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JournaUGancet
INDEX TO
VOLUME LXIX
New Series
January 1949 - December 1949
The Official Journal of the
American College Health Association
Great Northern Railway Surgeons’ Association
Minneapolis Academy of Medicine
North Dakota State Medical Association
Northwestern Pediatric Society
South Dakota Public Health Association
North Dakota Society of Obstetrics and Gynecology
Lancet Publishing Company, Publishers
Minneapolis, Minnesota
1949
442
INDEX OF AUT
Ayash, John J., Headache and
Bajrd, Mary E.; Cronheim, Geor
taining Therapeutic Penicillin
ministration, 56
Bass, Lee; Tudor, Robert B., The
Mumps, 188
Bernstein, William C., Malignant Lesions of the Anal Canal,
33
Bicek, Joseph F., Puerperal Sepsis, 11
, New Vaginal Speculum, 433 ^
Black, B. Marden, Recent Advances in Sui^fy of the Colon,
275 [? Hilger, JeroM^ A., Carcinoma of the Larynx, 358
The Journal-Lancet
oway, John D. B., The Treatment of the Recurrent Con-
ital Club Foot, 177
, Marcus S., Medical Group Practice in the United
: V. Growth of Groups, 42
GrinneiIZ Ernest L., The Diagnosis and Treatment of Mold
" fgy, 205
, Practical Aspects of Allergy, 82
roskloss, H. Hoffman, A Roentgenometric Study of the
Female Pelvis, 237
Blumenthal, J. S., The Antihistamine
ment of Hay Fever in the Adult, 215
Borland, V. G.; Johnston, W. H., T
Cholecystitis, 87
Brandon, Harvey; Hodas, Joseph H.; Malon
Treatment of Rheumatic Diseases with Glucuronic
385
Brown, Gerald, Prepartum Care, 7
Buchstein, Harold F., Protruded Intervertebral Disc, 264
Hawn, Hugh, Postpartum Optic Neuritis Due to Multiple
Sclerosis, 43 1
A.; Moore, John H., Interstitial Pregnancy, 435
Jose^-i ' J-L; Brandon, Harvey; Maloney, John,
f Rheumatic Diseases with Glucuronic Acid,
ilson; Nelson, D. F.; Darner, C. B., Saddle
esia in Obstetrics, 291
Jacobson, M. S., Report of the Committee on Rural Health,
103
Johnston, W. H.; Borland, V. G., Treatment of Acute
Cholecystitis, 87
Cameron, Angus L„ Surg.cal Therapy for Duodenal Ulcer, J°RD ife° Sy n d r^e ^por "cases' ’ 3^°lfT-ParkmSOn-
360
Canuteson, Ralph I.; Jordan, Robert I., Wolff -Parkinson-
White Syndrome: Report of Two Cases, 38
Chisholm, Tague C.; Wyatt, Oswald S., Ovarian Tumors
in Infancy and Childhood, 160
Clarke, Eric Kent; Fleeson, William, Some Problems in
Dealing with Parents, 163
Corbus, B. C., Urological Complications in Obstetrical Prac-
tice, 294
Countryman, Roger S., Discussion and Case Report on Con-
comitant Extra-uterine and Intra-uterine Pregnancy, 24
Cronheim, Georg; Baird, Mary E., A New Method of
Maintaining Therapeutic Penicillin Blood Levels on Oral
Administration, 56
Darner, C. B.; Hunter, G. Wilson; Nelson, D. F., Saddle
Block Anesthesia in Obstetrics, 291
Dodds, G. Alfred, Carcinoma of the Lung, 351
Durfee, Max L., Tuberculosis Control in Colleges, 124
Ebert, Richard V., Chronic Pulmonary Emphysema and Cor
Pulmonale, 243
Eisenstadt, William Sawyer, The Management of Status
Asthmaticus, 201
Epstein, Stephen, Allergic Skin Disorders in Pediatrics, 209
Fleeson, William; Clarke, Eric Kent, Some Problems in
Dealing with Parents, 163
Friedlaender, Alex S.; Friedlaender, Sidney, Antihistamine
Therapy in Allergy, 220
Friedlaender, Sidney; Friedlaender, Alex S., Antihistamine
Therapy in Allergy, 220
Kass, Irving, Use of Iodine in a Solusalve as an Antiseptic, 436
Keettel, William C.; Lee, James G.; Randall, John H.,
Stromal Endometriosis, 261
Kernwein, Graham A., The Surgical Treatment of Degenera-
tive Disease of the Hip Joint, 74
Larson, L. W.; Peters, C. H., Bone Marrow Aspirations, 98
Lee, James G.; Keettel, William C.; Randall, John H.,
Stromal Endometriosis, 261
Lindsay, Douglas T., Late Rickets — with Moderate Vitamin
D Resistance, 171
Loosli, Clayton G., The Problem of Control of the Respira-
tory Tract Infections, 245
Lucy, Robert E., A Study of Congenital Malformations, 80
Lueck, Wallace W., Poisoning in Children, 155
MacCarty, Collin S., Surgery of the Sympathetic Nervous
System, 377
Maeder, Edward C., Congenital Absence of Vagina, 271
Maietta, A. L., A Clinical Evaluation of Aqueous Thephorin,
282
Maloney, John F.; Hodas, Joseph H.; Brandon, Harvey,
Treatment of Rheumatic Diseases with Glucuronic Acid,
385
McCaffrey, F. J., Peritoneal Irrigation in Treatment of Severe
Oliguria Caused by Transfusion Reaction, 17
McDonald, Charles A.; O’Connell, William J., Analytical
Hypertension: Clinical Observation of 2,163 Male Stu-
dents, 395
December, 1949
443
McDonald, John R.; Woolner, Lewis B., Cytologic Diag-
nosis of Carcinoma, 355
McPhee, Harry R., Ankle Protection: A Study of Methods
Used in Athletics, 426
McPheeters, H. O., Value of Estrogen Therapy in the Treat-
ment of Varicose Veins Complicating Pregnancy, The, 2
Meyer, K. F., Immunobiologic versus Exposition Prophylaxis
of Disease in Medical Students, Particularly Tuberculosis,
129
Miller, H. E., Fungus Diseases of the Lungs, 136
Miller, Seward E., Control of Communicable Diseases, 279
Mitchell, Mancel T., Massive Hemorrhage Into the Gastro-
intestinal Tract in the Last Trimester, 26
Moe, Russell J., Postpartum Hemorrhage, 5
Moore, John H.; Hill, Frank A., Interstitial Pregnancy, 435
Murphy, James D.; Winterhoff, Ernest H., Tuberculous
Osteomyelitis of the First Rib Resulting in Brachial Plexus
Compression, 145
Nelson, D. F.; Hunter, G. Wilson; Darner, C. B., Saddle
Block Anesthesia in Obstetrics, 291
Norman, Paul P.; Norman, Samuel P., The Clinical Evalua-
tion of Glycerite of Hydrogen Peroxide in Vaginal and
Cervical Infections, 60
Norman, Samuel P.; Norman, Paul P., The Clinical Evalua-
tion of Glycerite of Hydrogen Peroxide in Vaginal and
Cervical Infections, 60
O’Connell, William J.; McDonald, Charles A., Analytical
Hypertension: Clinical Observation of 2,163 Male Stu-
dents, 395
Peters, C. H.; Larson, L. W., Bone Marrow Aspirations, 98
Platou, E. S.; Scherling, S. S., Acute Bacterial Meningitis,
181
Quattlebaum, Frank W., Acute Pancreatitis, 418
Randall, John H.; Keettel, William C.; Lee, James G.,
Stromal Endometriosis, 261
Roemmich, William, Active Pulmonary Tuberculosis Follow-
ing Negative 70 mm. Film Impressions in Minneapolis
Mass Chest X-Ray Survey, 122
Rosenow, Edward C., Bacteriologic Studies by New Methods
of a Major Epidemic of Poliomyelitis, 1947, 47
Rottino, Antonio, The Effect of Adenosine-5 Monophosphate
on Pruritus, 285
Sadler, William P., Concomitant Extra-uterine and Intra-
uterine Pregnancy, 22
Scherling, S. S.; Platou, E. S., Acute Bacterial Meningitis,
181
Schmidt, Clayton H., Medical Students and Tuberculosis,
128
Seibert, C. W., Management of Neglected Transverse Presen-
tation by Waters Extraperitoneal Cesarean Section, 9
Siegel, Sheldon C., Diphtheria Trends in Minnesota, 167
Siemers, Dorothy P.; Todd, Ramona L., Results of Reducing
Diets for Overweight University Students, 43 1
Silverman, Louis B., Methemoglobinemia: Report of Two
Cases and Clinical Review, 94
Sinykin, Melvin B., Basal Temperature Records in Obstetrics
and Gynecology, 13
Skinner, H G., Well Baby Care, 403
Slater, S. A., The General Practitioner’s Part in the Eradica-
tion of Tuberculosis, 120
Smith, Baxter A., Primary Epithelioma of the Ureter, 233
Stohsser, Albert V., Allergic Rhinitis in Pediatrics, 198
Thompson, John V., Pneumonotomy with Open Drainage of
Tuberculosis Pulmonary Cavities (Cavernostomy) , 141
Todd, Ramona; Siemers, Dorothy P., Results of Reducing
Diets for Overweight University Students, 429
Tudor, Robert B., Craniotabes, 165
; Bass, Lee, The Serum Amylase Levels in Mumps,
188
Wangensteen, Owen H., The Cancer Problem Today, 344
Wightman, Henry B., Study of 258 Cases of Appendicitis
Based on Pathological Findings, 415
Winterhoff, Ernest H.; Murphy, James D., Tuberculous
Osteomyelitis of the First Rib Resulting in Brachial Plexus
Compression, 145
Woolner, Lewis B.; McDonald, John R., Cytologic Diag-
nosis of Carcinoma, 355
Wyatt, Oswald S.; Chisholm, Tague C., Ovarian Tumors
in Infancy and Childhood. 160
Zarafonetis, C. J. C., Infectious Mononucleosis, 364
INDEX OF ARTICLES
Active Pulmonary Tuberculosis Following Negative 70 mm.
Film Impressions in Minneapolis Mass Chest X-Ray Sur-
vey, William Roemmich, 122
Acute Bacterial Meningitis, S. S. Scherling and E. S. Platou,
181
Acute Pancreatitis, Frank W. Quattlebaum, 418
Allergic Rhinitis in Pediatrics, Albert V. Stoesser, 198
Allergic Skin Disorders in Pediatrics, Stephen Epstein, 209
American College Health Association News, 32, 66, 166, 228,
250, 281, 340, 370, 405, 447
Analytical Hypertension: Clinical Observation of 2,163 Male
Students, Charles A. McDonald and William J. O’-
Connell, 395
Antihistamine Drugs in the Treatment of Hay Fever in the
Adult, J. S. Blumenthal, 215
Antihistamine Therapy in Allergy, Sidney Friedlaender and
Alex S. Friedlaender, 220
444
Bacteriologic Studies by New Methods of a Major Epidemic
of Poliomyelitis, 1947, Edward C. Rosenow, 47
Basal Temperature Records in Obstetrics and Gynecology,
Melvin B. Sinykin, 13
Bone Marrow Aspirations, C. H. Peters and L. W. Larson, 98
Cancer Problem Today, Owen H. Wangensteen, 344
Carcinoma of the Larynx, Jerome A. Hilger, 358
Carcinoma of the Lung, G. Alfred Dodds, 351
Chronic Pulmonary Emphysema and Cor Pulmonale, Richard
V. Ebert, 243
A Clinical Evaluation of Aqueous Thephorin, A. L. Maietta,
282
The Clinical Evaluation of Glycerite of Hydrogen Peroxide in
Vaginal and Cervical Infections, Samuel P. Norman and
Paul P. Norman, 60
Concomitant Extra-uterine and Intra-uterine Pregnancy, Wil-
liam P. Sadler, 22
Discussion and Case Report, Roger S. Countryman, 24
Congenital Absence of Vagina, Edward C. Maeder, 271
Control of Communicable Diseases, Seward E. Miller, 279
Craniotabes, Robert B. Tudor, 165
Cytologic Diagnosis of Carcinoma, John R. McDonald and
Lewis B. Woolner, 355
Diagnosis and Treatment of Mold Allergy, Ernest L. Grin-
nell, 205
Diphtheria Trends in Minnesota, Sheldon C. Siegel, 167
Effect of Adenosine-5 -Monophosphate on Pruritus, Antonio
Rottino, 285
Fungus Diseases of the Lungs, H. E. Miller, 136
General Practitioner’s Part in the Eradication of Tuberculosis,
S. A. Slater, 120
Headache and Headache Pain, John J. Ayash, 389
Immunobiologic versus Exposition Prophylaxis of Disease in
Medical Students, Particularly Tuberculosis, K. F. Meyer,
129
Infectious Mononucleosis, C. J. D. Zarafonetis, 364
Late Rickets — with Moderate Vitamin D Resistance, Douglas
T. Lindsay, 171
Malignant Lesions of the Anal Canal, William C. Bernstein,
33
Management of Neglected Transverse Presentation by Waters
Extraperitoneal Cesarean Section, C. W. Seibert, 9
Management of Status Asthmaticus, William Sawyer Eisen-
stadt, 201
Massive Hemorrhage Into the Gastro-intestinal Tract in the
Last Trimester, Mancel T. Mitchell, 26
Medical Group Practice in the United States: V. Growth of
Groups, Marcus S. Goldstein, 42
The Journal-Lancet
Medical Students and Tuberculosis, Clayton H Schmidt
128
Methemoglobinemia: Report of Two Cases and Clinical Review,
Louis B. Silverman, 94
New Method of Maintaining Therapeutic Penicillin Blood
Levels on Oral Administration, Georg Cronheim and
Mary E. Baird, 56
Ovarian Tumors in Infancy and Childhood, Tague C. Chis-
holm and Oswald S. Wyatt, 160
Peritoneal Irrigation in Treatment of Severe Oliguria Caused
by Transfusion Reaction, F. J. McCaffrey, 17
Pneumonotomy with Open Drainage of Tuberculous Pulmo-
nary Cavities (Cavernostomy) , John V. Thompson, 141
Poisoning in Children, Wallace W. Lueck, 155
Practical Aspects of Allergy, Ernest L. Grinnell, 82
Postpartum Hemorrhage, Russell J. Moe, 5
Prepartum Care, Gerald Brown, 7
Primary Epithelioma of the Ureter, Baxter A. Smith, 233
Problem of Control of the Respiratory Tract Infections, Clay-
ton G. Loosli, 245
Protruded Intervertebral Disc, Harold F. Buchstein, 264
Puerperal Sepsis, Joseph F. Bicek, 1 1
Recent Advances in Surgery of the Colon, B. Marden Black,
275
Report of the Committee on Rural Health, M. S. Jacobson,
103
Results of Reducing Diets for Overweight University Students,
Ramona Todd and Dorothy P. Siemers, 431
Roentgenometric Study of the Female Pelvis, H. Hoffman
Groskloss, 237
Saddle Block Anesthesia in Obstetrics, G. Wilson Hunter,
D. F. Nelson and C. B. Darner, 291
Serum Amylase Levels in Mumps, Lee Bass and Robert B.
Tudor, 188
Some Problems in Dealing with Parents, William Fleeson
and Eric Kent Clarke, 163
Stromal Endometriosis, William C. Keettel, James G. Lee
and John H. Randall, 261
A Study of Congenital Malformations, Robert E. Lucy, 80
Surgical Therapy for Duodenal Ulcer, Angus L. Cameron,
360
Surgery of the Sympathetic Nervous System, Collin S. Mac-
Carty, 377
The Surgical Treatment of Degenerative Disease of the Hip
Joint, Graham A. Kernwein, 74
Transactions of the North Dakota State Medical Association,
Sixty-second Annual Meeting, 297
Treatment of Acute Cholecystitis, V. G. Borland and W. H.
Johnston, 87
Treatment of Rheumatic Diseases with Glucuronic Acid,
Joseph H Hodas, Harvey Brandon and John F. Ma-
loney, 385
December, 1949
445
Treatment of the Recurrent Congenital Club Foot, John D. B.
Galloway, 177
Tuberculosis Control in Colleges, Max L. Durfee, 124
Tuberculous Osteomyelitis of the First Rib Resulting in Brachial
Plexus Compression, Ernest FI. Winterhoff and James
D. Murphy, 145
Urological Complications in Obstetrical Practice, B. C. Corbus,
294
Use of Iodine in a Solusalve as an Antiseptic, Irving Kass, 436
Value of Estrogen Therapy in the Treatment of Varicose Veins
Complicating Pregnancy, H. O. McPheeters, 2
Well Baby Care, H. G. Skinner, 403
What Can Be Done for the Deaf Patient, William K.
Wright, 398
Wolff-Parkinson-White Syndrome: Report of Two Cases,
Robert A. Jordan and Ralph I. Canuteson, 38
INDEX OF EDITORIALS
Erythrocyte Sedimentation Rate, 105
Four State Meeting, 30
How the Minneapolis War Memorial Blood Bank Can Serve
Hospitals, Physicians and the Public, 255
Hypersensitivity in Man, 224
Jennings Crawford Litzenberg, 29
Revised Principles of Ethics, 407
Role of Health Councils in Minnesota, 286
Role of Pediatrician and General Practitioner in Mental Hy-
giene, 189
Since Hippocrates, Cyrus Owen Hansen, 255
Social Security Administration Plans Our Totalitarian State,
108
Social Security for Employees of Physician, 67
Spontaneous Pneumothorax, 149
Tests Offer Hope in Cancer Diagnosis, 370
The $25.00 Assessment — Your Contribution to Society, 107
Urgent Need for Geriatric Care, 440
INDEX OF BOOK REVIEWS
Aesculapius Comes to the Colonies, by Maurice Baer Gor-
don, 290
A M. A. Interns’ Manual, 227
Blakiston s New Gould Medical Dictionary, 413
Child in Elealth and Disease, by Clifford G. Grulee and
R. Cannon Eley, 227
Clinical Allergy, by Alexander Sterling, 227
Diabetes and Its Treatment, 127
Differential Diagnosis of Jaundice, by Leon Schiff, 68
Fundamentals of Psychiatry, 68
Fundamentals of Pulmonary Tuberculosis and Its Complica-
tions, edited by Edward W. Hayes, 227
Handbook of Communicable Diseases, by Franklin H Top,
290
Management of Common Gastro intestinal Disease, edited by
Thomas A. Johnson, 227
Occupational Marks and Other Physical Signs, by Francesco
Ronches, 25
Office Endocrinology, by Robert B. Greenblatt, 25
Outlines of Internal Medicine, edited by C. J. Watson, 413
Progress in Neurology and Psychiatry: An Annual Report, 25
Radiologic Exploration of the Bronchus, by S. di Rienzo, 412
Roentgen Diagnosis of the Extremities and Spine, by Albert
D. Ferguson, 290
Textbook of Pathology, by E. T. Bell, 25
The 1948 Year Book of General Medicine, 68
The 1949 Book of Medicine, 413
Treatment in General Practice, by Harry Beckman, 127
War Neuroses, by Roy R. Grinker, 127
MONTHLY INDEX OF ARTICLES
January, 1949 (No. 1)
The Value of Estrogen Therapy in the Treatment of Varicose
Veins Complicating Pregnancy, by H. O. McPheeters, 2
Postpartum Hemorrhage, by Russell J. Moe, 5
Prepartum Care, by Gerald Brown, 7
The Management of Neglected Transverse Presentation by
Waters Extraperitoneal Cesarean Section, by C. W.
Seibert, 9
Puerperal Sepsis, by Joseph F. Bicek, 11
Basal Temperature Records in Obstetrics and Gynecology, by
Melvin B. Sinykin, 13
Peritoneal Irrigation in Treatment of Severe Oliguria Caused
by Transfusion Reaction, by F. J. McCaffrey, 17
Concomitant Extra-uterine and Intra-uterine Pregnancy, by
William P. Sadler, 22; Discussion and Case Report by
Roger S. Countryman, 24
Massive Hemorrhage Into the Gastro-intestinal Tract in the
Last Trimester, by Mancel T. Mitchell, 26
February, 1949 (No. 2)
Malignant Lesions of the Anal Canal, by William C. Bern-
stein, 33
Wolff-Parkinson-White Syndrome: Report of Two Cases, by
Robert A. Jordan and Ralph I. Canuteson, 38
Medical Group Practice in the United States: V. Growth of
Groups, by Marcus S. Goldstein, 42
Bacteriologic Studies by New Methods of a Major Epidemic
of Poliomyelitis, 1947, by Edward C. Rosenow, 47
A New Method of Maintaining Therapeutic Penicillin Blood
Levels on Oral Administration, by Georg Cronheim and
Mary E. Baird, 56
The Clinical Evaluation of Glycerite of Hydrogen Peroxide in
Vaginal and Cervical Infections, by Samuel P. Norman
and Paul P. Norman, 60
446
The Journal-Lancet
March, 1949 (No. 3)
The Surgical Treatment of Degenerative Disease of the Hip
Joint, by Graham A. Kernwein, 74
A Study of Congenital Malformations, by Robert E. Lucy, 80
Practical Aspects of Allergy, by Ernest L. Grinnell, 82
Treatment of Acute Cholecystitis, by V. G. Borland and W. H.
Johnston, 87
Methemoglobinemia: Report of Two Cases and Clinical Re-
view, by Louis B. Silverman, 94
Bone Marrow Aspirations, by C. H. Peters and L. W. Larson,
98
Report of the Committee on Rural Health, by M. S. Jacob-
son, 103
April, 1949 (No. 4)
The General Practitioner’s Part in the Eradication of Tubercu-
losis, by S. A. Slater, 120
Active Pulmonary Tuberculosis Following Negative 70 mm.
Film Impressions in Minneapolis Mass Chest X-Ray Sur-
vey, by William Roemmich, 122
Tuberculosis Control in Colleges, by Max L. Durfee, 124
Medical Students and Tuberculosis, by Clayton H. Schmidt,
128
Immunobiologic versus Exposition Prophylaxis of Disease in
Medical Students, Particularly Tuberculosis, by K. F.
Meyer, 129
Fungus Diseases of the Lungs, by H. E. Miller, 136
Pneumonotomy with Open Drainage of Tuberculous Pulmo-
nary Cavities, by John V. Thompson, 141
Tuberculous Osteomyelitis of the First Rib Resulting in Bra-
chial Plexus Compression, by Ernest H. Winterhoff and
James D. Murphy, 145
May, 1949 (No. 5)
Poisoning in Children, by Wallace W. Lueck, 155
Ovarian Tumors in Infancy and Childhood, by Tague C. Chis-
holm and Oswald S. Wyatt, 160
Some Problems in Dealing with Parents, by William Fleeson
and Eric Kent Clarke, 163
Craniotabes, by Robert B. Tudor, 165
Diphtheria Trends in Minnesota, by Sheldon C. Siegel, 167
Late Rickets — with Moderate Vitamin D Resistance, by Doug-
las T. Lindsay, 171
The Treatment of the Recurrent Congenital Club Foot, by
John D. B. Galloway, 177
Acute Bacterial Meningitis, by S. S. Scherling and E. S. Pla-
tou, 181
The Serum Amylase Levels in Mumps, by Lee Bass and Robert
B. Tudor, 188
June, 1949 (No. 6)
Allergic Rhinitis in Pediatrics, by Albert V. Stoesser, 198
The Management of Status Asthmaticus, by William Sawyer
Eisenstadt, 201
The Diagnosis and Treatment of Mold Allergy, by Ernest L.
Grinnell, 205
Allergic Skin Disorders in Pediatrics, by Stephen Epstein, 209
The Antihistamine Drugs in the Treatment of Hay Fever in
the Adult, by J. S. Blumenthal, 215
Antihistamine Therapy in Allergy, by Sidney Friedlaender and
Alex S. Friedlaender, 220
July, 1949 (No. 7)
Primary Epithelioma of the Ureter, by Baxter A. Smith, 233
A Roentgenometric Study of the Female Pelvis, by H. Hoffman
Groskloss, 237
Chronic Pulmonary Emphysema and Cor Pulmonale, by Richard
V. Ebert, 243
The Problem of Control of the Respiratory Tract Infections,
by Clayton G. Loosli, 245
Antibiotics in the Treatment of Infections, by John W. Brown,
251
August, 1949 (No. 8)
Stromal Endometriosis, by William C. Keettel, James G. Lee
and John R. Randall, 261
Protruded Intervertebral Disc, by Harold F. Buchstein, 264
Congenital Absence of Vagina, by Edward C. Maeder, 271
Recent Advances in Surgery of the Colon, by B. Marden
Black, 275
Control of Communicable Diseases, by Seward E. Miller, 279
A Clinical Evaluation of Aqueous Thephorin, by A. L. Mai-
etta, 282
The Effect of Adenosine 5-Monophosphate on Pruritus, by
Antonio Rottino, 285
September, 1949 (No. 9)
Meningitis in Infancy and Childhood, by L. G. Pray and M.
H. Poindexter, Jr., 333
The Retropubic Approach in the Treatment of Cancer of the
Prostate, by Joseph J. Stratte, 339
Case Report of Drug Delirium Clinically Interpreted as Being
Due to Pyribenzamine, by George M. Lott, Edgar S.
Krug and Herbert R. Glenn, 342
October, 1949 (No. 10)
The Cancer Problem Today, by Owen H. Wangensteen, 344
Carcinoma of the Lung, by G. Alfred Dodds, 351
Cytologic Diagnosis of Carcinoma, by John R. McDonald and
Lewis B. Woolner, 355
Carcinoma of the Larynx, by Jerome A. Hilger, 358
Surgical Therapy for Duodenal Ulcer, by Angus L. Cameron,
360
Infectious Mononucleosis, by C. J. D. Zarafonetis, 364
November, 1949 (No. 11)
Surgery of the Sympathetic Nervous System, by Collin S.
MacCarty, 377
Treatment of Rheumatic Diseases with Glucuronic Acid, by
Joseph H. Hodas, Harvey Brandon and John F. Malone,
385
Headache and Headache Pain, by John J. Ayash, 389
Analytical Hypertension: Clinical Observation of 2,163 Male
Students, by Charles A .McDonald and William J. O -
Connell, 395
What Can Be Done for the Deaf Patient, by William K.
Wright, 398
Well Baby Care, by H. G. Skinner, 403
December, 1949 (No. 12)
A Study of 258 Cases of Appendicitis Based on Pathological
Findings, by Henry B. Wightman, 415
Acute Pancreatitis, by Frank W. Quattlebaum, 418
Ankle Protection: A Study of Methods Used in Athletics, by
Harry R. McPhee, 426
Results of Reducing Diets for Overweight University Students,
by Ramona L. Todd and Dorothy P. Siemers, 429
Postpartum Optic Neuritis Due to Multiple Sclerosis, by Hugh
W. Hawn, 431
A New Vaginal Speculum, by J. F. Bicek, 433
Interstitial Pregnancy, by John H. Moore and Frank A. Hill,
435
The Use of Iodine in a Solusalve Base as an Antiseptic, by
Irving Kass, 436
7
Foreword
A fine innovation occurred on March 10, 1945,
when the obstetrical and gynecological societies of
Iowa, Minnesota, North Dakota and Wisconsin
held a combined meeting in Minneapolis. This
apparently set the precedence for regular meetings
of these societies and might well be an example
for societies in various other fields of medicine and
surgery operating in the same general area. Rapid
transportation has so reduced travel time that prac-
tically any point or city is quickly and easily
leached by those residing elsewhere in the area.
Physicians working in towns, cities and states de-
velop new diagnostic, therapeutic and preventive
procedures or modify old ones so as , to improve
them. Therefore, they have contributions to make
to the knowledge of others, which add signifi-
cantly to the value of a combined meeting of those
working in several states. In addition to the formal
presentation of papers and their discussions there
is the opportunity before, between and after ses-
sions to informally discuss controversial subjects
and often to learn something new from those who
do not appear on the program. Reports indicate
that all of this and much more of mutual value
also occurred at the second combined meeting of
the obstetrical and gynecological societies held in
Minneapolis on October 9, 1948.
A considerable number of the obstetricians and
gynecologists of the four societies represented had
been students of Dr. J. C. Litzenberg and all others
had known him or his work; therefore a fine spirit
prevailed throughout the day, in that the meeting
was dedicated to his memory. There was time to
recite anecdotes, to discuss his unique teaching
ability, his conviviality, his keen personal interest
in each student, the large practice that he conduct-
ed for so many years in a strictly ethical manner
and his contributions to knowledge.
The scientific program consisted of 1 3 papers
on numerous phases of obstetrics and gynecology
by expert essayists of the four societies and a tew
who appeared by special invitation. In addition.
Dr. M. Edward Davis of the Lying-In Hospital of
Chicago, presented the final afternoon address on
Steroid Therapy in Pregnancy Complications. Dr.
Frederick M. Loomis, of Piedmont, California, was
the evening banquet speaker. Thus, the four so-
cieties produced a program that would have been
suitable for any national or international organi-
zation.
The officers, including Everett Hartley as presi-
dent, and John Haugen, secretary, together with
the entire membership of the Minnesota Society,
were honored with the opportunity to arrange the
program, and the Minneapolis members were espe-
cially complimented in that their city was chosen
for the meeting.
The Journal-Lancet takes great pride in present-
ing this special issue on obstetrics and gynecology,
which includes many of the papers read before the
combined meeting. The publishers and the edi-
torial board have the complete assurance that as
this issue goes forth to its readers in all of the
states of the nation and to some foreign countries,
it will be received and read with great profit. The
readers will be better informed and, hence, their
teaching and practice will be approved. This ap-
plies not only to experts, but to that large and im-
portant group of general practitioners who have
always done the lion’s share of practice in the fields
we now call specialties. Our great appreciation is
due those who have made this special issue possible.
They have contributed to the ideals and high
standards which numerous persons have tried to
maintain and improve since the Journal-Lancet
first appeared in 1870.
J. A. Myers, M.D.,
Chairman , Board of Editors
2
The Journal-Lancet
The Value of Estrogen Therapy in the Treatment
of Varicose Veins Complicating Pregnancy
H. O. McPheeters, M.D.
Minneapolis, Minnesota
Troublesome varicosities often develop rapidly in
the latter part of the first trimester and the early
part of the second trimester in pregnancy. Also they
often increase very rapidly from day to day until about
the beginning of the last trimester, after which time
the advancement seems to stop. The varicosities appear
in the labia, sometimes even in the groin, and at any or
a number of places in either one or both legs. These
varicosities appear in varying size and at times may form
"bunches” of veins and are frequently characterized by
being painful when the patient is in the upright posi-
tion, often to such a degree as to seriously handicap the
pregnant woman in her usual activities. Another feature
is the so-called "bursts” or telangiectasis in which the
small venules often become dilated over large areas and
give rise to an unsightly appearance. This last condition,
although usually only of cosmetic importance, may be
very painful toward the end of the day and even the
cause of disability. In fact the general appearance of
the extremity with the large tense varices, so much
more extensive at times over the thigh and leg than one
would expect from the size of the vein at the groin,
together with the cyanotic color of the skin is so typical
that we often suspect a pregnancy before the patient
does.
The cause of varicose veins under any circumstances
is unknown. Further, the rapid development of those
associated with early pregnancy is even more obscure.
Generally it is assumed that varicose veins, as hernia,
are congenital defects, conditioned later by the individ-
ual’s environment. In pregnancy, there are those who
assume that an increase of pelvic pressure is responsible.
Such an assumption does not seem logical because en-
largement of the uterus to the same size due to other
conditions, such as myoma, generally reveals no particu-
lar effect on the veins. Further, the development of seri-
ous vein conditions in pregnancy, even in twin preg-
nancy, is not common. Consequently the "pelvis pres-
sure” hypothesis is untenable. Marazita,'1 writing in the
Medicdl Record of July 1946 says: "It has been my
opinion for some time that varicosities in pregnancy were
not due to pressure of the gravid uterus upon the veins
of the pelvis, nor to increased abdominal tension. The
development of varicose veins and particularly telangiec-.
tases in some women in the eighth and twelfth weeks of
pregnancy lead one to suspect that perhaps some circu-
lating hormone plays a part. It was with this view that
this work was done. Pathologically a varicose vein is one
whose wall is thinned out and relaxed. What then causes
this relaxation? Since the uterine muscle (the cervix)
relaxes, Hegner’s sign exists, and the joints also greatly
relax, it is highly probable that an ovarian hormone is
present and circulating in the blood stream in early
pregnancy.”
It is conceivable that standing for long periods may
be effective in the aggravation of varicosities throughout
pregnancy, but the fact that during the last war period
many mothers stood long hours in industrial occupations
in the early months of pregnancy without a notable in-
crease in the incidence of painful varicose veins would
not support such a thesis as the major activating factor.
Foote J in "Letters to the Editor” published in London
Ldncet says, "Further information is required about the
influence of hormones on varices. The fact that varices
tend to swell at puberty, during menstruation, in early
pregnancy, and at the menopause is accepted. During
the premenstrual phase every woman is in a state of
pseudo-pregnancy, and one may regard the menstrual
flow as a miscarriage of the unfertilized ovum. The en-
largement of varices in the premenstrual phase and in
the early days of pregnancy may therefore be accounted
for by the same hormonal influence.”
The work of McLennan ‘ on the changes of venous
pressure during pregnancy was most thorough and com-
plete. This work was completed at the University of
Minnesota while on a fellowship. He checked the ante-
cubital and femoral venous pressures in normal non-
pregnant females, normal pregnant women, normal post-
partum patients, pregnant women with hypertensive tox-
emias and gynecologic patients with pelvic tumors. He
checked the venous pressures in thirty normal pregnant
women and found that the average femoral pressure was
11.43 cm. water pressure while that in the antecubital
vein was only 7.88 cm. He also found that the femoral
venous pressure tends to rise during the second trimester
and through the twentieth to thirtieth week of gestation
to a peak of 24 cm. water pressure. He found that it
fell quickly postpartum and even below non-pregnant
level while the patient was in bed.
It is conceivable that given an inherent weakness of
the vein wall the increase in femoral vein pressure in
early pregnancy could result in varicosities. This, how-
ever, would explain only those cases that had a marked
reverse flow of blood from the groin but not at all those
cases with a competent valve at the sapheno-femoral
junction and yet very extensive varices over the thigh
and lower legs. This is often the case. The author pre-
fers to consider it merely as one of the contributing
factors. McCausland working at the Los Angeles
Maternity Service, reports on 150 cases. He noticed the
January, 1949
3
marked relaxation of the uterus, joints and tissues in
general during pregnancy. He was one of the first clin-
icians (1939) to actually try and connect the hormone
theory to the development of varicose veins in pregnancy.
It is well known that during early pregnancy there
is an increase in the level of the urinary gonadotropins,
later to be followed by a greatly increased level of the
steroid hormones both in the serum and the urine.
Whether or not some alteration in the hormone metab-
olism in pregnancy particularly the steroids is related to
venous physiology is entirely unknown. This report is
on the use of sex steroid therapy in the treatment of
varicose veins in pregnancy. It is agreed by both ob-
stetricians and those specializing in the treatment of vari-
cose veins that during pregnancy is not the time to insti-
tute radical treatment such as the "routine” injection of
sclerosing solutions or venous "ligation.” Too many in-
stances of almost complete recovery after the pregnancy
has terminated contra-indicates this usual non-pregnancy
treatment.
In casting about for some way in which to help these
patients, McCausland 4’5,6 considered the possibility of
sex steroid deficiency in pregnancy. Consequently, he
subjected some of his patients to Progynon B. (alpha-
estradiol-benzoate) therapy. With 10,000 I.U. hypoder-
mically he thought he observed some improvement in
symptoms. When this dosage was made available twice
weekly and then increased to 50,000 I.U. weekly, defi-
nite improvement was noticed. Marazita ! treated his
cases by the use of estrogenic substance in the form of
Di-Ovocylin given parenterally. He reported on the
treatment of twenty-seven cases in his series and obtained
the best results with larger doses, 50,000 I.U. weekly.
In 1946 Aguero (Caracas) reported good results in the
treatment of varicose veins in pregnancy by estrogen
therapy.
The author became interested in this subject because
of his generally poor results in the treatment of varicose
veins in pregnancy by both the injection and operative
method, though an occasional case responded well to
treatment. In most cases the varicose veins seemed to
form more rapidly than they could be treated. Follow-
ing the work of McCausland some good results were
obtained with the larger doses of Progynon B (alpha-
estrodiol-benzoate) therapy, 25,000 to 50,000 I.U. Be-
cause of the economic factor oral therapy was tried.
Diethylstilbestrol and Premarin (estrone sulphate) gave
good results but the best results from oral medication
were obtained from estinyl (estnyl estradiol) tablets 0.05
mg. B.I.D. for the first doses and gradually increased
to Q.I.D. The patient may complain of headache and
nausea from a sudden large dose given orally. The oral
medication should be continued until past the seventh
month.
Recently McKenzie 10 has reported spectacular results
in the treatment of the relief of varicosities in pregnancy
through the use of Estrolutem (estrodiol 20,000 I.U.-
Progesterone 10 mg.) . His patient experienced nausea
with the exhibition of all forms of oral estrogen therapy
but with the parenteral type of therapy had almost in-
stant relief.
This presentation covers the care and treatment of
34 cases of varicose veins complicating pregnancy and
followed through confinement (Fig. 1). Most patients
Figure 1
Number of Patients Cared for — 45
COMPLAINTS
Pain in labiocele 4 patients
Pain in legs 16
Cosmetic 12
MONTH WHEN PATIENT WAS FIRST SEEN
1st month 3 patients
2nd month .... 6
3rd month 1 12
4th month .. 8
5th month 8
6th month 8
that came direct were seen in the third month while most
of those sent by the obstetrician came in the fifth and
sixth months. The doctor had recognized the varicosi-
ties as complicating the pregnancy only when the patient
complained of the pain and distress. Several patients
had been told that the varicosities were just one of the
things to endure and that nothing could be done to
help them. The chief complaint was of pain and a
sensation of fullness and pressure in the legs. Four
patients complained of pains in the labiocele and a few
came for cosmetic effect only. They had little pain or
distress.
Following the treatment with the large doses paren-
terally all patients had relief from the labiocele pain.
This usually came within four days following treat-
ment (Fig. 2) . Complete relief from the feeling of
Figure 2
RESULTS OF TREATMENT
Complete on 34 cases — no report on 9
Relief of Pain
Pain in labiocele 4 patients
n • . 1 l A ”
Pain in legs
.. 14
Varicose vein development checked
.. 17
No change in development ...
.. 3
Pleased with results -
20
pressure, fullness and pain in the legs
was noticed by
41 per cent of the patients; 50 per cent felt sure that
the varicose vein development had been checked. A few
cases were sure that they had improved. Fifty-eight per
cent of all the cases were pleased with their results, even
though many were seen too late to be of much help to
them.
All cases of varicose veins complicating pregnancy
should wear a supportive bandage of some kind. This
should be worn all the time to give the most help. In
this series all patients wore the support except for short
periods of time now and then,
4
The Journal-Lancet
Conclusions
Varicose veins during pregnancy may become very
painful and disabling. They may also entirely disappear
postpartum. The telangiectatic or "burst” type of vein
seldom disappears after becoming well developed, even
with the best of care. Even though the pain can be con-
trolled with the supportive bandage on the lower leg
and a tight fitting jock strap for the labiocele, their ex-
tensive enlargement will mean more pain and disfigure-
ment when treated later.
The operative treatment of varicose veins during preg-
nancy is a failure in a high percentage of cases. The
injection treatment should be used in only the special
cases here and there and for some definite reason.
This report is made with the thought in mind that
varicose veins during pregnancy are really complicating
that condition and should be looked for and treated by
the obstetrician. There is much evidence in favor of the
assumption that the rapid development of the varicose
veins, in all their forms, is in a large measure due to the
presence of a hormone elaborated at times with the preg-
nancy and circulating in the blood stream.
In almost every case the symptoms directly due to the
varicose vein development in itself can be completely
relieved, the progress of the varicose vein formation be
checked, and the woman assisted through her pregnancy
by the judicial use of some ovarian hormone. The best
results when considered over all, were obtained by the
use of Estinyl tablets 0.05 mg. and the hypodermic use
of Progynon B or Estrolutem for those patients with
severe nausea.
The author wishes to give credit to the obstetricians co-
operating in this effort and in particular to Doctors C. J. Ehren-
berg, T. W. Weum and Chas. H. McKenzie, for their kind
criticism and suggestions in the preparation of this paper.
The Progynon B. and Estinyl tablets were supplied by the
Schering Corporation of Bloomfield, New Jersey, the Estrolutem
ampoules by the Lincoln Laboratories of Decatur, Illinois.
Bibliography
1. Aguero, O.: Estrogen Therapy of Varicose Veins Com-
plicating Pregnancy. Rev. obst. y. ginec. Caracas. 6:155-159.
2. Foote, R. Rowden: Varicose Veins. Letter to Editor,
London Lancet. 1:83-84 (Jan. 11) 1947.
3. Marazita, A. J. D.: The Action of Hormones on Vari-
cose Veins in Pregnancy. Medical Record. 159:422 (July)
1946.
4. McCausland, A. M.: Varicose Veins in Pregnancy.
West. Jr. of Surgery, Obstetrics & Gynecology. 47:81 (Feb.)
1939.
5. McCausland, A. M.: Varicose Veins in Pregnancy. Cali-
fornia & Western Medical. 50:258-262 (April) 1939.
6. McCausland, A. M.: The Influence of Hormones upon
Varicose Veins in Pregnancy. West. J. Surg. 51:199-200
(May) 1943.
7. McLennan, Chas. E.: Antecubital and Femoral Venous
Pressure in Normal and Toxemic Pregnancy. Am. Jr. Obst. &
Gynec. 45:568-591 (April) 1943.
8. McLennan, Chas. E.; McLennan, Margaret T.; Landis,
Eugene M.: The Effect of External Pressure on the Vascular
Volume of the Forearm and Its Relation to Capillary Blood
Pressure and Venous Pressure. Jr. of Clinical Investigation.
21:319-338. 1942.
9. Siegler, Julius: The Treatment of Varicose Veins in
Pregnancy. Am. Jr. Surg. 44:403-408. (May) 1939.
10. Dr. Chas. H. McKenzie, Minneapolis, Minn, A personal
communication.
WISCONSIN MEDICAL SCHOOL TO PRESENT INTENSIVE COURSE
IN GASTROENTEROLOGY
The University of Wisconsin Medical School through its division of graduate medical
education is presenting an intensive five-day course in gastroenterology starting Monday,
February 14, and running through Friday, February 18, 1949, according to Dr. Llewellyn
R. Cole, Co-ordinator of Graduate Medical Education at the Wisconsin Medical School.
The course will be exceedingly practical and will be under the direct supervision of Dr.
K. L. Puestow and Dr. F. L. Weston with the assistance of other members of the medical
staff.
The course content will include proctoscopic and gastroscopic demonstrations with dis-
cussion of techniques, parasitic diseases of the intestinal tract, food poisoning, toxemias, ma-
lignant disease of the tract, X-ray and surgical aspects of therapy, jaundice and its causes,
along with other disorders of function and physiology. Enrollment in this course will be
limited to twelve physicians and applications may be made out to Dr. Llewellyn R. Cole,
the Medical School, 418 North Randall, Madison 6.
J. B. JOHNSTON LECTURESHIP
Dr. Paul C. Bucy, professor of neurology and neurological surgery at the Illinois
Neuropsychiartic Institute, will deliver a lecture at the University of Minnesota January 27
at 8 P.M. He will speak in the auditorium of the Minnesota Museum of Natural History.
Dr. Bucy’s topic will be "The Cerebral Control of Muscular Activity. The lecture is
sponsored by the J. B. Johnston lecture in neurology and is open to all medical men.
January, 1949
3
Postpartum Hemorrhage
Russell J. Moe, M.D.
Duluth, Minnesota
The last decade has brought a considerable decrease
in maternal deaths due to infection and toxemia.
Unfortunately, however, there is an apparent lag in im-
provement in the puerperal death rate from hemorrhage.
In 1941 Minnesota recorded 107 maternal deaths (2.0
per 1,000 live births) . Of these 18, or 16.8 per cent,
were due to hemorrhage. In 1947 the total deaths had
dropped to 47 (0.6 per 1,000 live births), but hemor-
rhage was responsible for 9, or 21.3 per cent. Statistics
reveal that approximately one-half of the deaths due to
obstetric hemorrhage occur in the postpartum period.
Further analysis of these studies indicates that 9 to 15
per cent of all obstetric deaths may be grouped in the
category of postpartum hemorrhage. A blood loss of
500 cc., or an amount equal to 1 per cent of the body
weight, has been set up as the criteria to define this
complication.
The etiologic factors concerned in postpartum hemor-
rhage may be divided into three main groups:
1. The atonic uterus
2. Mismanagement of the third stage of labor
3. Lacerations of the birth canal
Atonic Uterus
The atonic uterus can usually be anticipated as it is
often secondary to prolonged difficult labors, hydram-
nios, multiple births, placenta previa, and in conjunction
with fibromyomata and degenerative changes in the
uterine muscle. The alert obstetrician will anticipate ab-
normal bleeding following labors of this type and will be
prepared to deal with hemorrhage and shock in its earli-
est phases. Evidence indicates that heavy sedation and
certain types of inhalation anesthesia predispose the
uterus to atony. To those using local, saddle block or
caudal anesthesia it is apparent that there is a definite
shortening of the third stage of labor, better uterine
tone, and a decreased blood loss.
Conduct of the Third Stage of Labor
The second important cause of postpartum hemor-
rhage is the result of premature attempts to deliver the
placenta. This practice is frequently responsible for in-
creased bleeding, and occasionally results in partial or
complete inversion of the uterus. Too frequently one
has an unconscious desire to remove the placenta by
massage or Crede expression immediately after the de-
livery of the fetus, forgetting that a certain time element
must be allowed for its separation. The uterine muscle
must regain sufficient tone to contract and separate the
placenta from the uterine wall. Cosgrove has aptly
stated that the conduct of this stage constitutes the pri-
mary responsibility of the obstetrician and that he had
better delegate to a subordinate the actual delivery of the
baby rather than this important responsibility.
Dieckmann and associates have recently called atten-
tion to the statement made by Davis and Boynton in
1941 that the proper management of the third stage of
labor begins in the late second stage. They suggest that
"for the proper separation of the placenta it is of the
utmost importance that the baby be delivered slowly,
in stages, with a thirty- to sixty-second pause after the
delivery of each shoulder, requiring a total of at least
three minutes.” They claim that this allows the uterine
wall time to contract and retract, thereby tearing itself
away from the placenta. When the uterus assumes a
globular form the placenta is delivered by compression
of the uterus and tension on the cord. They do not be-
lieve that an oxytocic drug is necessary for the separa-
tion of the placenta, but may be given intravenously
after the delivery of the posterior shoulder, if the doctor
is experienced; if he is not, then after the delivery of
the placenta.
In the presence of analgesic drugs or certain inhala-
tion anesthetics the time necessary for placental separa-
tion may be prolonged. Massage or manipulation of the
uterus before normal separation has been accomplished
merely leads to prolongation of this stage of labor and
frequently to unwarranted blood loss. The retention of
a partially separated placenta or of individual cotyledons
as a result of "manhandling” the corpus of the uterus
invites complications which reports and experience prove
are too often disastrous. In the majority of instances
the best policy is "hands off.” Allow time for the con-
traction of the uterine muscle to separate the placenta
and deliver it into the lower uterine segment or into the
vagina. If the placenta has not separated in one hour
it should be delivered manually, using aseptic technique.
At the termination of the third stage a critical and com-
plete examination of the placenta and membranes must
be a routine procedure.
Lacerations of the Birth Canal
Deep lacerations of the tissues of the birth canal may
be the underlying cause of postpartum hemorrhage. Con-
tinued bleeding before or after the delivery of the pla-
centa may be due to tears in the cervix, and these tears
may extend well into the lower uterine segment or even
into the broad ligaments. Lacerations of the vaginal
mucosa, with extension into varicose veins of the vagina
and lacerations of the perineal body, may contribute to
excessive blood loss. Thus, early recognition and im-
mediate surgical repair of these injuries is important.
Treatment
Although the clinical picture of shock following hem-
orrhage is readily recognized there has been in the past
and there still exists a lack of appreciation of the impor-
tance of detecting its early signs and symptoms. To
await the development of a cold, clammy skin, pallor?
6
The Journal-Lancet
cyanosis, shallow respirations, marked drop in blood pres-
sure, faint, rapid pulse, and finally unconsciousness, is
to invite disaster. A slight drop in the systolic blood
pressure or an accelerated pulse in the presence of even
moderate bleeding should be a signal to initiate steps to
control the bleeding and combat impending shock. Pack-
ing of the uterine cavity undoubtedly has some value in
the control of bleeding from an atonic uterus, but it is
frequently ineffective in the severe cases. Packing of
the vagina alone has no value.
The administration of intravenous saline or glucose is
of transient value only. Ingraham and Wiggers have
demonstrated that a sixth-molar sodium lactate solution
in infinitely more valuable in maintaining the alkali re-
serve and thus delaying the development of irreversible
shock. In the management of a sudden massive hemor-
rhage the rapid administration of adequate amounts of
whole blood has no equal, although plasma is a good
temporary substitute. Large amounts of plasma should
be given to maintain the blood pressure while waiting
for blood to be typed and crossmatched. The adminis-
tration of oxygen also during this time is a valuable pro-
cedure. It is well known that increased oxygenation will
improve the tone of the uterine muscle, thereby decreas-
ing further blood loss. Frequently large amounts of
blood and plasma are required to treat shock due to
massive hemorrhage. In one instance the author used
1250 cc. of plasma and 3500 cc. of whole blood when
faced with a sudden massive hemorrhage caused by re-
tention of a succenturiate lobe. Hunt has reported eight
cases of massive obstetric hemorrhage that necessitated
hysterectomy. Some of these patients lost as much as
or more than their total blood volume but nevertheless
survived their hemorrhage and subsequent hysterectomy
because of rapid and adequate blood replacement. The
rapidity of this replacement is of prime importance.
This may be accomplished by stripping the tubing or by
using the pressure mechanisms described by Cole.
Plasma is now readily available to all obstetricians,
and may be stored either in its dry or liquid form. It
is imperative that liquid or dried plasma be available in
all hospitals, and that dried plasma should be an integral
part of the obstetric kit for home deliveries.
Categorically, it may be stated that in obstetrics shock
is due to loss of blood, and in the treatment of shock
there is no substitute for blood. It is hoped that the
National Blood Program recently launched by the Red
Cross will be successful in making blood available to
everybody, everywhere, at any time.
In the Minnesota Maternal Mortality Study (1941-
42) a total of 112 deaths were thoroughly analyzed. In
the critical analysis of the 10 deaths from postpartum
hemorrhage 8 were classified as definitely preventable,
1 as probably preventable, and 1 as possibly preventable.
Case
As an example of a preventable death, the following
case report may be cited:
A patient whose labor was initiated by a medical in-
duction was delivered by podalic version after two un-
successful attempts at forceps delivery of a fetal head
in the right occipitoposterior position. Although feeble
attempts were made to replace blood loss, the patient
died of shock and hemorrhage one hour and fifteen min-
utes later. Autopsy revealed extensive lacerations of the
cervix, vagina and external genitalia, a third degree
laceration of the perineum, and hemorrhage into the
retroperitoneal tissues of the pelvis. The record states
that a vaginal examination made a few minutes prior to
delivery revealed a "questionable anterior lip of the cer-
vix.” This, coupled with the extensive lacerations of
the cervix found at autopsy, would lead one to believe
that the cervix was not completely dilated at the time
of delivery, and that the patient had not yet entered the
second stage of labor. The indications for the radical
procedures used in the delivery of this patient are ob-
scure. Apparently the need for replacing the blood loss
was not recognized, nor was any attempt made to pre-
vent further blood loss by repair of the lacerations. The
fluids administered by vein during the one and one-half
hours before death consisted of 200 cc. 10 per cent glu-
cose and 200 cc. of citrated blood. The criticism of the
management of this case as related to the cause of death
is as follows:
1. Incompetent management of the actual delivery.
2. Inadequate treatment for hemorrhage and shock.
3. Failure to check hemorrhage by repair of lacera-
tions.
Summary
1. Statistics reveal an apparent lag in improvement of
the incidence of postpartum hemorrhage as the cause of
maternal deaths.
2. Emphasis is placed on the detection of the early
signs and symptoms of shock to indicate prompt treat-
ment.
3. Anticipating the development of an atonic uterus
will often prevent serious blood loss.
4. Premature attempts to deliver the placenta fre-
quently cause unnecessary bleeding.
5. Rapid and adequate blood replacement are of para-
mount importance in the presence of massive hemor-
rhage.
6. Plasma is a good temporary substitute while waiting
for blood.
7. Maternal mortality studies indicate that the ma-
jority of fatalities resulting from postpartum hemor-
rhage are preventable.
References
1. Chesley, A. M.: Minnesota Department of Health Re-
ports, 1941-1947.
2. Day, Lois A., Mussey, Robert D., and DeVoe, Robert
W.: Am J. Obst. & Gynec., 55:231-243, 1948.
3. Cosgrove, S. A.: Discussion, Am. J. Obst. & Gynec.,
55:238, 1948.
4. Dieckmann, Wm. J., Odell, L. D., Williger, V. M.,
Seski, A. G., and Pottinger, R.: Am. J Obst. Si Gynec.,
54:415-427, 1947.
5. Davis, M. E., and Boynton, M.: Am. J. Obst. & Gynec.,
43:775, 1942.
6. Ingraham, R. C., and Wiggers, H. C.: Am. J. Physiol.,
144:505, 1945.
7. Hunt, Arthur B.: Am. J. Obst. & Gynec., 49:246-252,
1945.
8. Cole, John T.: J.A.M.A., 135:142-144, 1947.
9. Minnesota Maternal Mortality Study: Minn. Med.,
27:726-730, 1944.
January, 1949
7
Prepartum Care
Gerald Brown, M.D.
Grand Forks, North Dakota
During the past twenty-live years wonderful prog-
ress has been made in obstetrics. Today the ma-
ternal mortality record has approached the figure of
1 per 1,000, that ten years ago was called the irreducible
minimum. However, during this time, I feel sure, many
large institutions and clinics have bettered this figure.
In spite of this low mortality figure, it is my impression
that there seems to be an increase in deaths due to tox-
emias and hemorrhage. The fetal mortality is working
well down toward the irreducible minimum. I believe
these results come from a lot of hard work and very
careful observations by the doctors who are doing ob-
stetrics. If one studies the figures as compiled by our
states, he can see what progress has been made.
During the war the birth rate increased at an almost
unbelievable rate, and it is still at the nearly all-time
high. True, there was a doctor shortage during these
same years. However, today the same conditions are not
true. During the past twenty-five years there has been a
definite effort to educate the public about many of their
ailments. Not to be outdone by other branches of medi-
cine, the obstetricians have had their field well publicized
too. The public has taken well to this endeavor and,
as a result, they are asking for better care than they
obtained in years past.
The American people are great migrators, and it is not
at all unusual for one to see many new people each year.
The Americans are great talkers, and if one has the
patience and is a good listener, he can soon learn con-
siderable about many things, including the type and
standard of medicine being practiced in most regions of
our great United States. It seems to me that during the
war years, most doctors were crowded beyond reasonable
limits; many short-cuts had to be taken so that a few
minutes could be given to each individual seeking care.
The people were aware of this, and took it in their
stride. Today, they are not nearly as tolerant, at least
in our part of the country, and they are only too willing
to let us know. They also know the difference between
careful and careless medicine. If one doctor doesn’t
measure up, they will find one who will. Perhaps we
haven’t had quite enough time to recover from the habits
we acquired during the war, but I think sufficient time
has elapsed. It seems to me that I have been able to
detect some dissatisfaction on the part of the patient
because of poor or careless prepartum care, and as the
result, I have written this paper. I will outline briefly
what I consider adequate prepartum care.
Because of education, the people in our community are
seeking care earlier. Most of our patients appear during
the first trimester, a few during the second trimester,
and only a rare case appears late in pregnancy. This is
excellent, and as obstetricians we must do our part to
keep abreast of this development.
The first visit is the most time-consuming, but I feel
is perhaps the most important. It is at this time that the
obstetrician gets to know the patient. We can win her
confidence or lose control before it is established. A care-
ful, detailed history must be taken. This should be very
meticulous when covering any previous illnesses, espe-
cially regarding the heart, kidneys, liver or any meta-
bolic disturbance. Certainly, one should find out about
any previous pregnancies and labors. Next, a complete
physical examination should be done, which should be
as complete and careful as any examination in medicine.
Not only are we to determine that the woman is preg-
nant, but we must know that her body is in such a con-
dition that she can carry the pregnancy and later, that
she can deliver a term pregnancy. The obstetrician
should have better than just a passing knowledge of
medicine in general. If he doesn’t have this knowledge,
he can’t answer the above questions. As a result some-
thing important may be missed and the case turn out
poorly. A chest x-ray is very useful, and if there is any
question of pulmonary pathology, a chest plate should
be taken. We have been fortunate in that the mobile
x-ray units have recently done a very thorough job in
our community, and practically everyone has been
screened.
To say that a careful pelvic examination should be
done sounds juvenile, but when a multiparous patient
says, after a complete prepartum examination has been
finished, "Doctor this is the first time I have been thor-
oughly examined,” one is at a loss as to what to reply.
A careful speculum examination will reveal any cervical
pathology, such as erosions, lacerations, polyps or tumors.
Any vaginal infections with yeast, trichomonas, etc., are
discovered and can be treated. We get an excellent idea
about the condition of the soft tissues and at the same
time get a fairly good idea about the capacity of the
pelvis. If any gross or suspected deformity is found, the
x-ray can be used to give us more definite and accurate
information. X-ray pelvimetry has been worked out so
that it is now quite accurate, but still can’t beat good
clinical judgment in all cases. I believe that it should be
reserved for those doubtful problems and not used as a
routine for all obstetrical cases, as it is too expensive to
use routinely in private practice.
The urine should be examined; a hemoglobin, red cell
and white cell count, blood serology, Rh factor and
blood typing should be done on the first visit. With all
this information at hand one is now able to honestly and
intelligently start to take care of the prepartum patient.
I have found that much time can be saved m the
future care of a case if I assume nothing, and unless
I have recently confined the patient, talk to her as if
this is her first experience with pregnancy. She is told
what to expect during the following month. This is gone
8
The Journal-Lancet
over in detail, which really only takes a few minutes, and
usually relieves any apprehension she may have. Unless
a patient is overweight I do not put her on any strict
dietary regime. She is simply asked to follow a well
rounded diet including meat, eggs, dairy products, vege-
tables and fruits, and to go easy on the intake of bread
and desserts. I suggest that she try to hold her weight
gain to about two to three pounds per month. The ma-
jority of the patients will follow this and do very well.
There does seem to be one group of people who just
gain weight in spite of what anyone does. I have found
that it does not help to fuss at them as this only serves
to make them dread their following visits. As a result
a good deal of the doctor-patient contact is lost. I firmly
believe that the prepartum visit should be a pleasant one
for both the doctor and the patient.
During each subsequent visit the patient is weighed,
her blood pressure taken, and when necessary, any fur-
ther laboratory work ordered. Then, in a friendly chat
I tell her, in detail, what changes will take place in the
coming month. This certainly answers most of the ques-
tions before they arise and the patient gains considerable
confidence in her doctor. Maybe, for want of a term,
one may call this the psychiatry of the prepartum period.
I firmly believe it is a very important part of the pre-
partum care. The patient certainly tolerates a great
many of the little annoying discomforts much more
readily, and with very little or no fuss. She is better
prepared for the onset of labor and usually will be a
calm and collected person who has a good idea about
what is going to take place. The result, I believe, is a
person quite relaxed, who often requires considerably less
sedation during her labor. Consequently, the experience
is made easier for all concerned.
With the recent increased knowledge about the Rh
factor, today we can save some children who would oth-
erwise have been lost a few years ago. Whenever one
finds a setup that is right to produce an Rh baby with
the dreaded erythroblastosis fetalis, we should be on the
lookout anytime after the 28th to 30th week of the ges-
tation. A very simple test can be run on the mother’s
blood to determine the Rh antibody titre. This should
be checked frequently from this time on, and when the
titre begins to show, one must do something to bring
about delivery before the baby gets into serious difficul-
ties. I am well aware that it is by no means established
that the rise in antibody titre is a definitive measure that
labor must be induced, but to date it is the best test yet
devised. True enough, we often get a premature infant,
but if left to the forces of nature, the result would be
a dead fetus.
Similarly, with the recent development in measuring
the pelvis by x-ray we can prevent most of the emergency
cesarean sections. Near term, when one suspects any
type of pelvic disproportion, x-ray pelvimetry by a com-
petent roentgenologist is of untold value in many of
these cases, particularly with the deformed inlet and the
serious mid-plane contractures. Intelligent interpretation
of these findings will allow us to do the sections by
choice and unhurriedly. The results are invariably better.
Prepartum visits should be at increasingly shorter in-
tervals during the last trimester when we are on the look-
out for any developing toxemia. Careful attention to
excessive weight gain, increasing blood pressure, edema
and albuminuria should give us an excellent idea as to
what is happening. We must not ignore these signs of
beginning toxemia and should institute intelligent and
positive treatment as is deemed necessary.
One of the members of the Minnesota Society is do-
ing a very intensive investigation in this field. He is
attempting to find the cause and to detect the onset of
toxemia by serologic means. I am sure we all hope that
he succeeds in solving this age-old problem.
In our obstetrical practice at the Grand Forks Clinic,
the incidence of toxemia is 4.6 per cent in our last 1,624
consecutive cases. It is my impression that, of late, there
is an apparent increase of this complication.
With this apparent increase in the late toxemias, the
stubborn fact remains that the cause is not known.
Therefore, careful clinical observation of the triad, hy-
pertension, albuminuria, and weight gain, still is our
first line of defense. In other words, we must be on
our toes all of the time so as to achieve even better re-
sults than we have today.
E. STARR JUDD LECTURE
The sixteenth E. Starr Judd Lecture will be given by Dr. Alton Ochsner, William
Henderson Professor of Surgery at the Tulane University, New Orleans, Louisiana, Tuesday
evening, January 18, 1949, at 8:15 in the Auditorium of the Museum of Natural History,
University of Minnesota. Doctor Ochsner’s subject is "The Treatment of Postphlebitic
Sequelae by Vasodilatation and Other Measures.”
The late E. Starr Judd, an alumnus of the Medical School of the University of Minne-
sota, established this annual lectureship in Surgery a few years before his death.
January, 1949
9
The Management of Neglected Transverse
Presentation by Waters Extraperitoneal
Cesarean Section
Report of Two Cases
C. W. Seibert, M.D.
Waterloo, Iowa
The following two cases are presented to illustrate
the use of the Waters extraperitoneal cesarean sec-
tion in actually or potentially infected cases occurring
in young women in whom the termination of further
child-bearing by the Porro operation is undesirable.
Report of Case No. 1
Mrs. L. D., age 21, Gr. 1, whose E.D.C. was April
21, 1947, was first seen in the hospital of a neighboring
town at 11:00 P.M. April 10, 1947. The membranes
had ruptured spontaneously at 3:30 P.M. April 8, 1947,
a large amount of fluid escaping. Pains had begun at
6:00 P.M. of April 10, 1947, shortly after which the
malpresentation was discovered and consultation called.
General physical examination was entirely negative.
Blood pressure was 120/80, urine negative and R.B.C.
4,630,000; W.B.C. was 21,160 and Hb 14.35 Grams.
Pelvic measurements were within normal limits. The
temperature was 98.8 and pulse was 90.
Examination of the abdomen revealed the fetus to be
near term in right acromium posterior presentation, the
right shoulder being deeply impacted in the pelvis. The
fetal heart was clearly heard in the midline. X-ray ex-
amination of the abdomen verified these findings.
Under ether anesthesia, a sterile vaginal examination
was carried out which revealed the cervix to be 2 centi-
meters dilated, thick, and very little effaced. The pre-
vious impression of deep impaction of the presenting
part was verified. Because of the above findings, it was
felt that delivery by Waters extraperitoneal cesarean sec-
tion would serve the best interests of both mother and
child. The patient was therefore moved by ambulance
to Allen Memorial Hospital in Waterloo, arriving at
1:05 A.M. April 11, 1947. Under spinal anesthesia a
7 lb. 6’/2 oz. female infant was delivered at 3:15 A.M.
by Waters extraperitoneal section. The infant was de-
livered through the uterine incision by version and ex-
traction without extension of the incision or tearing into
the peritoneum. The baby cried immediately and was in
good condition.
The mother’s postoperative course was entirely un-
eventful, the highest temperature being 100.2 degrees on
the first postoperative day. The Foley catheter was re-
moved in eighteen hours and the patient voided spon-
taneously without residual. She was allowed out of bed
at will after the first twenty-four hours. The wound
healed by primary union. The patient received penicillin
for forty-eight hours postoperatively. Mother and baby
were discharged the ninth postoperative day in good
condition.
Case No. 2
Mrs. R. B., age 27, Para 1, Gr. 11, E.D.C. July 10,
1947, was admitted to Allen Memorial Hospital at 6:40
P.M. on July 6, 1947, following telephone consultation
with her physician in a neighboring town. Active labor
had begun at 11:00 A.M. on July 5, 1947, and had
progressed slowly. The membranes had ruptured spon-
taneously at 4:30 A.M. July 6, 1947, followed by hard
pains every three to four minutes. At 4:00 P.M., July
6, 1947, a transverse presentation with prolapse of a
hand and arm of the fetus into the vagina was dis-
covered.
General physical examination of the patient was nega-
tive. The blood pressure was 110/60, R.B.C. 4,200,000,
W.B.C. 15,000 and Hb. 13.15 gm. The temperature
was 98.4 and the pulse was 84. Examination of the ab-
domen revealed a term pregnancy with the fetus pre-
senting in the transverse, the head being markedly hyper-
extended in the right iliac fossa, the back being an-
teriorly. The fetal heart was clearly heard in the right
lower quadrant. Rectal examination revealed the cervix
to be approximately 4 centimeters dilated with the left
shoulder impacted in the pelvis, the left hand and arm
being prolapsed into the vagina. The lower uterine seg-
ment was extremely tender to palpation and it was the
impression of the examiner that it was unusually thin.
X-ray examination verified the fetal position. After due
consideration it was decided to deliver this patient by
cesarean section and in view of the thirty-six hours of
labor and ruptured membranes for sixteen hours, the
extraperitoneal route was chosen.
Under spinal anesthesia a 7 lb. 10 oz. female infant
was delivered at 9:45 P.M. by Waters extraperitoneal
section. The infant was delivered from the uterus with
moderate difficulty, by version and extraction but the
incision did not extend nor was the peritoneum opened.
Upon exposing the lower uterine segment it was found
to be almost paper thin, and certainly would have tol-
erated little stress without rupture. The infant cried
immediately, and was in good condition, but held the
head in marked hyperextension for thirty-six hours or
more after birth. The prolapsed arm and hand were
edematous and cyanotic at birth but this disappeared
spontaneously in a period of a few hours.
The patient had an uneventful postoperative course,
the highest temperature being 99 on the first and second
10
The Journal-Lancet
postoperative days. The Foley catheter was removed in
eighteen hours, and she voided spontaneously without
residual. Penicillin was given for forty-eight hours post-
operatively. She was allowed up freely within twenty-
four hours of delivery. The wound healed by primary
union. Both mother and baby were discharged in good
condition on the ninth postoperative day.
The question of low cervical, versus extraperitoneal
approach in the actually or potentially infected case is
one that is now being considered frequently in obstetric
literature. Many now feel that with the use of the new
antibiotics and more wide-spread availability of blood,
the scope of the low cervical transperitoneal operation
may be extended. However, it may well be argued that
these measures are just as efficient in the patient who has
been delivered by the extraperitoneal route plus the add-
ed advantage of complete lack of peritoneal spill.
Certainly the need for the extraperitoneal operation
will not arise frequently, but I do feel that it will find
a place in the armamentarium of the obstetric surgeon.
AMERICAN BOARD OF OBSTETRICS AND GYNECOLOGY, INC.
A number of changes in Board requirements and regulations were made at the annual
meeting of the Board held in Washington, D. C., May 16 to May 22, 1948. New Bulletins
are now available for distribution upon application and give full details of all new regula-
tions. These relate both to candidates, and to hospitals conducting residency services for
training.
Foremost are the following:
1. The ruling that applicants must receive adequate training in both obstetrics and gyne-
cology has been defined as meaning a minimum of six months, full-time, in the branch of
either obstetrics or gynecology relegated to a minor role in a candidate’s training and pref-
erence for practice.
2. Acceptable preceptorship training is defined.
3. The present regulation requiring at least six months of practice in the specialty fol-
lowing the completion of an acceptable training period, has now been extended, effective
December 31, 1949, to a requirement of two years post-training practice limited to the
specialty.
4. Specific requirement for approval of hospital services for residency training are
outlined.
5. Effective immediately, there will be no further temporary approvals of hospital serv-
ices for residency training. It is planned that all hospitals holding any type of residency
training approval will soon either be resurveyed or initially surveyed by the Council on Med-
ical Education and Hospitals of the A.M.A. so that all future approvals, new or old, will
be based entirely upon inspection following application. It is expected also that certain re-
surveys will result in withdrawal of present residency approval from institutions where the
educational and training standards are not being maintained.
The next scheduled examination (Part I), written examination and review of case his-
tories, for all candidates will be held in various cities of the United States and Canada on
Friday, February 4, 1949.
January, 1949
11
Puerperal Sepsis
A Case Report
Joseph F. Bicek, M.D.
St. Paul, Minnesota
The original intention was to present a paper on the
Newer Aspects of the Management of Puerperal
Sepsis, covering briefly the history, course, clinical con-
siderations, and dwelling mainly on the modern treat-
ment. However, due to the long program, and the much
needed time, it was decided to only present a case report
on Sepsis. Today we have many controversial problems,
viz.: Should we treat carcinoma of the cervix only by
irradiation, or should we utilize only surgery, or a com-
bination of both? Should we remove the whole adnexa
in a case of ectopic pregnancy, or save a good ovary?
What is the best analgesia in labor, by chemotherapy,
or by spinal, or by local infiltration? There are a score
of other debatable procedures too numerous to mention,
but one thing is a certain non-debatable fact, and that
is the possibility of infection in the puerperal state.
Puerperal infection whether it is autogenous or heteroge-
nous, endogenous, or exogenous still does exist, and in
spite of such excellent chemotherapy and antibiosis that
we have at the present time, still is a dreaded malady, and
still is highly dangerous. Nothing in this presentation
is going to be claimed to be spectacular, absolutely in-
novating, or brilliantly original, but a brief case report
will be given to bring back to our minds that there still
exists a condition known as puerperal sepsis.
Mrs. D. M., age 25, gravida IV, para II, was admit-
ted to St. Luke’s hospital in St. Paul at 2:07 P.M. on
March 3, 1948, in labor. She delivered without any
difficulty at 4:35 P.M.; she had one dose of Demerol
and Scopalamine only. There were no tears. The infant
weighed only 6 lbs. 4 oz., and unfortunately had a double
harelip and cleft palate. This was not too enthusing but
unfortunately was not to be the last. Intravenous er-
gotrate was not used when the head was being delivered,
but after about ten minutes an unsuccessful attempt was
made to express the placenta. Many more attempts were
made, but the placenta did not deliver for a period of
40 minutes. At the end of this time the patient was thor-
oughly anesthetized and using sterile technique the va-
ginal tract was entered to try to determine the cause and
if possible to extract the placenta.
The cervix was partially closed up and the cord was
followed up, but the placenta was not lodged in the
lower uterine segment, as is frequently the case. Care-
ful entering • of the whole hand revealed the placenta
to be up in the uterus, over the fundal and the anterior
surface. It apparently had made no attempts to separate
and likewise would not peel off. When grasped and
pulled, the uterus came down as one piece. Peeling de-
tached only small pieces, and luckily no bleeding was en-
countered. After about six minutes of trial at the end
of which the whole hand was almost paralyzed by the
contraction of the uterus, in spite of the anesthesia the
hand was withdrawn along with small pieces of placenta
that were loosened. Still there was no bleeding. After
some deliberation, again the vaginal tract was entered
with a fresh sterile long glove, and the same results were
achieved as the first time. There still was no bleeding.
Less than one-half of the placenta was removed. A
definite diagnosis of Placenta Accreta was made.
The patient was given pitocin, and intravenous er-
gotrate and put to bed. She was given plasma and saline.
Ergotrate was ordered by mouth, every four hours.
Penicillin, 50,000 units every four hours, was started
intramuscularly. Hemoglobin estimation on March 5,
1948, was 9.8 gm. Sahli. On March 5, also, she expelled
a large blood clot which showed a small amount of de-
cidual tissue. On March 6, the lochial flow was normal
in amount. Because of the anomaly in the baby she
could not nurse, so she did require stilbestrol for drying
up the breasts, and also occasional pain relief. Penicillin
was continued throughout March 8. On March 10, she
passed a very small clot, and a very few small ones on
March 12th. She felt very good, and was left to walk
on March 10th. There was no temperature following
the delivery except on March 13th, she registered 100.2
at 8:00 P.M. Otherwise 99.2 was the highest it ever
reached during the nine day stay. Due to her financial
state she could not afford to stay any longer, and it was
with reluctance that she was discharged at 2:00 P.M. on
March 14th. She was given strict instructions to come
back immediately if cramps and bleeding appeared. She
did not disappoint us for too long. On March 15th, at
3:30 P.M., at her home, she started to bleed. Instead of
calling an ambulance to go back to the hospital, a neigh-
bor got excited and summoned the emergency squad car.
Unfortunately, the police surgeon not knowing the case,
did not save what the patient had passed, which by his-
tory was quite a lot, and therefore we had nothing to go
by when she was readmitted at 6:45 P.M. on the same
day. She was quite exsanguinated, and on admission had
a temperature of 98.8. Hemoglobin on admission was
8.8 gm. Sahli. The very next day the temperature rose
to 104.6 and from there on she ran a sawtooth septic
temperature continually until March 23rd, from which
point it slowly tapered off to normal. Her condition on
the readmission appeared quite bad. The hemoglobin
was 8.8 gms. and dropped quickly to 7.7 gms. the next
day. She was immediately given 500 cc. of plasma and
two hours later when a donor was obtained, 500 cc. of
whole blood. Fortunately on admission she was not
bleeding. On March 16th she was given 500 cc. of blood
again and also one-half gram of sodium sulfathiazole
intravenously. This was repeated on March 17th and
also on March 18th. On March 18th penicillin at the
rate of 50,000 units every four hours was started. On
12
The Journal-Lancet
March 19th penicillin was continued and in addition
.2 gm. of streptomycin was .started about every five
hours. Both penicillin and streptomycin were continued
throughout March 27th. On March 22nd 500 cc. of
blood was given. In all, the patient received 2,000 cc.
of blood and 500 cc. of plasma. Throughout her septic
course the patient was quite sick, had occasional chills,
and required pain relief mainly because of leg pains.
There never was any evidence of thrombophlebitis. Cal-
cium intravenously relieved most of the pains. No di-
cumerol was used at any time because of the fear of
bleeding. Also as long as no bleeding was encountered,
no pelvic examinations were made. Not until the second
of April with a normal temperature existing for about
three days, did I attempt a cautious bimanual and found
an involuting uterus which was not out of proportion to
the postpartum time. The complication that this patient
did definitely develop was rheumatic pain in the right
shoulder and left ankle. No bleeding followed the bi-
manual, her temperature was normal; patient walked
around, felt good and therefore was discharged on
April 3rd. Further follow-up showed the uterus to be
involuting normally. At the present time she is perfectly
well, having a normal menstrual cycle and showing no
adnexal indurations in the pelvis anywhere.
This case presents many angles. There is little doubt
as to the diagnosis of Placenta Accreta. A few pro-
cedures might be questioned. Ergotrate was not used
intravenously when the head was being delivered; how-
ever, that probably would not have altered the adherence
of the placenta and facilitated expulsion. Trying to ex-
tract the placenta manually is contradictory to the mod-
ern concept, which is to leave the patient alone and
watch and wait, but where trained observance and quick
necessary action is highly essential, which was not to be
had in this case, a careful attempt at manual removal
is indicated. One entry and out under the most sterile
conditions should be the rule. Apparently in this case
the villous attachement into the muscle finally detached
after the fetal circulation ceased. This, however, does
not always happen and in Placenta Accreta, the doctor
may often have to resort to uterine packing first, with
ultimate hysterectomy. In this case there was no sepsis
for nine days. Under direct control no evidence of in-
fection was present. What happened when the patient
left the hospital is unknown. When the patient was re-
admitted after apparently expelling the placenta at home,
she immediately showed signs of sepsis. Was it Sapre-
mia? The real organism was never determined but strep-
tococcus was most likely.
A brief summary and comments on the new and mod-
ern method of management of sepsis are noted here:
1. A careful prenatal study will cut down the possi-
bility of infection, be it autogenous or heterogenous.
2. During labor extreme asepsis should be employed
and intravaginal manipulation reduced. Unneces-
sary vaginal entries should be avoided and neces-
sary ones must be done under extreme caution.
3. In suspected contaminations, use sulfonamides and
penicillin prophylactically.
4. In definite sepsis it is essential to resort to sulfona-
mides, paying attention to urinary excretion and
maintaining blood levels up to 15 mgm. per 100 cc.
if possible and if tolerated. All the organisms will
not be hit, but certainly the most dangerous, the
streptococcus. Penicillin in large doses should be
started concomitantly. If no appreciable alleviation,
immediately start streptomycin. About .2 gm. every
four hours is sufficient. There is no doubt that the
advent of chemotherapy and antibiosis has revolu-
tionized our treatment of sepsis.
5. Blood by transfusion should not be spared.
6. Where bleeding is not a factor, controlled dicu-
merol therapy to prevent deleterious thrombophle-
bitis should be used. Recent results show heparin
to be even more desirable.
As a final statement this author believes that radical
and effective treatment will certainly cut down the num-
ber of puerperal sepsis cases that eventually have to come
to surgery.
CONTINUATION COURSES
The University of Minnesota announces a continuation course in Cardiovascular Dis-
eases to be given at the Center for Continuation Study on February 14 and 15, 1949. The
course is intended for general physicians and is sponsored by the Minnesota Heart Associa-
tion.
The University is also offering a continuation course in Pediatrics to be given at the
Center for Continuation Study on February 7, 8, and 9, 1949. The course is intended for
general physicians and is sponsored by the Minnesota Department of Health.
January, 1949
13
Basal Temperature Records in
Obstetrics and Gynecology
Melvin B. Sinykin, M.D.
Minneapolis, Minnesota
The normal fluctuation of basal body temperature
in the human female produces a biphasic curve dur-
ing the menstrual cycle. Although this curve is subject
to variation between individuals and to a lesser extent
from cycle to cycle in the same individual, the general
pattern is sufficiently characteristic to have aroused in-
terest and study by numerous investigators during the
past century.1 The interpretation of this pattern had to
await the development of knowledge concerning ovarian
function in relation to the menstrual cycle. As early as
1905 Van de Velde related the occurrence of mittel-
schmerz and ovulation to the low point of the basal
temperature curve.1
The biphasic curve of the basal temperature record
in the normal menstrual cycle has been shown to be
closely related to ovarian hormone production. Cyclic
therapy with estrogen followed by progestin in women
who are amenorrheic as a result of ovarian failure or
surgical castration reproduces the biphasic curve.2,3,4
Chorionic gonadotropin administered in large dosage
during the luteal phase will cause the prolongation of
the postovulatory temperature rise probably by stimu-
lating luteinization and thereby continued progestin
secretion. When chorionic gonadotropin is administered
to ovariectomized women who have been primed with
estrogen, no temperature rise occurs since there is no
ovarian tissue to be stimulated.3
The basal temperature is obtained by the patient be-
fore she arises each morning. Rectal temperatures were
favored in the past for this purpose but the oral tem-
perature has been shown to be equally reliable. The
patient must be carefully instructed in the technic of
taking her temperature and she must be warned against
late retiring, alcoholic excesses, and emotional upsets.
The temperature may be recorded on ordinary graph
paper or on specially prepared graphs. If the patient
cannot be relied upon to keep the graph she may be
instructed to write down the temperature, the date, and
other pertinent data each morning. The graph can then
be quickly drawn at the time of her office visit. The
reliability of the completed record depends upon ade-
quate instruction, cooperation by the patient, and the
absence of such disturbing factors as infection, emo-
tional disturbances, and alcoholic hangovers. According
to Davis and Fugo,2 who have reviewed 1,000 tempera-
ture graphs, about 75 per cent of patients present graphs
which are sufficiently typical to provide valid data con-
cerning ovarian function.
During the normal cycle the temperature remains low
during menstruation and the preovulatory period. A rise
in temperature then occurs, usually over a period of
one to three days and usually from 0.6 to 0.8 degrees F.
The elevation is then maintained in the form of a pla-
teau for about 14 days and drops just before or at the
time of onset of the next menstrual period. If pregnancy
occurs the temperature is maintained until mid-preg-
nancy when it gradually drops to preovulatory levels.
A drop in temperature just before the rise has been con-
sidered typical by some observers. However, this drop
is not constant and is not a reliable indicator that the
shift in temperature is about to follow.
To evaluate the reliability of the basal temperature
record, a series of 50 cycles from 15 patients were ana-
lyzed. The temperatures were taken orally before arising
and after holding the thermometer in the mouth for at
least four minutes. A smaller rise in temperature pre-
ceding the main rise occurred in 14 cycles or 28 per cent.
A drop in temperature before the shift was found in
13 or 26 per cent of the cycles. The duration of the
temperature rise was one day in 15 cycles, two days
in 9, and three days in 11. The remaining cycles showed
a duration of rise varying from four to seven days.
Thus the temperature rise in 35 or 70 per cent of cycles
was of one to three day duration. The amount of the
temperature rise varied from 0.4 degrees F. to 1.2 de-
grees F. In most cycles the rise fell into a range of 0.6
to 0.8 degrees F. The duration of the temperature eleva-
tion preceding menstruation was 12 to 15 days in 78 per
cent of the cycles. In no case was the duration greater
than 15 days although in the remaining cycles the dura-
tion of temperature elevation was as short as nine to
eleven days. In general these figures agree with pre-
viously reported estimates that 75 per cent of the basal
temperature records are characteristic enough to be of
value.
A close relationship between the time of ovulation and
the temperature shift has been determined by numerous
studies utilizing other signs of ovulation such as the
vaginal smear,0 increase in the quantity of cervical mu-
cus,6 endometrial biopsies,7 and known dates of concep-
tion.8,9 The most direct evidence has been produced by
Greulich 10 who performed laparotomy at the time of the
temperature rise and determined the gross and histo-
logical appearance of the ovaries in about 70 patients.
His observations indicate that ovulation occurs during
the temperature rise. A dissenting opinion in this regard
is that of Farris11 who reports the known dates of con-
ception of 27 women who kept basal temperature records
and in whom the probable date of ovulation was deter-
mined by the rat ovulation test. He found that 41 per
cent of the conceptions took place before the tempera-
ture change, 37 per cent during the rise, 15 per cent
during the low point and 7 per cent after the rise.
Despite its limitations, the basal temperature record
(hereafter designated as BTR) is proving to be a sim-
14
The Journal-Lancet
pie, economical, and useful aid in the practice of ob-
stetrics and gynecology. Although the widest applica-
tion of this method has been found in sterility study,
it is equally valuable for other conditions. Some exam-
ples of the use of the BTR in practice are presented to
illustrate the diversity of its application.
Use of BTR in patients with menstrual abnormali-
ties: Fig. 1 illustrates the appearance of the BTR in
Fig. 1.
normal and abnormal menstrual conditions. Case 1
is a good example of the typical normal curve. Case 2,
K. R., is a 25 year old patient with irregular and pro-
fuse periods of uterine bleeding. The BTR reveals a
monophasic curve indicating failure of ovulation. Case
3, M. J., age 38 years, complained of prolonged and
profuse menstrual periods. Diagnostic curettage per-
formed at the University of Minnesota Hospital two
years previously revealed irregular shedding of the endo-
metrium. The menorrhagia persisted and she was sent
to a special study clinic in the outpatient department
where she was instructed in the use of the BTR. This
revealed a persistence of the temperature elevation into
the menstrual period. Since the delayed temperature
drop suggests delay in the regression of the corpus
luteum, this finding is in agreement with the observations
of McKelvey and Samuels 1L' that the excretion of so-
dium pregnandiol glucuronidate persists into the early
menstrual period in irregular shedding. Nieburgs 13 also
reported that in menorrhagia the basal temperature does
not fall as it normally does in the premenstrual period
but remains at a high level until the end of the men-
strual phase. The BTR is being used in the irregular
shedding clinic as a guide to timing experimental hor-
monal therapy to the late premenstrual period.
Use of BTR in infertility: The greatest value of the
BTR to the infertile couple obtains when the menstrual
cycles are irregular and the time of ovulation is there-
fore variable in relation to the time of the preceding
period. The value in using the BTR is dependent on the
ability of the patient to recognize the time of tempera-
ture shift and to utilize that period of time for attempt
Fig. 2.
at conception. Fig. 2 shows the temperature records of
five patients who achieved pregnancy. In each instance,
except in Case 2, coitus occurred at the time of the tem-
perature rise. In Case 2 the probable date of conception
occurred twenty-four hours previous to the time of tem-
perature rise. Case 5 illustrates an unusually long inter-
val between the preceding menstrual period and the time
of conception. According to the date of her last men-
strual period R. L. would be given an estimated date of
confinement as April 11. From the probable date of con-
ception this was revised to May 8, and delivery occurred
May 27 after a total period of gestation of 284 days.
The usually accepted figure for the average interval
between ovulation and delivery is 266 days. It is inter-
esting to note that the average length of gestation of the
five patients in Fig. 2 is 267 days.
Fig. 3 shows the BTR of R. L. carried through the
entire period of pregnancy. The temperature is main-
tained at its postovulatory level through the fifth cal-
endar month and then gradually drops to pre-ovulatory
levels. Buxton and Atkinson 3 have reported four com-
plete pregnancy records and Dr. Charles McKenzie 14
has obtained the complete BTR of two pregnancies.
In all of the pregnancy records the general pattern is the
same. The temperature level is maintained until the
fourth or fifth month and then gradually drops. Since
progestin has been found to elevate the basal tempera-
ture and since pregnandiol excretion studies reveal a
gradually rising level during the last trimester of preg-
January, 1949
15
Fig. 3.
nancy, one would expect a gradually rising temperature
at this time. The reason for the discrepancy is not clear.
Use of the BTR as an aid to the rhythm method of
contraception: The BTR is useful as an aid to the
rhythm method during lactation and when menstrual
cycles are irregular in length. Fig. 4 illustrates such use
Fig. 4.
of BTR by two patients. R. L. is a patient with mitral
heart disease who for religious reasons is unable to use
mechanical methods of control. During lactation she
was asked to abstain from marital relations unless a
typical temperature rise occurred and was maintained
for five days. During lactation she had an anovulatory
bleeding period. Following cessation of lactation she
ovulated and after five days of temperature elevation
intercourse was permitted. The arrows indicate the
periods of abstinence. Following menstruation she was
directed to abstain after the eleventh day of her cycle
and not to resume marital relations until the tempera-
ture rise had been maintained for five days. These fig-
ures were arrived at as follows: Since by history her
cycles varied from 30 to 36 days, the earliest probable
date of ovulation would be 30 minus 14 or day 16 of
the cycle. To allow for variation in the time of ovula-
tion and for the probable life span of the sperm an
additional five days are subtracted thus arriving at the
figure 1 1 for the cycle day at which abstinence starts.
Following the temperature rise an additional five days
of abstinence allow for the life span of the ovum and
sperm and for errors in the interpretation of the BTR.
The advantage in the use of BTR as an aid to the
rhythm method lies in the increased length of the safe
period afforded in the postovulatory part of the cycle.
Case 2, M. D., has mentrual cycles varying from 28 to
35 days in length. During a 28 day cycle her safe
period following ovulation would be nine days with the
use of the B.T.R. and only two days using the mathe-
matical calculations of the rhythm method. If her cycle
were 35 days the safe period would be the same with
either method.
Use of the BTR as an early pregnancy test: The life
span of the corpus luteum and likewise the duration of
the postovulatory temperature elevation is rarely longer
than fifteen days in the absence of pregnancy. There-
fore when the temperature elevation persists for 20 days
and the pattern of the BTR is biphasic, the diagnosis
of pregnancy may be made with considerable assurance.
At this time, less than one week after the missed men-
strual period, palpatory findings and the usual biological
pregnancy tests are not reliable. The diagnosis of preg-
nancy at this early stage in the patient with evidence of
predisposition to abortion may be of considerable value
since prophylactic steroid hormone therapy can be start-
ed within one week of the missed menstrual period.
Fig. 5 illustrates the use of BTR in two such cases.
Fig. 5.
F. S., age 28 years, gave a history of irregular men-
strual periods occurring at intervals of two to nine
months since their onset. She was told three years pre-
viously that her uterus was infantile and she was given
a series of hormone injections to develop the uterus.
On examination she presented a masculine type of body
build, generalized hirsutism of moderate degree, enlarged
clitoris, small conical cervix, and a definitely hypoplastic
uterus. Vaginal smear revealed many castrate cells. She
was given directions for keeping the BTR and was
asked to return in one month. At the time of the next
office visit her BTR was reviewed and pregnancy of
about 22 days duration was diagnosed. Steroid therapy
was started immediately because of the small size of her
16
The Journal-Lancet
uterus. She carried her pregnancy uneventfully except
for an episode of spotting during the second month.
E. A., age 26 years, first appeared in June 1946 for
treatment of sterility of 414 years duration. Her history
revealed irregular menses occurring in cycles of three
to eleven weeks. Examination revealed a hypoplastic
uterus. B.M.R. was minus 25 per cent. After thyroid
therapy she became pregnant in September 1946 but
aborted at five weeks gestation. She again conceived in
April 1947 and aborted at eight weeks gestation. The
uterus remained small and her menstrual period irreg-
ular. In January 1948 cyclic therapy with stilbestrol was
started in an attempt to develop the size of the uterus.
She was unable to tolerate the drug so dinestrol was sub-
stituted. The BTR shows an anovulatory bleeding period
in January 1948. Dinestrol was stopped in February
1948. On March 14 she phoned that she suspected preg-
nancy because of nausea and breast soreness. She was
asked to resume keeping her BTR and report in one
week. Although the BTR was incomplete, pregnancy
was considered very probable. Prophylactic steroid hor-
mone therapy was started and continued during the first
four months of pregnancy. Despite recurrent episodes
of uterine cramps she carried her pregnancy until three
weeks before term.
Other uses of the BTR: The diagnosis of obscure
pelvic pain may be aided by use of BTR. This is illus-
trated by the case of R.A., age 36 years who five years
previously had a pelvic laparotomy at which time sub-
total hysterectomy and left salpingo-ovarectomy was per-
formed for myoma of the uterus and cystic left ovary.
Since the time of surgery she has complained of inter-
mittent right lower abdominal pain. On bimanual ex-
amination the right ovary was felt to be normal in size
but fixed to the cervical stump and to the lateral pelvic
wall. She was asked to keep a BTR and mark the days
when pain occurred and to grade the pain from one to
four. Examination of the record at monthly intervals
revealed a biphasic type of curve with the time of pain
mostly in the follicular or preovulatory phase. The in-
tensity of the pain was greatest just preceding the tem-
perature shift. From the BTR it seems likely that the
pain is a form of mittelschmerz possibly related to the
fixation of the ovary by postoperative adhesions.
The BTR has also been used to determine the effect
of estrogen therapy on ovulation in the treatment of
dysmenorrhea. Estrogen given in adequate dosage start-
ing early in the menstrual cycle will inhibit ovulation.
The resulting anovulatory bleeding period is almost
always painless. The BTR can be used to verify the
inhibition of ovulation. If the patient complains of mid-
line crampy pain during an anovulatory bleeding period
the cause of the pain is probably psychic.
Conclusions and Summary
1. Abundant evidence exists that indicates a close
relationship between the biphasic basal temperature curve
and hormonal changes incident to the process of ovula-
tion and corpus luteum formation.
2. The interpretation of the BTR as a reflection of
ovarian function is valid in the majority of patients.
Difficulties may be due to poor cooperation of the pa-
tient, occurrence of infection, and individual variation in
the duration and the amount of temperature shift.
3. Analysis of variations in the BTR kept for 50
cycles by 15 patients is presented. Temperature rise pre-
liminary to the main temperature shift was found in
28 per cent of cycles. Temperature drop just before the
rise was present in 26 per cent. The duration of the
temperature shift was found to fall within a three day
range or less in 70 per cent and the degree of shift was
from 0.6 degrees F. to 0.8 degrees F. in the majority
of cycles.
4. Examples are presented of the practical value of the
BTR in menstrual abnormalities, in infertility, as an aid
to rhythm contraception, as an early pregnancy test, for
estimating the date of confinement and for determining
the relation of obscure pelvic pain to the ovarian cycle.
5. The BTR during pregnancy is characterized by per-
sistence of the postovulatory temperature elevation until
the fifth month when it gradually drops until delivery.
The pregnancy pattern of the BTR cannot be explained
by the known hormone levels during pregnancy.
References
1. Barton, D. S.: A Study of Temperature and Electric
Potentials in the Menstrual Cycle (Historical Review). Yale
J. Biol. & Med. 12:503-523, 1940.
2. Davis, M. E., and Fugo, N. W.: The Causes of Physio-
logic Basal Temperature Changes in Women. J. Clin. Endo-
crinology 8:550-563 (July) 1948.
3. Buxton, C. L., and Atkinson, W. D.: Hormonal Fac-
tors Involved in Regulation of Basal Body Temperature During
the Menstrual Cycle and Pregnancy. J. Clin. Endocrinology
8:544-549 (July) 1948.
4. Barton, M., and Wiesner, B. P.: Thermogenic Effects of
Progestin. Lancet 2:671-672, 1945.
5. Rubenstein, B. B., and Lindsley, D. B.: Relation Between
Human Vaginal Smears and Body Temperatures. Proc. Soc.
Exper. Biol. & Med. 35:618-619, 1937.
6. Viergiver, E., and Pommerenke, W. T.: Measurements
of Cyclic Variations in Quantity of Cervical Mucus: Correlation
with Basal Temperature. Am. J. Obst. & Gynec. 48:321-328
(Sept.) 1944.
7. Martin, P. L.: Detection of Ovulation by Basal Temp.
Curve with Correlating Endometrial Studies. Am. J. Obst. St
Gynec. 46:53-62 (July) 1943.
8. Zuck, T.: The Relation of Basal Body Temperature to
Fertility and Sterility in Women. Am. J. Obst. & Gynec.
36:998-1005, 1938.
9. Tompkins, P.: The Use of Basal Temp. Graphs in
Determining the Date of Ovulation. J.A.M.A. 124:698
(March 11) 1944.
10. Greulich, W. W.: The Reliability of Basal Body Temp.
Changes as an Index of Ovulation in Women. Tr. Am. Soc.
Study Sterility 1:76-97, 1946.
11. Farris, E. J.: Temperature Compared with Rat Test
Prediction of Human Ovulation. J.A.M.A. 138:560-563 (Oct.
23) 1948.
12. McKelvey, J. L., and Samuels, L. T.: Irregular Shedding
of the Endometrium. Am. J. Obst. & Gynec. 53:627-636 (Apr.)
1947.
13. Nieburgs, H. E.: Body Temperature — Diagnostic Aid in
Disorders of Menstruation. J. Obst. & Gynec. Brit. Emp.
52:435-467 (Oct.) 1945.
14. McKenzie, C.: Personal communication.
January, 1949
17
Peritoneal Irrigation in Treatment of Severe
Oliguria Caused by Transfusion Reaction
F. J. McCaffrey, M.D.
Minneapolis, Minnesota
This discussion is concerned with the experiences
gleaned from the management of one case of severe
hemolytic transfusion reaction and is in no way to be
construed as applicable to all cases of temporary renal
insufficiency arising from such reactions.
This particular case is being presented because it again
serves to re-emphasize the extreme importance of the Rh
factor in transfusion therapy, and because it involves
several rather major and specific therapeutic procedures.
Further, it affords the opportunity of adding to a sparse
literature on the subject, another successful application
of peritoneal lavage in the treatment of renal insuffi-
ciency. No attempt will be made to discuss the many
intricate metabolic, biophysical and technical problems
involved in the use of the peritoneum as a dialyzing
membrane. This is merely a summation of the pertinent
data in chronological sequence pertaining to this particu-
lar case.
Case Report
The patient, Mrs. A. E., age 40, was admitted to the
Minneapolis General Hospital on April 15, 1948, with
the complaint of a heavy dragging sensation in the pel-
vic region with stress incontinence. Omitting the details
the patient was in generally good physical condition with
the exception of a pronounced anterior and posterior
vaginal wall relaxation. Her weight was 186 lbs., and
cardiac examination including an electrocardiograph was
normal. Her blood pressure was 140/100.
The hemoglobin was 85 per cent (Sahli) and the
blood group was O, Rh positive. Her blood was cross-
matched with group O, Rh positive blood. The blood
urea nitrogen was 20 mgms. per cent. Catheterized urine
specimen was normal. Careful medical work-up revealed
nothing unusual. Observation cystoscopy and ureteros-
copy was done on April 16, 1948. On the morning of
April 19, 1948, a combined vaginal plastic procedure
and a pelvic laparotomy were performed. Although
there was at no time excessive bleeding the patient sus-
tained a drop in blood pressure to 96/ 60. Consequently,
during the course of the surgical procedure she was
transfused with one liter of whole blood. She was dis-
charged to the ward in apparently good condition.
By early afternoon of the same day the patient became
cyanotic with associated rapid respiration. She developed
a chill with a subsequent temperature elevation to
104 F. Urinary output by retention catheter was almost
negligible and what was obtained was highly colored and
concentrated. A diagnosis of a moderately severe hemo-
lytic transfusion reaction was made and the following
treatment was instituted: oxygen was given, normal
saline was administered intravenously, and an attempt to
alkalinize was made with one-sixth normal sodium molar
lactate. The temperature dropped slightly. By that eve-
ning blood stained urine was draining from the catheter.
Free hemoglobin determinations on the plasma were not
done but the Benzidine and Guiac tests for blood in the
urine were positive. The icteric index and the serum
bilirubin rose steadily in the next 36 hours and the pa-
tient became clinically jaundiced.
The next day the patient’s blood was again grouped.
The patient actually was Group O, Rh negative, and
during surgery had received Group O, Rh positive blood.
Her husband was later found to be Rh positive, but she
had six uneventful full term pregnancies with six nor-
mal living children.*
In conjunction with the Medical Department a con-
servative course of management was decided upon, in-
volving primarily maintenance of proper electrolyte and
nonelectrolyte and fluid balances; treatment of the sec-
ondary anemia with small compatible blood transfusions;
and watchful waiting. It was hoped that an increase in
kidney function would result. Some reports in the lit-
erature have mentioned successful outcomes with this
method of treatment even though the period of oliguria
existed for as much as fifteen days.
By the fourth postoperative day the daily 24 hour
urine output was ranging between 100 and 300 cc. The
serum blood urea nitrogen rose to 100 mgm. per cent.
Cystoscopy at this time revealed that the ureters were
patent.
Caudal Analgesia
On the fifth postoperative day the blood urea nitro-
gen was 120 mgm. per cent and the patient’s general
condition was getting progressively poorer. Because it
has been shown to be of some value in the relief of the
vasospastic element present in the various oligurias and
anurias associated with the pre-eclampsias and eclampsias
of pregnancy it was suggested that caudal analgesia
might be tried.1 Present knowledge of the renal histo-
pathology involved in this disease points primarily to
tubular damage with degeneration and obstruction.
However, vasospasm being of uncertain significance, it
was decided to proceed with the caudal.
On the afternoon of the fifth postoperative day caudal
analgesia was instituted using a total of 495 mgm. of
*Recent blood studies done by Dr. Levine at the Ortho Re-
search Laboratory reveal the fact that the husband is Rh posi-
tive (Rh, heterozygous), and the patient is Rh negative with
serum containing blocking antibodies in a titer of 1:512.
18
The Journal-Lancet
metycaine and raising the level of analgesia to T6. This
was maintained for six hours and then allowed to regress
for four hours. Additional injections were made (the
inlying catheter technic being used) again maintaining
the level to T5 for another six hour period. The caudal
was then discontinued in accordance with the original
plan which was not to exceed 18 hours in total length.
During the period of analgesia no demonstrable change
in the urinary output was observed. The blood urea
nitrogen continued to rise. The patient did experience
her most comfortable hours since surgery, but as far as
could be determined it was the only benefit obtained.
Renal Decapsulation
By the seventh postoperative day the blood urea nitro-
gen was 146 mgm. per cent, the serum creatinine was
17.6 mgm. per cent, and the patient’s condition was gen-
erally poorer. The 24 hour urinary output had dropped
to 150 cc. Although conflicting reports have appeared
in the literature, the Department of Urology felt that
a renal decapsulation was indicated.1,6 It was apparent
that the patient was rapidly growing worse and any pos-
sible helpful procedure was felt to be indicated. On the
evening of the seventh day, under local infiltration anes-
thesia, the left kidney was decapsulated. The kidney
appeared enlarged and purplish in color but on incision
of the capsule there was no significant bulging of the
parenchyma. Because of this it was felt that the element
of increased intrarenal pressure was probably non-exist-
ent. LJnfortunately, no biopsy of the kidney was taken.
During the three days following renal decapsulation
the patient grew progressively worse clinically. She was
disoriented and lethargic. The urinary output in 24
hours was now only 25 cc. The blood urea nitrogen was
185 mgm. per cent, and the creatinine had risen to 22.8
mgm. per cent. Because of the increasing and profound
uremic condition it was decided in conjunction with the
Department of Surgery to institute peritoneal lavage.
Peritoneal Lavage
On the morning of the eleventh postoperative day,
under local analgesia, peritoneal irrigation was begun and
was continued for approximately 82 hours. Without
mentioning details the procedure involved numerous and
burdensome laboratory determinations, continuous suc-
tion with an electric pump, preparation and sterilization
of the irrigating fluids in large quantities, scrupulous
attention to the problem of fluid balance and almost con-
stant observation. N^’4,5*8, 9
An inflow was established by placing a mushroom type
soft catheter in the left upper quadrant of the abdomen,
and the outlet by fixing a regular surgical sump drain
in the right lower quadrant. The inflow was connected
to an intravenous Murphy drip and the outflow was at-
tached to the the electric pump suction. A trap bottle
was interposed in the outflow setup between the patient
and the pump to prevent moisture from reaching the
motor. Regardless of the length of the tubing in the
outflow system condensation will take place and reach
the motor unless the trap bottle is employed. For irriga-
tion, Hartmann’s solution was used with 5 per cent glu-
cose added to raise the hypertonicity of the fluid. In the
first twenty-four hour period approximately 30 liters
were run through the circuit and later this was increased
to from 36 to 40 liters in 24 hours. Many daily studies
of the blood metabolites were done, plus daily urea nitro-
gen and chloride determinations on the urine and di-
alyzed fluid. In addition cultures were also run on the
recovered irrigating solutions daily. Streptomycin was
administered in doses of 0.25 Grams every four hours
orally, and 0.25 Grams every six hours intramuscularly.
Sixty thousand units (60,000 units) of penicillin were
given intramuscularly every three hours and 100,000
units were added to each liter of irrigation fluid. Twenty
(20) mgms. of heparin were also added to each 1000 cc.
of irrigation fluid.
By the fourth day, even with these antibiotic precau-
tions, the patient showed signs of early peritonitis as
evidenced by a rise in temperature, minimal but definite
peritoneal irritation with rebound tenderness, and posi-
tive cultures from the dialyzed fluid. Pseudomonas
sroginosa was the prominent organism found.
Figure 1 demonstrates and recapitulates graphically
the progress of the uremia leading to the institution of
the lavage. Note that about the time this procedure was
started the blood urea nitrogen had risen to 211 mgm.
per cent, and the creatinine 24.6 mgm. per cent, and
that at the end of 82 hours of lavage the blood urea
nitrogen was 104 mgm. per cent with the creatinine at
12.5 mgm. per cent.
The patient was clinically much improved from the
standpoint of orientation and both subjective and ob-
jective symptomatology. Because of the beginning peri-
tonitis, however, the lavage was discontinued and 1,000,-
000 units of penicillin plus 2.0 Gms. of streptomycin
were left in the peritoneal cavity. It was felt that a ful-
minating generalized peritonitis would not only disturb
the dialyzing potentialities of the peritoneum but destroy
the patient as well. It was not certain that later re-
institution of the procedure might not be necessary.
Figure 2 shows that on the last day of the lavage
(fourteenth postoperative day) the urinary output was
450 cc. — the highest of any day since surgery. During
the subsequent days this was followed by successive out-
puts of 550 cc., 1000 cc., 1200 cc., 1750 cc. This di-
uresis seemed to indicate a return of kidney function.
Four days after discontinuing the lavage the blood
urea nitrogen rose again to 165 mgm. per cent, and the
creatinine to 18 mgm. per cent. The peritonitis, however,
was improved. The re-establishment of the lavage was
considered, but was withheld when a slight drop in me-
tabolites and a steady increase in urinary output was
noted on the nineteenth postoperative day. The patient’s
course from here on showed continued improvement and
ended with complete recovery.
January, 1949
19
Fig. 1. Peritoneal lavage in treatment of temporary renal insufficiency effects on blood electrolytes
and non-electrolytes. (Case of A. E.)
In recapitulating and evaluating the charts the blood
urea nitrogen and creatinine recordings are self-explana-
tory.
The blood chlorides remained at normal levels but
with institution of peritoneal irrigation it will be noted
there was a distinct rise. This is explained by the in-
evitable absorption of irrigation fluid from the perito-
neum despite the hypertonicity obtained by the addition
of glucose.’* Sodium chloride was administered in gram
quantities on the days designated in Figure 1. Note that
no chlorides were necessary from the first postoperative
day until diuresis had been fairly well established.
The carbon dioxide combining power was kept for the
most part within normal limits with maximum effort to
maintain an alkaline rather than an acid tendency.
Sodium bicarbonate was used in this connection and
administered as indicated.
Calcium levels were controlled by the intravenous use
of calcium gluconate in gram quantities on the desig-
nated days.
The story of the fluid intake and output is graphically
illustrated in Figure 2. Note that the weight showed
some decrease during the lavage indicating partially
that the body fluid balance was not out of control.
There were never signs of pulmonary edema though a
mild state of overhydration was evidenced by the pres-
ence of peripheral and sacral edema which persisted until
the patient was nearly ready for discharge.
The secondary anemia associated with the uremia de-
veloped rapidly and was most resistant to therapy. Trans-
fusions were given as indicated in Figure 2 and oral
hematopoietic stimulants were administered, but the
hemoglobin was still only 60 per cent on the 58th post-
operative day.
The patient’s diet for the days immediately following
lavage consisted in high carbohydrate, high fat, zero pro-
20
The Journal-Lancet
mm ini
II II II II
mnn 11 phi n i
1 1 ii ii ii I i ii ii n ii
1 1 ii ii ii ii i ii ii ii ii
i ii ii i « i ii ii ii ii
l i ii ii i ii i ii ii ii
i i ii ii i ii i ii ii ii ii
Fig. 2.
Peritoneal lavage in treatment of temporary renal insufficiency fluid balance.
(Case of A. E.)
tein content. It was felt that the damaged kidneys were
incapable of handling more than the already existent
enormous load of nitrogenous metabolites.
Comment
This case demonstrates the use of several major thera-
peutic procedures in the treatment of temporary renal
insufficiency. It offers an unusual opportunity to com-
pare the results of these as separate entities even though
they were applied in sequence to one individual patient.
It also demonstrates the importance of careful and
adequate blood grouping with particular reference to the
Rh antigen. While whole blood is without doubt the
most efficacious agent in parenteral fluid therapy, this
case emphasizes the lethal dangers of poorly or improp-
erly controlled administration.
With this case there can be little doubt that the caudal
analgesia or the renal decapsulation had the slightest
effect. Neither procedure in any way altered the pro-
gressive development of the uremia.
Relative to the effect of peritoneal lavage it is clear
that this procedure was related chronologically to the
beginning return of kidney function. The patient would
probably have progressed into an irreversible uremic
syndrome with an inevitable fatal outcome if the diuresis
and the dramatic lowering of blood metabolites had not
been brought about by peritoneal dialysis.
A better answer to the treatment of these problems is
likely. The perfection and clinical application of exter-
nal dialysis may become a better procedure than the one
here employed. Peritoneal lavage on the other hand is
probably better than dialysis applied through various seg-
ments of either the large or the small bowel.1' Peritoneal
lavage is fraught with technical difficulties and requires
scrupulous attention to the details of fluid balance and
avoidance of peritonitis. Careful selection of irrigating
January, 1949
21
fluids is essential. Because fluid is absorbed from the
peritoneum under any circumstances the hypertonicity
of the irrigating fluid is very important in combating
overhydration. Dehydration is much easier to control
than overhydration, and wide variations in the hyper-
tonicity of the irrigation fluids are to be avoided.
Peritonitis seems to be the foremost hazard and may
at times be impossible to avoid. This case would support
the ideas of Kolff who is one of the leading advocates
of intermittent lavage in clinical uremia.9 A full blown
peritonitis not only places the patient’s life in jeopardy,
but reduces seriously the dialyzing potentialities of the
peritoneum. For this reason the shorter, intermittent
type of lavage periods, which undoubtedly reduce the
risk of serious peritonitis and retain the dialyzing prop-
erty of the peritoneum, are to be recommended.
Finally, more experience with this and other methods
of treatment are necessary before the relative therapeutic
value of peritoneal lavage may be determined. The re-
sult in this case would seem to recommend it in any case
of uremia that threatens to terminate fatally.
Summary
1. A case of temporary renal insufficiency due to a
hemolytic transfusion reaction is presented.
2. Several therapeutic methods are evaluated includ-
ing caudal analgesia, renal decapsulation, and peritoneal
lavage.
3. Caudal analgesia and renal decapsulation failed to
alter the progress of the uremic syndrome.
4. Peritoneal irrigation effected an immediate dra-
matic lowering of the blood metabolites with marked
clinical improvement in the patient.
5. Returning renal function began on the fourteenth
postoperative day and improved progressively thereafter.
This return of kidney function is not believed due di-
rectly to the use of peritoneal lavage, but it is felt that
the marked lowering of the blood metabolites in the
short span of 82 hours of lavage halted the progress of
the uremia from an inevitable fatal termination for a
sufficient period to enable the kidneys to regain their
normal functions.
6. The method is recommended as worthy of serious
consideration in any case of uremia that threatens to
have a fatal outcome.
Bibliography
1. Abeshouse, B. S.: Renal Decapsulation. J. Urol. 53:27,
1945.
2. Frank, H. A., Fine, J., and Seligman, A. M.: The Suc-
cessful Treatment of Uremia Following Acute Renal Failure by
Peritoneal Irrigation. J.A.M.A. 130:703, 1946.
3. Goodyear, W. E., and Beard, D. E.: The Successful
Treatment of Acute Renal Failure by Peritoneal Irrigation.
J.A.M.A. 133:1208-1210, 1947.
4. Grossman, L. A., Ory, E. M., and Willoughby, D. H.:
Peritoneal Irrigation. J.A.M.A. 135:273, 1947.
5. Localio, S. A., Chassin, J. L., and Hinton, J. W.: Peri-
toneal Irrigation. J.A.M.A. 137:1592, 1948.
6. Lucke, B.: Lower Nephron Nephrosis. Mil. Surg.
99:371, 1946.
7. Lull, C. B., and Hingson, R. A.: Control of Pain in
Childbirth, 2nd edition.
8. Murhead, E. E., Small, A. B., and McBride, R. B :
Peritoneal Irrigation for Uremia Following Incompatible Blood
Transfusion. Arch. Surg. 54:374-381, 1947.
9. Smith, B. A., and Eaves, G. B.: Temporary Renal In-
sufficiency. Univ. of Minn. Hosp. Bull. 18:191-210 (Jan. 24)
1947.
"U” GETS CANCER RESEARCH GRANT
An $11,356 grant for study of cancer at the University of Minnesota during the com-
ing year was announced by the National Cancer Institute in Washington.
The money will enable university researchers to continue studies started under a similar
grant for 1948. The research on synthesis and maintenance of intracellular enzymes — essen-
tial body chemicals — will be directed by Drs. John J. Bittner, H. Buss Steinbach and Sol
Spiegelman.
In addition, the university regents were granted $10,800 to finance new studies of
stomach cancer.
The awards to the University of Minnesota are part of a $508,527 program of labora-
tory and clinical cancer research to be conducted in 1949 by non-federal institutions.
22
The Journal-Lancet
Concomitant Extra-uterine and
Intra-uterine Pregnancy
William P. Sadler, M.D.
Minneapolis, Minnesota
The coexistence of an extra- and intra-uterine preg-
nancy is more correctly termed combined pregnancy.
Parry so designated this condition as combined preg-
nancy in 1876. Simultaneous pregnancies are sometimes
termed compound pregnancies. This latter term should
be reserved more appropriately for those cases in which
an intra-uterine pregnancy supervenes weeks, months, or
years after spontaneous resolution, mummification, litho-
pedian formation, or adipocere degeneration of an extra-
uterine gestation.
Historical
This interesting condition has existed since the begin-
ning of man. The first case reported in the literature is
credited to Duverney, in 1708. His case was diagnosed at
autopsy. In 1898, Strauss was able to collect only 32 cases.
Since the turn of the century, the number of reported
cases has grown rapidly. Zinke reported 88 cases in 1902.
In 1904, Simpson collected 113 and Neugebar increased
the number to 244 by 1913. Novak added 32 through
1926. Since then, many authors, notably Gemmell and
Murray, Mitra, Mathieu, Ludwig, Studdiford, and many
others have added to the number reported, so that the
total through 1946 had reached 357. It may be said that
up to the present, less than 400 cases have been reported.
Stander does not consider the condition rare. The author
agrees with Stander’s opinion.
Nevertheless, many gynecologists in active, private,
and clinic practice, have never seen a case. For this rea-
son, it was considered worthwhile to discuss some aspects
of this condition and to report a recent case cared for
at the Minneapolis General Hospital.
Mechanism of Occurrence
Combined pregnancy occurs usually as a result of
twinning. In one reported instance (Furniss case) it
resulted in a triplet pregnancy. In this case, the patient
was operated upon for a ruptured left tubal pregnancy.
Intra-uterine pregnancy was recognized at operation and
243 days later the patient was delivered of twins, a boy
weighing 7% pounds and a girl whose weight was 7
pounds.
Doubtless, the usual occurrence results from binovular
fertilization. One fertilized ovum imbeds in the tube
or ovary and the other fertilized ovum imbeds within
the uterine endometrium. This may result from a single
coitus, or two ova may be fertilized at different copula-
tions within a relatively short interval, true superfecun-
dation. Theoretically, combined pregnancy may result
from superfetation, but no case of superfetation has ever
been cited which will stand critical analysis.
Diagnosis
It is obvious that the preoperative diagnosis of con-
comitant pregnancy is extremely difficult. In Neugebar’s
first series of 170 cases, the diagnosis was made either
antepartum, or preoperatively in only 7 cases (4.1 per
cent) . In his second series of 74 cases, 8 cases were cor-
rectly diagnosed ( 10.8 per cent) . In Novak’s 32 col-
lected cases, plus two postscript cases, 34 in all, the diag-
nosis was made in 3 (8.8 per cent). An unequivocal
correct diagnosis in ordinary ectopic pregnancy is not
easy. In a series of 102 ectopics reported by me in 1942,
a correct diagnosis was made in 65.6 per cent, compared
with an average correct diagnosis of 64.6 per cent in
915 reported cases.
Many factors obscure the condition in combined extra-
and intra-uterine pregnancy. Threatened or incomplete
abortion of the uterine pregnancy may dominate the
picture. Conversely, the extra-uterine pregnancy may
obscure the situation with its attendant symptoms being
predominant.
At operation, the intra-uterine pregnancy may be
missed, if not very far advanced, because the uterus is
usually slightly enlarged and softened in tubal preg-
nancy. So able, competent, and experienced a gynecolo-
gist as Novak missed the diagnosis of the intra-uterine
pregnancy in his case. He stated, "There was no way
for us to determine the existence of uterine pregnancy
at operation.” In the series of ectopics reported by me,
previously mentioned, the uterus was described as being
enlarged in only one fourth of the cases.
When the intra-uterine pregnancy is more advanced
and the extra-uterine pregnancy is silent, the diagnosis
is even more difficult.
Fate of the Extra- and Intra-uterine
Fetus
Termination of the combined pregnancy is analyzed
by several authors. Allowance must be made for some
overlapping and reduplication.
In the Novak series of 34, 17 aborted, 3 probably
aborted, hysterectomy was done twice on the pregnant
uterus containing fibroids, one probably went to term,
one delivered prematurely at eight months gestation, and
the remaining 10 went to term. An abdominal section
was done on 3 cases at or near term (cases of Bogdano-
vich, Dubose, and Araujo) . Of these six babies, one intra-
uterine child died at birth, one extra-uterine child 18
hours after birth. Both extra- and intra-uterine children
were living 22 months after birth in Dubose’s case, and
Araujo’s case the intra-uterine baby died; the extra-
uterine baby survived.
January, 1949
23
There were three maternal deaths, a maternal mor-
tality of 8.8 per cent in the Novak series. Gemmel and
Murray classified 93 cases discovered before abortion
of the uterine ovum in the first half of pregnancy. In
this group 32, about one-third, went to term, and 36
aborted after operation for the ectopic gestation. There
were nine maternal deaths, a mortality of 9.7 per cent.
Ludwig summarized 20 cases including three of his
own from 1934 to 1938. Three of these went to term
with a salvage of two uterine children and one extra-
uterine child. One delivered a hydrocephalic infant at
eight months gestation which died one hour after birth.
Mathieu added 57 reported cases through 1936.
Twenty-five of his series aborted and twenty-four did
not abort after laparotomy for the ectopic pregnancy.
He states the majority of the twenty-four went to term.
The combined collected cases of the four authors
(Novak, Gemmel and Murray, Mathieu, Ludwig)
total 204. Of these, 69 surely went to term and one
probably did so, a percentage of approximately 33 per
cent.
Our case at the Minneapolis General went to term.
The case history briefly is as follows:
A 28 year old colored girl was admitted to the hos-
pital July 16, 1947. She had delivered six full term
babies, all living and well. The oldest child was age 13.
The youngest was aged four months, delivered March
16, 1947. She menstruated normally one month after
the birth of her last child, the onset being April 16,
1947, duration seven days. On May 15, she started men-
struating, flow moderate, and the duration was only three
days. She had had no miscarriages, menarche at age 13.
The interval was 30 days, the duration was seven days,
flow profuse for three days. She always had severe back-
ache and cramps during her menses.
Past History. Bronchopneumonia at age 2. Had a
nontoxic colloid goiter. Venereal disease denied.
Present Complaint. On admission she complained of
low abdominal pain, crampy in character, similar to her
usual menstrual pain. Her last menstruation started
June 18, 1947, duration four days, instead of usual
seven days. One week after this period ceased she had
some vaginal bleeding, spotting in character, but in-
creased in amount on exertion. She had intermittent
cramps for two weeks previous to admission. At 9:00
A.M. the day of admission, she experienced sudden se-
vere lower left quadrant pain. Pain was described as
crampy in character, lasted for 30 minutes, subsided,
then recurred.
Physical Examination. Her admission blood pressure
was 116 systolic, 88 diastolic; pulse 76; temperature
97.8 F. Aside from a diffuse colloid goiter, the essen-
tial findings were a palpable mass in the left lower
quadrant, no muscle spasm; slight rebound tenderness;
very slight vaginal bleeding. Speculum examination
showed a closed cervix, a small amount of old blood in
the vagina. Bimanual examination revealed slight ten-
derness on motion of the cervix, a uterus described as
about the size of an eight weeks pregnancy, and a tender
adnexal mass to the left of the midline and just above
the symphysis.
Diagnosis. ( 1 ) Intra-uterine pregnancy with threat-
ened abortion; (2) associated left salpingo-oophoritis;
(3) possible ectopic pregnancy.
Hospital Course. From July 16, 1947, to July 21,
1947, she was fairly comfortable. Her bleeding stopped
and recurred in minimal amount. Her blood pressure
ranged from 110-124 systolic, 60-74 diastolic. Hemo-
globin was 70 per cent, WBC 8100, Kline was negative,
cultures and smears were negative for Neisserian infec-
tion.
On July 21, 1947, she became nauseated, vomited,
pain became severe in lower abdomen, more pronounced
on the left. She was taken to the operating room. At
operation, about 200 cc. of old blood and clots were
found in the abdominal cavity. At the middle third of
the left tube extending from a perforated area, was a
small amniotic sac enclosing an embryo 2 cm. in length.
At operation the intra-uterine pregnancy was noted.
A left salpingo-oophorectomy was done. The right
ovary was examined. It was increased in size and con-
tained a corpus luteum of pregnancy.
Postoperative course was uneventful, and she was dis-
charged on her tenth postoperative day. Friedman tests
on July 21, 1947, and July 30, 1947, were positive.
Subsequent Course. This patient was referred to the
prenatal clinic where her course was uneventful. She
was admitted to the hospital February 7, 1948, in labor.
She labored four hours and delivered a normal female
infant weighing 2775 grams. It is now 7/4 months of
age and in excellent condition.
Discussion
This patient may be classified as the type of combined
pregnancy in which the intra-uterine pregnancy first
dominated our attempt at diagnosis, until her recurrent
acute flareup of symptoms on July 21, 1947, after five
days of relative comfort with minimal vaginal bleeding.
We always had ectopic pregnancy in mind, but on the
day of operation, we considered the diagnosis of torsion
of the left tube and ovary complicating an intra-uterine
pregnancy.
Summary
1. This study shows that combined pregnancy is not
so rare as we are wont to believe.
2. It should be kept in mind in abortions and ectopic
gestations.
3. The diagnosis of this condition is extremely diffi-
cult.
4. Approximately a third or more cases will go to
term if properly handled. More mothers and babies can
be salvaged if we are more alert in our diagnosis, even
at laparotomy.
5. The mortality for mothers and fetus is very high.
6. The author is of the opinion that intra-uterine
twinning occurs much more frequently than we suspect —
with one twin being destroyed or resorbed early.
24
The Journal-Lancet
7. He also holds the view that ectopic gestation occurs
quite frequently and that the fertilized concept is ab-
sorbed or extruded during the first two weeks in the
ovum stage.
References
1. Gemmell, A. A., and Murray, H. Leith: Jr. of Obstet-
rics & Gynecology of the British Empire — 1933, Vol. 40:67-74.
2. Mitra, Subadh: Jr. of Obstetrics & Gynecology of the
British Empire — 1940, Vol. 47:206-212.
3. Novak, Emil: Surgery, Gynecology & Obstetrics — 1926,
Vol. 43:26-37.
4. Mathieu, Albert: American Jr. Obstetrics & Gynecology
- 1939, Vol. 37:297-302.
5. Ludwig, David B.: American Jr. Obstetrics & Gyne-
cology— 1940, Vol. 39:341-344.
6. Howard, G. Turner: Southern Medical Jr. — 1945, Vol.
38:788-789.
7. Studdeford, William E., and Speck, George: American
Jr. Obstetrics & Gynecology — 1944, Vol. 47:118-121.
8. Powell, Cuthbert, and Gottschadt, Robert H.: American
Jr. Obstetrics & Gynecology — 1947, Vol. 54:132-134.
9. Sison, H. Acorta: American Jr. Obstetrics & Gynecology
— 1947, Vol. 54:698-699.
10. Sadler, Wm. P.: Mtnn. Med., Vol. 25:714, 1942.
11. Stander, A. J.: Text Book of Obstetrics. D. Appleton
Co., 1945.
DISCUSSION AND CASE REPORT
Roger S. Countryman, M.D.
St. Paul, Minnesota
Concomitant intra- and extra-uterine pregnancy is of
such infrequent occurrence, as Dr. Sadler has so ably
demonstrated in his excellent review of the subject, that
none of us is likely to recognize the condition when first
encountered. So far as I can determine, my case is the
only one on record in the Charles T. Miller Hospital
since its opening in December, 1920; and I offer no
apologies for presenting it now, nor for failing to diag-
nose the remaining intra-uterine pregnancy until several
weeks following the extra-uterine operation. I believe,
also, that routine curettage, before laparotomy for sus-
pected ectopic pregnancy, should be avoided even though
we might thus salvage but one infant in many years of
practice.
The case I wish to report is that of a 3 1 /i year old
para one who was admitted to the Miller Hospital at
2:50 A.M. July 21, 1943, complaining of irregular va-
ginal bleeding associated with recurring bilateral lower
abdominal, chest and shoulder pains, nausea, vomiting
and fainting spells.
Her last normal period began June 9th (usual cycle
being 25-28 days with previous periods March 27th,
April 21st, and May 17th). She had nausea and vom-
iting beginning about July 15th. On July 18th, she had
a rather sudden attack of sharp pain across the lower
abdomen which doubled her up, but soon subsided leav-
ing her fairly comfortable the next day except for the
nausea and vomiting. July 20th nausea and vomiting
increased with severe headache, and by evening ab-
dominal pains recurred, extending into the chest and
shoulder girdle, vaginal bleeding was noted and she
fainted several times.
On admission, examination revealed: Moderate va-
ginal bleeding; marked tenderness and rigidity of ab-
domen; apprehension; B.P. 120/68 — T.P.R. 97M04-24;
cervix boggy, closed, mobility limited and palpation in-
creased spasms of pain; fornices tense and uterus and
adnexa not clearly outlined.
Laboratory Report: Hgb. 9.8 gms. (or 58 s.u.) ; RBC,
2,980,000; WBC, 14,300 with 83 per cent neutrophiles,
15 per cent lymphocytes, 2 per cent monocytes and
RBC’s normal.
At operation there was a gush of liquid blood with
small clots on opening the peritoneal cavity. Left tube
was moderately thickened and the dilated fimbriated end
contained a partially extruded, adherent blood clot.
Lying free in the liquid blood-filled lower abdomen and
cul-de-sac was a larger semi-organized clot about the size
of a hen’s egg. Uterus was forward, appeared about
normal except for slight congestion, and the right tube
and both ovaries were normal. (Unfortunately no note
was made of the presence or location of a corpus lu-
teum.) The left tube was excised at the cornu, leaving
the ovary, clots were removed and the abdomen closed,
leaving the liquid blood and an added 500 cc. of warm
saline in the peritoneal cavity.
Pathologist’s Report. Gross: The specimen consists
of a tube about normal in length and 15 mm. in great-
est diameter. The wall is swollen and edematous. The
fimbriated end is open. The lumen contains blood clot.
There is also a large blood clot free from the tube about
the size of an egg. This clot does not seem to contain
any organized tissue. Microscopic: The mucosa of the
tube is distorted, flattened, edematous and congested.
The wall is likewise diffusely edematous and congested.
It is infiltrated with a small number of leukocytes. The
lumen is dilated and filled with a clot of blood and
fibrin which is infiltrated with many leukocytes and also
a few clumps of chorionic cells. Diagnosis: Ectopic
tubal pregnancy. (Dr. Kano Ikeda.)
One thousand cubic centimeters of 5 per cent glucose
in distilled water was given intravenously on patient’s
return from surgery.
Convalescence was uneventful aside from a tempera-
ture rise to 102° twenty-four hours postoperative, which
dropped to 100° that evening and leveled to normal the
fourth postoperative day. There was little or no vaginal
bleeding after the second day following surgery, also
the recurrence of her nausea and vomiting on first sit-
ting up the sixth day failed to arouse any suspicion of
January, 1949
25
her subsequent course. She was discharged July 31st
without any transfusion in spite of a Hgb. of 8.5 gms.
(or 51 s.u.) .
When seen August 14th she still complained of nau-
sea and vomiting, especially each morning, had nocturia
and examination showed uterus quite boggy soft in upper
corpus and fundus, adnexa negative, Hgb. 60 s.u. Only
then was there a thought that a possible simultaneous
(concomitant, co-existent, combined) intra-uterine preg-
nancy might be continuing in spite of the lost ectopic
twin. On her return August 30th the uterus was found
to correspond in size to a pregnancy of nine to ten weeks
duration. Motion was felt early in October, and on
March 17, 1944, a 7 lb. 3(4 oz. female was delivered
spontaneously, the infant being perfectly normal except
for a very moderate cleft palate which necessitated breast
expression and bottle feedings with a special type of
nipple.
Examination two months postpartum revealed a pig-
mented mid-line suprapubic scar with moderate keloid
formation, uterus anteverted, well involuted, right ad-
nexa and left ovary apparently normal.
Previous and Subsequent History: Married Sept. 21,
1940. Husband A & W. No history of twins on either
side. No serious illnesses or previous operations.
Cta. 13 yrs., 28 day cycle, duration 6 to 7 days; pro-
fuse flow with cramps first 24 to 36 hrs. Leucorrhea
always.
1st pregnancy: L.M.P. June 5, 1941; motion 10/20±.
Outlet forceps delivery of 6 lb. 5(4 oz. female March 4,
1942.
2nd pregnancy: L.M.P. June 9, 1943 — ectopic (left)
operation July 21. Motion 10/early. Spontaneous de-
livery of 7 lb. 3(4 oz. female March 17, 1944.
3rd Pregnancy: L.M.P. June 15, 1945. Motion
10/20±. Spontaneous delivery of 6 lb. 12 oz. female
March 24, 1946.
Book Reviews
Occupational Marks and Other Physical Signs, by Fran-
cesco Ronchese, M.D., 181 pages, 151 illustrations. New
York: Grune & Stratton, 1948. $5.50.
One’s mode of life leaves telltale signs on every individual.
This interesting book catalogs the various occupational marks
on the human body resulting from habits, diseases, accidents, or
operations. The text, though brief, describes accurately the
stigmata seen in members of various professions and trades.
The mode of acquisition of the characteristic marks or cal-
luses is clearly described. There are many interesting illustra-
tions to supplement the text. The illustrations constitute a large
part of the volume as is fitting in a book of this type. The
similarity between some of the stigmata and changes produced
by various dermatoses is also illustrated. One can readily see
what confusion can arise and what care must be exercised in
evaluating some of the changes seen on the body.
Doctor Ronchese makes his essay one of considerable value
in forensic medicine and criminology where personal identifica-
tion by means of acquired markings has its greatest value. The
information given makes the book a valuable manual for the
pathologist and criminologist as well as fine reading for all
physicians. I. F.
Office Endocrinology, by Robert B. Greenblatt, M.D.,
3rd edition, 280 pages, illustrated. Illinois: Chas. C. Thomas
Co., 1947, $4.75.
This manual on endocrinology is written for the practicing
physician. The third edition includes a new chapter on the in-
terpretation of basal temperature records; the two hour preg-
nancy test of Kupperman is described. It is well illustrated, and
concisely brings the reader up-to-date on the ever-changing
views regarding hormone therapy.
As in the previous editions, salient points on the physiology
of menstruation are given and a colored plate of secretory type
of endometrium is included. The treatment of irregular uterine
bleeding is well outlined. More emphasis could have been placed
on thyroid medication but it is mentioned in a short chapter.
This synopsis includes the handling of acne, obesity and sterility
which are common complaints today.
The physician who reads this manual will probably prescribe
hormones less frequently but more judiciously than heretofore.
Every practicing physician will welcome this book from a reliable
source as a guide to better understanding of such a confusing
subject as endocrinology. JSJ w
A Textbook of Pathology, by E. T. Bell, Professor of Path-
ology, University of Minnesota. Contributors, B. J. Clawson,
M.D., and J. S. McCartney, M.D.; 6th edition, enlarged and
thoroughly revised with 500 illustrations and four color plates;
910 pages. Philadelphia: Lea & Febiger, 1947. $10.00.
Physicians who are familiar with Dr. Bell’s textbook will wel-
come this new edition. Those who have not read it or consulted
it might profitably do so. The sixth and latest edition is in the
same tradition, as a teaching book, as the predecessors. The
publishers have aptly characterized it as "brief yet comprehen-
sive, clear and definite, well-written and well-organized.”
Dr. Bell has drawn upon his large personal experience. Con-
troversial material is sometimes presented from the author’s
point of view, and some interesting points are treated briefly.
Without this sort of compromise, it is doubtful if so much
could have been written in this convenient-size volume. The
chapter on renal diseases clearly explains and illustrates the
author’s concepts, which are expanded in his book, Renal Dis-
ease, recently published. Sufficient references are placed through-
out the book so that the reader may easily be directed to the
more extensive works.
This is an up-to-date textbook of pathology, and it is recom-
mended to students and practitioners alike for reference or
study. It is probably the best textbook of pathology in the
English language. FT W.
Progress in Neurology and Psychiatry: An Annual Re-
view. Volume III, edited by E. A. Spiegel. New York:
Grune & Stratton, 1948, 661 pages.
This is the third year that this review has been published.
The excellency of this work points toward a continued success
of this project. This volume comprises one of the finest reviews
of the fields of neurology and psychiatry. The editor has ob-
tained the assistance of sixty-eight contributors each of whom
has done an excellent job in selecting his articles and presenting
his material in a brief but clear and comprehensive fashion. The
book contains thirty-seven chapters covering the basic sciences,
neurology, neurosurgery, and psychiatry. Each chapter is well
organized. With the increasing number of publications in these
fields, this book appears as a welcome aid to anyone interested
in a complete and instructive review of the literature in neuro-
psychiatry. A. B. B.
26
The Journal-Lancet
Massive Hemorrhage Into the Gastrointestinal
Tract in the Last Trimester
A Case Report
Mancel T. Mitchell, M.D.
Minneapolis, Minnesota
This case is presented because of the unusualness of
this hemorrhagic complication late in pregnancy,
the diagnostic problems involved, and the decision in re-
gard to management.
Duodenal ulcer is a rare complication of pregnancy.
It is not mentioned in the standard obstetric text books
in wide use in American medical schools. Sandweiss re-
ported only one case with active ulcer symptoms in
70,310 pregnancy hospital admissions.1 This is in rather
sharp contrast to other complications of the gastrointes-
tinal tract such as appendicitis, cholecystitis, and ulcera-
tive colitis.
Case 1. The patient, S. R., MGH No. 663 1-A, age
28 years, para 2-0-0-2, an unregistered multipara, was
admitted to the obstetric service of the Minneapolis Gen-
eral Hospital at 4:07 P.M., August 30, 1948. Her last
menstrual period began Jan. 7, 1948; her expected date
of confinement was calculated to be Oct. 14, 1948.
The patient was ambulatory. She complained of dull
pain in the upper portion of her abdomen, more notice-
able when she was recumbent, of five days duration. She
also stated that her abdomen seemed unduly large. She
had had no regular antepartum care. She had experi-
enced some nausea and vomiting during the second and
third months. She consulted a private physician on July
26, 1948 (one visit) at which time she was told that
there was sugar in her urine. A salt-free diet was advised
because of slight ankle edema. Otherwise, her pregnancy
had been uneventful until the onset of the upper ab-
dominal pain which caused her to come to the hospital.
The patient described the pains in her upper abdomen
as sharp and shooting in character. The pains seemed
to spread laterally across the top of her uterus when she
turned from side to side in bed. She stated that her
abdomen had increased so in size during the last two
months that it was now difficult for her to walk during
the last week. She had noted considerable fetal motion
on the right side of her abdomen. Since the first week
of July 1948 she had noted swelling of her ankles. This
did not subside on bed rest. She had noted a weight
gain of approximately 40 lbs.
Her past health had been generally good. She had
had measles, mumps, varicella, and pertussis when a
child. Sugar had been noted in her urine when she had
been pregnant. She had had no operations, serious in-
juries, or illnesses. History review by systems was essen-
tially negative.
The patient was married in January, 1941. Her hus-
band, age 45 years, is living and well.
CTA: Menarche at 14 years of age; menses regular
q. 24-28 days; 4 to 5 days duration; moderate discomfort
on the first day.
Her first pregnancy was a normal full term gestation.
Delivery Aug. 1, 1941, was instrumental; infant was said
to weigh 10 lbs.; child is living and well. No other
details are available.
Her second pregnancy was uneventful and unsuper-
vised. She noted swelling of her ankles during the last
trimester. She was delivered spontaneously of an appar-
ently normal 12 lb. male infant at Minneapolis General
Hospital on April 15, 1944. Glycosuria was noted at
this time.
Family history: Father, 70, and mother, 70, are both
living and well. One brother, 33, and one sister, 30, are
living and well. No data on grandparents.
OH: Housewife.
Physical examination on admission to the hospital was
essentially negative except for the findings incident to
her pregnancy. TPR normal. BP 116/60. Weight 148
lbs. The patient’s abdomen was so large that she had
moderate difficulty in resting comfortably in bed. It was
quite difficult for her to walk. The height of the fundus
was 33 cm. above the symphysis; the uterus was very
tense; fetal parts were ballotable but it was impossible to
accurately outline the fetal position by abdominal palpa-
tion because of the marked hydramnios. There was
four plus pitting edema of both feet, ankles, legs, ex-
tending upward to involve the thighs and vulva to a
mild degree. Rectal examination revealed the cervix soft
and undilated. The presenting part was floating.
A provisional diagnosis of twin pregnancy was made.
The patient was placed on a regimen of strict bed rest,
a salt-free diet, and ammonium chloride gr. xv q.i.d.
An x-ray film of her abdomen confirmed the diagnosis
of twin pregnancy, an ROA and an LSA.
Laboratory examinations: Aug. 31, 1948: Blood serology
test for syphilis was negative. Hemoglobin 88 per cent
(Sahli) . Leukocyte count 4,500 with 68 per cent neu-
trophiles, 29 per cent lymphocytes, 2 per cent monocytes,
1 per cent eosinophiles. A catheterized urine specimen
was acid, sp. gr. 1.030, faint trace of protein, negative
sugar, 5 to 8 leukocytes/HPF. Blood urea nitrogen
16 mgm. per cent. On Sept. 1, 1948: Fasting blood
sugar 70 mgm. per cent; plasma proteins 5.3 Gm. per
cent.
The patient was continued on bed rest and observa-
tion without any particular change in her status. Her
blood pressure remained within normal limits. Her
weight remained stationary until Sept. 7, 1948, when it
January, 1949
27
was noted as 143 54 lbs. The edema of her lower ex-
tremities decreased somewhat but not remarkably.
At 9 A.M. ward rounds on Sept. 7, 1948, it was re-
ported that the patient had had an emesis during the
night (no details as to content or character) and that
she had passed a large black-brown tarry stool early that
morning. Her upper abdominal pain was somewhat more
intense. Dr. Mary Magee examined the patient and
noted that both fetal hearts were regular and of good
quality. The patient appeared quite pale. Her pulse rate
was regular at 80/min. An emergency hemoglobin de-
termination was requested and found to be 54 per cent.
At 1:30 P.M., Dr. Magee again saw the patient and
noted that she was pale and apprehensive. She had
passed two large brown stools. Her pulse rate was
112/min.; her blood pressure 140/92. The stool grossly
appeared to be brown-red in color and apparently con-
tained fresher blood than had been passed earlier that
morning. The patient passed several large, partially
liquid brown-red stools that afternoon. The fetal hearts
remained regular and of good quality. A re-check on
the patient’s hemoglobin at 3:45 P.M. was found to be
53 per cent.
A transfusion of 500 cc. of cross-matched whole citrat-
ed blood was started at 4:30 P.M. Another was started
at 7:15 P.M. At this time the patient complained of
being thirsty, and of soreness in her epigastrium and
back. She was given morphine sulphate gr. 1/6 and
scopolamine HBr gr. 1/200 hypodermically. A provi-
sional diagnosis of hemorrhage into the upper gastro-
intestinal tract, probably from a duodenal ulcer, was
made. It was decided to treat the patient expectantly
with multiple blood transfusions. Dr. Paul Larson was
asked to see the patient and he concurred with the diag-
nosis and the course of treatment. Another 500 cc. of
blood was started at 10:45 P.M. and another 500 cc.
at 1:15 A.M., Sept. 8, 1948. The patient’s pulse rate
ranged between 100 and 130/min. Her blood pressure
ranged between 120 — 130 systolic and 80 — 90 diastolic.
By 3 A.M., Sept. 8, 1948, her pulse rate was fairly stable
at 100/min. and her blood pressure 134/92.
At this time the patient began to complain of irregular
menstrual-like uterine cramps. These became progres-
sively more severe, and it became apparent by 5 A.M.
that she was definitely in labor. At 6:35 A.M. she was
transferred to the delivery room and prepared and
draped for delivery. She was given nitrous oxide with
her pains. At 7:01 A.M., she was delivered of the first
twin, a double footling breach, from the right sacrum
posterior position, a normal female, 2900 Gm., by Dr.
M. E. Baker. The infant was a little slow to breathe
but responded with oxygen. The second twin, a normal
female, 2880 Gm. from the right occiput anterior posi-
tion followed almost immediately at 7:04 A.M. This
infant also was slow to breathe but responded in a few
moments. There were no lacerations of the birth canal.
The placentas were delivered by expression from the
lower uterine segment, the first by the Schultze and the
second by the Duncan mechanism, grossly normal and
intact. The placentas were separate. The twins were
fraternal (dizygotic) . There was minimal blood loss
during the third stage of labor. She was given ergono-
vine maleate 0.2 mgm. and Hykinone 4.8 mgm. intra-
muscularly. The patient was returned to her room in
good condition.
Her blood pressure, pulse, and respirations remained
stable and were checked at frequent intervals through-
out the remainder of the day. Her blood count was
checked and found to show: Hemoglobin 65 per cent;
erythrocytes 3.2 million; leukocytes 14,800 with 87 per
cent neutrophiles. Morphological studies of the stained
blood film were reported as normal. The hematocrit was
28 per cent. Her bleeding time was 7' 3"; clotting time
3' 30". Her prothrombin time was 15' .1" for the pa-
tient and 13' .1" for the control. She was given another
500 cc. blood transfusion. Her general condition re-
mained fairly good and there was no further apparent
bleeding into her gastro-intestinal tract.
Her feces were checked on Sept. 13, 1948, for occult
blood and found 4 plus; subsequent checks on Sept. 17,
18, 27 and 29, 1948, were negative for occult blood.
The remainder of the patient’s immediate puerperium
was uneventful.
The first twin was placed on formula feedings and did
very well (she weighed 3525 Gm. when subsequently
discharged from the hospital on Sept. 30, 1948) . The
second twin expired at 10% hours after progressive
periods of anoxia of undetermined cause. An autopsy
was requested and permission for this refused.
X-ray studies of the esophagus, stomach, duodenum
and small intestine were made on Sept. 13, 1948, and
no apparent abnormalities were found. On Sept. 18,
1948, x-ray studies of the large intestine with a barium
enema showed no apparent pathology. An x-ray film of
the chest was also reported as negative.
A glucose tolerance test on Sept. 16, 1948, revealed:
Blood Sugar Urine Sugar
Zi hour 135 mgm. per cent Negative
1 hour 405 4-|-
2 hour 430 4 +
3 hour 470 4-(-
A diagnosis of diabetes mellitus was entertained and the
patient was transferred to the medical service for regula-
tion. She was placed on a basal plus 20 per cent diet
supplying 1990 calories. This was subsequently in-
creased to C 200, F 150, and P 110. Her blood sugar
ranged between 160 and 215 mgm. per cent and there
was no glycosuria. She was discharged from the hospital
on Sept. 30, 1948, to be followed in the Out-patient
Department.
In a critical evaluation of the handling of this patient
there are several interesting points to be emphasized. In
spite of the history of glycosuria the definite diagnosis
of diabetes mellitus was delayed because of the false
security which one fasting blood sugar determination
gave. A careful review of her old chart plus the history
of two overlarge infants should have made us more alert
to the possibility of diabetes in this case. One can only
speculate on the association of diabetes mellitus and mild
28
The Journal-Lancet
toxemia and the bleeding into the gastro-intestinal tract.
There is little question but that the hypoxemia attendant
with the massive bleeding had some part in the start of
premature labor. The cause of the bleeding was not defi-
nitely determined but most probably was from a duo-
denal ulcer. Gastroscopy was not done but probably
should have been included in the diagnostic work-up
after the patient had recovered from the active bleeding
phase of her illness. One can only speculate on the pos-
sible other sources of such massive bleeding — perhaps
from a Meckel’s diverticulum or from another diverticu-
lum of the small intestine. In regard to the expectant
management of this case, the importance of ready avail-
ability of adequate supplies of blood for transfusion can-
not be overstressed.
Reference
1. Sandweiss, D. J., Podolsky, H. M., Saltzstein, H. C.,
and Farbman, A. A.: Am. J. Obst. & Gynec. 45:131, 1943.
Meet Our Contributors
H. O. McPheeters, M.D., Minneapolis, Minnesota, has
practiced in Minneapolis for 31 years; specializes in cir-
culatory diseases; was graduated from Northwestern Med-
ical School, class of 1915, M.D.; member, Hennepin
County Medical Society, Minneapolis Surgical Society,
American College of Surgeons, A.M.A., and Asbury and
Northwestern Hospital Staffs.
Russell J. Mce, M.D., Duluth, Minnesota, was grad-
uated from the University of Minnesota in 1928; special-
izes in Obstetrics and Gynecology; President, Minnesota
Obstetrical and Gynecological Society; Vice President,
Central Association of Obstetricians and Gynecologists;
Diplomate, American Board of Obstetrics and Gyne-
cology.
William P. Sadler, M.D., Minneapolis, Minnesota, was
graduated from the Johns Hopkins Medical School in
1921; Diplomate in American Board of Obstetrics and
Gynecology, Fellow in the American College of Surgeons;
Staff Physician at Minneapolis General Hospital.
C. W. Seibert, M.D., Waterloo, Iowa, was graduated
from the University of Iowa in 1937; Diplomate of
American Board of Obstetrics and Gynecology; member
of Central Association of Obstetrics and Gynecology;
Past President of Iowa State Obstetrics Society.
Melvin Bernard Sinykin, M.D., Minneapolis, Minne-
sota, was graduated from the University of Minnesota
Medical School; Diplomate of the American Board of
Obstetrics and Gynecology; Secretary, Maternity and
Eitel Hospitals; Clinical Instructor, University of Minne-
sota Medical School; member, Minnesota State Society
of Obstetrics and Gynecology, Minneapolis Academy of
Medicine.
PROGRAM
Combined Meeting of the
Obstetrical and Gynecological Societies of Minnesota,
Iowa, Wisconsin, North Dakota
Dedicated to the memory of
JENNINGS C. LITZENBERG
Saturday, October 9, 1948
Minneapolis, Minn.
Morning Session — 9 A.M.
1. "Tubo-Uterine Implantation for Re-establishment of Tubal
Patency, Preliminary Report” — E. F. Schneiders, Madison,
Wisconsin.
2. "Abdominal Stromatosis” — Wm. Keettel, Iowa City, Iowa
3. "Concomitant Intra- and Extrauterine Pregnancy” — Wm.
A. Sadler, Minneapolis, Minnesota Discussion and Case
Report — Roger Countryman, St. Paul, Minnesota.
4. "Disturbance in Absorption of Iron During Pregnancy” —
Roy G. Holly, Minneapolis, Minnesota (by invitation) .
Discussion — John L. McKelvey, Minneapolis, Minnesota.
5. "Prenatal Care” — Gerald Brown, Grand Forks, North
Dakota.
6. "The Alleviative Treatment of Varicose Veins in Preg-
nancy”— H O McPheeters, Minneapolis, Minnesota (by
invitation) .
Fabian John McCaffrey, M.D., Minneapolis, Minne-
sota, was graduated from the University of Minnesota in
1940; Specialist in Obstetrics and Gynecology; advanced
training at Minneapolis General Hospital and North-
western Hospital.
Gerald Brown, M.D., Grand Forks, North Dakota, was
graduated from the University of Chicago in 1937; spe-
cialist in Obstetrics and Gynecology; member in Central
Association of Obstetrics and Gynecology, North Dakota
Society of Obstetrics and Gynecology; Diplomate of
American Board of Obstetrics and Gynecology.
Roger S. Countryman, M.D., St. Paul, Minnesota, has
practiced in St. Paul 26 years; Graduate of the Univer-
sity of Minnesota in 1920; Specialist in Obstetrics and
Gynecology; Diplomate of the American Board of Ob-
stetrics and Gynecology; member of Minnesota State
Medical Society, Minnesota Obstetrics and Gynecology
Society, Central States Obstetrics and Gynecology Society.
Mancel Talcott Mitchell, M.D., Minneapolis, Minne-
sota, was graduated from the University of Minnesota in
1935; Diplomate of American Board of Obstetrics and
Gynecology; Clinical Assistant Professor of Obstetrics
and Gynecology, University of Minnesota; Attending
Obstetrician and Gynecologist, Minneapolis General Hos-
pital; Attending Gynecologist, Veterans Administration
Hospital; Member of Minnesota Obstetrical and Gyneco-
logical Society.
Joseph F. Bicek, M.D., St. Paul, Minnesota, was grad-
uated from the University of Minnesota Medical School;
Clinical Instructor, University of Minnesota; member,
Minnesota Obstetrics and Gynecology Society, Alpha
Omega Alpha.
7. "Extraperitoneal Cesarean Section in Neglected Transverse
Presentation”- — C. W. Seibert, Waterloo, Iowa.
Afternoon Session — 2 P.M.
8. "Ruptured Endometriotic Cysts” — Joseph H. Pratt, Roches-
ter, Minnesota (by invitation).
9. "Massive Intestinal Hemorrhage in the last Trimester”
(case report) — Mancel Mitchell, Minneapolis, Minnesota
(5 minutes).
10. "Pleuropneumonia-like Infections of the Pelvis” — J. H. Ran-
dall, Iowa City, Iowa.
11. "Management of Severe Transfusion Reactions” — F. J. Mc-
Caffrey, Minneapolis, Minnesota (by invitation) .
12. "Management of Puerperal Sepsis” (case report) — Jos. F.
Bicek, St. Paul, Minnesota (5 minutes).
13. "Further Studies on the Milwaukee Cesarean Section Prob-
lem”— L. H. Verch, Milwaukee, Wisconsin.
Guest Speaker (4 P.M.) — "Steroid Therapy in Pregnancy Com-
plications”— Dr. M. Edward Davis, Lying-in Hospital,
Chicago, Illinois.
7:00 P.M.— BANQUET
Speaker — Frederic M. Loomis, M.D., Piedmont, California
January, 1949
29
Official Journal of the American College Health Association, Great Northern Railway Surgeons' Association, Minneapolis Academy of
Medicine, North Dakota State Medical Association, Northwestern Pediatric Society. Sioux Valley Medical Association. South Dakota
Public Health Association, North Dakota Society of Obstetrics and Gynecology.
Dr. A. B. Baker
Dr, Ruth E. Boynton
Dr. Gilbert Cottam
Dr, H. S. Diehl
Dr, Ralph V. Ellis
Dr. W. A. Fansier
Dr. J . C. Fawcett
Dr. A. R. Foss
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee
Dr. A. D McCannel
Dr, J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H . Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J. H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. T uohy
Dr. M B. Visscher
Dr. R. H. Waldschmidt
Dr. O H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
ADVISORY COUNCIL
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor. President
Dr. R. C. Webb, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O. Hanson. Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey. Treasurer
Dr. Henry E. Hoffert, Recorder
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak. Secretary
Dr. E. J. Larson, Treasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
Sioux Valley Medical Association
Dr. W H. Holloran, President
Dr. Walter Benthack, Vice President
Dr. Martin Blackstone, Secretary
Dr. Anton Hyden, Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Dr. Gilbert Cottam, Secretary-Treasurer
Editorial
JENNINGS CRAWFORD LITZENBERG
For age is opportunity no less
Than youth itself, though in another dress,
And as the evening twilight fades away
The sky is filled with stars, invisible by day.
Thus did Longfellow portray one side of a Great
Man, taking from History’s pages the names of some
of those who missed not opportunity to grow with the
passing years.
Our mid-west had such a man — still has him — for
such was the Life and Character of Jennings Crawford
Litzenberg that anyone who knew him would say that
his influence lives on. Men gain prominence sometimes
through circumstances beyond their control. They attain
a measure of true greatness only when they make contri-
butions to human betterment. When they make such
contributions, they demonstrate one aspect of a great
Truth: "The Kingdom of God is within you.” One
need look no farther for finite evidence of Immortality.
Doctor Litzenberg or "Litz” or "The Chief,” as he
was variously known to thousands of his friends, made
many such contributions. He was a Great Man.
It would not be possible in far-too-brief editorial com-
ment to list them all. Nor is it necessary. He would
not like it for he always shrugged off the many honors
which came to him with the remark that they were not
meant for him, personally, but for the Ideals which he
served.
His chief Ideal was a reduction in Maternal Mor-
tality. How well he accomplished that can best be illus-
trated by noting the enviable record in his beloved Min-
nesota, and in the neighboring States where the force of
his personality and teaching were so strikingly apparent.
When he retired as Head of the Department of Ob-
stetrics and Gynecology at the University of Minne-
sota, he deserved a rest. But he did not take it! Instead,
he seized the opportunity to personalize, even more, his
teaching by countless visits to Committees on Maternal
Welfare, small State Obstetric and Gynecologic Societies
and State Medical Association meetings. Effective and
forceful as he was upon the platform, it was to the in-
formal groups, who always gathered about him on such
occasions, that he talked most freely. Many in those
groups were his "Boys”. They had seen him lug "the
30
doll” into the amphitheater when, as undergraduates, he
had taught them the mechanism of labor. They now
came to him with obstetric problems far more serious,
for this time more than a doll was involved, but he em-
ployed the same kindly, personal and helpful interest
that is always the mark of a Great Teacher. Many a
mother owes her life to those informal conferences just
as, through his years of Professorship in Obstetrics and
Gynecology, he saved so many by the sound fundamen-
tals which he taught. And so another star was added
to the firmament which already shone upon him!
There is but one more star to add to the galaxy which
surrounds his memory. This one is the Star of Faith,
present throughout his life and giving character to his
words and deeds, but shining even more brightly to
those who were privileged to see it more intimately as
the shadows lengthened.
It was on a February night, not too many years ago.
A heavy snow had blanketed East River Road and traf-
fic had not yet churned it to slush. Even the traffic of
one’s mind was calm when Doctor Litzenberg arose
slowly from his place by the open fire, walked to the
window overlooking the road and, as though to himself,
said, "and what doth the Lord require of thee, but to do
justly, and to love mercy, and to walk humbly with thy
God?”
The firmament is filled.
So when a great man dies,
For years beyond our ken,
The light he leaves behind him lies
Upon the paths of men. J. H. M.
FOUR STATE MEETING
The recent meeting of the four state obstetrical and
gynecological societies held in Minneapolis in October
brought forth many interesting comments from members
and guests. There had been one similar meeting in
1945, also held in Minneapolis. Because of the favorable
reaction to the first meeting generally held by those who
attended, the plan was repeated.
When the Iowa, North Dakota and Wisconsin groups
received their invitations, they were prompt in their re-
plies and enthusiastic in their acceptance. Perhaps the
most accurate assay of the general acceptance of the
combined meeting idea was the high percentage of at-
tendance of the four memberships. The four societies
have a combined membership of 246. Forty-seven per
cent of the total membership were present at the meet-
ing. As might be expected because of the meeting’s
location, the Minnesota group had the highest actual
and percentage membership attendance. It is noteworthy
that the three out-of-state groups were also present in a
high percentage of their memberships.
This favorable attendance prompted many to suggest
some plan whereby this type of combined meeting might
be repeated at regular intervals in the future. It is
hoped that the subject will be discussed at future meet-
ings of the four individual societies and concrete sugges-
tions recorded for consideration later.
The general plan of having all groups participate
equally seemed to have much in its favor. For one group
The Journal-Lancet
to act as host, with the program being made up entirely
by members of the host society, and with the other three
groups being present only as guests would not seem to
carry as much interest and it is doubted whether the
attendance at such a meeting would be as high. The
local arrangement committees were given splendid co-
operation by the committees of the three out-of-state
societies. This is the obvious reason for the good attend-
ance and high degree of interest in the presentations.
John A. Haugen
News Items
North Dakota
Speaker at a meeting of the Northwest District Med-
ical Society in Minot in November was Dr. R. Ebert,
heart specialist of the University of Minnesota Medical
School, who discussed the diagnosis of heart conditions.
The meeting was held in conjunction with a dinner
at Trinity Hospital dining room. Dr. Malcolm Mc-
Cannel is president of the district society, and Dr.
Henry Kermott is secretary.
Attending the meeting also was Forsyth Engebretson
of Bismarck, executive secretary of the North Dakota
State Medical Association, who was in Minot to make
preliminary plans for the 1949 convention of the state
association. The convention will be held in Minot and
the dates are May 15, 16 and 17.
The Northwest group is to vote next month on the
question of approval of the pre-payment medical plan
put forward by the state medical society. The plan has
been submitted to all district and local medical societies
for their approval. The Northwest group will be the
last district society to vote on it, officers said.
New honors have come to one of Bismarck’s leading
physicians and surgeons, Dr. Norvel O. Brink, 723
First Street, with his election to the International Col-
lege of Surgeons. Dr. Brink has recently returned home
from a trip to Fargo and St. Louis, Mo. In Fargo he
attended meetings of the boards of directors of the
Lutheran Hospital and Home Society and of the James-
town Crippled Children’s Hospital. He was made a
member of the College of Surgeons at a convocation
Friday evening in St. Louis.
Dr. G. A. Miners of Bemidji, Minnesota, has opened
an office in Hettinger for the practice of medicine, ac-
cording to a report given the Adams County Record.
Dr. Miners, who is now director of the Minnesota De-
partment of Health, will begin practice shortly after
the first of the year.
Dr. Martin Hochhauser, Fargo physician and sur-
geon, has taken over the practice of Dr. E. C. Stucke,
Garrison, North Dakota, who is retiring after serving
this community faithfully the past 37 years. Dr. Hoch-
hauser has been a resident physician at St. Luke’s hos-
pital in Fargo and was also on the staff of the Fargo
Clinic.
January, 1949
31
Dr. T. W. Buckingham, Bismarck, was elected presi-
dent of the Sixth District Medical Association at its
December meeting, attended by about 35 doctors from
this area and a few visiting doctors.
Also elected were Dr. Charles A. Arneson, Bismarck,
vice president; Dr. C. H. Peters, Bismarck, secretary-
treasurer, and Dr. M. Jacobson, Elgin, delegate to the
state medical association’s convention. Carry-over dele-
gate to the state convention is Dr. Robert Radi, Bis-
marck. Re-elected to the association’s board of censors
was Dr. F. F. Griebenow, Bismarck.
Dr. Robert Schoregge and Dr. Gregory A. Dahlen,
both of Bismarck, and Dr. W. Enders, Hazen, were
elected to membership in the district association. Dr.
Walter A. Craychee and Dr. Philip L. Blumenthal, both
of Mandan, received their first reading of approval of
membership following approval of their applications by
the board of censors.
Scientific speaker at the dinner meeting was Dr. M.
G. Fredricks, of the Duluth Clinic at Duluth, Minn.,
who spoke on "Treatment of Common Skin Disorders.”
A number of Dickinson doctors were guests of the
Eastern Montana Medical Society at a dinner and meet-
ing held at Glendive, Montana, in December. Doctors
attending from here were Dr. Paul Weir, Dr. H. E.
Guloien, Dr. R. W. Rodgers, Dr. H. L. Wright, Dr.
L. H. Reichert, Dr. D. J. Reichert and Dr. C. R.
Dukart. Dr. Bernard G. Sarnet from the department
of oral and facial maxillary surgery of the University
of Chicago spoke on cancer of the head and face.
South Dakota
Dr. Paul Tschetter of Huron is the new president of
the Fifth District Medical Society, having been elected
at the organization’s regular meeting in November.
