unknown.
Magnesium 20 mg
Requirements not yet de-
termined.
7
ING TO THE MEDICAL PROFESSION
!Vx
Roc/re
VITAMINETS
Q VITAMINS
+ C MINERALS
-1J, VITAL
“ l*t ELEMENTS
Circumstances today render it expedient for the physician
to advise many of his patients of the desirability of using
a good, balanced, vitamin-mineral supplement ... as
sound diet insurance.
The new Roche product, Vitaminets, provides a particularly
appealing preparation for professional prescription:
COMPREHENSIVE FORMULA — Each tablet incorporates 9
vitamins and 5 minerals in significant amounts, appropriate
for administration three times a day.
PHARMACEUTICAL ELEGANCE — The tablet is so palatable
that it can be chewed and swallowed without water.
ECONOMICAL — It costs no more than most products that
provide vitamins only — the minerals constitute an "extra
dividend."
STRICTLY ETHICAL — It will not be advertised to the laity
in any way — either directly or by drugstore display.
Vitaminets are packaged in bottles of 30 and 100. Your
local pharmacy should have Vitaminets awaiting your
prescription.
AVAILABLE AT ALL LEADING PHARMACIES
HOFFMANN-LA ROCHE, me.
NUTLEY, N. J.
Rocfe' THE VITAMIN-MINERAL SUPPLEMENT
382
The Journal-Lancet
September 24 — Rapid City. An inspection of the very
up-to-date health center, a cooperative enterprise between
the State Board of Health and the city Health Depart-
ment. Here a blood slide of a malaria patient was shown
and mention was made of other cases which had occurred
in that city.
From Aberdeen to Rapid City the trip was made in
an automobile with Dr. Gilbert Cottam, superintendent
of the State Board of Health, and Dr. A. Triolo, deputy
superintendent. Dr. Cottam, formerly dean of surgeons
of South Dakota, retired at the age of 70, but was im-
mediately drafted by the Governor to head the state
medical service, a very fortunate choice for the post.
South Dakota is one of our greatest states. Its beautiful
clean, modern small cities, the proverbial hospitality and
friendliness of its people, the spirit and atmosphere of
the great West, all combine to make it a fine place to
live and work.
There is a definite need for young well-trained physi-
cians. They would be welcomed and every possible aid
given them. It was Dr. Cottam’s expressed opinion that
the campaign accomplished its purpose.”
Dr. George Brecher, American physician of Olmutz,
Czechoslovakia, is leaving America to take residence in
Port-au-Prince, capital of the Republic of Haiti. For the
past year he has been a fellow in pathology at Mayo
Clinic, Rochester, during part of which time he was first
assistant in the section on pathologic anatomy. Two years
of training were spent at the University of London, Eng-
land, School of Hygiene and Tropical Medicine. Dr.
Brecher will engage in public health service in Haiti,
under the joint auspices of the Haitian and United
States governments.
The discovery of a new anti-malaria drug, totaquine,
was disclosed in a report read at the opening meeting of
the United States Association of Military Surgeons at
Philadelphia in October.
The University of Minnesota study of breast cancer
has received additional impetus from the entry of the
Dight Institute of Human Genetics into participation.
The program will be under the direction of Dr. Jno. J.
Bittner, now a professor of cancer biology at Minnesota,
collaborating with Dr. Robt. G. Green, professor of bac-
teriology, Dr. Chas. Evans, Dr. C. P. Oliver, Dr. Mau-
rice Visscher for the department of physiology and Dr.
Wm. O’Brien, professor of preventive medicine.
Yankton, South Dakota, District Medical Society held
its annual fall meeting September 30 at the state hospital.
Dr. J. C. Ohlmacher, president of the South Dakota
State Medical Association, was the guest of honor, speak-
ing during the course of the evening. Physicians repre-
senting localities throughout the southeastern part of
the state heard two scientific lectures. Senior students
from the University of South Dakota school of medicine
in Vermillion were invited guests. A separate meeting of
the Women’s Auxiliary of the district society was held
at which Mrs. Ohlmacher was reelected president. Mrs.
L. J. Brookman was named secretary-treasurer. Mrs.
Geo. S. Adams, first vice president and chairman of or-
ganization for the Auxiliary, was hostess at a dinner for
the out-of-town visitors. Present were Dr. Frank W.
Haas, assistant superintendent at the state hospital, Mrs.
Elward Joyce, state Auxiliary historian, Mrs. Jno. C.
Hagin, state Auxiliary president, Mrs. E. R. Schwartz of
Wakonda, Mrs. Arthur P. Reding of Marion, Mrs. Jno.
D. Thomas of Charlestown, New Hampshire, and Mrs.
Eli M. Morehouse of Yankton. The attending physi-*
cians, auxiliary members and students made a group of
about 100.
Dr. D. W. Gross of Woonsocket, South Dakota, has
removed to Brookings.
Dr. A. R. Foss of Missoula, Montana, was elected
president of the Montana board of medical examiners at
a reorganization meeting in Helena, October 5. Vice
president is Dr. Cedric Nelson, Billings, Dr. Otto G.
Klein, Helena, was reelected secretary, other members
are Dr. Earl Porter of Lewistown and Dr. J. H. Gar-
berson of Miles City.
Dr. Owen H. Wangensteen, Director of the Depart-
ment of Surgery, University of Minnesota Medical
School, announces the eleventh E. Starr Judd lecture
which will be given by Major General Norman T. Kirk,
Surgeon General, United States Army, War Depart-
ment, at the University of Minnesota, Monday evening,
December 6, 8:15, in the Museum of Natural History
Auditorium. The subject is "Surgery in War.”
Minnesota State Medical Auxiliary met in all-day ses-
sion in Minneapolis October 22 to discuss sharing respon-
sibility for the execution of the war service program.
For outstanding work in the fight against tuberculosis
Dr. C. L. Sherman, Luverne, Minnesota, received the
Christmas seal plaque of the Minnesota Public Health
Association at ceremonies conducted in his home city
October 12. For three decades Dr. Sherman has been a
leader in anti-tuberculosis work in southwestern Minne-
sota.
Dr. F. J. Hill of the North Dakota State Department
of Health, has announced that the district health office,
which has been maintained at Valley City for the past
six years, is being discontinued as a result of the action
of the Board of County Commissioners. They are said
to have repudiated a promise made the state authorities
to sign a contract which contemplated the appropriation
of funds to carry on a county program. The city of
Valley City had voted cooperation and funds but gave
the state health department a release from its arrange-
ments following the county commissioners’ action of
refusal to enter the program. This change results in Dr.
E. L. Sederlin, former Fargo city health officer and
lately district health officer at Valley City, being trans-
ferred to Bismarck.
Dr. M. D. Wagar of Michigan, North Dakota, has
removed to White Plains, New York. Dr. Paul Reed
of Rolla, North Dakota, is now engaged in practice at
Virginia, Minnesota. Dr. A. C. Burt, Fargo, North
Dakota, is a recent addition to the medical practitioners
of Minneapolis.
The Psychiatric Problem in War and Peace
J. C. McKinley, M.D., Ph.D.j
Minneapolis, Minnesota
PUBLISHED studies of combat casualties from
various theaters of the war indicate that 30 to 50
per cent or more fall into the neuropsychiatric
field. Mere displacement of predisposed individuals from
neutral, protected environments to the more exacting
demands of military existence, even without any imme-
diate prospect of combat, takes its psychiatric toll as in-
dicated in the following article by Heersema. "Combat
fatigue,” "convoy fatigue,” "traumatic neuroses,” "war
neuroses,” "shell shock” all come in for comment or
discussion in this issue of the Journal-Lancet; recogni-
tion, screening for selection of soldiers, appropriately or-
ganized and suitably placed teams for psychotherapy
provide a mitigation of the problem, as several of the
authors point out.
Following the war we can expect an inevitable incre-
ment in the hospital facilities for these patients. Before
the war psychiatric cases had already occupied more than
half of all the hospital beds in the country. What the
magnitude of the problem will become in the non-institu-
tFrom the Department of Neuropsychiatry, University of Min-
nesota Medical School, Minneapolis,
tionalized population can only be guessed at but its full
exposition will doubtless be staggering.
Every medical man should orient himself as best he
can to make his contribution to this situation since the
problems are in principle the same in civilian life as they
are obviously desirable trends pending a more direct ap-
quency and degree of environmental impact on the in-
dividual.
More psychiatrists, increased facilities, improved med-
ical appreciation of the problem in the individual patient
are obviously desirable trends pending a more direct ap-
proach to preventive measures. What these measures
should be involves controversial issues in ethics, religion,
the law and the like. Some day the medical profession,
sociologists, the clergy and indeed all thinking people
are likely to find themselves participating in discussions
on these points by the very weight of the threat that the
neuroses, the psychoses and the borderline states in psy-
chiatry hold for us. The sooner we begin our funda-
mental thinking, fact finding and debate, the sooner will
we be in a position for the instigation of effective mea-
sures of control,
384
The Journal-Lancet
GuillaiivBarre’s Disease (Encephalo-Myeio-Radiculitis)
A Review of 33 Cases
A. B. Baker, M.D.f
Minneapolis, Minnesota
ALTHOUGH many publications have appeared de-
scribing this symptom-complex, our knowledge
Lconcerning this condition still remains far from
complete. Any observations that might enhance our un-
derstanding of this disease seem of definite value. It is
for this reason that a comprehensive review of those cases
wh ich we have considered as belonging to this symtom-
complex has been undertaken. We have attempted to
procure follow-up studies of the older cases in order to
determine objectively the degree and severity of any re-
sulting residuals. Finally, detailed pathological studies
were carried out on 2 fatal cases and revealed some very
unusual findings which seemed to us to suggest the pos-
sible pathogenesis of this disease.
The symptom-complex commonly referred to as Guil-
lain-Barre’s syndrome has been recognized since 1892
when Osier1 first described it under the term of "acute
febrile polyneuritis.” Since that time, cases apparently
belonging to this same group have been described under
a wide variety of terms, "radiculoneuritis” (Guillain,
Barre and Strohl,2 Guillain1), "acute ascending paraly-
sis” (Casamajor4) , "acute infective polyneuritis” (Brad-
ford, Bashford and Wilson ’) , "infective neuronitis”
(Kennedy1') , "polyneuritis with facial diplegia” (Fran-
cois, Zuccoli and Montus7 and Taylor and McDonald8),
"myeloradiculitis” (Strauss and Rabiner9) , "neuronitis”
(Gilpin, Moersch and Kernohan10), "myeloradiculoneur-
itis” (Shaskan, Teitelbaum and Stevenson11) and "en-
cephalo-myelo-radiculitis” (Polan and Baker12). Since
this disease seems capable of involving almost any part
of the nervous system, the resulting clinical symptoms
and signs naturally are most variable, hence making the
differentiation of this illness from variants of already
well-known neurological disorders often very difficult.
Therefore, it is impossible at present to determine defi-
nitely whether the numerous cases reported in the litera-
ture actually belong to the same symptom-complex or
whether they are the result of totally unrelated disease
processes. Most of the cases reported, however, do have
so many features in common, which definitely differ from
the characteristics observed in other neurological dis-
orders, that one is unable to avoid the conviction that
they represent a specific disease entity, probably of virus
origin. Such an impression is strengthened when one con-
siders the histopathological alterations observed in our
fatal cases which, in many aspects, resembled those lesions
observed in both proven and suspected virus infections.
These will be discussed in a later paragraph.
In a previous publication we reported 8 cases of Guil-
lain-Barre’s disease under the title of "encephalo-myelo-
radiculitis.”12 This descriptive term was selected because
tFrom the Department of Neuropsychiatry, University of Minne-
sota. This study was aided by a grant from the University of
Minnesota Graduate School.
it seemed most adequately to describe the distribution of
the clinical symptoms in our cases and appeared to be a
much more inclusive term than the more limited names
used to date by other investigators. However, even such
a title has certain definite defects. Primarily, it is too
complicated for general use. Even more important is the
fact that this disease may confine itself to selected re-
gions of the nervous system, and the resulting clinical
picture would, therefore, not necessarily correspond to
such an inclusive title as "encephalo-myelo-radiculitis.”
In order to avoid the confusion of conflicting terminolo-
gy, it would seem best, at least until some specific etio-
logical agent is isolated, to refer to this condition as
Guillain-Barre’s disease, since these investigators did em-
phasize the characterizing features of this illness. Guil-
lain, Barre and Strohl,2 and Guillain8 first reported on
this illness in 1916 and again in 1936, recording a total
of 12 cases. Their patients all developed a flaccid paraly-
sis of the limbs with some involvement of both deep and
superficial sensation. In all their cases, the spinal fluid
contained an elevated protein without pleocytosis; and it
was the cell-protein dissociation that these authors con-
sidered specific for this illness. No attempt will be made
to review the literature completely, since such reviews
already have been published. (Gilpin, Moersch, Kerno-
han,10 Polan and Baker12). Most of the more recent
publications have consisted of descriptions of isolated
cases. (Saurer,13 Glen,14 Anderson,1'' Santi,10 Casa-
major and Alpers1').
Characterizing Features of Guillain-
Barre’s Disease
In order to describe adequately the criteria used in the
diagnosis of this disease, it becomes necessary to discuss
briefly those features which characterize this illness. It
is only after one has a clear picture of the entire morbid
process, including its differentiating characteristics and
its clinical course, that one is able to identify this illness
from among the many similar diseases encountered in the
neurological field.
1. A rather sudden onset occasionally preceded by a
history of some antecedent infection, chiefly of the respir-
atory passages. In the majority of cases, mild premoni-
tory symptoms suggestive of some antecedent infection
of the upper respiratory tracts appear a few days or even
a number of weeks prior to the acute illness. These pre-
liminary symptoms may vary from such mild complaints
as malaise, fleeting pains, muscle tenderness, backache,
mild lethargy, to such acute disturbances as nausea, vom-
iting, severe persistent headaches, chills, severe muscular
aching, anorexia, and soreness in the neck. In the occa-
sional case, there may be a prolonged period of head-
aches, often very severe, and some soreness in the neck.
The acute illness, when it occurs, is usually fairly sudden
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in onset, and may follow directly after the vague pre-
monitory complaints or may appear only after a latent
period of well being, lasting many days or even weeks.
In one of our cases, an entire month elapsed between the
preliminary symptoms and the acute illness, and during
the interval, the patient had no complaints. In some indi-
viduals, the neurological symptoms and signs appear
acutely with no preliminary warning and with no history
of any preceding infection of any type.
2. Absence of those findings suggestive of a septic or
j| toxic reaction in spite of the severe clinical symptomat-
ology. The patients as a rule show almost no hyper-
pyrexia, unless there is some complicating infection in
the urinary or respiratory tracts. It is very impressive to
observe so little effect upon the body temperature in indi-
viduals with such acute severe generalized nervous sys-
tem involvement. The pulse also is unchanged and con-
tinues to be full and regular. The blood picture gen-
erally is unaltered, but at times the leukocytes may be
slightly elevated, counts as high as 15,000 cells per cubic
millimeter having been recorded. Usually, the leukocytes
range between 7,000 to 9,000 and show a normal differ-
ential count. Even the sedimentation rate remains within
[normal limits, although on occasions, these rates have
been somewhat elevated. Whenever the laboratory find-
ings indicate definite variations from normal, one must
check carefully for some complicating infection, since in
our experience, this disease in itself will not excite any
of those changes associated with the more common bac-
terial or toxic reactions.
3. A cell-protein dissociation in the spinal fluid with a
normal cell count and a high protein. This finding has
been advocated as being one of the most characteristic
features of this illness. Guillain, Barre and StrohF first
pointed out this observation and have since gone so far
as to insist that the presence of 1 to 2 grams of protein
in the spinal fluid is necessary before one is justified in
making a diagnosis. Guillain has also refused to recog-
nize as belonging to this syndrome any condition with a
spinal fluid pleocytosis. It was primarily because of their
emphasis upon this spinal fluid finding, that this condi-
tion has come to be known as Guillain-Barre’s syndrome.
Many investigators, however, have felt that too much
emphasis has been placed upon this cell-protein dissocia-
tion and that it alone is neither pathognomonic nor abso-
lutely necessary for a diagnosis of this disease. The ab-
sence of such protein elevation in otherwise fairly typical
cases has been reported by Taylor and McDonald,8 Mar-
gulis,18 and Polan and Baker.12 It has been generally
accepted that the degree of protein in the spinal fluid
varies with the stage of the illness, and the presence of
an elevated protein will naturally depend a great deal on
how frequently the spinal fluid is examined. Since there
is often little clinical indication for repeated spinal punc-
tures, this cell-protein dissociation may occasionally be
overlooked in cases where it would have been observed
had repeated spinal examinations been made. We have
observed in many of our cases a normal fluid at the onset
of the illness only to have the protein become elevated
later in the course of the disease. Similar observations
have been reported by Stone and Aldrich11’ and Madigan
and Marietta.20
Investigators have also taken issue with Guillain’s firm
stand against a pleocytosis. The presence of a mild or
moderate cell increase, chiefly mononuclears, is not un-
tenable with a diagnosis of this disease. Gilpin, Moersch
and Kernohan10 in their cases reported a cell variation
from 1 to 80. Similar cellular elevations have been re-
ported by Taylor and McDonald,8 and Polan and Baker.12
In our present series of cases, the spinal fluid cell count
ranged from 0 to 154 cells — chiefly mononuclears.
4. Radicular involvement. This is one of the most con-
stant features of this disease regardless of the region of
the nervous system predominantly implicated at the
height of the illness. The radicular pain is early in
onset and, although involving primarily the extremities,
may appear in any region of the body. The pain may
be widespread and comprise an outstanding part of the
entire clinical picture, or it may become well localized to
small regions of the body and eventually be overshad-
owed by the subsequent symptoms referable to involve-
ment of the peripheral nerves, cord, or cerebrum.
5. Facial nerve palsy. So frequent has been the involve-
ment of the facial nerve, that some of the original de-
scriptions of this syndrome were reported as a "facial
diplegia associated with a polyneuritis” (Patrick21). The
frequent palsy of the facial musculature has been well
recognized, but the emphasis placed upon this finding has
varied greatly in different publications. Taylor and Mc-
Donald,8 for example, excluded from their series all indi-
viduals who failed to show a facia! diplegia, regardless of
other findings. These authors felt that although the
facial nerve was not the only one involved, it was in
general the most constant and conspicuous clinical fea-
ture. On the other hand, Gilpin, Moersch and Kerno-
han10 observed facial weakness in but 35 per cent of
their 20 reported cases. Generally, one can say, that the
presence of a facial weakness is very helpful and ex-
tremely suggestive of this syndrome but is by no means
necessary for a diagnosis.
6. Absence of mental symptoms even in the presence
of a very severe illness. Very few investigators have re-
ported mental symptoms in this disease. Occasionally,
however, in the more severely involved cases, mild deliri-
um with disorientation, restlessness, and excitement may
occur. Somnolence and mild lethargy are by no means
uncommon and are usually observed early in such pa-
tients.
7. Favorable prognosis usually with fairly good func-
tional recovery. Guillain'1 has emphasized this feature as
one of the essential characteristics of this illness. He felt
that the disease is always benign, and that should the con-
dition terminate unfavorably, the diagnosis has been in-
correct. Most investigators, however, have not accepted
this dogmatic point of view. It is becoming more and
more apparent that the outcome is not always favorable
and that cases can terminate fatally or recover with result-
ant residuals. Taylor and McDonald'8 reported one death
and 5 cases with residuals out of a total of 16 patients
presenting a typical facial diplegia. Bradford, Bashford
and Wilson'1 reported 8 deaths in 30 cases, while Gilpin,
386
The Journal-Lancet
Moersch and Kernohan1" recorded a 20 per cent mor-
tality rate. In our 33 cases we have had but 3 deaths;
however, many of our patients in spite of a satisfactory
recovery after a stormy illness, have developed residuals
which have persisted for many years. In order to check
carefully the frequency and degree of such residuals, a
follow-up study of many of our earlier cases was under-
taken and will be discussed more fully in a later para-
graph. Generally one can say that recovery is the rule
in this illness regardless of the severity of the clinical
picture, but that in many of the more severe cases,
residuals or even fatalities will eventuate.
From a review of the above features of this illness,
it is readily apparent that there is no single characteristic
that can be designated as diagnostic. In view of the ab-
sence of any specific etiological agent, one is forced to
accept a more practical attitude in regard to this illness
and to consider in the diagnosis all the features pre-
sented. It is only after a careful consideration of all the
symptoms and signs that one can arrive at a final satis-
factory diagnosis. This frequently will necessitate a fairly
prolonged period of observation, before one feels justified
in classifying the illness and venturing a prognosis.
Clinical Forms
Many descriptions of the clinical features have ap-
peared in the literature. One finds, however, that gen-
erally the symptomatology has been too greatly over-
simplified. The neurological complaints and findings may
be most variable and will naturally depend upon the part
or parts of the nervous system implicated. Usually, the
involvement tends to be accentuated within certain re-
gions, thus producing a predominating symptomatology,
modified, however, by the less striking and often scat-
tered complaints from the remaining nervous system im-
pairment. For convenience, therefore, one might classify
the clinical pictures seen in this condition into five forms,
depending upon the region most severely involved; name-
ly, the abortive or mononeuritic, the polyneuritic, the
myelitic, the bulbar and the cerebral types of illness.
Although all the above forms of this disease seem to
differ greatly clinically, they do present certain related
features. Probably the most outstanding are the radicular
pain, the acute muscle tenderness and the marked clin-
ical improvement in spite of an apparently severe dam-
age to the nervous system. The radicular pain may in-
volve any part of the body, most commonly occurring in
the proximal parts of the limbs. These spontaneous pains
may be mild or very violent and are often provoked by
pressure on the muscles or by movement of the limbs;
they persist for weeks and require heavy medication for
relief of the extreme discomfort. Severe muscle tenderness
almost always accompanies the radicular pain but may
occur independently and persist for a longer period of
time. Certain other observations already discussed under
the "characterizing features of this illness,” also appear
fairly consistently in all forms, and are helpful diagnos-
tically. The course of the disease is usually afebrile with
little or no alteration in the leukocyte count; and the
spinal fluid, some time during the course of the illness,
probably will show an elevated protein with a relatively
normal cell count,
Aside from these general features, the clinical symp-
tomatology differs radically from case to case as will be
demonstrated by the illustrative material to be reported.
Type I. Abortive or mononeuritic form. There can be
no doubt that slight attacks of this illness do occur and
pass unrecognized, thus making the frequency probably
much greater than is generally recognized. In our ex-
perience, it is this form that has been most greatly under-
emphasized, probably because the rigid criteria set up by
Guillain have been too closely adhered to. During that
period when we were seeing most of our cases, many
patients were studied who presented complaints which
were identical with those observed in the early stages of
Guillain-Barre’s syndrome. These individuals gave a his-
tory of a sudden onset of severe radicular pain often
preceded by some antecedent infection of the upper re-
spiratory passages. The radicular pain was at first fleet-
ing in character, involving the limbs or the trunk, and
was often associated with some muscular aching and
severe headache. This pain would not uncommonly dis-
appear within a few days, only to return after a latent
period of several weeks; occasionally it did not disappear
but become localized to a single limb where it was soon
followed by muscular weakness or paralysis, distal hyper-
esthesias and very painful aching muscles. In spite of
the predominantly mononeuritic symptomatology, careful
neurological examination almost always revealed other
scattered findings indicative of the more diffuse nature
of the actual involvement (Case 31). In some patients,
this form of the illness made its appearance as a classical
Bell' s palsy, only to reveal on examination associated find-
ings of such a mild nature that they would not be ex-
pected to produce functional disturbances and hence,
would almost invariably be overlooked by the patient.
Case 6 was typical of such a symptomatology. The pa-
tient, a 16 year old female, after a period of headache
and neck pains, developed a complete right-sided facial
palsy. She had no other complaints but, when examined
carefully one month later, still revealed extensive find-
ings consisting of paresis of both lower limbs with hyper-
active reflexes, and positive toe signs on the right. In
many instances, such a patient would have been diag-
nosed as a typical Bell’s palsy and would have received
no further studies. Similar cases have been mentioned by
Bradford, Bashford and Wilson’’ in their report.
Usually in the abortive form, the illness begins to re-
cede after about two weeks with complete recovery event-
uating in about a month. In an occasional severe case,
the weakness may persist for many months and be accom-
panied by a mild but definite muscular atrophy (Case
31). The following two cases illustrate this form of the
disease.
Case 31: T. S. (H.N. 726426) first noticed periodic pain in
the popliteal region in December 1941. This pain was moder-
ately severe, persisted for several weeks and then gradually dis-
appeared. A few months later his pain recurred but was now
localized to the anterior lateral surface of the left knee and
soon spread up the anterior surface of the left thigh and down
the leg to involve both the leg and the foot. At this time he
complained of no systemic symptoms. His pain became so severe
that he was forced to discontinue his work. Shortly after the
recurrence of his pain, there also appeared a progressive loss of
strength in the left leg and in both upper limbs, being particu-
December, 1943
387
larly marked in the hands. After a few months of partial in-
activity, the pain subsided, but paresthesias and particularly the
paresis persisted, especially in the left lower limb, upon which
the patient was unable to bear weight. This weakness gradually
improved enough so that the patient was able to walk; how-
ever, because of the slowness of his recovery, he finally sought
medical aid almost one year after the onset of the illness.
At this time neurological examination revealed the cranial
nerves to be normal. There was a slight weakness of the left
hand as well as of the entire left lower extremity. The biceps
reflex was reduced and the knee jerk was absent on the left.
There was some atrophy of the abductor and of the quadriceps
muscles on the left, and patchy areas of hypesthesia over the
medial surfaces of the left lower leg and the lateral surface of
the left thigh. The ankle reflexes were normal.
Laboratory studies revealed a leukocyte count of 10,650 with
59 per cent neutrophiles. The spinal fluid contained no cells;
76 mgm. per cent of protein; and 50 mgm. per cent of sugar.
Even at this late date, there still appeared a mild elevation of
the spinal fluid protein.
The patient was placed on a high vitamin diet and dis-
charged.
Case 33: P. H. (H.N. 627350) , a 62 year old farmer, while
plowing, suddenly developed a severe momentary sharp pain in
the upper medial aspect of the right thigh followed within a
few hours by some soreness and stiffness in the same extremity.
That evening he developed tenseness in the adductor muscles.
The pain became progressively worse, was not relieved by medici-
nal treatment and prevented him from sleeping. Because of the
persistence of this pain, he was hospitalized after a few days for
further treatment.
Examination revealed the patient’s pupils to be slightly ir-
regular. The middle and lower abdominal reflexes were absent
as was also the right knee jerk. There was considerable limita-
tion in the movement of the right leg due to pain, and the
muscles in this limb were very sensitive to pressure. There was
an area of hyperesthesia over the medial aspect of the right
thigh. Laboratory studies revealed a blood count of 7,500 with
65 per cent polymorphonuclears and 35 per cent mononuclear.
A spinal puncture showed no cells and 75 mgm. per cent of
protein.
The patient remained in the hospital for three weeks, during
which time he gradually improved. Ten days after admission he
developed hiccoughs which continued for one week with only
short intervals of relief. During this same period he became
mildly confused and disoriented. Following recovery from the
hiccoughs, the confusion also cleared up, but the patient con-
tinued to be somewhat irritable and suspicious.
The pain in his thigh gradually decreased, so that at the time
of his discharge, he appeared to be completely recovered. The
entire course of his illness was afebrile.
Type II. Polyneuritic form. This is the most frequent-
ly described form of this illness although many cases list-
ed as a polyneuritis actually show extensive signs of cord
involvement. These patients usually, after a few pre-
monitory signs suggestive of the abortive form of the ill-
ness, or after a latent interval following an upper respira-
tory infection, develop either a gradual or often a sudden
4anset of motor weakness involving the limbs, primarily
the lower extremities. This motor weakness is flaccid in
type and at its onset almost always involves the entire
extremity. Individual muscles are almost never picked
out, and there appears to be a definite tendency to impli-
cate the larger muscle groups of the proximal regions of
the limbs, namely, the thighs, the pelvis and the shoulder
girdle. Weakness in the upper extremities usually occurs
later than the involvement of the lower limbs and is
often less severe. Not uncommonly the muscles of the
trunk and of the anterior abdominal wall are also impli-
cated, resulting in difficulty in rising or sitting up in
bed. Only exceptionally does the distal musculature be-
come weakened early in the disease and even in these
cases the palsy soon spreads to the entire extremity with
the most severe disabilities occurring in the shoulder and
hip regions.