Other officers elected include: Dr. Harold Adams, vice-
president; Dr. Ted Hohm, secretary-treasurer; Dr. R. A.
Buchanan, delegate to state medical association conven-
tion; and Dr. B. T. Lenz, councillor. All are from
Huron. David Buchanan talked on his impressions of
socialized medicine in Norway and England, gained
while he was a summer student at the University of
Oslo.
Donald H. Breit, Sioux Falls, is the newly elected
president of the South Dakota cancer commission.
Other officers are Dr. A. C. Brock, Rapid City, vice
president; Chester C. Lind, Watertown, secretary; Dr.
Paul V. McCarthy, Aberdeen, executive chairman, and
Mrs. Harry T. Dory, Watertown, state commander.
Circuit Judge V. G. Wohlheter was re-elected treasurer.
Dr. David Brown, physician and surgeon, of Elk
Point, has moved to Tyndall to practive.
Col. Howard W. K. Zellhoefer, faculty member of
USAF school of aviation medicine at Randolph Field,
Texas, has been appointed fellow of the International
College of Surgeons at the recent annual meeting of the
United States chapter, held in St. Louis, Missouri. Col.
Zellhoefer is son of Mr. and Mrs. Guy W. Zellhoefer
of Sioux Falls, where prior to entering the air force serv-
ice he was surgeon of the Dakota Clinic.
Dr. Lyle Hare, Spearfish, was named by the Ameri-
can Medical Association as runnerup in the contest for
"Family Doctor of the Year” at the convention held in
St. Louis, Missouri.
Dr. Helen Jane Hare, daughter of Dr. Lyle Hare of
Spearfish, is opening offices in Rapid City. The der-
matologist, well known throughout the Black Hills, is
coming here from Milwaukee, Wisconsin, to open her
practice in the treatment of skin diseases.
Four representatives of the South Dakota State Med-
ical Association attended national medical association
meetings in St. Louis, Missouri. Dr. R. G. Mayer, Aber-
deen, secretary of the association and editor of its Jour-
nal, headed the delegation attending the national con-
ference on medical public relations, the national confer-
ence of medical secretaries and editors, and the interim
session of the American Medical Association. Also at
the meetings were John C. Foster, executive secretary of
the state association, and Dale C. Whitcomb, assistant
editor of the Journal, both of Sioux Falls, and Dr. H.
Russell Brown, Watertown, South Dakota’s delegate to
the American Medical Association.
Minnesota
Dr. J. F. Weir was elected president of the staff of
the Mayo Clinic at the annual meeting when three mem-
bers who have reached retirement age were honored.
Drs. M. S. Henderson, W. A. Plummer and Charles
Sheard were honored upon reaching emeritus status.
Other officers named include Dr. Della G. Drips, vice
president; Dr. Edw. N. Cook, re-elected secretary.
Dr. Werner Ogden was named president-elect of the
Ramsey County Medical Association at a recent meeting
and will take office in 1950. Installed as president for
1949 was Dr. J. R. Aurelius. Other officers elected are
Dr. Wm. A. Kennedy, vice president; Dr. Laurence
Hilger, secretary-treasurer.
Election of officers and discussion of professional prob-
lems occupied the membership of the Blue Earth Valley
Medical Society at its annual meeting in November.
Dr. Robert Hunt of Fairmont was elected president of
the association, which includes Faribault and Martin
counties; Dr. Lewis Hanson of Frost was elected vice
president; retiring president Dr. Mark Virnig of Wells
was elected to the board of directors. Secretary-treasurer
of the group is Dr. Herbert Boysen of Madelia.
Dr. Ralph Creighton, past president of the Hennepin
County Medical Society, has been appointed to the
board of directors of the Community Chest and Council.
Dr. Victor Johnson, Rochester, Minn., was named
to a seven-man American Medical Association committee
to survey American medical education.
The survey will seek to improve medical education;
determine whether or not medical schools are turning
out enough doctors and tell the public how medical edu-
cation is working. The new survey will begin January 1
and will last three years.
32
The Journal-Lancet
Dr. Charles N. Hensel, a member of the Charles T.
Miller hospital staff since the hospital opened in 1920,
has been named chairman of the medical division of the
Hospital building fund campaign.
Dr. P. F. Eckman has been renamed chairman of the
Duluth Chamber of Commerce public health committee.
A. W. King is vice president and A. W. Taylor, director
chairman.
The appointment of Dr. Edward D. DeLamater, for-
mer Mayo Clinic staff member, as associate research pro-
fessor in the department of dermatology and syphilology
of the University of Pennsylvania was announced. He
will act as director of research in the department and
will develop a mycology laboratory. A graduate in 1942
of the Columbia University College of Physicians and
Surgeons, Dr. DeLamater recently served here as Mayo
Clinic consultant in mycology and Mayo Foundation
assistant professor of bacteriology.
Dr. B. M. Spock of the Mayo Clinic staff received
the second Mead Johnson award for outstanding contri-
butions to pediatrics at the meeting of the American
Academy of Pediatrics in Atlantic City. Dr. Spock is
associate professor of psychiatry in the Mayo Founda-
tion and consultant in psychiatry in the Mayo Clinic.
On December 6, 1948, Dr. Vernon L. Hart delivered
the Annual Detroit Orthopedic Lecture. This lecture-
ship was established in 1922 to "foster orthopedic sur-
gery at large and in our midst.” The lecture was de-
livered under the auspices of the Wayne County Med-
ical Society. Dr. Hart presented a paper on "Congeni-
tal Dislocation of the Hip: Recognition and Treatment
During Infancy Before Weight Bearing.”
Dr. Clyde A. Undine, M.D., Minneapolis, attended
the Regional Meeting of Illinois, Indiana, Michigan,
Minnesota, and Wisconsin American College of Physi-
cians at Detroit in November.
A. S. H. A. News
The American Student Health Association held their
annual Council meeting on December 30 and 3 1 in San
Francisco, California. It was decided that the name be
changed from American Student Health Association to
American College Health Association. It was further
decided that the 1949 meeting should take place in
December in New York City.
The new officers of the A.C.H.A. are as follows:
President, L. B. Chenoweth, M.D., University of Cin-
cinnati; President Elect, Irwin Sander, M.D., Wayne
University; Vice President, Grace Hiller, M.D., Gau-
cher College; Secretary-Treasurer, Edith Lindsay, Ph.D.,
University of California.
Kansas State College of Agriculture and Applied
Science at Manhattan, Kansas, is in need of two full-
time staff physicians. Apply to B. W. Lafene, Medical
Director, Student Health Service.
The University of Colorado, Boulder, Colorado, is
in need of one full-time staff physician. Apply to L.
W. Holden, M.D., Director of Student Health Service.
Classified Advertisements
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includes residence, dental office, barber shop. Located
twenty miles south of the Twin Cities. Write Box 876,
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FOR SALE
Lucrative practice, established 25 years, and modern
office and apartment building for sale. Will introduce
newcomer. Modern public hospital planned. County
seat town of 2500 in northeastern Montana, predom-
inantly Scandinavian wealthy farm and livestock area.
Unlimited opportunity, ideal for young surgeon. Write
Box 879, Journal-Lancet.
FOR SALE
One Scott Resectoscope, never been used. Write Box
880, Journal-Lancet.
FOR SALE
One Tompkins Rotary Compressor, manufactured by
J. Sklar Company. Excellent condition. Price, $50.
C. J. Meredith, M.D., Valley City, North Dakota.
DOCTORS’ OFFICES FOR RENT
Suite of rooms, recently vacated, over drugstore at
Lowry and Emerson Avenues North. Suitable for two
doctors or doctor and dentist combination. Write to Mr.
M. J. Leyne, 1122 Lowry Avenue North, Minneapolis.
FOR RENT
Modern, fireproof concrete block building, one story,
65x32 feet, 3 to 4 rooms partitioned, cork insulated, con-
crete floor, 150-foot artesian well. Industrial section, 5
minutes from loop. Ideal for pharmaceutical, packaging,
or food distribution. Write Box 877, Journal-Lancet.
ASSISTANCE AVAILABLE
Woodward Medical Personnel Bureau (formerly Aznoes
— Established 1896) have a great group of well trained
physicians who are immediately available. Many desire
assistantships. Others are specialists qualified to head
departments. Also Nurses, Dietitians, Laboratory, X-Ray
and Physiotherapy Technicians. Negotiations strictly
confidential. For biographies please write Ann Wood-
ward, Woodward Medical Personnel Bureau, 185 North
Wabash, Chicago.
Orthopedic Appliances
• Fracture apparatus
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are of paramount importance. . . We
measure accurately, fit carefully, follow
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•
AUGUST F. KROLL
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CEDAR 5330
Malignant Lesions of the Anal Canal
William C. Bernstein, M.D.
The anal canal is a structure which is lined by strati-
fied squamous epithelium and extends from the
anorectal line (pectinate line, dentate line or mucocuta-
neous junction) above to the anal verge below. The anal
verge has been described by Buie as the line formed by
the walls of the anal canal as they come in contact with
each other at their external margin during their normal
state of apposition. The anal canal varies in length in
different individuals, the average canal measuring be-
tween one and one and a half inches.
The anal skin, sometimes referred to as anoderm,
differs from ordinary skin on other parts of the body
in that it contains no hair follicles and rarely contains
sebaceous glands.
The need for all clinicians and investigators to adopt
a uniform understanding of the true limits of the anal
canal is extremely urgent since many articles have been
appearing in recent literature indicating the lack of such
an understanding. One author includes all tumors in
the three centimeters above the anorectal line in his
group of anal lesions while another includes perianal
skin lesions under the heading of anal growths.
Malignant lesions of the anal canal are relatively rare
but they do occur frequently enough to warrant more
attention than has been accorded to this subject in the
past. The importance of this region as a site of malig-
nant tumors has been so overshadowed by the rectum
and colon that one may be led to minimize symptoms
of early lesions in this area.
Four cases of malignant disease of the anal canal have
recently been observed by the author. Two of these
patients have been seen at the University Ffospitals and
two in private practice.
Incidence
Various clinics have reported on the incidence of ma-
lignant tumors of the anal canal and from available in-
formation it appears that the incidence is somewhere
between 3 and 5 per cent of all cancer of the rectum.
It has not been possible to determine accurately in given
papers whether the figures have been for cancer of the
rectum alone or for the entire colon.
Lahey Clinic
..... 1.7%
600 cases
Bacon, Linde, Murray
. 3.0%
472 ”
Gazetta and Cole
4.0%
100 ”
Lawrence
. 3.3%
635 ”
Mayo Clinic
. 1.73%
2,939 ”
Kaplan & Rubenfeld
- 4.6%
”
University of Minnesota
.. 2.8%
214 ”
There were 214 cases of cancer of the rectum (figured
at 13 cm. and below) at the University of Minnesota
Hospitals from January 1942 through June 1947. Of
this number there were six proven cases of anal car-
cinoma, three of which were inoperable when first seen.*
Diagnosis
Early malignant lesions of the anal canal are diag-
nosed by either a thorough and painstaking investigation
of the anal canal or by microscopic section of tissues re-
moved at surgical operations on this region. There are
no set symptoms that one can use as a guide specifically
Unpublished data of Dr. Robert Toon.
33
34
The Journal-Lancet
for cancer of the anal canal. Unfortunately the symp-
toms of this disease may be exactly the same as those
which accompany many benign conditions such as hem-
orrhoids, fissure, pruritus ani, perianal fistula, etc. These
ordinary anal affections are usually so benign in their
early eymptoms and so chronic in their course that it is
extremely easy to permit early malignant lesions to pro-
gress to far advanced stages insofar as curability is con-
cerned before an accurate diagnosis is made. The usual
anal and rectal complaints of bleeding, pain, protrusion,
discharge and itching must be regarded as significant in
every patient and must suggest the possible presence of
a malignant tumor until a thorough examination has
proven the benignancy of the condition.
Malignant lesions which affect the anal canal may be
situated either inside or outside the body cavity. If the
tumor is external to the anal aperture it may be entirely
visible without the use of scopes and may resemble some
type of skin lesion. On the other hand the tumor may
be entirely confined within the sphincter area and can
be exposed only through the anoscope or proctoscope.
External inspection, palpation and digital examination
are not sufficient to rule out early lesions in the anal
canal. Complete visualization of the entire canal com-
bined with biopsy of suspicious lesions must be carried
out to insure a high degree of accuracy in diagnosis.
For many years it has been felt that benign lesions of
the anal canal may be significant factors in the produc-
tion of malignant tumors. In 1931 Rosser published a
paper in which he stressed the importance of the benign
lesions, notably perianal fistulae, as precursors of anal
carcinoma. Seven of his thirteen cases of anal carcinoma
began in patients who had pre-existing fistulae. The re-
mainder were associated with hemorrhoids, cryptitis and
papillitis. Subsequent investigators, namely Buie and
Brust, Tucker and Hellwig, Drueck and others have
noted a similar relationship.
Buie, Fansler and others have repeatedly stressed the
responsibility of the physician who is called upon to ad-
vise patients with benign anal lesions. Patients afflicted
with hemorrhoids, fissure, fistulae and other benign con-
ditions of the anorectal region usually inquire if there
is danger in procrastinating before undergoing surgery.
In the light of existing information as regards fistulae
in particular, the evidence would point to the fact that
a definite danger does exist in untreated perianal and
perirectal fistulae. Binkley and Derrick have pointed out
that the incidence of anal cancer in patients with chronic
anal manifestations of lumphopathea venereum suggest
that the latter disease may be a predisposing factor in
the genesis of this type of cancer. They suggest that
all patients with anal manifestations of lymphopathea
venereum be examined by means of skin biopsy for
squamous cell carcinoma.
Assuming the investigations mentioned above to be
significant, it is quite logical to assume, therefore, that
all benign lesions removed in the operating room should
be exammed microscopically. Only by such a program
can early malignant lesions be detected in otherwise
benign-looking specimens. Tucker and Hellwig found
1.9 per cent of unsuspected tumors in tissues from 951
anorectal operations for benign lesions.
One of the cases to be reported in this paper was re-
cently diagnosed at St. Joseph’s Hospital in St. Paul.
Sections of some very large hemorrhoidal specimens re-
vealed the presence of a lymphosarcoma which had not
been suspected.
Types of Tumor
1. Squamous cell epithelioma (epidermoid car-
cinoma)
2. Adenocarcinoma
3. Basal cell epithelioma
4. Lymphosarcoma
5. Melanoepithelioma
6. Hemangioendothelioma
7. Bowen’s disease
1. The squamous cell epithelioma or epidermoid car-
cinoma is by far the most frequent malignant tumor
affecting the anal canal. In the series of 51 cases re-
ported by Buie and Brust there were 43 squamous cell
carcinomas. These tumors may have the same appearance
as do squamous cell epitheliomas on the other parts of
the body or they may simulate a hemorrhoid, fissure,
fistula, venereal wart or other type of anorectal lesion.
The lesions may be ulcerated or they may be hard and
nodular.
This type of lesion seems to affect more women than
men and the disease has its highest incidence in the fifth
decade of life.
The microscopic sections of squamous cell epithelioma
of the anal canal are not particularly significant in any
respect except that there are wide variations in the histo-
logic appearance of the tumors, varying from the uni-
form type of cells to the completely undifferentiated
types of tumors. A high percentage of these tumors are
in the grade three and four classifications.
2. Adenocarcinomas of the anal canal do not arise
from the covering of the canal itself but invade the anal
wall either from the mucous membrane just above the
anorectal line or extension from an anal duct gland or
other glandular structure which may be contained with-
in or deep to the anal wall itself. As stated above, the
anal skin does not usually contain sebaceous or apocrine
glands but, when it does, malignant lesions of these
glands may develop. Scarborough has reported a pri-
mary adenocarcinoma of an anal gland which metasta-
sized to the brain. A case of adenocarcinoma of the anal
canal will be reported in this paper.
3. Basal cell epitheliomas of the anal canal have been
reported by several authors. It is, however, a relatively
rare tumor and probably somewhat less malignant than
the squamous cell carcinoma. Bell states that basal cell
and squamous cell carcinomas are associated in about
10 per cent of the cases and when both basal cell and
squamous cell features are present the tumor generally
follows the clinical course of the more malignant squa-
mous cell type.
In the records of 150,000 biopsies at the State Insti-
tute for Malignant Disease as reported by Lawrence
February, 1949
35
there were no cases of basal cell cancer of the anal canal.
Buie and Brust reported 2 cases in their series of 51
malignant tumors of the anal canal while Lawrence re-
ported 2 cases from the records of the Pondville Hos-
pital, Wrenthan, Massachusetts, an institution for per-
sons with cancer, where 17,462 patients were treated in
13 years. In this series there were 635 cases of carcinoma
of the anal canal and rectum. Of this group 21 or 3.3
per cent were classified as primary anal carcinoma. There
were 15 squamous cell epitheliomas, 4 adenocarcinomas
and 2 basal cell epitheliomas. One case of basal cell
epithelioma will be reported in this paper.
4. Lymphosarcoma. This type of tumor is extremely
rare in the anal canal. Sarcomas of any type are found
in exceedingly small numbers in any part of the large
bowel. Drueck has reported a case of a highly undiffer-
entiated sarcoma of the anal canal in a boy five years
of age. The case which is presented here is an early
lymphosarcoma in the hemorrhoids removed from a
45 year old female.*
5. Melanoepithelioma.
6. Hemangioendothelioma. Cases representing types
5 and 6 have been reported in the literature. Their oc-
currence is, however, extremely rare.
7. Bowen’s Disease. This is a condition which may
occur on either skin or mucous membrane. In 1941
Freund reported a case and states that Bowen’s disease
attacks the anal region occasionally and differs from
Paget’s disease and other precancerous lesions. The dis-
ease produces metastases in lymph nodes and distant or-
gans. The histologic picture resembles the epithelial
overgrowth seen in animals receiving inunctions of tar
products.
Case Histories
Case 1. White male, age 82. This patient presented
himself for treatment because of acute, knife-like pain
on defecation. There was no history of bleeding, pro-
trusion, weight loss or other symptoms of serious mo-
ment. On examination a very painful, raised area was
encountered on the upper margin of the right anal wall.
The patient chose to go elsewhere for a local excision
of his tumor and this was done. He expired suddenly
on the second postoperative day. Microscopic sections
revealed a basal cell epithelioma of the anal canal.
Case 2. White female, age 45. This patient presented
herself for examination because of rectal bleeding. Her
physician found large interno-external hemorrhoids. He
performed a hemorrhoidectomy and the tissue was sent
to the pathologic laboratory. Microscopic sections re-
vealed the presence of unsuspected lymphosarcoma of
the anal canal.
Case 3. White female, age 81. This patient had had
pain on defecation and bleeding for three years. She
was examined by her local physician, who found a tumor
of the anal canal and referred her to the University
Hospital for treatment. Nodes were found in her in-
guinal regions but because of her general condition a
■'Reported by the courtesy and permission of Dr. H. R.
Tregilgas.
local resection of the lower end of her rectum only was
performed. Microscopic section of the tumor showed it
to be a squamous cell epithelioma.
Case 4. White male, age 70. This man stated that
he had had pain and the feeling of a mass in the rec-
tum for the past two years. He is a chronic alcoholic
and is not too interested in his own welfare. So far he
has not submitted to treatment. Biopsy of the tumor
revealed the presence of adenocarcinoma of the anal
wall.
Metastasis in Anal Cancer
Although cancer of the anal canal is, in many respects,
an external form of cancer, it has been a most discour-
aging type of tumor to treat because of the obscure and
bizarre patterns which the metastases follow. Until re-
cent years the metastatic spread of this disease was not
too well understood. Methods of treatment in vogue
a few years ago were entirely inadequate, in the light
of our present knowledge of the spread of this type of
tumor. Because the lymphatic drainage of the anal canal
may be either to the inguinal nodes which are reached by
lymphatic vessels which pass forward from the anus on
either side in the fold between the thigh and perineum,
or to the nodes in the ischiorectal fossae, or to those in
the rectum and perirectal chains, the assumption must be
made in every case that all methods of spread may have
taken place, regardless of the external appearance of
the tumor.
These tumors also spread by direct extension and by
involvement of the blood vessels. Metastases to the liver
are, however, rare in cancer of the anal canal. Cattell
and Williams state that in 200 cases collected from the
literature, metastases to the liver was noted in only
2 cases.
The lymphatic spread of the disease is very common
and has been well described by Keyes. He states that
carcinoma of the anal canal follows the description of
the downward and lateral spread of Miles and that the
upward spread of Miles is rarely seen. The downward
spread consists of the perianal skin, the sphincter ani
muscle and the ischiorectal fat. The lateral spread re-
fers to the levator ani and coccygeal muscles, the pelvic
peritoneum, the prostate gland, the base of the urinary
bladder, the cervix uteri and the base of the broad liga-
ment. Keyes pointed out that in his cases there was no
involvement of the rectorectal (lowermost mesocolic
nodes) , the pelvic mesocolon, the pericolic nodes, the
nodes about the bifurcation of the left common iliac
artery and the aortic nodes. In his series of 27 cases of
anal carcinoma, Keys found inguinal metastases in 4
cases and some type of metastases in 19 or 70 per cent
of his series. Failure of clinicians to recognize the exact
pattern that metastases may take, coupled with the
willingness to assume that absence of visible metastases
is sufficient indication for conservative therapy, is the
most plausible reason for the high recurrence rate for
this disease.
Baronofsky has called attention to the free anasto-
mosis which exists between the lymphatic vessels which
drain the anal canal, perineum and genital organs and
36
The Journal-Lancet
stresses the importance of bilateral dissections of the in-
guinal lymphatics for malignant lesions in these areas.
The inguinal nodes may be enlarged from inflamma-
tory disease alone, but on the other hand, metastatic car-
cinoma may be preesnt in the nodes before actual en-
largement has taken place. The nodes in the deeper tis-
sues cannot be seen nor felt until marked enlargement
has taken place. For these reasons it must be assumed
in every case of cancer of the anal canal, regardless of
how early the lesion may appear, that extension of the
process through the lymphatic channels has taken place.
Treatment
A review of the literature of the past 20 years re-
veals the fact that the treatment of anal malignancies
has been carried out in a haphazard, hit and miss, and
entirely inadequate manner and has resulted in a five-
year survival rate which is much lower than that for
cancer in other parts of the large bowel. In spite of the
admonition of Miles in 1931, we are just today begin-
ning to assume the rational approach towards anal ma-'
lignancies that malignant lesions in any location require,
namely, a radical dissection and removal of the tumor
bearing area and the avenues of spread. It is rather
shocking, in the light of our present knowledge, to read
statements to the effect that early lesions should be
treated conservatively, that inguinal nodes should not be
removed until they become enlarged, and that X-ray or
radium should be given a trial before resorting to rad-
ical surgery.
There are several groups in this country who are of
the opinion that irradiation therapy is still the treatment
of choice. Meland, writing in the American Journal
of Roentgenology reports 6 patients still alive in 1947
out of a group of 13 patients treated with X-ray and
radium in 1939. He states that there is a high degree
of sphincter incontinence due to anal atresia, radionecro-
sis, etc., but feels that a poor anus is better than a
colostomy. His optimism towards this type of treat-
ment does not seem to be shared by others.
Richard Sweet reported a 17.3 per cent five-year sur-
vival rate and states that irradiation therapy is not as
satisfactory as radical excision either as a method of cure
or as an attempt to secure relief from the distressing
local symptoms of epidermoid carcinoma of the anal
canal.
Kaplan and Rubenfeld feel that the treatment of anal
malignancies should begin with irradiation of the in-
guinal lymphatics and the local area of involvement.
Surgery can then be left to the judgment of the operator.
Stenstrom feels that radical surgery should be per-
formed on all operable lesions and that irradiation
therapy may or may not be used subsequently, depend-
ing upon the judgment of the clinicians.
Wangensteen has employed the radical approach sug-
gested in this paper on several patients who are alive
and well after six years.
As has been pointed out above, the five-year survival
rate for anal malignancies has been much lower than
that for lesions in other parts of the large bowel, despite
the fact that one would expect anal lesions to be diag-
nosed at an earlier stage. This situation must, of neces-
sity, be explained on the basis of the types of treatment
which have been carried out. It is our belief that if the
same radical approach to anal cancer is carried out as is
done for carcinoma elsewhere that the curability rate for
this disease will be just as acceptable.
Considering the avenues of spread of anal carcinoma
it is logical to suggest that no operative attack short of
a radical Miles abdominoperineal excision of the anal
canal, rectum and pelvic colon, together with the struc-
tures adjacent to the anal canal followed by a radical
excision of the inguinal lymphatics is an adequate cura-
tive procedure.
This method of treatment must, of course, be reserved
for those patients who are not too far advanced in the
course of the disease and who are proper surgical risks.
Emphatic, however, is the suggestion that this form of
treatment is the procedure of choice for the apparently
early and local tumors. Experience has proved that in-
guinal node metastases may appear long after the local
lesion has been removed and the absence of enlarged
inguinal nodes is no assurance that the disease will not
appear at a future date.
In 1931 Miles stressed exactly what he meant by a
radical abdominoperineal operation and it would be well
for many surgeons to read his description of the opera-
tion. Miles stated as follows: "By this means the whole
of the pelvic colon (with the exception of the portion
to be utilized for colostomy) , together with the whole of
the rectum encased in its sheath of fascia propria; the
whole of the pelvic mesocolon; the peritoneum lining the
floor as well as the walls of the true pelvis; the whole of
the levator ani and coccygeus muscles; the external sphinc-
ter muscle; as much as possible of the ischiorectal fat
and a wide area of perianal skin, are removed.” Miles
states further: "Although the operation is comprehensive
in its aim, it should not be reserved for advanced cases
only. It should be the procedure of choice for early
cases; in fact the earlier the better, because then we may
hope to circumvent the invisible spread of the disease.
Should it be reserved for advanced cases only, as advo-
cated by some, then the invisible spread will have ad-
vanced beyond the confines of the operative field and
recurrence will be inevitable.”
Summary and Conclusions
1. Between 3 and 5 per cent of all malignancies sit-
uated below the rectosigmoid junction have their origin
in the anal canal.
2. Cancer of the anal canal should always be kept in
mind when a patient presents symptoms referable to the
anal canal.
3. Metastases from anal lesions may involve the in-
guinal lymphatics in addition to all other structures
which are involved in any other low-lying rectal lesion.
4. Radical surgical treatment must be carried out early
in cancer of the anal canal if recovery statistics are to be
improved. A radical Miles abdominoperineal operation
followed by bilateral excision of the inguinal lymphatics
February, 1949
37
is the treatment of choice. Conservative therapy must
be limited to those patients who are not proper surgical
risks and to those in whom the disease has progressed
to the inoperable stage.
References
1. Buie, L. A.: Practical Proctology. Phila. and London,
W. B. Saunders Co., 1938.
2. Cattell, R. B., and Williams, A. C.: Epidermoid Car-
cinoma of the Anus and the Rectum. Arch, of Surg. 46:336,
1943.
3. Bacon, H. E., Linde, A. S., and Murray, F. H.: Sur-
gical Lesions of the Lower Bowel. The Rev. of Gastroenterol-
ogy, 14:305 (May) 1947.
4. Gazetta, P. C., and Cole, W. N.: Carcinoma of the
Rectum and Anus. The American Practitioner, 2:73 (Oct.)
1947.
5. Lawrence, K. B.: Basal Cell Epithelium of the Anus.
Arch, of Surg. 43:88, 1941.
6. Buie, L. A., and Brust, J. C. M.: Malignant Anal Le-
sions of Epithelial Origin. Journal-Lancet 53:565 (Nov.) 1933.
7. Kaplan, I. I., and Rubenfeld, S.: Carcinoma of the Anus.
Am. Jour. Roent. 44:265 (Aug.) 1940.
8. Rosser, C.: The Etiology of Anal Cancer. Am. Jour.
Surg. 1 1:328 (Feb.) 1931.
9. Tucker, C. C., and Hellwig, C. A.: Proctologic Tumors.
J.A.M.A. 111:1270 (Oct. 1) 1938.
10. Drueck, C. ).: Malignant Diseases at the Anus. Urol.
& Cutaneous Rev. 47:432 (July) 1943.
11. Binkley, Geo. C., and Derrick, W. A.: The Association
of Squamous Carcinoma with Anal Manifestations of Lympho-
granuloma Venereum. Am. Jour. Digest. Dis. 12:46 (Feb.)
1947.
12. Bell, E. T.: Text Book of Pathology. Lea & Febiger,
Phila., p. 329, 1938.
13. Freund, M. D.: Bowen’s Disease of the Anus and Anal
Region. Tr. Am Proct. Soc., p. 149, 1941.
14. Keys, E. L.: Squamous Cell Carcinoma of the Lower
Rectum and Anus. Ann. Surg. 106:1046 (Dec.) 1937.
15. Baronofsky, I.: Inguinal Node Dissection. Staff Meeting
Bull. U. of Minn. Hosps., Vol. 19 (Jan. 23) 1948.
16. Miles, W. E.: The Pathology of the Spread of Cancer
of the Rectum and Its Bearing upon the Surgery of the Can-
cerous Rectum. Surg., Gyn. & Obst. 52:350 (Feb.) 1931.
17. Meland, O. J.: Cancer of the Anus. Am. Jour. Roent.
43:706 (May) 1940.
18. Sweet, R. H.: Results of Treatment of Epidermoid Car-
cinoma of the Anus and Rectum. Surg., Gyn. and Obst.
84:967 (May) 1947.
19. Stenstrom, W.: Personal communication.
POSTGRADUATE FELLOWSHIPS ANNOUNCED
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are now available through the National Foundation for Infantile Paralysis. Application may
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Research fellowships are available in virology, orthopedic surgery, pediatrics, epidemi-
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basic sciences as they apply to the particular specialty and to research, and experience in re-
search, which need not be immediately related to poliomyelitis.
In physical medicine, clinical fellowships are available for physicians who wish to prepare
for eligibility for certification by the American Board of Physical Medicine. Public health
fellowships are available to physicians for one year of postgraduate study leading to a Master
of Public Health degree at a school of public health approved by the American Public
Health Association. Further information may be obtained from the Foundation.
POSTGRADUATE COURSE IN DISEASES OF THE CHEST
The Council on Postgraduate Medical Education of the American College of Chest
Physicians and the Laennec Society of Philadelphia announce a Postgraduate Course in Dis-
eases of the Chest to be held at the Warwick Hotel, Philadelphia, Pennsylvania, February 28
through March 5, 1949. This course will emphasize the recent developments in all aspects
of diagnosis and treatment of diseases of the chest.
The course is open to all physicians, although the number of registrants will be limited.
Applications will be accepted in the order in which they are received. The tuition fee is $50.
Application may be made through the Executive Offices of the American College of
Chest Physicians, 500 North Dearborn Street, Chicago 10, Illinois.
38
The Journal-Lancet
Wolff-Parkinson- White Syndrome
Report of Two Cases
Robert A. Jordan, M.D., and Ralph I. Canuteson, M. D.
Lawrence, Kansas
Wolff, Parkinson and White1 in 1930 reported a
series of cases of healthy young people without
demonstrable heart disease who were found to have
short PR intervals and prolonged QRS complexes on
their electrocardiograms. A tendency to attacks of par-
oxysmal tachycardia was noted in this group of patients;
however, the prognosis of this condition was generally
considered to be good.
During the past ten years increasing evidence has accu-
mulated in the literature to show that the Wolff -Parkin-
son-White syndrome is not such a benign condition as it
was previously thought to be. Several authors 2-8 have
reported cases of paroxysmal ventricular tachycardia oc-
curring in patients with the Wolff-Parkinson-White syn-
drome. Paroxysmal ventricular tachycardia is a danger-
ous condition which seldom occurs in the absence of
severe heart disease. At least eight deaths of a cardiac
type have been reported !,_1 4 in patients known to have
the Wolff-Parkinson-White syndrome. Most of these
deaths were the result of repeated or prolonged attacks
of paroxysmal tachycardia.
In this paper two additional cases of the Wolff-Par-
kinson-White syndrome are reported. One of these pa-
tients was shown to have an attack of paroxysmal ven-
tricular tachycardia. The other patient died a cardiac
type of death probably as the result of an attack of
paroxysmal tachycardia.
Case Reports
Case 1. A white male patient, age 26, was admitted
to the hospital at 1:00 P.M., March 29, 1946, complain-
ing of palpitation, "light-headedness,” and nausea. The
attack had started suddenly the previous evening after
the patient had run about fifty yards. At the onset he
Fig. 1. An electrocardiogram taken on Case 1 during an attack of paroxysmal ventricular tachycardia March 29, 1946.
February, 1949
39
nearly fainted, however, his symptoms abated to the ex-
tent that he was able to carry on until shortly before
admission when the palpitation, dizziness and nausea
again became quite severe.
The patient had suffered a similar attack lasting only
a few minutes in February 1943. This first attack came
on after running a short distance. In November 1944
he suffered a second attack about two hours in duration.
Review of the patient’s past medical history revealed
that he was supposed to have had rheumatic fever at the
age of twelve, but no detailed account of his findings
at that time could be given. He had been under medical
observation from 1938 to 1940 because of an early mini-
mal tuberculosis in the apex of the right lung. This
lesion had become calcified and apparently stable by
February 1940. The patient had been a conscientious
objector during World War II. He had served for
thirty-two months as an experimental subject for studies
on the effects of high altitude, and later for experiments
on thiamin and riboflavin deficiencies. After his dis-
charge from conscientious objector camp in April 1945
the patient suffered frequent attacks of palpitation, but
had never experienced an attack as severe or prolonged
as the one described in this paper.
Physical examination on admission revealed a young
male adult who was pale and apprehensive, but not
cyanotic. Examination of the lungs was negative. The
pulse was totally irregular averaging 80 to 85 at the
radial artery and the apex. There was no pulse deficit.
The blood pressure was 135 systolic and 80 diastolic.
The P.M.I. was found in the fifth left interspace in the
mid-clavicular line. No murmurs were heard on auscul-
tation.
An X-ray film of the chest showed the heart to be
within normal limits in contour and size.
Shortly after admission to the hospital, an electro-
cardiogram was made on the patient (figure 1). Within
a few minutes of this time the pulse rate suddenly be-
came regular and the patient’s symptoms subsided. No
treatment was administered other than bed rest and mild
sedation for a period of three days after which he was
dismissed free of symptoms.
An electrocardiogram taken during the paroxysm is
shown in figure 1. The ventricular rhythm is totally
irregular with an average rate of about 140. The QRS
complexes are markedly distorted, widened and slurred,
and show considerable variation in form. The P waves
are difficult to identify, but seem to occur independently
of the ventricular complexes. This tracing is considered
to be typical of paroxysmal ventricular tachycardia. In
figure 2 are shown some electrocardiograms made on the
patient one year prior to this attack. Tracings were
taken before and immediately after exercise. In the elec-
trocardiogram taken before exercise there is a PR inter-
val of 0.08 second with a QRS interval of 0.12 second
in Lead I. The PR interval is 0.10 second in Lead III
Lead III
Before Exercise After Exercise
Fig. 2. The electrocardiograms shown here were made on Case 1, April 3, 1945,
about one year prior to the paroxysm of ventricular tachycardia shown in figure 1 The
tracings on the left were taken before exercise, and those on the right were made im-
mediately after exercise.
40
The Journal-Lancet
and the QRS interval is 0.12 second. The RTi segment
is depressed and Ti is inverted. There is little change
seen in the tracing taken immediately after exercise.
The short PR intervals and prolonged QRS complexes
persist in Leads I and III. The RTV segment is no
longer depressed and T, has become upright. Both of
the tracings shown in figure 2 are considered to be
typical examples of the Wolff-Parkinson-White syn-
drome.
Case 2. This 23 year old white male student was first
admitted to the hospital at 1:00 A.M., February 18,
1945, complaining of rapid heart action and nausea
which had started suddenly thirty minutes prior to ad-
mission. The patient had attended a fraternity dance
for several hours immediately preceding the onset of his
symptoms.
The patient stated that he had suffered a similar at-
tack while serving in the Army in March 1944. At
that time a diagnosis of paroxysmal tachycardia was
made and he was given a medical discharge from the
Army. There was no past history of rheumatic fever
or of any severe illness which might have damaged the
heart.
Physical examination on admission showed a pale,
perspiring young man who was quite nauseated and dur-
ing the examination vomited once. There were no re-
markable findings in the lungs. The pulse was irregular
and varied in rate from 140 to 160. The blood pressure
was 118 systolic and 88 diastolic. The P.M.I. was visible
in the fifth left interspace in the mid-clavicular line. No
murmurs were noted either during the attack or after-
ward.
The attack ceased suddenly about three hours after
its onset. Prior to this the patient had vomited at inter-
vals of ten to thirty minutes. The pulse slowed to 80
and the rhythm became regular. The nausea and vom-
iting subsided and the exhausted patient fell into a deep
sleep. After a rest of three days, he was dismissed from
the hospital with no complaints.
An electrocardiogram made on the patient one month
after the first admission is shown in figure 3. The auricu-
lar and ventricular rates are 62. The PR interval is 0.10
second and the QRS interval is 0.12 second. This tracing
fulfills the criteria necessary for the diagnosis of Wolff-
Parkinson-White syndrome.
The patient was admitted to the hospital a second
time on September 13, 1945, at 2:30 A.M., complaining
of palpitation and weakness. He was not nauseated on
this occasion. The pulse was somewhat irregular and the
rate was about 140. There were no other remarkable
physical findings. The attack subsided suddenly about
two hours after admission at which time the pulse rate
became 60. The patient left the hospital at 11:30 A.M.
the same day without a dismissal order from his physi-
cian.
On November 24, 1945, the patient died suddenly
during an attack of rapid heart action. A description
of this terminal episode was obtained from the patient’s
father. The attack had started suddently with rapid
heart action, weakness and extreme nausea while the
Lead I
Lead II
Lead III
Lead IV F
Fig. 3. An electrocardiogram made on Case 2 on March 19,
1945.
patient was attending a football game. The patient left
the stadium, returned to his home, and went to bed.
His parents found him there about three hours later.
At that time he was still complaining of severe palpita-
tion, and was quite weak and nauseated. He vomited or
attempted to do so every few minutes. Suddenly he
threw back his head, gasped, and was dead. A physician
had not seen the patient. An autopsy was not performed.
From the description of this terminal attack, it would
appear that the immediate cause of death was paroxys-
mal tachycardia.
Summary
Two cases of the Wolff-Parkinson-White syndrome
are reported. The first case was seen during an attack
of paroxysmal ventricular tachycardia. The second case
died during what apparently was an attack of paroxys-
mal tachycardia.
Bibliography
1. Wolff, L., Parkinson, J., and White, P. D.: Bundle
Branch Block with Short P-R Interval in Healthy Young Peo-
ple Prone to Paroxysmal Tachycardia. Am. Heart Jr., 1930,
v. 685.
February, 1949
41
2. Arana, R., and Cossio, P.: Fibrilacion auricular y taqui-
cardia ventricualr como cventualidad posible en cl P-R corto con
QRS ancho y mellado, Rev. argent, de cardiol., 1938, v, 43.
3. Hunter, A., Papp, C., and Parkinson, J.: The Syndrome
of Short P-R Interval, Apparent Bundle Branch Block and
Associated Paroxysmal Tachycardia, Brit. Heart Jr., 1940, ii,
107.
4. Levine, S. A., and Beeson, P. B.: The Wolff-Parkinson-
White Syndrome with Paroxysms of Ventricular Tachycardia,
Am. Heart Jr., 1941, xxii, 401.
5. Palatucci, O. A., and Knighton, J. E.: Short P-R Inter-
val Associated with Prolongation of QRS Complex; a Clinical
Study Demonstrating Interesting Variations, Ann. Int. Med.,
1944, xxi, 58.
6. Missal, M. E., Wood, D. J., and Leo, S. D.: Paroxysmal
Ventricular Tachycardia Associated with Short P-R Intervals
and Prolonged QRS Complexes, Ann. Int. Med., 1946, xxiv,
911.
7. Klainer, M. J., and Joffe, H. H.: A Case of Short P-R
Interval and Prolonged QRS Complex with a Paroxysm of
Ventricular Tachycardia, Ann. Int. Med., 1946, xxiv, 920.
8. Stein, I,: Short P-R Interval, Prolonged QRS Complex
(Wolff-Parkinson-White Syndrome) ; Report of 14 Cases and a
Review of the Literature, Ann. Int. Med., 1946, xxiv, 60.
9. Wilson, F. N.: Recent Progress on Electrocardiography
and the Interpretation of Borderline Electrocardiograms, Proc.
Life Insurance Med. Dir., 1938, xxiv, 96.
10. Vakil, R. J.: A Case of Mitral Stenosis with Apparent
Bundle Branch Block, Short PR intervals and Attacks of Par-
oxysmal Tachycardia, Indian Med. Gaz., 1942, lxxvii, 521.
11. Wood, F. C., Wolferth, C. C., and Geckeler, G. D.:
Histologic Demonstration of Accessory Muscular Connections
Between Auricle and Ventricle in a Case of Short P-R Interval
and Prolonged QRS Complex, Am. Heart Jr., 1943, xxv, 454.
12. Nielsen, A. L., Mortensen, V., and Eskildsen, P.: Nord.
Med., 1943, xxi, 450 (quoted from reference 14)
13. Ohnell, R. F.: Pre-excitation, a Cardiac Abnormality,
1944, P. a. Norstedt and Soner, Stockholm (quoted from ref-
erence 14).
14. Kimball, J. L., and Burch, G.: The Prognosis of the
Wolff-Parkinson-White Syndrome, Ann. Int. Med., 1947, xxvii,
239.
DIGEST REPORTS UNIVERSITY OF MINNESOTA WORK ON
UNDULANT FEVER
The success of University of Minnesota medical scientists in working out an effective
treatment for human brucellosis (undulant fever) is reported by Paul de Kruif, author of
Microbe Hunters, in the January issue of The Reader’s Digest. In the article, "Undulant
Fever — Cause and Promising Cure,” de Kruif tells how the Minnesota scientists, headed
by Dr. Wesley W. Spink, professor of medicine, learned that the combined use of strep-
tomycin and sulfadiazine would cure undulant fever sufferers.
The writer also relates Dr. Spink’s success with a new drug, aureomycin, in treating bru-
cellosis patients in Mexico last summer when he served as a consultant in Mexico’s undulant
fever control program.
CANCER DETECTION CLINIC
More than half of the 292 persons examined by physicians at the cancer detection clinic
held in St. Cloud in December, 1948, were found to be in need of medical care. A total of
166 persons were advised to obtain further examination and treatment from their own phy-
sicians. The one-day detection clinic at St. Cloud was sponsored by the Stearns-Benton
County Medical Society, the Cancer Committee of the State Medical Society, and the Min-
nesota Division of the American Cancer Society.
Cancerous or precancerous conditions were found in 38 of the persons examined. Other
conditions included 17 cases of hypertension, 13 cases of keratosis, 5 or more cases of cys-
tocele, cervical polyp, and cervical erosion, and 3 or more cases of umbilical mass, hemor-
rhoids, lipoma of the chest, rectocele, cervical ulceration or laceration, vaginal discharge, and
vaginitis.
Females examined numbered 213, males 79. Ages ranged from 20 to over 70. There
were 17 different nationalities represented.
42
The Journal-Lancet
Medical Group Practice in the United States:
V* Growth of Groups
Marcus S. Goldstein, Ph.D.
Public Health Administrator,
U. S. Public Health Service
The individual physician in his day by day practice
undoubtedly plays a vital part in maintaining the
public health. On his proper diagnoses of infectious dis-
eases and the quarantine of the patients concerned may
depend the safety of the community at large. In terms
of persons involved, the aggregate of patients seen dur-
ing a year by the practicing physicians of a community
probably includes the major proportion of its popula-
tion. Other examples of the public health role of the
ordinary physician could be cited. Any mode of prac-
tice, therefore, that might make medicine generally more
effective would seem to merit consideration as a public
health measure.
Group practice,' especially in instances where both
diagnostic and therapeutic services are offered, has in-
creasingly come to be recognized as, potentially, at least,
a mechanism for providing highly effective medical care.
This fact is attested by the unanimous endorsement of
the group practice principle by the National Health As-
sembly of 1948 (8) and perhaps by the accelerated de-
velopment of medical groups in recent years (3). An
estimation of the stability of this form of medical prac-
tice therefore should be of specific interest. The present
report attempts such an estimate based on the longevity
and growth in staff members of a fairly large proportion
of existing groups. Related questions such as the number
of physicians leaving a group and the kinds of vacancies
in groups are also examined.
A complete discussion of the growth of medical group
practice would require information on all groups within
a given period of time, disbanded groups as well as those
which have survived. Available data on disbanded groups,
however, are scanty and mostly indirect, and the discus-
sion is largely limited to consideration of surviving
groups as represented by the present sample.
Previous quantitative information on the age of med-
ical groups in the United States is limited to that pro-
vided by Rorem in 1931 (5) and the reports of the
Bureau of Medical Economics of the American Medical
Association in 1933 and 1940(6,7). These papers, and
one of the present series (3), also consider numerical
'This is the fifth of a series of studies on medical group prac-
tice from the Division of Public Health Methods (1, 2, 3, 4).
As defined, a medical group is a formal association of three
or more physicians providing services in more than one medical
field or specialty, with income from medical practice pooled and
redistributed to the members according to some pre-arranged
plan. For a full discussion of the attributes of a medical group,
the reader may be referred to the first study of the series ( 1 ) .
The survey covered the latter months of 1946 and most of
increase of medical groups in the United States as well
as size of staff.
Present Material
Ninety-eight medical groups in existence during 1947
are represented in the present sample, although not with
regard to every item considered.3 The sampling plan
employed in locating the group was to have a member
of the survey staff visit most of the known groups with-
in a reasonable distance of the main routes of his travel
in 21 states. The sample thus obtained is about one-
fourth of all the known medical groups in the country
as of mid-1946 (3). It varies from the latter in (a)
comprising a higher proportion of groups from the West
South Central region of the country and a lower repre-
sentation of the Mountain and Pacific states, and (b)
having a greater proportion of large groups (36 per cent
compared with 20 per cent) .4 The sample resembles all
the known groups of 1946 in relative number of the
various types of group organization represented."
Longevity of Groups
Disbanded groups. The Bureau of Medical Econom-
ics of the American Medical Association (7) estimated
chat "approximately 42 per cent of the 239 groups
studied (by them) in 1932 had disappeared or ceased
to operate as groups during the succeeding eight years.”
A more recent questionnaire survey (3) found that some-
where between 20 and 32 per cent of groups listed by
the Bureau of Medical Economics in 1940 were appar-
ently no longer medical groups in 1946. The group
mortality during the latter period was undoubtedly in-
fluenced by war conditions. The reasons for dissolution
of former groups, as remarked in many of the returned
questionnaires, were mainly retirement or death of a
physician in the group (presumably very small groups
or single owner groups) , and "scarcity of younger phy-
sicians” in civilian practice.
Other evidence of the rate of group mortality is sug-
gested by the data of Rorem (5) who lists the 55 or-
ganizations included in his study. Questionnaires were
sent to 47 of these medical groups in a 1946 survey by
1947, but only the date 1947 is used for the sake of con-
venience.
'Size of group, unless otherwise specified, refers to number of
full-time physicians. The definitions are: small group, three to
five physicians; medium group, six to ten physicians; large
group, eleven or more physicians. On occasion, the first two
categories are combined and referred to as smaller groups.
A definition and discussion of the several types of groups is
given in the first paper of the series (1).
February, 1949
43
Table 1
Distribution of 98 Medical Groups by Date of Organization
Total
Mean Age
r
Date of Organization
x
Number
(years)
Before 1919
1919-1923 1924-1928 1929-1933 1934-1938
1939-1943
1944-1947
Number of Medical Groups
98
19.9
23
18 14 9 19
10
5
’Date of
1947 are
organization refers to
taken into account in
time when 3 or
the last interval
more full-time physicians practiced as a group. Only about the first 8
months of
Hunt and Goldstein (3) and 45 replies were received.
Of the latter, 4 stated the group had disbanded, and
1 claimed to be an informal group.1’ Thus at least 85
per cent of 47 clinics listed by Rorem in 1930 were still
active some 17 years later.
Surviving groups. Table 1 gives the date of origin and
mean age of the 98 practicing medical groups.1 These
groups have been in existence an average of 20 years.
Nearly a fourth of the total number were organized 30
or more years ago, the oldest in 1904. Many of the
groups were founded as two-man teams before the date
when they were organized as a group of three or more
full-time physicians.
The distribution of the groups by date of organiza-
tion, as shown in Table 1, suggests special activity in
group formation during 1919-1923 and 1934-1938, and
a low point in the organization of new groups in 1929-
1933. This phenomenon was also noted in the 1940 re-
port of the Bureau of Medical Economics(7) . It must be
remembered, however, that these trends refer to surviv-
ing groups only; there is no record, certainly no com-
plete one, of groups disbanded during these periods.
Some groups may have organized during the early part
of 1929-1933, for example, and dissolved within the same
period, perhaps because of the acute economic depression.
The comparatively small number of groups founded in
1939-1947, according to the present sample, is probably
a reflection of war conditions.
With regard to type of group organization, the nu-
merical representation of all except the partnership
groups is in each case too small for detailed considera-
tion and hence the average age of each (except the part-
nership groups) can be no more than suggestive. The
mean age of 81 partnership groups was 19.7 years; of
7 single owner groups, 18.1 years; of 4 voluntary non-
profit hospital groups, 28.2 years; of 3 industrial groups,
24.7 years; and of 3 cooperative consumer groups, 14.7
years.
Medical group practice is undoubtedly an older phe-
nomenon in certain parts of the country than in others.
Here too, however, the sample is too small for elabora-
tion. All that may fairly be said is that individual
groups have been in operation in most, if not all, major
'An informal group is one in which the members share office
space and possibly secretarial and other personnel overhead, but
in all other respects practice as individuals (1).
regional divisions of the country over a period of at
least 20 years.
Table 2 relates age and present size of the group to
the size of the community in which the group is located.
According to the present sample, groups in communities
of less than 10,000 population seem to be on the average
definitely smaller in size than those in cities of 10,000
or more, and correspondingly, the average age of groups
m the very small communities is considerably less than
Table 2
Age and Size of Medical Groups in 1947 in Relation to
Size of Community
Population of Community
in which group
was located
Num-
ber
Mean
Age
(years)
Mean Size
(full-time
physicians)
Less than 10,000
30
13.4
6.2
10,000 to 25,000
20
22.2
11.0
25,000 to 50,000 .
..... 21
22.9
10.2
50,000 to 100,000
12
24.3
12.7
100,000 and over
15
21.5
16.3
that of existing groups in cities of 10,000 or more pop-
ulation. Figure 1 illustrates the general relationship
between age and size of group and size of community.
A possible explanation of these relationships may be
that small communities generally can support only small
groups of 3 or 4 members. Such small groups, in turn,
would be likely to dissolve if even one member died or
retired. Any new group formed in the same community
and still in operation would of course show a shorter
life-span when compared with large groups which might
lose several physicians without having the group dis-
band.
Groups comprising only 3 or 4 physicians were found
in the following ratios to all groups in the different
sized communities: 13 of 30 groups in towns of less
than 10,000; 6 of 41 groups in communities of 10,000
to 50,000; and only 2 of 27 groups in cities of 50,000
or over.
The median in the present instance, and throughout, has
been essentially like the corresponding mean, and hence the lat-
ter only is used unless otherwise specified.
44
The Journal-Lancet
Fig. 1. Relationship between age of a sample of existing
groups and size of community and size of group.
group was, on the average, remarkably constant, rang-
ing from 3.7 to 4.5 throughout the period under con-
sideration. Further, and as might have been expected,
the oldest groups, i. e., those organized before 1919, show
the greatest average increase in medical staff, from 4
to 14 full-time physicians.
The mean size of the 81 groups was 4.2 physicians
when initially formed, and 9.0 physicians in 1947. Of
the total number, 82 per cent show an increase in size
since their initial formation, some having grown to a
great extent; one group had increased from 5 to 52
physicians. Some 1 1 per cent of the groups had the
same number of physicians at the time of the interview
as when they first organized, on the average 1 1 years
earlier, and only 7 per cent had fewer physicians in
1947 than at the time of their origin.
Physicians Leaving the Groups
An important consideration in evaluating the stability
of group practice would seem to be the incidence of phy-
sicians leaving a group in the course of time. The avail-
able material permits only a tentative answer to this
question, yet even limited information may be useful in
view of the apparent lack of quantitative data on the
subject.
The number of original members who left their
groups, in relation to age of the organization, is available
for 63 medical groups. Of this number, 38 per cent still
retained all their original members over a mean period
Date of
Organization
MEAN SIZE OF GROUPS
0 0 Z
1 I T
Initial
4 Z
Present (1947)
4 6 8 10
1Z 14
r
T
T
J L
0 0
8
10
Fig. 2. Growth in size of groups (full-time physicians) in relation to date of organization.
Before 1919
3.9 l 1
g:
1919 - 19Z8
4.5 |
10.0
19Z9 - 1938
4.5 11
7 . Z
1939 - 1947
3.7 I |
II 4.5
14. Z
1Z 14
Increase in Size of Groups
Figure 2 illustrates the growth in size of 81 medical
groups classified according to the date of their initial
organization. s The number of physicians starting as a
Of the 81 medical groups providing information on size of
staff at present and when initially organized, 16 were formed
before 1919, 26 during 1919-1928, 26 in 1929-1938, and 13 in
1939-1947.
of 12.8 years; 18 per cent had lost one original member
during a mean interval of 17.0 years; 28 per cent were
minus 2 or 3 of their charter members over a span of
about 25 years; and 16 per cent had lost 4 or more
initial members over a period of 22.7 years.
The 63 groups, in existence 18.8 years, had lost an
average of 1.7 physicians. Of the 105 physicians who
left the groups during this time, 52 per cent had done
February, 1949
45
so voluntarily, i. e., gone into private practice or to an-
other group; 37 per cent had died while with the group;
and 1 1 per cent had been retired. None of the original
members had left voluntarily in 57 per cent of the
groups during a mean existence of 16 years of these
groups, and one physician only did so in 24 per cent
of the groups over a period of 21.9 years. In short, most
of the groups of the present sample have retained their
original members until death or retirement.
Additional information on physicians leaving the or-
ganization was obtained from 18 groups for the period
1940-1946. A mean of 3.3 physicians had left the groups
during this time, including those who died or retired,
or 41.2 per cent of the average number of physicians
in the groups during this period of 6 or 7 years.1’ The
range in the number of physicians having left a group
during this interval varied between none and 10, with a
maximum ratio (physicians leaving to mean size of the
group) of 100 per cent.
In considering the number of physicians leaving the
groups between 1940-1946, cognizance must be taken of
the fact that this was an unstable period, with induc-
tion of large numbers of physicians into the armed serv-
ices during the war. It should be noted also that stafF
changes in some of the groups involved physicians em-
ployed on a temporary or "probationary” basis.
Medical Vacancies in Groups
The responsible authorities of a number of medical
groups were asked whether new physicians were to be
added to their staffs in the immediate future. Affirma-
tive answers were counted as such only when definite
measures had been taken to obtain the services of a new
physician. In many instances arrangements had already
been made for a new physician to join the group at a
specified date. It is felt, therefore, that the information
on this question of medical vacancies, obtained from 66
groups, is substantially realistic.
The number of groups seeking a specified number of
physicians is indicated below:
NUMBER OF NEW PHYSICIANS SOUGHT
BY GROUPS IN 1947
0 1 2 3 4 5
Number of groups 24 25 10 4 2 1
Thus 42, or 64 per cent, of these groups were plan-
ning to increase their staff, the addition averaging
nearly 2 physicians per group. It may be noted in this
connection that the persons in authority in many groups
commented on their inability to expand the medical staff,
despite a definite need for such expansion, because of
inadequate physical facilities and current difficulties in
procuring building materials and services. Scarcity of
The ratio of persons leaving to size of the group was com-
puted thus: the number of full-time physicians in a group in
1940 and at the time of the interview were averaged; this av-
erage was then divided by the number of physicians having left
the group between 1940-1946. The average number of physi-
cians in the 18 groups in 1940 and at the time of the interview
was 8.7 and 11.3, respectively.
building space and of materials, combined with high
general construction costs, have probably postponed the
organization of at least some new groups in the last few
years.
There seems to be no special relationship between
size of group and number of medical vacancies to be
filled.
The fields of practice of the 70 physician vacancies
in medical groups cover a wide range, although physi-
cians qualified as specialists in eye, ear, nose and throat
(20 physicians) and radiology (10 physicians), appear
to be especially in demand. Six of the groups were add-
ing internists to their staffs, while only 3 had openings
for a general practitioner.10 The additional physicians
would bring new specialties to about half the groups and
would add physicians to existing departments or services
in the other half. All 4 groups seeking an orthopedic
surgeon, and 7 of the 10 groups seeking a radiologist
had no specialists in these fields; on the other hand,
all 6. groups planning to add an internist, and all 3
groups seeking a general surgeon already had one or
more of these specialists.
Some relationship between size of group and special-
ists sought could be discerned in a few instances. Thus,
no small group was planning to take on an ophthalmolo-
gist; openings in pathology were in the large groups
only; and all but one of the groups seeking specialists
in combined eye, ear, nose and throat were of small or
medium size.
Comments
As noted in the section on longevity, the survival of
a medical group may be significantly influenced by its
size. The loss of one member in a three-man group, for
example, would immediately change its status by defini-
tion. Since a previous study (3) has indicated a recent
general trend toward increase in size of groups, the im-
portance of this factor in the survival of groups may
correspondingly diminish in the course of time.
The type of organization of the group probably also
has a considerable effect on its survival. Thus, regard-
less of size, a medical group may have to dissolve on
the death or retirement of a single owner or even of a
couple of partners when all other physicians in the group
are employed by the owner or partnership. When, on
the other hand, all or most of the physicians, especially
in medium size or large groups, participate in ownership
of physical assets and distribution of net income, the
death or retirement or voluntary withdrawal of one or
two members will not necessarily affect the continuity
of the group. The survival of groups sponsored by con-
sumer organizations, community hospitals or industrial
companies, also would not likely be affected by the with-
drawal of an individual member, providing the minimum
number of three physicians is maintained.
In conclusion, it may not be amiss to note again that,
according to the present sample, medical group practice
'"Two of the three groups were having two general practi-
tioners join their staffs, the only instance of groups seeking
more than one physician of the same type.
46
The Journal-Lancet
has been in many instances a long-lived, relatively stable,
mode of practicing medicine.
Summary
Consideration of the growth of medical groups, based
on a sample of approximately a fourth of all such groups
known to exist in the United States in 1946, indicated
the following:
1. The mean age of functioning medical groups was
20 years and nearly a fourth of the total sample had
been organized 30 or more years ago.
2. A significant relationship seems to exist between
age of practicing groups, size of group, and size of com-
munity, namely, the larger the community the larger
and older the group.
3. The number of physicians initially organizing the
groups averaged 4 to 5. The oldest groups have the
largest average staff at present, while size of group
diminishes with recency of organization. The average
staff of all the groups increased from 4 at the time of
founding to 9 physicians by 1946-1947.
4. Number of original members leaving 63 groups,
in existence an average of about 19 years, was 1.7 physi-
cians per group. In 18 groups the rate of all physicians
leaving between 1940 and 1946, in relation to average
size of the groups during this period, was 41.2 per cent.
5. Sixty-four per cent of 66 groups reported they were
definitely increasing their medical staffs in the immediate
future. The average increase was to be nearly 2 physi-
cians per group. Physicians qualified to provide eye,
ear, nose and throat and radiological services were most
in demand.
References
1. Hunt, G. Halsey: Medical Group Practice in the United
States. I. Introduction. New Eng. J. Med. 237:71-77, 1947.
2. Hunt, G. Halsey, and Goldstein, M. S.: Medical Group
Practice in the United States. II. Survey of Five Groups in
New England and the Middle Atlantic States. New Eng. J.
Med. 237:719-731, 1947.
3. Hunt, G. Halsey, and Goldstein, Marcus S.: Medical
Group Practice in the United States. III. Report of a Ques-
tionnaire Survey of All Listed Groups in 1946. J.A.M.A.
135:904-909, 1947.
4. Goldstein, M. S.: Medical Group Practice in the United
States. IV. Organization and Administrative Practices.
J.A.M.A. 136:857-861, 1948.
5. Rorem, C. R.: Private Group Clinics. The Administra-
tive and Economic Aspects of Group Medical Practice as Repre-
sented in the Policies and Procedures of 55 Private Associations
of Medical Practitioners. Pub. No. 8 130 pp., Washington,
D.C. Committee on Costs of Medical Care, 1931.
6. Bureau of Medical Economics, American Medical Asso-
ciation. Private Group Practice. J.A.M.A. 100:1605-1608,
1693-1699, 1773-1778. 1933.
7. Bureau of Medical Economics, American Medical Asso-
ciation. Group Medical Practice. 70 pp. Chicago, 1940.
8. Ewing, Oscar R.: The Nation's Health: A Ten Year
Program. 186 pp. Government Printing Office, Washington,
D. C., 1948.
Acknowledgments
The writer is indebted to Miss Ruth Wadman and J. Ross
Hague, M.D., who collected the material under discussion,
largely under the supervision of G. Halsey Hunt, M.D.
Thanks are due Dr. Hunt, Leslie A. Falk, M.D., Miss Martha
D. Ring, and Mr. Isidore Altman, for a critical perusal of the
manuscript. To Dr. Antonio Ciocco, Deputy Chief of the Divi-
sion of Public Health Methods, the writer is deeply obligated
for most helpful suggestions in organization of the paper.
NATIONAL HEART WEEK
National Heart Week in 1949 has been designated as the week of February 14 to 21.
It will be a period of intensified public education and fund raising within the national cam-
paign of the American Heart Association, February 7 to 28.
Though limited drives were conducted in 1947 and 1948, this will be the first major
campaign of the Association. It will be nation-wide in scope, and will seek contributions
totalling $5,000,000. Local affiliated heart associations have been provided with top central
leadership, field guidance and practical campaign material. They will retain 70 per cent of
the funds collected in their areas to facilitate locally needed projects in research, education,
clinical and other community services.
Physicians everywhere have been giving willing and invaluable assistance to local cam-
paign efforts, considering themselves as the group basically concerned with the fight against
heart disease. Reports from various regions indicate that physicians not only have been assist-
ing in organizational activities, but have rendered important services by speaking on heart
disease before civic and club groups. These first-hand reports by physicians have spurred the
recruiting of volunteer workers.
February, 1949
47
Bacteriologic Studies by New Methods of a
Major Epidemic of Poliomyelitis, 1947
Edward C. Rosenow, M.D.
Cincinnati, Ohio
The epidemic of poliomyelitis studied occurred dur-
ing the summer of 1947, and it was the fourth an-
nual epidemic in a large city in the Midwestern section
of the United States. Two hundred and forty-six frank
cases, and a much larger number of suspected cases,
occurred among the population of more than 350,000
inhabitants in 1947, fifty-nine cases in 1946, forty cases
in 1945 and one hundred and twenty-three cases in 1944.
The 1947 epidemic was one of only three sizeable out-
breaks in the United States one year after the severe and
extremely widespread epidemic of poliomyelitis of 1946.
The reasons for this abnormal incidence of poliomyelitis
had remained obscure. Various possible causes, such as
flies and mosquitoes, sewage, the polluted water of an
abandoned canal, swimming pools and the "smudged”
atmosphere, were considered. The water and milk sup-
plies were rigidly tested and found satisfactory, accord-
ing to present day standards. The epidemic was charac-
terized by a high incidence among the general popula-
tion, especially among children, of a peculiar, relatively
mild infection of the throat associated with fever for
several days. The symptoms referable to the upper res-
piratory tract and to the central nervous system were
similar among all persons ill, regardless of whether typ-
ical poliomyelitis did or did not develop. There was a
high incidence of abortive or nonparalytic cases. The
mortality rate was low, despite a high incidence of the
bulbar type of the disease. The range in age incidence
was wide; infants, young and older children and adults
being afflicted. The range of involvement of muscles in
different persons also was wide but, in agreement with
the low mortality rate, complete paralysis of muscle
groups was uncommon.')'
From epidemiologic considerations,1 this epidemic
should not have occurred because of the previous high
annual incidence of the disease. A special reason, there-
fore, seemed to be operative. By the use of special and
new methods I attempted to determine the reason for
this abnormally high incidence of poliomyelitis.
Methods of Study
Serial dilution cultures 2 were made in freshly pre-
pared dextrose-brain broth, of nasopharyngeal swabbings
and of the water and milk supplies. The dextrose-brain
broth, as used, was prepared by adding pieces of fresh
calf brain, approximately one part by volume, to six or
’"Presented at the meeting of the Ohio Branch of the Society
of American Bacteriologists, Columbus, Ohio, October 25, 1947.
I Grateful acknowledgment is hereby made for the coopera-
tion of superintendents of .hospitals, nurses and children’s
homes; and directors of city and county health and water de-
partments which made this study possible.
seven parts of 0.2 per cent dextrose broth before auto-
claving. The finished medium was placed in 15 ml.
amounts in test tubes (6”x %"). Blood-agar plates were
inoculated with nasopharyngeal swabbings and with the
milk. Nasopharyngeal swabbings were made from be-
hind and above the soft palate, without touching the
tongue, using cotton wrapped aluminum wire bent to a
suitable angle. The adherent material on the swabs was
washed off in 2 ml. of solution of sodium chloride. Of
this washing, 0.15 ml. was inoculated into the first tube
of a series of five tubes of dextrose-brain broth; 1.5 ml.
of water containing the sedimented organisms from
15 ml. of centrifuged water representing samplings of
water supplies, and 1.5 ml. of each sample of milk were
likewise added to the first tube in each series of five
tubes of dextrose-brain broth. The samples of milk had
been kept well refrigerated with ice until the cultures
were made, which was usually within twenty-four hours
after pasteurization. After thorough mixing with a ster-
ile 1 ml. pipette, 0.15 ml. was transferred from tube
to tube in each series. One pipette was used in each
series to mix and transfer the respective materials from
tube to tube. The dilutions of the nasopharyngeal
washings ranged from 1:100 to 1:10,000,000,000; the
dilutions of the milk ranged from 1:10 to 1:1,000,000,-
000 and of the water from 1:1 to 1:100,000,000. In
making serial dilutions of sodium chloride solution sus-
pensions or broth cultures containing specifically viru-
lent streptococci, without changing pipettes, it was found
that dilution of viable organisms often was far less than
that of the liquid menstruum and that serial dilutions
in the highly favorable medium, dextrose-brain broth,
served to separate the pathogens from saprophytes, just
as if the pathogens adhered to the surfaces of the pipette
and the saprophytes did not.
The streptococcus used for inoculation of animals, for
preparation of very dense suspensions of partially de-
hydrated streptococci in glycerol (2 parts) and saturated
sodium chloride solution (1 part) for agglutination and
precipitation studies and for the preparation of thermal
antibody and of antigen, were obtained either from the
end point of growth, usually in the third, fourth or fifth
serial dilution, or from the first, second or third rapidly
repeated sub-culture in dextrose-brain broth.
Young white mice of the Swiss type, weighing 15 to
18 gms., were inoculated routinely, under ether anes-
thesia, intracerebrally with 0.03 ml. or intraperitoneally
with 1 ml., of 10: 1 suspensions in solution of sodium
chloride of the streptococcus from the nasopharynges of
persons ill and from the milk, before and after from
one to four pasteurizations in milk and after one or two
animal passages.
48
The Journal-Lancet
The resistance to heat of the streptococcus isolated
from nasopharynx and from the pasteurized milk and
other sources was determined by subjecting suspensions
of the respective streptococci in autoclaved milk con-
tained in 15 ml. amounts in rubbed capped bottles, to
145° F. or 158° F. for 30 minutes. The temperature
inside of control vials containing milk was checked with
certified thermometers. Sterility cultures were made in
dextrose-brain broth.
The agglutinating action of normal and convalescent
serum was determined in three five-fold dilutions of 1:10
to 1:250. That of "natural” antibody present in the
serum of immunized horses and of thermal antibody pre-
pared in vitro with streptococci isolated, respectively, in
studies of poliomyelitis, arthritis and epilepsy was de-
termined at four five-fold dilutions of 1:10 to 1:1,250.
Two-tenths ml. of the respective dilutions of serums or
thermal antibody, and 0.2 ml. of the respective suspen-
sions containing approximately 6,000,000,000 strepto-
ccoci per ml. were added to test tubes measuring 3”x%".
The mixtures were thoroughly shaken and then incu-
bated at 45 to 48° C. for eighteen hours. Readings were
made under the edge of a shaded 100-watt light bulb
against a non-reflecting black velvet cloth in a dark
room. For the sake of brevity and clarity, the agglutina-
tive titers in tables and text are given in per cent of the
total possible. Maximal agglutination of 4 plus for each
dilution was considered 100 per cent. The percentage
was obtained by dividing the observed degree of agglu-
tination by the total possible (12 for the three dilutions
and 16 for the four five-fold dilutions) .
In studies on the production of streptococcal anti-
bodies in vitro, it has been found that as the bacteria
disintegrate in sodium chloride solution suspensions, on
application of heat in the autoclave, toxic components
are destroyed, the remnants of organisms become sharply
agglutinated and brownish in color and substances re-
sembling antibodies suitable for diagnostic tests of spe-
cific antigen in skin or blood become demonstrable in
the supernatant of the suspension/-4
Sodium chloride solution suspensions of streptococci
(10,000,000,000 organisms per ml.) which had been iso-
lated in studies of poliomyelitis, and other diseases, were
autoclaved for ninety-six hours and heated at 65° C. for
one hour, respectively. To these suspensions phenol was
added to equal 0.2 per cent. The bacteria-free super-
natant of the autoclaved and heated suspensions repre-
sented antibody and antigen, respectively, and were in-
jected intradermally for the detection of specific antigen
and antibody in the skin or blood of persons ill, of well
contacts and of noncontacts. Solutions similarly pre-
pared from streptococci unrelated to poliomyelitis and
NaCl solution containing 0.2 per cent phenol were in-
jected as controls. Immediate erythematous reactions oc-
curred after intradermal injection of 0.03 ml. of the
supernatant solution containing antibody, provided an-
tigen specifically related to the streptococcus from which
the antibody was prepared was present in skin or blood.
A similar, although usually a less intensive, erythema
occurred immediately surrounding the site of injection
of the antigen, provided antibody specifically related to
the streptococcus was present in the skin or blood. In
studies to be reported elsewhere of persons suffering
from diverse diseases associated with specific types of
streptococci, including poliomyelitis, erythematous re-
actions, indicating streptococcal antigen in skin or blood,
that occurred after intradermal injection of thermal and
natural antibody ran closely parallel and reactions ob-
tained on injection of solutions of respective antigen and
specific polysaccharide also ran closely parallel.
Results of Cultures of the
Water Supply
Serial dilution cultures in dextrose-brain broth were
made of 10:1 suspensions of the centrifuged sediment
of forty samplings of water. Fourteen of these samplings
were collected for me by the Water Department from
widely separated parts of the city from outlets routinely
tested. Seven were collected by the Department of
Health in homes where poliomyelitis had recently oc-
curred. Four samplings were of polluted water from a
canal traversing the city and samplings were obtained
from four swimming pools. I collected eleven samples
from water supplies of buildings equipped with flush
types of toilet valves, four at the inlet and seven within
the buildings. Streptococci were isolated from but one
of the fourteen samples representing the city supply
routinely tested. This culture proved nonvirulent, was
killed by standard pasteurization in milk and was not
agglutinated by convalescent serum or by the poliomy-
elitis antistreptococcic serum. Streptococci grew in mix-
ture with gram-negative, gas-forming bacilli in but one
of the four samples of water from the canal and in four
of the seven samples from within buildings equipped
with the flush type of toilets. Thus, of the forty samples
cultured, a streptococcus was isolated in pure culture
from but one sample. Streptococci grew in mixture with
other bacteria in cultures from five and streptococci did
not grow in cultures of thirty-four of the forty sam-
plings.
Results of a Study of the Milk Supply
The results of a microscopic examination and cultural
study of the milk supply by making serial dilutions in
dextrose-brain broth, according to the "flash” or "hold-
ing” methods of pasteurization, and of raw milk are
summarized in Table 1. It will be seen that the number
of streptococci found on microscopic examination of
stained films and the incidence of isolations were uni-
formly higher, especially isolations in pure culture, from
specimens that had been pasteurized by the "flash”
method than by the "holding” method. In most in-
stances, streptococci grew at extremely high dilutions of
the milk in the serial dilution cultures in dextrose-brain
broth, indicating the presence of large numbers of viable
streptococci. Altogether, mixed or pure cultures of the
streptococci grew in serial dilution cultures in fifty-four
instances and pure cultures were obtained in twenty-two
instances (37 per cent) of the sixty samples of thirty-
two brands cultured, representing virtually the entire
February, 1949
49
Table 1
Summary of a Bacteriologic Study of the Milk Supply
Results of microscopic and bacteriologic studies of
SAMPLINGS OF THE MILK SUPPLY
Condition of milk
Number
of
brands
Sam-
plings
exam-
ined
Microscopic examination
of gram-safranine stained
films
Serial dilution
cultures in
dextrose-brain
broth
Streptococci present in
Large
num-
bers
Moder-
ate
num-
bers
Small
num-
bers
Total
(per
cent)
Mixture
or in
pure
culture
Pl
cult
Num-
ber
re
□ re*
Per
cent
Pasteurized
by
"Flash” method
(161° or 165° F.,
17 or 25 sec.)
3
19
6
5
6
89
19
18
95
"Holding” method
(145° for 30 min.)
25
37
5
8
11
65
33
13
35
Unpasteurized
4
4
0
2
1
75
2
1
25
Total
32
60
11
15
18
73
54
22
37
*From end point of growth
Table 2
Resistance of Pasteurization in Milk of Streptococci Isolated from Nasopharynges of Persons Having Poliomyelitis, and from the
Milk Supply
Number
of
strains
Strains of streptococci that resisted pasteurization in
MILK. AT
Source of streptococci
145° F. for
30 minutes
158° F. for
30 minutes
Number
Per cent
Number
Per cent
Nasopharynges of persons having acute
poliomyelitis
39
22
56
Pasteurized milk supply
51
33
64
Control: nonvirulent streptococci
15
2
13
Persons having poliomyelitis, and the
milk supply
15
10
67
4
27
milk supply of the city. Only relatively small numbers
of streptococci grew on blood-agar plates.
The results of a study of the heat resistance in milk
of the streptococci isolated from the nasopharynges of
persons having poliomyelitis and from the milk supply
are summarized in Table 2. The high incidence of iso-
lations of the streptococcus, alike from nasopharynx
and from the milk supply, and the low incidence of iso-
lations of control strains after heating to 145° F. for
thirty minutes and the low incidence of isolation of the
specific strains after heating to 154° F. for thirty min-
utes are well shown and are in accord with previous
studies.'1 The four of fifteen specific strains that resisted
pasteurization at 154° F. for thirty minutes had resisted
three previous pasteurizations at 145° F. Each of these
four strains produced flaccid paralysis in mice on isola-
tion after commercial pasteurization by the "flash” meth-
od, and all proved nonvirulent after three additional
pasteurization including pasteurization at 154“ F. for
thirty minutes.
Results of Experiments in Mice
The results following inoculation of a large number
of mice with the streptococcus isolated from the naso-
pharynges of persons having acute poliomyelitis, from
the milk supply of the epidemic under study, and from
outdoor air during September and early October, 1947,
representing five Middle West states, in contrast to those
obtained in mice similarly inoculated with streptococci
50
The Journal-Lancet
Table 3
Results in Mice Inoculated with Streptococci Isolated from the Nasopharynges of Persons Having Poliomyelitis and from the Milk
Supply of a Major Epidemic, in Contrast to Results Obtained with Streptococci from Sources Other Than Poliomyelitis
source ot
streptococci
MAS A ' 1 It'bO 8 ,
a-
Strains
1 nocu-
lated*
Observed to have
Mor-
tality
(per
With
lesions
of lungs
(per cent)
Cultures from
brain after
death
Num-
ber
Per cent
yielding
strepto-
cocci
Paralysis
(per cent)
Spasms
(per cent)
■n^^CAL ug
^^f^utis
Pasteurized
Milk
Supply
25
54
83
5
72
1
31
96
In relation
to epidemic
poliomyelitis
19
165
75
4
44
4
76
87
Outdoor
air
7
22
41
5
68
2
15
68
Remote from
epidemic
poliomyelitis
Epilepsy
22
123
0
75
80
4
45
91
Epidemic
Respirator)'
Infections
32
60
0
9
67
62
32
75
Schizo-
phrenia
10
**
6
0
59
0
17
100
Miscel-
laneous
48
126
5
3
68
6
OO |
]
71
*About one-third of the animals in the first five groups were inoculated intraperitoneally.
All others were inoculated intracerebrally.
wenty of the 32 mice became extremely excitable.
isolated from the nasopharynges of persons ill with di-
verse diseases remote from epidemic poliomyelitis, are
summarized in Table 3. The strains isolated from per-
sons having poliomyelitis, from the milk supply and, to
a lesser but significant degree, from the outdoor air in
September caused a high incidence of paralysis, usually
flaccid in type, which was not the case following iden-
tical inoculations of streptococci from the control groups.
In sharp contrast, streptococci isolated in studies of idio-
pathic epilepsy caused a very high incidence of spasms,
often associated with generalized convulsions, and strep-
tococci similarly isolated from nasopharynges of persons
suffering from epidemic respiratory infections caused a
high incidence of lesions of lungs. The mortality rate
and isolations of streptococci from the brains of animals
that succumbed, while significant, were not as distinctive
as the symptoms and lesions that developed after inocu-
lation of both the test and the control strains.
Results of Agglutination Tests
The agglutinative titer of the serum of horses pre-
pared, respectively, with streptococci isolated in previous
studies of poliomyelitis and arthritis, and that of thermal
antibody prepared with streptococci isolated from the
nasopharynges of persons having poliomyelitis in the
epidemic under study, and of persons having epilepsy
remote from poliomyelitis are summarized in Table 4.
The much higher percentage of agglutination by the
homologous natural and thermal antibody than that by
heterologous antibody is strikingly shown.
The agglutinative titer of serums from persons was
determined separately. A summary of the results of the
different groups is shown in Table 5. It will be seen that
the average percentage of total possible agglutination
by the serums from persons having nonparalytic polio-
myelitis was uniformly higher, and often much higher,
both at five to twelve days and thirteen to twenty-one
days after onset of the disease than the serums from per-
sons of the same age having paralytic poliomyelitis.
Moreover, there was a striking parallelism between ag-
glutinative titer of the serums and antibody titer in skin
or blood as determined by intradermal injection of spe-
cific streptococcal antigen. The agglutinative titer of the
serum of well persons remote from the epidemic was
always much lower than that of the serum of persons
convalescing from mild poliomyelitis.
Results of Cutaneous Tests
The results of erythematous reactions to intradermal
injection of thermal antibody and of antigen are sum-
marized in Table 6. It will be seen that the average
reactions in square centimeters and percentage of re-
actions 5 sq. cm. or more, indicating specific streptococcal
antigen in skin or blood, was greatest among persons
suffering from paralytic poliomyelitis ( 14.57 sq. cm.) ,
next greatest in non-paralytics (13.90 sq. cm.); greater
February, 1949
51
Table 4
Agglutinative Titer of Antiserum Prepared in Horses and Thermal Antibody Prepared in Vitro with Streptococci Isolated in
Studies of Poliomyelitis, Arthritis and Epilepsy for the Respective Streptococci
Percentage of total possible agglutination at five-fold dilutions
(1-10 TO 1-1250) OF anti-serum and thermal antibody of streptococci
isolated in 1947 from:
Source of “natural” and artificial
antibody
Nasopharvnges ot
persons having
poliomyelitis in
Milk
supply
of
Nasopharynx remote from
epidemic poliomyelitis
Well
persons
(2-21)
Persons having
1946
(2-78)
Epidemic under study
Epi-
lepsy
(1-28)
Arth-
ritis
(1-30)
(3-11)
(2-24)
Antiserums prepared in horses
Poliomyelitis
56
50
50
6-
0
6
previous studies ot
Arthritis
31
25
31
0
19
56
Artificial or thermal anti-
body prepared from strepto-
cocci isolated from nasophar-
ynges of persons having
Poliomyelitis
during current
epidemic
88
88
69
19
31
38
Epilepsy
38
38
38
25
69
19
Table 5
Agglutinative Titer of the Serum of Persons Suffering from Poliomyelitis for Streptococci Isolated in Studies of Poliomyelitis in
Relation to the Titer of Streptococcic Antibody in Skin or Blood, Duration of the Disease and Degree of Paralysis
Percentage of total possible agglutination by five fold
DILUTIONS OF 1-10 TO 1-250 OF THE SERUM OF PATIENTS, CONTACTS
AND NONCONTACTS OF STREPTOCOCCI ISOLATED IN STUDIES OF
Duration
Ser-
ums
cutaneous
Epidemic poliomyelitis from
Well per-
sons re-
Groups
of
disease
reaction
indicating
.Nasopharynx
Pasteurized
milk supply
of a major
epidemic
1947
days
antibody
(sq . cm.)
1 946
1947
Spinal fluid
brain and
spinal cord
1935-44
Well per-
sons in
epidemic
/one 1947
more
from
poliomyeli-
tis
1947
c n
<L»
£ c JJ £ «
None
5-12
7
34
32
19
45
37
8
Mr . 2 S* W;‘ <7>
of) £ u ■
C '
'-P *- T3 .. f2
Severe
6
22
19
13
43
32
0
o
O "3 jy — 5
8
Slight
13-21
9
39
38
19
46
49
7
<-£'-5 c 0
Severe
7
21
15
7
33
29
6
^ <*>
g to
reac- j
:ating |
a skin |
»d
Large
15
11.02
37
35
17
46
41
7
rt o
Small
8
2.01
19
16
12
31
1
1
C/5 2
.£ 0
y o
Lj O
o O
U c
H 0 c .5.0
0 j;-- 0
S) « »£ 0
Large
8
10.63
29
32
18
43
40
7
< s 0 s
0 'V> rt
Small
5
5.49
23
18
8
27
so
Of
5
Well persons remote from
epidemic poliomyelitis
13
9
1
0
7
12
29
in persons that had not been exposed to poliomyelitis
in 1946 (12.34 sq.cm, and 12.50 sq.cm.) than in per-
sons that had been exposed in 1946 (10.08 sq.cm.) and
slightly less in contacts and non-contacts (9.71 sq.cm.).
In sharp contrast, reactions to antigen indicating specific
streptococcal antibody in skin or blood were least among
persons having paralytic poliomyelitis (4.06 sq.cm.),
somewhat greater in non-paralytics (6.35 sq.cm.), still
greater among well persons living in widely separated
homes but not directly exposed to poliomyelitis in 1946
(8.08 sq.cm.) and well contacts and non-contacts (8.91
sq. cm.) ; reactions indicating antibody were greater
among well physicians and nurses that had been exposed
to poliomyelitis in 1946 (9.12 sq.cm.) than in those not
52
The Journal-Lancet
Table 6
Erythematous Reactions of Persons with Poliomyelitis and of Well Contacts and Noncontacts During the Epidemic of Poliomyelitis
in Akron, Ohio (1947), Following Intradermal Injection of Streptococcic Thermal Antibody and Streptococcic Antigen
Erythematous reactions to thermal antibody and to antigen
PREPARED FROM STREPTOCOCCI ISOLATED IN STUDIES OF
Well persons
Respiratory
remote from
Epidemic poliomyelitis | infections
poliomyelitis
Reactions indicating presence in skin or blood
of streptococcic
Per
Antigen
Antibody
Antigen
Antigen
Groups ot persons tested
(September, 1947)
sons
test-
ed
Aver-
age
age*
Sq. cm.
% 5 sq.
cm. or
more
Sq. cm.
% 5 sq.
cm. or
more
Sq. cm.
% 5 sq.
cm. or
more
Sq. cm.
% 5 sq.
cm. or
more
Cases of nonparalytic polio
myelitis
-
35
8
13.90
100
6.35
100
5.70
33
3.28
23
Cases of paralytic polioms
elitis
29
13
14.57
100
4.06
45
3.84
24
3.38
21
Well contacts and noncontacts:
children at a children’s home
25
11
9.71
100
8.91
92
3.25
40
2.61
20
Well contacts: physicians,
nurses and hospital per-
sonnel in relation to
exposure to poliomyelitis
in 1946
Not ex-
posed
23
19
12.34
82
4.58
39
4.36
31
2.47
17
Exposed
37
34
10.08
100
9.12
100
4.95
51
2.35
16
Well noncontacts: adult persons
living in widely separated homes,
exposed to poliomyelitis in 1946
25
31
12.50
96
8.08
96
3.27
40
3.82
36
Hospital personnel, Cincinnati,
Ohio, remote from cases ot
poliomyelitis
31
37
5.82
61
2.58
23
2.32
16
2.23
13
*Years
Table 7
Erythematous Reaction to Intradermal Injection of Thermal Antibody and to Antigen prepared from Streptococci Isolated from
the Nasopharynges of Persons 111 with Poliomyelitis, and from the Pasteurized
Milk Supply in the Epidemic of Poliomyelitis under Study
Groups
studied
Degree
of
paral-
ysis
Average
dura-
tion of
disease
(days)
Per-
sons
tested
Erythematous reactions in sq. cm. to intradermal injec-
tion OF THERMAL ANTIBODY AND TO ANTIGEN PREPARED FROM
STREPTOCOCCI ISOLATED IN STUDIES OF
Epidemic poliomyelitis
Controls*
Under study
Elsewhere
Naso-
pharynx
Milk
supply
Nasopharynx
Reactions indicating presence in skin or
blood of streptococcic
Antigen
Antigen
Antigen
Antibody
Antigen
Persons having
poliomyelitis
Severe
14
7
8.75
11.20
12.48
2.27
1.15
Slight
or none
6
6
6.86
10.73
12.67
8.01
2.82
Well contacts in epidemic
under study
7
7.42
9.40
10.96
6.80
2.75
Non contacts remote from
poliomyelitis
6
3.93
3.31
3.78
1.12
2.81
*\Vell persons remote from poliomyelitis
February, 1949
53
so exposed (4.58 sq.cm.). (See also Table 7). Reactions
indicating antigen and antibody were far lower for the
control group than for groups living in the epidemic
under study. Reactions to injections of control antibody
prepared from streptococci isolated from nasopharynges
of persons suffering from respiratory infections and of
well persons remote from poliomyelitis were uniformly
far less than to antibody prepared from streptococci
isolated in studies of poliomyelitis. However, reactions
of persons ill, of contacts and non-contacts and other
well persons in the epidemic under study, where mild
infection of the throat was common, were significantly
greater to antibody prepared from streptococci isolated
in studies of respiratory infection than to antibody pre-
pared from streptococci isolated from the nasopharynges
of well persons.
Since the streptococcus isolated from the milk supply
was agglutinated in a manner similar to the streptococcus
isolated from persons suffering from poliomyelitis, in-
dicating antigenic identity, then thermal antibody pre-
pared from it should incite cutaneous reactions similar
to those that occurred after injection of antibody pre-
pared from the streptococcus isolated from the naso-
pharynges of persons having acute poliomyelitis. This
proved to be so, as shown in Table 7. Moreover, similar
reaction to intradermal injection of antibody prepared
from the streptococcus isolated from the milk supply,
from the nasopharynges of persons having poliomyelitis
in the epidemic under study and in an epidemic else-
where were obtained in persons who had contracted
poliomyelitis and in well contacts in other mild out-
breaks. Minimal reactions among non-contacts remote
from poliomyelitis, tested as controls, also ran closely
parallel. It is well shown too that there was a much
higher antibody titer among persons with little or no
paralysis (8.01 sq.cm.) than among persons severely
paralyzed (2.2 sq.cm.).
On the basis of these findings and the fact that anti-
gen and antibody titer of skin or blood were uniformly
greater among persons residing in the epidemic under
study than occurred in other epidemics (in 1946 and
1947, to be reported elsewhere), it was decided to study
the effect of the ingestion of the milk by well persons
remote from the epidemic.
Experimental Induction of Specific
Cutaneous Reactions by Ingestion of the
Contaminated Milk
One of the most used brands of homogenized milk
from the epidemic zone, which was pasteurized by the
"flash” method and from which the specific type of strep-
tococcus was isolated, as well as from three previous
samplings, was taken properly refrigerated to Cincinnati.
1 his milk was ingested in parallel manner with a local
brand of milk pasteurized at 145° F. for thirty minutes,
from which the specific type of streptococcus was not
isolable, by volunteer persons who did not react posi-
tively to intradermal tests. The conditions of the tests
and the results obtained are shown in Figure 1.
The cutaneous reaction to thermal antibody prepared
alike from the streptococcus isolated from nasopharynges
of persons suffering from poliomyelitis and from the
milk supply of the epidemic under study, indicating spe-
cific streptococcic antigen in skin or blood, had increased
sharply in each person in two and ten hours after in-
gestion of two quarts of the milk during thirty-six hours.
The reaction to repeat cutaneous tests had diminished in
twenty-four hours for both antibody solutions. After
eighteen days, the reaction to antibody prepared from
the streptococcus isolated from the milk was negative
whereas that to antibody prepared from the streptococcus
isolated from nasopharynx was still elevated. Antibody
to both strains had developed in eighteen days. In sharp
contrast, there was no significant increase in antigen or
antibody, measurable by intradermal injection of anti-
body and antigen prepared respectively, from streptococci
isolated in studies of arthritis remote from poliomyelitis,
in the group which ingested the milk from the epidemic
under study. Moreover, no change in "poliomyelitic”
or "arthritic” antigen or antibody content of the skin or
blood occurred in the control group that ingested the
control pasteurized milk from which the specific type of
streptococcus was not isolable, or in the additional con-
trols tested in parallel manner who did not receive milk
during thirty-six hours.
Summary and Comments
The results of a bacteriologic study, made by special
and new methods, of a major epidemic, the fourth an-
nual epidemic, of poliomyelitis in a large city are re-
ported. A specific type of streptococcus, similar to the
streptococcus isolated consistently in previous studies,1''1
was isolated from the nasopharynges of all persons stud-
ied in whom poliomyelitis had developed and from the
pasteurized milk supply in high incidence. Cutaneous
reactions, indicating specific streptococcal antigen and
antibody in skin or blood, and hence the presence of a
specific type of streptococcal infection, were demon-
strated consistently among persons suffering from abor-
tive and paralytic poliomyelitis and among well contacts
and non-contacts.
The cutaneous reactions, indicating specific strepto-
coccal antigen and antibody, of virtually all persons
tested were so much greater, especially reactions indicat-
ing antibody, than those obtained in studies of other epi-
demics and of sporadic cases as to suggest a source, or
sources, of the streptococcus and perhaps virus other
than, or in addition to, contact infection. Since strep-
tococci having certain respective specific properties had
been isolated previously from persons ill *’• ' and from
unpotable water and from water and milk supplies °«8
during epidemics of poliomyelitis, encephalitis and respir-
atory infections, since the streptococci thus isolated failed
to grow in the aerobic mediums now universally used for
the control of the bacterial content of milk supplies, and
since they often resisted pasteurization at 145° F. for
thirty minutes,'1 the water and milk supplies — even the
pasteurized milk chiefly used — were considered as pos-
sible sources of infection. On the basis of these facts
and the high incidence of the unusual type of infection
of the throat in children, a bacteriologic study of the
water and milk supplies was made by the special and
new methods.
54
The Journal-Lancet
F1GURF. 1
Cutaneous reactions indicating absence of “poliomyelitic” streptococcal antigen and antibody in skin or blood
OF persons before, and their presence after, incestion of pasteurized milk from which the
“poliomyelitic” streptococcus was isolated
Average erythema-
tous reactions in sq.
cm. following intra-
dermal injection of
thermal antibody
» » and of
antigen o- o ,
prepared from strep-
tococci isolated in
studies of
Naso-
pharynx
Milk
supply
under
studv
Naso-
pharynx
Time of cutaneous tests: B, before;
2, 10, 24 hours, anti 18 days after,
ingestion of milk
I wo quarts of milk ingested in 8 ounce
amounts during 36 hours, by each of
three persons in each group remote
from epidemic
/
^JD
10 24 li
24
18
Pasteurized milk
Homogenized
Standard from
from epidemic
local supply
area
From which the
“poliom yeli tic”
type of streptococcus was
Isolated
Not isolated
10
24
18
Control:
three persons
not receiving
milk for
36 hours
The specific type of streptococcus was not isolable
from any of the forty samplings of water, including the
drinking supply, from the polluted water of the canal
and from swimming pools. Streptococci grew or were
isolated from fifty-two of fifty-six samplings of pasteur-
ized milk and from two of four samplings of raw milk.
Only relatively small numbers of streptococci grew on
aerobic blood-agar plates. The bacterial count of the
milk supply adequately tested by the health departments
using the prescribed methods was well within the pre-
scribed limits. However, mixed and pure cultures of the
streptococcus grew in high, and often in extremely high,
serial dilutions in dextrose-brain broth, indicating the
presence of large, and often of extremely large, numbers
of viable partial tension streptococci. This was especially
true of samplings from milk that had been pasteurized
by the "flash” method and which constituted the major
supply of the city. The streptococcus isolated from the
milk resembled the streptococcus isolated from the naso-
pharynges of persons in whom poliomyelitis had de-
veloped in the epidemic under study and elsewhere, in
cultural requirements, morphology, staining reactions, in
resistance to pasteurization, in serologic properties and
in virulence. Strains from both sources were agglu-
tinated specifically by convalescent serum, by the serum
of horses that had been immunized previously with the
streptococcus isolated in studies of poliomyelitis, and by
thermal antibody prepared from the streptococcus iso-
lated from the nasopharynges of persons ill in the epi-
demic under study. The streptococcus from both naso-
pharynx and milk produced flaccid paralysis in high in-
cidence in mice following intracerebral or intraperitoneal
inoculation and were isolated in pure culture from the
brains of mice that succumbed.
The production in mice of the all-important symptom
of poliomyelitis, flaccid paralysis, associated with edema,
hemorrhage and degeneration of ganglion cells in the
anterior horns of the spinal cord with the streptococcus
isolated from persons ill and the milk supply is consid-
ered of fundamental importance even though some of
the clinical and histological findings as seen in epidemic
poliomyelitis in humans and experimental "virus” polio-
myelitis in monkeys were lacking.
Cutaneous reactions to thermal antibody prepared
from the streptococcus isolated from the milk and from
the nasopharynges of persons in whom poliomyelitis had
developed ran closely parallel in persons having polio-
myelitis, in contacts and in non-contacts. Ingestion of
February, 1949
55
the contaminated milk caused skin test negative persons
to become skin test positive to thermal antibody and to
antigen, indicating respectively, the absorption of spe-
cific streptococcal antigen, the formation of specific an-
tibody and the source of the abnormally high titer of
antigen and antibody in persons ill and in well persons
of the population.
The close parallelism between antibody titer in skin
or blood, as determined by intradermal injection of an-
tigen, and antibody titer in the serum as determined by
agglutination tests, the presence of antigen in skin or
blood in highest titer and antibody in lowest titer in
paralytic poliomyelitis, and vice versa in well persons,
further indicate causal relationship of the streptococcus
or antigenic identity of the streptococcus and the virus.
The low antibody titer in paralytic poliomyelitis which
was found in this study, and also in similar studies made
elsewhere in 1947 and last year during the severe epi-
demic, is in striking accord with the low viral neutraliz-
ing titer in the serum of persons who had paralytic polio-
myelitis, reported by Jensen.9 Whether this striking lack
of antibody formation in paralytic poliomyelitis is ex-
pressive of familial or "autarceologic” susceptibility, as
suggested by Aycock 10 and as emphasized by Ander-
son,1 or whether due to a particularly severe infection
by the streptococcus or virus is not clear.
The data adduced in this study indicate that the strep-
tococcus isolated alike from the nasopharynges of per-
sons ill and from the milk supply was causative and per-
haps indirectly a source of the virus as the infection by
the streptococcus occurred, and that ingestion of the milk
from which the streptococcus was isolated in such high
incidence and in such large numbers played an impor-
tant role in pathogenesis. On the basis of these and pre-
vious studies in which the specific type of the strepto-
coccus was isolated consistently by my methods from
milk obtained in a sterile manner from cows on farms
where polio occurred from composite samples of milk
and cream in epidemics, )’G’7 and the fact that one epi-
demic traced to a milk supply came to an abrupt end
by discontinuance of the use of the contaminated milk,-'
it was strongly urged that the milk supply of the city be
pasteurized at a temperature shown to be adequate to
kill the resistant specific type of streptococcus, and that
the methods herein used be adopted for the isolation of
specific types of streptococci and for the bacteriologic
control of milk supplies.* The type of streptococcus
isolated from the nasopharynges of persons and from
the milk in this study has been isolated consistently in
previous studies, by the special methods employed, from
poliomyelitis virus, even from filtrates of the virus, 2,11
*In accord with the fact that the pasteurizing temperatures
for the milk supply has not been increased; an abnormally high
incidence of poliomyelitis again occurred in 1948 — the fifth con-
secutive year.
from the cerebrospinal fluid in the very early stages of
the spontaneous disease and as fever appears in monkeys
following intracerebral inoculation of virulent virus, and
from the spinal cord after death in epidemic and experi-
mental poliomyelitis.11 Moreover, filtrable transmissible
agents resembling poliomyelitic virus have been pro-
duced experimentally from neurotropic streptococci iso-
lated in studies of poliomyelitis and from sources wholly
remote from poliomyelitis.12 It is suggested that the
primary infection in poliomyelitis is streptococcal and
that as this occurs a virus phase of the streptococcus may
develop. The streptococcus, on the basis of present
knowledge, is considered to be the large, cultivable, toxi-
genic, highly antigenic phase of the small, filtrable,
highly invasive, but relativedly nonantigenic, virus.
The studies on the virus made now for nearly 40
years have been so alluring that the solution of the
problem has quite naturally been sought from this stand-
point, almost to the exclusion of forthright bacteriologic
studies. It is hoped that the results, reported herewith,
will lead to a broader approach at the solution of this
problem than that hitherto employed, to a study of both
the streptococcus and the virus.
References
1. Anderson, G. W.: Epidemiology of Poliomyelitis. Jour-
nal-Lancet, Minneapolis, 67:10-13, 1947.
2. Rosenow, E. C.: Isolation of Bacteria from Virus and
Phage by a Serial Dilution Method. Arch. Path. 26:371-377,
1938.
3. Rosenow, E. C.: Production in vitro of Substances Re-
sembling Antibodies from Bacteria. Jour. Infect. Dis. 76:163-
178, 1945.
4. Rosenow, E. C.: Studies on the Nature of Antibodies
Produced in vitro from Bacteria with Hydrogen Peroxide and
Heat. Jour. Immunol. 55:219-232, 1947.
5. Rosenow, E. C.: Isolation from Milk Supplies of Spe-
cific Types of Green-Producing (alpha) Streptococci and Their
Thermal Death Point in Milk. Minn. Med. 27:550-556, 1944.
6. Rosenow, E. C.: An Institutional Outbreak of Polio-
myelitis Apparently Due to a Streptococcus in Milk. Jour.
Infect. Dis. 50:377-425, 1932.
7. Rosenow, E. C., Rozendaal, H. M., and Thorsness, E. T.:
Acute Poliomyelitis: Studies of Streptococci Isolated from
Throats and Raw Milk in Relation to One Epidemic. Jour.
Pediatrics 2:568-593, 1933.
8. Rosenow, E. C.: Specific Types of Alpha Streptococci
and Streptococcal Antigen in Unpotable Water and Water
Supplies. Am. J. Clin. Path. 15:513-528, 1945.
9. Jensen, C.: The 1934 Epidemic in Denmark. Proc.
Roy. Soc. Med. (Sec. Path.) 28:13-32, 1935.
10. Aycock, W. L.: Nature of Autarceologic Susceptibility
to Poliomyelitis. Am. Jour. Public Health 27:575-582, 1937.
11. Rosenow, E. C.: Poliomyelitis. The Relation of Neuro-
tropic Streptococci to Epidemic and Experimental Poliomyelitis
and Poliomyelitic Virus. Diagnostic Serologic Tests and Serum
Treatment. The International Bulletin, New York, Vol. A-44,
1-87, 1944.
12. Rosenow, E. C.: Studies on the Virus Nature of an
Infectious Agent Obtained from Four Strains of "Neuro-
tropic” Alpha Streptococci. Jour. Nerv. & Ment. Dis. 100:229-
262 (Sept.) 1944.
56
The Journal-Lancet
A New Method of Maintaining Therapeutic
Penicillin Blood Levels on
Oral Administration
Georg Cronheim, Ph.D., and Mary E. Baird, A.B.
Bristol, Tennessee
The simultaneous administration of penicillin and
sulfonamides is finding an ever increasing use in
medical practice. This is undoubtedly due in part to the
fact that there are certain difficulties involved to actually
determine the organism causing a given infection so that
the most specific drug could be chosen. In addition,
however, a number of recent investigations indicate that
a combined treatment with penicillin and sulfonamides
is more effective than with any one of these drugs. Thus
Gottlieb and Forsyth 8 reported that in infections with
hemophilus influenza, which are relatively insensitive to
penicillin recovery can be expected if massive doses of
penicillin are given together with sulfadiazine. On the
basis of in vitro tests Klein and Kalter 111 explain this
additive effect of penicillin-sulfonamide mixtures as a
result of the reduction by penicillin in the total number
of bacterial cells to limits within which the sulfonamides
become completely inhibitory. Dowling and his asso-
ciates 6 have shown that a combination of penicillin and
sulfadiazine is much more effective in reducing the mor-
tality in patients with pneumococcus pneumonia than
sulfadiazine alone.
A detailed study concerning synergistic activities of
several chemo-therapeutic agents including penicillin and
sulfadiazine or sulfathiazole in the treatment of various
experimental infections in mice has been published by
Kolmer.11 The results demonstrate very clearly that a
true synergism exists between penicillin and sulfonamides
towards infections by staph, aureus, hemolytic strepto-
coccus (Group A), pneumococcus (Type I) and eber.
typhosa.
In a recent paper, Oettinger and Cronheim 13 reported
studies on the use of a sulfadiazine-sulfathiazole mixture
combined with sodium citrate and lactate as systemic
alkalizers. Using the microcrystalline form of the sul-
fonamides, they obtained average free sulfonamide blood
levels of 6.6 mg. per cent in children and 7.7 mg. per
cent in adults. At the same time, the incidence of renal
complications in the form of crystalluria was reduced to
2.5 per cent. Since sodium citrate is known to protect
penicillin from the destructive action of gastric juice it
seemed possible to add penicillin to this sulfonamide
preparation for the simultaneous administration of these
drugs. The results of this investigation are presented in
this report.
The sulfonamide preparation used had the following
composition:
Sulfadiazine (microcrystalline) 5%
Sulfathiazole (microcrystalline) .... 5 %
Sodium Citrate 10%
Sodium Lactate 12%
in an aqueous suspension base containing vegetable
gums.* The pH of this preparation is 6.5 and the
sodium salts are equivalent in their systemic alkalinizing
effect to 16.6 per cent of sodium bicarbonate (Cronheim
and Bullock ’) . Varying amounts of penicillin were added
in the form of calcium penicillin (Fdeyden) as indi-
cated. Preliminary experiments had shown that the peni-
cillin dissolved in the sulfonamide preparation was stable
for about two weeks if kept in a refrigerator.
IN VITRO TESTS: To investigate the effect of the
systemic alkalizers on the acidity of artificial gastric
juice** the pH was measured after the addition of vary-
ing amounts of the penicillin-sulfonamide preparation.
The values thus obtained are shown in Table 1, indi-
cating the strong buffering capacity of the medication.
It is also apparent from this table that the presence of
*This preparation is supplied by the S. E. Massengill Com-
pany, Bristol, Tennessee.
* *Hydrochloric acid Pepsin 5.0 gm.
(36%) 16.3 cc. Lactic acid 1 gm.
Sodium chloride 9.0 gm. Amino-acetic acid 1 gm.
Disodium phosphate 2.0 gm. Distilled water, q.s. 1000 cc.
Table I
pH of a Mixture of 25
cc. of Artificial
Gastric
Juice
with Varying Amounts of
Vehicle Used
Vehicle
1
CC. 0
2
if vehicle added
3 4
to 25 cc.
5
of artificial gastric juice
6 7 8
9
10
Sodium Salts + Sulfonamides
+ Suspension Base 'o 3
1.7 3.10
3.95
4.35
4.60
4.75
4.90
5.00
5.08
5.15
5.20
Sodium Salts + Sulfonamides ? ^
1.8 3.30
4.00
4.50
4.70
4.90
5.10
5.20
5.25
5.30
5.35
Sodium Salts + Suspension Base
1.8 3.00
4.05
4.30
4.50
4.70
4.85
5.00
5.08
5.15
5.20
February, 1949
57
the sulfonamides or the vegetable gums has no influence
on the buffer action of the sodium citrate or the sodium
lactate.
In order to study the protective action of the buffers
25 cc. portions of the artificial gastric juice were heated
to 37.5° C and 10 cc. of the penicillin sulfonamide
preparation preheated to 37.5° C and containing 50,000
units of penicillin were added. The penicillin content
was determined immediately after mixing and after an
incubation period of 30 minutes at 37.5° C using the
FDA cup method with staph, aureus (No. 9144-ATCC) .
For control purposes one or several of the components
of the penicillin-sulfonamide preparation were omitted
as indicated in Table 2.
lowed as to the time of the day when the medication
was given. One blood sample was taken from each per-
son at the end of either two or three or four hours.
The penicillin serum levels were assayed according to
the method of Fleming et al. ' by using staph, aureus
(No. 9144-ATCC*) instead of hemolytic streptococcus.
Since sufficient serum was available, the volumes of all
liquids were increased so that the tests could be made
in small test tubes, each tube containing after the serial
dilution a total of 0.2 cc. The amount of inoculum
used was 0.1 cc. of a 24-hour broth culture of staph,
aureus added to 10 cc. of the serum-dextrose-phenolred
medium. The penicillin concentration may be judged by
the color change of the indicator and by the appearance
Table 2
Stability of Penicillin in Artificial Gastric Juice and in Water
50,000 units of calcium penicillin in 10 cc. of vehicle
added to 25 cc. of artificial gastric juice
or water and
incubated
for 30 minutes at 37.5° C. Penicillin determinations
made in dilutions containing 1 unit per
cc. using agar-plate cup
method with staph, aureus.
Artificial
Gastric Juice
Water
Width of Zone of
Inhibition in
mm.
Before
After
Before
After
Incubation
Incubation
Incubation
Incubation
Sulfonamides Sodium Salts Suspension Base ...
7.3
7.0
8.4
8.1
7.6
7.2
Sulfonamides 4 Suspension Base
6.1
0
6 0
0
8.3
7.0
Sodium Salts + Suspension Base
7.7
7.2
8.3
7.4
Sodium Salts
7.5
7.6
8.0
7.6
Suspension Base
6.8
0
8.4
8.1
Water
6.9
0
8.3
8.2
Fasting Gastric Juice
Sulfonamides + Sodium Salts + Suspension Base
8.0
7.6
Gastric
Juice after Alcohol Test Meal
Sulfonamides J~ Sodium Salts + Suspension Base
7.9
xr\
The figures show clearly the protective action afford-
ed the penicillin by sodium citrate and lactate which is
apparently due to the buffering capacity of these alkali
salts. As to the other components of the preparation,
they have no effect under the conditions of the experi-
ment.
Using genuine gastric juice both from fasting indi-
viduals and after an alcohol test meal, the results were
the same, namely full protection of the penicillin in the
presence of sodium citrate and sodium lactate.
IN VIVO TESTS: After the protective action of
sodium citrate and sodium lactate had been established,
it was of interest to determine penicillin blood levels
when this drug was given orally together with the sul-
fonamide-sodium salt preparation. For this purpose 51
non fasting healthy adult volunteers, mostly men, were
used regardless of size, weight or age. Every person
took one single 10 cc. dose of the sulfonamide prepara-
tion with varying amounts of penicillin added ranging
from 50,000 to 300,000 units per dose followed by from
100 to 150 cc. of water. No particular plan was fol-
of a sediment. Thus it is possible to estimate concentra-
tions in between those of a simple serial dilution. How-
ever, due to the inaccuracies inherent in any dilution
procedure all intermediate readings were disregarded and
the figures reported represent always the lower concen-
tration as calculated from the serial dilution. It might
be mentioned that a comparison of the data obtained
with this technique with those found with the B. sutilis
method of Randall et al.14 showed the same results. No
blood samples were taken before the beginning of the
experiment because the studies by Buggs et al/' and by
Hoffman and Volini u had shown that normal serum
does not inhibit the growth of staph, aureus.
Special attention was given to the question whether
or not the presence of sulfonamides in the serum of
these subjects would interfere with the penicillin deter-
mination. No effect of either sulfadiazine or sulfathia-
zole or an equal mixture of both in a concentration
equivalent to a blood level of 10 mg. per cent could be
*This strain is designated by the Food and Drug Adminis-
tration as F.D.A. 209-P.
The Journal-Lancet
58
found within the accuracy of the method. This was
demonstrated by control tests in which penicillin and
sulfonamides individually or in combination were added
to normal serum. In another series of controls the sul-
fonamides present in the serum were inactivated by
addition of p-amino-benzoic acid.
The individual as well as the average penicillin blood
levels are summarized in Table 3. In addition to the
Table 3
Serum Concentration of Penicillin in Units per cc.
After Single Dose
Hours after Administration
Dose (units)
2
3
4
300,000 .
0.96
0.24
0.24
0.24
0.24
0.12
0.48
0.48
0.12
Average 0.56
Average 0.32
Average 0.16
100,000
0.24
0.12
0.12
0.24
0.06
0.03
0.12
0.12
0.06
0.12
0.12
0.12
0.12
0.24
0.06
Average 0.17
Average 0.13
Average 0.08
50,000
0.12
0.03
0.03
0.03
0.12
0.06
0.06*
0.12**
0.06
0.12*
0.06**
0.06
0.06*
0.12**
0.03
0.03
0.06**
0.06
0.12
0.03*
0.03
0.03
0.06*
0.03
0.06
0.03*
0.03
Average 0.07
Average 0.07
Average 0.03
*Plasma used in assay.
**Gums were omitted in the suspension base.
rather expected fact that higher doses of penicillin will
result in higher blood levels there are two observations
which should be pointed out.
1. Smaller doses of penicillin give a relatively higher
blood level than larger doses thus indicating a better
utilization of small amounts of the drug.
2. The protective action of the sulfonamide-sodium
citrate-sodium lactate preparation is such that even four
hours after a single oral dose of 50,000 units the peni-
cillin blood level is still of the order of about 0.03 units
per cc., an amount which is considered therapeutically
significant.
The time of the administration of the drugs in rela-
tion to food intake did not seem to influence the results.
This is in accord with the observations by Broh-Kahn
and Pedrick,-’ that if sodium citrate is given orally to-
gether with penicillin the blood levels obtained are the
same regardless whether the medication is given one
hour before or after breakfast.
Since a blood level of approximately 0.03 units per cc.
four hours after oral administration of 50,000 units is
rather high, the question arose whether it might be due
to some form of a temporary renal block caused by the
administration of a total of 2.2 gm. of sodium salts. In
order to investigate this possibility 10 cc. doses of the
sulfonamide preparation plus 50,000 units of calcium
penicillin were given to four hospitalized patients every
four hours for periods ranging from twenty-four to
thirty-two hours. The penicillin levels four hours after
the last dose are listed in Table 4. It can be seen that
Table 4
Serum Concentration of Penicillin in Units per cc. after
Repeated Doses of 50,000 Units. (Determination 4 hours after
the last dose.)
Patient 1 0.06 u/cc.
Patient 2 0.06 u/cc.
Patient 3 0.12 u/cc.
Patient 4 0.03 u/cc.
a remarkably good penicillin blood level is obtained even
after repeated oral doses of the medication. This result
seems to exclude the possibility of a renal blockade. It
might be added that no renal impairment had been
observed when the sulfonamide preparation (without
penicillin) had been used clinically in a series of 34 hos-
pital patients. (Oettinger and Cronheim, 1. c.) . The
fact that the penicillin blood level after repeated doses
is somewhat higher than after a single dose — at least in
this very small number of cases — can probably be ex-
plained on the basis of a slight cumulative effect. A
similar observation has been reported Hoffman and
Volini (1. c.) after repeated oral doses of 50,000 units
of penicillin. These authors explain this "priming ef-
fect" by stating that "penicillin with the first doses was
distributed to all the body fluids leaving a residual con-
centration at the end of each interval which, though
not necessarily high enough to be measurable, allowed
the attainment of a higher level with the succeeding
doses.”
Discussion
The results reported in this investigation are remark-
able in one respect, namely, that comparatively good and
persistent blood levels are obtained after oral doses of
50,000 units of calcium penicillin. Apparently, this is
due to the rather large amount of systemic alkalizers
which is administered simultaneously in the form of
sodium citrate and sodium lactate, since the presence or
absence of the vegetable gums did not seem to have any
noticeable influence (see Table 3). As to the mechanism
involved, it has already been mentioned that these alkali
salts due to their buffering capacity are able to prevent
the destruction of penicillin by gastric juices. Since the
amount of these alkali salts is greater than that usually
employed, and since the buffering action persists until
these salts are absorbed, the protection of penicillin in
the gastro-mtestinal tract is extended over a compara-
tively long period of time during which the penicillin
may be absorbed into the circulation. Such an assump-
tion is in accord with the reported observation that small
amounts of penicillin are relatively better utilized than
larger ones.
February, 1949
59
While the buffering action of sodium citrate and
sodium lactate unquestionably contributes to the better
utilization of orally administered penicillin, there are
probably other factors present which add to or support
this process. This is shown indirectly by the observations
of McDermott, et al.12 that even in subjects with com-
plete achlorhydria the greater portion of orally given
penicillin does not enter the circulation, but is lost in the
alimentary canal. These authors conclude that it is more
a problem of poor absorption of penicillin than destruc-
tion by acid. Thus one may perhaps assume that the
presence of sodium citrate and sodium lactate results in
a better utilization of the penicillin possibly because the
pH in the stomach and in the duodenum is maintained
at or near optimum conditions for absorption.
It is well known that the absorption of many drugs
from the gastro-intestinal tract may be influenced by the
vehicle or by some other substances given simultaneously.
In the case of penicillin, Stewart and May 10 have shown
that glucose sometimes has such an effect. These inves-
tigators found that in a certain number of individuals
higher and more persistent blood levels of penicillin can
be obtained when the drug is given orally in 5 or 20
per cent glucose solution.
Undoubtedly, there are other factors which have to be
considered. While the pH of the gastric and duodenal
contents has probably no effect upon the emptying time
of the stomach, a number of substances including lactic
acid and sodium bicarbonate in therapeutic doses are
known to increase gastric tonus and peristalsis.1 This
latter observation may be of importance, because of the
physical properties of the preparation used in this study.
This suspension with a specific gravity of about 1.15 will
not mix easily when poured into water, but will collect at
the bottom of the container. Thus it seems not unrea-
sonable to assume that at least a part of the ingested
medication quickly reaches the lowest point of the great-
er curvature of the stomach where it will be exposed to
peristalic waves, the strength of which is increased by the
presence of lactic acid in the preparation. As a result,
the drug will be transported fairly rapidly into the duo-
denum and thus be removed from the destructive action
of the gastric secretion to that part of the gastro-intes-
tinal tract where most of the absorption takes place.
In addition to this purely mechanical explanation con-
siderable attention has been given by us to other possible
protective mechanisms which may account for the good
utilization of penicillin when given together with sulfona-
mides and systemic alkalizers. In a series of such in vitro
experiments, it was found that suspensions of various
sulfonamides in microcrystalline form are able to pre-
vent the destruction of penicillin by penicillinase. (Cron-
heim and Baird 4.) It could also be shown that this pro-
tection is due to an adsorption of the enzyme on the
microcrystals of the sulfa drugs. The possible implica-
tions of these observations to the problem of oral admin-
istration of penicillin plus sulfonamides has to be de-
cided in future investigations.
Mention should also be made of the possibility that
sulfonamides may protect penicillin by preventing or re-
tarding the growth of penicillinase producing micro-
organisms, although Stewart and May 15 have recently
reported that this type of destruction in the upper di-
gestive tract is negligible.
While the foregoing experiments indicate that quite
consistent and clinically significant penicillin blood levels
are obtained when 50,000 units are given every four
hours, it is also obvious that individual variations are
fairly wide. Therefore, it seems advisable to establish
for a therapeutic regimen a dosage of 100,000 units of
penicillin n 10 cc. of the sulfonamide preparation every
four hours after an initial dose of from two to three
times this amount. With such a schedule it should be
possible to maintain adequate blood levels of both peni-
cillin and sulfonamides. As a further precaution it is
advisable to give the preparation on a fasting stomach
or between and not immediately following meals. These
recommendations are based only on the penicillin blood
levels and do not take into consideration a possible
synergistic effect of the sulfonamides.
Summary
Penicillin has been administered orally, dissolved in
an aqueous suspension of sulfadiazine and sulfathiazole
together with sodium citrate and sodium lactate as sys-
temic alkalizers. Therapeutically significant blood levels
are quickly reached, and are maintained for at least three
hours following an oral dose of 50,000 units of peni-
cillin. It is suggested that the physical properties of the
preparation together with the buffering action of the
systemic alkalizers account for the good utilization of
the penicillin.
For therapeutic use a dosage of 100,000 units of peni-
cillin in 10 cc. of the sulfonamide-sodium citrate-lactate
preparation at four hours interval is recommended after
an initial dose of from two to three times this amount.
References
1. Best, C. H and Taylor, N. B.: The Physiological Basis
of Medical Practice. 3d Ed. Baltimore. 1943, p. 808 ff.
2. Broh-Kahn, R. H., Pedrick, R. E.: Am. J. Med. Sci.
212, 691, 1946.
3. Buggs, C. W., Bronstein, B., Hirshfeld, J. W., and
Pilling, M. A.: Science, 103, 363, 1946.
4. Cronheim, G., and Baird, M. E.: To be published.
5. Cronheim, G., and Bullock, C. F.: J. Am. Pharm. Assn.
(Pract. Ed.) 8, 263, 1947.
6. Dowling, H. F., Hussey, H. H., Hirsh, H. L., and Wil-
helm, F.: Annals Intern. Med. 25, 950, 1946.
7. Fleming, A., Lond, M. B., and Smith, C.: Lancet 1,
401, 1947.
8. Gottlieb, B., and Forsyth, C. C.: J A M. A. 135, 740,
1947.
9. Hoffman, W. S., and Volini, I. F.: Am. J. Med. Sci.
213, 513, 1947.
10. Klein, M., and Kalter, S. S.: J. Bacteriol. 51, 95, 1946.
11. Kolmer, J. A.: Am. J. Med. Sci. 215, 136, 1948.
12. McDermott, W., Bunn, P. A., Benoit, M., DuBois, R.,
and Reynolds, M. E.: Science, 103, 359, 1946.
13. Oettinger, L., and Cronheim, G.: Am. Practitioner
2, 526, 1948.
14. Randall, W. A., Price, C. W., and Welch, H.: Science,
101, 365, 1945.
15. Stewart, H. C., and May, J. R.: Lancet, 857 (Dec.)
1947.
60
The Journal-Lancet
The Clinical Evaluation of Glycerite of Hydrogen
Peroxide in Vaginal and Cervical Infections
Preliminary Report
Samuel P. Norman, M.D., and Paul P. Norman, M.D.
Malden, Massachusetts
Glycerite of hydrogen peroxide has been so suc-
cessful in the treatment of dermatological infec-
tions, that it occurred to us that the solution might be
useful in the treatment of infections of the mucous
membranes, especially as seen in vaginal and cervical
conditions.
The solution used consisted of glycerite of hydrogen
peroxide as available in a 90 per cent solution of hydro-
gen peroxide dissolved in anhydrous glycerol to a dilu-
tion of 2.5 per cent.* For its fungicidal potency and
for stabilizing purposes, oxine is present in a concentra-
tion of 0.1 per cent. Previous reports have described
glycerite of hydrogen peroxide as bacteriotoxic for Gram-
positive and Gram-negative organisms,1 as well as for
B. tetanus and C. Welchii ~ infections. It has been de-
scribed as clinically effective for postoperative wound in-
fections and for infections of the skin and mucous mem-
branes.11''' Used orally, it lessens the number of patho-
genic bacteria.1
Compounds containing glycerol and also hydrogen
peroxide have been used for many years for the treat-
ment of vaginal infections, and require therefore no
detailed description. Oxine (8-hydroxy-qumoline) and
its salts are used commonly as trichomonacides. The
mixture, however, possesses properties desirable in a
vaginal preparation in that the glycerol is hygroscopic;
the peroxide, bacteriotoxic and deodorant; and the oxine,
lethal to flagellate parasites.
Twenty successive patients were given treatment. All
complained of vaginal discharge and clinically presented
a typical syndrome of (1) acute vaginitis (mixed type);
(2) cervical erosion with discharge; (3) vaginal trichom-
onas infestation. For this preliminary series, no bacterio-
logical studies or hanging drop preparations were made,
since we did not anticipate the results achieved, which we
felt, however, warranted early publication. More de-
tailed studies will be incorporated in subsequent com-
munications.
For each patient a vaginal tampon was saturated with
glycerite of hydrogen peroxide (2.5 per cent) and in-
serted vaginally. This was removed and the vagina and
cervix inspected when the patient returned in twenty-
four hours. When necessary (in 5 of 20 patients), a
second tampon similarly medicated was inserted. The
following brief protocols, typical of the first 12 patients,
illustrate the clinical results.
*The glycerite of hydrogen peroxide (2.5 per cent) was sup-
plied by the International Pharmaceutical Corporation, of Bos-
ton, Massachusetts.
1. M.C.: (70) — vaginal discharge, yellow, profuse,
thick, foul-smelling, requiring a vaginal pad. Duration:
1 year. Examination: vagina — inflamed and covered with
yellow, putrid, mucopus. Cervix eroded and similarly
affected. Tampons, saturated in glycerite of hydrogen
peroxide were inserted at 24-hour intervals. After 48
hours, the discharge ceased and the vagina was clean
and odorless, although still inflamed. The patient re-
ported one month later that there had been no recur-
rence of vaginal infection.
2. S. D.: (49) — supravaginal hysterectomy one year
previously; profuse vaginal discharge. Duration: one
week. Examination: erosion of cervix and severe cervi-
citis. No active vaginal infection. The medicated tam-
pon was inserted and the patient returned in 48 hours,
at which time, inspection of the cervix proved the ab-
sence of further discharge. No recurrence.
3. E. R.: (34) — erosion of cervix; endocervicitis;
acute, nonspecific vaginitis. Exact duration unknown.
Following tamponage with glycerite of hydrogen perox-
ide for 24 hours the cervix appeared as though it had
been cauterized. Re-check visits 30 and 60 days follow-
ing treatment proved that there had been no recurrence
of the condition.
4. E. L.: (44) — vaginal discharge. Exact duration un-
known. Examination showed the vulva reddened and the
vagina inflamed and streaked with red. The cervix pre-
sents individual bleeding points and thick purulent dis-
charge. One treatment completely cleared the infection.
No recurrence.
5. P. R.: (33) — vaginal discharge. Duration: 3 weeks.
Examination: vaginal bleeding points, cervical erosion,
typical trichomoniasis. One treatment completely con-
trolled the infection and the infestation. No recurrence.
6. R. K.: (30) — vaginal discharge and vulval pruritus.
Duration: 1 month. Examination: thick, tenacious mu-
cus, several superficial eroded areas on cervix, typical
trichomoniasis. Result: complete clearing of condition;
no recurrence.
7. F. W.: (37) — vaginal discharge. Duration: 3
months. The vagina blue and edematous; considerable
mucopurulent discharge at vulva and cervix; typical
trichomoniasis; complete cessation of discharge with one
treatment; no recurrence.
8. R. S.: (35) — vaginal discharge. Exact duration
unknown. Cervical erosions. Complete disappearance of
lesion and discharge in one treatment; no recurrence.
9. D. S.: (45) — vaginal discharge. Duration: 6
months. Supravaginal hysterectomy six months pre-
February, 1949
61
viously; lacerated and eroded cervix. Thick, profuse dis-
charge (trichomoniasis?). Complete remission following
one treatment; no recurrence.
10. E. L.: (44) — vaginal discharge, white, glistening.
Duration: unknown. Inflamed vagina and erosion of
cervix; trichomoniasis. Tamponized with glycerite of hy-
drogen peroxide on two successive days. Complete re-
mission; no recurrence.
11. S. R.: (27) — vaginal discharge, erosion of cervix.
Cauterized (8/20/47); returned 11/26/47 — discharge
more severe than on previous examination — trichomonia-
sis. On treatment with glycerite of hydrogen peroxide
tamponage the condition cleared completely. No recur-
rence.
12. E. K. (33) — vaginal discharge. Duration: un-
known. Erosion of cervix. Required treatment by tam-
ponage on two successive days; complete remission; no
recurrence.
In 15 of 20 patients, only one treatment was neces-
sary. In 5, a second tampon was required. In one pa-
tient, the discharge recurred. In all of the others studied
there has been no recurrence over a period of eight
months. No patient complained of pain associated with
the treatment. A larger second series, with basic labora-
tory studies and longer follow-up data is planned for
a later report.
Summary
Twenty successive patients, presenting typical vaginal
and cervical infections, bacterial and parasitic, were treat-
ed with glycerite of hydrogen peroxide tamponage. Fif-
teen patients had complete remission following one treat-
ment. Five patients required a second treatment and in
only one patient did the condition recur.
References
1. Brown, Ethan Allan, Krabek, Wilfred, and Rita Skiffiing-
ton: A New Antiseptic Solution for Topical Application. Com-
parative in vitro Studies. N.E.M.J., 234:468-472 (April 4),
1946.
2. Brown, Ethan Allan, Krabek, Wilfred, and Rita Skiffing-
ton: Glycerite of Hydrogen Peroxide: A Comparison of its
Bacteriotoxic Effect on Clostridia, with that of Other Anti-
septics. Amer. Jr. Surg. (in press).
3. Jenkins, James T.: The Effect of Glycerite of Hydrogen
Peroxide Upon the Healing Time in Anorectal Surgery. Amer.
Jr. Surg. 74:428-430 (Oct.), 1947.
4. Lynch, George: The Effect of Glycerite of Hydrogen
Peroxide Upon Oral Infections (in press).
5. Thurmon, Francis M., and Brown, Ethan Allan: The
Effect of Glycerite of Hydrogen Peroxide Upon Infections of
the Skin and Mucous Membranes. Arch. Derm. & Syph.
55:801-809 (June), 1947.
Meet Our Contributors
Win. C. Bernstein, M.D., St. Paul, Minnesota, was
graduated from the University of Minnesota in 1928;
specializes in Proctology; Clinical Instructor in Proctolo-
gy at the University of Minnesota; Chief of Proctology
Service, U. S. Veterans Hospital, Minneapolis; Fellow of
the American Proctologic Society.
Ralph I. Canuteson, M.D., Lawrence, Kansas, was
graduated from the University of Minnesota in 1927;
Council member and Past-President, American College
Health Association; Vice-President, Kansas Tuberculosis
and Health Association.
Robert A. Jordan, M.D., Rochester, Minnesota, was
graduated from Kansas University in 1944; specializes
in Internal Medicine; Fellow in Internal Medicine, Mayo
Clinic; formerly with Kansas Student Health Service.
Paul P. Norman, M.D., Malden, Mass., is a graduate
of Middlesex University School of Medicine; Junior Vis-
iting Physician, the Malden Hospital, Malden, Mass.
Samuel P. Norman, M.D., Malden, Mass., was gradu-
uated from Boston University School of Medicine; spe-
cializes in Obstetrics and Gynecology; Associate Surgeon,
the Malden Hospital.
Marcus L. Goldstein, Ph.D., Washington, D.C., spe-
cializes in Medical Economics; Member, American Public
Health Association; Fellow, American Association Ad-
vancement of Science, Society for Research in Child
Development.
Georg Cronheim, Ph.D., Bristol, Tennessee, was grad-
uated from the University of Berlin in 1930; Member,
American Chemical Society, American Pharmaceutical
Association.
Mary E. Baird, Bristol, Tennessee, was graduated from
the University of Tennessee; specializes in Bacteriology.
Edward C. Rcsenow, M.D., Cincinnati, Ohio, was grad-
uated from Rush Medical College in 1902; Professor
Emeritus, Mayo Foundation; specializes in Bacteriologic
Research.
Dana L. Farnsworth, M.D., Cambridge, Mass., was
graduated from Harvard Medical School in 1933; spe-
cializes in Psychiatry; Medical Director, Massachusetts
Institute of Technology; Assistant Physician, Massachu-
setts General Hospital; Consultant in Neuropsychiatry,
U. S. Naval Hospital, Chelsea, Massachusetts; Member,
American Psychiatric Association, Boston Society of Psy-
chiatry and Neurology; Diplomate, American Board of
Psychiatry and Neurology.
62
The Journal-Lancet
American College Health Association
Psychotherapy in a College Health Center"
Dana L. Farnsworth, M.D.
Cambridge, Massachusetts
Since the first college psychiatric service was estab-
lished at West Point in 1920, great strides have been
made in meeting the mental health needs of students,
but a great deal more needs to be done. The most
troublesome feature of the problem is the shortage of
trained psychiatrists, and it is not likely that this will
be relieved in the near future. In the meantime the
emotional difficulties of students must be met. If we ac-
cept the concept that a sound personality is equally as
important as a good education or a healthy body, then
furnishing psychiatric help is a legitimate and necessary
function of an educational institution. If this function
is accepted as necessary and there are not enough avail-
able psychiatrists to do the work, then someone else must
assume the responsibility. The physician to students
must do some psychotherapy whether he wishes to do so
or not, or even if he is not properly trained. The only
question is whether he shall do a poor or a good job.
This paper, therefore, is written primarily for the gen-
eral physician who is interested in students as human
beings having their normal quota of problems and con-
flicts, and who considers that the formation of sound
attitudes and patterns of adjustment is a dignified and
worthy aim of education. It is recognized that this is a
field in which much harm can be done, but it is not con-
ceded that partial training is worse than none. The fact
that a problem is complex and difficult is no reason for
ignoring it.
The small college situated away from a medical cen-
ter is in a peculiarly difficult position to meet its stu-
dents’ mental health needs. Under ordinary circum-
stances the smaller colleges have relatively few illnesses
of a psychotic nature, and hence the problem is not acute
or spectacular. Because the common concept of the role
of the psychiatrist is that of caring for psychotic pa-
tients, he seems to be an unnecessary part of the college
organization. There is no reason to suspect that no men-
tal health problems exist in small colleges. Experience
has shown that under ordinary circumstances about 10
per cent of the student body at any college is apt to
need psychiatric help at some time during each year.
Students who need help are usually normal in almost
every respect but are temporarily incapacitated by some
difficulty in interpersonal relationships or in adjustment
to the college environment. Frequently, students are
labeled queer or eccentric when they are really struggling
with a serious personal problem. Such persons are in
the best position to profit by a mental health program.
*Read at the 26th annual meeting of the American Student
Health Association, Detroit, May 7, 1948.
In many sections of the United States the smaller
colleges are so located that one psychiatrist might be able
to supervise the mental health program in several col-
leges, possibly up to three or four. Such a psychiatrist
would be on call by telephone or otherwise for consulta-
tions regarding acute emergencies. In the meantime
regular visits at weekly or bi-weekly intervals by the psy-
chiatrist would enable the college physician to keep up
with a continuous on-the-job training program. While
it is recognized that such a program is far from ideal,
it is a great deal better than none.
Psychotherapy will be discussed from the broad cam-
pus viewpoint as well as from the standpoint of the in-
dividual treatment of a student. Even the fully trained
psychiatrist with no college health experience will find
that there are several modifications of practice due to
special conditions prevailing on the college campus which
will enable him to make his work effective as well as
accepted by faculty and students. Colleges have person-
alities which are as distinctive and individualistic as those
of their students and many subtle characteristics of each
college as well as of the academic scene must be kept
in mind.
The attitude of the therapist toward the student and
toward mental illness is of extreme importance. As
Rennie and Woodward' have said it, he should hold the
conviction that individual persons have great worth re-
gardless of the presence or absence of economic assets,
that all behavior has real and adequate causes, that per-
sonal attitudes are extremely significant both for the sat-
isfaction of the individual and as a determinant of the
number and quality of his relationships to others, and
finally that people have a marked capacity for adjust-
ment. He should be fond of students but not weaken
his position and influence by identifying himself too
closely with any individual or group. Consideration of
emotional problems involves much tolerance, subtlety,
and delicacy, and if a physician does not possess such
qualities and attitudes, it would be unwise for him to
attempt psychotherapy no matter what his training.
Students come to the health center for an astonishing
variety of symptoms that are not due to any organic
cause. As a general rule most of the symptoms are an
expression of anxiety in one form or another, but this
takes varied and frequently puzzling forms. The pre-
senting symptom in cases treated in our clinic during the
past few months and which were definitely found to be
functional in origin included such physical symptoms as:
fatigue, headache, nausea, fainting, urethral burning,
palpitation, substernal oppression, epigastric distress,
February, 1949
63
neurodermatitis, and hyperacousis. Many students had
difficulty in interpersonal relations especially with par-
ents and persons of the opposite sex. Some were quite
depressed, others very critical of the college and its edu-
cational methods, while others had unnatural fear of
examinations. Interference with concentration, memory,
and inability to make decisions were frequent even when
clear-cut depression was not present. Sexual and marital
relationships caused a great deal of conflict in several
others. The number and variety of such symptoms and
situations is virtually limitless.
The early college years are frequently marked by vary-
ing degrees of revolt against one or both parents, par-
ticularly the mother. In some instances the revolt takes
the form which almost seems a conscious attempt to em-
barrass or disturb the parents; in others the symptom-
atology is vague and diffuse, consisting mainly of lack
of interest in school work, poor .motivation, indecision,
and a seemingly carefree attitude which is not appro-
priate to the circumstances. This set of symptoms may
occasionally progress to a true depression. It is a kind
of "psychological sitdown strike” and in most instances
when the student becomes aware of what he is protesting,
he can make the necessary changes to effect an improve-
ment in his circumstances.
If a student is having a great deal of difficulty eman-
cipating himself from parents who are too dominant, he
may acquire a sensitivity to authority in any form. This
may show itself in severely critical attitudes toward his
college and toward anyone who represents it. Then
again other students acquire a strong competitive spirit
and do everything with a sense of urgency, are con-
stantly overmobilized, and they wonder why they are so
easily fatigued and lacking in any sense of accomplish-
ment. The more they work the less they get done and
finally they find themselves taking less and less time
for sleep but going to sleep constantly in class and work-
ing ineffectively at other times.
Still another group who have revolted against au-
thority, convention, and "respectability” as they call it
find themselves so isolated and forlorn that their anxiety
becomes almost more than they can bear. Such indi-
viduals, while rejecting the old standards, look for
something stable and meaningful that they can live for,
and not finding it, are apt to accept uncritically some
unusual or bizarre belief or adopt political doctrines of
the extreme right or left.
Although a good percentage of patients will seek help
of their own volition, there are many others who will of
necessity have to be referred by other students, faculty
members, or the Dean’s Office. If a student shows any
of the following types of behavior, he should be referred
for examination: (1) Signs of preoccupation with some
personal concern, leading to social isolation or change of
living habits. (2) Impairment of memory and concen-
tration. (3) Sudden lowering of scholastic standards.
(4) Excessive cutting (one week plus or minus) when
he has been an otherwise reliable and serious-minded
person. (5) Any threat of suicide. (6) Peculiar or
bizarre thought content in papers submitted. (7) Good
evidence of homosexual activities. (8) Over-activity
accompanied by irritability and repeated exercise of poor
judgment.
Psychotherapy is the treatment of sick patients by
psychological means. Its aim is to help the individual
to adjust in a more satisfying manner to his environ-
ment, but this is a very broad aim indeed. It includes
the treatment of anxiety and distress that occur in the
course of all kinds of organic illnesses. It may be very
helpful in the management of those individuals who are
going to be subjected to disabling or mutilating opera-
tions.
As stated by Romano,2 the variations of psychotherapy
fall into two great types. The purpose of the one type
is to help in the management of the individual by chang-
ing his environment, by assessing his physical state, and
by reassurance so that his anxiety is allayed. In the other
type methods and techniques are used which aim at find-
ing some of the motivations for behavior as they relate
to inner forces which may come into conflict. In the
management of student problems by the physician who
is interested in psychiatry but who is not fully trained
the first type will be the one largely used.
It is well to keep in mind that treatment begins as
soon as the student starts to relate his problem; there-
fore it is desirable not to interfere with him to any
more than a minimal extent since the way that he re-
lates his problem may give a clue as to what is bothering
him most. Periods of silence need not be awkward if
the physician does not become impatient or embarrassed.
Sometimes he may tell about the most important feature
of his history first and at other times he may spend
several hours talking around his real problem and trying
to avoid it. It is probably undesirable to have a sys-
tematic history form for students with emotional disor-
ders, but the physician can bring out all pertinent ma-
terial necessary by careful questions as the story un-
folds. It is usually desirable to understand clearly the
relationships in the patient’s home, the general charac-
teristics of his father, mother, brothers, and sisters,
rivalries within the home, unusual behavior in childhood
that attracted attention, neurotic determinants, school
history, religious background, development of sexual
attitudes, instances that lowered the patient’s self-esteem
emotionally, traumatic episodes of a dramatic nature,
and his capacity for entering into satisfactory human
relationships. In addition, his physical history should be
correlated with his emotional history. It is well to know
why the student chose to come to that particular school,
whether he was disappointed or not, what kind of an
adjustment he made, the extent of his participation in
extracurricular activities, the variety of his friendships,
and the quality of work done in his college courses. Re-
cent social activities are nearly always of importance.
While getting necessary information from the patient
the mechanics of getting a record should be as unob-
trusive as possible.
Close attention should be paid to signs or symptoms
that may indicate the onset of dangerous developments
in the student’s illness. This is particularly true for the
64
The Journal-Lancet
physician who has had limited experience in this field.
First of all any threat of suicide should not be dis-
missed lightly, and its implications should be thoroughly
explored with the patient without getting him still fur-
ther disturbed. For instance, the bold question, "Do
you feel like you would like to commit suicide?” might
do irrevocable harm and should be replaced by some
such question as, "Do you sometimes feel so blue that
life hardly seems worthwhile?” The manner of the phy-
sician often conveys much information to the patient,
which may be either desirable or undesirable. If the
patient gets the feeling that the physician is secure in
his own emotional life and that his questions are mo-
tivated by a sincere desire to help him, then he will
usually cooperate well. If, on the contrary, he feels
that the physician’s questions are too personal or are
being put in an urgent or aggressive way, then he is
likely to "shut up like a clam” or else give misleading
answers to questions in order to get out of the situation
quickly. Withdrawal from social activities, the develop-
ment of grimacing or unusual mannerisms, evidence of
frank hallucinations, and other similar symptoms should
call for a consultation with a psychiatrist of wide ex-
perience.
Although the plan of treatment may seem aimless
to the student, yet it is very definite in the therapist’s
mind. While he is listening to the patient’s story, he
is constantly evaluating the personality of the patient,
and by skilled direction of the interview he gradually
builds up a concept of the type of individual who is
under treatment and the nature of his problem or con-
flict. He may thus help the student understand his own
problem and get him on the way to solving the parts
of it that can be solved or tolerating that which can not
be changed.
During the course of the therapeutic interviews there
are several principles to be observed that are almost
axiomatic to the psychiatrist. The physician must not
appear to be in too much of a hurry and so discourage
his patient from revealing painful or embarrassing ma-
terial. He must never become angry at a patient who
has become a nuisance to him. When he does so he
has lost a great portion of his influence on the patient.
He must be a good listener and not take up the stu-
dent’s time by relating his own experiences and diffi-
culties. He should not impose his own views on the
patient. He should avoid putting interpretations into
the patient’s mind but lead him to make his own. He
should never reassure the patient unless it is clearly
justified. He should avoid taking a moralistic view of
the student’s behavior. He must not be shocked by any-
thing he hears. He should not react to the irritability
of others. He should avoid sweeping, dogmatic state-
ments, because they are all too frequently misleading and
damaging to the patient’s confidence in the physician.
It is entirely possible to maintain a manner which will
inspire confidence without being dogmatic or too de-
cisive. It is well to remember that the patient is making
up his mind about the physician while the physician is
studying the patient. The interaction between the two
personalities forms a psychotherapeutic relationship,
which, if favorable, will go a long way toward solving
the patient’s problems, but which, if unfavorable, may
confirm him in his symptoms. The physician must have
a good knowledge of himself and his own emotional
makeup in order to make and maintain a favorable im-
pression on the patient. In one’s early enthusiasm for
psychotherapy great care must be taken not to empha-
size psychosomatic symptoms to the exclusion of other
types of illness. A missionary spirit can be just as
harmful in this field as in any other, and care must be
taken at all times to hew closely to the line of the pa-
tient’s difficulty and not get out of the general stream
of medicine. Psychiatry is sometimes as badly served
by its friends as by its enemies.
Since interest in the borderline problems between in-
ternal medicine and psychiatry is now increasing rap-
idly, the physician who goes into this field must not
make the mistake of becoming too enthusiastic. It is
no more awkward to do a laparotomy on a patient with
a gastric neurosis than it is to treat a patient with a brain
tumor for psychoneurosis. Simply because the physician
has found a new method for treating his patients is no
reason why this method should be used all the time.
In general it is wiser to make mistakes in the direction
of doing too little than in doing too much. The physi-
cian must try to remain objective although at the same
time his relationship with the patient must be warm and
understanding.
If one assumes responsibility for treating emotional
problems of his patient, then he must be prepared for
occasional unpleasant surprises. It is nearly impossible
to predict in all cases whether a depressed patient is
suicidal or not. Of course, it is assumed that all patients
with a depression are potentially suicidal, but if one
acted in every instance to protect himself from criticism
if something goes wrong, he would indeed do a great
deal of harm. About the best that one can do is to keep
the possibility of suicide in mind and to take the neces-
sary precautions when overt signs are present. It is prob-
ably better in the long run to have an occasional suicide
than to deprive a large number of people of their liberty
unnecessarily and in this way possibly causing even more
tragedy.
There is a constant tendency on the part of the physi-
cian who has had relatively little experience in solving
emotional problems to be aggressive in a therapeutic
sense. The average physician is called upon to make de-
cisions quickly and to act definitely and with authority
when treating organic disease, and this attitude is apt
to persist to an undesirable degree when treating func-
tional diseases.
The physician may do harm by being too aggressive,
by talking too much, by giving direct advice, by imposing
his standards on others, by casting a reflection, if only
by inference, on the patient’s religious, racial, or social
background, as well as by failure to recognize the more
serious signs of mental illness. If the student’s disclosure
reveals material which would be punishable if known in
the Dean’s Office, then the physician must remember
that his relationship with the patient is a confidential
February, 1949
65
one. Close cooperation and mutual discussion of com-
mon problems with the Dean is very necessary and de-
sirable and can be done without violating the student’s
privacy in an essential way. The therapist must never
laugh at a patient. He must keep himself aware of the
attitudes of his patients on such questions as religion,
sex modesty, and other emotionally charged areas. He
must never belittle the patient’s symptoms or tell him
they are imaginary. Whether the symptoms are impor-
tant to the doctor or not they certainly are to the patient
or else he would not have bothered to consult the physi-
cian. In talking at any public meeting on the campus,
the physician must exercise a great deal of care in choos-
ing examples from his practice which will illustrate the
points he wants to develop. Illustrations had better be
taken from textbooks or even made up in a composite
way from several individual cases in order that patients
will not be embarrassed.
It is frequently desirable to give the student a full and
accurate description of how his physical symptoms are
produced. This may and usually does involve a rather
extended description of the functions of the autonomic
nervous system and a discussion of how the body mo-
bilizes its resources to protect itself by fight or flight.
From that point it may be desirable to give fairly simple
examples of disordered system function together with an
explanation as to how symptoms may become unleashed
from their moorings, so to speak, and hence lose im-
mediate relationship to emotional stress. The simpler
mental mechanisms may need to be explained.
Since the first job is to help the student become in-
dependent rather than to encourage his dependence, it
is desirable to avoid giving direct advice except in very
simple matters. For instance it is practically never de-
sirable to advise a person on matters involving major
life decisions such as marriage, divorce, sexual relation-
ships, choice of occupation, and so on. To give advice
is to assume more responsibility than the physician is
justified in assuming, and it may perpetuate a dependent
relationship which has already been harmful to the pa-
tient. By exploring all the possibilities of an important
decision the student can be aided to make a wise de-
cision, but it should be strictly his own.
Homosexual conflicts are always considered from a
purely medical standpoint unless the individual con-
cerned has violated the privacy of others. In that case
disciplinary measures are taken by the Dean’s Office
just as in any other offense against the person or privacy
of another individual.
In the students who are rebelling against their par-
ents or authority in general in one way or another the
aim of the physician may be to help him learn the char-
acteristics of maturity and give him suggestions for
attaining them gradually. There is no clear-cut defini-
tion of maturity, but the points listed by Saul3 serve very
well for discussion with the patient when the time is
opportune. His definition of maturity assumes that "the
adult is predominantly independent and responsible, with
little need to regress, and also is giving and productive,
although still able to relax and to receive normally; he
is cooperative rather than egotistical and competitive;
he is in relative harmony with his conscience, which
easily integrates with his mature feelings and behavior;
his sexuality is free and integrated with mating and re-
sponsible productive activity, both sexual and social; his
hostility toward others and toward himself is minimal
but is freely available for defense and constructive use;
his grasp of reality is clear and unimpaired by the emo-
tional astigmatisms of childhood; and freed from child-
hood patterns he is discriminating and highly adaptable.
And among the many results of such development, his
anxiety is at a minimum.”
Sometimes a student comes for an interview and
almost literally refuses to talk. As a general rule this
lack of cooperation is based on fear and embarrassment,
and he usually becomes cooperative when the physician
assures him that the relationship is confidential, that he
can speak freely about anything which is on his mind,
and when he becomes convinced that the physician is
genuinely interested in him. Repeated and aggressive
questioning may prevent him from talking at all. Some-
times it is advisable to give simple examples that are
similar to the problem that the student probably has and
then indicate to him that other people have received help
and if he will open up he might likewise find a solution.
Some students come to rely on the physician to an
extent which encourages too great dependence. When
this becomes evident, it may be desirable to decrease the
length of each interview or the time between visits. Oc-
casionally a patient begins to show his growing inde-
pendence by "forgetting” an appointment, and this is
frequently a hopeful sign. Some patients may need
only an hour or two of time, while others may need help
through their college course at various times. It is un-
usual for any one student to require more than 20 or
25 hours of time; if so, he is probably too ill to remain
in school and should withdraw for treatment.
There are occasional special situations where it may
be desirable to treat individuals in small groups. This
has been done with patients who have peptic ulcers and
with stammerers as well as those with severe anxiety
states. The applicability of this method of treatment is
somewhat limited in colleges both because of rigid sched-
ules and because of questions of privacy. Further ex-
perience along this line would be highly desirable.
From the long term point of view it is desirable not
to misrepresent psychiatric treatment by indulging in
subterfuges to get the student to accept treatment. Since
one function of a student health center is to inculcate
desirable medical attitudes into the thinking of the stu-
dents, the term psychiatry and psychiatric treatment
should be used freely and accurately. Of course, it is
not desirable to publicize psychiatric illnesses, but on the
other hand a resort to elaborate secrecy and misrepre-
sentation only invites increased publicity. If physicians
themselves took a mature and sound attitude toward
mental illness it would be much easier to develop such
attitudes in the lay public.
The success of a mental hygiene program depends to
a very large extent on its reputation among the students
66
The Journal-Lancet
and faculty. If the program is begun slowly, is not over-
sold, and word gets around that the physician is inter-
ested in his patients as persons, acceptance will then
come naturally. A good way to spread information about
the program is by talks to the faculty, to various clubs
on the campus, to student government or activity groups,
and in numerous conversations in the ordinary day-by-
day campus contacts.
In the attempt to convince the faculty of a school or
college that psychiatry does have a sound and worth-
while program to offer, students should not be put in the
position of being able to profit from their illnesses. No
special favors should be asked for a patient other than
those based on time considerations of the same nature
as occur in the patient with pneumonia or a serious in-
jury. The confidence of the patient must be very care-
fully respected, and his permission secured before con-
sulting with other faculty members except in unusual
circumstances when the situation demands action and the
best interests of the patient and his family call for
secrecy.
In this paper there has been no attempt to discuss
definitive psychotherapy such as would be carried on by
the experienced psychiatrist. If one indulges in uncover-
ing techniques of a deep nature, then he must be pre-
pared to deal with whatever he uncovers, and that calls
for full-fledeged psychiatric training. In the relatively
superficial problems that most students present the well
trained internist with a warm interest in human beings,
an understanding attitude, and a willingness to study
psychiatric concepts, can do a very creditable job, and
at the same time add to his efficiency in the rest of his
medical practice.
Mental Hygiene Reading List
Alexander, F.: Our Age of Unreason, Lippincott, Philadel-
phia, 1942.
Alexander, F., and French, T. M.: Psychoanalytic Therapy,
Ronald Press, New York, 1946.
Bauer and others: Teaching Psychotherapeutic Medicine,
Commonwealth Fund, New York, 1948.
Binger, Carl: The Doctor’s Job, W. W. Norton & Com-
pany, New York, 1945.
Cobb, C.: Borderlands of Psychiatry, Harvard University
Press, Cambridge, 1943.
Cobb, S.: Foundations of Neuropsychiatry, Fourth Edition,
Williams and Wilkins Company, Baltimore, 1948.
Dunbar, Flanders: Mind and Body: Psychosomatic Medi-
cine, Random House, New York, 1947.
Dunbar, Flanders: Psychosomatic Diagnosis, Paul Heober,
New York, 1944.
English and Pearson: Emotional Problems of Living, W. W.
Norton & Company, New York, 1945.
Fry, C. C.: Mental Health in Colleges, Commonwealth
Fund, New York, 1942.
Halliday, J. L.: Psychosocial M edicine , W. W. Norton &
Company, New York, 1948.
Hinsie, L. E.: The Person in the Body, W. W. Norton it
Company, New York, 1945.
Hinsie, L. E.: Understandable Psychiatry , Macmillan, New
York, 1948.
Menninger, K. A.: The Human Mind, Third Edition,
A. A. Knopf, New York, 1945.
Menninger, W. C.: Psychiatry in a Troubled World, Mac-
millan, New York, 1948.
Preston, G. H.: Psychiatry for the Curious, Farrar and
Rinehart, New York, 1940.
Preston, G. H.: The Substance of Mental Health, Farrar
and Rinehart, New York, 1943.
Rennie, T. A. C., and Woodward, L. E.: Mental Health in
Modern Society, Commonwealth Fund, New York, 1948.
Ross, T. A.: The Common Neuroses, Second Edition, Wil-
liam Wood & Company, Baltimore, 1937.
Saul, L. J.: Emotional Maturity, Lippincott, Philadelphia,
1948.
Strecker, E. A., and Appel, K. E.: Discovering Ourselves,
Second Edition, Macmillan, New York, 1943.
References
1 Rennie, T. A. C., and Woodward, L. E.: Mental Health
m Modern Society, Commonwealth Fund, New York, 1948.
2. Bauer and others: Teaching Psychotherapeutic Medicine,
Commonwealth Fund, New York, 1948.
3. Saul, L. J.: Emotional Maturity, Lippincott, Philadelphia,
1948.
A. C. H. A. News
The San Francisco meeting was very successful with
an attendance of 111 at the meetings and the luncheon.
Attendance was divided up as follows: West coast 30;
Mountain states 17; Central states 30; East 4; Canada 2;
and Guests (mostly west coast) 28.
The result of the vote as to choice of meeting time
which was taken by mail in December 1948 came out
as follows: May — 82; December — 46 votes; and other —
10 votes. It was felt by the Council that May 1949
would be too soon for another meeting mostly because
two meetings in one year would be impossible in terms
of expense. The Council also felt that a year and half
is too long to go without a national meeting. They,
therefore, decided upon December 1949 as the best
alternative.
In the general business meeting the following twelve
new institutions were accepted for membership: Colo-
rado A. & M. College, Fort Collins, Colorado; Asso-
ciated Colleges, Claremont, California; Cornell College,
Mt. Vernon, Iowa; Eastern Illinois State College,
Charleston, Illinois; Fort Hays Kansas State College,
Hays, Kansas; George Peabody College for Teachers,
Nashville, Tennessee; Illinois Institute of Technology,
Chicago, Illinois; Otterbein College, Westerville, Ohio;
Loyola University of Los Angeles, California; De Paul
University, Chicago, Illinois; Union Theological Sem-
inary, New York City, New York; and University of
Western Ontario, London, Ontario, Canada.
L. W. Holden, Secretary
February, 1949
67
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association, Minne-
apolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society, Sioux Valley
Medical Association, South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology.
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H . Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H . Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O. Hanson. Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert, Recorder
ADVISORY COUNCIL
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
Sioux Valley Medical Association
Dr. W. H. Holloran, President
Dr. Walter Benthack, Vice President
Dr. Martin Blackstone, Secretary
Dr. Anton Hyden, Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Dr. Gilbert Cottam, Secretary-Treasurer
Editorial
SOCIAL SECURITY FOR EMPLOYEES
OF THE PHYSICIAN
Federal Social Security, in principle, has a great deal
in common with preventive medicine. The prudent doc-
tor, when consulted, perhaps too infrequently, by the
healthy individual who wants to stay healthy, will pre-
scribe a logical, sensible regime of diet, rest and exercise.
In a like manner, this Federal statute makes orderly,
logical provision in advance against personal economic
ills — ills that plague most workers or their families when
old age or death interrupt a healthy flow of income.
Your secretary, your laboratory assistant, the janitor
who sweeps out your office, are covered under this insur-
ance system. Each calendar quarter you report their
earnings, together with their full name and Social Secur-
ity number. The premiums for this insurance are the
1 per cent deductions which you, as employer, make
from their salaries each pay-day, matched by a similar
contribution from you. The face value of their policy is
represented by payments to them at retirement, or to
their survivors, should they die.
One or two illustrations may serve to show how this
program operates to prevent or alleviate dependency.
Take the case of the girl who has helped you keep your
appointments, sent out your statements, and kept your
office callers happy for the past ten or twelve years.
Suppose she dies quite suddenly, leaving a wholly de-
pendent mother. Monthly Social Security payments,
representing a percentage of her average taxable earn-
ings, will be sent, upon application and proof of depend-
ency, to this girl’s mother for life. Or, consider your
janitor, now sixty-eight, whose age and general debility
makes it necessary for him to retire. Regular monthly
payments for him and his wife, for the balance of their
lives, are provided for under this Federal program of
Old-Age and Survivors Insurance.
Like the art and science of medicine, methods of meet-
ing social and economic problems can not and will not
remain static in a restless, changing world. Social Secur-
ity is now a going concern which provides monthly in-
come maintenance payments to well over two and a
quarter million beneficiaries. Through any of its field
offices, it is willing and anxious to serve you or your em-
ployees on any matter within its jurisdiction.
68
NEW KENNY INSTITUTE SETUP
Announcement of a new relationship between Sister
Elizabeth Kenny and the medical profession assures the
Kenny Institute of first-class medical supervision.
The institute, operated by the Elizabeth Kenny Foun-
dation, now is headed by Dr. E. J. Huenekens, pediatri-
cian, as chief of staff. Medical men head the various
departments and are in charge of the technicians. Sister
Kenny will remain with the institute as consultant and
teacher. She has recently made the following statement:
"This is a goal I have been working years for and at
last have achieved. I quite agree with procedures of
members of the medical profession for their caution in
not embracing new ideas that may from time to time be
presented, including my own, until they are satisfied they
are effective.
"That is wisdom, and proves the public can confi-
dently put its trust in their activities.”
As background to Sister Kenny’s statement, Dr. Hue-
nekens said: "Four months ago I accepted the position
of chief of staff of the Kenny Institute because I firmly
believe in the value of Sister Kenny’s treatment.
"There were two conditions to my acceptance: first,
that I be given full responsibility for the medical direc-
tion of the hospital; second, that Dr. Miland E. Knapp
have complete charge of the physical medicine aspects
of the treatment with sole authority over the technicians,
The Journal-Lancet
as he now has at University hospital and at Sheltering
Arms.
"These conditions have been fully met.”
Dr. Huenekens explained a further reason for accept-
ing the position was to establish such relations with the
University of Minnesota that the facilities of the insti-
tute would be open to its staff for research and evalua-
tion of treatment.
"Most important of all, we hope to do away with the
antagonism that exists between Sister Kenny and the
medical profession, which has caused both to be mis-
understood by the public.
"If these misunderstandings can be resolved, physi-
cians will be able to judge the Kenny method objectively
and to that end will be welcomed at the institute in the
future to observe for themselves the treatment and the
results.
"A wider service for children with other neuromuscu-
lar conditions who need physiotherapy will now be pos-
sible.”
As chairman of the Minneapolis polio committee dur-
ing the 1946 epidemic, Dr. Huenekens established close
working relationships between the various groups aiding
the treatment of polio.
At that time the medical profession studied all types
of polio treatment and three recommended methods were
adopted.
Book Reviews
The Differential Diagnosis of Jaundice, Leon Schiff,
Ph D., M.D. Chicago: The Year Book Publishers, Inc.,
1946, 313 pp. with index, illustrated. Price, $5.50.
Precise determination of the cause of jaundice is now of con-
sequential importance. Recent experience with infectious hepa-
titis has illuminated long dark phases of ictric hepatic disease.
Knowledge of the functions of the liver derived from chemical
and metabolic studies has fructified therapeusis. Bold surgery,
sanely justifiable because of ancillary and supportive measures
now available, is actually curative for conditions previously con-
sidered to be intractable. Estimation of extent of liver damage
and degree of dysfunction is possible from results of several
well-proved methods. Under these circumstances, a discussion
of the differential diagnosis of jaundice is not only timely, but
mandatory.
Leon Schiff, Associate Professor of Medicine of the Univer-
sity of Cincinnati, has presented currently accepted ideology of
liver disease, and recounted specific procedures for identification
of the several causes for jaundice. Recognition of the basis for
icterus, in a particular instance, should lead to definitive treat-
ment.
J.C.
The 1948 Year Book of General Medicine. Chicago: Year
Book Publishers, Inc. $4.50.
A medical practitioner who today seeks to learn the latest
and most effective diagnostic and therapeutic methods and pro-
cedures from a personal perusal of current medical literature
is doomed to a state of confusion and despair. Attempts to
read all that is printed about a single specialty are futile. At-
tendance at medical meetings and exchange of ideas and opin-
ions by personal communication yield information of limited
and uneven value.
One of the best sources of medical refreshment and nourish-
ment is a Year Book of General Medicine, or of one of the
specialties. The Year Book of General Medicine covers current
topics in diseases of chest, blood, heart and blood vessels, di-
gestive system and metabolism, and infectious diseases. Each
subject is edited by an authority — Amberson, Minot, Harrison,
Eusterman and Beeson. The material is chosen by each editor
with discrimination and judgment and presented in abstract.
Particularly useful are the editor’s comments, which offer em-
phasis and criticism from a sound background of ample experi-
ence.
Uncertainties with respect to use of vaccine for influenza;
antacids for neutralization of gastric acidity; folic acid, liver and
iron; and of caronamides, are, if not thoroughly resolved, at
least clarified. Reliable diagnostic methods are explained, their
application directed and interpretation explained.
The size of the volume is convenient, the illustrations — un-
usual in reviews — are helpful.
J. B. C.
Fundamentals of Psychiatry, Edward A. Strecker, M.D.
Philadelphia: J. B. Lippincott Company, 1947, 310 pages,
$4.00.