Paresthesias, hyperesthesias and anesthesias with severe
muscular pain may precede or accompany the motor
weakness. In some cases, the sensory involvement may
be much more extensive and severe than the motor im-
pairment and may comprise the predominant part of the
clinical picture. Occasionally, when the sensory involve-
ment is severe, it not uncommonly follows a glove-stock-
ing distribution. In such cases the paresthesias may per-
sist throughout the entire course of the illness and may
create a serious treatment problem. Headaches of a
most intense type occur and may continue throughout
the early part of the disease.
This type of illness, although superficially resembling
many of the better known forms of peripheral neuritis,
does possess certain definite differentiating features which
will be discussed in a later section on differential diag-
nosis.
Case 11: K. B. (H.N. 723461) , a 23 year old housewife,
first became ill in July, 1942. At that time she suddenly de-
veloped headaches, vomiting, diplopia and some dizziness. These
symptoms were periodic and occurred every other day for about
two weeks and then disappeared. Two weeks later and five days
before her admission to the hospital, she first noticed low back
pain followed by numbness in her hands and feet and some dif-
ficulty in walking. At first she was able to get around but be-
came very tired on the slightest exertion. A few days later she
noted that when she raised either of her arms to the level of
her shoulders there was a tingling sensation in the arms and
hands. The involvement of her extremities continued to pro-
gress until she was unable to walk and was finally forced to
enter the hospital. At the time of her admission she was able to
get around only with assistance.
Neurological examination showed a slight ocular imbalance
with a fine lateral nystagmus in gazing either to the right or
the left. There was a left lower facial paralysis and a paresis of
all limbs with a generalized areflexia. The abdominals were ab-
sent; and the Babinski reflexes were negative. She had a fine
tremor of the hands and on coordination showed a slight past-
pointing to the left. There was a hypesthesia and a hypalgesia
in both hands and in both legs below the knees. Vibration
sense was decreased at the wrists and ankles.
Laboratory studies were negative except for the spinal fluid
which contained one cell and a protein content of 217 mgm.
per cent.
The patient was treated by complete bed rest and a high
vitamin intake. She showed a very definite but gradual im-
provement both subjectively and objectively. Ten days after
admission, sensation began to return to her extremities, fol-
lowed within a few days by improvement also in her motor func-
tion. By the time she left the hospital, one month after her
admission, sensation was normal as was also most of her muscle
strength. The abdominal reflexes were still absent, and the only
muscular impairment was a slight weakness of grip in her left
hand. During her hospital stay, her blood studies showed 8,600
leukocytes with 75-25 differential. Sedimentation rate was 17.5.
Case 30: F. H. (H.N. 725737) . On August 3, 1942, three
months prior to our observation of him, this 46 year old white
male began to have pains on the outer side of his right foot.
These pains increased and gradually spread to involve the entire
right leg from the hip down. Next, the right shoulder became
involved so that pain resulted on voluntary movement. These
aching pains persisted in the right arm for ten days and then
disappeared. Subsequently the left leg from the knee down be-
came involved. The increasing pain made it necessary for the
The Journal-Lancm
388
patient to quit his job as a machinist on August 17, 1942. On
September 2, 1942, he had some teeth pulled, but the pain in
his legs increased. About one week later, he first noticed gait
difficulty due to weakness in his right knee. This weakness pro-
gressed fairly rapidly, so that in two weeks he was unable to
bear weight on his right leg. At this same time he also noticed
a developing weakness of the right shoulder. Raising the limb
became very difficult although strength in his hands remained
good. He entered a local hospital where he remained for 18
days. His pain decreased but his weakness progressed to involve
the hand as well as the rest of the right upper limb.
During the weeks following his hospital discharge, he con-
tinued to experience slight spontaneous pain in his legs, extreme
muscle tenderness, and some paresthesias. His pain again began
to increase in severity; but now, he also noticed "shooting pains’’
which started near the inner malleoli of both ankles and radi-
ated to the soles, penetrating throughout his feet and spreading
especially to the inner toes.
Examination on admission on November 15, 1942, revealed a
slight tremor of the tongue. There was a generalized weakness
of all limbs with some atrophy of the intrinsic muscles of the
hands, of both arms, and of the calf muscles of the right leg.
There was also a marked paresis of the trunk muscles, the pa-
tient being unable to arch his back or sit up in bed unassisted.
All the reflexes in the extremities, both deep and superficial, were
absent. There was a glove and stocking hypesthesia in the ex-
tremities and scattered areas of hypesthesia over the right side
of the face. Deep sensation was decreased on the left with posi-
tion sense bilaterally impaired.
Spinal puncture revealed the fluid to be under normal pres-
sure and containing no cells but 153 mgm. per cent of protein.
Laboratory tests for the various chemicals capable of producing
similar nervous system damage all proved negative.
Under treatment consisting of bed rest, uniform heat on the
extremities, sedatives, high vitamin intake, and exercise for
strengthening the limbs, the patient showed gradual progressive
improvement. The hypesthetic areas progressively grew smaller
and some (specifically those above the right eye) disappeared.
The "shooting pains” disappeared completely from the feet and
partially from the right arm. The ankle jerk on the right re-
turned and strength gradually improved in all muscle groups.
On discharge from the hospital after a two and one-half
months stay and six months after the onset of his illness, the
patient had shown a very marked recovery. He could now walk
unassisted although there still was a definite weakness of the
right lower limb. In spite of an atrophy of most of the muscles
of the upper limbs, strength was good except in the right hand.
The trunk muscles still were somewhat paretic, although the
patient could now arch his back and raise himself in bed.
Spontaneous pain had disappeared. All the deep reflexes in the
upper limbs were normal; in the lower extremities, only the
right ankle jerk was present.
Type III. Myelitic form. In our experience, this form
of the illness appears to be the most frequent, comprising
almost one-half of our cases. The progress of the illness
is very dramatic and a severely involved individual may
make a fairly rapid and almost spectacular recovery in a
very short time. More often than in any other form, the
onset may he sudden and the course rapid with no pre-
monitory symptoms. These patients complain of a slight
numbness and tingling in the lower limbs followed within
a few hours by a marked paresis that may develop into
a complete paralysis within a very short time. The motor
involvement is usually of a flaccid type, although in some
cases it may be partially spastic indicating involvement of
the upper motor neuron. The deep reflexes are usually
reduced or absent, but may be hyperactive, associated
with sustained or unsustained clonus. Early in the dis-
ease there is definite muscle tenderness which, as it dis-
appears, reveals a loss of muscle and tendon pain. If the
illness is very severe, there may develop a similar involve-
ment of the upper extremities. Sensory disturbances pri-
marily of the superficial type comprise a prominent part
of the clinical picture and are of a definite segmental na-
ture, ascending with the progression of the disease and
producing a definite sensory level as is so often seen in a
transverse myelitis. Bowel and bladder dysfunction occur
relatively early, resulting in urinary retention and bowel
incontinence or constipation. Aside from the typical cord
involvement, these patients also develop severe radicular
pain and scattered cranial nerve palsies. The spinal fluid
protein becomes elevated early, thus facilitating the diag-
nosis. The spinal fluid cell count at first may also be
elevated, bur soon returns to within normal limits.
The course is very impressive. After a continued pro-
gression for from two to four weeks, the illness suddenly
begins to recede and the rapid recovery can be followed
clinically by checking the level of the sensory disturb-
ance, which diminishes daily and is associated with a con-
comitant improvement in the muscular palsies. The pares-
thesias disappear as soon as improvement begins. Recov-
ery is usually complete although some residuals do re-
main in the form of a persistent paresis of scattered
muscle groups.
Case 26: H. I. (H.N. 725 158) , a 40 year old farmer, first
complained of severe occipital headaches and pain behind the
eyes. One week later while at work he experienced an attack of
general malaise, chills, and fever, and, at the same time, de-
velopd a numbness and tingling in his feet which he stated,
"felt like walking on a deep carpet or on cotton.” This disturb-
ance progressed, his legs became weak, and, finally, he was able
to walk only with support. Within a few days, he also devel-
oped urinary retention, bowel incontinence and, later, severe
constipation. At about this time, he began to complain of vague
pains in his muscles, calf tenderness and hyperesthesias. Ten
days after the onset of his illness, he had a spell of nausea and
vomiting. A spinal tap was done locally and showed no cells.
He was then sent to the hospital for further study.
On admission, September 28, 1942, the neurological examina-
tion revealed negative cranial nerves. The upper extremity re-
flexes were hyperactive and equal. The great toe signs were posi-
tive on the right; equivocal on the left. The right ankle jerk
was increased; the left, decreased. There was an unsustained
ankle clonus on the right. Finger to nose tests showed a mod-
erate ataxia on the right. Heel to knee tests were normal. The
next day, it was noted that the abdominal reflexes were absent;
there was a slight paresis of the upper and a moderate paresis
of the lower extremities; and there was hypesthesia below the
knees.
By September 29, incoordination was noted in finger to nose,
finger to finger, and heel to knee tests. The last of these was
especially poor on the left. The hypesthesia now extended up to
the mid-thigh and was progressively more intense distally. By
October 1, three weeks after the onset of the illness, both upper
extremities were spastic and there was an unsustained wrist
clonus bilaterally. The Hoffman reflexes were now positive bi-
laterally. There was a paresis of all movements of the arms.
Both legs showed flaccid paralysis with many fibrillary twitch-
mgs. The Babinski tests were negative but the Gonda reflex
was positive on the right. Hypalgesia was present below the
eighth dorsal cord segment. The intercostals showed some weak-
ness and respiration was only fair. There was a marked con-
striction of the visual fields.
On October 2, pain and temperature sensations were absent
below the second dorsal level; and light touch, below the seventh
dorsal segment. Respirations were now shallow and rapid, and
the patient appeared critically ill. On October 5, definite im-
provement was noted. Sensation was now normal above the
eleventh dorsal segment, and motor power had partly returned
December, 1943
389
to the upper limbs. The knee jerks were active and the toe
signs wre still positive. Fecal and urinary retention continued.
On the 9th of October, sensation was normal above the first
lumbar segment. Complete anesthesia was limited only to the
lateral aspects of the left leg, the right big toe and the plantar
surfaces of both feet. By October 12, there were no areas of
complete anesthesia and hypesthesia was limited to the legs.
There was almost no weakness in the upper extremities. By
October 24, there was only mild impairment of pain and touch
on the medial aspects of the legs. Great toe signs were still
present. The retention catheter was removed October 28, but
the ability to void spontaneously did not return for a few more
days. The visual fields had returned to normal by this time.
At the time of discharge on December 15, three months after
the acute illness, the patient was up and about with almost com-
plete recovery of muscle power.
During his hospital stay, the urinalyses at various times
showed traces of albumin, red blood cells and white cells. His
white blood count was 11,800 with 86 per cent neutrophiles.
The blood urea nitrogen was normal. Spinal puncture shortly
after admission showed a cell count of 154 with 80 per cent
mononuclears; these cells rapidly dropped to one within a few
days. The spinal fluid protein remained elevated around 118
mgm. per cent, but dropped shortly before discharge to 53
mgm. per cent. Bacteriological studies on both blood and spinal
fluid were negative. Body temperature throughout varied be-
tween normal and 101.8°. The pulse varied from normal to 128.
The treatment consisted of strict bed rest, large doses of vita-
mins, especially B. and C, and sedation. Sulfadiazine was given
to prevent urinary infection resulting from the Foley catheter.
Mild laxatives and enemata were used to combat the fecal re-
tention. Pilocarpine was used to aid in voiding after the catheter
was removed. The patient was kept on a soft diet until No-
vember 18. Physiotherapy was introduced when the patient was
well enough.
Case 13: Mrs. I. P. (H.N. 726506) was well until the morn-
ing of November 1, 1942, when she awoke to find that she had
bladder and bowel incontinence. She found it very difficult to
walk to the bathroom because of the weakness of her lower
limbs. She also noticed numbness and tingling in both lower
extremities and anesthesia in the area of the buttocks. During
the next four days her weakness and sensory involvement pro-
gressed and she was finally hospitalized for three weeks in a
local hospital from where she was transferred to our care on
November 28, 1942.
At the time of her admission she showed a complete paralysis
of the lower limbs with hyperactive knee jerks, but absent ankle
jerks and abdominal reflexes. There was a hypesthesia below the
tenth dorsal cord level, and muscle pain was markedly in-
creased.
A spinal puncture revealed no increase in pressure, 1 cell, 132
mgm. per cent of protein and a negative colloidal gold curve
Her white blood count was 7,300 with 63 per cent polymorpho-
nuclears. The serology was negative.
Under symptomatic treatment, she showed a very slow but
definite improvement. After two weeks, her severe muscle ten-
derness disappeared and she became much more comfortable.
Her sensory involvement gradually receded and within a few
weeks had entirely cleared up, leaving only a small anesthetic
area about the buttocks. Strength also gradually returned to her
limbs so that after one month she was able to move her legs
freely even though they were definitely paretic. Sphincter con-
trol was also regained at this time and the catheter was removed.
The neurological examination at the time of discharge after a
three months hospital stay, revealed a slight right lateral nystag-
mus, absence of the abdominals, and slightly increased muscle
pain in the left leg. Her knee jerks were still hyperactive and
her ankle jerks absent. She had not gained sufficient motor
strength to support herself in walking. Periodically during her
hospitalization, she had recurrences of most severe radicular pain
localized to various regions of the limbs or trunks and lasting
from hours to days.
Type IV. Bulbar form. This type of the illness is
almost invariably accompanied by involvement of other
parts of the nervous system, even though the bulbar
symptoms do comprise the most impressive part of the
clinical syndrome. In most cases, the bulbar symptoms
occur only after the illness has been in progress for some
time, although in the occasional case the cranial nerve
damage appears suddenly and early, and overshadows all
other findings. Almost any of the cranial nerves may be
implicated resulting in ophthalmoplegias, diplopia, ani-
socoria, facial anesthesia or hypesthesias, vertigo, dysar-
thria, dysphagia, and dysphonias. Unilateral or bilateral
facial palsies are extremely frequent and often very
severe. In an occasional case the medullary damage may
be so severe that even respiratory and cardiac irregulari-
ties occur. One of our patients (Case 17) developed a
complete external ophthalmoplegia with subsequent in-
volvement of almost every cranial nerve. Aside from the
facial palsies, the most common bulbar symptoms consist
of disturbances in articulation and deglutition. Speech
becomes nasal in type and fluids are regurgitated through
the nose.
In most cases, there occurs an associated involvement
of the limbs with pareses, sensory disturbances and reflex
irregularities. Curiously enough, cerebral findings are
not more common in this form of the illness, the pa-
tients remaining mentally clear in the face of a most ex-
tensive bulbar damage.
In spite of the apparently severe involvement in such
a vital region, the prognosis is usually good, although the
occasional case does terminate fatally from a respiratory
paralysis. Residuals when they occur are chiefly limited
to the facial muscles, although persisting diplopia, ocular
imbalance and even limb pareses have been observed.
Again, in this form of the illness, certain associated fea-
tures readily allow for an accurate diagnosis and hence a
more favorable prognosis. These consist of an early bi-
lateral facial weakness, the afebrile course, the associated
limb involvement with radicular complaints and, finally,
the cell-protein dissociation in the spinal fluid. This latter
finding, however, is not always observed, since the spinal
fluid protein does not become elevated until late in the
illness and may not be detected unless repeated spinal
punctures are performed.
Case 17: Mrs. R. S., a 30 year old housewife, became ill one
week after she returned from a trip to California. Shortly after
her return home, she developed a mild diarrhea but no other
symptoms. On March 12, 1941, while getting on a streetcar,
she suddenly felt a numbness in both lower limbs. There were
no other complaints until the following morning, when she dis-
covered that she had difficulty in opening her right eye, and
blurring of vision on looking to the right. Her legs continued
to be numb and weak, resulting in an unsteady gait.
She was seen three days after the onset of her illness, at
which time her cranial nerves were negative with the exception
of a slight ptosis of the right lid. Deep reflexes were hyper-
active with a bilateral positive Hoffman, but negative Babinski’s.
The abdominal reflexes were reduced on the right and absent
on the left. There was marked weakness of the right arm and
shoulder girdle. Her coordination was intact, as was also her
deep sensation. Superficial sensation revealed hypesthesia in the
right upper extremity along the dorsal cord level. There was
also a hypesthesia over the left thigh and leg. During the next
few days the patient’s condition progressed very rapidly. Within
four days she developed signs of a bulbar involvement, for
which she was hospitalized.
390
The Journal-Lancet
On March 17 examination revealed a partial involvement of
all the extraocular muscles, a ptosis of both lids, paresthesia and
hypesthesia over the face, bilateral facial and palatal paralysis,
and bilateral weakness of the tongue. Deep reflexes were re-
duced, although obtainable. She had a diffuse patchy involve-
ment of superficial sensation involving primarily the limbs.
During the next few days her condition continued to progress.
She developed complete paralysis of all the extraocular muscles
with bilateral involvement of the fifth, seventh, ninth, tenth and
twelfth cranial nerves. The vagus involvement at times became
very alarming because of the resulting bradycardia. She also ex-
perienced severe pain in all her limbs and very severe muscle
tenderness. Mentally she remained clear, and showed elevation
neither of temperature nor of leukocyte count.
Spinal puncture done on the day of her hospital admission
revealed a normal cell count with normal protein. The spinal
fluid studies were not repeated. After a period of 10 days the
patient’s illness began to subside and she was discharged from
the hospital one month after admission, at which time she still
had a severe diplopia, a nasal type of speech and a bilateral
facial weakness. She was now able to swallow and her pulse
had returned to normal. There was still slight weakness in the
extremities, although all sensory disturbances had disappeared.
The patient was followed for over two years. Throughout this
period improvement has continued, and when she was examined
two years after the acute illness, her cranial nerves were negative
with the exception of a persistent mild bilateral facial weakness.
Strength had returned to all limbs, and her reflexes were now
normal.
Type V. Cerebral form. This is an extremely rare and
not usually recognized type of Guillain-Barre’s disease.
It usually begins with severe headaches, malaise, vertigo
and nausea. The patients feel weak and remain in bed
for a few days. The symptoms may then subside only
to be followed by mild facial weakness or scattered
radicular pains. After a few days, the headaches again
return and are often accompanied by a mild lethargy
which tends to increase in severity. As the illness pro-
gresses, signs of cord or bulbar involvement may develop.
Some patients become confused, noisy, restless and agi-
tated. It is in this form of the illness that papilledema
usually appears. The prognosis must be guarded, although
many patients make a fairly complete recovery.
Case 24: E. H. (H.N. 713471), a 39 year old housewife,
became ill in the latter part of September, 1941, at which time
she complained of a sub-occipital headache, generalized malaise,
anorexia, chills and a mild elevation of temperature. Within a
few days she became mildly lethargic and tended to sleep ex-
cessively. Her headaches were very intense and persistent, but
there was no nausea or vomiting. Within a week these symp-
toms began to subside, but she now developed urinary reten-
tion. She was catheterized by the local doctor, who finally sent
her to the hospital for further investigation.
General examination revealed a very^obese female. Neuro-
logical findings showed a mild papillitis ' of both discs. There
was an anisocoria, the right pupTTbeing larger than the left.
The deep reflexes were normal, except for the right knee jerk
which was slightly more active than the left. There was gen-
eralized muscular weakness of all four extremities. The patient
was unable to void.
Laboratory studies showed a white count of 8,350 with 84-16
differential. Spinal fluid showed 22 cells with a protein content
of 58 mgm. per cent.
The patient remained under observation for one month. Dur-
ing that time she regained her bladder control and the papillitis
disappeared. At the time of her discharge from the hospital,
she still had a marked weakness of both lower limbs and her
deep reflexes were now slightly hyperactive. She was seen two
months later and during that period had improved to such an
extent that she was now neurologically negative, having made
a complete recovery.
Case 14: Mrs. P. L. (H.N. 702680), aged 27 years, became
ill November 1940. The first symptom noticed by this patient
was a peculiar feeling over the skin of her face, which lasted for
a few days and then cleared up. At this time she felt very tired.
A few weeks later she suddenly developed chills and fever fol-
lowed by vertigo, nausea and vomiting. The vomiting was un-
related to meals and was most severe in the morning. She was
taken to the hospital, where she remained for ten days. During
her stay in the hospital the vomiting disappeared. Shortly after
returning home, she developed numbness of the entire left side
This was soon followed by a widespread motor involvement
which first appeared in the left foot and leg and, then shortly
afterward, spread to the entire right side, including both the
lower and upper extremities. Two weeks before her examination
by us and a week after the onset of her numbness and weak-
ness, she developed some diplopia, dysarthria and occasional dif-
ficulty in swallowing. Because of the rapid progression of her
illness she was brought to the hospital.
On her admission December 14, 1940, the examination re-
vealed an anisocoria with the right pupil larger than the left.
There was a nystagmus present on lateral gaze and a marked
dysarthria. The deep reflexes were reduced; the abdominal re-
flexes were absent. There was a generalized flaccid paralysis in-
volving all extremities, the weakness being most marked in the
proximal part of the limbs. There was a left-sided hypasthesia
and hypalgesia, including the face. Vibratory sensibility was
lost and position sense reduced in both lower extremities. There
was marked ataxia in both upper and lower limbs.
Laboratory examination revealed a white count of 10,600 with
67 per cent polymorphonuclears and 33 per cent mononuclears.
Spinal fluid contained 7 cells, with 177 mgm. per cent of pro-
tein and 83 mgm. per cent of sugar.
The patient’s course was very rapidly downhill. After a few
days, she became markedly confused, noisy, restless and agi-
tated and had to be transferred to the Psychiatric Unit for fur-
ther care. She developed a complete left-sided facial palsy and
her bulbar symptoms became very marked. She gradually be-
came more lethargic, less cooperative and at times very noisy.
She was treated with a high vitamin intake, blood transfusions,
and intravenous fluids. Her temperature, which had remained
between 98 and 99° during the first two weeks in the hospital,
gradually began to rise and she expired after a hospital stay of
19 days. No autopsy was obtained.
A summary of all our cases is given in Table I. The
disease affected both sexes about equally and occurred in
all age groups; the ages in our series varying from 154
to 62 years. Although cases were seen throughout the
year, the majority tended to occur at two definite periods,
namely, during the winter and summer months. Sixteen
(49 per cent) of the cases occurred in winter during the
months of November, December and January; while 7
(21 per cent) appeared during the summer. It is curious
and perhaps significant that this condition occurs most
frequently after the peak of poliomyelitis, and it has
been this predominance during the winter months that
has often been the primary factor in arousing suspicion
that this disease was some form of infantile paralysis.
This seasonal tendency also allows for some speculation
regarding the pathogenesis of this illness. Infections
spread by insect vectors tend to disappear abruptly with
the onset of cold weather (equine encephalitis) ; while
those spread by contact exposure increase during the win-
ter months. However, Guillain-Barre’s disease, in spite
of its frequency during the winter, shows no indication
of being spread by direct contact. In none of our cases,
in spite of careful questioning, was there any suggestion
of a similar illness in other members of the same family
or community. Moreover, although we have not made a
December, 1943
391
custom of instituting isolation technic in these patients,
we have not as yet had any indication of contact infec-
tion within our personnel, many of whom have had a
most intimate exposure to these individuals.
In spite of the general impression that this disease ap-
pears chiefly as a polyneuritis (Patrick,21 Taylor and Mc-
Donald,8 Bradford, Bashford and Wilson,1' etc.) , the
most common clinical picture observed by us, was refera-
ble to involvement of the spinal cord (Group III in
Table I) . Forty-five per cent of our patients presented
such findings as compared to 24 per cent with mono-
neuritic symptoms and but 21 per cent with predomi-
nantly polyneuritic findings. The cerebral type was ex-
tremely uncommon, appearing in but three cases. This
latter form has received very little emphasis in the litera-
ture but warrants more attention.
Facial palsies appeared in only 27 per cent of our cases,
but was observed in all five clinical forms of the disease,
thus emphasizing the unusual specificity of this illness for
the seventh cranial nerve, regardless of the location of
the predominant tissue injury. In some of the very mild
abortive forms, the associated facial palsy was the one
feature that helped strengthen the diagnostic impression.
Involvement of other cranial nerves was not uncommon,
appearing in 39 per cent of the cases; in 4, the bulbar
symptoms comprised the predominant part of the clin-
ical picture and implicated chiefly the third, fifth, sixth,
ninth, tenth and twelfth cranial nerves. Choked discs
were observed in 6 cases. The presence of increased intra-
cranial pressure does seem to indicate a more grave form
of the illness, since 2 of our 3 deaths occurred in patients
with such papilledema.
The spinal fluid findings were most variable, but a
high protein with a low cell count did constitute one of
the most constant features. None of our cases showed
the extreme spinal protein increase of 1 to 2 gms. as re-
ported by Guillain. The greatest increase observed by us
was 345 mgm. per cent. On the other hand, 6 of our
cases showed a normal spinal fluid protein at the time of
examination. Only 4 of the patients showed a spinal
fluid pleocytosis, the remaining cell counts being well
within normal limits.
In spite of the often severe clinical symptomatology,
our patients showed little or no hyperpyrexia unless there
was some complicating urinary or respiratory tract infec-
tion. In most cases the temperature varied between 98
and 99.6°. The blood picture was usually normal but
occasionally showed a moderate leukocytosis reaching as
high as 15,000 cells.
Recently we have observed another unusual laboratory
finding in many of our patients. In the course of a gen-
eral medical workup on one of our milder cases (Case
18) a slightly elevated heterophil antibody titrej22 (ag-
glutination of sheep red cells) was discovered. In view
JHeterophil antibody is the antibody produced by a non-species
specific antigen which has the ability to agglutinate sheep red cells.
These antibodies were discovered by Forssman who injected rabbits
with emulsions of guinea-pig organs, thereby producing these hem-
olysins against sheep corpuscles. Similar sheep cell-agglutinating
antibodies can be produced with tissues of many other animals. The
Forssman agglutinin is normally present in human sera in titres of
1:24, but when evident in higher concentration indicates some
abnormality.
of this observation, similar studies were made on the sera
of 4 subsequent cases and all were found to have elevated
titres, often as high as 1-224. The significance of this
finding is as yet unknown, but the presence of this Forss-
man antibody in the sera of these patients may offer
another test which, if positive, may aid in the differentia-
tion of this disease from other neurological syndromes.
The testing for these antibodies is a very simple labora-
tory procedure.28 It consists of mixing a fresh suspension
of sheep corpuscles with varying dilutions of the patient’s
serum, and, after a time (12 hours), recording the high-
est dilution of serum that produces a macroscopic agglu-
tination of the sheep cells. Because of the ease with
which this test can be performed, it would seem of defi-
nite interest to have the sera tested in every patient suf-
fering from Guillain-Barre’s disease in order to determine
whether this elevation in the heterophil antibody titre
continues to be a constant finding.
Course and Prognosis
Guillain2,3 in his publications insisted that the outcome
of this disease was always favorable and that all cases
recovered fairly promptly and completely after an illness
of a few weeks or months. He felt that the real syn-
drome was always benign. It is apparent from a review
of the literature as well as from a study of our own
cases, that this point of view is too extreme. It is true
that in spite of a fairly severe clinical involvement these
patients usually show a gradual and continuous improve-
ment over a period of many months or years with fairly
complete recovery. However, the more cases one studies
and the longer one follows the recovered patients, the
more cautious one becomes regarding the ultimate prog-
nosis.
In the abortive or mononeuritic form, the entire course
of the illness may be very mild and last but a few weeks
with complete recovery. But even in such cases, if care-
ful followup studies are performed years afterwards, re-
sidual weakness and reflex abnormalities may be elicited.