The fourth edition of this well known manual can be recom-
mended to the medical profession as an excellent review of the
field of psychiatry. It includes an unusual wealth of material
in 310 pages of text written in a lucid fashion. Not only are
the more basic ideas covered in a pleasing style but also new
sections on psychosomatics and nomenclature are presented. The
sections on psychiatric nursing and war neuroses are particularly
commendable. Dr. Strecker’s enthusiasm for his subject and
his wise treatment of it make this volume most readable, in-
formative, and timely.
F. T.
February, 1949
69
News Items
North Dakota
Dr. W. L. Diven was recently elected president of the
staff of St. Alexius Hospital, Bismarck, North Dakota,
succeeding Dr. W. B. Pierce. Dr. E. D. Perrin was
named vice president and Dr. A. C. Grorud will serve
as secretary-treasurer.
Dr. Edmund C. Stucke, veteran country doctor and
one of North Dakota’s most colorful political leaders,
has announced his retirement from the active practice
of medicine.
His practice in Garrison is being taken over by Dr.
Martin Hochhauser, a native New Yorker who has re-
cently practiced in Fargo.
Dr. S. C. Bacheller was appointed Enderlin city health
officer at the January city council meeting.
Dr. Bacheller fills the vacancy created by the death
of Dr. Gilbert Hendrickson, who had served as health
officer a number of years.
Two pioneer North Dakota physicians and surgeons
have announced their retirement from the Quain and
Ramstad clinic at Bismarck. They are Dr. N. O. Ram-
stad, who with Dr. E. P. Quain founded the clinic in
1901, and Dr. V. J. LaRose, a member of the clinic since
1909. Both retired from the clinic and as members of
the staffs of the Bismarck Evangelical and St. Alexius
hospitals January 1.
For Dr. Ramstad, retirement marked the end of 49
years of medical and surgical service to the people of
this area. For Dr. LaRose, it marked the completion of
46 years service. Dr. Ramstad came to Bismarck in
1900 to begin the practice of medicine, taking over the
practice of Dr. E. P. Quain, who had come here in
1899, when the latter went to Europe for postgraduate
study. When Dr. Quain returned, he and Dr. Ramstad
associated themselves in a partnership which was the
beginning of the present Quain and Ramstad Clinic.
Dr. LaRose came to Bismarck in 1902 and was asso-
ciated with Drs. Quain and Ramstad for two years be-
fore establishing a practice in Mandan, where he was
located for four years. In 1909, he returned to Bismarck
and became a member of the clinic.
Two physicians have been added to the staff of Fargo
clinic. Both native Minnesotans, they received their
medical degrees from the University of Minnesota and
served as interns at Minneapolis General Hospital. Both
are World War II veterans.
Named to head the department of psychiatry is Dr.
Marvin J. Geib, who practiced for a time at West Fargo.
Becoming associated with the department of orthopedics
is Dr. G. S. Ahern, who comes to Fargo from the Love-
lace Clinic at Albuquerque, New Mexico.
The Northwest District Medical Society at a meeting
held recently in Minot elected Dr. M. W. Garrison of
Minot as its president for the coming year, succeeding
Dr. Malcolm McCannel. Dr. Robert Goodman of
Powers Lake was elected vice president, and Dr. Henry
Kermott of Minot was re-elected secretary.
The board of county commissioners at a meeting in
January appointed Dr. R. E. Mahowald and Dr. G. G.
Thorgrimsen, Grand Forks, Dr. Robert St. Clair, North-
wood, and Dr. C. O. Haugen, Larimore, as county
physicians.
Dr. J. H. Mahoney, Devils Lake, was elected presi-
dent of the Devils Lake district medical society at the
January meeting. Other officers are Dr. Robert Fawcett,
vice president; Dr. D. W. Fawcett, secretary; Dr. G. W.
Toomey, delegate; Dr. William Fox, Rugby, alternate
delegate; Dr. John Fawcett, councillor; and Dr. John
D. Graham, program chairman.
Speakers were Dr. W. A. Liebler, Grand Forks, pres-
ident of the state medical association, and Don Eagles,
Fargo, manager of the North Dakota Hospital Service.
Dr. A. M. MarCia has come to Drayton and will
assist Dr. H. M. Waldren in caring for the ills of the
inhabitants of the community.
Dr. MarCia, a graduate of the North Dakota Uni-
versity Medical School and the Illinois University Med-
ical School, served his internship in General Hospital
in Fresno county, California, and later at St. Luke’s in
New York City, where he finished in July of this year.
South Dakota
Dr. H. M. Dehli, Colton, was named president of
the Sioux Falls District Medical Society at a recent busi-
ness meeting of that organization. About 50 doctors
of the Sioux Falls area were present at the meeting.
Other officers named by the medical men were Dr.
C. J. McDonald, Sioux Falls, vie president; Dr. Don H.
Manning, Sioux Falls, secretary; and Dr. Paul C. Rea-
gan, Sioux Falls, treasurer.
The Twelfth District Medical Society, comprising
Roberts, Grant and Day counties, held its quarterly
meeting in Sisseton December 8th. The following offi-
cers were elected for the coming year: president, Dr.
Lovering, Webster; vice president, Dr. Brauer, Sisseton;
secretary-treasurer, Dr. D. L. Dawson, Milbank.
Following a dinner and the business meeting, the so-
ciety was addressed by Dr. Slaughter, dean of the med-
ical school, University of South Dakota. Dr. Slaughter
spoke on new and old pain-killing drugs.
Dr. H. G. Skinner, Rapid City, has been named a
full-time health officer for that city. The announce-
ment was made Monday by Dr. G. J. Van Heuvelen,
state superintendent of health. Dr. Skinner formerly
was with the university medical school and later prac-
ticed at Mobridge.
70
Thf Journal-Lancet
Dr. Paul V. McCarthy of Aberdeen is the new presi-
dent of the Aberdeen District Medical Society. He was
elected at a meeting of members in December to suc-
ceed Dr. G. J. Bloomendaal of Ipswich.
Other officers chosen were: Vice president, Dr. J. C.
Rodine, Aberdeen, succeeding Dr. W. D. Farrell; secre-
tary-treasurer, Dr. Granville Steele, Aberdeen, succeed-
ing Dr. Rodine.
A paper was read at the dinner meeting by Dr. E. A.
Banner, of the department of obstetrics and gynecology
at Mayo Clinic, Rochester, Minnesota.
The South Dakota State Medical Association award-
ed its first 50-year practitioner pin to Dr. S. M. Hohf,
long-time Yankton surgeon. Dr. Hohf was presented
the pin at the annual meeting of the Yankton District
Medical Society by Dr. John L. Calene of Aberdeen,
president of the state association.
The Yankton District Medical Society elected Dr.
C. B. McVay, president; Dr. F. H. Haas, vice president,
and Dr. F. J. Abts, secretary-treasurer, as officers for
1949.
Officers for the Whetstone District Medical Society
for next year are Dr. Lovering, Webster, president; Dr.
Harry Brauer of Sisseton, vice president, and Dr. Daw-
son of Milbank, secretary-treasurer.
St. Bernard Hospital, Milbank, recently received sev-
eral pieces of equipment purchased by the local physi-
cians and donated in memory of their former colleague,
the late Dr. F. N. Cliff.
Minnesota
Dr. D. A. Dukelow, director of the health and med-
ical care division of the Hennepin County Community
Chest and Council since 1945, is to become medical con-
sultant on health and fitness for the American Medical
Association, with headquarters in Chicago. He is to
assume his new post in March.
Dr. S. T. Baetz, Maple Lake, was elected president
of the Stearns-Benton County Medical Society at a re-
cent meeting. Others named were Dr. R. C. Smith,
Holdingford, vice president; Dr. J. N. Libert, St. Cloud,
secretary-treasurer; Dr. J. E. Conway, St. Cloud, mem-
ber of the advisory committee. Dr. J. F. DuBois, Sauk
Centre, and Dr. C. S. Donaldson, Foley, delegates to
the convention; and Dr. P. L. Halenbeck, St. Cloud,
and Dr. Conway, alternates.
Dr. W. R. Schmidt, a surgeon with the Worthington
Clinic for the past nine years, announced that he has
resigned his position at the local clinic, effective Jan-
uary 1, 1949, to take a position with the veterans’ hos-
pital in Minneapolis in connection with the University
of Minnesota.
Forty years of medical service to Worthington was
ended by Dr. B. O. Mork, Sr., 81, when he retired
January 1st. Dr. Mork, a native of Norway, came to
the United States when he was 19. He worked several
years for the Indian agency at Granite Falls. Later he
attended Hamline university and was graduated in 1898.
He returned to Hamline to finish his requirements for a
medical degree which he did at the age of 40. Dr.
Mork came to Worthington in 1908, formed a partner-
ship with Dr. Henry Wiedow and the two operated the
city hospital. Dr. Mork and four associates organized
the Worthington Clinic in 1920.
Dr. J. J. Smyth of Lester Prairie and Dr. C. A.
Anderson of Hector are now members of the Glencoe
Municipal Hospital staff. Both are well-known prac-
titioners in their respective communities and are a wel-
come addition to the staff.
Dr. P. G. Hoeper was elected president of St. Jo-
seph’s hospital staff physicians after an annual Christmas
banquet for the group. Thirty-seven physicians attended
the affair. Other officers elected for 1949 were: Dr. J.
A. Butzer, vice president; Dr. A. A. Schmitz, secretary-
treasurer; and, on the executive committee, Dr. M. I.
Howard, chairman, Dr. A. E. Sohmer and Dr. J. A.
Butzer.
Dr. E. H. Dewey, Owatonna, was elected president;
Otto B. Fesenmaier, New Ulm, vice president, and Dr.
Roger G. Hassett of Mankato, secretary-treasurer of the
southern Minnesota branch of the American academy
of general practice at a recent annual meeting of the
organization.
Dr. T. A. Estrem of Hibbing was elected president
of the Range Medical Society at a recent meeting in
Chisholm. Dr. Sidney Blackbourne of Keewatin was
voted vice president and Dr. R. E. Hansen of Hibbing,
secretary-treasurer.
Dr. Robert L. Nelson, Duluth, president, St. Louis
County Heart Association and Dr. F. J. Hirschboeck,
Duluth, member, state board of directors, Minnesota
branch, American Heart Association, are among local
leaders participating in plans for a major campaign by
the A.H.A. in February to raise funds for heart dis-
ease research.
Dr. A. A. Schmitz was elected president of the Blue
Earth County Medical Society at the recent annual
meeting. Dr. R. W. Kearney was named vice president
and Dr. O. H. Jones, secretary-treasurer.
Dr. James C. Masson, 67, chief of the Mayo clinic’s
surgical staff since 1935, has retired. A well-known ab-
dominal surgeon, Dr. Masson had been chief surgeon
since the death of Dr. Edw. Starr Judd, successor to
Dr. Wm. J. Mayo in the past.
Annual grant to the Dr. Wm. A. O’Brien memorial
professorship in cancer research at the University of
Minnesota was announced by officials of the Minnesota
Division of the American Cancer Society. The sum of
$5,000 was given to the University to finance Dr. Robert
A. Huseby’s work in cancer biology.
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The Journal-Lancet
his practice and had been serving the communities of
Driscoll, Steele, Tuttle and Braddock from his office in
Steele for the past 19 years.
Dr. Swan G. Wright, 70, Minneapolis, died Decem-
ber 13 at Swedish hospital, where he was a staff mem-
ber. Born in Sweden, Dr. Wright had been in the
United States for 66 years. He was a graduate of
Hamline University Medical School, St. Paul, and a
life member of Hennepin County Medical Association.
Dr. A. DeVries, 74, Platte, South Dakota, died
December 15 after serving his community as a pioneer
school teacher and doctor for 40 years.
Dr. W. E. White, 64, Ipswich, South Dakota, died
January 4 after a long life of untiring service to his
community. For many years Dr. White was the physi-
cian and surgeon for the Milwaukee Railroad and also
served Edmunds county as superintendent of the board
of health for many years, a position to which he was
repeatedly appointed by the state superintendent of
public health at Pierre. The doctor was also a lifelong
member of the Aberdeen District Medical Association
and during his life missed only one convention of that
group.
Dr. Harry F. Bayard, 50, Minneapolis physician, died
January 14. Born in St. Paul, he had lived in Minne-
apolis since 1931. He graduated from the University
of Minnesota medical school in 1921 and practiced in
Stewartville, Minnesota, before becoming a fellow in
proctology at the Mayo clinic, Rochester, in 1928.
Dr. George C. Jensen, 57, St. Paul eye specialist, died
December 23rd. Dr. Jensen had offices at 512 Bremer
Arcade.
Dr. Ralph B. Kettlewell, 45, Sauk Center, Minne-
sota, died January 6. He was graduated in 1932 from
the University of Minnesota medical school and had
since practiced medicine in Sauk Center.
Dr. Jerome Charles Evanson, 27, died November 19,
1948. He was born December 5, 1921, at Grand Forks,
North Dakota. He received his AB degree from St.
Olaf College in 1942, entered Marquette University,
Milwaukee, Wisconsin, where he received his Doctor of
Medicine.
Dr. Gerald C. Raskilly, 57, Minneapolis physician,
died December 22.
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Foreword
The April, 1948, issue of Journal-Lancet was devoted almost exclusively to
medical activities in North Dakota. Physicians from throughout the state contrib-
uted splendid articles on the results of research, medical organizations, private
practice, etc. These published papers brought forth much favorable comment
from many sources. The medical profession of North Dakota is composed of
men and women who have graduated from many of the best medical schools in
this country and Canada. A considerable number have taken graduate work in
special fields. A large percentage have spent long years in practice, which has
equipped them with a vast store of information unobtainable in any other way.
Excellent clinics have been developed in several of the larger cities which have
become widely known throughout this country. Many physicians practicing alone
in villages have equipped their offices and laboratories so well that they are afford-
ing their communities most modern medical service. Thus medicine in all of its
phases is on a high level in North Dakota. This was so emphasized by the presen-
tations in the April, 1948, issue of the Journal-Lancet that the publishers and
editorial board decided to devote the March, 1949, issue to contributions of North
Dakota physicians. The potentialities are so enormous and the North Dakota
physicians have cooperated so whole-heartedly that the editorial board has recom-
mended that this become an annual event.
J. A. Myers, M.D.,
Chairman, Board of Editors
74
The Journal-Lancet
The Surgical Treatment of Degenerative
Disease of the Hip Joint
Graham A. Kernwein, M.D.
Minot, North Dakota
The term degenerative disease is used in lieu of the
various other synonyms, osteoarthritis, hypertrophic
arthritis, senile arthritis, arthritis deformans, and de-
generative arthritis, because it better describes the path-
ology.
The principal pathological changes as described by
Nichols and Richardson1 in their original monograph
are classical. The cardinal points, therefore, are sum-
marized.
The earliest and primary gross change in the joint is
degeneration of the hyalin articular cartilage in the
weight bearing portion. Microscopically, this appears
first as a fibrillation of the cartilage with a disappear-
ance of the spindle-celled perichondrium. These changes
occur at right angles to the articular surface and as they
progress into the deeper layers, the neighboring cartilage
cells are set free and finally disintegrate and disappear
(Fig. 1.) The depth to which these changes occur varies
Fig. 1. Beginning fibrillation of the surface of the hyalin
articular cartilage — Region A — Note the irregularity of the peri-
chondriac layer.
from superficial ulceration to extension through the en-
tire cartilage layer into the subchondral bone (Fig. 2).
To compensate for this erosion and depression of one
surface, the perichondrium of the contiguous portion
of the opposite joint surface is stimulated and develops
a papillary elevation. Erosions are opposed by papillary
elevations, giving the surface a saw-tooth appearance.
The changes occur slowly but progressively and motion
is continued. Finally, bone is exposed and due to fric-
tion of motion, the involved trabeculae of the underlying
bone hypertrophy. Eventually focal cavity formation
Fig. 2. Extensive surface erosion as evidenced by the irregular
surface. In region (A) the degenerative process has extended
through the entire thickness of the articular cartilage, with in-
terruption of the bony articular cortex. (B) shows hypertrophy
of subchondral bony trabeculae.
occurs (Fig. 3). In the roentgenogram, these regions
of hypertrophied trabeculae then appear more dense and
are called sclerotic or eburnated.
Slow progression of the erosion of one surface with
overgrowth of the other, may result in sufficient changes
Fig. 3. Degenerative process so extensive the hyalin articular
cartilage has been entirely destroyed, leaving the denuded bony
articular cortex (A) exposed. As a result of the trauma of fric-
tion the subchondral trabeculae have hypertrophied (B) and in
region (C) there is a cavity. The hypertrophied trabeculae are
seen in a roentgenogram as region of sclerosis or increased den-
sity. The cavity appears in a roentgenogram as an area of lesser
density.
March, 1949
75
in the joint surfaces to cause subluxation. The range
of motion may be diminished greatly but true bony
ankylosis never occurs.
Common among the little understood changes is an
overgrowth of the perichondrium at a point where the
cartilage and capsule come together. This results first
in an irregular formation of cartilage about the circum-
ference. When this cartilage becomes ossified, the spurs
are seen in roentgenographic studies of the joint as
osteophytes. To describe these latter changes, the roent-
genologist coined the term hypertrophic arthritis (Fig. 4) .
Fig. 4. Reduction of cartilage space in weight bearing area
(A) with hypertrophy of the local trabeculae seen as local
sclerosis (B) . Cavity formation is visualized at (C) as focal
region of lesser density. Marginal lipping or osteophyte forma-
tion at (D).
Characteristically, there is no great thickening of the
joint capsule and usually the synovia appears quite nor-
mal. Inflammatory exudation is uncommon.
From the foregoing description, it is obvious that the
characteristic changes are degenerative and not inflam-
matory in nature.
The primary changes are in the articular cartilage,
degenerative in character, appearing earliest and being
most marked in the weight-bearing areas.
The commonest cause of degenerative changes is the
trauma of wear and tear in everyday life. Keefer et al.~
studied a series of knee joints from normal individuals
who, so far as could be determined, never had symp-
toms of joint disease. The joints were obtained at
necropsy and at least six joints, representing each decade
from the first to the tenth, were obtained. The joints
were studied roentgenographically, microscopically, and
macroscopically. These studies revealed increasing de-
generative changes in the hyalin cartilage with each suc-
ceeding decade beyond the second. The changes often
were not demonstrable by X-ray examination. Arterio-
sclerosis did not appear to play a part. The synovial
tissues were normal or showed only minimal change.
There was little or no attempt at repair. These changes
from the earliest to the latest were indistinguishable
from those commonly spoken of as characteristic of
degenerative arthritis. As these changes were present
without causing symptoms and often were not demon-
strable by roentgenographic studies, it seems likely that
they result from daily use and increasing age.
Therefore, if daily use and increasing age will suffice
to produce degenerative changes in cartilage, constant
use or unusual trauma should enhance these changes.
Working upon this hypothesis, Bennett and Bauer ' col-
lected a group of cases that confirmed this concept. As
an example, in one case, a woman who had worked as
a cutter in a tailoring establishment for fifteen years
had a prominent Heberden’s node on the thumb of the
hand used for cutting, but no such change was demon-
strable on any of the other fingers.
It seems logical to conclude, therefore, that the patho-
logical changes characteristic of so-called degenerative ar-
thritis, are the result of the trauma of daily wear and
tear. Other factors, either intrinsic or extrinsic, may
enhance these changes.
Extrinsic enhancing factors include the trauma inci-
dent to the use of pneumatic tools, occupational overuse
of one joint (as in the case of the seamstress cited
above) , malaligned fractures of the bones adjoining a
joint, unusual stresses or strains upon a joint, loss of
proprioceptive and pain sensation as seen in the arthropa-
thies with lues, syringomyelia, leprosy, and peripheral
nerve lesions.4
Intrinsic enhancing factors include changes as seen in
Legg-Calve-Perthes disease of long standing, slipped
capital epiphysis, unreduced congenital dislocation of the
hip with shelf formation in a secondary acetabulum,
vascular changes following traumatic dislocations of the
hip, intracapsular fractures of the neck of the femur
and the trauma incident to loose bodies within a joint.
Pain is the usual presenting complaint. The pain may
be located in the knee, thigh, low back or hip. Pain in
the thigh or knee unassociated with objective findings
in the local region of the complaint always should sug-
gest hip disease. Hip disease with pain referred to the
thigh or knee often goes unrecognized for many years
because the aforementioned fact apparently is not gen-
erally appreciated.
Pain in the back is the result of strain placed on the
lumbo-sacral joint. This appears only after there has
been loss of motion in the hip joint. Restriction of mo-
tion with flexion-adduction deformity develops so grad-
ually, the patient usually is unaware of it, although he
may have limped for many years. Fixed flexion and
adduction of the hip result in considerable functional
shortening. In order to get the foot on the ground, the
patient must tilt the pelvis sufficiently to overcome flexion
deformity. As the flexion deformity may at times be as
much as 45 to 60 degrees, it is obvious that to over-
come it, the lumbo-sacral joint is placed under great
strain.
A limp is perhaps the next most common complaint.
The limp is an attempt to compensate for the functional
76
The Journal-Lancet
shortening due to the flexion deformity and also, may
help to lessen the pain. It usually is most marked im-
mediately upon resuming activity following a period of
rest. The limp and pain abate somewhat when the joint
gets "warmed up” and recur after prolonged use.
Restriction of motion develops so insidiously and is
so readily accommodated for by pelvic tilt, the patient
usually is unaware that restriction has occurred until it
is marked. Early, the restriction is due to muscle spasm.
Occasionally it may be the result of residual deformity
of some such condition as slipped capital epiphysis or
Legg-Calve-Perthes disease. Eventually, however, muscle
spasm develops and the powerful adductors when in
spasm, result in the development of a flexion and adduc-
tion deformity. If this is permitted to remain uncor-
rected, the capsule becomes fibrosed and a so-called
fibrous ankylosis develops.
The Patrick or Faber test is a simple and readily
effected means of detecting hip disease. This test is
accomplished with the patient in a supine position. The
extremity to be examined is flexed so that the heel may
be placed upon the knee of the opposite limb. Holding
the hip flexed, the heel fixed upon the opposite knee, the
flexed knee normally should be brought into a plane
parallel with the abdomen and in many persons may
be placed upon the examining table (Fig. 5). Failure
to accomplish this test, painlessly, signifies hip involve-
ment (Fig. 6) . This test described by Patrick was called
Faber, as it tested F flexion, AB abduction, and ER
external rotation. The finer points of determining ex-
actly the amount of limitation can be accomplished best
by having the patient flex the normal leg until the thigh
is held lying upon the abdomen. This fixes the pelvis.
If a flexion deformity is present in the opposite leg, it
immediately will become apparent (Fig. 7) . Adduction,
internal and external rotation range, determined with
the good leg fixed, will be found to be entirely different
from that which obtains when this simple point is over-
looked.
Measurement of thigh and calf circumference should
be recorded and if the patient has favored the leg over
a period of years, an atrophy of disuse will be found in
the musculature.
Roentgenological examination may reveal some pri-
mary condition as a cause for the additional strain re-
sulting in a degenerative disease of the hip joint. Among
these are slipped epiphysis, Legg-Perthes disease, mal-
aligned fracture, loose bodies, etc. Early in the course
of degenerative disease, roentgen changes are absent as
cartilage is translucent to the X-ray and, therefore, not
visualized. Narrowing of the cartilage space and eburna-
tion of the bone in the weight-bearing portion are the
first roentgenological changes to appear. Later, osteo-
phytes may develop and in the subchondral portion,
focal regions of lesser density appear (Fig. 4).
The prime function of treatment is to eliminate pain.
Each patient must be evaluated individually and very
carefully. Ideal treatment will eliminate pain, overcome
deformity and restore motion. In evaluating any indi-
Fig. 5. Patient in supine position with right heel on left
knee and right hip flexed, abducted and externally rotated. The
right knee and thigh are in same coronal plane as the body.
This is a normal or negative Patrick test in right hip.
Fig. 6. The left heel is on the right knee. The left hip is
flexed but cannot be abducted or externally rotated. This is a
positive Patrick test of the left hip and indicates disease.
Fig. 7. Same individual as depicted in Figs. 5 and 6. Nor-
mal hip flexed until the thigh lies on the abdomen. This fixes
the pelvis so that spine motion cannot compensate for loss of
hip motion. Using this maneuver the left hip is seen to have
a flexion deformity of 45 degrees. Rotation and abduction
adduction motion is absent.
March, 1949
77
vidual case, many factors must be considered. For pur-
poses of clarity, the several methods of treatment giving
the best results will be presented with their indications
and contra-indications.
Resection of the obturator nerve for the treatment of
degenerative disease of the hip was described first in
1933 by Camitz of Sweden.5 Camitz observed veterinary
surgeons performing resections of sensory nerves in the
hoofs of horses and thought of applying the same prin-
ciple in the treatment of human hip joints. Subsequently,
Tavernier'' published the results of denervation of the
hip joint with section of the obturator nerve and of the
nerve to the quadratus femorus muscle on the posterior
aspect of the joint. Tavernier reports a series of 24
cases with 17 excellent results, 5 fair and only 2 com-
plete failures after two years. Padovani,7 1947, extend-
ed the operation to include the branches of the femoral
(anterior crural) nerves and stated that in this way, com-
plete denervation of the hip joint was obtained. Obletz,'s
1948, obtained satisfactory relief in 28 of 42 patients
in whom abdominal section of the obturator nerve, to-
gether with a resection of the quadratus femorus nerve,
was carried out.
Obturator neurectomy is an ingenious addition to the
armamentarium of the surgeon in the care of degenera-
tive hip disease. It possesses the tremendous advantage
of being widely applicable. The procedure is accom-
plished extraperitoneally and intrapelvically under spinal
anesthesia. The patient may be ambulatory the next day.
The operation is little more shocking than is the liga-
tion of a varicose vein. Hospitalization will average less
than four days so that economically the procedure is
within the reach of many who cannot afford the expense
of an arthroplasty or arthrodesis. Obesity, although it
enhances the technical difficulties, is not a contra-indica-
tion. As the patient can be active without pain, dieting
is more practical. For those persons who refuse an ar-
throdesis and those with neither the temperament nor
ability to cooperate sufficiently for arthroplasty, the ob-
turator neurectomy may give complete relief. In fact,
we believe a neurectomy is indicated first in any painful
hip. Should it suffice, the problem is solved. Should the
pain return or fail to be relieved, either the arthrodesis
or arthroplasty then may be accomplished.
Section of the obturator nerve is best performed intra-
pelvically and extraperitoneally, as described by Chand-
ler.9 Using a Phannenstiel incision in the lowest trans-
verse skin crease just above the pubic, the anterior sheath
of the rectus abdominalis muscle is exposed. The sheath
is slit vertically in the center of the distal portion of the
muscle. The lateral portion of the rectus sheath is re-
flected and the lateral borders of the muscle defined and
retracted medially. The index finger follows the pos-
terior sheath to the attachment to the horizontal ramus
of the pubis and then more deeply and laterally displac-
ing the bladder and peritoneum posteriorly until the ob-
turator nerve is palpated as it lies in the pelvic wall.
Flat, lighted retractors are inserted and the nerve picked
up and stimulated for purposes of identification. A sec-
tion of the nerve is removed between ligatures.
Case Reports
Case 1. Mrs. T.A.O., age 56, a large obese white
female, complained of gradually increasing low back-
ache and pain in her right thigh and knee of five years
duration. The discomfort was aggravated greatly by
activity and relieved by rest. The leg ache was not ag-
gravated by coughing. Neurological examination was
negative. During recent months, the patient had rested
poorly at night because the back and leg ache would
awaken her. The intensity of the pain often necessi-
tated her getting out of bed for relief.
Examination of the lower back revealed considerable
increase in the lumbar curve. Spinal movements were
associated with mild discomfort. Paravertebral muscle
spasm was absent. The gait was characterized by a
marked limp. The pelvis tilted forward acutely with
each step, throwing a strain on the lumbo-sacral joint.
The range of motion in the left hip joint was within
normal limits. There was marked restriction of motion
of the right hip joint. The Patrick test was positive.
The left femur was flexed 45 degrees and all attempts
to move it through as much as 10 degrees in any direc-
tion caused the patient to complain bitterly of pain.
Roentgenological examination showed degenerative
disease of the right hip joint with similar changes in-
volving the lower back.
On September 15, 1948, the patient was operated
upon and an obturator neurectomy performed. The re-
sults were spectacular. The flexion deformity disap-
peared upon the operating table following severance of
the obturator nerve. The patient was ambulatory the
first postoperative day and went home the fourth. She
was relieved completely of all night pain in back and
leg. The range of motion in the hip joint was increased
considerably and entirely painless. A barely perceptible
limp remained. When last seen, the patient’s back ached
only occasionally.
The obturator is a mixed nerve. Neurectomy, there-
fore, eliminates painful stimulae that pass from the hip
centrally over the obturator nerve. Interruption of the
motor fibers paralyzes the adductor muscles and releases
the muscle spasm. In many instances the range of mo-
tion greatly will increase as it did in this patient. With
the correction of the flexion deformity the lumbo-sacral
strain was eliminated and the backache greatly relieved.
Destruction of the entire nerve supply to a joint has
been known to result in the development of a so-called
Charcot joint.4 Attempts to produce Charcot joints ex-
perimentally in animals by sectioning the posterior roots
has failed, universally, except when trauma to the joint
was used in conjunction. The best evidence favors the
view that a Charcot joint is the aftermath not of some
trophic disturbance of the bone as the result of cutting
the nerve supply but, rather, is a degenerative change.
This change results from oft repeated trauma. It is the
lack of proprioceptive sensation, that results in an un-
78
The Journal-Lancet
usual amount of trauma and as the joint is painless, it
lacks this protective factor.
Arthroplasty is a technically difficult, painstaking,
shocking surgical procedure, requiring prolonged hospi-
talization and postoperative physical therapy. Patients
should be selected carefully with particular reference to
their age (chronological and physiological), tempera-
ment, musculature, occupation, and the nature of the
hip deformity. In certain well selected cases, arthro-
plasty gives ideal results. A painful hip with a fixed
deformity may be transformed into one which will have
painless motion. The only absolute indication for ar-
throplasty is bilateral hip disease in which motion in
both hips is lost or may be anticipated.
The vitallium cup technique generally is considered
superior to other types. The technique commonly in use
is that described by Smith-Peterson.10 This author re-
cently reported 600 cases without a death. As the origi-
nator of the procedure, he perhaps is overly enthusiastic,
feeling there is no indication for either an arthrodesis or
osteotomy. Bickel 11 in a recent review of the cases
operated upon at the Mayo Clinic reported slightly more
than 50 per cent of the results as very good or good
and 26 per cent as poor. The greatest percentage of
good and very good results was obtained among the
middle-age group.
Case 2. A small white male had experienced grad-
ually increasing pain, limp and restriction of motion in
his left hip over a period of eleven years. During the
last year, the pain had become so intense he had quit
work. Despite his use of a crutch and relative inactivity,
he was miserable most of the time.
Examination revealed the essential pathology limited
to the left hip. All attempts at active or passive motion
caused the patient to complain bitterly. Some motion
was present but because of pain and muscle spasm, ac-
curate evaluation was impossible.
As the patient was a slender male who was eager to
regain motion in his hip, an arthroplasty was advised.
Fig. 8 shows the postoperative roentgenographic exam-
ination. This was an excellent result. All pain was elim-
inated, patient walked with a barely perceptible limp.
Motion was through an arc from zero or complete ex-
tension to 110 degrees of flexion; about 20 degrees of
internal and external rotation was present. This patient
is delighted with the end result. The possibility exists,
however, that an equally satisfactory result might have
been obtained with an obturator neurectomy.
The indications for arthrodesis of the hip in degenera-
tive disease are: (1) failure to relieve pain by means of
a lesser surgical procedure, (2) unilateral hip disease
with the configuration of the joint such as to preclude
arthroplasty, (3) occupational requirements placing a
premium upon a painless, stable hip, (4) willingness of
the patient to accept a stiff hip. Arthrodesis is contra-
indicated with significant degenerative disease of the
spine or other hip.
Intra-articular arthrodesis is a formidable surgical pro-
cedure and the patient must be selected carefully so as
Fig. 8. Vitallium cup arthroplasty. Considerable new bone in
region (A) from which glutii muscles were stripped. Patient
has range of motion almost equivalent to his right hip. Motion
painless and no limp. An excellent result.
Fig. 9. Arthrodesis of the left hip. The cartilage was re-
moved from the acetabulum and head of femur and internal
fixation accomplished using a 6-inch Smith-Peterson nail and
two screws. No external fixation was used. The above film was
taken eight months after operation.
to eliminate poor surgical risks. Campbell 12 disadvises
its use after age sixty. Watson-Jones 13 used a long
Smith-Peterson nail without intra-articular fusion and
without postoperative fixation in those patients whom he
March, 1949
79
considers as poor surgical risks or beyond the age limit
suitable for intra-articular fusions.
Solid fusion of the hip is slow to occur regardless of
the nature of the underlying disease. We prefer the
technique of intra-articular fusion, using the Smith-
Peterson arthroplasty approach and fixation by means of
a long Smith-Peterson nail (Fig. 9). Two additional
screws inserted at right angles to the pin will immobilize
the hip completely. Casts are unessential and the patient
can be ambulatory with crutches in three weeks.
Case 3. Mrs. G. S., age 57, had experienced gradually
increasing pain in her left hip, thigh and knee over a
period of eight years. The pain was aggravated by activ-
ity and relieved by rest. When first seen at the North-
west Clinic, she was totally incapacitated by pain, unable
to walk except with a crutch and then only short dis-
tances. She was very nervous and irritable, a change
that was attributed by her to inability to rest at night
because of leg ache.
Examination revealed the significant changes were lim-
ited to the right hip. There was marked restriction of
motion. A fairly fixed flexion deformity of 30 degrees,
adduction of 20 degrees and external rotation of 20
degrees were present. The patient walked with a crutch
and obviously suffered acute distress whenever she
changed position.
Roentgenographic examination revealed findings typ-
ical of degenerative disease of the right hip.
As the patient was 57, obese and extremely nervous
and irritable, an arthrodesis of the hip joint was advised.
This was accomplished and the postoperative results are
seen in Fig. 8. The patient had an excellent result. She
completely was relieved of all pain and resumed her nor-
mal duties as a housewife with a barely perceptible limp.
This is an excellent result and the patient is very well
satisfied. In lieu of our experience with the obturator
neurectomy, however, we now would advise it be accom-
plished first.
This patient spent seven weeks in the hospital. It was
two months after she went home before she was able
to resume her usual duties. Comparison of the economic
aspects of the foregoing procedure with those of the
usual obturator neurectomy which requires only four
days in the hospital are all in favor of the latter.
Summary
Degenerative disease of the hip is a common cause
of painful limp. A review of the clinical, pathological
and roentgenological findings in such cases briefly is pre-
sented. The surgical treatment is outlined. The use of
the obturator neurectomy in lieu of so-called conserva-
tive management is urged. Indications and contra-indi-
cations with illustrative cases are presented for obturator
neurectomy, arthrodesis and arthroplasty.
Bibliography
1. Nichols, E. H., and Richardson, F. L.: Arthritis Defor-
mans. J. Med. Research 21:149, 1909.
2. Keefer, C. S., Parker, F., Jr., Myers, W. K., and Irwin,
R.: The Relationship Between the Anatomical Changes in the
Knee Joint with Advancing Age and Degenerative Arthritis.
Trans. Assoc. Am. Physicians 48:59, 1933.
3. Bennett, G. A., and Bauer, Walter: Degenerative Changes
in Joints Resulting from Continued Trauma and Increasing
Age, and Their Relation to Hypertrophic Arthritis. Am. J.
Pathology 9:951, 1933.
4. Kernwein, Graham, and Lyon, W. F.: Neuropathic Ar-
thropathy of the Ankle Joint Resulting from Complete Sever-
ance of the Sciatic Nerve. Ann. Surg. 115:267:42.
5. Camitz, H.: Die deformierende Hiiftgelenksarthritis und
speziell ihre Behandlung. Act. Orthop. Scandinav. 4:193:33.
6. Tavernier, L.: La place de 1’ enervation articulaire dans
ce traitment. Rev. d’orthop. 32:109:46.
7. Padovani, P.: L’ enervation totale de la hanche. Presse
Med. 55:225:47.
8. Obletz (48) : Congress of American Academy of Ortho-
pedic Surgeons, Chicago, 1948.
9. Chandler, F. A.: An Obturator Neurectomy. Quoted by
Campbell, W. C.: Operative Orthopaedics, p. 974. C. V. Mosby
Co., St. Louis, 1939.
10. Smith-Peterson, H. N.: Arthroplasty of the Hip. Jour.
Bone and Joint Surg. 21:269:39.
11. Bickel, W. H., and Babb, F. S.: Cup Arthroplasty of
the Hip. Jour. Bone and Joint Surg. 30A:643:48.
12. Campbell, W. C.: Operative Orthopaedics, p. 314. C. V.
Mosby Co., 1939.
13. Watson-Jones, R.: Arthrodesis of the Osteoarthritic Hip.
J.A.M.A. 110:28:1938.
DEPARTMENT OF HEALTH ON THE AIR
The Minnesota Department of Health inaugurated its first regular series of radio pro-
grams on Monday, February 14. The programs will be given at 11:15 every Monday morn-
ing over Station KUOM in the Twin Cities.
Dr. Robert N. Barr, chief of the Health Department’s Section of Maternal and Child
Health, has taken over the KUOM radio spot left vacant by the departure of Dr. Donald
A. Dukelow for a position with the American Medical Association in Chicago. Dr. Barr
was introduced to his radio audience by Dr. Dukelow on the broadcast of February 14.
Dr. Barr’s program subjects for March will be: March 7, It’s Your Health Depart-
ment; March 14, Health Days and Health Councils; March 21, Why Vital Statistics?
March 28, Tracking Down Epidemics.
80
The Journal-Lancet
A Study of Congenital Malformations
Robert E. Lucy, M.D.
Jamestown, North Dakota
Congenital malformations are a problem with which
every physician, especially the obstetrician, has to
deal. Usually one of the first questions parents ask is,
"Is the baby all right?” Even though the mother has
been reassured, it is not uncommon to see the mother
inspecting the baby and counting the fingers and toes
when she sees the baby for the first time.
If a physician delivers a baby with some type of ab-
normality, he is immediately confronted with the ques-
tions as to the cause of the malformation and whether
any other children born of these parents will be mal-
formed. In the past there was little the parents could
be told regarding the cause of malformations. The par-
ents were usually informed that these things happened
occasionally and they need not fear having any other
babies with malformations.
However, the very thorough work of Dr. D. P.
Murphy 1 has recently given us more scientific facts by
which we can answer the parents. Dr. Murphy’s work
included a five year survey of all deaths between Jan-
uary 1, 1929, and December 31, 1933, in Philadelphia,
Pennsylvania. A total of 130,132 death certificates was
analyzed; and of these, 1476 recorded congenital mal-
formations. Personal interviews with the mothers of
some 546 of these were carried out and a five page ques-
tionnaire was filled out concerning the health of both
parents, history of all previous pregnancies, economic
status, type of diet, etc. As a result of this work, Dr.
Murphy found that there were "47 births of malformed
infants per 10,000 of all live births in Philadelphia, or a
ratio of 1 in 213.”
He also showed "that in a family possessing a mal-
formed child, the birth of a subsequent malformed off-
spring takes place with a frequency that is 25 times the
general population.” 1
A significant point that Dr. Murphy brought out in
this work was that environmental factors that he inves-
tigated did not play a significant role in the etiology of
malformations found in the random sample of popula-
tion. The malformations were genetic in origin and were
from factors inherent in the germ cells prior to fertiliza-
tion. However, he did show that after fertilization has
taken place congenital defects may be produced either
by the action of therapeutic amounts of maternal, pelvic
radium or roentgen irradiation or by a maternal attack
of rubella. He believes that any pregnant woman who
has has an attack of rubella or has undergone X-ray or
radium treatment in pregnancy should be aborted.
‘Murphy, D. P., M.D.: Congenital Malformations: Lippin-
cott & Co.
A study of this problem at Ball Memorial Hospital
in Muncie, Indiana, was carried out. The object was
to see if the rate of congenital malformations as evi-
denced at birth or shortly thereafter was greater than
that previously reported based on death certificates (see
Table 1.)
Table 1
Nervous System Diagnoses:
Anencephalic and spina bifida 13
Hydrocephalus 17
Spina bifida 15
Hydrocephalus and meningocele 3
48
Defects in Gastro-intestinal Tract:
Congenital hypertrophic pyloric stenosis _ 12
Congenital stenosis of esophagus with tracheo-
esophageal fistula 1
Atresia lower ileum 1
Congenital atresia of esophagus 1
Malrotation of the bowel 1
Imperforate anus 1
17
Cutaneomusculoskeletal System Defects:
Harelip — cleft palate 15
Polydactyhsm 9
Club feet 35
Hernias : 37
Absence of leaf of diaphragm with hernia 2
Congenital absence of bones of arm or hand 3
Syndactylism 2
Intrauterine amputation of fingers 2
105
Cardiovascular Defects:
Congenital heart 20
Congenital anomaly of left subclavian artery _ 1
21
Genito-urinary System Defects:
Horseshoe kidney 1
Past insertion of renal pelvis 1
Hydrocele 3
Hypospadias 6
Absence of kidney and ureters 1
Deformed bladder 1
Undescended testicles 5
Congenital hypoplasia of kidney 1
19
The situation was ideal in that the hospital was the
only one in a town of 50,000 with even a larger drawing
territory of the entire county. For the basis of study,
birth records, reports to the State Board of Health, ad-
mission to the pediatric and pediatric surgery depart-
ment, and reports of autopsies on stillbirth and neonatal
deaths were used. The greatest majority of all births
in this county are in the hospital. Any malformation
March, 1949
81
not evident at birth but that required further hospitaliza-
tion would be in this hospital. Examples of such defor-
mities are congenital heart disease, hernias, and congeni-
tal hypertrophic pyloric stenosis.
It is believed that the congenital malformations re-
ported on this basis give a more accurate picture of the
incidence of congenital deformities.
All the birth records between January 1, 1942, and
December 31, 1947, were reviewed as well as the admis-
sions to the hospital of patients who had been born there
and were later hospitalized for treatment of congenital
defects. During this period there were 11,881 births in
the county and of these 10,751 were born in the hospi-
tal (see Table 2). There were 210 congenital defective
report and Dr. Murphy’s is that Dr. Murphy’s were
taken from death certificates. A large portion of the
deformities found in this study were not fatal and were
correctible, such as cleft palate, hare lip, club feet, all
types of hernias, hydroceles, hypospadias, undescended
testicles and hypertrophic pyloric stenosis. When this is
taken into consideration even though the incidence of
congential defects is high, the outlook for the majority
of babies with anomalies is good.
In summary, as a result of these surveys, when a phy-
sician is questioned by the parents of a malformed baby
he can inform them that anomalies occur in ratio of
1:61 live births, and that a large percentage of these de-
fects are correctible. Another fact the physician should
Table 2
Year
1942
1943
1944
1945
1946
1947
Total
Total county births
1,925
1,855
1,841
1,688
2,099
2,473
11,881
Home deliveries
447
272
180
104
76
51
Total number of malformations
33
26
26
36
37
52
210
Live malformed infants
26
20
19
30
33
48
176
Percentage of total malformations
1.71
1.40
1.41
2.13
1.76
2.10
1.77
Hospital births
1,478
1,583
1,661
1,584
2,023
2,422
10,751
Percentage of hospital malformations
2.23
1.64
1.57
2.27
1.83
2.15
1.95
Stillbirths
7
6
7
6
4
4
Corrected hospital percentage (malformed percentage of live births)
1.76
1.26
1.14
1.89
1.63
1.98
1.64
Twins
1
0
0
3
1
0
babies present in this series or a percentage of 1.77 for
the county. However, of the 210 births only 176 were
live born (22 of these lived from 15 minutes to as long
as six weeks before expiring). If we count all the con-
genital malformations (210) for the 10,751 hospital
births the percentage is 1.95 or by counting only the
live births (176) the percentage is 1.64 or an incidence
of one congenital defect in 61 live births. This is almost
four times as many congenital defects per 10,000 as pre-
viously reported. Another interesting fact revealed in
this survey was the five sets of twins with similar defects.
A point that must be considered in comparing the dis-
crepancy between the incidence of malformation in this
ascertain is whether or not the mother was subjected to
therapeutic amounts of X-ray or radium during preg-
nancy or if she had an attack of rubella during preg-
nancy. If she has, then he can tell her that the X-ray,
or radium or rubella was probably the cause of the mal-
formation and other children would not be affected in
any greater proportion than the general population.
However, if the defect is genetic in origin, then the
physician should inform the parents that any subsequent
children are 25 times more likely to be defective than
children whose parents have never produced a malformed
baby.
U. OF M. COURSE IN PROCTOLOGY
A course in Proctology will be presented at the Continuation Center for one week start-
ing April 16. The course is intended for doctors of medicine who are engaged in general
practice. Emphasis will be placed upon those aspects of proctology which are of particular
concern to the general physician. Presentation will be by means of lectures, discussions, mo-
tion pictures and operating room demonstrations. Enrollment will be limited to 20.
82
The Journal-Lancet
Practical Aspects of Allergy
Ernest L. Grinnell, M.D.*
Grand Forks, North Dakota
Numerous investigators have estimated the incidence
of allergic disease in the general population at
from 10 to 50 per cent. Even assuming that the minimal
figure is correct, it is apparent that the physician is called
upon to diagnose and treat a large number of patients
with allergic manifestations. Naturally, the form of
allergic disease encountered in practice will vary some-
what with the geographical location, industrial status,
age level, and other factors. Neverthless, a wide range
of allergic entities from simple hives to severe asthma
is certain to be seen frequently.
The unfortunate sufferer with an obscure allergic dis-
ease is often shunted around, and the allergic nature of
the disease is not recognized. All too frequently the rela-
tives and the physician have a tendency to regard these
patients as harboring a neurosis. Conversely, a danger
nearly as great lies in the course of treating all comers
as being allergic. There has been widespread acceptance
of the theory of histamine release in the causation of
allergic symptoms. Concurrently with this acceptance,
there has developed a glowing enthusiasm for the his-
tamine-antagonist drugs which offer for the first time a
new era of palliative relief for the allergic patient.
Faulty handling of the allergic individual is usually
the result of one of two common errors: (1) Busy clin-
icians are prompted by the ease of treatment to prescribe
one of the antihistaminic drugs. The patient receives
some symptomatic relief and no further study is made.
(2) One of the stock diagnostic sets prepared by a phar-
maceutical house is utilized and a few desultory tests
are made. This frequently results in arriving at the
erroneous conclusion that the patient is not allergic or
that he is sensitive to one or more allergens which may
or may not be of clinical significance. The allergens
actually responsible for the patient’s symptoms are often
omitted in testing for sensitivity.
Either of these courses precludes a satisfactory out-
come. Allergists have long recognized that the successful
management of the allergic state is only achieved through
exact coordination of the diagnostic and therapeutic fac-
tors. Any course short of this end may well result in
undeserved discredit to the entire field of allergy. The
goal of permanent relief of distressing symptoms and
the prevention of irreversible pathologic change in shock
tissues should not be sacrificed simply for immediate
symptomatic relief. It is easy to condemn the negligence
of a physician for allowing a child’s appendix to per-
forate. The responsibility is no less for failure to inves-
tigate and treat the mild allergic manifestations in child-
hood which become severe and intractable in later life.
*From the Section on Dermatology and Allergy, Grand
Forks Clinic,
Allergy is a serious and dangerous disease. Neither
the diagnosis nor the treatment should be undertaken
lightly in view of the reports of deaths due to the use
of potent extracts which run through the literature in
an endless stream. When a fatal allergic reaction occurs
it is a sudden and unwelcome visitor. It is the purpose
of this paper to attempt a practical approach to the field
of allergy; and to formualte certain general principles
which it is believed the physician can utilize to make his
allergic investigation more accurate and the treatment
less hazardous.
The Mechanism of Allergy
The most popular concept of the mechanism of allergy
conceives of an allergen-antibody reaction. Allergens
enter the host as inhalants, ingestants, injectants or con-
tactants. The allergen (antigen) arrives in the "shock”
tissues in which a large amount of antibody is already
present. If the antibody is present in the "shock” tissues
in sufficient quantities, reaction symptoms occur. These
symptoms are generally regarded as due to the liberation
of histamine as a result of cell injury by the antigen-
antibody reaction. Why this reactions takes place is a
phenomenon as yet unexplained.
Etiology
The three main etiological factors will be considered
briefly: (I) The constitutional basis. (2) The exciting
elements. (3) The contributory factors.
Of these three, the constitutional factor is of the
greatest importance. Allergic individuals show a familial
history of allergy in 60 to 70 per cent of cases. The dis-
ease itself is not inherited, only the tendency to allergic
disease. If the person with a constitutional tendency to
allergic disease were never to come in contact with pro-
teins of high allergenic potential, allergic disease would
be minimal. Since this is obviously impossible, it follows
that repeated contact with exciting factors such as wheat,
eggs, ragweed pollen, etc., first sensitize the allergic in-
dividual and subsequently bring on attacks when the
antigen is introduced into the host in sufficient quanti-
ties to cause a reaction.
However, the constitutionally allergic individual who
has been sensitized to an allergen such as dust, eggs, or
wheat may have no allergic manifestations even when
subsequently exposed to these exciting agents. It may
be necessary for the contributory factors such as heat,
light, cold, fatigue, nervous exhaustion or bacterial infec-
tion to break down the patient’s resistance before an
allergic attack may be launched.
Diagnosis
Of first importance is the preliminary processing of
the individual. Frequently the apparent absence of or-
March, 1949
83
ganic disease invites a snap diagnosis of an allergic con-
dition with the subsequent prescribing of a histamine-
antagonist drug. That this is a serious error is evident
without elaboration.
A history that is thoughtful without necessarily being
unduly detailed will usually avoid this difficulty. Cer-
tainly the first and most important requisite in the diag-
nosis of allergy should be a history covering the follow-
ing essential points:
1. The Patient:
a. Present Complaint: with particular reference to
mode of onset of attacks; duration and means
of alleviation, if any; night or day; seasons of
the year; aggravated by being inside or outside;
suspected cause as horses, grain dust, feathers,
plants, foods, etc.
b. Past History: Inquiry should be made particu-
larly of infantile eczema, hay fever or asthma,
food or drug idiosyncrasies, frequent colds, sinus
trouble, migraine or gastro-intestinal upsets as
manifested by gas, belching, heartburn or diar-
rhea; cold, heat or light sensitivity.
2. The Environment:
a. Inquiry should be made in regard to the home:
type of heating, rugs, plants, mattresses, pets,
etc.
b. Occupational exposures: dust, plants, gas, chem-
icals, animals, paints, etc.
Frequently when the essential points of the history
have been summed up, it is found that the patient com-
plains of many minor symptoms. Usually this is a
rather strong indication that this individual is allergic.
Often a patient with allergic rhinitis also has occasional
attacks of hives, migraine, or vague gastro-intestinal
symptoms.
After the history has been taken it should be thought-
fully reviewed. If it appears probable that the disease
is allergic in nature, jotting down a few notes will assist
in determining the causal allergens. For example, the
patient has asthmatic symptoms worse during the warm
summer months but extending well beyond the season
for ragweeds, sagebrush, and pigweed. Further inquiry
indicates that his symptoms begin too early for weed
pollens and later than one would expect symptoms to
develop from either grass or tree pollens. The patient
states that he feels better while indoors but his symptoms
are aggravated by harvesting operations. His symptoms
are entirely relieved while snow is on the ground. These
salient points taken from the history give a strong indica-
tion that the patient may be sensitive to one or more of
the common seasonal fungi.
The importance of close attention to the details of the
history is well illustrated by the following case history:
A. H., aged 16, student, came to the Clinic complain-
ing of asthmatic attacks and nasal symptoms. Onset was
late in the summer, usually about August 1, and contin-
ued until November or later. His symptoms were always
severe in summer but were never present in the winter.
Usually they were very much aggravated by being
around haying or threshing operations. As a general
ru le he suffered more outside of the house than inside.
Complete testing was done. Positive reactions to the
following were found:
Cottonseed
Mustard
Peas
Strawberry
String bean
Yeast
Orris root
Grain mill dust
House dust
Alternaria
Sagebrush
Hormodendrum
Blue grass
Russian thistle
Short ragweed
Giant ragweed
Ash
Cottonwood
Oak
Orchard grass
Pigweed
Comment : This patient had been tested and treated
previously to ragweed extract with poor results. The his-
tory clearly implicated the molds due to continuation of
symptoms long beyond the usual termination of the
pollen season. Attention was also directed to the molds
by the fact that proximity to haying and threshing opera-
tions aggravated his symptoms. A successful therapeutic
result was achieved in this case by adding the proper
mold extract to the pollen mixture.
It has been repeatedly shown that a careful history is
more important in the diagnosis of allergy than are skin
tests. Often the history will arouse a strong suspicion
that certain allergens are responsible for the symptoms.
In this case, skin tests frequently confirm the diagnosis.
The following case history again illustrates the impor-
tance of close attention to the details of the history.
In this instance the story told by the patient strongly
suggested sensitivity to non-seasonal molds.
Mrs. O. F., aged 34, farm housewife, came to the
Clinic complaining of cough, sneezing and wheezing.
She was usually somewhat worse in the summer but her
symptoms persisted the year around. She was definitely
made worse by house dust and dust from wheat flour.
Her symptoms were usually greatly aggravated by going
into the basement or attic. Complete testing revealed
the following positive findings:
Tomato Hormodendrum
Aspergillus niger House dust
Aspergillus fumigatus
Comment : In this case the history definitely placed
house dust and the molds high on the list of suspects.
Failure could easily have resulted, however, if testing to
pollens and common miscellaneous inhalants and foods
had not been carried out.
Having completed the history, the main allergens sus-
pected may be listed and further confirmation made by
means of skin tests. It is the consensus that skin tests
are far from being infallible. However, in spite of the
absence of uniform standardization of allergic extracts,
false positive reactions, and numerous other difficulties,
the practice of skin testing is by and large the most prac-
tical and satisfactory method available for the confirma-
tion of suspected sensitivities.
Numerous other diagnostic methods are available,
among them the elimination diets, determination of leu-
84
The Journal-Lancet
cocytic index after ingestion trials, nasal, ocular and
other tests. It is generally agreed that they all have their
proper place. They may be used to good advantage by
the clinician seeking to diagnose an allergic disease.
However, in a large number of cases, carefully planned,
executed and interpreted skin tests will give reasonably
satisfactory results.
At this point, it should be strongly emphasized that
only failure can result from allowing pharmaceutical
firms to do the thinking. Each case should be carefully
individualized and tested accoridng to the particular
needs of that individual.
Testing is desirable and valuable only if done thought-
fully, keeping in mind the history given by the patient.
It is extremely important, for example, to know what
allergens the patient is apt to be subjected to. A few
desultory tests are worse than useless because all they do
is discourage both clinician and patient, and do not re-
veal any significant facts. It is highly desirable, for in-
stance, for the physician to study the situation in his own
locality, making his own chart of the prevalence of cer-
tain inhalant allergens at specific times of the year.
There is little to be gained testing patients who reside
in the prairie states with caddis fly (normally appearing
in great numbers along the shores of Lake Erie.)
A practical point of considerable importance in the
interpretation of the tests is the fact that positive tests
must be shown to be of clinical significance. This can
usually be demonstrated without great difficulty. This
point is well illustrated by the following case history:
E. F., aged 21, female, complained of recurrent attacks
of abdominal pain. She had had an appendectomy prior
to being seen at the Clinic. Her history was not enlight-
ening from the standpoint of the ordinary causes of pain.
A complete physical examination was negative. Labora-
tory examinations, including colon X-ray, gastrointes-
tinal study, and cbolecystogram were all negative. Final-
ly, after a careful review of her case history, she was
given a thorough allergic investigation. Skin tests re-
vealed sensitivity to lettuce which has repeatedly been
confirmed as the causal allergen by clinical trial.
Again illustrating the same point is the case of a
school girl, aged 10, who repeatedly refused to go to
school because of abdominal pains. During these attacks
she was exceedingly unruly and her mother was at her
wit’s end to know what to do with her. She would lie
in bed and refuse to get up. She whined continuously
and became more and more irritable. Routine complete
physical and laboratory examinations were entirely nega-
tive. A review of her dietary habits revealed that she
was eating large quantities of chocolate. An allergic in-
vestigation revealed marked sensitivity on skin tests to
chocolate and several other common foods. The offend-
ing foods were withdrawn from her diet with complete
alleviation of her symptoms. They were returned again
one at a time until she was given chocolate, at which
time her symptoms returned. Chocolate and cocoa in all
forms were immediately removed from her diet and since
then the child has been well and happy and makes no
objection to going to school.
While there is considerable difference of opinion as
to which foods and inhalants should be included in a
thorough survey of an allergic condition, the following
common causal allergens are routinely included in our
Clinic:
Foods
Milk
Fish
Peanut
Egg white
Banana
Buckwheat
Egg yolk
Lamb
Coconut
Wheat
Peas
Cornmeal
Oats
Carrots
Cottonseed
Rye
String beans
Celery
Chicken
Chocolate
Cantaloupe
Orange
Spinach
Navy beans
Tomato
Salmon
Potato
Beef
Pollens
Pork
Short ragweed
Pigweed
Mixed oak
Giant ragweed
Russian thistle
Cottonwood
Bluegrass
Sagebrush
Boxelder
Cockleburr
Timothy
Molds
Elm
Alternaria
Aspergillus fumigatus
Hormodendrum
Penicillum
Miscellaneous
Aspergillus niger
Cotton
Goose feathers
Orris root
Chicken feathers
Glue
Pyrethrum
Cat dander
Goat hair
Rabbit hair
Cow dander
Horse dander
Sheep wool
Dog dander
House dust
Hog hair
Duck feathers
Kapok
Camel hair
As a routine measure it will be found satisfactory in
most cases to test with Alternaria and Hormodendrum,
omitting Helminthosporium. This is possible because of
the low atmospheric concentration of the latter spore and
also due to the fact that generically and antigenically
it is closely related to the common molds — Alternaria
and Hormodendrum. Aspergillus should be included in
all routine testing because of its well-known wide occur-
rence, and also because it has no specific seasonal occur-
rence. It has been frequently incriminated as causal in
the production of perennial asthma or rhinitis especially
in patients living in old, damp houses or with old furni-
ture. Two strains of Aspergillus are included because of
their relative importance and the fact that Aspergillus
niger is not closely related either antigenically or gen-
erically to the fumigatus species. It is important to em-
phasize at this point that the previously listed allergens
are not the only molds or miscellaneous inhalants used.
Usually this should be the minimum number used in any
suspected case of inhalant allergy.
The physician, after a careful review of the case, may
make his own selection of allergens from the lists as
given using one of the groups or part of each according
to the needs of the individual case. In general, it may
be said that if a patient does not react positively to any
of the foods listed, there is very little chance that he is
a food sensitive case. The same may be said for the
pollens, molds, and miscellaneous inhalants. It must be
March, 1949
85
remembered, however, that this is only true in general.
No rule is without exception. Cases ate on record of
asthma being due to sensitivity to pigeons alighting on
the window sill of a patient’s room, with no other known
sensitivity.
Two schools of thought exist today with widely diver-
gent opinions as to the relative merits of the scratch
tests versus the intracutaneous. In our Clinic we have
adopted a routine procedure in which scratch tests are
applied first, followed by intracutaneous, nasal, ocular,
or passive transfer only when the scratch tests are con-
fusing or inconclusive. The most satisfactory results can
be obtained, and the dangers minimized, by adhering to
a rigid policy which should encompass the following sug-
gestions:
1. In the absence of considerable clinical experience
with allergenic extracts, sets of intradermal tests which
are made up of groups of allergens should be avoided.
Dangerous, even fatal, accidents can occur from the in-
judicious use of such extracts when injected intra-
dermally in a highly sensitive host.
2. Individual cutaneous (scratch) tests present a wide
margin of safety. For the novice, they are the most sat-
isfactory, and with some practice can be applied with
amazing rapidity. Usually excellent results can be ob-
tained by testing first with a few inhalants such as the
ragweeds. Since there is a high incidence of ragweed
sensitivity, the occurrence of large wheal reactions fore-
warns the clinician that he is dealing with a hypersensi-
tive individual. His subsequent investigations thereby
are to be made with caution. He is forewarned to split
his groups, lending special caution to known highly aller-
genic substances such as cottonseed, fish, meats, etc.
3. The intradermal method is best avoided unless the
clinician wishes to confirm previous positive scratch tests
or desires a more sensitive test in the event the cutaneous
test proves negative to a highly suspicious allergen.
4. Intradermal tests should be scrupulously avoided
in small children. These tiny allergic individuals are best
tested by the scratch method. Subsequent intradermal
and elimination studies may be made as indicated.
5. Intradermal tests are best never applied to any por-
tion of the body other than arms or legs. Rapid absorp-
tion with edema and wheal formation and early evidence
of constitutional reaction can be partially blocked by the
prompt application of a tourniquet.
6. Severe hypersensitive individuals, especially asth-
matics, should never be tested intradermally without pre-
liminary evaluation by the cutaneous method.
7. The same meticulous care should be exercised to
avoid mistakes in dilution of intradermal extracts as is
used in measuring any potent drug. Labels should be
clearly typed and firmly fastened to the vial. Techni-
cians charged with the care of the extracts should be
required to check labels and dosage before and after
drawing the extract into the syringe.
8. Patients tested intracutaneously or treated with ex-
tracts should be required to remain in the physician’s
office under observation for at least twenty minutes.
Treatment
The subject of treatment may be conveniently divided
as follows:
1. Preventive treatment
2. Specific treatment
3. Non-specific treatment
Much can be accomplished by aiming at the preven-
tion of allergic disease. While not too feasible in actual
practice, the fact remains that theoretically marriage
between allergic individuals should be discouraged.
When either parent exhibits allergic manifestations of
any nature, the offspring are potentially allergic indi-
viduals.
In order to minimize the chances of sensitizing the
infant, some investigators have advocated restricting the
pregnant woman’s diet in so far as this is consistent with
the maintenance of health in pregnancy. This method
of preventing allergy in the newborn, by having the
mother avoid the ingestion of large quantities of known
highly allergenic foods, has not, as yet, been proven too
successful and has not been widely accepted.
The newborn infant, however, who is potentially
allergic, presents a challenge to the physician, and the
parents should be encouraged to place him under careful
medical supervision. The necessary precautions should
be taken to help him grow and develop naturally with
adequate rest, fresh air and exercise and a balanced diet
with ample minerals and vitamins. He should be put
through his immunization program the same as any nor-
mal child. Nervous tension should be minimized, foci
of infection eliminated, and care taken to avoid excessive
exposure to highly allergenic substances such as pollens,
dust, feathers, kapok, orris root, and the animal ema-
nations.
Specific treatment consists of the elimination of the
causal allergens as completely as possible, and hyposensi-
tization with extracts of those which cannot be removed
from the patient’s environment. Hyposensitization is
most successful when carried out on the perennial plan.
After the patient has been advanced through his series
of extracts of gradually decreasing dilution and has
reached a maximum of the concentrated extract (gen-
erally 0.5 cc.), in most instances he may be reduced to
a lower maintenance dose given at twice monthly inter-
vals. The length of time an individual requires treat-
ment is a matter only decided after careful consideration
of each case.
Emphasis cannot be placed too often on the fact that
satisfactory results cannot be achieved by treatment
which is not specifically individualized. If the patient
has been completely studied and adequate testing per-
formed, concomitant sensitivities have been discovered.
For example, an individual sensitive to ragweed who has
milder symptoms during the season when ragweed is not
prevalent in his locality, will not get a satisfactory thera-
peutic result unless he is treated also for sensitivity to
other inhalants to which he may have shown positive
reactions.
86
The Journal-Lancet
Foods may be of great importance, perhaps represent-
ing the major allergens in a given case. They should
defintiely be withdrawn when they react positively unless
it is well known that they are not of clinical significance.
Having been withdrawn, they should be returned one
at a time under careful observation, thereby establishing
the clinical accuracy of the skin test.
Multiple sensitivities are not uncommon. Hay fever
patients especially often show positive reactions to many
foods and inhalants to which they are clinically sensitive.
A grievous blunder may easily be committed by failure
to test to all the common pollens as well as to all the
ordinary inhalant allergens to which the individual is
exposed. Frequently the symptoms of hay fever patients
are intensified during the pollen season by the ingestion
of certain foods such as peaches, apricots, watermelon
and cantaloupe. Hyposensitization without the elimina-
tion of secondary or minor allergens such as these may
prove to be a complete failure.
Non-specific treatment consists of the therapeutic
measures utilized when a specific cause cannot be dis-
covered or when the usual specific treatment has proven
to be a failure. It is essential, of course, for the patient
to have a proper diet, adequate rest, elimination of foci,
and abundant vitamins. Worry, overwork, and nervous
tension should be avoided. Psychotherapy frequently has
proven beneficial.
Summary
A brief review of the subject of allergy with special
emphasis on some of the practical aspects of diagnosis
and treatment has been presented.
NORTH DAKOTA PROVIDES FOR THE DISPLACED PHYSICIAN
Provisions for placement of a limited number of Displaced Physicians were made in
Grand Forks. The announcement was made by Dr. O. W. Johnson, Rugby, President of
the North Dakota State Board of Medical Examiners. Dr. Johnson said that not to exceed
eight Displaced Physicians per year for three consecutive years would be permitted to take
the State Board Examinations for a temporary license after first serving a general internship
for one year in North Dakota Hospitals approved for that purpose. Dr. Johnson pointed
out that inasmuch as the accredited social agencies which sponsor D.P.’s are responsible for
D.P.’s until they have attained citizenship, the temporary licenses will be valid only in the
community where the Displaced Physician has been located by the Sponsoring Agency.
"When the Displaced Physician is granted his final citizenship,” said Dr. Johnson, "he will
be granted full license upon review by the State Medical Board.”
It was explained by Dr. Johnson that several difficult problems had to be overcome in
making the above arrangements. "The sole responsibility of the State Medical Board is
to make sure that only doctors of high professional standings and good moral character be
permitted to practice in North Dakota,” said Dr. Johnson. He pointed out that "in the case
of these Displaced Physicians no records of medical education, medical attainment or cre-
dentials are available to help the Board in their determination.” He said, "the Board never-
theless feels that as much as possible should be done to help out the worthy among these
unfortunate persons who have been forced, by circumstances, to live in D.P. camps in
Europe.” We think that with the supervision now provided that the people in North Dakota
may be safely protected, and the year’s internship will provide a period of adjustment dur-
ing which the Displaced Physician may learn the English language, American customs, and
refresh himself in the advancement in Medical Science as practiced in the United States.
Resolution as Adopted by the North Dakota State Board of Medical Examiners
January 6, 1949
It was moved that a total of not to exceed eight (8) Displaced Physicians per year for a period of
not to exceed three (3) consecutive years who have been sponsored by accredited social agencies be per-
mitted to take the State Board Examinations for a temporary license after first serving a year’s general
internship in a North Dakota hospital, such internship to be approved by the State Board of Medical
Examiners. This temporary license is only valid at the location designated by the sponsoring group and
approved by the Board of Medical Examiners. This temporary license shall apply only to Displaced
Persons as defined by the current Act of Congress. When the Displaced Physician attains full citizen-
ship, the temporary license may be made permanent by the action and approval of the State Board of
Medical Examiners.
March, 1949
87
Treatment of Acute Cholecystitis
V. G. Borland, M.D.,* and W. H. Johnston, M.D.t
Fargo, North Dakota
Approximately five years ago one of us had occasion
Lto observe two patients suffering from acute chole-
cystic disease develop serious complications because of a
policy of delay in instituting surgical treatment. They
are reported briefly as follows:
Case 1. Mrs. J. E., age 60, was first admitted to St.
Luke’s Hospital on February 14, 1943, with a two-day
history of upper abdominal pain suggestive of acute gall-
bladder colic. Some nausea had been present but no
vomiting. Her pain had been severe and required sev-
eral hypodermics for relief. The pulse, temperature, and
respirations were within normal limits. The blood pres-
sure was 150/90. No abnormalities were noted on phys-
ical examination except for slight epigastric tenderness.
Neither muscle spasm nor palpable mass was present.
Routine urinalysis was negative. The red blood count
was 4,980,000. The hemoglobin was 14.8 gm. and the
leukocytes numbered 16,450, 82 per cent of which were
neutrophiles. A diagnosis of acute cholecystitis was made
and conservative treatment instituted. In three days all
symptoms and findings had subsided and her leukocyte
count had returned to normal. She was discharged on a
fat-free diet and advised to return for detailed studies.
A cholecystogram one week later revealed a nonfunction-
ing gallbladder. Operation was advised but she elected
to continue conservative handling since she was feeling
well. She was readmitted on September 6, 1943, having
been quite free from symptoms until two weeks prior to
this admission during which period she had experienced
repeated attacks of sharp upper abdominal pain. These
attacks had been of short duration but had been present
almost daily. She had noticed no chills or fever nor
change in the color of her stools but the urine had been
dark. On admission she was in severe pain and the con-
junctivae were slightly icteric. The upper right abdomen
was markedly tender, moderately rigid, and a sensation
of a mass was present on palpation. The temperature
was 100 degrees. Leukocytes numbered 22,600, 92 per
cent of which were neutrophiles. A trace of bile was
present in the urine and the icterus index was 20. A diag-
nosis of acute cholecystitis was made. Some improve-
ment was noted in the next five days and the leukocyte
count and temperature gradually subsided to within nor-
mal limits. Suddenly the severe pain recurred. Chills
were noted and her condition became markedly worse.
She was explored through a right subcostal incision under
local anesthesia, supplemented with a small amount of
sodium pentothal. An abscess was encountered between
the liver and the anterolateral costal margin and incised.
Bile and necrotic material were evacuated. Following
*Fargo Clinic.
fSurgical Resident, St. Luke’s Hospital.
this she continued critically ill for one week after which
gradual improvement was noted. She was out of bed
and eating quite well by the fourteenth postoperative day
when a severe headache developed. She also complained
of vertigo and numbness in the left arm and hand.
Rigidity of the neck was noted and paralysis of the left
upper and lower extremities developed. A septic type of
temperature curve was present. She died on the thirty-
first postoperative day. Autopsy was not permitted. The
cause of death was thought to be brain abscess, secon-
dary to pericholecystic abscess.
Case 2. Mr. O. L., age 46, was first admitted to St.
Luke’s Hospital on October 10, 1942, with a twenty-
four-hour history of recurrent colicky upper abdominal
pain. Nausea was present and he had vomited once.
The past history was non-contributory and this was his
first attack of upper abdominal distress. Physical exam-
ination revealed a middle-aged somewhat obese white
male in moderate distress. Positive findings were absent
except in the abdomen where marked tenderness was
present over the entire right abdomen but more marked
under the right costal margin. Moderate rigidity was
present. No masses were palpable. His temperature was
100 degrees, blood pressure 140/90. The pulse was 90
beats per minute and the leukocytes numbered 17,500.
Urinalysis was negative. A diagnosis of acute chole-
cystitis was made and conservative therapy instituted.
He improved gradually and by the fifth hospital day
the temperature and pulse were normal. The white blood
count was 7,500 and only slight tenderness was present
under the costal margin. He was discharged on a fat-
free diet. He remained symptom-free and a cholecysto-
gram was made on October 26, 1942, sixteen days after
the onset of his illness and it was reported as a non-
functioning gallbladder. X-ray of the stomach and duo-
denum was negative. Surgery was advised but refused.
He was readmitted to the hospital four days later with
recurrence of pain in the right upper abdominal qua-
drant. This time he did not improve. Moderate fever,
leukocytosis and tenderness persisted. Ten days after
this admission, a mass was detected for the first time
beneath the right subcostal margin and a pericholecystic
abscess drained on the twelfth hospital day. Following
profuse drainage of purulent and bile-stained fluid, he
gradually improved and was discharged on the fifteenth
day after operation and the twenty-eighth day after ad-
mission. A draining sinus closed spontaneously two
months later. Surgery was again advised but refused.
It was evident that there should be a better method
of treating people with acute gallbladder disease than
by simply watching them perforate. It is probably true
that the majority of patients seen with acute gallbladder
88
The Journal-Lancet
colic and even those with early acute cholecystitis will
undergo spontaneous resolution of the acute phase of the
disease with conservative management allowing a more
accurate diagnosis and surgery at a more carefully se-
lected time. There will remain the occasional fatality
as recorded above under such a policy as well as the
distressingly increased morbidity for often patients will
spend two or three weeks in the hospital while waiting
for the acute phase to recede only to return later at
another period for the elective surgery. It should also
be mentioned that under a conservative plan of treat-
ment of acute cholecystitis an occasional subhepatic ap-
pendix may rupture and an occasional walled-off per-
forated peptic ulcer go undetected. If one pursues the
plan of early operation for these cases, the exact pro-
cedure to be employed comes up for consideration. If
cholecystostomy were to be employed frequently, the
argument for lessened morbidity and lessened expense
loses its force for it is quite generally conceded that the
patient with cholecystostomy will commonly need chole-
cystectomy at a later date. However, it appears that
cholecystectomy can be done with safety in almost every
case. That operations can be done on patients with acute
gallbladder disease with reasonable mortality rates is
recorded in the recent literature.
During the past five years, largely as a result of the
cases cited, we have advised early surgery in our patients
with acute cholecystitis. We have become increasingly
satisfied with this way of handling these patients and
feel that a study of this material together with several
cases similarly treated prior to this time would be worth
reporting, particularly since it emanates from a small
hospital.
Review of Recent Literature
The ramifications of the problem have been discussed
at length in the literature. There is divergence of opin-
ion on many points. All feel that while the diagnosis
itself is seldom difficult, it is often extremely difficult
to know how far the disease has progressed. There seems
to be no clinical or laboratory procedure at present that
will tell the surgeon when gangrene is present and per-
foration imminent. It is this fact that makes most sur-
geons today feel that on being confronted with a patient
with acute cholecystic disease, it will save both himself
and the patient possible serious trouble to relieve the con-
dition surgically as soon as the necessary few hours have
elapsed for the proper preparation. Best1 reported 44
cases of acute gallbladder disease, one-half of which was
treated by a conservative policy and the latter half treat-
ed by a policy of early surgical intervention, the author
having changed his mind because of a distressingly high
mortality rate in the first half. "The lack of parallelism
between the pathology and the laboratory-clinical find-
ings is often more astounding in acute cholecystitis than
in acute appendicitis.” He then quoted different authors
who stated that acute cholecystitis if untreated will pro-
gress to gangrene, abscess, and perforation in from 10
to 30 per cent of cases. The total white count may fall
to normal or even subnormal values in the presence of
a progressive lesion of the gallbladder. Best feels that
careful analysis of the differential count is more valuable.
If the staff forms increase to over 10 per cent it is im-
portant. Thus, if the total white blood count is 6,000
but the staff count is 12 per cent, he then places three
zeros after the 12 and arrives at a figure of 12,000
which he considers the total white count. This rule
he feels is of considerable importance in all acute condi-
tions of the abdomen.
Edwards - stated that the gallbladder will perforate in
approximately 10 per cent of cases of acute cholecystitis
and favors early operation in all cases. Eliason and
Stevens 1 reported on studies made at the gastrointes-
tinal clinic at the University of Pennsylvania and found
that biliary tract disease accounted for 40 per cent of all
the cases seen there. Of these, 20 per cent were classified
as the acute type. They feel that a true obstructive gall-
bladder disease of more than two days’ duration will not
subside under any treatment except surgery. The patho-
logical state of a gallbladder cannot safely be estimated
by any physical or laboratory test; hence, the danger of
delay. They feel that if an acute cholecystitis patient is
seen within twenty-four hours, one should operate im-
mediately. As further emphasis on the failure to be able
to correlate the pathologic state of a gall-bladder with
the clinical and laboratory signs, Eliason and Stevens in
135 cases, found that the white blood count was normal
in 21 per cent, the temperature was normal in 23 per
cent. No mass was palpable in 30 per cent. Even local
tenderness was absent in 4 per cent.
Saint 4 stated "It is true that the majority of patients
will recover spontaneously from an acute attack of biliary
disease, but knowledge that this is so may prove a dan-
gerous possession.” He disagrees with the statement so
often quoted in the literature that there is often no
reliable correlation between the clinical symptoms and
the degree of inflammatory change in the ballbladder
because he claims that if impending gangrene and per-
foration are present one can always feel a palpable gall-
bladder. Hallendorf,'’ however, disagreed with Saint’s
rule and found that in 100 cases, in only 39 per cent was
a palpable mass felt on physical examination. He felt,
therefore, that Saint’s rule of waiting for a palpable
mass would seem to be misleading in many cases.
McNealy 0 reported 500 cases of acute gallbladder dis-
ease seen at the Cook County Hospital. The white blood
count was over 10,000, fairly consistently with perfora-
tion, gangrene, or empyema, but he states that one can-
not rely on it. In 99.6 per cent, pain was present. This
was the most reliable sign. In only 29 per cent of his
cases was a palpable mass present. Wallace and Allen '
reported on 2,273 operations for gallbladder disease dur-
ing a 10 year period at the Massachusetts General Hos-
pital. Of these 415 or 18.2 per cent had acute gallblad-
der disease with a 6 per cent mortality. This correspond-
ed with a mortality rate of 1.74 per cent in the chronic
cases. They stated that age, temperature, and white
blood count are unreliable guides for estimating the stage
of the disease process. In the cases reported, they pur-
sued a policy of watchful waiting and operated only if
March, 1949
89
failure of steady improvement was present. Of the pa-
tients that perforated, 30 probably perforated while un-
der observation in the hospital! Therefore, since no
reliable criteria to indicate the presence of gangrene or
perforation can be found, they advised a change in their
policy of watchful waiting to one of operating as soon
as optimum conditions of the patient and operating fa-
cilities are established. They found gangrene was present
very rarely before the sixth day of the illness. Therefore
early intervention would practically eliminate the hazard
of gangrene and perforation.
Marshall 8 stated that attempts have been made to
classify patients with acute cholecystitis from a clinical
standpoint into various groups and to give fixed rules
concerning when operation should be done. The results
in groups of cases are cited to indicate the effectiveness
of such effort to classify cholecystitis from the stand-
point of acute inflammation, age of the patient, rapidity
of progression of symptoms, and presence of complica-
tions. Although commendable it has caused great con-
fusion. Abdominal signs and laboratory findings do not
always give reliable indices as to the severity of the in-
flammatory process in the gallbladder and watchful wait-
ing may lead to serious complications. It is therefore
the custom at the Lahey Clinic, says Marshall, "to re-
gard every case of acute cholecystitis as an emergency
and to operate as early as possible.” He also feels that
acute cholecystitis commonly represents an acute inflam-
mation superimposed on an old chronic cholecystitis
associated with stones, a process which in many cases
should lead to the diagnosis and treatment before the
occurrence of the acute inflammation.
Cowley and Harkins !i in 25 cases of perforated gall-
bladder, found the white blood count in 24 per cent to
be below 10,000. Tenderness was present in 100 per cent
of cases and a mass was present in only 24 per cent.
Glen and Moore 111 have reported a wide experience with
acute cholecystitis at the New York Hospital since the
policy of early surgical intervention was instituted there
in 1932 by Heuer. They stated "In our total experience
with acute cholecystitis we have concluded that we are
unable to distinguish acute cholecystitis with gangrene
from perforation with walled-off abscess.” Free perfora-
tion of a gangrenous gallbladder into the peritoneal cav-
ity is rarely recognized early enough to save the patient’s
life. Because perforated ulcer, acute appendicitis, acute
pancreatitis, and acute gallbladder disease may lead to
death if surgical intervention is withheld, a differential
diagnosis appears less important than an attitude that
leads to early surgical treatment.
The evidence appears to favor the view that given a
case of acute cholecystic disease, one cannot know
whether it will go on to spontaneous resolution or
whether the complications of gangrene, pericholecystic
abscess and possibly free perforation may supervene.
How often do these complications occur? They occur
fairly frequently as attested by numerous reports in the
literature, apparently falling between 10 and 46 per cent
of all acute cases. Edwards - stated that the gallbladder
will perforate in approximately 10 per cent of cases.
Hallendorf found evidence of pericholecystic abscess
in 24 per cent of 100 cases of gangrenous cholecystitis
seen at the Mayo Clinic. Kunath 11 stated that 22 per
cent of acute gallbladders would perforate if left un-
treated surgically. Rubenstein reported several cases
of acute typhoid cholecystitis in which the incidence of
perforation was as high as 45 per cent. Johnston and
Otsendorph 1-5 attempted to determine the true incidence
of perforation of the gallbladder in 12,000 autopsies at
the Los Angeles County Hospital. In these 12,000
autopsies, 32 people died of perforated gallbladder dis-
ease, an incidence of 0.26 per cent. In other words, of
all causes of death, 1 person in 375 succumbed to per-
forated gallbladder. Surely this is a higher incidence
than heretofore believed. In 50 per cent of the per-
forated cases, no diagnosis had been made before com-
ing to autopsy. Johnston and Ostendorph believe that
physicians should accept early operation as the logical
means of limiting the morbidity and mortality of acute
cholecystitis. Heretofore, physicians have not realized
the incidence and the gravity of perforations. Cowley
and Harkins !) found that perforation occurred in 2.8
per cent of 12,915 collected cases of operations on all
types of gallbladder disease and that perforation occur-
red in 13 per cent in 2,261 cases of acute gallbladder
conditions in which the mortality rate was 20 per cent.
Heuer 14 in 1937 concluded that gangrene and perfora-
tion of the gallbladder occurred in 20 per cent of acute
cases treated conservatively in which the mortality rate
averaged 45 per cent. Heuer also found that perforation
in acute appendicitis occurred in 17.5 per cent in a series
of 593 cases and that perforation of the gallbladder in
a series of acute gallbladder conditions observed during
that same period occurred in 15.7 per cent. This should
dispel any contention that perforation of the gallbladder
is rare. Thus it occurs about as often as perforation of
the appendix. Frank Glenn 10 felt that the mechanism
of perforation may be accounted for by the fact that
Rokitansky-Aschoff sinuses were found in one-third of
all the gallbladders that had perforated. These sinuses
associated with infection and calculi account for the
mechanism of perforation in many cases. They also
account for the occasional case seen where more than one
perforation was present. They state that one cannot dif-
ferentiate preoperatively between the acutely inflamed
empyema and gangrene.
Most all agree that in a patient over 50, the mortality
rate in acute cholecystic disease rises sharply. Thus
Glenn 1,1 reports 93 patients over 50 years of age with
acute gallbladder disease. In all of these it represented
a process of long standing. Many had co-existing dis-
orders of age such as diabetes, high blood-pressure, ar-
teriosclerosis, which often complicated the problem con-
siderably. Sixty-nine of these were treated with chole-
cystectomy. The others were treated by cholecystostomy.
The over-all mortality rate was 6.4 per cent. Heuer,
Hallendorf, and McGuigan also stressed the increased
mortality rate in the older age groups. McLannahan 1,1
found that the mortality rate was eight times greater in
patients over 60 years of age.
90
The Journal-Lancet
On examination of the reported mortality figures, one
finds wide variation due to many factors. Seldom are
any two cases alike as we all know. Some surgeons favor
immediate operation after a brief period of preparation
and others favor delay. Some attempt to find rules to
fit every case and others attempt greater individualiza-
tion. Cholecystectomy is recommended by many when
"feasible.” Cholecystostomy is employed more often by
others. Partial cholecystectomy as described by Ritchie1 1
is popular with a few authors. In this procedure the
gallbladder is split down to the cystic duct. The contents
are removed. The free portions of the gallbladder wall
are cut away leaving only the portion attached to the
liver. In acute cholecystitis, the mucosa in this segment
can be disregarded as it is usually necrotic and will
slough. We have had no experience with this procedure,
but it appears to have considerable merit in difficult
cases. The reported results make it appear to be a better
operation than cholecystostomy (Morse and Barbls).
Common duct stones are found in approximately the
same ratio as in chronic cases and most authors recom-
mend common duct exploration if indicated. Jaundice
may occur in acute cholecystitis in the absence of com-
mon duct stones so that the decision as whether or not
to explore the common duct may be a difficult one. It
was formerly thought that the very factor which usually
produced the acute gallbladder attack; namely, impaction
of a stone in the cystic duct, often precluded the possi-
bility of common duct stones. This, evidently, is dis-
proved by reported figures.
The mortality rates reported following the early sur-
gical treatment of acute gallbladder disease while almost
uniformly slightly higher than the mortality rates report-
ed following operations for chronic gallbladder disease,
offer a considerable advantage to the patient were he
to be allowed the alternative of facing a 10 to 46 per
cent possibility of perforation with its attending 40 to
50 per cent mortality rate. Thus, Adams and Stranna-
han 10 in reporting 1,104 cases of gallbladder disease of
all types treated at the Lahey Clinic found 55 or 5 per
cent fell into the category of acute cholecystitis. All of
these were treated by early cholecystectomy with two
deaths, a mortality rate of 3.6 per cent. The incidence
of common duct stones in these 55 cases was about the
same as in their chronic cases. Best1 reported stones
were present in the common duct in 20 per cent of his
acute cases and while he advocates exploration of the
common duct in those cases where it is technically fea-
sible, if too much edema is present in the ductal area,
he relies more on his biliary flush to eradicate possible
remaining stones. Eliason and Stevens 1 in their 135
reported cases of acute cholecystic disease treated by
early operation, found only two deaths, a mortality of
1.5 per cent. They advocate the following plan for
acute cases. If the patient is seen early, prepare and
operate. This represents in their opinion the ideal type
of cholecystectomy for acute cholecystitis when very little
edema is present, but if the patient is seen after twenty-
four to thirty-six hours, then they give him morphine,
glucose, and a period of starvation for the next twelve
to eighteen hours. If, after this time, any one of the
symptoms of acute cholecystitis fail to subside, they op-
erate. In their cases, cholecystostomy was performed in
68 per cent with a mortality of 2.1 per cent. Chole-
cystectomy was done in the remaining 32 per cent with
no deaths. Of all the cholecystostomies done, 21 per
cent required secondary operations later, in all of which
there was no mortality.
Heuer 20 was one of the first advocates of early sur-
gical intervention, having seen Halstad remove an acute
gallbladder in 1910 at which time he was impressed by
the remarkably smooth convalescence. He was respon-
sible for initiating a policy of early surgical intervention
in cases of acute cholecystitis at the New York Hospital
in 1932. Since that time up to and including 1945 they
have had 527 cases treated with early surgery with 13
deaths, a mortality of 2.4 per cent. These were reported
by Glenn and Heuer.20 In 87.4 per cent, cholecystec-
tomy was done and in the remainder cholecystostomy.
In this latter group there were five deaths. They go on
to state, however, that the latter operation may occa-
sionally be a life-saving measure in a very sick patient,
although it is not to be preferred if cholecystectomy
seems safe. In the presence of gangrene and perforation
with general peritonitis, a long procedure should be
avoided, but if local abscess is found, they usually do a
cholecystectomy. The common duct was explored only
in those with very definite indications and was done in
8.9 per cent of cases. Of these, stones were recovered
in 61 per cent. They made no distinction between the
number of days the disease had been present, but indi-
vidualized each case. The mortality rate thus reported
in their cases was comparable to that of the non-acute
type.
Goldman 21 reports on bacteriologic studies in 160
cases of acute gallbladder disease. This study coincides
with a current feeling that acute gallbladder disease is
first of all a mechanical, circulatory, or chemical one.
They found a low incidence of positive cultures found
in the first three days of the disease. The highest mor-
tality rate was between the fourth and eighth day when
the incidence of positive cultures was the highest. In
53 per cent of these cases there were complications due
to secondary bacterial invasion. Therefore, the logical
conclusion is that one can avoid these complications by
early surgery and the use of antibiotics. Graham 22
stated "The time will come when an educated profession
and an educated public will demand a prompt operation
in acute gallbladder attacks. Cholecystostomy should
seldom if ever be performed.” Hallendorf ° stated that
in 100 cases of gangrenous cholecystitis, cholecystectomy
was done in all cases although it was difficult in some.
Three patients died. The results of the remaining cases
were classified as good. Heifetz and Senturia 23 report
on acute pneumo-cholecystitis, a condition in which an
acute infection is present and characterized by the pro-
duction of gas within the gallbladder. They collected
a total of 8 cases from the literature and reported 2 of
their own. Surgery alone, according to these authors,
is an effective treatment for this condition.
March, 1949
91
McGuigan 24 made a comparative study of the mor-
tality rate after immediate and delayed operations in
acute gallbladder disease. He feels that if there be evi-
dence of progression of the infection as shown by in-
creased fever, leukocytosis, pulse rate, or increase in size
of a tender area with muscle spasm that operation should
be performed without delay. He studied 123 cases of
acute gallbladder disease seen during the past decade.
All of these came to operation, the mortality being 5.6
per cent. The most important signs and symptoms in
his cases were pain, tenderness, and rigidity. Thus, one
sees the same sequence as in acute appendicitis although
in a different location. He believes that cholecystectomy
is the procedure of choice after a brief period of pre-
operative preparation. There were only 2 cases of per-
foration in this series, but he stated that 10 more may
have perforated if surgery had been longer delayed as
gangrene was present in those 10.
McLannahan 10 reported 140 cases of acute gallblad-
der disease seen at the Union Memorial Hospital in
Albany, New York. The total mortality rate in his
series was 8.6 per cent. Jaundice was seen in 20 per cent
in which only 5 had common duct explorations. Chole-
cystostomy offered a 25 per cent mortality and chole-
cystectomy a 4.5 per cent mortality, cholecystostomy
however being used in those patients who were desper-
ately ill so that it was not fair to compare the mortality
rates in the two groups. McNealy 0 reported 500 cases
of acute gallbladder disease seen at the Cook County
Hospital. In 6.9 per cent, perforation was present. This
was attended with a 42 per cent mortality rate. In
slightly less than one-half of these cases, namely 216,
was operation performed. He concluded that it was best
to operate within the twenty-four to forty-eight hour
initial period, but only 23 per cent of his cases were seen
within that period so that it was hard to lay down any
definite rule of conduct so far as either the patient or
the doctor was concerned. Many patients had weath-
ered previous attacks of gallbladder colic and each
day that went by they seemed to feel that it would
be the last and after it was apparent that the attack
would not subside, oftentimes four or five days had
gone by. Thus, it was impossible in many instances
to treat these patients in the so-called early period.
The mortality rate rises sharply if operated three days
or more after the onset, according to McNealy. He
favors a policy of careful evaluation. If the symp-
toms do not abate promptly, operation is advised. He
prefers partial cholecystectomy to cholecystostomy in
difficult cases. Myers 2,1 favors early operation in all
cases of acute gallbladder disease while Sanders 29 feels
that many acute attacks will subside but still favors
early operation. The latter author reviewed 3,000 cases
of all types of gallbladder disease. The signs according
to him that demand urgent surgery are sustained pain,
tender mass, abdominal rigidity, rising leukocyte count,
and rising temperature. Smith 27 reported 332 cases of
acute gallbladder disease from the Presbyterian Hospital
in New York City in which cholecystectomies were done
in 223 with a mortality rate of 3.5 per cent. The remain-
ing 103 cases had cholecystostomies with a mortality rate
of 11.6 per cent. He points out that these mortality
rates are difficult to evaluate because the patients having
cholecystostomies were the critically ill ones. Wallace
and Allen ‘ in reporting their 415 cases of acute gall-
bladder disease studied at the Massachusetts General
Hospital during a ten year period, advised cholecystec-
tomy as the ideal procedure. Zollinger and Cutler 28
feel that no rigid rule can be formulated for the treat-
ment of each case as each case should be treated as an
individual surgical problem and should always be treat-
ed in a hospital with careful watching. They reported
146 cases of acute cholecystitis with a 2.6 per cent mor-
tality rate. Cholecystectomy was done in 70 with no
deaths and in only one-half of these cases was a positive
culture found at operation \yhich again emphasizes the
fact that mechanical or chemical factors were the ini-
tiating causes. Exploration of the common bile duct was
done in 5 per cent of those cases and only 15 per cent
of which were stones found. Cholecystostomy was done
in the remaining 28 cases with a mortality of 10.7 per
cent. This was again reserved for the more serious cases
so that a comparison of the two mortality rates was diffi-
cult to evaluate. In the 4 deaths, all had the disease at
least eight days.
Cowley and Harkins 9 feel that cholecystectomy is
practically always feasible if the patient is seen within
forty-eight hours. They report a mortality rate of 2.9
per cent in 86 cases coming to operation within forty-
eight hours. This rate compares favorably with the non-
acute type. Morse and Barb 18 found that by dividing
the type of acute cholecystitis into four pathologic
groups, that is acute, purulent, gangrenous, and perfor-
ated, the mortality ascends from 6 per cent in the first
to 33 per cent in the perforated group. Thus increasing
severity of the disease is accompanied by mathematical
progression of the mortality rate. They favor partial
cholecystectomy and report 12 cases with no deaths.
These cases were drained with a catheter in the cystic
duct and a cigarette drain. Root and Priestley 29 re-
ported 127 cases of acute cholecystitis seen at the Mayo
Clinic in which there were eight deaths or a mortality
rate of 6.2 per cent. They favor prompt operation if
seen within seventy-two hours. Evidence of hepatitis and
pancreatitis were present in 16 per cent. They feel that
the mortality and complications were considerably in-
creased in operations performed for acute cholecystitis
as compared with those performed for chronic chole-
cystitis. On this account, if seen after the initial seventy-
two hour period, they advise delay if possible until the
acute process subsides. In this series, cholecystectomy
was done in 64 per cent, cholecystostomy in 3 1 per cent,
and partial cholecystectomy in 2.3 per cent. MacDon-
ald 30 suggests a two-stage management of the acute
cholecystitis patients; namely, a cholecystostomy with a
mushroom catheter under local anesthesia which disturbs
the patient only slightly, and advises a later curative
cholecystectomy when common duct exploration if neces-
sary can be done with greater ease. Twelve cases treated
in this manner were reported.
92
The Journal-Lancet
Analysis of Material Used in
Present Study
During a seven-year period from January 1, 1942,
to January 1, 1949, there were 531 operations done at
St. Luke’s Hospital for non-malignant disease of the
gallbladder. Of these, 48 were classified as acute. This
was done by careful analysis of the surgeon’s notes and
the pathologic reports. In a few cases, the pathologic
reports were missing but the surgeon’s notes and the
clinical record of the patient justified placing those pa-
tients in this group. Thus the acute cases constituted
9 per cent of the total group. There were 7 deaths from
all causes in the total of 531 operations, a mortality of
1.3 per cent. There were no deaths in the 48 acute
cases. Of the 48 acute cases operated, the ages ranged
from 19 to 75 years, the average being 52.2 years.
Thirteen or 27 per cent were males. The symptoms had
been present on admission from seven hours to twelve
days, the average being two and one-half days. There
seemed to be no correlation between the duration of
symptoms and the postoperative morbidity. Sixty-four
and four-tenths per cent gave a history of previous
attacks. The total white blood count in 20.8 per cent
was within normal limits and in all averaged 15,400.
However, 92 per cent had an increased polymorpho-
nuclear count which appears to be more important than
the total count in this series. The staff forms were not
recorded often enough to be of any significance. Hence,
Best’s 1 rule cannot be applied in this study. It was
possibly to do a cholecystectomy in 45 of the 48 cases.
Thus, in only 3 or 6.2 per cent were technical difficulties
such as to require cholecystostomy. In only 4 cases was
the common duct explored and stones were recovered
in 2. This would seem to be low in comparison with
the experience of others and yet to our knowledge, no
case has symptoms of residual common duct stone. By
way of comparison in the non-acute cases, the common
duct was explored in approximately 30 per cent. In 8
patients or in 16.6 per cent of the acute cases, perfora-
tion was present at the time of operation. We could find
no significant correlation to perforation in these 8 pa-
tients with duration of symptoms. The postoperative
period was considered uneventful in 33 or 68 per cent.
In the remainder, wound infection occurred in 3 cases
(in two of these perforation of the gallbladder had been
present at operation) . In 2 patients, the wound sepa-
rated and required secondary closure. Oliguria was re-
corded in 3 cases, inhibition ileus in 2, cardiac decom-
pensation in 2, thrombophlebitis in 1, and pneumonia
in 1. In 2 cases, subhepatic abscesses developed; one
required incision and drainage, the other drained spon-
taneously. In both of these patients oxycel sponges were
left in the gallbladder bed to control bleeding. We feel
that these oxycel sponges were responsible for the de-
velopment of the abscesses and in several other cases a
persistent low grade fever was thought to be due to the
presence of oxycel sponges. We no longer use them.
The postoperative hospitalization period averaged twelve
and one-half days for the whole group. In the last three
years, the average postoperative hospital period has been
cut to nine and one-half days, this decrease probably
being due in no small degree to the routine use of anti-
biotics. In this last figure, one case is excluded who re-
mained in the hospital forty-five days because of the
development of a duodenal fistula. This is one of the
patients cited above with a subhepatic abscess due, we
feel, to the oxycel sponges. The fistula closed spon-
taneously and she has remained well.
It is agreed that when one attempts cholecystectomy
on the acutely inflamed gallbladder it is more difficult
than on the non-acute type. Subcostal incisions were em-
ployed in all with complete division of the right rectus
muscle and extension of the incision across the mid line
and laterally if necessary to obtain good exposure. The
gallbladder was usually completely covered with edem-
atous omentum which was easily separated with gloved
finger as a rule. It was almost always necessary to
aspirate the gallbladder contents with a trocar, open the
fundus widely and remove the stones, being especially
careful to remove impacted stones, for the proper ex-
posure of the ducts was then made easier. It was com-
monly possible to brush the edematous peritoneum-cov-
ered fatty tissue away from the ducts with gauze. Some-
times this was made easier with the left forefinger inside
the gallbladder. We make it a rule not to divide what
may appear to be the cystic duct until the common duct,
the cystic duct, and the cystic artery are all clearly iden-
tified and separated from surrounding structures. In a
few instances, the ductal areas were so difficult of iden-
tification that the gallbladder was dissected from the
liver before proper dissection in the ductal area could be
carried out. All cases were drained with a single pen-
rose drain brought out through a stab wound to the right
of the incision. The wounds were closed with interrupt-
ed linen sutures.
It was interesting for us to discover that in only 18
of the 48 acute cases was operation carried out in the
so-called early period, that is, twenty-four to forty-eight
hours after onset of symptoms. In one instance, sixteen
days had elapsed since onset but this patient had re-
mained at home for twelve days before seeking relief.
Even so, the gallbladder was not perforated, although
pathologically acute. On the other hand, 1 patient per-
forated only forty-eight hours after onset of symptoms.
This emphasizes again the remarkable variations present
in acute gallbladder disease and that attempts to classify
and base treatment on the time factor alone seem with-
out real value. We feel after a study of the subject in
the literature and our own small group of cases that we
shall continue to advise early operation after the elapse
of sufficient time in which to study and prepare the
patient carefully.
Summary
1. Acute cholecystic disease if untreated surgically
will result in gangrene, abscess or perforation in from
10 to 46 per cent of cases.
2. Perforation may result with a mortality rate as
high as 45 per cent.
March, 1949
93
3. There are no known clinical or laboratory signs
that are of any real value in determining when gangrene
is present and perforation imminent.
4. Operation should be advised in acute gallbladder
disease as soon as the patient can be properly prepared.
5. Forty -eight cases of acute gallbladder disease are
reported herein which were treated surgically with no
deaths.
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Am. J. Surgery 61:38-41, 1943.
30. MacDonald, Dean: Treatment of Acute Cholecystitis;
Suggested Two-Stage Treatment. Arch. Surg. 47:20-25, 1943.
UNIVERSITY OF MINNESOTA CONTINUATION COURSES
The University of Minnesota announces the following courses: On March 28, 29 and
30 a course in Physical Medicine will be presented at the Center for Continuation Study.
This course is intended for doctors of medicine who are engaged in general practice. The
various forms of physical therapy will be discussed and the indications, contra-indications,
dangers and limitations will be emphasized. Special emphasis will be placed upon the role
of physical medicine in such conditions as arthritis, fractures, and various psychosomatic dis-
turbances. Faculty for the course will include members of the staff of the University of
Minnesota Medical School and the Mayo Foundation.
A course in Pediatrics will be presented April 7, 8 and 9 in the Center for Continuation
Study for doctors of medicine who are specializing in Pediatrics. The first day of the course
will be devoted to problems of allergy in pediatric practice. Emphasis will be placed upon
diagnosis and management of hay fever, asthma, and skin allergy. Immunological concepts
will be emphasized. An evaluation of the newer drugs will also be presented. Two days of
the course will be devoted to infectious diseases in pediatric practice. Subjects to be presented
include common respiratory diseases, toxoplasmosis, histoplasmosis, tuberculosis, and rheu-
matic fever.
94
The Journal-Lancet
Methemoglobinemia:
Report of Two Cases and Clinical Review* *
Louis B. Silverman, M.D.
Grand Forks, North Dakota
Interest in the subject of methemoglobinemia has been
stimulated by recent reports in the literature
of poisoning in infants caused by excessive content of
nitrate in well water. We wish to report two cases and
to give a brief review of the clinical aspects of methemo-
globinemia.
Case 1. The patient, a boy aged one month, became
cyanotic on the evening of October 2, 1947. The mother
thought the infant might have had a slight blue spell
two days before. There were no other complaints and
the infant had been well until the evening of admission.
The birth weight was 2.87 kg. The delivery and neo-
natal history were uneventful. He was receiving a for-
mula containing 225 cc. of evaporated milk, 375 cc. of
boiled water, and 24 grams of carbohydrate (dextri-
maltose No. 1). The water was obtained from a well
on the farm. The infant had received ten drops of
cod liver oil concentrate daily for one week but had
refused orange juice.
The infant was brought to the hospital about four
hours after onset of symptoms. He was acutely ill.
There was a striking brownish grey cyanosis of the skin
and mucous membranes. The infant was very dyspneic,
and the heart tones were rapid, with suggestion of tic tac
rhythm. The peculiar cyanosis was intensified when the
baby cried. Oxygen inhalation by mask gave no relief.
The rest of the examination was negative.
A chest film was normal. The urine contained one plus
albumin but was otherwise negative. The hemoglobin
was 97 per cent Sahli. Erythrocytes numbered 4,930,000.
Leukocytes were 12,750 with 72 per cent lymphocytes,
16 per cent neutrophiles, 10 per cent mononuclears, and
2 per cent eosinophiles.
Since there was no evidence of cardiac or pulmonary
disease, a diagnosis of methemoglobinemia was enter-
tained, and 5 cc. of blood were withdrawn from the
femoral vein for inspection. The blood had a definite
chocolate color. A solution of 1 per cent aqueous meth-
ylene blue was made up and autoclaved. Four hours
after admission 0.5 cc. of 1 per cent methylene blue
was given intravenously. Fifteen minutes later the color
was definitely improved. Within thirty minutes the in-
fant’s color was pink and he appeared normal. The
infant was discharged from the hospital the next morn-
ing apparently none the worse for his experience. Sub-
sequent examinations at the office revealed the infant
to be normal and doing well. Samples of water from
*From the Grand Forks Clinic.
the well were eventually obtained and were found to con-
tain nitrates in the amount of 107 parts per million.')'
Case 2. The patient, a boy aged 2 months, was ad-
mitted to the hospital on June 6, 1948. About three
hours before admission, while giving the infant his morn-
ing bath, the mother noted that he was blue and that
he seemed "lifeless.” The mother stated the infant was
unusually sleepy the day before admission. There had
been no other complaints.
The infant’s birth weight was 3.4 kg. The immediate
birth and newborn periods were uneventful. The mother
discontinued the breast feedings at three weeks because
she thought the infant was not getting enough milk.
She gave him a formula containing 225 cc. of evaporated
milk, 375 cc. of boiled water, and 24 grams of carbo-
hydrate (dextri-maltose No. 1).
He was examined at five weeks, at which time he
weighed 4.2 kg. The infant was found to be normal.
At this time the feeding mixture contained 390 cc. of
evaporated milk, 570 cc. of boiled water, and 38 grams
of carbohydrate (dextri-maltose No. 1). He received
5 drops of a cod liver oil concentrate daily, but the
mother had neglected to give orange juice. The rest of
the history was negative.
Examination revealed a dusky slate grey generalized
cyanosis of the skin and mucous membranes. The in-
fant was irritable. He was well hydrated and the rest
of the examination was negative. The hemoglobin was
80 per cent Sahli. Erythrocytes were 3,650,000. Leuko-
cytes numbered 9,900 with 66 per cent lymphocytes,
29 per cent neutrophiles, monocytes 3 per cent, and
eosinophiles 2 per cent. Five cc. of blood withdrawn
from the femoral vein revealed a chocolate color. Spec-
troscopic examination of the blood* revealed absorption
bands compatible with the presence of methemoglobin.
About 45 minutes after admission, 100 mgms. of
ascorbic acid was given intravenously. There was some
perceptible improvement in the color of the trunk and
lips within 20 minutes. However, the greyish color of
the skin and the cyanosis of the nails persisted. This
was especially accentuated when the infant cried. Venous
blood was still chocolate colored.
The status remained the same for the next four and
one-half hours, after which time 14 cc. of 1 per cent
methylene blue was given intravenously. Within five
'(■Analyses of water for nitrate were made by Division of
Laboratories, North Dakota State Department of Health;
Melvin E. Koons, Director.
*Spectroscopic examination performed by Dr. G. A. Abbott,
Chemistry Department, University of North Dakota.
March, 1949
95
minutes the finger nails began to lose their cyanosis, and
the baby became pink while crying. Ten minutes after
injection of methylene blue the blood withdrawn for
inspection was of normal color. Within 20 minutes the
color of the infant appeared entirely normal.
The infant was discharged from the hospital the same
day. Several days later samples of the well water were
analyzed and were found to contain nitrates in amounts
of 200 p.p.m.
Discussion
Hemoglobin ■’ combines with oxygen by reason of the
iron which it contains. This combination is not a stable
one. When hemoglobin is exposed to oxygen pressure,
oxygen is taken up, but no true oxide is formed. The
iron remains in the ferrous state, two atoms of oxygen
uniting with one atom of iron. This oxygenated hemo-
globin (not oxidized) is defined as oxyhemoglobin.
Methemoglobin is a true oxide, in which an atom of
oxygen combines with an atom of iron. This is a stable
compound, and the gas can only be removed by chem-
ical reaction. It is normally present in the circulating
blood in the amount of about 0.1 gram per 100 cc.
(0.6 per cent.) When methemoglobin amounts to 3
grams per 100 cc. of blood it gives rise to a peculiar
cyanosis. Grossly the blood has a characteristic choco-
late color. The color of the serum is normal, since the
pigment is in the red cells. Clinically the cyanosis is
described as brownish or slate grey.
Methemoglobin itself is not toxic, but it is incapable of
giving up oxygen to the tissues. Symptoms will depend
on the extent to which it replaces oxyhemoglobin. Met-
hemoglobin has a specific absorption band which can be
identified by spectroscopic examination. It can also be
measured quantitatively by manometric methods. It
differs from the cyanosis of cardiac or pulmonary dis-
ease, which is caused by an excessive amount of reduced
hemoglobin in the capillaries.
Methemoglobinemia is divided into two types: (1)
congenital idiopathic methemoglobinemia, (2) acquired
methemoglobinemia.
Sievers and Ryon 0 reported a case of congenital met-
hemoglobinemia in a 19 year old woman, and have writ-
ten a good review of the subject. They found 18 cases
reported up to 1945. The first case to be confirmed by
spectroscopic method was reported by Slosse and Wy-
houw 7 of Belgium in 1912. However, most of the cases
have been reported since 1930.
It has been suggested that the conversion of methemo-
globin to hemoglobin is dependent on the reducing sys-
tem present within the red cell. Methemoglobin is con-
stantly being produced in the circulating blood. It is
postulated that in cases of congenital methemoglobine-
mia, this reducing system within the red cell which nor-
mally keeps the methemoglobin at low concentration,
is totally or partially inactive. This defect is apparently
congenital, and a few of the cases have been present
in siblings.
So far, no definite hereditary pattern has been estab-
lished. However, Codounis 8 and co-workers in France
recently reported 14 cases in four successive generations
of one family tree. They state that methemoglobinemia
is both congenital and familial, that it is transmitted
as a dominant characteristic, is transmitted by both male
and female, and has no predilection for either sex. On
the basis of this study they suggest that the term heredi-
tary methemoglobinemic cyanosis be applied to the dis-
ease, and that it should be considered another hereditary
disease of the blood, such as, for example, hemophilia
and congenital hemolytic icterus.
It is of interest to note that methemoglobin produced
by oxidation in vitro will disappear after standing in a
test tube at room temperature for 24 hours. It has been
demonstrated that the blood of a patient with congenital
idiopathic methemoglobinemia will maintain a constant
level for days.9
In patients with congenital idiopathic methemoglo-
binemia, dyspnea on exertion and tachycardia are fre-
quent findings. They may complain of nervousness,
irritability, and frequent headaches. The skin presents
the characteristic brownish grey color, especially about
the lips, ears, nose, cheeks, finger nails, and mucous
membranes of the mouth. So far, no clubbing of the
fingers has been reported.
Acquired methemoglobinemia may follow ingestion,
and/ or absorption of sulfanilamide, nitrobenzene, ana-
line, nitrites, nitrates, and acetanilid. Promin,1" the drug
used in conjunction with streptomycin for treatment of
tuberculosis, is said to produce methemoglobinemia. The
nitrates are one of the frequent causes of acquired met-
hemoglobinemia.
There have been a number of cases of methemoglo-
binemia caused by the ingestion of diarrhea mixtures
containing bismuth subnitrate. A case of severe poison-
ing in a five week old infant was recently reported by
Wallace,11 who also reviewed the literature of bismuth
subnitrate poisoning. Adults have developed methemo-
globinemia after ingestion of ammonium nitrate over a
period of time for the purpose of initiating diuresis.12
Comley 1 in 1945 demonstrated that infants ingesting
well water containing large amounts of nitrate (more
than 10 parts per million) developed methemoglobin-
emia. Since that time there have been additional re-
ports of well water poisoning in infants by reason of
excessive nitrate content. 2,3,4
The actual cause of methemoglobinemia by nitrate
ingestion is the nitrite ion. On the basis of bacteriologic
studies, it is generally accepted that the nitrates are con-
verted to nitrites by the intestinal flora. Upon absorp-
tion from the bowel, the nitrites bring about the patho-
logic oxidation.
The reported cases of well water poisoning have been
in young infants, their ages varying from two to five
weeks. Our second case was two months old, and the
later onset may be due to the fact that the infant was
breast fed the first three weeks. The cases reported by
Comley had diarrhea. Whether this predisposed to the
poisoning or was a result of other contaminations in the
water is not known. In other cases reported there is no
96
The Journal-Lancet
history of intestinal complaint, nor was there such in
our two cases. A damaged intestinal mucosa may favor
the absorption of nitrite, and methemoglobinemia has
been associated with diarrhea in adults.
The first infant reported in this paper had a one year
old brother and a four year old sister, neither of which
demonstrated any evidence of methemoglobinemia. Faw-
cett and Miller ~ reported methemoglobinemia in four-
teen day old twins; a six month infant living in the same
house was free. The older infant had been using a for-
mula containing less water. The greater turnover of
water in proportion to body weight has been cited as one
of the reasons for the apparent exclusive incidence in
newborn or very young infants.
In addition to relatively high fluid intake, Comley 1
feels there are other factors which make the infant more
susceptible to nitrate. Among these are the fact that the
infant contains much less oxidizable hemoglobin than the
adult, that the intestinal flora may contain more nitrite
converters, that the infant’s intestinal mucosa is more
easily damaged, and that the limited excretory power of
the young infant’s kidney may favor nitrite retention.
It is also suggested that the infant’s enzymatic reduction
and oxydation system may be more firmly bound to the
nitrite ion. Darrow 1,! believes that the methemoglobin-
emia found in advanced stages of dehydration in infan-
tile diarrhea may in some degree be due to alterations
of the enzyme system brought about by circulatory and
electrolytic changes.
Cornblath and Hartmann,10 on the basis of a recent
study, claim that only younger infants develop methemo-
globinemia upon ingestion of water containing nitrate
because of the low gastric acidity characteristic of the
neonatal period. They found that when the pH of the
gastric juice is over 4.0, nitrite producing organisms can
exist high in the gastro-intestinal tract in sufficient num-
bers to reduce nitrate to nitrite before the former can
be completely absorbed. In a control group of infants
whose gastric acidity was increased by lactic acid milk
feedings, they were unable to produce methemoglobin-
emia with mixtures containing high nitrate content.
The diagnosis of methemoglobinemia once considered
as a possibility should not be difficult. Clinically the
brownish grey cyanosis is characteristic, and once seen is
not difficult to recall to mind. Venipuncture will reveal
the chocolate color of the blood. Spectroscopic examina-
tion will identify the methemoglobin absorption band.
The laboratory with proper facilities can measure blood
levels by manometric methods.
In idiopathic types there may be a congenital and/or
a familial history. Although responding to treatment,
once therapy is discontinued, the cyanosis in idiopathic
cases returns. In acquired types, a history of drug inges-
tion or chemical contact can usually be confirmed. In
rural areas, well water should always be considered a
possibility if used in the infant’s feeding mixture. A
nitrate content much in excess of 10 ppts. per million
establishes the cause as well as the source. The prompt
response to treatment confirms the diagnosis.
The only other pigment which may impart to the
blood a chocolate color is sulfhemoglobin. Most of the
drugs which cause methemoglobinemia may also cause
sulfhemogiobinemia. However, acetanilid and phenacitin
are the most frequent cause of this condition, which is
relatively rare. They sensitize hemoglobin so that it com-
bines with hydrogen sulphide which can be absorbed
from the intestinal tract. Hydrogen sulphide is said to
be absorbed in appreciable amounts from the intestinal
tract in extreme cases of "intestinal putrefaction.” In
sulfhemogiobinemia the cyanosis has a lead blue or
mauve lavender tint.14 The cyanosis from sulfhemo-
giobinemia remains for several weeks after the offending
agent is removed, while methemoglobinemia disappears
in several days under similar circumstances. Sulfhemo-
globin can be differentiated from methemoglobin by
spectroscopic examination. This condition has been called
enterogenous cyanosis, and arises when the abnormal
pigment amounts to over 3 grams per 100 cc. of blood.
In the acquired type of methemoglobinemia, the treat-
ment will depend on the extent to which, and the ra-
pidity with which anoxia develops. Despite visible
cyanosis, if the symptoms are mild, merely the removal
of the offending agent will allow the spontaneous re-
conversion of methemoglobin to oxyhemoglobin within
a day or two. However, if the onset is rapid or anoxia
is threatening to life, the introduction to methylene blue
in proper amount will quickly terminate any danger.
Wendel,1'1 in 1939, controlled nitrite induced met-
hemoglobinemia in dogs with methylene blue. Subse-
quently, Hartmann 16 and his associates successfully
used the dye in the prophylaxis and treatment of met-
hemoglobinemia caused by ingestion of sulfanilamide.
Methylene blue introduced in large amounts causes
methemoglobinemia. This property has been utilized in
the treatment of cyanide poisoning. In small concentra-
tions it apparently serves to initiate a catalytic reaction
which reduces methemoglobin to hemoglobin in the ery-
throcyte.
No toxic effects from small doses of methylene blue
have been reported. For intravenous use, the recom-
mended dose is 1 to 2 mgm. per kg. It is quite pos-
sible that smaller doses are as effective. In our second
case we used 0.5 mgm. per Kg. The drug can be ob-
tained in sterile ampules containing 1 per cent solution
for intravenous use. However, a I per cent solution can
be easily made and autoclaved. This can be kept in the
emergency treatment room and autoclaved from time to
time. It is not necessary to dilute as has been previously
recommended. A fourth or half cc. of a 1 per cent solu-
tion given by hypo needle into the vein simplifies the
procedure in the treatment of an infant. Subcutaneous
administration is to be avoided. Methylene blue can be
given orally. It is recommended that the oral dose be
ten times the intravenous dose. Vomiting, diarrhea,
headache, and tinnitus may occasionally occur with oral
administration.11'
Ascorbic acid is capable of reducing methemoglobin
in vitro and in vivo.10 It was first used for this purpose
March, 1949
97
by Lian, Trumusan, and Sassier,1 ' in France who dem-
onstrated its effectiveness by injecting 100 mgm. daily
in a case of congenital methemoglobinemia. Fiowever,
ascorbic acid acts rather slowly. Sievers,1’ et al, cite a
case of idiopathic methemoglobinemia in which 400
mgm. of ascorbic acid were given daily. By the seventh
day the methemoglobin had dropped from 25 per cent
to 1 1 per cent. On the eighth day, 7 cc. of 1 per cent
methylene blue was given intravenously and the cyanosis
disappeared in 30 minutes. In congenital idiopathic met-
hemoglobinemia, ascorbic acid is the treatment of choice.
The effective dose is 100 mgm. four times daily for an
adult, and smaller amounts would probably be effective
for younger patients. Larger dosage is apparently of
no value. The ascorbic acid either serves as a catalyst
or activates another reducing system. Ascorbic acid is
not recommended for the treatment of acute acquired
methemoglobinemia.
The prognosis in acquired methemoglobinemia is good
if treatment is instituted before severe anoxia occurs.
A rapid onset may cause shock or death similar to that
from a rapid exsanguination. Congenital methemoglo-
binemia cannot be cured at the present time. Continu-
ous treatment with ascorbic acid orally can prevent
symptoms and alleviate cyanosis.
Public health considerations are important. Bismuth
subnitrate could well be dispensed with in the treatment
of diarrhea. Nitrite containers should be labeled and
kept away from foodstuffs. Substances containing ana-
line should not be incorporated in clothes or toys. Nitro-
benezene contained in shoe and furniture polish has
caused poisoning. Physicians practicing in areas where
water is obtained from wells should be familiar with
this condition. The writer now makes it a practice to
inquire about the water supply of newborn infants who
obtain their water from wells. If the description and
location of the well make it suspect, the mother is ad-
vised to send in a sample of the water to be examined
for nitrate content. If local facilities for such testing
are not available, most state health departments will
offer the services of a chemist.
Summary
Two cases of methemoglobinemia in infants caused
by ingestion of water containing excessive nitrate and
successfully treated with methylene blue intravenously
are described. Clinically there are two types of met-
hemoglobinemia: (1) congenital idiopathic methemo-
globinemia, (2) acquired methemoglobinemia. There is
reason to suspect that the former is both congenital and
familial and is caused by an inherited defect in the re-
duction system of the erythrocyte. At present there is
no permanent cure, but symptoms can be alleviated with
large doses of ascorbic acid. Acquired methemoglobin-
emia can be caused by the ingestion or absorption of
certain drugs, mainly, sulfanilamide, analine, nitroben-
zene, nitrates, nitrite, and Promin. Young infants are
especially susceptible to well water containing nitrates
in excess of 10 ppts. per million. Recent studies indicate
that the low gastric acidity in the neonatal period allows
nitrate converting bacteria to flourish high in the gastro-
intestinal tract and permits conversion of nitrite before
absorption of nitrate is effected. Diagnosis is made by
the peculiar greyish brown cyanosis, the chocolate color
of the blood, spectroscopic examination of the blood for
methemoglobin absorption band, and by manometric
studies for blood levels. For acute poisoning, the intra-
venous injection of 1 per cent methylene blue in dosage
of 0.5 to 1.0 mgm. per Kg. is treatment of choice.
References
1. Comly, H. H.: Cyanosis in Infants Caused by Nitrates
in Well Water. J.A.M.A. 129:112, 1945.
2. Faucett, R. L., and Miller, H. C.: Methemoglobinemia
Occurring in Infants Fed Milk Diluted With Well Water of
High Nitrate Content. J. Pediat. 29:593, 1946.
3. Ferrant, M.: Methemoglobinemia, Two Cases in New-
born Infants Caused by Nitrates in Well Water. J. Pediat.
29:585, 1946.
4. Medovy, H.: Well Water Methemoglobinemia in In-
fants. Its Occurrence in Rural Manitoba and Ontario. Journal-
Lancet 68:194, 1948.
5. Best, C. H., and Taylor, N. B.: Physiologic Basis of
Medical Practice, 4th Edition, The Williams and Wilkins Co.,
Baltimore, p. 44, 1945.
6. Sievers, R. F., and Ryon, J. B.: Congenital Idiopathic
Methemoglobinemia. Arch. Int. Med. 76:299-307, 1945.
7. Slosse, A., and Wyhouw, R.: Un cas de methemoglo-
binemie idiopathique. Ann. et Bui. Soc. Roy. d Sc. Med. et
Nat. de Bruxelles 70:206-214, 1912.
8. Condunins, A., Loucatos, G., and Loutsides, E.: New
Hereditary Disease of Blood: Hereditary Methemoglobinemic
Cyanosis. Sang. Paris 19:65-128 (No. 2) 1948.
9. Diekman, W. J.: Methemoglobinemia. Arch. Int. Med.
50:574, 1932.
10. Cornblath, M., and Hartmann, A. F.: Methemoglobin-
emia in Young Infants. J. of Pediat. 33:421, 1948.
11. Wallace, W. M.: Methemoglobinemia in an Infant as
the Result of the Administration of Bismuth Subnitrate.
J.A.M.A. 133:1280, 1947.
12. Eusterman, G. B., and Keith, N. M.: Transient Met-
hemoglobinemia Following Administration of Ammonium Ni-
trate. Med. Clin. N. A. 12:1489, 1929.
13. Darrow, D. C.: Advances in the Treatment of Diarrhea
in Infants. Texas Reports on Biology and Medicine, vol. 5, No.
I, Spring, 1947.
14. Whitby, L. E. H., and Britton, C. J. C.: Disorders of
the Blood, Third Edition, Blakiston Co., Philadelphia, 1939,
p. 515.
15. Wendel, W. B.: The Control of Methemoglobinemia
with Methylene Blue. J. Clin. Investigation 18:179, 1939.
16. Hartmann, A. F., Perley, A. M., and Barnett, H. L.:
A Study of Some of the Physiologic Effects of Sulfanilamide:
II. Methemoglobin Formation and Its Control. J. Clin. Inves-
tigation 17:699, 1938.
17. Lian, C., Trumusan, P., and Sassier: Methemoglo-
binemie conjenitale et familiale: action favorable de l’acid
ascorbique. Bull, et Mem. Soc. Med. d. Hop. de Paris 55:1194,
1939.
98
The Journal-Lancet
Bone Marrow Aspirations
C. H. Peters, M.D., and L. W. Larson, M.D.
Bismarck, North Dakota
The diagnosis of diseases of the blood and of the
blood forming organs is often difficult. This is due
to the complex nature of hemopoiesis, the numerous fac-
tors influencing blood cell genesis and maturation, the
bizarre morphological picture of the cells so often en-
countered in peripheral blood, and the frequent failure
of the peripheral blood picture to reveal the true nature
of the disease process present in the body.
Actual examination of the organs concerned in hemato-
poiesis was formerly limited to palpation of enlarged
lymph nodes, liver and spleen. The study of biopsy
material removed from the organs has often been help-
ful, but there remains a large number of cases in which
the diagnosis from biopsy material warrants confirma-
tion or in which the morphologic picture is not conclu-
sive. A study of the bone marrow will usually reduce
this difficulty to a minimum.
The purpose of this presentation is to review briefly
the technic of bone marrow aspiration and the indica-
tions for the procedure, and to emphasize its value in
the diagnosis of obscure diseases of the blood and blood-
forming organs. In addition, a few conditions other than
those due to diseases of the blood and blood-forming
organs will be discussed in which the study of material
aspirated from bone marrow will usually establish the
diagnosis or confirm a diagnosis based on clinical find-
ings, radiographic studies, etc.
Technic
There are two methods of studying the bone marrow.
In the one a plug of sternal bone and marrow are re-
moved for histologic study. The disadvantages of this
method are obvious. It is a surgical procedure and the
removed material must be decalcified, embedded in par-
affin, cut, and stained. This procedure preserves the re-
lationships of the bone marrow elements, but the cellular
detail is impaired.
The other method is that of bone marrow aspiration
which we employ in our Clinic. It was first introduced
by Arinkin 1 in 1929, and has gradually gained favor
as a diagnostic procedure. Its advantages are as fol-
lows: (1) It may be performed at the bedside, eliminat-
ing the use of the operating room; (2) it is a rapid
method requiring a minimum amount of time; (3) re-
peated aspirations can be done, if the necessity arises,
as no scar tissue is left behind; (4) most patients do not
object to a second puncture, whereas many object to a
second trephining; (5) smears obtained give a very clear,
detailed picture of the cellular structure present. Un-
fortunately, the method is not without its limitations in
that a dry tap is occasionally encountered, or if a marked
hypoplasia of the bone marrow exists, insufficient ma-
terial may be obtained to warrant a diagnosis. However,
these limitations are seldom encountered.
The method of bone marrow aspiration which we em-
ploy was first described by Limarzi 2 in 1939. The pa-
tient is placed on his back, the region from the first to
the fourth costal interspace in the midline is prepared
with iodine and alcohol, and the site of the puncture
selected opposite the second interspace in the midline.
Fig. 1. Outline of sternum with site of aspiration indicated
by dot.
(Fig. 1). This site is then anesthetized with novocain
down to the periosteum. An especially constructed 16
gauge needle is used for the aspirations.* This is of large
caliber and of great strength and can stand the pres-
sure applied without breaking. It is advisable to have
the needle equipped with a guard or flange so that pene-
tration will not be too deep. Such a guard or flange is
also of value in permitting the operator to exert greater
pressure, and at the same time exercise greater control
over the needle. The needle is inserted at an angle be-
tween 45 and 90 degrees (Fig. 2) ; pressure is applied
until the point of the needle enters the marrow cavity.
This can usually be determined when there is a "give” to
the needle similar to that experienced in a spinal punc-
ture. This sensation may not be present, in which event
one must aspirate in order to determine whether or not
the marrow cavity has been penetrated. Following pene-
tration of the marrow cavity the stylet is removed and a
tight fitting 5 to 10 cc. syringe is applied. Suction is then
applied and 1 cc. of bone marrow content is aspirated
^Presented before the North Dakota State Medical Associa-
tion at Jamestown, North Dakota, May 25, 1948.
*Modification of Klima-Rosegger needle made by V. Mueller
& Co., 408 South Honore Street, Chicago, Illinois.
March, 1949
99
Fig. 2. Needle in place at 45° angle.
(Fig. 3). If the bone marrow has been entered, as-
piration will usually cause a severe sharp, momentary
pain. Only a small amount ( 1 cc.) is aspirated for
Fig. 3. 5 cc. syringe inserted and 1 cc. of bone marrow
aspirated.
two reasons: (1) to maintain a roughly quantitative
standard procedure between patients and with the same
patient, if further aspirations are done; (2) to pre-
vent too great a dilution with sinusoidal blood. Some
hematologists prefer an aspiration of only 0.1 to 0.2 cc.
of marrow, thus keeping sinusoidal dilution to a mini-
mum. However, in this method concentration of the
marrow elements is impossible, and less material is avail-
able for study. After the material is aspirated it is im-
mediately placed in small, paraffin lined Kahn tubes in
which a small amount of powdered heparin as an anti-
coagulant has been placed. After the material has been
thoroughly mixed 1 cc. is pipetted into a Wintrobe hem-
atocrit tube and centrifuged for five minutes at about
2000 R.P.M. Following this procedure the tube will re-
veal four distinct layers (Fig. 4). The first layer will
consist of fat measuring 2 to 4 mm. in depth; the next
layer will be clear plasma and will vary from a few
millimeters in depth to 50 or 70 mm., depending upon
Fig. 4
Hematocrit tube after
centrifuging for 5 min-
utes indicates:
(1) layer of bone
marrow fat
(2) plasma
(3) myeloid-erythroid
elements
(4) red blood cells
the degree of anemia and the amount of marrow pres-
ent; the third layer is the one in which we are primarily
interested, and consists of myeloid-erythroid elements of
the marrow plus megakaryocytes and some lymphoid
elements; the last layer at the bottom is merely a column
of red blood cells. The myeloid-erythroid layer averages
5 to 8 mm. in depth in a normal individual. This can
be very low in hypoplastic states, such as aplastic anemia,
hypothyroidism or fibrosis of the marrow. In contrast,
this layer at times measures 20 to 40 mm. if the marrow
is hyperplastic, such as is found in leukemia and perni-
cious anemia. Thus, we have a rough quantitative esti-
mation of bone marrow activity. Fat and most of the
plasma from the Wintrobe tube are removed, leaving a
small portion of the plasma to mix with the myeloid-
erythroid layer. This material is aspirated from the tube
separately and placed on paraffin lined watch glasses and
thoroughly mixed. A small amount is then used to pre-
pare blood films in the usual manner on clean micro-
slides. They may then be stained in the usual way by
Wright or May-Grunwold-Giesma stains.
Recently the spinus processes of the vertebrae and the
iliac crest have been used as the sites of the aspiration.
It is likely that these sites would be accompanied by less
psychic trauma than using the sternum. Obviously the
technic is the same.
Diseases in Which Bone Marrow Is
Diagnostic
Diseases in which the bone marrow is diagnostic or
of great value in contributing to the diagnosis are as
follows:
1. Pernicious Anemia (Fig. 5): The patient is fre-
quently cachectic with severe pallor. Malignancy or one
of the debilitating diseases is often suspected. Frequently
long periods of hospitalization are needed to determine
100
The Journal-Lancet
Fig. 5. Megaloblasts in pernicious anemia. Cells character-
istically large, deep blue cytoplasm, large nucleus with clump-
ing of chromatin network, and frequently a nucleolus.
the response to liver therapy. Study of the bone marrow
reveals numerous megaloblasts. Megaloblastic hyper-
plasia occurs in cases of primary deficiency such as per-
nicious anemia, sprue, pernicious anemia of pregnancy,
megaloblastic anemia of infancy, and relatively rare cases
of nutritional deficiency. When a megaloblastic bone
marrow is found the anemia will almost invariably re-
spond to liver or folic acid therapy, thus giving a ra-
tional approach to the treatment and often saving con-
siderable time, distress, and expense to the patient.
Fig. 6. Acute blast cell leukemia. Bone marrow filled with
blast forms characterized by thin rim of cytoplasm and a very
fine chromatin network in the nucleus. Nucleoli are also com-
mon.
2. Acute Leukemia (Fig. 6) : In this disease the per-
ipheral leukocyte count is often normal or a leukopenia
may be present. The stained blood smear may not re-
veal sufficient immature cells to establish the diagnosis,
or, if only an occasional immature cell is present it may
be mistaken for a lymphocyte. The bone marrow in these
cases, however, is usually filled with immature cells in-
cluding blast forms making the diagnosis obvious. This
is one condition in which sternal puncture will usually
establish the diagnosis promptly and indicate the prog-
nosis, whereas studies of the peripheral blood may not
be diagnostic for days or weeks.
3. Primary T hrombocytopenic Purpura : This is one
disease in which sternal puncture is of great value in
determining the indication for splenectomy. It is a dis-
ease characterized by bleeding and absence or decrease
of platelets in the peripheral blood. Surgical removal
of the spleen is curative in most of these cases, but it
is necessary that a diagnosis prior to surgery be con-
firmed without a question of doubt. Sternal marrow as-
piration separates this condition from secondary throm-
bocytopenic purpuras, aplastic anemias, leukemias, infec-
tions, metastatic tumors or conditions due to other toxic
elements such as X-ray radiation or heavy metals. If the
bone marrow contains the normal number, or an in-
crease, of megakaryocytes, then removal of the spleen
will stop the bleeding. However, if the megakaryocytes
are absent or decreased, splenectomy will not correct the
disease. As this is the case in most instances due to sec-
ondary thrombocytopenic purpura, differentiation prior
to surgery is important to prevent a disaster or failure.
4. Aplastic Anemia: If the marrow is hypoplastic,
showing a very low myeloid-erythroid layer, the blood
smears also show only scattered cells of the myeloid-
erythroid series. They are usually the more mature type
with very little shift to the left, with an increased num-
ber of lymphocytes and with no evidence of regeneration
occurring. Megakaryocytes are also absent or decreased.
By bone marrow aspiration a differentiation between
leukemia, agranulocytosis, and the purpuras can be more
easily made.
5. Agranulocytosis: In this disease one can often ob-
tain some indication of the ultimate prognosis. If the
marrow shows few myeloid cells with no effort at re-
generation, the prognosis is decidedly poor. If, on the
contrary, the marrow is well stocked with myeloid cells
and actual regeneration is occurring, then the agranulo-
cytosis is usually of a temporary character and will re-
spond to large doses of penicillin given to combat the
infection and tide the patient over. There are usually
two types of marrow in agranulocytosis: (1) The more
mature forms of myeloid series are absent, a so-called
maturation arrest. The more immature forms are pres-
ent and often increased. (2) A complete hemopoietic
aplasia exists which results in a so-called "empty mar-
row.” This can be confused with aplastic anemia and
with myelophthisic anemia.
6. Primary Splenic Neutropenia and Splenic Panhem-
atocytopenia: Primary splenic neutropenia and splenic
panhematocytopenia, as described by Doan,! may pre-
sent problems in differential diagnosis and therapy.
These diseases may be easily confused with other neu-
tropenias and especially with aplastic anemias, aleukemic
leukemias, etc. Splenectomy is curative. Before this is
done, it is essential that bone marrow studies do not
reveal a hypoplastic marrow which is a contra-indication
to splenectomy.
March, 1949
101
Fig. 7. Multiple myeloma. Numerous plasma cells and plas-
mablasts characterized by cells with eccentric placed nucleus;
frequently with a nucleolus; deep blue cytoplasm often with an
irregular border; and with a light zone adjacent to the nucleus.
7. Multiple Myeloma (Fig. 7) : Bone marrow aspira-
tion is pathognomonic. All other approaches to the diag-
nosis are indirect. Clinically, there are six cardinal diag-
nostic signs of this disease 4:
(1) Multiple involvement of the skeleton in the adult.
(2) Pathological fracture of the ribs.
(3) Bence-Jones bodies in the urine.
(4) Characteristic backache with signs of early para-
plegia.
(5) An unexplained anemia.
(6) Chronic nephritis with nitrogen retention, low
blood pressure and high serum proteins.
Confusion is common with metastatic lesions, hyper-
parathyroidism, spondylitis, nephritis, and leukopenic
leukemia. Bone marrow aspiration offers a direct ap-
proach to the diagnosis by demonstration of typical
myeloma cells.
8. Bone Marrow in Chronic Leukemias : Bone mar-
row examination is of little value in chronic leukemia
for the purpose of diagnosis. It is of importance only
in those cases presenting atypical, clinical, or hemato-
logical findings. In lymphocytic leukemia the presence
of a large percentage of lymphocytes in the bone mar-
row is necessary for an arbitrary diagnosis. Many dis-
eases will have a slight elevation of the lymphocyte count
which may be misleading. Therefore, a diagnosis of
chronic lymphocytic leukemia must be made with consid-
erable caution, if the increase in lymphocytes is only
slight, and especially if the marrow is hypoplastic. As
in all blood dyscrasias, the presence of immature cells,
however few in number, is more helpful than an in-
creased number of the mature forms.
9. Anemias of Pregnancy : In anemias of pregnancy
bone marrow studies will frequently make a differential
diagnosis between the megaloblastic anemia of preg-
nancy and those due to iron deficiency or to the normal
anemia of pregnancy. Peripheral blood changes are
often misleading due to a natural hydremia that occurs
during this physiological state. The bone marrow in
megaloblastic anemia will respond to liver therapy.
The megaloblastic anemia of infancy which has been
emphasized recently in the literature can be rapidly and
correctly diagnosed by a study of the sternal marrow
and proper therapy instituted.
Fig. 8. "L.E.” cell in acute disseminated lupus erythematosis.
The primary cell is a mature polymorphonuclear leukocyte whose
nucleus is pushed to one side by a large amorphous staining
mass.
10. Acute Disseminated Lupus Erythematosis (Fig.
8) : This clinical syndrome is characterized by involve-
ment of the skin, pleural cavities, various organs, and
the bone marrow. The symptoms and signs are often
bizarre. In the past, diagnosis has usually been made
by elimination of all other known clinical syndromes.
The disease should be suspected in any patient with a
chronic debilitating illness who has fever, leukopenia,
signs of an acute or chronic nephritis accompanied by
normal blood pressure, ascites or pleural effusion, cardiac
murmurs, generalized adenopathy, and joint involvement
with or without typical skin manifestations.
Recently, Hargraves and his associates ;j of the Mayo
Clinic have described the cells seen in cases of acute
disseminated lupus erythematosis and have coined the
term "L.E.” cell. This finding may prove to be of con-
siderable value in the diagnosis of an often obscure dis-
ease. An "L.E.” cell is found in mature neutrophilic
polymorphonuclear leukocytes and is characterized usual-
ly by an amorphous staining mass crowding the nucleus
of the cells to the periphery. Although this phenomenon
has not been demonstrated in all cases and cannot as yet
be said to be pathognomonic of the disease, it does sup-
port the diagnosis, when present.
11. Many other diseases of relative rarity can be diag-
nosed by sternal puncture, such as Kala-Azar and Gau-
cher’s disease, metastatic carcinoma, histoplasmosis, and
malaria. Finally, one cannot ignore the negative value
of sternal puncture when so much anxiety and appre-
hension can be relieved and suspected lesions can be
ruled out.
102
Conclusions
1. Bone marrow aspiration is indicated in those cases
in which a diagnosis cannot be made, or a prognosis
given, by means of the usual history, physical examina-
tion, and studies of the peripheral blood.
2. Bone marrow aspiration is simple, harmless, and less
painful than a surgical biopsy; if further examinations
are needed, repeated punctures may be readily and
easily done.
3. Loss of physiological structure and mixture of
sinusoidal blood are the disadvantages of sternal aspira-
tion. We believe these disadvantages are outweighed by
the concentration of cells and the detail obtained.
4. If proper technic is followed and experienced in-
The Journal-Lancet
terpretation available, sternal aspiration will reveal the
diagnosis in most instances.
Bibliography
1. Arinkin, M. I.: Die intravitale Untersuchungsmethodik
des Knochenmark. Folia Hcemot. 38:238-240 (June) 1929.
2. Limarzi, L. R.: Diagnostic Value of Sternal Marrow As-
pirations. Illinois Medical Journal 75:38-46 (Jan.) 1939.
3. Doan, C. A., and Wright, C. C.: Primary Congenital
and Secondary Acquired Splenic Panhematopenia. Journal of
Hematology 1:10, 1946.
4. Geschickter, C. F., and Copeland, M. M.: Tumors of
Bone. American Journal of Cancer, p. 441, 1936.
5. Hargraves, M. M., Richmond, H., and Morton, R.:
Presentation of Two Bone Marrow Elements, the "Tart” Cell
and "L.E.” Cell. Proceedings of the Staff Meetings of Mayo
Clinic 23:25, 1948.
NORTH DAKOTA STATE MEDICAL ASSOCIATION
1949 ANNUAL MEETING
The Sixty-second Annual Meeting of the North Dakota State Medical Association, to-
gether with the Third Annual Meeting of the Woman’s Auxiliary, will be held in Minot,
North Dakota, May 14, 15, 16 and 17, 1949.
The House of Delegates will meet the evening of Saturday, May 14, and on Sunday,
May 15. The Scientific Program will be held on Monday and Tuesday, May 16 and 17,
in the Gold Room of the Clarence Parker Hotel, with the exhibits on display in the Saddle
Room of the Hotel.
The Northwest District Medical Society is in charge of all local arrangements. Local
committees have been appointed and plans are being made for an even larger attendance
than in past years. Reservation cards will be forwarded all members of the Association well
in advance.
Plans for the Third Annual Meeting of the Woman’s Auxiliary are under the super-
vision of the General Chairman, Mrs. J. L. Devine, Jr., Minot, North Dakota.
Meet Our Contributors
Graham A. Kernwein, M.D., Northwest Clinic, Minot,
North Dakota, was graduated from the University of
Chicago Medical School, 1930; specializes in Orthopedic
Surgery; Chief of Staff, Orthopedic Surgery Section,
Northwest Clinic; Postgraduate for six years, University
of Chicago Clinics, St. Luke's Hospital, Chicago; Diplo-
mate, American Board of Surgery, American Board of
Orthopedic Surgery; Member, Chicago Surgical Society,
Central Surgical Association, American Academy of Or-
thopedic Surgeons, Dakota-Minnesota Orthopedic So-
ciety, Northwest Medical Society.
Robert E. Lucy, M.D., DePuy-Sorkness Clinic, James-
town, North Dakota, was graduated from the University
of Arkansas School of Medicine, 1944; specializes in
Obstetrics and Gynecology; Staff Member, Trinity and
Jamestown hospitals.
Ernest L. Grinnell, M.D., Grand Forks, North Dakota,
was graduated from Northwestern University Medical
School, 1931; specializes in Dermatology and Allergy;
Graduate Study, University of Minnesota, Northwestern
University, and Cook County Hospital, Chicago; Chief
of Staff, Grand Forks Deaconess Hospital.
V. G. Borland, M.D., Fargo Clinic, Fargo, North Da-
kota, was graduated from the University of Minnesota
Medical School, 1932; specializes in General Surgery;
Member, Central Surgical Association; F.A.C.S.; Diplo-
mate, American Board of Surgery.
W. H. Johnston, M.D., St. Luke’s Hospital, Fargo,
North Dakota; was graduated from the University of
Illinois Medical School, 1947; Surgical Resident, St.
Luke’s Hospital, Fargo.
Louis B. Silverman, M.D., Grand Forks Clinic, Grand
Forks, North Dakota, was graduated from Rush Medical
School, 1937; specializes in Pediatrics; Pediatric Resi-
dency, Children’s Hospital, Detroit, Michigan, Beth-El
Hospital, Brooklyn; Residency in Communicable Dis-
eases, Kingston Avenue Hospital, Brooklyn; Member,
Northwest Pediatric Society.
C. H. Peters, M.D., Bismarck, North Dakota, was grad-
uated from the University of Illinois Medical School,
1938; specializes in Internal Medicine; Diplomate, Amer-
ican Board of Internal Medicine; Associate, American
College of Physicians, associated with Quain and Ram-
stad Clinic.
L. W. Larson, M.D., Bismarck, North Dakota, was
graduated from the University of Minnesota Medical
School, 1922; specializes in Pathology; Director of Clin-
ical Laboratories, Quain and Ramstad Clinic; Fellow,
College of American Pathologists, American Society of
Clinical Pathologists; Member, Council of Scientific As-
sembly, A.M.A.; Chairman, A.M.A. Committee on Liai-
son with American Red Cross National Blood Bank pro-
gram; Member of Board of Directors, American Cancer
Society.
March, 1949
103
Report of the Committee on Rural Health
North Dakota State Medical Association
During the past year approximately 42 doctors have
come into North Dakota to practice. During the same
period of time, approximately 24 have retired. While
the shortage of practitioners is slowly being remedied,
it is thought that no great increase can be expected as
long as the large medical centers, primarily outside of
the state, still offer openings for newly trained specialists.
The trend toward the desire of becoming a specialist
clearly indicates that the location of the rural general
practitioner will be among the last to be filled.
There still continues to exist a shortage of nursing
personnel even though there has been a considerable in-
crease in the number of nurses this year over last. This
year approximately 1000 nurses are registered and living
in North Dakota, while last year approximately 800
were available. It is thought that there exists a present
shortage of approximately 150 registered nurses. The
State Medical Association in 1945 cooperated with the
State Board of Nurse Examiners toward the passage of
a practical nurses training program. There have been
set up, during the past year, three such practical nurses
schools and it is thought desirable that these schools
should be expanded to at least six in number. It is be-
lieved by the Committee that this plan may make avail-
able satisfactory bedside nurses thus freeing the regis-
tered nurses so that their advance training may be util-
ized in a more satisfactory manner.
In at least one rural hospital in North Dakota the
training of additional registered nurses is being encour-
aged by a subsidization of the student’s tuition. Appli-
cations by students are examined so that applicants hav-
ing good qualifications but lacking in funds for the train-
ing program will be accepted.
MEDICAL TRAINING
The 1947 Legislature passed a concurrent resolution
which placed on the general ballot an initiated measure
providing for a one mill levy for the financing of a
University Medical Center. This measure appeared on
the general election ballot and was passed by the voters
in the state by a wide margin. It will make available an
adequate amount of money for the proper administra-
tion of the University Medical School. These funds
should be expended in the most efficient way possible to
the end that the two year medical school be removed
from the probation list and established as a sound med-
ical institute. It is hoped that the proper utilization of
these funds may result in the education of physicians
and, possibly, under the program, graduate nurses who
will see fit to practice in the state of North Dakota.
RURAL HEALTH COUNCIL
The House of Delegates at its Annual Meeting has
authorized this Committee to proceed with the establish-
ment of Rural Health Councils. The first council under
the sponsorship of the Committee on Rural Health of
the North Dakota State Medical Association will be
established in the community of Elgin, North Dakota,
in January 1949. The purpose of the local Health Coun-
cil will be to exchange information and attempt to adopt
programs for the improvement of rural health in its
broadest aspects. A wide participation in the member-
ship will be sought and will include professional groups,
church groups, lay groups, governmental agencies and
farm groups. It is thought that rural doctors particu-
larly must be ever cognizant of the desires and attitudes
of the people living within the area in which they prac-
tice. It is therefore obvious that the rural practitioner
must take an active part in the attendance of all rural
health council meetings. As soon as this test council is
organized efforts will be made by the Committee to ex-
pand the utilization of Rural Health Councils to other
parts of the state. It is further felt that these various
rural Health Councils, in order to work efficiently, must
have close liaison with several organizations on the state
level, such as the Governor’s State Health Planning
Committee. The Governor’s State Health Planning
Committee, which is an advisory committee to the State
Health Council, which in turn is the governing body of
the State Health Department, is undertaking a most
important work and is ably headed by Chairman E. J.
Haselrud, Director of Extension Work at the Agricul-
tural College. Through its deliberations and through
the deliberations of the expanded State Health Council
more and more organizations are becoming aware of the
difficult problems involving the health of the citizens of
the State of North Dakota.
HILL-BURTON PROGRAM
While the program for the construction of hospitals
under the Hill-Burton Act is showing considerable prog-
ress in North Dakota, serious difficulties have neverthe-
less arisen. The principal cause for alarm is the ever-
increasing cost of hospital construction. Many commu-
nities making their initial application have found that
their original estimates of costs have been entirely too
low. This has necessitated additional campaigns for the
raising of money which campaigns have encountered
more resistance than the original money-raising drives.
At least one community in North Dakota has been
forced to give up its undertaking. At the present time
applications from six communities have received the ap-
proval of the state agency and have had allocations of
funds made toward construction. Two more communi-
ties have been listed as those who will receive allocations
as soon as additional money becomes available July 1,
1949. Of the six already approved by the state agency,
three have been approved by the Surgeon General. No
payment of federal funds has been made as yet. Ap-
104
The Journal-Lancet
proximately eight communities have proceeded with hos-
pital construction plans without the aid of Hill-Burton
money; these being largely communities which did not
fall within the A priority group. It is hoped that the
development of these small rural hospitals will attract
young physicians to North Dakota. It is emphasized,
however, that these young physicians must be of an ex-
traordinary type. They must be young doctors who are
interested in making a success of rural hospitals as well
as interested in the practice of medicine. In this connec-
tion it is recommended that rural practitioners where
new hospitals are developed attempt to obtain endow-
ments for their institutions. Such endowments on a
smaller scale are as available in rural communities during
these days as they are in the urban centers. Again it
should be stressed that rural hospitals should be so
spaced and sufficient distance from each other and from
the major medical centers so as to insure a large enough
trade territory from which they may expect financial
support. So far but two hospitals have been completed
since the close of the war in rural communities, neither
of which participated in federal money under the Hos-
pital Construction Act.
PREPAID MEDICAL CARE
The House of Delegates in May 1948 authorized the
expansion of the North Dakota Physicians Service on
a statewide basis. Considerable work has been accom-
plished in the enrolling of physicians in this plan. The
expansion will be effected on the basis of the Local Dis-
trict Medical Society, beginning December 1, 1948. In
North Dakota this program is affiliated with the Blue
Cross and the administration of the program will be
effected through their office under the direction of the
Board of Directors of the North Dakota Physicians
Service. Sales will be made only in those districts where
a workable majority of the physicians enroll in the pro-
gram. Attention has continuously been given to make
this prepaid medical care plan of value to the rural prac-
titioner. To this end tonsillectomies, fractures and OB
work is now permitted outside the hospital. Further, the
Blue Cross will now pay hospitalization benefits to those
policyholders having deliveries in licensed nursing homes
provided the delivery is attended by a licensed physician.
This it is hoped will encourage the holder of North
Dakota Physicians Service policies to stay in the rural
community and have his services performed by his local
practitioner.
1948 GENERAL PRACTITIONER’S AWARD
In an effort to create a greater awareness of the ex-
treme value of the rural practitioner, the State Associa-
tion authorized the presentation of a General Practi-
tioner’s Award. This award has been given this year to
Dr. J. G. Vigeland of Brinsmade, North Dakota. Dr.
Vigeland has practiced in North Dakota for 36 years
and is held in high esteem not only by his fellow prac-
titioners but by the members of the community in which
he has practiced. It is thought extremely desirable that
the importance of the general practitioner in the rural
community be stressed in every way possible, both to
encourage young physicians into this field of high serv-
ice and to aid in the creation of further understanding
on the part of the various communities as to problems
besetting the rural practitioner.
HEALTH AND EDUCATION PROGRAM
We still report little progress in health education
work. Again the need is recognized, but so far funds
are not available to carry on this expensive work. Much
can be accomplished in the future through the local
Health Councils and also through the Health Units of
the North Dakota State Health Department.
M. S. Jacobson, M.D., Chairman,
Committee on Rural Health,
Elgin, North Dakota
MEETING OF THE WOMAN’S AUXILIARY OF THE A.M.A.
Haddon Hall will be the headquarters for the Annual Meeting of the Womans Auxil-
iary to the American Medical Association, which will be held in Atlantic City, New Jersey,
June 6th to 10th, 1949.
Requests for reservations should be sent at once to Dr. Robert A. Bradley, Chairman,
Subcommittee on Hotels, 16 Central Pier, Atlantic City, New Jersey.
AMERICAN COLLEGE OF ALLERGISTS MEETING
April 14, 15, 16 and 17 are the dates for the annual meeting of the American College
of Allergists. The meeting is to be held in Chicago at the Palmer House. Anyone interested
in attending is requested to make his own reservation with the Reservation Manager, Palmer
House, Chicago 90, Illinois.
March, 1949
105
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association, Minne-
apolis Academy of Medicine. North Dakota State Medical Association, Northwestern Pediatric Society, Sioux Valley
Medical Association, South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology.
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
BOARD OF EDITORS
Dr. 1 A. Myers. Chairman
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor. President
Dr. R. C. Webb, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O. Hanson, Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert, Recorder
ADVISORY COUNCIL
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
Sioux Valley Medical Association
Dr. W. H. Holloran, President
Dr. Walter Benthack, Vice President
Dr. Martin Blackstone, Secretary
Dr. Anton Hyden, Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Dr. Gilbert Cottam, Secretary-Treasurer
Editorial
THE ERYTHROCYTE SEDIMENTATION
RATE
The erythrocyte sedimentation rate is a valuable aid
in diagnosis and prognosis over a wide field of clinical
problems. Repeated observations of the E.S.R. mirror
reliable response to therapy in many inflammatory and
malignant states. Despite its recognition by Hewson
in 1772, the first practical application of erythrocyte sedi-
mentation was introduced by Fahreus in 1918 as a test
for pregnancy. Ensuing years have seen its status in
clinical medicine much maligned and provoking as great
controversy as any other laboratory procedure. This mis-
judgment of a proven laboratory aid has been occasioned
by the uncritical adoption of technical refinements and
faulty performances of same; plus a profound laxity in
appreciating the limitations of the E.S.R. as but a lab-
oratory procedure, and as such, being non-specific. The
inherent limitations of blood sedimentation must be rec-
ognized. Interpretation must necessarily be based on the
individual case, and, above all, on a basic understanding
of the fundamental principles governing blood sedimen-
tation and of the errors attendant upon its technical
performance.
The sedimentation of erythrocytes occurs in three
phases, and these phases are conditioned by an abnor-
mality of plasma seen in certain physiological states and
disease. The first phase is an aggregation of corpuscles
into clumps or rouleaux; the greater the aggregation of
the corpuscles, the more rapid the sedimentation. Appar-
ently physico-chemical phenomena controlled by changes
in the plasma proteins (fibrinogen and euglobin) lower
the stability of a blood suspension in various disease
states. There evokes a roughness and granularity of cor-
puscles which is evident on a blood smear — this making
the corpuscles adhere to one another and form clumps
of agglutinated cells (auto-agglutination). That the
character of plasma and not the cells is the deciding
factor is shown by suspending cells of a high sedimenta-
tion rate (pregnancy) in plasma of a low rate, in which
case a low rate of settling occurs. The second phase of
sedimentation is therefore conditioned by the first phase;
since the rate of sedimentation depends upon the velocity
of rouleaux formation and on the size of the resulting
aggregations. The third phase is a progressive slowing
as the corpuscles become packed in the bottom of the
estimating tube.
Obviously, extrinsic factors disturb this relationship.
The variations in technique, though basically alike, must
106
The Journal-Lancet
be judged individually. The differences are in the vol-
ume of blood used and the size and shape of the recep-
tacle. In cylindrical or spherical columns, the same blood
in varying volumes, heights or diameters will settle differ-
ently. Greater volumes sediment more rapidly, and with-
in limits, sedimentation is more rapid in long columns of
blood than in short columns. Yet, different volumes of
blood reach their point of maximum settling at approxi-
mately the same time. Thus, sedimentation may be meas-
ured by the fall of blood in a given period of time or
by the time required for the blood to settle a given dis-
tance. The latter has been proposed as an index of sedi-
mentation; the amount of sedimentation during the first
fifteen minutes expressed in the percentage of total fall
of the erythrocytes after twenty-four hours. There are
various factors which govern the accuracy of the test;
namely, constant temperature, avoidance of venous stasis,
making the test promptly on collection, using a constant
amount of anticoagulant in a perfectly vertical tube.
It follows, then, that intrinsic factors, too, disturb this
relationship. Alterations in the number, shape or size of
erythrocytes, or more aptly stated, the relative amount
of plasma in the blood, is important in determining the
sedimentation rate. For this reason, the need to correct
for an anemia in a few techniques is obvious; however,
several objections have prohibited general acceptance.
It is time-consuming for the average worker, and all
methods of manipulation of the established alteration
of cells to plasma which may interfere with the under-
lying mechanics of sedimentation. In the case for cor-
rection charts, the chart is strictly valid only for the
blood sample having the same sedimentation rate and
the same initial erythrocyte concentration.
The choice of a method of determining sedimentation
of erythrocytes seems dependent upon personal fancy,
familiarity and little thought as to which procedure is
the more practical for any given situation. The frequent
readings of the Cutler and Roarke-Ernastene techniques
are too time-consuming for adoption in routine use, and
there is little if any practical advantage in their use.
Wintrobe’s technique permits hematocrit determinations
after the sedimentation rate has been determined, which
is convenient for correcting an anemia. The Westergren
technique has the advantage of reduced susceptibility to
the effects of anemia and simplicity of performance.
Whichever of the many techniques is used, it seems im-
perative, because of the number of purely technical fac-
tors involved, that a standard technique be rigidly ad-
hered to.
Variations of the sedimentation rate in health must
be recognized in interpreting this test. During the last
trimester of pregnancy, menstruation and also during
excitement in children, the rate is increased.
Realization, then, that variations in health, tissue de-
struction or infectious processes produce an elevated rate,
makes the test non-specific and but a laboratory pro-
cedure to be interpreted much as is tachycardia, fever
and leukocytosis. Attempts to read much more than this
belies clinical acumen, but together with clinical observa-
tions and other laboratory aids, its diagnostic and prog-
nostic value is great in inflammatory disease and malig-
nancy.
The E.S.R. is the best available criterion with which
to follow the course of acute rheumatic fever and to
detect rheumatic activity. The effect of salicylates on
the sedimentation rate is in doubt. Coburn has shown
that the first administration of large doses of salicylates
in the first acute attack of rheumatic fever is followed
by a rapid fall in the E.S.R. Butts, however, feels that
patients with polycyclic rheumatic fever do not respond
clinically nor does the E.S.R. respond to administration
of salicylates in a manner comparable to an acute attack.
It seems probable that rheumatic activity subsides before
the return of the sedimentation rate to normal. In infec-
tious arthritis the sedimentation rate is elevated and the
rate parallels the severity of the disease and exacerba-
tions of same as estimated clinically, then recedes as re-
covery ensues. In hypertrophic arthritis the E.S.R. is
normal. In allergic states the rate is little affected. In
multiple myeloma the E.S.R. is greatly elevated, prob-
ably in direct proportion to the elevation of serum globu-
lin. In severe anemias and leukemias the sedimentation
rate is likewise elevated and in sickle cell anemia it is
decreased. The value of the E.S.R. in judging prognosis
and response to therapy in tuberculosis (pulmonary and
extrapulmonary) is time-honored and seemingly with
good reason. In latent syphilis, nephritis and especially
nephrosis, thyrotoxicosis and severe hepatic disease the
rate is also elevated. In virus diseases the sedimentation
rate is apparently of little value. A study of the sedi-
mentation rate in infectious hepatitis revealed the sedi-
mentation rate to be but slightly elevated in one-half
the cases. The E.S.R. is of definite value in differen-
tiating lower abdominal conditions. It is little affected
in early appendicitis, but in acute salpingitis, chronic
salpingitis and even Bartholinitis and ectopic pregnancy
after ten weeks the rate is increased. The E.S.R. be-
comes elevated shortly after myocardial infarction and
returns to normal over a six to twelve week period.
Malignancy or extension of tumor through metastasis
is associated with a prolonged sedimentation rate, and,
as such, the E.S.R. is playing an increasing role in the
differential diagnosis of benign from malignant lesions.
Clinically benign growths with an elevated E.S.R. should
lead to a search for infection or malignancy. Patients,
who have been symptom-free after treatment of malig-
nancy, who subsequently have a rise in the E.S.R., should
be suspected of malignant recurrence or metastasis.
This, then, is a plea for greater understanding and
patience with a valuable laboratory procedure, which,
though non-specific, is informative of inflammatory or
malignant disease and tissue disintegration. The type of
estimating procedure should be adopted for its simplicity
and accuracy, and the technique should be strictly ad-
hered to. It then becomes a valuable adjunct in diagnosis
and prognosis.
j.S.
March, 1949
107
THE $25.00 ASSESSMENT—
YOUR CONTRIBUTION TO SOCIETY
The House of Delegates, at the recent Interim Session
of the American Medical Association in St. Louis, unani-
mously voted to assess each member of the Association
$25.00. This is the first time in the 101 years of the
Association’s history that an assessment has been levied.
What caused this unprecedented action? What will the
money be used for? What are the chances that the ob-
jectives will be realized? Every member of the Associa-
tion should know the answers to these questions.
Since its organization in 1847, the A.M.A. has fur-
thered the objectives as set forth in its constitution: "to
promote the science and art of medicine and the better-
ment of public health.” Its policy has been conservative,
emphasis being placed on the scientific side of the prac-
tice of medicine and the formation of advances in the
public health of the nation. The economics of the prac-
tice of medicine were largely disregarded until the de-
pression of the thirties when millions of our citizens, and
many members of our profession, were in serious finan-
cial condition. True, doctors became alarmed over the
threat of government medicine after World War I when
the Veterans Bureau built hospitals and many veterans
obtained free medical and hospital care for non-service
connected disabilities, but the program enlarged under
pressure of veterans and politicians, and gradually be-
came accepted as a normal function of the government.