In most cases, usually after an acute onset and after
progressing rapidly for a few days or weeks, this illness
becomes stationary or starts to subside with improvement
often being very slow and continuing for many years.
The sensory recovery is much more rapid than the mo-
tor, and not uncommonly some motor weakness and re-
flex alterations can be observed for many years after the
acute illness. We have obtained followup studies on
many of our patients, and have been impressed by the
frequency and often the severity of the neurological
sequelae present after two to three years. In none of the
more involved cases had complete recovery eventuated,
and many of the patients still had incapacitating residuals
such as sphincter disturbances, unilateral or bilateral limb
weakness. The one optimistic feature in all these cases
was that improvement apparently was still in progress in
spite of the long interval since the primary infection, and
it is possible that in time complete functional return
might occur.
Recurrence of symptomatology occurred in only one of
our cases (Case 17), who, during the course of two years,
Thp Journal-Lancet
3 92
had repeated relapses requiring complete bed rest. In
most cases, it appears that improvement once begun con-
tinues uninterrupted, providing moderate care and rest
are obtained.
Contrary to the belief of Guillain, fatalities do occur.
If the illness continues to progress after a period of six to
eight weeks after its onset, the prognosis must always be
guarded, since it is frequently this type of case that con-
tinues to a lethal outcome.
Differential Diagnosis
Because of the wide variability of the clinical symp-
toms in this disease, it is often confused with variants of
other well known neurologic disorders, from which it
must be differentiated before an accurate diagnosis can
be made. For this reason, it might be well to discuss
briefly a few of the differential points between the Guil-
lain-Barre syndrome and other neurological disorders.
1. Peripheral neuritis of an infectious or toxic type.
Usually in this illness the course is febrile and an ele-
vated leukocyte count may be present. The nervous sys-
tem involvement tends to remain localized to the limbs
and only uncommonly extends to the brain or spinal
cord; hence, cranial nerve palsies, segmental cord lesions,
and weakness of the trunk and back muscles almost never
occur in the average case. The spread of the involve-
ment within the extremities is fairly constant, progressing
symmetrically from the distal to the proximal regions and
producing first, sensory and later, motor impairment.
Scattered radicular pain usually does not occur, the pares-
thesias observed being evenly and consistently distributed
to the distal portions of the extremities. In Guillain-
Barre’s disease, on the other hand, the entire limb often
becomes weak at one time, with the predominant func-
tional disturbances within the proximal muscle groups,
such as those of the pelvic and shoulder girdle. The in-
volvements spread consistently to the trunk with resulting
weakness of the back and abdominal musculature. An
elevated protein with a cell-protein dissociation is exceed-
ingly uncommon in the toxic or infectious peripheral
neuritis.
2. Postdiphtheretic peripheral neuritis. This form of
neuritis often shows an elevated spinal fluid protein and
a low cell count similar to Guillain-Barre’s disease. The
history of the preceding diphtheritic infection, however,
facilitates the diagnosis. The spread of this form of
neuritis is very similar to the toxic-infectious types and
is usually not associated with accompanying signs of
spinal cord or brain injury.
3. Poliomyelitis. This disease may produce a very diffi-
cult differential problem and, no doubt, many cases diag-
nosed as atypical poliomyelitis actually are instances of
Guillain-Barre’s disease. Certain features, when carefully
evaluated, aid greatly in the differentiation. In polio-
myelitis, the course is usually more febrile, and the pa-
tients more constantly show manifestations of meningeal
irritation with some nuchal rigidity and an increased cell
count in the spinal fluid, the spinal protein remaining
within normal limits. The involvement is predominantly
and usually exclusively of a lower motor neurone type
and tends to select scattered muscles or muscle groups
rather than an entire extremity as is so common in Guil-
lain-Barre’s disease. Spastic weakness and sensory dis-
turbances are almost never seen. The prognosis in polio-
myelitis is usually not so favorable, since residual weak-
ness and severe muscle atrophies are much more frequent
and pronounced.
4. Landry’s paralysis. This condition is probably not a
clinical entity but a symptom-complex, consisting of a
sudden flaccid paralysis of the lower limbs which ascends
rapidly to the abdominal and intercostal musculature and
eventually to the upper limbs. In fatal cases, a bulbar in-
volvement ensues with medullary damage. This symptom-
complex in contrast to Guillain-Barre’s disease is extreme-
ly uniform in its attack, almost always starting in the
lower limbs and ascending symmetrically. Spasticity is
never seen and sensory involvement dees not occur. The
course and prognosis are much more grave and, when
medullary paralysis occurs, the outcome is usually fatal.
In spite of the occasional cranial nerve implications in
Landry’s paralysis, the facial nerves which are so com-
monly involved in Guillain-Barre’s disease are almost
never damaged. Finally, the spinal fluid usually shows no
changes.
5. Myelitic syndromes secondary to infections. The
course of the disease in an infectious myelitis is usually
much slower than in Guillain-Barre’s disease, and the pa-
tients appear much more toxic. After reaching its peak,
the infectious process tends to remain unchanged for
long periods, resulting in extensive trophic changes asso-
ciated with motor and sensory residuals. These patients
often remain bedridden for long periods and produce
some of the most difficult nursing problems encountered
in the neurological field. Radicular and cerebral involve-
ments are almost never seen, and the sensory impairment
when it occurs, is usually of seqmental rather than of rad-
icular distribution. The spinal fluid may show an elevated
protein but usually contains an associated cell increase.
6. Epidemic encephalitis. Since the first recognition of
Guillain-Barre’s disease occurred shortly after the large
epidemic of lethargic enceohalitis, many investigators
have suggested a poss'ble relationship between these two
conditions (Bassoe,24 Beriel and Devic,2 ’ Sands,20 Strauss
and Rabiner0) . These investigators feel that Guillain-
Barre’s disease may be a variation of epidemic encephali-
tis and caused by the same virus. To emphasize such a re-
lationship, Margulis18 reported a case of polyneuritis de-
veloping in connection with an unquestionable case of
epidemic encephalitis, while Strauss and Rabiner reported
6 cases of "myeloradiculitis” in which 1 case later de-
veloped a parkinsonian syndrome. Generally, these two
diseases do not resemble one another clinically. In epi-
demic encephalitis, the disease process tends to remain
localized to the cerebrum and almost never spreads to the
rest of the central and peripheral nervous system. The
cranial nerve involvements characteristically appear as
ocular findings rather than facial palsies, as is so frequent
in Guillain-Barre’s disease. Finally in epidemic encepha-
litis there is usually a pleocytosis but no elevation in the
spinal fluid protein.
December, 1943
393
TABLE I
Clinical Features of Guillain-Barre’s Disease
Case
No.
Name and
Hospital
No.
Sex
Age
Date
of
Onset
Type
of
Illness
Facial
Palsy
Other
bulbar
Symp-
toms
Chok-
ed
disc
Spinal Fluid
Tem-
pera-
ture
Period
Followed
Leuko-
cyte
Count
Outcome
Heter-
ophil
Titre
i
1). J.
728919
F
18
mo.
Jan.
1943
in
-
-
-
88
1
97-
99
1 mo.
4.700
Paresis all limbs
2
L. M.
F
6
Aug.
1940
HI
-
-
-
142
1
99-
100
11 mo.
8,200
Complete recovery
3
R. B.
718941
F
12
March
1942
III
-
-
-
41
2
98.6
3 mo.
1 1 .000
Complete recovery
G. K.
4 728610
M
14
Dec.
1942
11
-
-
-
43
4
98-
99.6
2 mo.
10.300
Paraplegia
1-
224
5
S. H.
M
15
Dec.
1942
II
+
+
-
197
2
98
1-
112
6
E. C.
F
16
Oct.
1940
1 +
-
-
24 mo.
Residual paresis right arm and leg
7
L. R.
084598
F
19
Dec.
1938
I
-
-
-
46
0
97.8
99
24 mo.
6,400
Complete recovery
8
B. J.
679553
M
20
March
1939
III
-
-
-
58
57
101.6
3 mo.
7,200
Residual paresis of lower limbs.
9
E. YV.
723962
F
24
Sept.
1942
IV
+
+
-
345
5
99-
101
2 mo.
7,200
Residual paraplegia
10
L. B.
706995
M
25
April
1941
II
-
+
-
98.6
20 mo.
7,600
Complete recovery
—
11
K. B.
723461
F
26
July
1942
II
+
+
-
217
,
98.6
99.6
1 mo.
8.600
Generalized hyporetiexia
12
H. S.
686385
F
26
Dec.
1939
III
-
+
+
109
0
98.6
102
36 mo.
10,650
9,000
Paresis lower limbs
13
I. P.
726506
'
27
Nov.
1942
III
-
-
-
132
0
98.6
3 mo.
7,300
Paresis legs, Sphincter disturbance
1
56
14
P. L.
702680
F
27
Nov.
1940
V
4-
+
-
177
7
98-
101
1.5 mo.
10,600
Death
15
R. H.
684560
M
28
Julv
1939
III
-
+
-
23.8
2
97-
98.6
4 mo.
5,800
Complete recovery
16
A. R.
695338
F
29
April
1940
III
+
+
-F
243
0
99
8 da.
12,000
Death
17
R. S.
F
30
March
1941
III
IV
+
+
-
0
99
23 mo.
Persistent facial weakness
18
L. YV.
F
30
Jan.
1943
I
-
-
-
34
0
98.6
1 mo.
Persistent radicular pain
1—56
19
A. B.
693303
M
34
Dec.
1939
III
IV
+
+
+
3+
Nonne
1
99-
100
6 mo.
13,400
Death
20
V. A.
694689
M
35
Dec.
1939
II
+
-
—
134
97-
99
36 mo.
6,300
Paresis lower limbs
21
T.H. H.
M
36
Dec.
1941
I
-
-
—
98.6
3 mo.
Complete recovery
22
M. N.
667969
F
37
March
1938
V
-
-
+
18.4
1
98-
99.8
48 mo.
15,000
Complete recovery
23
A. B.
708849
M
38
May
1941
II
-
+
+
253
ii
98.6
99
21 mo.
9,700
Paresis lower limbs
24
E. H
713471
F
39
Oct.
1941
III
V
-
+
+
58
22
98-
99.2
3 mo.
8,350
Complete recovery
25
M. H.
684609
F
40
July
1939
III
-
-
-
38
16
99-
100
18 mo.
8.800
Paresis lower limbs
26
H. I.
725158
M
40
Sept.
1942
III
-
-
-
65.9
118
1-154
98-
100
3 mo.
11,800
Complete recovery
27
E. A.
718854
F
41
Dec.
1941
III
-
-
—
190
0
97.8
98.8
13 mo.
7,500
Quadriplegia
28
M. A.
717275
M
44
Dec.
1941
I
-
—
-
38.12
1
98.2
99.6
12 mo.
5,500
Complete recovery
29
N. G.
M
45
Dec.
1941
I
-
-
-
-
-
98.6
3/2 mo.
Complete recovery
30
F. H.
725737
M
46
Aug.
1942
II
-
-
-
153
0
98.6
6 mo.
Paresis right leg and both hands
1-56
31
T. S.
726426
M
57
Dec.
1942
I
-
-
-
76
0
97-
98.6
12 mo.
10,650
Paresis left leg
1-56
32
J. C.
72617
M
57
Dec.
1941
III
-
-
-
151
5
98.6
12 mo.
5,700
Paresis right leg, Hypesthesia left
hand
33
P. H.
627353
M
62
May
1940
I
-
+
-
75
I 0
98.6
4 mo.
7,500
1 Complete recovery
•I. Abortive or Mononeuritic; II. Polyneuritic; III Myelitic; IV. Bulbar; V. Cerebral.
394
7. M ultiple sclerosis. This condition is often difficult to
differentiate from the myelitic form of Guillain-Barre’s
disease, especially when the latter tends to show involve-
ment of the pyramidal system. Generally, however, mul-
tiple sclerosis produces much more spastic weakness and
less sensory disturbance. Radicular pain and severe
muscle tenderness almost never occur. Although cranial
nerve findings are present, they usually involve the sec-
ond rather than the seventh cranial nerve, producing
optic atrophy rather than a facial palsy. A speech dis-
turbance may be present in both illnesses but in multiple
sclerosis it is scanning in type and can occur independent
of a severe bulbar involvement, while in Guillain-Barre’s
disease, the dysarthria appears only after the disease has
spread to the bulb and is the direct result of the exten-
sive bulbar palsy.
Treatment
The treatment at present is entirely symptomatic. The
following are a few of the measures that, in our experi-
ence, have proven beneficial.
1. Strict bed rest during the acute stage of the illness.
This is a most important therapeutic measure. In those
patients who have refused to accept complete bed rest
and have continued to be up and around during the early
stages of the illness, the involvement has invariably con-
tinued to progress and has often become most severe.
Immediate hospitalization not uncommonly results in a
much more rapid arrest of the disease process with sub-
sequent improvement in both the sensory and motor im-
pairment.
2. Medication and particularly heat to combat the
severe discomforts of the radicular pain and muscle ten-
derness. The treatment of these painful limbs often con-
stitutes one of the most trying therapeutic problems in
this disease, especially since these pains may persist
throughout the course of the illness. One hesitates to
resort to the opiates, but we have found that codeine in
small doses often offers by far the most satisfactory re-
sults. The barbiturates, especially sodium phenobarbital
intramuscularly, have been found helpful but not entire-
ly satisfactory when used alone. In children, chloral hy-
drate by rectum frequently offers satisfactory sedation.
Hot wet packs completely surrounding the painful ex-
tremities and applied every alternate hour, produce great
comfort to the patient and are most useful in relieving
some of the more intractable pain.
3. Large doses of vitamins Bi and C, especially in those
cases which appear to have a radiculitis or a polyneuritis.
It has been our practice to give our patients 150 mgm.
each of thiamine chloride and cevitamic acid daily during
the first week of the illness; thereafter, the dosage is re-
duced to 9 mgm. of vitamin Bi, and 75 mgm. of vita-
min C. It has been our impression that the best results
are obtained when these two vitamins are used together,
and we have therefore had them combined in a single
tablet to facilitate their use.
4. Tidal bladder irrigation and the sulfonamide group
of drugs to combat urinary involvement and infection in
those cases with sphincter disturbances.
The Journal-Lancet
5. Multiple small transfusions in the acutely ill
patient.
6. Maintenance of an adequate nourishment in the
acutely ill patient. Not infrequently when the illness is
severe, an inadequate intake results, either because of an
unwillingness of the patient to eat or because of a bulbar
palsy with dysphagia. This may become quite alarming
since these patients frequently will go into a negative
nitrogen balance and remove the necessary proteins from
the various body organs, particularly the liver, which or-
gan may already be involved by the disease process.-’ ' In
order to prevent such an occurrence, one should not delay
in instituting tube-feeding preferably by means of a slow
continuous drip method. The formula used should con-
tain an excess of protein, at least 4 gm. per kilo body
weight for the adult, in order to maintain a positive nitro-
gen balance. One can easily supplement such a feeding
by an adequate quantity of the necessary vitamins.
Through the use of such a continuous drip feeding, one
avoids overloading the stomach, and vomiting is fre-
quently prevented. On our service for our feeding for-
mula, we have adopted the Vorco diet,28 supplemented
by Dietene§ and brewers yeast to furnish an adequate
vitamin intake. A sample of this feeding formula is
given in Table II.
TABLE II
Daily Feeding for an Adult
(Vorco Diet containing 2420 calories)
Milk 1000 cc.
Eggs — : 6
Egg whites 2
Skimmed milk powder 1 cup
Dextrose 1.5 cups
Salt 5 gms.
Supplemented by Dietene and Brewers Yeast
containing 1106 calories.
Milk 100 cc.
Dietene 60 gms.
Brewer s yeast 60 gms.
7. Physiotherapy for the muscular involvement as re-
covery begins. Throughout the course of the illness mild
muscle massage and even passive motion should be insti-
tuted. This can be increased as recovery continues and
the limb tenderness decreases. Some form of physical
therapy may be necessary for long periods after the pa-
tient has left the hospital.
Pathology
It has been definitely established that extensive altera-
tions do occur throughout the nervous system, the patho-
logical lesions varying with the extent and locations of
the disease process. Most investigators have described the
most severe changes within the peripheral nerves and the
spinal cord. Bradford, Bashford and Wilson/ Casa-
major4 and Mirus20 all observed alterations primarily
within the motor cells of the spinal cord. Many of these
cells had undergone a patchy degeneration consisting of
pyknosis or swelling, partial to complete chromatolysis,
cytoplasmic vacuolization, and a nuclear eccentricity. The
neuronal damage was usually distributed irregularly along
the various cord segments, the injured cells frequently
being surrounded by many structurally intact elements.
§Dietene is prepared by the Dietene Co., Minneapolis. It can be
mixed with milk and readily passes through a nasal tube. One hun-
dred (100) grams is equivalent to 338 calories and contains: pro-
tein— 18 gms.; fat — 4.4 gms.; carbohydrate 69 gms.; calcium —
.60 gms.; phosphorus — .55 gms.; Fe .15 gms.; vit. A — 10,000
units; vit. Bi — 2.5 mgm.; vit. C — 75 mgm.; vit. D — 1,000 units;
riboflavin — 3.3 mgm.; nicotinic acid — 2.2 mgm.
December, 1943
395
Fig. 1. (Case 19). Multiple areas of perivascular demyeliniza-
tion within the subcortical white matter. The myelin destruction is
only partial with early vacuolization. Weil’s stain.
Casamajor also observed an increase in the cellular glia
within the central gray matter while Shaskan, Teitel-
baum and Stevenson11 described definite degeneration
within the myelin sheaths of the posterior columns and
of the dorsal-spino-cerebellar tracts.
Changes within the dorsal root ganglia have been con-
sistently reported. (Casamajor,4 Bashford,'’ Gilpin,
Moersch and Kernohan10) . These ganglion cells appar-
ently undergo severe changes with swelling and loss of
tinctorial properties. Some become pyknotic with begin-
ning neuronophagy. Gilpin, Moersch and Kernohan re-
ported a diffuse lymphocytic infiltration within the dorsal
ganglia.
Changes within the peripheral nerves have been report-
ed by Shaskan, Teitelbaum and Stevenson,11 Gilpin
et ah, 18 Casamajor,4 Mirus,28 and Bashford, Bradford
and Wilson.'' The larger nerves showed a partial irregu-
lar destruction with myelin degeneration, and even frag-
mentation of the axons and a Schwannian proliferation.
In a previous publication,12 Case 19 was briefly re-
ported.
This was a 34 year old male who first noticed a weakness in
his lower limbs 6 months before his admission to the hospital.
This weakness gradually increased in severity during the next
five months, at which time there first appeared a bilateral facial
palsy. Within the next few weeks, the course of the illness was
very rapid with the appearance of respiratory difficulty, diplopia
and weakness of the arms.
On admission to the hospital, the patient had marked respira-
tory difficulty and was placed in a respirator. Neurological ex-
amination revealed an extensive involvement of the cranial
nerves with nystagmus, bilateral facial palsy, masseter weakness
on the left, dysphagia, and some dysarthria. All deep and super-
ficial reflexes were absent, there was a paresis of all limbs and
an impaired superficial sensation to the fourth dorsal segment.
Spinal puncture revealed one cell and a 3+ Nonne. The pa-
tient’s course continued rapidly downhill and he died six days
after admission from an apparent respiratory paralysis.
Pathologic observations. External examination of the brain re-
vealed an extreme vascular congestion. Microscopic studies with
the various special technics (hematoxylin-phloxin, Nissl’s stain
[thionin], Weil’s stain and the Bodian technic) showed wide-
spread lesions scattered throughout the nervous system. The
most striking alterations consisted of scattered areas of peri-
vascular demyelinizadon involving primarily the gray and white
Fig. 2. (Case 19). Numerous small areas of demyelinization
scattered around the cortical vessels. Weil’s stain.
matter of the cerebral hemisphere and, to a lesser degree, the
basal nuclei (Fig. 1 and 2) . The rest of the nervous system
contained none of these changes. These perivascular alterations
varied from a moderate distention of the perivascular spaces to
an extensive tissue destruction. Within the damaged tissue, the
changes seemed to be limited primarily to the myelin sheaths,
the axons usually showing only a mild swelling and irregularity.
Besides this perivascular demyelinization, many of the smaller
cerebral vessels showed a marked endothelial proliferation with
a partial to a complete lumen occlusion.
Nerve cell damage, although fairly extensive, was limited
almost entirely to the brain stem. The cortical neurons were un-
involved. A few cells within the basal ganglia showed a mild
swelling with a partial chromatolysis. The most severe neuronal
alterations were observed within isolated cranial nerve nuclei,
namely, the facial and the dorsal nuclei of the vagus (Fig. 3,
4). Here, many of the cells were swollen and chromalytic with
pale nuclei. A few of these swollen cells were irregular in out-
line, vacuolated and had lost most of their tinctorial properties,
appearing as ghost cells (Fig. 4).
The spinal cord contained surprisingly few changes. A few
scattered motor cells within the various cord segments showed
mild alterations of a definite reversible nature. The cord white
substance was uninvolved. The rootlets, especially in the lumbar
regions, revealed a partial destruction of their myelin sheaths
with some swelling, fragmentation and even myelin disappear-
ance. The axons were only partially altered, a few being en-
tirely absent. The damaged portions of the rootlets were re-
placed by a moderate Schwannian proliferation.
The peripheral nerves, especially the lower limbs, revealed an
extensive patchy myelin injury which selected isolated areas
throughout the nerves. The neurokeratin network within these
damaged regions was condensed into geometric figures. The
axons were swollen, irregular and in certain areas fragmented.
No cellular reaction was visible in any of the nerves.
Case 9: A. R. (H.N. 695338), a 29 year old housewife,
first became ill two weeks prior to her admission to the hos-
pital in April, 1940. Shortly after washing her car, she noticed
some soreness in the calves of her legs which continued to in-
crease in severity and soon spread to involve the muscles of the
hips. The following evening, she developed severe shooting
pains through her back and was forced to go to bed, where she
remained until the time of her admission. While in bed, she
developed muscular pain and some numbness in both arms and
hands, especially the left arm, which became weak and difficult
to use. She also began to complain of severe pain in her neck
and lower back, associated with a moderate frontal headache.
Shortly before admission, the patient noticed some difficulty
in speech, although at this time she had no difficulty in swal-
lowing. Turning in bed would make her dizzy and nauseated.
Just before she was brought to the hospital, she developed a
396
The Journal-Lancf.t
Fig. 3. (Case 19). Facial nucleus. Note the irregular involve-
ment of the nerve cells. Many are swollen, chromolytic and have
lost their tinctorial properties. Nissl stain.
bilateral facial palsy, which was mild at first, but gradually in-
creased in severity. Examination on her admission revealed the
patient to be fairly comfortable. She had slight pain on antero-
flexion of the neck, and her optic discs were hyperemic. There
was a slight horizontal nystagmus on lateral gaze. An anisocoria
was present, the right pupil being larger than the left. There
was a bilateral fifth nerve involvement with hypesthesia over the
face and a bilateral absence of the corneal and conjunctival re-
flexes. All the muscles of the face were paretic. The uvula
moved only slightly on phonation and the pharyngeal reflexes
were decreased. There was a marked paralysis, involving all ex-
tremities as well as the abdominal and back muscles. This paral-
ysis was of a flaccid type and was associated with a total are-
flexia. The patient was unable to arch her back or use her inter-
costals in breathing, although her diaphragm was intact. Super-
ficial sensation was severely impaired in both lower extremities
to the region of the iliac crest, and was much less involved from
the crest to the region of the clavicles.
While in the hospital, the patient's condition seemed to pro-
gress. She developed a partial diaphragmatic paralysis with
periods of cyanosis and respiratory embarrassment, which re-
quired the use of the respirator. Her weakness was so pro-
found that she was almost helpless. In spite of the extensive
cranial nerve involvement, she continued to be able to swallow.
Her bilateral facial palsy became more marked, as did also her
dysphonia, until she was able to speak only in a whisper. She
developed a complete bladder retention, requiring catheteriza-
tion. Her numbness spread to involve all her limbs. In spite
of being kept in the respirator, the patient developed increasing
breathing difficulty and expired eight days after admission.
Laboratory studies revealed a leukocyte count of 12,000 with
a 78-22 differential. Spinal puncture showed no cells and 243
mgm. per cent of protein. Throughout her stay in the hospital,
she remained afebrile except terminally when her temperature
rose to 101 °F.
A complete autopsy was performed. Grossly, the nervous
system was normal in appearance. Sections were taken from
various regions and stained with the various special technics
used to denote tissue changes.
Throughout the cerebral hemispheres there was a marked
distention of the perivascular spaces involving the vessels both
of the gray and white matter. The brain tissue adjacent to these
distended spaces varied greatly in appearance, usually staining
very deeply and appearing to be compressed by the distended
vascular space. Around a few vessels, the tissue immediately
adjacent to the distended spaces showed a very mild demyelini-
zation with a swelling and a tinctorial loss of many of the
myelin sheaths. The axons in these regions appeared intact.
Within the subcortical white matter, especially within the parie-
tal regions, there was some diffuse demyelinization. These areas
Fig. 4. (Case 19). Dorsal nucleus of the vagus nerve. These
cells show a complete chromatolysis and a loss of their processes.
Nissl stain.
did not seem to be perivascular in arrangement but could very
well have resulted from confluent perivascular foci.
The small cerebral vessels showed numerous structural changes.
Many contained a definite endothelial increase with a resulting
lumen occlusion; others showed a homogeneity of their walls
with a partial loss of tinctorial properties. Many vessels ap-
peared to have undergone a swelling of their wall elements, pro-
ducing a definite lumen reduction or even occlusion. Around a
few scattered vessels, there were seen a few mononuclears dis-
tributed within the perivascular space. These vascular changes
were much less conspicuous within the brainstem and were not
observed within the cerebellum or spinal cord.
The nerve cell alterations were very striking and were again
limited almost entirely to the brainstem. Only an occasional
shrunken cell could be found within the cerebral cortex. Very
severe neuronal alterations were present within the nuclei of the
fifth, seventh, tenth, and twelfth cranial nerves. Here the cells
were frequently swollen, rounded, and contained either a partial
or complete chromatolysis. Many had lost most of their tinc-
torial properties and stained very lightly or not at all to form
ghost cells (Fig. 5). A few of the cells were fragmented or
even pyknotic with shrunken cell processes. The cell nuclei were
generally less severely involved, many appearing entirely normal
in spite of the extensive cytoplasmic changes. In the sixth cranial
nerve nucleus, the cells showed only a mild swelling and a par-
tial diffuse tigrolysis.
The spinal cord contained no histological changes. The per-
ipheral nerves revealed an extensive demyelinization with frag-
mentation and often complete disappearance of many of the
myelin sheaths (Fig. 6) . In spite of the extensive myelin altera-
tions, the axis cylinders were usually spared and demonstrated
only slight swelling and irregularity, but no fragmentation
(Fig. 7). In the more severely damaged regions, Schwann cells
had proliferated to replace much of the injured nerve tissue.
Discussion
The concept of Guillain-Barre’s disease has been too
greatly restricted, primarily because the criteria suggested
by Guillain have been too closely adhered to. This dis-
ease probably is much more frequent than is generally
recognized. Since this illness may involve any or all parts
of the central or peripheral nervous system, the neuro-
logical complaints and findings may be most variable and
no single symptom-complex can be offered as character-
istic. We have elected to describe five different forms of
this illness, depending upon the region of the nervous
system most severely implicated. Such a classification has
the advantage of broadening our concept of this illness
December, 1943
397
Fig. 5. (Case 9). Dorsal nucleus of the vagus nerve. The cell
changes are most variable and consist of swelling, chromatolysis,
loss of cell processes and even fragmentation. Some neurons are
much more severely injured than others. Nissl stain.
Fig. 6. (Case 9). A section through the sciatic nerve showing a
partial myelin injury. Note the extensive vacuolization and the
tendency to form geometric figures. Weil’s stain.
and facilitating its differentiation from other similar
neurological disorders. There are certain features, how-
ever, which are suggestive of this disease, even though
not in themselves diagnostic. Probably the most out-
standing are the radicular pain and the striking clinical
recovery in spite of an apparently severe damage to the
nervous system. Certain other features are helpful diag-
nostically. The temperature and leukocyte count are not
greatly altered and the spinal fluid often shows a cell-
protein dissociation. The latter observation will depend
upon how frequently the spinal fluid is examined during
the course of the illness. In our series it was present in
68 per cent of the patients.