However, when the New Deal pushed a bill through
Congress in 1938 to enlarge the Children’s Bureau and
to provide Maternal and Child Care to the large seg-
ment of the population, the profession really woke up.
A special session of the House of Delegates was called,
the Children’s Bureau Program was denounced, and a
set of principles was drawn which is as applicable today
as it was then. This action, plus repeated objections
raised by prominent members of the profession and by
the organized profession in the states, softened the Chil-
dren’s Bureau program somewhat. But war clouds were
gathering and we soon became too busy saving our lives
to worry much over the Children’s Bureau.
In the same year (1938) the A.M.A. was indicted in
Federal Court for violation of the Sherman Anti-Trust
Law. The case was fought but a verdict of guilty was
returned in April 1941. The country was plunged into
war eight months later and the profession was hard
pressed to supply adequate medical officers and medical
care for the civilian population. It was in the midst of
this struggle that the Wagner-Murray-Dingell Bill, call-
ing for compulsory health insurance, was introduced in
1943. This was mute evidence that the health of the
nation and the future of the profession were in jeopardy.
Yet the A.M.A. House of Delegates created the Council
on Medical Service and Public Relations with evident
reluctance in June 1943 because by doing so the old con-
servative policy of the Association was being changed to
* Abstract of paper presented before Conference of District
Medical Society Officers in Bismarck, January 16, 1949.
a more progressive policy in which newer techniques were
to be employed to meet changing social, economic and
political trends. It is unnecessary to review the contri-
butions made by this Council, and those of many mem-
bers of the Association and State and County Medical
Societies in holding the Wagner-Murray-Dingell Bill in
committee.
Many members, and a few State Associations, were
not satisfied with the Public Relations job being done by
the Association. Accordingly the Public Relations func-
tion of the Council was removed in 1946 and placed
under the direct supervision of the Secretary and Gen-
eral Manager. A staff was acquired, and, with the Re-
publicans in control of Congress and the election of Mr.
Dewey a certainty, everything seemed lovely. Disregard-
ed were the warning signs such as the spread of socialism
even to England, the threat of a Communist-dominated
world, and Mr. Truman stumping the country in behalf
of not only the forgotten man but of all men except the
few whom he effectively included among the "vested
interests.” Mr. Truman campaigned vigorously for his
health program which includes compulsory health insur-
ance. When the smoke of the last election had cleared
the profession awoke to realize the magnitude of the
fight it has on its hands. It faced the issue within a
month’s time, agreed on a statement of policy in which
socialized medicine is denounced, and authorized a pro-
gram of education of the public which will awaken the
people to the danger of a politically controlled, compul-
sory health insurance system , acquaint the people with
the superior advantage of American medicine over gov-
ernment-dominated medical systems of the other coun-
tries, and stimulate the growth of voluntary health insur-
ance systems and prepaid medical care plans.
What will such a program cost? No one knows!
There will be no lobbying in Washington. The Wash-
ington office will be expanded but will continue as an
"information bureau” for interested Congressmen. Em-
phasis will be placed on informing the public through
the press and the radio, who, when informed, will make
their wishes known to their Congressmen. Proponents
of socialized medicine will have the support of President
Truman, the Federal Security Administration and many
citizens who either have a lust for power or are blinded
by emotion or misinformation. It may well prove the
battle of the century for our country because it will
determine whether we are to continue our system of free
enterprise or are to drift into a completely socialized
nation.
Certainly no member of our Association can refrain
from this call to duty by paying his assessment promptly,
informing himself as to the content of the legislation for
socialized medicine, which is already introduced in the
Eighty-second Congress, and discussing the issue in an
intelligent manner with his patients and friends. The
profession has never failed its country in an emergency
and it will not fail this time.
L. W. Larson, M.D.,
Bismarck, North Dakota
108
The Journal-Lancet
THE SOCIAL SECURITY ADMINISTRA-
TION PLANS OUR TOTALITARIAN STATE
In the fight which the medical profession is making
against National Compulsory Health Insurance, we need
to be very careful lest the unproven remarks of Ewing,
et ah, regarding the "deplorable” condition of the na-
tion’s health as his spurious argument for government
control, divert our attention from the main objective of
the Social Security Administration. That objective ap-
pears to be the creation of a totalitarian state!
If one will agree with the well-established principle
that "the power to tax is the power to destroy,” he will
look twice at the not unlikely chance that the Senate
Committee on Labor and Public Welfare will have a
new version of S. 1290, which died in committee of the
80th Congress, ready for discussion on the floor of the
Senate in the not-too-distant future. Bipartisan support
for such a bill is not unlikely, chiefly because, if it fol-
lows the pattern of S. 1290, it would follow the now
all-too-familiar pattern of "Federal grants-in-aid to the
States” with the appealing provision to make more ade-
quate provision for the health of school children. Such
provisions, if they run true to previous forms, would pro-
vide appropriations for the development of school health
services for the prevention, diagnosis and TREAT-
MENT of physical and mental defects and conditions.
Of course, the Federal Security Administration would
administer the program; no doubt with the Children’s
Bureau as its willing stooge.
While the foregoing may still be in the field of spec-
ulation, it might be well to review what is not a matter
of speculation but of record, and see how the Children’s
Bureau took what was merely a deficiency appropriation
in its incipiency, and developed it into the multi-million
dollar E.M.I.C. program. Has it ever been known that
a governmental bureau ever relinquished, voluntarily,
its power?
Now comes Arthur J. Altmeyer, Commissioner for
Social Security, speaking on the expansion of the social
security program. His remarks were apparently intend-
ed for the delegates to the Second National Conference
on Unfinished Business in Social Legislation, held on
February 7 and 8, 1949. Discussion apparently centered
around Federal intervention in the fields of housing,
education, social security, civil liberties, and medical care
insurance.
This is a formidable list! It seems to leave out nothing
but the old-fashioned but still vital american principle
of free enterprise. This principle has been in jeopardy
ever since 1932 when the "forgotten man” was taught
the most pernicious and false doctrine: that "Security”
and "Freedom” were synonymous. This country was
originally settled, and its independent government set up
by people who came here for freedom from too much
government.
A few illustrations should illustrate how "Security”
may be purchased at the expense of "Freedom.” Alt-
meyer, if we are to believe his recommendations, would
immediately extend old age and survivors’ insurance to
25 million persons not now covered and, as rapidly as
possibly, extend National Compulsory Social Security
for the entire population. Insurance companies and their
millions of policy-holders whose careful and thoughtful
savings have built up the creative capital which has so
abundantly strengthened America’s free and creative en-
terprise system in good times and bad, in war and in
peace, may well ask what security this would bring to
these United States. Freedom, if it has not yet disap-
peared, could not survive this blow for it would be taxed
out of existence.
State Legislatures, with their own complex and differ-
ent problems in the fields of State Unemployment In-
surance and Workmen’s Compensation Laws, would be
asked to transfer these legitimate state functions to the
Federal Government. It would make no difference that
such problems differ widely in such neighboring States
as Minnesota and North Dakota or that widely diver-
gent viewpoints, as well as geography, separate the Legis-
latures of Maine and California. The universal com-
pulsion that such a program would force upon all of the
State Legislatures in dealing with this one phase of the
problem would be enough to complete the central con-
trol which guarantees the totalitarian State.
Within our own ranks, it might be well to look rather
closely at some of the contributions we may, knowingly
or unknowingly, make to the creation of the totalitarian
state. The American Academy of Pediatrics, recently
and properly rebuked for seeking Federal subsidy in the
field of pediatric education, may not be the only of-
fender! The Dean of a medical school who, under one
guise or another, seeks federal funds to augment his
budget, is likely to find that his school is controlled
from Washington. Likewise, the hospital administrator
who may seek and obtain "free” Federal funds for what
may be a worthwhile addition to his hospital will discover
that no Federal funds are "free” and that he and his
community have lost control of their institution.
College and university presidents and school super-
intendents, hard-pressed as they are for funds, would do
well to think clearly on that problem, sacred to all edu-
cators, of "Academic Freedom” before they come to
depend too much on Federal Grants-in-Aid to Educa-
tion. Hitler followed such a course in Germany and
it was not only the books but the souls of men that
were burned.
The American Medical Association has recently asked
its members for a voluntary assessment of $25.00 each
for an educational campaign to enlighten the people of
the United States against the dangers of a compulsory
National Health Insurance Program. This is fine and
it deserves our whole-hearted, unanimous support. It
may be the means whereby we can point out to the ma-
jority, but inarticulate, citizens of our country a far
greater danger than the socialization of medical practice:
namely, the creation of a totalitarian state. Its major
aim should be the repeal, through congressional action,
of the Social Security Act which, through the Federal
Security Administration that now administers that act,
is attempting to create a totalitarian state just as surely
as it has been done and is being done by dictator nations
throughout the world.
J.H.M.
I
I
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110
The Journal-Lancet
We are pleased to announce
MISS NELL COLLINS
former professional service representa-
tive of S. H. Camp & Company for
eighteen years, is now associated with
our shop to give
individual corset
fitting problems her
personal attention
and to work closely
with physicians on
garments recom-
mended.
You are invited to
call her without
obligation.
Her specialized
knowledge
may help you
on some individual figure problem.
* Al/ss Nell Collins will make
hospital fittings when desired
3 ranee 4 J^ynn
Corset Shop
1115 Nicollet Avenue - MAin 401 2
CAMP
Camp Surgical Supports Fitted to Your Doctor's Prescription
NORTH DAKOTA COMMUNITIES
DESIRING SERVICES OF A GENERAL
PRACTITIONER
Anamoose, McHenry County. Estimated population
600. Estimated drawing territory: 25 miles to south,
west and north, 10 miles to east. Distance to nearest
hospital: 16 miles to Harvey. Two room office space
available with adjoining waiting room, completed 1947.
These spaces adjoin those of the dentist. Living quar-
ters, a four room apartment to the rear of the office space
on the same floor level, available. There are no doctors
between Anamoose and Minot and only one within the
county. Nearest competition to the south is the doctor
at McClusky; to the northwest, Towner, and to the
northeast, Rugby. Hospital at Harvey is open to any
doctor who wishes access to the hospital. Dentist set up
practice in September 1948. Contact Dr. L. C. Misslin,
D.D.S., Anamoose, North Dakota.
Gackle, Logan County. Estimated population 850.
Estimated drawing territory: 25 mile radius. Distance
to nearest hospital 40 miles. Community building mod-
ern health center, to be completed about December 1,
1948. 4900 sq. ft. building, brick and tile construction.
Includes doctor’s office, lobby, dentist office, laboratory,
consultation room with dressing rooms; doctor’s lab and
x-ray; four double bed rooms with baths, delivery -oper-
ating room; utility rooms, kitchen and storage rooms,
etc. Radiant heat in the floor. Board of trustees plan
to permit the doctor to have more or less free rein in
this project. Center being built by private individuals,
without government assistance. Contact C. C. Lehr,
First State Bank, Gackle, North Dakota.
Glen Ullin, Morton County. Estimated population
1300. Estimated drawing territory: 30 miles all direc-
tions. Distance to nearest hospital 30 miles to Elgin.
Office space (very nice) available. Housing can be ar-
ranged. Heart Butte dam is under construction by the
Bureau of Reclamation 18 miles south of Glen Ullin.
Town growing rapidly and can use a progressive doctor.
Presently wonderful hunting facilities and with the com-
pletion of the dam, the best fishing possible. Further
information may be obtained by contacting Jack Curtis,
Publisher, The Times, Glen Ullin, North Dakota.
Goodrich, Sheridan County. Estimated population:
600. Estimated drawing territory: 90 miles south, 30
miles north, 60 miles east, 20 miles west. Distance to
nearest hospital: 30 miles. Office space will be made
available by Goodrich Commercial Club. Living quarters
will be made available. (24 business places in town,
six churches, good school, good bank) . Need for doctor
is great. Contact W. A. Muralt, Goodrich, North
Dakota.
Hope, Steel County. Estimated population 500. Huge
drawing territory. Nearest doctor, northwest 18 miles,
northeast 30 miles, south, east and west, almost 40 miles.
Nearest hospital: Mayville, 30 miles, where they are
planning a new improved hospital. Hospital at Sharon
also, about 30 miles distant. Cooperstown, about 28
miles distant, is planning a new hospital. Hope Civic
Club is gathering money toward a modern office build-
ing to be started fall of 48, completed in spring of 49.
In conditions of faulty body mechanics,
the nonuse of the abdominal muscles al-
lows the pelvis to rotate downward and
forward, bringing the sacrum up and back.
There results an increased forward lumbar
curve with the articular facets of the lum-
bar spine crowded together in the back.
The dorsal spine curves backward with
compression of the dorsal intervertebral
discs and the cervical spine curves forward
with the articular facets in this region
closer together. Therefore, chronic strain
of the muscles, ligaments and joints of the
spine and pelvis occurs.
Camp Anatomical Supports have an ad-
justment by means of which their lower
sections can be evenly and accurately
brought about the major portion of the
bony pelvis. When the pelvis is thus stead-
ied, the patient can contract the abdominal
muscles with ease and then with slight
movement straighten the upper back.
Relieving back strain and fatigue due to faulty body mechanics is a feature of the
Camp Support illustrated and other types for Prenatal, Postnatal, Postoperative,
Pendulous Abdomen, Visceroptosis, Nephroptosis, Hernia and Orthopedic conditions.
S. H. CAMP AND COMPANY • JACKSON, MICHIGAN
World' s Largest Manufacturers of Scientific Supports
Offices in New York • Chicago • Windsor, Ontario • London, England
112
The Journal-Lancet
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Surgical & Hospital Equipment
901 Marquette Ave.
AT. 6508 Minneapolis, Minn.
House will be provided by Civic Club for a doctor. Large
prosperous territory with people having wonderful crops
in the past years. Need for a doctor is great. Further
information may be obtained by writing Rev. Lambert
A. Dierks, Hope, North Dakota.
McHenry, Foster County. Estimated population 300.
Serves rural area of 17 mile radius which includes three
towns of 150 population each. Distance to nearest hos-
pital, 34 miles. Nearest doctor, 3 1 miles. Home, con-
veniently located so it would serve equally well as an
office, is available. Community nurse with considerable
experience would be willing to assist doctor if desired.
Town served by state and county highways that are
maintained all year. Also served by McHenry Flying
Service with all weather flying. Community composed
of prosperous farmers of mixed ancestry. Two churches,
and several new buildings in business section. Contact
S. J. Hoffman, President, McHenry Commercial Club.
Pembina, Pembina County. Estimated population 750.
Rural area with drawing territory 3 miles north to Ca-
nadian border and a 15 mile radius in other directions.
Distance to nearest hospitals, 22 miles to Hallock,
Minn., and 28 miles to Drayton, North Dakota. Mod-
ern community. Office and dwelling accommodations
could be arranged. For further information contact
F. F. Moris, City Auditor, Pembina, North Dakota.
Rutland, Sargent County. Estimated population 300.
Estimated drawing territory a 25 mile radius. Distance
to nearest hospital 32 miles. Community has a large
house with surrounding lots, ideal for a hospital of six
to eight beds or more, with office downstairs, or ideal for
office and doctor’s home. If doctor should not wish to
purchase it himself, the town is prepared to form an
association to remodel, purchase and assist in equipping
same for the doctor. Many new commercial buildings
being built in town. Has supported a doctor in the past.
Nurses available. Further information may be obtained
by contacting Mrs. Otto Meyers, Rutland, North Da-
kota.
Strasburg, Emmons County. Estimated population
850. Estimated drawing territory: 25 miles west, 6 miles
north, 25 miles east and 30 miles south. Towns south
of Strasburg have no doctor. Distance to nearest hos-
pital, 78 miles northwest to Bismarck, with very good
hard-surfaced all-weather road. Office space available.
Living quarters can be arranged. Located in rich grain
belt and cattle community with the last nine years very
prosperous. Community made up mostly of German-
Russians with a Holland settlement south of town. Fur-
ther information may be obtained by contacting J. M.
Klein, Secretary, Strasburg Civic Club, Strasburg, North
Dakota.
Wilton, McLean County. Estimated population 850.
Serves rural area of 12 mile radius. Distance to nearest
hospital, 25 miles, hard-surfaced highway. Office space
and living quarters available. Good territory, well paying
people. Some coal-mining nearby. Further information
may be obtained by writing the city of Wilton, North
Dakota.
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MAIL THI S C OU PON T O D AY —
FOR SALE
Building, practise and equipment for sale. Building
includes residence, dental office, barber shop. Located
twenty miles south of the Twin Cities. Write Box 876,
J ournal-Lancet.
FOR SALE
Slightly used: Burdick Diathermy — Bovie Davis Dia-
thermy— A. C. M. I. Diathermy — recommended for
prostatic resection. Main 5622 or 516 LaSalle Building,
Minneapolis.
PHYSICIAN WANTED
Community tired of having no medical service within
radius of 25 miles; widow wishes general practitioner
would utilize estate at either modest rental or lenient pur-
chasing arrangement. Property suitable for small hospi-
tal and clinic or home with office. Community will fully
back any effort made to establish practice, rich farm
area, towns around without doctors also, hospitals 25
miles distant, good schools and churches, southeastern
North Dakota. Write Box 881, Journal-Lancet.
OFFICE SPACE FOR RENT
Internist, Medical Arts Building, Minneapolis, Minne-
sota, wishes to sublet portion of office space with use of
complete laboratory, basal metabolism and electrocardio-
gram machines, and fluoroscope. Arrangements can be
made for part time use of entire space. Box 882.
PRECEPTORSHIP
An opportunity to specialize in Ophthalmology. A two
year preceptorship in a Minneapolis oculist’s office. Both
basic and clinical phases of the specialty presented under
supervision. Satisfactory financial arrangements. Med-
ical background of applicants desired. Write Box 883JL.
TECHNICIAN WANTED
Starting April 1. In city of 7500, Northwestern Min-
nesota, leading community rich territory. General labora-
tory and x-ray. Laboratory work consists of routine
urines, blood, blood chemistry, smears, sputums and gas-
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fication but adequate. Write Box No. 884, Journal-Lancet.
FOR SALE
Finely equipped modern medical suite, suitable for eye,
ear, nose and throat or general practice. Located in the
Black Hills. Good opportunity for trained doctor inter-
ested in permanent, steady practice. Desirable living
quarters available. Anxious for immediate action because
of need of community and desire to close estate. Address
Mrs. W. L. Matlock, Deadwood, South Dakota.
DOCTORS’ OFFICES FOR RENT
Suite of rooms, recently vacated, over drugstore at
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doctors or doctor and dentist combination. Write to Mr.
M. J. Leyne, 1122 Lowry Avenue North, Minneapolis.
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Woodward Medical Personnel Bureau (formerly Aznoes
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116
The Journal-Lancet
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The Journal-Lancet
ADVERTISERS’ ANNOUNCEMENTS — (Continued )
iodide), phosphorus 32 solution (sodium phosphate), and Pen-
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REFERENCES
"Spasm and Fibrosis of the Sphincter Ani Due to Reflex
Action” — Francis C. Newton and Charles A. Macgregor,
New England Jour. Med. July 22, 1948, vol. 239,
No. 4, p. 11 3.
"Rectal Dilators in the Treatment of Constipation” — M. D.
Finkel, M.D., and A. J. Levine. M.D., Journal-Lancet,
Minneapolis. Dec. 1948, vol. 68, No. 12, p. 467.
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Foreword
It is a privilege to have been requested by Dr. J. Arthur Myers to write the introduction
to this year’s special tuberculosis issue of the Journal-Lancet. Dr. Myers was one of my
professors when I attended the University of Minnesota School of Medicine, and was one
of the first to enkindle in me an interest in the control of tuberculosis.
I feel further honored when I look over the list of distinguished authors for this issue,
most of whom I have come to know personally and who are making outstanding contribu-
tions in furthering our knowledge of tuberculosis and its control.
The accelerated reduction in the tuberculosis mortality rate since the last world war is
one of the most exciting public health phenomena of recent years. When it is realized that
this acceleration has occurred in spite of the fact that insufficient time thus far has elapsed
for some of the newer tools in control to have been applied extensively, it is even more en-
couraging. It causes even the more conservative tuberculosis workers to speak hopefully of
the possibility of actual eradication of tuberculosis in the United States within half a century.
This improved outlook concerning the ultimate eradication of tuberculosis is due in no
small part to the splendid co-operation of physicians, nurses, other professional workers, and
laymen both in governmental and voluntary capacities in the efforts to reach this goal. The
variety of fields represented even among the medical profession in this concerted effort is
indicated by the various positions held by the authors in this issue, representing as they do
sanatorium superintendents, municipal tuberculosis control officers, professors in medical
schools, bacteriologists, students’ health service physicians, and physicians in private practice.
It gives me a great deal of pleasure to present these papers to you.
James E. Perkins, M.D.,
Managing Director, National Tuberculosis Association
120
The Journal-Lancet
The General Practitioner’s Part in the
Eradication of Tuberculosis
S. A. Slater, M.D.*
The statement has been made many times recently
that if we had the money (usually many millions
of dollars) tuberculosis could be eradicated in a short
time; some placing it as early as in 10 years. Such
statements are made by irresponsible persons ignorant
of the real problem in handling tuberculosis. It seems
to be a recent custom to feel that anything can be ac-
complished by the expenditure of large sums of money.
These inexperienced idealists usually have some special
plan they are promoting, saying if the funds were avail-
able to carry it out tuberculosis would be wiped out
almost over night. Such statements are absurd to one
who has been actively interested in the fight to eradicate
tuberculosis for more than 35 years. There is no plan
regardless of how much is spent that will be suitable
for all localities and conditions; none will bring the de-
sired result without the cooperation and wholehearted
support of the general practitioner.
Forty years ago some persons thought it would only be
necessary to build sanatoria to take care of the known
cases of tuberculosis to wipe out the disease. They failed
to take into account the big job of finding all cases of
tuberculosis and even today with all the effort that has
been made many cases reach the far advanced stage or
even die before being discovered. Cases discovered early
may live many years without recovering or dying. The
sanatorium has contributed greatly to the reduction in
the death rate from tuberculosis but it did not bring
about the eradication of the disease.
Some sanatoria have contributed proportionately more
than others. Some have contributed only by caring for
the known cases of tuberculosis, others have done much
more; they have been actively engaged in the prevention
of tuberculosis as well as the treatment. The success of
any sanatorium will have to depend in final analysis on
the help and cooperation of the general practitioner of
the locality which the sanatorium serves.
Recently we have heard and read much about mass
surveys and it is emphasized that if everyone were x-rayed
all cases of tuberculosis could be discovered. It would
be wonderful if everyone could be x-rayed, and if it
were done many cases of tuberculosis would be found.
There is much more to such a program than just x-ray-
ing the individual. If such a program is to be a success
much preliminary work must be done before the pictures
are taken so that a high percentage of the population
responds. Following the taking of the picture, follow-up
work has to be done to determine which cases are clin-
ically active. Many x-ray pictures show shadows sugges-
tive of tuberculosis in which no clinical disease is present,
*Superintendent and Medical Director, Southwestern Minne-
sota Sanatorium, Worthington, Minnesota.
on the other hand, many pictures appear negative in which
clinical tuberculosis is present. The x-ray survey can be
made a valuable aid. There are dangers that must be
eliminated if its full value is to be obtained, one of the
most common of which is the average layman’s belief
that if the x-ray shows his chest to be negative it is
infallible evidence that he does not have tuberculosis,
and the other the confidence of some that they will not
have it in the future, both of which are sadly erroneous.
It cannot be too strongly emphasized that while the x-ray
is a valuable aid in the diagnosis of tuberculosis, a defi-
nite diagnosis should never be made from the x-ray alone,
nor is it possible to rule out tuberculosis from the x-ray
alone.
The success of an x-ray survey depends on the follow-
up of all suspicious cases. The responsibility rests largely
with the General Practitioner.
The tuberculin test while not applicable to all parts of
the country is a most valuable aid in eradicating tuber-
culosis, as has been demonstrated in Southwestern Min-
nesota in the Riverside and Southwestern Minnesota
Sanatorium districts. The results accomplished in these
districts would not have been possible had it not been
for the whole-hearted support and cooperation of the
physicians of those areas.
My experience with the tuberculin test convinces me
it will play a most important part in the eradication of
tuberculosis. It is true I have been in a locality which
lends itself admirably to its use, but little would have
been accomplished had it not been for the cooperation
of the general practitioner. The tuberculin test is most
valuable where the death rate is low and where there are
comparatively few reactors. It is effectual after the death
rate has been reduced and there are comparatively few
cases to be found. The mass x-ray surveys are useful
where the death rate is high and the incidence of tuber-
culin reactors is high. Many demonstrable cases of tuber-
culosis can be found by the use of the x-ray but the
co-operation of the physicians of the locality is necessary
to reduce the death rate and incidence of infection to
the point where the tuberculin test can be used effec-
tively.
The tuberculin test will have to be used in the final
stages in eradicating tuberculosis. It is a most valuable
agent when properly used. It is not a big undertaking
to test all children of school age. A child who reacts
should be considered a potential case of clinical tubercu-
losis and kept under observation. It is useful further
in helping to find the unsuspected source of infection.
When a child is found who reacts in a locality such as
Southwestern Minnesota and surrounding territory it is
not difficult to study the suspected contacts to find the
April, 1949
121
case spreading infection. There are two adults now un-
dergoing treatment in the Southwestern Minnesota Sana-
torium who were found because their children in school
were tuberculin reactors. One of them would never have
been suspected for he was the picture of health, weigh-
ing 200 pounds and feeling well. When his children
were found to be infected with tubercle bacilli he was
induced to see his family physician whose examination
revealed open tuberculosis with involvement of both
lungs. He was fortunate in having a physician who did
not rely on appearance of patient in making a diag-
nosis, but who realized that a child who reacts to tuber-
culin had been in contact with someone who had con-
tagious tuberculosis. This physician also knew that every
contact should be suspected until proved free from the
disease and that the search should be continued until
the source of infection had been discovered. This case
demonstrates an important part of the general practi-
tioner’s work and the results obtained will depend largely
on him.
This emphasizes the fact that the general practitioner
is a most important factor in any plan for the eradica-
tion of tuberculosis. Any program regardless of how
good it may be will fail without his support. He is the
very foundation on which any plan will have to depend
if it is to be a success, and without his support it is
doomed to failure. What can be done to insure his sup-
port and interest in this fight to eradicate tuberculosis?
Every physician is interested in doing all he can to help
eradicate any disease as well as doing everything possible
to cure diseases amenable to treatment. It is therefore
necessary first to convince him of the importance of what
he can do in the control of tuberculosis, second to edu-
cate him so he will be in a position to do the most good.
His interest will then be enlivened to the point where
he will be in a position to render the important service
of which he is capable.
Many advances have been made recently in the treat-
ment of tuberculosis. Surgery has played an important
part and has taken a high place in treatment. The sur-
geon is practically helpless without the aid of the gen-
eral practitioner who is often the first to see the patient,
make a diagnosis, and start him in the right direction
on the road to recovery. The sanatorium likewise is in
the same position, not being able to render maximum
results without the co-operation of the general practi-
tioner who finds the case and refers him to the sana-
torium where he can get the proper treatment and at
the same time protect the public. The tuberculosis spe-
cialist is in a similar position for most of his cases are
referred to him by the general practitioner who suspects
or has made a diagnosis of tuberculosis.
This paper is intended to emphasize the importance
of the general practitioner in the campaign to eradicate
tuberculosis. No plan can be a success without his assist-
ance and cooperation. He has a significant responsibility
and as usual he will arise to the occasion and do his part
in seeing that tuberculosis is eradicated. Tuberculosis
as a killer has been markedly reduced but the big job
is to find the remaining cases which will need unrelin-
quished effort on the part of all. With everyone work-
ing and doing his part tuberculosis can be eradicated.
INAUGURAL MEETING OF THE MINNEAPOLIS SOCIETY
OF INTERNAL MEDICINE
The Minneapolis Society of Internal Medicine, a new organization, held its inaugural
meeting in the Auditorium of the Hennepin County Medical Society, Wednesday evening,
March 9, 1949.
The following officers were elected: President, Reuben A. Johnson; vice president,
Reuben Berman; secretary, George N. Aagaard; recorder, Russell M. Wilder; treasurer,
Harold E. Miller.
The scientific program consisted of two papers: (1) "Cardiac Catheterization as an Aid
in the Diagnosis of Heart Disease,” by R. V. Ebert, M.D. (2) "Congenital Isolated Dextro-
cardia,” by Carleton Chapman, M.D., and Thomas Gibbons, M.D.
122
The Journal-Lancet
Active Pulmonary Tuberculosis Following Negative
70 mm. Film Impressions in Minneapolis
Mass Chest X-ray Survey
William Roemmich, M.D.*
In a recent editorial1 there appears this opinion: "It
has been emphasized in recent years that the most
effective method of controlling tuberculosis is by means
of chest x-ray examinations of the adult population in
a definite period of time.” Our experience has been too
recent to evaluate the survey’s effectiveness in controlling
tuberculosis.2 This discussion is concerned in trying to
determine the definite period of time ("time element”)
required to make surveys most effective as case finding
techniques.
The following questions appear related to the "Time
Element”: How often is pulmonary tuberculosis present
though not yet manifest on photofluorographic film?
How many have been or will be infected and develop
progressive lesions shortly after the report of a negative
film? How frequently should or can an x-ray survey be
repeated and reveal enough epidemiologically significant
new cases? What portion of the new cases discovered
after a survey will come from the surveyed and non-
surveyed groups of a community?
After the Minneapolis community-wide x-ray survey
negative project records were alphabetized. All new
cases — regardless of how diagnosed — reported to the
Health Department after the survey started, were
checked against the negative project records. This pro-
cedure revealed the number of people who had negative
survey films and later developed tuberculosis. For this
discussion, a case of pulmonary tuberculosis is one in
which a bacteriological diagnosis has been made.
By December 1, 1948, 23 bacteriologically diagnosed
cases of pulmonary tuberculosis were reported from that
group of people who had negative films in the survey
May 5 to August 25, 1948.
Of the 23 new cases, 15 (65 per cent) were studied
because they developed symptoms; three (13 per cent)
were studied as contacts; three (13 per cent) had rou-
tine x-rays and two (9 per cent) were under the care
of a physician for other diseases. Of the 15 who de-
veloped symptoms, only three were minimal; nine mod-
erately advanced and one far advanced. Two had
pleurisy with effusion. Of 23 cases, 13 (57 per cent)
had no contact with known cases; seven (31 per cent)
had contact with known cases but were not being fol-
lowed; three had known contact and were being fol-
lowed. Contact examinations revealed 13 per cent of
new cases. All were contacts of recent open cases. None
were contacts of cases revealed by the mass survey. In
*Surgeon, Division of Tuberculosis, United States Public
Health Service. Formerly Tuberculosis Control Officer, Minne-
apolis Division of Public Health.
nine of the 15, symptoms were present at the time the
negative film appeared. Of course, there is no way now
to relate these symptoms to what later appeared as pul-
monary tuberculosis.
Nine were between 15 and 24 years of age; seven
between 25 and 34; one was 42; one 47; one 64 and
two were 81.
There was no relationship between stage of disease and
interval between negative x-ray and subsequent positive
x-ray as illustrated in table 1. This information would
be even more pertinent if we knew the tuberculin sensi-
tivity as well as x-ray findings. We are certain of only
one instance (case 4) in which a person became infected
and developed an x-ray lesion after a negative survey
film. We have no tuberculin information on the others;
and whether the infection took place after the negative
film, or whether infection had taken place ten years
previously and disease developed now, we shall never
know. This information is a minimum essential for
planning case finding programs.
Table 1
Interval between negative survey Stage of Disease
film and later positive film No. M. M,A. F.A.
Less than 12 weeks 5 13 1
More than 12 and less than 24 weeks ... 6 4 2 0
More than 24 and less than 36 weeks 4 2 2 0
More than 36 and less than 48 weeks 6 1 5 0
More than 48 weeks _ 2 0 11
Total 23 8 13 2
The following case histories illustrate the acuteness
with which tuberculosis may progress. The cases are sig-
nificant only in that previous negative films were avail-
able. That tuberculosis may develop acutely is well
known.3’4 These cases also illustrate the fact that symp-
toms and apparent disease may precede x-ray lesions as
much as ten months.
Case 1. (612585). This is a 22-year-old male student
who had known exposure in military service two years
before present illness began. In January 1947 he de-
veloped malaise and began losing weight. During Jan-
uary and February he lost 10 pounds. By October 1947
he had lost 30 pounds. He had an x-ray in the survey
on July 2, 1947, which was negative. On October 10, 1947,
he had a lesion. We do not know when this patient be-
came a reactor to tuberculin. The evidence indicated that
progressive tuberculosis was present ten months or longer
before it was revealed by x-ray shadow.
April, 1949
123
Case 2. (22939). This is an 80-year-old man. No
known exposure. No tuberculin test. History: Sixteen
weeks after the negative survey film, the patient pre-
sented himself with swollen draining cervical lymph
nodes. Culture confirmed the diagnosis of tuberculosis
of cervical lymph nodes. Six months after the negative
survey film he developed a small infiltrate in the right
first and second anterior interspace. Two cultures of
sputum were negative for acid-fast bacilli. He then de-
veloped a mass in the right upper lung with rapid pro-
gression and death on July 5, 1948, eleven months after
his negative survey film. The clinical diagnosis was
tuberculous cervical adenitis, minimal pulmonary tuber-
culosis and bronchogenic carcinoma of the lung. Autop-
sy revealed normal tracheobronchial lymph nodes. Lung
shows caseous necrosis, Langhans cells, tumor in right
upper lung field, solid caseous necrosis. Small bronchial
nodes and cervical nodes, caseous necrosis and giant
cells. Culture, positive for tubercle bacilli. Cause of
death, tuberculosis.
Case 3. (101166). This is a 22-year-old stenogra-
pher. Her only known contact was a fellow employee
with arrested tuberculosis. No history of tuberculin test.
Present illness began in late April 1947 with cough,
expectoration and malaise. Survey x-ray was taken on
May 6th and interpreted negative. Symptoms continued
and she consulted a private physician July 7th, when a
diagnosis was made of pulmonary tuberculosis, far ad-
vanced, active. Bacteriological confirmation followed on
August 18th. This case developed from a negative x-ray
to a far advanced lesion in less than eight weeks. Pul-
monary disease was apparently present but not yet
manifest on x-ray.
Case 4. (60409). This is a 16-year-old female fol-
lowed as a contact of Case 3. On June 2, 1947, survey
film was negative. On August 15th a follow-up film
was negative and there was no reaction to the Mantoux
test with 1 mgm. old tuberculin. On November 16th
a moderately advanced lesion was present. Tuberculin
test was now positive. Sputum cultures were positive
December 11, 1947.
Case 5. (600406). This is a 27-year-old male. His-
tory of exposure in Navy. No history of reaction to
tuberculin test. This patient had a negative survey film
May 6, 1947. At the time he was losing weight, he
began coughing, July 3rd, and had lost 10 pounds since
the survey film. X-ray film taken in July 1947 was diag-
nosed pneumonia. Bacteriological diagnosis was estab-
lished October 5th, tuberculosis moderately advanced.
Hospital film was repeated October 12, 1947.
Discussion
It has been demonstrated in animals that lesions may
be present grossly before they can be demonstrated ra-
diologically.0 This is also frequently seen in man when
at autopsy there are macroscopic lesions which were not
manifest on x-ray. There are two other reasons chest
x-ray may fail to reveal the presence of a lesion.3 Twenty-
five per cent of the lung is obstructed by diaphragm,
heart, etc., and canont be seen, and lesions are located
in other organs of the body.
Nine of our patients who had symptoms at the time
the survey film was made apparently illustrate instances
of this type. From the standpoint of case finding with
the x-ray we need to know how frequently this happens.
A review of the time interval, Table 1, and the cases
cited illustrates "fundamental aspects” of pulmonary
tuberculosis.4 The disease develops acutely. Forty-eight
per cent of our cases developed within 24 weeks — five
to the minimal and six to the advanced stages of the
disease. Secondly, stage of disease is not related to time.
After 12 weeks, four out of five (80 per cent) were
advanced; after 24 weeks, six out of eleven (55 per cent)
were advanced. After 48 weeks, 14 out of 21 (66 per
cent) were advanced.
It has been suggested that very little, if any, tubercu-
losis appears in the surveyed group following mass sur-
veys by chest x-ray/’ We know that every community
has a given incidence of new infections with human
tubercle bacilli each year. This incidence can be ascer-
tained by tuberculin tests for non-reactors in those areas
where bovine infection is minimal. It has been shown
that of these new first infections the majority develop
progressive manifest lesions within two years or less fol-
lowing infection. ''s In our study, new cases of progres-
sive bacteriologically positive disease appeared as 7.7 per
100,000 over a 19-month period. This is truly low inci-
dence and seems to support the suggestion made by
others/’ If this represents the true incidence of disease
for the surveyed group over a 19-month period, the out-
look for control and eradication appears most hopeful.
Can it be that there are many more cases not yet mani-
fest who will appear in succeeding years when the dis-
ease becomes more "symptom or x-ray shadow produc-
ing”?
Bibliography
1. Hilleboe, H. E.: The Time Element in Tuberculosis
Control, Public Health Reports, 62:825.
2. Mass survey results of Minneapolis. Unpublished.
3. Myers, J. A., McKinley, C. A.: The Chest and Heart,
Charles C Thomas, 1949, p. 862.
4. Pinner, M.: Pulmonary Tuberculosis in the Adult,
Charles C Thomas, 1945, p. 236-50.
5. Medlar, E. M.: Comparison of X-ray Appearance with
Autopsy Findings in Experimental Tuberculosis. Am. Rev.
Tuberc., 50:1-23.
6. Davies, R., Hedberg, G. A., Fischer, M. A.: Mass Sur-
vey of Ely Minnesota, Am. Rev. Tuberc., vol. 58:1-14.
7. Badger, T. L.: Notes from a paper presented at the
National Tuberculosis Association, New York, 1948.
8. Holm, J.: Tuberculosis Control in Denmark, Public
Health Reports, 61:1426.
124
The Journal-Lancet
Tuberculosis Control in Colleges*
Max L. Durfee, M.D.f
Oxford, Ohio
For 17 years the Committee on Tuberculosis of the
American College Health Association has prepared
an annual report entitled, "Tuberculosis Among College
Students.” The title suggests that the disease tubercu-
losis, per se, is a major problem among the college stu-
dents of America. Such emphasis is not justified by the
facts. However, the control of tuberculosis is a problem
of world-wide scope which most certainly extends to our
college campuses. Review of but a few elementary facts
about tubercuolsis clearly indicates the importance of
establishing measures directed toward the control of this
disease among college students.
Within the past 40 years tuberculosis has dropped
from first to seventh in the list of major causes of death
in the United States. However, it continues to cause
the death of more young women between 15 and 35
years of age than anv other single affliction. Men of
approximately the same age die more frequently only as
a result of accidents.
This communicable disease is caused by a germ. Con-
trary to a former widely held opinion, tuberculosis is not
hereditary. But, owing to the fact that it is spread from
the sick to the well by frequent contact between the two,
several members of the same family may acquire the
disease if one of their number is a victim.
In many respects, life in the college environment is
similar to that within the family. One of the main dif-
ferences is the increase in numbers of persons involved
in situations such as the dormitory, the dining hall, or
the recreation center. If an active, open case of tubercu-
losis is permitted to mingle in these groups, tuberculous
infection may spread to untold numbers of others. Some
of these will acquire the disease and thus a vicious cycle
of disease and infection may be established.
The task of preventing such an occurrence would be
less difficult if tuberculosis were like other infectious dis-
eases. The obvious offender would be apprehended and
isolated until no longer a danger to others. But, among
all the germ-caused diseases that may produce disability
and result in the death of man, none is the counterpart
of tuberculosis. Usually, it is a slow, insidious ailment.
It does not ordinarily make its presence known by acute
and fulminating illness. In fact, tuberculosis may be
present for as long as two years, or more, even in a
moderately advanced and communicable form, without
causing a sign or symptom to cast suspicion as to its
presence. For this reason, it is frequently possible to dis-
cover evidence of tuberculosis in apparently healthy peo-
*Presented before the Southwestern section of the American
Student Health Association at Dallas, Texas, November 29,
1947.
t Chairman, Committee on Tuberculosis, American College
Health Association.
pie if special steps are taken to look for the disease.
These "special steps” are the measures employed in a
case-finding program for the control of tuberculosis.
Tuberculosis control among the students of a college
or university is usually organized as a function of an
already existing student health service. Ideally, these
programs have two main objectives. One is to determine
the incidence of primary tuberculosis among young men
and women of college age; the other is to find all cases
of active clinical disease, and to get them under adequate
treatment, immediately.
At first glance, the two objectives may appear to be
the same, especially if considered in the light of our
knowledge of other infectious diseases. But, to under-
stand the difference between primary tuberculosis (tuber-
culous infection) and clinical tuberculous disease is to
appreciate one of the most striking peculiarities of tuber-
culosis. The human body has a remarkable defense
against a first invasion by the germ of tuberculosis. If
not able to destroy the invaders, it imprisons them, even
going so far as to fill the prison walls with a concrete-
like deposit of calcium salts. In the process of creating
this prison, the body becomes allergic, or sensitized to
the protein products of the germ’s life processes. Allergy
to tuberculo-protein may persist for years, lasting as long
as there remains a spark of life in the imprisoned germ.
This allergic state may be detected by a simple skin test
— the tuberculin test. Therefore, since allergy means
presence of the living germ, and since this in turn means
infection, we have a method for discovering persons in-
fected with the germ of tuberculosis. Searching for per-
sons with primary tuberculosis (tuberculous infection),
is important because if these people subsequently acquire
fresh infection, they may develop progressive disease.
Or, a breakdown of resistance to the imprisoned germs,
allowing them to grow and multiply, may also lead to
the active, communicable form of tuberculosis.
The Committee on Tuberculosis has for some time
advocated that a certain routine be used for the control
of tuberculosis in the college population of the country.
Those in authority, perhaps sensing the possibility of
criticism because of the controversial nature of the whole
question, were wise in adding to the committee of health
service workers, an advisory committee of nationally
known experts on tuberculosis. In May, 1947, the com-
mittee met in New York as a part of the Third Na-
tional Conference on Health in Colleges. Their purpose
was to make recommendations for the best possible meth-
ods of tuberculosis control for colleges, these recommen-
dations to be published in the proceedings of the Third
National Conference.1 The recommendations were dis-
cussed and drawn up under the watchful and critical
eyes of Dr. Charles E. Lyght, then Director of Health
April, 1949
125
Education for the National Tuberculosis Association;
Dr. Esmond R. Long, Director of the Henry Phipps
Institute for the Study of Tuberculosis; and Dr. Francis
Weaver, Director of the Division of Tuberculosis Con-
trol of the United States Public Health Service, they
being the only members of the advisory committee able
to attend the meetings.
The case-finding procedure that has been recommend-
ed by the committee for some years past is as follows:
1. All students new to a given campus are tuberculin
tested except those known to be reactors because of hav-
ing been recently tested elsewhere. For better results,
and to insure greater uniformity, tuberculin testing is
done intradermally (Mantoux), using Purified Protein
Derivative (P.P.D.) in two strengths. The first dose,
prepared according to directions, is 0.00002 milligrams.
If no reaction occurs after 72 hours a second dose of
O. 005 milligrams is given. Equally dependable results
may be obtained if a reliable brand of Old Tuberculin
(O.T.) is used. The first dose of the latter, injected
intradermally, is 0.1 milligrams. When no reaction oc-
curs after 72 hours a second dose of 1.0 milligram is
given. Failure to react to the second dose of either
P. P.D. or Old Tuberculin may be taken as evidence of
freedom from tuberculous infection.
2. Chest x-ray inspection is made on all new students
who react to tuberculin, or who are known to be reactors.
3. All non-reacting upperclassmen are retested an-
nually.
4. All reactors are re-x-rayed annually, or more often.
As a result of the New York deliberations, only one
change was made in these recommendations. Mass x-ray
techniques, so widely used in the general population,
and in the armed forces almost from the beginning of
World War II, brought to light many unsuspected, non-
tuberculous chest lesions. Such has been the case in stu-
dent health service practice, as well, and frequently these
signs of non-tuberculous chest pathology have important
significance. In addition to this, many physicians have
voiced the desirability of having a "base” film on all stu-
dents to be used for comparison, should the need arise at
a later date. It was, therefore, decided that not only
should all new students be tuberculin tested, they should
also have chest x-ray inspection. The routine now advo-
cated therefore adds this one new item, — namely, all new
students are to be both x-rayed and tuberculin tested,
and in subsequent years of attendance, all non-reactors
are retested and all reactors are re-x-rayed annually, or
more often.
This recommended program has both immediate and
long range significance. Of immediate importance, de-
termination is made of the number of students needing
further study in the search for active cases of pulmonary
tuberculosis. By this, we do not wish to detract from
the possibility of active tuberculosis being present in
some part of the body other than the lungs. There is,
however, no convenient method like the x-ray for deter-
mining the presence of extrapulmonary tuberculosis.
Nor does tuberculosis in other parts of the body have
the public health significance that is inherent in pulmo-
nary tuberculosis. Tuberculosis in organs other than the
lungs is not readily communicable.
Of further immediate importance, results of the tuber-
culin test indicate those among the student body who are
not yet allergic to tuberculin, and probably, therefore,
not infected with the germ of tuberculosis. The test is
very sensitive and accurate to the point of near infalli-
bility. It is true that exceptions to this occur. But, if
the test is properly applied and correctly interpreted, the
chance for error is one of the rarest in medical diagnosis.
The result of a tuberculin test is of long-range impor-
tance to both the reactor and the non-reactor. When a
non-reactor is found to have changed to a state of re-
action, this evidence of newly acquired sensitivity is
said to be very significant. One authority designates
these people as "converters” and believes they need care-
ful and frequent examination and x-ray, perhaps every
three to six months, for the first year or two following
discovery of their infection. J
For the reactor, his smoldering infection may flare into
activity at any time. Reactors are the potential future
cases of tuberculosis. They are the ones who must order
their lives to conform as nearly as possible to the ac-
cepted standards of healthful living.
Many colleges may find it difficult or impractical to
incorporate the approved method of case finding into
the structure of their health service program. As a mat-
ter of fact, of course, individual schools have found it
necessary to build their tuberculosis control program
from modest beginnings, even though they constantly
point toward the development of an ideal type of pro-
gram. The section on Tuberculosis in the report from
the Third National Conference on Health in Colleges
contains some modifications of the optimum program.
Variations have also been presented in some detail in
previous annual reports of the committee. Largely they
are variations in frequency of testing and size of test
doses, the latter usually being a single, intermediate dose
of P.P.D. (0.0002 mgm. or 0.0001 mgm.), or O.T.
(0.5 mgm.) .
One type of modified program which has come into
wide use in recent years has certain limitations which
should be recognized if the decision is made to use it
as the case-finding method of choice. A discussion of
tuberculosis control in Amercian colleges and universi-
ties would be incomplete unless the fact were included
that an increasing number are using the x-ray alone as
their initial screening method. Many cases of tubercu-
losis are brought to light when the x-ray alone is used
as the initial screen. However, the considered opinion
of the Tuberculosis Committee is that tuberculosis can
not be controlled with the ultimate goal eradication if
only cases are searched for which have advanced to the
stage where they cast a shadow on x-ray.
In the absence of definite evidence of disease, the x-ray
can not tell us, with any degree of assurance, whether
tuberculous infection is present or not. Abnormal x-ray
findings which in the past have been thought to be due
126
The Journal-Lancet
to tuberculosis, are now known to be due to a variety of
causes, non-tuberculous as well as tuberculous. Among
the non-tuberculous calcified "scars” often reported seen
on chest films are those which, in recent years, have been
considered to be due to certain fungus infections such as
histoplasmosis and coccidioidomycosis.
Attention is also called to the considerable numbers
with obvious x-ray evidence of lung pathology, even ap-
pearing "typically” like tuberculosis, but which are not
tuberculous. Regardless of whether x-ray is used as the
initial or secondary screen in a tuberculosis case-finding
program, the diagnosis of tuberculosis can not be made
from the x-ray alone. No one should ever be saddled
with a diagnosis of tuberculosis on less evidence than
would be the result of careful clinical study. This in-
cludes history and physical examination, tuberculin test-
ing, serial x-ray inspections of the chest, sputum exam-
ination, gastric washings examination, animal innocula-
tion and culture, and these in combinations appropriate
to the case at hand.
Thus, one of the main requirements of a screening
method in a tuberculosis control program is that indi-
viduals be discovered who are in need of further study.
The x-ray is an invaluable tool in this respect especially
when it is used as a means instead of an end.
An increasing number of colleges are developing tuber-
culosis control programs through the use of photofluoro-
graphic equipment furnished to them by one of the offi-
cial health departments or a non-official health agency.
Others have installed their own miniature film equip-
ment. It seems to make little difference what size film
is used in chest x-ray surveys. The important thing is
that various size films be interperted by someone experi-
enced in the reading of that size film. This holds true
whether the film is 35 mm., 70 mm., 4x5 inches, 14x17
inches, either celluloid or paper, or any other.
A few colleges have reported using the ffuoroscope as
their case-finding method. While perhaps better than
no x-ray the ffuoroscope leaves no permanent record for
future comparison should the need arise. Furthermore,
it is believed by some that early, soft lesions, the very
ones to be looked for, may be missed on fluoroscopic
examination of the chest.
Non-student Participation
Every effort may be put forth to protect students from
each other but a program for tuberculosis control runs
the risk of failure if protection is not afforded against
other sources of infection in the campus community.
Among these other sources of infection must be includ-
ed everyone, from the college president to the equip-
ment room manager. No one on the instructional staff
should escape, nor should those responsible for the main-
tenance of student rooms. Food handlers especially
should be examined. It is perhaps unwise to point to
any one group as being more in need of survey than
another, tuberculosis being the ubiquitous disease that
it is. As in the student body, if everyone is not included
the very one we seek may be missed, thereby defeating
our purpose.
Rehabilitation
The ultimate goal of a case-finding program is the
return of the unfortunate victim of tuberculosis to a
useful place in society. This suggests an important jus-
tification of all the time and effort spent on the pro-
gram. Many cases found on the routine survey of ap-
parently healthy people are discovered to have the disease
in an early or minimal stage. This means everything
to the attainment of that final goal, a world free from
tuberculosis. It means a great deal to the individual
found to have the disease. For him, it is discovered at
a time when chances for early, complete recovery are
best. For his associates, the untold number who are to
gain or lose, depending on when the disease is discov-
ered, early discovery usually means discovery before the
disease has become communicable. Early diagnosis means
tuberculosis control, whether on a campus or in any
other community.
The majority of students upon whom a diagnosis of
tuberculosis is made have been wise in the election of
sanatorium care as the best possible source of correct,
scientific treatment of their disease. For the school year
1946-47, 230 cases were reported to have entered sana-
toria as compared with 61 who were said to be under
treatment at home/ Following successful arrest of their
disease a large number of these former students will ex-
pect to return to college to complete their interrupted
careers. During the 1946-47 school year, 590 arrested
cases of tuberculosis were reported as having returned
to college.
These arrested cases require special attention and sym-
pathetic understanding. Most of them are not able to
pursue the usual routine of collegiate activities, both
academic and extracurricular. A large proportion should
occupy private living quarters. And even under the best
possible living conditions for their particular needs they
must be checked at frequent intervals to make certain
of the continued inactivity of their latent disease.
Conclusion
The foregoing discussion of the recommended routine
for conducting tuberculosis control programs in Ameri-
can colleges and universities, and the general remarks
concerning the implications of these programs, pertains
particularly to undergraduate colleges. Additional tech-
niques may be employed under special circumstances
such as are found in medical and nursing schools where
danger of exposure to tuberculosis is greatly increased.
Here it is deemed wise to examine students at more fre-
quent intervals than the yearly surveys advised for un-
dergraduates. Some medical and nursing schools are
considering the use of, or are actually using, BCG in an
attempt to immunize their frequently exposed students.
BCG is not advocated for use in the general student pop-
ulation. There has, as yet, been no definite proof of the
superiority of BCG over the tried and proved methods
of tuberculosis control, similar to those herein described,
and used so successfully in the United States for many
years.
April, 1949
127
Finally, under no other circumstances may education
regarding the true nature of tuberculosis have the in-
fluence for good that is possible on our college campuses.
From many sources we hear the statement that our stu-
dents of today will be the community leaders and teach-
ers of tomorrow. It is through their potentiality for wise
community leadership that programs may be instituted
in all parts of the nation, embracing all groups in the
population. Colleges and universities, through their stu-
dent health services and other facilities for health educa-
tion, are in an unique position to contribute largely to
the final elimination of tuberculosis from the list of
prominent disablers and killers of mankind.
Bibliography
1. "A Health Program for Colleges.” Report of the Third
National Conferences on Health in Colleges. National Tuber-
culosis Association, New York 19, New York.
2. Hilleboe, Herman E.: Public Health Reports 61:44
(Nov. 1) 1946.
3. Tuberculosis Among College Students.” Seventeenth
Annual Report of the Tuberculosis Committee, American Stu-
dent Health Association, for the school year 1946-1947. The
Journal-Lancet, 68:435, 1948.
. . . BOOK REVIEWS . . .
Treatment in General Practice, by Harry Beckman. M.D.,
Professor of Pharmacology, Marquette University School of
Medicine, Milwaukee. Philadelphia: W. B. Saunders Co.,
6th edition, 1948, 1129 pages, $11.50.
Because this book is kept so thoroughly up to date (the last
edition was in 1945), and because it covers every logical demand
made in a general practice, Beckman’s T reatment has become
a standard reference in modern medical literature.
The new edition (the sixth) seems to be a worthy successor
to its predecessors. Thirty-three entirely new discussions have
been added and over 1000 additional have been rewritten and
revised. Some of the new and revised material includes data on
psychogenic rheumatism, Rickettsialpox, 1 1 new uses in strep-
tomycin administration, the Rh factor, epilepsy and manage-
ment of penicillin reactions.
The general practitioner unfamiliar with Beckman's book will
find it highly valuable as a quick and thorough reference; phy-
sicians who have used it in the past (and their number must be
enormous) will find the new edition substantiates the publisher’s
statement that this is a thorough presentation of the world’s
latest and best treatments. J. N.
War Neuroses, by Roy R. Grinker and John P. Spiegel.
Philadelphia: Blakiston Company, 145 pp, 1945, $2.75.
In this book on war neuroses the authors have done an ex-
cellent job in analyzing and grouping the various psychiatric
syndromes seen during the war and have presented them in a
simple understandable form. Throughout this work the authors
emphasize, and rightly so, that the war neuroses are not new
clinical entities but represent an expression of the individual’s
personality make-up when exposed to the severe stress of war.
The authors have included in this book a fine discussion of
certain general criteria that may be used in establishing a prog-
nosis in these mental disturbances as well as an excellent sum-
mary of treatment. Of particular interest in the latter is the
description of the recently popularized therapy of narcosyn-
thesis.
This book comprises one of the most concise, clearly written
volumes in the field of psychiatry. The material discussed is
illustrated by well selected case reports. Although the subject
matter is limited to war experiences, still the basic principles of
classification, prognosis, treatment, and dynamics can easily be
transposed into the milder stresses of civilian life. As such,
this book assumes tremendous value as a psychiatric guide and
can be most highly recommended not only for the psychiatrist
but to the entire medical profession which inevitably must be
exposed to similar clinical syndromes in every-day practice.
A. B.
Diabetes and Its Treatment, Joseph H. Barach, M.D.
New York: Oxford University Press, 326 pp., $10.00, 1949.
The general practitioner seems to be coming into his own in
more ways than a simple recognition and high sounding plati-
tudes in the editorials of the medical press. A new book just
released, Diabetes and Its Treatment, by Joseph H. Barach,
M.D., was written especially for the busy general medical man.
By design the book is organized to help the doctor provide
the maximum medical care with the greatest economy of his
own time. Simplification of dietetic bookkeeping for the patient,
and avoidance of diet-value guessing appears to be a keystone
in Barach’s presentation. Approximately one-third of the book
is devoted to a "system of diets” clearly set forth for a wide
variety of caloric requirements. Food portions are stated in lay
language so that the diabetic patient will have no difficulty in
following the prescribed diet. Since each diet is precalculated,
selection of the proper diet is all that is needed, after which the
details can be turned over to the office nurse.
Sections on clinical and laboratory diagnosis, clinical path-
ology, complications and treatment are succinctly presented with
adequate illustrations, charts and diagrams to provide a work-
able understanding. It does not have the usual labyrinth of
confusing references and footnotes. Nonetheless, each section
carries a well documented bibliography for those who wish to
delve into original source material.
Diabetes and Its T reatment is recommended to the general
medical man for a highly acceptable clinical approach and a
time saving understanding of diabetes and its treatment.
A. W. H
128
The Journal-Lancet
Medical Students and Tuberculosis
Clayton H. Schmidt, M.D.
Milwaukee, Wisconsin
The purpose of this paper is to complement that writ-
ten by Dr. J. Harold Schultz on "Medical Students
and Tuberculosis,” (Journal-Lancet, April 1944.)
Data for this paper was gathered by sending question-
naires to the 24 members of the class who transferred
from this same midwestern, two-year, medical school in
1945. From these 24 students, now located in all parts
of the United States, 22 replies were received which
form the basis of this report.
In his report, based on the class that transferred in
1940, Dr. Schultz found that one year previously 83.3
per cent were nonreactors to tuberculin, while on gradua-
tion in 1940 only 8.3 per cent failed to react. Later fully
one-third of the class required treatment for active pul-
monary tubercuolsis.
The class that transferred in 1945 followed much the
same curricula as classes of previous years. The only
known contacts with tubercle bacilli were in the second
year when students performed autopsies, many on pa-
tients with tuberculous cavities in their lungs. Autopsy
technic remained about the same, those few students do-
ing the work wore rubber gloves, masks and gowns over
their street clothes, the rest of the students observed.
It is said that an effort was made to exclude tuberculous
patients from student autopsies, but autopsy findings re-
vealed that exclusion was far from perfect. During the
second year, too, students continued to have physical
diagnosis classes, the subjects being, for the most part,
inmates of the same institution that supplied most of the
autopsy material, many of whom had active tuberculosis.
Of the 22 students whose replies comprise this report,
two showed a tuberculin reaction on entering medical
school, and 20 were negative. Of the 20 students who
were negative, 14 or 70 per cent had their first reaction
either at this two-year school or at the time of their first
tuberculin skin test after they had transferred, which in
most cases was at the time of their entrance physical ex-
amination. Of these 14, three can definitely state that they
changed during their first two years, seven more were
found to be reactors at the beginning of their third year,
while four more became reactors later. In the case of
these latter four students it is not known whether an
initial test was recorded, or whether a skin test was not
performed until later in their educational program. Thus
only six, or 30 per cent of the group of 20 nonreactors
on entrance to medical school, still remain so.
It is unfortunate that only one compulsory skin test
was made during the first two years of medicine at this
school. This was done at the beginning of the pathology
course, but even a single check-up later in the course
seemed to be studiously avoided. A few students realized
the danger and had periodic skin tests done, those who
changed had chest x-ray inspection periodically. At the
time of this writing one student has undergone a course
of bed rest therapy, and a second is in the process of
having the nature of his chest lesion determined. The
histories of these students in brief are as follows:
The first showed no skin reaction during the first two
years but he reacted on the first test after transferring
to a third year school. At this time x-ray inspection re-
vealed no evidence of diseases in his chest. A small hem-
optysis at the end of the third year prompted further
study, and a diagnosis of early, minimal tuberculosis of
the left lung was made. Bed rest was instituted imme-
diately, lasting for four months, with curtailed activity
for the remainder of the year. He is now continuing
his fourth year, and may be classed as an arrested case.
The second student was a nonreactor during the first
two years, on transferring no test was done, but photo-
fluoroscopy revealed no evidence of a lesion. In the
spring of 1947 he had a brisk hemoptysis, and reacted
to tuberculin. A minimal lesion was located and further
studies are now in progress to determine the actual status
of the disease.
It is gratifying to know that the incidence of active
tuberculosis is much lower, and that the incidence of
tuberculin conversions has been reduced in this two-year
medical school. However, the incidence is still high (70
per cent) and can be interpreted only as meaning that
students continue to be exposed to tubercle bacilli. Of
the students questioned, well over one-half felt that they
acquired infection during the first two years, only two
thought it may have occurred later. Most of them felt
that their two-year medical school was grossly negligent
in not adopting more strenuous measures for the protec-
tion of the students.
It is the purpose of this paper to again stress the im-
portance of prevention of tuberculosis, and to urge
schools to adopt every practical measure to protect the
health of students. The one arrested case cited again
stresses the good results that may be obtained through
early case-finding and prompt treatment. It is to be
hoped that all schools will keep a close check on their
students with the tuberculin test and periodic x-ray in-
spection of the chests of all reactors.
April, 1949
129
Immunobiologic versus Exposition Prophylaxis
of Disease in Medical Students,
Particularly Tuberculosis
K. F. Meyer, M.D.*
San Francisco, California
Student health services in medical schools throughout
the country employ the classical procedures and tech-
niques to prevent transmission of infective agents when-
ever practical. It is well known that sanitation effectively
suppresses, in fact, eliminates, the diseases which are col-
loquially designated as "avoidable.” Protection of water
and food supplies thus controls the infection chains in
which the parasite must pass from the intestines of one
to the intestines of another. These general measures are
mostly ineffective in the control of the "civilization dis-
eases,” since contagion is eventually a function of crowd-
ing and intimate contact of human beings, and thus
"unavoidable.” Exposure is frequently not preventable,
thus protection of the susceptible human being through
immunization before infection, has acquired increased
importance. Immunization procedures are systematically
carried out by the majority of the health services in
co-operation with departments of preventive medicine or
of bacteriology for the immunobiologic control of such
diseases as typhoid, diphtheria and smallpox. Students
benefit from this program both in protection and edu-
cation.
The data leave no doubt that the protection afforded
against accidental laboratory infections has been marked,
particularly in the laboratories where students work with
experimental typhoid carriers in animals. Inoculated stu-
dents either fail to contract typhoid fever or have mild
and not infrequently abortive attacks.
Since 1930 immunization against diphtheria has been
practiced by second-year medical students as a part of
their exercises in medical bacteriology. The proportion
of second-year medical students susceptible to diphtheria
was strikingly high from the early and late thirties until
recently when from an all high of 65 per cent it had
dropped to a low of 35 per cent. This low rate is prob-
ably attributable to the preventive measures applied dur-
ing their childhood. Immunization of susceptible med-
ical students with diphtheria toxoid is regularly practiced,
and stimulation or "booster” injections are recommended
when the risk of exposure is great. Reviewing the inci-
dence of diphtheria among the medical personnel dur-
ing the past 30 years, it is gratifying to note that diph-
theria is now unknown, while in the period 1910 to 1925
occasional infections which required specific serum ther-
apy of persons allergic to horse serum proved serious
problems, giving cause for hours of anxiety while these
patients underwent treatment.
^George Williams Hooper Foundation, University of Cali-
fornia, San Francisco.
On several occasions emergency smallpox vaccination
has had to be instituted because many students have been
accidentally exposed to a patient with florid smallpox
who floated into the out-patient services. It was always
surprising to find that 50 per cent of the medical stu-
dents and 60 per cent of the dental students had a vac-
cinoid or accelerated reaction. Moreover, in the early
1920’s over 20 per cent of the students who had been
vaccinated showed primary vaccinia reactions. With the
universal recognition that potent vaccines are important
and their use rather generally accepted, primary vac-
cinia reactions have disappeared in the student group
with histories of previous vaccination. Furthermore, ob-
servations on medical students emphasize that the im-
munity conferred by smallpox vaccines is not always of
a high order, and moreover it is frequently temporary.
Thus, it must be appreciated by the student health serv-
ices that whenever unexpected exposure threatens the
students, re-vaccination with a potent vaccine is essential.
Until 1939 the major health problem of medical stu-
dents— tuberculosis — failed to receive the attention it
deserves. Personal experience had taught that prior to
this date it was by no means uncommon that one or two
students dropped out of school each year because of
tuberculosis. The Student Health Service of the Uni-
versity of California Medical School became greatly con-
cerned when in 1939 in a group of 60 students not less
than five became ill with clinically recognizable active,
primary pulmonary tuberculosis. This experience had a
very bad effect on the morale of the students, and pre-
vention became the subject of consideration and discus-
sion by the faculty. As epidemiologist and adviser in
public health matters I was asked to collect information
relative to certain preventive measures used in other
schools and hospitals.
In a short report in 1940 it was emphasized that the
situation at the University of California differed in no
way from that in other institutions. The fact that med-
ical students with a negative tuberculin reaction would,
after receiving instruction in the tuberculosis wards of
the San Francisco Hospital, become tuberculin-positive
had been recognized in connection with a program start-
ed in 1935 by Charles E. Shepard at the University of
California and Stanford University under the auspices
of the San Francisco and Alameda Counties and Cali-
fornia State Tuberculosis Associations. Examinations
made under this program had shown that among a
group of 60 medical students the percentage of tuber-
culin-positive students rose from 78.3 per cent in the sec-
130
The Journal-Lancet
ond year to 97 per cent in the fourth. When the tuber-
culin-allergic state of the students was below 40 per cent
the "conversion” to tuberculin-positive reaction was cor-
respondingly lower, and approximately 60 per cent re-
acted in the fourth year. These figures corresponded
with those reported by Myers and his associates who
found that the 37.5 per cent of the students at the Uni-
versity of Minnesota School of Medicine who gave a
positive reaction to the tuberculin test on entrance con-
verted to 72 per cent at the end of the fourth year.
On the other hand, in the School of Education the inci-
dence of positive reactors increased from 24.8 per cent on
entrance to 28.5 per cent on graduation. Ruth E. Boyn-
ton, who analyzed the data on tuberculosis among two
groups of nurses and one group of university students
in Minnesota, estimated that the tuberculosis infection
rate for student nurses on a general hospital service was
ICO times as great, and for student nurses on a tubercu-
losis service 500 times as great as for students in the
School of Education.
Additional evidence that occupational exposure to
tuberculosis increases tuberculosis morbidity among tu-
berculin-negative students was and has recently again
become available in reports from a diversity of sources.
Among the medical students in Oslo, that Scheel has
observed since 1926, 4.3 per cent tuberculosis morbidity
per observation year was found in the tuberculin-nega-
tive group, 1.4 per cent in those positive without a his-
tory of symptoms, and 2.9 per cent in those who had
such a history. Equally important is the statement by
Gullbring that the junior members of the Soderby Hos-
pital Staff furnished a subsequent tuberculosis rate sev-
eral times greater among the originally negative reactors
than among the positive reactors. He concluded and rec-
ommended that a tuberculin-negative applicant for work
with the tuberculous should not be accepted for such
service. Ulmar and associates found a 2 per cent tuber-
culosis morbidity among nurses. Rist, in a study on
1,047 medical students at Paris for a period of four to
six years, reported that at the beginning of their clin-
ical studies 11.35 per cent were tuberculin-negative. This
figure compares unfavorably with 38.05 per cent, 45.84
per cent and 50.9 per cent found in students of the
same age at three different high schools. Of the tuber-
culin-negative medical students a primary infection ac-
companied by clinical signs and symptoms developed in
34 per cent. In only 4.37 per cent of the positive re-
actors did the disease become clinical. It is important to
note that in the experience of Rist a qualitative differ-
ence between the disease in the two groups was observed.
LJnder the conditions prevailing among the students in
Paris, disease in the previously tuberculin-positive group
was markedly more severe than the primary infection in
the tuberculin-negative group. However, early treatment
resulted in arrest of the disease in 90.9 per cent of cases
and the patients returned to work. Anyone familiar with
the findings reported by Morris will agree that the tuber-
culin-positive rate of 100 per cent, positive x-ray findings
rate of 16.7 per cent and case fatality rate of 10.7 per
cent in a group of women medical students attest to an
inestimable social and economic loss which must be cor-
rected by the physicians of the student health services.
At the time the available information concerning tu-
berculosis in hospital personnel, medical students and
other members of frequently exposed groups was ana-
lyzed, the very important paper by Flahiff furnished
provocative observations that among persons admitted to
an institution in which tuberculosis was prevalent, the
rate of onset and the death rate from the disease were
higher in those who did not react to tuberculin on ad-
mission than in those who were sensitive to tuberculin
when admitted. Ferguson, after study of conditions in
Saskatchewan, concluded that the chance of contracting
progressive, clinical tubercuolsis when exposed to tubercu-
lous infections is higher in tuberculin-negative than in
tuberculin-positive persons. The latest observations by
Heimbeck in the Ullevaal nurses indicate that the tuber-
culosis morbidity among the tuberculin-negative was
about nine times greater, and the mortality rate more
than ten times greater than among those who were
tuberculin-positive.
The well-known report on the Prophit Tuberculosis
Survey, which covered nurses, medical students, contacts
of tuberculous persons, etc., in the Royal Navy —
although presenting evidence (a) on the high incidence
(82.8 to 84.5 per cent for medical students) of sensi-
tization and (b) on the liability of students negative to
tuberculin — clearly emphasizes that the morbidity rate
varies in different hospitals irrespective of the initial
tuberculin reaction. In some hospitals the rate is con-
sistently higher than in others. With a 13 per cent posi-
tive tuberculin rate on admission and 28 per cent on
graduation, Levine found no clinical tuberculosis among
980 nurses at Michael Reese Hospital in Chicago.
On the whole, the evidence suggests that young men
and women who enter the career of medicine and who
have passed safely through their primary infection are
less subject to manifest tuberculosis when exposed to
fresh infection than are those with no previous experi-
ence with the tubercle bacillus. Furthermore, in the
heavily infected milieus of a tuberculosis hospital, the ad-
vantage of escaping the professional hazard of tubercu-
losis is definitely with the allergic.
At the beginning of 1940 it was fully realized that,
from the standpoint of preventive medicine and in the
interest of the future health of the students entrusted
to the care of the University, it was imperative to devise
means and to take steps to reduce the risk of incapaci-
tating clinical tuberculosis while attending services and
classes offering a special hazard. In consultation, Dean
Langley Porter recommended that it might be proper to
extend to students who are tuberculin-negative the privi-
lege of refusing to take courses in tuberculosis at the
San Francisco Hospital. In the course of a spirited dis-
cussion which followed this recommendation, it was
pointed out that many other services may play a role and
that the average medical man could hardly expect to
escape exposure to the tubercle bacillus in the course of
his professional duties whether as a student, an intern
or later as practicing physician. It likewise appeared in
April, 1949
131
1940 that the problem of tuberculosis in medical stu-
dents and graduates will not be solved by denying them
the experience on special tuberculosis services or sana-
toriums which for reasons too numerous to mention were
not in a position to enforce rigid contagious disease tech-
nique. The proponents of exposition prophylaxis against
infection in tuberculosis wards had only in part appraised
the risk of air-borne infection in other localities in the
hospital, and they knew relatively little concerning the
adequacy of the masks they recommended. Indeed,
Pressman (1937) using a simple expedient of exposing
four dishes containing saline in the corners of a room
for one week was able to demonstrate the presence of
tubercle bacilli in 87 per cent of 55 samples taken from
four tuberculosis hospitals and sanatoriums. Certain
technical procedures involving centrifugation of sputum
specimens, the examination and, in particular, the man-
ual palpation of autopsy specimens from tuberculous pa-
tients and several others doubtless represented a risk of
infection which could only be reduced by the most pains-
taking supervision. No one will quarrel over the dogma
that students should never be permitted to participate in
the care of tuberculous patients without the assurance
that protective contagious disease techniques are rigidly
enforced. Unfortunately, these specifications are not
readily met and the risk of exposure continues to exist.
The members of the committee fully appreciated the
limitation of the exposition prophylaxis and therefore
devoted considerable time to an appraisal of the immuno-
biologic method.
Preventive vaccination with the Bacillus Calmette-
Guerin had received considerable attention, particularly
in view of the encouraging result which had been re-
ported by Heimbeck with student nurses at Ullevaal
Communal Hospital in Oslo; the studies by Scheel and
Malmros and Hedvall emphasized striking differences
in the disease incidence among tuberculin-negative and
tuberculin-positive medical students at the University of
Lund in Sweden. Heimbeck had shown that a positive
tuberculin reaction can be produced by BCG vaccina-
tion, and it was quite a natural step to make an attempt
to protect tuberculin-negative medical students and
nurses by means of vaccination. These studies conveyed
already in 1940 to the immunologist the factual convic-
tion that BCG raises the threshold of infectability in the
vaccinated so that nurses, attendants, interns and others
exposed to tuberculous infection are better protected than
the unvaccinated.
The report on BCG from the United States was lim-
ited to the paper by Kereszturi and Park, who produced
satisfactory evidence that the BCG vaccine reduces the
tuberculosis death rate to one fourth in the children
parenterally vaccinated. Although it had been proved
through exhaustive legal and scientific investigations that
the "Liibeck tragedy” in the summer of 1930 when 73
of 249 perorally vaccinated newly born infants died with
generalized tuberculosis of gastro-intestinal origin was
caused by a contaminated culture, opposition to BCG
took its roots in this event. That the culture of BCG
distributed by the Liibeck Laboratory had been contam-
inated with the Kiel strain of virulent human tubercle
bacilli was confessed by the laboratory technician. This
explanation was plausible because the culture used for
making up the vaccine had been used extensively in
France and Rumania and elsewhere without any un-
toward results that might justify the claim that it had
reverted to a virulent state in the human body.
Another report made an impression on the Committee:
G. G. Kayne, in his detailed inquiry into the use of BCG
in western Europe, said: "Two facts with regard to
BCG are, nevertheless, now emerging: it is harmless ,
and it is of some value if used, under certain conditions,
as an adjunct to other methods of prophylaxis.” Con-
cerning its use in adults, he made the following state-
ments: "The work of Heimbeck and Scheel among
nurses and students has indicated the use of the vac-
cine in the field. Before any such measure is applied in
another country, however, it is essential to know whether
the same problem exists in the latter. In England we
are hardly in a position to dogmatize as to the tubercu-
lin sensitization of nurses and students beginning hos-
pital work, or as to what may be the subsequent danger
they run. Such investigations must, therefore, precede
any consideration of the use of vaccination in them.”
It is further stated that "certain conditions as regards
the vaccine and its administration must be fulfilled and
the vaccination of tuberculin-negative adults likely to be
in much contact with tuberculous patients must be con-
sidered.”
In order to secure the opinion from those who are
fully acquainted with the problem of BCG vaccination
in the United States, a series of questions were submit-
ted to Dr. Esmond R. Long, Director of the Henry
Phipps Institute for the Study, Treatment and Preven-
tion of Tuberculosis, University of Pennsylvania. Under
date of January 31, 1940, Dr. Long kindly answered the
questions and added the significant statement:
"We are thinking of inaugurating a program in nurses.
We have so few tuberculin-negatives in the School of
Medicine in the University of Pennsylvania that a re-
search program could hardly be organized, and we still
feel that a BCG program if attempted should be set up
on a research basis. We are confident that no harm
whatsoever is caused, but up to the present we have not
instituted any indiscriminate vaccination.”
After carefully weighing the evidence available and
fully cognizant of the responsibility involved, the Com-
mittee (Drs. S. J. Shipman, S. T. Pope, Jr., J. C. Geiger
and K. F. Meyer) recommended in March, 1940, to Dr.
William G. Donald, University physician, as follows:
(a) That the infirmary physician, assisted by the in-
structors in tuberculosis, acquaint the medical students
in the second-year medical curriculum with the facts rela-
tive to the liability of tuberculin-negative reactors to
tuberculosis while taking courses in the San Francisco
Hospital or subsequently while practicing medicine. This
factual information should precede all other actions and
should be objective in its presentation.
(b) That the infirmary physician be authorized to
offer on a strictly voluntary basis the intracutaneous vac-
132
The Journal-Lancet
cination with BCG at least four months before the stu-
dents enter the tuberculosis wards.
(c) That he institute such methods and procedures
of surveillance, examination, etc., as outlined in the letter
by Dr. E. R. Long, and that the tuberculin-allergy
should be determined before the vaccinated students are
admitted to the wards.
(d) That the vaccine be secured by air mail from the
Henry Phipps Institute, since it would be impractical to
prepare the vaccine under proper supervision on the
West Coast and deterioration during 48 to 72 hours is
slight.
In the acknowledgment of the recommendation, Dr.
William G. Donald added the significant paragraph:
"The danger to the health and life of medical school
students is greater, I am entirely convinced, in the tuber-
culin-negative student who is unvaccinated. There is to
me conclusive evidence that some measure of immunity
to tuberculosis is obtained by vaccination with BCG.
Medical students, after being adequately informed as
to all the facts of the vaccination, should be encour-
aged to avail themselves of this protection on a volun-
tary basis until such conclusive evidence is gathered
which would justify mandatory vaccination.”
By the end of 1940, 12 second-year medical students,
proved totally unreactive to the stronger dilution of
P.P.D. and O.T. (0.1 cc. of 1:100) had received BCG
obtained from the Henry Phipps Institute. They be-
came tuberculin-positive. In 1941 it was again offered
and a smaller number of students volunteered. No overt
incident attended the immunization, and the students
reacted to tuberculin three months later. The speed-up
program interrupted not only the follow-up, but likewise
the continuation of the vaccination and an analysis of
the results. By 1947, under the impact of the intensified
interest in BCG created by the reports that if rigidly
supervised it may have a place in anti-tuberculosis work,
the Student Health Service again offered the vaccine to
the medical students. Of 35 first-year medical students
who were unreactive to tuberculin, 28 volunteered and
received BCG. They all reacted to tuberculin three
months later, but by the end of 1948, three had reverted
to a negative state. Another group of 33 first-year med-
ical students were vaccinated in April, 1948. By the time
they enter clinical courses and increased exposure to the
tubercle bacillus in the ward, nearly 98 per cent of the
students will be tuberculin-positive. Despite the fact that
the students were given the facts available concerning
BCG and with the definite understanding that they were
given an opportunity to participate in a critical evalua-
tion concerning the merits of a procedure already in use
in colleges of medicine in Chicago, Wisconsin and Ohio,
some of the instructors on the subjects of tuberculosis
and bacteriology unloosed a barrage of derogatory criti-
cism against the action of the Student Health Service.
The impact of this propaganda has been so vicious that
when the members of the class of 1947 were asked
whether they were glad or sorry for having received
BCG vaccine, 20 of the 25 treated students promptly
responded that they were sorry. In view of these devel-
opments it is only proper to inquire if newer knowledge
justifies the antagonism and opposition at the University
of California at a time when the students of the med-
ical school of Western Reserve University appealed for
greater protection against tuberculosis and were granted
the privilege to receive BCG.
As a guide for further action, the following facts are
of interest:
1. Tuberculosis in the medical students in the San
Francisco Bay Area. The data of the University of
California for the years 1942 to 1948 indicate that ap-
proximately 30 to 40 per cent of the students are tuber-
culin-positive on admission. By the time they are jun-
iors, approximately 50 to 70 per cent have become re-
active. The figures are quite in harmony with those re-
cently published by Charles E. Smith, in which he showed
that by the end of the senior year 72 per cent had re-
acted to tuberculin. The total "conversion” rate from
tuberculin-negative to tuberculin-positive was 16.4 per
cent in the junior and 16.2 per cent in the senior year.
Smith made the same observation that the level of the
tuberculin sensitivity as sophomores has been much
lower in the last four classes. There is definite indication
that the rate of conversion has declined; Smith ascribed
this to the more careful elimination of exposure both in
the classrooms and in the wards. In particular, he men-
tioned in a conversation that the examination of fresh
autopsy material from the tuberculous has been discon-
tinued. Lees likewise mentions that until recently only
two or three members of the graduating classes in medi-
cine at Pennsylvania remained tuberculin negative.
In 1945 and 1946, however, the picture was as follows:
fourth year, 70 per cent; third year, 64.4 per cent; sec-
ond year, 55.8 per cent and first year, 43.6 per cent.
This significant decrease reflects the general reduction
of the incidence of tuberculous infection in the United
States.
At the University of California Medical School, clin-
ical tuberculosis has been diagnosed since 1945 in 1 jun-
ior, 2 seniors and 2 interns. Two had been tuberculin-
negative and 3 tuberculin-positive when tested routinely
in the second year of medicine. The problem of tuber-
culosis in the medical students in recent years is, there-
fore, not too serious in this instance. However, the ap-
pearance of cases during the intern years demands addi-
tional safeguards. It is doubtless advisable to protect
these students in every way practical and the immuno-
biologic approach may be necessary.
2. Further knowledge of the value of BCG vaccina-
tion. (a) In general. The studies by Ferguson in Sas-
katchewan, by Aronson and Palmer among American
Indians, by Rosenthal in Chicago, Hertzberg, Birkhaug
in Norway, Wallgren in Sweden and Holm in Denmark
have greatly enhanced the knowledge of BCG and fos-
tered the hope that those unduly exposed to tuberculosis
may have added protection. With the exception of the
study of Aronson and Palmer, there exists a noteworthy
lack of unassailable statistical proof of the effectiveness
of BCG under rigidly controlled conditions in man,
although such evidence is highly suggestive in animal
April, 1949
133
experimentation. Nevertheless, unanimity exists as to its
harmlessness and incomplete, but significant protection
against clinical pulmonary tuberculosis in adults. With
scrupulous care, Aronson and Palmer analyzed the data
on six years of the vaccination program for North
American Indians. From February 1936 to February
1938 they vaccinated 1,550 persons from 1 to 19 years
of age who failed to react to tuberculin. A similar group
of 1,457 was not vaccinated. Both groups were followed-
up for six years with annual tuberculin tests and chest
x-ray examinations. At the end of this period they found
among the 1,550 vaccinated persons 40 cases of tubercu-
losis and 4 deaths, whereas among the 1,457 nonvacci-
nated there were 185 cases of tuberculosis and 28 deaths.
These observations have been detailed because they are
generally quoted as the most convincing experimental
study on the value of BCG, although it may be ques-
tioned whether the conclusions are transferable to civil-
ized people having a higher degree of genetic immunity.
(b) Medical students, nurses and schools. Holm pre-
sented evidence in favor of BCG vaccination of medical
students at the University of Copenhagen. Of 863
tuberculin-negative students, 52 presented positive x-ray
changes in the lungs, while of 2,071 tuberculin-positive
students 17, or one third of the negative group, had posi-
tive chest x-ray findings. Positive x-ray findings were not
encountered among 175 medical students whose reaction
became positive after vaccination with BCG. The latest
reports by Nordwall and by Heimbeck, covering observa-
tions over periods of 10 to 20 years, emphasize that the
tuberculosis morbidity of nurses of 141.2 per 1,000 obser-
vation years resulting from natural primary infection in a
hospital was reduced to 24.1 in the group vaccinated
with BCG, and the mortality from 14.6 to 2.1, that is —
to one sixth and one seventh, respectively. Rosenthal,
et ah, vaccinated 109 medical students at the University
of Illinois. Over a period of four years there were no
cases of pulmonary tuberculosis. Four cases were report-
ed in the nonvaccinated groups. One of the most inter-
esting and important observations on the value of BCG
has been reported by Hyge in an epidemic of tuberculosis
in one of the Danish State Schools in 1947. This school
had 368 girl pupils between 12 and 19 years of age.
They had been repeatedly examined for tuberculosis and
133 pupils had been vaccinated with BCG. There were
105 tuberculin-negative pupils who had entered since the
last examination, and these were not vaccinated with
BCG. In January and February, 1943, an influenza-like
epidemic broke out, almost exclusively among the pupils.
As several pupils presented erythema nodosum, the sus-
picion arose that the epidemic disease might be tubercu-
losis, and a thorough examination was made of the pu-
pils and the school personnel. The source of infection
was a female teacher with apical lesions; tubercle bacilli
were found in the gastric washings. She taught exclu-
sively in a poorly ventilated basement classroom. The
classes which she taught included many whose negative
tuberculin reaction had turned positive, as well as stu-
dents with tuberculosis. The same condition prevailed in
the classes that occupied the classroom immediately after
her lessons. Among the students who were not taught
by her and did not come into this room, no negative
tuberculin reactors had turned positive, nor did any of
them have tuberculosis. Follow-up examinations revealed
that 40 per cent of her students had x-ray changes, and
in 35 per cent tubercle bacilli were found as well; clin-
ical pulmonary tuberculosis was found in 6.7 per cent
of the 105 tuberculin-negative nonvaccinated pupils.
Among the 133 BCG vaccinated pupils, clinical pulmo-
nary tuberculosis was found in 3.1 per cent. It is most
important to note, however, that the primary phenomena
of illness occurred exclusively in the previously tubercu-
lin-negative pupils and in no instance among the BCG
vaccinated pupils. This furnishes, in the opinion of
Hyge, strong proof for the protective role played by
BCG vaccination in preventing the morbid sequelae
ensuing upon a primary tuberculous infection. In com-
paring the BCG vaccinated group with the tuberculin-
negative group, it is found that BCG vaccination has
offered considerable protection against the development
of pulmonary tuberculosis. By further comparison be-
tween the BCG vaccinated group and the tuberculin re-
actors by natural infection, it appears that BCG vaccina-
tion has given at least as effective protection against pul-
monary tuberculosis as has natural infection. These in-
vestigations were not intended to demonstrate whether
BCG had any effect, and therefore are of significance.
3. Criticism and failure of BCG. With the exception
of the few contributions mentioned, the reports on BCG
only too often tell little, but they tell it optimistically.
In this connection, it is well to emphasize that the avail-
able information on BCG received an unbiased, critical
appraisal by the British bacteriologist, G. S. Wilson. It
should be read by everyone interested in BCG. Since it
would lead too far to discuss his very sound arguments
against the universal use of the vaccine, a part of his
conclusions is herewith quoted. "Vaccination, if it is
used, should be restricted to specially exposed groups,
like nurses, medical students and children in tuberculous
families.” According to a recent report, the Minister of
Health of Great Britain advised Parliament that plans
to make trial use of BCG for professionally exposed
groups are under consideration. Hilleboe, in detailing
the position of the United States Public Health Service,
stated that the effectiveness of BCG vaccination as an
auxiliary method of tuberculosis control should be tested
on persons exposed so intensely that they are almost cer-
tain to become infected. The studies should concern
themselves with special groups, inmates and employees
of mental institutions, employees of general hospitals
and sanatoriums (where danger of infection is excessive
because control measures are lacking) , medical students
in schools where the services include exposure to tuber-
culous patients and other exposed groups.
The many critical papers on BCG published during
the past two years reflect the position taken by the Med-
ical Section of the American Trudeau Society in the
blunt statement that further studies are necessary, in
fact, imperative to determine the value of BCG. It
cannot be regarded as a substitute for approved public
health measures, nor can the vaccination of the general
population be advocated. However, in the light of pres-
134
The Journal-Lancet
ent knowledge, vaccination of doctors, medical students
and nurses who are exposed to infectious tuberculosis
and all hospital and laboratory personnel whose work
brings them in contact with the bacillus of tuberculosis
is recommended.
These authoritative statements have been opposed for
the following reasons: (1) The use of BCG destroys
the value of the most potent weapon in finding those
who are infected with tuberculosis — the tuberculin test.
This criticism does not apply to medical students and
nurses who are regularly subjected to roentgenograms.
This is done at three-month intervals as soon as rever-
sions have been detected. (2) Tuberculosis among stu-
dents of nursing and medical schools has been brought
under control through the use of well-established and
dependable methods which are more satisfactory than
through the use of BCG. This is probably true for
many schools. The data which in recent years have been
collected clearly indicate that demonstrable lesions de-
velop relatively infrequently among students. But the
recent findings must be appraised in the light of future
observations. If the risk of exposure is definitely elim-
inated, the Student Health Service would have little
justification for promoting the use of BCG.
3. Some of the opponents have offered another means
of controlling tuberculosis. It deals with the use of strep-
tomycin or any other effective antibiotic in the early
stages of tuberculosis. The Student Health Service
would administer the drug to every tuberculin reactor,
even in the absence of all other findings, and thus pre-
vent through chemoprophylaxis the development of pro-
gressive tuberculosis. Unpublished observations and
theoretical considerations furnish little support to encour-
age this procedure.
Anyone familiar with the problems of BCG fully re-
alizes that the important problems of virulence and sta-
bility of a vaccine composed of live organisms require
careful consideration. Techniques of preparation of a
potent and stable vaccine must be standardized, and the
best method of vaccination must be developed. Until
further research offers answers to the many questions,
it is doubtless premature to consider the commercial
licensing for the sale of BCG. Work along these lines
is in progress, but several other questions, for example,
How much immuinty does BCG vaccination confer?
and How long does such immunity last? can be an-
swered only after long-range studies under proper scien-
tific supervision and control. That the immunity con-
ferred by BCG may sometimes be inadequate is recog-
nized by Bergqvist who, according to an abstract of his
article, described a tuberculosis epidemic in the School
of Dentistry in Stockholm.
In September, 1944, radiographic and tuberculin ex-
aminations were undertaken of most of the 115 students
admitted to the school. A year later one of these stu-
dents was found to be suffering from pulmonary tuber-
culosis. A few weeks later several of his fellow students
showed signs of tuberculosis, and there were a total of
18 such cases. Among 57 students who had from the
outset been tuberculin-positive and who had not been
given BCG, there were 4 cases (7 per cent), and among
44 students who had been given BCG, there were 10
cases (23 per cent). Among 12 tuberculin-negative stu-
dents who had refused BCG vaccination, there were 4
cases (33 per cent). Only in 2 or 3 cases was the prog-
nosis bad, and as many as 13 or 14 of the 18 students
in whom signs of tuberculosis developed were able to re-
sume their studies. Investigations are being undertaken
to ascertain if the tubercle bacilli responsible for this epi-
demic were of a particularly virulent type. The reasons
why the immunity achieved by BCG proved inadequate
have not been satisfactorily determined.
4. Measures to reduce exposure of medical students
to tuberculous infection. The analysis made in 1940 pre-
sented little concrete evidence relative to the sources of
tuberculous infection which contributed to the incidence
of tuberculosis in medical students. Aside from the open
tuberculosis wards, casual contact exposures which might
be encountered during the clinical years through exam-
ination in undiagnosed cases of tuberculosis in various
ward services and in the out-patient departments were
suspected. Recent studies by Hedvall of Lund Univer-
sity and particularly the thorough epidemiologic inquiries
by Meade at the University of Rochester Medical School
definitely incriminate contact with tuberculous materials
in autopsy rooms and laboratories. After more stringent
precautions were adopted which provided that students
were not permitted to participate in autopsies in known
cases of tuberculosis or to handle tuberculous material,
both the infection rates and the incidence showed strik-
ing reductions. According to Lee, the University of
Pennsylvania Medical School pays attention to the au-
topsy room technique with the result that infections have
been very materially reduced.
Summary and conclusions. The immunobiologic meth-
od of prophylaxis continues to furnish excellent protec-
tion of students against smallpox, diphtheria and such
diseases. Its value in the control of tuberculosis deserves
further careful investigation.
Since 1940 the rates of tuberculous infection among
medical students as measured by the rate of conversion
from tuberculin unreactive to reactive, and by the inci-
dence of clinical tuberculosis has definitely declined from
the surprisingly high rates during 1930 to 1940.
This reduction reported from western, midwestern
and eastern medical schools is in all probability attrib-
utable to enforcement of protective measures in path-
ology departments which reduce the risk of exposure.
It may likewise reflect the gains made in the over-all gen-
eral control of tuberculosis in the United States.
The many critical papers published in recent years
justly condemn the indiscriminate use of BCG vaccina-
tion. However, they invariably agree that the procedure
is safe, and they recommend the use of the vaccine for
doctors, medical students, laboratory workers and others
who are exposed to infectious tuberculosis. The recom-
mendations of the University of California Committee
made to the University physician in 1940 require no
changes. Since cases of clinical tuberculosis continue to
April, 1949
135
occur among the students, the Health Service is fully
justified in recommending its use on a voluntary basis.
However, it is only proper to insist on annual critical
appraisal by qualified epidemiologists and immunologists
of the tuberculosis infection trends among the students
in order to decide whether or not BCG vaccination is
really needed to give the young men and women added
protection.
BCG vaccination, whenever practiced on medical stu-
dents, should be supervised competently and treated as
a scientific experiment.
References
Aronson, Joseph D., and Palmer, C. E.: Experience with
BCG vaccine in the control of tuberculosis among North Amer-
ican Indians. Pub. Health Rep. 61:802, 1946.
Bergqvist, S.: En tuberkulosepidemi. Nord. med. 36:2146,
1947. Abstract: Tuberc. Index 3:31, 1948.
Birkhaug, Konrad: BCG vaccination in Scandinavia. Twenty
years of uninterrupted vaccination against tuberculosis. Am.
Rev. Tuberc. 55:234, 1947.
Boynton, Ruth E.: The incidence of tuberculosis infection
in student nurses. Am. Rev. Tuberc. 39:671, 1939.
Daniels, Marc, Ridehalgh, Frank, Springett, V. H., and
Hall, I. M.: Tuberculosis in young adults. Report on the
Prophit Tuberculosis Survey 1935-1944. London: H ,K. Lewis
& Co., Ltd., 1948, 227 pp. Abstract: Bull. Hyg. 23:476, 1948.
Ferguson, R. G.: BCG vaccination in hospitals and sanatoria
of Saskatchewan. A study carried out by the National Research
Council of Canada. Am. Rev. Tuberc. 56:325, 1946.
Flahiff, E. W.: The occurrence of tuberculosis in persons who
failed to react to tuberculin, and in persons with positive tuber-
culin reaction. Am. J. Hyg. (Sect. B) 30:69, 1939.
Gullbring, A.: Precautions to be taken to lessen danger of
infection of personnel in hospital for tuberculous patients.
Hygiea 98:865, 1936.
Hedvall, Erik: The incidence of tuberculosis among students
at Lund University. Am. Rev. Tuberc. 41:770, 1940.
Heimbeck, J.: Incidence of tuberculosis in young adult wom-
en, with special reference to employment. Brit. J. Tuberc.
32:154, 1938.
Quoted by Ustvedt, H. J.: Noen nyere BCG-arbei-
der. Tidsskr. f. d. norske laegefor. 67:573, 1947. Abstract:
Tuberc. Index 3:33, 1948.
- BCG vaccination of nurses. Tubercle 29:84, 1948.
Hertzberg, Gerh.: Recent experience with BCG vaccination
in Norway. Tubercle 28:1, 1947.
Hilleboe, H. E.: BCG. Am. Rev. Tuberc. 57:102, 1948.
Holm, Johannes: BCG vaccination in Denmark. Pub. Health
Rep. 61:1298, 1946.
Hyge, T. V.: Epidemic of tuberculosis in a State School.
Acta tuberc. Scandinav. 21: 1, 1947.
Irvine, K. N.: The BCG vaccine. London: Oxford Univer-
sity Press, 1934, 70 pp.
Kayne, G. G.: BCG vaccination in western Europe. Am.
Rev. Tuberc. 34:10, 1936.
Kereszturi, Camille, and Park, W. H.: The use of the BCG
vaccine against tuberculosis in children. Eight years’ experience.
Am. Rev. Tuberc. 34:437, 1936.
Lees, H. D.: Fifteen years of tuberculosis control at the
University of Pennsylvania. Journal-Lancet 67:255, 1947.
Levine, E. R.: Incidence of tuberculosis in student nurses.
Journal-Lancet 67:142, 1947.
Malmros, Haquin, and Hedvall, Erik: Primary tuberculous
infection in adults. Am. Rev. Tuberc. 41:562, 1940.
Meade, G. M.: The prevention of primary tuberculous infec-
tions in medical students. The autopsy as a source of primary
infection. Am. Rev. Tuberc. 58:675, 1948.
Morris, Sarah I.: The hazard of tuberculosis during med-
ical training. An abridged report of a case-finding and follow-
up regime among women medical students, with an effective
control program against tuberculosis. Journal-Lancet 66:109,
1946.
Myers, J. A., Ch iu, Philip T. Y., and Streukens, Theodore
L., Jr.: Primary infection in adults: its clinical and epidemio-
logical aspects. Am. Rev. Tuberc. 39:232, 1939.
National Tuberculosis Association: Medical students, first
in Ohio, will get BCG. Bull. Nat. Tuberc. A. 33:95, 1947.
Nordwall, Ulf: The influence of BCG vaccination on the
tuberculosis frequency at the Sophiahemmet School for Nurses
in Stockholm. Acta tuberc. Scandinav. 18:45, 1944.
Pressman, R.: Isolation of pathogenic bacteria from air;
dissertation in bacteriology. Am. Rev. Tuberc. 35:815, 1937.
Rist, E.: La tuberculose des estudiants en medecine. Schweiz.
Ztschr. f. tuberk. 4:94, 1947. Abstract: Am. Rev. Tuberc.
Abstr. 57:8, 1948.
Rosenthal, S. R., Leslie, Eleanor I., and Loewinsohn, Erhard:
BCG vaccination in all age groups. Methods and results of a
strictly controlled study. J A M. A. 136:73, 1948.
Scheel, O.: Tuberculosis among medical students and Cal-
mette-Guerin (BCG) immunizations. Nord. med. tidskr. 9:481,
1935.
Smith, C. E.: The prevention of infectious disease in med-
ical students. Stanford M. Bull. 6:127, 1948.
Ulmar, David, Ornstein, G. G., and Epstein, H. H.: Pul-
monary tuberculosis as an occupation disease in a tuberculosis
hospital. Quart. Bull. Sea View Hosp. 2:49, 1936.
Wallgren, Arvid: Value of Calmette vaccination in preven-
tion of tuberculosis in childhood. J.A.M.A. 103:1341, 1934.
Wilson, G. S.: The value of BCG vaccination in control of
tuberculosis. Brit. M. J. 2:855, 1947.
POSTGRADUATE COURSE
The Department of Postgraduate Medical Education, University of Minnesota, an-
nounces a continuation course in Dermatology for general physicians to be held at the Center
for Continuation Study May 26 and 27. The course will be devoted to the diagnosis and
management of the common skin disorders.
136
The Journal-Lancet
Fungus Diseases of the Lungs
H. E. Miller, M.D.
Minneapolis, Minnesota
While we have few cases of fungus diseases of
the lungs in this area, they occur with sufficient
frequency to justify their consideration in the differen-
tial diagnosis of any obscure pulmonary condition. Some
of the mycoses, such as moniliasis, geotrichosis, and
actinomycosis, are endogenous and may occur at any
time, in any climate, and in any level of society. Others,
such as coccidioidomycosis, histoplasmosis, and American
blastomycosis, have limited geographic distribution. How-
ever, with increasing intersectional travel, diseases which
were once considered to be endemic to certain isolated
areas may appear far removed from their original locale.
This was well demonstrated in the Armed Forces during
the war. Correct identification of any fungus isolated
is extremely important so that innocent saprophytic
organisms are not given as the etiology of an obscure
condition, thus masking the true pathology.
Actinomycosis
One of the most common of the severe systemic my-
cotic infections is actinomycosis. A discussion of this
disease is difficult because of the confusion regarding
both the nomenclature and the pathogenicity of the vari-
ous species of actinomycosis found in the literature.
Henrici and Waksman 1 in 1943 offered a new classifi-
cation, which, when generally accepted, will help to elim-
inate this confusion.
It is repeatedly noted in the literature that actinomy-
cosis may be caused by two different fungi, although the
clinical course and therapy are the same. The first or-
ganism, Actinomyces bovis, is anaerobic and difficult to
culture. It is credited with causing approximately 90
per cent of the infections and, according to Skinner,
Emmons, and Tsuchuya,J should be considered the only
cause of true actinomycosis. The second organism, No-
cardia asteroides, is aerobic, is easily grown in culture,
and, according to Skinner, Emmons, and Tsuchuya, gives
rise to a similar but different clinical entity.
Actinomycosis bovis occurs as a saprophyte, especially
in the mouth of man and some of the domesticated ani-
mals, such as the cow. It has been found in the tonsils
and between the teeth of normal individuals. Such fungi
are ideally located to be aspirated into the lungs, where
they set up a pulmonary infection. Nocardia asteroides
is reported to be common in soils; Actinomycosis bovis,
however, has never been cultured from soil nor from
stems of grass.
Actinomycosis affects many parts of the body, most
frequently the head and neck, next the abdominal cavity,
and third the lungs and thoracic cavity. While this pul-
monary condition is relatively rare, it is of considerable
importance because of its high fatality rate. The symp-
toms in the first few weeks of a pulmonary actinomycosis
are those of any subacute pulmonary infection, with
fever, cough, and mild expectoration. As the disease pro-
gresses, it resembles advanced tuberculosis or lung ab-
scess resulting from some other cause. The infection
usually extends to the pleura and to the ribs; occasion-
ally pleural effusion develops, but more often the infec-
tion extends directly to the ribs and to the subcutaneous
tissues. Subcutaneous abscesses and draining sinuses may
develop. The sedimentation rate and leucocyte count are
elevated. The physical signs are the same as those in
tuberculosis, except that actinomycosis more often in-
volves the base of the lungs and is usually bilateral.
The x-ray picture often shows massive areas of con-
solidation without cavitation, or with small irregular
areas of rarefaction. As a rule, the lesions are found
bilaterally in the lower lobes, but any part of the lung
may be included. In advanced cases, the pleura is usually
involved with adhesions or with pleural effusion. The
ribs frequently show both destructive and proliferative
changes. Occasionally areas of consolidation project
from the mediastinum and give the appearance of neo-
plasm. There is nothing characteristic in the x-ray pic-
ture that will differentiate actinomycosis from other
chronic pulmonary infections. The diagnosis must be
established by isolation and identification of the causative
organism.
Actinomycosis presents a varied clinical picture and
must be differentiated from tuberculosis, syphilis, neo-
plasm, osteomyelitis, blastomycosis, coccidiomycosis, cryp-
tococcosis, sporotrichosis, and botryomycosis. This last-
mentioned disease, botryomycosis, is caused by a granule-
producing staphylococcus and gives rise to chronic drain-
ing abscesses. Such a case was recently reported by Doc-
tors Campbell and Plimpton at a meeting of the Staff
of the Abbott Hospital in Minneapolis, in which a drain-
ing sinus followed an appendectomy.
The prognosis in pulmonary actinomycosis is grave,
but it is much better since the introduction of the sul-
fonamides and penicillin. Up to 1940, four methods of
treatment were generally used: iodine, thymol, x-ray
irradiation, and surgery. None of these offered satisfac-
tory results unless the infected tissue could be completely
excised. Since 1940 numerous authors have reported re-
covery from serious infections with sulfonamide therapy.
Lyons, Owens, and Ayers/ however, concluded in 1943
that dramatic initial response of these infections to sul-
fonamides is somewhat misleading. The drugs induce a
remission and apparently diminish the intensity of the
recurrence, but it can hardly be claimed that the disease
has been completely cured. As early as 1941, Florey and
his associates reported that certain strains of actinomy-
ces were inhibited by penicillin in vitro. These observa-
tions have since been confirmed by other workers. In
September 1943, Herrell and Nichol 1 reported a case
April, 1949
137
they had tried clinically; and since 1943 there have been
many reports in the literature of remarkable cures of ac-
tinomycosis with penicillin and with penicillin and sul-
fonamide mixtures. Sulfadiazine seems to be the sulfona-
mide of choice. Many authors have suggested the use
of potassium iodide with penicillin and sulfonamides.
I have had three cases which responded favorably to
chemotherapy. In one the Actinomyces bovis grew in
a culture to which sulfathiazole had been added, and in
a culture containing penicillin, but was definitely inhib-
ited in a culture to which a mixture of the two com-
pounds had been added. The combined therapy was
given to the patient, who had a large lung abscess, for
a period of five weeks, with marked clinical and x-ray
improvement. Unfortunately, the patient left the hos-
pital against advice and we were unable to follow his
further progress.
In the second case, a 27-year-old man was observed for
several months with pneumonitis in the lower lobe of
the right lung before Actinomyces bovis was isolated.
After the diagnosis was established, he was given two
courses of penicillin and sulfadiazine with clinical and
x-ray recovery of his pulmonary condition.
The third case was that of a 26-year-old colored man
who suffered from a chronic bronchopneumonia and
pleurisy with a febrile course for a period of 10 months.
He developed several areas of decreased density in the
ribs. One of these was explored surgically and a cavity
having the appearance of a cold abscess was described.
The microscopic appearance was that of caseating tuber-
culosis of the bone. Acid-fast granular organisms were
seen in the smears made from the fresh tissue. A diag-
nosis of tuberculosis was considered, but culture for tu-
bercle bacillus was negative. Later a needle biopsy from
another of these rib lesions revealed on culture the aero-
bic acid-fast Nocardia asteroides. The patient was given
penicillin 40,000 units every three hours for a total of
two and a half million units, plus sulfadiazine in doses
sufficient to maintain a blood level of 10 milligrams per
100 cc. This therapy resulted in recovery from the
disease.
With longer experience and increased supplies of the
drug, the dose of penicillin has gradually been increased;
and recent evidence indicates that extremely large doses,
1,000,000 units daily for four to six weeks, may be
more effective.0
In addition to chemotherapy, in cases in which ade-
quate drainage is not obtained through the bronchus,
surgical drainage and wide excision of necrotic tissue
should be carried out. Dr. Owen Wangensteen, of the
University of Minnesota, had conducted studies before
the advent of the present-day chemotherapeutic and anti-
biotic agents, and his conclusion that necrotic tissue
should be removed still holds today. The prognosis is
much brighter with a combined therapeutic approach.
Coccidioidomycosis
Coccidioidomycosis, caused by the coccidioides immitis,
occurs as either a benign, acute infection, or as a chronic,
malignant one. Formerly the chronic condition, which is
a progressive, disseminated disease involving the cutane-
ous, visceral, and osseous tissues, was the one known and
feared. Today coccidioidomycosis is recognized in epi-
demic form, particularly during the dry, dusty months
in endemic areas; and only a small percentage of the
cases progress to the malignant form. The disease was
first described in the endemic type in the San Joaquin
Valley in California and was known locally as valley
fever. During the war, troops stationed in the semi-arid
regions of the southwestern states, especially California,
Arizona, and western Texas, were subjected to this in-
fection; and several epidemics were reported. Positive
skin tests with coccidioidin have been reported in from
60 to 80 per cent of the inhabitants of certain areas.
Rodents in the endemic area have also been found in-
fected with coccidioides immitis.1’ Smith 7 at Leland
Stanford University has studied coccidioidomycosis thor-
oughly and has given us a good picture of the disease.
Although primary skin lesions have been reported in
a few isolated instances, the important portal of entry
is the respiratory tract. The incubation period varies
from 8 to 21 days. The symptoms of primary pulmo-
nary coccidioidomycosis, in the average case, are indis-
tinguishable from those of an acute upper respiratory
infection, and the pneumonitis may not be suspected
unless a roentgenogram is made. Occasionally the symp-
toms are more severe and simulate those of lobar or lob-
ular pneumonia. Still other cases may imitate pulmonary
tuberculosis. Smith * has stated that coccidioidomycosis
can mimic every type of picture seen in pulmonary tuber-
culosis.
In an epidemic which occurred in 85 soldiers, Gold-
stein and McDonald !l reported the incubation period
to vary from one to three weeks. Fever was present in
100 per cent, cough in 88 per cent, pain in the chest in
88 per cent, chilis in 66 per cent, sputum in 65 per cent,
sore throat in 37 per cent, and hemoptysis in 18 per cent
of these cases. Physical signs were present in only 26
per cent, and these were largely limited to alterations in
breath sounds. Dullness and rales were rare. Erythema
nodosum developed in 19 per cent, erythema multiforme
in 2.6 per cent, morbilliform rash over the trunk and
lower extremities in 4 per cent, and arthralgia in 28 per
cent. These allergic reactions appeared 8 to to 14 days
after the onset of symptoms and were usually accom-
panied by eosinophilia.
Colburn 70 reported the x-ray studies made in these
same 85 soldiers with primary coccidioidomycosis. No
detectable x-ray changes were found in 4 per cent. Fan-
shaped densities extending out from the hilus were
present in 38.7 per cent. These lesions required from
15 to 90 days to resolve, with an average of 40 days.
In 24 per cent, hilar adenopathy was present without
parenchymal involvement of the lung. In an additional
26 per cent, there were both peripheral and sublobular
infiltrations in the upper and lower lobes. Thin-walled
pulmonary cavities, which are characteristic of the dis-
ease, developed in 4 per cent. Some of these cavities
healed in 60 days and some in 95 days, while others
persisted. Cavities of this kind have been known to re-
138
The Journal-Lancet
main for years. From 1942 to 1946 I had the oppor-
tunity to study a large number of cases of subacute pul-
monary coccidioidomycosis at an Army chest center, and
this thin-walled cavity was the most consistent and char-
acteristic x-ray picture. Some of these were watched over
a period of months and showed very little change. Occa-
sionally calcification occurred in both the peripheral
lesion and in the hilar nodes.
The diagnosis is made from the clinical story plus
isolation of the organism from the sputum. The sputum
is examined either directly in 10 per cent sodium hy-
droxide or by culture on Sabouraud’s media. Skin test
with coccidioidin is also helpful. This test is made with
1:1000 coccidioidin and read in the same manner as a
tuberculin test. Precipitin and complement-fixing anti-
bodies are absent in mild cases, but are present in more
severe ones. These antibodies disappear with recovery.
The acute disease must be differentiated from other
acute pulmonary infections, while the more severe pro-
gressive type must be distinguished from tuberculosis,
syphilis, glanders, tularemia, osteomyelitis, neoplasms,
and other mycoses.
The prognosis is excellent in primary pulmonary coc-
cidioidomycosis, and is good in the cutaneuos and glan-
dular types of primary infection; but the outlook is
grave in the progressive form, and most victims even-
tually die. However, only a few of the primary infec-
tions develop the disseminated form of the disease.
Among the cases mentioned above, we saw only two
patients with the progressive type. One died from coc-
cidioidomycosis meningitis. The second had generalized
bone involvement with a draining sinus in one clavicle
from which the organism could be isolated. This second
case had been studied at Leland Stanford University by
Dr. C. E. Smith’s staff, and the diagnosis was established
by them before he was seen by us.
The treatment is symptomatic. The patient should be
kept in bed until his temperature and white blood cell
count are normal and the x-ray films are also normal or
show progressive clearing. Most cavities heal with rest
and time, but the larger ones which fail to heal may
require lobectomy. There is no known specific treatment.
North American Blastomycosis
North American blastomycosis is a fungus infection
of man and animals, caused by a double-contoured, bud-
ding, yeast-like organism, blastomyces dermatitidis. This
organism is not a true yeast, however. On Sabouraud’s
medium a fuzzy, white, aerial growth develops. On
blood agar the fungus produces the round or oval blas-
tomycetes which has a thick doubly-refractive cell wall
and cytoplasm containing refractive granules and vac-
uoles. In the tissue and on blood agar the organism re-
produces by budding. The organism is not spread from
man to man, but is derived from some source in nature.
The disease occurs much more commonly in males than
in females. Many of the reported cases of the systemic
type have been in indigent people living in a damp, un-
hygienic environment. Martin and Smith 11 in 1939
published a review of the disease and reported in detail
several cases of their own. Smith 12 reported the disease
as being found anywhere in North America, with the
greatest frequency in the Mississippi valley, across Ten-
nessee, and down into North Carolina.
Cutaneous blastomycosis is the common form of the
disease and the most frequently infected skin areas are
around the nose and eyes, on the back of the hands, and
the front of the legs. The infection may begin in the
skin and remain localized for months or years before it
spreads to the internal organs. Bell 13 states that one-
half the systemic cases start this way; the other half
begin as respiratory infections. Invasion of the blood
stream from the lungs may result in widespread meta-
static abscesses involving any organ or tissue.
The onset of pulmonary blastomycosis may be insidi-
ous. The symptoms may resemble those of an acute or
subacute pulmonary infection with dry cough, pain in
the chest, and fever. As the disease progresses, it may
simulate massive tuberculosis. The mediastinum may
be invaded. The pleura may be affected and draining
sinuses may develop in the chest wall as they do in ac-
tinomycosis. In the terminal stages, symptoms due to
invasion of other internal organs may develop, such as
pain in the bones or prostate, or paralysis from extension
to the central nervous system. The physical findings are
similar to those of massive pulmonary tuberculosis or
lung abscess.
The x-ray film in the early stages may show enlarge-
ment of the mediastinal lymph nodes without obvious
parenchymal involvement. Usually, however, dense in-
filtrations are seen. The pulmonary density frequently
suggests neoplasm. I have studied two cases of pulmo-
nary blastomycosis. One was diagnosed as a neoplasm,
and the correct answer was not found until after a pneu-
monectomy. The patient died after the surgery. The
second case was observed for several weeks as a case of
far-advanced pulmonary tuberculosis, but the doubly-
refractive budding, yeast-like organism was isolated; and
the correct diagnosis was made antemortem by Dr. Wil-
liams of Nopeming, Minnesota.
A positive skin test to blastomyces vaccine develops
in the more extensive skin cases and in almost all of the
systemic ones. The diagnosis is made by isolating the
blastomyces from the sputum. Tuberculosis, syphilis,
neoplasm, lung abscess, sarcoidosis, silicosis, actinomyco-
sis, coccidioidomycosis, sporotrichosis, and moniliasis
must be considered in the differential diagnosis.
The prognosis is extremely unfavorable in the sys-
temic disease, the mortality rate being reported at about
90 per cent. Iodides have been used but seem to have
little effect on the infection and may even cause a rapid
spread of the disease. Martin and Smith recommend par-
tially desensitizing the patient by injecting increasing
doses of a skin-testing material prepared from the fun-
gus until little or no reaction is elicited. Following this
desensitization, iodides can be safely given and sometimes
this combination may cure the infection. Surgical drain-
age and excision of necrotic tissue should be carried out
April, 1949
139
as in actinomycosis. The mortality from the cutaneous
type of the disease is low; here, iodides seem to be bene-
ficial.
South American Blastomycosis
South American blastomycosis is a fungus infection
beginning in the skin and mucous membrane, but even-
tually involving the internal organs. The disease is
caused by infection with a fungus that resembles cocidi-
oides immites. It reproduces by multiple budding and
has been given the name Blastomyces brasiliensis. The
largest incidence of the disease is reported in Brazil,
from which it derives its name; but sporadic cases have
been reported in other South American countries. In
contrast to North American blastomycosis, where 50 per
cent of the cases start as a respiratory infection and pul-
monary involvement is present in over 90 per cent of the
cases, in South American blastomycosis the lungs are in-
volved late and in only about 20 per cent of the cases.
Sulfadiazine is reported as the drug of choice in treat-
ment, but most of the reported cases have had a fatal
termination. A good summary of the literature has been
written by David T. Smith.14
Cryptoccosis
Torulosis, or cryptoccosis, is caused by Cryptococcus
neoformans (also known as Torula histolytica and Euro-
pean blastomycosis) . This organism is a true yeast. The
disease is widespread throughout the world. Although
the portal of entry is believed to be the respiratory sys-
tem, the organism shows marked predilection for the
brain and meninges. The pulmonary lesions have been
described as miliary nodules, large gelatinous masses,
chronic lung abscesses, and chronic bronchopneumonia.
There is nothing characteristic about the plumonary
symptoms, signs, or x-ray pictures of patients with cryp-
tococcosis. The pulmonary lesion must be differentiated
from tuberculosis, actinomycosis, North and South
American blastomycosis, coccidioidomycosis, moniliasis,
and other non-tuberculous infections.
The prognosis is grave and no specific therapy is
known. Some favorable results have followed the use of
sulfadiazine, but there have been reported cases of spon-
taneous recovery; so the efficacy of the sulfonamides
must await further trial.1’’
Histoplasmosis
Histoplasmosis is a fungus disease caused by Histo-
plasma capsulatum. The first three cases were described
in 1905 and 1906 from Panama by S. T. Darling. 1(’
The fourth case, 20 years later, was reported from Min-
nesota, by Riley and Watson.1' Since 1926, less than
one hundred cases have been reported.
Histoplasma capsulatum occurs in the tissues in the
form of small, round or oval, yeast-like bodies, which
measure from one to five micrans in diameter. They
show a sharply-defined, clear, achromatic capsule. The
chromatic mass in the center is irregular in distribution.
The fungus grows slowly on the commonly-used media,
but usually it is hard to isolate because of contamination
by other organisms. If grown on a medium rich in pro-
tein at 37 C., the yeast-like form appears, but at room
temperature the mycelial form develops.
The infection manifests itself in many different forms.
There may be ulcerative lesions of the skin and of the
mucous membranes. There may be localized or gener-
alized lymphadenopathy. Most of the viscera may be
involved, or only one organ may be affected, such as the
adrenal. The intestinal tract is frequently the site of
ulcerated lesions. Parsons and Zarafonetis 18 in 1945
reported seven cases and reviewed 71 from the literature.
They found the disease to be sporadic and widespread
throughout the tropical, subtropical, and temperate zones.
No race is exempt. Males seem to be infected much
more often than females. Every age group is suscep-
tible.
They reported from the 71 cases that cough was pres-
ent in 11, rales were mentioned in 13, and a friction rub
in 4 cases. A diagnosis of pneumonia was made eight
times. In 1 1 cases a diagnosis of tuberculosis had been
considered before death. The clinical evidence for tuber-
culosis in these cases had been apical opacities and cavi-
ties seen by x-ray, miliary lesions scattered throughout
the lungs, or acid-fast bacilli in the sputum. In some of
these 1 1 cases the two diseases existed together at au-
topsy. The lungs rarely if ever are the primary site of in-
fection and they seldom show the most extensive lesions.
These same authors found that the great majority of
the infections last less than one year. Four patients were
still living at six, five, two, and two years after the diag-
nosis was established. Three of them had ulcerative
lesions on the tongue as the only presenting sign of histo-
plasmosis. No form of treatment has been found that
appears to alter the course of the disease.
Parsons and Zarafonetis, in discussing the antemortem
diagnosis, stated that the yeast-like organism of hysto-
plasma capsulatum may be seen in the monocytes and
neutrophiles of a smear of circulating blood. The or-
ganism was thus demonstrated in four of their cases.
However, some of these were in review of the blood
smear after the autopsy. The organism also has been
found on examination of smears of bone marrow and
in culture of bone-marrow material.
While isolation of the organisms is at present the
only definite method of diagnosis, skin tests, are being
developed. Inoculation has been found successful in sev-
eral laboratory animals, including mice, guinea pigs,
rats, rabbits, dogs, monkeys, and chick embryos.
I saw one case of histoplasmosis in 1945. The patient
came in with melena and was admitted to the hospital.
No cause for the bleeding was found. About one week
after admission, he expired suddenly in a state of shock.
At autopsy, large granulomata were found in each ad-
renal. The organism was demonstrated on microscopic
examination and isolated in cultures.
Following this case and because of interest created by
the recent publication of Parsons and Zarafonetis, we
became excited when one of the technicians pointed out
a yeast-like organism in the blood smear of a patient
with clinical bacterial endocarditis. Dr. Henry Bradford,
140
The Journal-Lancet
now of Denver, asked me to do a sternal puncture.
I made some direct smears from the bone marrow,
stained them, and found the same yeast-like organisms
we had seen in the blood smear. It appeared that we had
another case of histoplasmosis until the next day, when
we found there was some kind of yeast growing in the
bottle of stain we were using. The patient’s blood cul-
tures later showed streptococcus viridans. He was treated
for six weeks with penicillin and apparently recovered.
This experience again emphasizes the care that must be
taken to identify any fungus isolated.
Moniliasis
Monilia or Candida are found frequently on the mu-
cous membrane and skin. These fungi reproduce by
budding and at times by formation of mycelium but do
not produce ascopores. Of all the species of Candida,
only Candida albicans is reported to be pathogenic. Ten
to fifteen per cent of normal individuals harbor Candida
albicans in the mouth or throat, so the mere demonstra-
tion of this fungus does not mean that the disease pres-
ent is caused by it. Bell 10 states that Monilia albicans
"only seems to be pathogenic for man”; and Colonel
Geo. F. Aycock,20 who was Chief of Medicine at Fitz-
simmons General Hospital and had had many years’
experience in pulmonary diseases, stated that he had been
looking for a proved moniliasis for 30 years, but he still
was not sure he had seen one.
The disease is described as causing chronic bronchitis.
Occasionally pneumonitis or bronchopulmonary monilia-
sis is reported. The disease has no characteristic x-ray
findings, showing only a non-specific type of peribron-
chial thickening. A peculiar, hazy type of linear fibrosis
has been described. Physical findings are those of a
chronic bronchitis. The favorable response to postassium
iodide is given as evidence that the disease is caused
by Candida albicans. Other less common pulmonary
fungus infections result from geotrichosis, sporotrichosis,
aspergillosis, penicilliosis, mucormycosis, and conio-
sporiosis.
In conclusion, it should be re-emphasized that while
these diseases of the chest are not common in this area,
it is still a fact that every patient with an undiagnosed
pulmonary condition is a potential victim of a fungus
infection. Unless this possibility is kept in mind, many
cases wll not be recognized or will not be diagnosed
until autopsy. On the other hand, knowing that fungi
occur universally, we must establish a positive identifica-
tion of any and all fungi isolated. Recent developments
in chemotherapy and antibiotics ahve changed the prog-
nosis of many of these infections. We may look forward
to new therapeutic agents which will offer cures for most
fungus diseases. As specific treatment becomes available,
it is increasingly important that an etiological diagnosis
be made and the proper therapy be instituted.
Bibliography
1. Waksman, S. A., and Henrici, A. T.: The nomencla-
ture and classification of the actinomycetes. J. Bact., 46:337,
1943.
2. Skinner, C. A., Emmons, C. W., and Tsuchuya, H. M.:
Henrici’s molds, yeasts, and actinomycetes. New York: John
Wiley & Sons, Inc., p. 371-383, 1947.
3. Lyons, C., Owens, C. R., and Ayers, W. B.: Sulfona-
mide therapy in actinomycotic infections. Surgery 14:99, 1943.
4. Herrell, W. E., and Nichols, D. R.: The calcium salt of
penicillin. Proc. Staff Meet., Mayo Clinic, 18:313, 1943.
5. Herrell, W. E.: Clinical use of antibiotics with special
reference to penicillin and streptomycin. Journal-Lancet, 68:6,
1948.
6. Emmons, C. W.: Coccidioidomycosis in wild rodents. A
method of determining the extent of endemic areas. Pub. Health
Reports, 58:1, 1943.
7. Smith, C. E.: Coccidioidomycosis. Med. Clinics N.
America, pp. 790-807, 1943.
8. Smith, C. E.: Parallelism of coccidioidal and tuberculous
infections. Radiology, 38:643, 1942.
9. Goldstein, D. M., and McDonald, J. B.: Primary pul-
monary coccidioidomycosis; follow-up of 75 cases with 10 more
cases from new endemic area. J.A.M.A., 124:557, 1944.
10. Colburn, J. R.: Roentgenological types of pulmonary
lesions in primary coccodioidomycosis. Am. Jour. Roentgen-
ology 51:1, 1944.
11. Martin, D. S., and Smith, D. T.: Blastomycosis. Am.
Rev. Tuberculosis, 39:275, 1939.
12. Smith, D. T.: Fungus diseases of the lungs. Springfield,
111., Charles C. Thomas, p. 9-14, 1947.
13. Bell, E. T.: Textbook of Pathology. Philadelphia: Lea
& Febiger, pp. 231-234, 1947.
14. Smith, D. T.: Fungus diseases of the lungs. Springfield,
111.: Charles C. Thomas, pp. 14-16, 1947.
15. Ibid.: pp. 25-28.
16. Darling, S. T.: A fatal infectious disease resembling
Kala-Azar found among natives of tropical America. Arch. Int.
Med. 2:107, 1908.
17. Riley, W. A., and Watson, C. J.: Darling’s histoplasmo-
sis in the United States. Minnesota Med., 9:97, 1926.
18. Parsons, R. J., and Zarafonetis, C. J. D.: Histoplasmosis
in man, report of 7 cases and a review of 71 cases. Arch. Int.
Med., 75:1, 1945.
19. Bell, E. T.: Textbook of Pathology. Philadelphia: Lea
& Febiger, pp. 240, 1947.
20. Aycock, Col. Geo. F.: Personal communication.
COURSE IN HEMATOLOGY AND ALLERGY
The Department of Postgraduate Medical Education, University of Minnesota, an-
nounces a continuation course in General Medicine to be held at the Center for Continuation
Study May 12, 13, 14. The course will be devoted to lectures and clinics on Hematology
and Allergy. Particular emphasis will be placed on methods of diagnosis and treatment of
the various allergic states.
April, 1949
141
Pneumonotomy with Open Drainage of Tuberculous
Pulmonary Cavities (Cavernostomy)
John V. Thompson, M.D.
Indianapolis, Indiana
Most of the older attempts at open drainage of
tuberculous pulmonary cavities reported in the
literature* were marked by an apparent lack of consid-
eration for the other pulmonary lesions. The recent pa-
per of O’Brien et al."7 contained a number of cases
among others where, due to complicating cardio-respira-
tory difficulties, apical sclerotic cavities were drained
without previous thoracoplasty which was so stressed by
Eloesser, Shipman and Rogers.1" The latter authors,
however, were concerned principally with residual tension
type cavities and they emphasized a valvular opening in
the thorax produced by a cutaneous flap. However, a
limited thoracoplasty was performed by them.
All cases in this series were far advanced, bilateral,
and of the poor risk type. The average duration of dis-
ease prior to pneumonotomy was eight years. Pneumo-
thorax was attempted in all cases, and in addition, these
patients had submitted to an average of six operative
procedures. Eight patients had preoperative hemorrhages
with none since. Eight patients had bronchial disease,
two with sepsis, which improved. Nine had contralateral
pneumothorax or thoracoplasty.
There were 23 patients in the series under considera-
tion upon whom 24 pneumonotomies were performed.
Seventeen were operated on from two to five years ago,
and all followed to-date (Fig. 1). Fourteen had a re-
current, new or residual cavity beneath apparent maxi-
mum thoracoplasty, two of which had a paradoxical
chest wall due to excessive formalization. Five patients
had a recurrent or residual cavity where thoracoplasty
was not maximum, but could not be extended because
of bronchial disease; contralateral collapse; unstable con-
tralateral lesion; and other complications. Three had
isolated lower lobe cavities over diaphragmatic paralysis,
with good upper lobes. One with an isolated giant upper
lobe cavity with contralateral pneumothorax and respira-
tory embarrassment improved after drainage.
It would appear that other pulmonary tuberculous
lesions, particularly in the regions adjacent to the cavity,
probably should be relatively stable or have good possi-
bilities of control. The trauma incident to operation and
the contraction of fibrous tissue in obliterating the heal-
ing cavity must affect the adjacent lung areas biologi-
cally as well as mechanically. In all the patients of this
series the lesions surrounding the cavitation had been
brought under at least the partial effect of some collapse
procedure.
In these patients there was present either a single
cavity or a multiloculate cavity with communicating
chambers within the lung at the time of operation. It
would seem possible to drain a closely adjacent but sepa-
rate cavity at the same time.
Case Pneumonotomy Indications Used
1. S. 3/42 Cavity beneath revised 9-rib thoraco.2 Diaphrag-
matic paralysis.
2. S. 4/42 Recurrent cavity beneath 6-rib thoraco.- One kid-
ney with occasional anuria. Bil. bronchial stenosis.
3. S. 11/42 Contra, pnx. Residual cavity beneath 5-rib thoraco.
Early respiratory embarrassment.
4. S. 2/43 New cavity, left, below bil. thoraco., 5-rib. Gran-
ulomatous bronchial lesions and hemorrhages.
5. S. 2/43 Cavity beneath revised 7-rib thoraco. and ant.
stage.
6.
7.
8.
9.
10.
12.
13.
14.
15.
16.
17.
6/45 Second recurrent cavity adjacent to above situation.
S. 4/43 Recurrent multiple cavitation beneath thoraco. -
Sepsis, bronchiectasis, bil. bronchial stenosis.
S. 10/43 Residual cavity beneath 7-rib thoraco. and an-
terior - stage. Neurologic and G.U. problem.
S. 1/44 Mulfiloculated residual cavitation beneath 7-rib
thoraco. supplemented by anterior stage. Contra,
pnx.
S. 1/44 Residual lower lobe cavity over diaphragmatic pa-
ralysis and pneumoperitoneum. Hemorrhages,
mild bronchial lesion. Remaining upper lung good.
S. 2/44 Residual cavity as unable to tolerate stages of
thoraco. close enough together to prevent regen-
eration due to hematologic and G.I. complications.
S. 2/44 Residual cavity after insufficient thoraco. which was
not extended because of contra, spread thought to
need collapse.
S. 3/45 Recurrent cavity beneath 7-rib and ant. thoraco.
Bronchial lesions.
S. 4/45 Residual cavity beneath 7-rib thoraco. and contra,
pnx.
S. 4/45 Recurrent cavity beneath 7-rib and ant. revised
thoraco.
R. 6/45 Residual cavity after 7-rib thoraco.- and contra,
pnx.
P R. 12/45 Residual cavity after 7-rib thoraco.- and contra.
pnx. Paradoxical movement of chest-wall from
lack of rib regeneration.
P.I. 12/45 Residual cavity after 7-rib thoraco.2 due to lack
of regeneration of rib bed probably from for-
malin. Paradoxical chest wall; marked respiratory
embarrassment.
18. R. 4/47 Residual cavity after extensive 8-rib thoraco.2
19. R. 6/47 Residual lower lobe cavity over diaphragmatic pa-
ralysis, with good upper lung. Contra, empyema.
20. C. 6/471 Residual lower lobe cavity over paralyzed dia-
phragm and pneumoperitoneum. Fair upper lobe.
Streptomycin.
21. P.S. 7/47 1 Giant upper lobe cavity. Contra, pnx. Marked
respiratory embarrassment.
22. H. 9/47 Residual cavity after revised 9-rib thoraco. and
anterior stage. Bronchial disease. Coronary oc-
clusion.
23. H. 9/47 Residual cavity after twice revised 7-rib thoraco.
and anterior stage. Contra, pnx.
S.: Sunnyside Sanatorium, Indianapolis. P.: Private. R.:
Rockville Sanatorium, Rockville, Ind. I.: Irene Byron, Fort
Wayne. C.: City Hospital, Indianapolis. H.: Healthwin, South
Bend, Indiana. 1: 2 stage. 2: Performed by others.
Fig. 1.
142
The Journal-Lancet
It would be, no doubt, good judgment to have lesions
in the contralateral lung under control or at least good
possibilities of same before proceeding with pneumonoto-
my. The impression has been gained that pneumonotomy
could be performed where contralateral lesions were
slightly more unstable than the condition required for
thoracoplasty, because there has been less reaction to the
operation and little collapse effect.
Where thoracoplasty had been performed and it ap-
peared that drainage might be necessary, a period of sev-
eral weeks was allowed to elapse before operation was
considered in order that the tissue planes became sealed
and the maximum effect noted from the collapse.
The cavities were localized by planigrams. Prepara-
tion for the operation was the same as for thoracoplasty
including postural drainage. All anesthetics were local
plus intercostal nerve block occasionally supplemented
with sodium pentothal. The approach was made in the
region where the cavity was situated closest to the chest
wall.
The patient was placed in the position of lateral re-
cumbency and a paravertebral incision made in the re-
gion of the old thoracoplasty scar where such existed.
The deep muscles of the chest were divided. Usually,
electrocoagulation or suture was used for hemostasis
throughout the operation. Several centimeters of the ribs
or regenerated bone were removed over the region of
the cavity. The resection was not extended more than
necessary because of the danger of creating a dead space
which might become infected. For like reason, the peri-
osteum was carefully left on the unresected ribs. The
intercostal vessels were doubly ligated and the intercostal
muscles, nerves and vessels, together with the remaining
periosteum were excised over the area.
In order to avoid empyema, it was well ascertained
that the pleurae were densely adherent. A needle con-
nected to a manometer and syringe was used to locate
the cavity. Then, with the electro-cautery, an incision
was made slowly along the needle through the pleurae,
lung and cavity wall. This was dried and explored and
then completely unroofed over its widest diameter. It
was observed that the more widely the cavity was opened
to the exterior without cutting excessively into lung tis-
sue, the better it appeared to heal and obliterate. This
is true particularly where nontension sclerotic cavities are
concerned. There was ntaurally less shelving and pocket-
ing with good drainage. If daughter chambers were pres-
ent, they were opened widely into the main cavity by
excising the outer peripheral portion of the partition.
Exposed lung tissue and bleeding points were well
coagulated or sutured, if necessary, to avoid air em-
bolism and postoperative hemorrhage. No large vessels
were encountered as the blade was only used in the lat-
eral periphery of the cavities and the mediastinal aspects
were avoided. Strands crossing the cavity were ligated
even if fibrosed. The remaining medial cavity wall was
coagulated to destroy it as much as possible.
The deep muscles of the chest were sutured over the
exposed rib ends to the pleura if possible and approxi-
mated somewhat at either end. A large skin flap was
dissected up laterally after the method of Eloesser 11
and the free end sutured to the cavity wall or pleura.
These flaps appeared later to keep the wound open and
also acted as a point from which epithelization took place
over the deeper parts of the wound. Likewise the medial
edge of the skin was sutured to the muscles and each
end of the incision brought together to some extent.
Chromic catgut No. 1 was used as the suture material
for closure. The wounds were loosely packed open with
gauze and vaseline strips placed around the wound edges
to protect the soft tissues where wounds were widely
open (Fig. 2).
Fig. 2.
The two stage procedure with gauze pack should be
used where the pleurae are not adherent and the tissue
planes are not sealed by previous surgery. In only one
case was it necessary to administer plasma for the pre-
vention of shock. The patients otherwise tolerated the
procedure as well as a small second stage thoracoplasty,
if not better.
The postoperative care consists of a long period of
daily light packing with gauze which may be soaked in
penicillin, streptomycin, tyrothricin or codliver oil to
keep the wound as clean as possible. Occasional stimula-
tion of the granulations with silver nitrate or the cautery
is beneficial. After about nine months of such manage-
ment, if the wounds are not nearly healed, a plastic
closure of the defect may be considered in most cases.
There is apparently too much active infection present to
attempt closure before this time though streptomycin
may alter this consideration.
The wound is prepared for several days with wet dress-
ings and antibiotics are administered and continued post-
operatively. A plane of cleavage is established between
the granulation tissue and the underlying tissues and the
former is bluntly dissected out of the defect. The defect
April, 1949
143
is then obliterated by reapproximating the tissues in lay-
ers with interrupted number 20 and 40 cotton thread;
thus suturing lung to lung, pleura to pleura, etc. If a
bronchial fistula is present, in addition a pedicled muscle
graft is obtained from the adjacent musculature and
sutured into the orifice of the bronchus.
Seven plastic closures of sinuses and fistulae were per-
formed, five of which healed and two broke down. These
were two of three closed between three and nine months
after the pneumonotomy, while all of those repaired at
a later postoperative date healed. Of the 17 patients
followed for over two years, seven have healed wounds
(2 spontaneous and 5 plastic closures) ; two patients are
dead, and another will probably die. The wounds of
the seven others are expected to heal or be closed, though
two have had complicated sinuses requiring revisions.
The recent cases appear to be healing better with strep-
tomycin and experience.
All patients had sputum conversion and absence of
acid-fast bacilli in the sinus postoperatively. There were
no secondary organisms present in the cavities at opera-
tion in those cases studied. Eighteen (70 per cent) of
the 23 patients still have negative sputa, of the other
five, one developed positive sputum after four years due
to the appearance of a contralateral cavity; another after
four years became positive following an exacerbation of
tuberculous bronchiectasis; a third patient became posi-
tive in 18 months due to the appearance of a contra-
lateral cavity, and another in 18 months due to an ipsi-
lateral cavity. The other patient, after a year, became
positive from an exacerbation of the original focus on
which a plastic closure was done too early.
The recent cases are semi-ambulant. Of the other 17
patients, seven are working, two are ambulant, and one
is semi-ambulant. Five are in bed and two are dead. The
result has been good in eight of the patients operated on
over two years ago; all of these have healed wounds,
negative sputum, and are working or ambulant. In four
patients the wound healing has been delayed, but will
probably be good. These patients still have some sinus
formation, but the sputum is negative with one excep-
tion. In this patient an exacerbation occurred in the
sinus tract.
In two patients the results are uncertain. Both were
working and the sputum was negative for four years in
both instances before becoming positive again; this was
due in one case to the appearance of a contralateral
cavity, and in the other to an exacerbation of bronchi-
ectasis. Both still have small unhealed granulomatous
areas, but not sinus formation.
The result may be considered a failure in three cases.
One improved and was negative for 18 months post-
operatively; then developed a contralateral cavity and a
general breakdown of the sinus. The situation was ag-
gravated by a domestic situation. Death resulted in the
other two patients. One died postoperatively following
an attempt to drain a second later developed cavity by
another surgeon. The cause of death was thought to
be a pneumonia. The third died four years postopera-
tively of a tuberculous spine and cardiac insufficiency
though the pulmonary lesions were controlled. The total
mortality was thus 12 per cent for the 17 patients op-
erated on between two and five years ago, or 9 per cent
for the entire group. There were no direct operative
deaths following operations performed by the writer.
In at least 12 per cent of the patients the result is un-
certain. The 12 good and probable good results would
make a salvage of approximately 70 per cent. Six pa-
tients recently subjected to operation appear to be doing
somewhat better than the previous ones, possibly due to
increased experience and the aid of streptomycin.
Conclusions
Pneumonotomy with open drainage of an isolated tu-
berculous pulmonary cavity over 2 cm. in diameter may
be of value in the following limited circumstances, par-
ticularly if hemorrhage or sepsis is present: After the
maximum degree of collapse possible has been achieved;
when further collapse is contraindicated; and where addi-
tional collapse or resection would result in the loss of
function of an excessive amount of relatively good lung
tissue. Other plumonary lesions should be under con-
trol or have good possibilities of same.
The procedure is well tolerated by such poor risk pa-
tients and the results are relatively satisfactory for such
a group. It would appear that a complicating sinus
which persists after nine months may be excised and the
defect closed with reasonable expectancy of healing.
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The Journal-Lancet
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W. B. Saunders Co., 1926.
25. MacEwen, W.: West London M. J., 11:163, 1906.
Cited by Thornton and Adams.
26. Nissen, R.: Cited by Rogers, Shipman and Daniels. :1-
27. O'Brien, E. J., O'Rourke, P. V., Test, F. C., and Skin-
ner, E. F., Detroit, Mich.: Cavernostomy, J. Thoracic Surg
16:602, 1947.
28. Potau: Cited by Sauerbruch and O’Shaughnessy. •'4
29. Quicke: Cited by Archibald. '
30. Rankin, H. P., and Weigel, B. J.: Chemical Steriliza-
tion of Large Tuberculous Pulmonary Cavities, J.A.M.A.
82:461, 1924.
31. Riviere, Clive: The Pneumothorax and Surgical Treat-
ment of Pulmonary Tuberculosis, second ed., London, Hum-
phrey Milford-Oxford University Press, 1927.
32. Rogers, W., Shipman, S., and Daniels, A.: Flap Drain-
age of Residual Tuberculous Cavities, J. Thoracic Surg. 12:88,
1942.
33. Sarfert, H.: Die operative Behandlung der Lungen-
chwindsucht, Leipzig, Johann, Ambrosius Barth, 1901. Cited
by Alexander.1
34. Sauerbruch, F., and O’Shaughnessy, L.: Thoracic Sur-
gery, London, William Wood and Co., 1937.
35. Sauerbruch, F.: Die Cherurgie der Brutsorgane, second
ed., Berlin, Julius Springer, Vol. 1, 1920. Cited by Alexander.1
36. Thompson, J. V.: Pneumonotomy with Open Drainage
of Tuberculous Pulmonary Cavities, Discussion, Am. Rev.
Tuberc. 51:12, 1945.
37. Thornton, T. F., and Adams, W. E.: The Resection of
Lung Tissue for Pulmonary Tuberculosis, Surg., Gynec. and
Obst. 75:312 (abstracts), 1942.
38. Tuffier, T.: Collapsetherapie par decollement pleuro-
parietal pour tuberculose limitee au sommet du pouman, greffe
d un fragment de tissue adipeux dans l’espace decode, Bull, et
mem. soc. de Chir. de Paris, 49:1249,1923. Cited by Alexander.1
39. Willis: Cited by Sauerbruch and O’Shaughnessy.'14
A.C.H.A. NEWS
The American College Health Association (formerly the American Student Health
Association) maintains its interest in bringing together both college and physician for the
fulfillment of existing vacancies in Health Services. The following colleges have indicated
a need for physicians:
Dr. Harold D. Cramer, Director of University Health Service, University of Idaho,
Moscow, Idaho.
Dr. Malcolm Price, President, Iowa State Teachers College, Cedar Falls, Iowa.
Dr. K. D. McClelland, Acting President, Knox College, Galesburg, Illinois.
Dr. Roxie A. Weber, Assistant Director, Student Health Service, Oklahoma Agricul-
tural and Mechanical College, Stillwater, Oklahoma.
The Association urges that any information concerning College Health Service vacancies
or names of interested and qualified physicians be forwarded to the American College Health
Association, Dr. Edith M. Lindsay, Secretary-Treasurer, School of Public Health, Univer-
sity of California, Berkeley 4, California.
FIRST ANNUAL A.A.G.P. ASSEMBLY
The first Annual Scientific Assembly of the American Academy of General Practice
met in Cincinnati, Ohio, March 7, 8, and 9.
Over 2,500 physicians registered for the Academy which has as its immediate aim the
expansion of facilities for postgraduate training in general practice and revision of the under-
graduate curricula to insure medical graduates of an education which can meet the demands
of modern day general practice.
April, 1949
145
Tuberculous Osteomyelitis of the First Rib Resulting
in Brachial Plexus Compression
A Case Report
Ernest H. Winterhoflf, M.D., and James D. Murphy, M.D.
Oteen, North Carolina
Tuberculous involvement of the ribs, sternum or
clavicle occurs in about 7 per cent of cases of tuber-
culosis of the bone.1 Involvement of the first rib is un-
usual but has been reported.1’ The following case is in-
teresting in that a tuberculous osteomyelitis of the first
rib was the underlying cause of a brachial plexus com-
pression resulting in partial paralysis of the left arm.
Case Report
History: E. W., a 34-year-old negro war veteran, was
admitted to this hospital October 23, 1947, by transfer
from a nearby veterans’ hospital where he had been
under treatment for pulmonary tuberculosis. He gave
a past history of pulmonary tuberculosis of about one
years duration. Treatment had consisted of bed rest
and pneumoperitoneum. After an interval of six months,
the collapse therapy was discontinued as ineffectual.
Early in June, 1947, and about five months before
admission, an abscess developed in the anterior chest wall
to the right of the sternum. This abscess was incised
and drained about a month after onset. The pus was
found to be positive on culture for Mycobacterium tu-
berculosis. The abscess gradually subsided but left a
residual draining sinus. In September, 1947, an abscess
developed in the lower lumbar region which gradually
increased in size. This was treated by multiple aspira-
tions and the pus removed was found to be positive on
direct smear for Mycobacterium tuberculosis.
Three months before entry this patient began to com-
plain of pain and spasm in his left shoulder and at the
base of the neck on the left. He also noticed that his
left shoulder was higher than the right and that his neck
was thrust forward and to the right. The pain was
aggravated on turning the head to the left. About one
week after the onset of pain in neck and shoulder, the
patient became aware of a sensation of "needle pricks”
in the left deltoid region. By the following morning the
paresthesia had extended downward along the inner as-
pect of the left arm to the lateral side of the elbow and
persisted for three to four days. In the course of the
next two weeks this paresthesia spread down the inner
aspect of the left arm and into the fingers. About two
weeks after the onset of these sensory changes he de-
veloped weakness, paralysis and atrophy of the left arm.
The process was gradual, the patient first noting loss of
abduction of the arm. Paralysis then extended down the
arm, forearm, and finally into the hand and fingers.
Treatment was symptomatic — vitamins, heat and mas-
sage to the affected arm and shoulder. No improvement
was noted, however, and the cause of the paralysis re-
mained obscure.
The remainder of the history is non-contributory.
On admission to this hospital the patient complained
of the following symptoms: generalized weakness, a daily
elevation of temperature, a loss of about 30 pounds in
weight during the past year, pain in the left shoulder
and left side of the neck, weakness and partial paralysis
of the left arm.
Physical Examination: The patient was a poorly nour-
ished colored male who appeared chronically ill. His
temperature was 100° F., pulse 90, respirations 20. The
blood pressure was 100 systolic, 70 diastolic in both arms.
The abnormal posture of the patient with left shoulder
held higher than the right and neck thrust forward and
to the right was plainly visible (Fig. 1). There was
depression of the supraclavicular area on the left.
Examination of the chest revealed a small persisting
sinus 1.5 cm. in diameter which was draining a slight
amount of pus. This sinus was situated in the fourth
interspace just lateral to the right of the sternum. Pet-
146
The Journal-Lancet
cussion of the chest revealed impaired resonance over the
left upper portion posteriorly. There were no other
positive physical findings in the thorax.
Examination of the back showed a slight left dorsal
scoliosis. In the lower lumbar region was a fluctuant
swelling 14 cm. in diameter which was non-tender and
not warm on palpation.
Except for the left arm, the extremities were not ab-
normal. The left arm, forearm, hand and shoulder
showed marked wasting. The deltoid prominence was
absent on the left as a result of the atrophy, which was
most apparent in forearm and hand. The thumb was
unopposed and there was marked thenar atrophy as seen
in medial nerve lesions. The patient was unable to exe-
cute any of the finer movements of the hand. All mo-
tions of the left upper extremity except flexion of the
forearm were impaired and a slight degree of supination
of the forearm was produced by the biceps muscle. For
all practical purposes the left arm was of no functional
value. A muscle evaluation study by electrical stimula-
tion was not done. Evaluation of the motions of the arm
and shoulder was done by palpation of the muscles. All
the muscle groups contracted voluntarily but were weak
with the exception of the flexors of the forearm and the
external rotators of the shoulder which showed appar-
ently normal tone and function.
Neurologic examination was negative except for the
left arm. The only positive motor findings were absent
radial and triceps reflexes on the left. No pathologic
reflexes were present. The biceps reflex on the left was
equal to that on the right. No definite sensory changes
could be elicited. There was no dilatation of the pupils
of the eyes.
Laboratory Examinations: The routine urinalysis and
serology were negative. The sputum was negative for
acid-fast bacilli on concentration and culture. The differ-
ential blood count on admission showed a mild hypo-
chromic anemia. A spinal fluid examination done at the
other hospital shortly before the patient was transferred
to Oteen was negative.
X-ray Examination: A roentgenogram of the chest
on November 4, 1947, revealed a destructive lesion in-
volving the first and second ribs on the left near their
junction with the transverse process. The first rib ap-
peared to be fracture (Fig. 2). A tentative diagnosis
of tuberculous osteomyelitis of the first and second ribs
was made. The eighth posterior rib on the right also
appeared to be affected by an incipient tuberculous
process. The parenchyma of both lungs showed a tuber-
culous process with cavitation in the left upper lobe.
The trachea was slightly shifted to the left. The left
shoulder was elevated and there was a slight left dorsal
scoliosis. Roentgenograms of the spine were negative.
Hospital Course: The patient was admitted to a med-
ical ward at this hospital on October 23, 1947. On No-
vember 4 he was transferred to the surgical service. On
the following day the abscess in the lower lumbar area
was incised and drained. A wide incision was made and
the abscess cavity packed with dry sterile gauze. Dress-
ings were done daily and the wound repacked with sterile
Fig. 2.
dry gauze. The abscess area closed rapidly and in three
and one-half months healing was complete. No under-
lying bony pathology has been demonstrated to date.
The patient was started on streptomycin therapy
November 12, 1947, for the draining chest wall sinus
and the lumbar abscess. A dose of 0.5 gram was given
at 9:00 A.M. and 0.5 gram at 9:00 P.M. and continued
in daily doses until February 21, 1948. The sinus in
the chest wall closed one month after the institution of
the streptomycin therapy.
The chief concern of the patient was the uselessness
of the left arm. This paralysis seemed to become more
extensive and more marked after admission here, espe-
cially in the hand. The etiology of the paralysis was
thought to be compression of the brachial plexus by the
tuberculous process involving the first and second ribs
on the left. Symptoms were not unlike those found in
a posterior and medial cord compression of the brachial
plexus. It was decided to perform a four-rib thoraco-
plasty on the left side in order to remove the diseased
portions of the first and second ribs, and at the same
time to give the patient a permanent collapse of the
upper lobe in an attempt to close the left apical cavity.
After the patient had been on streptomycin therapy
for 22 days, a first-stage, left posterolateral thoracoplasty
was performed December 4, 1947, under cyclopropane-
nitrous oxide-ether anesthesia. Through a classical in-
cision the fourth and third ribs were disarticulated and
removed subperiosteally from their attachment to the
vertebrae posteriorly to the anterior axillary line. The
second and first ribs were found to be the site of a de-
structive process which involved the posterior third of
April, 1949
147
Fig. 3.
both ribs. There was a pathological fracture of the first
rib just lateral to its junction with the transverse process.
As a result of this fracture, the anterior three-fourths of
the first ribs was displaced anteriorly and inferiorly.
Surrounding the necrotic portion of the first rib was a
small abscess just lateral to the first and second vertebrae
which on evacuation yielded half an ounce of thick,
greenish pus. The second rib just below the necrotic area
showed the same typical moth-eaten appearance with a
small caseating mass encircling it.
These two ribs were disarticulated subperiosteally at
the transverse process and removed from their attach-
ments anteriorly to the costochondral junction. The bra-
chial plexus was not identified but the location of the
first rib and the abscess surrounding it left no doubt as
to the underlying etiology of the brachial compression.
Two rubber tissue drains were placed in the first and
second rib beds and brought out through the middle of
the incision, which was then closed in layers with inter-
rupted chromic sutures. The skin incision was closed
with interrupted dermal sutures.
Pathologic examination of the rib fragments showed
grossly the typical moth-eaten appearance of an osteo-
lytic process. Microscopic examination of the necrotic
bone tissue showed frayed cancelli. The encircling
fibrous tissue contained many plasma cells and lymph-
ocytes with ill-defined masses of epitheloid cells and
Langhans giant cells. In many areas delicate acid-fast
bacilli were seen. The microscopic diagnosis was tuber-
culosis of the rib.
The patient’s postoperative course was uneventful.
Sutures were removed on the seventh postoperative day.
Removal of the drains was begun on the third day and
y
Fig. 4.
completed on the fourth. In one month the incision had
healed completely with no signs of a draining tubercu-
lous sinus.
Two days following operation there was a dramatic
beginning of return of function to the left arm. The
patient was started on a course of physiotherapy. Func-
tion of the left arm improved steadily and at the pres-
ent time (four months after surgery) function has re-
turned to about normal. All muscles are active and exer-
cises are now being directed toward increasing muscle
tone. Streptomycin therapy was discontinued February
21, 1948, and throughout the course no toxic reactions
were noted. The patient has regained his lost weight
and the pulmonary lesions show definite signs of clear-
ing (Figs. 3 and 4) .
Comment
Brachial plexus compression by a tuberculous bone
lesion is of rare occurrence and the case reported above
is the first in this category to be recorded at this hos-
pital. Clinical symptoms indicated that the posterior and
medial cords of the plexus were compressed. Paralysis
was not complete and no sensory changes were apparent
while the patient was under our care. In compression-
type injuries of the brachial plexus we do not always
find the sensory changes seen in those cases in which
there has been complete severance of the plexus. In our
patient the muscles affected were those served by the
axillary, medial, radial and ulnar nerves.
We are of the opinion that four factors contributed
to bring about paralysis in this case: (1) elevation of
the left shoulder; (2) spasm of the muscles of the neck
and shoulder produced by the abscess; (3) thrusting of
the neck forward and to the right; and (4) the patho-
148
logical fracture with anterior displacement of the first
rib.
This case represents the value of streptomycin as an
adjunct in the treatment of tuberculous abscesses. Our
experience before the advent of streptomycin in the
treatment of these abscesses was most discouraging.
Several years before the appearance of this antibiotic,
the thoracoplasty performed in this case would have en-
tailed several possible complications. The most common
would have been the development of a large tubercu-
lous abscess undermining the scapula with sinus forma-
tion. Another distinct possibility would have been a
hematogenous spread of the disease.
Since the introduction of the use of streptomycin in
the treatment of tuberculosis we have become increas-
ingly bolder in our handling of abscesses of tuberculous
origin. We believe that if a tuberculous abscess can be
adequately drained and the abscess cavity kept open to
the outside, it will close in the vast majority of cases
in from one to four months. Streptomycin therapy com-
bined with surgery promises the patient a cure of the
The Journal-Lancet
abscess provided the tuberculous organism is sensitive to
streptomycin/
Summary
A case of brachial plexus compression with resulting
partial paralysis has been presented. The underlying
cause of the compression was a tuberculous osteomyelitis
of the first and second ribs. The case was successfully
treated by surgery and streptomycin therapy.
References
1. Babcock, W. W.: Principles and Practice of Surgery.
Philadelphia, 1944, Lea & Febiger, p. 789.
2. Donaldson, J. K.: Surgical Disorders of the Chest — Diag-
nosis and Treatment. Philadelphia, 1947, Lea Si Febiger, p. 23.
3. Riggins, FL M., and Gearhart, R. P.: Antibiotic and
Chemotherapy of Tuberculosis. Am. Rev. Tuberc. 57:35-52,
1948.
From the Department of Medicine and Surgery, Veterans
Administration, Oteen, North Carolina; published with permis-
sion of the Chief Medical Officer, Department of Medicine and
Surgery, Veterans Administration, who assumes no responsi-
bility for the opinions expressed or conclusions drawn by the
authors.
Meet Our Contributors
Sidney A. Slater, M.D., Worthington, Minnesota, was
graduated from the Medical College of Virginia, 1909;
specializes in Diseases of the Chest; Superintendent and
Director, Southwestern Minnesota Sanatorium; Member,
American College of Chest Physicians, American Tru-
deau Society, National Tuberculosis Association.
William Roemmich, M.D., Baltimore, Maryland, was
graduated from the University of Columbia Medical
School, 1945; Fellow, University of Maryland: Instructor,
School of Public Health, Johns Hopkins University;
Surgeon, Division of Tuberculosis, United States Public
Health Service; formerly Tuberculosis Control Officer,
Minnesota Division of Public Health.
Max L. Durfee, M.D., Oxford, Ohio, was graduated
from the University of Michigan, 1930; Director, Miami
University Student Health Service, Wade MacMillan
Hospital, Oxford, Ohio; formerly University Physician,
University of Michigan Health Service and Health Di-
rector, Iowa State Teachers College; Chairman, Commit-
tee on Tuberculosis, ACHA.
Clayton H. Schmidt, M.D., Milwaukee, Wisconsin, was
graduated from the University of Pennsylvania, 1948;
Interning in Milwaukee, Wisconsin.
K. F. Meyer, M.D., San Francisco, California, is a
graduate of Zurich University, Switzerland; specializes
in Experimental Pathology and Bacteriology; Professor,
University of California; President, Society of American
Bacteriologists, Society of Immunologists; Member, Na-
tional Academy of Science.
H. E. Miller, M.D., Minneapolis, Minnesota, was grad-
uated from the University of Minnesota, 1936; special-
izes in Internal Medicine; Member, American College of
Physicians, Minneapolis Society of Internal Medicine.
John V. Thompson, M.D., Indianapolis, Indiana, was
graduated from the Univeristy of Illinois, 1938; special-
izes in Thoracic Surgery; Consultant Thoracic Surgeon,
Irene Byron Sanatorium, Indiana State Sanatorium,
Flower Mission Hospital; Member, Thoracic Surgery
Division, Indianapolis General Hospital; Diplomate,
American College of Chest Physicians.
Ernest H. Winterhoff, M.D., Indianapolis, Indiana,
was graduated from Ohio State University in 1945; Sur-
gery Resident, Indianapolis Veterans Hospital; formerly
of the Thoracic Surgery Section, Oteen Veterans Hospi-
tal, Oteen, North Carolina.
James D. Murphy, M.D., Oteen, North Carolina, was
graduated from Northwestern University Medical School,
1924; specializes in Thoracic Surgery; Chief, Surgical
Service, Oteen Veteran’s Hospital; Member, American
College of Surgeons, American Association for Thoracic
Surgery, Southeastern Surgical Congress, American Col-
lege of Chest Physicians, Buncombe County Medical So-
ciety; Director, Resident Training in Thoracic Surgery.
April, 1949
149
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. Gilbert Cottam
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J . C. Fawcett
Dr. A. R. Foss
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
BOARD OF EDITORS
Dr. I. A. Myers. Chairman
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H . Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A, Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
ADVISORY COUNCIL
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella. President
Dr. Cyrus O. Hanson. Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert, Recorder
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Dr. Gilbert Cottam, Secretary-Treasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
Editorial
SPONTANEOUS PNEUMOTHORAX
The initial symptoms of spontaneous pneumothorax
may closely simulate those of acute disturbance of coro-
nary circulation. Sudden excruciating pain, often pre-
cordial, with shock has frequently caused physicians to
make a presumptive diagnosis of coronary disease. If
the pneumothorax is small, it may not be found by the
conventional physical examination. In most cases x-ray
film inspection and, in many, fluoroscopy reveals the con-
dition. Severe pain may persist for a few minutes to
an hour or so, after which it gradually subsides and
usually has disappeared within 24 hours or less. Short-
ness of breath is a common symptom soon after the pain
appears, but breathing is presently restored to normal
unless extensive collapse of the lung occurs as the result
of positive intrapleural pressure. The onset of spontane-
ous pneumothorax is not necessarily associated with stren-
uous exertion. Individuals have been awakened from
sound sleep by the initial pain. Others have had the
first symptoms appear while reading in bed. From these
relatively inactive states cases have been reported which
developed through all degrees of activity to the most
strenuous physical exertion.
This condition occurs in all ages of life, from infancy
through senility. It has been reported as an accompani-
ment of many pulmonary diseases, such as malignancy,
tuberculosis, silicosis and even chronic fibrosis of undeter-
mined etiology. In such cases, if the underlying disease
has not previously been known, it can usually be found
soon after the attack or when the lung expands.
Spontaneous pneumothorax has frequently been seen
when no evidence of disease could be found after expan-
sion of the lung. Such cases were long classified as idio-
pathic. However, it has been learned that a frequent
cause is small vesicles or blebs immediately subjacent
to the visceral pleura which rupture into the pleural
space. Such blebs may represent localized areas of em-
physema or congenital weaknesses in the pleura. The
resulting collapse, Kjergaard designated as pneumothorax
simplex. In 1934 we reported 31 cases of spontaneous
pneumothorax, of which 19 failed to show any evidence
of pulmonary disease. We have since seen many more
of the same type. Large numbers of such cases have
been reported by other authors.
Simple spontaneous pneumothorax has been most
often observed in young adult males. Indeed, it created
a significant problem during World War II in the mili-
tary services; so much so that the National Research
Council issued a special pamphlet prepared by J. J.
Waring of Denver, on the diagnosis and management
150
The Journal-Lancet
of spontaneous pneumothorax. This was made available
to our medical officers everywhere.
In the majority of cases the lung only partially col-
lapses. The symptoms promptly subside and expansion
occurs within a few days to a few weeks. It is remark-
able in how few cases significant amounts of fluid accu-
mulate in the pleural cavity except when hemo-pneumo-
thorax results from bleeding at the point of pleural
rupture.
Occasionally when the pleural break occurs, a flap-like
opening is created which acts as a one-way check valve.
Thus air enters the pleural space on inspiration, but
closure of the valve prevents its escape on expiration with
the development of high positive pressure in the pleural
cavity. This situation immediately becomes an emer-
gency as pressure results in marked mediastinal displace-
ment with severe embarrassment of respiratory and car-
diac function. If the condition is not recognized death
can result in a short time. Such deaths have been re-
ported as due to coronary disease.
If the condition is recognized in time, prompt relief
is observed by thrusting an 18-gauge needle through the
chest wall. Enough air escapes to remarkably reduce the
pressure in a few seconds. It may then be necessary to
pump air from the pleural cavity but high negative intra-
pleural pressure should be avoided. Every physician
should carry a two-way air pump, rubber tubing and
needles in order to cope with this emergency should it
occur in his practice. In some cases, after the needle is
removed air accumulates so fast and aspirations are re-
quired so frequently that an indwelling needle or cath-
eter and check valve are advantageous to provide contin-
uous escape of air from the pleural cavity until air no
longer accumulates through the pleural opening to cause
positive pressure.
In cases of spontaneous pneumothorax resulting in
partial collapse of a lung, emergencies may be created
by ascent to an altitude of 5000 feet or more as in air-
plane travel. This was observed in World War II when
evacuating by airplane cases of pneumothorax from any
cause. The volume of air in the pleural space increases
with altitude. At 18,000 feet it is doubled and at 34,000
feet, quadrupled. Three thousand cubic centimeters of
air in the pleural cavity at sea level assumes the volume
of 3720 cc. a mile above. Therefore, a person with
pneumothorax may be in distress at an altitude of one
mile and his life jeopardized at higher altitudes.
Two or three decades ago it was recommended that
every person with simple uncomplicated pneumothorax
be placed on strict bed rest for at least one year because
it was thought tuberculous lesions were the underlying
cause, although they could not be demonstrated. In a
sizable group of cases (soon to be reported), we have
seen only one who subsequently developed clinical tuber-
culosis. Spontaneous pneumothorax occurred in 1923
and pulmonary tuberculosis was not in evidence until
1928. Experience has shown that in the vast majority
of cases of simple spontaneous pneumothorax no treat-
ment is required except sedation for pain at the begin-
ning and a few days of bed rest. The pleural rent soon
closes and the lung expands without incident. However,
the condition may recur once or many times, occasion-
ally bilaterally. If recurrences become too frequent, an
attempt may be made to adhere the visceral and parietal
layers of pleura by introducing into the pleural space
when the lung is practically expanded, 25 to 50 cc. of a
mildly irritating substance, such as hypertonic glucose
solution (30 to 60 per cent) lipiodol or mineral oil.
J. A.M.
News Items
North Dakota
Committee appointments for the Cass County Med-
ical Society were announced by Dr. Charles Heilman,
Fargo, elected president at the recent annual meeting.
Dr. Earl Haugrud is vice president and Dr. John H.
Bond, secretary-treasurer. Both are from Fargo.
On the board of censors are Drs. B. A. Mazur and
William C. Nichols, both Fargo, and S. C. Bacheller,
Enderlin.
Dr. Robert Rogers, Fargo, is program chairman, with
Drs. Allen Moe and Coy Kaylor, both Fargo, on the
committee.
Others include public health and public relations, Drs.
G. A. Dodds, chairman, Mazur and F. A. deCesare, all
Fargo; cancer, Drs. John LeMar, R. D. Weible and A.
C. Burt, all Fargo; medical economics, Drs. E. H. Rich-
ter, Hunter, chairman, A. L. Klein and Joseph Schnei-
der, Fargo; national and state medical legislation and
information, Drs. O. A. Sedlak, A. C. Fortney and W.
E. G. Lancaster, all Fargo.
Dr. W. C. Vogelwede of Carrington was elected presi-
dent of the Tri-County Medical Society.
Other officers include Dr. P. A. Boyum, Harvey, vice
president; Dr. D. W. Matthai, Fessenden, secretary-
treasurer; Dr. R. F. Gilliland, Carrington, delegate; Dr.
C. G. Owens, New Rockford, alternate delegate, and
Dr. E. J. Schwinghammer, New Rockford, councillor.
Dr. Nelson A. Youngs was elected president of the
Grand Forks District Medical Society at the monthly
meeting in January. Dr. Ralph E. Mahowald was named
vice president and Dr. L. B. Silverman was re-elected
secretary-treasurer.
Five Grand Forks men recently attended a meeting of
the North Dakota Medical Center advisory council in
Bismarck. They were Prof. John A. Page, council chair-
man, and Dr. R. E. Leigh, Harry D. Keller, W. F.
Potter and J. Lloyd Stone, advisory members. The com-
mittee will study recommendations growing out of the
passage of the one-mill tax levy for a medical center in
the November election.
Three physicians have been added to the staff of the
De-Puy-Sorkness clinic. They are Dr. Robert E. Lucy,
obstetrics; Dr. Robert Lee McFadden, eye, ear, nose and
April, 1949
151
throat; and Dr. James V. Miles, Jr. Dr. Miles is a staff
member of Trinity hospital and is secretary of the staff
at Jamestown hospital.
The Grand Forks Clinic announces the addition of
Dr. Robert C. Turner to the clinic staff. Dr. Turner’s
practice is limited to internal medicine.
Dr. E. G. Vinje, Hazen physician for the past three
years, has taken Dr. Walter R. Enders into partnership
in medical practice.
Dr. Enders came here last August to assist Dr. Vinje,
following completion of his internship at Ancker hospital
in St. Paul.
The two recently moved their offices into a new clinic
building, which was completed in December.
Dr. Louis F. Pine of Worcester, Mass., a graduate of
the University of Vermont, has become a member of the
staff of the Lake Region Clinic, specializing in genito-
urinary diseases.
Dr. Pine is the fourth member of the clinic staff.
Other members of the clinic are Drs. John, Donald and
Robert Fawcett.
Dr. R. J. Carlson, formerly of New England, has
made arrangements to locate in Watford City and will
have his office in the Stenslie building formerly occupied
by Dr. A. G. Skjelset.
Dr. Carlson received his medical degree from the
University of Iowa in 1933, and served his internship
in Covenant Hospital, Omaha. He received his North
Dakota license last July.
Dr. G. A. Stokes, 70, who has just completed 25
years of service in Streeter, was honored by the people
of the community for his fine work.
The physician, who has been considering retirement,
told the assemblage "after this party I should be good
for another 25 years.”
Added to the staff of Fargo Veterans Hospital is
Dr. John S. McNeil, native of Little Rock, Ark., and
formerly in private practice at Albion, Nebr. Dr. Mc-
Neil, who came to Fargo in February, is examiner with
the outpatient and reception service. A graduate of
University of Arkansas, he served as interne at Lincoln,
Nebr., and was 3 % years in the army medical corps in
World War II.
Dr. A. K. Johnson was elected president of the Ko-
tana Medical Society at its annual business meeting in
Williston in February.
Dr. I. S. AbPlanalp, the retiring president, presided
at the meeting, at which medical topics of current inter-
est were discussed.
Other officers elected were Dr. J. P. Craven, vice presi-
dent, and Dr. E. J. Hagen, secretary-treasurer.
South Dakota
Dr. J. L. Stewart of Spearfish, retired medical prac-
titioner and former member of the Homestake medical
staff, received special recognition at a meeting of the
Black Hills District meeting in February. He was pre-
sented with an honorary pin from the State Medical
Society in recognition of 50 years of active medical prac-
tice in South Dakota.
Names of 14 physicians admitted to practice, in South
Dakota through reciprocity were announced by Dr. G.
J. Van Heuvelan, superintendent of the state board of
health. The physicians and the cities at which they are
entering practice include:
James N. Berbos, Aberdeen; David Scott Berkman,
Rapid City; Thomas Edward Eyres, teaching at the State
University; Donald Nels Fedt, Watertown; Robert W.
Huber, Watertown; H. E. Kicenski, McIntosh; Irvin I.
Kaufman, Freeman; Arthur Walter Kilness, Sioux Falls;
Richard Harmon Lindquist, Canova; Luther Arnold
Nelson, Faulkton; Edwin Takayasu Nichimura, Mid-
land; Norris S. Rothnem, Sioux Falls; Marion A. War-
pinski, McLaughlin, and Rudolph J. Wieseler, Sioux
Falls.
Dr. W. A. George, Selby, South Dakota, pioneer phy-
sician, was honored in January on his 75th birthday and
in recognition of his 43 years of service in the Selby
community.
Dr. H. M. Hardwicke, medical director of the Co-
operative Health Federation of America, gave the prin-
cipal address at the annual meeting of the Rosebud
Community Hospital in Winner on February 26.
A powerful and intensive speaker, Dr. Hardwicke
stressed what members should know about their clinic-
to-be. He assisted in selection of the medical staff of
Group Health Co-operative of Puget Sound, a 22-
physician Seattle clinic, and is now engaged in assisting
in the selection of a staff for the Rosebud Community
hospital.
Thomas B. Schultz, administrative officer, division of
hospital facilities, South Dakota state board of health,
who is in charge of the federal hospital construction
program in this state, presented a large check, the first
Federal payment to the hospital, at the meeting. This
was the first payment, under the federal one-third match-
ing funds plan, to be made in South Dakota.
An address by Dr. R. Perry Elrod, professor of Micro-
biology at the University of South Dakota, and a
smoker as guests of the Sioux Falls District Medical
Society opened the 53rd annual meeting for members of
the Sioux Valley Medical Association in January.
Speakers here for the convention besides Dr. Elrod
were Dr. E. G. Holmstrom, Salt Lake City, Utah; Dr.
James W. Martin, Omaha, Nebr.; Drs. R. A. Bieter,
Paul Dwan and Clarence Dennis, all of Minneapolis;
Drs. C. F. Lake and Walter F. Kvale, Rochester, Minn.,
and W. O. Samuelson, Omaha, Nebr., who was the
guest speaker at the annual banquet.
152
The Journal-Lancet
Minnesota
Dr. George E. Moore, clinical instructor in surgery at
the University of Minnesota, is one of 13 United States
doctors chosen to receive five-year, $25,000 medical schol-
arship grants for their work in medicine.
The grants, from the John and Mary R. Markle
Foundation, New York, are intended to keep young doc-
tors on the teaching and research staffs of the country’s
medical schools. Dr. Moore, a graduate of West high
school and University of Minnesota, has worked with
radio-active materials in the early detection of cancer.
A young University of Minnesota biologist who spe-
cializes in cancer research was named the outstanding
young man of Minneapolis in 1948 by the Minneapolis
Chamber of Commerce.
Dr. Robert A. Fduseby, assistant professor, was given
the award at the annual Minneapolis Jaycee "Bosses’
Night” dinner.
Dr. Huseby has engaged in cancer investigation since
1941. Last year he was awarded the William A. O’Brien
assistant professorship in cancer research. He is a native
of Minneapolis.
Dr. John A. Anderson, formerly of the University of
Minnesota, will become head of Stanford University
pediatrics department September 1.
Dr. Anderson has been chairman of the pediatrics
department at the University of Utah. He is a grad-
uate of the University of Minnesota.
From 1937 to 1943 he was on the faculty of the Uni-
versity of Minnesota medical school.
Dr. Corwin Hinshaw, a member of the Mayo Clinic
staff since 1933, said at Rochester, Minn., he will leave
April 1 to become clinical professor of medicine at
Stanford University, Palo Alto, California.
Dr. Robert F. McGandy was elected president of the
Hennepin County Medical Society in February.
He will be installed to succeed Dr. Edward Dyer
Anderson the first Monday in October.
Other officers elected, who will be installed at the same
time, are: First vice president, Dr. John H. Moe; second
vice president, Dr. Ernest R. Anderson; board of di-
rectors, Dr. L. Haynes Fowler and Dr. Horatio B.
Sweetser, Jr.; board of censors, Dr. Thomas J. Kinsella
and Dr. Donald McCarthy; board of ethics, Dr. Mal-
colm B. Hanson and Dr. Robert L. Wilder; board of
trustees, Dr. Arthur C. Kerkhoff and Dr. Malcolm C.
Pfunder; delegates to Minnesota State Medical Associa-
tion, Dr. James K. Anderson, Dr. Lawrence R. Boies,
Dr. Ralph H. Creighton and Dr. Willard D. White.
Dr. Robert Semsch was named county physician by
the county board today, replacing Dr. Charlotte Mor-
rison, whose term expired January 1.
Malmstedt’s
1 1 1 South 7th Street
Minneapolis
meeting realistic needs
in smooth muscle spasm . .
The realistic need to allay nervous tension
in patients with smooth muscle spasm is
met with Syntronal which combines
dependable antispasmodic Syntropan with
phenobarbital. It selectively inhibits
parasympathetic activity, directly relaxes
smooth muscle cells and at the same time
relieves the causative or accompanying
tension. Syntronal is indicated for the
relief of spastic disorders of the gastro-
intestinal and genitourinary tracts, and in
dysmenorrhea with uterine muscle spasm.
Each sugar-coated tablet contains 50 mg
of Syntropan and 15 mg of phenobarbital.
Bottles of 30 and 100.
1 HOFFMANN -LA ROCHE INC. • NUTLEY 10 . N. J.
Syntronal
'Roche*
* Syntropan (R) & Syntronal (§)
154
The Journal-Lancet
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Obituaries
Dr. B. O. Mork, Sr., 82, Worthington, Minnesota,
dean of the southwestern Minnesota medical profession
and one of the founders of the Worthington Clinic,
died March 2nd in the Tenth Street Hospital, where
for more than 30 years he had brought thousands of
others back to health and strength. Dr. Mork, who on
December 21 announced his intention of retiring Janu-
ary 1 from the active practice of medicine, had little
time to enjoy his freedom from care. Byron Olaf Mork
was born in Hjorundford, near Aalesund, Norway,
March 28, 1867.
Dr. Frederick Arthur Drakem, 78, Lanesboro, Minne-
sota, pioneer physician and surgeon and civic leader of
this community, died in the Lanesboro Hospital January
31st. He had been a patient for one year and nine
months in the hospital and ill for five years. Dr. Drake
came to Lanesboro to practice 51 years ago and imme-
diately threw himself into the life of the community in
a manner which made him an important civic figure as
well as a physician loved by the entire community. Dr.
Drake was born July 8, 1870, in Rushford, Minn.
Dr. Gilbert Cottam, 75, former Minneapolis doctor
and leader in Minnesota and South Dakota medicine,
died March 4th, in Pierre, South Dakota. A well-known
surgeon and medical spokesman, Dr. Cottam left Min-
neapolis in 1940 to practice in Sioux Falls, South Da-
kota. He became superintendent of the South Dakota
state board of health, at Pierre in 1943. Dr. Cottam was
born in Manchester, England, and came to the United
States at 16. He was graduated from St. Louis, Mo.,
University, in 1893, practiced at Rock Rapids, Iowa,
until 1910; at Sioux Falls until 1930, and then for ten
years in Minneapolis.
Dr. Angus W. Morrison, prominent in Minneapolis
medical and civic affairs for 35 years, died January 28th
at Eitel Hospital. He was 65 years old. Dr. Morrison
was a member of a pioneer Minneapolis family. Dr.
Morrison was born in Minneapolis July 18, 1883, the son
of Clinton and Julia Washburn Morrison. He lived his
entire life in the Twin Cities area. His home was at
Maplewoods, Wayzata.
Dr. Roy G. Spurbeck, 59, widely known Cloquet phy-
sician, died at his home at 629 Chestnut Street, shortly
before midnight, February 12th. He had been in ill
health for a number of years. Born in Mantorville,
Minn., Dr. Spurbeck moved with his parents to Two
Harbors as a boy, residing there several years. He was
a graduate of Northwestern University Medical School.
He practiced medicine at Proctor for a couple of years
and in 1917 came to Cloquet, continuing until poor
health forced his retirement.
Dr. Edwin H. Maercklein, 68, for 45 years a physi-
cian in Ashley, North Dakota, died March 7th in Vet-
erans Hospital, Minneapolis.
Poisoning in Children
Newer Methods of Treatment
Wallace W. Lueck, M.D.*
Minneapolis, Minnesota
Approximately 500 children in the United States die
L from poisoning each year. Poisoning ranks third
as a cause of accidental death in the home when all ages
are considered and is exceeded only by deaths from falls
and burns. About one-third of all poisonings occur in
children under 5 years. In the pediatric age group about
90 per cent are below this age.1 It is estimated that
1 per cent of pediatric hospital admissions are for poi-
soning.
Hundreds of agents have been known to cause acute
poisoning, and strychnine is usually listed as the com-
monest agent causing death with methyl salicylate rank-
ing second. In the South and in rural areas, lye and
kerosene tend to be the most frequent type of poisoning.
Clinical Analysis
From 1940 to the middle of 1948, 117 patients in the
pediatric age group (birth to 15 years) were hospitalized
at the Minneapolis General Hospital for acute poison-
ing. This number does not include those admitted for
food poisoning. Six deaths occurred in the group. Two
girls were attempted suicides at age 13 and 14 years.
There were 73 males and 44 females. The number of
patients according to age groups is shown in Table 1.
The largest single age group was age 1 to 2 years and
82 per cent were 3 years old or younger.
Over 50 different agents were incriminated and the
commonest group of poisons was listed as insecticides or
rodenticides. Twenty patients were in this group and
*From the Minneapolis General Hospital and Department of
Pediatrics, University of Minnesota Medical School, Minne-
apolis, Minnesota.
ingested such things as lead arsenate, lead arsenite, so-
dium fluoride, sodium arsenite, red squill, thallium sul-
fate, DDT, and phosphorus. Kerosene was the com-
40-
38
Table 1
35-
30-
Incidence of poisoning
31 according to age of patient
=one potient
25-
20-
-O
E
Z 15-
10-
21
155
156
The Journal-Lancet
monest single agent and 15 patients were in this group.
Twelve patients ingested liniments, the majority of which
contained methyl salicylate. Of the remaining patients
there were 11 who took barbiturates; 6 swallowed lye;
4 turpentine, alcohol, furniture polish, iodine and "Ex-
Lax.” Other poisons included aspirin, boric acid, lead,
opium, lysol, atropine, hilex, moth balls, etc.
These children obtained their poisons by almost every
method. One very common source was the ingestion of
poisons stored in soft-drink bottles. Many of the insect
and rodent poisons were mistaken for food and were
even cooked and served as cereal by well-meaning par-
ents. Exploration of the medicine cabinet or of a moth-
er’s purse was another common source. Boric acid solu-
tion and an increasingly more common agent, potassium
bromate, present in home permanent hair waving sets,
were inadvertently mixed with infant’s formula.
The difficulties encountered in diagnosing certain cases
of poisoning are exemplified by the case of a 14-year-old
boy brought to the hospital in coma. He was transferred
to another hospital after four hours of observation where
bilateral trephinations were performed on suspicion of
subdural hematoma. Three days later the patient recov-
ered consciousness and gave a history of ingesting bar-
biturates. Poisoning should be suspected in every pa-
tient presenting unusual symptoms.
The six deaths in this group were all due to different
agents. A 19-month-old infant expired four hours after
ingesting an ant poison containing arsenic compounds.
A 22-day-old infant died as a result of two 6-minim
doses of tincture of opium substituted for camphorated
tincture of opium. The remaining four deaths were in
children 2 years of age. One died as a result of inges-
ting barium sulfide which is a constituent of a commer-
cial hair remover, one from ingesting "Drano” which
contains sodium hydroxide, one from drinking methyl
salicylate and one as a result of boric acid poisoning
following the use of boric acid packs for eczema.
DISCUSSION
Only a brief resume of some of the common and more
recently emphasized poisons and the procedures for the
treatment of these will be presented.
DDT
The recent wide-spread use of DDT as an insecticide
makes it a potential source for frequent poisoning in
children. Death has been reported in a 19-month-old
infant following ingestion of 150 mg. of DDT in kero-
sene per kilogram of body weight."
DDT is relatively insoluble in water and in the pow-
der form the particles presumably are too large for much
absorption by inhalation. DDT, however, may be readily
absorbed when present in an organic solvent and toxic
effects have been reported from ingestion, inhalation
and contact.
Symptoms of acute poisoning from DDT include
nauesa, vomiting, hematemesis, melena, anuria, transi-
tory "yellow vision,” instability, extreme excitability,
tremors, twitching, muscular weakness, feeling of tired-
ness, aches in muscles, joint pain, spasms of extreme
nervous tension, sleeplessness, anxiety, convulsions, coma
and death.-’3’4
Recommendations for therapy of the toxic effects are
based largely on experimental evidence.3 Experimentally,
Urethane gave the best results for control of the neuro-
logical symptoms with sodium diphenyl hydantoinate
(Dilantin) the next most effective drug. Diets high in
protein contributed slightly to a decrease in toxicity to
the liver and to a decrease in the mortality. Choline pro-
duced return of function of the vagus. Calcium glu-
conate intravenously is reported to be of value. Since
DDT is excreted by the kidney, diuresis produced by
forced fluids is recommended.
BAL
The discovery of BAL (British Anti-Lewisite; 2,3 di-
mercaptopropanol) resulted in an effective agent for the
treatment of poisoning due to certain heavy metals.
BAL is a compound containing two sulfhydryl (-SH)
groups. A number of body proteins and enzymes con-
tain sulfhydryl groups and it is believed that certain
metal ions produce their toxic effects by combining with
these sulfhydryl groups, thereby inhibiting important
enzyme systems. The BAL sulfhydryl groups compete
successfully with the body protein and enzymes, thereby
"detoxifying” the metal ions.
Randall and Seeler 0 have recently reviewed much of
the literature on BAL including its apparent effects on
human and experimental poisonings due to arsenic, mer-
cury, gold, lead, cadmium, silver, antimony, tellurium,
copper, bismuth, chromium, nickel, zinc, thallium, sele-
nium, vanadium, alloxan and phenylthiourea. They sum-
marize by saying, "BAL has been shown to be of clin-
ical value in the treatment of arsenic, mercury and gold
poisonings. Further clinical studies are necessary before
the efficacy of BAL in other metal poisonings can be
evaluated. Studies on animals suggest that BAL actually
enhances the toxicity of certain metals. Therefore, BAL
should not be used indiscriminately in the treatment of
metal poisonings.” It is also reported to be of value
in acrodynia.7,8
BAL is supplied commercially as a 10 per cent solu-
tion with Benzyl Benzoate 20 per cent in peanut oil for
intramuscular administration. Specific dosage schedules
for heavy metal poisonings are still not absolute. Woody
and Kometani '' treated 42 infants and children with
BAL for arsenic poisoning. They gave 2.5 mg. of BAL
per kilogram of body weight every four to eight hours
for three to six doses to children treated on suspicion of
arsenic ingestion but having no symptoms. Children
with mild symptoms received 2.5 to 3.5 mg. per kilogram
every four to eight hours for six to twelve doses and
those with severe symptoms received 3.5 mg. to 5.0 mg.
per kilogram every four to eight hours for six to twelve
doses. In addition they used general and supportive
measures as indicated.
Toxic symptoms from BAL reported by them include
anorexia, restlessness, vomiting, pain at injection site,
salivation, hypertension, fever, tachycardia, convulsions,
"Leukotoxic effect,” and reducing substance in the urine.
Reactions were related to the size of individual doses
and also to the cumulative amount of BAL given. Re-
May, 1949
157
actions were also more frequent when treatment was
given on "suspicion” of arsenic poisoning.
Tye and Siegel 10 report that relief of toxic symptoms
in adults was accomplished by 0.6 cc. of a 1:1000 solu-
tion of epinephrine hydrochloride given intramuscularly.
They could prevent the development of toxic symptoms
by giving 25 to 50 mg. of ephedrine sulfate a half hour
before administration of BAL.
Methemoglobin Producing Agents
Reports continue to be published on poisoning from
methemoglobin producing agents. The mechanism, eti-
ology and treatment of methemoglobinemia and sulf-
hemoglobinemia have recently been reviewed by Finch.11
In methemoglobin the iron has been oxidized from the
ferrous to the ferric form. The change is easily revers-
ible and in itself is not accompanied by any red-cell
damage. Methemoglobin is unable to transport oxygen
and therefore should be regarded as a temporarily inert
pigment. Symptoms of methemoglobinemia appear at
concentrations of about 20 per cent and death in dogs
occurs at levels of about 85 to 90 per cent. The exact
level at which coma and death supervene in man is not
known.
Under ordinary circumstances the red cell energetically
reduces methemoglobin by an enzymatic process in which
glucose and lactate are the principal substrates. Clinical
states of methemoglobinemia can be caused either by
dysfunction of this reconversion mechanism or by the
action of oxidants which produce methemoglobin more
rapidly than the cell mechanism is able to reduce it.
Substances reported by Finch which act as oxidants pro-
ducing secondary methemoglobinemia are shown in
Table 2. Pediatric sources for these compounds include
laundry ink on diapers, color crayons, and contaminated
well-water used in preparing the formula.
Table 2
Amino and nitro compounds producing methemoglobinemia
Aromatic Drugs:
Aliphatic and Inorganic Drugs:
Aniline
Sodium nitrite
Anifinoethanol
Hydroxylamine
Phenacetin
Dimethylamine
Acetanilid
Nitroglycerin
Methylacetanilide
Amyl nitrite
Hydroxylacetanilide
Ethyl nitrite
Prontosil
Bismuth subnitrate
Sulfanilamide
Sulfapyridine
Sulfathiazole
Phenylenediamine
Aminophenol
Toluenediamine
Alphanaphylamine
Paraminopropiophenone
Phenylhydroxylamine
T olylhydroxylamine
Nitrobenzene
Dinitrobenzene
Trinitrotoluene
Nitrosobenzene
Paranitramline
Ammonium nitrate
By French.
In the treatment of methemoglobinemia, three mech-
anisms may be employed, namely, reconversion to hemo-
globin by reducing substances, the normal cell reconver-
sion mechanism or the catalysis of this normal process.
Ascorbic acid and glutathione are effective as reduc-
ing agents although ascorbic acid only has been used
clinically. It is effective in the therapy of the primary
or congenital type of methemoglobinemia in dosage of
100 to 500 mg. a day. The action of ascorbic acid is
relatively slow.
Methylene blue acts faster and is the drug of choice
for treatment of secondary methemoglobinemia. It brings
about reversion of methemoglobin not by its own reduc-
tion capacity but through acceleration of the normal cell
reconversion mechanism. It is given in dosage of 1 mg.
methylene blue (as 1 per cent sterile solution) per kilo-
gram of body weight in adults and 2 mg. per kilogram
in infants. It is injected intravenously slowly over a
period of five minutes. If cyanosis has not disappeared
within an hour, a second dose of 2 mg. per kilogram
may be given again. Methylene blue may be given
orally in doses of 3 to 10 mg. per kilogram.
Methemoglobin itself is useful in combating cyanide
poisoning. Cyanide produces paralysis of tissue respira-
tion by combining with cytochromes. The toxicity of
cyanides is reduced by combination with methemoglobin
which is produced therapeutically. The cyanide has a
greater affinity for the methemoglobin than for the other
tissues. The usual therapeutic regime consists of 0.5
gram of sodium nitrite intravenously over 5 to 10 min-
utes to produce methemoglobin. Inhalation of amyl
nitrite is even more rapid and is used while waiting for
the preparation of the intravenous medication. Sodium
thiosulfate is also given intravenously in dosage of 10
to 25 grams as 25 per cent solution. This combines
with the cyanide to form thiocyanate, which is relatively
non-toxic and is excreted.
Salicylates
All the salicylates except phenyl salicylate cause the
same type of intoxication. Doses as small as 4 cc. of
methyl salicylate (oil of wintergreen) have been fatal
and the increased toxicity of this substance is attributed
to its relative retention in the body. A fatality has been
reported from skin absorption of salicylic acid oint-
ment.12
Symptoms of salicylism include hyperpnea, apathy and
lassitude, anorexia, tinnitus, convulsions, thirst, sweating,
hyperpyrexia, abdominal pain, pallor and cyanosis, epi-
staxis and hemorrhagic phenomena, dehydration, diffi-
culty in hearing, dimness of vision, mental confusion,
nausea, vomiting, diarrhea, skin lesions of many varieties
and death. Death usually results from respiratory failure
after a period of unconsciousness.13,14
Laboratory findings include increased prothrombin and
coagulation time and an elevated blood chloride level;
reduction of copper by salicylate in urine; positive Ger-
hard’s test, acetone, diacetic acid, albumin, casts white
and red cells in the urine; salicylate blood levels over
158
The Journal-Lancet
32 mg. and commonly over 40 mg. per cent. The pH
of the blood is initially elevated, later the pH may be
reduced and the carbon dioxide combining power is nor-
mal or decreased.
The mechanism of salicylate intoxication in cases other
than drug idiosyncrasy is generally explained on the basis
of hyperventilation or hyperpnea due to a direct stimu-
lation of the respiratory center by the salicylate. Carbon
dioxide is blown off, causing a loss of blood CCL, a de-
crease in bicarbonate and a transient predominance of
base. This results in alkalosis with a high pH value
early. Later there is some compensation by increase in
serum chlorides and by gradual loss of base in the urine
so that an acidosis develops. High salicylate levels are
also supposed to increase muscle lactate and acid metabo-
lites contributing to acidosis.1'1
The treatment of acute intoxication in addition to re-
moving the unabsorbed salicylate by lavage and other
symptomatic therapy is aimed at correction of acid-base
balance. Obviously the best guide for therapy is close
observation of the pH and treatment with appropriate
electrolytes which by the time most patients are seen is
usually sodium lactate or sodium bicarbonate. If the
pH is not available the recommended therapy is adequate
amounts of 5 per cent glucose and normal saline. Since
much of the salicylate is excreted in the urine, treat-
ment is directed at increasing the urinary output.
Deficiencies of glycogen and thiamine are reported to
increase the sensitivity to intoxication, therefore glucose
and thiamine are probably indicated. Vitamin K is in
order for the correction of the hypoprothrombinemia.
Hemorrhagic tendencies are further combated by small
repeated whole-blood transfusions and vitamin C. Mor-
phine and barbiturates have been used to slow the res-
piratory rate and thus diminish loss of CCL from the
lungs.
Lye
The treatment of acute lye poisoning in children is
discussed in a recent report from Duke University.11’
The essential points of the treatment are as follows:
"Immediately after the ingestion of the alkali, an at-
tempt should be made to neutralize the corrosive sub-
stance with a weak acid, such as diluted vinegar, lemon
juice or orange juice. Removal of the caustic from the
stomach by lavage is probably needless because of the
neutralization of the alkali by gastric hydrochloric acid,
while the resulting trauma may be harmful. Visible
burns should be treated with an emollient such as olive
oil, and the patient given a sedative to relieve pain.
Liquids and soft foods may be given as tolerated. By
the fourth day a soft rubber, eyeless catheter filled with
mercury or small lead shot should be passed without
force into the stomach and allowed to remain in place
for 2 minutes. This procedure should be carried out
for every patient, unless the esophagus is seen by direct
illumination to be undamaged. In instances in which
there is doubt, oral burns from caustic should be consid-
ered presumptive evidence of esophageal burns and suf-
ficient indication for early esophageal dilations. The
dilations are repeated daily, with a gradual increase in
the size of the catheter and the period of dilation, until
by the tenth day a No. 30 to 34 French catheter is kept
down for five minutes. After daily dilations for two
weeks, the number of them is gradually decreased to
three a week for two weeks, two a week for one month,
one a week for one month, two a month for three
months, and one a month for six months and two or
three a year for several years. If increasing difficulty
is encountered during the course of treatment, daily dila-
tions are again performed. Also, fluoroscopic examina-
tion with barium sulfate or an esophagoscopic study is
advisable if difficulty is encountered.” Emetics are contra-
indicated.1 1
Kerosene
Steiner 18 has reviewed some of the literature on kero-
sene poisoning and reports 35 cases in children. He
divided his cases into three groups on the basis of sever-
ity and complications: (1) acute toxicity and depression
of the central nervous system with minimal pulmonary
changes and with rapid recovery; (2) severe pneumonia,
hyperpyrexia and prolonged recovery; and (3) severe
pneumonia with evidence of degenerative changes in the
myocardium, the liver, the kidney and the gastrointes-
tinal tract.
Treatment consisted of carefully performed gastric
lavage with copious amount of weak sodium bicarbonate
solution for the removal of the kerosene and the preven-
tion of further absorption and damage to the gastro-
intestinal mucosa. Nikethamide and/or caffeine were
used as stimulants. Penicillin was instituted early to pre-
vent bacterial pneumonia and hypertonic (50 per cent)
dextrose solution with oxygen seemed helpful in dimin-
ishing early pulmonary edema. Adequate fluids, blood
transfusions and digitalis were also used when indicated.
Emetics are contra-indicated.1 ‘
General Considerations
Arena summarizes the handling of emergencies due
to poisoning under seven steps.1 1
1-. Identify the poison as soon as possible so that spe-
cific measure may be promptly instituted.
2. Evacuation: Remove the bulk of the poison from
the stomach by
a. Gastric lavage.
b. emetic. Emetics are contra-indicated in kero-
sene and caustic alkali or if the patient is
semi-comatose.
3. Antidoting the residual poison not removed by gas-
tric lavage.
4. Antagonist when available.
5. Elimination from the system of the poison that has
been absorbed.
6. Symptomatic treatment as indicated.
7. When the nature of the poison is unknown give
the following universal antidote:
Pulverized charcoal (burnt toast) 2 parts
Tannic acid (strong tea) 1 part
Magnesium oxide (milk of magnesia) 1 part.
I should like to emphasize the importance of the
proper performance of gastric lavage. Kantor 111 and
Moller -° who systematically studied the problem, found
May, 1949
159
that with the use of relatively large amounts of fluid for
each washing, lavage frequently was ineffective and re-
sulted in the recovery of only a small amount of poison.
Also, lavage promoted passage of the poison into the
intestine and was only exceptionally effective when four
hours had elapsed after a poison had been taken and in
unconscious patients there was evidence of aspiration
into the pulmonary passages.
Gastric lavage should be performed with a relatively
large tube, to the proximal end of which can be fitted
an aspirating bulb (250 cc. size). The first step after
inserting the tube is complete aspiration of the stomach
contents by repeated aspirations. After evacuation is
complete, one begins the lavage proper by alternate in-
jecting of a bulbful of water and then aspirating, the
alternate injection and aspiration of bulbfuls being re-
peated until the returns are clear. The foot end of the
bed should be elevated, the head turned to one side and
an aspirator used to remove vomitus or other material
from the mouth.
In the 117 cases in this study, 95 were lavaged. Eleven
patients developed pneumonia following the ingestion of
the poison and 100 per cent of these patients had re-
ceived gastric lavage on admission. Undoubtedly some
of these cases of pneumonia were due to aspiration of
stomach contents during the lavage.
Summary
One hundred seventeen cases of acute poisoning in
children with six deaths are reviewed.
A resume of some recently emphasized poisons with
recommendations for therapy and the use of BAL are
presented.
The importance of the proper performance of gastric
lavage is emphasized.
References
1. Aikman, J.: Round Table Discussion, Pediatric Emer-
gencies. Pediatrics 2:209-221 (Aug.) 1948.
2. Hill, K. R., and Robinson, G.: Brit. M. J. 2:845-847
(Dec. 15) 1945.
3. Case, R. A. M.: Toxic Effects of 2,2 Bis (P-chlorphenyl)
I, 1,1-Trichlorethane (DDT) in Man. Brit. M. J. 2:842-845
(Dec. 15) 1945.
4. Smith, N. J.: Death Following Accidental Ingestion of
DDT. J A M. A. 136:469-471 (Feb. 14) 1948.
5. Smith, M. I., and Stohlman, E. F.: Further Studies on
the Pharmacologic Action of 2,2 Bis (P-chlorphenyl) 1,1,1-
Trichlorethane (DDT). Public Health Reports 60:289-301
(March 16) 1945.
6. Randall, R. V., and Seeler, A. O.: BAL. New Eng.
J. Med. 239:1004-1009 and 1040-1045, 1948.
7. Bivings, L., and Lewis, G.: Acrodynia: New Treatment
with BAL. J. Pediat. 32:63-65, 1948.
8. Elmore, S. E.: Ingestion of Mercury as a Probable Cause
of Acrodynia and Its Treatment with Dimercaprol (BAL):
Report of 2 Cases: Pediatrics 1:643-647, 1948.
9. Woody, N. C., and Kometani, J. T.: BAL in the Treat-
ment of Arsenic Ingestion of Children. Pediatrics 1:372-378,
1948.
10. Tye, M., and Siegel, J. M.: Prevention of Reaction to
BAL. J.A.M.A. 134:1477 (Aug.) 1947.
11. Finch, C. A.: Methemoglobinemia and Sulfhemoglo-
binemia. New Eng. J. Med. 239:470-478, 1948.
12. Gillespie, J. B., and Dukes, R. E.: Acetylsalicylic Acid
Poisoning with Recovery. Am. J. Dis. Child. 74:334-338, 1947
13. Hill, L. F., and Byrum, R. J.: Conference at Raymond
Blank Memorial Hospital for Children, Des Moines, Iowa; Sali-
cylate Intoxication. J. Pediat. 33:381-383 (Sept.) 1948.
14. Goodman, L., and Gilman, A.: The Pharmacological
Basis of Therapeutics. The Macmillan Co., New York, 1941.
15. Dubow, E., and Solomon, N. H.: Salicylate Tolerance
and Toxicity in Children. Pediatrics 1:495-504 (April) 1948.
16. Kernodle, G. W., Taylor, G., and Davison, W. C.: Lye
Poisoning in Children. Am. J. Dis. Child. 75:135-142 (Feb.)
1948.
17. Carver, G. M., Davison, W. C., Arena, J. M., Kernodle,
G. W., Taylor, H. M., and Berheim, F.: Conference at Duke
University, Clinic on Poisoning. J. Pediat. 32:207-214 (Feb.)
1948.
18. Steiner, M. M.: Syndromes of Kerosene Poisoning in
Children. Am. J. Dis. Child. 74:32-44 (July) 1947.
19. Kantor, J. L.: Gastric Lavage. J.A.M.A. 133:1238
(April) 1947.
20. Editorial: Value of Gastric Lavage in Treatment of
Acute Poisoning. J.A.M.A. 133:545-546 (Feb. 22) 1947.
OREGON ACADEMY OF OPHTHALMOLOGY AND OTOLARYNGOLOGY
The Tenth Annual Spring Postgraduate Convention in Ophthalmology and Otolaryn-
gology will be held in Portland, June 19-24, 1949. Another fine program has been arranged
by the Oregon Academy and the University of Oregon Medical School. They are particu-
larly fortunate in having four outstanding men in their respective fields as guest speakers.
Dr. Lawrence R. Boies, Professor of Otolaryngology at University of Minnesota Med-
ical School, Minneapolis.
Dr. Leland Hunnicutt, Associate Clinical Professor of Otolaryngology at University of
Southern California, Los Angeles.
Dr. James H. Allen, Professor of Ophthalmology at Iowa State University School of
Medicine, Iowa City.
Dr. Edmund B. Spaeth, Professor of Ophthalmology at Graduate School of Medicine,
University of Pennsylvania, Philadelphia.
There will be lectures, clinical demonstrations and ward rounds.
Preliminary programs will be out about May 1st and you may secure yours, and further
information, from Dr. David D. DeWeese, Secretary, 1216 S.W. Yamhill Street, Portland 5,
Oregon.
160
The Journal-Lancet
Ovarian Tumors in Infancy and Childhood
Tague C. Chisholm, M.D., and Oswald S. Wyatt, M.D.*
Minneapolis, Minnesota
Ovarian tumors are in no sense a disorder strictly
confined to adulthood for care by the gynecologist.
In children, in fact, they more frequently first come
under the care of the family physician or of the pediatri-
cian. During the past three years we have had the
unique privilege of assisting in the care of six separate
ovarian tumors which have occurred in children ranging
from four months to sixteen years of age. This small
series seems worthy of review in order to emphasize the
more common presenting symptoms, physical findings,
tumor-cell types and prognosis.
Figure I represents a comprehensive table of the gen-
eral types of ovarian tumors; those starred indicate the
ones which have occurred in our series. It is at once
apparent that we have met with only a few of the entire
group but these starred types are representative of the
most common ones seen in infancy and childhood, the
single exception which we have not encountered being
the feminizing granulosal cell carcinoma.
OVARIAN TUMORS
CYSTIC TYPE SOLID TYPE
benign:
benign:
*Follicular
Fibroma
*Paraovarian
Corpus luteal
Brenner
Germinal inclusion
malignant:
Endometrial
Non-functioning
*Dermoids
*Teratoma
Serous cystadenoma
*Sarcoma
Pseudomucinous
Dysgerminoma
cystadenoma
Functioning
MALIGNANT:
Granulosal cell
Serous cystadenocarcinoma
*Arrhenoblastoma
Pseudomucinous
Adrenal
cystadenocarcinoma
Thyroid
Figure 1. Schematic representation of the principal types of
ovarian tumors Those marked with an asterisk were encoun-
tered in the series reported here.
Over two hundred ovarian neoplasms have now been
reported in the pediatric literature. Approximately 60
per cent of these have been of the solid malignant va-
riety; about 20 per cent are dermoids; and about 20
per cent are simple cysts.
Cystic Tumors of the Ovary
Cysts of the ovary and paraoophoron structures have
been noted at birth, in early infancy and at all stages
of childhood. They have been detected as discrete ab-
*Clinical Professor of Surgery, University of Minnesota.
dominal masses on routine office examinations and they
have attracted attention (1) by intermittent lower ab-
dominal discomfort, (2) by progressive enlargement of
the abdomen and (3) by acute episodes of severe ab-
dominal pain resulting from torsion of the pedicle. Gen-
eral abdominal and rectal examinations reveal a cystic
mass which is usually non-tender but which may be
quite tender if it is twisted and infarcted. Simple cysts
contain a clear amber fluid and dermoids contain hair,
sebaceous material, teeth and other ectodermal elements.
Teeth and bone, when present, can usually be detected
roentgenologically.
Case Reports
1. Paraovarian Cyst: B. B. was a 4-month-old female
infant who had a right lower quadrant mass palpated on
a routine office visit. There had been no symptoms. Phys-
ical examination revealed an egg-sized, round, moderately
firm, non-tender mass in the right lower quadrant of the
abdomen. Nothing was detectable upon rectal examina-
tion. Pyelograms were normal. At surgery a large, oval,
bluish-grey, translucent cyst was found at the lower end
of the right abdominal gutter. This proved to be a
paraovarian cyst which measured 15x10x10 cm. It was
removed without sacrifice of the normal tube and ovary.
Convalescence was uneventful.
2. Ovarian cyst: L. D. was a 13-year-old adolescent
girl who, two years before admission, had a mild attack
of right lower quadrant abdominal pain. At that time
her temperature and white blood count were normal.
The local physician thought she had an appendiceal ab-
scess. When Dr. Wyatt saw the child in consultation,
he felt she had a right lower quadrant cyst about 6 cm.
in diameter and recommended surgery which then was
not carried out. Menses had been entirely regular from
the age of 10 years. Twenty-four months later she was
brought to Minneapolis because of her embarrassment
over her enlarged abdomen. Now the cystic mass filled
the entire abdomen. Pyelograms were normal but a large
soft-tissue shadow filled the abdomen to above the um-
bilicus. By x-ray no fetal parts were seen. At surgery
a large, smooth-surfaced, thin-walled right ovarian cyst
was visualized, the pedicle of which was twisted 360
degrees. The tube was stretched and partially infarcted.
A right tube-oophorectomy was done. The specimen
weighed 14 pounds and measured 28x22x14 cm. Con-
valescence was uneventful.
3. Dermoid Cyst: A. N. was a 15-year-old female
who had suffered from vague abdominal discomfort for
two and a half weeks. Once during that time her tem-
perature spiked to 104° F. and she had one attack of
vomiting. Menses had been regular from the age of
May, 1949
161
13 years. Upon admission to the hospital she had left
lower quadrant and left vault tenderness. The white
blood count was normal. A flat film of the abdomen
showed two shadows in the pelvis consistent with teeth
(Fig. 2). At surgery a glistening, gray, smooth-walled
left ovarian tumor measuring 9x8x6 cm. was removed
together with its tube. This proved to be a dermoid con-
taining sebaceous material, hair and two teeth (Fig. 3).
Convalescence was uneventful.
Solid Tumors of the Ovary
Benign solid tumors of the ovary are extremely rare
in childhood. Of the malignant solid tumors many more
are non-functioning than are functioning. Of the for-
mer the teratomas are fortunately the most common;
generally they have slow local extension, late metastases
and infrequent recurrence. Sarcomas, on the other hand,
are quite rare, proliferate rapidly and metastasize early.
Of the functioning tumors the feminizing granulosal
cell type is the most common; a number of these have
been reported in the pediatric literature and they usually
exhibit enlarging breasts, fine pubic hair and premature
menstruation. Of the nearly 100 defeminizing arrheno-
blastomas now reported in the literature only eleven
have occurred in adolescent girls between 12 and 18
years of age; all have exhibited masculinizing signs in-
cluding amenorrhea, hirsutism, voice change, breast atro-
phy and hypertrophy of the clitoris. Between 10 and 14
per cent of these arrhenoblastomas have had metastases.
The clinical features of the solid ovarian tumors have
been those of an enlarging lower abdominal or pelvic
mass which may or may not be fixed. Pain is rare unless
torsion has occurred. Female sexual precocity, defem-
inization of the adolescent child and masculinization of
the female suggest endocrine dysfunctions consistent
with the appropriate ovarian tumor types, i. e., granu-
losal cell tumor, arrhenoblastomas and adrenal rests
within the ovary.
Case Reports
1. Ovarian Teratoma: K. B. was a 9-year-old female
who was sent to the hospital for intermittent, crampy,
lower abdominal pain of three days’ duration. For sev-
eral weeks the patient had been constipated but only
after the onset of acute pain did she have nausea with
vomiting. Physical examination revealed a small, hard,
oval, right vault mass which, on barium enema, com-
pressed the recto-sigmoid extrinsically. At surgery a solid
left ovarian tumor was readily removed sparing the fal-
lopian tube. This teratoid tumor measured 9x7x6 cm.
and contained sebaceous material, hair, bronchial struc-
tures and brain tissue. The follow-up, to date, had been
satisfactory although this has covered only two and
one-half years.
2. Ovarian Sarcoma: P. R. was a 5-year-old female
who was sent into the hospital for study. Three weeks
before admission she fell down and subsequently had
left pelvic pain which did not improve with two weeks
of bed rest. One week previously a non-painful swelling
occurred behind her left ear. Pelvic examination re-
Fig. 2.
Fig. 3.
vealed an orange-sized freely movable right adnexal mass.
Blood studies were normal. X-rays of the skull, chest,
pelvis and long bones were normal. At surgery the neck
node was biopsied but no tumor was found on frozen
section. After opening the abdomen both ovaries were
removed because they were involved with bilateral tu-
mors. Permanent sections showed that both ovarian
162
The Journal-Lancet
masses and the cervical node were all involved with rap-
idly growing sarcoma. The patient was dead in a very
few months.
3. Arrhenoblastoma: J. H. was a 16-year-old female
who was admitted to the hospital because of amenorrhea
of two years duration, deepening of her voice, atrophy
of the breasts, hirsutism of her face and chest, hyper-
trophy of the clitoris and an enlarging lower abdominal
mass. At surgery an enormous well-encapsulated left
tubo-ovarian tumor was removed which weighed 8.2
pounds and measured 20x20x15 cm. The original sec-
tions showed male testicular architecture consistent with
arrhenoblastoma. Convalescence was uneventful. Three
weeks later her menses were resumed, her voice went up
several notes higher, her breasts filled out again, the
hirsutism regressed and her clitoris slowly receded.
One year later her voice began to deepen again and
her clitoris enlarged to four times the normal size. At
re-exploration she had tumor implants removed from the
omentum, visceral and parietal peritoneum and the left
broad ligament. From this operation the tumor sections
show mostly striated skeletal muscle fibers. Final inter-
pretation of this tumor is still undeterminable: numer-
ous sections of the material removed at the first opera-
tion were entirely consistent with arrhenoblastoma while
those from the second operation are more suggestive of
malignant teratoma. No matter what it finally proves
to be, x-ray therapy has been carried out, the girl is
alive and well but the prognosis is poor.
Conclusions
Brief comments are made on the symptoms, signs,
pathology and prognosis in the more common types of
ovarian tumors in infancy and in childhood.
Six case reports are included on patients treated dur-
ing the past three years (Fig. 4).
Addendum:
Since this material was presented before the Northwest Pe-
diatric Society in October, 1948, we have had two additional
cases of dermoids of the ovary. One was in a five-year-old and
the other in an eight-year-old. Both tumors were easily re-
moved; convalescence was uncomplicated; and no evidence of
malignancy was found on microscopic examination.
No.
Age
Type of Growth
Side Affected
Size (cm.)
Weight
Operation
Follow-up
1.
4 months
Paraovarian cyst
Right
15x10x10
—
Excision of cyst
Excellent
2.
13 years
Simple cyst
Right
28x22x14
14 lbs.
Salpingo-oophorectomy
Excellent
3.
15 years
Dermoid
Left
9x8. 5x6
—
Oophorectomy
Excellent
4.
9 years
Teratoma
Left
9x7x6
—
Salpingo-oophorectomy
Excellent
5.
5 years
Sarcoma
Bilateral
7x5. 5x4
4. 5x3. 5x3
—
Bilateral
oophorectomy
Dead
6.
16 years ...
Arrhenoblastoma
Recurrent
Left
20x20x15
17x12x12
8.2 lbs.
Oophorectomy;
Excision of implants
Still alive
Figure 4. Summarizing chart of the six cases of ovarian tumors in infancy and children reported in this series.
DR. E. T. BELL TO BE HONORED
On June 15, 1949, Dr. E. T. Bell, Professor of Pathology, reaches the age of retirement
and will relinquish the chair. He has served the University since 1910, first teaching in
Anatomy, and from 1911 until the present time in the Department of Pathology. He was
appointed head of the department in 1921 and in this capacity has directed its activities in
the intervening years. Everyone who has had any contact with medicine in the Northwest
knows how profound his influence has been, not alone on teaching and research in pathology,
but on the practice of medicine, as a whole.
Many physicians and former students have brought to the Minnesota Medical Founda-
tion the request that a fund be established in Dr. Bell’s honor, to perpetuate in some measure
his influence as a teacher, investigator, and consultant.
As a result of these requests, an advisory committee was appointed and has recom-
mended the establishment of a fund of $100,000 to create and maintain for teaching and
research a Museum of Pathology in the Medical School, which will bear his name.
The Sponsoring Committee feels confident that there will be a gratifying response to
requests to his many friends and admirers for subscriptions to this fund. It has been suggest-
ed that contributions might range from $100 to $1,000 or higher in individual instances.
The Bell Fund will be launched at a dinner given in Dr. Bell’s honor at the Minnesota
Medical Association Meeting in May.
May, 1949
163
Some Problems in Dealing with Parents
William Fleeson, M.D.,* and Eric Kent Clarke, M.D.*
Minneapolis, Minnesota
This paper is concerned with the way in which a
Child Guidance Unit approaches parent-child rela-
tionships, particularly from a parent’s point of view.
Much has been written and said about the child’s point
of view and there is a growing mass of literature about
techniques for working with children. Too often, how-
ever, it has seemed to us that the parents are ignored or
dismissed with the statement: "Parental attitudes were
found to be faulty and were corrected.” One wonders
if it is really as simple as that. Does this statement
imply that there was really nothing wrong with the child;
are we saying it was all mother’s fault or father was
crabby? "Just stop being crabby and tired and irritated,
parents, and your children won’t develop behavior prob-
lems; they will stop biting their nails, their beds will be
dry, temper tantrums will cease, school marks will rise
and the little angels will love milk and eat all their
suppers — just give them a chance.” We see quite a
different picture in our office.
The statement "there are no problem children, only
problem parents” is often quoted. It seems to us that
this is only another way of saying "the sins of their
fathers shall be visited upon them, yea, even unto the
third and fourth generations.” As a reaction to these
moralistic concepts we, at least, prefer to subscribe to
minority reports such as that of Dorothy Baruch who
wrote an excellent book called Parents Can Be People.
It seems to us that parents do have rights, parents are
people, struggling, suffering, feeling persons who are,
more frequently than not, as disturbed and unhappy as
their children.
Our job in child guidance then is only half done if
we concentrate on the child to the exclusion of his par-
ents. The point of attack on the problem, as we see it,
is the relationship between the child and his parents.
This relationship may be difficult to evaluate at first but
usually can be pretty clearly defined in a few interviews.
For example, a mother and her ten-year-old son came to
us some time ago because of the mother’s concern over
the child’s extreme fears. In the course of a few inter-
views it became very clear that the mother, whose mar-
riage had always been unhappy, was attempting to get
emotional satisfactions, which she otherwise might have
obtained from her husband, from the ten-year-old. She
was, without being aware of it, exploiting the boy by-
expecting him to give her emotional support which he
did not have to give. In that relationship the boy was
trying to meet his mother’s emotional needs and the
parent was trying to make up for her own deprivations.
The emotional growth of both was hindered; the needs
of neither were satisfied. We were able to help these
^Minnesota Psychiatric Institute, Minneapolis.
people find satisfactions outside of their relationship so
that each became freer to give to the other and to de-
velop independently of one another.
This mother came to us saying, "I don’t know how to
handle my son’s fears. Tell me what to do.” This is the
most common problem which we have to face with par-
ents who come to us for help: "Tell me what to do.
I know that something is wrong with Joey and if you
can just tell me how to handle him, I am sure that every-
thing will be all right.” In other words, "Give me a
formula or rule book for rearing my children.” If such
a formula or rule book were only 75 per cent effective,
I am sure that it could be placed in ten million homes
next week.
Of course, it is flattering to us as professional people
to be asked for such advice. But it is equally obvious
that there is no pat answer. Advice is a treacherous
therapeutic approach. Even when we speak the literal
truth we may stir up anxieties instead of allaying fears
as we intend. For example, parents often ask for advice
on what to do about masturbation. You and I know
that it is the parents’ concern which makes this a prob-
lem in many instances. But the facts of puerile mastur-
bation are not acceptable to a large number of parents.
A mother told me recently, "Doctor So-and-So told me
that I shouldn’t worry if Jimmy plays with himself but,
Doctor, I can’t stand to have a child of mine do that
... it just makes me sick to my stomach every time
I see him do it ... I don’t know where he could have
picked up such a nasty habit.” To tell Mrs. S. not to
worry accomplishes nothing. Mrs. S.’s anxieties about
sexual matters, never under good control, have been mo-
bilized by her son’s interest in his sexual apparatus. And
so there is a very considerable tension between Jimmy
and his mother. Fde begins to resent and to react to the
constant surveillance; mother becomes more anxious.
She feels she can’t return to Doctor So-and-So because
she is being a "bad” parent by not following his advice.
Father has a talk with Jimmy but the habit continues
or is replaced by aggressiveness which mother is unable
to take and she may go to a child guidance clinic and
say, "Tell me what to do.”
The next most common problem in our experience is
that of the parent who feels guilty and depressed because
she is sure that she is to blame for the child’s misbe-
havior or his illness. In the same category is the very
defensive parent who has been sent unwillingly to us
for help and who seems to expect to be scolded or brow-
beaten into changing her method of handling her child.
Basically both the guilty and the defensive parent feel
intimidated and insecure. Both are unhappy with the
knowledge that they must seek help for problems which,
in their eyes, other parents handle as a matter of course.
164
The Journal-Lancet
By this time you may be saying, "Yes, yes, but what
do you do about it? We see these parents every day.
How do you help them?”
First of all, with the decision to seek help a parent
makes the first step towards change. By introducing
specialized help into the relationship between parent and
child, the parent indicates some capacity for growth and
a desire for change. With the first step there is some
relaxation of the tensions between mother and child.
Each relaxation of tension makes more relaxation pos-
sible and, ideally, there is eventual resolution of the im-
mediate problem as well as growing strength to be used
in handling problems which arise later. Dr. Spock speaks
of this as a descending spiral. Once in the office the par-
ent finds that though we will not tell her "what to do”
we can and will listen to her story sympathetically.
Though we have no formula we will help a parent to
find what is right for her to do based on her feelings
rather than on some theoretical standard. There are few
parents who really want to be told how to raise their
own children.
In an atmosphere of acceptance and understanding,
even very disturbed mothers and fathers can come to
understand and accept themselves. Previously repressed
"bad” feelings find their way to the surface once a par-
ent is sure that he or she will not be criticized for hav-
ing such feelings. With support from the therapist the
patient then can begin to deal with the "bad” feelings
instead of repressing them.
Some parents cannot admit any negative feelings for
their children, even to themselves. They seem to feel
that to do so would be a social and personal disgrace.
They keep repeating: "But I do love my child,” as if
they themselves doubted it. One such mother said, near
the end of treatment, "I was afraid to let myself be
angry because somehow I think I blamed Jerry for be-
ing sick so much. Now when I am cross with him, it
is because of something he has done, not because I
blame him for being born.”
A more difficult problem is one in which the child’s
symptoms of maladjustment are the result of long stand-
ing parental discord. The child is almost invariably
aware of the parents’ negative feelings for each other;
his awareness cannot but make him insecure and un-
happy. The parents’ views on rearing of children may
be quite divergent so that the child becomes confused as
to what is expected of him. In such instances it is im-
perative that the parents clarify and work through their
basic problem before the child can receive lasting benefit
from treatment. This may be a long and difficult job.
In families with several children the problem of sibling
rivalry can reach major proportions. Here parents can
be helped to understand how threatened the older child
becomes when a younger sibling appears. Both the older
and younger siblings need support if they are to acquire
the feelings of security and adequacy needed for them
to develoo the initiative for independent functioning as
individuals. Most of us underestimate the rapidity with
which children acquire the desire for independence. In
our efforts to provide protection we may erect so many
limitations that the child loses self-confidence or he may
react with rebellious and defiant attitudes towards the
restrictions designed to protect him.
When problems of sibling rivalry arise or when it is
obvious that the parent has not recognized the child’s
need for independence, there may be rapid improvement
as the parent acquires an understanding of the child’s
needs. Too often, this improvement in the child’s be-
havior comes before the parent recognizes any of the
deeper attitudes which are really basic to the problem.
They may discontinue their visits to the clinic, then
when a new facet of maladjustment appears, as it usually
does when the deeper problem remains untouched, the
parents may project onto the school, bad companions,
or the doctor. Other individuals may go on from a dis-
cussion of the parent-child relationship to psychiatric
treatment for problems unrelated to the matter which
brought them to the office. We must then be equipped
to go on with treatment which is no different from
usual psychiatric practice.
Sometimes we are asked to help parents accept the
fact that their child is permanently handicapped. This
may take as much time and skill as a difficult treatment
problem. Or we may be asked to see a parent who is
confused as to whether or not she should place her child
for adoption. For most mothers, giving up a child is a
difficult and painful experience, even though it is the
only feasible course open to them. Parents who adopt
children, as well as the children who are adopted, present
another special case. In all of these instances it is im-
portant to see clearly the relationship between parent
and child.
In summary, child guidance, as we see it, involves
guidance for parents also. In helping parents to unravel
their relationships with their children, it is not enough
to give advice. We must be prepared to work with dis-
turbed and unhappy children and their mothers and
fathers who may all be confused and suffering people.
May, 1949
165
Craniotabes
Robert B. Tudor, M.D.
Bismarck, North Dakota
Softening of the skull is known as craniotabes. It
occurs in newborns, particularly prematures, hydro-
cephalus, osteogenesis imperfecta, and in rachitic infants.
According to the generally accepted view, the under-
lying metabolic disorder in rickets caused by vitamin D
deficiency is an inability to maintain and stabilize the
levels of calcium and inorganic phosphorus in the blood
serum which results in defective calcification of the
bones. During the first eight months of life, the skull
bears the brunt of the attack. It grows with great rapid-
ity at this time. The stress caused by the recumbent
posture is almost continuously applied. Rachitic cranio-
tabes is rarely present before the third month and tends
to be localized in the parietal or occipital bones in the
vicinity of the lambdoidal suture.1 Most cases of cranio-
tabes after the fourth month are due to rickets sup-
posedly. It is important to recognize this early sign be-
fore other rachitic deformities develop. Changes in con-
centration of serum calcium, phosphorus, and alkaline
phosphatase are the earliest manifestations of rickets and
will antedate x-ray changes in the long bones.
In Table 1 are the blood chemistries of four normal
children.* In Table 2 are the blood chemistries of six-
teen children with craniotabes only. In Table 3 are the
* All the children in this study were Negroes.
Table 1
Age
Calcium
Mg. %
Phosphorus
Mg. %
Alkaline
Phosphatase
Bodansky
Units
Total Serum
Protein
Gm. %
1 yr. 2 mos.
11.7
7.2
12.0
7.6
1 1 mos.
10.2
6.0
14.4
6.7
1 1 mos.
10.9
7.6
11.2
6.6
9 mos.
11.6
5.9
8.9
6.1
Table 2
Age
Codliver Oil
Calcium
Phosphorus
Alkaline
Phosphatase
Total Serum
Protein
7 months
10 drops since 6 weeks
10.9
5.4
7.0
6.0
6 months
none
6 months
5 drops since birth
11.0
9.6
q.n.s.
7.4
5 months
1 teaspoon
11.0
7.6
7.6
5.5
8 months
2 tsp. till 6 months
10.6
5.6
15.2
cloudy
10.9
7.0
21.0
5.2
6 months
irregularly
10.2
4.8
11.4
5.4
8 months
2 tsp. irregularly
11.2
5.1
11.1
q.n.s.
4 months
10 drops irregularly
10.1
3.0
12.2
5.9
11.2
6.0
10.6
5.7
5 months
10 drops irregularly
11.3
6.0
10.4
6.1
5 months
10 drops started at 3 mos.
11.1
5.4
13.0
7.0
4 months
2 tsp. from birth
11.0
6.2
15.4
5.5
4 months
1 tsp. irregularly
11.8
6.0
21.2
6.0
5 months
2 tsp. since 1 week
11.4
6.0
13.2
6.0
5 months
12.6
5.8
19.0
5.6
Table 3
Age
Codliver Oil
Calcium
Phosphorus
Alkaline
Phosphatase
Total Serum
Protein
3 months*
no codliver oil
7.2
7.0
40.6
5.0
no orange-juice
5.5
5.6
31.4
6 months
no codliver oil
no orange-juice
9.9
3.0
75.0
6.5
5 months
10 drops codliver oil
irregularly
8.3
3.0
149.0
4.8
7 months
none
10.0
3.6
20.0
1 year
none
10.3
3.0.
21.0
5.8
*This patient had tetany with generalized convulsions.
166
The Journal-Lancet
blood chemistries of ten children with craniotabes and
x-ray evidence of rickets in the long bones.
In these sixteen children who had craniotabes without
other evidence of rickets at the time the chemistries were
drawn, the values for serum calcium, phosphorus, and
alkaline phosphatase invariably fell within the limits of
normal.
Summary
Chemistries of children under one year of age with
craniotabes as an isolated phenomenon were compared
with those of rachitic children and well children.
Bibliography
1. Holt and McIntosh: "Diseases of Infancy and Child-
hood,” Appleton Century, N. Y., 11th ed., 1940.
NORTH DAKOTA STATE MEDICAL ASSOCIATION
1949 ANNUAL MEETING
The Sixty-second Annual Meeting of the North Dakota State Medical Association, to-
gether with the Third Annual Meeting of the Woman’s Auxiliary, will be held in Minot,
North Dakota, May 14, 15, 16 and 17, 1949.
The House of Delegates will meet the evening of Saturday, May 14, and on Sunday,
May 15. The Scientific Program will be held on Monday and Tuesday, May 16 and 17,
in the Gold Room of the Clarence Parker Hotel, with the exhibits on display in the Saddle
Room of the Hotel.
The Northwest District Medical Society is in charge of all local arrangements. Local
committees have been appointed and plans are being made for an even larger attendance
than in past years. Reservation cards will be forwarded all members of the Association well
in advance.
Plans for the Third Annual Meeting of the Woman’s Auxiliary are under the super-
vision of the General Chairman, Mrs. J. L. Devine, Jr., Minot, North Dakota.
American College Health Association News
The annual meeting of the American College Health
Association will be held at the Henry Hudson Hotel,
353 West 57th Street, New York 19, New York, on
December 29-30, 1949. Hosts for the meeting will be
New York University, represented by Dr. J. E. Saw-
hill, and Columbia University, represented by Dr. C. R.
Wise.
Dr. William G. Beadenkopf will assume the director-
ship of Chicago University Student Health Service
beginning July 1, 1949. Dr. Clayton G. Loosli is leav-
ing this position to become Head of Preventive Medi-
cine in the Department of Medicine at the University.
Copies of A Health Program for Colleges, a report
of the Third National Conference on Health in Col-
leges, may be procured from Dr. L. W. Holden, director,
Student Health Service, University of Colorado, Boul-
der, Colorado, at $1.25 each, including postage. This
report is out in book form and should be in every stu-
dent health service and college library.
The American College Health Association welcomes
the following institutions into its organization:
Colorado Agricultural & Mechanical College, Duane
Hartshorn, M.D., Ft. Collins, Colorado.
Cornell College, Marian A. Van Fossen, R.N., Mt.
Vernon, Iowa.
Eastern Illinois State College, Charles L. Maxwell,
M.D., Charleston, Illinois.
Fort Hays, Kansas State College, R. B. Michener,
M.D., Hays, Kansas.
Illinois Institute of Technology, Charles J. Smith,
M.D., Chicago, Illinois.
Loyola University of Los Angeles, Carl G. Kadner,
M.D., Los Angeles, California.
Otterbein College, Dale E. Putman, M.D., Wester-
ville, Ohio.
Union Theological Seminary, Howard W. Brown,
M.D., New York, New York.
University of Western Ontario, Helen N. Rossiter,
London, Ontario, Canada.
Since the March issue of the Journal-Lancet, the
American College Health Association has received no-
tice of the following college health service position:
Director of Health Service, full time, for University
of Maine. Physician with administrative as well as pro-
fessional skill is needed to handle administrative matters
pertaining to the Health Service and to supervise work
of seven nurses and various other employees. The Health
Service includes examinations, preventive measures, clinic
and dispensary services, infirmary care, etc. Student body
numbers 4,000 and is co-educational. Write: E. E.
Wieman, Chairman, Faculty Committee on Student
Health, University of Maine, Orono, Maine.
Each month the American College Health Association
will list new vacancies as they are received. Any infor-
mation concerning positions or applicants may be for-
warded to the A.C.H.A., Dr. Edith M. Lindsay, Secre-
tary-Treasurer, School of Public Health, University of
California, Berkeley 4, California.
May, 1949
167
Diphtheria Trends in Minnesota
Sheldon C. Siegel, M.D.*
Minneapolis, Minnesota
Until recently there had been a progressive decrease
in the incidence and mortality rate of diphtheria
in the English-speaking countries and in Europe. In
1947 a new all-time low diphtheria death rate, 0.53
deaths per 100,000, had been reported in the large cities
of the United States.1 This special report concluded
that "diphtheria, like typhoid, continues to approach the
vanishing point."
Despite the fact that diphtheria is not the great prob-
lem it was a few years ago, the disease has, by no
means, been eradicated, nor have all of the perplexing
questions concerning it been solved. An illustration of
this fact is the increase in number of diphtheria cases in
the state of Minnesota since 1942. Some idea of the
magnitude of the incidence and mortality of this pre-
ventable disease may be obtained from Table 1, showing
reported cases and deaths from diphtheria and polio-
myelitis in Minnesota for the ten year period from 1937
to 1947. 2
Table 1
Year
Diphtheria
Cases Deaths
Poliom
Cases
yelitis
Deaths
1937 ..
*364
13
354
50
1938
*286
*12
48
10
1939
188
11
563
53
1940
122
6
258
26
1941
129
7
296
35
1942
.. *139
*12
81
6
1943
*375
*20
160
10
1944
_____ 508
16
534
37
1945
*476
22
235
27
1946
764
43
2,881
221
1947
*499
*20
176
19
Total
3,840
182
5,586
494
^Indicates the morbidity or mortality of diphtheria exceeded
that of poliomyelitis.
Surprisingly enough, one can see that the actual inci-
dence of diphtheria was greater than the incidence of
poilomyelitis in six of the ten years. The number of
deaths from diphtheria surpassed those from poliomyeli-
tis in four of the ten years. If 1946 had the usual num-
ber of poliomyelitis cases, or say, 1000 instead of an epi-
demic number of 2,881, the number of diphtheria cases
for that ten year period would have been greater than
the total number of poliomyelitis cases.
Because diphtheria is far from the vanishing point in
Minnesota, it was thought worthwhile to review all of
the cases of diphtheria that had been hospitalized at the
Minneapolis General Hospital from 1937 to 1947, with
*From the Department of Pediatrics of the University of
Minnesota Medical School.
the hope of learning where the medical profession might
have failed in preventing this disease.
Some of the findings from this review of 210 bacterio-
logically proved cases of diphtheria will be presented,
particularly in regard to age incidence and immunization
records. Later in the discussion some literature pertinent
to the immunization of the young infant, the older child,
and the young adult, will be reviewed.
Not only has there been a change in the actual inci-
dence of diphtheria, but there have been a great many
reports in the literature which show that there has been
a shift in the age incidence of diphtheria throughout
the world. In most places the shift has been from the
pre-school age to the school-age group. In other areas,
however, the shift has been to older age groups. In
reviewing the age incidence of diphtheria during an
epidemic in Canada, Gibbons 1 stated that 45 per cent
of their cases occurred in persons over 15 years of age.
Similar types of age incidence have been reported by
Walker 1 in Germany, Ipsen •’ in Denmark, Russel
in England, and Galperin ' and Geiger 8 in this country.
Fleming !l has shown that this same trend, that is,
a trend for adolescents and adults to become afflicted,
has occurred in our own state of Minnesota.
In the 210 Minneapolis General Hospital patients,
18.1 per cent (38) were in the 0-4 age group, 35.7 per
cent (75) in the 5-14 age group, and 46.2 per cent (97)
were 15 years of age or older.
Why has this shift in age incidence come about? A
multiplicity of factors were and are present in bringing
about this change. Probably three of the most impor-
tant of these factors are the following:
1. Diphtheria immunization in infancy has become
widespread;
2. As a result of widespread immunization, the inci-
dence of diphtheria and diphtheria carriers has been
reduced;
3. The decreased number of diphtheria cases and car-
riers has resulted in a lack of natural immunity.
Since immunity to diphtheria wanes with the passage
of time, the older the individual gets, the more suscep-
tible he is to diphtheria. In the past, when diphtheria
was rampant among the population, the older individ-
uals maintained their immunity by being exposed to fre-
quent small doses of diphtheria bacilli. Now, with rela-
tively little diphtheria prevalent in the community, one
has to depend on artificial immunization for immunity.
This is clearly shown by the numerous reports in the
literature of the increased number of Schick positive
adults.
Previously, only about 20 per cent of individuals over
20 years of age were Schick positive; whereas, now, ac-
cording to extensive surveys in the English speaking
168
The Journal-Lancet
countries, 40 to 80 per cent of individuals over 20 years
are positive.10 Diehl 11 and Boynton 12 found in Uni-
versity of Minnesota students, 52 per cent and 63.6
per cent positive Schick tests respectively. The latter
study consisted of 34,244 students who were Schick
tested.
Another factor that has been considered important in
this age shift by other writers is the virulence of the
organism. McLeod 11 in his extensive review of the lit-
erature on the three types of diphtheria — gravis, inter-
midius, and mitis — pointed out that with the appearance
of the more toxic forms of diphtheria in Central Europe,
there was a coincident rise in age incidence. He attrib-
uted the latter partly to the introduction of the gravis
strains.
An additional explanation given by Cheeseman,14 et
al, on the basis of a statistical study, was that due to the
falling birth rate and general amelioration of social con-
ditions, there was decreased congestion of the population.
This in turn, they argued, led to fewer exposures in
childhood, and hence a larger proportion of susceptible
children in schools.
With this increase in age incidence, increased suscep-
tibility of older individuals, and the loss of artificial
immunity with the passage of time, the control of diph-
theria must be concerned not only with a wider age
group than previously, but also with the necessity of
maintaining immunity once it has been established.
That immunization is effective in helping to control
diphtheria can no longer be questioned. McKinnon,1'’
Gibbons,3 Schulze,11’ Glover,1’ and other authors have
shown that the incidence of diphtheria among immu-
nized individuals averages about 10 to 15 per cent of
that among non-immunized controls. Furthermore, the
remarkable reduction in case and death rates in this
country can undoubtedly be related to the increase in
diphtheria immunization. Moreover, Gibbard,ls Fan-
ning,19 Mortensen,20 Ipsen,21 and many others have
shown that diphtheria is much milder in the immunized
person.
The records at the Minneapolis General Hospital ap-
proximately conform to what these other authors have
reported in the literature (see Figure 1). Of the 210
cases, 118 (56.2 per cent) gave a history of having no
immunizations; 26 (12.4 per cent) gave a history of one
or more inoculations for diphtheria at intervals varying
from one month to twenty-one years prior to admission
to the hospital; and 5 (2.3 per cent) gave a history of
having had diphtheria some years before. The charts of
61 (29.1 per cent) patients contained no information of
immunization. It was interesting to note that 10 patients
had been in the Army or Navy and had received the
routine immunizations which did not include immuniza-
tion against diphtheria.
The cases were further divided into immunized and
non-immunized and compared on the basis of severity.
All patients who died, had tracheotomies, or were placed
on critical by the staff, were considered severe. The dif-
ferentiation of moderate and mild was based on the his-
tory and condition of the patient. Figure 2 illustrates
that the immunized group had a milder diphtheria and
Fig. 2. Immunization Record, 210 Cases.
that all the deaths occurred in the non-immunized group.
It is evident from the above figures that it is largely
the lack of immunization rather than defects in the type
of immuinzation that still gives rise to diphtheria cases
and deaths. And in some instances, it was the erroneous
beliefs of some physicians that all adults are immune
or that children maintain their immunity after once be-
ing immunized, that kept the patient from being im-
munized. In other instances, it was the fear of severe
reactions that was responsible for the seeming negligence.
Immunization in infancy, and the subsequent booster
doses prior to entry to school rarely give any severe
reactions, and mass immunizations can be carried out
without much thought to hypersensitiveness. It is the im-
munization of the older child, adolescent, and adult that
gives rise to relatively frequent reactions. Many of these
reactions can be avoided if only Schick positive individ-
uals are inoculated; when the Schick control consists of
a Moloney test (the test consists of injecting intracutane-
ously 0.1 cc. of a 1:20 dilution of the toxoid to be
used “) , and when very small doses of toxoid are used
in positive Moloney reactors.23
The experience at the University of Minnesota Health
Service has been somewhat different than that reported
in other parts of the world. In recent years, in immuniz-
ing university students, the Moloney test control has
been discontinued and all Schick positive students receive
a full dose of 1 cc. of alum precipitated toxoid with a
repeat dose of 1 cc. two months later. On this regime,
about 5 to 10 per cent of the subjects have systemic re-
actions of moderate severity, about 35 per cent report
May, 1949
169
swelling of their arms and 5 to 10 per cent subjectively
complain of severe redness and soreness at the injection
site. None of the several thousand students immunized
required hospitalization because of a reaction to the tox-
oid.J4
Though the above regime seems practical in mass im-
munization of young adults, the number of reactions
probably could be reduced if smaller doses or no im-
munizations were given in hypersensitive individuals.
Wishart, et al.,*'1 Leete,21’ Edsall,2’ and very recently,
Pappenheimer and Lawrence 2S have shown that there is
a high degree of correlation between severity of reaction
and the degree of immunity present, so that one can
safely leave the Moloney positive reactions without any
further stimulation. Furthermore, individuals who are
hypersensitive or have received primary immunization
usually develop a very high antitoxin titer when they re-
ceive minute booster dose stimulation.20 Therefore, the
Schick test and the Moloney test given to a sensitive
individual or one who has been previously immunized
will generally convert him to a Schick negative or im-
mune state, and no further immunizations are necessary.
Although reactions in infancy are rare, the problem of
when to begin immunization is still a controversial sub-
ject. With the decline of immunity in adults, there has
naturally been an increased number of newborns who do
not have a passive immunity from their mothers. This
has been shown by such studies by Vogelsang and Kry-
vi,"° who found 60 per cent of the newborns tested were
Schick positive. Fdowever, if one waits the customary six
months before immunizing, there is a long period in
which the child is susceptible to diphtheria. One partial
answer to this problem has been the antenatal immuniza-
tion of the mothers as suggested by Liebling and
Schmitz, ’1 and Cohen and Scadron/’2
Another possible answer came with the introduction
by Sako 33 of early immunization for pertussis with an
alum precipitated vaccine. Previously it had been be-
lieved that infants were poor antibody formers and that
the passive immunity inhibited antigen activity; there-
fore, immunization was usually deferred until about six
months of life. Sako and subsequent papers, including
one by Adams et al.,34 at the University of Minnesota,
proved that infants could form antibodies. Fdowever, in
a very recent paper, Cooke and his co-workers 35 found
that passive immunity interfered with active immuniza-
tion in diphtheria, especially in the first three months of
life. In the three to six months age period, only 10 in-
fants who had a passive immunity were studied, and cer-
tainly a larger study will have to be done before definite
conclusions are drawn.
In contrast to Cooke’s paper, Sauer 3,> indicated in a
recent round-table discussion on immunization that im-
munity to diphtheria and pertussis could be obtained
after the third or fourth month of life by four monthly
doses of an alum-precipitated mixture of diphtheria tox-
oid and Fd. pertussis.
Table 2 represents a schedule of active immunization
that was recommended by the Committee on Immuniza-
tions, Chicago Pediatric Society.3’ Three alternative
plans using triple or double antigens were recommended.
Until further studies are done to confirm or disprove
the work of Cooke, et al., or Sauer’s work, or unless
the mother or newborn is known to be Schick positive,
Plans B or C are preferable. In the ten year period re-
viewed, only one infant out of the 210 patients hospi-
talized at Minneapolis General Hospital was under one
year of age. This would further suggest that routine
immunization for diphtheria before six months of age
might not be necessary except under special circum-
stances, e. g., when older siblings or the parents have
been exposed.
In addition to the above program for young children,
children around twelve years of age should be Schick
tested, and the positive reactors given booster doses or
Table 2
Schedule of Active Immunization
(Three available alternatives)
A
B
c
Triple antigen
Pertussin vaccine
3 months
(slow absorbing)*
(slow absorbing)
Triple antigen
Pertussin vaccine
4 months
(slow absorbing*
(slow absorbing)
5 months
”
”
Triple antigens f
6 months
(fluid or slow absorbing)
Diphtheria and tetanus
7 months
Smallpox vaccination
antigens
8 months
”
”
9 months
10 to 12 months
Smallpox vaccination
Smallpox vaccination
Booster dose triple antigen
Booster dose triple antigen Booster dose triple antigen
2 years
(fluid or slow absorbing)
(fluid or slow absorbing)
(fluid or slow absorbing)
A booster dose or
smallpox revaccination is recommended when a
previously immunized child is
presumably exposed to these diseases.
* Antigens that have been so modified as to be slow absorbins (e. g., alum-precipitated, aluminum hydroxide, etc.)
■[Starting at 6 months of age or later, monthly doses of the antigens (fluid or slow absorbing) , giving them singly or in combi-
nations— as diphtheria-pertussis, diphtheria-tetanus, or diphtheria-tetanus-pertussis.
170
The Journal-Lancet
a full course of injections if they were not previously
immunized. This should likewise be done to young
adults whenever they are in frequent association and
contact, e. g., colleges and the armed services. Also, all
individuals who are likely to come in contact with diph-
theria, e. g., doctors and nurses, should have frequent
checks as to their immune status. And, of course, when-
ever there is an outbreak of diphtheria or an exposure,
immunization or booster doses should be instituted at
once in all individuals concerned.
This last recommendation should be emphasized be-
cause 25 of the 210 cases of diphtheria at the Minne-
apolis General Hospital could have been prevented or
at least modified, had immunizations been started as
soon as the exposure was known.
In all of the above immunizations, alum precipitated
toxoid or other purified concentrates are preferred, and
the injections should be at least one month apart. The
dosage, though usually 1 cc., varies with the product
used.
Summary
Two hundred and ten cases of diphtheria from the
contagious service of the Minneapolis General Hospital
are reviewed in regard to their age incidence and im-
munization history.
In addition, it is pointed out that diphtheria has shift-
ed to an older age group, and that many young adults
and newborns are susceptible to the disease, primarily
because of a lack of natural immunity. Hence, an im-
munization program covering a wider age group with
occasional booster dosages is necessary. Some recom-
mendations are given in regard to approved immuniza-
tion procedures.
Bibliography
1. Special articles, Diphtheria Mortality in Large Cities of
the United States in 1947, Twenty-third report; J.A.M.A.
137:1525, 1948.
2. Reported cases and deaths, 1910-1947, Minnesota De-
partment of Health, Section of Preventable Diseases.
3. Gibbons, R. J.: Diphtheria among Schick Negative Per-
sons in Halifax, Nova Scotia, Canada, J. Pub. Health, 36:341,
1945.
4. Walker, J. V.: Age and Sex Distribution of Diphtheria
in Oldenburg, Germany. Lancet, 252:422, 1947.
5. Ipsen, J : The Copenhagen Diphtheria Epidemic, 1943-
1945, Epid. Inform. Bull. U.N.R.R.A., 2:369, 1946.
6. Russell, W. T.: The Epidemiology of Diphtheria Dur-
ing the Last Forty Years, Privy Council, Medical Research
Council, Special Report Series No. 247, 1943.
7. Gelperin, A.: A Shift in the Age Incidence of Diph-
theria Morbidity, J. Med., 21:371, 1940.
8. Geiger, J. C. : Changing Trends in Diphtheria in San
Francisco, Arch. Ped., 62:510, 1945.
9. Fleming, D. S.: Diphtheria in Minnesota, J. Lancet,
67:32, 1947.
10. Goldsworthy, N. E., and Wilson, H.: The Schick Test
in Young Adults, M. J. Australia, 30:349, 1943.
11 Diehl, H. S.: Results of the Schick Test at the Univer-
sity of Minnesota, Minn. Med., 9:518, 1926.
12. Boynton, R. E., and Ellis, R. V.: Immunization of Col-
lege Students, Staff Meeting Bulletin Hospitals of the U. of
Minn., 12:120, 1940.
13. McLeod, J. W.: The Types Mitis, Intermedius, and
Gravis of Corynebacterium Diphtherial, Bact. Reviews 7:1, 1943.
14. Cheeseman, E. A., Martin, W. J., and Russell, W. T.:
Diphtheria, a Suggested Explanation of the Relative Change
in Age Incidence. J. Hyg. 39:181, 1939.
15. McKinnon, N. E., and Ross, M. A.: Reduction of Diph-
theria Following Three Doses of Toxoid: Further Observations,
J.A.M.A., 105:1325, 1935.
16. Schulze, H. A.: Schick Testing and Diphtheria Immuni-
zation of United States Troops in Europe, Am. J. Pub. Health,
38:1527, 1948.
17. Glover, B. T. J : Diphtheria in Inoculated Persons,
Lancet, 2:133, 1942.
18. Gibbard, J., Bynoe, E. T., and Gibbons, R. J.: Some
Observations on Diphtheria in Immunized, Canad. J. Pub.
Health, 36:188, 1945.
19. Fanning, J.: An Outbreak of Diphtheria in a Highly
Immunized Community, Brit. M. J., 1:371, No. 4498, 1947.
20. Mortensen, V.: On the Occurrence of Diphtheria Dur-
ing Recent Years with Special Reference to the Influence of
Anti-Diphtheria Vaccination. Ugesk. f. laeger, 108:629, 1946.
21. Ipsen, J.: Circulating Antitoxin at the Onset of Diph-
theria in 425 Patients, J. of Immunol., 54:325, 1946.
22. Moloney, P. J.: The Preparation and Testing of Diph-
theria Toxins (Anatoxine-Ramon) , Am. J. Pub. Health,
16:1208, 1926.
23. Bunch, C. P., Morrow, R. C., Timmons, J. R., and
Smith, D. T.: Studies on Immunization of Adults with Diph-
theric Toxoid, J. Immunol., 39:427, 1940.
24. Boynton, R. E.: Personal Communication, Results to be
Published.
25. Wishart, F. O , Waters, G. G., and Horner, C. M.:
The Rapidity of Antitoxin Response to a Recall Dose of Diph-
theria Toxoid, Canadian J. Pub. Health, 35:276, 1944.
26. Leete, H. M.: Diphtheria Immunization of Adults,
Brit. M. J. 2:121, 1942.
27. Edsall, G.: Active Immunization, New England J. Med.
235:256, 1946.
28. Pappenheimer, A. M., and Lawrence, S. H.: Immuniza-
tion of Adults with Diphtheria Toxoid, III, Highly Purified
Toxoid as an Immunizing Agent. Am. J. Hyg. 47:241, No. 2,
1948.
29. Wishart, F. O., and Reid, M. R.: A Study of Diph-
theria Antitoxin Response to Recall Doses of Specific Antigen,
Canadian J. Pub. Health, 38:131, No. 3, 1947.
30 Vogelsang, T. M., and Kyrvi, B. O.: Schick Reactions
in Recently Confined Women and Their New-born Infants,
J. Hygiene, 44:437, 1946.
31. Liebling, J., and Schmitz, H. E.: Protection of Infant
Against Diphtheria During First Year of Life Following Active
Immunization of Pregnant Mothers, J. Ped., 23:430, 1943.
32. Cohen, P., and Scadron, S. J.: The Placental Trans-
mission of Protective Antibodies Against Whooping Cough by
Inoculation of the Pregnant Mother, J.A.M.A., 121:656, 1943.
33. Sako, W., Treuting, W. L., Witt, D. B., and Nichamin,
S. J.: Early Immunization Against Pertussis with Alum Pre-
cipitated Vaccine, J.A.M.A., 127:379, 1945.
34. Adams, J. M., Kimball, A. C., Adams, F. H.: Early
Immunization Against Pertussis, Am. J. Dis. Child., 74:10,
1947.
35. Cooke, J. V., Holowach, J. Atkins, J. E., Powers, J. R.:
Antibody Formation in Early Infancy Against Diphtheria and
Tetanus Toxoids, J. Ped. 33:141, 1948.
36. Sauer, L. W.: Round-table Discussion, Practical and Im-
munologic Aspects of Pediatric Immunizations, Pediatrics,
2:722, 1948.
37. Report of Committee on Immunization of the Chicago
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No. 6, 1948.
May, 1949
171
Late Rickets -with Moderate Vitamin D Resistance*
Douglas T. Lindsay, M.D.
Minneapolis, Minnesota
The term "late rickets” has been given a variety of
meanings by various authors, depending upon classi-
fications according to etiology, pathology, metabolic
alterations, or age of the patient. In 1909, Schmorl,1
from pathologic studies of cases of florid rickets, stated
that under the conception of late rickets are to be in-
cluded . . . "not only those cases in which the disease
began in the earlier growth periods but never disap-
peared— persistent rickets — but also those cases in which
rickets developed for the first time in later periods of
growth — late rickets in the narrower sense.” He placed
the onset of late rickets at age four years, the time when
infantile rickets had statistically declined. More recently,
late rickets has been subdivided according to etiology.
Shelling and Hopper 2 have listed five divisions: per-
sistent infantile rickets, recurrent rickets, true late rickets
(juvenile osteomalacia), celiac rickets, and renal rickets.
To these groups have been added cases of rickets re-
sistant to ordinary doses of vitamin D,3,4,0,6, ' ,8 and
cases associated with more profound metabolic aberra-
tions. At the present time, a variety of causes must be
considered when a child past infancy is encountered who
shows clinical manifestations of rachitic activity. Boyd
and Stearns 9 have well stated that "the etiologic classifi-
cation of late rickets is not simple, nor can it be made
on the basis of casual or laboratory observations. Only
through familiarity with the causative mechanism in each
individual patient can therapeutic measures be directed
into channels of maximum efficacy.”
There are several conditions seen in children which
have as components clinical features resembling true
rickets. Perhaps the best known is renal rickets with
renal insufficiency, retention of nitrogen and phosphorus,
and compensatory depression of the serum calcium.
Marked growth retardation is commonly seen, but ra-
chitic deformities are less prominent. There is secon-
dary parathyroid hyperplasia in response to the low cal-
cium level, a factor which has prompted the name of
renal hyperparathyroidism10 for this condition. Fanconi'
has called attention to a syndrome of rickets associated
with renal glycosuria, polyuria, and mild acidosis. Boyd
and Stearns y reported three cases resembling the Fan-
coni syndrome, but with chronic bronchitis, or hepatic
impairment in addition. They found no evidence that
these children were vitamin resistant. The necessity of
differentiating between vitamin D resistant rickets and
hyperparathyroidism was noted by Highman and Hamil-
ton11 in reporting a case of "intractable rickets” before
the advent of massive vitamin D therapy. It is also rec-
ognized that a certain degree of overactivity of the para-
*Read before Northwest Pediatric Society at Bayport, Minn.,
September 1948.
thyroids is probably present in all cases of active rickets,
a response to the low level of the serum calcium.12
Lastly, we must recall the clinical group of cases with
disturbed epiphyseal growth, children with dyschondro-
plasia of several types. It is too easy to make this diag-
nosis on superficial physical examination in an older
child, without seriously considering the possibility of the
etiology being something for which there is specific
therapy: vitamin D resistant rickets.
The concept of "resistance” to vitamin D as a specific
clinical entity has developed with knowledge of the vari-
ous forms of the vitamin, activated ergosterol derivatives,
the "calcinosefaktor” of Holtz and Schreiber1'5 and studies
of the relative methods of action of vitamin D,12’14
dihydrotachysterol,1'1,1'’ and parathyroid hormone.14
This is not the place to review the tremendous literature
pertaining to the relative antirachitic and "calcemic prin-
ciple” in the activity of the preparations mentioned. Such
work has been well summarized elsewhere.5’1 4,1 When
the various vitamin D preparations were being clinically
standardized fifteen years ago, it was realized that cer-
tain cases of rickets required much larger therapeutic
doses than others, for no apparent reason.
Stearns and Boyd 10 in 1931 reported two cases of
late rickets which healed only after giving 60 drops of
viosterol daily. In that same year, Hess 1 ' reported a
5-year-old child which required 200 drops of viosterol
daily before evidence of healing of his rickets could be
demonstrated. This patient was given 1,600 drops daily
for therapy with no ill effects. Jampolis and Londe 1
pointed out "the need of larger doses of viosterol in
severe rickets” in a report of two brothers who required
20 cc. (600 drops) of viosterol daily before radiographic
reversal of the rachitic activity was accomplished. The
first report of a series of cases of late rickets successfully
treated by viosterol was by Shelling and Hopper.2 They
studied 23 children with late rickets, some of them pre-
vious therapeutic failures on codliver oil. Complete heal-
ing was accomplished by viosterol with a maximum dose
of 60 drops daily in every case except one which was lost
from the series. These authors stressed the value of
viosterol for the relative resistance of late cases because
of its high concentration of vitamin D.
As yet we have not mentioned cases of "refractory
rickets.” The term would suggest true rachitic activity
which did not respond clinically to even massive dosage
of vitamin D. Such was the intention of the name "in-
tractable rickets” as used by Highman and Hamilton.11
Several references in the German literature, 18,19,2° would
also fit into this group of cases, because the dosage given
did not control the rachitic process. Since the success of
Albright, Butler, and Bloomberg,4 in treating a "refrac-
172
The Journal-Lancet
tory” case with 1 /i million units of vitamin D daily,
other similar reports,5,6,8'10,21,22,23’24 have proven the
rationale of such massive therapy in the highly resistant
cases. To our knowledge, there have been no cases re-
ported which were truly refractory to "massive” therapy
as the term is now employed. At present it is more cor-
rect to speak of the relative resistance of the rachitic
activity to therapy with vitamin D concentrates.
The general features of resistant rickets have been de-
scribed by numerous authors, whose findings agree
closely. As with infantile rickets, the serum alkaline
phosphatase is elevated, the serum calcium low to nor-
mal, and the serum phosphorus always low. The serum
phosphatase does not return to normal until radiographic
evidence of healing is complete, being a reliable labora-
tory test of rachitic activity.4,25 The absorption of
vitamin D is not impaired, 4,6,9,25 blood levels in excess
of forty times normal having been observed in resistant
cases under intensive treatment. In contrast to cases of
infantile rickets, certain refractory cases tend to show
normal excretion of calcium and phosphorus in urine
and stools,4 even being in positive balance for these
elements during rachitic activity.11 Cases have been re-
ported 6 in which the above findings were not observed.
There is general agreement that the primary difference
in the resistant cases is merely their failure to respond
to the standard methods of treatment, their specific re-
sistance to the usual effects of vitamin D. A constantly
observed manifestation of this tendency is the persistent
low level of the serum phosphorus, even after radio-
graphic healing is complete. This is perhaps the distinc-
tive laboratory finding in highly resistant rickets. In
1931 Stearns and Boyd reported two cases 36 which
healed with persistent low serum phosphorus, positive
calcium and phosphorus balances, and a calcium-phos-
phorus-level product never above 35. Calcification was
noted with the Ca. x P. product as low as 22. Others
have since made similar observations.5,21,30 The original
successfully treated case of "refractory” rickets of Al-
bright, Butler, and Bloomberg has now been followed
since age 12 years until he was five years past cessation
of growth at last report.12 His serum phosphorus is
still low, having ranged between 1 and 3 mgm. per cent
during the period of observation. The massive dosage
of vitamin D was discontinued after the age of epi-
physeal closure, with no detriment to the patient’s clin-
ical condition. Gill 21 suggested that the vitamin resist-
ance stops when growth ceases, but Albright has found
that his first case must now be classified as adult osteo-
malacia, with low phosphorus and elevated serum phos-
phatase. The pathological physiology in these cases re-
mains unexplained. The problem has been clearly pre-
sented in "the fact that absorption of large amounts of
vitamin D by these patients was without effect on the
rickets indicates that vitamin D itself is ineffective as an
antirachitic factor. It is possible that this vitamin, like
carotene, must be converted in the body before it be-
comes biologically active, or that some other mechanism
is deficient.” 6
Clinical management of a case of vitamin resistant
rickets must be planned in reference to the possibility of
toxic manifestations resulting from dosage of vitamin D
in excess of the amount necessary to cause healing of
the rickets. It is recognized that doses which are not
curative, even though massive by the usual standards,
hold little possibility of causing the patient harm.2,5
In the modern refined preparations of calciferol (vios-
terol), any toxic effects encountered are due entirely to
excessive action of the therapeutic principle, rather than
some indirect acting "toxic factor” 13,14 The clinical
signs to be watched for, anorexia, nausea, vomiting,
diarrhea, headache, lassitude, polyuria, frequency, are
related to the ability of vitamin D to increase the serum
calcium by mobilizing it from the osseous stores, the
"calcemic principle.” Serum levels of calcium below
12 mgm. per cent will not give rise to signs of clinical
toxicity, such findings as albumin, calcium casts, or ery-
throcytes in the urine being encountered usually at the
higher levels. The qualitative urine calcium test of Sul-
kowitch 28 satisfactorily reflects the level of the serum
calcium, being strongly positive only when significant
elevations are present. In 1943 the Council on Phar-
macy and Chemistry of the American Medical Associa-
tion recognized the necessity for massive dosage in cases
of resistant rickets 29 and suggested a program of ther-
apy similar to that of Eliot and Park. The dosage of
vitamin D is to be doubled at intervals of three or four
weeks, studies of the serum calcium, phosphorus, and
alkaline phosphatase, as well as radiographic examina-
tion of the epiphyses to be made after each increase
before raising the dosage again. The urinary calcium
excretion and routine urinalysis should be noted at least
at weekly intervals during the period of increasing dos-
age. The usual adjuncts of adequate calcium and phos-
phorus in the diet, with supplementary ultraviolet radia-
tion, are still to be recommended. Such a program will
allow safe treatment of the most resistant case of rick-
ets, with full knowledge of the patient’s responses at
each step of the way.
Case History
G. N., female aged 8 years, was first seen at the
Shriners’ Hospital in February 1947 for bilateral genu
varus, pain in the knees and ankles, and short stature.
She was a normal infant, weighing 7 pounds 2 ounces
at birth. After nursing several weeks, a Dextri-Maltose
formula was prescribed. The infant disliked milk, but
always took 3 to 4 ounces per feeding. Orange juice
and 3 drops daily of viosterol were started at six weeks
of age. Until age 1 year, the dose of viosterol did not
exceed 5 drops per day. The child sat alone at 7 months,
cut her first tooth at 1 1 months, walked with support
at 19 months, at which time bowing of the legs was
definite. At age of 1 year the doctor stated definitely
that the child did not have rickets, in spite of marked
restlessness and profuse cold perspiration. She was given
15 drops of viosterol daily for some time, and then all
medication was discontinued. The child was first seen
by a pediatrician at age 5 years, radiographs taken, a
May, 1949
173
year of observation suggested, no medication prescribed.
At 6 years of age, surgical correction of genu varus was
recommended by the pediatrician, refused by the family.
The local physician prescribed 1 Multivitamin capsule
daily, increased to 2 capsules daily shortly before the
child appeared at the Shriners’ Hospital one and one-
half years later.
Other phases of the past medical history, systemic
review, and the family history were non-contributory.
The patient was referred as a case of disturbed epi-
physeal growth, possible achondroplasia or chondrodys-
plasia.
On physical examination the child was found to be
an 8-year-old white female in apparent excellent health,
but 6 inches shorter than average for her age. The find-
ings of clinical interest were definite fronto-parietal boss-
ing of the cranial plates, recent extraction of 1 1 decidu-
ous teeth because of decay, with the 13 remaining teeth
showing no rachitic stimata. The thorax showed visible
and palpable rachitic rosary. Heart and lungs were nor-
mal, blood pressure 94/ 56. There was mild diastasis of
rectus muscles, tonus good. Epiphyseal flaring was pal-
pable at wrists, knees, and ankles. The gross pathology
was in the lower extremities, with marked anterior and
lateral bowing of the femora, genu varus, bilateral in-
ternal tibial torsion of approximately 30 degrees, and
mild pes planus. The gait was markedly "rolling,” with
widenmg of the base. It was necessary to hold the hips
in full external rotation so as to overcome the natural
tendency to pigeon-toe gait. Patient complained of pain
in hips, knees, and ankles after moderate exercise. There
was no disproportion between relative length of vertebral
column and extremities.
Laboratory studies showed routine hemogram and uri-
nalysis normal. Serum calcium 10.0 mgm. per cent,
serum phosphorus 2.4 mgm. per cent, alkaline phos-
phatase 31.1 King-Armstrong units. Total serum pro-
teins were 5.9 gm. per cent. Other diagnostic tests were
considered normal, as follows: Kline and Kolmer nega-
tive, Mantoux negative, urine concentration to 1.029,
urine Sulkowitch negative, P.S.P. excretion 72.5 per
cent in one hour. Hanger’s cephalin-cholesterol floccula-
tion 0 in 24 and 48 hours, thymol turbidity 1.0 unit,
intravenous bromsulphthalein retention 7 per cent in
45 minutes, fecal fat 21 per cent of the dry matter
with dry matter 27 per cent of the total weight.
Radiographic studies on admission showed the gross
deformities noted above, plus retardation of bone age,
seven carpal centers being present. The epiphyseal re-
gions were flaring, cupped, osteoporotic, and had a defi-
nite moth-eaten appearance. The classic rachitic changes
are well demonstrated in the photographs (Fig. 1).
Initially the patient was placed on 1,000 units of
vitamin D daily. When the true nature of the patient’s
condition was established, she was given 7,000 units daily
of a concentrated vitamin D preparation for one month.
On thise regime definite radiographic evidence of heal-
ing at the epiphyses appeared, and the serum alkaline
phosphatase dropped from 31.1 to 20.7 K.-A. units.
Fig. 1. G. N., age 8 years, on admission. Epiphyses flar-
ing, osteoporotic, epiphyseal line indefinite.
With a slight reduction in the vitamin dosage (to 5,000
units daily, as viosterol) the phosphatase rose to 47.3
K.-A. units. Subsequently the dosage was stabilized at
2.0 cc. daily of viosterol (20,000 units vitamin D), an
amount which kept the phosphatase in the twenties, with
progressive radiographic healing of the rickets (Fig. 2).
During the course of observation in the hospital (13
Fig. 2. G. N., after four months on 20,000 units of vita-
min D daily. Closure of epiphyseo-metaphyseal gap, lines of
"growth arrest,” recalcification and clarification of epiphyses and
metaphyseal contours.
174
The Journal-Lancet
months), the serum calcium varied between 10.0 and
11.7 mgm. per cent, the phosphorus being always below
2.6 mgm. per cent (2.0 to 2.6) .
Six months after admission the patient underwent
bilateral tibial osteotomies, the correction being held with
long leg plasters. Due to the associated gross deformity
of a femora, a complete obliteration of genu varus defect
was not attempted at the tibial osteotomy sites. Post-
operatively the phosphatase rose to 60.2 K.-A. units as
osteoblastic activity developed at the osteotomy "fracture
callus.” Three months later it had fallen to 25 K.-A.
units with no change in vitamin dosage. The patient
was discharged seven months after surgery with com-
plete healing at the osteotomy sites. She was still taking
20,000 units vitamin D (viosterol) daily. The epiphyses
showed closure of the epiphyseo-metaphyseal gap, loss
of cupping and of the moth-eaten appearance. Mod-
erate flaring was still present.
Case History
D. C., female age 4 /i years, was first seen at the
Shriners’ Hospital for Crippled Children in November
1946 for severe bilateral genu varus and short stature.
The patient had weighed 5 pounds, 10 ounces at birth,
one month prematurely, the mother having been on pro-
phylactic calcium capsules for the first trimester, liver
and iron capsules the remainder of gestation. At six
weeks of age the baby was started on sunbaths, orange
juice, and Vi Delta codliver oil. She always took her
formula well and has enjoyed copious amounts of milk.
The infant was precocious, standing early, and walking
at age 10 months, by which time the bowleg deformity
was sufficiently evident to warrant medical advice. The
codliver oil concentrate was increased from 10 to 20
drops daily, more intensive sunbaths prescribed, and a
"tonic” given. Although the child’s health was radiant,
the deformity progressed. She cut her first tooth at 18
months. At age 23 months treatment was undertaken
by an orthopedic surgeon with osteotomy of the left
tibia, long leg plaster casts bilaterally, and 2 teaspoons
daily of U.S.P. codliver oil, her daily medical therapy
when seen by us two and one-half years later. Three
months after removal of the casts, the deformity was
recurring, so they were reapplied. The second course in
plaster did not appreciably benefit the patient, nor did
a series of chiropractic adjustments (although the latter
cured her enuresis) . At the time a second orthopedic
surgeon was being consulted, arrangements were com-
pleted for care at the Shriners’ Hospital.
The past medical history, family history, and systemic
review were normal.
The patient was a healthy appearing 4%-year-old
white female with severe bowing of the legs (Fig. 3).
Her height was 38% inches, 3 inches less than the
average for her age.
The physical findings of clinical interest were marked
fronto-parietal prominence, deciduous teeth in excellent
condition, no caries or rachitic stigmata, definite costo-
chondral beading, and Harrison’s grooves.
The heart and lungs were normal, the blood pressure
78/54. The abdomen was soft, protruding, with poor
muscular tonus, and diastasis of the recti. The gross
pathology was in the lower extremities, with a genu varus
deformity giving a space of 10.5 cm. between the knees
with the medial malleolae touching. The deformity in-
volved the femora and tibiae symmetrically. Generalized
epiphyseal flaring was present. No disproportion between
length of extremities and of vertebral column was present.
Laboratory studies showed normal routine urinalyses
and hemogram. Serum calcium was 11.8 mgm. per cent,
serum phosphorus 2.2 mgm. per cent, and alkaline phos-
phatase 27.3 King-Armstrong units. Total serum pro-
teins were 6.2 gm. per cent. Other diagnostic tests were
considered normal, as follows: Kline and Kolmer nega-
Fig. 3. D. C., age 4 years and 6 months, at admission.
Shown also ten months later, after bilateral tibial osteotomies
and 20,000 units vitamin D daily.
tive, Mantoux negative, urine Sulkowitch negative,
P.S.P. excretion 60 per cent in first hour with 65 per
cent in two hours, Hanger’s cephalin-cholesterol floccu-
lation zero in 24 and 48 hours, thymol turbidity 1.7
units, intravenous bromsulphthalein retention 4 per cent
in 45 minutes, fecal fat 15 per cent of the dry matter
with dry matter 35 per cent of the total weight.
May, 1949
175
Fig. 4. D. C., on admission, age 4!4 years,
picture easily mistaken for chondrodysplasia.
Radiographic
Radiographic studies on admission showed the classic
epiphyseal changes of active rickets (Fig. 4), with re-
tardation of bone age, three centers being present in the
carpus.
Initially a routine dose of vitamin D was administered,
1,000 units, daily, with no visible effect on the epiphyseal
changes. After one month, the dosage was increased
gradually to 8,000 units daily. This was found sufficient
to cause definite radiographic evidence of healing of the
rickets (Fig. 5), but the moderate elevation of the alka-
line phosphatase was not altered. After four months of
observation, the patient underwent bilateral osteotomies
of the tibiae and fibulae, a satisfactory correction of the
genu varus deformity being attained. Three months later
the plaster dressings were removed.
Postoperatively the alkaline phosphatase rose to 44.6
K.-A. units, and it appeared from the radiographs that
the rachitic activity was not being fully controlled. Ac-
cordingly, the patient was given increasing amounts of
viosterol, the dose being stabilized at 2 cc. daily (20,000
units) . Fdealing of the osteotomies and of the epiphy-
seal dysplasia proceeded uneventfully. During ten
months of observation, the serum calcium varied between
10.2 and 12.3 mgm. per cent, the phosphorus between
1.9 and 3.4 mgm. per cent. The patient was discharged
from the hospital 6/4 months after her surgery, still
taking 2 cc. viosterol daily. The functional and cosmetic
results appeared excellent.
In closing, let us stress a few observations of clinical
interest, from our own, and the experience of others.
It appears to be a common tendency for physicians to
fail to diagnose clinical rickets merely because the child
is on a vitamin D intake which is usually sufficient.
Fig. 5. D. C., after two months on 20,000 units of vitamin
D daily. Decrease in metaphyseal beaking, closure of epiphyses
— metaphyseal gap, apeparance of lines of "growth arrest,” clari-
fication of epiphyseal structures.
This can have a most unfortunate result for the occa-
sional case of resistant rickets. It has been noted that
as children grow older, they require increasing doses of
vitamin D for curative effects. Eliot and Park state that
in even an average case of rickets, an older child may
require 60,000 units of vitamin D daily. In these chil-
dren, the rachitic activity may be of a more "smoulder-
ing” nature, and require close radiographic and labora-
tory supervision to insure adequate therapy. When the
active rachitic phase has been arrested, cure may be
maintained by a daily intake of vitamin D much less
than that required as initial therapy.1 It is de-
sirable to be sure of the current state of affairs in any
"post-rachitic” child presented for orthopedic correction
of residual deformities. If the disease is still active, sur-
gical correction of deformity is apt not to give lasting
improvement and may even lead to further confusion
of the correct diagnosis. The diagnosis of active rickets
in an older child by radiographic evidence alone may be
made with hesitation by even an expert roentgenologist.
It is desirable to have close coordination between the
pediatrician, the radiologist, the clinical laboratories, and
the orthopedic surgeon to obtain optimum results with
a given case of vitamin D resistant rickets.
Summary
1. Attention is called to the group of children with
active rickets requiring larger than average doses of
vitamin D for curative effects, "massive therapy” in
rare cases.
176
The Journal-Lancet
2. The necessity for increased doses of vitamin D is
stressed in older rachitic children as a group.
3. Cases of resistant rickets are resistant to the spe-
cific biologic activity of vitamin D.
4. The toxic effects of vitamin D are due to excessive
action of its therapeutic properties, are not encountered
in sub-therapeutic doses even with "massive therapy.”
5. Clinical management of resistant rickets is dis-
cussed.
6. Two cases of resistant rickets are presented.
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191:1, 1930.
14. McLean, F. C.: J.A.M.A. 117:609, 1941.
15. Albright, F.: J.A.M.A. 112:2592, 1939.
16. Stearns, G., and Boyd, J. D.: J. Clin. Investig. 10:591,
1931.
17. Hess, J. H : Am. J. Dis. Child. 42:481, 1931.
18. Borscheuer, P.: Ztschr. f. Kinderh. 51:56, 1931.
19. Liebe, S.: Mschr. Kinderheilk. 78:221, 1939.
20. Holbertsma: Mschr. Kindergenesk. 4:267, 1935.
21. Gill, A. M.: Arch. Dis. Child. 14:51, 1939.
22. Nadrai, A.: Kinderheilk. 60:590, 1939.
23. Bessau and Lohr: Mschr. Kinderheilk. 90:1, 1942.
24. Beumer, H.: Zschr. Kinderheilk. 63:744, 1943.
25. Smith, J., and Maizel: Arch. Dis. Childhood 7:149, 1932.
26. Warkany, J.: Am. J. Dis. Child. 52:831, 1936.
27. Stearns, G., and Warweg, E.: Am. J Dis. Child. 49:79,
1935.
28. Barney, J. D., and Sulkowitch, H. W.: J. Urol., 37:746,
1937.
29. Council of Pharm. and Chem.: J.A.M.A. 123:287, 1943.
30. Brakeley, E.: Am. J. Dis. Child. 65:314, 1943.
Meet Our Contributors
Wallace W. Lueck, M.D., Minneapolis, was graduated
from the University of Minnesota in 1942; specializes in
Pediatrics; Clinical Instructor in Pediatrics, University of
Minnesota Medical School; Clinic Physician, Minneapo-
lis General Hospital.
Tague C. Chisholm, M.D., Minneapolis, was graduated
from the Harvard Medical School in 1940; specializes
in Pediatric Surgery; member, Northwest Pediatric So-
ciety, Minnesota Surgical Society, American Academy of
Pediatrics.
Oswald S. Wyatt, M.D., Minneapolis, was graduated
from the University of Minnesota in 1919; specializes in
Pediatric Surgery; Clinical Professor of Surgery, Univer-
sity of Minnesota Medical School; member, American
Academy of Pediatrics, Northwest Pediatric Society.
William Fleeson, M.D., Minneapolis, was graduated
from Yale Medical School in 1942; specializes in Child
Psychiatry; member, Northwest Pediatric Society, Ameri-
can Psychiatric Association.
Eric Clarke, M.D., Minneapolis, was graduated from
the University of Toronto in 1916; specializes in Psychia-
try; Chief of Staff, Minnesota Psychiatric Institute; Clin-
ical Professor of Psychiatry, University of Minnesota;
Diplomate, American Board of Neurology and Psychia-
try; member, Minnesota State Society of Neurology and
Psychiatry, National Committee for Mental Hygiene,
Minnesota Mental Hygiene Society, American Psychiatric
Association.
Robert B. Tudor, M.D., Bismarck, North Dakota, was
graduated from the University of Minnesota in 1937;
specializes in Pediatrics; associated with the Quain 6c
Ramstad Clinic.
Lee Bass, M.D., Baltimore, Maryland, was graduated
from Johns Hopkins in 1947; specializes in Pediatrics;
now on active duty with the United States Army.
Sheldon C. Siegel, M.D., Rochester, New York, was
graduated from the University of Minnesota Medical
School in 1946; specializes in Pediatrics; preceptor with
Dr. Jerome Glaser, Rochester, New York.
Douglas T. Lindsay, M.D., Minneapolis, was graduated
from the University of Minnesota in 1944; specializes in
Orthopedic Surgery; fellowship, Shriner’s Hospital for
Crippled Children, Mayo Clinic, University of Minne-
sota; Cole Fellowship in Orthopedic Surgery.
John Galloway, M.D., Minneapolis, was graduated
from Temple Medical School in 1934; specializes in
Orthopedic Surgery; member, Minneapolis Academy of
Medicine, Clinical Orthopedic Society; Fellow, American
Academy of Orthopaedic Surgeons; Diplomate, Ameri-
can Board of Orthopedic Surgery.
Erling S. Platou, M.D., Clinical Professor of Pediatrics,
University of Minnesota, has practiced in Minneapolis
for 23 years; graduate of the University of Minnesota,
class of 1921; member, Minnesota State Board of Health.
Sidney Saul Scherling, M.D., Minneapolis, was grad-
uated from the University of Minnesota Medical School
in 1935; specializes in Pediatrics; member, Northwest
Pediatric Society.
May, 1949
177
The Treatment of the Recurrent
Congenital Club Foot*
John D. B. Galloway, M.D.
Minneapolis, Minnesota
The congenital club foot is probably the most com-
mon of all congenital deformities.
The treatment of the congenital club foot is quite suc-
cessful in most cases if started early in infancy, pref-
erably during the first two weeks of life; if the foot is
overcorrected completely; if the post-corrective phase is
followed long enough, and if during this latter period,
treatment is re-instituted at the first sign of a recurrence.
In spite of this, the recurrent congenital club foot is
frequently encountered. These children come to us with
varying degrees of deformity. Most of them have de-
formed rigid feet that defy conservative therapy.
Many types of treatment have been devised for the
correction of this recurrent deformity. Not a new treat-
ment, but a combination of some of the more commonly
used methods will be presented here.
In treating the club foot at birth, the three major com-
ponents of the deformity, namely, the adduction of the
forefoot, the varus of the heel, and the equinus of the
foot are corrected in stages and in that order. The same
principle has been applied here except that in addition
to plaster or splint correction, surgery has been added.
The first stage consists of a mid-tarsal capsolotomy
through the talo-navicular joint and in some the naviculo-
cuneiform articulation. This procedure is done through
a small dorso-medial incision. The capsule and all sup-
portive structures are divided completely, which usually
permits correction of the forefoot adduction. No attempt
is made to correct the varus of the heel or the equinus
of the foot at this time. A plaster dressing is then ap-
plied holding the forefoot in the corrected position. This
plaster is usually changed twice, at an average interval of
five weeks. Each time the plaster is changed, the fore-
foot is still further corrected, if indicated, by manipula-
tion without anesthesia.
On an average of fifteen weeks, following the medial
capsulotomy, the second stage is begun and consists of
an Achilles tendon lengthening and a posterior capsol-
otomy. The Achilles tendon is exposed through a curved
medial incision and is divided by means of a Z plasty
with the posterior distal half attached to the calcaneus.
This provides an excellent exposure of the posterior
aspect of the tibia, talus, and calcaneus. The capsule
between these structures is divided and the incision is
carried forward on both sides as far as possible. This
permits correction of the varus of the heel and the equi-
nus of the foot. The Achilles tendon is re-approximated
under slight tension while the foot is held in its new
position. Before the plaster dressing is applied the fore-
*From the records of The Shriners Hospital, Minneapolis,
Minnesota.
foot is again manipulated if indicated. This plaster is
changed after an average period of five weeks and
usually a walking plaster is applied. This final plaster
is worn for an average period of five weeks. Following
the removal of the plaster, the child is fitted with metal
club foot splints to be worn day and night until shoes
are provided, and at night and during periods of rest
after this. Physical therapy treatments are started as
soon as the plasters are removed and consist chiefly of
exercises directed toward rehabilitation of the dorsi-
flexors and evertors of the foot. Most patients show a
rather marked weakness of the calf muscles following
this form of treatment so exercises for strengthening this
muscle group are stressed. Shoes are fitted usually of
the Sabel club foot variety. Some receive an ordinary
high-top straight last shoe with additional elevations
along the lateral border of the sole and heel, the eleva-
tion on the sole exceeding that of the heel (Fig. 1).
Fig. 1A. Fig. IB.
Types of shoes used postoperatively. Fig. 1A — Straight-last
shoe with added corrections. Fig. IB. Sabel type club foot shoe.
These children are dismissed from the hospital after
they are able to actively dorsiflex and evert the foot and
are approaching a near normal gait. They are sent home
with the night splints and instructions for exercising.
They return at six-month intervals for observation. After
the end of a year, if the deformity has shown no tend-
ency to recur, the night splints are discarded; however,
the special shoes are worn for a much longer period.
Since September, 1946, thirteen cases have been treat-
ed by this method. Eight, or 61.5 per cent, were males;
five, or 38.5 per cent, were females. The oldest was
10 years, the youngest 4 years, with an average age of
7 years (Table 1). Eight cases were bilateral, in six
of which both feet were treated, and in two of which
only the left foot required treatment. Five cases were
unilateral; of these the left foot was involved in four,
and the right foot in one (Table 1). The average hos-
pital stay for twelve cases was 34 weeks; one patient is
178
The Journal-Lancet
Table 1
Case
No.
Date of
Admis-
sion
Sex
Age
Uni-
lateral
Bi-
lateral
Time Interval
Post. Cap. to
Plaster off
Result
Follow-up
Med. Cap to
Post. Cap.
Plaster off to
Discharge
1.
11-12-46
F
7
X
18 wks.
1 8 wks.
9 wks.
Excellent position
12 mos. No recurrence
2.
5-18-48
M
6
Left
7 wks.
9 wks.
4 wks.
Good position
None
3.
6-3-47
M
10
X
14 wks.
1 1 wks.
2 wks.
Improved
6 mos. No recurrence
4.
6-10-47
M
5 .
X
15 wks.
18 wks.
7 wks.
Improved
5 mos. No recurrence
5.
7-22-47
M
4
X
15 wks.
1 1 wks.
1 1 wks.
Good position
3 mos. No recurrence
6.
7-15-47
F
8
Right
10 wks.
14 wks.
6 wks.
Good position
6 mos. No recurrence
7.
6-10-47
F
6
X
14 wks.
1 1 wks.
10 wks.
Good position
8 mos. No recurrence
8.
6-17-47
F
5
X
12 wks.
1 1 wks.
6 wks.
Good position
9 mos. No recurrence
9.
10-1-46
M
8
Left
34 wks.
5 wks.
3 wks.
Excellent position
6 mos. No recurrence
10.
9-3-46
M
8
Left
30 wks.
7 wks.
2 wks.
Excellent position
6 mos. No recurrence
11.
11-4-47
F
8
X
9 wks.
7 wks.
7 wks.
Improved
None
12.
8-19-47
M
7
X
9 wks.
9 wks.
5 wks.
Good position
6 mos. No recurrence
13.
2-3-48
M
9
Left
9 wks.
7 wks.
Good position
Still in Hospital
Average
15 wks.
10 wks.
6 wks.
6 14 mos.
still in the hospital. Ten of the patients dismissed from
the hospital have been seen in the out-patient depart-
ment at an average interval of six and one-half months,
the longest follow-up period being twelve months. Two
patients were dismissed too recently to have returned to
the out-patient department.
Following treatment, the result has been uniformly
good with all the feet showing good weight-bearing posi-
tion, and in practically every case active overcorrection
of the deformity has been possible. To date there has
been no recurrence of the deformity in the ten cases
seen in the out-patient department and in the one pa-
tient still in the hospital (Table 1).
Several cases will be presented to illustrate the typical
deformity, the problems encountered, and the results
obtained by this method.
Case 1. A girl, 7 years old, was admitted to the hos-
pital for the first time on January 30, 1940, at the age
of 3 months, with a severe bilateral club foot. She was
treated with the Denis Browne splint until April 10,
1940, and then with plasters until May 8, 1940. This
was followed by physical therapy until her dismissal on
October 23, 1940. At this time the deformity had ap-
parently been corrected for she was seen in the out-
patient department on February 25, 1941, and at this
time the feet were still in good position. In 1943, at the
age of 4 years, she wore plasters again for one month.
After February, 1941, she was not seen until November
12, 1946, when she was admitted with a severe bilateral
recurrent deformity (Fig. 2A, 2C, 2E) . On January 16,
1947, a mid-tarsal capsolotomy was done through the
right talo-navicular and naviculo-cuneiform articulation,
and on February 6, 1947, a similar procedure was done
on the left foot. On May 22, 1947, bilateral posterior
capsolotomies were done. She was dismissed from the
hospital on September 24, 1947, wearing a straight last
shoe with % inch elevation on the outer border of the
sole and !4 inch elevation on the outer border of the
heel. At the time of dismissal the feet were in excellent
position and she was able to actively overcorrect (Fig.
2B, 2D, 2F) . She was last seen in the out-patient depart-
ment on September 21, 1948, with no evidence of any
recurrence.
Fig. 2C. Fig. 2D.
Fig. 2E. Fig. 2F.
Case 1. L. S., Female, age 7 years. Fig. 2A and 2B, front
view, before and after treatment. Fig. 2C and 2D, plantar
view, before and after treatment. Fig. 2E and 2F, rear view,
before and after treatment.
May, 1949
179
Case 2. A boy, 6 years of age, who was treated at
birth for a left club foot with splints and manipulations.
Plaster correction was started at the age of one month
but the foot was never completely corrected by this
method according to the history obtained. He was ad-
mitted to the hospital on November 5, 1946, at the age
of 4 years. In December, 1946, the foot was wrenched
and an external rotation osteotomy of the tibia was per-
formed. He was not seen again until May 18, 1948,
when he was admitted with a severe rigid left club foot
(Fig. 3A, 3C, 3E). On May 20, 1948, a mid-tarsal
capsolotomy was done through the talo-navicular and
naviculo-cuneiform articulations. On July 8, 1948, a
posterior capsolotomy was done and the patient was
discharged from the hospital on October 5, 1948, wear-
ing a Sabel club foot shoe on the left. At the time of
dismissal the foot had been completely corrected. He
has not returned since that date.
Case 4. A boy, 5 years of age, whose treatment had
been started at the age of 6 weeks and who for seven
months had been treated by means of manipulations and
plasters. He had no further treatment until 1944, at
the age of 2 years, when bilateral fasciotomies, Achilles
tendon lengthenings, posterior capsolotomies and pos-
terior tibial tenotomies were done. He was admitted to
the hospital on June 10, 1947, with bilateral rigid club
feet with a marked forefoot adduction ( Fig. 4A, 4C,
4E) . On June 19, 1947, bilateral mid-tarsal capsoloto-
mies were done through the talo-navicular joints, and
on October 2, 1947, posterior capsolotomies were done.
He was dismissed from the hospital on March 28, 1948,
wearing Sabel shoes. At this time there was marked
improvement of the position of the feet (Fig. 4B, 4D,
4F) . He was last seen in the out-patient department on
August 31, 1948, and at this time the feet were easily
Fig. 3A.
Fig. 3B.
Fig. 4A.
Fig. 4B.
Fig. 3C.
Fig. 3D.
Fig. 4C.
Fig. 4D.
Fig. 3E. Fig. 3F.
Case 2. R. M., Male, age 6 years. Fig. 3A and 3B, front
view, before and after treatment. Fig. 3C and 3D, plantar
view, before and after treatment. Fig. 3E and 3F, rear view,
before and after treatment.
Fig. 4E. Fig. 4F.
Case 4. W. B., Male, age 5 years. Fig. 4A and 4B, front
view, before and after treatment. Fig. 4C and 4D, plantar view,
before and after treatment. Fig. 4E and 4F, rear view, before
and after treatment.
180
The Journal-Lancet
Fig. 5A.
Fig. 5B.
Fig. 5C.
Fig. 5D.
Case 11. B. S., Female, age 8 years. Fig. 5 A and 5B, dorsi-
plantar x-ray of left foot before and after treatment. Note de-
formity of the navicular. Fig. 5C and 5D, lateral x-ray of
left foot before and after treatment.
overcorrected and loose. There was still moderate weak-
ness of the calf muscles, but no evidence of any recur-
rence of the deformity.
Discussion
It is quite evident from the foregoing that all these
children had severe deformities, that in nearly every case
treatment had not been constant from the time of birth,
A
Fig. 6C. Fig. 6D.
Case 8. B. L., Female, age 5 years. Fig. 6A and 6B, dorsi-
plantar x-ray of both feet before and after treatment. Note the
normal relationship between the talus and navicular and between
the talus and calcaneus in Fig. 6B. Fig. 6C and 6D, lateral
x-ray of both feet before and after treatment. Note the im-
provement in the angle between the tibia and calcaneus.
and that in many there had been long intervals without
treatment. Ten of the patients had had previous surgery
of some type, one even had had a triple arthrodesis
(Case 13), and three had had at least one wrenching.
These factors of course made the present problem more
difficult. In several, structural changes had occurred in
the foot (Fig. 5A-D). These feet can be corrected by
this method as illustrated in Fig. 6A-D. Motion in the
foot and ankle is by no means normal, but the weight-
bearing position of the foot is good and these children
are able to walk with comfort. These children have not
been followed long enough to be certain of no recur-
rence, but indications would point to a maintenance of
the correction.
May, 1949
181
Acute Bacterial Meningitis
Revieiv of Therapy in 1 98 Cases at the Minneapolis General Hospital
S. S. Scherling, M.D.,* and E. S. Platou, M.D.*
Minneapolis, Minnesota
A review of the records at the Minneapolis General
Hospital for the years 1922-1936, 1937-1943, and
1943-July 1947 indicates a progressive increase of bac-
terial infections complicated by meningitis (Table 1).
This rise in incidence of meningitis among the civilian
population is of considerable significance in the face of
statistical evidence of a reduction in the rate of other
bacterial infections among the populace for the same
period. Further analysis of these records and perusal of
the literature reveals marked differences of opinion con-
cerning the management of bacterial meningitis.
dary to a bacteremia, and that even oto-rhinogenic men-
ingitis results from the entrance of the bacteria into the
blood stream.
Intense invasion of the blood stream by pyogenic or-
ganisms may be accomplished either by direct pouring in
from an infected lymph channel, vein wall, or heart
valve, or may be disseminated by means of infected em-
boli extending from small thrombosed vessels. In menin-
gococcic invasion, however, the extraordinary degree of
blood stream infection which is so often observed does
not suggest such means of implantation and is thought
Table 1
Comparative Statistics of Different Types of Meningitis Observed at Minneapolis General Hospital the last 25 years.
Etiology
1922-
-1936
1936-
1942
1943-
1947
No.
Cases
Deaths
No.
Cases
Deaths
No.
Cases
Deaths*
Meningococcus
240
92
34
5
123
17
4
Pneumococcus
85
85
20
17
26
13
10**
Hemophilus Influenzae
17
17
6
4
21
7
3
Streptococcus
-
137
135
13
3
9
4
1 **
Staphylococcus
15
15
3
1
2
0
0
Mycobacterium Tuberculosis
6
6
6
*Excluding cases died within 18 hours after admission. **Excluding cases receiving no treatment.
The purpose of this communication is to re-evaluate
diagnostic and therapeutic measures in the light of cur-
rent literature and to present a routine of diagnostic and
therapeutic procedures based upon our experience and
that of the majority of investigators as expressed in re-
cent literature. Inasmuch as the meningococcus, pneu-
mococcus, and the hemophilus influenzal bacillus were
the etiological agents in over 85 per cent of our cases
and since these organisms seem to have a specific
affinity for the meninges, in contrast to the meningeal
invasion by other bacteria which usually occurs as a re-
sult of an accidental generalized diffusion of the organ-
ism, this discussion will be limited to the three types
mentioned.
Discussion
It has been pointed out by Herrick,1 Hill J and others
that the organisms causing meningitis reach the menin-
ges by way of the blood stream. The occasional direct
implantation following trauma, or direct extension from
oto-rhinogenic foci is conceivable although Burman " and
others contend that most cases of meningitis are secon-
*From the Department of Pediatrics, University of Minne-
sota School of Medicine and the Contagious Service, Minne-
apolis General Hospital.
to result by invasion of the blood stream from minute
foci in the upper air passages.*
By means of microscopic sections of petechiae, Brown •'
clearly demonstrates evidence of damage to the arteriolar
and capillary walls resulting in loss of integrity of the
vessel walls. This is paralleled by the early pathologic
changes in the meninges.4 The conclusion, therefore,
that a liberated toxin effects vascular damage permitting
ready access of the organism to the vascular stream and
its escape to the meninges is inescapable.
Further evidence of diffuse vascular damage was re-
cently demonstrated by Hill and Kinney L' in a report
on the cutaneous lesion in 25 fatal cases of acute menin-
gococcemia. The widespread vascular damage was not
limited to the skin but was observed throughout the
serous surfaces and other organs of the body.
These authors show decided endothelial changes in the
smaller vessels and capillaries often to such a degree that
the continuity of the lining endothelium was broken.
Furthermore, meningococci could be identified in the
endothelial cells. On the basis of this report, it is evi-
dent that the cutaneous lesion can be explained by vas-
cular damage resulting from the presence of meningo-
cocci. The sequence of events in the pathogenesis of the
lesion being the localization of the organism in the endo-
182
The Journal-Lancet
thelium followed by endothelial damage and inflamma-
tion of the vessel walls resulting in necrosis and throm-
bosis.
As stated by Lange, et ah, 6 increase in capillary per-
meability is one of the basic processes of the functional
pathology in inflammation,- a phenomenon demonstrated
in the past by diffusion of dyes. These investigators in
a study involving 149 patients demonstrated a decided
increase of fluorescein in the spinal fluid of patients with
bacterial meningitis as compared to the normal.
However, the same principle apparently does not per-
tain to the diffusion of penicillin. Rammelkamp and
Keefer ‘ were unable to demonstrate the excretion of
penicillin in the spinal fluid when the drug was admin-
istered in large doses by intramuscular and intravenous
routes. Rosenberg and Sylvester, s on the other hand,
demonstrated adequate levels of penicillin in the spinal
fluid of eight patients treated with parenteral penicillin.
Of these, two cases received the drug intramuscularly
and six intravenously. The apparent difference is prob-
ably due to the fact that the former group studied non-
mfected individuals whereas the latter investigated pa-
tients with meningeal infections.
Subsequently Kinsman and Alonzo !l in a study in-
volving 36 cases demonstrated no penicillin in the spinal
fluid of 20 patients without meningeal involvement nor
in five cases of meningococcemia without evidence of
meningitis. In 11 patients with bacterial meningitis
treated with penicillin extrathecally, the appearance of
the drug in the spinal fluid was irregular, inconstant, and
in concentration considered inadequate for bactericidal
effect.
Hirsch and Lowe 10 demonstrated that the circulation
in some infected and non-infected thrombophlebitis can
be re-established by the use of anti-coagulants. Since
there is an increase in capillary permeability which may
be variable with the extent of break-down of the blood
brain barrier, is it reasonable to assume that this break-
down could be enhanced by artificial means, presumably
thereby facilitating the effect of chemotherapeutic and
antibiotic agents on the capillary bed and their diffusion
into the cerebrospinal system?
The intrathecal administration of heparin has been
successfully reported in a few cases of chronic meningitis
by Platou and Gibbs,3 1 Alexander,1' and Ross.12 From
the evidence presented above, extrathecal heparinization
or dicoumeralization of the patient with meningitis might
be a tenable subject for further study and investigation.
It has been shown 14 that the rise in anti-carbohydrate
antibody in pneumonia correlates with the crisis whether
spontaneous or induced and that immunity to meningo-
coccic infection as well as ability to withstand infection
is closely related to age.1'1 It is also well known that a
definite lack of immunity to pneumococcus exists in the
infant up to two years of age.1'* This has been well
demonstrated by the failure to elicit significant antibody
response by immunization against type 1 pneumococcus
in children under two years of age, whereas children
over two showed a sharp rise in antibody titre.17 Simi-
larly the blood of children between two months and
three years of age has been found to have no antibodies
against the hemophilus influenzal bacillus.1 s
Regardless of the source, whether fabricated by the
host or passively induced, antibody plays an essential
part in the recovery mechanism. The immunologic re-
sponse is largely responsible for the better results in the
young adult groups, regardless of treatment, as com-
pared to the extreme age groups whose facilities for fab-
ricating antibodies is known to be poor.
The meningococcus, pneumococcus, and hemophilus
influenzal bacillus which are responsible for the vast ma-
jority of bacterial meningitis constitute an immunological
group.14 Each of these organisms is surrounded by a
capsule containing a specific carbohydrate which is re-
leased and diffuses into the surrounding media. This
capsular substance is the element of the organism upon
which its specificity and power to invade the host de-
pends. The quantity of free capsular carbohydrate is
an index of the severity of the infection and may serve
as a guide as to the amount of specific antibody neces-
sary for neutralization and recovery. The free capsular
carbohydrate must be inactivated before the substance in
the capsule of the organism can be affected. Since this
free substance is excreted in the urine, diuresis by means
of parenteral administration of fluids prior to the admin-
istration of the specific anticarbohydrate is beneficial.
It is also conceivable that forced excretion of the free
capsule carbohydrate may prevent a violent antibody
antigen combination which probably contributes to the
high incidence of fatalities in fulminating cases.
In mild infection, interference with the growth and
metabolism of the invading organism by chemotherapy
is sufficient to allow the natural antibody response to
overcome the infection. Free antibody can be detected
earlier in the course of a disease when chemotherapy is
instituted than in those not so treated. There apparently
is an interference with the metabolism of the organism
resulting in less antigen or specific carbohydrate libera-
tion. The evidence indicates that the anticarbohydrate
antibody is the protective antibody in hemophilus influ-
enzae, penumococcic and meningococcic infections.1 2
The invasive power of the meningococcus, pneumo-
coccus, and influenzal bacillus varies with different types.
Mitman 111 is of' the opinion that the virulence is more
concerned with epidemic strain than with any particular
type and is reflected in the wide variations in the fatality
rate between one epidemic and another as well as epi-
demic and endemic cases. The variations in mortality
rates of the various epidemics and indeed in groups of
patients in the same epidemic may therefore be closely
related to the type of strain of the prevalent organism.
It is well known 20 that group I meningococcus account
for the vast majority of epidemic cases and group II
is responsible for the sporadic cases, the carriers, and the
disease in the extremes of life.
It is commonly accepted 21-20 that early diagnosis and
therapy is of paramount importance. However, early
diagnosis is particularly difficult in the extremes of life.
Consequently the high death rate in these groups may
May, 1949
183
not only be the result of poor immunological response
but may to a large measure be influenced by the late
diagnosis because of the bizarre clinical picture and the
absence of the classical findings. The combination of
favorable factors such as ideal age group, early diagnosis,
and early treatment, may account for the excellent re-
sults reported during the war."l>'_s
The significance of diagnosis prior to distinguishable
meningeal involvement lies in the speed with which the
infection can be brought to an end by the early admin-
istration of sulfonamides or antibiotics in therapeutic
doses.29 The apparent incongruity appearing in the 1944
Scottish report in which it was noted that patients with
the shortest duration of symptoms had a higher fatality
rate, merely serves to emphasize the familiar observation
of the rapidity of invasion in fulminating forms of this
disease. Certainly the report does not intend or justify
a delay in treatment.
Data
During the period covered by this communication,
198 cases of meningitis were admitted to the Minne-
apolis General Hospital (Table 2). Of these, 123 were
due to the meningococcus, 26 to the pneumococcus, and
21 were caused by the hemophilus influenzal bacillus.
Of the remaining 28, 10 were unidentified bacterio-
logically, although from the history, mode of onset, and
clinical response, they could readily be classified as men-
ingococcic. Of the other 18, six were caused by the
mycobacterium tuberculosis, nine of hemolytic strepto-
coccus, two by staphylococcus aureus and one as a result
of invasion by the Escherichia coli bacillus.
Meningococcic meningitis was observed in all age
groups (Table 3). The youngest patient was seven
weeks old and the oldest 74 years of age.
Although there were scattered cases of pneumococcic
meningitis among the various age groups, by far the
greatest number occurred in the adults. Only six of the
total reported were observed in the child age group.
Table 2
Incidence, Mortality and Corrected Mortality of Bacterial Men-
ingitis Observed at Minneapolis General Hospital from Jan-
uary 1943 to June 1947.
Etiology
No.
Cases
Deaths
""Corrected
Deaths
Meningococcus
123
17
4
Pneumococcus
26
13
11-10**
Hemophilus Influenzae
21
7
3
Mycobacterium Tuberculosis
6
6
6
Staphylococcus
2
0
0
Streptococcus
9
4
4_ i **
Escherichia coli
1
I
i
Undetermined
10
1
i
Total
198
49
30-26**
*Excluding cases died within 18 hours after admission.
**Excluding cases receiving no therapy.
In contrast, the hemophilus influenzal bacillus showed
a decided predilection for the very young. All the cases
of meningitis caused by this organism occurred in young
children, the oldest being seven years of age. Eighteen
of the twenty-one cases observed, however, were in chil-
dren under five years of age and eleven of these were
in infants under two.
The seasonal incidence (Fig. 1, page 184) correlates
closely to the season of the year when infections are
most prevalent. This observation has been noted in nu-
merous reports in the past and was especially well dem-
onstrated during the epidemic of bacterial meningitis
among the military personnel in the last war.30
The over-all mortality rate for this series compares
favorably with recent reports appearing in the litera-
ture,31'31 and comparing these statistics with previous
studies from this institution 38,39 there is noted a consid-
erable decline in the fatality rate in all forms of bacterial
meningitis with the exception of the tuberculous variety.
Table 3
Incidence and Deaths of Bacterial Meningitis Observed in Various Age Groups.
Age
Etiology
0—12 mo.
No. Died
1-2
No.
yrs.
Died
2-5
No.
yrs.
Died
5-10 yrs.
No. Died
10-
No
20 yrs.
Died
20-40 yrs.
No. Died
40-60 yrs.
No. Died
60-
No
77 yrs.
Died
Total
No. Died
Meningococcus
13
3
9
3
14
2
16
2
15
1
28
4
22
2
6
123
17
(2)*
(3)*
(1)*
(l)*
(D*
(4)*
(l)*
(13)*
Pneumococcus
1
1
3
1
0
1
1
3
1
11
4
6
6
26
13
(D*
(1) t
(D*
(2)
* (1) f
Hemophilus
8
4
3
1
7
3
2
0
0
0
0
21
7
(3)*
(1)*
(4)*
Myco. Tuberc.
0
1
1
0
1
1
3
3
0
1
1
0
6
6
Staphylococcus
0
0
0
0
0
1
0
1
2
Streptococcus
0
0
0
1
1
4
4
2
1
9
4
(3) t
(3)1
Escherichia coli
1
1
0
0
0
0
0
0
0
1
1
Undetermined
2
0
1
1
1
2
2
1
1
10
1
Total
25
9
(5)*
16
6
(3)*
22
2
(l)*
23
5
(2)*
21
4
(D*
38
(5)
9
* (3) t
38
(1)
7
* (1) t
15
7
(D*
198
(19)
49
* (4) f
""Expired in less than 18 hours. JReceived no specific therapy.
184
The Journal-Lancet
A significant and encouraging reduction in the fatality
rate is noted in meningeal infections caused by pneumo-
coccic, streptococcic and hemophilus influenzae bacillus.
As can be expected, the mortality was highest in the
extreme age groups, although it is gratifying that of 22
cases of meningococcic meningitis in children under two
years of age, there were only six fatalities. Justifiably
excluding the cases that expired in less than nine hours
following admission, there resulted only one death in
17 cases of meningococcic meningitis in the infant group.
Although the fallacy of comparing statistical data is well
recognized, there can be little doubt that these encour-
aging results are actual and were probably influenced in
no small measure by the chemotherapeutic and anti-
biotic agents.
Table 4 indicates the type of treatment employed.
Either sulfonamides or penicillin or a combination of the
two was employed in 71 cases of meningococcic menin-
gitis with a total of seven fatalities. All seven, however,
expired shortly after admission and can justifiably be
excluded in the records of corrected mortality. Fifty
cases were treated with sulfonamides plus antitoxin or
sulfonamide plus penicillin plus antitoxin. In this group
there was a total of eight deaths. Excluding those cases
that expired within 18 hours after admission, there re-
mained four deaths in 46 cases of meningococcic menin-
gitis treated in this manner. It would seem that the most
satisfactory results in meningococcic meningitis were ob-
tained with sulfonamide and penicillin therapy. The
poorer results with antitoxin treatment in conjunction
with chemotherapy may, however, be explained by the
fact that antitoxin was administered to the more seri-
ously ill and fulminating cases or its use was resorted to
when the patient failed to improve with the chemo-
therapeutic and antibiotic agents.
Intense infection as evidenced by numerous organisms
in the cerebrospinal fluid, marked pleocytosis, and
markedly reduced spinal fluid sugar unfavorably influ-
enced the prognosis. Delay in treatment accounted for
most of the prognosticated fatalities.
Treatment
From Table 4 it is readily obvious that there was a
considerable variation in the specific management of bac-
terial meningitis. This again merely serves to emphasize
the state of uncertainty and disagreement found in re-
cent literature concerning the management of this infec-
tion. Accordingly it is believed advisable to present a
routine of diagnostic aids and therapeutic measures based
upon our own experience and on the consensus of the
majority of investigators as reported in recent literature.
It must be recognized, however, that the recommended
routine is merely a working guide for the usual acute
meningeal infection and is not inviolate.
General Management
1. Draw a specimen for blood culture.
2. Take nose and throat cultures for predominant
organisms.
3. Perform a diagnostic lumbar puncture and examine
for (a) cell count and differential, (b) smear, (c) cul-
ture, (d) sugar, (e) protein, (f) chlorides, (g) pellicle
formation.
Table 4
Treatment employed in 198 Cases of Bacterial Meningitis. Serum was employed only for die Hemophilus Influenzae Meningitis.
Treatment
Meningo-
coccus
NO. D. D.*
Pneumo
coccus
NO. D.
D. *
Hemophil.
Influenzae
NO. D. D.*
Staphylo-
coccus
NO. D. D.*
Strepto-
coccus
NO. D. D.*
Mycobact.
Tuberc.
NO. D. D. *
Unde-
termined
NO. D. D.*
Sulfonamides
13
4
0
2
2
1
1
0
0
3
1
1
3 0
0
Sulfonamides and Serum or A.T
38
4
1
6
3
3
6** 2
1
2 0
0
Penicillin
1
1
0
1
1
1
1
1
1
Penicillin and Sulfonamides
57
2
0
10
4
4
3
2
0
2 0 0
3
0
0
2
2
2
4 1
1
Penicillin, Sulfonamides,
Serum or A.T.
12
4
3
4
0
0
5** 2
2
Penicillin, Sulfonamides,
Serum and Streptomycin
6** 1
0
2
2
2
No treatment
2
2
0
3
3
2
3
3
3
1
1
1
*Excluding cases expired within 18 hours of admission. **Alexander’s Anti-Hemo Type B Rabbit Serum.
May, 1949
185
4. Start an intravenous infusion of 1/6 M. lactate in
5 per cent glucose in quantities calculated to adequately
hydrate the patient.
5. Follow this infusion with sulfadiazine in 1:5 per
cent solution and give one-half the calculated dose to
raise the blood level rapidly to approximately 20 mgm.
per cent. The remainder of the dose is administered
orally in divided doses every four hours. If the patient
is comatose or does not tolerate oral medication, the
drug may be administered subcutaneously or intravenous-
ly every six to eight hours.
6. Further treatment depends upon the organism
involved. This will usually be confirmed bacteriologically
in most instances by the time the procedures outlined
above have been completed.
Meningococcic Meningitis
1. Continue the administration of sulfadiazine in ade-
quate doses orally if tolerated, parenterally if the oral
route is not feasible. Maintain a blood level of 20
mgm. per cent for at least ten days after the patient
becomes afebrile.
2. Continue penicillin for approximately seven days
after the patient is afebrile.
3. Draw a daily blood sulfonamide level to determine
the adequacy of the chemotherapy.
4. Observe the patient closely for evidence of toxicity
to the drugs by performing daily urinalysis and repeated
blood counts.
5. Maintain adequate fluid intake and assure good
urinary output by use of parenteral fluids consisting of
glucose, Ringer’s solution, or saline as indicated.
6. Provide a nutritious well-balanced diet, including
supplementary vitamins.
7. Resort to repeated small blood transfusions if ane-
mia is noted or as dictated by the general condition of
the patient.
Comment: The authors fully agree with Hoyne and
others who advocate only one diagnostic lumbar tap in
the usual case of meningococcic meningitis.
Sulfadiazine is the drug of choice for this type of
meningeal infection. Although some writers are of the
opinion -M that low sulfonamide levels are equally as
effective, Meacham 40 states emphatically that high sus-
tained levels are desirable and important. Oftentimes,
due to the rapid and over-zealous administration of th?
drug, much higher levels were obtained. However, the
only consequence observed was a microscopic hematuria
and on occasion gross hematuria. The presence of this
complication did not affect the treatment but measures
were taken to assure good fluid intake and urinary out-
put. It is believed that if an optimum urinary output
can be maintained, little harm will result from the hem-
aturia. Hoyne 44 reports levels of over 100 mgm. per
cent without any untoward effect. Probably the early
administration of 1/6 m. lactate minimizes the toxic
effects of sulfonamides.
A number of investigators 41-4! are of the opinion
that penicillin alone will control this type of meningitis.
However, Mead, et al., 44 as well as Thomas and Din-
gle 4iJ demonstrated the much greater susceptibility of
the meningococcus to the sulfonamides. Nevertheless,
intramuscular penicillin as an adjuvant is recommended.
The intrathecal administration of this drug is not indic-
cated and is not recommended as a routine.
Although the Council on Pharmacy 4,1 discredits its
value, there are some who still believe that chemo-sero-
therapy is superior to chemotherapy alone. The use of
serum is not advocated but if it is to be used, it should
be given in massive doses by the intravenous route and
never used intrathecally. Meningococcic antitoxin, if
used, must also be given in large doses intravenously.
It may be of some value in cases occurring in the ex-
tremes of life.
The value of heparin and intrathecal air is debatable
at the present and its use must be governed by evidence
of block or chronicity. It is a plausible assumption, how-
ever, that further clotting may be prevented and fine
adhesions may be broken by this means, thereby expos-
ing pocketed organisms to the bacterioacidal agents.
Pneumococcic Meningitis
The same general measures as outlined under meningo-
coccic meningitis pertain to this type as well. However,
the drug of choice in pneumococcic meningitis is peni-
cillin administered intramuscularly.
1. This is the only form of meningitis in which intra-
thecal penicillin might be considered in well diluted doses
not to exceed 10,000 units daily.
2. Continue massive doses of intramuscular penicillin
until two weeks of normal course has prevailed.
3. Prescribe sulfadiazine to maintain a level of 15 to
20 mgm. per cent for approximately 10 to 14 days.
4. Eradicate surgically any accessible focus of infec-
tion.
5. Maintain fluid intake and continue supportive
measures as outlined under meningococcic meningitis.
6. If available, type specific rabbit anti-serum may be
given intravenously. The reader is cautioned to test for
sensitivity prior to administration of the serum. Intra-
thecal complement (3 to 5 cc. fresh blood serum) is
recommended by some authors.
7. Infants — "Prophylactic” intrathecal Heparin 1 to
2 cc. plus air for one or two days cautiously.
Comment: The most favorable results in the treat-
ment of pneumococcic meningitis during the period cov-
ered by this report was obtained with the use of peni-
cillin by intrathecal and parenteral routes. The experi-
ence of Ross and others supports this view. However,
it is of equal importance to maintain a high blood peni-
cillin level as well as adequate concentration of the drug
in the cerebrospinal fluid in order to control the bac-
teremia and to enhance the eradication of foci of infec-
tion.
186
Recurrence of this infection was not uncommon in our
experience and in all instances was directly related to
early cessation of intrathecal penicillin. One 54-year-old
male patient suffered two relapses within a period of
18 days. Ultimately the infection was controlled by re-
sumption of daily intrathecal penicillin for ten successive
days and intramuscular penicillin as well as oral sulfa-
diazine for an additional two weeks.
Recent reports 4 '•4S stress the danger of residual cen-
tral nervous system damage as a result of too vigorous
intrathecal penicillin therapy. These complications can
be prevented by observing slow introduction of a diluted
solution containing not more than 1,000 units penicillin
per cubic centimeter of diluent and not to exceed a total
dose of 10,000 units. There are some who advocate that
large intravenous doses of penicillin twice a day will re-
sult in adequate levels in the spinal fluid and thus in-
validate the intrathecal route.
It is noteworthy that a focus of infection was dem-
onstrated in 18 of the 26 cases here reported and that a
fracture of the skull was found in three additional cases.
Similar incidence of foci of infection and the presence
of skull fracture in this type of meningitis has been
reported by others.13'16
Hemophilus Influenzal Meningitis
The general procedures outlined above are applicable
to this type of meningitis as well. However, inasmuch
as this infection is peculiar to the young infant and to
the child age group, the need for early and vigorous
treatment is urgent. Accordingly the following pro-
cedures are recommended.
1. Start a slow intravenous infusion of Alexander’s
anti-hemophilus type B rabbit serum diluted in Ringer’s
solution following routine testing for sensitivity. The
amount of serum in mgm. available nitrogen is deter-
mined by the spinal fluid sugar level as outlined by
Alexander.
2. Continue sulfadiazine by whichever route is most
practicable and in doses to maintain a blood level of
20 mgm. per cent. Chemotherapy must be continued
for about three weeks after the spinal fluid becomes
negative or the patient’s temperature has returned to
normal.
3. Twelve to twenty-four hours after administration
of the serum, draw a blood specimen and examine the
serum for evidence of capsular swelling of the organism
by the patient’s serum diluted 1:10. Failure to produce
swelling indicates a lack of antibody and therefore addi-
tional rabbit serum must be given.
4. In critical cases perform a daily lumbar tap and
instill streptomycin in doses of 25 to 35 mgm. for three
days. Prescribe streptomycin in divided doses, totaling
1.5 to 2 grams daily not to exceed five days.
5. Supportive measures as indicated for other types
must be continued.
The Journal-Lancet
6. Heparin and air intrathecally can be considered
in special cases.
Comment: Since the introduction of streptomycin
there have been reports 4il that this antibiotic agent in
itself will control hemophilus influenzal meningitis. How-
ever, in view of the seriousness of this infection and its
predilection for the very young age groups, it is recom-
mended that all available measures be employed. Pro-
longed use of streptomycin may be dangerous.
Discussion
Notwithstanding our present-day knowledge of the
pathogenesis of bacterial meningitis, the biologic charac-
teristics of the organism, and the changes produced,
there are still a number of controversial problems with
which one is faced concerning the practical aspects of
treatment. Among these are the value of passively in-
duced antibodies, the use of heparin, the choice of
chemotherapeutic or antibiotic, or both, agents, and a
method of administration of the drugs of choice.
Until the discovery of the sulfonamides, meningeal
infections regardless of the etiological agent, were treated
with anti-meningococcic serum from the time it first be-
came available in 1907 and until Ferrys antitoxin became
popularized. The results for that era were discouraging.
However, abandonment of intrathecal administration
of serum and substituting massive doses of serum or
antitoxin intravenously as suggested by Herrick and later
popularized by Hoyne, resulted in a precipitous drop
in the fatality rate approximating that later reported in
some series treated with sulfonamides.
Nevertheless, since sulfonamide therapy was intro-
duced and clarified, there has been a noticeable decline
in the fatality rate of meningococcic and streptococcic
meningitis. The death rate for the pneumococcic type
has also been lowered but to a lesser degree with the
advent of penicillin. The mortality rate of meningitis
caused by the hemophilus influenzal bacillus has been
reduced from over 90 per cent to less than 20 per cent
by means of the sulfonamides, Alexander’s serum, and
streptomycin.
Summary
1. 198 cases of meningitis observed over a 4)4 year
period at the Minneapolis General Hospital are reviewed.
The meningococcus, pneumococcus, and hemophilus
influenzal bacillus were the etiological agents in over
85 per cent of the cases.
2. The most favorable result with the meningococcic
infection was obtained by the use of sulfadiazine and
penicillin. The pneumococcic infection responded best
to penicillin intrathecally and intramuscularly as well as
sulfadiazine. Meningeal infection caused by the hemoph-
ilus influenzae bacillus was controlled by combined sulfa-
diazine, Alexander’s antihemophilus, rabbit serum and
streptomycin.
3. A diagnostic and therapeutic routine for these three
types of meningitis is outlined.
May, 1949
187
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188
The Journal-Lancet
The Serum Amylase Levels in Mumps
Lee Bass, M.D., and Robert B. Tudor, M.D.
Bismarck, North Dakota
Mumps is a contagious disease characterized by
swelling of the parotid and sometimes of the
other salivary glands.1 The constitutional symptoms are
usually mild. Evidence points to a filterable virus as the
etiologic factor." The total incidence of complications
at Charity Hospital, New Orleans, over a recent five-
year period was found to be about 25 per cent. These
complications almost always occur after puberty.'*
The determination of the serum amylase 4 offers a
convenient method of substantiating a diagnosis of
mumps, especially during epidemics when many atypical
cases may be expected to occur. It is known that mumps
and meningo-encephalitis may occur without any parotid
swelling. It seems reasonable to assume that other com-
plications, such as pancreatitis, might follow the same
pattern.
In Table 1 are the serum amylase levels of 15 patients
with parotid or submaxillary swellings. In Table 2 are
the serum amylase levels of 12 patients who for one rea-
son or another were suspected to have mumps but whose
serum amylase levels were normal. In Table 3 are the
serum amylase levels of two patients, one of whom de-
veloped memngo-encephalitis during a mumps epidemic.
The other had abdominal pain and tenderness and vom-
iting which were consistent with a diagnosis of pancre-
atitis.
Serum amylase values of 300 mg. per cent reducing
substance or over are probably elevated.
Table 1
Age in
Y ears
Tempera-
ture
Swelling
Serum
Amylase
Levels
3.7
38.0°
Right parotid
1600
5.7
38.0°
Bilateral parotid
Right otitis media
760
7.2
37.2°
Right parotid, right sub-
maxillary
1032
7.6
37.6°
Submaxillary 8 days
after parotid
940
4.10
38.2°
Right parotid
993
4.4
37.2°
Palpable parotid
878
8.1
37.2°
Post mumps 2 wks.
right submaxillary
335
1.0
37.7°
Mumps contact
400
7.8
37.4°
Left parotid
355
1.10
39.7°
Bilateral parotid
430
1.3
40.4°
Palpable parotid
960
5.5
37.4°
Bilateral parotid
2285
6.10
38.6°
Submaxillary
500
6.5
38.0°
Both parotid
2043
6.0
37.7°
Submaxillary 2 days
after parotid swelling
1715
Summary
Serum amylase levels of 15 patients with mumps are
compared with amylase levels in children with other
upper respiratory infections and with levels in two
mumps complications.
* * *
Thanks are due to the chemical laboratory of the Johns
Hopkins Hospital, without whose cooperation this study could
not have been done.
References
1- Holt and McIntosh: Holts Diseases of Infancy and
Childhood, Appleton Century, N. Y.; 11th ed., 1940.
2. (a) Johnson and Good Pasture: J. Exper. Med. 59:1,
1934; (b) Wollstein: J. Am. Med. Assn., 71:639, 1918.
3. Humphries, J.: Am. J. Med. Sci., 213, 354-357 (March)
1947.
4. Meyers, V. C., Free, A. H., Rasinski, E. A.: J. Biol.
Chem., 154:39, 1944.
Table 2
Age in
Years
Tempera-
ture
Involvement
Serum
Amylase
Levels
6.8
37.4°
Contact. Submaxillary
swelling
296
5.0
39.4°
Contact. Nasopharyn-
gitis
92
8.8
37.0°
Day before mumps
occurred
220
4 mos.
39.4°
Meningitis
7
12
39.0°
Typhoid
280
8 mos.
38.7°
Nasopharyngitis, right
submaxillary swelling
46
3.6
36.8°
Palpable parotid
256
7.8
37.4°
Post mumps 1 week
274
2.0
39.4°
Cervical adenitis
225
1.11
39.8°
Cervical adenitis
136
3.8
37.8°
Cervical adenitis
49
4.1
37.8°
Cervical adenitis
90
Table 3
Age in
Years
Tempera-
ture
Clinical Findings
Serum
Amylase
Level
6.11
38.8°
Meningo-encephalitis.
Bilateral parotid swelling
for 2 days. No known
2098
mumps exposure
5.7
38.7°
Abdominal pain, vomit-
1020
ing, mumps exposure.
1 day later developed bi-
lateral parotid swelling.
Pancreatitis?
May, 1949
189
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. Thos. Ziskin, Secretary
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J H. Moore
Dr. Martin Nordland
Dr. K. A Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr R H. Waldschmidt
Dr. O H. Wangensteen
Dr. S. Marx White
Dr. H. M N. Wynne
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
ADVISORY COUNCIL
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons* Association
Dr. W W Taylor. President
Dr. R. C. Webb, Secretary- Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O. Hanson, Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert. Recorder
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Editorial
THE ROLE OF THE PEDIATRICIAN
AND GENERAL PRACTITIONER IN
MENTAL HYGIENE
The importance of mental hygiene is being increas-
ingly recognized by the medical profession, by educa-
tors and the public at large. It is more apparent every
day that if the goal of widespread mental and emotional
health is to be attained it will have to come through
preventive mental hygiene rather than through the treat-
ment of those who are seriously emotionally disturbed.
It is also increasingly obvious that perhaps the only, and
certainly the most effective, way of preventing serious
and lasting emotional and mental illness must come
through constructive work with children. The pediatri-
cian and the general practitioner have for many years
been doing valuable work in mental hygiene. As their
interest, knowledge, and realization of its importance
increases, more of their time will be spent in this phase
of their practice. Some do not realize how much they
are already doing, or how much can be done in helping
the child to have healthy emotional growth and develop-
ment. The objection often raised by physicians regard-
ing the inclusion of mental hygiene in their function and
duty is that it takes so much time that it is impossible
to effectively carry on this type of work. This objection
may be valid if one is considering the treatment of those
children who have serious emotional and behavior prob-
lems, but it is not valid if considering the work that can
be done in the prevention of such difficulties. The phy-
sician in his contacts with the parents of children under
his care can do far more than he realizes in a compara-
tively short time if he will give them help and guidance
along some of the following lines.
1. Give them reassurance and confidence in their abil-
ity to properly direct and guide their children. Many
parents are frightened and feel insecure and inadequate,
and reassurance will make it possible often for them to
have a happier, more normal relationship with their
children.
2. Help them to know what to expect of a child at
various stages in his physical and emotional growth so
that they will not impose standards impossible for the
child to meet.
3. Help them to see that their role as parents is not
that of trying to mold and force their children into a
pattern which they have set up, but rather it is their
function to guide, lead and help the child to develop as
an individual.
190
The Journal-Lancet
4. Help them to recognize and understand the impor-
tance of allowing a child to have all possible freedom
and responsibility, with, at the same time, as little cor-
rection, nagging, forcing and punishment as possible.
Point out the importance of avoiding non-essential issues,
tensions and frictions.
5. Help them also to see that for the child’s healthy
emotional growth and development it is equally impor-
tant that parents meet essential issues surely, fairly,
wisely, and understandingly. Although the child must
be given as much freedom as possible it is equally im-
portant that he not be given license.
6. Finally, help parents to see that if their children
are to grow up emotionally happy, mature and well-
adjusted adults, they must have the assurance of being
tremendously loved, liked and accepted by their parents.
This fundamental need of children must be met from
earliest infancy, and must continue to maturity. In fact,
this need for love and liking and acceptance must be met
during one’s whole lifetime if one is to be emotionally
happy and well-adjusted. However, it is particularly im-
portant during infancy, childhood, and adolescence.
The physician dealing with children can and must
continue to play a leading role in preventive mental
hygiene.
Edward Dyer Anderson, M.D.,
Minneapolis, Minnesota
News Items
North Dakota
When the North Dakota State Medical Association
meets in Minot May 15-17, members will hear a report
of a study on mental hygiene in the state as compiled
by the mental hygiene committee of the association.
Members of that committee met Tuesday at the state
hospital at Jamestown. Dr. R. H. Breslin, Mandan,
chairman, presided, and other committee members are
Dr. G. S. Carpenter and Dr. A. M. Fisher of James-
town; Dr. J. R. Ostfield, Fargo, and Dr. J. G. Lamont,
Grafton.
Dr. Teodor Koivastik, a DP bacteriologist from Es-
tonia, has been attached to the staff of the Fargo Clinic.
Before the war, Dr. Koivastik worked with the bacterio-
logical institute of the University of Tartu and served
as department director of the state serum institute. He
was exacuated to Germany in 1944 and later was deputy
director of the DP hospital laboratory at Augsburg. He
left Germany last February 1.
At the regular March meeting of the Northwest Dis-
trict Medical Society at St. Joseph’s Hospital, guest
speaker was Dr. L. B. Woolner, of Rochester, Minn.,
pathologist of the Mayo Clinic.