The clinical manifestations of this disease indicate that
severe functional impairment of the nervous elements
occurs in almost every patient regardless of the duration
of the illness. From a follow-up study of the persistent
residuals and from a review of the autopsy studies in our
fatalities, it appears very likely that in many of the more
severe cases, definite permanent and irreversible struc-
tural alterations result, which in the chronic illness may
be very extensive and may localize within any part of
the nervous system, even the hemispheres. The histo-
pathologic alterations seem to vary directly with the
severity and duration of the illness. In the more acute
cases, th ere may occur only vascular changes with dis-
tention of the perivascular spaces, while in the more pro-
longed cases, there often results perivascular myelin de-
struction and extensive nerve cell alterations. The most
conspicuous neuronal changes seem to take place within
certain selected cranial nerve nuclei. It is impossible to
observe such severe nuclear alterations, especially within
the tenth cranial nerve nucleus without concluding that
in certain cases, a fatal termination may eventuate from
damage to the medullary centers.
Finally, the observations in our cases, tend to offer
some suggestions as to the pathogenesis of this disease.
The striking perivascular distribution of the cerebral
lesions certainly indicates a hematogenous spread of the
noxious agent. Such lesions resemble very closely those
observed in many of the proven and suspected types of
Fig. 7. (Case 9). Same section as Fig. 6, but stained to dem
onstrate the axons. Note that these structures are relatively intact.
Bodian stain.
virus involvements such as equine encephalitis, postvac-
cination encephalomyelitis, measles encephalitis, etc. Cer-
tainly both the perivascular demyelinization and the vas-
cular alterations have a striking resemblance to those al-
terations seen in the western form of equine encephalitis
(Baker and Noran,30 Noran and Baker31) . In addition
to these vascular alterations, one is confronted by a dis-
ease that also produces neuronal changes that have a defi-
nite selectivity for certain cranial nerve nuclei. This cellu-
lar specificity seems, to us, also to suggest a virus infec-
tion.
Summary and Conclusions
1. Thirty-three cases of Guillain-Barre’s disease are
reported. In 2 of the fatal cases, complete autopsy
studies were obtained.
2. Since this disease may involve any part of the per-
ipheral or central nervous system, we have divided the
resulting clinical syndromes into five forms, depending
upon the region of the nervous system most severely im-
plicated. These consist of (1) the abortive or mono-
neuritic, (2) the polyneuritic, (3) the myelitic, (4) the
398
The Journal-Lancet
bulbar, and (5) the cerebral types of Guillain-Barre’s
disease. The myelitic form is the most frequent, occur-
ring in 45 per cent of our patients as compared to 24
per cent with mononeuritic symptoms and but 21 per
cent with polyneuritic findings.
3. Certain features, when associated with any of the
above clinical forms of this disease, aid greatly in the
diagnoses. These consist of: marked radicular pain and
muscle tenderness; a normal or only slightly elevated
temperature and leukocyte count; a cell-protein dissocia-
tion in the spinal fluid; a facial palsy; and a favorable
prognosis in spite of an apparently severe illness.
4. In spite of the apparent optimistic outlook in this
disease, careful follow-up studies in older cases indicate
that neurological residuals do occur very frequently,
especially in the more severely involved individuals.
5. This disease seems tp occur predominantly during
the winter months, although scattered cases may be seen
throughout the year.
6. The visible histopathologic changes consist of peri-
vascular foci of demyelinization scattered throughout the
cerebral hemispheres, neuronal alterations within the
cranial nerve nuclei, and patchy areas of myelin destruc-
tion within the peripheral nerves.
7. The perivascular distribution of the cerebral lesions
suggest a hematogenous spread of the noxious agent.
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20. Madigan, P. S., and Marietta. S. U.: Polyradiculoneuritis
with report of a case, Ann. Int. Med. 12:819, 1938.
21. Patrick, H. T.: Facial diplegia in multiple neuritis, J. Nerv.
& Ment. Dis. 44:322, 1916.
22. Topley, W. W. C.. and Wilson. G. S.: The Principles of
Bacteriology and Immunology, Balt., Wm. Wood QC Co., 1938,
p. 854.
23. Stitt, E. R.. Clough, P. W., and Clough, M C.: Practical
Bacteriology. Hematology and Animal Parasitology, Philad., Blakis-
ton Co., 1938, p. 244.
24. Bassoe. P.: Delirious and meningoradicular types of epi-
demic encephalitis, J.A M.A. 74:1009, 1920.
25. Beriel, L.. and Devic, A.: Les formes peripheriques de
l’encephalite epidemique, Presse med. 33:1441, 1925.
26. Sands, I. J.: Acute benign infectious myelitis, J.A. M.A.
96:23, 1931.
27. Sabin. A. B.. and Aring, C. D.: Visceral lesions in infec-
tious polyneuritis (infectious neuronitis, acute polyneuritis with
facial diplegia, Guillain-Barre syndrome, Landry’s paralysis) , Am.
J. Path. 17:469, 1941.
28. Unpublished data — personal communication from author.
29. Mirus, E.: Beitrage zur Frage der Stellung des Guillain-
Barreschen Syndroms un Rahmen der Polyneuritis, Deutsche Ztschr.
f. Nervenh. 150:39, 1939.
30. Baker, A. B., and Noran, H. H.: Western variety of equine
encephalitis in man, Arch. Neurol. Qc Psychiat. 47:565, 1942.
31. Noran, H. H., and Baker, A. B.: Sequels in equine encepha-
lomyelitis, Arch. Neurol. 6c Psychiat. (in press).
War and Peace Neuroses*
W. G. Richards, M.D.
Billings, Montana
THE subject assigned to me in this series was en-
titled, "Shock to the nervous system.” As this
covers a wide field, and as some aspects of it have
already been or will be considered by my colleagues, I
shall confine myself to the consideration of abnormal
mental states, the result of war experiences. By experi-
ences, I mean not only the actual physical traumas in-
flicted directly or indirectly by weapons used in warfare,
but the far more subtle effects upon the mind of the
stresses and strains produced by the existence of a state
of war, whether knowledge of it is acquired by actual
participation in the conflict or not. In other words, the
*Read February 8, 1943, at staff meeting of St. Vincent’s Hos-
pital, Billings, Montana, as part of a series on War Casualties.
effects of mental experiences upon physical conduct dur-
ing times of war.
This language, of course, implies a conceptual dualism,
that of mind and body, which should be explained. But
though it is easy enough to define the term body, it is not
so easy to define mind, and I am not going to attempt it,
for far abler minds than mine have failed to produce a
satisfactory definition. Instead, I shall imitate the school-
boy, who, on being asked to describe an elephant, replied
that this he was unable to do, but he could jolly well rec-
ognize an elephant when he saw one. Similarly, though
neither you nor I nor anyone else has ever seen the mind,
we know well enough what we mean by it.
December, 1943
This limitation of my subject excludes from my consid-
eration all conditions with recognizable tissue pathology,
whether this be the actual destruction of nervous tissue,
as in the more serious and plainly evident wounds, or the
microscopic hemorrhages of less violent traumata.
In the course of my discussion, I will have to wander
away from actual warfare, for there is nothing in the
symptoms produced which is peculiar to warfare. They
all have their counterparts in civilian life. It is only the
tempo and the intensity of them that are changed in war,
an intensity that multiplies many times the mental shocks
of ordinary time, and a tempo that squeezes into a rapid
crescendo emotional experiences which would be spread
out over long periods of time during peace, or, more
accurately, those intervals of relative quiet which we call
peace.
First, let us consider what are the effects of war trau-
mata, in other words, what symptoms or physical mani-
festations occur as the result of the mental impressions
produced by actual warfare. An individual is present, for
instance, in a place subjected to bombing by enemy air-
planes. Of course, he may be the victim of a direct hit
and pass at once out of the picture, or he may be phys-
ically injured by fragments of bombs or detritus, or suf-
fer from the effects of those atmospheric condensations
which we call blast. If so, we will turn him over to the
tender mercies of the surgeons, and let them work their
sweet wills upon him; possibly, if we are of a religious
frame of mind, dismissing him with a prayer, possibly,
remembering the remark of a congressional chaplain,
that he first prayed for the senators, but, after looking
them over, he prayed for the country. But all of those
in the bombed area will have been placed in deadly fear,
and I know of no better description of the physical
effects of fear than that of Darwin1: "The eyes and
mouth are widely opened, and the eyebrows raised. The
frightened man at first stands like a statue, motionless
and breathless, or crouches down as if instinctively to
escape observation. The heart beats quickly and violently,
so that it palpitates or knocks against the ribs. . . The
skin becomes pale as during incipient faintness. . . .
The hairs also on the skin stand erect, and the super-
ficial muscles shiver. . . . There is a death-like pallor;
the breathing is labored; . . . the uncovered and pro-
truding eyeballs are fixed on the object of terror; or they
may roll restlessly from side to side. . . . All the
muscles of the body may become rigid, or may be thrown
into convulsive movements. ... In other cases, there
is a sudden and uncontrollable tendency to headlong
flight; and so strong is this that the boldest soldiers may
be seized with a sudden panic.” Cannon, more recently
describes them in terms of modern physiology and endo-
crinology." Fear is purposive, has for its object the plac-
ing of the body in the best condition to meet and avoid
the danger, impelling it either to fight or to flee, and by
these means, the inner tensions are overcome and perma-
nent damage to the mind avoided. But during a bomb-
ing, the victim is helpless. He cannot fight the enemy
nor can he run away. The utmost he can do is to throw
himself upon the ground, or, if time permits, seek refuge
in some place which may or may not afford protection.
399
His terror can find no outward expression, but bombards
all the organs of the body with a series of violent and
concentrated stimuli. He may remain outwardly quiet,
but this only denies him the physical release of tension
by the muscular action of his vocal organs. Shakespeare,
good psychologist as he was, knew this when he said:
"Give sorrow words. The grief that does not speak whis-
pers the o’er-fraught heart and bids it break.” In de-
scribing the bombing of St. Thomas’ Hospital in London
a participating doctor says3: "In peace time, our psychol-
ogists had warned us to be prepared to have the hospital
stormed by screaming people, and to have outbreaks of
hysteria in the wards themselves. In point of fact, not
one whimper or lamentation was heard from start to
finish. . . . For a moment or two after the explosion,
there was absolute silence. Then a man’s voice said,
'Christ’, and a woman’s, rather plaintively, 'I don’t think
I am going to like this at all.’ ” Unconsciously and in-
stinctively, these people reverted to the defense mech-
anism of some of the lower animals, who sham dead in
hopes of deceiving their enemy, in this case, of course,
an utterly futile maneuver.
Now is it any wonder that such experiences may per-
manently affect the individual who has suffered them?
Indeed, fright alone may cause death, which, translated
into physiological terms, means that the heart may stop
beating, either by overstimulation of the vagus and con-
sequent inhibition, or by overstimulation and exhaustion
of the sympathetic system.
But after the immediate danger has passed, the effects
may remain. The highly organized nervous system of
man has acquired, to a degree above all other animals,
the function of memory, or the ability somehow or other
to store up past experiences and to recall them. In this
way, he practically lives at times in the past, and not
only does he see and hear all which he saw and heard
at the time of the occurrence, but he experiences the
inner feelings or the emotions which he then felt, and
these inner feelings can later produce the same effects
upon his bodily organs. You can prove this readily
enough to yourselves. Think of the loss of some dearly
loved relative or friend, and you will immediately feel
the emotion of sadness, and may even weep. Think of
some angry altercation with an enemy, and your pulse
will quicken, and you may even clench your fists. With
the temporary distractions of daily life, our attention is
switched to other objects and we forget, but, these dis-
tractions ceasing, the forgotten experiences crowd back
into our consciousness and plague us. In the stillness of
the night, they rise up to torture us, and we strive to
thrust them back into the unconscious and to seek a little
temporary oblivion in "sleep which knits up the ragged
sleeve of care,” vainly in most cases, as shown by the
wide use of barbiturates.
Man has also acquired the faculty of imagination.
From his past experiences he conjures up visions of the
future. This is of great value to him in enabling him to
anticipate dangers and to take steps to meet them. If we
and our allies had had more of it, we might have pre-
vented this war. But it can be carried to excess, and then
becomes a positive disadvantage. Thus, we have the man
400
Thf. Journal-Lancet
or woman continually fretting and worrying over things
which might happen, crossing all the bridges before com-
ing to them, and living in a continued state of fear. Dur-
ing times of war, this type of person develops war hys-
teria. Though he may be far from actual danger, he
visualizes himself at the mercy of the enemy and fusses
over perfectly unnecessary precautions. He makes up the
ranks of those who pass sedition laws; and he sees a com-
munist or other menace in all those who do not think as
he does. Fortunately, this is not as bad in this war as it
was in the last, when it actually assumed epidemic pro-
portions.
All these fears not only affect us when we are actually
conscious of them, but they exert their pernicious influ-
ence in the realm of the unconscious, producing such
psychosomatic combinations as neurocirculatory asthenia,
hyperthyroidism, and peptic ulcer. There is evidence that
these have increased in the countries which have been
long in the war, and we, here, may expect similar results,
for we are not the least excitable of the human race.
Though there have always been in America plenty of
people forced to live on the very margins of existence,
at the same time there are probably more people who
have enjoyed actual luxuries in it than in any other coun-
try. The vigor of their protests at such minor incon-
veniences as restrictions upon coffee, rubber and gasoline
shows, too, that they have come to expect all their accus-
tomed pleasures as an inalienable right, and we may an-
ticipate that the deprivation of them and consequent
frustrations will produce their symptoms.
This matter of previous experience, pleasant or other-
wise, is of profound importance in the war neuroses. The
mother’s darling, whether the mother be the actual phys-
ical maternal progenitor or a country fortunately blessed
with an abundance of material wealth, will suffer badly.
There have been taken away from civil pursuits and
thrust into the armed forces, millions of men. Most of
them have gone in against their will, and nearly all of
them have relatives emotionally affected by their depar-
ture. In the services, they will find their liberty curtailed
in all directions. Every detail in their lives will be de-
termined for them. Though they may have been accus-
tomed to depend upon the automobile for physical trans-
portation even for the shortest distances, and though
they may have been used to sitting in the bleachers and
applauding the physical prowess of others, they will now
have to depend largely upon their own organs of locomo-
tion, not only for the transportation of their persons but
also of their belongings; and they will be active partici-
pators themselves in the most gruelling and crudest sport
of all — war. For these purposes, they will be subjected
to severe and arduous training, often under the unsym-
pathetic direction of so-called and well-called, hard-boiled
superiors. Any attempt to avoid these things will be vis-
ited with punishment. And, in addition, and as the goal
to which all their training is directed, they will be com-
pelled to face physical mutilation and death itself.
Of course, among them are many men who have all
their lives been enduring hardships. For these, it will not
be much of a change, often, indeed, it will be a change
for the better, for, while the army may be a hard task-
master, it is also a solicitous one, taking much pains to
see that each man is well fed and well clothed, and re-
ceives both preventive and curative medical attention
when needed. Gone, fortunately, are the days when
greedy contractors could make fortunes by supplying an
army with embalmed beef and paper shoes, or with de-
fective guns which were as likely to kill cr wound the
shooter as the shootee. But even the hardy are likely to
chafe under the restrictions placed upon their personal
conduct. Men value most the liberty to go and come as
they please. If this were not so, there would be no justi-
fication for anybody fighting this war. It is very doubt-
ful whether the negro in this country is a bit better off
since slavery was abolished. Oftentimes his "freedom” is
little more than the freedom to starve or near-starve.
But I think it perfectly safe to predict what the result
would be, if the question of freedom or slavery, with the
implications of both, were submitted to the negroes them-
selves for a vote.
Much more will those men who have been used to
comfortable living be likely to resent army life and dis-
cipline. It will be very different from the mild discipline
of contemporary American homes, and the feeble at-
tempts of spinster schoolteachers to lead them into the
ways of learning. Most of them, I think, will make a
satisfactory adjustment, but there will be a minority who
will not. They will convert their mental conflicts into
physical symptoms, be the despair of the medical officer,
a nuisance to their company commander, and, after the
war is over, tearful applicants for compensation for disa-
bilities supposedly incurred during service.
Among these during the last war were the so-called
cases of "shell-shock”. A man suffers from the explosion
of a shell either with or without physical injuries. Fol-
lowing this, he becomes anxious, sleepless, with trembling,
mental irritability, oftentimes developing paralysis, or
such sensory disorders as blindness or deafness. Funda-
mentally, what has happened is that the man has gone
through a terrifying experience, which may or may not
be concussion, which he reproduces in memory, and
which keeps him in a chronic state of fear. There is fear
of the permanent results of his recent experience, and
fear that he may again be placed where a repetition of
the experience may occur; and, as the continuance of his
physical symptoms will prevent his being sent back to
military duties, he has nothing to gain by recovery. Now
do not misunderstand. These are not conscious, delib-
erate reactions. It is the automatic — instinctive, if you
like — part of the man which is reacting. He truly knows
not what he is doing, any more than people generally rec-
ognize their motivation in most of their every-day con-
duct. The higher cerebral functions, by which one super-
vises and criticises one’s conduct in relation to some ac-
quired system of ideals and conventionalized behavior,
no longer act, and he is at the mercy of his emotions.
He really has had a "nervous breakdown,” and this has
produced a somatic disorganization. This somatic dis-
organization may produce actual pathological changes in
his tissues and organs, giving rise to such diseases as
hyperthyroidism and peptic ulcers.
December, 1945
401
Whether or not an individual will so react in times of
stress will depend upon his past experiences. Our con-
duct at any one time is always determined by our past.
Give a man, trained to standards of honesty, one hun-
dred dollars for delivery to someone else, and it is pretty
certain he will so deliver it, but give it to a man brought
up among thieves, and it is equally certain that he will
keep it himself. A child is brought into the world with
certain tendencies to particular types of reactions, call
them urges, instincts, or what you will. These are all
directed to his own preservation and happiness. But the
world he is brought into is a pretty tough place, com-
posed of many other individuals all seeking the same
object. Conflicts are bound to occur, and hard knocks
will be the lot of all. For many years, the child will de-
pend upon his parents for protection. But if that pro-
tection goes too far and he is shielded too much, he will
never develop the ability to resist "the slings and arrows
of outrageous fortune.” He will come to expect a consid-
eration he is not likely to receive in later life. A child
brought up in such a way is liable to develop tantrums,
or sulk when he cannot get his own way, the counterpart
of the neuroses of later life. His training has to teach
him how to live with his herd, to make compromises with
others, and to give and take. He learns that certain
forms of conduct receive the approval and other forms
the disapproval of his herd. He is taught certain ideal
patterns of behavior which he is expected to follow. Civ-
ilized society could learn, from those we are pleased to
call savages, something worth while in this matter. All
these have ceremonies which mark the boy’s passage
from childhood to adolescence, when he is initiated into
adult society. Some of these are severe, inflicting upon
him prolonged hardship and actual physical pain. Fail-
ure to acquit himself honorably in these will place upon
him a stigma from which he will never recover. Small
wonder that traumatic neuroses are unknown among
savages.
When a man goes into the services, he receives some-
thing of this training. Rudyard Kipling pointed out the
changed outlook upon life of a man brought up in the
underprivileged classes, upon his induction into the army.
Here he finds himself a member of a group with a com-
mon purpose, to the achievement of which all his con-
duct must be directed. In everything he does, he must
subordinate himself and even sacrifice himself for this.
He acquires, too, a set of traditions up to which he must
live. He learns of the glorious deeds of his regiment,
and becomes conscious that, as part of the regiment, he
shares these glories, and that upon him, too, devolves
the onus of continuing that tradition and adding his part
to further glories. He must not let the regiment down.
Now you see why, when the burden laid upon him be-
comes greater than he can bear, and he breaks, he takes
refuge in physical sickness. That lets him out, and he
avoids the obloquy of the coward. Before you condemn
him, remember Whitfield’s remark on witnessing a crim-
inal going to the gallows: "There, but for the grace of
God, go I.” For every man has his breaking point, or,
if you prefer Wechsler’s way of putting it, "every nor-
mal person is a littie neurotic, and every neurotic, much
normal.”
And all these war neuroses have their counterpart in
civilian life and during times of peace. Indeed, the study
of them has added much to our understanding of these
peace conditions which are always confronting us. We
see them in men, as the result of accidents or business
failures or worries, in women, as the result of marital
difficulties or the failure of their love lives. From all
these, they have sought refuge in physical sickness. It
is their way of meeting their troubles. When you see a
man or woman with a rapid heart, a flushed skin, and a
tremor, even a raised basal metabolic rate, do not at once
incriminate the thyroid; before you remove it, search
diligently for a mental origin, even though they may
deny these. Before you operate on a woman’s genitalia,
even though there are some abnormalities, make sure the
symptoms she complains of are really due to the abnor-
mality, and are not a defense reaction to some continu-
ing psychic trauma. Be careful not to emphasize a harm-
less premature systole or an unimportant murmur. Many
people have been made cardiac invalids for life by over-
emphasis of these. Even electrocardiographic changes
simulating coronary thrombosis, such as alterations in the
level of the S-T segment or negative T waves, can be
caused by fear. And please do not give digitalis unless
the indications are definite and positive. Digitalis will
never bring back a wandering lover or husband, nor
rescue a business rapidly going to the dogs. Nor will
teeth extraction, either. And for the nurses, be careful
how you suggest to your women friends possible phys-
ical causes for their symptoms. Your prestige as a nurse
will add weight to your remarks, and may render very
difficult an appreciation of the true basis of the ill health.
It is so important to avoid fixing in the minds of these
people the idea of a physical origin of their symptoms.
This is what they want, for it provides the escape from
the disagreeable situation, and especially do they want
the authoritarian confirmation of tbe doctor. I am afraid
that after the war is over we will see many of these war
neuroses. We did after the last one, and ill-judged sym-
pathies for ex-soldiers, or mistaken diagnoses have cost
the country millions of dollars, and made many men
parasitic upon the community for life. Sympathy for
others in their troubles is good, but can easily become
mere sentimentality. Approbation and disapprobation,
rewards and punishments, are a potent factor in keeping
all of us toeing the line. A stiff upper lip and the avoid-
ance of self-pity do much to help in meeting adversities.
After all, many people have carried on and distinguished
themselves with serious physical handicaps; our own pres-
ident sets a brilliant example of how a physical handicap
can be overcome. Certainly, a man who develops some
of these physical disabilities when simply confronted with
the possibility of military service is of little value to a
community, and one may well doubt the wisdom of com-
pelling another man to risk or lose his life in defending
him.
Many of the current hasty marriages, too, are going
to cause trouble, and develop their own crop of neuroses,
when the emotional let-down comes and life resumes its
402
The Journal-Lancet
humdrum character. The man out of work and in civil-
ian costume will seem to the woman who has married
him a very different individual from the hero in his
uniform.
In all probability after the war, we will have what
one might call a collective neurosis. After their battle
experiences, the men who come back will never be quite
the same. Their background will be different, particu-
larly for those who previously had known nothing but
the humdrum life of a small community. After risking
their lives, they will feel themselves entitled to special
consideration and privileges. But many of them will find
their places taken by some of their contemporaries, who,
for various reasons, good or bad, were able to stay safely
at home, and they will have to begin all over again.
Naturally, they will have little love for these stay-at-
homes — often, indeed, plain slackers — who will try to
hang on to what advantages they have gained. Inci-
dentally, medical practice may be profoundly affected.
Men who have become used to receiving medical atten-
tion whenever they have needed it, or thought they need-
ed it, will demand a continuance of such privileges. So
we may expect a widening of the field of activities of the
Veterans’ Bureau, and, possibly, an extension of the serv-
ices to the families of ex-service men, or even to the gen-
eral public. Indeed, if all men are to be potential mili-
tary material, it is only common sense to provide them,
especially in their younger years, with all the facilities
to make them good material, and so avoid the appalling
number of rejections of the present war. Consequently,
state medical service in some form or other, in spite of
the opposition of many of the profession, is likely to re-
ceive an increased measure of support.
Soon, too, the soldiers will cease to be regarded as
heroes, for the country will have had enough of heroics,
and will want to get back to "normalcy” again — silly
term that, as if anyone can say what is "normal” in this
ever-changing world!
When the danger is over, our pacifist and isolationist
friends will probably again find full voice, and may per-
suade a disillusioned and war-weary people to attempt
another flight from reality, and to disclaim any share in
the responsibility of maintaining the peace for which
they have fought. This happened before, and is not un-
likely to happen again, particularly if it offers any im-
mediate advantage to one or other of the political parties.
And so the merry old game will go on as before; and in
a few years we will have a bigger and a better war, for
a vicious circle exists, in that the neuroses of peace pro-
duce war, and war, in its turn, produces another crop
of neuroses.
References
1. Quoted by William James: Principles of Psychology, New
York, Henry Holt 6c Co., 1890. vol. 2, p. 446.
2. Cannon, W. B.: Bodily Changes in Pain, Hunger, Fear QC
Rage, D. Appleton &C Co., New York, 1929.
3. Lancet 2:625 (Nov. 16) 1940.
Convoy Fatigue and Traumatic War Neuroses
in Seamen
Daniel Blain, M.D.j'
Florence Powdermaker, M.D.j:
THE men of the Merchant Marine were among
the first victims of the war since the submarine
warfare had already gotten under way before we
were combatants. In those early days and during the
first months of the war the seamen who were ill or in-
jured were taken care of in Marine Hospitals and in
clinics operated by the U. S. Public Health Service for
the care of the American Merchant Marine. Many
neuropsychiatric casualties occurred, and as their num-
ber increased, it was necessary to make other provisions
for their care. It was also found that a hospital was not
the best place for them.
In order to meet this emergency the War Shipping
Administration appropriated funds to the Recruitment
and Manning Organization in July, 1942, to set up a
medical division staffed by commissioned officers of the
U. S. Public Health Service. The United Seamen’s
t Senior Surgeon (R). U. S. Public Health Service; deputy med-
ical director, War Shipping Administration; medical director, Unit*
ed Seamen’s Service.
^Surgeon (R), U. S. Public Health Service; chief of health edu-
cation. War Shipping Administration (RMO) and United Seamen’s
Service.
Service, a private organization closely connected with the
War Shipping Administration and working in behalf of
seamen, has contributed generously to the work. Soon
after the program got under way it became apparent
that it should be broadened, to include particularly the
prevention of the traumatic neuroses or at least to en-
deavor to diminish their severity.
Definition
We call the milder reactions "convoy fatigue” to dif-
ferentiate them from traumatic war neuroses. The for-
mer term does not have the connotation of mental dis-
ease for the patient and the public. The latter implies
that the patient’s symptoms are directly connected with
his war experiences. Traumatic war neurosis may be de-
fined as an unconscious or partly conscious explosion of
anxiety and fear at a primitive psychological level, result-
ing in the disorganization of the psychosomatic mech-
anisms.
Certain neuro-psychiatrists limit the diagnosis of trau-
matic war neurosis to cases with a history of previous
December, 1943
403
good adjustment; onset following combat, showing ob-
jective symptoms of anxiety and probability of recovery.
They consider cases of nervous reaction not fulfilling
these criteria to be recurrences of old psychoneurotic dis-
orders. Our experience leads us to diagnose traumatic
war neurosis also in cases in which the patient has a
neurotic history, but his reaction is a response to a real
and immediate situation. It appears to be discreet and
encapsulated, is at first unrelated to the past and may
remain so for a short time. In some cases the traumatic
neurosis may clear up. We also feel that the diagnosis
is justified when the symptoms occur after a prolonged
period of exposure to the probability of enemy action
without actual combat. We consider as criteria the pres-
ence of physical signs and symptoms associated with un-
conscious or partly unconscious anxiety and fear follow-
ing the stress and strain of active duty and the tendency
to recovery.