Dr. Woolner is a specialist in tumors of the lung, said
Dr. Henry Kermott, secretary of the association.
The district medical group is making plans for the
entertainment of the North Dakota State Medical Asso-
ciation at its convention here May 15-16-17, and Minot
medics report that an outstanding program is being
arranged.
Dr. M. W. Garrison of Minot is president of the
Northwest society.
New pathologist at St. John’s Hospital is Dr. Jack
Spier. He succeeds Dr. T. L. Donat, former acting
pathologist, who now heads the department of Roent-
genology.
Trained in pathology in New York City hospitals
following his completion of university work, Dr. Spier
later was instructor in pathology at the school of medi-
cine of George Washington University, Washington,
D. C. Afterwards, he served as assistant professor of
pathology of University of Arkansas at Little Rock,
until 1948, when he became acting head of the depart-
ment of pathology, also teaching in hospitals in the city.
Deciding to leave the academic field, Dr. Spier ac-
cepted an appointment here, effective April 1. He is
the author of several papers on tumors and general
pathology.
The Grand Forks Clinic announces the addition of
Dr. Frank A. Hill to the clinic staff. Dr. Hill’s prac-
tice is limited to obstetrics and gynecology.
The name of the Roan and Strauss medical clinic is
now changed to the Missouri Valley Clinic. Neither of
the two founding doctors are associated with the clinic
any longer, therefore the name was changed.
The clinic was founded by Dr. M. W. Roan and the
late Dr. F. B. Strauss, who died in 1946. Dr. Roan
retired from his medical practice about two years ago.
Members of the clinic today include Dr. P. L. Owens,
senior member, who has been on the staff for 20 years,
Dr. C. A. Arneson, Dr. J. C. Cartwright and Dr. R. B.
Cochran.
Minnesota
Dr. E. J. Huenekens, chief of staff at Sister Elizabeth
Kenny Institute and clinical professor of pediatrics at
University of Minnesota, has been appointed national
medical director of the Kenny Foundation, it has been
announced by Donald C. Dayton, Foundation president.
In his new position with the Foundation, Dr. Huene-
kens will be in contact with medical leaders throughout
the country with the aim of creating broader understand-
ing of the Kenny concept and treatment of polio.
Dayton also announced that Dr. Wallace H. Cole
of St. Paul, director of the division of orthopedic sur-
gery of University of Minnesota medical school, has
accepted the position of consulting orthopedist on the
Kenny Institute staff.
Dr. Cole was one of three medical men who originally
observed the work of Sister Kenny when she first came
to Minneapolis in 1940 and his announced affiliation
with the Institute renews close association with the other
two, who are presently members of the staff.
JUST MAI LJJ. T° youC fan-todaY-
?o7r chUkoTmoney order in an envelope
addressed to Can'* / d to the Amer.-
pas. office, wdl be del ^ ^ yQur #tote.
can Cancer Society
...to help to
lere's my *
4AME
ZONE-.
STATE
Give and keep giving to help science defeat the disease
that strikes, on the average, one out of every two
homes in America. Say to yourself . . . here is life-giving
money to help those stricken by Cancer to live again.
EVERY NICKLE AND DIME I give helps support an
educational program teaching new thousands how to
recognize Cancer and what to do about it.
EVERY QUARTER I give helps set up and equip new
research laboratories where scientists are dedicating
their lives to find the cause — and cure of Cancer.
EVERY DOLLAR I send helps buy new equipment, helps
establish new facilities for treating and curing
Cancer, both still pitifully scarce in this country . . .
Guard those you love! Give to conquer Cancer!
AMERICAN CANCER SOCIETY
192
The Journal-Lancet
They are Dr. Miland E. Knapp, chief of physical
medicine in charge of training and treatment, and Dr.
John F. Pohl, orthopedic consultant.
Dr. Knapp is a former president of the American
Congress of Physical Medicine and former chief of staff
at St. Barnabas Hospital. He is associate clinical pro-
fessor of physical medicine at University of Minnesota.
Dr. Pohl is former medical supervisor at Kenny Insti-
tute.
Dr. Ralph Rossen, superintendent of Hastings state
hospital, lead a discussion on personnel problems at a
nation-wide mental hospital institute in Philadelphia
April 11 to 15.
The institute, which attracted state hospital superin-
tendents, state officials and outstanding psychiatrists, was
sponsored by the American Psychiatric Association.
Theme of the five-day conference was "practical ways
of improving treatment and care of mental hospital pa-
tients under existing circumstances.” Others who at-
tended from Minnesota include Dr. Edmund Miller,
superintendent of Anoka state hospital, and Dr. Royal
Gray, head of the mental hygiene unit of the state divi-
sion of public institutions.
Dr. Arthur C. Skjold was elected chief of staff at
Fairview Hospital, Minneapolis. Dr. Silas Anderson was
elected vice chief of staff; Dr. Harry Mixer, secretary,
and Dr. Stanley Stone, treasurer. Elected to the execu-
tive committee were Dr. Donald B. Frane, Dr. Harry B.
Hall, Dr. Louis J. Roberts and Dr. R. W. Kouchy.
Dr. Myron M. Weaver, assistant dean of the Uni-
versity of Minnesota medical school, has been named
dean of a new medical school at the University of Brit-
ish Columbia, near Vancouver, Canada.
Finishing his sixth year at Minnesota, Dr. Weaver
will take over his new job July 1, and spend a year
preparing to open the new medical school in the fall
of 1950.
Dr. Reuben A. Johnson has been elected first presi-
dent of the newly-organized Minneapolis Society of
Internal Medicine.
It includes nearly 70 physicians practicing the spe-
cialty in Minneapolis and Hennepin county, a number
of full-time specialists in chest diseases at Glen Lake
Sanatorium and several full-time members of the staff
at University and Veterans hospitals.
Other officers include Drs. Reuben Berman, vice presi-
dent; George N. Aagaard, secretary; Russell M. Wilder,
recorder, and Harold E. Miller, treasurer. The execu-
tive committee includes the officers and Drs. Moses Bar-
ron, Henry Ulrich, George Fahr, Douglas P. Head,
and Richard V. Ebert.
Dr. Owen H. Wangensteen, head of University of
Minnesota, left the States for Puerto Rico, where he
took part in a conference of the Puerto Rico Medical
Association.
South Dakota
Most of Yankton’s medical men were in Vermillion
to attend the annual spring meeting of the Yankton
District Medical Society. The group discussed plans
and arrangements for the State Medical Association
meeting to be held in Yankton three days, May 21-23.
State Secretary John Foster of Sioux Falls was present
to discuss the convention with the doctors.
Presiding over the meeting of the Society was Dr.
C. B. McVay, Yankton, president, and an attendance
of about 50 doctors was noted. The scientific program
was presented by members of the faculty of the Uni-
versity School of Medicine, Dr. Donald Slaughter, dean,
and Dr. R. L. Ferguson, professor of pathology. They
discussed newer treatments of cancer and illustrated the
subject with a sound-color film.
Four Huron doctors were welcomed into the South
Dakota Medical Association’s "50-year-club” and pre-
sented gold lapel pins, boosting the state club member-
ship to six.
Doctors honored were O. R. Wright, who has prac-
ticed medicine 56 years; H. L. Saylor, 55 years; F. L.
Class, 51 years and T. J. Wood, 52 years.
John T. Foster, executive-secretary of the state med-
ical association, made the pin awards at a meeting of
about 40 doctors at the Huron Country Club.
Another public servant who has reached his fifty years
of continuous activity in the medical service is Dr. Fred
A. Richards of Sturgis.
Dr. Richards came to Whitewood in 1889. He took
his medical education at the College of Physicians and
Surgeons, the medical department of the University of
Illinois at Chicago.
He graduated from the University of Illinois medical
school in 1899. After his graduation he took special
training at the Chicago Lying-In hospital under Dr.
De Lee, and later a special course at the Chicago Poly
Clinic.
More than 400 persons from Tabor and community,
other South Dakota cities and several other states paid
tribute to Dr. and Mrs. Frank M. Blezek for their 45
years of "unselfish service to this community.”
Obituaries
Dr. H. P. Sawyer, 78 years old, a resident of Good-
hue for 44 years, died March 10 at a Red Wing hos-
pital. He had been ill for the past several years.
Born in Steele county November 25, 1870, he attend-
ed county schools and was graduated from the Owa-
tonna high school in 1899. He taught school for two
years and then entered the medical department of the
University of Minnesota. Following graduation, he be-
gan practicing in Goodhue in 1905 and continued work
until 1931, when he retired.
Otto Friederich Schusler, 75, retired orthopedic sur-
geon, died April 19.
Dr. J. Leland Van Gorden, 74, a Minneapolis physi-
cian for 33 years, died April 19 in Eitel hospital. Dr.
A new sedative-hypnotic
. . . not a barbiturate
Presidon, a new quick-acting,
mild sedative-hypnotic for insomnia
and nervous tension, is a pyridine
derivative chemically different from
the barbiturates, bromides and ureides.
Therapeutically it differs in the low
incidence of usual by-effects. Clinical
trials show that needed relaxation
or sleep is obtained without likelihood
of drowsiness on awakening,
"hangover,” excitation or headache.
Available in scored 0.2 Gm tablets,
bottles of 20 and 100.
HOFFMANN-LA ROCHE INC. • NUTLEY 10 • N. J.
Presidon
T.M. Presidon
'Roche'
194
The Journal-Lancet
Van Gorden was a graduate of the University of Iowa
and practiced at Emmetsburg and Des Moines before
coming to Minneapolis.
Dr. William A. Plummer, 65, a member of the staff
of the Mayo Clinic for almost 40 years, died of a heart
attack at his home March 22.
Dr. Plummer, the youngest brother of the late Dr.
Henry Plummer, came to the Mayo Clinic in June, 1910,
after his graduation from the Northwestern University
Medical School.
Dr. Plummer was born at Racine June 30, 1883.
Both his father and grandfather were doctors. His
father, Dr. Albert Plummer, was well known in south-
eastern Minnesota.
Dr. Harold E. Foster, 54, superintendent of the Fort
Meade veterans hospital, died April 19 of a heart attack.
Dr. Foster, a veteran of both world wars, assumed
administration of the hospital last July. He had been
connected with the Veterans Administration since 1927.
Dr. Henry Lester Baker, Chicago, formerly of Dres-
bach, Minn., died at his home in Chicago March 5.
Dr. E. H. Maercklein of Ashley, who has been in the
medical practice at Ashley since 1903, passed away at
the Veterans Hospital at Fort Snelling, Minn., Sunday
evening, March 6th.
Dr. Maercklein began the practice of medicine in
Ashley in partnership with his brother Fred in 1903 and
has been in Ashley since that time, with the exception of
about two years.
Word was received in Gretna and Neche of the death
of Dr. J. A. McKenzie at his home in Milwaukee, Wis.
Dr. McKenzie was a former Gretna doctor and was well
known in this community.
Advertisers ’ Announcements
PRISCOL BECOMES PRISCOLINE
A change in name from Priscol to Priscoline has been an-
nounced by Ciba Pharmaceutical Products, Inc., for its new
vasodilator which has gained wide medical acceptance since its
introduction last September. The change in name has been
made to avoid conflict with Drisdol, manufactured by Winthrop
Stearns. Priscoline is the first effective vasodilator that has
been available in prescription form. It can be taken in the form
of tablets or administered by injection both intravenously and
intramuscularly. It has proved highly effective as a sympatho-
lytic and adrenolytic agent in peripheral vascular diseases and
a recent report in the New York State Journal of Medicine
from a group of doctors at the Kingston Avenue Hospital in
Brooklyn told of the dramatic relief from pain that administra-
tion of this new drug gave to polio victims suffering from spas-
tic conditions.
HIGH-POTENCY HEPARIN PREPARATION
Organon Inc., of Orange, N. J., (formerly known as Roche-
Organon Inc.) has announced to the medical profession a new,
high-potency heparin preparation — Liquaemin (High Potency)
'Organon’ — containing 50 mg. of heparin sodium per cc. of
solution This preparation is especially well suited for adminis-
tration by intermittent injections — the method which is cur-
rently being recommended in many cases requiring anticoagu-
lant therapy because of the noteworthy advantages over continu-
ous intravenous drip.
Recent studies have indicated that adequate therapy with
heparin materially reduces the dangers of certain thrombo-
embolic complications, in particular those which occur during
coronary thrombosis, acute myocardial infarction, phlebothrom-
bosis, and thrombophlebitis. Liquaemin (High Potency) finds
its chief usefulness in the treatment of these conditions, although
it may be used as well in frostbite, vascular surgery, blood
transfusions, and all other disturbances in which anticoagulant
therapy has been shown to be of value. By the intermittent in-
jection method — intravenous, subcutaneous, or intramuscular in-
jections— the dosage of Liquaemin ranges from 25 to 100 mg.
given at intervals of 3 to 12 hours, depending upon the pa-
tient’s response as determined by the clotting time. The coagu-
lation time should be maintained at 20 to 30 minutes by the
Lee- White method or about 15 minutes by the capillary tube
method.
Liquaemin (High Potency) is available in 10-cc. vials contain-
ing a total of 500 mg. of heparin sodium per vial. Liquaemin
Organon’ is still available in its original strength of 10 mg.
of heparin sodium per cc. in 10-cc. vials.
BECOMVITE TABLETS
Sharp & Dohme, Inc., Philadelphia, announces the national
release of 'Becomvite’ Tablets, a B-complex and ascorbic acid
preparation highly successful in the treatment of vitamin B and
C deficiency states.
A well-balanced formula of the principal B-complex factors
and ascorbic acid, Becomvite’ Tablets were developed by the
Medical Research Division of Sharp & Dohme in response to a
trend toward the use of massive B-complex therapy. Ascorbic
acid has been incorporated in the formula for the purpose of
mixed vitamin therapy, which often is desired by physicians.
'Becomvite’ Tablets are indicated in the treatment of beri-
beri, pellagra, riboflavin deficiency, scurvy and selected sub-
marginal B-complex avitaminoses. This new product is also use-
ful as a supplement in the therapy of typhoid fever and other
infections in which there is a markedly elevated metabolic rate
during the period of high fever. It is also used to replace vita-
min losses following surgery.
Each 'Becomvite’ Tablet contains thiamine hydrochloride
(vitamin Bi) , 10 mg.; riboflavin (vitamin B2) , 10 mg.; pyri-
doxine hydrochloride (vitamin Bn) , 1 mg.; niacinamide, 100
mg.; calcium pantothenate, 5 mg.; ascorbic acid (vitamin C) ,
100 mg.
The suggested adult dose of 'Becomvite’ Tablets is one tablet
daily. If the symptoms are severe this dosage may be increased
at the discretion of the physician in accord with the patient’s
requirements.
'Becomvite’ is supplied in bottles of 30 and 500 tablets.
GERILAC, DIETARY SUPPLEMENT
Official recognition that there is a place in the diet of the
elderly for a special dietary supplement was the recent accept-
ance of Gerilac by the Council on Foods and Nutrition of the
American Medical Association.
Extremely gratifying results from using Gerilac as a diet sup-
plement in 38 surgical and non-surgical cases, ranging in age
from 50 to 86, were reported by Joseph L. DeCourcy, M.D.,
of Cincinnati, in the November-December, 1948, issue of
Geriatrics.
This official recognition of the special food coincides with a
marked increase in popular interest in geriatrics which results
from health education activity, articles in the lay press, and the
publishing of an official journal by the American Geriatrics
Society. The Borden Company, makers of Gerilac, reports in-
creasing inquiries about Gerilac which indicate public awareness
of the importance of special diet in advanced years.
Gerilac, the first special dietary supplement for the aged, is a
modified dried milk fortified with vitamins and minerals. Di-
luted with water, it makes a palatable beverage, and may also
be used in a variety of recipes. Two 8-ounce glasses of standard
dilution daily supply substantially more than minimum require-
ments of calcium, phosphorus, iron, vitamin A, thiamine, ribo-
flavin, ascorbic acid, and vitamin D, plus adequate high-value
protein. The caloric value of the two glasses is only 300.
In the Treatment of Prenatal Patients . .
K ULVICAL "Ulmer
JJ
ULVICAL "Ulmer” is a Calcium, Iron and Vitamin Tablet designed to supply
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Each Tablet Contains:
Vitamin B, (Thiamine Chloride) .. . 1.0 Mg. (167 USP Units)
Vitamin B2 (Riboflavin) 2.0 Mg. (1,000 Micrograms)
Vitamin A (Ester) 1,500 USP Units
Vitamin D (Irradiated Yeast) 200 USP Units
Vitamin C (Ascorbic Acid) 16 2-3 Mg. (333 USP Units)
Vitamin E (Tocopherol) — - 2 Mg.
Calcium Pyrophosphate - 7 */2 grs. (Ca. 150 mg., P. 100 mg.)
Ferrous Sulfate (Dried) (eq. Approx, to 3 Gr. USP) ... 2 Grs. (Fe. 38 Mg.)
Plus inert compounding ingredients.
DOSAGE: Two to six tablets per day
Prescribe ALPRINE "Ulmer’’
For the Quick Relief of Pain
Analgesic and Sedative
ALPRINE "Ulmer” has proved highly effective for the relief of severe
pain. Its action is quick, analgesic, antipyretic and sedative. The seda-
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action from Acetyl-salicylic Acid 3 Vi grs. and Acetphnetidin 2 grs.
Two-Fold Action
ALPRINE "Ulmer” is particularly effective because of its two-fold action
which not only relieves severe pain but also helps to control the nervous
excitability which often accompanies these manifestations. It has a tend-
ency to reduce fever, yet does not affect body temperature where it is
normal.
Rapid Vasomotor Action
ALPRINE "Ulmer” quickly reduces the sensibility of the sensory nerves.
Moderate doses, which are rapidly absorbed and quickly eliminated, are
usually adequate. Pain relief is prolonged, without producing drowsiness.
Available in bottles of 100, 500, 1000 and 5000 tablets.
ULMER PHARMACAL COMPANY Products - NOT ADVERTISED TO THE LAITY
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MINNEAPOLIS
MINNESOTA
196
The Journal-Lancet
Class ified A die rtisements
DOCTORS’ OFFICES FOR RENT
Suite of rooms, recently vacated, over drugstore at
Lowry and Emerson Avenues North. Suitable for two
doctors or doctor and dentist combination. Write to Mr.
M. J. Leyne, 1122 Lowry Avenue North, Minneapolis.
RESIDENT PHYSICIAN
An opening for two Resident Physicians on April 1
and July 1, 1949. Mixed residency, excellent preparation
for general practice. Salary $300 a month and mainte-
nance or $300 a month plus three room apartment.
Address inquiries Administrator, St. Luke’s Hospital,
St. Paul, Minn.
FOR SALE
Maico Audiometer in perfect condition, used only by
Maico of Fargo and guaranteed by them. $150, F.O.B.
Fargo. Write Student Health Center, N. Dakota Agric.
College, Fargo, N. Dak.
ASSISTANCE AVAILABLE
Woodward Medical Personnel Bureau (formerly Aznoes
— Established 1896) have a great group of well trained
physicians who are immediately available. Many desire
assistantships. Others are specialists aualified to head
departments. Also Nurses, Dietitians, Laboratory, X-Ray
and Physiotherapy Technicians. Negotiations strictly
confidential. For biographies please write Ann Wood-
ward, Woodward Medical Personnel Bureau, 185 North
Wabash, Chicago.
FOR RENT
Doctor’s suite. Lovely offices in a wonderful location
in South Minneapolis. This is on second floor of a new
building at 4213 E. 41st St. This suite, in connection
with the dental suite, would be suitable as a clinic. Wm.
L. Cochrane, 4054 - 42nd Ave. So., DR. 4307.
YOUNG M.D. WANTED
for general practice at Henry Clinic. $600 per month to
start. Permanent or long term association desired. Spe-
cial percentage system later. Contact Dr. J. C. Henry,
Milaca, Minn.
ABBOTT HOSPITAL
(JANNEy CHILDREN S PAVILION)
110 East 18th Street ^ Minneapolis, Minn.
PEDIATRICIANS, PARENTS AND PATIENTS
a complete, conveniently located division devoted to PEDIATRIC SERVICE, maintaining the highest
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DR. REUBEN A. JOHNSON, Internal Medicine President and Chief of Staff
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ELIZABETH LOWRY, Pediatrics Secretary
Patronized by all the recognized pediatricians in Minneapolis
ACTIVE
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Foreword
The physician of today is confronted by a body of information of ever increasing scope
and depth. Medical societies, medical publishers, schools of medicine, and all those organiza-
tions which hope to assist in keeping the physician informed must decide which of two
approaches they will utilize. Shall they adopt the first method of presenting a number of
unrelated pertinent subjects or shall they use the second approach, that of concentrating
attention upon a group of diseases or a system of the body. The University of Minnesota
Medical School through the Center for Continuation Study is more and more following the
second policy, that of covering more thoroughly a limited area of medical science.
The Journal-Lancet has frequently devoted its pages to a similar purpose and has
presented symposia of interest to the practicing physician. In the pages that follow, the edi-
tors present a series of articles on the allergic states. Some of the material has been pre-
sented by the authors in continuation courses offered recently at the Center for Continuation
Study.
It is particularly fitting that allergy should be presented at this time. In recent years,
many new drugs have been released for use in the treatment of allergic disorders. In addi-
tion allergic mechanisms or immune mechanisms have been shown to play an important part
in the etiology and pathogenesis of such diseases as rheumatic fever and lupus erythematosis.
It is important, therefore, that practicing physicians have an understanding of the funda-
mentals of the allergic response.
This symposium is presented with the hope that it will not only be of practical value
in the diagnosis and management of the allergic disorders, but that it will also contribute
to a greater understanding of the mechanisms through which such disorders arise.
George N. Aagaard, M.D.
198
The Journal-Lancet
Allergic Rhinitis in Pediatrics
Albert V. Stoesser, M.D., Ph.D.*
Minneapolis, Minnesota
This discussion is limited to allergic rhinitis in infants
and children. The condition has been referred to
as vasomotor rhinitis, perennial hayfever, or atopic co-
ryza. For many years this allergic manifestation was
considered to be most common in the older child but
more accurate observations have revealed that it may
be found in the young child. There are cases in which
the infant has had a chronic nasal discharge. At first
this was thought to be due to an irritation of the nasal
mucosa by the vomitus of babies who regurgitate fre-
quently. Then the lint from blankets and fuzzy gar-
ments was named as the cause. Occasionally infections
in other members of the family were blamed. In the
latter instance, however, the nasal symptoms are usually
present for the average duration of any inflammation
of the nose. The infants with a clear nasal discharge
with or without obstruction for a relatively long period
of time offer a difficult problem for the physician.
From early life the symptoms move on into childhood.
Periodically there are flareups with fever and the dis-
charge becomes mucopurulent. These episodes may oc-
cur quite frequently and there was a time in the past
when removal of the adenoids was recommended as the
best form of treatment, regardless of the age of the
child. Some of the patients responded well, but many
did not and with the introduction of sulfonamides, the
latter group received these drugs frequently. Later peni-
cillin was employed, and now aureomycin has been tried
with doubtful results.
The question is whether the children are suffering
with a chronic infection or repeated infections, or an
allergic manifestation. Most important is the family
background. Often this is forgotten. A history of aller-
gy or allergic disease in the mother and/or the father
is most significant. It must be investigated. Then, too,
the infant may have a concomitant allergic condition
such as eczema or urticaria. Such a situation makes the
diagnosis much easier. One of the recent important de-
velopments is the close watch of the patient. Sulfona-
mides or penicillin are not to be administered for all
flareups in nasal symptoms. Instead, make every effort
to convince the parents that the child must be observed
over a fairly reasonable length of time.
Examination of the patient usually will reveal nothing
except some disturbance in the nasal passages. In the
infant and young child the turbinates are frequently
moderately swollen, the mucous membrane is pale and
Presented at Continuation Course in Pediatrics, University of
Minnesota Center for Continuation Study, Minneapolis, Minn.,
April 7, 1949.
*From the Division of Pediatrics of the Minneapolis General
Hospital and the Department of Pediatrics of the University
of Minnesota Medical School.
quite moist, and there is much thin clear discharge.
Older children may have the same picture but there are
instances in which the nasal mucosa is greatly swollen
and deep red in color. Obstruction is the chief symp-
tom and there is little secretion. Often these cases are
hard to differentiate from those suffering from chronic
infections.
A history of allergy in the family warrants an exam-
ination of the nasal secretion. A clear discharge may
reveal on examination of a stained smear a predomi-
nance of eosinophiles and a cloudy almost mucopurulent
one may be loaded with clumps of the same cells. In
such cases the cutaneous allergy tests are indicated.
This procedure has been recommended by some physi-
cians, condemned by others. Extensive observations have
shown that the tests have gained favor in the hands of
the clinicians who have investigated this diagnostic tool
thoroughly enough to know what constitutes a good
procedure. Fresh allergens must be employed. The
method of application must be uniform and in children
nothing is better than the puncture technique. The in-
terpretation of the positive reactions must be made in
the light of the age of the child, the food habits, the
environment and the severity of the allergic rhinitis.
The greater the number of children offered the com-
plete set of cutaneous tests, the larger the percentage of
satisfactory results.
The treatment of the infant and child with a nasal
allergy involves a thorough clinical study. First, the
general condition of the patient should be considered.
What is the nutritional status? Is the hemoglobin at
the proper level? Do the urine and blood examinations
reveal any evidence of infection? If so, is it located
in the teeth, throat, ears, or the urinary tract? All these
questions must be considered. If any trouble is found
it should be corrected, but there is one exception, namely
the removal of the tonsils and adenoids. If this opera-
tion is necessary, it would be best to wait until after the
child is under control from the allergic standpoint.
The emotional status also is important. Many homes
are in constant turmoil and the allergic child appears
to be upset most of the time. Meals are irregular, hours
of sleep are too few. As a result the young patient is
irritable, the older one tired and disinterested. Progress
can not be obtained with any form of therapy for aller-
gic rhinitis until the home life of the child is made as
cheerful and regular as possible.
The sensitivities of the patient require plenty of con-
sideration. In the infant there are the foods, occasionally
the inhalants. The preschool child has both food and
inhalant sensitivities. The school years bring more em-
phasis on the inhalants, including the pollens and molds.
A few children have a true sensitivity to bacteria.
June, 1949
199
What can be done about these so-called allergies?
The majority of the patients have only a few, although
physicians have discouraged parents by telling them that
their children are sensitive to many things. After years
of investigation in the allergy clinics, the handling of
these cases has developed into a definite pattern. The
results have been most encouraging.
It takes much time on the part of the clinician and
good cooperation from the parents to fight the child’s
sensitivities. A good history and set of skin tests may
be the basis for recommendations as to the way the child
is to live. During the interviews with the parents, the
following must be discussed in detail:
1. Diet eliminations
2. Household pets or animals
3. Reduction of allergens in bedroom
4. Avoidance of dust in other parts of home
5. Blooming house-plants
6. Perfumed things containing orris root
7. Insecticides
8. Odors and smoke
9. Drafts in the home
10. Bathing and swimming
11. Nasal medication (nose drops)
12. Exertion (too active play)
Never should the physician assume that the mother
and father know much about the handling of their aller-
gic child. The parents must be shown that a progressive
interest in the care of the sick individual is most essen-
tial. Nothing is more encouraging than to have them
return for further advice and at the same time indicate
how much they have already accomplished. Intelligent
questions clearly reveal that the parents are looking for
more and more things to do in order to improve the
child’s way of living.
The elimination of the offending foods from the diet
and/or the removal of the irritating inhalants from the
environment is important before any drug therapy is
considered. No medication is to be placed in the nasal
passages, nothing is to be inhaled, no suction is to be
employed. The so-called antihistaminic preparations may
be prescribed with the warning that they be discontinued
as soon as possible. Neo-hetramine, Neo-antergan and
Pyribenzamine are recommended for the average case
especially as a daytime medication. The infant and
young child may be given Syrup of Neo-hetramine or
Elixir of Pyribenzamine. Histadyl, Thenylene, Diatrin,
Tagathen and Chlorothen offer a moderate amount of
sedation. Small children tolerate Syrup of Histadyl
most satisfactorily. Trimeton, Pyrrolazote, Decapryn and
Benadryl must not be forgotten. The latter two have a
definite sedative effect and can be employed at bedtime
and during the night, as Syrup of Decapryn or Elixir
Benadryl.
Some patients appear to be quite tired in connection
with their nasal allergy. Many of these children are
benefited by the antihistaminic called Thephorin, which
may be prescribed as a syrup or tablet. Furthermore,
this drug has been used in cases who have a tendency
to cough. It has helped. However, the same response
has been obtained from Hydryllin. Definite coughing
spells have been controlled by Benylin, Pyribenzamine
Expectorant or Syrup of Hydryllin Compound.
A chronic cough may develop in association with the
allergic rhinitis. This can be a forerunner of bronchial
asthma, especially if there is no evidence that an infec-
tion is present. These children must be watched closely
for the first signs of wheezing. More emphasis than
ever before should be placed on the elimination and
reduction of the offending allergens in the child’s en-
vironment. The antihistaminic drugs must not be pushed.
Sometimes it is best to discontinue their use and substi-
tute preparations containing a little ephedrine and an
iodide.
Hyposensitization therapy in the infant and young
child with allergic nasal symptoms exclusive of polhnosis
is over-rated. After seventeen years of observation of
the various methods recommended, the conclusion has
been reached that there is still much room for improve-
ment. It must be remembered that foods and inhalants
are relatively poor antigens. They do not easily stimu-
late antibody formation of lasting significance. It makes
little difference as to whether one employs the subcu-
taneous or the intracutaneous route of administration,
and uses very low or rather high doses of allergens.
Occasionally the response to this form of treatment is
encouraging, but it usually is of short duration. Most
often the house-dust inoculations do appear to be of
some value. However, many parents soon discover that
their children do just as well without the specific therapy
provided they are very careful with the way each child
lives.
The general welfare of the patient, mental as well as
physical, must be considered in connection with repeated
inoculations. Quite a number of children are upset by
this procedure, especially after they are old enough to
learn that there appears to be no definite time for the
termination of the treatment. Happy is the youngster
who knows what to leave out of his diet and avoid in
his surroundings, thereby requiring no so-called "shots.”
Many of the cases responding quite satisfactorily to
the various allergenic preparations have been analyzed.
They have revealed that there may be a release of anti-
bodies as a result of shock from the injection of a
foreign substance. Boiled milk and typhoid vaccine have
given the same results. The element of specificity be-
comes questionable.
The frequent administration of sulfonamides and
penicillin or aureomycin to children who have a definite
allergic rhinitis with repeated elevations in temperature
is a poor procedure. Most of the trouble is located in
the posterior aspect of the nasal passages or in the naso-
pharynx. Better ventilation of the former through a
more thorough control of the child’s allergic condition
including the use of antihistaminic drugs, and the re-
moval or reduction in the lymphoid tissue on the pos-
terior wall of the pharynx will help. Radium therapy
can be considered.
200
The Journal-Lancet
Summary
Allergic rhinitis may appear early in infancy and ex-
tend in increasing incidence through childhood. A his-
tory of allergy in the family is an important diagnostic
factor.
Inspection of nasal passages, examination of the nasal
secretions, and a good set of skin tests are of much help
in establishing the proper treatment.
Therapy takes into consideration the general condition
of the children, physical as well as mental. Elimination
or reduction of the offending allergens as applied to the
way the child lives is more satisfactory than specific
treatment.
The antihistaminic drugs may be employed but dis-
continued as soon as possible. Coughing, leading to
wheezing, is a contra-indication in the use of these
preparations.
REPORT OF THE NORTH DAKOTA STATE MEDICAL MEETING
Election of officers concluded the business meeting of the 62nd annual North Dakota
State Medical Association Meeting. Dr. W. A. Wright of Williston was installed as presi-
dent, succeeding Dr. W. A. Liebeler of Grand Forks. Officers elected were: Drs. L. W.
Larson, Bismarck, president-elect; W. E. Lancaster, Fargo, first vice president; O. W. John-
son, Rugby, second vice-president; O. A. Sedlak, Fargo, secretary; E. J. Larson, Jamestown,
treasurer; A. E. Speak, Dickinson, speaker; G. A. Dodds, Fargo, vice-speaker.
Councillors elected were Dr. J. C. Fawcett, Devil’s Lake; Dr. Joseph Sorkness, James-
town; and Dr. A. R. Gilsdorff, Dickinson. Recommended to the governor for appointment
to the state board of medical examiners were Drs. C. J. Glaspell, Grafton; D. J. Halliday,
Kenmare, and Joseph Sorkness, Jamestown. Dr. M. S. Jacobson of Elgin was recommended
for appointment to the state health council and Dr. L. W. Larson of Bismarck was ap-
pointed to the medical center advisory council.
The last two days of the convention were scheduled for the scientific program. The
main speakers included: Drs. G. A. Kernwein, Minot; Jerome Hilger, University of Min-
nesota; G. Alfred Dodds, Fargo; N. O. Brink, Bismarck; J. R. McDonald, Mayo Clinic;
Oswald Wyatt, University of Minnesota; A. L. Cameron, Minot; E. A. Haunz, Grand
Forks; J. J. Ayash, Minot, and Colin S. MacCarty, Mayo Clinic.
Special luncheon meetings were held by the North Dakota State Pediatric Society, So-
ciety of Obstetrics and Gynecology, and the Academy of Ophthalmology and Otolaryngology.
JOURNAL-LANCET LECTURESHIP
Dr. Leslie J. Witts, Nuffield Clinical Professor of Medicine at Oxford University, Eng-
land, is the speaker for the annual lectureship sponsored by the Journal-Lancet for the
University of Minnesota Medical School. His lecture, "Intestinal Macrocytic Anemia,” will be
presented Wednesday, June 8th at 3:00 p.m. in the Todd Amphitheater, University Hospital.
Dr. Witts has gained world-wide recognition for his work in blood and liver disease.
In England he is particularly well known for his work during the war as the Administrator
of Civilian Medical Affairs.
The Journal-Lancet Lectureship was established nine years ago and has afforded many
fine speakers for the advancement of medical knowledge in the upper midwest.
June, 1949
201
The Management of Status Asthmaticus
William Sawyer Eisenstadt, M.D.
Minneapolis, Minnesota
Status asthmaticus is a condition of severe, continu-
ous asthma, unrelieved by injections of epinephrine
even when frequently repeated and in increased dosage.
The patient is very ill and may die unless the attack of
asthma is broken. When this occurs, its treatment taxes
the ingenuity of the best clinician.
When these patients are first seen, they give the class-
ical picture 1 of severe asthma. They are usually in a
sitting position with the body slightly forward from the
waist, their hands grasping the edge of the bed or chair.
The accessory muscles of respiration are forcibly in use,
the face is drawn and ashen. The pallor may at times
give way to cyanosis. Perspiration is profuse, for these
patients are laboring for breath. The patient is terrified
because of the repeated failure of the usual therapeutic
medications. In addition, the family is anxious. There
is a generalized spirit of hopelessness present and, not
infrequently, the physician shares this feeling. This
period of intense dyspnea may last from a few days to
a week or two.
Status asthmaticus occurs chiefly in the group of in-
trinsic or infectious asthmatics, a group usually develop-
ing asthma for the first time in middle or later life.
This condition occurs less frequently in the extrinsic
asthmatic and then it is usually due to specific sensitivi-
ties. As a rule, when intractable asthma occurs in the
extrinsic asthmatic, the solution of the problem may be
relatively simple, representing nothing more than the
removal of the offending agent or agents from the pa-
tient’s environment, or the removal of the patient from
them.
Most of the fatalities in bronchial asthma occur in
status asthmaticus. Death may be due to asphyxia or
cardiac failure, but just as often, perhaps, it is due to
exhaustion and dehydration.
The most consistent pathological finding in patients
who have died in status asthmaticus 2 is the presence in
the small, medium or large bronchi of thick, tenacious,
gelatinous secretions which the patient was unable to
raise. Much of the bronchial tree may be entirely oc-
cluded. In addition to these mucous plugs, edema of
the bronchial walls and bronchospasm contribute to this
bronchial occlusion.
Examination of the chest elicits surprising findings to
the uninitiated. Everyone is familiar with the "band-
box” heard in mild cases of asthma where there is only
partial but widespread occlusion of the bronchi, as a
result of which the sounds are widely distributed. In
status asthmaticus, one finds areas of diminished and
absent breath sounds, areas of quiet that to the experi-
enced observer are ominous. In these patients, areas of
lung have ceased to function normally because the bron-
chi serving those portions may be partially or totally
occluded by thick, tenacious, gelatinous plugs of mucus.
When one listens to such a chest, the need for prompt
and vigorous therapeutic measures is immediately ap-
parent.
The basic principles involved in a proper therapeutic
approach in the treatment of status asthmaticus are (1)
to increase the lumen of the respiratory passageway,
and (2) to decrease the minute volume of respiration.
The following discussion sets forth a routine for the
treatment of status asthmaticus which has produced the
most favorable response.
Hospitalize
Hospitalization should be insisted upon immediately.
This will accomplish several indispensable purposes.
First, the patient is removed from intimate contact with
over-anxious relatives. Further, the hospital offers trained
personnel, equipment and medicinal agents not readily
available in the home.
Although most of the patients fall in the intrinsic or
infectious group, environmental factors should not be
overlooked. Thus, the removal of the patient from the
environment in which this condition developed may fre-
quently be beneficial. If the status asthmaticus is due
to pollen in the air, air conditioning with filtration is
desirable if available. The ordinary precautions for the
preparation of a dust-free room should be adhered to.
It is wise to cover both the pillows and mattress with
non-allergic encasings. Flowers should be prohibited.
Stop all epinephrine and ephedrine compounds
We believe that this is the most important procedure
employed. If nothing else can be done, this is the one
thing to do. These patients have already received epi-
nephrene, epinephrine-like, ephedrine and ephedrine-hke
compounds, to the point of nervous irritability and tox-
icity. They are "epinephrine-fast.” Further epinephrine
will only increase the patient’s irritability and nervous-
ness, produce tachycardia, palpitation, headache, pallor
and weakness, with no effect on the dyspnea itself. The
continuance of status asthmaticus proves the medication
to have been ineffective, and a new start should be made.
All sympathomimetic medications should be removed for
a period of 48 to 72 hours, preferably the latter, and
only then reintroduced. During this interval there is a
strong temptation to reintroduce epinephrine, especially
when the patient continues in relatively severe asthma
and substitute therapy is of relatively little value. How-
ever, the discontinuance of epinephrine should be ad-
hered to strongly during this interval.
When reintroduced, small quantities should be given,
0.3 to 0.5 cc. (5 to 8 minims), and repeated as often
as necessary, even within 15 or 30 minutes. The smaller
202
quantities will obviate the side effects of epinephrine and
will produce the same therapeutic effect as larger quan-
tities. It is preferable to use the aqueous (1-1000) epi-
nephrine, rather than the prolonged type ( 1-500) in
sesame oil, peanut oil, or gelatin. In a hospital there is
no particular advantage in using the prolonged acting
preparations for there is always the danger of overdosage
from too rapid absorption, especially if the syringe is
wet, with resultant side effects.
The problem in the treatment of status asthmaticus
resolves itself into keeping the patient alive and as com-
fortable as possible for the next 48 to 72 hours follow-
ing admission, for whatever the cause, when epineph-
rine is again introduced, invariably the patient will re-
spond, especially if the other measures recommended in
this paper are adhered to. If there is no accompanying
infection in the bronchi, or the infection is minimal, the
response will usually be immediate and fairly complete.
If the accompanying infection is moderate, the response
to epinephrine will be modified. The greater the accom-
panying infection, the less the response, but there will
be a response. In the presence of infection, methods to
combat the infection should be instituted immediately.
The use of antibiotics, which are of great importance
here, will be discussed subsequently.
Hydration
This extremely important phase of treatment is almost
always neglected. These patients are dehydrated. They
have been sick for a number of days without sleep, food
or fluids. This is evidenced on admission by the very
noticeable relative increase of the blood hemoglobin, red
blood cell count, white blood cell count with a normal
differential, along with a minimal increase of body tem-
perature of about a degree. These soon return to nor-
mal after adequate hydration within 24 to 48 hours.
We routinely give 2 to 3 liters of 5 per cent glucose
in distilled water or in isotonic sodium chloride solution
alternately during the first two or three days of hospitali-
zation. Additional fluids should be given orally as tol-
erated. These fluids will replace lost body water and
bring about a positive water balance. They tend to
thin out the bronchial secretions and thus promote ex-
pectoration of the thick, gelatinous, inspissated mucous
plugs in the bronchi. The dextrose used in hydration
therapy will supply needed calories and replace liver
glycogen, badly depleted because of the previous repeated
injections of epinephrine and the failure of the patient
to take adequate nourishment. Glaser 1 suggests that
this depletion of glycogen may be a factor in the de-
velopment of epinephrine fastness.
In the past, hypertonic dextrose ’•<> solutions up to
50 per cent, given in quantities from 50 to 100 cc., at
intervals of six to eight hours, have been recommended.
The idea was to produce dehydration of the lungs and
thus lessen the edema of the bronchi. However, its
accompanying effect of dehydrating the patient gen-
erally and thickening the bronchial secretions defeated
one of the major objectives of treatment — the evacua-
tion of the thick, inspissated mucous plugs. Because of
The Journal-Lancet
this effect, the use of hypertonic dextrose solutions
should be discarded.
Aminophyllin ( Theophylline with Ethylenediamine)
The bronchodilating effect of aminophyllin intra-
venously at times is lifesaving. Initially, the patient
should receive 0.25 grams (3)4 grains) in 10 cc. of
diluent given slowly, preferably through a fine needle.
If this dose is sufficient for symptomatic relief, it can
be repeated every four to six hours. If relief is only par-
tial, the dosage may be increased to 0.5 grams (7(4
grains) in 20 cc. of diluent. When given slowly and
regulated to the patient’s tolerance, the toxic effects of
aminophyllin, such as vertigo, faintness, headache, tachy-
cardia, palpitation, extreme flushing and sense of heat,
substernal distress, and nausea and vomiting may be
obviated. If they do occur, they may be minimal. In
uncomplicated asthma, aminophyllin is not a dangerous
drug. However, in the presence of cardiac complica-
tions caution must be used. The need for repeated intra-
venous injections of aminophyllin may be lessened by
inserting 0.5 gram of aminophyllin per liter of fluid
during the period of venoclysis.
The drug is also moderately effective when given
rectally, either in suppository form or as a retention
enema. The suppository contains 0.5 gram of aminoph-
yllin. One-half gram of aminophyllin powder dissolved
in 30 to 60 cc. of tap water may be used as a retention
enema.
Continuous intravenous aminophyllin in status asth-
maticus has recently been introduced by Goodall and
Unger.' Dosage consisted of up to 2 or 3 grams of
aminophyllin dissolved in 2,000 cc. of 5 per cent glucose
in physiological salt solution or distilled water alter-
nately, given at the rate of 28 drops per minute. The
solution is given continuously over a 24 hour period for
several days until relief is afforded.
We see no particular advantage to this method, be-
cause the same coverage can be achieved by employing
repeated intravenous injections of aminophyllin together
with rectal suppositories or retention enemas, without
the extreme inconvenience to the patient of having a
needle in his vein continuously for three or four days.
This is extremely important when considering that the
patient in status asthmaticus is already in extreme dis-
comfort because of his marked dyspnea.
Occasionally patients may become refractory to the
intravenous administration of aminophyllin. Recently.
Prigal * has recommended the aerosolization of aminoph-
yllin when this occurs. The contents of a 10 cc. (0.25
gram) or 20 cc. (0.5 gram) ampule are nebulized at six
to eight hour intervals. We have employed this pro-
cedure in a limited number of patients. Definitive judg-
ment as to its relative value remains to be determined.
As in the case of "epinephrine fastness,” when pa-
tients become refractory to aminophyllin by intravenous
injection or aerosolization, its use should be discontinued,
as further dosage will serve only to increase its toxic
effects.
June, 1949
203
The use of intravenous aminophyllin in the treatment
of children may be employed in the same manner, the
dosage being .006 grams per kgm. (1/20 grain per
pound) .
Inhalation Therapy
Inhalation therapy is directed toward decreasing the
minute volume of respiration. It rarely of itself will
interrupt status asthmaticus. Its use is therefore em-
ployed to make the patient more comfortable by dimin-
ishing the extreme respiratory effort caused by the an-
oxia, by enriching the surrounding air with oxygen.
Oxygen may be employed with a tent, nasal catheter,
or B.L.B. mask. At times, patients will rebel against the
use of a tent because of a feeling of claustrophobia.
This may increase their anxiety and nervousness, with
resultant increase of their exertional dyspnea.
Barach 11 introduced a mixture of 80 per cent helium
and 20 per cent oxygen, a mixture which has one-third
the density of air. It therefore should diffuse more
readily through the partially obstructed bronchioles. Its
cost, however, is a limiting factor and, in our personal
experience, oxygen has been equally as good.
Sedation
In employing sedation, one must guard against over-
sedation. However, measures to insure sleep and to over-
come nervous tension are very necessary. We have used
Demerol repeatedly, but with considerable caution. Used
judiciously, it has proven to be a most effective drug.
Its action 10 has apparently been twofold, sedation and
a direct bronchodilating effect. In status asthmaticus,
one must be extremely careful about respiratory depres-
sion and depression of the cough reflex, effects which are
relatively minimal with Demerol as compared to the
opiates.
In this connection, mention should be made concern-
ing the use of morphine. In the past it has been used
extensively, occasionally beneficially. However, one can
say it should never be used in asthma, and especially so
in status asthmaticus, where the patient is anoxic, ex-
hausted and battling for life. Morphine depresses the
respiratory center, diminishes the cough reflex and dries
the bronchial secretions (especially if given with atro-
pine) . Thus, morphine actually promotes further an-
oxia— to the point of asphyxia — which is the very thing
we are trying to combat. Because of the stagnation of
the bronchial mucous plugs, the patient literally drowns
in his own bronchial secretions. Vaughan 11 and Lam-
son 1J have shown that in many deaths due to asthma
during status asthmaticus, morphine was given prior
to death. The use of all other opiate derivatives should
also be avoided.
The dosage of Demerol should be regulated with ex-
treme care. Adults should never be given an initial dose
exceeding 50 mgm. intramuscularly. It may later be nec-
essary to increase to 75 mgm., and only rarely to 100
mgm. This can be repeated at 6 to 8 hour intervals.
It should be used for relatively short periods, three, four
or five days, because of the possibility of addiction.1'5
The routine use of Demerol for the relief of the usual
acute attacks of bronchial asthma, as has been advo-
cated, is to be condemned because of its properties of
addiction. When using Demerol we have avoided using
other sedatives, because of the possibility of over-sedation
and the depression of all body functions.
Demerol may be used in a similar manner in chil-
dren, the dosage being 1)4 mgm. per kgm. (1/5 minim
per pound) .
Other sedative measures have been advocated by
others/ Our experience with them is limited, but we will
mention them- briefly. (1) Paraldehyde may be given
rectally, 15 cc. in 100 cc. of olive oil at twelve hour
intervals. (2) Barbiturates may be given at four to eight
hour intervals. (3) Chloral hydrate, 1 gram, and sodium
bromide, 4 grams, may be given at four hour intervals
until the patient becomes drowsy; then stop. (4) A
mixture of ether, 2 oz., and olive oil, 4 oz., mixed thor-
oughly, may be administered as a retention enema.
If any of the above are employed, only one should
be used and not a combination. If used properly and
carefully, sedation is extremely beneficial and life-saving.
Its drastic use in an already exhausted and anoxic indi-
vidual may be dangerous and disastrous.
Expectorants
Methods which will thin out bronchial secretions and
thus will help clear the bronchi of their mucous plugs
are highly desirable. The best medication to achieve this
is potassium iodide. It has been shown by Tuft 1 1 that
the iodides are excreted in the bronchi in high concen-
tration. Ten to fifteen drops of a saturated solution of
potassium iodide are recommended four times daily until
the patient is free of expectoration. If there is an in-
tolerance to potassium iodide, enteric coated ammonium
chloride tablets in 0.5 gram doses may be given four
times daily.
Manual Elevation of the Diaphragm
In the presence of status asthmaticus physiological
pulmonary emphysema is present. There is trapped air
because of the partially and completely occluded bron-
chioles. Manual elevation of the diaphragm, as sug-
gested by Gay,10 is often followed by subjective relief
as well as an increase in the vital capacity from 200 to
1000 cc. The procedure is carried out as follows: the
palm of either hand is placed underneath the ribs on one
side and pushed upward and inward during the latter
half of expiration. Then this is repeated on the other
side. The escape of trapped air may frequently be heard
as a wheeze. This procedure should be repeated three
to four times daily.
Bronchoscopy
Although we have not had occasion to use bronchos-
copy, its use should not be overlooked. The mechanical
removal of thick, tenacious mucus from the bronchi
would appear to be a most reasonable treatment. Bron-
choscopy has undoubtedly been restricted in its use be-
cause patients seem so gravely ill that any procedure
which places a greater strain upon them would almost
appear to be inadvisable. In skilled hands it is a rela-
204
tively safe procedure and the risk is much less than that
of possible asphyxia from the disease. However, pre-
operative medication should be kept at a minimum.
Morphine and opiate derivatives are definitely to be
avoided.
Antibiotic Therapy
With the advent of antibiotic therapy, another power-
ful weapon has been added. As stated earlier, most pa-
tients in status asthmaticus belong in the intrinsic or
infectious group. Frequently an accompanying infection
of the bronchi has been the cause of the intractable
asthma. The presence of infection is noted clinically by
an increase in body temperature, elevated sedimentation
rate, the presence of mucopurulent or purulent sputum,
and leucocytosis with an increase in the polymorpho-
nuclears.
Our routine is to use combined parenteral and aerosol
penicillin therapy, so that the penicillin may reach the
more superficial and deeper lying tissues of the bronchi
in high concentration. Fifty thousand units of penicillin
in 1 cc. of distilled water, to which 3 or 4 drops of
glycerin are added to stabilize the aerosol, are nebulized
every three hours, with a six hour interval during the
sleeping hours. If the penicillin aerosol is to be con-
tinued after the adrenalin-fastness has been broken,
it is advisable to precede the inhalation of penicillin by
the inhalation of a few breaths of 1:100 epinephrine,
or 1:200 isuprel, so as to widen the lumen of the lung.
Very often, this therapy will have to be prolonged for
five to ten days following responsiveness to adrenalin,
until the patient’s bronchial secretions are free of dis-
coloration and are at a minimum. At the same time,
penicillin is administered parenterally with daily injec-
tions of 300,000 units of prolonged acting penicillin.
Because of the possible toxic effects of streptomycin
and dihydrostreptomycin, its routine or combined use
with penicillin is initially avoided. It is added only when
the sputum remains purulent or in the presence of peni-
cillin-resistant organisms in the sputum. Dihydrostrep-
tomycin, because of its lower incidence of toxic effects,
is then given by aerosolization in seven divided doses of
1 cc. each per 24-hour period in a similar manner as
penicillin. The total dose per day ranges from 0.5 gm.
to 1.5 gm. Its parenteral use is withheld. In our experi-
The Journal-Lancet
ence it has rarely been necessary to use streptomycin or
dihydrostreptomycin.
A ntihistaminics
The recently introduced antihistaminic drugs are of
little or no value in this condition. In fact, they are
contra-indicated, as they possess an atropine-like effect
in drying up bronchial secretions, and thus aid in pro-
ducing mucous plugs. Before substituting these medi-
cations, the action of which is neither so certain nor
so prolonged, it is well to remember that epinephrine
and epinephrine-like compounds are the most powerful
antihistaminic agents now in use.
In summary, when one is confronted with a patient
in status asthmaticus, the danger of death is ever pres-
ent. The judicious use of the above procedures may be
lifesaving.
Bibliography
1. Bubert, Howard M., and Cook, Sarah: Status Asthma-
ticus, Southern M. J. 41:146, 1948.
2. Weisman, Joseph R.: Status Asthmaticus, Regional
Course, American College of Allergists, 1945.
3. Sheldon, J. M.: Intravenous Use of Fluids in Bronchial
Asthma, J.A.M.A. 139:506, 1949.
4. Glaser, J.: The Symptomatic Treatment of Bronchial
Asthma in Infancy and Childhood, American Practitioner
1:185, 1946.
5. Lepak, J. A.: The Relief of Acute Asthma by the Intra-
venous Administration of Concentrated Glucose Solutions.
Report of Cases, Minn. Med. 17:442, 1934.
6. Kibler, C. S.: Management of Intractable Asthma,
Southwestern Med. 21:196, 1937.
7. Goodall, R. J., and Unger, L.: Continuous Intravenous
Aminophyllin in Status Asthmaticus. Ann. Allergy 5:196, 1947.
8. Prigal, S. J., Brooks, A. M., and Harris, R.: The Treat-
ment of Asthma by Inhalation of Aerosol of Aminophyllin,
J. Allergy 18:28, 1947.
9. Barach, A. L., and Eckman, M.: The Use of Helium
in the Treatment of Asthma and Obstructive Lesions in the
Larynx and Trachea, Ann. Int. Med. 9:739, 1935.
10. Barach, A. L.: Treatment of Intractable Asthma,
J. Allergy 17:352, 1946.
11. Vaughan, W. T., and Graham, W. R.: J.A.M.A.
119:556, 1942.
12. Lamson, R. W., Butt, E. M., and Stickler, M.: J. Al-
lergy 14:396, 1943.
13. Wieder, H.: Addiction of Meperadine Hydrochloric
Acid: Report of 3 Cases, J.A.M.A. 132:1066, 1946.
14. Tuft, Louis, and Levin, Nathanial M.: Studies of the
Expectorant Action of Iodides, 12:416, 1941.
MINNESOTA STATE MEDICAL ASSOCIATION OFFICERS
Dr. Frank J. Elias, Duluth, is president-elect of the Minnesota State Medical Associa-
tion. Other new officers, named at the group’s convention, are Dr. William F. Hartfiel, St.
Paul, first vice president, and Dr. Clarence W. Moberg, Detroit Lakes, second vice president.
Dr. Benjamin B. Souster, St. Paul, and Dr. William H. Condit, Minneapolis, were re-
named secretary and treasurer, respectively. Dr. A. E. Cardie, Minneapolis, and Dr. George
Earl, St. Paul, were elected delegates to the American Medical Association convention.
June, 1949
205
The Diagnosis and Treatment of Mold Allergy
Ernest Grinnell, M.D.*
Grand Forks, North Dakota
Extensive investigations during the past two decades
have demonstrated conclusively that the air-borne
spores of common fungi are the frequent causes of aller-
gic manifestations. Although molds long had been sus-
pected as a cause of allergy, the consensus for a number
of years was that they represented the isolated case and
were something of a medical curiosity, occurring in rare
instances where there was exposure to damp, moldy
basements.
Indeed, from an historical viewpoint, the significance
of molds as a cause of allergy was suspected more than
200 years ago. Sir John Floyer,1 an English physician,
reported the case of an asthmatic who suffered a severe
attack, which appeared to be precipitated by going into
a wine cellar. It is not surprising that the first of a
great host of modern reports on the molds should have
come from Holland, where climatic factors predispose to
a rather marked fungus growth. Van Leeuwen wrote
extensively as early as 1924 about "miasms” which con-
taminated the air. Cadman 2 in Canada did much more
to focus attention upon the fungi by his work with
grain rust. Others quickly followed his leadership, and
the past ten years have witnessed truly noteworthy prog-
ress in the understanding of the role of molds in allergic
disease.
There no longer can be any doubt of the clinical re-
ality of mold allergy. Numerous investigators have
shown by surveys the high atmospheric concentration of
molds, especially during the summer months. That this
concentration is especially heavy in the grain-producing
states of the Midwest has been well-established. Clin-
ical experimentations have demonstrated that these molds
are causal in the production of allergic disease. Increas-
ing evidence has been accumulated to demonstrate that
a large number of pollen-sensitive individuals are aggra-
vated by concomitant sensitivity to seasonal molds.3,4
Major and Minor Molds
The major molds from a viewpoint of widespread
occurrence, high atmospheric concentration and anti-
genicity are Alternaria, Hormodendrum, Aspergillus
and Penicillium. Of these, Alternaria and Hormoden-
drum are seasonal molds occurring during the warm sum-
mer months. On the contrary, Aspergillus and Penicil-
lium are nonseasonal molds of widespread occurrence
and may be found at any season of the year, but reach
highest atmospheric concentration when the air is warm
and humid. These four varieties of fungi are especially
significant in the production of respiratory allergic dis-
ease.
Sensitivity has been shown to exist to a large number
of other molds which are of less significance due to
* From the Grand Forks Clinic.
numerous factors. From a clinical viewpoint they may
be regarded as the minor molds: Helminthosporium,
Mucor, Chaetomium, ergot, Phoma, yeasts, Monilia,
Fusarium, Trichophyton, etc. Smuts and rusts, as causa-
tive allergens in the production of allergic manifesta-
tions, are now known to be of especial significance in
grain-producing areas due to the noteworthy observa-
tions by Wittich.3,5
Clinical Types of Manifestations
Mold allergy may manifest itself in various forms.
For convenience, the following classification may be
adopted:
1. Respiratory
2. Cutaneous
3. Miscellaneous
The Respiratory Group
Individuals who are sensitive to the molds may suffer
from respiratory symptoms of varying degrees depend-
ing largely upon the molds to which they may be sensi-
tive, as well as concomitant sensitivities to pollen, house
dust, miscellaneous inhalants and food. The patient sen-
sitive to a seasonal mold such as Alternaria or Hormo-
dendrum without complicating sensitivities usually has
symptoms only during the mold season from the onset
of warm spring days until snow covers the ground in
the fall.
This purely seasonal mold type may show, in certain
individuals, very interesting variations. If he is sensi-
tive to pollens, he may have marked exacerbation of his
symptoms during that particular pollinating season. On
the other hand, sensitivity to house dust, common in-
halant allergens and foods, in addition to the seasonal
molds, frequently presents a picture of symptoms of
equal severity the year around.
Sensitivity to some of the common nonseasonal fungi
(in particular Aspergillus) , usually results in a continua-
tion of symptoms beyond the usual mold season, but of
a somewhat milder nature. Often these patients are defi-
nitely made worse by going into damp basements, store-
rooms or attics.
The Cutaneous Group
Numerous reports occur in the literature of atopic
dermatitis 0 due to ingestion or inhalation of molds, and
contact dermatitis as a result of contact with the oil
fraction of fungus spores. Conjunctivitis has been
shown to occur, and Simon 7 reported an individual who
had a specific conjunctivitis from molds without any
other sensitivity.
The Miscellaneous Group
Ample evidence has been accumulated to show that the
ingestion of certain fungi, in particular, yeast, causes a
206
The Journal-Lancet
variety of allergic manifestations, from simple hives and
atopic dermatitis to asthma and migraine.
Diagnosis
The diagnosis of mold allergy is facilitated by a good
history. It is quite possible to tentatively diagnose, or
at least to strongly suspect, mold allergy in many cases
on the basis of the history alone. Careful attention to
details gleaned from the patient’s story reveals a number
of highly significant facts: The majority of fungus-
sensitive patients are usually aware of definite aggrava-
tions of symptoms during the warm months with relative
freedom after snow covers the ground. Occasionally,
symptoms of a considerably milder nature persist through
the winter. Mold allergy is not apt to be confused with
sensitivity to the pollens if close attention is paid to the
history. Almost invariably, mold cases will not demon-
strate the sharp seasonal delineation of pollen patients
who can usually specify almost exact dates of onset or
alleviation of symptoms, such as Memorial Day, Labor
Day, etc.; or they may be equally positive in stating that
such symptoms begin about June 1 and continue for
four weeks. On the contrary, mold sensitive individuals
indicate a far wider spread of season, depending largely,
of course, on the degree of sensitivity. Suspicion should
be directed toward the molds when there is an onset
before the usual pollinating season for any of the com-
mon pollens or a continuation beyond the usual season.
It must be remembered that multiple sensitivity, i. e.,
sensitivity of a high degree to seasonal, as well as non-
seasonal mold, such as the Aspergilli, results in symp-
toms of almost equal intensity the year around. The
important thing to consider is the possibility of mold
sensitivity in any allergic individual and to suspect them
as possible concomitant allergens even when the history
indicates a pollinosis. Even more essential, of course,
is to investigate them when there is evidence of slight
deviation from the usual regular pattern of pollen sensi-
tivity. (In this Clinic, testing for the common seasonal
molds is done routinely even when there appears to be
no doubt that the case presents a pure pollinosis.)
Further details of the history frequently reveal that
the patient relates that he is worse in the country. Prox-
imity to a threshing machine, harvesting and haying
operations, a barn or a haystack often precipitates an
acute attack. Illustrating this point is the following case
report:
Case 1. A farmer, aged 21, complained of seasonal
rhinitis with occasional severe asthmatic attacks. There
was a definite familial history of allergic disease. The
patient had had asthmatic attacks since he was a child.
Questioning elicited the information that he was worse
in summer and that the season extended beyond the
usual limits of pollinosis. He was sure that proximity to
threshing, haying and harvesting operations aggravated
the symptoms. Even the act of shoving down hay from
the haymow was apt to bring on a mild attack. Cu-
taneous testing revealed positive reactions to Aspergillus
niger, Alternaria and H or mod end rum, barn dust, grain
dust, stem rust, wheat smut and oat smut. Also house
dust, pyrethrum and Russian thistle gave positive re-
actions.
Comment: This case history clearly implicated the
molds due to prolongation of the symptoms beyond the
pollen season. The fact that the patient was unable
to actively engage in threshing operations also directed
suspicion toward the molds. Treatment with an extract
of the molds and Russian thistle gave very marked
relief.
The history may reveal a definite sensitivity to foods
containing edible fungi. In most instances, the individ-
ual is able to anticipate an attack from eating mush-
rooms or ingesting foods very high in yeast content.
The following case history is interesting in that it
reveals sensitivity to only one of the fungi:
Case 2. A young woman complained of attacks of
rhinitis and wheezing, which came on very soon after
the ingestion of beer. Skin tests revealed a strongly posi-
tive reaction to yeast, but negative to Aspergillus, Alter-
naria, Hormodendrum, etc.
If the history indicates that there has been an unsuc-
cessful attempt at hyposensitization in what appears to
be a pure pollinosis, suspicion should be aroused and
especial care taken to uncover the cause. While it may
be due to inadequate dosage or to a selection of the
wrong pollen extracts, it may be indicative of a compli-
cating fungus allergy.
The following case report from the files of the Clinic
is an interesting illustration of this point:
Case 3. A male student, age 17, gave a history of
the onset of rhinitis and mild wheezing during the pre-
ceding six weeks. There was an allergic background in
the family history. Persistent questioning finally brought
forth the following pertinent facts: (1) That he had
complained of summer asthma for years. (2) That he
was free of symptoms every winter when there was snow
on the ground. (3) That his asthmatic symptoms did
not come on until about one month after he moved from
town to the farm for the summer. Usually this onset
of symptoms occurred about the last week in June. (4)
That symptoms then persisted until late in the fall, well
beyond the end of the customary pollen season. (5)
That he was certain to have an attack within a short
time after being in a barn, around threshing or harvest-
ing operations. (6) That when he stayed in town or
inside the farmhouse, he was relatively free of symp-
toms. (7) That he previously had hay fever injections
without relief.
Skin tests showed positive tests for Alternaria and
Hormodendrum. He was also positive to house dust,
giant ragweed, short ragweed, bluegrass and orris root.
Comment: An attempt at hyposensitization with pol-
len extract had failed in this case, and the reason is ob-
vious. In this instance the need for correlation of the
pertinent facts of the history with the results of the
skin tests in deciding upon a course of therapy is well
shown. Certainly extracts of house dust and orris root
should not be included in the treatment set, because
June, 1949
207
(1) his symptoms were entirely seasonal, and (2) he
was invariably better while indoors, rather than outside.
The diagnosis of mold sensitivity may usually be con-
firmed by skin tests. It is good practice to do a com-
plete physical examination, urinalysis, and a complete
blood count. After this has been accomplished, the pa-
tient is ready for skin tests.
Space and time do not permit a lengthy discussion of
specific examinations to determine the patient’s sensitivi-
ties. As previously indicated, too much reliance should
not be placed on the results of nasal, intra-ocular or skin
tests. It is the practice in this Clinic to do routine
scratch (cutaneous) tests. If the results are inconclusive
or confusing, intradermal tests are done. Careful eval-
uation with the history as given by the patient is essen-
tial when the tests are interpreted. It must be remem-
bered that as a general rule the scratch tests are less
sensitive than the intracutaneous, but at the same time
there are less false positive reactions. Furthermore, there
is no doubt that the scratch test offers a far wider range
of safety. Taub 8 reported a patient with cottonseed sen-
sitivity who suffered a severe asthmatic attack following
intracutaneous testing with a 1 to 1,000,000 dilution
of cottonseed extract.
It is a routine procedure in this Clinic to test all indi-
viduals suspected of mold allergy with endo-house dust
extract.1' Repeated investigations have demonstrated that
house dust is a potent allergen, and sensitivity to it is
common in respiratory allergy. It is interesting to note
that usually fungus-sensitive cases react positively to
house dust. Conversely, house dust-positive patients do
not so often react to the molds.
There can be little doubt that the molds contribute
materially to the potent allergens which form house dust.
Cohen 10 in 1929 demonstrated that overstuffed furni-
ture contained more of the active dust principle than did
rugs or draperies. This is also true of pillows. Old
feather pillows have been shown to contain more active
dust than new ones. Subsequent investigations have
shown in innumerable instances that old overstuffed fur-
niture, pillows, mattresses, etc., are excellent places for
the propagation of mold growth.
Treatment
The first principle in the treatment of mold allergy
differs in no way from that of other allergies. Every
effort should be made to remove the causal allergen from
the patient’s environment. While this is quite obviously
a physical impossibility due to the atmospheric concen-
tration of seasonal molds, the fact remains that much
can be done to eliminate the nonseasonal molds and sec-
ondary irritating factors found in ordinary house dust.
The physician should insist upon thoroughly cleaned
and aired basements and attics. All unnecessary furni-
ture, rugs, books, clothing and pictures should be re-
moved from the patient’s room, and dust-proof cover-
ings provided for feather pillows. Members of the fam-
ily who have occasion to visit barns, granaries and grain
mills should be trained to leave outer garments in an
outer room before entering the house. In this Clinic
the importance of dust contact is deemed so important
that the patient is given the following mimeographed
sheet and requested to observe it as closely as possible:
DIRECTIONS FOR AVOIDANCE OF DUST
(A) 1. Remove everything from the patient’s room.
2. Empty all closets and shelves and place contents else-
where.
(B) 1. The room must be thoroughly washed and cleaned,
and all movable furniture thoroughly dusted and
scrubbed.
2. To be washed weekly : Bedstead and open springs,
floors, baseboards, mouldings, sills; walls if painted, rag
rugs, window curtains, Venetian blinds, bedclothing,
such as sheets, blankets, pillow cases, etc. For wallpaper
use wallpaper cleaner.
(C) Room may contain the following:
Plain curtains, washable wooden furniture (steel furniture
is preferable) , rag rugs.
(D) Room MUST NOT CONTAIN:
Heavy rugs or floor coverings, heavy drapes, hangings.
Upholstered furniture of any type.
Knickknacks, pictures, wall hangings, books.
Clothing or furs.
Quilted bed pads.
Face powder, bath powder, perfumes, toilet water or
colognes.
Toys — especially those with fuzzy hair and fur.
Fresh cut flowers and live plants.
(E) USE ONLY WASHABLE TOYS MADE OF RUB-
BER OR WOOD.
(F) The house should be aired frequently and dust avoided in
every possible way.
(G) Pets (birds and animals) must be kept out of the house.
(H) Avoid cosmetics, perfumes, insect sprays or powders, and
odoriferous substances such as camphor, tar, etc.
(I) Allow no plants in the house without specific instructions
Special Directions: Mattresses and pillows should be covered
(Special instructions will be given in regard to this.)
Leave garments in an outer room when you have been
in a barn, granary or feed mill.
Specific treatment by means of hyposensitization with
an extract of the molds is indicated because of the im-
possibility of breaking contact with the causal allergens.
When a course of hyposensitization has been decided
upon, the physician is confronted with the problem of
which molds to include in his mixture. No hard and fast
rules can be adopted which will cover every case. Per-
haps nowhere in the entire field of allergy is the thought-
ful judgment of the clinician so important as here. Each
case must be carefully considered, taking into account
three factors: (1) the geographical location, (2) the pa-
tient’s history, (3) the results of the skin tests.
In this Clime, due to its geographical location in the
valley of the Red River of the North, Alternaria and
Hormodendrum present an atmospheric concentration
as high or higher than any other spot in continental
United States. Since they are of well-known high anti-
genic potential, they must be included in the event the
patient’s history and skin reactions indicate sensitivity.
On the other hand, since there is a certain antigenic
specificity between molds, if there is a reaction to Hel-
mmthosporium usually it can be safely left out of the
mixture, because of its rather low atmospheric concen-
tration and close relationship to Alternaria.
In general, it may be said that a positive reaction to
Alternaria necessitates the inclusion of that extract for
treatment in almost every part of the United States.
208
The Journal-Lancet
If there is a strong or moderately strong reaction to
Hormodendrum, it, too, should be included, since it is
highly antigenic and is present in the atmosphere in
large numbers. If the case at hand presents a reasonably
well-marked case of seasonal mold allergy, in most in-
stances the treatment mixture will require at least 50
per cent of Alternaria and Hormodendrum, with the
other half made up of reactors to other molds and smuts.
The usual case presenting mold allergy will be found to
respond favorably to equal parts of Alternaria and Hor-
modendrum, although frequently Aspergillus will be
found to be necessary. In the event that a complex
mixture appears indicated, the judgment of the clinician
is often severely taxed. The seasonal occurrence, geo-
graphical location, atmospheric concentration and degree
of cutaneous reactivity to the tests will all be called upon
to formulate a proper proportion of causative mold an-
tigens in the treatment mixture.
As has been indicated previously, mold-sensitive indi-
viduals often react to house dust. In this Clinic, when
the patient exhibits nonseasonal symptoms of any degree
and there is a positive reaction to house dust, dust ex-
tract is included as a part of the course of treatment.
Hyposensitization treatment should be instituted as
soon as the diagnosis has been made, regardless of the
season of the year.
Rapidity of treatment will depend in a large measure
upon the imminence of the mold season for the partic-
ular individual. In general, a perennial treatment plan
similar to that widely used for hay fever patients is no
doubt the most successful. In this Clinic, a mixture of
the mold extract in a dilution of 1 to 10,000 is admin-
istered, starting with .05 to .1 cubic centimeter. Usually
the dose is increased .1 cubic centimeter at five to seven-
day intervals until .5 cubic centimeter of the concen-
trated solution is well-tolerated. Usually this constitutes
a maintenance dose, although no hard and fast rule can
be adopted. In many instances the dose may be de-
creased and the patient satisfactorily maintained on a
dose of .2 cubic centimeter of the concentrated extract
at two to four-week intervals. Only by careful individ-
ualization can a program be outlined. House dust ex-
tract is administered concurrently whenever it appears
to be indicated. The dosage is the same as for mold
extract, and, if desired, may be combined with the mold
mixture.
The success of specific treatment in mold allergy is
well-established. Numerous investigators report excel-
lent results in from 75 to 85 per cent of cases. The
physician may expect results equally as good as in cases
of pollinosis if the diagnosis is correct and the treat-
ment mixture properly balanced.
Summary
The air-borne spores of common fungi constitute one
of the causes of allergic disease. The most frequent
manifestations are rhinitis and asthma, but other allergic
effects such as dermatitis, migraine, conjunctivitis and
gastro-intestinal reactions are known to occur. The
molds of prime importance are Alternaria and Hormo-
dendrum, although some of the less common offenders
must be regarded with suspicion. Mold allergy is recog-
nized clinically by the history of summer occurrence not
coinciding with the pollen season and by frequent exacer-
bation when the patient is near hay or straw. Nonsea-
sonal mold allergy may occur.
Treatment can be expected to yield a high degree of
satisfactory results, especially if the entire allergic study
is carefully correlated. Mold and house dust hyposensi-
tization should be utilized where indicated, together with
proper management of pollen sensitivity, food sensitiv-
ity and miscellaneous inhalant sensitivities. Experience
indicates that the best results are obtained with the per-
ennial method of treatment.
References
1. Floyer, Sir John: A Treatise of the Asthma. Third
edition, London, 1726.
2. Cadman, F. T.: Asthma Due to Grain Rusts. J.A.M.A.,
83:27, 1924.
3. Wittich, F. W.: Further Observations on Allergy to
Smuts. Journal-Lancet, 59:382, 1939.
4. Eisenstadt, W. S.: Incidence and Significance of Molds
in Allergic Respiratory Symptoms. Journal-Lancet, 68:217,
1948.
5. Wittich, F. W.: The Nature of Various Mill Dust
Allergens. Journal-Lancet, 60:48, 1940.
6. Feinberg, S. M.: Seasonal Atopic Dermatitis; the Role
of Inhalant Atopens. Arch. Dermat. & Syph., 40:200, 1939.
7. Simon, F.: Allergic Conjunctivitis Due to Fungi.
J.A.M.A., 110:440, 1938.
8. Taub, S. F.: Essentials of Clinical Allergy. Williams
and Wilkins, p. 77, 1945.
9. Endo Products Incorporated. Richmond Hill, New
York.
10. Cohen, M. B.: Asthma Due to Household Articles:
Report of 19 Cases Due to Dusts from Mattresses. Journal
of Laboratory and Clinical Medicine, 14:837, 1929.
s
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June, 1949
209
Allergic Skin Disorders in Pediatrics*
Stephan Epstein, M.D.f
Marshfield, Wisconsin
Allergic skin disorders in pediatrics cover a very wide
k. field. Although allergy plays a greater or lesser role
in most skin diseases, especially infectious disorders, cus-
tom has restricted the term allergic dermatoses essen-
tially to three groups:
1. Eczema - Dermatitis
2. Urticaria
3. Drug Eruptions
These are the same allergic skin conditions which also
plague the adults. But the same disorders frequently look
and react different during infancy and childhood. We
are all familiar with the differences in reactions, pref-
erences and locations of the same disease in childhood
and adult life; although the reasons are far from being
understood. Ringworm is perhaps the best example of
a different behavior of a skin disease in the child and
in the adult. It is well known that the superficial form
of tinea capitis occurs almost exclusively in children
before puberty. Recently Rothman ' has demonstrated
that the hair of the scalp of the adult contains some
fungicidal fatty acids which are lacking in the hair of
the child. In allergic skin diseases the differences be-
tween child and adult are perhaps just as great, although
not so apparent.
There is another special aspect of skin diseases in
children. The association of skin disorders with changes
of the general organism is more obvious. General health,
state of nutrition, anemia, rickets, vitamin deficiencies
play a still greater part in skin disorders in children than
in grownups.
Infantile Eczema
The most difficult skin problem of the pediatrician
is infantile eczema. It is also one of the most difficult
tasks for the dermatologist. However, with proper treat-
ment, with an open mind and interest on the physician’s
part, and a desire for cooperation on the parents’ side,
most cases can be managed satisfactorily.
When we speak of infantile eczema, we mean all
forms of eczema or dermatitis occurring in infants be-
low two years of life. Customarily we distinguish the
following groups shown in Table 1:
Table 1
No. of Cases Observed
Diagnosis Between 1937-1948
Atopic dermatitis 247
Seborrheic dermatitis 93
Contact dermatitis .. . 108
Infectious eczemas 18
Miscellaneous eczemas 21
* Presented at the Continuation course in Pediatrics, Univer-
sity of Minnesota Center for Continuation Study, April 7 to 9,
1949.
t From the Marshfield Clinic, Marshfield, Wisconsin, and
the Division of Dermatology (Dr, H. E. Michelson), Univer-
sity of Minnesota Medical School.
It is not always possible to distinguish the various
entities clinically. This is especially the case when the
face alone is involved. For some, yet unknown, reason,
infants respond frequently with an exudative dermatitis
especially on their face regardless whether this may be
an atopic, a contact, or seborrheic dermatitis. Further-
more, two or more forms of eczema may be combined.
Most frequent, apparently, is a combination of atopic
dermatitis and seborrheic dermatitis.
In spite of these difficulties, the experienced physician
usually will be able to distinguish the various forms cor-
rectly. This distinction in many cases is important for
correct management of the case. Atopic dermatitis, also
called allergic eczema, is the most common form of in-
fantile eczema. Among the 546 cases seen by us during
the last twelve years (see Table 1), 247 were diagnosed
as atopic dermatitis. Most cases presented the pure
form, some suffered from a combination with other
forms of eczema such as seborrheic dermatitis, or contact
dermatitis. Furthermore, there were 57 instances of in-
fantile eczema which might have been atopic, but could
not be classified definitely.
Infantile Atopic Dermatitis
In many instances, this form of eczema starts around
the second to the fourth month. This condition fre-
quently presents a typical picture. The face is nearly
always involved. We find an acute, at times weeping
dermatitis, with swelling of the cheeks that may extend
to the ears, scalp, and neck. In severe cases, the eczema
is covered with yellowish and bloody crusts showing
marks of severe scratching. The rest of the body is fre-
quently involved and often shows patches of sharply
outlined dermatitis that are more or less infiltrated.
Favorite locations are the arms and legs, but the whole
body may be afflicted. On arms and legs it may turn
into a diffuse severe dermatitis, but usually less acute
than the face. Signs of scratching are always present.
Infantile atopic dermatitis is one condition where skin
tests are of very great help, especially in the severe
cases. Scratch tests are the method of choice. Where
feasible, passive transfer is recommended; this method
is preferable to intradermal testing in babies. In my
experience, scratch tests are helpful in determining the
offending allergens in nearly three-fourths of the cases
of severe infantile eczema.
Many infants with atopic dermatitis present a positive
scratch test to eggs, even if they never ingested this food.
It is believed that this sensitivity is transmitted from the
mother. This reaction does not necessarily mean that
the child is allergic to eggs. However, it classifies the
child as an atopic individual. Excluding the whealing
reaction to egg, about one-fourth of these infants will
react to foods, one-fourth to environmental allergens,
210
The Journal-Lancet
and one-half to both. It is said that during the first year
of life, foods only have to be considered. This concept
needs revision. Our experience shows that, in a rural
area at least, environmental allergens are just as impor-
tant as causative allergens as foods, even during the first
six months of life.
These tests allow us to map a better plan. Or course,
tests have to be interpreted properly. Although positive
scratch tests are often significant, a positive reaction to
dust may not be connected with the child’s eczema, but
with the accompanying rhinitis. And a perfectly nega-
tive test does not exclude sensitivity. This holds true
especially for foods. For example, I have seen a number
of instances of sensitivity to orange with repeatedly nega-
tive skin tests. In my clientele — disregarding the re-
actions to egg — wheat ranks first as reactor in infantile
eczema, potatoes next and milk as a third. In regard
to environmental allergens, cattle and horses are on top
of the list, followed by house dust and feathers. This
is not surprising, as about one-half of my infants with
infantile eczema are farmer’s children.
Treatment of Atopic Infantile Eczema
After reading the history and examining the child,
it is essential that an explanation of the situation be
given the parents. This is the real eczema. The par-
ents cannot expect a "cure” like in ringworm. There
is no magic formula. The possible later association with
asthma and hayfever must also be explained, especially
if there is a family history of these conditions. Of
course, this should be done without frightening the par-
ents unduly. The difficulties to be encountered should
not be kept from them. There is consolation, however,
for infantile eczema is not a very serious disease in re-
gard to life, and most cases can be managed satisfac-
torily, including their later asthma and hayfever.
Local treatment: All irritation should be avoided. The
eczema should be treated according to the stage — acute,
subacute or chronic and whether it is secondarily infected
or not. The principles which apply to the treatment of
dermatitis in general also go for infantile eczema. In
the acute phase, bland treatment is indicated, wet com-
presses with aluminum acetate, soda or chamomille. The
use of wet dressings in infantile dermatitis has recently
been discussed thoroughly by Perlman.4 In case of sec-
ondary infection, potassium permanganate 1:9,000 may
be used. The use of boric acid, both as a solution or
an ointment, is frowned upon by some because of
the toxic qualities of boric acid (Watson s). When wet
compresses are applied to a baby, it must be watched
constantly, especially if the baby is tied down and the
compresses applied to the face where the cloth may lead
to obstruction. Even in the very acute phase, a wet com-
press can at least be alternated with mild ointments or
a zinc oil consisting of 40 per cent zinc oxide in olive oil
or corn oil.
Ichthyol 2.4 gm.
Zinc oxide ... 48.0 gm.
Olive Oil or Corn Oil q.s. ad 120.0 cc.
Where the eczema is drier, a more greasy ointment
containing equal parts of vaseline and eucerin with
3 per cent liquor burrow is applied.
In the presence of infection, an antiseptic should be
incorporated — ammoniated mercury 2 to 3 per cent, or
rivanol 1 per cent. Penicillin or sulfonamides as an
ointment is not indicated. If the secondary infection
is severe, it is advisable to use parenteral penicillin.
Usually relatively small amounts are sufficient. One to
two per cent aqueous solution of gentian violet is of
great help in reducing the secondary infection and
drying up the skin. It is a messy procedure, but a good
standby.
In contradistinction to adults, tar may be used in in-
fantile eczema rather early. It is applied either in zinc
oxide ointment, 3 to 5 per cent, or sometimes as crude
coal tar. Both preparations can be tried where the ec-
zema is still rather acute, especially if it does not respond
to the milder preparations. Tar is toxic and therefore
should not be used over too great an area at a time.
In milder cases tarlike substances, such as Naftalan or
Dernaftan, are helpful:
Naftalan or Dernaftan 1.5 to 3.0
Castor oil .. . 6.0
Lassar’s paste ad 30.0
S. — Apply and bandage.
Three per cent ammoniated mercury in zinc oxide oint-
ment is often helpful in milder cases.
Contrary to general opinion, soaps and baby oils
are often tolerated, and only at times irritating. In this
instance the modern sulfonated oils may be substituted
for soap, and castor oil — externally — as a mild lubricant.
General Measures
First of all, a thorough examination, including a com-
plete blood count and urinalysis, should be done.
A child with infantile eczema must be considered and
treated from every possible angle. The following are
our routine measures for all more severe cases of infan-
tile eczema:
Multibeta 15 to 25 drops t.i.d.
Drisdol 10 drops b.i.d.
Ascorbic acid 50 mgms. daily
Elixir feosol or fergon 54 to 1 teaspoonful t.i.d.
The following measures are used as indicated:
Phenobarbital gr. % to 54 t.i.d. as needed and accord-
ing to age.
Elixir benadryl 1 to 2 teaspoonfuls q.i.d., or Elixir
pyribenzamine 54 to 1 teaspoonful q.i.d. or some
other antihistaminic.
Crude liver extract 1.0 cc. every other day, when prog-
ress is slow.
Amino acids
General ultraviolet treatment, but protect areas treat-
ed with tar, as tar is a photo sensitizer.
Lard, in stubborn cases.
My personal experience with lard is very limited. But
the experiences of Finnerud, Kessler and Wiese, and of
Hansen,2 reveal that over one-half of the patients with
intractable eczema are greatly benefited by the dietary
June, 1949
211
inclusion of fats rich in the unsaturated fatty acids.
In most of the recent studies, fresh lard has been the
source of fat. Most patients appear to have little diffi-
culty in taking lard in teaspoon or tablespoon quanti-
ties, although some prefer to take it with salads as dress-
ings, on cereals, or as a spread on crackers, toast or in
sandwiches. It is felt that a therapeutic trial should com-
prise a period of about two months or so, using one to
two ounces per day. At the present time, it appears that
this regimen should supplement but not substitute for
a careful allergic work-up and the use of local thera-
peutic measures.
Psychological Treatment : These children frequently
come from high-strung and nervous parents. The par-
ents should be instructed to give the children adequate
care, and allow them as much rest as possible. The
child may need sedatives to begin with, and so may the
mother. The children should have the loving care of
the mother or nurse, but should not be spoiled; they
should not be taken up every time they cry.
Allergic Management
Most important is elimination of offending contacts.
Skin tests act as an excellent guide. Whenever dust
sensitivity seems important, a regime as dust-free as pos-
sible is recommended. Wool is a frequent irritant, prob-
ably not always on an allergic basis. The following in-
structions are given to the parents:
Instructions for Infantile Eczema
"Please prepare for the child a room as dust-free as
possible according to the program you have just received.
Remove the feather pillow as the child does not need
a pillow at all.
"Be very strict to avoid contact with wool as much as
possible. Fuzzy wool is worse than smooth wool. There
should be no woolen rugs where the baby plays. Put on
a washable cotton dress when handling the baby. Try
not to handle the baby while wearing your wool coat.
"Do not allow other members of the family or friends
to fondle the child while wearing their overcoats or work-
ing clothes as they may carry dust from the working
place or the barn with them.
"As far as the child’s own clothing is concerned, put
on woolen garments only when necessary. If you dress
the child in a woolen snow suit, be sure to have long
cotton sleeves and long cotton stockings underneath. Do
not let the child wear the snow pants inside the house.
"Do not allow the child to play on the mohair furni-
ture or on the rugs in the living room. Yet try to let
the child live a life as normal as possible.
"The child should have a normal diet according to the
age. Keep chocolate, nuts, pickles, sour foods, and sea
foods away from the child and those other foods which
we have eliminated in this particular case. Do not re-
strict the child’s diet more than necessary.
"The child should have the loving care of the parents,
but should not be spoiled. Do not worry about the
child’s eczema. Nervousness and upsets on the part of
the parents will also upset the child.
"You may expect a flare-up of the eczema when the
child cuts a tooth or gets a cold. If the child does not
get along as well as expected, notify your doctor.”
In regard to diet, the severe cases are placed on a
strict elimination diet, consisting of evaporated milk,
oatmeal, carrots, and pears.
This diet is used only in severe cases, usually hospi-
talized. Such a restricted diet is enforced only for a
short time, and always supplemented by vitamins, iron,
etc. In milk sensitive patients a soybean preparation is
used instead of milk. Probably goat milk can be sub-
stituted in some cases sensitive to cow’s milk. As soon
as there is improvement, more foods may be added.
In ambulatory, milder cases, a less rigorous diet is per-
missible. Before using a strict diet, we eliminate those
foods which are incriminated by the history or the skin
tests, and also common offenders. Wheat, potatoes,
chocolate, nuts, fish oil, citrus fruit, and all fancy foods
are removed from the diet.
When the child is well or nearly so, we try to add
the allergic or suspected foods very gradually.
In regard to dust sensitivity, I have tried desensitiza-
tion only in recent years. There have been promising
results in some severe cases. Dosage must be watched.
The 1:1 million dilution or less is recommended for a
start. If there are reactions, dilution ten times weaker
is used. Desensitization in atopic dermatitis seems even
more difficult than in asthma. It should probably not
be a routine procedure.
We do not urge hospitalization of a patient with in-
fantile eczema except in the presence of severe secondary
infection, or some other complication such as Kaposi’s
varicelliform eruption, bronchitis, pneumonia. Hospi-
talization is not without danger. Most babies with infan-
tile eczema acquire some upper respiratory infection,
if one is not already present. But with good care, peni-
cillin and sulfonamides, fatalities are now avoidable.
The child is placed in a room as dust-free as possible.
The same nurse usually takes care of the baby. Exter-
nal irritations are avoided. Visitors are excluded when-
ever possible.
It is usually not difficult to clear up most cases of in-
fantile eczema at the hospital. The real .test, however,
is to keep the infant in good condition after it returns
home. Where environmental allergens play a role, the
parents are instructed to prepare conditions as dust-free
as possible. Where certain contacts cannot be avoided
completely, for instance cattle dander on a farm, the
parents are advised to move the infant away from the
farm for another four to six weeks. If a child is kept
away from environmental allergens for a period of about
two months, the sensitivity seems to decrease to some
degree so that minor unavoidable exposures later on
usually are tolerated without much trouble.
Infantile Seborrheic Dermatitis: Infantile seborrheic
dermatitis is characterized by relatively sharply outlined
patches of a round or oval contour measuring from 2 to
212
The Journal-Lancet
5 cm. in diameter. They show a yellowish color. Favor-
ite locations are the face and arms, but they may occur
on any part of the body. There is usually a dry scaly
dermatitis of the scalp present, the so-called cradle cap,
or a history of its prior existence can be elicited. Lesions
of seborrheic dermatitis may occur also in the folds and
then become more moist and give rise to a mistaken
diagnosis of atopic dermatitis. However, there are no
scratch marks in pure seborrheic dermatitis.
General examination of the severe cases frequently
brings out some underlying systemic condition such as
malnutrition and secondary anemia. Treatment with
usual doses of iron and large amounts of vitamin B
complex frequently is beneficial without any change of
the local treatment. Locally, 2 per cent ammoniated
mercury in zinc oxide ointment is all that is needed. In
more stubborn cases, sulphur as a 30 to 40 per cent paste
in vaseline or coal tar 1 to 3 per cent in zinc oxide oint-
ment are helpful. General ultraviolet treatments may
be used in resistant cases.
Infantile Contact Dermatitis: Contact dermatitis in
the infant is probably less frequent than generally as-
sumed. Dermatitis from sensitivity to local medication
does occur; usually it can be easily tracked down. Baby
oils, soaps, and powders may also be a cause of contact
dermatitis, but not a very frequent one. If the face is
involved, distinction from atopic dermatitis may be diffi-
cult or impossible. However, there is usually a more
sudden onset in contact dermatitis.
There exists a rather peculiar form of dermatitis in
infants which probably also belongs to contact dermatitis.
This is a papular dermatitis occurring mostly on the legs
and buttocks and starting around the age when a child
begins to creep around on the floor or the porch or
outdoors. It is also seen on the arms, and usually con-
sists of relatively hard papular lesions which become con-
fluent and may turn into an acute weeping dermatitis.
The cause usually cannot be determined; the eruption
takes its own course, lasting for about three to eight
weeks. It occurs mostly in spring and early summer.
Local treatment with a mild ichthyol lotion alternating
with bland softening ointments is often all that is need-
ed; in debilitated children, cod liver oil, iron, vitamin B
complex or light treatments are indicated.
Infectious Eczema: Infectious eczemas, mycotic, bac-
terial and parasitic (scabetic forms) constitute the small-
est group of infantile eczemas. The more common form
is intertrigo. Intertrigo is manifested by eroded, usually
more or less sharply outlined patches of eczema in the
folds along the neck, axillae, and groins. It is a form
of infectious eczema, partly of bacterial origin (strepto-
coccus or other bacteria), partly of fungus nature (mo-
nilia or other yeast-like fungi) . Heat and moisture and
the ensuing maceration are important contributing fac-
tors.
Eczema in the Older Child
In children between 2 and 14 years the distribution
and the frequency with which the various forms are en-
countered are different from those in infants, and be-
come more similar to what we find in the adult popula-
tion. Contact dermatitis becomes more prevalent.
There are, in childhood, some other forms of eczema
which are more difficult to classify. A condition called
prurigo, with pin-point to pin-head sized itching papular
lesions, is frequently found, especially on the extensor
surfaces of the arms and legs. There might be a very
severe pruritus connected with it. There may be also scat-
tered lesions on the body and on the buttocks, and the
picture may be suggestive of scabies. As a rule, this
form of dermatitis is not scabies but one of the follow-
ing three conditions:
First, it may be a manifestation of an atopic derma-
titis.
Second, if there is a history that the eruption occurs
usually in winter, and is aggravated by wearing wool
or especially part-wool underwear, and if it is associated
with a dry skin, the chances are this is the "winter itch,”
prurigo hiemalis. This condition is much more fre-
quently encountered in adults in the cold dry climate
of the northern mid-western states. It is seen, however,
also in children. Vitamin A, 100,000 units daily, and
a mild greasy ointment are usually helpful. Excessive
bathing and use of soap should be avoided.
More frequent and perhaps still less known is the
third causation: prurigo due to pinworm infestation.
In this condition scattered scratched and papular lesions
on the body are usually found, also on the extremities,
especially thighs and, most suggestive, on the buttocks.
Here lesions frequently are excoriated. This picture is
usually mistaken for scabies, especially as more than one
member of the family may be afflicted. A search for
pmworms is usually successful, and treatment of the pin-
worm infestation usually clears up the condition. Anti-
histaminics at times relieve the pruritus quickly; an anti-
pruritic lotion such as the following is applied externally:
Ichthyol 1.2
Zinc oxide 6.0
Calamine lotion ad 60.0
14 to 1 per cent menthol or phenol may be added. The
addition of 5 to 10 per cent calmitol is preferable, if
the pruritus is more severe.
Another form of eczema so frequently overlooked is
the "scabetic eczema” in children. These cases do not
present the typical picture of scabies. They show more
or less severe eczematoid lesions on the hands with sec-
ondary infection, roundish patches which resemble sebor-
rheic dermatitis on the arms and body. To the experi-
enced examiner there are enough scratch marks on the
body to suggest the presence of scabies. Not infrequent-
ly there is a history that there was scabies in the family,
and that the child had been treated for scabies.
The diagnosis is difficult because often one is not able
to find a burrow which will yield the mite or its eggs.
There is reason to believe that these eczemas are not
just due to secondary infection or contact dermatitis
from medication but may represent true sensitization to
some substances of the scabies mite.
June, 1949
213
These cases are much more difficult to treat and
usually require at least two or even more courses of
treatment. The milder antiscabetics are of no help.
Kwell, which can be used in the presence of secondary
infection and eczema, offers promising results. If the
usual treatment doesn’t help, these cases can often be
treated with an old-fashioned sulfur and balsam of Peru
ointment of the following composition:
Sulfur praec. 5.0
Balsam of Peru 8.0
Castor oil 12.0
Vaseline ad 60.0
This ointment is applied for three nights all over, ex-
cept the face. On hands and wrists it is used for a week
longer, also on the ankles, if necessary. The eczema
is treated afterwards with tar and x-ray treatments, if
it proves more stubborn.
Urticaria
Urticaria in children is usually less difficult a problem
than in adults. The clinical picture is the same; in most
instances we have only hives, but angio-neurotic edema
may accompany more severe cases.
Three types are the most common: Urticaria in in-
fancy. A child with atopic eczema suffers from attacks
of urticaria. Frequently the mother is able to tell the
story and traces it to a food. Ingestion of the food is
by no means necessary. One instance is that of a severely
wheat-sensitive infant with infantile eczema. Whenever
the mother sifted flour in the kitchen, the child became
itchy and the urticaria appeared.
Then there is the occasional or acute type of urticaria
in children of any age. Frequently there is a history of
a previous, often milder attack. These cases of acute
urticaria are usually on an allergic basis, mostly foods
or drugs; however, contactants such as silk, wool, feath-
ers, may also cause hives. A careful history is most im-
portant. It is surprising to find how many more cases
of urticaria turn out to have an allergic background,
when the investigation becomes more thorough. Often
it is not possible to find the responsible food at the time
of the first attack. It may be some fish, nuts in a candy
bar, peaches, strawberries, or some other fruit or vege-
table. By alerting the mother to the possible causes and
by keeping track of the child’s diet, the parents them-
selves may present one with the solution when the child
suffers another attack.
Among the drugs that cause hives in childhood, cough
drops rank first in my experience, whereas in adults the
favorite drugs to produce urticaria is aspirin. The search
for an offending drug is often more difficult than that
for a food. One must explain what one means with the
word drug or medicine. Cough drops are not even con-
sidered that. In some cases there is a history of an
upper respiratory infection. The mother is inclined to
incriminate the sulfonamides or vitamins the child
received from the family physician, but more often it is
the cough drops.
The treatment of this allergic urticaria is rather simple
now: Avoidance of the allergen, if it has been identified
or suspected; a mild laxative, to remove as much as pos-
sible of the causative factor. Even so, the urticaria may
linger on for several days. Small amounts of adrenalin
will produce immediate relief. The antihistamines, pyri-
benzamine, benadryl, histadyl or others will relieve the
urticaria and especially the itching until the other meas-
ures become effective. Local treatment is not of great
value. A hot bath may bring out the hives more, and
afterwards help to a better rest at night. Calamine lotion
with or without phenol can be applied, and will divert
the mind of mother and child from the trouble. I always
like to give some calcium. Don't forget sedation for the
child and the parent where this seems necessary.
Physical allergy, urticaria from sunlight, heat or cold
is rather rare in children. Antihistamines are useful in
such cases.
But there is another form of urticaria tn children.
When these patients are seen, the urticaria has been
present for a few weeks. The attacks are daily, or nearly
so, but there is no rhyme or reason. Some days are much
better, then there is a severe new eruption. Often this
form of urticaria can be traced to an infection, usually
of the upper respiratory tract. Elimination diets, avoid-
ance of drugs does not help. Treatment of the under-
lying infection with sulfonamides or penicillin is usually
successful. One has to be familiar with this form of
urticaria, because it becomes embarrassing when these
children are subjected to all forms of allergic manage-
ment. Bivings 1 has again called attention to it. Speak-
ing of infection and urticaria, one must always remem-
ber that scabies and insect bites, bedbugs and others, may
cause urticaria.
These insect bites bring to the mind a dermatosis
which is usually discussed with urticaria, although it is
a different disease, called lichen urticatus, but also known
as papular urticaria or strophulus.
This common disease of childhood is characterized by
small wheals which subside in the course of a few hours
and leave hard itchy papules, papulovesicles or occa-
sionally small bullae. Hullstrug 3 believes that lichen
urticatus may be caused by various single or combined
factors. External factors such as foods and insect bites,
and internal allergens, for instance, from intestinal para-
sites, may play a role. Allergic investigation is usually
negative. Some of the children with lichen urticatus are
atopic individuals; but the positive reactions elicited do
not seem to bear any relationship to their condition.
Insect bites, for a long time, have been suspected. Re-
cently Shaffer et al.G brought good evidence for this
etiology.
However, not all cases of lichen urticatus are due to
insect bites. In some, food allergies appear to be a fac-
tor. Treatment of these cases of lichen urticatus is diffi-
cult. Elimination diets are not too helpful. General
hygienic measures are recommended. Antihistaminics
should be tried. From my experience with lichen urti-
catus in adults, I would consider also a trial with hapa-
mine (histamin-azo-protein) .
214
The Journal-Lancet
Drug Eruptions
Drug eruptions in children, besides urticaria, probably
did not play too great a role or did not receive enough
attention until the advent of sulfonamides. Then the
practitioner and the pediatrician became aware of them.
It is not only the sulfonamides and penicillin that may
cause these rashes. Any and every drug may do that.
When a skin eruption looks strange or odd so that it
does not fit into a given category, or if it shows simul-
taneously signs of different dermatoses, think of a drug
rash, especially if this rash develops while the patient
is under your care. It may look like measles, scarlet
fever, or erythema nodosum, or acne, or erythema multi-
forme. But if one looks more closely, it does not look
exactly like one of these conditions — measle-like, but no
Kophk’s spots, and perhaps an urticarial component
which is not seen in measles. Another case may look
like erythema multiforme at first sight, but the experi-
enced observer notices a brownish pigmentation. This
is not encountered in true erythema multiforme, but is
very suggestive of an erythema-multiforme-/;Te drug
eruption.
Pediatricians have an easier job in finding out what
drug was the cause, because children usually take fewer
medicines. Sometimes there is only one, according to the
history. A check list of the common drugs and home
remedies comes in very handy at times.
In the hospitalized child that has taken a number of
medications usually it is something either taken within
24 hours preceding the eruption, or a drug which was
started six to nine days earlier. In this latter instance,
the child has become sensitized to a new drug; in the
former instance, the child is sensitive to a drug he or
she has had before. Sometimes a history will reveal some
previous, milder experience of intolerance to this drug.
There is another clue that may help in finding the
culprit. Although any drug may cause nearly any form
of an eruption, there are definite patterns preferred by
certain drugs. Aspirin, for instance, is likely to produce
a scarlet fever-like eruption, bromides, acneform lesions.
A thorough discussion of the various forms of eruptions
caused by different drugs has been given by Sulzberger
and Baer.'
One form of drug sensitivity which is rather little
known outside dermatologic circles, although Brocq de-
scribed it more than 50 years ago is the so-called fixed
drug eruption. In this condition usually only one or two
erythematous spots occur, and always in the same loca-
tion. The hands, wrists and the genital area are pre-
ferred. But they may appear on any part of the body.
Sooner or later, the center becomes pigmented, and then
the diagnosis is practically sure. Antipyrin, phenacetin,
and phenolphthalein are probably the most common
drugs causing these fixed eruptions.
Most drug eruptions are on an allergic basis. That
usually means that the drug should be withdrawn. When
the drug is continued through necessity, often nothing
happens. The incriminated drug may have been inno-
cent. The rash was blamed on the sulfonamide, whereas
actually it was caused by the barbiturate or codeine,
which the child had received earlier, and which had been
stopped before. Or the "drug eruption” may have been
on a different basis. We do know that some drugs may
provoke a toxic eruption in a different way. Somehow
antiseptics and antibiotics may stir up a latent infection
and in this way produce a measle-like rash or an eryth-
ema nodosum-like eruption. In such a case, the drug
usually can be continued with impunity.
There is still another possibility that applies especially
to penicillin. Treatment with this drug can at times be
continued without much trouble in spite of the presence
of an urticarial type of sensitivity, especially when anti-
histaminics are given simultaneously.
These occurrences should not make one less conscious
of the dangers of drug eruption. Fatalities have occurred
from drug sensitivities. Disastrous results have been
seen at times when the drug was continued. At present
we may choose from such a variety of antibiotics that
it should be nearly always possible to substitute another
drug for the suspected one. At times part of the alarm-
ing condition, such as a high fever and prostration, may
be due to the patient’s drug sensitivity and not to his
original disease.
The drugs should be eliminated wherever possible.
Desensitization, except perhaps in the case of penicillin,
is not a practical procedure. Symptomatic treatment con-
sists of antihistaminics, fluids, and general measures as
indicated.
I have tried to present a few phases of allergic skin
disorders in pediatrics. The management of these cases,
especially the eczemas, is usually difficult, often time-
consuming and sometimes disappointing. The results are
not perfect, and not always what we would want them
to be; but in many isntances we can accomplish some-
thing worth while if we give the proper attention and
time to these disorders.
Bibliography
1. Bivings, Lee: Acute Infectious Urticaria. J. Pediat.,
28:602-604, 1946.
2. Hansen, Arild E.: Disturbances in Lipid Metabolisms
in Children. South Med. J., 39:32, 1946.
3. Hullstrung, H.: Hautreaktionen nach Ungezieferstichen
unter dem Bild eines Lichen Urticatus. Arch. f. Dermat. u.
Syph., 183:315-323, 1943.
4. Perlman, Henry Harris: On the Use of Wet Dressings
in the Management of Dermatoses in Infants and Children.
Urol. & Cutaneous Rev., 53:170-173 (March) 1949.
5. Rothman, S., Smiljanic, A., Shapiro, A. L., and Weit-
kamp, A. W.: The Spontaneous Cure of Tinea Capitis in
Puberty. J. Invest. Dermat. 8:81-98, 1947.
6. Shaffer, Bertram, Spencer, M. C., and Blank, Harvey:
Papular Urticaria. Its Response to Treatment with DDT and
the Role of Insect Bites in Its Etiology. J. Invest. Dermat.
11:299 (Oct.) 1948.
7. Sulzberger, M. B., and Baer, R. L.: Yearbook of Der-
matology and Syphilology, pp. 7-36. Chicago: Year Book
Publishers, 1945.
8. Watson, E. H.: Boric Acid. J.A.M.A., 129:332-333,
1945.
# * * *
Further references may be found in MacKee and Cipollaro:
Skin Diseases in Children (Paul B. Hoeber, New York, 1946)
and in the author’s reviews on allergic skin diseases [Annals
of Allergy, 2:247 (May-June) 1944; 3:301 (July-Aug.) 1945;
4:476 (Nov. -Dec.) 1946; and (with W. L. Macaulay) 6:442
(July-Aug.) 1948.]
June, 1949
215
The Antihistamine Drugs in the
Treatment of Hay Fever in the Adult
J. S. Blumenthal, M.D., F.A.C.P.
Minneapolis, Minnesota
From the time that Hippocrates in the fifth Century
B.C. described what is today recognized as a food
allergy to cheese, the interest in all phases of allergy has
been of great and of increasing importance. It was,
however, not until 1565 that Botallus of Pavia1 described
seasonal vasomotor rhinitis elicited apparently by smell-
ing roses. To this day hay fever is often called by the
laity "rose fever.” For the first time in medical litera-
ture John Bostock 2 in 1828 mentioned the term hay
fever. He reported on 28 patients suffering from "sum-
mer catarrh” and noted that the symptoms were elicited
by hay. In 1831 Elliotston 3 called attention to the fact
that patients had the idea, probably correct, that their
catarrh was caused by grasses. Swett 4 in 1852 described
both summer and autumnal types of hay fever in the
United States. Outstanding above all others in the field
of hay fever, however, is the figure of Charles H. Black-
ley.5 It was he who in 1873 said that pollen catarrh
was really a more appropriate term than hay fever and
established the positive skin scratch tests with adequate
controls.
In 1910 Barger and Dale 6 isolated histamine beta
imidozolethylamino from ergot and in 1911 ‘ found his-
tamine in the intestinal mucosa. Its precursor, histidine,
is a common cell constituent. Best and McHenry 8 re-
ported it is found most often in barrier tissue such as
skin and intestinal mucosa. Histidine may be converted
to histamine by the removal of carboxyl group not only
by antigen antibody reaction but also by bacterial ac-
tion.Dr. R. Bieter notes that histamine tends to act
on cells that are ennervated by the autonomic nervous
system.
Histamine is known to produce constriction of smooth
muscle, dilation and increased permeability of capillaries
and to act as a secretagogue on the glands of exocrine
secretion. It appears in the blood immediately after
administration of an antigen, and in the guinea pig the
phenomenon of anaphylaxis and the administration of
histamine seem to be identical.10
While as pointed out by Dragstedt 11 histamine re-
lease is at least a major factor in the causation of allergy
symptoms, it is probably not the only factor. It is be-
cause of this that Sir Thomas Lewis 12 called the factor
' H subtance,” and said, "I shall speak of an H sub-
stance, and in using it shall mean any substance or sub-
stances liberated by the tissue cells and exerts on the
minute vessels and nerve ending an influence culminat-
ing in the 'triple response.’ ” The relationship between
the amount of histamine activity in the blood and
the symptoms is not as direct as one would desire. The
identification of histamine itself in the blood, Dragstedt
has repeatedly pointed out, is always difficult. As Katz 13
has shown, there is always the problem of differentiation
between histamine bound to cells and histamine in the
free state. He 14 added horse serum in vitro to the blood
of a rabbit sensitized with that serum and noted that the
cell-free plasma showed a great increase of histamine.
Rose and Brown lj got essentially the same results and
repeated the experiment with use of egg albumin added
to the blood of egg sensitive rabbits with the same effect.
While we thus have evidence from these experiments
as well as others 18,17 that there is a transfer of the
bound to the free state, we as yet do not have defi-
nite evidence that the reverse is also true. There are
indications that it is.18 This change in the state of his-
tamine makes it hard to assay its exact role in allergy.
In the main, however, the histamine theory is plausible.
In discussing the treatment of hay fever, it would
seem appropriate here to give a concept of what takes
place in the hay fever patient. As in all patients with
allergic symptoms, we first must have the so-called
"asthmatic state” — a state defined by Rackemann 18,19
as an inherited one in which a patient is more likely to
develop these symptoms than do others in exactly the
same environment. It is the condition which may be the
background in which allergy in the usual sense can de-
velop. We have, further, the capacity in these individ-
uals to develop sensitiveness and to produce or react to
H substance so as to cause a variety of symptoms of
vasomotor origin. In hay fever pollens acting on such
a person whose eyes, nose and throat are sensitized
causes the production of antibodies of two types —
a thermostabile and a thermolabile antibody. The re-
action, we can postulate, of the thermolabile antibody
and the pollen allergen causes the release of histamine
or H substance which in turn causes the symptoms of
hay fever. In this concept, it is easy to see that the
logical point of attack would be the fundamental asth-
matic state. Unfortunately we know so very little about
that beyond the important hereditary factor which makes
attack here very difficult. Indeed, it would seem at times
that hay fever victims seem to have an affinity for each
other, for misery loves company. Allergies seem to tend
to propagate their heredity.
The next logical point of attack would be the allergen.
Here again, though desirable, the economic and social
factors make it frequently impossible to have the patient
go where the pollen is not. Beyond that, the patient fre-
quently becomes sensitized to other pollens. This factor
was called forcibly to my attention on a recent visit to
Mexico City. I met two Minnesota natives, doctors who
had gone to live in Mexico City because of their severe
hay fever. After a few years there, ragweed pollenosis
had been replaced by an equally distressing pollenosis
due to Bermuda grass pollens. Ragweed is present in
216
The Journal-Lancet
the vicinity of Mexico City, but the amount is extremely
small. Again, two years ago while visiting at the Uni-
versity of Havana, I met a native Iowa allergist who
informed me that his hay fever of Iowa due to ragweed
had been replaced by a pollenosis due to grass pollen
which is found in the air of Cuba in varying amounts
throughout the whole year. These people are taking
hyposensitization with good results, but they could not
get away from their primary allergic state by getting
merely away from the original offending pollen.
In 1911 Noon-’1 and Freeman-'-’ used specific active
hyposensitization in hay fever by repeated injections of
increasing amounts of allergen. In 1935 Cooke Bernard
Hebald and Stull 2(1 first presented evidence for an anti-
body which could block the union of ragweed antigen
with the ordinary neutralizing antibody, that is, there are
really two antibodies in hay fever — the sensitizing ther-
molabile antibody destroyed by heat at 56° Centigrade
and the thermostabile antibody not so destroyed. Love-
lace 2:4 states that the amount of blocking antibody is
proportional to the symptomatic relief following treat-
ment. Cooke,24 however, found that it is not, and it
is true that frequently a high blocking antibody titre
does not always accompany good clinical results. It is
equally true, however, that adequate hyposensitization
does give relief in a great percentage of hay fever pa-
tients. In our own experience, the larger the dosage used
the better the clinical results.
There are two parts to the treatment of hay fever by
hyposensitization — the particular extract used and the
way it is used. The methods used in the series here
reported is simple. Skin tests by the usual scratch meth-
ods are correlated with the history of onset of symptoms
of the patient and a specific solution made for each.
History is most important. A positive skin test to a
pollen that gives rise to no significant symptoms when
that pollen is present in the air can not be of too great
clinical significance in spite of the positive skin test. At
the present time, there are only two crude methods of
selection; one is the history to indicate the date of onset
of symptoms as accurately as possible and to correlate
this date with the onset of pollenation. The other is a
field survey confirmed by pollen slides to make sure that
a particular plant is capable of putting sufficient pollen
in the air where a particular patient is exposed to it.
Where scratch tests did not confirm the impression of
history and pollen survey, intradermal tests were care-
fully applied. When atypical in onset and duration or
when conventional treatment had given unsatisfactory
result, molds were incorporated in the extract. Molds,
although not apparently as important in adults as in
children and through a field wherein a tremendous
amount of work remains to be done even as to identifi-
cation, occasionally gave better results when used either
together with the pollen extracts or by themselves usually
in the form of alternaria, hormodendrum or aspergillus.
The initial dose injected subcutaneously is usually 20
units using .00001 mg. of pollen nitrogen by the Kjel-
dahl method as the unit. The dosage was increased
at 4 to 7 day intervals by 50 per cent, aiming at getting
the 20,000 units or more before the patient’s symptoms
began. Dosage increases, of course, depend upon the
reaction of the individual. The maximum dose was then
continued throughout the pollen season unless reaction
or symptoms so dictated otherwise. It was at times re-
duced when the season started. Where possible, treat-
ment is continued throughout the year at reduced dos-
age, usually 50 per cent; i. e., usually 10,000 units.
Since histamine or H substance has been designated
as a common denominator for allergic manifestations,
it is natural that many attempts should have been made
to find some substance which could inhibit all anaphylac-
tic and allergic reactions by counteracting or neutralizing
histamine, the end product of the allergen antibody re-
action. The second method of treatment, therefore, here
reported is with the use of some of the so-called anti-
histamine drugs. Antihistamine drugs or histamine an-
tagonists have been defined by Earl R. Loew 2'' and as
Dr. Bieter points out, as drugs which diminish or pre-
vent several of the pharmacological actions of histamine
by a mechanism other than by the production of phar-
macological responses diametrically opposed to those pro-
duced by histamine. In other words, these drugs antag-
onize histamine and prevent its action without producing
any pharmacological actions of their own. As Gilman 2,1
points out, the antihistamines are really blocking agents,
and the term histaminalytic would really be more appro-
priate. They prevent the histamine from gaining access
to the receptor mechanism of the cell and exerting the
characteristic effect. The incomplete results and varying
results in allergic manifestations with treatment by the
antihistamine drugs may be explained in part by the
fact that histamine within the cell itself is not affected
or the amount of histamine released is too great to be
neutralized by the amount of drug given.
Hill and Martin 2‘ in 1932 listed 165 methods which
have been used to attempt to inhibit anaphylaxis. Most
were too toxic to use clinically. Among substances listed
were atropine, barium, chloral, ether. Other substances
used in the past decade — the amino acids — have been
disappointing. Bovet 8 and Staub 28 in 1937 found two
substances synthesized by E. Fourneau (hence the so-
called F compounds) thymoxyethyldiethylamine and
N: phenyl N ethyl N-diethylethylenediamine, called
929F and 1 57 IF. These had marked antihistamine prop-
erties but were too toxic for clinical use. In 1942 Hal-
pern 29 reported promising results with the new com-
pound called Antergan. Since then extensive research
has resulted in the production of a great many of these
drugs until their number seems legion. A list of the
more prominent antihistamines is as follows: (1) phenyl-
amines — Antergan and Antistine; (2) pyridine amines —
Neoantergan, Pyribenzamine and Trimeton; (3) thenyl,
pyridine amines — Histadyl or Thenylene, Tagathen or
Clorothen, Diatrin and Bromothen; (4) benzhydryl alka-
mine ethers — Benadryl and Decapryn; (5) pyridindene —
Thephorin; (6) pyrimidine amines — Hetramine and
Neohetramine; (7) phenothiazines — 3015 Rhone-Pou-
lene or 1627 Searle, 1721 Searle and Pyrrhoazote.
June, 1949
217
We have used these drugs both in hay fever and in
other allergic conditions. Results in conditions other
than hay fever will be reported at a later date. On
the whole results with the use of these drugs in hay fever
has afforded, according to the literature, relief of up to
94 per cent. In reviewing some of the extensive litera-
ture, it is apparent that the drugs resemble one another
in degree and duration of relief.'50'39 The effect persists
four to six hours and results are apparent in one-half
to one hour after oral administration.
Side effects 44,40.43 have been many, and though not
usually serious are annoying. Among the most common
are sleepiness, dizziness, skin eruptions, epigastric dis-
tress, headache, change of shock tissue. A very impor-
tant and interesting report on the use of these drugs in
their less obvious effects is that of Haltkamp and Ha-
german and Whitehead.44 They report on the effects
on the mental ability, reaction time, and minimum dis-
tance of two point discrimination. They report definite
alteration in 50 per cent of college students. Blasman
and Hagens 4o report a case of exacerbation of asthma
with fatal result in the use of Benadryl. Here again the
exact role of Benadryl is very difficult to evaluate as is
the case of any therapeutic agent in asthma.
In the series of patients now being reported, all were
seen once a week or oftener. Symptoms were recorded
as were degree of relief and side effects. They were ques-
tioned as to nasal discharge, difficulty in breathing, itch-
ing, sneezing, increased flow of tears, smarting and red-
ness of the eyes, wheezing, coughing and expectoration.
New drugs were given as soon as evaluation was made.
Dosage was prn and not at regular intervals. The re-
sults were evaluated according to the patients’ own de-
scription and judgment and the overall picture includ-
ing objective findings. Those who experienced 50 per
cent relief or more were considered to have fair results.
Patients who had mild to practically no symptoms were
considered to have had good results. It was evident that
this is at best a very rough method of assaying conclu-
sions, but as in most conditions in which the subjective
symptoms are very important, we must use as non-
prejudicial an attitude as possible and keep all aspects of
the condition under consideration in judging the figures
given. It has been well said that there are three kinds
of lies — white lies, black lies and statistics. Certainly in
no field of medicine do statistics lie and lie and lie as
frequently and as profusely and as efficiently as they do
even in so simple a field of allergy as hay fever. This is
understandably so, for here is a condition in which the
statistics of results of therapy are affected not only by
the usual enthusiasm of the investigator, not only by the
psychosomatic aspects of the patients, but even by the
very furniture and people by which the patient is sur-
rounded, the food he consumes and the very air that he
breathes.
Table 1
Hyposensitization — 108 Patients
No Relief Appreciable Relief Good Relief
16 (14.8 per cent) 32 (29.6 per cent) 60 (56 .6 per cent)
One hundred eight patients were treated by hypo-
sensitization by method described. Of these as seen in
Table 1, 16 (14.8 per cent) had no or very slight im-
provement, 32 (29.6 per cent) had appreciable relief
where the patient thought treatment was worthwhile,
and 60 (56.6 per cent) had good relief.
Table 2
Placebos — 20 Patients
No Relief Appreciable Relief Good Relief
18 (90 per cent) 1 (5 per cent) 1 (5 per cent)
Twenty patients were given placebos. It is interesting
to note as emphasizing the psychosomatic aspects of any
allergic condition that one (5 per cent) had appreciable
relief and one (5 per cent) had marked relief, though
18 (90 per cent) had no relief whatever.
Table 3
Benadryl — 62 Patients
No Relief Appreciable Relief Good Relief
22 (35.5 per cent) 12 (19.3 per cent) 28 (45.2 per cent)
Sixty-two patients were given Benadryl in doses of
50 to 100 mg. up to four times a day as needed. Of
these, 22 (35.5 per cent) had no relief, 12 (19.3 per
cent) had appreciable results and 28 (45.2 per cent) had
good relief of symptoms.
Table 4
Histadyl — 22 Patients
No Relief Appreciable Relief Good Relief
7 (31.8 per cent) 8 (36.4 per cent) 7 (31.8 per cent)
Histadyl was given in the same dosage as Benadryl.
Of 22 patients 7 (31.8 per cent) had no relief, 8 (36.4
per cent) had appreciable relief and 7 (31.8 per cent)
had good relief.
Table 5
Pyribenzamine — 55 Patients
No Relief A ppreciable Relief Good Relief
17 (30.9 per cent) 16 (29.1 per cent) 22 (40 per cent)
As noted in Table 5 Pyribenzamine was prescribed
to 55 patients. Of these, 17 (30.9 per cent) had no
relief of symptoms, 16 (29.1 per cent) had appreciable
relief and 22 (40 per cent) had good relief of symp-
toms.
Table 6
Most Favorable Drug — 72 Patients
No Relief Appreciable Relief Good Relief
19 (26.4 per cent) 19 (26.4 per cent) 34 (47.2 per cent)
It would seem from summaries so far given that the
percentage of patients relieved by these drugs are essen-
tially the same, but it was evident that some were re-
218
The Journal-Lancet
lieved by one drug and some by another. There were
differences in the amount and quality of the relief ob-
tained. Therefore, 72 patients were given the oppor-
tunity to try different antihistamine drugs and use the
one best suited to them. Of these, 19 (26.4 per cent)
had no relief with any of them, 19 (26.4 per cent) had
appreciable relief and 34 (47.2 per cent) had good re-
lief. Though hard to express in figures alone, it was
evident that by changing to various drugs and using
different ones when one drug had less benefit or gave
undesirable side effects, that better results could be
obtained.
A very limiting factor in the use of antihistamine
drugs since they were first used has been the toxic or
side effects. While usually not too marked, they are
often very annoying and limit their usefulenss in clin-
ical practice. The effects vary in different patients for
the same drug and often in the same patient with the
same drug. Usually the larger the dose the greater the
side effects in degree and frequency. There is fortu-
nately no correlation apparent between the symptomatic
relief and the side effects except insofar as larger doses
may be required. The side effects are tabulated.
Table 7
Side Effects
Bena-
Pyri-
dryl
benzamine
Histadyl Placebo
Drowsiness
36
12
4 1
Weakness
32
8
2
Hypnosis
1
Dizziness
18
5
Urticaria ...
1
Nervousness
6
6
Nausea ...
2
5
2
Vomiting
Asthma
1
1
3
As noted in Table 7 drowsiness was the most promi-
nent symptom noted. This was a prominent factor in
36 patients of 62 taking Benadryl, in 12 of 55 taking
Pyribenzamine, in 4 of 22 taking Histadyl and in one
taking Placebo. Dizziness was a prominent action with
Benadryl and Pyribenzamine while 6 patients of both
the Benadryl and Pyribenzamine group complained of
increased nervousness; weakness was noted particularly
in the Benadryl group. Other side effects were hypnosis,
urticaria, nausea and vomiting. We only had one patient
in whom we felt that respiratory difficulty or asthma was
apparently aggravated by Benadryl. Even here it is diffi-
cult to be certain as so frequently hay fever patients
develop this complication who had never seen an anti-
histamine drug. I realize that change of shock tissue
with development of asthma has been reported as a fre-
quent side effect by some allergists, but this can not be
too frequent. Certainly we have not had that experience
in the adult patient. We must also realize that the anti-
histamines themselves may be antigens and cause allergic
manifestations. The side effects were often combined in
the same patient.
Table 8
Hyposensitization plus Antihistamines — 108 patients.
No Results A ppreciable Results Good Results
8 (7.4 per cent) 12 (10.2 per cent) 88 (82.4 per cent)
The patients who had been hyposensitized were given
the drugs to use as needed for symptomatic relief. In
this group, much smaller and less frequent doses were
required to control symptoms. The incidence of side
effects was practically nil. The very hypnotic effect was
at night very desirable. There seemed to be no marked
preference for any of the drugs, and at times one would
seem to work better than another, while often in the
same patient the same drug would have different results
as to efficacy in relieving symptoms. In that case a
change would have marked benefit. By combining the
antihistamines with hyposensitization as noted in Table
8, only eight patients were unable to obtain at least some
degree of benefit. It is interesting to note that practically
all of the patients found it desirable to use the drugs
at some time during the season — even those who had the
best results with hyposensitization. In this group again,
as noted, 8 (7.4 per cent) had slight or no improvement,
12 (10.2 per cent) had appreciable relief and 88 (82.4
per cent) had good results which in these cases were
such as to make them very comfortable even to com-
pletely free them of symptoms.
Comment
A study of the results here given would indicate that
the antihistamine drugs are a great help in the control
of hay fever patients and would certainly justify the
conclusion that histamine must play some very definite
role in the allergic reactions. It is very evident also that
the drugs here reviewed are a long ways from ideal.
The side effects are a very real and serious obstacle, and
often the patient changes one set of symptoms for an-
other. The itching, nasal discharge and eye symptoms
are much more relieved than the nasal stuffiness and
blockage. The patients very often object to taking drugs
continually through a long period of time, even though
only seasonal. The results are purely palliative, and
there is a recurrence of symptoms as soon as medication
is stopped. They do not immunize the patient and pro-
tect him from the effects of an allergic reaction for any
prolonged period. Beyond that, the effects are often
very disappointing, especially in the severe cases. We
have made attempts at various times to use benzedrine,
caffeine, ephedrine to counteract the drowsiness of the
large percentage of patients having this side effect but
with no great success. In our experience, in instances
where ephedrine was of benefit we found that the re-
lief was better with no antihistamine at all.
The best results as noted are obtained not only in
quantity but in quality which is difficult to express in
figures, is by the combination of hyposensitization with
the antihistamine drugs. The side effects, though not in
direct ratio to the symptomatic relief, are very often in
direct proportion to dosage used. It is, therefore, de-
June, 1949
219
sirable to use a smaller dosage which is exactly the case
when used in conjunction with hyposensitization. It
must also be emphasized that while the antihistamine
drugs seldom have marked benefit on the respiratory or
seasonal asthmatic symptoms, hyposensitization fre-
quently will give marked relief of asthma even when
the symptoms referable to the nose and eyes are little
affected. While it is evident that we will get better anti-
histamine drugs as regards potency and toxicity, it is also
evident that it would be preferable to attack the prob-
lem in a more fundamental way at the beginning rather
than by neutralizing the end product of the allergen-
antibody reaction.
Conclusion
In conclusion it is probably justifiable to say that the
antihistamine drugs used here are a very valuable addi-
tion to our methods of treatment of hay fever but are
often not efficient and have serious side effects. A large
percentage of patients will get relief with one or an-
other in an appreciable degree. The preferred method,
however, at present is the combined method of hypo-
sensitization with the antihistamine drugs. Here the re-
sults are the best up to the present period.
sft He
I wish to thank Dr. R. Bieter, Chief of the Department of
Pharmacology, for his help in obtaining and using these drugs.
I also wish to express my appreciation to Dr. S. Hirsh and
Dr. W. Peterson for their help in administering some of these
drugs and tabulating some of the data.
References
1. Botallus, L.: Commentarioli duo Lugduni. Apud. A.
Gryphium 1565.
2. Bostack, J.: Case of Periodical Affection of Eyes and
Chest. Med. — Chir. Tr. London, 16:161, 1819.
3. Elliotston, J : Clinical Lecture on Hay Fever. London
M. Gaz. 8:411, 1831.
4. Swett, J. A.: A Treatise on Diseases of the Chest.
N. Y., D. Appleton and Co., 1852.
5. Blackley, C. H.: Experimental Researches on the Cause
and Treatment of Cattarrhus Aestivus (Hay Fever or Hay
Asthma). London, Baillere, Tindall and Cox, 1873.
6. Barger, G., and Dale, H. H.: The Presence in Ergot
and Physiological Activity of B. Imidazolethylamine. J. Physiol.
40:38, 1910.
7. Barger, G., and Dale, H. H.: Biminazolylethylamine: A
Depressor Pressor Constituent of Intestinal Mucosa. J. Physiol.
41:499, 1911.
8. Best, C. H., and McHenry, E. W.: Histamine. Physiol.
Rev. 11:371, 1931.
9. Best, C. H., Dale, H. H., Dudley, H. W., and Thorpe,
W. V.: Nature of Vasodilator Constituents of Certain Tissue
Extracts. J. Physiol. 62:397, 1927.
10. Best and Taylor: Physiological Bases of Medical Prac-
tice. 2nd Ed. 588.
11. Dragstedt, C. A.: The Significance of Histamine in
Anaphylaxes and Allergy. Quart. Bull. N. W. Univ. M.
School 17:102, 1943.
12. Lewis, T.: The Blood Vessels of the Human Skin and
Their Responses. London, Shaw and Sons, Ltd., 1927.
13. Katz, G.: The Role of Bloods Cells in the Anaphylactic
Histamine Release. J. Pharmacol. & Exper. Therap. 72:22.
14. Katz, G., and Cohen, S.: Experimental Evidence of
Histamine Release in Allergy. J.A.M.A. 117:1782, 1941.
15. Rose, B., and Brown, J. S. L.: Studies on the Release
of Histamine from the Blood of the Rabbit by the Addition
of Horse Serum or Egg Albumin in Vitro. J. Immunol. 41:403,
1941.
16. Rose, B.: The Role of Histamine in Anaphylaxis and
Allergy. Am. J. Med. 3:545, 1947.
17. Rocha, E., Silva, M.: Recent Advances Concerning the
Histamine Problem. J. Allergy 15:399, 1944.
18. Rackemann, Francis M.: Allergy. Arch. Int. Med. 77:6,
1946.
19. Rackemann, Francis M.: Allergy. Arch. Int. Med.
81:5, 1948.
20. Cooke, R. A., Barnard, J. H., Hebald, S., and Stull, A.:
Serological Evidence of Immunity with Coexisting Sensitization
in a Type of Human Allergy (Hay Fever). J. Exper. Med.
62:733, 1935.
21. Noon, L.: Prophylactic Innoculation Against Hay Fever.
Lancet 1:1572, 1911.
22. Freeman, J.: Further Observations on the Treatment of
Hay Fever by Hypodermic Innoculation of Pollen Vaccine.
Lancet 2:814, 1911.
23. Lovelace, M. H.: Immunologic Studies of Pollenosis: VI.
Shortening of Treatment of Hay Fever. J. Allergy 15:311,
1944.
24. Cooke, R. A.: A Consideration of Some Allergic Prob-
lems: II. Serologic Studies of the Skin Reacting Allergies (Hay
Fever Type). J. Allergy 15:212, 1944.
25. Loew, E. R., MacMillan, R., and Kaiser, M. E.: The
Antihistamine Properties of Benadryl. J. Pharmacol. & Exper.
Therap. 86:1, 1946.
26. Gilman, A.: Pharmacology of Drugs Used in Allergic
Conditions. J. Allergy 19:281, 1948.
27. Hill, J. H., and Martin, L.: Review of Experimental
Studies of Non-Specific Inhibition of Anaphylactic Shock.
J. Med. 11:141 (March) 1932.
28. Bovet, D., and Staub, A.: Action protectrice des ethers
Phenolignes au cours de l’intoxication histaminique. Compt.
Rend. Soc. de Biol. 124:547.
29. Halpern, B. N.: Experimental Research on a Series of
Chemical Substances with Powerful Antihistaminic Activity.
The Thtodiphenylamme Derivatives. J. Allergy 18:263, 1947.
30. Rose, J. M., Feinberg, A. R., Friedlaender, S., and
Feinberg, S. M.: Histamine Antagonists: VII. Comparative
Antianaphylactic Activity of Some New Antihistamine Drugs.
J. Allergy 18:149, 1947.
31. McElin, T. W., and Horton, B. T.: Clinical Observa-
tions on the Use of Benadryl: A New Antihistamine Sub-
stance. Proc. Staff Meet., Mayo Clinic 20:417, 1945.
32. Bernstein, T. B., Rose, J. M., and Feinberg, S. M.:
New Antihistaminic Drugs in Hay Fever and Other Allergic
Conditions. 111. M. J. 92:8, 1947.
33. Woldblott, G. L.: Clinical Results with Benadryl. Jr.
Allergy 17:142, 1946.
34. Feinberg, S. M.: Histamine and Antihistamine in
Agents: Their Experimental and Therapeutic Status. J.A.M.A.
132:702, 1946.
35. Henderson, A. T., and Rose, B.: Pyribenzamine in the
Treatment of Allergy. Canad. M.A.J. 57:136, 1947.
36. Feinberg, S. M.: The Antihistamine Drugs: Pharma-
cology and Therapeutic Effects. A. J. Med. 3:560, 1947.
37. Arbesman, C. E.: The Pharmacology, Physiology and
Clinical Evaluation of the New Antihistamine Drugs. N. J.
State J. Med. 47:16, 1947.
38. Kleckner, M. S.: Clinical Appraisal of Benadryl, Pyri-
benzamine and Anthallan in the Treatment of Allergic Dis-
orders. Annal. Int. Med. 28:3, 1948.
39. Weiss, W. I., and Howard, R. M.: Antihistamine Drugs
in Hay Fever: Comparative Study with Other Therapeutic
Methods. Jr. of All. 19:215, 1948.
40. Slater, B. J., and Francis, N.: Benadryl, a Contributing
Cause to an Accident. J.A.M.A. IV, 1946.
41. Weil, H. R.: Unusual Side Effect from Benadryl.
J.A.M.A. VI, 1947.
42. Borman, M. C.: Danger with Benadryl of Self Medica-
tion and Large Dosage. J.A.M.A. VI, 1947.
43. Geiger, J., Rosenfield, S., and Hartman, D. L.: Un-
usual Reaction Following Benadryl Administration. J.A.M.A
133:392, 1947.
44. Holtkamp, D. E., Hageman, D. D., and Whitehead, R.
W.: Side Effects of Three Antihistamine Drugs. Jr. All
19:6, 1948.
45. Blasman, N. E., and Hagens, J. C.: Fatality Associated
with Benadryl Therapy. Jr. All. 19:6, 1948.
220
The Journal-Lancet
Antihistamine Therapy in Allergy
Sidney Friedlaender, M.D.,f and Alex S. Friedlaender, M.D.f
Detroit, Michigan
The recent development of the group of synthetic
drugs known as "antihistaminics” is the result of
several decades of theoretical and practical research in
the field of histamine metabolism. A great deal of evi-
dence regarding histamine points to its participation in
the allergic reaction; yet much of this is indirect and
based to a great extent on the close relationship that
appears to exist between human allergy on the one hand
and animal anaphylaxis on the other.
To review some of the pertinent data in support of
the histamine hypothesis, it may be recalled that Dale
and Laidlaw 1 were the first to point out the similarity
between the toxic effects of histamine in guinea pigs and
those of anaphylactic shock. Later, Lewis and Grant 2
while studying the minute vessels of the human skin re-
marked upon the close resemblance of histamine and
allergic wheals. The experiments of Best,3 Dragstedt,
and others, 4,;> subsequently showed that histamine is a
natural constituent of living tissues, where it exists in
the cell in a bound, inactive form. It may be liberated
as a result of antigen-antibody union, then becoming free
to exert an injurious effect on the surrounding tissues.
Recognition of the probable importance of histamine
in allergic disease stimulated a search for means of com-
bating its injurious actions. Some of the principal phar-
macologic actions of histamine are the contraction of
smooth muscle, vasodilatation, increase in capillary per-
meability, and stimulation of secretory glands. Many of
the manifestations of allergy are remarkably similar to
these known toxic effects of histamine. Certain effects
of histamine can be effectively counteracted by the spe-
cific pharmacologic action of such drugs as epinephrine,
ephedrine, aminophyllin, and the iodides, which repre-
sent some of the most effective symptomatic remedies
used in allergy.
The process of desensitization to the specific allergen
indirectly combats histamine action by preventing the
union of antigen and reagin through the interposition of
a ' blocking antibody.” However, a more direct approach
to the histamine problem has been sought. One method,
which received widespread trial, attempted to increase
the tolerance to histamine by immunization with hista-
mine 11 or a histamine-protein conjugate.7 This met with
very little success. Another therapeutic method which
has now been discarded was based on the use of the
enzyme "histaminase.” While this enzyme is capable of
neutralizing histamine rrin vitro” , it is ineffective under
the conditions existing in the living organism.8 The
most recent and promising approach to the histamine
’'Read at the 26th Annual Meeting of the American Student
Health Association.
‘('From the Departments of Bacteriology and Medicine,
Wayne University College of Medicine, Detroit, Michigan.
problem is the development of chemical blocking agents,
the so-called antihistaminic drugs, which are the subject
of the present discussion. These compounds apparently
produce their effect by displacing histamine from its
receptor site on the cell through competitive action.1’
The early work on synthetic antihistaminic agents was
carried out in France, where for several years a system-
atic search was made for chemical agents capable of
blocking the action of histamine in much the same man-
ner that atropine opposes acetylcholine, or ergotoxine
annuls the pressor action of epinephrine. In 1942 the
first synthetic antihistaminic suitable for use in the
human subject was introduced in France under the trade
name, Antergan.10 Its favorable effect in alleviating
certain symptoms of allergy, gave added support to the
histamine theory of allergic reactions, and spurred a
more active search both here and abroad for new chem-
ical agents which might be even more effective and less
toxic.
Benadryl and Pyribenzamine were the first antihista-
minic drugs developed by American chemists, and met
with considerable clinical success. In Europe, Antistine
and Neoantergan have now largely replaced the earlier
drug Antergan, and these are being introduced into this
country. Several other antihistaminics, the majority
chemically related to earlier compounds, have recently
been synthesized and made available for clinical use.
Among these are Thenylene, also known as Histadyl,
Thephorin, Decapryn, Neohetramine, Diatrin, Pyrollo-
zote, Trimeton and Tagathen.11 Their pharmacology
and clinical action compare closely with those of Bena-
dryl and Pyribenzamine.12 They are effective in varying
degree in the same conditions, and induce for the most
part the same range of side effects. A certain number
of the new drugs, however, appears to be much better
tolerated, and may be used in those patients previously
unable to take drugs of this type.
While many reports have appeared concerning the
favorable action of antihistaminics in conditions not gen-
erally considered to be of allergic origin, the majority of
these claims require further investigation and critical
evaluation before they can be established. At this time
it is quite well accepted that these drugs have great use-
fulness in allergic disorders. Their effect in these condi-
tions, however, is limited. They do not help all types of
allergic manifestations, and they do not necessarily bene-
fit all individuals with any particular form of allergy.
They are purely symptomatic agents having no perma-
nent curative action, and rarely do they completely eradi-
cate all the symptoms of an allergic attack. Yet they
frequently induce a palliative effect in cases resistant to
other therapeutic measures. They are exceedingly help-
ful in cases of urticaria, angioneurotic edema, dermo-
June, 1949
221
graphism, and in those increasingly frequent "serum
sickness-like” reactions which are seen following the use
of penicillin, sulfonamides, horse serum, and other drugs
and biologicals. The acute bouts of urticaria are gener-
ally more responsive to this type of medication than are
the chronic cases. In these conditions, pruritus is fre-
quently alleviated and edema diminished. Joint swell-
ings, if present, remain more resistant to such therapy.
The extreme pruritus of atopic eczema and contact der-
matitis is frequently helped, and considerable benefit may
be observed in some cases of pruritus ani and vulvae.
Relief of itching is often noted in other skin conditions
not necessarily allergic in origin.
Considerable discussion has resulted from the apparent
benefit achieved in some of these pruritic skin condi-
tions, since the evidence for histamine release in such
situations is meager, or at least far less than that estab-
lished for the whealing eruptions of the urticarial type.
It is possible that these drugs may exert a favorable
effect through other than an antihistaminic mechanism.
They have other pharmacologic properties, among which
is a strong local anesthetic action, several times that of
procaine. Mayer 1,1 in recent work on experimental con-
tact dermatitis in animals, observed an interference with
hyaluronidose activity, and suggested this as a possible
reason for the benefit observed in some skin eruptions.
In hay fever, a large percentage of patients obtain
benefit from these drugs, though complete relief of
symptoms is unusual. Rhinorrhea and itching of the
eyes and nose are more often benefited than nasal block-
ing. More relief is usually noted early in the pollen
season, and on days when the pollen concentration of the
air is low. Later in the season, even in the presence of
a diminishing pollen count, the beneficial response ap-
pears less. In general, mild cases of hay fever are bene-
fited more than severe ones. Those who have received
some degree of protection through desensitization ther-
apy to the specific pollen obtain greater benefit than
those totally unimmunized. In the more chronic condi-
tion of perennial allergic rhinitis, the incidence of favor-
able response is somewhat less than that observed in
acute hay fever.
The action of these drugs in asthma is usually not
striking. While some asthmatics note a beneficial effect,
the majority fail to obtain appreciable relief of dyspnea
from their use. A more favorable action, which occurs
more frequently in children, is the relief of the asthmatic
cough. Recently, aminophylline and ephedrine have been
combined with antihistaminics, in the hope they may be
of greater benefit to asthma patients. The simultaneous
administration of such drugs to the asthmatic is often
desired, and while such combinations offer greater con-
venience, we would hesitate to say from our own obser-
vations that any synergistic action occurs.
Experience with these drugs in miscellaneous allergic
conditions, such as gastro-intestinal allergy and allergic
headache have been quite variable. Certain cases obtain
marked help, while other similar cases fail to attain any
appreciable relief.
As previously mentioned, beneficial action of antihista-
minic medication has been reported in many conditions
in which an allergic component is absent, or is at least
extremely doubtful. Among these might be mentioned,
herpes simplex, scleroderma, dermatomyositis, transfusion
reactions, dysmenorrhea, radiation sickness, morphine
withdrawal syndrome, and the common cold. In relation
to the latter it may be interesting to note in passing that
there is some experimental evidence pointing to the in-
crease of histamine content of the nasal secretion during
the early stages of the common cold.14 This aspect de-
serves further study and is receiving critical analysis in
our own laboratory at the present time.
The usual mode of administration of these drugs is
by the oral route. The drugs are rapidly absorbed from
the gastro-intestinal tract, and destroyed or excreted
within a relatively short period of time. The effect of
a single oral dose is usually evident within 30 minutes
and may last for several hours. From present knowledge
at least, it would appear that the use of these drugs in
the absence of active symptoms accomplishes little.
Where symptoms are continuous, it is usually necessary
to administer the drugs at intervals of 2 to 6 hours
in order to maintain a palliative effect. The usual adult
dose varies from 25 to 100 mgm. Some drugs are gen-
erally effective in smaller amounts, while others require
larger doses. The individual response to these drugs is
quite variable, and it is frequently necessary to give sev-
eral doses before the requirements of the patient can be
accurately gauged. Usually the drug is taken after meals
since gastro-intestinal irritation is less when food is in
the stomach. Children for the most part tolerate these
drugs very well and may be given 25 to 50 mgm. doses.
Elixirs and syrups containing 10 to 20 mgm. per tea-
spoonful have been found especially useful in infants,
and in the occasional adult who requires smaller amounts
or objects to the use of the pills or capsules.
It is sometimes desirable to administer antihistiminics
parenterally.1,1 Several drugs have been prepared in suit-
able form and at the present time Benadryl is generally
available in sterile solutions containing 10 mgm. per cc.
We have found it advisable, when giving Benadryl intra-
venously, to test the patient’s tolerance with an initial
dose of 10 mgm. and then to increase subsequent doses
up to 50 mgm. depending upon the response obtained.
The solution may also be injected intramuscularly, in
which case the effect is slower and less intense. Subcu-
taneous administration is somewhat irritating, and occa-
sionally produces local redness and swelling. Severe cases
of urticaria and angioneurotic edema, and the serum
sickness type reactions, who have failed to benefit from
oral therapy, are often controlled by the parenteral ad-
ministration of the drug. Marked to moderate sedation
is often obtained with this preparation, and in an occa-
sional case of asthma, relief of bronchospasm has been
observed.
The local application of antihistaminics is occasionally
beneficial in allergic and other pruritic dermatoses.11’ At
the present time Pyribenzamine is available in the form
222
The Journal-Lancet
of a 2 per cent ointment or cream. Our results with the
water washable cream have been more favorable than
with the anhydrous preparation. Some claim has been
made for the use of such a cream in the prevention of
sunburn. The effect of Pyribenzamine in such cases is
more likely due to the screening out of the ultraviolet
rays similar to that obtained from so-called suntan lo-
tions, rather than to any specific pharmacologic action.
This is suggested by the fact that other antihistaminics
such as Benadryl do not have this property, and the anti-
sunburn effect may be obtained when Pyribenzamine is
applied to a quartz plate overlying the skin.
While most antihistaminics are too irritating for top-
ical application to mucous membranes, some have been
prepared in buffered solutions for use in the eye, nose,
and for bronchial nebulization. Our own experience with
eye medication thus far has been limited to a 0.5 per cent
solution of Antistine.1 ‘ A few drops of this solution will
afford temporary relief in some cases of allergic conjunc-
tivitis. The effect of the same solution in the nose is not
striking, but in combination with Privine HC1 0.025
per cent, the decongestant action on the nasal mucosa
appears to be more intense and prolonged than from
either drug alone. Such combinations are receiving fur-
ther study. A 2 per cent buffered solution of Pyribenza-
mine has sometimes been found helpful in relieving an
asthmatic paroxysm when administered by nebulization,
but the majority of asthmatics fail to obtain any appre-
ciable benefit.
Untoward side effects from antihistamine drugs have
limited their use in many instances. These appear to be
less frequent with some of the newer drugs. Drowsiness
is the most frequent untoward action, while vertigo,
headache, fatigue, nervousness and gastro-intestinal irri-
tation are also very common. In addition, many bizarre
effects difficult to reconcile with the known pharmaco-
logic actions of the drug have been encountered. The
toxic effects in animals are almost totally different from
those occurring in humans, and it has not been possible
to predict from toxicity studies in animals, the type or
probable extent of untoward action in man. At times the
sedative effect of these drugs is a desirable feature. It
is sometimes advisable to prescribe a well tolerated anti-
histaminic for use during the day, and one with a higher
incidence of sedative action at bedtime. Sedation is also
helpful in urticarial and other pruritic eruptions. As yet
there have been relatively few reports of serious toxic
effects from the use of these compounds. With increas-
ingly wider use, the possibility that some may occur
should be kept in mind, and frequent examinations of
the blood and urine should be carried out in those receiv-
ing the drugs continuously for long periods of time.
It is quite possible that the full potentialities of ther-
apy with antihistamine drugs have not been fully re-
alized. Further study may show that some of the effects
produced by these agents are not necessarily related to
histamine antagonism, and they may be found helpful
in situations where histamine release is not a factor. At
the present time their usefulness in allergic states is gen-
erally acknowledged, but it is well to keep in mind the
limitations as well as the indications for their use. They
are purely symptomatic agents, and do not produce a
cure. While they are more helpful in relieving certain
allergic symptoms, they are often less effective than
older symptomatic drugs in the relief of others. Their
use by no means eliminates the need for an immunologic
study of each case of allergy, since it is only by careful
attention to the etiologic factors involved that permanent
or long standing relief is possible. As an adjunct to spe-
cific therapy, the anti-histamine drugs represent a val-
uable addition to the list of effective anti-allergic meas-
ures.
References
1. Dale, H. H., and Laidlaw, P. P.: The Physiological
Action of B-iminazolylethylamtne, J. Physiol., 41:318, 1911.
2. Lewis, T., and Grant, R. T.: Vascular Reactions of the
Skin to Injury: Notes on the Anaphylactic Skin Reaction.
Heart, 13:219, 1926.
3. Best, C. H.; Dale, H. H.; Dudley, H. W., and Thorpe,
W. V.: The Nature of the Vasodilator Constituents of Cer-
tain Tissue Extracts, J. Physiol., 62:397, 1927.
4. Dragstedt, C. A., and Gebauer-Fuelnegg, E.: Studies in
Anaphylaxis: I. The Appearance of a Physiologically Active
Substance During Anaphylactic Shock, Am. J. Physiol.,
102:512, 1932.
5. Dragstedt, C. A., and Mead, F. B.: The Role of His-
tamine in Canine Anaphylactic Shock, J. Pharmacol, and Exper.
Therap. 57:419, 1936.
6. Farmer, L.: The Histamine Treatment of Allergic Dis-
ease, J. Lab. and Clin. Med., 26:802, 1941.
7. Sheldon, J. M., Fell, N., Johnston, J. H., and Howes,
H.: A Clinical Study of Histamine Azoprotein in Allergic
Disease, J. Allergy, 13:18, 1941.
8. Best, C. H.: Disappearance of Histamine from Antalyz-
ing Living Tissue, J. Physiol., 67:256, 1929.
9. Wells, J. A., Morris, H. C., Bull, H. B., and Drag-
stedt, C. A.: Observations on the Nature of the Antagonism
of Histamine by B-dimethylaminoethyl Benzhydryl Ether Hy-
drochloride (Benadryl), J. Pharm. and Exper. Therap., 85:122,
1945.
10. Halpern, B. N.: Experimental Study of Synthetic Anti-
histaminic Substances: Chemotherapeutic Trials in Allergic
States, J. de Med. deLyon, 23:409, 1942.
11. Friedlaender, S., and Friedlaender, A. S.: Newer Anti-
histammic Drugs in the Symptomatic Treatment of Allergic
Manifestations, American Practitioner, 2:643, 1948.
12. Friedlaender, A. S., and Friedlaender, S.: Correlation
of Experimental Data with Clinical Behaviour of Synthetic
Antihistaminic Drugs, Ann. Allergy, 7:83, 1949.
13. R. L. Mayer: Hyaluronidase Activity and Contact Der-
matitis. Paper presented before 3rd Annual Session, American
College of Allergists, Atlantic City, N. J., June, 1947.
14. Traescher-Elam, E., Ancona, G. R., and Kerr, W. J.:
Histamine-like Substance Present in Nasal Secretion of Com-
mon Cold and Allergic Rhinitis, Ann. J. Physiol., 144:711,
1945.
15. Friedlaender, S., and Friedlaender, A. S.: Parenteral
Benadryl in Allergy, Am. J. Med., 4:863, 1948.
16. Feinberg, S. M., and Bernstein, T. B.: Tripelenamine
"Pyribenzamine” Ointment for Relief of Itching, J.A.M.A.,
134:874, 1947.
17. Friedlaender, A. S., and Friedlaender, S.: An Evalua-
tion of Antistine, a New Antihistaminic Substance. Ann.
Allergy, 6:23, 1948.
June, 1949
223
DISCUSSION OF
DR. FRIEDLAENDER’S PAPER
Donald Cowan, M.D.
University of Minnesota
Dr. Friedlaender has given us a very concise picture of
the present status of this new group of drugs. It is ap-
parent that the list of different antihistaminics available
is quite long already, and more of them will be placed
on the market from time to time, as the very active
search for newer and better ones continues.
Dr. Friedlaender has pointed out some of the limita-
tions of their use. Among these are: First, they are not
equally effective in all persons with a given allergic con-
dition. Second, they are not equally effective in all types
of allergic disease. Thus asthma is not nearly as well
controlled by the antihistaminics as are the eye symptoms
and rhinorrhea of hay fever, for example. Third, side-
effects occur which may limit their usefulness in some
persons. These side effects are unpredictable except that
some of the drugs are more prone to produce them than
others. Certainly there is no correlation between side
effect and symptomatic relief obtained.
Like many others who are interested in allergy, we
have experimented with the various antihistaminic drugs.
On the basis of controlled experiments conducted last
year with hay fever patients, both with and without asth-
ma, we have satisfied ourselves on two points:
1. By trying out a number of different antihistaminics
on the same patient, a drug can almost always be found
which will prove effective in the control of hay fever
symptoms without troublesome side effects, for that par-
ticular patient. In our group there were only 7 per cent
failures — that is, only 7 per cent of the patients had
poor or no relief. And, again for the group, while taking
their individual "best” drugs, the incidence of side effects
amounted to only 6.6 per cent.
Thus we agree with Dr. Friedlaender, that one will
have better results by trying several antihistaminic drugs
on the same patient, if need be, to find the best one for
him.
2. Contrary to Dr. Friedlaender’s impression, we be-
lieve that an antihistaminic plus an antispasmodic yields
good results in the control of asthma. We have used
three types of such medication:
(1) An antihistaminic (it matters little which one)
plus an antibarium (the strongest of which are
Trasentin, Pavatrine, Amethone and 1721 Searle),
(2) An antihistaminic plus aminophylline (such as
Hydrallin) ,
(3) Drugs which are strongly antihistaminic and anti-
spasmodic in the same molecule (for example, the
chlorotheophylline salts of 1721 Searle and 1627
Searle) ,
and we are now interested in trying a fourth combina-
tion— an antihistaminic plus a sympathetic stimulant.
With these combinations, and again changing from
one to another in the same patient, until the best one
for him is found, we have had failure (that is, poor
or no relief) in only 21 per cent of pollen asthmas, and
50 per cent had excellent (that is, 75 to 100 per cent)
relief.
Unfortunately, the side effects with these combina-
tions were much more frequent than with the antihista-
minics alone. Side effects occurred in 30 per cent of the
patients while they were taking their best drugs. Fur-
thermore, the reactions were so severe for some of the
drugs (specifically, 1721, 1695, and 1913 Searle), that
it is doubtful whether they should be introduced into
routine therapy for that reason.
It seems to me that as time goes on and newer and
better antihistaminics and combinations become available,
there is real hope for good symptomatic relief for most
of the allergic states in a very large percentage of people
who have them. It is to be remembered, of course, that,
as Dr. Friedlaender has pointed out, the availability of
these drugs allows only for better symptomatic treatment
and does not lessen the need for etiological diagnosis and
more specific therapy of the allergic condition at fault.
NORTH DAKOTA SYMPOSIUM ON CHEST DISEASES
The Grand Forks District Medical Society will conduct a symposium on chest diseases
on Saturday, June 30, beginning at 1 o’clock in the Hotel Dacotah, Grand Forks, North
Dakota. The symposium will last all afternoon.
Those who will address the society will be Dr. William L. Wallbank of San Haven,
North Dakota, on "Some Aspects of Pulmonary Tuberculosis”; Dr. Herbert Schmidt, Mayo
Clinic, Rochester, Minnesota, on "Medical Bronchoscopy”; Dr. Chauncey N. Borman, Min-
neapolis, Minnesota, on "Roentgen Diagnosis, Nontuberculous Pulmonary Conditions”; and
Dr. Thomas J. Kinsella, Minneapolis, Minnesota, on "Surgical Aspects of Pulmonary Dis-
ease.” Discussion of papers will take place in the form of a round table discussion with
questions and answers.
There will be a banquet in the evening for all the attending physicians and their wives.
The Grand Forks District Medical Society extends an inivtation to all physicians and their
wives who are interested in attending. Those who wish to attend the dinner should write in
for reservations.
224
The Journal-Lancet
Official Journal of the American College Health Association. Great Northern Railway Surgeons’ Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association. Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J . C. Fawcett
Dr. A R. Foss
Dr. C. J . Glaspel
North Dakota Society of Obstetrics
and Gynecology
Dr. H A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
ADVISORY COUNCIL
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary- 1 reasurer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
Minneapolis Academy of Medicine
Dr. Thomas J . Kinsella, President
Dr. Cyrus O. Hanson, Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert, Recorder
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Editorial
HYPERSENSITIVITY IN MAN
Despite unceasing investigations at the bedside and in
the laboratory for more than forty years, the diseases of
allergy remain an enigma of medical science.
The hypersensitive states as seen in general practice
include allergic rhinitis of the perennial and seasonal
hay-fever type, asthma, urticaria, angio-edema with cu-
taneous, cerebral and visceral manifestations, allergic
dermatitis and allied dermatoses, serum disease, serum
shock, the Arthus type of hypersensitivity, and, prob-
ably, drug idiosyncrasies. In addition to these manifesta-
tions of hypersensitivity a variety of other human ill-
nesses, such as rheumatic fever, acute glomerular nephri-
tis, and the acute inflammatory reactions that occur fol-
lowing serum and drug therapy, are commonly accepted
as having an allergic component. The protean manifes-
tations of the hypersensitive state in man, moreover,
have led physicians and patient alike to accept as pos-
sible evidence of hypersensitivity isolated signs or symp-
toms that occur during the course of a wide variety of
other illnesses.
The appreciation that these variegated manifestations
are secondary to an antigen-antibody reaction has oc-
curred slowly over a period of more than a half a cen-
tury. Soon after the discovery of diphtheria toxin it was
recognized that serum disease and serum shock in man
and anaphylactic shock in animals resulted as the re-
sponse of the host to secondary contact with the same
antigen, usually a foreign protein. Such exaggerated
responses on contact with the specific antigen led to con-
flicting theories in explanation of what took place. When
it was learned that not all antigen-antibody reactions
gave rise to exaggerated responses, efforts were made to
explain what took place. The importance of hereditary
influence was early recognized for the atopic types. The
studies by Dale and his associates led to the conclusion
that a histamine-like substance is responsible for the im-
mediate symptoms. Prevention has been stressed. This
is accomplished through avoidance of the specific aller-
gen, or by employing it in minute doses parenterally for
desensitization. More recently a variety of newer prepa-
rations have been added to epinephrine and ephedrine
for relief in hypersensitive states of the physiological
effects of the histamine-like response to antigen-antibody
combinations. These preparations have opened up new
avenues for investigation and for the relief of the dis-
comforts of the hypersensitive state.
It is through such authoritative presentations as have
been reproduced in the Journal-Lancet in this issue
and many preceding issues that newly established and
accepted facts in allergy are made known to the physi-
cians that can apply them in their daily practice.
June, 1949
225
North Dakota State Medical Association
Report of the Grand Forks Diabetes Detection Drive
E. A. Haunz, M.D.,* and T. Q. Benson, M.D.f
The first "Diabetes Week” in history, sponsored by
the American Diabetes Association, December 6-12,
1948, has proven both justifiable and successful in its
objective on the basis of preliminary reports. The favor-
able response by both the public and physicians has been
unanimous wherever doctors’ committees and diabetes
associations have carried out an intensive program. Ma-
terial for nearly 500,000 urinalyses was distributed free
of charge through the office of the secretary of the
American Diabetes Association. Preliminary reports on
113,000 tests indicate that in adults, about 1 per cent
new cases may be anticipated.
October 10-16, inclusive, has been designated "Dia-
betes Week” for 1949. Dr. Howard F. Root, chairman
of the National Committee on Diabetes Detection, has
announced the following objectives for "Diabetes Week”
in 1949: (a) that county medical societies form diabetes
committees, preferably to consist of general practitioners,
rather than specialists in this disease; (b) that postgrad-
uate instruction in diabetes be sponsored by county so-
cieties and hospital staffs; (c) that talks be given on
diabetes in civic clubs, women’s clubs, industrial groups,
etc., again by general practitioners, rather than special-
ists; (d) that films prepared by the U. S. Public Health
Service will be available upon request from Dr. Hugh
L. C. Wilkerson, Diabetes Section, U. S. Public Health
Service, 695 Huntington Avenue, Boston 15, Massachu-
setts; (e) that free urinalyses and blood sugar tests be
offered all editors, reporters and employees of newspa-
pers as an introductory gesture.
Earlier detection of diabetes can be achieved without
public expense if each physician will agree to urge dia-
betic patients to perform urinalyses on their relatives.
If any of these prove suspicious, the family doctor will
carry out further investigation.
There is considerable latitude in the process of organ-
izing and operating local diabetes detection drives. The
Grand Forks community diabetes detection drive of
December 6-12, 1948, is briefly reported below to exem-
plify merely one of the many plans which have succeed-
ed throughout the country.
According to Dr. Root, the total of 1,810 tests per-
formed in Grand Forks was "a far better report than
has been submitted by most communities of comparable
size.” At its November, 1948, meeting the Grand Forks
District Medical Society voted unanimously to support
a local diabetes detection drive. The society president
Read at the 62nd annual meeting, North Dakota State
Medical Association, May 16, 1949.
"Chairman of North Dakota Organizing Committee,
i Chairman of Grand Forks Diabetes Detection Drive.
appointed a chairman and four committee members,
the latter to serve as a board of censors for all types
of publicity. Three detection centers were set up in the
two local hospitals and in the dispensary at the Univer-
sity of North Dakota, each supervised by a separate
committee. An appropriation of $100 was voted by the
District Medical Society to defray expenses of the drive.
In addition to the above participants, 28 physicians of
the society cooperated generously in giving public ad-
dresses on the two radio stations during the period from
November 28 to December 5, inclusive. Radio publicity
was well-counterbalanced by the full cooperation of the
Grand Forks Herald.
The ultimate success of the drive was attributed
chiefly to the extensive radio and newspaper publicity
which far exceeded the expectations of the committee.
The campaign was launched with the publication of a
group picture of the committee’s inaugural luncheon,
together with spot radio announcements. This was fol-
lowed by daily news articles on the subject of diabetes,
including a front-page editorial. The daily radio ad-
dresses were prepared by individual physicians them-
selves, but always subject to approval by the board of
censors before being broadcast. The keynote of all pub-
licity was consistently that of optimism, and alarming
words, such as coma and death, were generally avoided.
The excellent prospects for normal longevity in the well-
controlled diabetic was the dominant theme. Detection
centers were open from 2 to 6 and 7 to 9 P.M. daily,
and it was emphasized that everyone report within one
hour after a full meal. Each individual reporting to a
detection center was given a slip of paper with the fol-
lowing statement: "If the results of your test indicate
that you may have diabetes, you will be notified promptly
by mail. If the results of your tests are entirely normal,
you will hear no further.” Individuals with positive tests
were sent the following letter:
Name
Address
Dear Mrs. Smith:
The results of your recent diabetes test indicate that you
may have diabetes. This means that you should report to your
physician as soon as convenient for further tests to determine
whether or not you are actually diabetic. This is your respon-
sibility. Do not delay. Remember, if you have diabetes, there
is no cause for alarm. Proper treatment will insure a normal
life span for you. Please notify us immediately what doctor
you are selecting to investigate your case.