Numerous references1 •2*3>4*i,<6 in the literature have
emphasized the importance of the physical condition of
the men and of heredity as well as of previous neurotic
difficulties as predisposing to traumatic war neurosis. It
has been our experience that hereditary and constitu-
tional elements appear to play a comparatively small part
in these reactions. Many men of poor background go
through combat with amazingly little disturbance. Even
those with a history of neurosis frequently experience
enemy action without increase in their symptomatology.
While men of good background are more likely to with-
stand stress and strain, some will break unexpectedly and
all will show some signs of breaking if the stress is great
enough. Each man has his breaking point, as was shown
at Guadalcanal.' Predictions from a man’s background
are, therefore, impossible, and no one can foretell what
he may be called upon to endure. Undoubtedly, good
physical condition makes a man feel able to cope with
situations and that helps his mental state. In addition
factors on board ship are important. A great deal of
mental tension can be built up on a ship if there is dis-
satisfaction over conditions and anxiety over lack of
proper safety measures. Accounts seem to indicate that
there are fewer breakdowns on a happy ship.
The fact that the seamen were exposed at the begin-
ning of the war to enemy action with no means of de-
fense was important. The sense of complete helplessness
and frustration under attack and the pent-up hostility
could be nerve-racking. This has improved since the
ships have been armed and sail in well-protected convoys.
While all of these external factors are important, the
neurotic reaction frequently is heightened, if not at times
caused by, a sense of shame and of fear and the obvious
physical reaction to it. In these cases every effort, — in
some consciously, in others unconsciously, — is made to
repress it. When the effort of repression is successful,
the neurotic symptoms, of course, increase.
Symptoms
Symptoms are varied and may involve any parts of the
body-mind mechanism. At times the picture is that of
a chaotic state similar to that described by Pavlov and
Cannon in animals when in acute mental states. The
total organism may be affected. For convenience the
symptoms may be classified as follows, though any com-
bination or all may be present:
1. Emotional. Anxiety, panic, confusion, amnesia,
stupor, over-excitement may occur, and occasionally, psy-
chotic or epileptic attacks. Irritability, restlessness, in-
somnia, as indications of a state of tension, are common
during long voyages through danger zones even if there
has been no actual contact with the enemy.
2. Motor. Tremor and, occasionally, cataleptic state
may occur.
3. Vegetative. Nausea, vomiting, anorexia, severe con-
stipation, diarrhea, tachycardia may occur. Any of these
symptoms may be found in the tension states and con-
sidered as part of convoy fatigue as well as of the more
serious traumatic war neuroses.
4. Deferred reactions. There may be no apparent ef-
fects immediately after the trauma but symptoms may
suddenly appear after the return home, after an illness,
exposure to a prolonged tropical temperature, or some
form of emotional strain, such as difficulties at home.
One man, aged 50, an oiler in the engine room of a
tanker, was torpedoed twice, got malaria on the west
coast of Africa where his lifeboat landed, and on the
return voyage was subjected to twelve days of unusually
torrid tropical weather. The ship was torpedoed and he
suffered a minor injury. Up to that point he apparently
had had no nervous symptoms but this seemed to be the
last straw and he suffered a severe traumatic neurosis.
5. Physical injuries with psychological concomitants.
Injuries from blasts, punctured ear drums, subdural hem-
atomas, and skull fractures may be found, as well as all
of the usual types of wounds. Immersion foot is found
after long exposure to the weather. Any of the psycho-
somatic symptoms mentioned above may accompany these
physical injuries. Slow healing and subsequent discour-
agement may retard recovery from the neurosis, particu-
larly in men unaccustomed to illness.
Development
1. Early stage. The early stage lasts from the onset
of symptoms until there is evidence of a change of phase.
Either there is an improvement after external strain has
been removed and treatment started or the symptoms in-
crease in severity. In these cases reaction ceases to be
associated solely with the traumatic events. Most cases
come in the first category. They recover spontaneously
without going on to the next stage.
2. Subacute stage. Failure to clear up after the early
phase is marked by a tendency to connect the traumatic
event with later experiences and to over-react to events
in the present and to ideas about the future. There may
be periods of improvement with relapses to the original
symptoms in between. Failure to improve is likely to
occur if events following the original trauma are discour-
aging and harassing rather than helpful, and if there is
lack of appreciation of the patient’s condition.
3. Subchronic stage. In these cases the patient begins
to seek a secondary gain from the neurosis. The need to
defend himself against further trauma gains the ascend-
ancy over the desire to go back to sea and over ideals of
404
The Journal-Lancet
loyalty, bravery, and sacrifice. The present reactions be-
come related to the neurotic patterns of his early develop-
ment. The patient tries to find a comfortable niche in
which to settle and to look for aid to increase his de-
pendence.
4. Chronic stage. The situation described in (3) takes
on a more permanent character and there is considerable
evidence of regression into invalidism.
Treatment
Psychological first aid should be administered at the
onset. This has not been possible in the case of seamen,
but experience in the British and Spanish Loyalist armies
as well as our experience with casualties seen later indi-
cates the advisability of immediate therapy. To this end
we are educating those who are most likely to be on
hand at the onset to understand the emotional condition
of the man, the need for prolonged sleep, and, after that,
for companionship, the proper use of sedatives and the
typ>es of restraint, should any be necessary. Those in
charge of United Seamen’s Service for seamen in the
main ports of the world, officers in charge of the ship’s
medicine chest and the men themselves, are being given
this information.
Survivors landed in foreign ports are taken care of by
the Government and other agencies such as the United
Seamen’s Service and the Red Cross. Arrangements are
made to bring home the casualties as speedily and under
as favorable conditions as possible. They are met on ar-
rival by doctors of the Public Health Service and War
Shipping Administration officials. From here they are
taken to Marine Hospitals, sent to Rest Centers, or re-
turned home.
The United States Merchant Marine Rest Centers
have been established for the treatment of both convoy
fatigue and the traumatic war neuroses except in cases
having physical disabilities requiring hospital care. These
centers, which are attractive, home-like, and very in-
formal, accommodate from 30 to 50 men. They are sit-
uated in the country near the large sea ports. There is
a psychiatrist in charge. Nurses are selected for their
capacity to participate wholeheartedly in the program.
The length of stay is limited to three weeks since the
centers are not planned to care for chronic cases.
The Work-Recreation Program. There is a hobby
shop, which is a less pretentious modification of the high-
ly organized occupational therapy department of a men-
tal hospital. Its equipment is simple and only short term
projects are undertaken. The managers also call for vol-
unteers among the men to assist in maintenance repair
jobs, modest construction projects, and various tasks
about the grounds.
This work program is an important instrument in re-
storing the patient’s self-confidence, giving him a sense
of personal achievement, re-establishing his assurance in
his usefulness, and gradually reconditioning him for the
active life he will resume.
Recreation is of two types. In the first, the patient par-
ticipates actively in games, social dancing, community
singing, amateur theatricals, etc. These activities are
shared by the doctors, nurses, other employees, and vol-
unteers. The second type of recreation is passive. A
local committee invites artists in various fields to donate
their services and the patients constitute the audience.
Such activities are not only diverting but are a means
through which the personnel and community express their
special interest in the patient’s welfare and make him feel
an honored member of the community. Care is taken to
relate the activities of each man to his condition.
Psychotherapy is conducted through group discussions
and personal interviews. It has two chief aims — to con-
tribute to the man’s understanding of himself and his
symptoms and to send him back to sea better equipped
to take care of himself physically and mentally. The
more a man knows how to understand and handle his
fears, how to use every available means to help himself
in dangerous situations, the less likely he is to break
down.
Each man is given a physical examination and is inter-
viewed on admission. The length of the interview de-
pends on his condition and willingness to talk. No pres-
sure is put on the patient. Emphasis is put on the neces-
sity to restore good sleeping habits and good physical con-
dition. The work-recreation program is discussed in rela-
tion to the man’s interests and condition. When neces-
sary, special diet, vitamins and physiotherapy are pre-
scribed. The number of personal interviews depends on
the needs of the individual patient. No attempt is made
to do other than superficial therapy. It is our experience
that the best results are obtained by a thorough airing of
the traumatic experiences and by the release of the attend-
ant emotions. Only such earlier personal experiences are
obtained as are spontaneously brought out by the man
and they are not pursued further. In selected cases,
sod:um amytal is given intravenously as a hypnotic to
aid in the recall of the traumatic events.
An understanding of the psychosomatic mechanism,
expressed in simple terms, is emphasized in both inter-
views and group talks. Considerable relief is experienced
by the patients through an understanding of the relation
between their symptoms, which are such a mystery to
them, and the emotional reactions to their experiences.
The naturalness of fear reactions is repeatedly stressed
and the physiological reactions to fear are discussed.
Group therapy may be carried out in small or large
groups depending on the subject and the technics of the
individual doctor. It is very informal and wherever pos-
sible is illustrated by charts and films. Anatomy, phys-
iology and psychology are discussed from the standpoint
of the man’s own psychosomatic symptoms. Relations
between officers and men and problems of authority are
discussed and many "gripes” are gotten rid of. The men
themselves suggest subjects. An understanding of con-
valescence and fatigue is important, as many are over-
eager to get back to sea. A sense of group solidarity is
festered and there is great comfort in the knowledge that
others have the same feelings and difficulties so that
shame tends to disappear.
First aid may be taught by local Red Cross teachers.
This is particularly important, both actually and as a
psychological aid, as there are no doctors aboard mer-
chant ships and a man never knows what he will be up
December, 1943
4CH
against in a lifeboat. Damage control, ways of leaving
the ship and swimming through oil are taught with Navy
films. Handling of lifeboats is practiced with regulation
boats, and swimming ^nd life-saving are taught. This is
greatly appreciated by the men and adds to their morale
and security.
Approximately 80 per cent of our men are ready to go
back to sea in three weeks. Of the remainder a large
percentage ship on the Great Lakes or work in the fish-
ing industry and shipyards and return later to sea.
Prevention
We are now accepting in the Rest Centers men who
do not suffer from war neuroses but who are tired or in
poor physical condition after a trip at sea. Often a few
days or a week will put them in good condition and we
are hopeful that this will prevent breakdowns or at least
d nrn’sh their severity. The educational program also
helps. Men who have been at the Rest Centers are en-
couraged to return to rest up for a few days after sub-
sequent voyages.
Every effort is made to prevent the man from getting
into the chronic or subchronic state by helping him bring
his fears to the surface and by reconciling them with his
pride and ideals. Another branch of the maritime in-
dustry which is without danger may be made acceptable.
It is important that the Rest Center should not assume
the appearance of a "Snug Harbor.”
The educational program is being extended to union
halls, and United Seamen’s Service hotels and recreation
centers. It includes discussions of physical care, psycho-
logical reactions related to the men’s situations, first aid
and taking care of oneself in dangerous situations.
After Care
A medical social worker to whom the man is assigned
on admiss:on takes care of any necessary arrangements
until the man signs up. Contact is kept with the doctor
Employment of Mental Hygiene Principles in
Improved Selection of Armed Forces*
Philip H. Heersema, M.D.t
Rochester, Minnesota
which it is necessary to wade in order to institute certain
procedures. In spite of such restricting forces, valuable
methods of selective service screening and aids to dis-
criminative selection that have been put into operation in
the past year are a credit to various state organizations
of social welfare and selective service as well as to certain
individual champions of the program. It should be of
general interest to become acquainted with some of the
history of what has been done in this state regarding this
problem in the past year, as well as to emphasize the
objectives.
Much interest in this problem stems from the practical
aspect of how to avoid the end result of military neuro-
THE problem of an adeauate screening program
for the State Selective Service to prevent indi-
viduals who are socially and mentally ill from
joining the armed forces has been of vital interest to
military and civilian physicians, social and welfare work-
ers and civic minded citizens for at least the past two
years, that is, even before our actual participation in war.
Many persons have felt the need of a more adequate
program, but have felt themselves thwarted and frus-
trated by the military and professional red tape through
’Delivered before the State Conference of Social Workers, St.
Paul, Minnesota, May 6, 1943.
fSection on Neurology, Mayo Clinic. Vice President, Minnesota
State Mental Hygiene Society.
through two addressed postcards given the man when he
leaves the Rest Center and which he mails from any
ports in which he lands, giving a statement of his con-
dition.
Conclusion
Traumatic war neuroses of all degrees are seen in many
merchant seamen who have been subject to more strain
than they are physically and emotionally able to bear.
They occur in men who are neurotic and in those who
seem to have been relatively stable and do not always
seem to be in proportion to the strain involved. The
symptoms may include all of those which the psycho-
somatic mechanism is capable of producing.
Treatment should be instituted as early as possible and
include (1) sleep, induced if necessary, (2) removal of
all strain in the environment, (3) adequate diet, (4)
psychotherapy directed toward the full expression of the
traumatic events coupled with the expression of the emo-
tions associated with them and toward an understanding
of the causes of the breakdown,, and (5) treatment of
physical d'fficulties.
Prevention consists in (1) getting the man in the best
possible condition before going to sea, (2) providing as
much train:ng as possible to cope with any emergency
that may arise and (3) giving him an understanding and
acceptance of his emotional reactions under strain.
Bibliography
1. Dunn, William H.: War neuroses, Psychol. Bull. 38:6
(June) 1941.
2. Zabrskie, Edwin G., and B~ush, A. Lou’se; Psychoneuroses
in war time, Psvchosom. Med. 1 1 1 : 3 (July) 1941.
3. Lewis, Audrey Psvch atr:c aspects of effort syndrome, Proc
Roy. Sc c^ M-d. XXV IV : 5 3 ^ fM^rch 25) 1 941.
4. K^rdm^r. Abram: The Traumatic Neuroses of War, Psy-
chosom. Med. Monograph II-III, 1941.
5. Rado, Sandor: Pathodvnanvcs and treatment of traumatic
war neuroses (traumatophobia ) , Psychosom. Med. IV: 4 (Oct.)
1942.
6. Blain. Daniel: MedVal Studies on Merchant S?amen, No. 1,
Med. D v.. W.S.A . 107 Washington St., New York 6. N. Y.
7. Smith. E. Rogers: Neuroses resulting from combat. Am. J.
Psychiat. 100:1 (July) 1943.
406
The Journal-Lancet
psychiatric casualties. Through contact with clinical con-
ferences at one of our state hospitals, I personally be-
came acutely aware of the military neuropsychiatric cas-
ualties that were being dumped upon the state hospitals
as an additional load for the hospitals and their over-
worked staff. We realized that in many of these cases
the individuals had been working as productive units in
their own community before they had been subjected to
military induction. I saw one particular case in which a
farm hand, aged twenty-one years, had been making a
favorable adjustment on the farm prior to induction
although there had been evidence of a previous mal-
adjustment at the age of seventeen years when he had
felt that he had been hypnotized and had had a quarrel
with his father, had struck him and had caused consid-
erable comment among the neighbors. The father was
a religious fanatic and one brother has been hospitalized
for mental disease continuously since 1939. Actually, the
whole family is considered below par mentally. In De-
cember, 1941, the young man enlisted and went through
the usual induction into the army. The local board was
undoubtedly aware of the fact that the family was con-
sidered somewhat unstable, that one brother, four years
older, was an inmate of a state hospital, and even that the
patient had had a "nervous breakdown,” but no mention
was made of these facts and there was no machinery for
presenting them to the induction board. The patient
went on into the army, only to have a rather severe
period of excitement and subsequent catatonic behavior
about six weeks or two months after his induction. The
result was his eventual discharge from the army because
of dementia praecox and his return to his home county,
from where he was sent to a state hospital. This appears
to be a needless waste of a farm worker, resulting in
another social dependent for the state and a considerable
amount of futile expenditure of energy on the part of
the army doctor, as well as an unnecessary expense to the
government in terms of dollars and cents.
In the early part of 1942, when these casualties began
to appear rather prominently in our state hospitals, this
entire screening and selection situation was the subject
of discussion by the executive committee of the Minne-
sota State Mental Hygiene Society. At no time did we
direct any unfavorable criticism at the induction board
or the Selective Service medical department for their
failure to have anticipated these military psychiatric cas-
ualties; but instead, our interest concerned what means
might be used, or what means were available by which
we could logically anticipate such casualties and scien-
tifically employ the information available in the various
state departments and bureaus. In May, 1942, we had
the opportunity of discussing this problem with Dr.
George Stevenson, the medical director of the National
Committee on Mental Hygiene, who very graciously gave
us much valuable information as to the functioning of
the screening program and the psychiatric social work
being performed in this field in New York and Con-
necticut. Furthermore, he indicated that the problem
was of such importance that a special co-ordinator was
about to be appointed to the staff of the National Com-
mittee on Mental Hygiene for the purpose of co-ordinat-
ing the programs employed in the various states and fur-
thering this project to become national in scope.
During the summer of 1942 we investigated the avail-
able facilities that were not being utilized in the state,
but which would give information, at least, of such indi-
viduals as had been inmates of state institutions. This
critical information was often omitted by the registrant,
even purposely, with the hope that he might achieve
through enlistment what could not be obtained otherwise,
namely, recognition of being of sound mind and body.
We recognized that it was not just a simple procedure
of writing a letter to the State Selective Service head-
quarters asking why the Central Index of Registration
was not being used. This index registers all inmates of
state institutions, criminal offenders and juvenile delin-
quents who come to the attention of state agencies. Ob-
viously this matter of transferring information from a
civilian source to a military organization required a series
of sanctions and authorizations for which machinery had
not yet been set up. In addition to this, there was a cer-
tain amount of resistance to any radical departure in
method because of the fact that Minnesota had been
showing a highly favorable record with a relatively small
return of psychiatric casualties. Then too, the officials at
the Selective Service Headquarters had been harassed,
from the very day the organization was established, by
busy-bodies, cranks and aggressive individuals with pet
ideas about how to run Selective Service. We had no
intention of being relegated to the "crank” heap. A brief
glance at statistics derived from the last war indicated
that 47 per cent of veterans hospitalized at the time of
a special survey in 19271 were of a neuropsychiatric char-
acter. Even if Minnesota’s immediate record was better
than that of other states, the percentage would still be
much higher than it should be unless we were able to use
some anticipatory measures to prevent these psychopathic
individuals from becoming inducted.
Certainly it was deemed worth while to acquaint the
Selective Service Headquarters with the fact that a very
understanding group of social workers were willing to
donate their services as needed, and that the Central In-
dex was a valuable source wherewith a minimum of work
might logically produce valuable information. A formu-
lation of a plan was drawn up whereby Selective Service
might utilize these facilities, but it was not until October
12, 1942, through the initiating force of Miss Mildred
Thomson of the Division of Public Institutions, that a
committee was actually brought together. This committee
included representatives of the Division of Public Insti-
tutions, of the medical department of the State Selective
Service, of the State Division of Social Welfare and of
the State Mental Hygiene Society. This meeting result-
ed in recommendations from the Division of Social Wel-
fare relative to the need of co-operation with the local
draft boards in preventing induction of persons mentally
unfit, with concomitant directives from the medical de-
partment of the State Selective Service Headquarters
to the same end.
It was the plan that some one person in the local wel-
fare board should have the responsibility of checking the
lists of registrants and of listing any information known
December, 1943
407
to be of value to the draft board. Lt. Col. Hullsiek, then
the medical director of Selective Service, agreed to in-
struct the draft board at the time of posting a list of
the men to be inducted, to send a duplicate to the local
welfare board and another to the Division of Public In-
stitutions for checking against the Central Index. There
were to be no interviews and no exhausting search of rec-
ords, as it was assumed that we could utilize facilities
that were available without having to set up any separate
or cumbersome machinery which would admittedly have
provided further information on each registrant but
which the Selective Service Headquarters was not yet
convinced was necessary. This procedure could be used
throughout the state, but it was recognized that it would
be most effective in the rural communities where local
crack-pots and ne’er-do-wells would be known to the wel-
fare worker because of greater opportunities for inci-
dental knowledge of a personal nature in the rural com-
munity. That is to say, it was recognized that a cursory
examination of the list as it was sent out by the local
draft board could not be of as much value in personality
estimation of registrants in the urban centers where a
much larger, and therefore more impersonal, organiza-
tion was set up as it would be in the rural communities.
When one considers the large number of plans, mostly
of a highly unworkable character which had been sub-
mitted by telephone and letters to the State Selective
Service as to how to improve its organization, one has a
fuller appreciation of Lt. Col. Hullsiek’s prompt response
in his offer to issue a directive to the local draft boards
instructing them to set machinery in motion to utilize
these new sources of information.
At the same time that this so-called state plan was
being organized, a much more comprehensive and intrin-
sically urban plan was being formulated by a group of
social workers, psychologists, and psychiatrists under the
able guidance of Mr. Allan Stone of St. Paul, with the
object of putting such a plan into effect in Ramsey Coun-
ty. I am much indebted to Mr. Stone2,3 for the presen-
tation of the following factual material regarding the
working plan in Ramsey County. It was my early im-
pression upon being acquainted with this plan — the so-
called urban plan — which was later confirmed in personal
interviews with Mr. Stone, that the authors of the plan
were seeing the problem in its fuller implications, that is,
not only of the immediate need to improve the army, but
also of the need to avoid an increasing load of social
dependents during the war and in the rehabilitation
period. Sometime in the latter part of October, 1942,
this urban plan was presented to the Selective Service
Headquarters but it was temporarily tabled by that board
as a state plan was in the process of being adopted.
It might seem that there were two plans which were
serving as competition to each other. However, the adop-
tion of a so-called state plan did not involve the exclu-
sion of a more refined and necessarily detailed urban
county plan. Rather, an initial program of taking ad-
vantage of the facilities of the Central Index and county
welfare board information should really serve as an open-
ing wedge of an adequate state-wide program and, for-
tunately, it appears that this is just about what has hap-
pened. Since January 1, this urban plan as formulated
by Mr. Stone and his colleagues has been in effect in
Ramsey County and has obtained the complete approval
of the medical department of the State Selective Service
as expressed by Major R. B. Radi,4 its medical director. £
It may be of value to go briefly into the workings of
the plan devised by Mr. Stone and his co-workers, which
I shall designate as the Ramsey County plan, which has
subsequently served as a model for the selective service
screening programs of other urban counties. This pro-
gram is officially a part of the St. Paul council of social
agencies. According to the Ramsey County plan, an ex-
ecutive committee is set up, composed of psychiatrists,
welfare administrators, and paid workers who are respon-
sible in general for the operation of the program, while
the case work committee is responsible for the review of
case histories and the preparation of case summaries for
the induction station. The Minnesota State Selective
Service Headquarters officially ordered the twelve local
boards in St. Paul and Ramsey county to furnish the
screening committee with identifying information on each
registrant in class 1A. This information was prepared
on standard cards with sufficient information to identify
the registrant properly. These identification cards were
prepared by the local board four to eight weeks prior to
the induction of the registrant. Then these cards were
submitted to the Central Registration Bureau of the
County Welfare Board, which is the social service ex-
change for all aid and welfare agencies in the St. Paul
area. The worker clears the registrant’s card at the Cen-
tral Registration Bureau from a master file, noting Bu-
reau registration of the Selective Service registrant and
his family. The registrations are in turn referred to the
various family agencies, guidance clinics and health and
welfare organizations and are completed by the case
workers in these selected agencies.
The major headings of information include: (1) psy-
chologic report, (2) history of neuropsychiatric disability,
(3) health history, (4) police and court records, (5)
personality traits, (6) school history, (7) employment
history and (8) heredity. The case work committee then
reviews the reports from the various agencies and a brief
case summary is prepared, outlining the available and
verified information. This summary is so organized as
to permit a medical examiner at the induction station to
scan it in a very brief period, a matter of a few seconds,
and to provide him with the necessary data to clarify his
estimation of the individual’s personality. When these
summaries are prepared, they are placed in a plain en-
velope, marked "confidential, for the use of the neuro-
psychiatric department at the induction station,” and are
sent to the local board, from where they are transmitted
to the induction station at the time the registrant is in-
ducted. It is, of course, important that the information
contained in the summary be kept confidential and this
has been thoroughly respected by all persons and officials
including the local draft boards, who have retained the
privilege of examining the summary before passing it on
JSince this paper was written, active screening programs have
been instituted in Hennepin (Minneapolis) and St. Louis (Duluth)
counties and arrangements have been made for organizations of
programs in other counties in Minnesota.
The Journal-Lance i
408
to the army induction station. Three copies of the sum-
mary are made, the first copy going to the local draft
hoard. It is sealed by them and given to the adjutant in
charge for transmission to the Induction Center medical
officer. A second copy goes to the State Selective Service
headquarters for the medical officers and the third copy
is retained for the office of the county screening program
headquarters, as the Ramsey County headquarters, for
example. From January 1, when this plan went into op-
eration in Ramsey County, until March 26, a total of
3,343 cards was traced and the Ramsey County Central
registration bureau identified 2,178 or 69.2 per cent of
these cards. One hundred and eighty-five summaries had
been prepared which represented 5.5 per cent of the total
1A registrants or 8.5 per cent of the identified 1A regis-
trants. These figures are rather astounding, particularly
the identification of two out of three of the cards which
had been cleared. Working through Captain Burgess at
the State Induction Center, Mr. Stone found that a sam-
ple of twenty-three summaries broke down into the fol-
lowing categories: in thirteen instances the men were re-
jected on a neuropsychiatric basis; in eight instances they
were accepted; in one instance, there was a possibility of
epilepsy and the man later was rejected; and in one in-
stance the man was rejected on a physical basis before
the social history was utilized. Summing up the figures
which this sample brings out, and eliminating the one
man rejected on a physical basis, it can be seen that
fourteen of twenty-two positive summaries were effective
in supplying factual material which aided in the rejection
of the registrant, but even for those who were accepted,
every summary provided information which allowed the
examining neuropsychiatrist to make a more effective
and time-saving evaluation of the particular examinee.
If one wishes to convert these into dollars and cents,
it will be found that the estimated cost of a neuropsy-
chiatric casualty'1 to the Government is $30,000. The
cost in military expenditure of simply arranging the dis-
charge of a man who had been inducted into the service
might be expected to run into thousands of dollars, at
least $2500, even if the government were absolved of all
future responsibility. One might then say that in this
sample alone, of these fourteen cases, this screening plan
has materially aided in saving the government about
$35,000. Applying these figures comparably to the total
185 summaries prepared in the first three months in
Ramsey county alone, it is fair to say that this program
should be saving the government a good many hundred
thousand dollars a year. However, certainly one of the
immediate major accomplishments of this program has
been the recognition by the army medical officers of the
value of the information and factual material which has
been provided. Under date of March 16, 1943, Major
(now Lt. Col.) R. B. Radi notified all Ramsey county
draft boards saying that any volunteer’s name should be
sent to the Ramsey county headquarters office to get the
social information to the Induction Center more quickly
than usual. This is a particularly valuable directive inas-
much as a volunteer frequently has ulterior motives for
enlisting, such as the social absolution of some physical
infirmity by his being openly accepted by the army. In
this regard, epileptics are frequent offenders and any
source which will provide information that the volunteer
wishes to hide is of inestimable value.
Much of the work of all urban county programs has
been done as after-hour and volunteer work, but it seems
we have reached a point where we are perfectly justified
in saying that this should be a part of the regular social
service duties, for certainly there is no more vital program
in the social services than the screening program with its
objectives today. We do not have actual figures of the
result of the state plan, that is, the results of the work of
the rural county welfare boards. However, we know that
any material that has been presented by them has been
informative material, that it is of a positive character (as
only positive information is passed on to the Induction
Center) and that it has been extremely valuable in spe-
cific cases. Recently, state and national selective service
regulations have included directives for the local boards
of the induction centers to use any social service data in
arriving at the eligibility and desirability of the registrant.
It is probable, however, that each of the local boards
would benefit by some instruction and acquaintance with
the set-up for utilizing social service data. Many of the
men on local boards throughout the state are not instruct-
ed in the humanities and do not perceive the ill effects of
trying to fit the village ne’er-do-well into the army in
order that the army should try to make a man of him.
It becomes the particular patriotic duty of the medical
officer of the local board to prevent occurrence of such
travesties, as he knows better than anyone in the com-
munity that the psychopathic adolescent who breaks
down under the rigors of army life is very likely to be
a social dependent for the rest of his life.