Very truly yours,
Committee on Diabetes Detection
By:
Grand Forks Deaconess Hospital
or St. Michael’s Hospital
P. S.: Use the enclosed postal card for your reply.
226
The Journal-Lancet
Of the total of 1,810 tests performed, each of which
consisted of a Clinitest and Galatest, 27 specimens
showed one plus or more glycosuria and 24 additional
tests showed a trace of sugar. Of this a total of 16
cases of diabetes mellitus were later proven to exist, or
an incidence of approximately .88 per cent, which is only
slightly less than the preliminary incidence reported on
a nation-wide basis. The lower incidence is probably
best explained by the fact that 500 tests were performed
on University students, in whose age group the incidence
of diabetes is known to be considerably lower than those
in the third, fourth and fifth decades of life. Undoubt-
edly the incidence would also have been higher if the
Wilkerson-Heftmann blood sugar screening tests could
have been incorporated in the detection program. It is
anticipated that this new screening test will be included
in the 1949 detection program. The Grand Forks dia-
betes detection drive was a "pilot test” to evaluate the
feasibility of conducting a program on a state-wide basis
in North Dakota during "Diabetes Week” in 1949. We
are definitely of the opinion that a more inclusive pro-
gram will prove invaluable to the health of the nation.
Indeed, such a program enjoins much greater therapeu-
tic promise for the undiscovered diabetic than present-
day science can extend in such fields as heart disease,
cancer, poliomyelitis, multiple sclerosis, etc., for which
untold millions are volunteered by the public annually.
Coupled with this fact, "Diabetes Week” is unique in
that it is not the usual drive for funds, but instead a
gratuitous service to the public-at-large.
Despite the repeated announcement that known dia-
betics should not report, three known cases reported for
the detection tests in the Grand Forks drive. These are,
of course, not included in the totals.
The success of "Diabetes Week,” both nationally and
locally in 1948, should serve as a stimulus for a much
greater response to the 1949 detection drive. Certainly
the end justifies the means. Perhaps a good slogan for
the next diabetes detection drive would be Sir William
Osier’s famous remark, "The way to live a long life is
to contract a chronic disease and take care of it,” altered
to read, "One way to live a long life is to have diabetes
and take care of it.”
Meet Our Contributors
A. V. Stoesser, M.D., Minneapolis, was graduated from
the University of Minnesota in 1925, specializes in Pedi-
atrics and Allergy; member, American College of Aller-
gists, American Association of Immunologists; Associate
Professor of Pediatrics, University of Minnesota.
William Sawyer Eisenstadt, M.D., Minneapolis, was
graduated from the University of Minnesota in 1938;
specializes in Allergy; member, American Academy of
Allergy, American College of Allergists, Association of
Allergists for Mycological Investigation.
Stephan Epstein, M.D., Marshfield, Wisconsin, was
graduated from the University of Erlangen, Germany, in
1923; specializes in Dermatology.
Jacob S. Blumenthal, M.D., Minneapolis, was gradu-
ated from the University of Minnesota in 1924; special-
izes in Internal Medicine and Allergy; Assistant Clinical
Professor, University of Minnesota; President, St. An-
drews Hospital; member, American College of Physi-
cians, Trudeau Society, Minnesota Pathological Society,
Minneapolis Society of Internal Medicine, Alpha Omega
Alpha.
E. L. Grinnel, M.D., Grand Forks, North Dakota, spe-
cializes in Dermatology and Allergy; Fellow, American
College of Allergy; contributor to the March 1949
J ournal-Lancet.
Alex S. Friedlaender, M.D., Detroit, was graduated
from Wayne University Medical School in 1935; spe-
cializes in Allergy; Fellow, American Academy of Aller-
gy, American College of Allergists; member, Michigan
Allergy Society, American Association for the Advance-
ment of Science; Instructor, Department of Medicine,
Wayne University College of Medicine.
Sidney Friedlaender, M.D., Detroit, was graduated
from Wayne University Medical School in 1938, special-
izes in Allergy; Diplomate, American Board of Internal
Medicine; member, Committee on Therapy, American
Academy of Allergy, American College of Physicians,
Michigan Allergy Society, New York Academy of
Sciences.
Donald Cowan, M.D., Minneapolis, was graduated
from the University of Minnesota in 1931; specializes
in Allergy; Assistant Director, Student Health Service;
Associate Professor of Public Health, University of Min-
nesota; member, Alpha Omega Alpha, Sigma Xi.
E. A. Haunz, M.D., Grand Forks, North Dakota, grad-
uated from the University of Buffalo in 1943; specializes
in Internal Medicine; member, American Diabetes Asso-
ciation, American College of Physicians, National Board
of Medical Examiners; Chairman, North Dakota Organ-
izing Committee for Diabetes Detection; Instructor in
Medicine, University of North Dakota; Fellow in Medi-
cine, Mayo Clinic, 1944-1947.
T. Q. Benson, M.D., Grand Forks, North Dakota, was
graduated from the University of Minnesota in 1930;
specializes in Internal Medicine; member, Grand Forks
District Medical Society.
June, 1949
111
Book Reviews
Fundamentals of Pulmonary Tuberculosis and Its Compli-
cations. Edited by Edward W. Hayes. Sponsored by the
American College of Chest Physicians. Pp. 470, with 182
illustrations. 1949. Springfield, Illinois: Charles C Thomas.
#9.50.
This authoritative and widely useful book will serve other
purposes besides pointing the way to the control and eventual
eradication of tuberculosis — the foremost reason for its prepa-
ration. The point is effectively emphasized to practitioners and
medical students that knowledge of the natural history, diag-
nosis and treatment of tuberculosis is fundamental in all phases
' of medical practice; the possibility of its presence enters into
every differential diagnosis; where present there must be modi-
fication of treatment in a variety of other diseases.
The panel of co-authors, under a distinguished editor and
editorial committee, has supplied outstanding individual contri-
1 butions, illustrations and bibliographies. Every medical student
should own and study this book. Every practitioner and med-
ical teacher should be thoroughly familiar with its contents.
M.M.W.
Clinical Allergy, by Alexander Sterling, M.D. New York:
International Universities Press, 198 pages, 1947, #5.00.
This is a monograph on the management and treatment of
allergic diseases. It is based on the results of the clinical re-
search and practical experience in the field of allergy obtained
by the author at various clinics. There are 16 chapters, each
one of which discusses in a practical way the necessary steps in
properly diagnosing and successfully taking care of an allergic
patient. Throughout the book the author has tried to be thor-
ough but at the same time brief and clear in his presentation
of the subject matter. There are no long discussions. The
monograph is highly recommended for general practitioners and
students of allergy.
A.V.S.
Management of Common Gastro-Intestinal Diseases, by
Thomas A. John:on. 1948. Philadelphia: J. B, Lippincott
Company. #7.00.
The several sections of this compendium are not of uniform
value or quality. The first four chapters offer well established
advice which may safely be accepted by anyone with less ex-
perience in these matters than the authors. Schindler and Blom-
quist on chronic gastritis, Kirsner and Palmer on gastric car-
cinoma, and Sara Jordan on benign gastric ulcer all present
their subjects aptly and succinctly. Andresen’s discussion of
bleeding peptic ulcer is exceptionally sensible. His recommen-
dations are based on physiologic principles and include admin-
istration of whole blood by numerous small transfusions or con-
tinuous slow drip infusions, and early feeding of milk and gela-
tin mixtures.
Chapters 5 and 6, concerned with enterogastrone and protein
hydrolysate respectively are probably of evanescent interest.
Chapter 7 deals with psychosomatic aspects of gastro-intestinal
disorders with emphasis properly placed upon positive and not
negative, exclusive diagnosis. The assumption that peptic ulcer
and ulcerative colitis are purely psychosomatic diseases is un-
warranted. The typical psychiatric mannerism of submitting
reports of single cases with broad generalizations therefrom as
proof of etiologic and therapeutic claims is glaringly illustrated.
Psychiatrists must soon conform to the rigid standard statis-
tical judgment of results demanded of other therapists. After
thorough consideration by Crohn and Yarnis of regional en-
teritis, the identity of this disease is still obscure. The primary
cause of the granulomatous, infiltrative invasion of segments of
the small and large intestines may be multiple.
Chapters 10 and 11 on the pancreas summarize present
knowledge of the diseases of this enigmatic organ, but yield
very little definitive diagnostic information.
Cirrhosis of the liver is presented in orthodox manner with
perhaps insufficient stress on early, presumptive diagnosis, before
appearance of ascites, jaundice and bleeding from collateral and
congestive vascular sources. In chapter 12 the relation of chronic
infectious mononucleosis to infectious hepatitis, with respect of
glandular, pulmonary, pleural and nervous system manifesta-
tions of each is recognized, and the distinction between infec-
tious and homologous serum hepatitis is well made; but the
importance of hepatitis in establishment of persistent, chronic
liver damage is not clearly stated.
Idiopathic ulcerative colitis and segmental enterocolitis are
not sharply distinguished in chapter 13, and discussion of time
and circumstances for medical and surgical treatment of par-
ticular forms of colitis is meager. The attitude toward psycho-
therapy of colitis is properly conservative. Elucidation of irrita-
ble colon is sane and sound.
Essential facts about cancer of the colon are given in chapter
15, although the arrangement of the material is somewhat dis-
orderly. Bercovitz authoritatively expounds the diagnosis and
treatment of amebiasis. J.B.C.
The Child in Health and Disease, by Clifford G. Grulee,
M.D., and R. Cannon Eley, M.D., 1066 pp., illustrated
1948. Baltimore: The Williams & Wilkins Company. #12.00,
Periodically comprehensive textbooks of pediatrics have been
offered to the practitioner and student of medicine. This book
is a new one which has been under preparation for some time.
This fact alone is revealed in the subject matter of the large
number of contributors. All of the material is up to date. The
91 chapters of the book are divided into 19 sections making it
rather easy to locate material for study. The diseases of infancy
and childhood are discussed under the headings of history and
incidence, etiology, pathology, symptoms and diagnosis, compli
cations and sequelae, treatment and prognosis. Research and in-
vestigation is only referred to by the various authors when it is
necessary to emphasize something on the practical side of
pediatrics. Of course it is difficult to keep a textbook of this
size in step with the rapid advancements in the field of medi-
cine, but nevertheless this book is recommended as a reference
and textbook for all who are interested in the health and care
of infants and children. A.V.S.
A.M.A. Interns’ Manual. 209 pages. 1948. Philadelphia &
London: W. B. Saunders Co. #2.25.
This pocket-size volume was planned, written and published
explicit from the title, for use by hospital interns. Conse-
quently, the opinion of an active, studious and conscientious
intern was solicited with respect to the obvious purpose of the
book. His comments and criticism, with which the reviewer
from many years of practical teaching experience is inclined to
agree, are presented.
Section I, describing and explaining desirable, essential and
required characteristics of internship and residency, is unneces-
sary. Presumptively the buyer and reader of this manual is estab-
lished in a hospital, and should or could have acquired the
knowledge offered in this section from current sources — issues
of the Journal of the A.M.A.
Section II expounds clinical and laboratory data which, in
many particulars, are incomplete or obsolete. Procedures advised
for ordinary contingencies are often inadequate, notably those
for gastro-intestinal bleeding. And, hospitals which quality for
internships have well-seasoned directions for management of all
medical and surgical conditions. More complete and pertinent
information about drugs and therapy may be found in other
handbooks, specifically Cutting’s Manual of Clinical Therapeu-
tics, also published by Saunders, or the Physician' s Handbook-
Cutting’s Manual is slightly more expensive than the A.M.A.
Manual, but it is pocket size and more complete and is gen-
erally preferred by interns.
The pragmatic attitude of an intern is expressed in an obser-
vation about Section V which is concerned with poisons. The
suggestions of antidotes to be used would be valuable if the
poison in a particular instance were known, but usually the
cause of the obviously critical physical condition of a suddenly
confronted patient is obscure. A description of definitive signs
and symptoms for specific toxic agents if possible would be
helpful. J.B.C.
228
The Journal-Lancet
American College Health Association News
The American College Health Association is happy
to announce the Executive Committee’s acceptance of
the following colleges into its membership:
Xavier University, Mr. Warren P. McKenna, Di-
rector of Health Service, New Orleans, Louisiana.
National College of Education, Dr. Josephine Early-
wine, Director of Health Service, Evanston, Illinois.
The final election for membership will be taken at the
Association’s annual meeting in December, 1949.
The Council of the American College Health Associa-
tion has voted an increase in Association dues from
$10.00 to $15.00 a year beginning January 1, 1950.
The South Central Section of the A.C.H.A. held its
annual meeting on April 9 in Pittsburgh, Kansas. The
following officers were elected for the coming year:
President, S. I. Fuenmng, M.D., Director of Student
Health Service, University of Nebraska, Omaha.
Vice President, William E. Taylor, M.D., Director of
Student Health Service, Southwest Missouri State Col-
lege, Springfield.
Secretary-Treasurer, J. Ralph Wells, M.D., Director
of Student Health Service, Kansas State Teachers Col-
lege, Pittsburgh.
Word has just been received that Dr. John G. Frisch
is now Director of the Medical Department, Wisconsin
State Teachers College, Milwaukee. He replaces Dr.
Elsa Edelman, former director.
The University of Colorado Student Health Service
is in need of an assistant director experienced in student
health work. Write: L. W. Holden, M.D., Director of
Health Service, University of Colorado, Boulder, Colo-
rado.
Smith College, Northampton, Massachusetts, is in
need of one, perhaps two, women physicians for the col-
lege year, 1949-50, beginning in mid-September, to prac-
tice general medicine. Write: Dr. Edith C. Stackpole,
Director of Clinic, Smith College, Northampton, Massa-
chusetts.
Duke University Women’s College desires a woman
physician for its Student Health Service. Write: Dean
R. Florence Brinkley, Duke University Women’s Col-
lege, Durham, North Carolina.
Knox College, Galesburg, Illinois, is interested in
finding a physician for the Student Health Service.
Write: President K. D. McClelland.
On April 22nd and 23rd, 1949, the second meeting
since the war, or the Eleventh Annual Meeting of the
North Central Section of the American College Health
Association, was held at Winona, Minnesota, under the
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The Journal-Lancet
sponsorship, jointly, of St. Mary’s College and The
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232
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Advertisers ’ Announcements
Price Cut Announced on Parenamine 6 Per Cent
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Wyeth-Nepera Allergy Film Fascinates Doctors
A color and sound moving picture summarizing the most
a|“vanced medical views on allergy proved a big attraction at
the annual convention of the American College of Physicians
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film was produced under the direction of Dr. Leo H. Criep,
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are of the delayed reaction of tuberculin type, which are un-
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including atopic dermatitis, contact allergy, asthma, allergic
rhinitis, serum reaction, hives, and angioneurotic edema.
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COBBE PHARMACEUTICAL CO., 217 N. Wolcott Ave., Chicago 12, III.
Primary Epithelioma of the Ureter
Baxter A. Smith, M.D.
Minneapolis, Minnesota
In the past, tumors arising in the ureter have been
considered rare and of very poor prognosis. This
report is intended to lend support to a conviction to
the contrary.
Several extensive reviews of the literature have been
made in the last fifteen years. Scott has an extensive
bibliography. It is interesting to note that two-thirds of
the reported cases have appeared in the last decade.
Higgens reported five cases in 1938, bringing the total
to ninety-one at that time. Probably about 250 cases
are now reported. The lesion was first described in 1841.
Foord and Ferrier reported that only eight cases had
been reported before 1900. The first case in which the
correct diagnosis was made preoperatively was reported
in 1902. Colston reported two cases in 22,000 urological
admissions at Johns Hopkins to 1933. Bell (quoted by
Stang and Hertzog) found one case in 37,000 autopsies
at the University of Minnesota.
There were eighteen cases seen at the Mayo Clinic
in nineteen years as reported by Cook and Counseller in
1941. In 1944 they added nine new cases. At the Uni-
versity of Minnesota Hospitals and in private practice
eight cases were diagnosed between January 1946 and
January 1948. One case had previously been seen in
the University of Minnesota Hospitals in 1941; while
no new cases of primary ureteral tumor have been seen
in 1948 to date, it would seen that the condition should
' Inaugural thesis: read before the Minneapolis Academy of
Medicine meeting, November 15, 1948.
not be considered rare. Thomas and Regnier stated that
5 to 7 per cent of all renal tumors were tumors of the
pelvis and ureter, and of these about 15 per cent were
of the ureter alone. In the last three years, primary
ureteral neoplasms have been as common as tumors of
the renal pelvis in our experience.
Etiology is unknown except for the relationship to
aniline dye exposure. Associated stone in the ureter has
been seen, usually in infiltrating squamous or transi-
tional carcinoma. In similar lesions of the renal pelvis,
stone is present in 50 per cent of the cases. Most cases
appear in the sixth decade; the youngest reported was
22 years of age. Most of the reported cases have been
in males; one-half occur in the lower one-third of the
ureter, and the right ureter is involved about twice as
often as the left (Scott) .
Pathologically the epithelial tumors of the ureter
closely resemble similar lesions of the bladder or renal
pelvis. They may be papilloma (papillary carcinoma
Grade I), papillary carcinoma, or squamous or transi-
tional carcinoma. Scott states 50 per cent were papillary.
Mesenchymal tumors of the ureteral wall have been de-
scribed but are quite uncommon. Metastatic tumor of
the ureter (excluding carcinoma of the cervix) has been
considered uncommon, but eleven cases have been en-
countered by us; the primary manifestation of the neo-
plasm has been its ureteral involvement in three in-
stances. It has been accepted generally that the prog-
nosis has been poor because extension through the rela-
233
234
The Journal-Lancet
tively thin ureter occurred earlier than through the rela-
tively thick bladder. Metastases from primary ureteral
neoplasms involve mainly the regional lymph nodes, then
distant lymph nodes and liver, adjacent bones, lung,
kidney, and adrenals in that order of frequency, but
most organs have been reported as the site of metastases.
Symptoms are hematuria 70 per cent; pain (renal
colic, renal ache, metastatic pain) 60 per cent; and mass
in 40 per cent. The mass is usually the hydronephrotic
kidney. The tumor may be palpated vaginally at times,
and extension and metastatic lesions may be palpable if
large. Symptoms of vesical irritation or secondary infec-
tion may be present, and evidence of extensive carcinoma
may predominate. Hematuria following nephrectomy,
if seen to come from the ipsolateral ureter, is diagnostic
of ureteral neoplasm.
Urinary findings vary. Usually hematuria is present
in some degree and evidence of infection may be present.
Cytologic study may show neoplastic cells, and should be
an adjunct in differentiating non-opaque calculus from
tumor, particularly when complete obstruction of the
ureter to the retrograde injection of dye with impacted
bulb or Garceau catheter is present. KUB film shows
an enlarged renal shadow if hydronephrosis is present,
and excretory urogram usually shows no function or
hydronephrosis and hydroureter, sometimes demonstrat-
ing the filling defect.
Cystoscopic procedures usually make the diagnosis pos-
sible. Vest states that the tumor protrudes from the
ureteral orifice in 30 to 35 per cent of the cases. This
occurred in only one of our cases. At times the tumor
may be visible only during ureteral peristalsis. Secondary
"implants” may be present in the bladder. There may
be bulging or edema of the intramural ureter. Renal
function of the involved side usually is impaired or ab-
sent. Bleeding from the ureteral orifice may be seen,
and if it occurs in a steady trickle rather than associated
with spurts of urine, it is particularly significant of
lower ureteral disease. Upon attempting the passage of
ureteral catheters, impassable obstruction is frequently
encountered. This usually doesn’t feel like stone in the
lower ureter, but above 5 centimeters one can attach
no significance to the "feel”. Associated with prodding
of the catheter, rather profuse bleeding may occur. If
the urethral efflux is bloody, the renal urine obtained
by catheter may be clear or less bloody, and if the renal
urine is not more bloody than the bladder urine, the
fact is significant.
Retrograde pyeioureterograms are most important in
the diagnosis. Filling of the ureter may be best ob-
tained by impacting an acorn bulb, a Braasch bulb, or
a Garceau catheter in the lower ureter after ascertain-
ing all air bubbles have been evacuated, and then inject-
ing dye, colored with indigo carmine, under cystoscopic
vision. A pyeloureterogram may be obtained showing
hydronephrosis and hydroureter above a characteristic
filling defect of papillary tumor. Complete or almost
complete obstruction to the injection of dye may be seen,
and often even then, filling defect can be observed. In
infiltrating carcinoma the lumen may be irregularly nar-
rowed over considerable distance.
Ureterogram is of the utmost importance in any in-
vestigation of the upper urinary tract for bleeding be-
cause coincidental renal disease is not uncommon. One
of the patients here reported had hydronephrosis due to
incomplete rotation and ureteropelvic junction obstruc-
tion in addition to hydroureter below, secondary to ob-
struction of ureteral tumor. Another had nephrectomy
for renal tumor which proved to be cyst. Another had
nephrectomy for calculous pyonephrosis. Ureteral tumor,
primary or metastatic , must be considered when hydro-
ureter is seen at the time of renal surgery unless the
hydroureter has been adequately explained.
In differential diagnosis one must consider any lesion
giving obstruction and filling defect. Blood clot, fibrin,
non-opaque calculus, tumor metastatic to the ureter, en-
dometriosis, inflammatory infiltrations from within or
without, and foreign body are most likely to confuse.
Ureteral tumor is commonly secondary to epithelial
tumors of the renal pelvis, of course, and tumor of the
renal pelvis must be excluded before ureteral tumor may
be called primary. Squamous and transitional carcinoma
are occasionally associated with ureteral stone, and ex-
ploration may be necessary to establish the presence or
absence of neoplasm in the case of a long-impacted cal-
culus with much ureteritis. In the presence of bleeding,
repeated films may be necessary to exclude clot.
Treatment advised is complete nephroureterectomy to
include a cuff of bladder containing the intramural ureter.
Most observers feel quite strongly that ureteral tumors,
despite a microscopically benign appearance, should not
be treated conservatively unless the preservation of renal
function is essential. Conservative measures to be con-
sidered in such an instance would be resection of the
tumor-bearing ureter with anastomosis or transplant to
bladder, renal pelvis, bowel, or skin, or nephrostomy.
Nephroureterectomy may be done in two stages if the
patient’s condition indicates it. If a two-stage procedure
is decided upon, the tumor-bearing ureter should be re-
moved in the first stage, making a cutaneous ureteros-
tomy if the tumor is in the lower ureter. Foord and Fer-
rier reported the mortality in forty-four reported one-
stage nephroureterectomies to be 40 per cent, and in
twenty-two two-stage nephroureterectomies to be 5 per
cent.
At the present time, the operative mortality of one-
stage nephroureterectomy should not be appreciable in
any standard risk patient. A one-stage procedure should
be done by choice, preferably beginning with the lower
ureter, coiling the vesical end high in the wound, and
removing the specimen intact with the kidney, thereby
opening the urinary tract only once, and decreasing the
chance of implantation. The change from supine posi-
tion to the "kidney position” affects blood pressure more
adversely than the reverse procedure, however. Mac-
alpine does not advocate removal of the bladder cuff
because of danger of "seeding” of tumor, but most sur-
July, 1949
235
geons believe the danger of subsequent tumor involve-
ment of the intramural ureter makes excision of the
intramural ureter mandatory.
Colston suggested fulguration of the intramural ureter
to destroy its epithelium, but no longer advocates it.
Radiation therapy is of little value.
Treatment continues for at least five years in the form
of periodic cystoscopies relative to vesical recurrence.
Appropriate therapy is instituted if there is vesical re-
currence. Eleven of the twenty-seven cases reported by
Counseller and Cook had bladder recurrences.
Prognosis depends upon the degree of malignancy of
the lesion, and the extent of its growth at the time of
therapy. O’Conner states that papillary tumors of the
upper urinary tract are the only tumors of the upper
urinary tract where the prognosis is appreciably improved
by early diagnosis and treatment. Foord and Ferrier re-
ported six cases, all with metastases, and Fdiggens report-
ed five cases; four died within a year, and the other was
terminal within a few months. Counseller and Cook
found ten of eighteen cases to be Grade I and II car-
cinomas, eight to be III and IV. Of the ten followed
cases in Grade I and II, seven were alive four years or
more, and one thirteen years after surgery. Of the pa-
itents with Grade III and IV tumors, one died postop-
eratively. Six died in less than two and one-half years,
and one was living twelve years after surgery, but was
believed to have vesical recurrence at time of writing.
Only one of our cases had squamous carcinoma; he was
most recently operated upon, and is the only patient now
dead. Vest reported three cases in which conservative
surgery was employed. One was well without recurrence
seven and one-half years; one two and one-half years, and
one fifteen months after surgery. He stated he wrote
to many authors and none reported metastases in "be-
nign” ureteral tumors.
Of the papillary tumors we have seen,8 one (M.B.)
has known recurrence, that at the site of the excision of
intramural ureter. She also has two skin carcinomas
(buttock), and a transitional cell carcinoma of the
parotid (metastatic or primary?); for many years she
ingested arsenic as a tonic. Her symptoms were of about
six months duration, but seven years before she had had
identical symptoms for a period of time. Two-stage
procedure was employed; there was extensive papillary
carcinomatosis of almost the entire ureter including the
intramural ureter. Recurrence appeared one year later,
intra- and extravesical, at the site of the excision of
intramural ureter. Repeated transurethral resections, and
the implantation of radon have kept the lesion under
control to the present time.
The patient (M.S.) with squamous carcinoma was
seen twenty-one months before he allowed investigation
beyond an excretory urogram. When first seen, an ex-
cretory urogram showed left hydronephrosis filling only
a few calices. When next seen, seventeen months later,
an excretory urogram showed no renal function on the
left, and a vesical filling defect at the site of the left
ureter was seen. Diagnosis of probable primary ureteral
tumor was made, but further investigation was refused
until bleeding interfered with voiding. At cystoscopy
a tumor the size of a golf ball presented from the ureter,
and involved the vesical mucosa for a centimeter radius
from the dilated ureteral meatus. At ureterectomy a
large segmental resection of the bladder was done, but
there was extensive fixation of the lower ureter to adja-
Patient
Sex
Age
Pain
Mass
Hema-
turia
Level in
Ureter
Side
Duration
Symptoms to
Definitive
Surgery
One Stage
Nephro-
ureter-
ectomy
Two Stage.
Elect.
Two Stage,
( bleeding
ureteral stump)
Path-
ology
Follow-up
D. M
F
57
X
0
X
L
L
4 mo.
x:>
Papilloma
Neg. 7 yrs.
E. B.
F
71
X
0
X
M
L
3 mo.
X
Pap. ca.
Neg. 2 yrs.
H. H.
F
74
0
X
X
L
L
1 mo.
X'
Multiple
pap. ca.
Neg. 2 yrs.
T. O.
M
65
0
0
X
L
R
1 9 mo.
X5 EAW
T wo
papillomas
Neg.
1 8 mo.
A H.
M
51
X
0
X
U
R
2 mo.
X EAW
Pap. ca.
Neg. 1 yr.
M. B.
F
76
X
X1
X
X^
R
7 yrs.(?)
8 mo.
X
Papillary
carcinoma
tosis
Recurrence
1 yr.
( See text )
C. S.
M
61
0
0
X
L
L
2 mo.
X CDC
T wo
papilloma
Neg. 1 yr.
B D
F
64
X
0
X
M
L
1 mo. ( ? )
X
Pap. ca.
Neg 9 mo
M. S.
M
72
X
0
X
L
L
22 mo.
X
Squam.
ca.
D ed 8 mo
< See text )
1 Renal and vaginal.
2 Entire ureter except immediately adjacent to pelvis.
:1 Intramural ureter not removed.
^ Renal cyst, hydroureter. Renal surgery 13 months before definitive surgery.
•’ Calculous pyonephrosis and pyoureter. Renal surgery 1 4 months before definitive surgery.
Fig. 1.
236
cent structures. Postoperatively, transurethral resection
of the prostate was done and roentgen therapy was
given. No local recurrence was discernible at cystoscopy
four months later, but the patient died eight months
after surgery in terminal uremia with an immense pain-
ful liver, presumably due to metastases.
The chart summarizes data in the nine cases described.
I gratefully acknowledge the permission to include the
cases operated upon by Dr. C. D. Creevy and Dr. E. A.
Webb.
Summary
The rather pessimistic attitude prevalent until recently
does not seem to be warranted when one compares
ureteral neoplasms with many of the more prevalent
carcinomas of the genito-urinary and other organs. Edu-
cation of the public to the danger signal, hematuria,
is being accomplished gradually. If the diagnosis is
made early and proper therapeutic measures are insti-
tuted, papillary lesions should offer a really good prog-
nosis.
Conclusion
1. Primary ureteral neoplasm does not appear to be
the rare lesion it was once considered.
2. Neither does its prognosis seem to be as grave as
earlier opinions would indicate. The lesion tends to
follow the pattern of the epithelial tumors of the bladder
and renal pelvis. Prognosis depends upon the degree of
malignancy, and the extent of the lesion at the time of
surgery.
3. A good ureterogram is essential in the judicious
treatment of upper urinary tract bleeding despite renal
pyelographic deformity. Frequent use of the acorn bulb
is suggested.
4. Hydroureter seen at the time of nephrectomy must
be adequately explained.
5. Bleeding from the ureteral stump after nephrec-
The Journal-Lancet
tomy should be considered as diagnostic of ureteral
tumor.
6. One-stage complete nephroureterectomy is the treat-
ment of choice.
Since this paper was presented, a case of infiltrating, un-
differentiated carcinoma of the left ureter, 4 centimeters above
the bladder, has been seen. This man had been followed for
twelve years because of recurrent papillary tumors in the blad-
der. The pathological diagnosis of the bladder tumors was
papilloma except April, 1945, and April, 1947, when papillary
carcinoma Grade II was found. Papillary carcinoma Grade I
was found in July, 1945. Excretory urogram in April of 1947
was negative. Four papillary lesions since April, 1947, were
papillomata.
Since the ureteral lesion was infiltrating in type, it is be-
lieved to be primary since infiltrating sessile lesions do not occur
in association with papillary lesions. Metastases to the regional
nodes were present.
Bibliography
1. Colston, J. A. C.: Primary tumor of the ureter. Bull.
Johns Hopkins Hosp., 56:361, 1934.
2. Colston, J. A. C.: Discussion of O’Conner.
3. Cook, E. N., and Counseller, V. S.: Primary Epithelio-
ma of the Ureter. J.A.M.A. 116:123-127 (Jan. 11) 1941.
4. Counseller, V. S., Cook, E. N., and Seefeld, P. H.:
Primary Epithelioma of the Ureter: a follow-up study of 18
cases with the addition of 9 new cases. J. Urol. 51:606-615
(June) 1944.
5. Foord, A. G.; and Ferrier, P. A.: Primary Carcinoma
of the Ureter. J.A.M.A. 112:596-601, 1939.
6. Higgens, C. C.: Primary Carcinoma of the Ureter.
Ann. of Surg. 108:271-284, 1938.
7. Macalpme, J. B.: Papillomatous Disease of the Renal
Pelvis. Brit. J. Surg. 35:113-132 (Oct.) 1947.
8. O’Conner, V. J.: Treatment and Prognosis of Papillary
Tumors of the Renal Pelvis and Ureter. To be published.
9. Scott, W. W.: A Review of Primary Carcinoma of the
Ureter. J. Urol. 50:45-64, 1943.
10. Stang, H. M., and Hertzog, A. J.: Primary Carcinoma
of the Ureter. J. Urol. 45:527-535, 1941.
11. Thomas, G. L., and Regnier, E. A.: Tumors of the
Kidney Pelvis and Ureter. J. Urol. 11:205-238, 1924.
12. Vest, S. A.: Conservative Surgery in Certain Benign
Tumors of the Ureter. J. Urol. 53:97-119, 1945.
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k.
J
July, 1949
237
A Roentgenometric Study of the Female Pelvis*
H. Hoffman Groskloss, M.D., F.A.C.S.
Minneapolis, Minnesota
Because of a preponderant number of women of
Scandinavian descent residing in this area of the
country, it has been alleged that the physician encoun-
ters relatively fewer contracted pelves than elsewhere.
Almost paradoxically, however, midpelvic arrests are not
in the least uncommon. This clinical and roentgeno-
pelvimetric study was conducted both for reasons of geo-
graphic comparison and to arrive at a true incidence and
recognition of contractions in a particular plane of the
pelvis. The shortening of any single diameter, except
perhaps for the conjugata vera, loses its importance in
favor of a spatial study of each individual plane of the
pelvis as a distinct integral part. Also, the finding of
normal external measurements may give one a false sense
of security in the sense that a troublesome midplane con-
traction may be overlooked at the time of the original
examination. A proper evaluation of this plane, clin-
ically, supported by a roentgenologic interpretation, is
not only possible but mandatory to a correct prognosis
of labor.
History of interest in the mechanism of labor and the
female pelvis dates back to the sixteenth century and to
such practitioners as Hippocrates, Celsus and Vesalius.1
Arantius 4 is thought to be the first to study the con-
tracted forms. The names of Van Deventer,41’ Barton,'’
Smellie,44 Baudelocque u are familiar to all. Hodge,1 ‘
about the middle of the nineteenth century, advanced
the presently-accepted principle of the four pelvic planes.
Also familiar to you in this vein are Litzmann,21’ Wil-
liams,'1" Pinard,42' Naegele 40 and Michaelis.2" There
have been many advances since Levy-Dorn2'1 submitted
patients to x-ray exposures of one and one-half hours
for the determination of a twin pregnancy. W. F.
Manges,2' I believe, was the first to employ the stereo-
scopic method of x-ray pelvimetry. Johnson 1 s^21 fol-
lowed in 1927 with his version of the parallex method
of stereoroentgenopelvimetry. Caldwell and Moloy,s~14
in introducing their precision stereoscope, made a great
contribution as regards cephalo-pelvic relationships and
the mechanism of labor to follow. These authors and
Thoms, et al.,4'1-44 working with the lead grid technique,
have contributed practical classifications of the bony
pelvis.
Admittedly, morphologic variations of the female
pelvis are many and varied. The essential diameters,
therefore, of any single plane are essential to the com-
pleteness of recognition of adaptability and represent a
true index to available space. Their mean averages may
be deducted within the limits, for example, of the work-
able classifications of Caldwell and Moloy, based largely
1
^Inaugural thesis: read before the Minneapolis Academy of
Medicine.
on inlet morphology, of the Gynecoid (normal female),
the Android (male), the Anthropoid (ape), and the
Platypelloid (flat) types. One may arrive at a clear rec-
ognition of these forms, and their respective diameters,
through the taking of stereo, inlet, antero-posterior and
isometric lateral projection roentgenograms. The "posi-
tion” method is employed for the various computations.
A study of the mean diameters alone is not enough to
allow for a high degree of correct prognosis of labor.
Such study represents a fixed factor. One must think
in terms of adaptability of the fetal head to each suc-
cessive plane as determined by moldability of the cranial
bones, the force of the uterine contractions, soft tissue
interference, fascial and ligamentous flexibility, and the
direction of the axis of fetal descent. Of probable great-
er importance is the area in square centimeters of any
one plane of the pelvis as determined by Allen.2 Allen
has adopted the plan of Nicholson of working with the
square root of the product of the essential diameters.
Williams and Phillips 4!l and, later, Mengert,28 have
utilized to great advantage lateral and frontal projection
charts. According to a scheme by Mengert, a mold, rep-
resenting the variable sizes of fetal heads, is placed on
a chart upon which the essential diameters are projected.
These latter methods presumably allow for more accurate
prediction of the outcome of labor.
Allow me to briefly enumerate the essential character-
istics of the various parent forms of pelves. (Figures in
parentheses are those taken from spontaneous deliveries.)
Gynecoid:
Inlet: Round, C.V. 11.5 (11.77) cm.; Trans., 13.0
(13.2) cm.; P.S. 4.0 cm. Area, 117 (121.96) sq.
cm. (critical level is 115 sq. cm.). Sum of the C.V.
and Trans., 24.4 (24.89) cm.
Midplane: Sidewalls straight — sacrosciatic notch aver-
age. Normal sacral concavity. Spines not prominent.
A.P., 11.5 (11.76) cm.; I.S., 10.5 (10.53) cm.;
P.S., 5.0 (4.10) cm. Area, 94.55 (98.20) sq. cm.
(critical level is 90.0 sq. cm.). Sum of A.P. and
I.S., 22 (21.94) cm.; of I.S. and P.S., 15.5 (14.53)
cm.
Outlet: Wide subpubic angle. Round arch. Biisch.,
10.0 (8.66) cm.; P.S., 8.5 (8.16) cm.; Sum, 18.5
(16.82) cm. Critical P.S., 6.5 cm.
Anthropoid:
Inlet: Longitudinally oval. Narrowing of the fore-
pelvis. Transverse shortened, posterior sagittal
lengthened. Pelvic tilt of high assimilation type.
Long concave sacrum. Sacrosciatic notch wide.
Spines blunt and short.
238
The Journal-Lancet
Midplane: Narrowing of forepelvis with sacrum
pointing well forward.
Outlet: May have contraction.
Platypelloid:
Inlet: Transverse oval in shape.
Midplane: Frequently resembles gynecoid feature with
a somewhat narrowed sacrosciatic notch.
Outlet: Although not common, may have narrowed
subpubic arch and some sidewall convergence.
Android: (less than a 3 per cent incidence
in fertile women) .
Inlet: Widest transverse more closely approximates
sacral promitory.
Midplane: Forepelvis narrowed. Lateral walls con-
verge. Spines sharp and long. Shortened pos-
terior sagittal. Sacrosciatic notch narrowed in all
diameters.
Outlet: Subpubic angle acute. Definite contraction
with shortened posterior and biischial.
Mixed:
Incidence varies according to individual interpretation.
The first essential feature refers to the nature of the
posterior pelvis, and the lesser-pronounced charac-
teristic is governed by the anterior segment.
Caldwell and Moloy describe five mixed types, namely
the anthropoid-gynecoid, the gynecoid-flat, the an-
droid-anthropoid, the android-flat, and the android-
gynecoid.
The incidence of these various types is given in
Table 1.
Table 1
Classifica-
tion
Caldwell
& Moloy
Walsh 4"
(400 cases)
Sloane
Hospital
for
Women
Pettit
et al.
Anthropoid
13
(14 pure
17.25 ( 3.25 mx.
22.7
18.0
Gynecoid
45
(28.25 pure
56.00 (27.75 mx.
50.6
51.0
Platypelloid
6
( 2.75 pure
3.00 ( 0.25 mx.
4.4
5.0
Android
12
(12.50 pure
23.75 (11.25 mx.
22.4
21.0
Mixed
1.8
5.0
Sloane Hospital for Women discovered a greater in-
cidence of ample anthropoid and android forms -with
a fewer number of anatomically characteristic android,
anthropoid and platypelloid types. The incidence (Ken-
nyJi) varies markedly when one confines the study to
the suspect pelvis alone. Of the contracted forms the
greater number conforms to the platypelloid and the
android types, and the least to the anthropoid pelvis.
Although it was not possible to compare the diameters
of a series of our own normals, some deductions can be
obtained from comparing a group of consecutive cases
with those of other authors. (Table 2)
Table 2
Pelvic
Ane & Menville 3
Judson --
Author
Planes
(400 consecutive cases)
(53 cases)
(450 consecutive cases)
Inlet:
sum
sum
sum
C.V.
11.88 cm.
12.60 cm. 3
11.40 cm.’]
(11.82) cm.
_ 25.44 cm.
> 26.50 cm.
h 25.10 cm.
Trans.
13.56 cm.
( 13.62) cm.
(25.44) cm.
13.90 cm. J
13.70 cm. J
Area
126.7
sq. cm.
137 sq. cm.
122.3 sq. cm.
Midplane:
sum
sum
A P.
11.41cm. J
1 1 .63 cm. 3
(11.59) cm.
21.71 cm.
l 21.94 cm.
IS.
10.30 cm. [
(22.04) cm.
10.26 cm. 1 3
(10.45) cm. J
1 14.33 cm.
> 14.10 cm.
PS.
0.43 cm.
(4.51) cm.
j ( 14.96) cm.
3.84 cm. J
Area
91.7 sq. cm.
94.4 sq. cm.
Outlet:
sum
A.P.
11.41 cm.
(11.59) cm.
Biisch.
11.13 cm.
(11.23) cm.
18.22 cm.
PS.
7.09 cm.
(7.05) cm.
"(18.73) cm.
Author
(Normal deliveries)
sum
11.77
13.12
24.89 cm.
(24.80) cm.
121.9 sq. cm.
sum
11.76
cm. )
22.90
10.53
cm. J
l 14.63
4.10
cm.
f (15.70)
97.0 sq. cm.
sum
9.42 cm.
7.89 cm.
17.40 cm.
July, 1949
239
It will be noted that although our average mean
diameter values differ significantly little from those re-
ported by authors studying patients from other areas,
the area values are at variance. The inlet areas are
smaller and those of the midplane are larger.
What are the indications for requesting a roentgeno-
pelvimetric survey? They may be listed as:
1. The clinical suspect pelvis to include all planes.
2. Primigravida with a large breech; one with unen-
gaged head (especially with occiput posterior posi-
tion whether or not accompanied by an extension
attitude) ; unengaged head with overriding unin-
fluenced by extreme lithotomy position and Hillis
maneuver.
3. Previous history of serious dystocia.
4. Malpresentations in elderly primipara.
5. Story of fracture or bony disease of the pelvis.
6. Previous cesarean section for disproportion.
Granted the fulfillment of the foregoing indications
what have the stereo- and isometric roentgenograms to
offer the accoucheur?
1. General morphology and essential diameter values.
2. Nature and degree of contraction present.
3. Depth of engagement of presenting part with a
note of degree of clearance; character of the sciatic
notch; inclination and angle of the symphysis;
sacral features; depth of the posterior pelvis; the
transverse diameter of the posterior pelvis; spine
characteristics; and the splay of the sidewalls.
4. Multiplicity and attitude of the fetus.
5. Viability and age of the fetus.
6. Location of placenta.
7. After the onset of labor — degree of molding, of
lateral flexion, change of station, and adaptation
of fetal head to pelvis.
With the presenting part well engaged one’s attention
is directed to the midplane, the plane of least pelvic
diameters. A midplane contraction should be suspected
if any or more of the following conditions accrue.
1. Constitutionally a male type of patient.
2. An android pelvis, or android influence of other
pelvic forms.
3. Prominent or close spines by palpation.
4. Contracted outlet in the presence of a narrowed
forepelvis and subpubic angle; and a flat sacrum.
5. Premature rupture of membranes.
6. Malposition (transverse or posterior arrests, with
or without full dilatation) .
A variety of workable schemes have been adopted by
many authors but the most dependable cannot escape
the help offered by roentgenopelvimetry, granted a com-
prehensive impression of cephalopelvic relationships is
essential. The android and platypelloid pelves are fre-
quently attended by a poor prognosis while the outlook
is favorable in the anthropoid type. A correct prognosis
of between 96 and 99 per cent is possible. The follow-
ing general rides, when dealing with the suspect pelvis,
are worthy of recording.
1. Trial of labor allowable where a free space of 1 cm.
exists between the fetal head and the inlet, pro-
vided the midplane and outlet measurements are
adequate (Torpin) .4u
2. A platypelloid pelvis with a C.V. of 9.0 to 9.9 cm.
is more efficient than an android form that ap-
proaches 10.0 cm. (Klingensmith et al.) ,24 A C.V.
of 11.0 cm. or more is desirable in respect to the
latter.
3. Dystocia may be anticipated with a combined C.V.
and Trans, of less than 24.0 cm., and a midplane
sum of I.S. and P.S. of less than 14.0 cm. In sup-
port of this contention Weinberg and Scadron 48
have presented a convincing table. These authors
also state that mid forceps extractions are common
with a summary measurement directed toward 14.0
cm.; that delivery from below is rarely accomplished
with a value of 13.5 cm. or less. Our experience
has not proven quite as severe as this. A midplane
sum of 14.9 cm. was common to their midforceps
applications, and one of 15.0 cm. to their cesarean-
ized patients.
4. One may anticipate a dystocia with a C.V. of less
than 9.0 cm. and a sum of the P.S. and I.S. of
less than 13.5 cm. (Guerriero 1(>).
5. Allen, (Table 3), shows that the critical area
for the inlet lies at 115 sq. cm. Normal delivery,
especially in a standard pelvis, may occur at a 90.0
to 100.0 sq. cm. level. Vaginal delivery is uncer-
tain with levels less than 90.0 sq. cm. If the area
Table 4 (Allen)
Probable Mode of Delivery
Conjuncta
vera in mm.
Brim area
in sq. cm.
Midplane
in sq. cm.
Interspinous
in mm.
Post-sagittal
(outlet) in mm.
Vaginal delivery certain without evidence
of disproportion
Over 130
Over 130
over 120
over 110
over 65
Vaginal delivery certain, but there may be
evidence of disproportion needing forceps
105-130
105-130
95-120
90-110
50-65
Vaginal delivery uncertain, and if posssible
will show clear evidence of disproportion
90-105
85-105
80-95
80-90
45-50
Vaginal delivery extremely unlikely.
Elective cesarean justified
under 90
under 85
under 80
under 80
under 45
240
The Journal-Lancet
or C.V. has a value of less than 105, one should
consider performing a cesarean section.
6. The critical levels for the midplane are:
a. Essential diameters: A.P. — 11.3 cm., I.S. — 9.5
cm., anterior transverse — 10.9 cm.
b. Areas: 104 sq. cm., using the anterior transverse
factor, and 90 sq. cm. employing the I.S. value.
Vaginal delivery is uncertain with these values
respectively at 85 sq. cm. and 75-70 sq. cm.
There is insufficient time allotted herein for a discus-
sion of the mechanism of labor that may be anticipated
in the various contracted forms. The reader, if inter-
ested, may refer to a paper to appear in the American
Journal of Obstetrics and Gynecology.
Because this paper is intended not to deal with par-
ticular pelvic forms but with degrees of contraction, a
discussion of matters of morphology away from the nor-
mal is purposely omitted. With the foregoing figures
as presented in Table 2 in mind, it is interesting to fol-
low through to the termination of labor in those pelves
of variable degrees of contraction.
The findings derived from the study of the inlet may
be tabulated thusly:
Conjugata vera of less than 10.0 cm.
1. Number of cases — 16 (4%).
2. Operative deliveries — 16 (4%) .
a. Elective cesarean sections — 7 (33.76 Gm.) 43.7%.
C.V. (9.39 cm.) plus Tr. (12.79 cm.) 1
equals 23.18 cm. > Justified.
Area equals 94.2 sq. cm. J
b. Intra-partum cesarean sections — 5 (3737 Gm.) 31.2%.
C.V. (10.8 cm.) plus Tr. (11.6 cm.) equals 22.40 cm.
Area equals 98.1 sq. cm.
c. Forceps deliveries — 4 (25%).
High— 2 (3375 Gm.)
Mid — 1 (3280 Gm.)
Low — 1 (2900 Gm.)
f C.V. (9.3 cm.) plus Tr.
I (12.3 cm.) equals 21.55 cm.
h Area equals 89.6 sq. cm.
f C.V. (9.6 cm.) plus Tr.
-s (13.6 cm.) equals 23.2 cm.
(_ Area equals 102 sq. cm.
J C.V. (9.0 cm.) plus Tr.
J (11.9 cm.) equals 20.9 cm.
] Area equals 84.6 sq. cm.
1 Stillborn.
Conjugata vera of 10.0 to 10.5 cm.
1. Number of cases — 18 (4.5%).
2. Operative deliveries — 15 (3.6%).
a. Elective cesarean sections — 10 (3300 Gm.) 66.66%.
C.V. (10.25 cm.) plus Tr. (12.47 cm.) J
(12.47 cm.)
equals 22.72 cm.
Area equals 110.8 sq. cm.
b Intra-partum cesarean sections — 3 (3538 Gm.) 20
C.V. (10.27 cm.) plus Tr.
(12.28 cm.) equals 22.55 cm.
Area equals 99.2 sq. cm.
c. Forceps deliveries — 2 (3368 Gm.)
High axis traction.
C.V. (10.2 cm.) plus Tr.
(12.7 cm.) equals 22.9 cm.
Area equals 101 sq. cm.
Spontaneous deliveries — 3 (3085 Gm.). One breech.
C.V. (10.3 cm.) plus Tr. (13.46 cm.)
13.3'
Justified.
Understandable.
Understandable.
equals 23.76 cm.
Area equals 108 sq. cm.
Understandable.
C.V. and sum of C.V. plus Tr. greater than
10.67 and 23.9 cm. respectively
1. Seven elective cesarean sections (3370 Gm.) with a mean
area of 110.6 sq. cm. might have been allowed a test of
labor.
2. Three intra-partum cesarean sections (3606 Gm.) were done
after an average of 41 hours of labor with no progress.
The mean area value was 106.4 sq. cm.
3. There were ten other cesarean sections and eight midforceps
deliveries. These were accounted for by reasons of previous
cesarean sections, breech presentations, and an accompany-
ing midplane crowding as an expression of android and
small gynecoid influence.
Findings derived from the midplane study :
Midplane sum of I.S. plus P.S. of less
than 13.0 cm.
1. Number of cases — 49 (12.2%).
2. Operative deliveries — 46 (94%).
a. Elective cesarean sections — 27 (3375 Gm.) 58.7%.
A.P. plus I.S. equals 20.16 cm. J
I.S. plus P.S. equals 12.12 cm. j- Justified.
Area equals 79.1 sq. cm. J
b. Intrapartum cesarean sections — 2 (3964 Gm.) 4.3%.
A.P. plus I.S. equals 21.5 cm.
I.S. plus P.S. equals 12.7 cm. > Understandable.
Area equals 68.2 sq. cm. J
c. Difficult midforceps — 17 (3514 Gm.) 4.3%.
A.P. plus I.S. equals 20.36 cm. J
I.S. plus P.S. equals 12.34 cm. r Understandable.
Area equals 80.8 sq. cm. J
d. Spontaneous deliveries — 3 (3173 Gm.) 0.75%.
A.P. plus I.S. equals 20.83 cm.
I.S. plus P.S. equals 12.57 cm.
Area equals 83.8 sq. cm.
Midplane sum of I.S. plus P.S. of
13.0 cm. to 13.5 cm.
1. Number of cases — 14 (3.5%).
2. Operative deliveries — 13 (93%).
a. Elective cesarean sections — 4 (3494 Gm.) 31%.
A.P. plus I.S. equals 21.78 cm.
I.S. plus P.S. equals 13.16 cm.
Area equals 94.7 sq. cm.
b. Intrapartum cesarean sections — 1
A.P. plus I.S. equals 20.9 cm.
I.S. plus P.S. equals 13.1 cm.
Area equals 84.4 sq. cm.
c. Mildly difficult midforceps — 8 (3585 Gm.) 61%.
A.P. plus I.S. equals 20.97 cm. J
I.S. plus P.S. equals 13.53 cm. > Understandable
Area equals 85.9 sq. cm.
d. Spontaneous deliveries — 1 (3480 Gm.) 7.7%.
/
(4048
Test of labor
indicated?
Gm.) 7.7%.
Understandable.
Added to the above study is the following survey of
an additional fifty cases. This review differs in that the
graduated break-down concerns primarily the mean area
values. The interspinous measurement is used in com-
puting the midplane area except where indicated. The
analysis agrees favorably in every instance.
Areas of 95 to 100 sq. cm.
Number of cases — 9. Average mean area — 97.39 sq. cm.
Elective cesarean sections — 4 (3124 Gm.).
a. Two accompanying midplane contractions — 81.5 and 64
sq. cm., using the I.S. diameter. Android character.
b. One pelvic fracture — oblique contraction.
c. One breech presentation (2760 Gm.).
July, 1949
241
Intrapartum cesarean section — 1 (2130 Gm.) — Ablatio.
Midforceps — 1 (2700 Gm.). Midplane area of 73.5 sq. cm. —
understandable (Android) .
Outlet forceps — 1 (3180 Gm ). Midplane area of 79.5 sq. cm.
— understandable. Small gyn.-flat.
Spontaneous — 2 (3497 Gm.). Midplane area of 88.0 sq. cm.
Flat.
No prolonged labors.
Comment: Expression of less favorable android and more favor-
able flat types of pelves. (There was one android pelvis with
areas of the inlet and midplane respectively of 83.9 and
70.6 sq. cm.) .
Areas of 100 to 105 sq. cm.
Number of cases — 10. Average mean area — 102.2 sq. cm.
Elective cesarean section — 1 (2661 Gm.). Flat — test of labor
allowable.
Intrapartum cesarean section — 1 (4048 Gm.). Android — arrest
understandable.
Outlet forceps — 4 (3124 Gm.) . Midplane area 88.5 sq. cm.
Spontaneous — 4 (3194 Gm.). Miplane area 87.7 sq. cm. (one
74.4— Pit.).
No prolonged labors.
Comment: The flat type of pelvis was again suggested in the
uncomplicated.
Areas of 105 to 110 sq. cm.
Number of cases — 4. Average mean area — 108.1 sq. cm.
Elective cesarean section — 1 (4140 Gm.).Flat — unengaged head.
Outlet forceps — 2:
a. One — 4140 Gm. Midplane area — 90.5. Scanzoni.
b. One — 3690 Gm. Midplane area — 85.5. Gynecoid-flat.
Spontaneous delivery — 1 (3210 Gm). Midplane area — 106.0.
Flat.
No prolonged labors.
Comment: Favorable gynecoid character in a flat pelvis.
Areas of 110 to 115 sq. cm.
Number of cases — 8. Average mean area — 115.5 sq. cm.
Elective cesarean section — 1 (2970 Gm.). Midplane area — 91.7
sq. cm. Previous section.
Intrapartum cesarean section — 1 (3000 Gm). Average mean
area — 85.5 sq. cm. Asynclitism.
Three prolonged labors (average number of hours was 67).
All uterine inertias:
a. One midforceps (Scanzoni) (4170 Gm.). Midplane
area — 91.0 sq. cm.
b. One low midforceps (Scanzoni) (3030 Gm.). Mid-
plane area — 96.0 sq. cm.
c. One low forceps (3480 Gm.) . Midplane area — 99.9
sq. cm.
Midforceps — 1 (3615 Gm.) (Scanzoni). Midplane area — 88
sq. cm. (ant. transverse of 106 sq. cm.). P.S. of outlet of
6.5 cm.
Low-midforceps — 1 (3737 Gm.). Midplane area — -76.9 sq. cm.
Outlet forceps — 1 (3539 Gm.). Midplane area — 99.9 sq .cm.
Comment: All above terminations understandable.
Areas of more than 115 sq. cm.
Number of cases — 18. Average mean area — 122. sq. cm.
Elective cesarean sections — 8 (3258 Gm.). Midplane area-
82. 0 sq. cm.
a. One — complicating pulmonary tuberculosis.
b. Two mild and two moderately severe midplane contrac-
tions (sums of P.S. and I S. diameters of less than 13.0
cm.). Difficult midforceps deliveries were anticipated.
c. One — an accompanying P.S. of the outlet of 3.0 cm.
d. Two — borderline midplane area values — 85.9 sq. cm.
(3512 Gm.).
Outlet forceps — 6 (3367 Gm.). Midplane area — 86.15 sq. cm.
Breech delivery — 1 (3640 Gm.). Midplane area — 83.6 sq. cm.
Stillborn.
Spontaneous deliveries — 3 (3648 Gm.). Midplane area — 84.2
sq. cm.
No prolonged labors.
Comment: All understandable except for two elective cesarean
sections (d). These patients may have been allowed to go
into labor.
Summary
A critical survey is presented of those pelves referred
for roentgenopelvimetric study because of a suspicion of
some degree of cephalopelvic disproportion. The mean
diameters and area values are compared with similar sta-
tistics as related by other authors. The mean inlet areas
compare reasonably well but this series of cases reveals
a somewhat larger midplane capacity.
The degrees of contraction found in this study are
graduated and the difficulties encountered obstetrically
therein are enumerated. The mean average weights of
the babies are correlatedly included. From the knowl-
edge gained thereby certain rules for confidently offering
a prognosis of labor are proposed. The area value for
each pelvic plane appears to be helpful in this regard,
except, perhaps, the consideration of the sum of the
antero-posterior and the widest (anterior) transverse
diameters of the midplane, than any one scheme con-
cerned with merely summarizing any two diameters.
It is hoped that continued interest in this subject will
serve to lessen the incidence of maternal morbidity and
mortality, to allow for a greater fetal salvage, and to
clarify the election of performing a cesarean section.
Bibliography
1. Adair, F. L.: Obstetrics and Gynecology. Vol. I, ch. 2.
W. B. Saunders & Co., Philadelphia and London, 1933.
2. Allen, E. P.: Brit. J. Radiol. 20:45-55 (Feb.) 1947. -
Idem: 20:108-118 (March) 1947. — Idem: 20:205-218 (May)
1947.
3. Ane, J. N., and Menville, L. J.: Am. J. Roentgenol.
49:742-749 (June) 1943.
4. Arantius, Julius Caes: Anatomical Observations, Vene-
tius, 1595.
5. Barton (see Adair reference above) .
6. Baudelocque (see Adair reference above) .
7. Borman, Chauncey: Journal-Lancet 60:312-318 (July)
1940.
8. Caldwell, W. E., and Moloy, H. C.: Am. J. Obst. &
Gynec. 26:479-505, 1933.
9. Caldwell, W. E., Moloy, H. C., and D’Esopo: Am. J.
Obst. & Gynec. 28:482-497, 1934.
10. Idem: 824-841, 1934.
11. Idem: 763-814, 1935.
12. Idem: 727-753, 1936.
13. Idem: and Swenson, P. C., Am. J. Roentgenol.
& Rad. Therapy 41: nos. 3, 4, 5, March, April and May, 1939.
14. Idem: Am. J. Obst. & Gynec. 40:558-565, 1940.
15. Groskloss, H. H., Robbins, O. W., and Moehn, J. T.:
Am. J. Obst. & Gynec. 56: 1090-1 103 (Dec.) 1948.
16. Guerriero, W. F., Arnell, R. E., and Irwin, J. B.: South.
M. J., 33:840-844 (Aug.) 1940.
242
The Journal-Lancet
17. Hodge: The Principle and Practice of Obstetrics, Blan-
chard and Lea, Philadelphia, 1864.
18. Johnson, Clayton R.: Tr. Sec. Obst. Gynec. & Abd.
Surg., A.M.A., 32-44, 1929.
19. Idem: Amer. Jour. Surg., n.s. 8:151 (Jan.) 1930.
20. Idem: Radiology 25:492-494, 1935.
21. Idem: Am. J. Roentgenol. & Rad. Therapy, 38:607-619
(Oct.) 1937.
22. Judson, H. A.: Am. J. Roentgenol. & Rad. Therapy
36:928-931 (Dec.) 1936.
23. Kenny, M.: J. Obst. & Gynec. Brit. Emp. 51:277-292
(Aug.) 1944.
24. Klingensmith, P. O., and Barden, R. P.: Pennsylvania
M. J. 44:891, 1941.
25. Levi-Dorn, M.: Deutsche med. Wochenschr. 23:566,
1897.
26. Litzmann: Die Formen des Beckens. Berlin, 1861. -
Idem: Das gespaltene Becken, Arch. f. Gynak. iv:266-284, 1872.
— Ide: Die Geburt bei engen Becken, Leipzig, 1884.
27. Manges, W. F.: Am. Quart. Roentgenol. 3:41, 1911. —
Idem: Am. J. Obst. & Gynec. 65:622, 1912.
28. Mengert, W. F. (Eller, W. C., and Mengert, W. F.) :
Am. J. Obst. & Gynec. 53:252-258 (Feb.) 1947.
29. Michaelis: Das enge Becken, Wigand, Leipzig, 1851.
30. Naegele, Franz Carl: Das weibliche Becken, etc., Carls-
ruhe, 1825.
31. Nicholson, C., and Allen, H. S.: Lancet 2:192-195
(Aug. 10) 1946.
32. Pettit, A. V., Garland, L. H., Dunn, R. D., and Shu-
maker, P.: West. J. Surg. 44:1-20, 1936.
33. Pinard and Varnier: Zentralbl. f. Gynak. 21:1145, 1897.
34. Smellie: A Treatise on the Theory and Practice of Mid-
wifery, London, 1774.
35. Thoms, H.: Surg., Gynec. & Obst.: 56:97-100, 1933.
36. Idem: Radiology 21:125-130, 1933.
37. Idem: Classical Contributions to Obstetrics and Gyne-
cology, Charles C. Thomas, 1935.
38. Idem: Surg. Gynec. & Obst. 60:680-683, 1935.
39. Idem: Am. J. Obst. & Gynec. 47:691-742 (March) 1940.
40. Idem: Am. J. Obst. & Gynec. 42:957-975 (Dec.) 1941.
41. Idem: Am. J Obst. & Gynec. 46:110-116 (July) 1943.
42. Idem: Surg. Gynec. & Obst. 77:153-156 (Aug.) 1943.
43. Thoms, H., and Greulich, W. T.: Yale J. Biol. & Med.
17:91-97 (Oct.) 1944.
44. Thoms, H., and Shumaker, P. C.: Am. J. Obst. &
Gynec. 48:52-57, 1944.
45. Torpin, R.: Am. J. Roentgenol. 47:717-729 (May) 1942.
46. van Deventer, Henry: Operationes Chirurgical novus
lumen exibentes obstetriciantibus, Lugd., Bat., 1701.
47. Walsh, J. G.: Am. J. Obst. & Gynec. 39:255-263
(Feb.) 1940.
48. Weinberg, A., and Scadron, S. J.: Am. J. Obst. &
Gynec. 46:245-254 (Aug.) 1943.
49. Williams, E. R.: Brit. J. Radiol. 16:173-181 (June)
1943. — Idem: and Phillips, L. G.: J. Obst. & Gynec.
Brit. Emp. 53:125-140 (April) 1946.
50. Williams, J. W.: Surg. Gynec. & Obst. 8:619-638, 1909.
AMERICAN ASSOCIATION OF BLOOD BANKS ANNUAL MEETING
The Second Annual Meeting of the American Association of Blood Banks will convene
in Seattle, Washington, at the Olympic Hotel, November 3, 4, 5, 1949. An excellent program
is being arranged which will be of interest to both scientific and administrative personnel
of blood banks and hospitals. Dr. Julius W. Davenport Jr., Director of the Blood Plasma
Service, Southern Baptist Hospital, 2700 Napoleon, New Orleans, Louisiana, is chairman,
and Dr. Paul I. Hoxworth, University of Cincinnati College of Medicine, Cincinnati General
Hospital, Cincinnati, Ohio; Mr. Charles G. Ransom, Director of the Blood Bank Foundation,
1911 Broadway, Nashville 4, Tennessee; Dr. Joseph Porter, Maine General Hospital, Portland,
Maine; and Dr. William Levin, John Sealy Hospital Blood Bank, 816 Strand, Galveston,
Texas; are members of the Program Committee. The King County Central Blood Bank of
Seattle will be host to convention delegates.
Dr. Ralph G. Stillman, 351 East 68th Street, New York 21, New York, President of
the Association, states he is confident there will be many interesting and informative papers.
Further, it is anticipated that a program will be presented for means of cooperation of all
blood banks in the country for united action in case of emergency or national disaster.
Although the distance for some will be great, said Dr. Stillman, the trip will be interesting
and it is believed we can safely promise that you will find the meeting well worth your while.
For further information contact the Office of the Secretary, 3301 Junius Street, Dallas
1, Texas.
NATIONAL CANCER INSTITUTE GRANTS
National Cancer Institute grants of $1,026,294 to finance laboratory and clinical research
in cancer were announced June 28 by Oscar R. Ewing, Federal Security Administrator.
The grants extended to the University of Minnesota were for the study of the biology
of human breast cancer, the relation of gastritus to cancer of the stomach, the Cancer De-
tection Center, and courses in cancer nursing and cancer control. Doctors who were particul-
arly designated to carry out the research are Sheldon C. Reed, Robert Hebbel, Owen H.
Wangensteen, and David State.
July, 1949
243
Chronic Pulmonary Emphysema
and Cor Pulmonale*
Richard V. Ebert, M.D.
Minneapolis, Minnesota
Chronic pulmonary emphysema is a disease which is
of importance to the practitioner of medicine be-
cause it is a common cause of great physical incapacity
and suffering and to the surgeon because, if unrecog-
nized, it may lead to death following thoracic or ab-
dominal surgery. In spite of the fact that pulmonary
emphysema is a common disease it is frequently over-
looked or an inaccurate diagnosis made. Laennec 1 in
1819 clearly outlined the basic features of the disease.
"The general symptoms of this affection are rather
equivocal. Dyspnea being its most striking feature, it is
one of the diseases usually confounded under the name
of asthma. In it the respiration is habitually impeded,
but is aggravated by occasional paroxysms which are
quite irregular in their return and duration. Like dysp-
nea from any other cause it is further increased by the
usual causes, such as indigestion, mental emotion, ele-
vated situation, violent exercise, especially that of mount-
ing, etc. It is unaccompanied by any fever, and the
pulse is, for the most part, regular. When the affection
exists in a high degree, the skin assumes a dirty aspect,
with a bluish tint in some places, especially the lips.
In all the cases I have seen there was a slight degree of
habitual cough, with a very slight mucous expectoration.
. . . Like other dyspneas it frequently, in the end, gives
rise to hypertrophia or dilatation of the heart.”
Why is the diagnosis of chronic pulmonary em-
physema so frequently overlooked in view of the clear
delineation of the signs and symptoms by Laennec? It
would seem to be because the symptom of dyspnea which
is so characteristic of this disease brings to the mind of
the physician the diagnosis of cardiac failure or bron-
chial asthma. Yet the dyspnea of emphysema can
usually be readily differentiated from the dyspnea of
cardiac failure by a study of the cardiac silhouette in
the roentgenogram of the chest and by examination of
the electrocardiogram. In left ventricular failure the
left ventricle of the heart is almost invariably enlarged
whereas in emphysema the cardiac shadow usually ap-
pears small in the posterior anterior view and if enlarge-
ment is present, it is chiefly of the right ventricle. The
electrocardiogram in left ventricular failure reveals a
left strain pattern or evidence of myocardial damage,
while in emphysema the electrocardiogram is normal or
shows a right strain pattern, and often high P waves in
leads 2 and 3 are present. In mitral stenosis with associ-
ated dyspnea the heart may appear normal in size but
the characteristic murmur readily identifies the valvular
lesion. The dyspnea of bronchial asthma may be differ-
*Inaugural thesis; presented at the Minneapolis Academy of
Medicine March 21, 1949.
entiated from that of pulmonary emphysema in that it
is paroxysmal in character. Between attacks the patient
with asthma should be free of dyspnea even on exertion.
If chronic dyspnea is present pulmonary emphysema
should be suspected.
The physical findings in emphysema may also be mis-
leading. It is true that the so-called barrel chest with
increase in anteroposterior diameter, flared costal mar-
gins, hyperresonance, and obliteration of the cardiac dull-
ness may be found in true chronic pulmonary emphys-
ema. Unfortunately a similar change in the chest may
occur in certain older individuals whose lungs function
entirely normally.- Moreover, certain patients with
chronic pulmonary emphysema do not exhibit a typical
barrel chest. The change in breath sounds may be
helpful but is not usually decisive in diagnosis. The
roentgenogram of the chest often fails in diagnosis of
this disease although it may be of great aid especially
if large blebs are present. Fluoroscopic observation of
the diaphragm may reveal it to be flattened and low in
position with only slight motion with respiration.
An understanding of the pathologic physiology of
emphysema may aid in the recognition of the disease
and in the management of the patient. Before discuss-
ing emphysema a few comments are necessary on the
normal physiology of respiration. The basic function of
the lungs is to supply oxygen to the blood and to excrete
carbon dioxide. This is accomplished by an interchange
of gas between the alveoli and capillaries. The respira-
tory movements of the chest are designed to ventilate
the alveoli so as to constantly introduce CL and remove
CO.. The partial pressure of Oj in alveolar air is nor-
mally 100 mm. Hg. and the partial pressure of CCL
40 mm. Hg. Increasing ventilation causes a fall in the
CCL tension and a rise in CL tension in alveolar air,
providing the metabolic rate remains constant. In nor-
mal persons the chemical regulation of respiration main-
tains the partial pressure of CL and CCL in alveolar air
relatively constant. The partial pressure of CL and CCL
in the arterial blood is nearly identical with that in the
alveolar air, there being no appreciable gradient for CCL
and only a slight gradient for CL across the alveolar
membrane.
In chronic pulmonary emphysema we find a marked
impairment of pulmonary function. The vital capacity
is reduced. This reduction is the result of an increase
in the residual air, by which is meant the air which re-
mains in the lungs at the end of a complete expira-
tion.ii4 The total lung volume is essentially normal.
The ability to increase ventilation is more markedly im-
paired than the vital capacity might indicate. This is
244
The Journal-Lancet
because it requires a prolonged period of time to expel
the air from the lungs due to their loss of elasticity.
Recently the ability to increase ventilation has been em-
phasized as a test for pulmonary function/’ A normal
person can increase his ventilation as much as 20 times
or to 100 liters per minute. A patient with severe pul-
monary emphysema is fortunate if he can double his
ventilation.
The alveoli in chronic pulmonary emphysema are
poorly ventilated. As a result the CL tension and CL
saturation of the arterial blood is low. In severe cases
the CL saturation of the arterial blood may be as low
as 70 per cent. The CCL tension of the arterial blood is
usually increased. To compensate for this increase there
is an increase in the bicarbonate of the blood with the re-
sult that the pH is normal or only slightly decreased. In
extreme cases the total CCL of the blood may rise to
over 100 volumes per cent. Attempts at hyperventilation
are usually ineffective in increasing the CL tension or
lowering the CCL tension of the arterial blood. It is
apparent that exercise by increasing the demand for CL
and the formation of CCL will further accentuate the
disturbance in the tension of these gases in the blood.
Finally a note should be made as to the effect of
chronic pulmonary emphysema on the circulation. It has
been known for many years that this disease may lead
to right ventricular hypertrophy and that right heart
failure may occur as a complication. Recent studies 6
have shown that elevation of the pulmonary arterial
diastolic pressure is a constant finding in pulmonary
emphysema. Usually the elevation in pulmonary arterial
pressure is mild but in a few cases it may be marked.
Those cases with the most marked elevation appear to
be prone to develop right heart failure.
Bibliography
1. Laennec, R. T. H.: A Treatise on the Diseases of the
Chest, p. 237, Translated by John Forbes, James Webster.
Philadelphia 1823.
2. Kountz, W. B., and Alexander, H. L.: Emphysema.
Medicine 13, 251, 1934.
3. Hurtado, A., Kaltreider, N. L., Fray, W. W., Brooks,
W. D. W., and McCann, W. S.: Studies of Total Pulmonary
Capacity and its Subdivisions. VI. Observations on Cases of
Obstructive Pulmonary Emphysema. J. Clin. Investigation 13,
1027, 1934.
4. Christie, R. V.: Emphysema of the Lungs. Brit. M. J.,
1, 105, 1944.
5. Baldwin, E. F., Cournand, A., and Richards, D. W.:
Pulmonary Insufficiency. Medicine 27, 243, 1948.
6. Borden, C., Wilson, R., Ebert, R. V., and Wells, H. S.:
To be published.
AMERICAN COLLEGE OF CHEST PHYSICIANS MEETING
Dr. Charles B. Craft, Bozeman, Montana, was elected Governor of the American
College of Chest Physicians at the Fifteenth Annual Meeting held in Atlantic City, New
Jersey, June 2-5, 1949.
Many other Northwest doctors were represented at this meeting. Doctors David Carr,
H. Corwin Hinshaw, Karl H. Pfuetze, and H. A. Brown, of Rochester, Minnesota, presented
a paper on "The Use of Dihydrostreptomycin in the Treatment of Tuberculosis.” Dr. John
R. McDonald, also of Rochester, presented a very interesting paper on "Carcinoma of the
Lung, Its Diagnosis by Cytologic Examination of Sputum and Bronchial Secretions.”
A small number of physicians received a fellowship certificate at the convocation held
June 4 in connection with the A. C. C. P. meeting. This honor was extended to Dr. Paul J.
Breslich of Minot, North Dakota.
MISSISSIPPI VALLEY MEDICAL SOCIETY MEETING AT ST. LOUIS,
SEPTEMBER 28, 29 and 30
The 14th Annual Meeting, Mississippi Valley Medical Society, will be held at the
Jefferson Hotel, St. Louis, Sept. 28, 29, 30, under the Presidency of Dr. Alphonse McMahon,
Associate Prof, of Medicine, St. Louis University. Over 30 clinical teachers from the leading
medical schools will conduct this great post-graduate assembly whose entire program is
planned to appeal to general practitioners. There will be some 60 scientific and technical
exhibits, noon round-table luncheons, etc. No registration fee will be charged and every
ethical physician is cordially invited and urged to attend. The entire program and all exhibits
will be held on the mezzanine floor of the Jefferson Hotel. The American Medical Writers’
Ass’n. will hold their annual meeting at the hotel on Sept. 28 and the Missouri Chapter of
the American Academy of General Practice on Sept. 30. Programs of all the meetings may
be obtained from Harold Swanberg, M.D., secretary, M. V. M. S. and A. M. W. A., 209-
224 W. C. U. Building, Quincy, 111.
July, 1949
245
American College Health Association News
The Problem of Control
of the Respiratory Tract Infections
Clayton G. Loosli, M.D.*
Chicago, Illinois
In the past ten years, great progress has been made in
the treatment of respiratory tract infections. At the
present time, however, there is no effective practical
means of preventing this group of diseases in individ-
uals in the industrial plant, office, school, or home. The
development of effective means of control is limited,
among other factors, by insufficient knowledge concern-
ing the nature of the etiological agents, clinical manifes-
tations, and modes of spread of acute respiratory tract
infections.
Etiology and Clinical Manifestation: In the routine
practice of medicine, the great majority of acute respira-
tory tract infections go undiagnosed so far as etiology
is concerned. They are usually characterized as "virus
infections” which may vary clinically from the "simple
common cold” to severe atypical pneumonia.1,2 From
studies on the transmission of acute respiratory infec-
tions in man by the Commission on Acute Respiratory
Diseases,1 it appears that several different viruses may
produce the same symptom complex of the "common
cold.” As yet, however, these virus agents are uncharac-
terized and have not been isolated for study in the ex-
perimental animal. Recent reports announcing the isola-
tion of virus agents from patients showing symptoms of
the "common cold” by the fertile egg technique are en-
couraging.4,r> During transmission experiments, how-
ever, similar symptoms could also be elicited by sterile
inocula. Transmission experiments by the Commission
on Acute Respiratory Diseases showed only a short
period of immunity to the "common cold virus”. Al-
though it is recognized that certain bacterial agents
(Beta hemolytic streptococci and pneumococci) may
elicit upper respiratory tract infections, the part the
common bacterial flora of the nose and throat plays
in the etiology and course of these diseases is not clear.
Modes of Spread: The causative agents of acute res-
piratory infections are harbored in the upper air pass-
ages of ill and asymptomatic carriers. It is now well-
known that individuals, whether ill or not, continually
extrude bacteria in droplets into the surrounding environ-
ment during the course of talking, sneezing, laughing,
coughing, and blowing the nose.6,7,8,9 Jennison has
demonstrated the expulsion of droplets during the above
activities (Figs. 1 and 2). The droplet-carrying bacteria
vary greatly in size. The large ones fall quickly and
become components of dust, while the smaller ones evap-
orate and become droplet nuclei (Fig. 3). Not only
does the dust on the floor, desks, table tops, and in the
Fig. 1 . Droplets resulting from a cough. Only a few hun-
dred droplets are produced in a cough compared with thousands
in a sneeze. (Published through the courtesy of Dr. M. W.
Jennison and the American Association for the Advancement of
Science. From Aerobiology, No. 17, p. 120, 1942.)
Fig. 2. Sneeze from subject with a head cold. The strings
of mucus are clearly evident. The large droplets result in part
from less effective atomization of these viscous secretions. (Pub-
lished through the courtesy of Dr. M. W. Jennison and the
American Association for the Advancement of Science. From
Aerobiology, No. 17, p. 116, 1942.)
air become soiled, but also the handkerchiefs, clothes,
hands (Fig. 4) , etc., of the "dispenser” become highly
conatminated.8,10,11,12,1'1 Presumably, the virus agents
of respiratory tract infections are dispersed into the en-
vironment in a like manner.
In intramural environments such as homes, classrooms,
dormitories, factories, offices, and hospitals, where peo-
ple congregate and spend several hours of the day, the
*From the Student Health Service, University of Chicago.
246
The Journal-Lancet
HEMOLYTIC STREPTOCOCCI RECOVERED FROM THE AIR OF A PHARYNGITIS-TONSILLITIS WARD
WARD QUIET
FLOOR BEING SWEPT
(DRY BROOM)
WARO QUIET
BEOS BEING MADE
Fig. 3. Photographs of blood agar plates made from bacterial air samples in a ward during varying
degrees of activity. The streptococci shown in each plate represent only a small percentage of the total
number recovered from the 10 cubic feet of air drawn through the collecting broth. (Published through
the courtesy of Dr. Morton Hamburger, Jr., who collected these data.)
(1) (2) (3)
Fig. 4. Photographs of blood agar plates made by inoculating aliquots of nutrient broth in which the nasal
carrier washed his hands. (1) Culture before washing. (2) Culture immediately after scrubbing hands
thoroughly with soap and water and rinsing in alcohol. (3) Culture after blowing nose. (Reproduced
through the courtesy of Dr. Morton Hamburger, Jr., and the Journal of Infectious Diseases, 79:39, 1946)
BEFORE SHAKING HANDS
IMMEDIATELY AFTER
SHAKING HANDS
Fig. 5. Photographs of blood agar plates made by inoculat-
ing aliquots of nutrient broth in which recipient washed hands
before and after shaking soiled hands of "nasal disperser’’ of
hemolytic streptococci (Published through the courtesy of Dr.
Morton Hamburger, Jr., who collected these data.)
bacterial and viral content may reach a high level. Al-
though respiratory tract infections have been considered
in recent years to be spread principally by the breathing
of airborne agents in dust and droplet nuclei,1'1 in such
environments other modes of transmission such as direct
contact (kissing, handshaking) with an infected person
or by contact with contaminated objects (clothes, pen-
cils, dusty desk surfaces, etc.) must be considered.1
Hamburger and associates 8,8a have graphically dem-
onstrated the potential role of the hands in the spread
of streptococcal infection (Fig. 5). Robertson 12 points
out that we have no knowledge as to what percentage
of colds, diphtheria, streptococcal disease, meningitis,
pneumonia, and tuberculosis is acquired by breathing in
the infectious agents and what percentage occurs as a
result of other means of inoculation. The opportunity
for intimate contact among students in the elementary,
July, 1949
247
high school and college environments is manifold, and all
modes of spread undoubtedly operate in the transmission
of respiratory infections but vary in importance with the
different age groups, diseases, and seasons of the year.
In recommending methods of prevention of respira-
tory tract infections, knowledge of the activities of the
individual and the different environments under which
they live is necessary. Baetjer points out that employees
spend only about one-third of their time at work and
that their chances of acquiring infections outside indus-
try are equally high.-1 Likewise, college students spend
only a portion of the day in the crowded classroom and
the chance of acquiring a "cold” while at the "coffee
shop,” a "gab-fest” in the dormitory, a sorority or fra-
ternity meeting, or while on a "date” is also equally
great.
Methods of Control
No fully successful program of respiratory disease
control has been developed. Certain recommendations
based on knowledge of the possible modes of spread
have been made. The spread by contact and droplets
is subject to control by altering individual activity such
as the promotion of personal hygiene, isolation, and
quarantine, and by increasing individual resistance by
chemoprophylaxis and vaccination. The spread of infec-
tion by droplet nuclei and dust is amenable to control
by methods of air sanitation.
Personal Hygiene
In the light of our knowledge of the manner of dis-
persal of respiratory disease pathogens, good health
habits are essential for the protection of the individual
and his associates. Of first importance are habits of
cleanliness, such as: (a) avoidance of spitting (if it
must be done, use a handkerchief or disposable tissue) ;
(b) avoidance of coughing, sneezing, and blowing the
nose without protection of face with handkerchief or
disposable tissue; (c) frequent washing of hands and
face with ample soap and water, particularly following
sneezing, coughing, and blowing the nose; (d) frequent
bathing and the wearing of clean clothes (outer as well
as inner garments) . Good habits of sleeping and eating
regularly a well-balanced diet promote well-being and
possibly resistance to respiratory infections. Reporting
to the physician or nurse at the early onset of illness for
prompt treatment diminishes the risk of serious compli-
cation and spread of infection to others.
Isolation and Quarantine
The value of these procedures in preventing the spread
of certain contagious and infectious diseases throughout
the community, hospital, and school is well established.
The isolation at home of nursery school and kindergar-
ten children, shown on morning inspection to have a
beginning "cold” or contagion, is a routine practice.
The carrying out of isolation procedures to prevent the
spread of respiratory tract infection in the elementary,
high school, and college student is the responsibility of
the individual and parents. College students with "colds”
continue to attend classes often throughout the course
of illness or until serious symptoms develop, for their
desire to keep up with class work is usually greater than
their immediate concern for health or their ability to
spread colds to others. There is no arrangement for the
student to take sick leave without penalty as there is for
the industrial worker. As Robertson points out, the iso-
lation of the vast majority of ambulatory persons afflicted
with common respiratory infections is impractical.20
Chemoprophylaxis
The routine use of antibiotics or chemotherapeutic
agents for the prevention of bacterial respiratory infec-
tions needs further study. It has been shown by Ham-
burger and associates 22 and Loosli 2 ' that both penicillin
and sulfadiazine markedly alter the bacterial flora of the
nose and throat and decrease the number dispersed into
the environment. At the same time, the use of these
agents should provide an unfavorable surface on the
mucous membranes for the irhplantation of inhaled
organisms.
In the case of streptococcal, meningococcal, or diph-
therial outbreaks, the mass prophylactic use (in thera-
peutic doses) of penicillin in preventing the spread
among the contacts seems warranted. The giving of
small doses of sulfadiazine by the Navy for mass pro-
phylaxis over a long period of time against streptococcal
infection resulted in the production of highly virulent sul-
fonamide-resistant strains of hemolytic streptococci.24,23
Therefore, the routine use of sulfonamides or penicillin
in small doses over long periods should be discouraged.20
There is no evidence that the use of antibiotics reduces
the incidence of the common cold and other virus infec-
tions of the respiratory tract.27
Vaccination
The Common Cold and Bacterial Infections. There is
no specific vaccine for the common acute respiratory in-
fections of virus and bacterial origin. The use of bac-
terial vaccines containing respiratory disease pathogens
and common flora of the nose and throat has not proved
effective. Studies by Diehl and associates28 have shown
that such preparations given either orally, subcutane-
ously, or instilled into the nasal passages elicit no spe-
cific resistance to respiratory tract infections. Summar-
izing the accumulated data up to December, 1944,
on the use of bacterial vaccines, the Council on Phar-
macy and Chemistry and the Council on Industrial
Health of the American Medical Association 29 con-
clude that "Decisive evidence of the value of any vac-
cine is not forthcoming and the weight of careful studies
clearly indicates that none of the vaccines now available
when administered by routes advised have proved of
value.” Therefore, vaccines for "colds” cannot be rec-
ommended for administration to industrial groups, stu-
dent groups, or to individuals. Any attempt to prevent
colds by the use of bacterial vaccines must be considered
purely experimental. Likewise, there is no evidence that
vaccination with Influenza A & B virus vaccines protects
against the "common cold” or respiratory infections of
bacterial origin.
Epidemic Influenza: Studies by Francis, Hirst, and
other members of the Influenza Commission on the use
of influenza virus vaccines during the 1943 30 and
1945 31,32 epidemics were highly successful. Employing
248
The Journal-Lancet
the same polyvalent vaccine during the 1947 epidemic,
a number of investigators 33,34 found no such dramatic
protection following vaccination. Failure to demonstrate
the usefulness of the vaccine during the 1947 epidemic
was found to be due to the absence of a close antigenic
relationship between the viruses in the vaccine and the
strains causing the epidemic. The efficiency of influenza
virus vaccines will depend then (1) on their ability to
initiate an adequate antibody response and (2) on a
close antigenic relationship between the virus components
in the vaccine and those initiating the epidemic. The lim-
itations of influenza virus vaccines then become obvious.
The gravity of the problem of the control of epidemic
influenza has resulted in the establishment of a World
Influenza Control program through the World Health
Organization. The Influenza Information Center in the
United States is located in the National Institutes of
Health, Bethesda, Maryland.30 Such an organization,
with laboratories in various parts of the world, may make
it possible to isolate in sporadic outbreaks, virus strains
which may be incorporated into vaccines in advance of
the epidemic spread of this disease. Student and indus-
trial populations provide excellent groups for the evalua-
tion of influenza vaccines.33,34 Such investigations should
be encouraged.
Scarlet Fever: Top 36 points out that immunization
against scarlet fever in the face of present knowledge
seems illogical. Scarlet fever over the past ten years has
become relatively mild. Injection of the toxin, in spite
of improvement in quality, often elicits moderate to
severe reactions. Immunization with the erythrogenic
toxin only protects against the rash but does not pre-
vent the septic complications which may follow strepto-
coccal infection with or without a rash. Strains and
types of Beta hemolytic streptococci vary in their ability
to produce scarlet fever. Hamburger and associates ’1
have shown that carriers of a given type of streptococcus
are able to transmit scarlet fever even though the carrier
himself has no rash. Conversely, cases of streptococcal
pharyngitis and tonsillitis are contracted from cases of
scarlet fever. During these studies, they found that
there was no significant difference in the numbers of
streptococci dispersed into the environment by patients
with scarlet fever and those with pharyngitis or tonsil-
litis without rash.
The many clinical and epidemiological studies of
streptococcal infections point to the fact that the exist-
ing quarantine laws governing scarlet fever patients are
in need of revision. It should be remembered, as Top
emphasizes, that scarlet fever is but one of a number of
hemolytic streptococcal infections; therefore, there is no
sound basis to quarantine only contacts to patients with
erythrogenic rash.
Diphtheria: Vaccination with toxoid for the protec-
tion of diphtheria is well established and needs no fur-
ther comment. Immunization against diphtheria should
be a routine preventive measure in pediatric practice and
in student and industrial health service clinics. All em-
ployees and students should be encouraged to have
booster doses periodically.
Pneumonia: Because of the large number of specific
types of pneumococci and the wide variety of other or-
ganisms which may cause pneumonia, little attempt has
been made in the past to develop vaccines for its preven-
tion. During World War II, the high incidence of
pneumonia among the personnel in a certain military
installation provided MacLeod and associates 38 an op-
portunity to evaluate the use of vaccines prepared from
the most prevalent pneumococcal types found in the
noses and throats of the camp population. It was shown
that purified pneumococcal capsular polysaccharides of
Types I, II, V, and VII employed as immunizing
agents reduced the carrier rate and the incidence of
pneumonia caused by these types. Kaufman 39 has re-
cently reported a study confirming the value of vaccin-
ating older individuals living in an institution with pol-
yvalent pneumococcus polysaccharides I, II, and III for
the prevention of pneumococcal pneumonia.
During the past ten years, however, there has been
a marked and steady decline in deaths due to pneumonia
from all causes. Some individuals consider this low mor-
tality rate due to the extensive use of sulfonamides and
antibiotics in the treatment of acute upper respiratory
tract infections. Because of the low incidence of pneu-
mococcal pneumonia, the large number of types which
may cause the diseases, and the lack of knowledge con-
cerning the duration of immunity following vaccination,
the wide-spread application of immunization with poly-
saccharides is not justified. MacLeod 38 recommends
such vaccines for workers in industrial environments in
which crowding, poor ventilation, and dust favors the
spread of the disease. As Kaufman 39 has shown, it
would appear to be desirable to vaccinate individuals
living for long periods of time in hospitals and other
institutions.
Hygienic Surroundings
The potential hazard of a dirty environment is great.
A clean environment in which to live, work, and study
will promote personal cleanliness. Clean toilet facilities
with ample soap and disposable or clean towels should
be readily available. For the comfort of the individual,
good lighting and ventilation, with appropriate tempera-
ture and humidity of the environment, are important.
Crowding and Ventilation: Other factors being equal,
the bacterial content of air in enclosed spaces is roughly
proportional to the number of individuals present. There-
fore, the overcrowding of classrooms and dormitories
increases the opportunity for spread of respiratory infec-
tions both by contact and indirectly by droplet nuclei
and airborne dust. Much can be accomplished in keep-
ing the bacterial content of the air below the infective
level by adequate ventilation.40
Air Disinfection: In addition to ventilation, three
methods have been employed for the prevention of the
spread of infection by droplet nuclei and dust. They are
ultraviolet irradiation,41-44 chemical disinfection with tri-
ethylene glycol vapor,20,27 and dust suppression pro-
cedures.10'10,11,4° These procedures when adequately ap-
plied reduce the bacterial content of the air from 60
to 85 per cent. They have been evaluated principally
with respect to their efficiency in preventing respiratory
July, 1949
249
tract infections and contagious diseases in hospitals,
schools, and military barracks.
Of the three, dust suppression by the application of
oil to floors, bedclothes, and wearing apparel is most
easily applied and is recommended as a measure of good
housekeeping. On the basis of available data, recently
reviewed by the Committee for the Evaluation of Meth-
ods to Control Airborne Infection of the American Pub-
lic Health Association, the general use of ultraviolet
irradiation and triethylene glycol vapor is not recom-
mended.40 No information is available as to their effec-
tiveness when used in the home, office, school, or fac-
tory. Therefore, any application of these methods should
be considered experimental. In areas or environments
where the evidence of respiratory tract infections is high,
further careful studies of the use of these methods are
encouraged. Ultraviolet irradiation and triethylene gly-
col vapor should be evaluated in relation to other means
of control of respiratory tract infections, such as the use
of antibiotic agents.” ‘
Treatment
As there is no effective over-all method for preventing
respiratory tract infections, the question of treatment
becomes important." In the early stages, it is impossible
to predict the course of respiratory tract infections.
Therefore, prompt reporting to the physician for care
is important. Most upper respiratory tract infections are
mild and treatment is symptomatic. The use of anti-
biotics should be limited to the more severe infections
where there is definite evidence or question of a bacterial
etiology. The use of aureomycin in the treatment of
primary atypical pneumonia is recommended.4'
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the Control of Dust-Borne Bacteria by Treatment of Floors and
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infection of Air. Am. J. Pub. Health, 38:409-415, 1948
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V. G.: The Problem of the "Dangerous Carrier” of Hemolytic
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Strongly Positive Nose Cultures Who Expelled Large Numbers
of Hemolytic Streptococci. J. of Inf. Dis., 77:96, 1945.
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46:311, 1947.
21. Baetjer, A. M.: Acute Infections of the Respiratory
Tract and Their Control in Industry. Occup. Med., 3:344,
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23. Loosli, C. G.: Unpublished data.
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26. Massel, B. F., Dow, E. F., and Jones, T. D.: Penicillin
Rheumatic Fever. J.A.M.A., 138:1030, 1948.
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son, O. H., and Puck, T. T.: Control of Cross Infections in
Infants' Wards by the Use of Triethylene Glycol Vapor. Am.
J. Pub. Health, 37:1385, 1947.
28. Diehl, S.: The Treatment of the Common Cold. J. of
Ind. Hyg„ 17:48, 1935.
29. Council on Pharmacy and Chemistry: The Use of Vac-
cines for the Common Cold. J.A.M.A., 126:895, 1944.
30. Commission on Influenza: A Clinical Evaluation of Vac-
cination against Influenza; Preliminary Report. J.A.M.A.,
124:982, 1944.
31. Francis, T., Jr., Salk, J. E., and Brace, Wm. M.: The
Protective Effect of Vaccination against Epidemic Influenza B.
J.A.M.A., 131:275, 1946.
32. Hirst, G. K., Vilches, A., Rogers, D., Robbins, C. L.:
The Effect of Vaccination on Incidence of Influenza B. Am. J.
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33. Francis, T., Jr., Salk, J. E., and Quilligan, J. J.: Experi-
ence with Vaccination against Influenza in the Spring of 1947.
Am. J. Pub. Health, 37:1013, 1947.
34. Loosli, C. G., Schoenberger, J., and Barnett, G.: Results
of Vaccination against Influenza During the Epidemic of 1947.
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35. Culbertson, J. T.: Plans for United States Co-operation
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fluenza Study Program. Am. J. Pub. Health, 39:37, 1949.
36. Top, F. H.: Communicable Diseases, pp. 84 and 370.
C. V. Mosby Company, St. Louis, 1947.
37. Hamburger, M., Jr., Green, M. J., and Hamburger, V.
G.: The Problem of the "Dangerous Carrier” of Hemolytic
Streptococci. I. Number of Hemolytic Streptococci Expelled by
Carriers with Positive and Negative Nose Cultures. J. Inf. Dis.,
77:68-81, 1945.
38. MacLeod, C. M., Hodges, R. G., Heidelberger, M., and
Bernhard, Wm G.: Prevention of Pnemococcal Pneumonia by
Immunization with Specific Capsular Polysaccharides. J. Exp.
Med., 82:445, 1945.
39. Kaufman, P.: Pneumonia in Old Age. Active Immuni-
zation against Pneumonia with Pneumococcus Polysaccharide
Arch. Int. Med., 79:518, 1947.
40. Yaglou, C. P., and Wilson, U.: Disinfection of Air bv
Air Conditioning Processes. Aerobiology. Amer. Assoc. Adv.
Science, 17:129, 1942.
41. Wells, W. F., and Wells, M. W.: Environmental Con-
trol of Epidemic Spread of Contagion. Aerobiology. Amer.
Assoc. Adv. Science, 17:206, 1942.
42. Willmon, T. L., Hollaender, A., and Langmuir, A. D.:
Studies of the Control of Acute Upper Respiratory Diseases
among Naval Recruits. I. A Review of a Four- Year Experience
with Ultraviolet Irradiation and Dust Suppressive Measures,
1943 to 1947. Am. J. Hyg., 48:226, 1948.
43. Jarrett, E. T., Zelle, M. R., and Hollaender, A.: Studies
of the Control of Acute Upper Respiratory Disease among
Naval Recruits. II. Limitations of Ultraviolet Irradiation in
Reducing Airborne Bacteria in Barracks with Low Ceilings.
Am. J. of Hyg., 48:233, 1948.
44. Langmuir, A. D., Jarrett, E. T., and Hollaender, A.:
Studies of the Control of Acute Respiratory Diseases among
Naval Recruits. III. The Epidemiological Pattern and the
Effect of Ultraviolet Irradiation during the Winter of 1946-47.
Am. J. Hyg., 48:240, 1948.
45. Commission on Acute Respiratory Diseases and the Com-
mission on Airborne Infections. A Study of the Effect of
Oiled Floors and Bedding on the Incidence of Respiratory Dis-
ease in New Recruits. Am. J. Hyg., 43:120, 1946.
46. Perkins, J. E.: The Present Status of the Control of
Airborne Infections. Am. J. Pub. Health, 37:13, 1947.
47. Schoenbach, E. B., and Bryer, M. S.: Treatment of
Atypical Pneumonia with Aureomycin. J.A.M.A, 139:275,
1949.
American College Health Association Neivs
The Executive Committee of the American College
Health Association has accepted the application for
membership of the following institutions: Jersey City
Medical Center — Dr. Leonhard Felix Fuld, Director,
Jersey City 4, New Jersey; University of Texas Med-
ical Branch — Dr. John W. Middletown, Director Stu-
dent Health Service, Galveston, Texas; Colorado School
of Mines — Dr. W. Lloyd Ulright, Director, Golden,
Colorado. The final election to membership of these
institutions will be made by a vote of the delegates at
the annual meeting in December, 1949.
The one volume Proceedings of the twenty-fifth and
twenty-sixth annual meetings is just off the press. The
Council voted to send one copy to each member insti-
tution. This copy has been mailed to the Director of
Health Service. If the college library or an individual
desires a copy of the Proceedings, it will be necessary to
order one. The price is $3.00. Back copies of the Pro-
ceedings are available for any institutions desiring to
make the files complete. These copies may be obtained
from the secretary for fifty cents each.
Virginia Polytechnic Institute, Blacksburg, Virginia,
reports a vacancy in the directorship of the College
Health Service. The college has over five thousand stu-
dents, an infirmary with fifty beds, a staff of two full-
time and one half-time physicians, two orderlies, five
registered nurses, and three student assistants. Write
to Dr. Charles R. Woolwine for further information.
A full-time physician is needed in September at Yale
University, Department of Health, New Haven, Con-
necticut. Write to Dr. Orville F. Rogers for further
information.
The Ohio College Health Association, the Ohio Sec-
tion of the American College Health Association, held
the twenty-fifth annual meeting of the Association in
April at Columbus, Ohio. Forty-three representatives
from seventeen colleges and universities attended the
two-day meeting. The name of the organization was
changed to conform with the parent association. The
officers of the Section are:
President — Dr. E. Herndon, Ohio University; vice-
president — Dr. Ted Allenbach, Ohio State University;
secretary-treasurer — Dr. William T. Palchanis, Ohio
State University.
The secretary reports a feature of the meeting was
the organization of the college health nurses into the
Nursing Section of the Ohio College Health Associa-
tion. This Nursing Section is probably the first of its
kind to be affiliated with any local section of the Ameri-
can College Health Association. The following officers
were elected:
Chairman — Mrs. Rena E. Coppess, R.N., Wittenberg
College; vice-chairman — Miss Mary L. Earhart, R.N.,
Denison University; secretary-treasurer — Mrs. Dorothy
A. Struhe, R.N., Miami University.
Miss Raidi Poole, R.N., chairman, College Nursing
Committee of the National Organization of Public
Health Nurses, gave a speech at the meeting.
The Ohio Section will hold the twenty-sixth annual
meeting as guests of Kent State University at Kent,
Ohio, in 1950.
The annual meeting of the Pacific Coast Section will
be held at Claremont Colleges, Pomona, California, dur-
ing the Thanksgiving recess, 1949. The Executive
Committee has planned several panel discussions for
the two-day meeting.
July, 1949
25 1
Antibiotics in the Treatment of Infections
John W. Brown, M.D.
Madison, Wisconsin
This brief discussion of antibiotic therapy will be lim-
ited to a few important aspects which are affected
by newer developments and changing trends. Progress
in this field has taken place at an unusually rapid rate.
We must evaluate it frequently in order to clarify the
real contributions to concepts and methods which apply
to the problems of our patients.
Antibiotic agents, especially penicillin, have come to
be used universally. Dramatic therapeutic benefit is ob-
served so regularly when conditions are appropriate as to
be commonplace. One trend is a tendency to expect too
much. A little reflection will at once reveal that routine
programs cannot have a place in antibiotic therapy. So
many factors modify the approach to the problem of
infection that careful evaluation of each patient is of
even greater importance than before the introduction of
active antibacterial substances. Fortunately, the ultimate
recovery of most patients is not dependent upon the ex-
actness of specific treatment. However, other patients
are encountered whose survival requires skillful applica-
tion of the principles which are fundamental to the suc-
cess of antibiotic therapy.
Penicillin
Penicillin is the antibiotic agent of most general im-
portance at present. The story of its development and
unparalleled success in the control of infections due to
many gram-positive and some gram-negative organisms
is well known. The evidence indicates that its effec-
tiveness depends upon the maintenance of antibacterial
concentrations in the tissues. These are presumably
reflected by the level in the blood. Penicillin has been
administered usually in the form of a soluble salt of
sodium, potassium or calcium penicillin G in aqueous
solution. With these preparations, effective levels can be
maintained if suitable amounts are given by frequent
intramuscular or by continuous intramuscular or intra-
venous injections. These methods have demonstrated
their reliability. With the present state of knowledge,
one of them probably should be used when adequate
penicillin therapy is crucial for the control of life-threat-
ening infections. The salts of penicillin are now provided
in crystalline form. It is stable at room temperature.
The crystalline form is less irritating when given intra-
muscularly than the older preparations of amorphous
penicillin. Penicillin is still measured in terms of units
because of popular experience with this expression. It
may be estimated accurately by weight.
The discomfort to the patient and the general incon-
venience of frequently repeated intramuscular injections
"From the Department of Preventive Medicine and Student
Health, University of Wisconsin Medical School, Madison.
with the soluble salt are real obstacles. A search for
other satisfactory methods of administration was insti-
tuted early. Penicillin is inactivated in the stomach to
a large extent but some absorption will occur from the
gastro-intestinal tract if large doses are administered at
intervals of 2 to 3 hours. Oral doses of approximately
five times those given intramuscularly will result in a
similar blood level in most individuals if the stomach is
empty when penicillin is taken. There is considerable
individual variation and the orai method of administra-
tion cannot be depended upon with assurance. It is
most often justified in the treatment of young children
and in others with infections which are highly suscep-
tible.
The excretion of penicillin through the kidney by way
of the tubules accounts for its rapid disappearance.
Methods to interfere with this mechanism have been
developed. Although several are partially successful,
the simultaneous oral administration of caronamide
(4' carboxyphenylmethanesulfonamlide) appears to be
the most efficient and to have the fewest drawbacks of
those at present available. 1,2 This drug when present in
the blood in concentrations of 20 to 40 mg. per 100 cc.
of plasma competes with penicillin for excretion by the
kidney tubules. It will result in increasing the concen-
tration of penicillin in the blood by from 3 to 10 times.
A dose of 3 to 4 grams by mouth every 4 hours will be
required in average individuals and somewhat less for
those over 60. Harmful effects, except for an occa-
sional reaction with fever and skin eruption, have not
been observed. Caronamide would seem to have a place
where levels of penicillin are required which are too
high to be attained readily with ordinary means.
Methods have been sought which slow the absorption
of penicillin after intramuscular injection. The first suc-
cess in this direction came with the preparation contain-
ing the soluble salt of crystalline penicillin G in peanut
oil and 4.8 per cent bleached beeswax (the Romansky
formula). An injection of 300,000 units in 1.0 cc. will
result in the persistence of a measurable concentration
in the blood for 24 hours in the majority of patients.
This preparation was widely used and constituted a sig-
nificant advance. Its drawbacks consisted of an increas-
ing tendency to local and systemic reactions, certain dif-
ficulties in administration, and uncertainty of effect after
twelve hours. During the past year other outstanding
advances have been made in the development of prepa-
rations which result in prolonged therapeutic concentra-
tions after a single injection. The newer products have
been made possible by the combination of procaine with
penicillin to form an insoluble compound of crystalline
procaine penicillin G. After injection intramuscularly
252
The Journal-Lancet
the compound breaks down to liberate penicillin slowly.
To facilitate administration procaine penicillin has been
incorporated in sesame oil, or with a stabilizing agent
(sodium carboxymethylcellulose) for aqueous suspension
and in peanut or sesame oil jelled with 2 per cent alu-
minum monostearate. None of these to date have re-
sulted in reactions other than those occasionally due to
penicillin itself. They can be stored indefinitely at room
temperature, are easy to administer and do not require
absolutely dry glassware. Each of these preparations will
maintain a blood level of 0.03 units or more per cubic
centimeter for twenty-four hours or longer in nearly all
patients after a single intramuscular injection of 300,000
units. That in oil with aluminum monostearate will per-
sist from 96 to 120 hours at concentrations of .03 to .06
and more in most patients. The levels are somewhat
higher during the first one to twelve hours, between
0.1 and 1.0 units in different patients and with different
preparations, but tend to remain low throughout.
The peaks of concentration which are so conspicuous
following the administration of the soluble salts do not
appear. The development of these preparations of crys-
talline procaine penicillin is forward progress of prac-
tical importance. Many of the earlier drawbacks of peni-
cillin therapy have been reduced. Experience under well
controlled conditions has demonstrated that the use of
this form of administration by widely spaced injections
is effective for most infections which are ordinarily re-
sponsive to penicillin. This development has created a
new trend and most patients are now being treated in
this way. Unfortunately, there is a tendency to place
too much reliance on this method of therapy. The great
value of the newer methods could be overbalanced by
harm if carelessness should develop as the result of sim-
plicity in available modes of therapy.
A consideration of fundamental principles seems to
demonstrate the direction which rational penicillin ther-
apy should take. Many uncomplicated infections due to
highly susceptible organisms are very responsive to treat-
ment with penicillin. These include pneumococcic pneu-
monia, streptococcic pharyngitis, cellulitis, and acute
gonorrhea. It has been shown that infections of this type
are responsive to low, even erratic, blood levels of the
agent. Success can be expected when soluble penicillin
is used in doses and at intervals which may fail to main-
tain measurable amounts in the blood for more than
half the interval between injections. With these infec-
tions the use of the oral route may be justified. Simi-
larly, reliance may be placed on widely spaced injections
of a slowly absorbed preparation of procaine penicillin
in the treatment of these highly susceptible infections.
On the other hand, the potentialities of many other in-
fections indicate a different approach. Staphylococcic
infections, as an example, with the tendency to tissue
destruction and slow healing which these present, and
the frequent occurrence of strains of the organism which
are relatively resistant to penicillin, do not always respond
readily. Here the maintenance of a therapeutically active
blood level for the particular strain encountered is essen-
tial and must be controlled by frequent intramuscular
injections. Similarly, the site of infection, even with
very susceptible organisms such as the pneumococcus and
streptococcus may indicate an unfavorable prognosis un-
less the optimum therapeutic concentration of penicillin
is maintained. Meningitis, cavernous sinus thrombosis,
subacute bacterial endocarditis, and actinomycosis are
examples. The relative importance of the high peak
level which follows the intermittent intramuscular injec-
tion of a soluble salt to that of the unvarying lower
level obtained by the use of continuous infusion or a
slowly absorbed repository product has not been estab-
lished. There are theoretic considerations which favor
the former. *’ There is reason to believe that higher
maximum levels result in better diffusion into tissues and
across serous membranes. This may be particularly sig-
nificant in the treatment of meningitis due to gram-
positive organisms where it seems likely that the use of
doses of penicillin of a magnitude of 8 to 12 million
units a day may obviate the need for its intraspinal
injection and provide better results than heretofore ob-
tained. Infections which have been considered resistant
to penicillin are coming within its range with the trend
toward the use of larger doses, or with the enhancement
effect of caronamlde, and the resulting very high blood
levels. Of these, lung abscesses, peritonitis, and endo-
carditis due to relatively resistant organisms are exam-
ples. When the infection encountered is suspected of
being relatively resistant, it seems reasonable to use
treatment which accomplishes high peak and continuous
minimal effective concentrations. Reduction in the num-
ber of injections required may be attained by adminis-
tering a product of procaine penicillin once daily sup-
plemented with two or three intramuscular injections of
a soluble salt during the day. When circumstances per-
mit, the accurate determination of the nature and peni-
cillin susceptibility of the etiologic agent is always worth-
while.
Streptomycin
The antibiotic streptomycin has been shown to be a
useful agent for the treatment of infections caused by
many gram-negative organisms which are usually not re-
sponsive to penicillin. Activity has also been demon-
strated for gram-positive bacteria as well, but streptomy-
cin is usually inferior to penicillin in the treatment of
infections caused by them. Occasionally it is effective
when a penicillin-resistant strain of gram-positive organ-
isms is encountered. The principles of therapy with
streptomycin are much the same as for penicillin. It is
excreted less rapidly so that intramuscular injections may
be spaced at intervals of six hours or more. It is not
absorbed when given by mouth. Methods for delaying
absorption from the site of intramuscular injection or
for delaying excretion by the kidney tubules have not
been developed. Caronamide is not effective. Streptomy-
cin is measured in terms of weight, expressed in micro-
grams or milligrams.
Streptomycin possesses features which render it a
much less ideal antibiotic agent than penicillin. The
July, 1949
253
maximum tolerated dose is scarcely more than two or
three times that required for the treatment of most in-
fections. Prolonged administration results in toxic effects
on the auditory apparatus in a significant proportion of
patients. This may range from transient damage involv-
ing vestibular functions to permanent bilateral nerve
deafness. Most bacteria have a tendency to develop re-
sistance to streptomycin with great rapidity. Treatment
is likely to be unsuccessful unless all infecting organisms
are eliminated early. This is in contrast to penicillin,
to which bacterial resistance after prolonged contact is
rarely of practical importance.
The dramatic effectiveness of streptomycin in tulare-
mia has been thoroughly demonstrated. It is also fre-
quently effective in the treatment of infections due to
gram-negative bacilli which have formerly proved fatal.
These include meningitis and endocarditis due to A.
aerogenes, E. coli, and many others. Streptomycin is
more effective in the treatment of H. influenzae menin-
gitis than the combination of sulfadiazine and specific
antiserum. It does not penetrate in satisfactory amounts
through the meninges so that intraspinal injections of
10 to 20 milligrams daily until the spinal fluid is sterile
are dictated. Sepsis and penumonia due to gram-nega-
tive organisms may be treated successfully with strep-
tomycin. When any of these life-threatening infections
are encountered it seems justified to disregard the dan-
gers of toxic effects and to administer the agent in
amounts up to 4 grams a day by the intramuscular route
for as long as necessary.
Streptomycin is a very efficient agent for the treatment
of acute urinary tract infections due to gram-negative
organisms which are not responsive or have become re-
sistant to other methods of therapy. The tendency to
the development of resistance by these organisms is dem-
onstrated rapidly in the urinary tract, however, and re-
currence usually occurs if structural defects or any ele-
ment of obstruction is present. For urinary tract infec-
tions a dosage of about 2 grams of streptomycin a day
for five to seven days will accomplish the maximum
therapeutic result without the danger of toxic effects.
A second course of therapy, if necessary, will usually
encounter a resistant strain of organisms.
Although streptomycin has a place in the treatment
of tuberculosis it must be considered only temporarily
inhibitive to the organism and thus, ancillary to the
general management.' It is most effective in the therapy
of acute exudative pulmonary and bronchial lesions. For
the latter it has proved valuable prior to pulmonary re-
section which could not be performed in the presence of
tuberculosis affecting major bronchi. Streptomycin has
a significant inhibitory effect on miliary and meningeal
tuberculosis but as the period of observation extends,
the number of patients who have remained well after
apparent recovery from this type of infection becomes
fewer. This antibiotic is, nevertheless, pointing the way
toward the development of effective methods of specific
therapy in tuberculosis.
Other Antibiotic Agents
Dozens of other antibiotic agents have been discov-
ered which possess activity against various organisms in
vitro. Only a few of them are applicable to the treat-
ment of infections. Tyrothricin was the first to be ac-
cepted for clinical use. It was isolated by Dubos in 1939
from a soil micro-organism, Bacillus brevis. s Tyro-
thricin possesses marked antibacterial activity against
most gram-positive organisms but is inactivated in the
tissues and is toxic when given parenterally. In concen-
trations of 0.5 to 1 mg. per cc. of aqueous suspension
or per gram of water-soluble cream it is highly effective
in the local treatment of chronically infected ulcers and
wounds. Penicillin and streptomycin were the next anti-
biotics to be accepted. The success of these stimulated
extensive programs directed towaird the discovery of new
agents with greater effectiveness. Of those discovered,
at least five warrant comment because they are of estab-
lished value already or have promise sufficient to deserve
continued investigation. Subtilin and Bacitracin are de-
rived from strains of Bacillus subtilis and are effective
against a variety of gram-positive organisms. Subtilin
has activity against the tubercle bacillus and has been
successful in the treatment of experimental tuberculous
infections. It has not received sufficient clinical trial.
Bacitracin is now accepted for local use in the manage-
ment of pyogenic infections. Concentrations of 100 to
500 units per cc. are recommended. Early trials by par-
enteral injection resulted in renal toxicity. If this prop-
erty can be eliminated as purified materials become avail-
able, Bacitracin may prove of great value for the treat-
ment of systemic infections. It also shows promise in
the therapy of gas gangrene. Polymyxin derived from
Bacillus polymyxa in the United States and Aerosporin
from Bacillus aerosporin in England are identical or
closely related. They may have value in the therapy of
infections due to gram-negative organisms. Early clinical
trials have been disappointing.
Penicillin possesses activity against the psittacosis-
lymphogranuloma group of viruses, or rickettsiae as these
are now being classified. Recently two other agents have
been discovered which have a wide range of effectiveness
in experimental infections with the entire group of rick-
ettsiae and against many gram-positive and gram-nega-
tive bacteria as well. Further, each is active when admin-
istered by the oral route, a property unique among anti-
biotics and suggesting the approach of a new era in the
specific treatment of infections. Chloromycetin was iso-
lated from a soil Streptomyces obtained form Venezuela
by Burkholder of Yale.9 Clinical trials have demonstrat-
ed remarkable effectiveness in the treatment of epidemic
typhus, scrub typhus, and Rocky Mountain spotted
fever.10 Chloromycetin seems also to have application
in the treatment of typhoid fever.1 1
Aureomycin was discovered by Duggar from Strep-
tomyces aureofaciens isolated from soil in Wisconsin.
It has now been accepted and is commercially available.
It possesses a range of activity very similar to Chloro-
mycetin.1" Therapeutic concentrations can be maintained
254
The Journal-Lancet
in the blood by the oral administration of 0.5 to 1.0
gram every four to six hours in adults. The only symp-
toms of toxicity noted have been nausea, vomiting, and
loose stools in occasional patients. Finland has shown
that aureomycin has a place in the therapy of several
resistant bacterial infections among which are gonorrhea,
pneumococcic pneumonia, salmonella infections and ty-
phoid fever.1'5 Spink has demonstrated a remarkable
effectiveness in the treatment of severe Brucella meli-
tensis infections.11 There is evidence that aureomycin
has application in the treatment of atypical pneumonia,
a disease of unknown etiology but for which a virus
cause is suspected. None of the true viruses, including
influenza and poliomyelitis, have been affected by either
chloromycetin or aureomycin. Experience now suggests
that aureomycin is not effective in the treatment of in-
fectious mononucleosis.
Summary
This discussion has been concerned with certain aspects
of antibiotic therapy which are of practical importance
in the light of present knowledge. The development and
the benefit of methods of penicillin administration
which provide prolonged concentrations in the blood
after single intramuscular injections have been consid-
ered. It has been emphasized that complete dependence
must not be placed on any routine method of therapy.
The place of streptomycin in the treatment of infections
is briefly summarized.
The discovery of chloromycetin and aureomycin has
extended the range of specific therapy to rickettsial and
some formerly resistant bacterial infections. The poten-
tialities of these agents are only now being explored.
It is likely that a new era in antibiotic therapy is begin-
nmg.
References
1. Boger, W. P., Miller, A. K., Tillson, E. K., and Shaner,
G. A.: Caronamtde: Plasma Concentrations, Uurinary Recov-
eries, and Dosage, J. Lab. & Clin. Med. 33:297 (March) 1948.
2. Seeler, A. O., Collins, H. S., and Finland, M.: Effect of
Oral Caronamide on Plasma Penicillin Levels Following Large
Intramuscular Doses of Penicillin, Am. J. Med. Sci., 216:241
(Sept.) 1948.
3. Robinson, J. A., Hirsch, H. L., Milloff, B., and Dow-
ling, H.: Procaine Penicillin; Therapeutic Efficiency and a
Comparative Study of the Absorption of Suspensions in Oil
and in Oil plus Aluminum Monostearate and of an Aqueous
Suspension Containing Sodium Carboxymethylcellulose, J. Lab.
& Clin. Med. 33:1232 (Oct.) 1948.
4. Thomas, E. W., Lyons, R. H., Romansky, M J., Rein,
C. R., and Kitchen, D. K.: Newer Repository Penicillin Prod-
ucts, J.A.M. A., 137:1517 (Aug. 21) 1948.
5. Hewitt, W. L., Whittlesey, P., and Keefer, C. S.: Serum
Concentrations of Penicillin Following the Administration of
Crystalline Procaine Penicillin G in Oil, New Eng. J. Med.,
239:286 (Aug. 19) 1948.
6. Eagle, H.: Speculations as to the Therapeutic Signifi-
cance oc the Penicillin Blood Level, Ann. Int. Med., 28:260
(Feb.) 1948.
7. Amberson, J. B., and Stearns, W. H.: Streptomycin in
the Treatment of Tuberculosis, Ann. Int. Med., 29:221 (Aug.)
1948.
8. Dubos, R. J.: The Effect of Specific Agents Extracted
from Soil Micro-organisms upon Experimental Bacterial Infec-
tions, Ann. Int. Med. 13:2025 (May) 1940.
9. Ehrlich, J., Bartz, Q. R., Smith, R. M., Joslyn, D. A.,
and Burkholder, P. R.: Chloromycetin, a New Antibiotic from
a Soil Actinomycete, Science, 106:417 (Oct. 31) 1947.
10. Pincoffs, M. C., Guy, E. G., Lister, L. M., Woodward,
T. E., and Smadel, J. E.: The Treatment of Rocky Mountain
Spotted Fever with Chloromycetin, Ann. Int. Med., 29:656
(Oct.) 1948.
11. Woodward, T. E., Smadel, J. E., Ley, H. L., Jr., Green,
R., and Mankikar, D. S.: Preliminary Report on the Bene-
ficial Effect of Chloromycetin in the Treatment of Typhoid
Fever, Ann. Int. Med., 29:131 (July) 1948.
12. Ross, S., Schoenbach, E. B., Burke, F. G., Bryer, M. S.,
Rice, E. C., and Washington, J. A.: Aureomycin Therapy of
Rocky Mountain Spotted Fever, J.A.M. A., 138:1213 (Dec. 25)
1948!
13. Finland, M., Collins, H. S., and Paine, T. F. Jr.: Aureo-
mycin, a New Antibiotic, J.A.M. A., 138:946 fNov. 27) 1948.
14. Spink, W. W., Braude, A. I., Castaneda, M. R., and
Goytia, R. S.: Aureomycin Therapy in Human Brucellosis
Due to Brucella Melitensis, J.A.M. A., 138:1145 (Dec. 18)
1948.
Meet Our Contributors
Baxter A. Smith, Jr., Minneapolis, Minnesota, was
graduated from the University of Minnesota in 1937;
specializes in Urology; member, American Urological
Association, Twin City Urological Society; Alpha Omega
Alpha, Diplomate, American Board of Urology.
H. Hoffman Groskloss, M.D., Minneapolis, Minnesota,
was graduated from Yale University in 1935; specializes
in Obstetrics and Gynecology; Instructor, University of
Minnesota and Minneapolis General Hospital; Head of
the Obstetrics and Gynecology Department, St. Barnabas
Hospital; member, Minneapolis Academy of Medicine,
Minnesota Society of Obstetrics and Gynecology; diplo-
mate, American Board of Obstetrics and Gynecology,
National Board of Medical Examiners.
Richard V. Ebert, M.D., Minneapolis, Minnesota, was
graduated from the University of Chicago Medical
School in 1937; specializes in Internal Medicine; mem-
ber, American Society for Clinical Investigation, Society
of Experimental Biology and Medicine; Chief of Medi-
cine, Veteran s Administration Hospital, Associate Pro-
fessor of Clinical Medicine, University of Minnesota.
Clayton G. Loosli, M.D., Chicago, Illinois, was gradu-
ated from the University of Chicago School of Medicine
in 1937; specializes in Infectious Diseases and Internal
Medicine; Director, Student Health Service and Associate
Professor of Medicine, University of Chicago; member,
Central Society for Clinical Research, American Society
for Clinical Investigation, American Epidemilogical Soc-
iety, American Public Health Association; Consultant to
the Secretary of War, 1941 to 1943; U. S. P. H. Service
grants for the study of epidemiology, etiology, and patho-
genesis of respiratory tract infections.
John W. Brown, M.D., Madison, Wisconsin, was grad-
uated from the University of California in 1935; special-
izes in Internal Medicine; Professor of Preventive
Medicine and Director of Student Health, University of
Wisconsin; member, American Federation for Clinical
Research, American Society for Clinical Investigation,
Western Society for Clinical Research, American Public
Health Association, Central Society for Clinical Research,
American Association for the Advancement of Science,
Alpha Amega Alpha and Sigma Xi.
July, 1949
255
The
(t\\y
LANCET
Official Journal of the American College Health Association, Great Northern Railway Surgeons' Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J . C. Fawcett
Dr. A . R. Foss
Dr. C. J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H Long
Dr. O. J . Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H. Moore
Dr. Martin Nordland
Dr. K. A Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E L. T uohy
Dr. M. B Visscher
Dr. R. H Waldschmidt
Dr. O. H. Wangensteen
Dr S Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Liebeler, President
Dr. W. A. Wright, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
ADVISORY COUNCIL
Northwestern Pediatric Society
Dr. L. G. Pray. President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons* Association
Dr. W W Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O Hanson, Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. HofFert, Recorder
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Editorial
SINCE HIPPOCRATES
Again, the Annual Minneapolis Academy of Medicine
issue of the Journal Lancet goes to press. It almost went
without the sigil of the incoming president, but our
newest wonder-drug, Aureomyecin, has reduced the fever
and brought the wonderful associated Cinderella-like
flights of fancy back to the level of the pumpkin, and
somewhat hollow.
In the board of convalescence, however, I picked up
a book which came from the library of the late Dr.
Thomas Roberts and wrote out my fever on the re-
discovery of the works of Hippocrates. The volume is
yellow with age and the title page carries an inscription
of some local interest, "Merry Christmas, ’01, Dr. James
E. Moore.” The translation was sponsored by the Syden-
ham Society and edited by Dr. Francis Adams, surgeon.
It is a scholastic masterpiece and one wonders in the
present days with the demephis of classes, studies if
modern scholars could redraw the fine shades of mean-
ing noted in the texts and footnotes.
Medical writings and records are a peculiar form of
literature, and the flux and changing thought as to the
nature of diseases and treatment, diagnosis and cognosis,
could be a science in itself. Galen’s commentaries on the
work of Hippocrates are in marked contrast to Dr.
Adams’ and to the modern practitioner the comments
of Dr. Adams are definitely dated by the advances since
that time. One is appalled by the mass of information on
record and it should humble one’s attitude before at-
tempting to add to the pile. In modern literature, many
things are rediscovered; very little really new is added.
The Minneapolis Academy of Medicine has had a
very successful season under the able guidance of retiring
president, Dr. Thomas J. Kinsella. He has set high
standards which are a challenge to those who are to
follow. — Cyrus Owen Hansen
HOW THE MINNEAPOLIS WAR MEMORIAL
BLOOD BANK CAN SERVE HOSPITALS,
PHYSICIANS AND THE PUBLIC
Ever since William Harvey first announced his ob-
servations on the circulation of blood in 1616, and
Richard Lower, the English physiologist, performed his
first successful transfusion on animals in 1665, and
Jean Baptiste Denis in 1667 transfused the blood of
a lamb into a young man, the concept of blood as a
therapeutic agent has persisted through the years.
It was not, however, until Landsteiner and his stu-
dents, Decastello and Sturli, at the turn of the century
*Read at the Upper Midwest Hospital Conference, May 28,
1949.
256
The Journal-Lancet
discovered the four blood groups, that blood transfusions
became safe and practicable. In recent years blood ther-
apy has become increasingly important in medical prac-
tice.
With the improvement of methods for blood storage,
many hospitals have found it to their advantage to estab-
lish blood banks. In order to have all types of blood
more readily available to patients, however, a new for-
ward step has been taken by some communities. Central
blood banks have been established in many cities of this
country and most of these have proven to be so success-
ful that there appears to be a definite trend toward this
cooperative venture in many of the larger cities. Any
city the size of Minneapolis would not be meeting its
responsibility to the people of the community if there
were not made available a large reserve of blood equal
to the needs of the sick and injured in normal times and
in times of disaster. Some of the most successful of
such banks have been established in Seattle, San Fran-
cisco, Denver, New York, Miami, Phoenix, Dallas, Fort
Worth, Milwaukee, and in some other cities.
The need for centralization of blood banking facilities
was recognized early in Minneapolis. In 1940 the Hen-
nepin County Medical Society began to discuss the possi-
bilities of establishing a central community blood bank
in Minneapolis. Fraternal orders and labor groups in
Hennepin County became concerned, and the Junior
Chamber of Commerce sought ways and means of im-
proving community blood transfusion programs and sup-
ported the idea as one of their community projects. By
consistent, untiring effort, the project advanced through
the various organizational phases. A Board of Directors,
consisting of hospital administrators, physicians, county
representatives of business, labor, churches, Jaycees,
LJniversity, State Health Department and other organi-
zations, was organized. The work was largely directed
by an executive committee elected by the Board. A cam-
paign for funds was successfully conducted and a beauti-
ful building was purchased at 1914 LaSalle Avenue, a
location in rather close proximity to the hospitals in
Minneapolis. This building was remodeled and eqiupped,
and on Armistice Day, November 11, 1948, it was dedi-
cated as a memorial to those servicemen of World War
II who did not return. I think it stands as a great trib-
ute to the vision and deep insight of the planners of
this worthy memorial. The Minneapolis War Memorial
Blood Bank began drawing blood on December 1, 1948.
The Minneapolis War Memorial Blood Bank is set
up on a community level and is incorporated as an in-
dependently-operating, policy-making, non-profit institu-
tion. As a general proposition the bank does not use
professional donors. Blood is neither bought nor sold
and publicity is resorted to as little as possible. This is
on the grounds that a promiscuous appeal to the public
for blood donors will not produce satisfactory results.
Instead, the Minneapolis War Memorial Blood Bank
concentrates on having the blood replaced by relatives
and friends of the recipient, which results in a steady
supply of blood. This supply is further augmented by
donor clubs, group insurance and other methods. Thus,
by working together, doctors, hospitals and the blood
bank staff succeed in obtaining a sufficient supply of
blood to insure the maximum welfare of a patient who
needs a transfusion, and at the same time easing the
financial burden on the family. The success of this bank
will always depend upon the complete cooperation among
the hospitals, doctors and patients.
I think it is important to emphasize the fundamental
principle that the centralization of all blood sources and
laboratory procedures is the first essential toward a well
functioning blood bank. A blood bank having the larg-
est supply of blood and reagents, and well qualified tech-
nical staff especially trained in serology and immunology,
and directed by a full time person, is far better equipped
to perform satisfactory service than are individual hos-
pital laboratories.
How, then, may The Minneapolis War Memorial
Blood Bank best serve hospitals, physicians, and the
public? It is quite obvious that the first and foremost
objective of any blood bank is to have on hand sufficient
blood of all types to enable the blood bank to honor
without delay the requisition of any physician at any
time. The physician should be able to write blood requi-
sitions as freely as he writes prescriptions, and with the
same confidence that his blood requisitions will be as
readily filled.
This objective is met by The Minneapolis War Mem-
orial Blood Bank in several ways. First of all, the bank
has not only been able to maintain a supply of blood
in its own refrigerators, but has been able to stock the
refrigerators of the hospitals it serves with a constant
supply of the various types of blood. This is accom-
plished largely through its program of donor replace-
ment. By requiring that a friend or relative of each
patient replace the blood used by him, unit for unit with-
out regard to type, the blood bank has been able to main-
tain a constant supply of blood and plasma equal to the
needs of the sick and injured within the area served by
the bank, and also maintain a comfortable reserve for
emergencies. This replacement of blood by relatives and
friends of the recipient brings a steady supply of blood
into the bank.
It should be pointed out that there is no charge made
for blood received by any patient. There is, however, a
modest service fee of $6.00 per unit of blood or plasma,
which covers the cost of typing, determination of Rh,
serology tests and other services. In cases where the serv-
ice fee cannot be paid by the patient, the cost is taken
care of by the blood bank. No request for blood or
blood bank service is ever refused because the patient
is unable to pay the modest laboratory fee. In order to
encourage the patient to have his friends or relatives
replace the blood in the bank, there is, besides the lab-
oratory fee, a deposit charged to the patient’s bill for
each unit drawn until his donors replace the blood to
the bank, at which time the deposit is refunded in full
to the patient. It is essential that the patient arrange for
replacements rather than forfeit this penalty deposit.
There is, however, a gap which always exists in the
blood bank between the actual output of blood and re-
July, 1949
257
placements. This is so because of the very nature of a
blood bank. Since blood is perishable and can be kept
in storage only a short time, it is necessary to collect
enough blood in excess of what is actually used to re-
place blood that becomes outdated, and also to back up
abnormally large withdrawals from the bank of any one
particular type of blood. This gap is taken care of in
the Minneapolis War Memorial Blood Bank by means
of donor group plans, group insurance, and other meth-
ods. Indeed, it was the Post Office Group and the Tay-
cees who initiated the setting up of "pools” in the blood
bank to insure their membership of blood for transfu-
sions with the least inconvenience to the group. Under
this plan members of these and other organizations de-
posit blood in the bank and build up a credit account
for the group. This is in the nature of an insurance
premium. As long as the group continues to send its
allotted number of blood donors, every member of the
group is insured — that is, the credit held at the blood
bank in the name of the group will be applied to any
members of the group who may later need transfusions.
If it is the wish of the group, its credits may also be
transferred to those in the immediate families of its
members.
Although an adequate supply of blood must always
Ibe available in a blood bank, it is, nevertheless, basically
unsound to drain the community of more blood than is
absolutely necessary. In the Minneapolis War Memorial
Blood Bank no blood is ever wasted, for when blood be-
comes outdated, the plasma is drawn off, treated by ultra
violet irradiation, and is made ready for patients where
such therapy is indicated. The outdated cells which
remain are used for extraction of the new Rh hapten.
Another invaluable service of the Minneapolis War
Memorial Blood Bank to hospitals, physicians, and the
public is the standardization of techniques and pro-
cedures by the employment of well trained specialists
in the community blood bank. It is only reasonable to
expect that with such an advantage fewer errors will
result in technical procedures which, in turn, will mean
better treatment for the patient.
Furthermore, this blood bank fosters and promotes
the exchange of ideas and material and the dissemination
of information relating to blood banking and its tech-
nical methodology by education, publicity and research.
Here we have a central blood bank and laboratory to
which technicians from laboratories throughout the state
and in adjoining states can come and receive refresher
(training in proved techniques and procedures of blood
bank work. This service is cordially offered to labora-
tory personnel in hospitals of this region.
With the expanding roll of blood transfusions in med-
ical practice, the problem of obtaining whole blood for
transfusion purposes in small rural communities becomes
one of increasing importance. The Minneapolis War
Memorial Blood Bank can be of help to hospitals located
in smaller communities in Minnesota and nearby states.
This may be done in one of three ways.
(1) By setting up satellite blood banks. This sort of
bank would be set up in a community in which there
are two or more hospitals. Such a branch bank could
function on the same basis as the blood bank in Minne-
apolis, and would be set up as an independently-operat-
ing and policy-making non-profit institution in close
proximity to the hospitals in the community. As is the
practice in the bank here, blood could be kept on hand
at all times in all hospitals served by these banks. The
Minneapolis War Memorial Blood Bank would be will-
ing to aid in establishing such subsidiary banks in com-
munities of th;s region should we be invited to do so
and if we would have the full backing of the medical
society and civic groups within the community. Such a
satellite bank would be sustained and enhanced by the
mother bank in times of emergency when abnormally
large amounts of blood of a certain type would be need-
ed at any one time. It is also conceivable that the Min-
neapolis bank might have occasion to call upon the
satellite bank in the exchange of blood of different types,
and thus maintain a more balanced distribution of the
bloods that are needed in the communities. It must be
remembered that the larger the pool of blood from
which to draw, the more adequate will be the blood sup-
ply for the people we serve. By pooling our blood re-
sources, our techniques and our procurement efforts, we
will become ever more efficient and adequate.
(2) By Supplementary Service. Another way in which
the Minneapolis War Memorial Blood Bank may be of
service to hospitals in outlying communities where blood
banks are already established is on a supplementary
basis. It is important to know that the central blood
bank located here can cooperate both in normal times
and in times of disaster with existing hospital blood
banks in outlying communities. Perhaps the most recent
instance of such cooperation in disaster was in Texas
City, in which the William Buchanan Blood Bank,
located in Dallas, because it was organized and function-
ing, was able to supply all the blood necessary to the
disaster area. This blood bank collected the blood, did
the serology, typing and Rh testing, and sent the blood,
together with pilot tube and transfusion set, to the John
Sealy Memorial Hospital in Galveston, where the cross-
matching and transfusions were done.
A central community blood bank such as ours must,
of course, be prepared to expand quickly and supply
blood in times of disaster; but during normal times there
are often emergencies which call for blood in such
amounts as to tax the capacity of hospital blood banks
beyond their ability to supply the blood. It is the earnest
desire of the board and administration of the Minne-
apolis War Memorial Blood Bank to assist in such
emergencies and strengthen hospital blood banks in
smaller communities.
(3) By assisting to establish rr walking blood banks”.
A third type of service is offered by the Minneapolis
War Memorial Blood Bank to those small rural com-
munities which, because of the infrequent calls for blood,
have no blood bank in their hospitals. In such commu-
nities blood cannot be maintained in a constant, adequate
supply in a local blood bank. Nevertheless, the occa-
sional need for blood may be acute.
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The Journal-Lancet
We believe there is a practical solution to this prob-
lem and that the bank in Minneapolis can render a
definite community service in helping to solve it. I refer
to a "walking blood bank” for these communities,
wherein each adult person in the community would have
his blood typed, Rh tested, and a serology test done.
The plan is rather simple. It would, however, require
a bit of organizing to set it up in the community. First
of all, there must be a local sponsoring group such as
the Junior Chamber of Commerce, the American Legion
Post, or some other community group. This group would
carefully organize the community and make plans for
obtaining specimens for typing, Rh determination, and
serology tests. Although the details would be worked
out by the local sponsoring group, the blood bank could,
nevertheless, assist in an advisory capacity and could
actually send personnel to the community according to
previous arrangements to draw blood specimens, which
could be brought back to the laboratories of the blood
bank for blood grouping, Rh determination, and serology
tests.
The benefits of such a program would far outweigh
the time and cost, which cost would be nominal and
could be defrayed by the local sponsoring group or
hospital.
The security which such a program would provide
against possible blood needs is invaluable. Individuals
of known blood group and Rh type in the community
could be called upon as donors when blood is needed for
transfusions. Furthermore, in such a program the com-
munity would be to a large degree independent of any
outside agency. In times of emergencies or disasters,
however, they would still have the opportunity of calling
on the Minneapolis War Memorial Blood Bank for
additional help.
Another service which can best be furnished by large
central community blood banks and is now being offered
by the Minneapolis War Memorial Blood Bank is that
of Rh consultancy, as well as consultancy service in
genetic studies in families where Rh and other blood
factors are concerned, non-paternity service, and other
special problems. Obstetricians, pediatricians, and doc-
tors in general practice may want to be apprised of this
service.
The Minneapolis War Memorial Blood Bank will
shortly be prepared to offer still another service to lab-
oratories in this area. There will be available for distri-
bution soon, high quality anti-A and anti-B blood group-
ing sera and Rh typing sera. You may be interested to
know that the funds obtained from consultancy service
and the sale of antisera will be turned directly into the
research department of this blood bank, in which will be
conducted studies of problems connected with blood
groups, Rh, Hr, and other hereditary factors in the
blood. Thus will be created a beneficent cycle which
will function for the help and blessing of the people
we serve.
G. Albin Matson, Ph.D.,
Director, Minneapolis War
Memorial Blood Bank, Inc.
News Items
South Dakota
The 68th annual meeting of the South Dakota State
Medical Association was held the end of May at
Yankton. Dr. William H. Saxton, Huron, was chosen
president to succeed Dr. John L. Calene, Aberdeen.
Dr. C. E. Robbins has taken the position of President
elect, while Dr. L. J. Pankow, Sioux Falls, was elected
vice president, and Dr. H. Russell Brown, Watertown,
was named speaker of the house.
Dr. F. W. Freyberg became the first Mitchell man
to become a member of the South Dakota State Med-
ical Association Fifty-Year Club. He was presented the
award at the annual state medical meeting. Dr. William
D. Farrell, Aberdeen, was also presented an award by
the state association for his fifty years of service in
medicine.
Dr. R. L. Ferguson, professor of pathology of the
University of South Dakota Medical School, has been
awarded membership in the American Society for Ex-
perimental Pathology. Election to membership is based
on research, training and general ability.
Dr. A. J. Miller of Aberdeen assumed duties as resi-
dent pathologist at St. Luke’s hospital in July.
Dr. C. F. Gutch of the Pierre Clinic left this month
for training in internal medicine at the U. S. Veteran’s
Administration Hospital in Lincoln, Nebraska.
North Dakota
The North Dakota State Medical Association formed
this year the Fifty-Year Club. The new group met
for the first time in Minot at the close of the state
medical convention.
One woman, Dr. Fannie Dunn Quain, Bismarck,
retired, who received her degree in 1898, is included in
the group of 19 eligible members.
Oldest doctor, in point of service, is Dr. F. N. Bur-
rows, Bathgate, who received his degree in 1885. Others
in the group are Drs. W. H. Bodenstab, Bismarck, 1893;
R. D. Campbell, Grand Forks, 1893; J. E. Countryman,
Grafton, now of Arch Cape, Oregon, 1893; A. B. Field,
Forest River, 1891; W. A. Gerrish, Jamestown, 1896;
A. T. Horsman, Devils Lake, 1890; C. S. Jones, Willis-
ton, 1896; J. G. Lamont, Grafton, 1895; A. W. Mac-
Donald, Valley City, 1897; O. A. Maercklein, Mott,
1897; E. P. Quain, formerly of Bismarck and now at
Eugene, Oregon, 1898; N. O. Ramstad, Bismarck,
1899; Olaf Sand, Fargo, 1897; J. F. Timm, Makoti,
1895; G. M. Williamson, Grand Forks, 1895; J. W.
Bowen, Dickinson, 1898; W. F. Sihler, Devils Lake,
1898.
July, 1949
259
Dr. E. P. Quain, Eugene; Dr. Bodenstab and Dr.
Fannie Dunn Quain of Bismarck, and Dr. Sihler of
Devils Lake were elected to honorary membership in
the state association by the house of delegates.
Dr. L. J. Hill has left Bottineau for St. Louis Uni-
versity where he will complete his remaining two year
study toward certification as a specialist in orthopedic
surgery.
Dr. Roy Eldred of the University of Minnesota and
formerly a member of the Cayuna Range Clinic at
Crosby-Ironton, Minnesota, is now associated with Dr.
Malvey in Bottineau.
Dr. L. J. Alger, oculist of Grand Forks, North Da-
kota, has recently purchased a Beechcraft Bonanza Air-
plane. Dr. Alger has been flying for the past seven years
and finds flying his own plane a time saver in attending
the monthly meetings of the Minneapolis Academy of
Ophthalmology and Otolaryngology.
Dr. and Mrs. H. Milton Berg of Bismarck have re-
cently returned home after a three month’s tour of
European medical centers. Dr. Berg is the roentgenolo-
gist for the Quain-Ramstad clinic in Bismarck.
Dr. Richard L. Varco of the University of Minnesota
was the speaker for the monthly meeting of the Stuts-
man County Medical Society which met in Jamestown.
Dr. Graham A. Kernwein, Dr. A. L. Cameron and
Dr. Paul J. Breslich of Minot attended the American
Medical Association meeting this past month in Atlantic
City. At the meeting of the American Association for
the Surgery of Trauma which met the week prior to
the A.M.A. meeting. Dr. Graham delivered an address,
"Surgery of the Spine.”
The following doctors have joined the North Dakota
State Medical Association: W. A. Craychee, Mandan;
Phillip Blumenthal, Mandan; C. A. Bush, Beach; W.
R. Enders, Hazen; R. C. Turner, Grand Forks; William
C. Hurley, Minot; and Lowell E. Boyum, Harvey.
The Cass County District Medical Society and the
Richland County Medical Society have merged. The
society is known as the First District Medical Society
and has the following officers: Dr. C. O. Heilman,
Fargo, president, and Dr. J. H. Bond, Fargo, secretary.
Dr. H. B. Huntley, a Cass county physician for years,
was honored by the residents of Kindred and Leonard
at an out door service. Dr. Huntley has served these
communities for forty years.
Dr. James D. Cardy of Alberta, Canada, a specialist
in pathology will join the North Dakota Medical staff
on July 1. In addition to teaching at the school of
medicine, Dr. Cardy will have the duties of extending
pathological services to North Dakota Hospitals, de-
veloping a modern laboratory for tissue diagnosis and
holding clinics to aid in early detection of pathological
diseases, especially cancer.
Minnesota
Dr. F. W. Hoffbauer of the University of Minnesota
addressed the Range Medical Society at their monthly
meeting in May.
The center for continuation study presented a three
day cancer course for physicians in Minnesota and
North Dakota. The guest speakers were Dr. Lauren
Ackerman of the department of surgery, Washington
University, St. Louis, and Dr. David P. Anderson of
the Austin Clinic.
Dr. B. O. Mork, Jr., has left the Worthington Clinic
after 17 years as a staff member to enter the public
health service.
Dr. Edgar V. Allen of Rochester was elected vice
president of the American Heart Association at the
association’s twenty-fifth annual meeting just concluded
in Atlantic City. His term of office will be for the
1950-51 term.
A $500 scholarship to be awarded annually to a Con-
cordia senior who plans to become a doctor has been
provided by Dr. B. T. Bottolfson, Moorhead physician
for over 30 years. It will be known as the Emma Nor-
bryhn scholarship. This year’s award goes to Miles Efte-
land of Erskine, Minnesota. He will enter either North-
western or Minnesota Medical Schools in September.
Outstanding work in the clinical fields of medicine
and surgery at the University of Minnesota Medical
School won John K. Meinert, 22, senior from Winona,
the 1949 Southern Minnesota Medical Association
award. Dean Harold S. Diehl of the University Med-
ical Sciences presented the top honor to Meinert.
Dr. Robert A. Stoy is now associated with Dr. R. V.
Fait and Dr. D. L. Johnson in the practice of medicine
in Little Falls. Dr. Stoy has recently been at LaFayette,
Indiana.
A Duluth pathologist, Dr. Arthur H. Wells, was
elected to the presidency of the Minnesota Society of
Clinical Pathologists at its meeting in St. Paul. The
session was held in conjunction with a testimonial dinner
for Dr. E. T. Bell, professor of pathology, University
of Minnesota School of Medicine. Dr. Wells is in
charge of the laboratory department at St. Luke’s hos-
pital.
Dr. Howard K. Gray, head of a section in surgery
at the Mayo Clinic, received a doctor of science degree
at the Lafayette college commencement exercises.
Seven new members have been admitted to the med-
ical staff of Glenwood Hills Hospital, it was announced
by Mrs. Stanley V. Hodge, chairman of the board of
trustees. All the new staff members have been certified
to practice by the American Board of Psychiatry and
Neurology. Their appointment brings the hospitals’
medical staff to nineteen members. New members are
Drs. Eric Kent Clarke, George M. Cowan, Stanley G.
Law, Zondal R. Miller, Leonard A. Titrud, David S.
Thorsen and Martin Sukov.
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The Journal-Lancet
Obituaries
Walter C. Popp, M.D., Rochester, Minnesota, died
June 4 of a heart attack. He was 47 years old.
Dr. Popp was educated at St. Vincent College and
the University of Pittsburgh where he received his
doctor’s degree in 1929. He entered the Mayo founda-
tion in 1930 and remained on the staff as an associate
professor until his death.
Benjamin F. Swezey, M.D., 75, Buffalo, Minnesota,
died June 2 in Minneapolis.
The pioneer physician was born in Nebraska in 1873
and took his medical training in Iowa. He graduated in
1903 from the College of Physicians and Surgeons,
Keokuk, Iowa, which since has been combined into the
State Medical College of Iowa. He then practiced with
his brother in Iowa until he came to Minnesota in 1906.
Dr. Swezey practiced in Nassau, Lac qui Parle county,
and in Bellingham until 1917 when he moved to Buffalo.
There he remained in active practice until his death.
Ignatius J. Murphy, M.D., St. Paul radiologist died
June 2 at 64.
A leader in public health, Dr. Murphy was director
of the Murphy laboratories. He served as a consultant
in roentgenology to doctors and hospitals throughout the
Northwest and specialized in the treatment of cancer.
He was former health officer of St. Louis county,
executive secretary of the Minnesota Public Health
Association, president of the Minnesota Sanitary Con-
ference and former editor of the Minnesota Health
Journal.
He held memberships in the Hennepin County Medi-
cal Society, Radiological Society of North America,
Minnesota Pathological Society and American Academy
of Physicians.
James S. Gilfillan, M.D., 81, of St. Paul, died June
13. Until his retirement in 1938, Dr. Gilfillan practiced
internal medicine in St. Paul and taught at the Univer-
sity of Minnesota medical school.
Lyle C. Bacon, M.D., St. Paul physician for 50
years, died June 4 at the age of 83. Dr. Bacon was
professor of obstetrics and gynecology at Hamline Medi-
cal school until it merged with the University of Minne-
sota.
John G. Ericson, M.D., 81, died in Minneapolis in
May. Born in Sweden, he lived in Minneapolis for 66
years. An eye, ear, nose and throat specialist, Dr.
Ericson was associated in practice with his son at the
time of his death.
Class ified A dve rtisements
FOR SALE
Shock-proof fluoroscopic X-Ray unit with tilt-table,
complete with all accessories. Address Bessessen, 1406
West Lake Street, Minneapolis, LOcust 9097.
WANTED
Hospital superintendent, X-Ray and Laboratory Tech-
nician, Nurses for New 20-bed community hospital to
be opened in August, 1949. Write Greenbush Community
Hospital Association, Greenbush, Minnesota.
FOR SALE
Physician’s office and home combination. Good loca-
tion for general practice. 3 20 East Main Street, Anoka,
Minnesota. Phone 121.
POSITIONS OPEN
Two positions will be available July 1, 1949, for second
year interns at St. Joseph’s Hospital, St. Paul 2, Minn.
Write: Superintendent.
POSITION OPEN
One year accredited residency in Internal Medicine
will be available at St. Joseph’s Hospital, St. Paul 2,
Minnesota.
RESIDENT PHYSICIAN
An opening for two resident physicians on April 1
and July 1, 1949. Mixed residency, excellent preparation
for general practice. Salary $300 a month and mainte-
nance or $300 a month plus three room apartment.
Address inquiries Administrator, St. Luke’s Hospital,
St. Paul, Minn.
FOR SALE
Maico Audiometer in perfect condition, used only by
Maico of Fargo and guaranteed by them. $150, F.O.B.
Fargo. Write Student Health Center, N. Dakota Agric.
College, Fargo, N. Dak.
PRACTICE FOR SALE
$25,000 cash practice for sale in northwest. Must have
some cash and balance paid out of practice. Require best
references and willingness to work. Write Box 884, The
Journal-Lancet.
FOR SALE
Hamilton "Hometone” office furniture. Excellent con-
dition. Instrument cabinet. Treatment cabinet with elec-
tric sterilizer. Waste receiver. Stool. Examining table
with removable arm rest. Will sell for about half price.
Box 886, Journal-Lancet.
WANTED
Full time student health physician in well known mid-
western junior college. Paid on twelve months contract,
school in session nine months. Good salary, many other
benefits. Available Sept. 1st. Box 887, Journal-Lancet.
ASSISTANCE AVAILABLE
Woodward Medical Personnel Bureau (formerly Aznoes
— Established 1896) have a great group of well trained
physicians who are immediately available. Many desire
assistantships. Others are specialists qualified to head
departments. Also Nurses, Dietitians, Laboratory, X-Ray
and Physiotherapy Technicians. Negotiations strictly
confidential. For biographies please write Ann Wood-
ward, Woodward Medical Personnel Bureau, 185 North
Wabash, Chicago.
Stromal Endometriosis
William C. Keettel, M.D.,* James G. Lee, M.D.,* John H. Randall, M.D.*
Iowa City, Iowa
The entity known as stromal endometriosis or "inter-
stitial endometrioma” was first described by Casler1
in 1930 in a woman in whom overgrowth of the endo-
metrial stroma predominated to the point of strangling
the glandular elements. Frank,2 in 1932, described a
similar case although he did not attempt to classify it
other than as "fibromyosis”. Present-day concepts of the
entity were most completely formulated by Goodall 3
in 1937.
Goodall presented 14 cases of "interstitial endometri-
osis” in which stromal cells predominated to the exclu-
sion of glandular elements. He pointed out that this is
essentially a benign disease in which the interstitial stro-
mal cells have grown vicariously beyond the normal
bounds of the endometrium. In the majority of cases,
benign penetration occurs, the extrauterine growth being
a true lymphatic extension with the line of continuity
from the parent growth well maintained. The tumor
grows by displacement of normal structures after pene-
tration of lymph channels.
Grossly, the uterine lesion may present one of sev-
eral pictures. One of the earliest changes consists in
moderate enlargement of the uterus due to thickening
of the uterine wall. When sectioned in the fresh or
unfixed state, the myometrium appears coarse, with mul-
tiple small rounded elevations. Under traction, these
bodies stretch like rubber bands. Cut surfaces of fixed
tissue show discretely outlined rounded, yellowish areas
resembling brain tissue. Occasionally there are peculiar
polypoid masses extending into the uterine cavity. The
peritoneal lesions, if they occur, are demonstrated by
small round masses that are yellowish on cut surface.
*Department of Obstetrics and Gynecology, State University
of Iowa.
The microscopic features of stromal endometriosis are
fairly constant and the chief difficulty in diagnosis is the
relative infrequency of the disease. The endometrium
is unaffected, but the myometrium is infiltrated with
stromal cells, particularly along blood and lymphatic
channels. This tissue consists entirely of stromal cells
with occasional mitoses. Silver stains demonstrate the
fibrils surrounding the cells in a circular or basket weave
pattern like that in normally placed endometrial stroma.
With hematoxin and eosin, the cells themselves are
spindle-shaped or round and contain deeply stained vesi-
cular nuclei.
Numerous endothelial lined vascular channels devoid
of erythrocytes are observed. Many of them are partly,
but never completely, filled with tongue-like extensions
of stromal cells. In addition, many blood vessels with
well defined walls are observed throughout the tissue.
In April, 1948, a patient with stromal endometriosis
stimulated our interest in the condition. I. K., 48-3932,
a 44-year-old gravida 5, para 5, entered the State Uni-
versity of Iowa Hospitals complaining of a bloated feel-
ing, fatigue, and increasing constipation. The menstrual
history was normal. There was slight ankle edema,
three pound weight loss in the past six months, and poor
appetite.
Physical examination revealed a thin patient in good
physical condition. The abdomen was moderately dis-
tended with fluid and numerous nodular masses were
felt throughout the lower quadrants. The liver edge
was palpable and smooth. The cervix was displaced be-
hind the symphysis. The uterus and adnexa could not
be identified from a 12x9 cm. fixed hard culdesac mass.
There was thickening in the left parametrium with en-
261
262
The Journal-Lancet
croachment on the rectum; the right parametrium was
fixed. Speculum examination showed a fungating mass
protruding through the posterior vaginal fornix.
Laboratory findings were normal except for mild hypo-
chromic anemia. The first vaginal smear was negative
for abnormal cells, but a second showed suspicious cells.
The chest was normal radiographically. The clinical im-
pression was carcinoma of the ovary with abdominal
carcinomatosis.
Biopsy of the vaginal lesion revealed endometriosis.
(See Fig. 1.) Prior to receipt of this report, the patient
had been referred to the Department of Radiology and
had received 1,800 roentgens (in air) to the paramet-
rium. Further studies were then instituted.
Fig. 1. Section of tissue which had penetrated through the
posterior fornix of the vagina. Shows dilated glands surrounded
by stroma. (Photomicrograph x 100.)
Barium enema showed an inconstant defect in the
proximal rectum beyond which no barium passed. The
roentgenologist diagnosed a pelvic mass exerting extrinsic
pressure on the rectum. Proctoscopic examination re-
vealed constriction of the rectum 2 inches (5.0 cm.)
above the anal orifice, while a mass of friable granular
tissue was seen 4 inches (10.0 cm.) above the orifice.
Biopsy showed endometriosis beneath the rectal mucosa.
Exploratory laparotomy was performed twelve days
after admission. On opening the abdomen, there was a
moderate amount of free fluid and numerous peritoneal
implants scattered over the visceral and parietal surfaces
from the pelvis to the diaphragm. The omentum was
studded with nodules. The uterus and adnexa were in-
corporated in a mass of dense adhesions and were not
identified as such. Since it was felt that the tumor could
not be removed, the abdomen was closed after several
biopsies were taken. Diagnostic curettage produced a
small amount of endometrium. The gross findings were
consistent with the diagnosis of abdominal carcinoma-
tosis. However, the histologic diagnoses were normal
atrophic endometrium (curettage) and abdominal stro-
mal endometriosis (Fig. 2). Despite the fact that no
other therapy was given, the patient’s postoperative con-
valescence was uneventful.
Fig. 2. Section of tissue taken from abdomen at time of
laparotomy. Relatively normal appearing stromal tissue is seen
and mesothelium is observed along the surface of the tissue.
Note numerous blood vessels. (Photomicrograph x 100.)
Two and a half months after laparotomy, examina-
tion revealed the abdominal mass undiminished in size;
the polypoid growths in the vagina were slightly smaller.
The patient was feeling well and the symptoms were
subsiding. She was seen again seven months after the
first admission. There were no complaints, except amen-
orrhea of six months’ duration. The abdominal masses
were perhaps slightly smaller, but the pelvic organs were
still fixed and the left parametrium infiltrated. The
polypoid masses in the posterior vaginal fornix had com-
pletely disappeared, but there was slight residual scarring.
Since Goodall’s publication of fourteen cases, there
have been twelve additional cases reported by Robertson
and co-workers,4 Miller and Tennant,0 DeCarle,6 and
others.' The majority of these reported patients were
in the childbearing age, but four were postmenopausal.
The principal symptoms mentioned were excessive bleed-
ing and abdominal pain. In the majority of cases the
pathologic process was confined to the uterus. How-
ever, in nine there was extra-uterine involvement. All but
six of these patients were treated by hysterectomy. Five
were irradiated because the involvement was so extensive.
Previous to Goodall’s recognition of this entity, the
microscopic diagnosis was most often fibromyoma with
sarcomatous degeneration. Most of his early cases were
subjected to laparotomy because of an abdominal mass
thought to be a fibromyoma. Clinically, these patients
did surprisingly well despite the histologic diagnosis and
the extension of the growth beyond the confines of the
uterus. Usually hysterectomy was the only treatment
necessary; in several patients with marked extension,
x-ray castration was employed with good results.
August, 1949
263
In hopes of finding other cases of stromal endometrio-
sis, all patients’ records with the diagnosis of sarcoma
of the uterus were reviewed. In eleven instances where
the patient was alive and well after two or more years,
Fig. 3. T issue obtained from same area as Fig. 2 which shows
the only glandular structure observed in abdominal biopsy.
(Photomicrograph x 200.)
the microscopic slides were reviewed. In none of these
sections was there histologic evidence of stromal endo-
metriosis. However, in light of more recent knowledge,
many of them would not now be diagnosed as sarcoma.
There is some evidence that adenomyosis and stromal
endometriosis may be variants of the same process and a
suspicion that this entity and external glandular endo-
metriosis may be related. However, the fact that stromal
endometriosis has been reported after the menopause
argues against any ovarian hormonal relationship.
This case was interesting because:
1. It brought this entity to the attention of the depart-
ment.
2. The extent of the abdominal stromal endometriosis
was greater than in other reported cases.
3. The finding of coexisting extra-uterine endometrio-
sis in the vagina and rectum is unusual.
4. Despite the inoperable nature of the lesion, x-ray
castration has brought symptomatic relief and re-
gression of the vaginal lesion.
5. The question still remains unanswered as to whether
the stromal or glandular elements, or both, respond-
ed to the castration dose of x-ray.
Bibliography
1. Casler, Dwight B.: Surg. Obst. & Gynec., 31:150, 1920
2. Frank, Robert F.: Am. J. Cancer, 16:1326, 1932.
3. Goodall, James R.: J. Obst. & Gynec. Brit. Emp., 47:13,
1940.
4. Robertson, Thomas D., Hunter, Warren C., Larson,
Chester P., and Snyder, Geo. A. C.: Am. J. Clin. Path., 12:1,
1942.
5. Miller, James R., and Tennant, Robert: Am. J. Obst. &
Gynec., 47:784, 1944.
6. DeCarle, Donald W.: West. J. Surg., 53:48, 1945.
7. Case Report of Massachusetts General Hospital: New
Eng. J. Med., 236:835, 1947.
MEDICAL SCHOOL SCHOLARSHIPS
A new program of scholarships, to start next fall, will be offered to undergraduate stu-
dents in the school of medicine at the University of Minnesota by the Minnesota Medical
Foundation, Dr. Owen H. Wangensteen, president of the foundation, announced.
The first such program to be established in the medical school, the scholarships will be
awarded annually by the foundation in amounts totaling $2,500. Individual grants will range
between $500 and $1,000.
Students who will be members of the sophomore, junior and senior classes in the fall are
eligible to apply for the scholarships, and application will be open from July 15 to Septem-
ber 1 for the coming school year.
The establishment of a scholarship program was authorized at a meeting of the board
of directors of the foundation a week ago, and Dr. Wesley W. Spink, professor of medicine
at the University, was named chairman of a committee to draw up plans.
"There has long been a great need for undergraduate medical scholarships. Many stu-
dents have had to take part-time jobs outside of school and it has been difficult for them to
devote the amount of time needed to their medical studies,” Dr. Spink said.
Other members of the committee which drafted the program were Dr. Howard Horns,
assistant dean of the medical school, and Dr. George N. Aagaard, director of postgraduate
medical education at the University and secretary-treasurer of the foundation.
264
The Journal-Lancet
Protruded Intervertebral Disc
Harold F. Buchstein, M.D.
Minneapolis, Minnesota
The clinical entity here under discussion is and has
been referred to by a number of terms: echondroma
or chondroma of the intervertebral disc, ruptured inter-
vertebral disc, herniated intervertebral disc, protruded or
protruding intervertebral disc, herniated nucleus pulpo-
sus, slipped disc or simply "disc.” It consists of a bulg-
ing or protrusion into the vertebral canal of a portion of
the intervertebral disc and is thus by definition a special
variety of intraspinal tumor. Although such protrusions
may occur at any spinal level, we will confine the present
discuss;on to such lesions at one or more of the lower
three lumbar levels, since these lesions provoke a charac-
teristic clinical syndrome, namely intractable sciatic pain.
Since organization of the neurosurgical service at this
hosp’tal on February 1, 1946, we have operated upon
one hundred patients in whom the presence of a pro-
truded intervertebral disc was postulated, suspected or
was to be excluded. Disc abnormality of some type was
found in 88 patients; two were found to have tumors
and ten were found not to have abnormal discs. Six of
this group were patients explored to exclude the presence
of disc protrusion prior to spinal fusion. A group of 43
patients from whom herniated discs (see below) were
removed was subjected to detailed analysis by Dr. C. K.
Olson for purposes of this report.
Historical
The intervertebral discs were long neglected by path-
ologists and clinicians. The classical studies of Schmorl
(1928) and Andrae (1929) called attention to hernia-
tions of the nuclear portion of the discs into the ver-
tebral bodies but made only passing mention of protru-
sion into the vertebral canal. From time to time neuro-
surgeons (Mixter, Adson, Elsberg, Dandy) encountered
and removed such lesions, usually while operating upon
presumed spinal cord tumors. They were described as
neoplasms of the discs and their true nature and fre-
quency were not appreciated.
The modern history of the intervertebral disc begins
with the reports of Mixter, Barr and Hampton from the
Massachusetts General Hospital in 1934. They were the
first to describe the true nature of lumbar protrusions,
point out their relationship to sciatica and describe
methods for their diagnosis and surgical treatment. Pres-
ently Love at the Mayo Clinic and many other neuro-
surgeons were reporting series of cases which rapidly
extended into the hundreds and literally staggered the
imagination of many physicians who were loath to be-
lieve that so common a lesion could so long have re-
mained undiscovered. Today the lumbar protruded disc
is generally recognized as the most frequent cause of the
sciatic syndrome.