I have gone into certain features of the past year’s
work in some detail to demonstrate the soundness as well
as the importance of this screening project. A program
of this type is essentially synonymous with the highest
type of mental hygiene program inasmuch as the promo-
tion of mental health and the prevention of mental break-
down are not only implied in this program but inherent
in its very workings. The Mental Hygiene Society as a
co-ordinating advisory body which includes professional
social workers, psychologists, psychiatrists, clergy and in-
telligent lay people who are interested in permanent social
organization, should most naturally embrace a program
of this type. But what is the individual job of physi-
cians? First of all, to become acquainted with the pro-
gram and to recognize its social importance, but more
than that, to take active steps, in their own district and
with the distinct security that they are a part of a state-
wide program which, thanks to the working statistics of
the Ramsey county group, is feasible. At the present
time, legislation0-'’8 is pending, or has been passed, to
provide hospitalization for practically every form of dis-
ease with which a soldier may be afflicted, whether it ex-
isted prior to his induction or not. Our experience with
hospitalization of veterans from World War I has shown
the tremendous expense involved with neuropsychiatric
casualties, the majority of which could have been pre-
dicted and prevented by a more careful weeding out at
the time of induction. Our experience also tells us that
DECEMBER, 1943
409
the benefits to veterans of World War II will most likely
be as broad as those to veterans of World War I. We
do not take issue with the character of benefits, but it is
well to point out the importance of preventing the un-
necessary tax load and payment of future benefits to
pred'ctable psychiatric casualties through the expedience
of supporting a program of screening which keeps these
registrants at work at home.
References
1. Summary of the experience of neuropsychiatry in the U. S.
Army in World War I. A memorandum of the selective process in
general and on the role of psychiatry in the selective process and
in the armed forces. New York, New York City Committee on
Mental Hygiene. (Aug.) 1942, pp. 2-4
2. Stone, Allan: Screening of selective service registrants.
Compass 24:13-15 (Apr.) 1943.
3. Stone, Allan: Personal communication to the author.
4. Radi, R. B.: Letter of March 27, 1 943, to Allan Stone,
Director of Ramsey County Selective Service Screening Program
5. Stilwell, L. E.. and Schreiber. Julius: Neuropsychiatric pro
gram for a replacement training center. War Med. 3:20-29 (Jan.)
1 943.
6. Senate Bill, No. 698, 78th Congress, 1st Session (Feb. 11)
1943.
7. House Representatives Bill, No. 21 58, 78th Congress, 1st
Session (Mar. 1 1 ) 1943.
8. H ouse Representatives Bill, No. 913, 78th Congress, 1st
Session (Jan. 8) 1 943.
Neuropsychiatric Emergencies
Philip K. Arzt, M.D. (Lieutenant, M.C.)
St. Paul, Minnesota
THE purpose of this presentation is to call atten-
tion to some of the more important conditions in
the field of neuropsychiatry which are frequently
encountered by every practicing physician and surgeon.
These conditions are considered as " emergencies,” be-
cause they constitute a threat to the life of the individual
or may result in permanent invalidism unless promptly
diagnosed and treated immediately.
Increased Intracranial Pressure
Increasing intracranial pressure is only a symptom or
indication of serious underlying pathology, but in itself
it constitutes a serious threat to the life of the individual.
It is a condition which must be relieved by correct differ-
ential diagnosis and treatment of the underlying cause,
before the increase in pressure causes serious permanent
destruction of centers in the brain and even death. It is
doubly important that it be recognized early, because the
underlying cause is frequently as much of an emergency
as the increase in intracranial pressure itself.
The normal pressure of the spinal fluid is 8 to 12 mm.
of mercury or 110 to 200 mm. of water. Generally, pres-
sure over 25 to 30 mm. of mercury is considered critical
and the more rapidly it develops, the more likely we are
to find early choking of the optic disks with resulting
blindness, or medullary compression with imminent re-
spiratory paralysis.
The syndrome of increasing intracranial pressure is
characteristic and constant. Headache, accompanied by
nausea and vomiting, with somnolence, restlessness, and
vertigo are the important subjective signs, and the objec-
tive signs are choked disk, projectile vomiting, mental
and personality changes, slow pulse, positive x-ray find-
ings, increased intraspinal pressure, and, occasionally,
extraocular palsies, especially of the sixth nerve, and con-
vulsions. When these symptoms occur together there is
never any question as to the diagnosis. One should sus-
pect increasing intracranial pressure, however, when any
combination of the above occurs.
Some of the more important and commoner causes of
^Presented at the annual meeting of the North Dakota State
Medical Association at Bismarck, May 1 1, 1943.
increased intracranial pressure may be classed as follows:
1. Trauma: (a) Concussion, contusion, and laceration
of the brain; (b) Injury of the middle meningeal
artery; (c) Subdural hematoma.
2. Spontaneous subarachnoid hemorrhage.
3. Acute infections: (a) Purulent meningitis; (b) En-
cephalitis; (c) Brain abscess.
4. Brain tumors: (a) Pituitary tumors; (b) Menin-
giomas; (c) Cerebellopontine-angle tumors.
1. Cranial Trauma: (a) In concussion, contusion, or
laceration of the brain, the important thing is to first
combat shock, and then relieve the pressure, and prevent
infection. If shock is present, the less done, the better.
Merely clean up the wounds, stop the bleeding, and
combat the shock with heat, transfusions, and morphine.
This is probably the only condition in which morphine is
indicated in all head injuries. In any trauma to the head,
with laceration of the scalp, it is wise to determine wheth-
er or not a fracture is present. This can be done by prob-
ing the wound with the finger, using strictly aseptic tech-
nic, and by x-ray. When all evidence of shock is past,
then other necessary procedures can be carried out.
Special attention is required in the case of escape of
spinal fluid through a fracture. When fluid escapes
through the ear, the cranial cavity is decompressed, the
pressure is relieved, and spinal puncture is not necessary.
As a matter of fact, a lumbar puncture is contraindi-
cated, as this tends to reverse the flow of the fluid with
the chance of drawing organisms into the subarachnoid
space through the ear. The ear is cleaned mechanically
and flooded (not syringed) with antiseptic solution and
a wick (not a plug) is inserted. The patient is then
turned over and the ear allowed to drain.
In basal fractures, the spinal fluid may escape through
the nose. Here, it is best to let the patient alone and
give adequate doses of one of the sulfa compounds in
order to prevent or combat an infection. If the exact
location of the fracture is known, and the patient is not
in shock, one may repair the dura by a transfrontal cra-
niotomy. If increasing intracranial pressure persists in
spite of the escape of spinal fluid through the nose, the
410
The Journal-Lancet
pressure may be relieved by dehydration or decompres-
sion. Spinal drainage should be resorted to only after all
other methods fail.
The basic treatment of any head injury is rest and
adequate sedation. The head of the bed may be elevated,
the lungs should be watched closely for signs of develop-
ing pneumonia. Mechanical restraints are contraindicat-
ed as this would tend to cause straining and restlessness
which in turn would only raise the intracranial pressure.
Sodium luminal in 5-grain doses is generally sufficient to
keep the patient quiet. The restlessness and irritability
frequently respond to paraldehyde, chloral hydrate, bro-
mides, or sodium amytal.
(b) Injury of the middle meningeal artery in trauma
of the head is relatively uncommon and easily over-
looked, but when recognized early, is amenable to treat-
ment with subsequent recovery. The history is quite
characteristic. There is usually a history of trauma gen-
erally followed by unconsciousness, then a lucid interval
followed by a lapse into drowsiness and coma. During
this third stage there are usually signs of increasing intra-
cranial pressure and focal signs of compression, such as
hemiparesis starting in the face and spreading to the up-
per and lower extremity on the same side as the clot or
the opposite side. The hemiparesis may be preceded by
Jacksonian fits. Occasionally the pupil on the same side
as the lesion may enlarge. With the hemiparesis, a posi-
tive Babinski sign, increased tendon reflexes and an ankle
clonis may be elicited. The treatment consists of a cra-
niotomy and removal of the clot. Without treatment,
death will result, usually from medullary paralysis due to
increasing intracranial pressure.
(c) Chronic subdural hematoma is a comparatively
common and frequently overlooked condition. It is due
to ruptured pial veins with collection of venous blood
(either clotted or liquid) between the dura and the
arachnoid membranes. Trauma, either severe or trivial,
is the most common cause, although it is not unusual for
the patient to have no recollection of any cranial trauma.
Unconsciousness may or may not have been present fol-
lowing the initial injury. The symptoms may come on
at any time from a few days to several months and even
years after the trauma. Headache, at first recurrent and
later continuous, is one of the most prominent com-
plaints. The headache may be lateralized to the side of
the lesion. Mental clouding or some alteration of the
intellect is another common finding. The signs of in-
creased intracranial pressure without definite localizing
signs should lead one to suspect this condition. There
may be a slight facial palsy, or an inequality of the re-
flexes, but generally the neurological signs are inconspic-
uous. In fact, the very diversity of symptoms is quite
characteristic of the condition. Somnolence is often pres-
ent and frequently all out of proportion to the degree of
increase in pressure. Encephalography or ventriculogra-
phy or trephining on the suspected side are aids in mak-
ing a diagnosis. The hematoma, when located, is washed
out through two or more burr holes, or a small flap is
turned down and the entire hematoma removed. It is
often necessary to explore both sides. In the majority of
cases, the results from operation are gratifying.
2. Subarachnoid Hemorrhage: Subarachnoid hemor-
rhage is due to rupture of a congenital aneurysm or an
otherwise diseased vessel of the circle of Willis or one of
its branches. This condition occurs frequently in young
individuals. When it occurs later in life it is generally
associated with hypertension. Trauma, in itself, will
never cause spontaneous subarachnoid hemorrhage, as
there must be pre-existing vascular disease present.1
Trauma, however, may be an aggravating factor in this
condition, but it must be severe. Straining and lifting a
heavy object may initiate the hemorrhage. The clinical
course is constant and characterized by sudden severe
persistent headache, drowsiness, signs of increasing intra-
cranial pressure and later signs of meningeal irritation.
Loss of consciousness is not uncommon. The diagnosis
can be established by the presence of blood in the spinal
fluid in the absence of trauma, infectious meningitis, and
other intracerebral disease processes. Later the fluid may
appear xanthochromic. There is generally an increase in
the globulin and protein in the spinal fluid (See table).
The treatment is aimed at keeping the patient quiet for
a period of several months. Immediate steps to relieve
the increased intracranial pressure are taken by adminis-
tering hypertonic salt solution intravenously or, if neces-
sary, lumbar puncture. This last procedure is not with-
out danger as it may initiate fresh bleeding from the
diseased vessel.
3. Acute Infections: (a) All of the various types of
meningitis have several features in common, notably signs
of meningeal irritation (neck rigidity, opisthotonos, Ker-
nig sign, and Brudzinski sign) . The various forms are
also similar from a clinical standpoint, but the causative
organism in each type is different. Staphylococci, strep-
tococci, pneumococci, B. influenzae, and meningococci
are the common causative agents. The organisms are
probably carried to the subarachnoid space via the blood
stream. In all types, other than the meningococcic form,
the meningitis is usually secondary to upper respiratory
infections such as pneumonia, lung abscess, empyema,
bronchiectasis, and, less commonly, to infections in other
parts of the body, such as otitis, paranasal sinus infec-
tions, endocarditis, puerperal infection, etc. In many in-
stances the initial signs and symptoms may point to pul-
monary or abdominal involvement and distract the atten-
tion completely from the central nervous system. In ev-
ery acutely ill individual, tests should be made for signs
of meningeal irritation, and one should look for signs
of increasing intracranial pressure. If the syndrome of
meningeal irritation (i. e., rigid neck, Kernig sign, and
Brudzinski sign) is present, early lumbar puncture is
indicated. The findings in the spinal fluid are of par-
ticular help in the diagnosis and management of the in-
fection (See table). Of definite value in the treatment of
these cases is sulfanilamide or one of its related com-
pounds. In the case of meningococcic meningitis, the
meningococcic antitoxin, used either alone or in conjunc-
tion with one of the sulfa compounds, is the treatment
of choice.
(b) Encephalitis is an acute disease which often takes
on epidemic proportions. The clinical picture is essen-
tially one of cerebral involvement, although occasionally
December, 1943
411
signs of meningeal involvement are present, especially the
Kernig sign. One of the striking features, aside from
the toxic signs and peculiar drowsiness or lethargy fre-
quently seen, is the presence of ocular palsies, i. e., diver-
gent or convergent squint. The spinal fluid findings are
often inconclusive, but when altered may help in making
the diagnosis. The treatment is often disappointing,
although Rosenow has recently developed an antiserum
which was used with some success in the recent epidemic
in this part of the country. The antistreptococcic enceph-
alitic serum (Rosenow) is not effective in all types of
encephalitis, but when indicated, often produces dramatic
results. The indication for its use is a positive skin test
with the u-globulin factor of serum of horses immunized
with the streptococci isolated from patients and horses ill
with the disease.
(c) Brain abscess , new growths (tumors), and hemor-
rhage are the mass lesions of the brain, and from a neu-
rologic standpoint alone, they are difficult to differen-
tiate. The greatest aid in the diagnosis is the history. A
history of infection points to an abscess. Abscesses of the
brain develop by direct extension (contiguity) and are
usually large and single, or are blood-borne (hematoge-
nous) and in this case more apt to be multiple. About
75 per cent of all brain abscesses occur as the result of
direct extension and about 75 per cent of this group
come from infection of the mastoid, 20 per cent from
the paranasal sinuses, and the remainder from osteomy-
elitis, trauma, infections of the scalp, etc. In the blood-
borne group of abscesses, 75 per cent are of pulmonary
origin (lung abscess, empyema, etc.), and the remainder
from any other infection in the body. It is important to
keep the above in mind when taking and evaluating a
history.
If the abscess is from the mastoid, the common loca-
tions are the adjacent temporal lobe or the cerebellum,
and if from the paranasal sinuses, the frontal lobe is
more often involved. The symptoms are the same as for
any other mass lesion, with signs of increased intracranial
pressure and focal signs depending on the location of
the lesion. An abscess, however, has in addition a his-
tory of infection, and the patient has a muddied intellect
and slow responses. In all patients with mastoiditis,
especially in children, who suddenly become drowsy and
more listless, a brain abscess should be suspected. It is
important to obtain visual fields, if possible, for if the
temporal lobe is involved there will be cuts in the fields
of vision. These are sometimes difficult to obtain in chil-
dren because of the age, inability to concentrate, and
drowsiness. The fields can be roughly tested, however,
by the " feeding test.” This is accomplished by bringing
a spoonful of food from the periphery into the field of
vision. If there is no defect in the field of vision, the
child will turn his head toward the food. If a defect is
present, the child will be unable to see the food and will
show no response. The treatment is entirely surgical and
is accomplished either by puncture of the abscess with a
needle through a small trephine opening and insertion of
a drainage tube, by a large opening through the cortex
to the abscess and inserting a drain, or by a bone flap
and drain. One of these methods combined with judi-
cious use of the sulfa compounds often enables one to
remove the abscess in toto after about ten days. Surgery
is not indicated until the abscess is walled off and encap-
sulated. This is a difficult time to determine, but surgery
should never be attempted before the cells in the spinal
fluid are predominantly lymphocytes. Operation should
then still be postponed as long as the patient’s condition
permits. If operation is instituted before this, it would
only interfere with the protective mechanism of the brain
in trying to wall off the infection.
4. Brain Tumors: The subject of brain tumors is too
large to discuss fully here. It is wise, however, to remem-
ber that tumors occur in the brain as frequently as they
do in other parts of the body. The majority of brain
tumors are gliomas and the prognosis is unfavorable.
Some tumors, however, when recognized early are amena-
ble to satisfactory treatment. A few of these tumors will
be discussed briefly.
(a) Pituitary tumors constitute about 17 per cent of
all primary tumors of the brain. These tumors are usual-
ly recognized late and only after irreparable changes have
taken place. Headache is a frequent early symptom, but
signs of increased intracranial pressure generally do not
occur until late in the course of the tumor’s growth. En-
docrine disturbances, such as impotence in the male,
amenorrhea and sterility in the female, acromegaly and
pituitary adiposity, occasionally disturbances in sugar and
water metabolism, and changes in vision (bitemporal
hemianopsia early, and complete optic atrophy and blind-
ness late) , usually betray the presence of pituitary tu-
mors. In the majority of cases, x-ray studies reveal a
characteristic deformity of the sella tursica with erosion
and destruction of the posterior clinoid processes. Rou-
tine eye studies, which include visual acuity, fields of
vision, and ophthalmoscopy should be made in all sus-
pected cases. Early treatment consists of x-ray radiation
of the pituitary and frequent eye studies. If, in spite of
this treatment, there is increasing impairment of vision,
surgery is indicated.
(b) Meningiomas, which constitute about 15 per cent
of all brain tumors, arise from the coverings of the brain
and cause symptoms by compression. The main symp-
toms and signs are those of increased intracranial pres-
sure or focal signs of compression, usually both. Menin-
giomas may be removed in toto with usually complete or
almost complete return of function and alleviation of
symptoms.
(c) Cerebellopontine-angle tumors constitute about 7
or 8 per cent of all primary brain tumors. If seen early,
practically complete relief may be obtained from opera-
tion, while if they are seen late, little or nothing can be
done for the patient. This tumor formerly held a hope-
less prognosis, but with the recent advances in neuro-
surgery and with the use of electrocoagulation to stop
the hemorrhage, the outlook for recovery is much
brighter. The true tumor is a growth of the neurolemal
sheath of the eighth cranial nerve. However, meningio-
mas and von Recklinghausen’s disease in this location
may cause the same symptoms. Generally, the first
symptom is unilateral tinnitus with subsequent nerve
deafness in the affected ear. Occasionally pains in the
412
The Journal-Lancet
face and partial peripheral paresis of the homolateral side
of the face are encountered early. Nystagmus and cor-
neal anesthesia, vertigo, and cerebellar signs on the same
side as the lesion (hypotonia, ataxia, and dysinergia)
occur later. Choked disk generally occurs later in the
course of the disease.
I recall seeing a case in a 35 year old female whose
only symptoms were a slight lagging of the right upper
lid, ataxia to the right with occasional vertigo, and dim-
inuation of hearing in the right ear. The Barany tests,
whose results are pathognomonic in this condition, re-
vealed the presence of a dead labyrinth on the right.
The x-ray examination showed evidence of beginning en-
largement of the internal auditory meatus and destruc-
tion of the adjacent petrous portion of the temporal
bone. Surgery relieved the symptoms completely, with
the exception of some diminution of hearing on the in-
volved side.
Spinal Cord Involvement
Some of the more important and more frequently en-
countered " emergencies ” involving the spinal cord are
protruded intervertebral disk, spinal cord tumors, and
spinal epidural abscess. Because these conditions lead to
compression and irreparable damage to the spinal cord,
early recognition and treatment are imperative. Early
surgery in all of these conditions yields, in the majority
of instances, excellent results. These conditions all have
the following in common: early backache and root pains.
Root pains are severe lightning-like pains with a seg-
mental distribution, often aggravated by coughing and
sneezing, bending, or straining, and are due to irritation
of the posterior root fibers as they enter the spinal cord.
Every case with a definite history of root pains and back-
ache should have a lumbar puncture and manometric
studies to determine the possibility of a subarachnoid
block. If a block, either complete or partial, as evidenced
by the Queckenstedt test and possibly xanthochromic
fluid and low pressure, is present, oil or air x-ray studies
may be made, in order to ascertain the level of the lesion.
Iodized oil should never be introduced into the spinal
subarachnoid space unless it is completely removed fol-
lowing the x-ray studies. The oil can be removed either
at the time of surgery, providing surgery is done im-
mediately, or through the spinal puncture needle, using
the fluoroscope to locate the oil. Complete and frequent
neurological examinations will often reveal an inequality
of reflexes, and occasionally sensory changes may be pres-
ent which will aid in determining the level of the lesion.
Spinal epidural infections are always secondary to an
infection elsewhere in the body, such as upper respiratory
infections, bacteremia, furuncles, and occasionally the
condition may be precipitated by, or follow trauma. In
making a diagnosis, one will find the history of a previ-
ous infection, backache, root pains, signs of meningeal
irritation, and later evidences of cord compression.
Peripheral Nerve Trauma
Peripheral nerve injuries are frequently the result of
lacerating wounds of the extremities, particularly in the
upper, and are often associated with section of tendons.
Often, such injuries to the nerve are overlooked at the
time of repair of the tendons, and will not become evi-
dent until weeks and sometimes months later when the
splints are removed and paralysis and muscular atrophy
are noticed. It is then next to impossible to effect a
union of the nerves — in the first place the nerve ends are
difficult to find, and in the second place it is difficult to
promote growth at this late date. The time for nerve
repair is immediately following the injury. Testing mo-
tor power and sensation will reveal the nerves involved.
Often motor loss is rightly confused with severed ten-
dons, but loss of sensation can occur only with an in-
jured nerve, and is an absolute indication for immediate
repair.
Deficiency Diseases
An "emergency” can be said to exist if the true nature
of a deficiency disease is not recognized before irrepara-
ble damage to the nervous system takes place. An ex-
ample of such a condition is pernicious anemia, which is
accompanied in the great majority of cases by symptoms
of cord involvement. Pernicious anemia causes an in-
volvement of the lateral (pyramidal or motor tract) and
the posterior columns (Goll and Burdock), causing mo-
tor weakness, a positive Babinski sign, and loss of posi-
tion and vibration sense in the lower extremities (deep
sensation) . There is no alteration of pain and tempera-
ture sense. If allowed to progress, a state of disabling
paraplegic ataxia will result. The presence of motor weak-
ness, spasticity, and ataxia of the lower extremities, no
matter how slight, calls for complete blood studies (in-
cluding a Wassermann test) , and if these are negative,
a gastric analysis and sternal puncture should be done.
It is not uncommon to find that spinal cord changes
often antedate the onset of other symptoms of pernicious
anemia, and early massive doses of liver extract, in com-
bination with thiamine chloride will produce, in most in-
stances, gratifying results. If the cord changes are already
irreversible, such therapy is still indicated in order to pre-
vent further involvement of the cord and progressive
invalidism.
Myasthenia Gravis
Myasthenia gravis, a syndrome combining rapid but
reversible fatigue, weakness, and occasionally wasting of
muscles,1’ especially those supplied by the cranial nerves,
has a resemblance to bulbar or bulbopontine palsies on
the one hand, and muscular dystrophies on the other.
The affliction is often unrecognized, always serious, and
frequently fatal. The diagnosis in a well-marked case is
easily recognized by the myasthenic facies, ocular palsies,
and nasal voice, with a history of fatigue. If thymic
hyperplasia is present (seen in about 50 per cent of the
cases) , the diagnosis is confirmed. In earlier cases, howev-
er, in which the patient complains of fatigue, especially
at day’s end, and on repetition of movement, occasional
diplopia, ptosis and inability to open or completely close
the eyes, fatigue and difficulty in swallowing toward the
end of a meal, this condition should be suspected. An
infallible diagnostic test, according to Bennett and Cash,s
is the administration of one-twentieth to one-fifth the
usual adult physiological dose of curare (intocostrin) .
The treatment, while not curative, but merely palliative,
December, 1943
413
DIFFERENTIAL DIAGNOSIS OF SPINAL FLUID FINDINGS
Disease
Appearance
Pressure
Cells
Globulin
Protein
Sugar
Chloride
Normal
Clear —
Colorless
8—1 2 mm. Hg.
1 1 0—200 mm.
h2o
0—1 0 lympho-
cytes
Neg.
1 5—40 mg.
per 100 cc.
50—90 mg.
per 100 cc.
700-760 mg.
per 1 00 cc.
Injury of middle
meningeal artery
Bloody
Marked increase
Varying num-
ber of R.B.C.
Trace
Normal to
slight increase
Normal to
slight increase
Normal
Subdural
hematoma
Xanthochromic
or bloody
Moderate
increase
Often few
R.B.C.
Trace
Normal to mod-
erate increase
Normal to
slight increase
Normal
Spontaneous
subarachnoid
hemorrhage
Bloody, super-
natent fluid
yellow, later
xanthochromic
Moderate to
marked increase
Crenated cells
Trace to
moderate
Slight increase
Normal to
slight increase
Normal
Staph, and
Strep.
meningitis
Turbid and
cloudy. Fre-
quently clots
Moderate to
marked increase
200-10,000
Pmn’s — Or-
ganisms
Moderate
to marked
increase
Moderate to
marked increase
Decrease 20 mg.
per 100 cc.
or less
Decrease
Pneumococcic
meningitis
Purulent.
Fibrin — fluid
escapes poorly
Marked increase
200+
Moderate
increase
Moderate to
marked increase
Decrease
Decrease
Meningococcic
meningitis
Turbid.
Occasionally
clear
Marked increase
200+
chiefly Pmn.
Intracellular
Diolococci
Moderate
increase
Moderate to
marked increase
Decrease
Decrease
Encephalitis
Normal or
xanthochromic.
Occ. fibrin web
Normal to
slight increase
Normal to
slight increase.
Lymphocytes
Trace
Normal to
slight increase
Normal to
slight increase
Normal
Brain abscess
Opalescent
Moderate
increase
Slight to mod-
erate increase.
Pmn’s, early;
Lymph., late
Normal to
trace
Moderate
increase
Normal
Normal
Brain tumor
Clear, may be
xanthochromic
Slight to mod-
erate increase
Normal to
slight increase
Trace to
moderate
increase
Moderate
increase
Normal
Normal
is often life-saving. Perhaps the most successful remedy
is prostigmin, 2 cc. of 1:200 or 1:400 solution given by
hypodermic, or 15 mg. t.i.d.a.c. This dosage may pro-
duce diarrhea as the drug accentuates intestinal peri-
stalsis. This may be counteracted by giving atropin,
gr. 1/200, with each dose of prostigmin. Other drugs
which also have a beneficial effect are ephedrine sulfate
( % to !4 gr. t.i.d.), KC1., 2 gm. five times daily or oft-
ener, and glycine, 5 to 10 gm. six times daily. In cases
of extreme respiratory embarrassment, with severe dysp-
nea, the Drinker respirator and oxygen inhalations are
indicated in order to prevent death. If the thymus gland
is enlarged, surgical removal will sometimes bring lasting
relief of symptoms. An interesting case came to my
attention a few months ago. This was the case of a
nurse, 3 1 years of age, who found she was becoming ex-
cessively fatigued toward the end of the day. She was
so tired, in fact, that she could barely open her mouth
to eat, and then swallowing became difficult. Rather than
give up her job, she tried taking ephedrine sulfate, to see
if it would pep her up. To her great relief she was re-
lieved of all her symptoms and was able to continue her
work. Later she found that increasing doses of the drug
were required to relieve her. She became alarmed and
thought she was becoming addicted to the drug. When
seen, the typical history, plus the findings on examina-
tion and the history of relief with ephedrine confirmed
the diagnosis. She was switched to prostigmin, 15 mg.
t.i.d.a.c. with complete relief. Following this she had an
apparent remission and now only requires occasional
small doses of the drug.
Status Epilepticus
Status epilepticus, a state of frequently recurring gen-
eralized convulsive seizures between which the patient is
apt not to fully recover consciousness, needs energetic
anticonvulsive medications, or various complications, such
as postepileptic psychosis, postepileptic paralysis, and even
death may occur. In many instances, this state may be
prevented. In epileptics, sudden withdrawal of anticon-
vulsant drugs or a change of medication, especially when
phenobarbital is being used, dietary indiscretions, alcohol,
and fatigue are all factors which might oroduce this con-
dition. There is no specific treatment for status epilep-
ticus, and the drug that will work in one case will have
no effect on another. Several methods may have to be
tried before the seizures are stopped. Sodium luminal,
given intravenously in 3 to 5 gr. doses for adults, will
usually stop the seizures. We have given as much as
12 gr. intravenously with no serious effects. Paraldehyde
in I to 4 dram doses, per rectum, can also be used. Ether
given by the open drop method to full anesthesia, avertin
given in two-thirds to three-fourths the usual anesthetic
dose, and magnesium sulfate, 10 cc. of a 25 per cent
solution given intravenously, are other methods that can
be employed in the treatment of this condition. Good
nursing care during the attack is essential. One must be
on the alert to prevent hyperthermia by encouraging heat
loss and inhibiting heat production. Fluids may be given
within reasonable limits. Precautions must also be taken
to prevent the patient from injuring himself by falling
out of bed or biting his tongue during a convulsion.
414
Tetanus
The best treatment of tetanus is in its prevention. In
the majority of instances, this can be accomplished by
the administration of the antiserum in all contaminated
injuries. In the event that this treatment is not success-
ful or in case serum had not been given, more energetic
treatment must be used. The diagnosis is based on the
history and evidence of a wound or injury, by stiffness
in the use of the neck and jaw muscles and cramps or
spasms in the region of the wound. As the infection pro-
gresses, the patient will have slowness in swallowing,
opening the mouth and extruding the tongue, increase in
tonus of the facial muscles and occasional twitches in the
muscles. Toxic symptoms will also appear, in the form
of restlessness, generalized aches and pains especially in
the back and head, and sweating. Dysphagia and trismus
or risus sardonicus appear later. This latter is character-
ized by elevation of the eyebrows, narrowing of the pal-
pebral fissures, exposing of the teeth and depression of
the angles of the mouth. When the diagnosis of tetanus
has been made, an initial intravenous injection of at least
50,000 units of antitetanic serum is made.4 This is for
the purpose of neutralizing all the toxin in the body
which is still free and unaltered. This dose is enough to
counteract the toxin in one who has a chance to recover.
Massive doses are not necessary, for if one full lethal
dose of tetanus toxin is fixed and altered by the central
nervous system, 1,000,000 neutralizing doses on antitoxin
will not save the patient. After this initial dose, daily
injections of 5,000 units are given to insure the neutrali-
zation of any additional toxin that may be absorbed. In
addition to the above treatment, 10,000 units of antitoxin
are infiltrated into the wound and about one hour later
the wound is incised to allow for full drainage. Fifteen
thousand to twenty thousand units of the serum can also
be given intrathecally in very severe cases. The convul-
sions must be controlled. Generally, this can best be
accomplished by giving paraldehyde per rectum every
three hours in doses varying from 10 to 40 cc. This can
also be given with normal saline intravenously by the
continuous drip method. Drugs which depress the re-
spiratory centers are definitely contraindicated. In very
severe cases, one may have to resort to artificial respira-
tion, tracheotomy, or oxygen inhalations. It is important
to maintain adequate fluid and nourishment during the
course of the illness.
Emotional Depression
A depression, whether of the neurotic (which occurs
in the various psychoneuroses and even with somatic dis-
ease) or the psychotic type (such as occurs in the manic
depressive psychoses and involutional melancholia) , is
always an emergency, in that there is a constant threat
of suicide present. One has only to note in the daily
newspapers the number of suicides by hanging, jumping
from high places, asphyxiation, poison, etc., in order to
realize the lack of appreciation of the dangers of depres-
sions. Every depressed patient is a potential suicide, and
means to protect the individual from himself should be
taken. It is a fallacy to presume that those individuals
who show no outward evidence of a depression but who
threaten suicide will not attempt it. I am reminded of
an instance, the case of an elderly woman who had nu-
The Journal-Lancet
merous somatic complaints of a functional nature, loss
of interest, and fatigue, who felt she had outlived her
usefulness and was only a burden to her family. No one
took her threats of ending her life seriously until one
night when she jumped out of a second story window
and was instantly killed.
The psychotic depressions, with retardation both of
psychic and motor activity, frank feelings of depression
with morning aggravation and evening amelioration, self-
accusation and preoccupation, are not difficult to recog-
nize, and adequate precaution should be taken with them
as well as with those who are only mildly depressed or
discouraged.
With the advent of the various forms of shock ther-
apy, especially electroshock, the number of hospital days
of treatment has been materially reduced, and in the
great majority, recovery takes place.
The following case histories are typical. The first is a
woman of 53 who had been in the hospital for three and
one-half years, suffering from a severe involutional mel-
ancholia. She was depressed and agitated, had numerous
self-accusatory ideas and wanted to die. She constantly
begged the nurses to let her jump out of the window or
to take her down to the river where she could drown
herself. She attempted suicide by hanging prior to her
admission to the hospital and once following admission.
She went on several hunger strikes in an effort to starve
herself to death. It was at this time that we began to use
metrazol (which I understand has now been replaced by
electroshock) at the North Dakota State Hospital, and
she was one of the first patients to receive this drug. She
made a rapid and complete recovery, was discharged
from the hospital and remains well and active today. The
other case is a 56 year old female who was admitted to
the hospital with a marked agitated depression. She had
attempted suicide by drowning prior to admission. This
patient felt she had sinned against the Holy Ghost, could
not be forgiven, and was doomed to hell’s fires. While
in the hospital she attempted suicide by hanging, but for-
tunately was discovered before she died. She was given
metrazol and made a complete recovery and has resumed
her church work with her husband who is a minister.
Summary
Several neuropsychiatric conditions have been discussed,
from the standpoint of " emergencies.” Prompt recog-
nition of certain definite syndromes and signs, such as
the syndrome of increasing intracranial pressure and of
meningeal irritation, inequality of tendon reflexes, cord
compression, root pains, pathological reflexes, and changes
in the mental and emotional state should lead one to
further special investigations which will result in early
diagnosis and prompt treatment, and will in the majority
of instances prevent death or possible chronic invalidism.
Bibliography
1. Hirshfield, B. A., Tornay, A. S., and Yaskin, J. C.: Spon-
taneous subarachnoid hemorrhage: an analysis of fifty cases, Arch.
Neurol. 6c Psychiat. 49:483-484 (March) 1943.
2. Wilson, S. A. Kinnier, and Bruce, A. Ninian: Neurology,
Baltimore, Williams &C Wilkins Co., 1940, vol. II. chapt. XC,
pp. 1595-1607.
3. Bennett, A. E., and Cash, Paul T.: Myasthenia gravis:
curare sensitivity; a new diagnostic test and approach to causation.
Arch. Neurol. & Psychiat. 49:537-547 (April) 1943.
4. Firor, Warfield M.: The treatment and prevention of tet-
anus— collective review, Surg., Gynec. &1 Obstet. 75:185-190
(April) 1942.
December, 1943
415
Differentiation of Functional and Organic
Neuropsychiatric Conditions*
Walter A. Carley, M.D.
St. Paul, Minnesota
THE similarity of the signs and symptoms of many
organic and functional conditions is well known.
In confusing cases the diagnosis has heretofore
usually been organic disease; this has been owing to the
lack of understanding on the part of the clinician, who
fears that diagnosing a patient as ill but not physically
so will carry with it a marked stigma to both patient and
family. This is demonstrated by the fact that organized
medicine recommends in its classification of diseases that
in case of doubt a diagnosis of arteriosclerotic dementia
should be preferred to one of senile psychosis.
In our undergraduate training much time was spent
on the organic aspects of such conditions as pneumonia,
peptic ulcer, brain tumor and fractures, but very little
time on the functional conditions. However, this attitude
is now changing, bringing with it new concepts of and
approaches to many human ailments.
The following case, to be considered in detail later on,
is an example of the similarity of functional and organic
symptoms. This patient first became ill with nausea and
pain in his epigastrium. Shortly after this, he felt dizzy
and it was necessary for him to lie down. Peculiar sen-
sations radiated through his arms and legs, and soon all
four extremities began to twitch. On examination the
patient was found to be conscious: along with the pre-
vious symptoms there were noted a marked fluttering of
the eyelids, generalized convulsive twitchings, and tachy-
cardia. Other physical findings were negative. The pa-
tient was given a further neurological examination, rou-
tine and special laboratory tests, and x-ray and spinal
fluid examinations.
Finding all of these tests negative, the neurologist
would probably make a diagnosis of encephalitis. How-
ever, further training would equip him with the means
of arriving at a more correct diagnosis and treatment.
The dislike for dealing with something that we cannot
see, feel, or put under a microscope is understandable.
Yet there is something that differentiates each of us
from a machine which always responds in the same man-
ner to the same stimulus. This something is important
to our remaining well, and is the factor to which the
organic clinician fails to attach proper significance. He
may feel that there should be no such diagnosis as hys-
teria, and that to make such a diagnosis merely means
that the physician is too lazy to seek out some structural
pathology. Some clinicians will admit the condition is
functional, but only upon being able to give no adequate
structural explanation for the patient’s condition. At
this point they are likely to dismiss the patient by telling
him to forget his ailment.
To say merely that a patient’s condition is organic or
functional means little to anyone. It is like saying that
*Read before the Ramsey County Medical Society, February
22, 1943.
the sounds we heard at a concert were musical. Yet, if
we are told what music we have heard, and if we can
be made to understand the music in its many phases, then
we come to appreciate its total value and then only know
how to criticize it.
Organic teachings have attempted exactly this. One
of the most important aspects of structural pathology is
its cause and pathogenesis, involving an understanding
of how the morbid process has developed so that we will
have a better knowledge of how to treat it. Similarly,
the cause and dynamic development of pathological func-
tional conditions are now being taught and studied.
The newer concept of diagnosing and treating these
conditions lies not only in excluding every organic con-
dition but in arriving at a positive functional diagnosis,
such as hysteria, schizophrenia, manic depressive psy-
chosis, etc., by a study of the patient as a whole.
Case Report
Applying these new concepts to the case referred to
above, we arrive at an entirely different understanding
of the patient and his sickness, which may lead us to a
satisfactory diagnosis, at least to a much more logical
basis from which to work. This is done, first, by a study
of the patient’s personality as it appears at the time;
secondly, by the study of his past experiences and his
adjustment to his previous problems. Perhaps these facts
alone will show a definite pathological background, in-
fluencing his present behavior.
A study of our patient according to these methods
reveals many significant findings. Shortly after his ad-
mission to the hospital it was noted that although he
seemed quite out of contact with reality and unable to
control his movements, he readily understood the doctor,
who told him that he would have to stop jerking his arm
if he did not want to cause himself additional pain dur-
ing an intravenous injection, and promptly curtailed the
convulsive movements of the arm.
A search into this man’s history revealed the early de-
velopment of a neurotic personality, as well as the pre-
cipitating factors in the present situation.
The fourth of seven children, he was born on a small
farm in southern Minnesota. As a child he was shy, sen-
sitive, and rather easily hurt. Although he played well
with his brothers and sisters, he tended to stay away
from strangers. He developed many fears and fantasies,
mostly concerned with impending personal disaster.
His mother was described as nervous, tense, and a hard
worker. His father was strict, demanding, but not brutal.
Both were extremely religious.
His parents had considerable difficulty in persuading
him to go to school and much of his first year there was
spent in crying. He did well in school, but worried con-
siderably about his marks, even though he passed readily.
416
The Journal-Lancet
He concentrated hard on sports and did fairly well; he
said his efforts were in order to get the recognition of his
schoolmates, to whom he felt inferior in every respect.
Although troubled by many problems, he found no one
to whom he could turn and so kept his feelings to him-
self. This habit has continued up to the present time
and is the cause of much of his distress.
He decided to study for the clergy. Here, too, his
fears and feeling of insecurity and inferiority followed
him in all his efforts. He worked hard. Each year
seemed to find him more exhausted and burdened with
increasing problems. His feeling of tension and exhaus-
tion, however, he kept to himself.
During his third seminary year the first symptoms of
his impending neurosis became evident. Because of his
tenseness, apprehension, indecisiveness, and poor sleep
he consulted a doctor, who examined him and prescribed
a sedative. His concern was somewhat eased by a vaca-
tion.
He finished his schooling and, after being ordained, he
remained fairly well adjusted for two years. During this
time he was associated with two other assistants whose
friendship he greatly enjoyed, and, although the work
was hard, he was happy.
Then he received an assignment as only assistant to
another pastor. The patient had been warned that this
pastor was a stern, pessimistic, nonjovial individual with
whom several assistants had had trouble, yet he decided
to accept the position. Incidentally, it is noted that the
pastor had had to be hospitalized for a "nervous break-
down” a few years previous.
For two and a half years the patient struggled under
an almost intolerable situation. There was no satisfac-
tion in his association with his pastor, who was so strict
that our patient took on many additional duties as an
excuse to get away from his elder.
He began showing signs of his neurosis two months
before his hospitalization — irritability, poor appetite, poor
sleep, and anxiety. These increased in intensity up to the
point at which hysterical manifestations incapacitated him
for work.
This history, revealing these previous periods of mal-
adjustment, provides a logical basis for further study and
treatment. Further personality studies might include psy-
chometric examinations, hypnosis, narcosis, various asso-
ciation tests, and psychoanalysis.
Psychiatry in Diagnosis
An understanding of the patient’s personality is im-
portant in many other fields besides neurology. This is
evidenced by the recent development in the field of psy-
chosomatic medicine. Certain types of dermatitis, thyroid
dysfunctions, allergies, colitis, and peptic ulcer have been
studied from this point of view.
At a recent medical meeting in a discussion of peptic
ulcer the internist said that he felt that surgical treatment
was inadequate, the surgeon that medical treatment was
insufficient. Although Pavlov’s classical experiments
proved that the gastric acidity of dogs varies directly with
emotional stimulation, yet there was no consideration on
the part of either clinician of any of the patient’s emo-
tional factors.
The past dislike of psychiatry on the part of most doc-
tors is well known and understandable. They disliked it
because it was too abstract, too full of vague terms, but
mostly because its only result was to classify the patient
under some diagnostic heading. This situation has grad-
ually changed, and psychiatry is no longer a descriptive
science that accepts an organic explanation for its find-
ings. Rather is it now a study of the causative and de-
velopmental factors embracing the treatment of patients
who are functionally ill.
News-Letter
of the American Student Health Association
DIGEST OF MEDICAL NEWS
Lt. Comdr. D. F. Smiley, MC, USNR
A New Conception of Fungus Infection of the Skin.
For many years the main emphasis in combating the
fungus infection of the feet and groin has been placed on
the prevention of new exposure to exogenous infection
by means of foot baths, spraying of floors, etc. Sulz-
berger, Baer and Hecht (Arch. Dermat & Syph., April,
1942) now express the belief that since conjugal and
familial transmission of ordinary fungus infections of the
feet and groin is either non-existent or a great rarity,
alterations in host susceptibility and loss of local im-
munity are more important factors than is exogenous
infection. According to this concept, frequent washing of
the feet and careful drying of the skin between the toes
is more important preventively than soaking the feet in
medicated foot baths.
Early Mobilization of Head Injury Cases. Many phy-
sicians have felt that head injury cases should be kept in
bed for a minimum of two or three weeks. As the result
of a wide experience in the Head Injury Centers in Great
Britain, Cairns reports that these patients recover and re-
turn to duty much more quickly if they are allowed to
be up and about as soon as they recover consciousness
and feel able. Shearburn and Mulford in the October
(1943) issue of the Bulletin of the Army Medical De-
partment concur in the opinion that early mobilization of
head injury cases is advisable.
Dermatitis Due to Resin-finished Shorts and Fabrics.
Harry Keil (Jour, of Allergy, Sept., 1943) presents evi-
dence that neither abietic acid nor glycerin abietate is the
cause of the contact dermatitis due to certain resin-fin-
ished fabrics. The etiologic agent is apparently a special
esther gum existing in a water-miscible, emulsified form
produced by the introduction of a wetting agent such as
December, 1943
417
lauryl sodium sulfate or triethanolamine oleate. This
emulsion is thoroughly worked into the fabric but is re-
moved (since it is water-miscible) by perspiration and by
washing. Since perspiration is present in larger amounts
in summer than in winter, the dermatitis is more often
seen in summer than in winter. According to the author,
shorts containing these irritative resinous emulsions are
still commonly found on the market.
Effect of Sulfonamide Therapy on the Common Cold.
Kanvar and Mount in the September (1943) issue of the
Journal of the Kansas Medical Society report their study
of 127 patients with upper respiratory infections of un-
known etiology as follows:
1. "There were 75 cases that were treated symptom-
atically and 52 comparable cases that were in addition
treated with sulfonamide.’’
2. "In this study there was no evidence that the chemo-
therapy influenced the course of the disease or prevented
complications.’’
3. "Complications secondary to chemotherapy admin-
istration tend to be more frequent and more severe than
those following the usual respiratory infection. Use of
chemotherapy in a trivial case may sensitize the individual
so that its subsequent use is contraindicated in a more
serious illness where it is urgently needed.’’
4. "Careful clinical observation should enable the phy-
sician to select those upper respiratory infections which
require sulfonamide administration.’’
False Positive Serologic Reactions in Symptomless
Malarial Carriers. T. R. Dawber in the October (1943)
issue of Internal Medicine presents two cases "in which
a diagnosis of syphilis was erroneously made on serologic
reactions found to be positive because of latent malarial
infection. In each case development of clinical malaria
occurred before antisyphilitic treatment was begun.’’ This
is definitely at variance with the statement of Mohr,
Moore and Eagle that such false positive serologic tests
were to be expected in malaria "only during, or shortly
after the acute febrile illness.”
Alkalis with the Sulfonamides. The Committee on
Chemotherapeutic and Other Agents of the Division of
Medical Sciences, National Research Council, at a meet-
ing, Sept. 3, 1943, passed the following recommendation:
"The incidence of oliguria, hematuria, and anuria follow-
ing sulfadiazine therapy may prove to be great under
conditions where the output of urine cannot be main-
tained above 600 or 800 cc. per day, as in tropical cli-
mates where a shortage of water exists. It is recommend-
ed that under conditions where such complications are
being encountered the medical officers shall administer
an initial dose of 4 grams of sodium bicarbonate together
with an initial dose of sulfadiazine, and shall follow this
with 2 grams of sodium bicarbonate every four hours
regardless of the dosage of sulfadiazine being employed.
In the management of complications, resulting from the
toxic action of sulfadiazine on the kidneys, the adminis-
tration of even larger doses of alkali, such as 3 or 4
grams every four hours may be helpful.”
Acute Poisoning from Cadmium-plated Food Con-
tainer. On October 2, 1943, ten men in a U. S. Naval
motor torpedo boat squadron were made acutely ill with
nausea, vomiting and diarrhea as the result of drinking
lemonade which had been stored for several hours in
cadmium-plated food containers. Frant and Kleeman
(J .A.M .A. 117:86-89, 1941) state: "The association of
immediate food poisoning of groups with the ingestion
of an acid liquid prepared in a metal container should
cause suspicion, and an immediate investigation for the
presence of cadmium-plated utensils should be made.”
The Treatment of Meningococcus Carriers with Sulfa-
diazine. Cheever, Breese and Upham in the October
(1943) issue of Internal Medicine make the following re-
port on the use of sulfadiazine prophylactically in an
outbreak of meningococcal infections occurring in a large
naval construction training center:
1. At the beginning of the experiment, 57.7 per cent
of the men showed nasopharyngeal cultures positive for
meningococci (46.7 per cent positive for Type I organ-
isms, 5.5 per cent positive for Type II organisms, 3.9
per cent positive for Type II Alpha organisms, 1.6 per
cent positive for untypable meningococci) .
2. Men from a barrack known to have a high carrier
rate were divided into two approximately equal groups.
One group (the treated) was given 3 grams of sulfadia-
zine in divided doses on the first day, 3 grams on the
second and 2 grams on the third — a total of 8 grams in
72 hours. The second group (the untreated) received
no special medication but lived, worked and messed with
the treated cases. Both groups were cultured at the be-
ginning, at 72 hours, and at 144 hours.
3. The results in the two groups in terms of percent-
age of total cultures positive were as follows:
Population 0 hrs. 72 hrs. 144 hrs.
Treated 203 79.31 00.00 00.49
Untreated 186 58.06 80.64 76.35
The authors conclude: "Sulfadiazine is effective in
clearing the nasopharynx of meningococci since all of 161
meningococcus carriers receiving 8 grams of the drug
over a period of 72 hours yielded negative cultures on
the fourth day.”
Caffeine Withdrawal FJeadache. Dreisbach and Pfeif-
fer, after finding that 25 of 128 migraine patients re-
ported that lack of their usual coffee resulted in head-
ache, attempted to produce this phenomenon. They ad-
ministered caffeine usually for a week and then abruptly
withdrew it. In 55 per cent of 38 trials on 22 subjects
sudden withdrawal of the caffeine produced as severe
headache as the patients had ever experienced. In 29
per cent of the trials there was definite headache but not
of severity to demand treatment. In 16 per cent of the
trials no headache of any importance occurred. Blood
studies appeared to show a lowered serum calcium, an
elevated serum phosphorus, and possibly an increased
blood volume accompanying the headache. (Jour, of Lab.
& Clin. Med., July, 1943).
Morphological Structure of Rickettsiae. Upon exam-
ination with the help of the electron microscope the rick-
ettsiae of epidemic typhus, of endemic typhus, of Rocky
Mountain spotted fever, and of Q fever were found to
be strikingly similar to each other in appearance. Dis-
tinguishing one species from another by appearance alone
is so far impossible. Each species does, however, present
418
great variation in its morphology. In all four species
bacillary forms and much smaller coccoidal forms were
demonstrated. This variation in morphology among
rickettsiae of the same species is quite in contrast to the
relative uniformity of viruses which have so far been
studied by means of the electron microscope. (Plotz,
Smadel, Anderson, Chambers, in Jour, of Experimental
Med., April 1, 1943).
Intradermal Vaccine Therapy in Brucellosis. Urschel
reports that 87.5 per cent of 28 undulant fever patients
who received intradermal injection of brucella vaccine
(mixed, heat-killed) obtained fair, good, or excellent re-
sults. The injections averaged 20 per patient and were
given at five- to seven-day intervals into the forearm or
The Journal-Lancet
medial surface of the thigh. (Indiana State Med. Assn.
Journal, August, 1943).
Futility of Intravenous Use of Arsenicals in Vincent’s
Infection. E. C. O. Jewesbury in the September 18
(1943) issue of the British Medical Journal reported the
development of typical Vincent’s infection of the gums
and buccal mucous membranes of two patients who were
under treatment for syphilis. One patient had received
5 grams of intravenous arsenical (N.A.B.), the other
had received one course of 5.55 grams two months pre-
viously and had had 4.65 grams on his second series
when the Vincent’s infection started. Such evidence
would certainly make it appear futile to give intravenous
arsenicals for the treatment of Vincent’s infections of
the mouth and gums.
LIST OF PHYSICIANS LICENSED BY THE MINNESOTA STATE BOARD OF MEDICAL EXAMINERS
ON NOVEMBER 5, 1943
OCTOBER EXAMINATION
Name School
Bacon, John Fremont U. of Pa., M.D. 1942
Blake, Allan John .... Marquette U., M.D. 1943
Cameron, John Minge _ -Harvard U., M.D. 1942
Collins, Royden Fred U. of Wis., M.D. 1942
Cronkite, Alfred Eugene Stanford U., M.D. 1938 ..
Geist, Susanne U. of Minn., M.B. 1942, M.D. 1943 ...
Hagedorn, Albert Berner ... Stanford U., M.D. 1943
Haines, Richard DeWayne U. of Rochester, M.D. 1942 ...
Hall, William Everett Marquette U., M.D. 1943
Huseby, Robert Arthur U. of Minn., M.B. 1943
Hutchins, Selwyn Percival Rice U. of Texas, M.D. 1941
lams, Alexander Murdoch — U. of Pa., M.D. 1942
Klontz, Charles E., Jr. U. of 111., M.D. 1942
Lenz, Gilbert Gordon U. of Minn., M.B. 1943
Levin, Louis U. of Cincinnati, M.D. 1941
McClellan, James Thomas U. of Okla., M.D. 1942
Millen, Francis Joseph Marquette U., M.D. 1942
Oliver, James Northwestern, M.B. 1943
Peterson, Floyd Russel ...U. of Minn., M.B. 1943
Rousuck, Asher Ashley Wayne U., M.D. 1940
Sborov, Abe Michael U. of Minn., M.B. 1943 ..
State, David U. of Western Ontario, M.D. 1939
Stevenson, Margaret Lydia U. of Minn., M.B. 1942
Stueland, A. J. Richard Temple U., M.D. 1943
Thomas, Henry Randall U. of Pa., M.D. 1939
Tompkins, Souther Fulton Washington U., Mo., M.D. 1942 ...
Williamson, Robert James Douglas U. of Toronto, M.D. 1940
Wilson, Hal Truax U. of Michigan, M.D. 1942
Wilson, Thomas Reid La. State U., M.D. 1941 .
Wood, Wilbur Donald U. of Minn., M.B. 1940, M.D. 1941
BY RECIPROCITY
Douglass, Bruce Eccles U. of Wis., M.D. 1942
Fair, Ellis Edwin U. of Okla., M.D. 1941
Graham, Russell Bion ..... U. of Colo., M.D. 1942
Guenther, Theodore August .. ... U. of Mich., M.D. 1940
Henry, Earl Wilson Johns Hopkins, M.D. 1940
Kirkland, William George Hahnemann Med. Coll., Pa., M.D. 1938
Pease, Gertrude Lorna ..Creighton U., M.D. 1941
Reif, Harold Alfred Wayne, U., M.D. 1937
Rickard, Elsmere Rife Northwestern, M.B. 1923, M.D. 1924 ...
Robson, John Theodore .... U. of Ore., M.D. 1942
Spar, Arthur Aaron U. of Neb., M.D. 1942
Address
.328 E. Henn. Ave., Minneapolis, Minn.
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Mayo Clinic, Rochester, Minn.
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Ancker Hospital, St. Paul, Minn.
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Ancker Hospital, St. Paul, Minn.
St. Luke’s Hospital, Duluth, Minn.
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University Hospital, Minneapolis, Minn.
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NATIONAL BOARD CREDENTIALS
Deterling, Ralph Alden, Jr. Stanford U., M.D. 1942
Gentry, Robert Wilton Harvard U., M.D. 1942
Heskett, Robert Glynn Harvard U., M.D. 1941
Jarboe, James Parran Georgetown U., M.D. 1942
Mickelsen, Emma Florence U. of Minn., M.B. 1937, M.D. 1938
Mayo Clinic, Rochester, Minn.
Mayo Clinic, Rochester, Minn.
University Hospital, Ann Arbor, Mich.
Mayo Clinic, Rochester, Minn.
4390 Coolidge Ave., Minneapolis, Minn.
American Student Health Assn.
Minneapolis Academy of Medicine
Montana State Medical Assn.
Montana State Medical Assn.
Dr J. P. Ritchey, Pres.
Dr. M. G. Danskin, Vice Pres.
Dr. Thos. F. Walker, Secy. -Treat.
American Student Health Assn.
Dr. J. P. Ritenour, Pres.
Dr. J. G. Grant, Vice Pres.
Dr. Ralph I. Canuteson, Secy.-T reas.
Minneapolis Academy of Medicine
Dr. Roy E. Swanson, Pres.
Dr. Elmer M. Rusten, Vice Pres.
Dr. Cyrus O. Hansen, Secy.
Dr. Thomas J. Kinsella, Treas.
The Official Journal of the
North Dakota State Medical Assn.
North Dakota Society of Obstetrics
and Gynecology
ADVISORY COUNCIL
North Dakota State Medical Assn.
Dr. Frank Darrow, Pres.
Dr. James Hanna, Vice Pres.
Dr. L. W. Larson, Secy.
Dr. W. W. Wood, Treas.
Sioux Valley Medical Assn.
Dr. D. S. Baughman, Pres.
Dr. Will Donahoe, Vice Pres.
Dr. R. H. McBride, Secy.
Dr. Frank Winkler, Treas.
South Dakota State Medical Assn.
Sioux Valley Medical Assn.
Great Northern Ry. Surgeons' Assn.
South Dakota State Medical Assn.
Dr. J. C. Ohlmacher, Pres.
Dr. D. S. Baughman, Pres.-Elect
D. William Duncan, Vice Pres.
Dr. Roland G. Mayer, Secy. -Treas.
Great Northern Railway Surgeons’ Assn.
Dr. W. W. Taylor, Pres.
Dr. R.C. Webb, Secy.-T reas.
North Dakota Society of
Obstetrics and Gynecology
Dr. John D. Graham, Pres.
Dr. R. E. Leigh, Vice Pres.
Dr. G. Wilson Hunter, Secy .-Treas.
Dr. J . O. Arnson
Dr. H. D. Benwell
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. Ruby Cunningham
Dr. H. S. Diehl
Dr. L. G. Dunlap
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. A. R. Foss
Dr. j ames M. Hayes
Dr. A. E. Hedback
Dr. E. D. Hitchcock
Dr. R. E. Jernstrom
Dr. A. Karsted
Dr. W. H. Long
Dr. O. J . Mabee
Dr. J. C. McKinley
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. C. H. Nelson
Dr. Martin Nordland
Dr. T. C. Ohlmacher
Dr. K. A. Phelps
Dr. E. A. Pittenger
Dr. T. F. Riggs
Dr. M. A. Shillington
Dr. J . C. Shirley
Dr. E. Lee Shrader
Dr. E. I . Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. W P. Smith
Dr. C. A. Stewart
Dr. S. E. Sweitzer
Dr. W. H. Thompson
Dr. G. W. Toomey
Dr. E. L. T uohy
Dr. M. B. Visscher
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 84 South Tenth Street, Minneapolis, Minnesota
W. L. Klein, 1851-193 1
Minneapolis, Minnesota, December, 1943
NEUROPSYCHIATRIC ADVANCES AT
THE WAR FRONT
Any classification of nervous diseases may well start by
dividing them into organic and functional. In the former
there is a demonstrable lesion as the causative factor, a
definite tissue change to which the disorder may be
ascribed while in the latter the etiology is more ambigu-
ous and often quite speculative due to the fact that in a
functional disease there is derangement of an organ’s
normal action without any structural change.
With our present state of knowledge, the term func-
tional disease is entirely proper but many feel that it is
rather unsatisfactory as a scientific expression of diag-
nostic entity. Perversion of function constitutes disease
but the realist likes to look beyond this for some morbid
change in the tissues to account for it as the underlying
cause. He shows a disposition to avoid the term by sub-
stituting such expressions as neurosis, anxiety states, and
neuropychiatric conditions.
Fatigue is a common symptom in functional disorders
and in addition to the purely subjective symptom it may
manifest itself by clumsiness and tremor of the hands,
diminished power of concentration at exacting tasks.
There is often headache, backache, anorexia and insom-
nia. Some individuals become tense, depressed, resentful
and irritable, portraying general anxiety. Mild forms of
anxiety neuroses are seen by the general practitioner ev-
ery day. Many of them get along on a mild sedative
that produces a relaxed indifference until adjustment of
internal to external relations shall have been accom-
plished by time and the further guidance of a wise
family doctor.
Sinistrosis will probably be a more popular name here-
after for that dreadful "shell shock” that so many of our
soldiers suffer from when frustrated in combat on our
battle lines. In the past only physical injuries were treat-
ed at the front and those suffering from any form of
neuropsychiatry were forced to wait for evacuation to
420
The Journal-Lancet
some remote establishment in the rear. Since the Tu-
nisian campaign when marvelous benefits became appar-
ent from forward area psychiatry in these cases, however,
there has been a demand from the medical corps for
more experts to treat them like other emergencies as soon
as they are found. The results so far reported have been
hailed as among the most outstanding advances in med-
ical treatment to come out of the war. A. E. H.
INTRATHORACIC INTEREST
Medical literature has recently given emphasis to four
intrathoracic conditions which seem to have assumed new
importance because of recent illumination. The diseases
referred to are bronchial adenoma, pulmonary embolism,
traumatic carditis, and coccidioidomycosis. They are re-
lated only in their locale.
Bronchial adenoma usually occurs in younger adults,
80 per cent under forty, and most of the symptoms are
those which arise secondary to mechanical factors. Early
diagnosis is difficult but important because satisfactory
treatment depends on operative removal, either by tho-
racic surgery or by the bronchoscope. In its early stage
it is most frequently misdiagnosed as pulmonary tuber-
culosis.
There is nothing particularly new about pulmonary
embolism except the new emphasis on single or repeated
emboli or infarcts arising from asymptomatic phlebo-
thrombosis of the deep vessels of the leg. Attacks of
faintness, prostration, unexplained fever, or more severe
symptoms attended by shock and resembling coronary
occlusion should not be dismissed without directing atten-
tion to the deep vessels of the calf where symptomless
thrombi frequently occur. Twenty per cent of pulmo-
nary emboli on the medical service at the Massachusetts
General Hospital were found to have their origin in the
deep venous plexus of the calf.
Traumatic carditis is another vague intrathoracic con-
dition. Symptoms resembling coronary sclerosis or myo-
carditis may appear any time up to three months after
the actual injury. In fact the injury is often forgotten
when substernal pain, dyspnea, and circulatory disturb-
ances bring the patient to the doctor. Investigators of
this subject find that serial electrocardiograms in addition
to other adjuncts of heart diagnosis are often necessary
to obtain a true conception of the frequency of this type
of injury.
Coccidioides immitis is a fungus indigenous to the
southwest desert areas. It frequently gives rise to a pul-
monary infection resembling tuberculosis in its pathology
and insidious manner of onset. Occasionally, however,
it produces an acute influenza-like illness or an arthritic
form known locally as San Joachim fever or a dissem-
inated granulomatous involvement which may be fatal.
It may be diagnosed by an intradermal test analogous
to the Mantoux. Its wider interest at this time is occa-
sioned by the large number of army troops undergoing
training in the desert areas.
The apparent increase in incidence of the above men-
tioned intrathoracic conditions is due for the most part
to improved diagnostic proceduers and advancing clin-
ical acuity. L. M. D.
THOMAS ANDREW STOREY, Ph.D., M.D.
1875 - 1943
Death has removed from our midst Dr. Thomas A.
Storey, Emeritus Professor of Hygiene and Physical Ed-
ucation at Stanford University, California. The end of
his distinguished career occurred October 27, 1943, at
Atlanta, Georgia, where he was directing an important
war educational program for the American Social Hy-
giene Association.
His passing has deprived this country of an able
scholar and stimulating teacher in the field of college
hygiene, physical education, and organized student health
work. Dr. Storey’s most potent contribution to the field
of hygiene was his philosophical approach to the subject
health based upon sound biological foundations. It was
his concept of hygiene that guided his activities during
all the years of his professional life; and the contribu-
tions he made to the field of knowledge in the form of
his teaching and his writing reflected always his belief in
the necessity of integrating the specific branches of hy-
giene into an organic whole.
He entered Stanford University in the pioneer period
of its founding, was a classmate of President Ray Lyman
Wilbur. His interests were in physiology and kindred
biological subject and led to a Ph.D. degree in 1902.
In 1905 he received his M.D. degree from Harvard
Medical School, and after his internship, he was called as
Professor and Director of Physical Education and Hy-
giene at the College of the City of New York. In 1926
he returned to his Alma Mater where he organized and
became director of the Department of Hygiene, Physical
Education and Athletics. During this interim he devel-
oped the Student Health Service. This is his monu-
ment. Author of textbooks, a syllabus, and many scien-
tific contributions, he was honored by being Consultant
of the American Social Hygiene Association, Secretary-
general of the Fourth International Congress of School
Hygiene, Ex-secretary to the President’s Committee of
Fifty on College Hygiene, and was President of the
American Student Health Association 1925-27 and a
member of the Council at the time of his untimely death.
As chairman of a committee he organized the Pacific
Coast Association, a component regional society of the
parent association, besides being a member of many na-
tional honor societies in medicine, physical education,
and public health. The Gullick prize medal was award-
ed him for distinguished services in the field of physical
education and allied subjects.
Dr. Storey is survived by his widow and three grown
daughters to whom the Association extends its heartfelt
sympathy.
At the services held in the beautiful Stanford Mem-
orial Church on November 12, faculty, friends, former
students, and many members of the American Student
Health Association attended to pay tribute to the sterling
character and kindly spirit of Dr. Storey, and to honor
and cherish the memory of one who helped to make the
world a better place to live.
Robert T. Legge, M.D.
American Student Health Association,
Berkeley, California
December, 1943
421
BmU HewU ws
Allergy, by Erich Urbach, M.D., with the collaboration of
Philip M. Gottlieb, M.D. New York: Grune and Stratton,
Inc., 1943; 1100 pages, 400 illustrations, 80 tables and charts.
Price #12.
Conceived by a writer and teacher of international promi-
nence,, with a quarter of a century experience, Doctor Urbach’s
book presents a concrete guide for the diagnosis and manage-
ment of all allergic diseases. It inclueds a basic critical analysis
of the accumulated scientific research upon which the principles
of allergy are based. Emphasis is laid on the clinical and tech-
nical advances of today. The new concepts of diseases of hyper-
sensitiveness are stressed as pathergy, heteroallergy, endogenons
allergy, and there is a comparison of the advantages of de-
allergizatron and hyposensitization. The author’s method of
deallergization by the method of oral skeptophylaxis is pre-
sented in detail.
There are three divisions of the text. Part I deals with the
fundamentals of hypersensitiveness and the principles of diag-
nosis and treatment. Part II discusses the entire range of
offenders responsible for allergic diseases — inhalant and food
allergens, contactants, physical agents, bacterial allergens, etc.
Part III extensively deals with the symptomatology and therapy
of allergic diseases.
The 400 illustrations and 80 tables and charts are invaluable
aids in differential diagnosis, and present at the same time a
most welcome visual survey of the clinical manifestations and
testing methods in every type of allergic condition. Nine full-
page graphic pollination calendars are another feature of the
book. There is a most comprehensive review of the literature.
The book is well bound, has good type and paper; and the pic-
tures carry a real meaning to the reader. General practitioner
and any specialist applying allergy to his practice will find it
complete, practical and accurate.
Nervous Indigestion and Pain, by Walter C. Alvarez,
M.D., New York: Paul B. Hoeber, Inc., 488 pp., 1943,
#5.00.
As a successor to Alvarez’s previous book Nervous Indiges-
tion, the present work is more detailed in the discussion of the
meaning of symptoms. The importance of such a discussion
stems directly from the circumstance that about half of the
patients who relate complaints to the stomach or bowel have
no organic lesion of the gastrointestinal tract, and most of them
have no bodily disease at all. From a wealth of personal ex-
perience, a broad physiologic background and a sympathetic
understanding of the miscalled "nervous” patient, Dr. Alvarez
is able to analyze and explain symptoms such as bloating, belch-
ing, nausea, vomiting, heartburn, diarrhea and constipation.
Each condition is illustrated by a sprightly anecdote and ex-
plained upon the basis of personally conducted experiments.
Adding to the entertainment and no little to the instructive
value of the book are the delightful quotations heading each
chapter; these alone comprise an education in classifical medi-
cine. The bibliography and suggestions for supplementary read-
ing constitute a postgraduate course in gastroenterology. The
facile, informal, flowing style is characteristic of the author.
The Compleat Pediatrician, by W. C. Davison, M.D.,
Durman, N. C.: Duke University Press, 256 pp., 1943, #3.75
Between the covers of this book there is an enormous amount
of material which helps the physician in one of the simplest
ways to diagnose and treat the diseases of infants and children.
Many of the illnesses of the child have symptoms and signs
which are not well understood by those who attempt to apply
the clinical findings of adults. The monograph straightens out
the situation and any physician actually using the book will
become enthusiastic to the point of being unable to resist em-
ploying it many times.
Views Items
Lt. Wm. Walter Wood, Jr., M.C., U.S.N.R., James-
town, North Dakota, a graduate of the University of
Minnesota, class of 1937, and later a fellow at Mayo
Clinic, Rochester, is now with a unit in Australia. On
October 1, Dr. Wood was raised to a full lieutenancy.
Dr. Fredk. T. Foard, medical director of the Rocky
Mountain states for the United States public health serv-
ice, with headquarters at Denver, Colorado, conferred in
Great Falls, Montana, November 4 with Dr. Thomas
F. Walker, city-county health official of the district. Dr.
Foard, previous to assuming the post of medical director,
was assistant surgeon general at Washington, D. C.
Dr. F. R. Schemm, Great Falls, Montana, presented
a paper, "Loss of Edema without Loss of Weight" at
the November 4 meeting in Chicago of the American
Federation for Clinical Research. This meeting, a re-
gional session, was followed the next day by a national
meeting of the Central Society for Clinical Investigation.
Dr. Joseph Tschetter, for the past two years resident
surgeon in ophthalmology at the University of Denver
medical school, has opened offices in Fduron, South Da-
kota, for practice in eye, ear, nose and throat.
Dr. James Smith Bates, former physician of Clear
Lake, South Dakota, for thirty years and recently prac-
ticing at Watertown and Sioux Falls, has resumed his
practice at Clear Lake.
Dr. Clayton H. Halverson, Minot, North Dakota,
after serving since September 1942 in the army medical
corps, recently at Camp Polk, Louisiana, is re-entering
private practice at Minot.
Dr. J. E. Low, formerly of Ronan, Montana, and Dr.
H. H. Parsons of San Bernardino, California, at one
time practicing at Sidney, Montana, from which place
he left to serve in the first World War, have established
practices in Sidney. Dr. Parsons will occupy the offices
that were left by Dr. Robert D. Harper when the latter
joined the naval reserve.
Dr. Gilbert Cottam, superintendent of South Dakota
state board of health, has added to his staff a public
health engineer specializing in food sanitation and an
associate bacteriologist attached to the laboratory division.
The recovery of Bernard Millar, farmer of Eagan,
South Dakota, from disease caused by staphylococcus
septicemia germs, through the administration of penicil-
lin, discloses a total of three issues of the drug to date
in this area; to McKennan hospital, Sioux Falls in this
instance, and to Mayo Clinic and the University of
Minnesota.
Dr. Joseph P. Merrett, Marion, North Dakota, who
for several months has maintained his office in the La
Moure hospital, will locate in Valley City, leaving La
Moure without a resident physician.
422
The Journal-Lancet
Dr. Albert D. Brewer, city-county health officer at
Bozeman, Montana, since the inception of the health
unit there in 1929, has resigned to accept a position as
staff physician at the state sanitarium, Galen, where he
is now situated.
Anna R. Skein, for thirteen years superintendent of
the Grafton Deaconess Hospital in North Dakota, and
distinguished for her leadership in establishing training
schools for nurses in Minnesota, has tendered her resig-
nation to members of the medical staff of the hospital.
Dr. Joel C. Swanson, Fargo, North Dakota, suing in
the district court at Wahpeton, was awarded $10,188 as
his one-sixth of 50 per cent of the accounts receivable of
a clinic with which he had been associated. On severing
his connections a year ago, Dr. Swanson petitioned for
a declaratory judgment and, after a month during which
the judge in the case had it under advisement, was noti-
fied of the decision in his favor.
Dr. Francis Ogg is the new chief medical officer of
the veterans’ administration facility at Hot Springs,
South Dakota, replacing Dr. F. C. Smith, whose retire-
ment was forced by disabilities resulting from sun stroke
this summer. Dr. Ogg, Kansas born, has been in the
service 15 years, most of the time at Bath, New York,
where he was chief of surgery.
Dr. David J. Almas, Chinook, Montana, delivered a
lecture at the nurses’ institute at Sacred Heart Hospital,
Havre, September 6.
Dr. Frank L. Unmack, Deer Lodge, Montana, has
been appointed by Dr. Ritchey, president of the Mon-
tana State Medical Association as a member of the med-
ical military preparedness and defense activity committee.
Dr. C. M. Kelsey of Minot, North Dakota, where he
has been associated with Dr. Alfred R. Sorenson for
three years since his internship at Trinity hospital, has re-
moved with his wife and two-year-old son to St. Paul
where he will practice medicine.
The North Dakota Society of Obstetrics and Gyne-
cology held its fall meeting in Devils Lake October 16.
The meeting was well attended. The program consisted
of these papers: "Low Dosage Roentgen Therapy in
Amenorrhea,” Dr. Chas. Heilman and Dr. G. Wilson
Hunter, Fargo; "Appendicitis in Pregnancy,” Dr. F. A.
DeCesare and Dr. J. F. Hanna, Fargo; "Abdominal
Pregnancy” (report of a case), Dr. John Graham, Devils
Lake; motion picture, "Caudal Analgesia”; "Manual and
X-ray Recognition of the Adequate Obstetric Pelvis,”
Dr. Everett C. Hartley, St. Paul, Minnesota.
SIXTH ANNUAL FORUM ON ALLERGY
The Forum on Allergy is an international postgraduate
society founded in 1938. By its annual oration gold
medal award it recognizes outstanding contributions to
clinical allergy. Its program is most intense, but infor-
mality and emphasis on the practical mark the conduct
of the meeting. This year the forum will hold its sessions
in the Statler Hotel, St. Louis, Missouri, on Saturday
and Sunday, January 22 and 23. All reputable physicians
are welcome. They are offered an opportunity to bring
themselves up to date by attending the review of the
progress of a rapidly advancing branch of medicine, to
receive intensive postgraduate instruction and to come
to know many distinguished authorities in the field.
There are fifteen study groups, any three of which are
open to the registrant. They are so divided that those
dealing with ophthalmology and otolaryngology, pediat-
rics, internal medicine, dermatology and allergy run con-
secutively. In addition the study groups are arranged
on the basis of previous registration. In this way, as
soon as the registrations are completed, the registrant is
expected to write the group leader and tell him just what
questions he wants brought up in the discussion. Atten-
tion is also called to the fact that during these last two
days almost every type of instructional method is em-
ployed: special lectures by outstanding authorities, study
groups, pictures, demonstrations, symposia and panel
discussions.
VUtMloqy-
Dr. Lewis Morgan Daniel, 49, Minneapolis, died
November 23 in Pompano, Florida. For the last few
months associated with the editorial department of this
publication (with a posthumous contribution appearing
in this issue over the familiar "L.M.D.”) Dr. Daniel was
cherished by all. A life-long resident of Minneapolis,
he was a graduate of West high school and University
of Minnesota academic and medical colleges, having re-
ceived his degree in medicine in 1924. He practiced in
Minneapolis and had been gone on a holiday for rest
only a short time when word was received of his death.
Dr. John Barlow James, 56, who had practiced medi-
cine at Page, North Dakota, for the last 3 1 years, died
November 8 at his home in Page. He was born at
Steele. A son, Dr. Basil James, is an army physician at
a South Carolina camp.
Dr. McCormick Smetters, 66, Butte, Montana, died
October 19 at Springfield, Illinois, following an illness
of several months. He came to Montana in 1901, prac-
ticed first at Hunters’ Hot Springs for six months, then
continuously since at Butte. A past president of the
Silver Bow Medical society he was active in state med-
ical association work for many years. He was renowned
as a horseman for over twenty-five years throughout the
west.
Dr. Frank J. Williams, 56, Butte, Montana, former
city physician, died October 22 at Butte. He was a
graduate of the Butte schools, Valparaiso college, In-
diana, and the Chicago College of Medicine and Sur-
gery, now connected with Loyola university, class of 1908.
Dr. Williams was a member of the army medical corps
in World War No. 1.
Dr. Fred G. Gilbert, 75, retired physician and resi-
dent of Rapid City, South Dakota, died November 14
in a Rapid City hospital.
Classified Advestis&neHts
EQUIPMENT FOR SALE
Hospital equipment including Westinghouse X-Ray
late model, tilt table, fluoroscope, Bucky Autoclave, Scan-
lan Morris Automatic, also portable O.R. light, gas ma-
chine, new operating table, beds, bedside tables, bed
lights, delivery table and numerous items of a hospital.
Address Box 800 A, care of this office.
HELP WANTED
A technician, nurse or receptionist or a person with a
combination of these qualities for service in a physician’s
office in a small town in rural Minnesota. Inquiries
should be addressed to Box 801 -A.
PHYSICIAN AVAILABLE
M.D. will supply for duration or locate permanently
where doctor is needed. Address Box 760, care of this
office.
EXCEPTIONAL OPPORTUNITY
for beginning or established physician to share suite of
offices with another physician or dentist. Individual treat-
ment room or laboratory, in new office building located
in very best residential retail section. Address Box 761 A,
care of this office.
Adue^Us€s'sA^MUHu*ne*tis
In Time of War, your doctor must ration
his time among the patients in his com-
munity . . . Your consideration in the
use of his services is earnestly requested.
★ ★ ★
HERE'S HOW YOU CAN HELP
YOUR DOCTOR
1. Come to the Doctor’s office instead of calling
him to your home, whenever possible.
2. Call for an appointment early in the morn-
ing so that he may schedule his calls more effi-
ciently.
3. Have an examination at the first sign of sick-
ness rather than risk a serious illness.
4. Keep your family and yourself in good
health and be immunized against all possible con-
tagious diseases.
Copyright, The Borden Company, New York 17, N. Y.
DR. MC KHANN JOINS PARKE, DAVIS &. CO.
Dr. Charles F. McKhann, who has for several years been on
the faculty of the University of Michigan, has resigned from
that institution to accept a position as Assistant to the Presi-
dent of Parke, Davis and Company. Dr. McKhann will devote
his time entirely to the scientific activities of the company. He
assumed his new duties October 15.
At the University, Dr. McKhann has held the positions of
Professor of Pediatrics and Communicable Diseases, in the
Medical School, and Professor of Maternal and Child Health,
in the School of Public Health. He has also acted as consultant
to the Secretary of War in the Control of Epidemic Diseases.
The summer of 1941, previous to coming to the University
of Michigan, he acted as consultant to the Board of Health,
Territory of Hawaii. From 1936 to 1940 he held the position
of Associate Professor of Pediatrics and Communicable Diseases
at Harvard Medical School and Harvard School of Public
Health. Before that he spent a year as Visiting Professor of
Pediatrics and Communicable Diseases at Peiping Union Med-
ical College, Peiping, China.
Since 1930 he has conducted and directed research on com-
municable diseases, immunology, renal diseases, nutritional dis-
eases, and on certain phases of toxicology. He developed and
introduced immune globulin and has contributed to the develop-
ment of several other products.
Dr. McKhann is a member of the Michigan State Medical
Society, American Medical Association, American Society for
Clinical Investigation (vice president, 1943), American College
of Physicians, American Academy of Pediatricians, Society for
Pediatric Research (president, 1936) and American Public
Health Association.
MORE PENICILLIN FOR ARMY
Work has begun on a five-story and basement reinforced
concrete and brick factory and laboratory building, 182' 6" by
82' 6", for the Lederle Laboratories, Inc., at Pearl River, N. Y.,
according to plans prepared by the Chemical Construction Com-
pany. The Chemical Construction Company and the Lederle
Laboratories are wholly owned subsidiaries of the American
Cyanamid Company, one of the largest chemical and allied
industry manufacturing concerns in America.
The job has high priorities from the War Production Board
and extreme speed is required in order to meet the Army’s
needs for penicillin, the remarkable new drug which the armed
forces need in large quantities.
New Aluminum Hydroxide Gel Preparation
The value of orally administered aluminum hydroxide gel in
promoting healing, relieving pain and controlling pain of gastric
and duodenal ulcer, and in controlling gastric hyperacidity, is
now well recognized. Various preparations have been available.
Many of these show obvious variations in consistency, color and
palatability. Submitted to laboratory tests they also show dif-
ferences in specific gravity, acid combining power, hydrogen ion
concentration and carbon dioxide content. Most of these prepa-
rations are marketed under proprietary names and some are
admixed with other antacids or vegetable gums.
The inclusion of aluminum hydroxide gel in New and Non-
official Remedies and its admission to U. S. P. Xll prompted
the Squibb Laboratories to offer the preparation under the offi-
cial name and, of course, in conformity with official specifica-
tions and standards.
As offered by E. R. Squibb & Sons, Aluminum Hydroxide
Gel is pharmaceutically an elegant preparation of a fluid con-
sistency. The suspension is practically snow white, pleasant to
take, lacking any suggestion of astringent taste. Diluted with
two or three parts of water the Gel may be administered by
gastric drip, or taken in 1 or 2 teaspoonful doses in water or
milk. Aluminum Hydroxide Gel Squibb is available in 12-
ounce bottles.
CORRECT FITTING
By skilled orthopedic me-
chanics. conforming to
professional specifica-
tions.
ARTIFICIAL
LIMBS
ORTHOPEDIC
APPLIANCES
TRUSSES
SUPPORTERS
ELASTIC
HOSIERY
A high type serv-
ice which '"'Njk means so
much in comfort
to your patients and in avoiding
embarrassment for you. Prompt,
painstaking service.
BUCHSTEIN-MEDCALF CO.
610 3rd Ave. So. Minneapolis, Minn.
THERE’S NONE BETTER OR MORE ECONOMICAL, DOCTOR!
SO t-f* FI E u/vt
The fine, sanitary PAPER SHEETING for all dry examinations. Durable, yet
comfortable to patients. No crackling noise. Comes in rolls and individual sheets
to fill all needs. Roll HOLDERS to fit and match all styles of tables. Endorsed
by physicians from coast to coast.
ASK YOUR SUPPLY HOUSE
TUAMINE SULFATE
"Tuamine Sulfate (2-Aminoheptane Sulfate, Lilly) is a sym-
pathomimetic amine with strong vasoconstrictive action, devel-
oped in the Lilly Research Laboratories. Clinical investigations
have confirmed the effectiveness of "Tuamine Sulfate” as a vaso-
constrictor. The action of a 2 per cent isotonic solution, com-
pared with a like concentration of ephedrine sulfate, brought
about much greater constriction and more pronounced ischemia.
The appearance of the nasal mucosa approximated that follow-
ing the application of a 1:1,000 solution of epinephrine. One
per cent "Tuamine Sulfate” was also found to exceed the effect
of the ephedrine, while 0.5 per cent was about equal in vaso-
constrictor action.
"Tuamine Sulfate” is unique among vasoconstrictor drugs
since it produces nontraumatic shrinkage of the nasal mucosa
without undesirable systemic effects. The isotonic solutions are
within the acid range of pH and are well tolerated even by
abnormally sensitive membranes without altering the flow of
nasal secretions.
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MEDICAL PLACEMENT REGISTER
525 Washington Ave. S. E., Minneapolis,
Olive Hill Kohner, Director,
Appraises, Prepares, Places
Personnel for Physicians.
For a medical secretary or technologist, x-ray
technician, receptionist, nurse or dietitian,
telephone
GLadstone 7235
Out-of-town requisitions solicited
For 16 years this simplified,
single- volume office record book
has saved precious time for busy
doctors. It was designed by a
practicing physician — has been
perfected by usage — now pro-
vides an ideal bookkeeping sys-
tem for pay-as-you-go tax reporting. Ex-
amine a copy for yourself, or write for fully
explanatory literature. $6.00.
DRILY
COLWELL PUBLISHING CO.
SOUTH DAKOTA WOMEN’S AUXILIARY
Plans for the 1944 activities of the Women’s Auxiliary
to the South Dakota State Medical Association were
formulated at an advisory board meeting held October
27 at the home of Mrs. D. S. Baughman, at Madison.
Present were Mmes. John C. Hagin, Miller, state presi-
dent, C. E. Sherwood, program chairman, and J. R.
Westaby, chairman benevolent fund committee, both of
Madison, E. T. Stout, Pierre, corresponding secretary
and treasurer, G. E. Burman, Carthage, chairman public
relations and publicity, R. A. Buchanan, Huron. Mrs.
Baughman is the state president-elect.
TRUSSES
CRUTCHES
ARCH SUPPORTS
ELASTIC STOCKINGS
ABDOMINAL SUPPORTERS
BRACES FOR DEFORMITIES
Scientific and Correct Fitting
CUSTOM WORK
House Calls Made
SEELERT
ORTHOPEDIC
APPLIANCE COMPANY
Largest Orthopedic Manufacturers
in the Northwest
88 South 9th Street MAin 1768
MINNEAPOLIS, MINN.
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lladiiilnpal and ('li
Assistance to Physicians
in this territory
MURPHY LABORATORIES
Minneapolis: 612 Wesley Temple Bldg. - - - - At. 4786
St. Paul: 348 Hamm Bldg. Ce. 7125
If no answer, call Ne.
i. 1291 £
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