Anatomy and Pathology
The structure of the intervertebral disc is relatively
simple. It consists of three parts: (1) Thin plates of
cartilage cover the intervertebral surfaces of the ver-
tebral bodies. (2) The annulus fibrosus, making up the
periphery of the disc, is composed of obliquely directed
bundles of fibers which bind together the adjacent ver-
tebral bodies and form a container for the central (3)
nucleus pulposus. This is the adult derivative of the em-
bryonic notochord and is a white, moist plastic, mucoid
appearing mass which is readily moldable. The inter-
vertebral disc is virtually avascular but has been shown
to contam numerous fine unmyelinated nerve fibers in
the dorsal (posterior) portion of the annulus fibrosus
and the overlying posterior longitudinal ligament.
The intervertebral disc gives the spine mobility and
compressibility, acting as a "shock absorber.” This latter
function is important in preventing the transmission of
sharp jolts from foot to head. It is obvious that the
discs in the lower lumbar region are subjected to a con-
siderable compressive force by the assumption of the
erect posture and to additional strains by almost any
sort of physical activity, such as lifting, carrying heavy
objects, twisting the trunk, etc.
Degenerative changes, in the form of dehydration and
loss of elasticity take place in the discs with increasing
age, and these changes are particularly marked in the
lower lumbar region. In certain individuals further
changes occur which give rise to the lesions here under
discussion. As observed at operation, several varieties of
lesion occur.
1. The posterior portion of the annulus fibrosus al-
though still unruptured may bulge or protrude into
the vertebral canal sufficiently to irritate or com-
press a spinal nerve root. It is difficult to distin-
guish the truly pathological from the extremes of
normal in this situation. Presumably when the
bulge occupies a well defined area it is pathological
whereas a broad and general bulging is probably
normal. Occasionally we have encountered cases
in which the structure of the vertebral canal was
such that a relatively minor bulge sufficed to cause
nerve compression. Lesions of this type were found
in approximately 40 per cent of our cases.
2. The classical situation is one in which a rent or
rupture has occurred in the posterior portion of the
annulus fibrosus and some of the tissue of the nu-
cleus pulposus has herniated through it forming a
discrete and well defined tumor mass. In most in-
stances this lies at one or the other lateral extreme
of the vertebral canal, in just such a position as to
lie in the path of the spinal nerve which is to
August, 1949
265
emerge from the vertebral canal through the inter-
vertebral foramen next below. That is, a protrud-
ing disc at the L4-5 interspace impinges upon the
fifth lumbar nerve root and a protruding lumbo-
sacral disc impinges upon the first sacral nerve root.
Depending upon the exact site of the herniation
and the contour of the vertebral canal (whose dor-
sal wall is composed of ligamentum flavum), one of
several things may happen to the nerve root: (1)
It may be trapped in the lateral gutter of the
canal, being compressed between the ligamentum
flavum laterally and superiorly and the herniate
disc medially and inferiorly. (2) It may be riding
over the crest of the herniating mass. (3) It may
be displaced medially.
In the second group of herniate discs, when the
bulging mass is opened into with a probe or knife,
there will follow in many instances the spontaneous
extrusion of the loose fragment of nuclear tissue
whose general appearance suggests that of a wad
of mechanic’s waste. In the others one or several
such fragments may be readily removed with a
forceps. The recovery of such a free fragment
establishes the diagnosis of herniated disc beyond
question. Herniated discs were found in approxi-
mately 60 per cent of our cases.
3. Occasionally, the free fragment will be found to
have escaped completely and to lie loose in the ver-
tebral canal. Such fragments may wander some
distance from the site of their origin.
4. Occasionally there will be found a huge herniating
mass arising from the center of the posterior aspect
of the disc and largely filling the vertebral canal.
Such herniations occur almost without exception at
the level of the disc between the third and fourth
lumbar vertebrae; they produce the symptoms of
a cauda equina tumor rather than those of herni-
ating disc.
5. In elderly individuals and about protrusions of
long standing there may be found a considerable
overgrowth of the borders of the adjacent vertebral
bodies, i. e., lipping. In such instances the protrud-
ing portion of the disc is usually firm and its con-
tents dry.
Patients may be found to have multiple protrusions
of the lumbar discs, either simultaneously or at some
interval of time. Such multiple protrusions are one
source of recurrence of symptoms after an initially suc-
cessful operation. In our series we encountered three
patients in whom two discs were pathological. Five other
patients had previously been operated upon elsewhere
presumably with the removal of protruded or herniated
discs at the same or other levels. Some authors have
reported a much higher incidence of multiple disc pro-
trusion, some as high as 30 per cent. I believe that these
figures are the result of regarding a pathological slight
protrusion which we would regard normal.
Symptoms
Protruded and herniated intervertebral discs occur
chiefly in young adults engaged in strenuous occupations.
The average age of the patients in our group was 35
years; all were male. In civil practice females constitute
about one third of operated cases. A survey of patients’
occupations shows that persons pursuing so-called seden-
tary occupation are by no means spared disc trouble.
This fact suggests that degenerative changes play a rela-
tively important role in the production of disc protrusion
and herniation.
Patients from whom a herniated intervertebral disc is
removed present clinical histories which are strikingly
similar in their essential details. The present discussion
will relate to herniations at the lower two lumbar levels,
i. e., L4-5 and LS, since these constitute about 95 per
cent of lumbar protrusions. In our surveyed group of
43 cases only one occurred at the third lumbar level,
i. e., between the third and fourth lumbar vertebrae.
An outstanding characteristic of the disc syndrome is
its prolonged and relapsing course. The first symptoms
relating to the lower back usually antedate those which
lead to the removal of the herniated disc by a consid-
erable time. In our series of cases the time intervals
varied from two months to 28 years and in approxi-
mately one third of the patients the interval was over
five years.
The first episode of back trouble recalled by most of
these patients was an attack of low back pain, either
midline or lateralized but not radiating beyond the gen-
eral vicinity of the sacro-iliac joint. In about half the
cases the patient related this to some unusual back strain,
such as heavy lifting, training in an obstacle course, falls
on the buttocks, etc. In the others the pain followed no
specific traumatic incident. But it may be recalled that
many occupations, such as farming, ammunition passing,
and working with a shovel, involve normally much activ-
ity which places severe stresses on the lumbar inter-
vertebral discs.
It should also be noted that the pain does not always
or even often follow immediately upon the traumatic
episode when there is one. More commonly the patient
may feel a sudden twinge of back pain but be able to
continue his activities, after a fashion, for the rest of
the day. The following morning upon attempting to
get out of bed the back may be found to be stiff and
any movement very painful.
These early attacks may confine the patient to bed or
limit his activities for a few days to a few weeks. Com-
monly they subside under no treatment other than rest
and limitation of activity. Taping of the lower back
and manipulative therapy (chiropractic, osteopathic) are
frequently credited by the patient with bringing prompt
relief.
The exact pathophysiology underlying such attacks
of pain is not known. It is assumed that they are due
to stretching or tearing of the annulus fibrosus and/or
the posterior longitudinal ligament.
266
The Journal-Lancet
Following such an initial attack of pain the patient
may go for many months or even years without further
trouble. More commonly, however, he has a succession
of similar episodes of "lumbago” or "sacro-iliac”. These
may follow any unusual exertion or may come on for no
apparent reason. A common experience is for the patient
to stoop over, feel a "catch” or "snap” in his lower back
and find it painful or even impossible to extend the
spine again.
Finally, after a few days or many years, the patient
develops the characteristic symptom of lumbar disc her-
niation, sciatic pain. This may develop as a shifting or
radiation of the low back pain or it may come on with-
out antecedent back pain during the current attack. It
may be precipitated by the same types of trauma as
were the former attacks of low back pain, i. e., move-
ments involving stooping, twisting and lifting. Or it
may appear for no assignable reason, e. g., the patient
may awaken and find it virtually impossible to get out
of bed because of pain.
The sciatic pain is typically confined to a single lower
extremity, but may shift from side to side in succeeding
attacks. The presence of bilateral sciatic pain suggests
the presence of a midline protrusion but should also en-
courage a careful search for other possible causes of
pain.
This sciatic pain is the result of irritation or compres-
sion of a nerve root by the herniated disc, i. e., it is a
mechanical mononeuritis. It possesses the general char-
acteristics common to all root pains. The pain follows
a consistent and specific course and does not wander
about; the patient can trace it out accurately on his limb.
Beginning in the buttock (often referred to as the
"hip”) it passes down the posterior aspect of the thigh
and the posterior or posterolateral aspect of the leg to
the ankle; at times it may extend into the foot, either
the heel, instep, or lateral border. During acute par-
oxysms of pain the pain will be felt along the entire
course. Most of the time it may be concentrated largely
in one region, as in the buttock or in the calf. Anything
which suddenly increases the tension or compression of
the nerve root will produce a sharp exacerbation of pain:
coughing, sneezing, jarring of the leg as in stepping off
a curb, straight leg raising.
Accompanying the sciatic pain are paresthesias in the
form of numbness, tingling or a "sleepy” feeling. This
may be described as being general throughout the leg
but is more often localized to discrete areas correspond-
ing to the dermatome of the nerve root being irritated.
In the case of the fifth lumbar nerve root this area in-
cludes the dorsum of the foot and the great toe; the
first sacral dermatome includes the lateral border of the
foot and the last two or three toes.
Related to the paresthesias is a feeling of coldness in
the foot complained of by some patients. Touching the
foot may show it to be actually cooler than its fellow.
As is so frequently true in cases of intraspinal tumors
of neoplastic character, these patients are prone to have
much pain while in bed at night. The positions of maxi-
mum comfort and distress vary greatly from patient to
patient, but a frequent complaint is that the sitting pos-
ture is the most uncomfortable. Such patients may be
seen standing in the reception room waiting to see their
physician.
Being mechanically produced, it is to be expected that
most patients will relate the severity of their symptoms
to the degree of their activity. Many learn to avoid cer-
tain movements because they know that they will almost
certainly be followed by distress. Careful management
may enable the patient to live with his disc fairly well.
Discogenetic pain is not related to changes in the
weather in as striking a fashion as is the pain of rheu-
matic afflictions. Nevertheless, there is a tendency for
some patients to suffer more in cold weather.
Physical Findings
The physical findings to be noted in a patient with
a herniated disc will vary with the acuteness of his
attack. Striking changes may appear suddenly and may
leave almost as rapidly in some instances. During an
interval between attacks of pain and absence of signifi-
cant physical findings does not mitigate against the
opinion that the patient’s attacks are discogenic.
At the height of a severe attack the patient is often
totally disabled, being confined to his bed and requiring
opiates. Attempts to assume the erect posture bring on
marked spasm in the erector spinae muscles of the lum-
bar region together with acute sciatic pain. The affected
extremity is "weak” because of the pain.
Other patients, though able to be up and about, pre-
sent obvious alterations in the alignment of their spinal
column which, together with the pain, produce altera-
tions in gait. Such patients walk with a limp favoring
the painful side and perform all movements slowly and
carefully to avoid jarring. Rolling over on the exam-
ining table is difficult for them. Examination of the back
shows most frequently a loss of the normal lumbar
lordosis. The lower back becomes flat or may even pre-
sent a reversed lordosis, i. e., a gentle kyphotic curve.
Almost as frequent is the presence of a list or tilt,
usually away from the painful side. In some patients
there is seen a so-called "sciatic scoliosis,” that is an
"S” shaped curvature of the spine associated with sciatic
pain. This finding is almost pathognomonic of a her-
niated intervertebral disc. A very interesting variant of
this finding is the alternating scoliosis, i. e., one in which
the patient can reverse the direction of the curve by
appropriate maneuvers but cannot bring the spine into
straight alignment except in the prone position. Sciatic
scoliosis is usually accompanied by a stooped posture, the
patient being unable to stand erect.
With the patient standing there is usually evident
spasm in the lumbar musculature. This, together with
pain, limits motion of the lumbosacral spine. Forward
bending is strikingly reduced. Hyperextension is like-
wise reduced and attempts to produce it passively may
bring on sharp pain in the region of the lumbosacral
joint. Lateral bending may be reduced, particularly to
the side of the lesion.
Upon assuming the prone position the muscle spasm
may subside to a considerable degree. Palpation with a
August, 1949
267
single finger tip will disclose discreetly localized areas of
tenderness; these are to be distinguished from diffuse
tenderness over the whole lumbar region. The latter sug-
gests that the case is not one of herniated disc. Tender-
ness will commonly be found between the vertebral
spines at the level of the lesion, i. e., between the fourth
and fifth lumbar spines or between the fifth lumbar and
first sacral spines. More significant, however, is tender-
ness located just a fingerbreadth lateral to the spines
and over the vertebral interspaces. This will be present
over the lesion and absent on the contralateral side. A
particularly significant finding is the reproduction of
the patient’s radicular pain by such paravertebral pres-
sure.
The sciatic nerve itself may be tender to pressure but
this is not often a prominent finding. However, tests
which put the nerve on stretch produce sharp exacerba-
tions of the patient’s pain and may also bring out pares-
thesias (numbness, tingling). Raising the extended leg
off the bed as the patient lies supine is the common
method of testing. Normally the leg can be raised to
or near to the vertical, but the presence of a herniated
disc pain and muscle spasm may limit elevation to a
marked degree. With the leg elevated to a painful angle,
further stretch may be applied to the sciatic nerve by
sharply dorsiflexing the foot, a maneuver sometimes er-
roneously referred to as the Naffziger test. Sharp exa-
cerbation of pain upon performance of the maneuver
indicates the presence of an irritated sciatic nerve.
A physical finding which is highly suggestive of the
presence of a herniated disc is the production of pain
on the affected side by elevation of the leg on the un-
affected side. The pain may be limited to the para-
vertebral region or may extend into the sciatic distribu-
tion.
Neurological examination will disclose findings indica-
tive of irritation of one or more spinal nerve roots. The
findings are a fairly reliable indicator of the level of
the lesion. The knee jerks are not altered by disc lesions
at the fourth and fifth lumbar levels. Occasionally some
decrease of activity of the knee jerk is seen on the af-
fected side but this is probably related to a tendency
to hold the extremity in a state of voluntary spasm. The
ankle jerk on the affected side is more significant. With
protrusions at the lumbosacral level it is typically
markedly reduced or absent, while with lesions at the
fourth lumbar level it is normal in one half of cases,
being moderately to severely reduced in the others.
Very occasionally a patient is seen in whom there is
present such a mild degree of irritation of the nerve
root that the reflex will be hyperactive rather than
reduced.
Sensory testing with a pin and whisp of cotton may
disclose alteration (reduction) in sensibility which usually
corresponds to the area of the patient’s maximum pares-
thesias. Lumbosacral lesions typically produce hypesthe-
sia and hypalgesia in the first sacral dermatome, i. e.,
along the lateral border of the foot, including the two
or three lateral toes. Lesions at the fourth lumbar level
produce similar changes in the fifth lumbar dermatome
which includes much of the dorsum of the foot and
the great toe.
Localization of the lesion by means of reflex and
sensory changes is not entirely reliable because the motor
and sensory distribution of nerve roots is subject to some
variation. For example, we have demonstrated in one
case that production of temporary interruption in the
patient’s first sacral nerve root produced sensory changes
in the area usually supplied by the fifth lumbar nerve.
Actual motor weakness is not a prominent feature of
most disc cases, since but a single nerve root is affected
and most muscles are supplied by several roots. With
lumbosacral lesions there may be some weakness of the
posterior calf muscles but this is difficult to demonstrate
clearly. With fourth lumbar protrusions, however, there
may frequently be demonstrated a discrete weakness of
dorsiflexion of the great toe. There may of course be
a good deal of apparent weakness as the result of pain
produced on movement.
A finding which we have come to place considerable
reliance upon is the presence of significant degree of
atrophy in the leg muscles as determined by measuring
the maximum circumference of the calves. Differences
of Zi inch or more were noted in 23 of the 30 cases in
our series in which it was checked.
Occasionally one sees a patient who presents a class-
ical history of low back pain followed by sciatica in
whom most or all of the pain has subsided but who re-
tains rather striking alterations in the lower back with
spasm, loss of lordosis and tilt. Presumably the altered
relationship of the vertebral components has served to
relieve the pressure on the nerve root, with subsidence
of pain. The bones cannot return to their normal posi-
tions, however, without there being precipitated a recur-
rence of the patient’s pain.
Laboratory and X-Ray Findings
Laboratory studies of the blood and urine are useful
only insofar as they help to exclude other possible causes
of sciatic pain. An elevated blood sedimentation rate
directs attention toward arthritic involvement.
If a myelogram is performed a specimen of cerebro-
spinal fluid is taken for examination. If no myelogram
is performed a lumbar puncture is not made because of
its slight value. The dynamics will not be altered. In
almost every case a normal cell count will be found;
the maximum count in our series was 14 cells per cubic
millimeter and the average was 2 cells. The protein con-
tent of the fluid will be moderately elevated in something
less than one half of cases. It was once felt that an
elevated spinal fluid protein was almost essential to the
diagnosis of herniated disc but this has long since been
found fallacious.
Plain roentgenograms of the lumbosacral spine in
both antero-posterior and lateral projections are made in
every case. Their chief value is in the exclusion of other
possible sources of sciatic pain, such as spondylolisthesis
and malignant metastases. In most cases they will be
reported by the roentgenologist as entirely negative. On
occasion one may note in the X-rays the straightening
268
The Journal-Lancet
and listing of the lumbar spine also noted on physical
examination; these are suggestive but not diagnostic
findings. More interest attaches to reports of narrow
interspaces. It will be recalled that the lumbosacral in-
terspace is subject to considerable variation and there-
fore slight changes are not significant. In our series of
43 cases seven were reported to have a narrow interspace.
In five of these the narrowing corresponded with the
level of the removed disc; in the other two it did not.
Thus this finding is not entirely reliable as either a
diagnostic or a localizing sign.
Myelography
When herniated lumbar discs were first recognized as
a clinical entity much doubt and confusion surrounded
their diagnosis. Much of this arose from a tendency to
regard them as rare and unusual lesions rather than as
the most frequent cause of "sciatica.” It was felt essen-
tial to establish the diagnosis by myelography in every
case. With increasing experience, however, many neuro-
surgeons have come to rely more and more upon the
diagnosis based upon a consideration of the history, phys-
ical findings and (negative) laboratory and X-ray exam-
inations. Most radical in this respect was Dandy who
stated that myelography was never necessary.
Myelography (known locally by the term "spino-
gram”) is the demonstration of the spinal subarachnoid
space by means of a contrast medium. The original sub-
stance employed was lipiodol, a poppyseed oil contain-
ing 40 per cent iodine. This gave excellent visualiza-
tion but fell into disfavor because it was felt to be occa-
sionally irritating and because it remained permanently
in the spinal subarachnoid space. Here it presently be-
came spread far and wide and presented a very startling
appearance on subsequent X-ray examination. For this
reason its use in cases involving litigation or compensa-
tion was often unfortunate.
To overcome these objections to lipiodol the technic
of air myelography was developed. This consisted simply
of filling the lumbar portion of the spinal subarachnoid
space with air or oxygen and taking X-ray films. The
contrast obtained was not sufficient to permit observation
by fluoroscopy. This method was far from satisfactory
since it was almost routinely followed by a severe head-
ache and because its diagnostic accuracy was poor even
with the best of films. The method has been abandoned.
The technic of aspirating the oil following fluoroscopy,
developed in 1941, made it possible to enjoy the advan-
tages of oil myelography while escaping its liabilities.
The subsequent introduction of a new contrast medium,
Pantopaque, has further simplified matters. Pantopaque
is less viscous than lipiodol and therefore much more
easily inserted and removed. While somewhat inferior
for use in the thoracic and cervical regions, due to its
tendency to break up into multiple droplets, in the lum-
bar region it is as good as if not better than lipiodol.
It has the further advantage of being gradually absorbed
from the subarachnoid space should it prove impossible
to aspirate it after the examination is completed.
There exists a considerable diversity of opinion among
neurosurgeons and orthopedists regarding the necessity
and advisability of performing myelography in the diag-
nosis of herniated intervertebral discs. Some employ it
routinely, and this is the policy of the Veterans Admin-
istration. Others resort to myelography only in doubt-
ful cases; this is probably the most common practice
among neurosurgeons. A few, such as Dandy, claim
never to employ it.
In favor of the performance of a myelogram are the
following considerations: With modern technics the pro-
cedure is in most instances simple and safe. Myelogra-
phy may establish the diagnosis in questionable cases and
may avoid exploration in others. It may indicate the
presence of multiple lesions. It may suggest the presence
of a neoplasm rather than a herniated disc. It serves
accurately to localize the lesion. And it provides the
only direct evidence of the lesion’s presence available
prior to operation; this may be of legal importance.
Against the routine performance of myelography it
may be noted: While usually simple and safe, the pro-
cedure is sometimes very uncomfortable to the patient
and is occasionally followed by a sterile meningitic re-
action which may produce alarming symptoms of a
week’s duration. (We have had at least one such ex-
perience.) It introduces an added element of time and
expense to the patient. It is not required for localization
since this may usually be accomplished on clinical
grounds and even if it is not the fourth and fifth inter-
spaces are readily explored through the same operative
exposure. Our experience has not suggested that mul-
tiple protrusions are frequent enough to justify the rou-
tine use of myelography and the same is true for neo-
plasms.
It should be emphasized that the interpretation of
myelographic findings, both at fluoroscopy and on films,
is a matter calling for considerable experience and judg-
ment and that even granted these there are still many
occasions on which the roentgenologist is able only to
report suggestive changes even though the patient is
subsequently found to have a very definite lesion. In
our series of 43 proven cases of herniated disc, myelo-
grams were not done in 17 cases, were reported as posi-
tive in 15 cases, were reported as suggestive in 9 cases
and were reported as negative in none. In one of the
suggestive cases the indicated level was the wrong one.
It should also be pointed out that it is perfectly pos-
sible to have a normal myelogram in a patient having
a herniated disc. This may occur when the dural sac
is relatively narrow in relation to the width of the ver-
tebral canal and the herniation takes place far laterally
in the canal. There was no example of this circumstance
in the present series, but they have been observed else-
where. The opposite also happens, namely the myelo-
gram may demonstrate a mass which is not discovered
at laminectomy. The cause of these false positives is
not clear, but they do emphasize the lack of precision
in the method.
Finally, an important objection to routine myelogra-
phy, in my opinion, is that it tends to discourage the
accurate clinical evaluation of the patient’s problem.
If a myelogram is performed there is too great a tend-
August, 1949
269
ency routinely to advise operative treatment if a disc is
demonstrated and to reject the patient if none is found.
In summary, I believe that myelography is not neces-
sary to accurate diagnosis in typical, relatively severe
cases of herniated disc. It is useful in milder or confus-
ing cases and as a means of checking on poor operative
results. It should not be allowed to take the place of
good clinical judgment.
Differential Diagnosis
Time does not permit a thorough consideration of
the other lesions which may produce symptoms suggest-
ing the presence of a protruding disc. The most impor-
tant of these are due to anomalies in the bone structure
in the lumbosacral region, such as spondylolisthesis.
They may be identified by X-ray study. Since protrud-
ing discs may coexist with such lesions, myelograms are
performed prior to spinal fusion and if there is any
suspicion of the presence of a disc the vertebral canal
is explored prior to fusion. In our experiences most such
explorations have proven negative.
Rheumatoid spondylitis may usually be identified by
means of X-ray changes, increased sedimentation rate
and decreased chest expansion.
Neoplasms of the cauda equina may cause the disc
syndrome but this is a rare occurrence. They will usually
interfere with sphincter function, which herniated discs
do not.
A most difficult problem is presented by the psycho-
neurotic patient with a back pain and/or sciatica. It is
perfectly possible for a neurotic person to have a pro-
truding disc. Long continued pain and loss of sleep may
serve to exaggerate the neurotic symptoms. But one
must beware of operating on such patients unless the
indications for so doing are unequivocal, since a failure
may lead to ever increasing complaint.
Treatment
The nonsurgical or so-called conservative treatment of
protruding intervertebral discs is advised under the fol-
lowing circumstances: (1) When the diagnosis, though
suspected, cannot be established with reasonable cer-
tainty. (2) During early attacks of pain, particularly if
the sciatic syndrome is not fully developed. (3) If the
attacks of pain are mild and respond readily to the
measures presently to be outlined. (4) If there is some
other contra-indication to surgery.
The essence of conservative treatment is rest for the
lumbosacral spine. This is best achieved by complete
bed rest, preferably in a semi-sitting position. Traction
to the lower extremities is sometimes beneficial but at
other times cannot be tolerated by the patient; this state
of affairs is highly suggestive of the presence of a pro-
truding disc.
Once the patient improves sufficiently to be allowed
up, or if the symptoms are only moderately severe from
the beginning, a support such as the Goldthwait brace
may be used to advantage. If support is to be provided,
it should be adequate. The usual so-called "sacro-iliac
belt” does not provide adequate immobilization for many
cases.
Manipulative therapy, as practiced by osteopaths and
chiropractors and occasionally by physicians, is of defi-
nite benefit to many of these patients particularly during
the early phases of their disorder, that is while still hav-
ing attacks of lumbago. Once the disc herniates and
sciatica sets in relief from manipulation is much less
certain and not infrequently the treatment serves only
to make the symptoms more acute.
Once over his acute attack the patient should be
warned to avoid movements which involve flexion and
rotation of the lumbar spine.
Surgical treatment is advised under the following cir-
cumstances: (1) When "conservative” therapy is no
longer truly conservative, that is, when obtaining relief
through rest requires such an expenditure of time and
acceptance of partial disability as to render it too dear
for the patient. (2) When the symptoms, even though
they be of the first attack, are so severe as to leave no
doubt that a complete herniation has taken place and
that less radical measures have a very poor prospect of
producing complete relief. The mere known presence of
a protruding disc is not alone a sufficient reason for op-
erating, for many persons, including not a few physi-
cians, manage to get along reasonably well by careful
limitation of their activity.
Injunctions against hasty operation in cases of pro-
truding intervertebral disc are based on considerations
other than the avoidance of unnecessary surgery. Even
a modest experience with the surgical treatment of these
lesions suffices to demonstrate that the quickest, most
thorough and most appreciated relief follows operation
in patients who have had a good deal of trouble and
severe distress and who are found at operation to have
a herniated disc, that is one from which free fragments
may easily be removed. It is not unusual for such
patients to require only one or two postoperative injec-
tions of morphine and to leave their beds on the third
postoperative day in relative comfort. Patients in whom
no disc abnormality or only a mild protrusion is found,
on the other hand, are prone to have much more pro-
longed postoperative discomfort and to experience a less
complete alleviation of their complaints.
The technic of operation for protruded and herniated
intervertebral discs is now fairly well standardized among
neurosurgeons. Its proper performance requires the pos-
session of certain specialized instruments and suction
and electrosurgical apparatus, together with an acquaint-
ance with the technic of intraspinal surgery. Technical
details lie beyond the scope of this presentation. It may
be pointed out, however, that the operation is conducted
through a short (2 to 3 inch) incision and does not in-
volve the removal of any bony structure important to
the weight-bearing function or stability of the vertebral
colunm. The protruding or herniated portion of the
disc is first removed following which all remaining tissue
of the nucleus pulposus that can be secured is removed.
The patient may be permitted out of bed within three
days to a week and is able to return to some activity in
from two to eight weeks depending upon his progress.
Strenuous activity is prohibited for six months.
270
The Journal-Lancet
Spinal fusion is performed in conjunction with re-
moval of the disc when the bony structure of the lower
back is defective or unstable, when the patient’s com-
plaint includes backache of a static character, i. e., one
relieved by rest and immobilization, and when the pa-
tient pursues a particularly arduous occupation and de-
sires maximum protection against future trouble. In our
series of 43 herniated discs only three were subjected to
spinal fusion; this figure is lower than those reported
from most clinics.
Results
Several factors influence the results of operation for
disc disease. As already indicated, patients from whom
a truly herniated disc are removed obtain results superior
to those obtained by patients with simply a protruding
disc. The adequacy of operation is an important factor.
We have had several occasions to remove further disc
material from the site of a previous removal which was
considered complete at the time of its performance.
Due to purely mechanical difficulties a few fragments
may be overlooked only to cause trouble later. Excessive
scarring in the epidural space following surgery may
cause prolonged symptoms. Re-exploration of such a
case dramatically emphasizes the necessity for avoidance
of all unnecessary operative trauma to the nerves and
other tissues of the vertebral canal.
The factor of compensation plays a significant role
in industrial and veteran cases. It is notoriously much
more difficult to obtain a good result in such patients
than in those who obtain no financial gain from con-
tinued disability.
The results which we have obtained compare favor-
ably with those reported elsewhere and demonstrate, we
believe, that operation in properly selected cases offers
the patient his best chance for rapid, complete and last-
ing relief from pain. At the time of their dismissal from
the hospital, from one to three weeks following opera-
tion, our 43 cases of herniated disc showed improvement
in the following degrees:
None 0 cases
Slight - 1 case
Moderate 2 cases
Marked 30 cases
No residual symptoms 10 cases
We have had opportunity to make follow-up exam-
inations on 20 of these patients at intervals varying
from 2 to 1 1 months. Thirteen of these patients were
free from backache, five had slight pain and one had
moderate distress in the lower back. Fifteen of the
twenty were free from radicular (sciatic) pain, four had
occasional twinges and one had moderate leg pain. An
estimate of the patients’ work capacity disclosed that
none of them were incapacitated. In two the work ca-
pacity was estimated as only fair, in seven as good and
in eleven as excellent. This latter group found them-
selves able to carry out any tasks they set themselves to.
Only three patients are known to be wearing a low
back support. One man, who has had two discs removed
at separate operations has been accepted for re-enlist-
ment in the AAF.
References
The literature relating to the intervertebral disc prob-
lem is voluminous but much of it is simply repetitious
of what has been said before, a characteristic shared by
this report.
Interested students are referred to the monograph by
Bradford and Spurling (The Intervertebral Disc, Charles
C. Thomas, 2nd ed., 1945) which contains an extensive
bibliography.
Attention may also be drawn to the symposium on
the intervertebral disc, edited by J. Grafton Love, in
Archives of Surgery, March 1940.
CONTINUATION COURSE IN ANESTHESIOLOGY
The Department of Postgraduate Medical Education of the University of Minnesota
Medical School announces a continuation course in Anesthesiology to be held September
12, 13, 14. The course is not intended for full-time anesthetists but is rather directed toward
those physicians who spend a portion of their time as anesthetists. Emphasis will be placed
on anesthetic agents commonly used by part-time anesthetists. Clinical problems frequently
encountered in anesthesiology will be stressed. Distinguished visiting physicians who will
participate as members of the faculty for the course include Dr. Stewart Cullen, Professor
of Anesthesiology, University of Iowa Medical School; Dr. John Adriani, Director, Depart-
ment of Anesthesia, Charity Hospital, New Orleans, and Dr. J. S. Lundy, Chief of Anes-
thesia at the Mayo Clinic, Rochester, Minnesota. The remainder of the faculty of the course
will be made up of full-time and clinical members of the staff of the University of Minne-
sota Medical School.
August, 1949
271
Congenital Absence of Vagina
Edward C. Maeder, M.D., F.A.C.S.
Minneapolis, Minnesota
Congenital absence of the vagina resulting from
faulty development or fusion of Mullerian ducts
is fortunately a rare malformation. Surgical correction
is certainly advisable in suitable cases and should be at-
tempted in young women with well established sex char-
acteristics not only for providing a means of cohabitation
but also to overcome any co-existing inferiority complex
or sex neurosis. Counseller1 advocates that the opera-
tion be done only in women who are normally developed
otherwise or those who contemplate marriage. TeLinde J
and Geist'1 believe that the optimum time for attempting
the formation of the vagina is usually about six months
prior to marriage if a cutting operation is planned.
Choice of Method
Many ingenious operations have been devised for the
formation of an artificial vagina. The purpose of all
these operations is to open a passage between the blad-
der and rectum to provide a suitable epithelialized pass-
age. Miller 4 and Wharton 5 prefer one of two pro-
cedures.
1. Formation of a channel between bladder and bowel
and continued use of an obturator until the epithelializa-
tion has taken place by ingrowth from vestibular epi-
thelium.
2. Dissection and use of an obturator covered by split
thickness graft.
The standard for a successful result is an epithelialized
soft, pliable, vaginal tube showing no unusual or excess-
ive amounts of scar tissue or contraction after three
months. The split thickness skin graft technique is be-
lieved to be superior. However, if there is only a par-
tial absence of the vagina, dissection and use of an ob-
turator may be entirely adequate. Biopsy and histologic
examination of the transplanted normal skin into the
artificially produced vaginal channel appears to assume
the histologic as well as physiologic characteristics of
normal vaginal mucous membrane.
There are numerous other and older methods which
have fallen somewhat into disrepute as they are more
time-consuming and yield less favorable results than the
Wharton technique and its modifications. Indeed some
of the operations are now merely of historical interest.
According to Masson the mortality rate is the greatest
objection to the Baldwin technique which cannot be
safely used in all cases, especially when the mesentery
of the ileum is too short. Masson '' favors the Mclndoe
method or modification of it using inlaying Thierch
graft from thighs implanted into the vagina over a non-
irritating lucite vaginoform. The Schubert method sub-
Presented at the meeting of the Minnesota Society of Obstet-
rics and Gynecology, St. Paul, Minnesota.
stitutes the rectum instead of the ileum for the vagina.
The Graves operation utilizes pedicle grafts from the
labia minor and adjacent surfaces of thighs to line the
artificially formed canal. It and the Brady modification
using a perineal skin flap are still useful procedures in
selected cases although considerable opportunity for scar
tissue formation is given. If the labia are small it is
almost impossible to use the Graves technique. Modifi-
cations were offered by Frank and Geist using tubular
grafts from the thighs. The use of skin and pedicle
grafts alone often requires prolonged hospitalization and
repeated operations due to secondary contraction.
"Use of Pressure” with Fall or Frank method seems
to be practical and to give satisfactory results in some
cases. The Frank non-surgical method although time-
consuming, does not require hospitalization and is simple
but demands intelligent cooperation of the patient. A
vagina that is created non-surgically is less apt to con-
tract than one formed by surgical methods. The Falls
operation is of value when a rudimentary vestibule is
present and in cases who cannot be depended upon for
the prolonged intubation required by the Frank tech-
nique. In the Fall method a disc of mucosa is undercut,
outlining the hymen. This is pushed in as far as possible
and allowed to rest on the posterior wall of the newly
created space. The pouch is further deepened by wear-
ing a vaginal plug as in the Wharton procedure. Fall ‘
considers this method totally devoid of danger.
Discussion and Surgical Considerations
There are some difficulties and possible accidents en-
countered in construction of a vaginal using the mold
with or without skin grafts. By observing certain pre-
cautions and operative considerations these obstacles can
be largely overcome. The requisites for a good result:
1. Meticulous care in obtaining a dry field to be
grafted.
2. Obtaining in one piece uniformly good thin grafts.
3. Use of an obturator for several weeks or until
marriage.
The dissection is usually easy, unless operations have
been performed before. It is well to put a rectal tube
into the rectum before operation and to instill a meth-
ylene blue solution into the bladder through a Foley
retention catheter or have an assistant hold a urethral
dilator in the bladder. Several molds of various sizes
covered with two thicknesses of rubber condom should
be available. Blunt and occasionally sharp dissection is
used to create the space between the rectum and bladder
which should be larger than normal since the walls tend
to contract. The diameter of the dissected space should
be wide enough to admit three fingers so that the form
can escape early if intrapelvic pressure is unduly in-
Ill
The Journal-Lancet
creased. The depth of the space should be 11 to 13 cm.
Complete hemostasis is essential so that the grafts may
lie on a dry surface. The lateral walls at the base of
the broad ligament are most likely to bleed. If they do
not yield with blunt dissection they must be cut, as they
will constrict the vagina. Some of these areas are vas-
cular and should be ligated by transfixation. The cervix
should be located if possible.
With the entire absence of the vagina there is usually
an associated absence or arrested development of the
uterus and not infrequently of the adnexae. One may
be able to feel the ovaries, rarely it is possible to feel
the bulbous median ends of the tube. The rest of the
genito-urinary system should also be examined as occa-
sionally there may be defects such as absence of one
kidney, double kidney, or ectopic kidney. Brady 8 ad-
vises that intravenous pyelograms should be taken before
operation in any women with congenital gynecologic
abnormality.
The condom-covered artificial phallus of balsa wood
is inserted into the artificially made vagina. The plug
should fit snugly but not too tightly. In placing it in
the cavity one must be certain that it does not compress
the urethra against the under surface of the symphysis
or make excessive pressure against the rectum. To avoid
the danger of rectovaginal septum perforation, Whar-
ton 1,1 has recommended: (1) the vaginal form should
never be so short that it lies completely above the mus-
cular plane of the pelvic diaphragm. The form should
be long enough to protrude slightly from the vaginal
orifice. (2) Make vaginal orifice so large that it could
not close or contract over the end of the form. The
opening should be large enough to allow the form to
escape if the intrapelvic pressure is increased. It should
always be easy to reach and remove the vaginal form.
(3) Constipation is to be avoided. If constipated, avoid
pressure to produce defecation. An indwelling urethral
catheter may be used, keeping it in the bladder for four
or five days.
The Thiersch grafts are sewed loosely over the cylin-
der with interrupted sutures of finest catgut. The form
is then inserted into the space and not disturbed for
Fig. 1. A. P. X-ray of lower portion of pelvis on October 20, 1947, showing vaginal mold in place
after bismuth paste had been applied to the vaginal walls and plug to act as an opaque contrast material.
August, 1949
273
about two or three weeks, at which time the graft should
have taken. Epithelialization is noted; the plug (after
being washed in normal saline) is then reinserted and
worn almost continuously for about a month. A sani-
tary belt is worn to keep the mold in place. After that
it can be worn only part of the time, if needed. Coitus
is begun carefully after epithelialization is firm and
complete, usually about two months after operation, if
lubricants are used and trauma is avoided. Thiersch
grafts avoid dependence on proliferation of vaginal epi-
thelium. If a skin graft is not used, complete epitheliali-
zation may require months.
Whitacre and Chen 11 emphasize the importance of
keeping the artificial vagina open once it has been con-
structed. This must be done by normal cohabitation or
by artificial dilatation.
Large doses of estrogen help to maintain vaginal
calibre and epithelium but with indifferent results. Ac-
cording to Counseller if the skin graft is accurately cut
as a Thiersch graft, practically no scar at end results.
If a full thickness graft is inadvertently taken a scar will
result. Radium therapy can be used for scars. The
grafts are usually taken from the abdomen or thighs.
Counseller 1J recently reported 70 patients in which
the technic of Mclndoe was employed or in which a
"lucite” mold covered by a Thiersch skin graft taken
from the abdomen or thigh was used. He states that
although the surgical treatment produces a high percent-
age of good results, there will be some poor results and
even failure in the management of any congenital anom-
aly by virtue of the defective quality of tissues with
which the surgeon must work.
Case Report
S. P., age 22, an unmarried white woman, was first
seen by me on September 20, 1946, complaining of fail-
ure to menstruate and being overweight. She had con-
sulted a physician several years ago because of primary
amenorrhea and was told that she had no uterus. She
was engaged to be married and had normal libido. Peri-
odically she had attacks of cramp-like pain and tender-
ness in her lower right quadrant.
Examination revealed a well-developed, moderately
obese young white woman. She was of high intelligence
and very desirous of having the congenital absence of
vagina corrected. General physical examination showed
essentially normal findings. Body contours were distinct-
Fig. 2. Vaginal biopsy taken on September 30, 1947. No hair follicles or glands present.
274
The Journal-Lancet
ly feminine. Breasts were well developed as were the
external genitalia. There was a slight dimple in the
perineum between the labia minora indicating the normal
location of the vaginal orifice. On recto-abdominal ex-
amination no uterus or cervix could be palpated.
Laboratory studies revealed a hemoglobin of 95 per
cent. Urinaylsis was normal. Blood Wassermann and
Mantoux tests were negative. Her basal metabolic rate
was — 12 per cent.
On February 17, 1947, at Swedish Hospital under
pontocaine spinal anesthesia, the abdomen was opened
suprapubically. Both tubes and ovaries were found to be
present, the tubes being connected across the dome of
the bladder by a thin fibrous band. No uterus was found.
As patient had had some trouble with pain in her right
side, the appendix was removed. An indwelling Foley
catheter was inserted into the bladder and a small
amount of Methylene blue instilled. A rectal tube was
inserted into the rectum. An artificial vagina was then
constructed using the Wharton technique with Thiersch
skin grafts. A space about 11 cm. deep and about three
fingers in width was created by blunt and sharp dissec-
tion up to the region of the peritoneum. Two Thiersch
skin grafts (about 4x3 inches in diameter and 2 mm.
thick) , were taken from the left side of the abdomen
and sewed loosely over a bulbous balsa wood plug 12 cm.
in length and 4.5 cm. wide. The skin graft was done
by Dr. Earl Henrikson. This vaginoform covered with
the skin graft was inserted into the dissected space. The
vaginal mold was large enough so that the lower end
projected over the vaginal orifice below the pelvic floor.
Postoperative course was uneventful. Patient placed on
estrogenic therapy. Vaginal mold removed easily on
March 9, 1947, and found that the skin grafts had taken
well. Patient discharged from hospital on March 11,
1947, after having been instructed how to remove and
re-insert vaginal plug. Biopsy taken from vagina on
March 20, 1947, and September 30, 1947, revealed a
negative vaginal biopsy with no hair follicles or glands
present. The vaginal graft gradually took on the ap-
pearance of vaginal mucosa, being soft, moist and pliable.
When last seen, on September 15, 1948, the patient had
a roomy, satisfactory vagina with no scar tissue or con-
traction.
References
1. Counseller, V. S.: Congenital Absence of the Vagina,
Treatment with Inlaying Thiersch Grafts. Am. J. Obstet. &
Gynec., 36:632-635, 1938.
2. TeLinde, R. W.: Gynecology, ed. 1, Philadelphia, J. B.
Lippincott Company, 1946, pp. 591-604.
3. Geist, F.: Operation for Congenital Absence of Vagina.
Amer. J. Obstet. & Gynec., 35:452-468, 1938.
4. Miller, N. F., Wilson, J. R., and Collins, J.: Surgical
Correction of Congenital Aplasia of Vagina. Amer. J. Obstet.
& Gynec., 50:735-747, 1945.
5. Wharton, L. R.: Gynecology, ed. 2, Philadelphia, B. B.
Saunders Co., 1947, pp. 65-69.
6. Masson, J. C., in Discussion of Falls, F. H.: Amer. J.
Obstet. & Gynec., 40:906, 1940.
7. Falls, F. H.: A Simple Method of Making an Artificial
Vagina. Amer. J. Obstet. & Gynec., 40:906-911, 1940.
8. Brady, L., in Discussion of Counseller, V. S.: J.A.M.A.
136:865, 1947.
9. Wharton, L. R.: Construction of Artificial Vagina.
Annals of Surgery, 121:530-533, 1945.
10. Wharton, L. R.: Difficulties and Accidents Encountered
in Construction of the Vagina. Amer. J. Obstet. & Gynec.,
51:866-875, 1946.
11. Whitacre, F. E., and Chen, C. Y.: Surgical Treatment
of Absence of the Vagina. Amer. J. Obstet. & Gynec., 49:789-
796, 1945.
12. Counseller, V. S.: Congenital Absence of the Vagina.
J.A.M.A., 136:861-866, 1947.
UNIVERSITY OF MINNESOTA CONTINUATION COURSES
A course in Psychosomatic Medicine for general physicians will be presented by the
University of Minnesota Medical School at the Center for Continuation Study, September
12 to 24. Emphasis will be placed upon interview techniques and the actual care of patients
with emotional problems. A major part of the teaching will be done in the Out-Patient
Department of the University of Minnesota Hospitals where the registrants will gain clin-
ical experience under the supervision of experienced advisors.
On October 3, 4, 5, a course in Infectious Diseases will be presented. This course is
intended for general physicians and will emphasize the diagnosis and management of the
more common infectious disease problems. Dr. Louis Weinstein of Boston, Massachusetts,
will be the visiting faculty member for the course and will discuss the pneumonias and
current concepts of the common cold and influenza.
Other members for the faculty of the courses will include full-time and clinical staff
of the University of Minnesota and the Mayo Foundation.
August, 1949
275
Recent Advances in Surgery of the Colon
B. Marden Black, M.D.* *
Rochester, Minnesota
As a basis for consideration of changes which have
..taken place during recent years in the field of sur-
gery of the colon, I should like to review briefly some
of the principles and practices established before the in-
troduction of chemotherapy. Present concepts of pre-
operative preparation and of postoperative care, apart
from chemotherapy, had been established. Technical
methods had become fairly well standardized and the
principle of staged operations was almost universally
accepted. Resection of any segment of the left portion
of the colon with immediate anastomosis was regarded
as a hazardous undertaking, and had been superseded
by exteriorization.1-4 Intraperitoneal anastomosis was
employed commonly after resection of the right portion
of the colon, but exteriorization was also carried out in
spite of the disadvantages of a temporary ileac stoma.
Success in reducing the incidence of peritonitis by such
technical methods was limited, and this complication still
accounted for the majority of postoperative deaths and
still developed unpredictably. The mortality rate in rela-
tion to resection of a segment of the left portion of the
colon remained in excess of 10 per cent and that asso-
ciated with the removal of the right part of the colon
was only slightly less. In general, the threat of peri-
tonitis and death was so great in operations on the colon
that all other considerations were secondary. Prolonged
hospitalization and multiple admissions to the hospital,
the time necessary to carry out resection in stages and
the nuisance of temporary or at times permanent colonic
stomas were accepted as more or less necessary evils in
the cause of diminishing the mortality rate associated
with operations on the colon.
Chemotherapy
During 1939 and 1940 the hospital mortality rate
associated with operations on the colon decreased by
more than 50 per cent, and this improvement in rate
coincided with the first use of sulfonamide drugs in the
peritoneal cavity. iJ At first these drugs were used in only
occasional cases, both because of skepticism that much
could be achieved by any such means and because of
the possibility of toxic reactions. By 1940, however,
sulfathiazole had become the drug of choice because of
its polyvalence and delayed absorption, and because ex-
perimental investigations and clinical experience had
demonstrated the safety of leaving 5 to 10 gm. of the
drug within the peritoneal cavity. Similarly, after sev-
eral months’ experience with the drug, the clinical re-
sults were so striking that it came to be used regularly.
I do not know of any reasonable explanation for the
Read at the meeting of the Northern Minnesota Medical
Association, Duluth, Minnesota, August 20, 1948.
*Division of Surgery, Mayo Clinic.
comparatively sudden decrease in mortality rate, apart
from chemotherapy. At the Mayo Clinic, during the
period in which the mortality rate decreased, the per-
sonnel of the surgical staff did not change, surgical
technics and methods of preoperative and postoperative
care remained essentially the same except for the local
use of sulfonamides and the patients seen during these
two years did not differ in any fundamental way from
those seen previously. The decline in hospital mortality
rate could not be attributed to selection of patients since
resectability rate actually increased during the two-year
period.
Further advances in the use of chemotherapy in co-
lonic operations have since been made. Poth and Knotts1'
in 1942 introduced succinylsulfathiazole (sulfasuxidine)
and demonstrated that the drug was capable of reducing
the bacterial content of the bowel many thousandfold.
Their demonstrations in the experimental laboratory of
the increased safety in opening the colon after prepara-
tion with sulfasuxidine have since been widely confirmed
both experimentally and clinically. More recently,
phthalylsulfathiazole (sulfathalidine) has been demon-
strated to be equally effective, in smaller doses than sul-
fasuxidine, in reducing bacterial counts, and one of these
two agents is now generally used in preoperative prepa-
ration. The value of penicillin in operations on the
colon is more equivocal. Its action against gram-negative
organisms is limited, but since complications are rare
there seems to be no serious objection to its use. The
use of streptomycin orally and systemically in operations
on the colon is so recent that it cannot as yet be ade-
quately evaluated." An incredible reduction in the num-
ber of organisms in the bowel occurs after its use orally.
The effect is fleeting, however, and within several days
the number of organisms returns virtually to the original
level, in spite of the same or increased doses of strep-
tomycin. The early development of streptomycin-resistant
organisms and the seriousness of complications of the
eighth nerve detract somewhat from its routine use. On
my service, the drug is used preoperatively only for those
patients with a known sensitivity to sulfonamides, and
postoperatively only when the development of infection
seems more likely than usual. Rarely, streptomycin is
administered for a period of forty-eight hours preceding
operation in addition to sulfasuxidine or sulfathalidine;
however, if safer modifications of streptomycin are de-
veloped some such scheme may be adopted routinely.
Current Methods
As a direct consequence of the decrease in risk in
colonic operations, marked changes, particularly in tech-
nic, have occurred. Since technical considerations differ
in the removal of different segments of the bowel, and
276
The Journal-Lancet
since methods for the removal of certain segments are
controversial, they will be discussed separately.
Lesions of the Terminal Portion of the Ileum and
Right Portion of the Colon. Two-stage resection of the
right portion of the colon has been almost entirely re-
placed by the single-stage operation. This is probably
the most satisfactory operation on the colon, from the
standpoint of both risk and extent of resection. The
methods of re-establishing continuity of the bowel have
not become standardized, and there does not seem to be
any essential difference in the risk involved or the results
obtained by use of side-to-side, end-to-end, or end-to-side
ileocolostomy.* The two-stage procedure of ileocolostomy
followed subsequently by resection is still occasionally
advisable. When malignant lesions are complicated by
obstruction or marked local inflammation, it may be safer
to carry out the operation in two stages rather than in
one stage. In many cases of regional enteritis, the pa-
tient’s general condition may be so poor that the first
operation should be limited to ileocolostomy with divi-
sion of the ileum. As a rule, this limited procedure is
followed by virtually complete recovery and resection
of the terminal portion of the ileum and the right por-
tion of the colon may be carried out subsequently. Dur-
ing the past few years at the clinic fewer than 10 per
cent of carcinomas of the right portion of the colon were
managed by two-stage resections, and in 1946 less than
5 per cent were so managed.
Lesions from M idtransrerse Colon to Rectosigmoid.
Perhaps the most striking change in operations on the
colon during the past decade has been the revival of
segmental resection with primary anastomosis in the
management of lesions of the left portion of the colon.
In spite of the many disadvantages of exteriorization
operations, their safety formerly was such, compared to
segmental resection with primary intraperitoneal anasto-
mosis, that the proposal to return to the older, notori-
ously hazardous method was met with much hostility.
As cases accumulated, however, it became evident that,
after preparation with sulfasuxidtne or sulfathalidine
and local use of sulfathiazole, intraperitoneal anasto-
moses were not unduly dangerous. It is probable that in
selected cases, at least, segmental resection with intra-
peritoneal anastomosis is as safe as, and perhaps safer
than, exteriorization. Certain conditions must be met,
however, if the safety of the procedure is to be preserved.
Obstruction must be absent; the sectioned ends of the
bowel to be used for the anastomosis must be free from
inflammatory thickening; both segments must have an
adequate supply of blood, and the suture line must be
without tension. Marked obesity, particularly an ex-
cessively fat mesocolon, also may be a contraindication.
The method has not proved particularly satisfactory in
cases of diverticulitis because of inflammatory change in
and about the bowel.
In cases of carcinoma the most frequent contraindica-
tion is obstruction. At the clinic in 1946, lesions of the
sigmoid were treated by some form of exteriorization
in about one third of the cases while in two thirds of
the cases segmental resection was possible. Earlier, seg-
mental resection with primary anastomosis was almost
always accompanied by a proximal colonic stoma which
completely diverted the fecal stream. The stoma was
established either at the time of resection or at a pre-
liminary operation. The addition of the stoma made the
entire operative procedure as time-consuming as an ex-
teriorization " and as many stages were required to com-
plete the operation. With increasing confidence in the
safety of intraperitoneal anastomosis, use of the proximal
colonic stoma is being gradually abandoned. The hos-
pital mortality rate associated with segmental resection
and primary anastomosis, without a colonic stoma, is
approximately 3 to 4 per cent, but I hasten to add that
patients must be selected for the operation and that
exteriorizations still have an important place in opera-
tions on the left portion of the colon.
In addition to the technical considerations previously
discussed, a profound change toward increasing the mag-
nitude of the operation has taken place in the removal
of lesions in the segment of bowel under consideration.
In cases of exteriorization, the extent of resection of
both bowel and mesocolon tended to be limited. In cases
in which primary anastomosis can be carried out, many
limitations of exteriorization are avoidable and the resec-
tion can be made far more radical. It is not uncommon
now, in operations for lesions of the splenic flexure or
descending colon, to carry out massive resection of the
left part of the transverse colon, splenic flexure, descend-
ing colon and corresponding mesocolon, and to re-estab-
lish colonic continuity by means of an anastomosis be-
tween sigmoid and transverse colon.1" There seems to
be little doubt that the more satisfactory late survival
rates after resection of the right part of the colon for
carcinoma as compared to those after more limited resec-
tions of a segment of the left part of the colon, as prac-
ticed in the past, were due in part to more radical re-
moval of regional lymph nodes. The increased magni-
tude of resection of the left portion of the colon which
is now being practiced should improve the late survival
rates.
Lesions of the Rectosigmoid. I should like to consider
lesions of the rectosigmoid as those situated so low in
the bowel that they cannot be satisfactorily exteriorized.
In the past, the standard operative procedure was com-
bined abdominoperineal resection, or one of its many
modifications, and the patient was left with a permanent
abdominal colonic stoma. Attempts have been made by
Dixon,11 and by others,12 since the early I930’s, to carry
out a segmental resection of this portion of colon (low
anterior resection) with primary anastomosis between
sigmoid and rectum in order to avoid a permanent co-
lonic stoma. The hospital mortality rate of approxi-
mately 20 per cent before 1940 discouraged wide usage
of the operation. When the safety of primary anasto-
mosis after resection of more proximal segments of
bowel was demonstrated, and particularly when Dixon,1'1
after the introduction of chemotherapy, was able to
carry out low anterior resection with a hospital mortality
rate of 1.5 to 3.0 per cent, resection of the rectosigmoid
with primary anastomosis was more widely adopted. At
August, 1949
111
the time of this report, low anterior resection at the
Mayo Clinic is associated with less risk than combined
abdominoperineal resection when employed to remove
lesions of the rectosigmoid. This, coupled with the avoid-
ance of a permanent colonic stoma, has made low an-
terior resection the standard procedure for many lesions
of the rectosigmoid at this institution. The danger of
leakage from the low anastomosis probably is greater
than that following anastomosis between more proximal,
peritonized segments of bowel so that a proximal colonic
stoma is generally established.
In carrying out anterior segmental resection the anas-
tomosis becomes increasingly difficult the lower the lesion
is situated in the bowel; in many cases in which lesions
are located in the upper part of the rectum or lower
portion of the rectosigmoid, particularly in cases of males
who have narrow, deep pelves, primary anastomosis by
suturing after resection cannot be carried out satisfac-
torily. In an effort to avoid a permanent abdominal
colonic stoma in such cases, sacral or perineal stomas,
with or without preservation of the anal canal or sphinc-
ter muscle, have been employed virtually since the begin-
ning of operations on the colon.14 Such operations were
gradually abandoned in English-speaking countries after
the introduction of combined abdominoperineal resection
by Miles 1,1 in 1908, but they were never given up in
Europe. Babcock 10 reintroduced the principle of pres-
ervation of the sphincter and formation of the perineal
colonic stoma in this country in 1933 and has remained
a vigorous proponent of the operation since. Such pro-
cedures were not widely adopted, however, until the past
few years, when, with the lessened risk associated with
operations on the colon, the question of preserving fecal
continence again has been raised. Whether the lower
portion of the rectum or the sphincter should be pre-
served if lesions are located in the rectosigmoid and
upper part of the rectum is most controversial.1 ' Com-
bined abdominoperineal resection for lesions in this level
has been accompanied by less satisfactory late survival
rates than has removal of lesions of either more prox-
imal or more distal segments of the bowel. In view of
this, efforts to decrease the magnitude of combined ab-
dominoperineal resection have been severely criticized.
The lymphatic spread of carcinoma of the rectosig-
moid and rectum has been studied intensively during
recent years, and Miles’s contention that the three zones
of lymphatics by which this spread takes place need to
be removed in every case has been challenged. The find-
ings in all studies 18-22 agree well and may be summar-
ized as follows: (1) The usual route of spread is by way
of the lymphatics which accompany the superior hem-
orrhoidal vessels. The spread may be discontinuous and
involved nodes may be found many centimeters proximal
to the lesion. (2) Lymphatic spread more than 1 cm.
distal to the primary lesion does not occur until proximal
lymphatics are blocked, and, in any case, distal spread is
not extensive. (3) Lateral spread, through lymphatics
that course along the levator am muscles and accompany
the middle hemorrhoidal vessels, does not occur when
the distal edge of the lesion is higher than 6 cm. above
the dentate margin.
Such findings obviously lend support to the concep-
tion that lymphatics distal to the lesion and those in
Miles’s lateral zone of spread need not be widely sacri-
ficed in many cases of carcinoma of the upper part of
the rectum and rectosigmoid. The widest possible re-
moval of proximal lymphatics is necessary, particularly
in view of the discontinuous spread observed in the su-
perior hemorrhoidal and inferior mesenteric zones. Be-
cause of the lateral spread of lesions in the distal 6 cm.
of rectum, the bowel should be amputated and effort
should not be made to preserve the sphincters and levator
ani muscles. The implications of these studies of spread
by way of the lymph nodes are being confirmed clinically
in that late survival rates after sphincter-preserving op-
erations and low anterior resection are comparable with
those achieved after combined abdominoperineal resec-
tion.
Of the operations which have been proposed with the
idea of preserving continence, the best known in this
country is that of Babcock.10 The original procedure
has been modified by him and by his colleague, Bacon,
but remains, as far as preserving continence is concerned,
a sphincter-preserving procedure. Control following such
operations is only relative, and usually the patient must
manage the perineal stoma much as an abdominal stoma
is managed; that is, by means of diet, irrigations or
cathartics. Currently, other operative procedures are be-
ing proposed with the idea of improving the degree of
control achieved by sphincter-preserving procedures.
From the experimental work of Gaston 2:1 it would ap-
pear that the lower few centimeters of rectum are essen-
tial to normal control, and I 24 have recently been able
to carry out satisfactory anastomosis 2 to 3 cm. above
the dentate margin, using a modified pull-through pro-
cedure. Control after this procedure, which can be de-
scribed as a combined abdomino-endorectal resection, is
normal. The operation is so promising that further trial
seems justified.
Rectum. Changes in surgical procedures for the man-
agement of lesions of the midrectum and lower portion
of the rectum have been less marked than those for
lesions of the rectosigmoid. In the majority of such cases
the rectum must be removed and questions of continence
and preservation of intestinal continuity cannot legiti-
mately be raised. The transition from staged operations
to one-stage abdominoperineal resection started before
1940 and within a few months after the introduction of
the sulfonamide drugs it was almost complete. The es-
tablishment of a proximal colonic stoma as the first
stage of a combined abdominoperineal resection is now
employed chiefly as a test of surgical procedures, in the
case of those patients who present unusually high op-
erative risks. Posterior resection, such as the Lockhart-
Mummery operation, is used less frequently than for-
merly. Posterior resection is far less radical in the re-
moval of proximal lymphatics than is combined abdomi-
noperineal resection, and the double-barreled colonic
stoma and blind segment of colon distal to the stoma are
distinct disadvantages. Formerly posterior resection was
used commonly to remove lesions in the lower third of
the rectum; now its use is restricted almost exclusively
278
The Journal-Lancet
to the treatment of extremely poor risk and obese pa-
tients whose lesions happen to be low in the rectum.
Combined abdominoperineal resection is a procedure of
considerable magnitude and is associated, at present, with
a risk of approximately 5 per cent. This is definitely
higher than the risk associated with the removal of more
proximal segments of the colon, and is attributable to
the magnitude of the operation. The morbidity and
time required for recovery have been greatly reduced by
primary closure of the posterior wound, which is now
commonly practiced.
Summary
The gratifying decrease in the risk of removing any
segment of the colon, which occurred during 1939 and
1940 and which I believe is due to chemotherapy, has
been followed by marked changes in colonic operations.
For lesions of the right portion of the colon, one-stage
resection with ileocolostomy has become the standard
procedure, the risk of which has been diminished to
2 to 3 per cent. For lesions from the midtransverse
colon to the lower part of the sigmoid, segmental resec-
tion with primary intraperitoneal anastomosis, usually
without a proximal colonic stoma, is now employed rou-
tinely. Exteriorization procedures still, however, have a
definite place in the management of such lesions and
should be employed whenever obstruction, marked in-
flammatory reaction, unusual obesity or other technical
factors make end-to-end anastomosis unsatisfactory tech-
nically. For lesions of the lower portion of the sigmoid,
the rectosigmoid and the upper part of the rectum, seg-
mental resection and primary anastomosis, usually with
a proximal colonic stoma, are employed widely at no
greater risk, in selected cases at least, than that incurred
with more proximal lesions. For the management of
somewhat more distal lesions, particularly those of the
upper part of the rectum, sphincter-saving and other
abdomino-endo-anal or endorectal operations have been
reintroduced, to avoid the necessity of a permanent ab-
dominal colonic stoma. For lesions of the midrectum and
lower part of the rectum, single-stage combined abdomi-
noperineal resection is the operation of choice. The hos-
pital mortality rate of a procedure of this magnitude
still remains at approximately 5 per cent, while seg-
mental resections of more proximal segments of the
bowel are associated with a mortality rate of approxi-
mately 3 per cent.
References
1. Bloch, Oscar: Om extra-abdominal Behandling af cancer
intestinalis (rectum derfra undtaget) med en Fremstilling af de
for denne Sygdom foretagne Operationer og deres Resultater,
Nord. med. Ark. 1:1, 1892.
2. von Mikulicz, J.: Small Contributions to the Surgery of
the Intestinal Tract. I. Cardiospasm and Its Treatment. II.
Peptic Ulcer of the Jejunum. III. Operative Treatment of
Severe Forms of Invagination of the Intestine. IV. Operation
on Malignant Growths of the Large Intestine, Boston M. & S. J.
148:608 (June 4) 1903.
3. Paul, F. T.: Colectomy, Brit. M. J. 1:1136 (May 25)
1895.
4. Rankin, F. W.: Resection and Obstruction of the Colon
(Obstructive Resection), Surg., Gynec. & Obst. 50:594 (Mar.)
1930.
5. Pemberton, J. dej.: The Effect of Chemotherapy on Sur-
gery of Malignant Lesions of the Colon, Proc. Staff Meet.,
Mayo Clin. 22:561 (Dec. 10) 1947.
6. Poth, E. J., and Knotts, F. L.: Clinical Use of Suc-
cinylsulfathiazole, Arch. Surg. 44:208-222 (Feb.) 1942.
7. Rowe, R. J., Spaulding, E. H., Madajewski, Dorothy S.,
and Bacon, H. E.: The Evaluation of Sulfathaladine and Strep-
tomycin as Adjuncts in Preparing the Large Bowel for Sur-
gery, Surg., Gynec. & Obst. 87:576 (Nov.) 1948.
8. Black, B. M., and McEachern, C. G.: Redundant Blind
Segments of Intestine Following Side-to-side Anastomosis with
Division of the Bowel; Report of 5 Cases, Surg., Gynec. & Obst.
86:177 (Feb.) 1948.
9. Mayo, C. W., and Smith, R. S.: Low Anterior Seg-
mental Resection, with or without Colostomy, Ann. Surg.
127:1046 (May) 1948.
10. McKittrick, L. S.: Principles Old and New of Resec-
tion of the Colon for Carcinoma, Surg., Gynec. & Obst. 87:15
(July) 1948.
11. Dixon, C. F.: Anterior Resection for Carcinoma Low in
the Sigmoid and the Rectosigmoid, Surgery 15:367 (March)
1944.
12. Wangensteen, O. H., and Toon, R. W.: Primary Resec-
tion of the Colon and Rectum with Particular Reference to
Cancer and Ulcerative Colitis, Am. J. Surg. 75:384 (Feb.)
1948.
13. Dixon, C. F.: Anterior Resection for Malignant Lesions
of the Upper Part of the Rectum and Lower Part of the Sig-
moid, Ann. Surg. 128:425 (Sept.) 1948.
14. Mandl, Felix: Technique and Results of Primary and
Secondary Pull-through Operation After Removal of Tumors
of the Rectum and Rectosigmoid, Surgery 18:318 (Sept.) 1945.
15. Miles, W. E.: A Method of Performing Abdomino-
perineal Excision for Carcinoma of the Rectum and Terminal
Portion of the Pelvic Colon, Lancet 2:1812 (Dec. 19) 1908.
16. Babcock, W. W.: The Symptoms and Operative Treat-
ment of Carcinoma of the Lower Bowel with a Method for the
Elimination of Colostomy, South. Surgeon 1:265 (Jan.) 1933.
17. Graham, A. S.: Current Trends in Surgery of the
Distal Colon and Rectum for Cancer, Ann. Surg. 127:1022
(May) 1948.
18. Coller, F. A., Kay, E. B., and MacIntyre, R. S.: Re-
gional Lymphatic Metastasis of Carcinoma of Rectum, Surgery
8:294 (Aug.) 1940.
19. Gabriel, W. B., Dukes, Cuthbert, and Bussey, H. J. R.:
Lymphatic Spread in Cancer of the Rectum, Brit. J. Surg.
23:395 (Oct.) 1935.
20. Gilchrist, R. K., and David, V. C.: A Consideration of
Pathological Factors Influencing Five Year Survival in Radical
Resection of the Large Bowel and Rectum for Carcinoma, Ann.
Surg. 126:421 (Oct.) 1947.
21. Glover, R P., and Waugh, J. M.: The Retrograde
Lymphatic Spread of Carcinoma of the "Rectosigmoid Region”:
Its Influence on Surgical Procedures, Surg., Gynec. & Obst.
82:434 (April) 1946.
22. Grinnell, R. S.: The Lymphatic and Venous Spread of
Carcinoma of the Rectum, Ann. Surg. 116:200 (Aug.) 1942.
23. Gaston, E. A.: Fecal Continence Following Resections of
Various Portions of the Rectum with Preservation of the Anal
Sphincters, Surg., Gynec. & Obst. 87:669 (Dec.) 1948.
24. Black, B. M.: Combined Abdomino-endorectal Resec-
tion. A Surgical Procedure Preserving Continuity of the Bowel,
for the Management of Certain Types of Carcinoma of the
Midrectum and Upper Part of the Rectum, Proc. Staff Meet.,
Mayo Clin. 23:545 (Nov. 24) 1948.
August, 1949
279
Control of Communicable Diseases
Seward E. Miller, M.D.*
Atlanta, Georgia
The control of communicable diseases is a community
problem that can be successfully resolved only by
united action on the part of the entire community. Busi-
ness men, home owners, health officers, nurses, sani-
tarians, educators, engineers, and practicing physicians
all have a vital part to play.
Techniques — Isolation and Quarantine
Among the techniques used in communicable disease
control, segregation, isolation, and quarantine have come
down to us from antiquity. In the Middle Ages people
fled from the plague-devastated cities of Europe, often
carrying the disease into other areas with them. Coun-
tries developed quarantine laws and inspection services
for self-protection, and although isolation and quaran-
tine are still practiced, we now regard them as imperfect
tools. During the past two decades there has been a con-
sistent tendency to decrease the arbitrary time assigned
for quarantine of many of the communicable diseases,
and to continuously restrict the number of specific dis-
eases for which it is employed. This is in line with pres-
ent-day knowledge of the spread of these diseases since
it has been amply proven that isolation and quarantine
are not broadly effective. For example, during the early
part of this century scarlet fever cases were isolated for
35 to 42 days, or until the termination of desquamation.
All who have studied this disease are impressed with the
lack of success in controlling and preventing scarlet fever
by isolation. There are communities in England and
Norway that for 30 years have practiced no isolation or
restrictions in scarlet fever, and their experience in the
incidence of the disease does not materially differ from
those communities that have practiced extended isolation
and quarantine. At the present time in New York City
the minimum period of isolation is only seven days.
Recent work would seem to attribute even less value to
the isolation of persons with other communicable dis-
eases. Actually, the best reason for continuing these
practices is to protect the patient from the public. It is
particularly important that cases of the childhood com-
municable diseases be protected from contact with per-
sons harboring hemolytic streptococci in their respiratory
passages, for such contacts may lead to the serious com-
plications of otitis media, mastoiditis, or pneumonia.
There is, however, no justification for failure to report
all cases of communicable diseases. All such cases should
be meticulously reported to the health department, for
frequently it is only through the summation of these in-
dividual reports that the health department can be the
first to recognize an epidemic and start the machinery
in motion to eradicate it. There are a few diseases,
* From the Communicable Disease Center, United States
Public Health Service.
notably smallpox, in which it is imperative that the
movements of all persons who have been exposed be
limited for a period of time at least equal to the longest
usual incubation period.
Isolation and quarantine have failed to control com-
municable diseases because frequently it is impractical
or impossible to achieve these measures in the home, and
because of the presence of carriers and missed cases.
Furthermore, many patients are most infectious during
the prodromal period when there are few symptoms and
before the diagnosis usually can be made. These facts
have caused us to turn our interests to the use of pre-
ventive vaccines.
Preventive Vaccines
The universal use of appropriate preventive vaccines
gives us hope of establishing community-wide immunity
for many diseases, for where there are no susceptibles
it is impossible for a disease to gain a foothold or an
epidemic to get started. Thus smallpox could be com-
pletely eliminated from this country. Fortunately, the
history of preventive biologicals in this country has been
consistently one of improving products at a lowering
cost. Fdowever, it is well to know the indications and
limitations of all such available products and to under-
stand the relative degree of protection afforded, and its
duration. In addition, it is necessary to know what age
groups, and in some instances what occupational groups,
need specific protection against pertinent infections. In
general, the preventive biologicals are most effective
when used to control person-to-person contact diseases.
Sanitation
In most instances diseases having animal reservoirs
and insect vectors, the intestinal infections, and particu-
larly those spread by water, food, and milk, are better
controlled by sanitation. Sanitary disposal of excreta,
sanitary water, and sanitary milk and food supplies for
the entire community have resulted in a miraculous de-
gree of control of typhoid fever, and in some instances
of the dysenteries.
Specific Therapy
Specific prompt therapy by physicians who recognize
the disease early and administer the appropriate specific
biological, chemical, drug, or antibiotic is now helping
to control a large number of diseases. Physicians have
at their disposal excellent well-equipped public health
laboratories to assist in making specific diagnoses by iso-
lation of the organisms involved. This is now more im-
portant than ever before. In order for the physician to
select the most appropriate therapeutic weapon, it is
absolutely essential that the causative organism be iso-
lated or evidence of its presence demonstrated by sero-
280
The Journal-Lancet
logical methods. However, it is fallacious to believe that
there is now a specific cure for all of the communicable
diseases. Unfortunately, there are still many diseases for
which no specific therapy is known.
Health Education
To make these control measures effective, all persons
of a community must intelligently comply with such iso-
lation and quarantine measures as are necessary. All
cases of communicable diseases must be reported, and
the carriers and missed cases must be sought out and
treated. The entire community must desire good sanitary
environment and the benefits of the protections afforded
by specific preventive vaccines. Furthermore, all indi-
viduals must seek the services of their physician promptly
when they become ill. This desire on the part of the
entire community can be fostered and achieved only
through continued health education, which is not some-
thing to be tossed lightly to one health educator or
nurse, but is a continuing job for all physicians, edu-
cators, and health workers.
It is quite impossible for this report to touch on every
communicable disease, but it can deal more specifically
with some groups and certain individual diseases.
Childhood Diseases
In recent years multiple antigen vaccines have been
found very effective, so that now combinations such as
diphtheria and tetanus toxoid, or diphtheria, tetanus, and
whooping cough vaccines are available and are recom-
mended. The immunological response of newborn babies
is rather poor, but all babies should be vaccinated early
for smallpox and whooping cough, and perhaps the mul-
tiple antigen vaccine can be safely administered at the
age of 4 months. The diphtheria toxoid booster dose
should be given the child before he enters school, and
another tetanus toxoid injection should be given at any
time he sustains a deep puncture wound or dirty lacera-
tion.
For chickenpox, there is no specific preventive bio-
logical or treatment. For measles, immune globulin can
greatly modify or prevent the infection, but its routine
use in children over 3 years of age is not recommended.
Though scarlet fever is well remembered as a very severe
and serious infection in the past, at the present time its
severity appears markedly decreased. There is available
an efficient preventive biological, scarlet fever toxoid,
which can be obtained in a purified form. It can be
given in three doses to children at about the age of
6 months. However, all facts considered, the importance
of routine scarlet fever immunization seems doubtful.
Epidemic diarrhea of the newborn is a disease for which
there is no specific vaccine, preventive biological, or
therapy. Continuous, strict aseptic nursery practice ap-
pears to be the best preventive measure now available.
Other Bacterial Diseases
Rheumatic fever is probably caused by various strains
of Group A hemolytic streptococci, and the only preven-
tive measure now known is the use of prophylactic doses
of sulfadiazine. For plague there is a good vaccine, but
sanitation — the "building out” of rats and their fleas —
offers the best long-term preventive measure. Typhoid
vaccine is effective but does not offer absolute protection.
Again, sanitation is the best means of preventing the
disease, although there still exist in this country many
communities with endemic foci where vaccination is nec-
essary. Tularemia has a widespread reservoir in animals
and other rodents. Dogs and cats have been the cause
of this infection in man, and it is well known that ticks
and biting flies may convey this disease. Even water in
flowing streams repeatedly has been reported by the
Rocky Mountain Laboratory of the United States Pub-
lic Health Service to be infected with tularemia organ-
isms. Tuberculosis shows some added signs of reduction
as a result of the photofluorographic case-finding tech-
nique. It is necessary, however, to prove the diagnosis
of all suspected cases by the laboratory demonstration of
the tubercle bacillus. In June 1948 the first International
Congress on Bacillus Calmette-Guerin in Paris reported
ten million vaccinations with B.C.G. during the past
25 years. The Congress further recommended the vac-
cination of all newborn, and of all frequently exposed
groups such as doctors, nurses, and medical students.
The diarrhea infections of Salmonella and Shigella ori-
gin recently have been studied extensively in Texas by
Dr. J ames Watt. He has shown that by controlling flies
on a community-wide basis the incidence of Shigella in-
fections was reduced by 30 to 50 per cent. Again it is
a sanitation job to remove and eliminate all man-made
fly-breeding places.
Rickettsial Diseases
Murine typhus fever is found in southeastern United
States, Rocky Mountain spotted fever all over this coun-
try, rickettsialpox in New York City at the present time,
and Q fever in California and Texas. These diseases all
have animal reservoirs, and except for Q fever they
have known arthropod vectors. The epidemiology of Q
fever is not yet complete, but indications are strong that
the infection may be conveyed by unpasteurized milk
from both cattle and goats. For these rickettsial infec-
tions there are effective vaccines and specific therapy.
The acute cases are most effectively treated by either
Duomycin or Chloromycetin, the latter also being effec-
tive in the treatment of acute typhoid fever. Ultimately
these two drugs may be shown to be effective in numer-
ous other bacterial diseases. However, the control of the
rickettsial infections is mostly a sanitation job through
the inspection of animals for these diseases.
Virus Diseases
For influenza, there is now a quite effective vaccine
offering good protection against the more common
strains. The duration of this protection is short, prob-
ably not exceeding one year. Against the common cold
there is no protective vaccine or specific therapy. In
the case of poliomyelitis all the vaccines to date have not
proven sufficiently innocuous to warrant their use. Con-
valescent serum, various drugs, and antibiotics have no
specific value in the treatment of acute or chronic cases.
The role of flies in the transmission of poliomyelitis
is as yet not completely determined, but it is the general
belief that they do not represent the principal mechanism
August, 1949
281
of transmission during an epidemic. Encephalitis of the
St. Louis type and of the equine types are accidental
infections in man from natural host reservoirs, birds and
animals, and transmitted by arthropod vectors. Mosqui-
toes, chicken mites, and lice have been shown to be
naturally infected vectors for these diseases.
In a further effort to assist in controlling communica-
ble diseases the Public Health Service established the
Communicable Disease Center in Atlanta, Georgia, in
1946. The Center has sought particularly to render
service in those areas where State and local authorities
are hardest pressed or where they have no facilities for
effective control. In 1947 the Communicable Disease
Center was designated by the Public Health Service
as its official office for emergency epidemic and disaster
relief. Therefore, the Communicable Disease Center
stands ready at present to assist States and local com-
munities through States, by:
1. Giving in-service type of training courses for sani-
tarians and engineers in insect and rodent control,
and general sanitation.
2. Lending expert personnel such as engineers, nurses,
veterinarians, scientists, sanitarians and physicians
for insect and rodent control, and for general sani-
tation programs.
3. Lending equipment, particularly for typhus and
malaria control programs, and also for epidemic
and disaster aid.
4. Lending training aids, filmstrips, and films covering
rodent and insect control, general sanitation, and
specific communicable disease diagnosis, prevention,
and treatment. These visual aids are especially de-
signed for use at the professional level.
5. Training of already employed technical and pro-
fessional laboratory personnel by short refresher
courses in the laboratory diagnosis of the various
communicable diseases.
6. Furnishing laboratory reference diagnostic services
for unusual specimens or for those presenting a
diagnostic problem.
7. Supplying consultation services in all fields of com-
municable disease control, sanitation, engineering,
nursing, laboratory procedures, epidemiology, and
preventive immunization.
Summary
1. Effective control of the communicable diseases is
a matter of teamwork for all members of a community.
2. People must want to prevent illness, and a tremen-
dous job in health education must be done.
3. A big sanitation job remains to be accomplished in
the prevention of many diseases.
4. Improved reporting with an all-out effort to find
and treat the carriers and atypical cases is essential.
5. Specific therapy, based on early diagnosis confirmed
by intelligent laboratory work, is absolutely necessary.
6. Community-wide immunization of infants and fre-
quently exposed groups is the only method to prevent
some diseases from gaining a foothold.
7. The Communicable Disease Center of the United
States Public Health Service is now rendering much
assistance to States and local communities (through the
States) in many phases of their communicable disease
control programs.
8. Communicable diseases can be effectively controlled
by the efficient and efficacious use of all these measures
on a community-wide basis, with the elimination of much
needless suffering and with marked reductions in mor-
bidity and mortality.
American College Health Association Neivs
Two hundred and thirty colleges and universities are members of the American College
Health Association. Membership dues for 1949 have been paid by 96 per cent of the mem-
ber institutions. What about the delinquent four per cent? The secretary hopes to hear from
these institutions soon.
Membership promotion is possible by nominations made by present members. Mem-
bership application blanks can be obtained from the office of the secretary.
Because of changes in the personnel of college health services, it is difficult to keep
records up to date. The secretary requests that any changes in staff be reported to her office.
5}c i}c ijc Jfl ijC
Ohio University is in need of an experienced clinician, preferably interested in chest
work. The position has attractive features, including new building. Address Dr. E. H.
Hudson, Director of Health Service, Ohio University, Athens, Ohio.
282
The Journal-Lancet
A Clinical Evaluation of Aqueous Thephorin.
A New Parenteral Antihistaminic Agent
A. L. Maietta, M.D.*
Boston, Massachusetts
In recent years, a large number of reports have ap-
peared in the literature attesting the therapeutic value
of antihistaminic preparations as palliatives for certain
allergic disorders. Commonly, these agents have been
administered by the oral route. Friedlaender and Fried-
laender1 recognized that the response to this type of
medication varied with different individuals depending
greatly upon (1) the location and intensity of the aller-
gic manifestation; (2) differences upon gastrointestinal
absorption; and (3) the amount of histamine which may
differ in some allergic disorders or the amount of hista-
mine release which, in certain instances, is too great to
be controlled adequately by the usual non-toxic oral
doses. They also noted that, in ambulatory patients, in-
ordinate oral doses, when required to control the symp-
toms, were undesirable because of frequent and pro-
nounced side effects and that, oftentimes, even large oral
doses failed to produce symptomatic relief.
Parenteral antihistaminic therapy should be considered
when (1) patients are unable to take antihistaminics
orally; (2) excessive oral doses, always potentially haz-
ardous because of their pronounced side reactions, are
required to alleviate the symptoms; (3) smaller doses,
administered parenterally and at less frequent intervals,
can control more adequately the allergic manifestation;
and (4) it is deemed advisable to interchange or combine
small oral and parenteral doses.
Further, according to Yonkman and Mohr," paren-
teral antihistaminic therapy appears to be indicated in
"epinephrine-fast” cases. These authors believe that the
asthmatic subject becomes epinephrine-fast because of
the predominance of histamine, produced or released by
the administration of epinephrine. The injection of an
antihistaminic agent should inhibit clinically the edema-
promoting action of histamine and should also nullify
contraction of the bronchial mucosa by histamine. Thus,
the bronchodilating effect of epinephrine is allowed to
predominate with attending dramatic relief to the gasp-
ing "epinephrine-fast” asthmatic. Successive doses of
epinephrine, if indicated, should relax the bronchi in the
presence of specific antihistaminic therapy.
For some time, an aqueous solution of Thephorin,'}'
containing 25 mg. of Thephorin per cc., has been made
available to us for clinical study. This preparation has
fSupplied by Hoffman-La Roche, Inc., Nutley, N. J.
*Junior Visiting Physician and Chief of the Allergy Clinic,
Carney Hospital, Boston Massachusetts; Physician, Winchester
Hospital, Winchester, Massachusetts.
been employed parenterally, as a palliative and a prophy-
lactic, in 65 allergic patients.
In the study, there were 28 males and 37 females.
Fifty-six patients were over, while nine were under
100 pounds. Their ages ranged from 4 to 63 years.
Aqueous Thephorin has been administered subcutane-
ously, intramuscularly, and intravenously, once or twice
daily as indicated. Subcutaneously, in doses of 25 mg.,
it usually caused a slight burning or stinging sensation
which occasionally was followed by a minimum amount
of induration and a small erythematous flare at the site
of injection. Deposited intramuscularly in doses of 15
or 25 mg., it caused a momentary feeling of burning
and stinging followed by local muscle soreness. These
local post-injection symptoms were inconsequential and
disappeared within a relatively short time. Intravenous
injections were reserved for the very serious cases. All
intravenous injections were diluted with equal parts of
sterile normal saline solution and were administered
slowly in about 10 seconds. For adults, the initial intra-
venous dose was 12.5 mg. (J 4 cc.) . If the first intra-
venous medication was well tolerated, successive doses
were 12.5, 15, 20, or 25 mg., as the clinical symptoms
dictated. Intravenous injections were unaccompanied by
any local effects.
Side reactions were surprisingly few when the paren-
teral route alone was employed. Drowsiness was the
only toxic manifestation encountered. It usually was
slight, did not induce sleep, and lasted from a few
minutes to a half hour. However, when Thephorin was
administered by both the parenteral and oral routes, side
reactions were more frequent. Drowsiness was the most
prominent; while jitteriness, insomnia, dizziness, numb-
ness, and fatigue also were noted occasionally. These
symptoms were relatively mild and disappeared in from
one to three hours.
Results
Bronchial Asthma. In contradistinction to previous
reports a that antihistaminics, administered orally, have
not been strikingly helpful in asthma, the antiasthmatic
action of parenteral Thephorin is marked. In our ex-
perience, its efficacy is distinct. Its palliative action,
though constantly beneficial, may vary, one dose occa-
sionally producing a more pronounced response than
another. It was employed as an adjunct to other accept-
ed forms of therapy and, oftentimes, appeared to possess
a synergistic action with epinephrine. When broncho-
dilator drugs failed to produce the desired result, paren-
teral Thephorin seemed to enhance their effect in sub-
sequent administrations. Aqueous Thephorin was given
August, 1949
283
parenterally with favorable results to 17 patients with
bronchial asthma, four of whom were in status asthmati-
cus. These patients received ephedrine orally and epi-
nephrine, both aqueous 1:1000 and in oil. In addition,
the four patients with status asthmaticus were given
aminophyllin intravenously or rectally by suppository.
With such a regimen, their symptoms were only briefly
or partially relieved. The administration of parenteral
Thephorin, either intramuscularly or intravenously, pro-
duced an amelioration of their symptomatology. Within
one hour, the wheeze and dyspnea lessened; the patient
became quieter; and the vital capacity, as determined by
the McKesson-Scott apparatus, generally was increased.
Subsequently, such valuable antiasthmatic drugs as
ephedrine, epinephrine, and aminophyllin, became more
effective and, not infrequently, the interval between their
administration could be lengthened. The dose of paren-
teral Thephorin was repeated once or twice daily, as
indicated.
Case Report. D. D., a male of 42, had asthma and eczema
for 39 years and, in latter years, hay fever during August and
September. He exhibited positive skin tests to egg, house dust,
bacterial vaccine of the Catarrhalis type, birch, orchard grass,
redtop, timothy, and ragweed. Smoke, sharp odors, paint fumes,
dusts, sudden changes in temperature, windy days, dampness,
and prolonged rain aggravated his asthmatic state. Egg was
eliminated from his diet and desensitization injections of house
dust and vaccine were given. During four months (November
1948 to March 1949), he had four hospital admissions for
severe status asthmaticus. The first three hospital stays were
stormy and averaged twelve days each. Treatment consisted of
ephedrine, epinephrine, both aqueous and in oil, Demerol,
aminophyllin intravenously, and Isuprel and penicillin aerosols.
During his last admission, he received 5 mms. of aqueous
epinephrine every three or four hours, as indicated, and 1 ampul
of epinephrine in oil together with an aminophyllin suppository
rectally every eight hours. In addition, he was given 25 mg.
of Thephorin intravenously once or twice daily. On the first and
second days, one intravenous injection of Thephorin daily pro-
duced such marked amelioration that epinephrine was not re-
quired for several hours. He experienced only slight, transient
drowsiness and, because his symptoms, for the time, were well
controlled, enjoyed the best sleep at night that he had had in
months. On the third day, the morning injection of Thephorin
did not improve his symptoms very much. Six hours later,
despite additional doses of epinephrine, his asthma became worse
and aminophyllin was given intravenously. During the course
of its administration, the patient vomited and its further injec-
tion was suspended. A few minutes later, he received 25 mg.
of Thephorin intravenously and 100 mg. of Demerol. Within
one hour he was improved and required no additional epineph-
rine until the next morning. On the fourth day, he was given
another 25 mg. dose of Thephorin intravenously and, since then,
his symptoms were well controlled with 1 ampul of epinephrine
in oil at bedtime and an occasional injection of aqueous epineph-
rine during the day. On the fifth day, he was ambulatory and,
on the seventh hospital day, was discharged with marked clin-
ical improvement.
Cutaneous Allergy. The favorable influence of paren-
teral Thephorin on cutaneous allergic manifestations was
striking. Eight patients, 5 with angioneurotic edema
and urticaria, 2 with urticaria, and 1 with eczema and
angioneurotic edema were benefited. Some of these
patients previously had received other antihistaminics
orally with only partial relief. Later, these drugs were
discontinued because of pronounced side reactions.
Case Reports. N. A., a 63-year-old female, with severe angio-
neurotic edema and generalized urticaria of forty-eight hours
duration following the ingestion of half an Anacin tablet taken
for the relief of a headache was improved with 25 mg. of
Thephorin intramuscularly. There was a noticeable recession
of the swelling within a relatively short time. Subsequently,
this favorable state was maintained with oral doses.
C. B., a 52-year-old male with a severe penicillin reaction
requiring hospitalization, exhibited generalized, giant urticaria
from scalp to toes and angioneurotic edema of the face, lips
and eyelids. Two intramuscular injections of parenteral Theph-
orin daily supplemented with oral doses were sufficient to so
improve his symptoms that he was discharged on the fourth
hospital day.
M. M., a 32-year-old female, had eczema and angioneurotic
edema for 20 years with frequent exacerbations. Elimination
diets, vitamins, and calcium therapy had proved relatively in-
effective. When examined, the symptoms were moderately
severe. Parenteral and oral Thephorin combined with the ad-
ministration of calcium gluconate and multiple vitamins pro-
duced a very satisfactory result.
Perennial Allergic Coryza. Three patients, with symp-
toms of perennial allergic coryza of several years dura-
tion, responded favorably to parenteral Thephorin. Ob-
jectively, they demonstrated boggy turbinates, an edema-
tous mucous membrane, and rhinorrhea. In the past,
one other antihistaminic orally afforded fair to moderate
relief but had to be discontinued because of its side
effects. A 25 mg. dose of Thephorin subcutaneously
produced a temporary but satisfactory alleviation. For
several hours thereafter, the nasal obstruction was de-
creased, breathing was easier, and the nasal discharge
diminished greatly.
Migraine. Two patients with migraine were spectacu-
larly relieved with parenteral Thephorin. Intravenous
administration produced recovery within a few minutes;
intramuscular within one hour.
Case Report. R. S., a 45-year-old male, had periodic attacks
of migraine for the past 25 years. A positive family history of
allergy was present, the mother having bronchial asthma and a
sister hav fever and eczema. His symptoms ran the classical
gamut, — scotomata, head pain, facial pallor, nausea, vomiting,
retching, exhaustion, and sleep. Seconal and Gynergen afforded
the best relief. Two hours usually would elapse after taking the
medication before he was able to be up and about. During the
last attack, as the severe headache developed, he received 12.5
mg. (/ cc.) of Thephorin intravenously. Within 12 minutes
after its administration, the sequence of symptoms was dis-
rupted and the patient made a dramatic recovery. He experi-
enced no drowsiness and was able to resume his normal activi-
ties.
Infrequency of Constitutional Reactions. The prophy-
lactic effect of parenteral Thephorin was demonstrated
in a group of 35 ragweed-sensitive patients on pernnial
treatment. Top pollen doses were given at bimonthly
intervals by combining the ragweed antigen with 25 mg.
( 1 cc.) of aqueous Thephorin in the same subcutaneous
injection which was supplemented by two double oral
doses of Thephorin, a 50 mg. dose being given 20 min-
utes prior to the injection (preinjection oral dose) and
another 50 mg. dose one hour afterwards (postinjection
oral dose) . The top pollen dose for 22 patients was
20.000 Coca-Noon Pollen Units and for 13 patients
10.000 pollen units. Each pollen unit contained 0.00001
mg. of total nitrogen. This group of patients received
the combined antigen-antihistaminic treatment at bi-
monthly intervals on four occasions, a total of 140 in-
jections. The significant observations in this study were
that 34 patients (97 per cent) safely tolerated their
massive pollen doses and constitutional reactions were
rarely encountered despite the fact that (1) top pollen
284
The Journal-Lancet
doses were administered instead of a substantially re-
duced amount of antigen as is customarily done in peren-
nial pollen therapy; (2) the interval between injections
was lengthened from the usual three or four to eight
to ten weeks; and (3) the amount of antigen, being
given at a time when the blocking antibody titre was
falling, constituted a deliberate overdose from which a
systemic reaction ordinarily could be anticipated. Only
one patient, whenever the top dose of 10,000 pollen units
was administered, exhibited mild, delayed constitutional
reactions which were adequately controlled with addi-
tional oral doses of Thephorin.
Summary and Conclusions
Aqueous Thephorin is a safe medicament and is suit-
able for parenteral administration. It has been given
subcutaneously, intramuscularly, and intravenously. Side
reactions have been negligible, slight drowsiness being
the outstanding symptom. Aqueous Thephorin, admin-
istered parenterally in doses of 12.5 to 25 mg., has been
employed as a palliative and a prophylactic. In a num-
ber of allergic manifestations, including bronchial asth-
ma, status asthmaticus, eczema, urticaria, angioneurotic
edema, perennial allergic coryza, and migraine, it has
exerted a distinctly beneficial influence. Oftentimes, in
bronchial asthma it apparently behaved as a synergist,
enhancing the action of epinephrine. As a prophylactic
agent, it has been combined in the same injection with
massive doses of pollen antigen and, in 97 per cent of
the cases, has prevented the anticipated constitutional
reaction which ordinarily may follow a deliberate over-
dose of pollen extract. When indicated, the parenteral
route can be interchanged or combined effectively with
small oral doses. Parenteral Thephorin appears to be
a valuable adjunct in the treatment of allergic diseases.
References
1. Friedlaender, S., and Friedlaender, A. S.: Parenteral
Benadryl in Allergy, Amer. Jour. Med., 4:863-865, 1948.
2. Yonkman, F. F., and Mohr, F. L.: An Approach to the
Problem of "Epinephrine Fastness,” Ann. Allergy, 7:60-61,
1949.
3. Beckman, H.: Treatment in General Practice, 6th edi-
tion, page 433, Philadelphia, Penn., 1948, W. B. Saunders Co.
Meet Our Contributors
William C. Keetel, M.D., Iowa City, Iowa, was grad-
uated from the University of Nebraska in 1936; special-
izes in Obstetrics and Gynecology; Assistant Professor of
Obstetrics and Gynecology, University of Iowa College
of Medicine; member, Central Association of Obstetrics
and Gynecology, Iowa Obstetric and Gynecologic Society,
Alpha Omega Alpha, Sigma Xi.
James G. Lee, M.D., Iowa City, Iowa, was graduated
from the University of Kansas in 1944; specializes in
Obstetrics and Gynecology; resident, Department of
Obstetrics and Gynecology, University of Iowa Medical
College.
John H. Randall, M.D., Iowa City, Iowa, was grad-
uated from the University of Iowa in 1928; specializes
in Obstetrics and Gynecology; Professor of Obstetrics
and Gynecology, University of Iowa College of Medicine.
Harold F. Buchstein, M.D., Minneapolis, was grad-
uated from University of Minnesota in 1934, M.D., M.S.,
in Neurosurgery, with graduate work at the Mayo Clinic
and Yale University; practicing Minneapolis neurosur-
geon since 1939; Fellow, American College of Surgeons;
Diplomate, American Board of Neurological Surgery;
attending Neurosurgeon, Veterans Administration Hos-
pital.
Edward C. Maeder, M.D., Minneapolis, was graduated
from the University of Minnesota in 1927; specializes in
Obstetrics and Gynecology; Ph.D., Obstetrics and Gyne-
cology; Diplomate, American Board of Obstetrics and
Gynecology; member, American College of Surgeons,
Minnesota Obstetrics and Gynecology Society, Alpha
Omega Alpha, Sigma Xi; Attending Physician, Minne-
apolis General Hospital.
B. Marden Black, M.D., Rochester, Minnesota, was
graduated from Stanford University Medical School in
1936; specializes in Surgery; member, American Goiter
Association, American Board of Surgery, Minnesota Sur-
gical Society, Alpha Omega Alpha, Sigma Xi, American
College of Surgeons; Head of Section, Division of Sur-
gery, Mayo Clinic.
Seward E. Miller, M.D., Atlanta, Georgia, was graduat-
ed from the University of Michigan in 1931; specializes in
Laboratory Medicine; Chief, Laboratory Division, Com-
municable Disease Center, U. S. Public Health Service;
member, American Public Health Association, Military
Surgeons, Coordinating Committee on Laboratory Meth-
ods of American Public Health Association.
A. L. Maietta, M.D., Boston, Massachusetts, was grad-
uated from Middlesex Medical School in 1930; specializes
in Allergy, member, Massachusetts Medical Society,
American College of Allergists, International Corres-
pondence Society of Allergists, Association of Military
Surgeons.
Antonio Rottino, M.D., New York City, was graduated
from New York University School of Medicine in 1929;
specializes in Pathology; member, New York Academy
of Science, New York Pathology Society, American So-
ciety of Pathology and Bacteriology; Vice President,
Hodgkins Disease Foundation; Secretary, New York
Pathology Society.
August, 1949
285
The Effect of Adenosine-5-Monophosphate
on Pruritus
Antonio Rottino, M.D.*
New York, New York
The following observation was made by chance while
treating patients suffering from Hodgkin’s disease
with adenosine -5 -monophosphate,** namely, complete
subsidence or amelioration of pruritus. The drug was ad-
ministered during the week of December 3, 1948, to a
group of Hodgkin’s disease patients to see whether it
might possibly increase their physical energy.^ In this
respect no results ensued, but two patients — the only
ones in the group suffering from pruritus — reported cas-
ually that this symptom had completely disappeared on
the sixth and seventh days of therapy. Approximately
thirty days after discontinuance of adenylic acid therapy
both patients suffered a recurrence of the pruritus; after
renewed administration of the drug the pruritus once
more disappeared. Following this experience many other
patients having pruritus due to various causes were treat-
ed by the author and by colleagues.^
To date, June 24, 1949, forty-four patients have been
treated. In five instances the pruritus was associated
with diabetes mellitus (four cases under insulin control
and one as yet untreated) , in ten instances with Hodg-
kin’s disease, in one with carcinoma of the ovary, in
one with Duhring’s disease, in one with hair dye sensi-
tivity, in one with obstructive jaundice. Twenty-two
cases were idiopathic and three occurred postpartum.
In the majority of cases the pruritus was severe, of long
standing, and had been previously subjected to numer-
ous therapies. Distribution of pruritus was in 23 in-
stances generalized, in 16 instances the genitals (vulva,
scrotum, anus) were involved, and in four instances the
extremities.
*From the Hodgkin’s Disease Research Laboratory (supported
by grants from the National Cancer Institute of the U. S. Pub-
lic Health Service, American Cancer Society, and the Damon
Runyon Memorial Fund), and the Department of Medicine,
St. Vincent’s Hospital, New York.
**The preparation used was "My-B-Den,” made and supplied
by Ernst Bischoff Company, Inc.
fThis was done at the suggestion of Prof. Kurt Stern, Poly-
technic Institute of Brooklyn.
JDrs. Lloyd Craver, A. Susinno, Richard Kennedy, O. Cani-
zares, A. Shapiro, J. Corr, W. Stankard, and F. Jost, to whom
I express my appreciation.
Results
Results were negative for 8 patients and positive for
36. There were 14 cases of complete subsidence, 15 of
marked improvement, 5 of moderate improvement and
2 of mild improvement. To date the pruritus has re-
turned in ten instances; five of these patients have been
retreated and have responded favorably to the second
series of medications, four with complete relief and one
with moderate relief.
Administration
The most favorable and uniform results were obtained
from intramuscular injection: 20 mg. dissolved in water,
five doses given at hourly intervals for three consecutive
days. As a rule the response, whether mild, moderate
or complete, occurred in one or two days. Response
usually occurred by the end of three days if at all,
although there were several exceptions to this. No toxic
symptoms were noted when the drug was given as out-
lined above. We are now experimenting with oral ad-
ministration; this promises to be successful but data are
not yet sufficient to include in this report.
Conclusions
The results would appear to indicate that the number
of patients reacting favorably to the drug is too large
to be the result of mere chance. Of interest also is the
fact that in some instances the pruritus not only dis-
appeared but the skin became softer and less dry. The
effect on the skin had been noted earlier 1 but not ex-
panded upon. Sufficient time has not yet elapsed to pre-
sent a complete evaluation, but the results to date seem
sufficiently dramatic to warrant presenting this prelim-
inary report. Not only is there promise of a valuable
therapeutic agent; the light which further study may
throw on heretofore unsuspected mechanisms related to
dermatological conditions in general and to the symp-
tom of pruritus in particular seems to be equally im-
portant. From available data it would appear that an
altered phosphorylation mechanism related to deficiency
of adenylic acid may be responsible for pruritus and
for certain forms of skin disease.
^Carlstrom, B., and Olle Lovgren: Acta Medica 110, 230
(1942).
286
The Journal-Lancet
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. A B. Baker
Dr. Ruth E. Boynton
Dr H S Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J . C. Fawcett
Dr. A R. Foss
Dr. C J . Glaspel
Dr. J . F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H Long
Dr. O J Mabee
Dr. A. D McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J . H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J . Simons
Dr. J . H. Simons
Dr. Joseph Sorkness
Dr. S. A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
North Dakota State Medical Association
Dr. W. A. Wright, President
Dr. L. W. Larson, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
ADVISORY COUNCIL
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Thomas J. Kinsella, President
Dr. Cyrus O. Hanson, Vice President
Dr. C. H. McKenzie, Secretary
Dr. Stuart Lane Arey, Treasurer
Dr. Henry E. Hoffert, Recorder
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
Editorial
THE ROLE OF HEALTH COUNCILS
IN MINNESOTA
Minnesotans are becoming more and more aware of
the important role local health councils can play in pro-
moting better health. We seem to have reached the stage
in public health where further progress calls for under-
standing and participation by informed lay citizens.
Although we have succeeded in reducing the infant and
maternal mortality rate to one of the lowest in the coun-
try, reducing the tuberculosis death rate, and almost
eradicating several other communicable diseases, we still
have many health needs that are not adequately met.
For example, Minnesota is lagging behind many other
states in providing for the health of its rural people.
Almost two million of our population have no full-time
local health services. Many villages are without sewage
treatment plants. Too many people are having needless
accidents. Too many industrial workers are subjected to
unnecessary health hazards. Cancer and heart disease
and diabetes are claiming too many young adults.
Professional health workers realize that they them-
selves are helpless in meeting these problems and similar
ones unless they have the interest, understanding, and
cooperation of all citizens. Most of these problems re-
quire concerted local action to bring about desirable
changes. Serving on a community health council is an
excellent way for citizens to learn how to gain better
health for themselves, their families, and their com-
munities.
A stimulus to the creation of health councils in Min-
nesota was provided during the past eighteen months by
the Health Days held in many centers throughout the
state. These Health Days were occasions when hundreds
of people gathered to discuss their community health
problems and listen to talks by experts in many health
fields. The Health Day idea originated with the wom-
en’s auxiliary of the Southwestern Minnesota Medical
Society. Auxiliary and medical society members in all
parts of Minnesota worked with the State Department
of Health and with a great many other official and vol-
untary health agencies in promoting these meetings.
Many citizens who participated in Health Days felt
that some permanent organization should be set up for
finding and solving community health problems. This is
just what a health council does. It may justly be said
that the health councils so far organized in Minnesota
developed directly out of the activities of Health Days.
What Is a Health Council?
A health council can be defined very simply as a group
of people who have joined together to improve commu-
August, 1949
287
nity health conditions. The main requirement for a suc-
cessful council is a group of citizens who are willing to
work in order to find, study, and solve their local health
problems. Health councils may be organized on a state,
district, county, village, or neighborhood basis.
Who Belongs to a Health Council?
Membership in a health council will vary from place
to place, depending upon local conditions. However,
it is generally agreed that it is wise to have the council
as inclusive as possible, with broad representation from
all community groups. Any citizen interested in the pro-
motion of health in the county is eligible for member-
ship in two of the county-wide health councils now oper-
ating in Minnesota. Any organization similarly inter-
ested may elect one representative to serve as a member
of the council.
Usually a community health council consists of repre-
sentatives from professional groups such as medical,
dental, nursing, engineering, welfare, and teaching; from
voluntary organizations interested in health, such as the
Red Cross, Christmas Seal organization, and Boy Scouts;
from churches; from civic groups such as Chambers of
Commerce and service clubs; agricultural, business, and
labor groups; city and county officials; and citizens-at-
large.
What Does a Health Council Do?
The purpose of a health council is to get citizens to
work together in improving health conditions in their
area. Generally speaking, a health council does the
following:
1. Coordinates health programs in the community.
2. Finds and studies health needs in the community.
3. Stimulates community interest and develops under-
standing of public health problems.
4. Undertakes health projects and programs in the
community.
The work of a health council is usually done through
committees. A currently active county-wide health coun-
cil may serve as an illustration.
Activities of the Nobles County
Health Council
The Sanitation committee, whose chairman is a farmer
active in the Farmers Union, recognized the need for
improving sanitary conditions in public eating places in
the county. The committee members got in touch with
owners and employees in food and drink establishments
and talked over some of their problems. Both the food-
handlers and the people in the community expressed an
interest in a short course on food handling. The com-
mittee secured Mr. Harold S. Adams, director of the
Division of Hotel and Resort Inspection, Minnesota
Department of Health, to teach the course. About 175
foodhandlers in the county attended and all of them
showed a real interest in improving conditions in their
own places of business.
The Mental Health committee, under the chairman-
ship of the judge of Probate Court, has been working
on a program for the prevention and elimination of
some mental health problems. This committee has en-
listed the help of Dr. Dale B. Harris, professor in the
Institute of Child Welfare, University of Minnesota,
to conduct a mental hygiene survey of the school chil-
dren in Nobles county. The committee feels that the
survey will give some idea of the extent of emotional
difficulties in school children in their county and will
develop a general awareness of this problem. The coun-
cil hopes that the county in the near future will employ
a person specially trained in mental health who will work
with parents, teachers, children, physicians, welfare work-
ers, and others in reducing this problem.
The School Health committee, led by a physician, has
made an extensive inventory of existing school health
services in the county. The aim of this committee is
to find the weak spots in school health programs and to
encourage improvements.
Organization of a Health Council
There are no set rules that must be followed in the
organization of a health council. Here again, methods
are best determined by local circumstances. What is
best for one community may not serve another. The one
requisite of a successful council is that citizens want the
organization and are willing to work together in it. Fre-
quently, interest is limited at first to a small nucleus of
people. They in turn have to interpret the idea to others.
Most health councils elect a chairman, vice-chairman,
and secretary as well as three to seven directors. This
group serves as a board of directors or an executive or
interim committee. They carry on business and make
any necessary decisions between meetings of the whole
council, which are usually held at least three times a
year. Meanwhile the various committees carry on their
work, which is determined by the chief health needs in
the community. Members of the council work on com-
mittees handling problems in which they have a particu-
lar interest. The Cottonwood County Health Council
has committees on Sanitation, Safety, Mental Health,
Public Relations, School Health, Rural Health, and
Finance.
People often have to learn how to work together on
health council committees. In the beginning it is usually
best for committees to undertake short-term projects that
they can actually do something about, in order that
workers will reap some reward for their effort. As the
group matures, it can undertake more difficult and time-
consuming projects.
Both laymen and professional health workers should
be included in each committee. Experience has shown
that such joint groups can work out community prob-
lems in accordance with the best public health standards.
The Role of the Physician
The physician is looked upon by all as the health
leader in the community. To be successful a health
council must have the approval and active cooperation
of the medical profession. The role of the physician,
however, is not in dictating policies and practices, but
rather in working with non-medical people in a way that
enables the whole group to discover real problems, un-
288
The Journal-Lancet
derstand the facts underlying those problems, and work
out methods for solving them.
Resources of Local Councils
Various state and national organizations are inter-
ested in the development of local health councils, and
are willing to help them.
Plans are under way in Minnesota for the creation
of a State Health Council. The original group will
consist of representatives from 27 agencies that have
a vital interest in public health. One of the main func-
tions of the state health council will be to assist the de-
velopment of local councils. Plans call for an executive
director and staff. Member organizations will be asked
to contribute to the support of the council. The Minne-
sota State Medical Society has already set aside funds
to contribute its share toward this project. Personnel
from the Minnesota State Department of Health will
give whatever help they can.
Then there is the National Health Council with head-
quarters at 1790 Broadway, New York City. This
group, organized in 1921, now includes 23 national
health organizations in its membership. Its main con-
cerns for the immediate future are to stimulate the pro-
motion of new state and local health councils, to co-
operate with existing ones to secure more efficient health
services, and recruit and train personnel for health
council work.
It is hoped that health councils will develop in many
more places in our state.
News Items
South Dakota
Deans of university medical schools from seven states
met in Deadwood July 14-15 to discuss problems of med-
ical education. In addition to Dr. Slaughter, dean of
the University of South Dakota, the state was repre-
sented by Dr. W. L. Hard and Dr. R. L. Ferguson.
Othere states represented were North Dakota, Nebraska,
Kansas, Colorado, Missouri and Iowa. Invitations to
attend the meeting were extended physicians at Belle
Fourche, Newell, Sanator, Custer, Hot Springs, Edge-
mont, Spearfish, Lead, Deadwood and Sturgis.
Dr. Warren R. Anderson, formerly of Cambridge,
Minnesota, is now associated with Dr. Will Donahoe,
Sioux Falls, in the treatment of children’s diseases.
Dr. Anderson is a 1942 graduate of the University
of Minnesota Medical School and took his internship
at Minneapolis General Hospital. He was commissioned
into the medical corps in 1943 and was discharged in
1946 following 18 months in the European theatre. He
then took residency training in pediatrics and children’s
diseases at Minneapolis General Hospital, University of
Minnesota Hospital and St. Barnabas Hospital in Min-
neapolis.
Pennington county commissioners have appointed Dr.
F. A. Rudolph to the post of county coroner until the
next general county elections. Dr. Rudolph, who is
county physician, was appointed to fill the position just
vacated by Dr. D. L. Kegaries, who resigned recently.
Garretson now has another doctor. Dr. E. Suckow,
M.D., arrived there in July with his family, and is get-
ting ready to start practice of general medicine and sur-
gery. Dr. Suckow is a graduate of the medical school
of Northwestern University in Chicago, and interned
at Wesley Memorial Hospital in Chicago. He has also
done considerable research work at the Northwestern
Medical School and was an instructor in physiology for
the medical students at the college.
North Dakota
Dr. Wayne E. LeBien recently joined the pediatric
staff of the Fargo Clinic.
Dr. LeBien, born and raised at McHenry, North
Dakota, attended North Dakota University and is a
graduate of N.D.A.C. with a degree in pharmacy. He
received his M.D. from the University of Minnesota
Medical School, interning at two Minneapolis hospitals,
Lutheran Deaconess and Minneapolis General. Dr. Le-
Bien also did postgraduate work and was a teaching
fellow in pediatrics at Minneapolis General Hospital.
Newest Bismarck surgeon is Dr. Myron W. Gough-
nour, who joined the staff of the Henderson and Orr
clinic in Bismarck in July. The new physician will
specialize in surgery in his practice in Bismarck.
Thirty-six applicants have been licensed to practice
medicine and surgery in North Dakota following the
completion of examinations given in Grand Forks by the
state board of medical examiners. Tests were completed
Friday, according to Dr. C. J. Glaspel of Grafton, sec-
retary of the board.
Newly-licensed doctors, their home address and the
town in which they intend to locate include: Richard H.
Leigh of Grand Forks; Louis F. Pine of Burlington, Vt.,
Devils Lake; E. Madison Paine of Grand Lodge, Mich.,
Minot; Wellington B. Huntley of Ann Arbor, Mich.,
Minot; John A. Beall of Gabon, Ohio, Jamestown;
William G. Ensign of Defiance, Ohio, Minot; and
Myron W. Goughnour of Hazelton, Bismarck.
Other successful applicants are Charles B. Porter of
Baltimore, Md., who plans to locate in Grand Forks;
Clifford F. Gryte of Hoople, Diedrich L. Oltman of
Hampton, 111., Minot; Gordon A. Salnes of Overly;
Fredrick N. Walsh of Winnipeg, Man., Drayton; James
DeVicardy of Edmonton, Alberta; David Hoehn of
Chattanooga, Tenn., Sharon; Gilbert S. Wheeler of
Winnipeg, Man., Portland; Amandus C. Kohlmeier of
Winnipeg, Man.; Julian Tosky of Transcona, Canada,
Larimore, and Duane W. Nagle of Marion, Enderlin.
Completing the list of new doctors with their home
addresses and intended locations, are Harry A. Ohrt of
August, 1949
289
Mileston, Sask.; William P. Teevens of Wawota, Sask.,
Minot; George L. Loeb of San Haven; William E.
Barker of Lewvan, Sask., Wesley E. Levi of Zeeland,
Linton; George M. Hart of Elgin, 111., Minot; William
S. Pollard of Winnipeg, Devils Lake; John T. Boyle of
Newark, N. J., Garrison; Bernice F. Andrews of Chat-
tanooga, Tenn., Sharon; Roy E. Eldred of Crosby,
Minnesota
On June 4, 1949, Dr. Vernon L. Hart presented a
paper entitled "Recognition and Treatment of Congeni-
tal Dislocation of the Hip During the First Six Months
of Life” at the Harvard Medical School. He also pre-
sented a paper on the same subject at the American
Medical Association meeting in Atlantic City. A motion
picture by Dr. Hart and his associate, Dr. Wesley H.
Burnham, was presented each day of the meeting in the
Scientific Exhibit.
Dr. J. Dewey Bisgaard, Omaha, president of the
Central Surgical Society of the United States and
Canada, and professor of surgery at the University of
Nebraska, was the principal speaker at the annual ban-
quet meeting of the St. Louis County and Range Med-
ical Society on Tuesday, June 28, at 6:30 P.M. at
Burntside Lodge. Dr. Jack P. Grahek, Ely, was in
charge of arrangements and served as toastmaster for
the banquet.
Dr. Robert N. Barr was appointed deputy executive
officer of the Minnesota health department in July by
the state board of health meeting at the University of
Minnesota.
Dr. M. B. Hesdorffer was named director of the
health and medical care division of the Community
Chest and Council of Hennepin county.
Dr. Hesdorffer is medical consultant for the Veterans’
administration insurance service program in this region.
He replaces Dr. D. A. Dukelow, who left March 1 to
become medical consultant on health and fitness for the
American Medical Association in Chicago.
Dr. H. B. Clark was again named as prize-winner of
the 1949 American Physicians Art Association exhibit
at the American Medical Association’s convention in
Atlantic City, N. J., June 12-15. Dr. Clark’s painting,
entitled "Sunflower Farm” is a scene taken from a farm
near St. Cloud.
New officers of the Minnesota Surgical Society, elect-
ed during the society’s meeting at Duluth, are Dr. M.
G. Gillespie, Duluth, secretary-treasurer; Dr. L. W.
Johnsrud, Hibbing, vice-president, and Dr. Gordon Mac-
Rae, Duluth, president.
Dr. Owen H. Wangensteen, chairman of the surgery
deparment of the University of Minnesota medical
school, was named president of the Minnesota Medical
Foundation. Dr. George N. Aagaard, director of the
university’s postgraduate medical education, was chosen
secretary-treasurer.
Obituaries
Dr. Herbert H. Hodgson, a practicing physician of
Crookston for 50 years, died Sunday, July 3, in St. Paul.
The end came for the long-time Crookston physician
while he and his wife were visiting his daughter, Dr.
Jane Quattlebaum of St. Paul. He was 79 years old.
Dr. Herbert A. Burns, 66, chief of the tuberculosis
control unit of the division of state institutions, died
July 8 at Veterans Hospital.
Dr. Burns had devoted his entire professional career
to the fight against tuberculosis and was a nationally-
recognized authority on the disease. He had been on
leave of absence from his official duties since July 1.
Dr. James H. Bentson, 31, former St. Paulite and a
fellow at the Mayo Clinic in Rochester, died June 28
in New York City after a brief illness.
A native of St. Paul, Dr. Bentson was educated at
St. Paul Academy and the University of Minnesota,
from which he was graduated in 1942. Since his grad-
uation he had lived in Rochester. He was on a vacation
in New York at the time of his death.
Dr. Wilhelm S. Anderson, 73, Northfield, retired
physician, died June 26 following a heart attack. He
was 73 years old.
After graduating from St. Olaf College and the Uni-
versity of Minnesota in 1903, Dr. Anderson practiced
in Warren, Minneapolis and Grand Forks, N. D. He
served in the medical corps during World War I, and
was at Ft. Snelhng from 1921 until his retirement in
1944.
Dr. Lloyd G. Dack, 59, St. Paul, died Saturday,
July 9. He had been in the practice of medicine in St.
Paul 21 years. Dr. Dack was bom in Stanton, Minn.,
attended Carleton college and obtained his medical
degree at the University of Minnesota.
Dr. William Henry Rumpf, 82, a physician and sur-
geon in Faribault for nearly a half century, died Sun-
day, June 26. Dr. Rumpf came to Faribault in 1902,
after being connected with Northwestern University
medical school ten years. He was educated at the Uni-
versity of Berlin and at Yale.
Dr. E. W. Benham, a prominent Mankato physician
for many years, died June 19 in Compton, Calif. Dr.
Benham was a member of the Mankato Clinic. He re-
tired from 47 years of practice five years ago.
Dr. Robert Fieck, 24, Plainview, who had been prac-
ticing in Plainview since last fall, died June 19.
290
The Journal-Lancet
Book Reviews
Classified Advertisements
Aesculapius Comes to the Colonies, by Maurice Baer
Gordon, M.D., Ventnor, Pa.: Ventnof Publishers, Inc.,
520 pp., illustrated, $10, 1949.
There are those who hold that to be a good doctor one must
be more than merely a good doctor. In this country one might
well be, also, a good American. Dr. Gordon makes it easy to
be both. The beginnings of medicine in this country, the debt
that the profession owes to the Scottish schools of medicine and
surgery, the impingement on and involvement with the wars,
patriots, personalities, politics and principles of the infant na-
tion are set down interestingly and instructively. Shot through
the rich and well printed volume are legends and facts, quota-
tions and opinions, fee schedules and case histories that paint
a vivid picture of medical life and labors in each of the original
colonies. Not since the Private Diary of Wm. Byrd, first gov-
ernor of Virginia, has there been such a comprehensive, photo-
graphic presentation of the daily duties and responsibilities of
the privileged and advantaged among their hardy and primitive
neighbors.
Not the least profitable reading in this voluminous compen-
dium is the story of the evolution of medical education and the
crystallizing of medical ethics and, in the light of recent dicta
handed down at Atlantic City, this makes for more than ordi-
narily interesting reading for the physician. Here is medical
history in the rough, personalized, broken down into sources
colony by colony, disease by disease, event by event, tjoctor by
doctor. As an evidence of how far American medicine has
come and yet, also, how far it had come by the time of the
founding fathers, the book is a valuable accomplishment and
a substantial contribution to medical recording of events and
development. M.W.
Handbook of Communicable Diseases, by Franklin H.
Top, M.D. Second edition, St. Louis: The C. V. Mosby
Company; 992 pp. with 93 text illustrations and 13 color
plates, 1947.
The first edition of this book was well received. A review
of the second edition reveals that the author has been fortunate
in securing as collaborators men of great eminence in the field
of infectious diseases. With their help numerous revisions have
been made. Three chapters have been completely rewritten;
namely, those on Influenza, Malaria and Rickettsial Diseases.
To indicate the scope of this review, it is sufficient to list the
14 new chapters which were added; namely. Coccidioidomycosis,
Rheumatic Fever, Primary Atypical Pneumonia, Epidemic Diar-
rhea of the Newborn, Infectious Hepatitis, Chancroid, Lympho-
granuloma Venereum, Granuloma Inguinale, Ophthalmia Neo-
natorum, Epidemic Keratoconjunctivitis, Leptospiral Jaundice,
Ringworm of the Scalp, Trachoma, and Infectious Mono-
nucleosis. Concerning most of the diseases there are sections on
definition, infectious causative agent, immunity, epidemiology,
pathogenesis, pathology, clinical features, clinical types, compli-
cations, differential diagnosis, prognosis, treatment, symptomatic
treatment, specific treatment, treatment of complications, and
prevention. This reference and text book is highly recommended
for both practitioner and student.
A. V. S.
Roentgen Diagnosis of the Extremities and Spine, by
Albert D. Ferguson, M.D. Second edition, New York:
Paul B. Hoeber, Inc., 1949.
The new edition of this authoritative text and atlas represents
a considerable expansion of the old edition in regard particu-
larly to the diagnosis of bone tumors. Further editions have
also been made in regard to the spine. The illustrations are
numerous and well reproduced. This book represents essentially
an atlas since the amount of text devoted to each lesion is rela-
tively small. L. G. R.
FOR SALE
Shock-proof fluoroscopic X-Ray unit with tilt-table,
complete with all accessories. Address Bessessen, 1406
West Lake Street, Minneapolis, LOcust 9097.
WANTED
Hospital superintendent, X-Ray and Laboratory Tech-
nician, Nurses for New 20-bed community hospital to
be opened in August, 1949. Write Greenbush Community
Hospital Association, Greenbush, Minnesota.
FOR SALE
Maico Audiometer in perfect condition, used only by
Maico of Fargo and guaranteed by them. $150, F.O.B.
Fargo. Write Student Health Center, N. Dakota Agric.
College, Fargo, N. Dak.
WANTED
Full time student health physician in well known mid-
western junior college. Paid on twelve months contract,
school in session nine months. Good salary, many other
benefits. Available Sept. 1st. Box 887, Journal-Lancet.
WANTED
Young physician and surgeon to take charge of estab-
lished practice in town of 6,000 population, with modern
hospital. Write Box 888, Journal-Lancet.
FOR RENT
Office suite for rent. Three rooms or more. Over
drug store on corner of 50th and France South in Edina.
Will decorate to suit renter. Lease if desired. Mr. A. L.
Stanchfield, 4424 W. 44th St., Ma. 3371, Wa. 4806.
ASSISTANCE AVAILABLE
Woodward Medical Personnel Bureau (formerly Aznoes
— Established 1896) have a great group of well trained
physicians who are immediately available. Many desire
assistantships. Others are specialists qualified to head
departments. Also Nurses, Dietitians, Laboratory, X-Ray
and Physiotherapy Technicians. Negotiations strictly
confidential. For biographies please write Ann Wood-
ward, Woodward Medical Personnel Bureau, 185 North
Wabash, Chicago.
Advertisers’ Announcements
New Dosage Strength in "Penalev” Tablets
For the convenience of physicians and patients, Sharp &
Dohme, Inc., Philadelphia, is now supplying "Penalev” Tablets,
a new penicillin dosage form, in tablets containing 100,000
units as well as 50,000 units of the antibiotics. Previously,
"Penalev” was available in only the 50,000 unit strength. Since
100,000 units of penicillin is the popular dosage for oral therapy
and sublingual administration, the addition of "Penalev” 100,000
unit tablets greatly facilitates administration. Designed especially
for penicillin aerosol therapy, oral administration in pediatrics,
sublingual administration and prescription compounding, "Pena-
lev” Tablets dissolve readily in water, salt solution, milk for-
mulas and saliva. They are free of excipients and binders. The
penicillin in "Penalev” Tablets retains its potency at room tem-
perature, so that refrigeration is not necessary.
In aerosol therapy, it is recommended that solutions for in-
halation be prepared so that each 0.5 cc. of normal saline con
tains 50,000 units of penicillin. Inhalations of 50,000 units in
1/2 cc. or 100,000 units in 1 cc. then may be prescribed at
suitable intervals. For oral penicillin therapy, "Penalev” Tablets
may be dissolved in milk or any suitably flavored liquid and
administered in a dosage of 100,000 units every three or four
hours. For sublingual administration, 100,000 units every three
hours are recommended. "Penalev” Soluble Tablets Crystalline
Sodium Penicillin G are supplied in vials of 12.
CET
Minneapolis, Minnesota
September, 1949
Vol. LXIX, No. 9
New Series
Saddle Block Anesthesia in Obstetrics*
G. Wilson Hunter, M.D.,f D. F. Nelson, M.D.,f and C. B. Darner, M.D.f
Fargo, North Dakota
IT has been said again and again that the ideal obstet-
rical analgesic agent has yet to be popularized. The
search for it continues. Over the years a considerable
experience has been gained with a number of methods
including the Gwathmey technique, using ether and oil
rectally; rectal instillations of paraldehyde; and pento-
barbitol with scopolamine. Later the combination of
demerol and scopolamine was begun and is still in use.
During this entire period 1 per cent novocaine local
anesthesia was employed on selected cases and in 1944
continuous caudal analgesia was introduced and used
extensively until June, 1948, when "saddle block” was
begun.
Today the safety and popularity of this agent is well
established and it is believed that experience with a care-
fully observed series may be worth reporting. "Saddle
block” or minimal dosage low spinal should be distin-
guished from surgical spinal anesthesia as it is generally
thought of.
Local infiltration, undoubtedly the safest anesthesia
when accepted by patient, has been used exclusively in
our deliveries at a foundling home for a number of
years. It is not, however, acceptable to the vast number
of private patients. Hypnotism and the Read method,
used in a few selected cases, was found to be impractical
because it is so time-consuming. Sodium pentothal has
been useful for rapid induction in some cases but there
must be no delay in delivering the baby. It is the writers’
‘Presented at the Devils Lake District Medical Meeting,
Devils Lake, North Dakota, April 6, 1949.
fFrom the Department of Obstetrics and Gynecology, Fargo
Clinic and St. Luke’s Fiospital.
impression that low dosage spinal anesthesia with heavy
nupercaine is the most satisfactory analgesic and anes-
thetic agent available. It may be used alone in rapidly
progressing labors or with preliminary demerol and
scopolamine in patients dilating slowly.
Material and Methods
A total of 304 cases is included in the study. Of these
106 were primiparae and 198 multiparae. During this
nine-month period 679 patients were delivered. We are
using "saddle block” in approximately 65 per cent of
our present cases (Table 1).
The fetal mortality is in no way connected with the
anesthesia. The anesthesia was repeated in 8 cases be-
cause of the wearing off of the anesthetic effect or un-
satisfactory initial induction. Manual removal of the pla-
centa was carried out in four instances following delivery
because of excessive bleeding and delay in separation. In
no instance was there as much as 500 cc. of hemorrhage.
The technique of induction is simple. The patient,
supported by a nurse, is placed on the edge of the de-
livery or labor bed in a sitting position and the area of
spinal puncture prepared with tincture of zephiran. A
22-gauge short bevel spinal needle is used and 2.5 to
5 mgm. of heavy nupercaine is introduced with the loss
of as little spinal fluid as possible. With experience it
is possible to note the appearance of spinal fluid and
apply the syringe without loss of as much as a drop.
After the injection the patient is kept in a sitting posi-
tion for 20 to 30 seconds, then placed in a recumbent
position with the head supported by a high pillow. Re-
peated blood pressure readings are taken throughout the
period of anesthesia and especially during the first 20
291
292
The Journal-Lancet
minutes. Care is taken not to make the injection during
a uterine contraction.
Observations
Complete relief was obtained in 280 cases. Twenty-
four patients, most of whom were early in our series,
obtained partial relief. There was a drop in blood pres-
sure to 90/60 or below in 21 cases. Fifty-four complained
of headache lasting from one to nine days. Only six of
Table 1
Infant mortality
Stillbirths — 3 (2 abruptio placentae, 1 hypertensive toxemia)
Neonatal deaths — 2 (both congenital anomalies incompatible
with life) .
Maternal mortality — 0.
Labor was terminated in the following manner:
Primiparae: 106 Multiparae: 198
Low forceps 94 Low forceps 146
Spontaneous 4 Spontaneous .... .... 46
Mid-forceps 7 Mid-forceps 3
Breech Extraction 1 Low cervical
cesarean section 2
Breech extraction 1
Number of infants requiring resuscitation: 8.
All of these 8 patients had had demerol and scopolamine
prior to the saddle block.
these were considered severe. The balance were transient
and lasted only one or two days when the patient was
in the upright position. Eight patients complained of
backache, a symptom which disappeared by the time of
discharge. One hundred eighty-four of these patients
voided spontaneously. Sixty required catheterization one
or more times during the first 24 hours. Thirty-two re-
quired catheterization after the first 24-hour period. All
were voiding spontaneously within six days. There were
no instances of residual paralysis.
Discussion
Patients were selected on the basis of their desire for
this type of anesthesia. Those with a systolic blood pres-
sure below 100 were excluded. The initial drop in blood
pressure below 100/70 was treated in most instances with
neosynephrine .25 cc. given intramuscularly. A dose of
1 cc. oenythol was used in some cases but it was not
felt to be as satisfactory a drug in sustaining the pres-
sure. In addition to the medication, the legs were raised
and oxygen inhalations given to combat drop in pressure.
The trend towards mild shock can usually be anticipated
by the subjective symptoms of the patient, including
faintness, air hunger, and nausea. In no instance was
the blood pressure drop sustained to a degree which
would cause alarm.
Many writers have felt that the size of the spinal
needle and the loss of spinal fluid were factors in the
causation of post-spinal headache. Some urge early
assumption of the sitting position in bed while others
suggest the recumbent position for the first 24 hours.
Schmitz and Baba 1 suggest assumption of the near up-
right position from the day of delivery as a measure to
prevent headaches. A large fluid intake is urged by one
group, pituitary extract and nicotinic acid intravenous
injections by others. Rogers 2 used caffeine sodium ben-
zoate intravenously for headaches. We have noted that
as our facility improved we have had fewer headaches.
It is suggested that patients remain in a recumbent posi-
tion for at least eighteen hours after delivery. In a few
instances it was felt that nicotinic acid intravenously has
been of benefit. Most of the headaches are controlled
with the routine capsule of codeine sulfate gr. ss and
ASA compound gr. x which is used for after-pains.
Anderson ! notes "a well being shown by women under
sDinal block; their condition is entirely different from
the morbid condition commonly observed when pro-
longed labor is terminated under general anesthesia.
Immed'ate improvement is often noted; nourishment is
retained and strength rapidly regained ...”
It is not felt that the incidence of catheterization is
any higher in this series than it is in the patients on
whom general anesthesia is used.
The period of anesthesia lasted from one to four
hours. Perineal anesthesia lasts one or more hours longer
than abdominal. Pains may come through on one side
without detracting materially from the anesthetic result.
The patients on whom only a partial success was
attained were for the most part satisfied and stated
merely that they felt some distress at delivery. There
were four patients who expressed complete dissatisfac-
tion with this method of analgesia.
The greatest objection to "saddle block” in obstetrics
seems to be the markedly increased operative procedures
which are entailed. With the perineum anesthetized, these
patients have no desire to bear down. In studying the
figures, it will be noted that the incidence of mid-forceps
is not increased but it is merely the figures for low for-
ceps which are higher. It can be seen that a moderate
number of multiparae do expel their babies spontane-
ously. It is felt that low forceps delivery in the hands
of trained obstetricians adds nothing to the morbidity
or mortality of either infants or mothers.
The impression gained by attending nurses and doc-
tors that labor is shortened for patients under "regional
block” is not true. Nicodemus,’' reporting a study of
patients under continuous caudal in 1945, maintained
that labor was not shorter but actually somewhat Ionser.
It seemed shorter, however, to comfortably progressing
patients and to those in attendance.
The following contraindications are suggested:
1. It is not suitable for individuals of a certain tem-
perament. A definite number of patients desire to
be asleep.
2. Diseases of the central nervous system or spine.
3. Initial systolic blood pressure below 100 mm. of
mercury.
The following advantages of low dosage spinal anes-
thesia are emphasized:
1. The ease of administration. In using caudal we
found that we were unable to introduce the anes-
thetic in 1 out of 10 cases. With "saddle block”
there have been no patients on whom we could not
introduce the needle.
September, 1949
293
2. The fact that the effect is immediate. This is par-
ticularly satisfying in rapidly progressing cases.
3. The safety for mother in the presence of upper
respiratory infection, vomiting, or other conditions
contraindicating general anesthesia. The absence of
danger of aspirating vomitus. Inasmuch as many
obstetric patients come to delivery with food in their
stomachs, this is a very real danger.
4. The increased relaxation of pelvic musculature
enables delivery.
5. The absence of need for accessory anesthesia for
delivery and repair.
6. The absence of detrimental effect on infant. De-
creased incidence of asphyxia and narcotization. In
cases where demerol and scopolamine were used as
preliminary medications it had largely worn off by
the time of delivery under "saddle block.”
7. The fact that it does not affect contractions of the
uterus.
8. The gratifying reaction of the patient when she is
able to be awake and hear the first cry of her baby.
9. The suitability for prematures because of the per-
ineal relaxation and absence of narcotization.
10. The suitability for patients with cardiac and pul-
monary complications. It spares the mother the
second, most taxing stage of labor.
Greenhill4 continues to call attention to the dangers
of high spinal anesthesia. We have great respect for
his judgment, but it should be emphasized that small
dosage low spinal should not be directly compared with
surgical spinal as it is given routinely. In his discussion
of "saddle block” in the 1948 Year Book he quotes ar-
ticles written by Hansen in 1937, Gaster in 1944, Fran-
ken in 1934, and several others, all of which were studies
made before the advent of minima! dosage spinal anes-
thesia in obstetrics so that they are hardly a fair basis
for comparison.
Summary
1. Three-hundred-four cases of "saddle block” anes-
thesia are presented.
2. Complete anesthesia and satisfaction were obtained
in 280 patients. Twenty-four patients had only partial
relief.
3. The complications were minor. They consisted of
headaches, backaches, and urinary retention and hypo-
tension.
4. Operative obstetrics in the form of outlet forceps
deliveries is increased.
5. The term "saddle block” instead of "spinal”
should be used in discussing this procedure with patients.
6. Minimal dosage low spinal anesthesia in obstetrics
using heavy nupercaine is a safe and effective procedure.
Bibliography
1. Schmitz, Herbert E., and Baba, George: Am J. Obst.
and Gynec. 54:838, 1947.
2. Rogers, Walter C.: West. J. Surg. 56:236, 1948.
3. Anderson, A. F.: J. Obst. and Gynaec. Brit. Emp
53:347, 1946.
4. Greenhill, J. P : The 1948 Year Book of Obst. and
Gynec.: 123.
5. Nicodemus, R. E.: Personal communication. Am. J
Obst. and Gynec. 50:312, 1945.
UNIVERSITY OF MINNESOTA SCIENTISTS OFFER HOPE FOR
PARALYSIS PATIENTS
Many chronic neurologic patients — some who have been paralyzed for up to 20 years —
can be rehabilitated, can walk again or even go back to work, according to two University
of Minnesota medical scientists. Dr. A. B. Baker, professor of neurology, and Dr. Joe R.
Brown, clinical associate professor of psychiatry and neurology, are the authors of a new
Veterans Administration pamphlet (No. 10-29) describing a program of retraining for per-
sons afflicted with neurologic disabilities.
"It is a principle of modern medical practice that all patients have assets as well as
liabilities,” Dr. Magnuson, chief medical director of the VA, wrote. "But what are the
assets of a chronic neurologic patient who has been hospitalized for 3, 5, 10, or even 20
years, so paralyzed that he cannot turn over in bed? This man, obviously, has a strong will
to live and enduring physical capacity to survive. Beyond this, he frequently has been looked
upon as largely helpless and hopeless, a liability to himself, his family and the hospital.”
Drs. Baker and Brown concluded that there is a great need for establishment of such
programs, which in the first year alone can save more than $1,000,000 in one hospital.
294
The Journal-Lancet
Urological Complications in Obstetrical Practice
B. C. Corbus, Jr., M.D.
Fargo, North Dakota
Pyelitis of pregnancy, more properly designated py-
elonephritis, occurs in 2 per cent of all women carry-
ing children and is the commonest cause of significant
fever in the second and third trimesters. In order to
institute adequate treatment of the disease it is necessary
to comprehend fully, first, the physiology of the urinary
tract in pregnancy and, second, the pattern assumed by
the actual pathology. Several factors present themselves
which, when analyzed, make one wonder why upper
urinary tract infection in the pregnant female is actually
not far more frequent than it is.
Reviewing the mechanism of the physiological hydro-
nephrosis of pregnancy, the changes may be divided into
(1) those affecting the kidney, and (2) those affecting
the ureter.
In the first instance, a uniform dilation of the minor,
major calices, infundibular and pelvic portions of the
collecting system may be noted. Regarding the ureter,
a generalized dilatation occurs predisposing to kinks,
tortuosity, and lateral displacement. Definite gross
changes are present on the right side in nearly all cases
but in only 66 per cent is the left ureter involved.
Authorities agree that four principal alterations occur
within the smooth muscle of the ureteral wall itself:
1. A loss of muscular tonus (atony) of the upper two-
thirds with
2. Softening
3. Hypertrophy of the external longitudinal muscle
fibers (sheath of Waldemyer) .
4. Generalized increased ureteral vascularity (else-
where attendant in pregnancy) with a resulting par-
tial obstruction or, more rarely, complete stricture
formation.
The actual cause of the physiological hydronephrosis
of pregnancy is unknown. Experimental evidence points
to the existence of two influences which probably have a
synergistic effect on the upper urinary tract. Placental
hormone is known to have a dilating action on ureteral
smooth muscle but why should it be selective and act
only on the upper two-thirds of the duct? Mechanical
obstruction by the fetal head, formerly thought to be
wholly responsible, undoubtedly contributes to the end
result. Reasons given why the left ureter is not dilated
as often as the right are solely mechanical — the cushion-
ing effect of the sigmoid colon plus the fact that the
ever-enlarging uterus has a tendency to incline to the
right.
It is a urological maxim that wherever significant uri-
nary stasis is encountered infection ultimately occurs.
As a prominent authority states, a paradoxical situation
is present whereby uterine atony retains the fetus in situ ,
whereas ureteral atony invites infection, impairs drain-
age, and retards recovery.
Let us now examine more in detail the pathological
aspect of an already significantly altered urinary tract.
The bacteriological agent in nine-tenths of the cases be-
longs to the coliform group, namely: Eschericia coli,
staphylococcus, streptococcus, proteus and, rarely, tuber-
culosis or gonococcus may also be present. Pre-existing
urinary tract bacteria may account for 6 to 10 per cent
of the cases. Over 80 per cent of the coliform infections
are thought to be derived from the intimate lymphatic
anastomosis between the right kidney and the ascending
colon. Extrinsic portals of entry involve the shortness of
the female urethra and careless hygiene attending bowel
action.
What morbid anatomy is encountered in the pyelo-
nephritis of pregnancy? The pathological chain of events
includes first of all a ureteritis, then pyelitis, then a
pyelonephritis. Infected hydronephroses progress to pyo-
nephroses. Perirenal inflammation leads to perinephritic
abscess and peri-ureteral inflammation, when healed, pro-
duces annular fibrosis with resulting stricture formation.
All of this emphasizes the absolute necessity of early,
adequate treatment in this type of individual.
The diagnosis of acute urinary infection in the preg-
nant woman is not difficult, especially when it has become
a disseminated urinary sepsis. Fortunately, with the ad-
vent of the chemotherapeutic agents this is encountered
far less frequently then formerly. High fever, sweats,
rapid pulse with frequency, and severe dysuria, plus ex-
quisite costovertebral angle tenderness, paint the picture
only too clearly. Vaginal examination often reveals a
tender bladder base and, frequently, a palpable, extremely
tender ureter may be present. With adequate treatment
this condition may last anywhere from ten days to three
weeks and carries a mortality of about 2 per cent. More
difficult to recognize is the subacute or afebrile type of
infection which so commonly characterizes the B. coli
urinary infection in the nonpregnant female. However,
it is equally important to recognize the milder types of
this disease in order to avoid the more serious complica-
tions; i. e., frank urinary sepsis. So whenever a pregnant
patient with fever or painful urination is encountered,
complete urological investigation is indicated. The fol-
lowing points are necessary in evaluating such cases:
1. Microscopic and cultural examination of a catheter-
ized urine specimen.
2. Cystoscopy and intravenous pyelograms if symp-
toms persist for longer than two weeks despite
chemotherapy. Commonest abnormal finding in
the pyelogram is the demonstration of a ureteral
kink requiring catheter drainage. This may be con-
September, 1949
295
tinued for a period of four to seven days, depend-
ent upon the subsiding of symptoms. A practical
method of keeping a ureteral catheter in place is
to splint it with adhesive tape to an indwelling
Foley urethral catheter.
3. When ample fluids and complete antibiotic therapy
together with instrumental drainage produce no
relief of symptoms, most obstetrical authorities
agree that a termination of the pregnancy is im-
perative as a life-saving measure. Often, however,
patients with severe infections in the second tri-
mester may be successfully carried to term with con-
tinued antibiotic medication.
A word about chemotherapy is timely at this point.
Sulfa compounds advocated earlier have not been found
the drug of choice. Penicillin and streptomycin have been
used widely and work well in combination. The individual
bacteriological agent involved must be recovered by urine
culture to determine the optimum therapeutic agent.
Recently a prominent urologist has had outstanding suc-
cess in the treatment of intractable low grade (B. coli)
urinary infections by the combinative use of sulfasuxi-
dine and mandelic acid or more recently streptomycin.
The sulfasuxidine sterilizes the bowel by eradicating the
B. coli at its source, and the mandelic acid and strep-
tomycin sterilize the urinary tract as a secondary meas-
ure. Results: a success of 96 per cent has been achieved
in chronic cases of long standing.
Postpartum care of these individuals is equally impor-
tant. A history of pyelitis of pregnancy necessitates uro-
logical investigation following delivery or prior to the
next pregnancy. A workable routine for the above is
as follows:
1. Catheterized urine specimen is to be taken each
month while continuing medication. If symptoms
no longer persist and the urine is culture-free, medi-
cation may be withdrawn.
2. If persistent infection exists, cystoscopy and pyelo-
grams are necessary.
3. If hydroureter remains after three months, ureteral
dilation should be carried out.
Patients of this type should be clinically well and
culturally negative a minimum of six months before
another pregnancy is begun.
It is to be noted in conclusion that 50 per cent of
pyelitis of pregnancy cases have had previous trouble
and that in fully half, the infection may be expected
to recur at some future time.
Due to prevalent factor of urinary stasis in the preg-
nant state, renal or ureteral calculi are twice as frequent
as in the nonpregnant state. Operative removal is rarely
necessary and then only when obstruction is complete.
Cystitis may be aggravated by the increased vascularity
attending gestation in the first and second trimesters.
During the last trimester the bladder may become irrita-
ble because of encroachment on its base by the enlarging
uterus. Bladder sedatives may be tried but usually are
of little value.
Hematuria may occur from any of the causes in the
nonpregnant state but in the main from the following:
1. Vesical varicosities,
2. Sulfonamid crystalluria,
3. Subclimcal bacteriological inflammation (B. coli)
Urological investigation is advocated immediately in the
presence of unexplained urinary bleeding.
Can patients with a single kidney have children? The
answer is yes with four exceptions:
1. Patients having had a tuberculous kidney removed
less than three years before are not advised to
become pregnant.
2. A kidney removed because of malignant disease
constitutes a contra-indication to pregnancy.
3. Pyelonephritis necessitating termination of gesta-
tion and not responding to treatment contra-indi-
cates pregnancy.
4. Finally, patients with polycystic kidney disease pos-
sess insufficient renal reserve to tolerate pregnancy
successfully.
Summary and Conclusions
1. The mechanism of physiological hydronephrosis is
reviewed.
2. The significance of the pathological physiology and
morbid anatomy of pyelonephritis of pregnancy is elab-
orated upon.
3. Diagnosis and treatment are given in detail.
4. Chemotherapeutic agents discussed and a rationale
for postpartum management offered.
5. The lesser urological complications of pregnancy
are taken up in order of their importance.
Bibliography
1. Dodson, A. I.: Urological Surgery, Mosby & Co., 1944.
2. DeLee and Greenhill: Textbook of Obstetrics, Saunders
& Co., 1947.
3. Hinman, Frank: Principles & Practice of Urology, Saun-
ders & Co., 1935.
4. Corbus, B. C., and Danforth, Wm.: Pyelitis of Preg-
nancy, Jour. Urol. 18:5, 1927.
5. Cummings, W. G.: Pregnancy and Solitary Kidney,
111. State Med. Jour. 14:274-276, 1938.
6. Moore, Robert: Textbook of Pathology, Saunders & Co.,
1944.
7. O’Conor, V. J., and Crowley, Ed.: Treatment of Chronic
Urinary Infection, S. G. & O. 86:499-501, April, 1948.
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The Journal-Lancet
Official Journal of the American College Health Association, Great Northern Railway Surgeons’ Association,
Minneapolis Academy of Medicine, North Dakota State Medical Association, Northwestern Pediatric Society,
South Dakota Public Health Association, North Dakota Society of Obstetrics and Gynecology
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J. Glaspel
Dr. J. F. Hanna
BOARD OF EDITORS
Dr. 1. A. Myers, Chairman
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. S.
Dr. Henry E. Michelson
Dr. J. H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr. J. H. Simons
Dr. Joseph Sorkness
A. Slater
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Sec.
ADVISORY
North Dakota State Medical Association
Dr. W. A. Wright, President
Dr. L. W. Larson, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
North Dakota Society of Obstetrics
and Gynecology
Dr. H. A. Wheeler, President
Dr. B. M. Urenn, Vice President
Dr. C. B. Darner, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Cyrus O. Hansen, President
Dr. Chauncey Bowman, Vice President
Dr. John Haugen, Secretary
Dr. Karl Sandt, T reasurer
COUNCIL
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
September, 1949
297
Transactions of the North Dakota
State Medical Association
Sixty-Second Annual Meeting
Minot, North Dakota, May 14-17, 1949
OFFICERS
President W. A. LIEBELER, Grand Forks
President-Elect ... W. A. WRIGHT, Williston
First Vice-President L. W. LARSON, Bismarck
Second Vice-President W. E. G. LANCASTER, Fargo
Speaker of House The late A. P. NACHTWEY, Dickinson
Acting Speaker of House A. E. SPEAR, Dickinson
Secretary O. A. SEDLAK, Fargo
Treasurer E. J. LARSON, Jamestown
Delegate to A.M.A. ... J. H. MOORE, Grand Forks
Alternate Delegate to A.M.A. G. W. TOOMEY, Devils Lake
COUNCILLORS
Terms expiring 1949
J. C. FAWCETT, Devils Lake
JOSEPH SORKNESS, Jamestown
F. W. FERGUSSON, Kulm
A. R. GILSDORF, Dickinson
Terms expiring 1950
J. F. HANNA, Fargo
C. J. GLASPEL, Secretary, Grafton
R. H. WALDSCHMIDT, Bismarck
Terms expiring 1951
A. D. McCANNEL, Chairman, Minot
C. J. MEREDITH, Valley City
E. J. SCHWINGHAMER, New Rockford
HOUSE OF DELEGATES
FIRST DISTRICT
A. C. FORTNEY Fargo
B. M. URENN Fargo
E. J. BEITHON Wahpeton
C. M. HUNTER, Alternate Fargo
E. M. HAUGRUD, Alternate Fargo
DEVILS LAKE
G. W. TOOMEY Devils Lake
W. R. FOX, Alternate Rugby
GRAND FORKS
T. Q. BENSON Grand Forks
GEORGE WALDREN Cavalier
R. W. VANCE Grand Forks
R. O. GOEHL, Alternate Grand Forks
KOTANA
J. D. CRAVEN Williston
A. K. JOHNSON, Alternate Williston
NORTTHWEST
D. J. HALLIDAY Kenmare
A. R. SORENSON Minot
M. G. FLATH Stanley
R. B. WOODHULL, Alternate Minot
A. F. HAMMARGREN, Alternate Harvey
SHEYENNE VALLEY
W. H. GILSDORF . Valley City
P. T. COOK, Alternate Valley City
SIXTH
R. B. RADL Bismarck
M. S. JACOBSON ... ... Elgin
SOUTHERN
F. W. FERGUSSON Kulm
V. D. FERGUSSON, Alternate ... ... Edgeley
SOUTHWESTERN
R. W. RODGERS Dickinson
H. E. GULOIEN, Alternate ... ... Dickinson
STUTSMAN
P. G. ARZT Jamestown
T. E. PEDERSON, Alternate Jamestown
TRAILL-STEELE
THOMAS M. CABLE ... Hillsboro
H. A. LaFLEUR, Alternate Mayville
TRI-COUNTY
R. F. GILLILAND Carrington
C. G. OWENS, Alternate ... . New Rockford
STANDING COMMITTEES
COMMITTEE ON MEDICAL EDUCATION
R. E. LEIGH, Chairman Grand Forks
C. R. TOMPKINS ... Grafton
CLIFFORD PETERS Bismarck
J. H. FJELDE Fargo
C. J. MEREDITH Valley City
F. R. ERENFELD ... Minot
H. A. WHEELER . Mandan
J. A. Mac DONALD Cando
W. F. BAILLIE Fargo
H. M. BERG Bismarck
J. H. MAHONEY Devils Lake
R. W. RODGERS ... ... Dickinson
COMMITTEE ON NECROLOGY AND MEDICAL HISTORY
r r a v L (Co-Chairmen
G. M. WILLIAMSON, Grand Forks )
W. H. BODENSTAB Bismarck
I. S. AbPLANALP - Williston
K. E. DARROW Fargo
E. M. RANSOM Minot
O. C. MAERCKLEIN Mott
W. A. GERRISH Jamestown
J. W. BOWEN .. Dickinson
COMMITTEE ON PUBLIC POLICY AND LEGISLATION
A. D. McCANNEL, Chairman Minot
A. E. SPEAR Dickinson
L. J. ALGER Grand Forks
D. J. HALLIDAY Kenmare
C. J. GLASPEL Grafton
A. R. SORENSON Minot
J. F. HANNA . Fargo
O. A. SEDLAK, ex-officio Fargo
W. A. LIEBELER, ex-officio Grand Forks
COMMITTEE ON PUBLIC HEALTH
R. O. SAXVIK, Chairman Bismarck
J. L. DACH Hettinger
T. Q. BENSON Grand Forks
V. A. MULLIGAN Langdon
R. C. LITTLE .. Mayville
A. C. ORR Bismarck
V. D. FERGUSSON Edgeley
H. B. HUNTLEY Kindred
E. J. BEITHON Wahpeton
J. C. FAWCETT ... Devils Lake
W. H. GILSDORF Valley City
L. H. LANDRY Walhalla
H. M. WALDREN, JR. ... Drayton
R. D. WEIBLE Fargo
C. O. McPHAIL Crosby
H. W. MILLER Casselton
Second District
Seventh District
Eighth District ...
Tenth District
First District
Third District ...
Sixth District
Fourth District
Fifth District
Ninth District
298
The Journal-Lancet
Sub-Committee on Public Health, Garrison Dam Project
R. O. SAXVIK, Chairman Bismarck
A. R. SORENSON _ Minot
W. B. PIERCE Bismarck
G. R. LIPP .. ._ Bismarck
E. G. VINJE ... Hazen
COMMITTEE ON TUBERCULOSIS
A. F. HAMMARGREN, Chairman Harvey
W. L. W ALLBANK Dunseith
C. O. HEILMAN Fargo
P. L. OWENS .. Bismarck
E. H. RICHTER Hunter
J. P. CRAVEN Wilhston
J. N. ELSWORTH Jamestown
C. V. BATEMAN Wahpeton
G. R. WALDREN Cavalier
G. A. DODDS Fargo
CHARLES VOGL ... Bowman
M. H. BERG Bismarck
RALPH DUKART Dickinson
T. Q. BENSON Grand Forks
H. E. NEVE ... Rolette
COMMITTEE ON OFFICIAL PUBLICATION
L. W. LARSON, Chairman Bismarck
W. H. LONG ... Fargo
P. G. ARZT .. Jamestown
G. W. TOOMEY . ... Devils Lake
COMMITTEE ON CANCER
L. W. LARSON, Chairman Bismarck
E. J. SALOMONE Elgin
C. M. LUND . , Wilhston
P. J. BRESLICH Minot
O. W. JOHNSON Rugby
G. W. HUNTER Fargo
E. J. LARSON - Jamestown
COMMITTEE ON FRACTURES
R H. WALDSCHMIDT, Chairman Bismarck
R. W. VANCE Grand Forks
E. J. LARSON Jamestown
J. C. FAWCETT Devils Lake
H. J. FORTIN Fargo
J. W. BOWEN Dickinson
V. G. BORLAND ... Fargo
G. CHRISTIANSON Valley City
A. F, HAMMARGREN .. Harvey
J. P. CRAVEN Williston
A. L. CAMERON Minot
COMMITTEE ON MEDICAL ECONOMICS
W. A. WRIGHT, Chairman Williston
W. E G. LANCASTER Fargo
TED KELLER Rugby
R. B. RADL Bismarck
P. H. WOUTAT Grand Forks
M. S. JACOBSON Elgin
F. E. WOLFE Oakes
A. E. SPEAR Dickinson
A. D. McCANNEL ... .. ..... Minot
O. A. SEDLAK Fargo
J. W. JANSONIUS Jamestown
P. G. ARZT ... ... Jamestown
Sub-Committee on Prepayment Medical Care
W. E. G. LANCASTER, Chairman . Fargo
P. H. WOUTAT .. . Grand Forks
D. J. HALLIDAY Kenmare
J. L. DEVINE, JR. Minot
J. C. FAWCETT ... Devils Lake
R. D. NIERLING _ Jamestown
R. F. NUESSLE ... Bismarck
Sub-Committee on Veterans Medical Service
R. B. RADL, Chairman Bismarck
C. A. ARNESON ... Bismarck
A. C. FORTNEY Fargo
P. T. COOK Valley City
Sub-Committee on Rural Health
M. S. JACOBSON, Chairman .. Elgin
L. W. LARSON .. ... Bismarck
D. J. HALLIDAY Kenmare
G. CHRISTIANSON Valley City
CHARLES VOGL _ Bowma .
W. A. SCHUMACHER Hettingc
COMMITTEE ON MATERNAL AND CHILD WELFARE
P. W. FREISE, Chairman Bismard
S. C. BACHELLER Enderlii
R. E. DYSON Mino.
L. G. PRAY Fargc
D. W. FAWCETT ... Devils Lake
G. L. COUNTRYMAN Grafton
E. A. CANTERBURY _ Grand Fork
F. A. DeCESARE Fargt
J. W. JANSONIUS ... Jamestowt
COMMITTEE ON CRIPPLED CHILDREN
A. R. SORENSON, Chairman Minoi
H. J. FORTIN Fargc
E. A. JONES Devils Lake
J. C. SWANSON Fargc
R. E. DYSON Minot
R. H. WALDSCHMIDT Bismarck
L. G. PRAY Fargo
A. E. CULMER, JR. Grand Forks
JOSEPH SORKNESS .. Jamestown
COMMITTEE ON VENEREAL DISEASE
F. I. DARROW, Chairman Fargo
W. C. DAILEY Grand Forks
M. M. HEFFRON Bismarck
A. J. GUMPER Dickinson
R. W. VAN HOUTEN Oakes
M. W. GARRISON Minot
J. L. DePUY Jamestown
E. G. VINJE Hazen
COMMITTEE ON PNEUMONIA
O. W. JOHNSON, Chairman Rugb,
R. W. HENDERSON Bismarck
E. A. HAUNZ Grand Forks
G. H. HOLT Jamestown
W. R. FOX Rugby
W. E. G. LANCASTER Fargo
D. W. MATTHAEI __.r Fessenden
SPECIAL COMMITTEES
COMMITTEE ON EMERGENCY MEDICAL SERVICE
A. C. FORTNEY, Chairman Fargo
C. M. GRAHAM Grand Forks
J. L. DEVINE, JR. Minot
C. A. ARNESON Bismarck
A. R. GILSDORF Dickinson
R. B. RADL Bismarck
COMMITTEE ON INDUSTRIAL HEALTH
C. J. GLASPEL, Chairman Grafton
W. H. BODENSTAB ... Bismarck
RALPH VINJE Beulah
W. A. GERRISH Jamestown
A. K. JOHNSON Williston
COMMITTEE ON MENTAL HYGIENE
R. H. BRESLIN, Chairman .... Mandan
G. S. CARPENTER Jamestown
J. R. OSTFIELD Fargo
A. M. FISCHER Jamestown
J G. LAMONT Grafton
COMMITTEE ON NURSING EDUCATION
G. W. TOOMEY, Chairman Devils Lake
M. M. HEFFRON Bismarck
H. E. GULOIEN Dickinson
G. W. HUNTER Fargo
J. P. CRAVEN ... Williston
M. P. CONROY Minot
R. O. GOEHL Grand Forks
J. VAN HOUTEN Valley City
JOSEPH SORKNESS ... Jamestown
September, 1949
299
COMMITTEE ON DISPLACED PHYSICIANS
A. C. FORTNEY, Chairman - Fargo
M. S. JACOBSON Elgin
F. E. WOLFE ... __ Oakes
REFERENCE COMMITTEES
To consider reports of the President, Secretary,
Executive Secretary and Special Committees:
M. S. JACOBSON, Chairman _ .. Elgin
B. M. URENN Fargo
R. B. WOODHULL Minot
G. W. TOOMEY Devils Lake
To consider reports of the Council, Councillors,
Delegate to the American Medical Association,
and Member of the Medical Center Advisory Council:
W. H. GILSDORF, Chairman Valley City
H. A. LaFLEUR Mayville
A. K. JOHNSON .. Williston
To consider reports of Standing Committees, except the report
of the Committee on Medical Economics and its Sub-Committees
on Prepayment Medical Care, Veterans Medical Service
and Rural Health:
R. W. VANCE, Chairman Grand Forks
GEORGE WALDREN Cavalier
F. W. FERGUSSON Kulm
M. G. FLATH _ Stanley
To consider reports of Committee on Medical Economics,
including the Sub-Committees on Prepayment Medical Care,
Veterans Medical Service and Rural Health:
T. Q. BENSON, Chairman Grand Forks
P. G. ARZT Jamestown
E. M. HAUGRUD ... Fargo
Committee on Resolutions, to include new business:
R. B. RADL, Chairman Bismarck
D. J. HALLIDAY ... .. Kenmare
E. J. BEITHON ... Wahpeton
Committee on Credentials:
A. C. FORTNEY, Chairman Fargo
H. A. LaFLEUR ..... Mayville
Nominating Committee:
A. D. McCANNEL, Chairman Minot
C. J. MEREDITH Valley City
J. C. FAWCETT ... Devils Lake
R. W. RODGERS ... Dickinson
Proceedings of the House of Delegates of the
NORTH DAKOTA STATE MEDICAL
ASSOCIATION
First Session, Saturday, May 14, 1949
The First Session of the House of Delegates of the North
Dakota State Medical Association was called to order by Acting
Speaker of the House, Dr. A. E. Spear, at 8:30 P.M. in the
Skyline Room of the Clarence Parker Hotel, Minot, North
Dakota, May 14, 1949.
Speaker Spears: "Before proceeding with the business of the
Sixty-second Annual Meeting of the House of Delegates of the
North Dakota State Medical Association, I can not but call
your attention to the unforeseen and unfortunate circumstance
which made it necessary that I act as your presiding officer to-
night. You elected Dr. Nachtwey of Dickinson as your Speaker,
and I am only acting in his stead. I will do my best, and I ask
your cooperation.
"May we hear from the Chairman of the Credentials Com-
mittee, Dr. A. C. Fortney?”
Dr. A. C. Fortney, Chairman of the Committee on Creden-
tials, announced that eighteen delegates had presented their cre-
dentials and were qualified.
The Secretary, Dr. Sedlak, called the roll and the following
responded: Drs. A. C. Fortney, Fargo; E. J. Beithon, Wahpe-
ton; E. M. Haugrud, alternate, Fargo; G. W. Toomey, Devils
Lake; T. Q. Benson, Grand Forks; George Waldren, Cavalier;
R. W. Vance, Grand Forks; A. K. Johnson, alternate, Willis-
ton; D. J. Halliday, Kenmare; A. R. Sorenson, Minot; M G.
Flath, Stanley; W. H. Gilsdorf, Valley City; R. B. Radi, Bis-
marck; M. S. Jacobson, Elgin; V. D. Fergusson, alternate,
Edgeley; R. W. Rodgers, Dickinson; P. G. Arzt, Jamestown;
H. A. LaFleur, alternate, Mayville; R. F. Gilliland, Carrington.
The Speaker declared a quorum present.
Minutes of 1948 Meeting Approved
On motion of Dr. Halliday, seconded by Dr. Radi, and car-
ried, the reading of the minutes of the 1948 session as published
and circulated in the September, 1948 issue of the Journal-
Lancet were dispensed with and the minutes adopted.
Introduction of President
The Speaker introduced the President, Dr. W. A. Liebeler,
who welcomed the Delegates to the convention and delivered the
following address:
"I am very grateful for your courtesy in giving me this op-
portunity to address you. I assure you it will be brief. I am
very grateful that you have accepted me so far as President of
the Association. I am also very glad that you have turned out
in such fine manner. I am quite anxious that this meeting be
a successful one, one of the most successful meetings in our
sixty-two years of existence. As anyone will know who holds
an office of this sort, they can not be anything but humble in
accepting, and if they have accepted it without humility, they
must accept humility soon afterward. If I have met with any
success, rest assured I will not take any of that as my respon-
sibility. It is the responsibility of you delegates. If there are
any misgivings, I will be very glad to take the burden of such.
I am very grateful to you for coming out this evening to con-
duct the business of this session. I assure you that your delib-
erations and conclusions will be my conclusions. I know you
will do everything properly. I know you are as serious about
this as I am. I thank you in advance for what you will do here
this evening.”
The Speaker then referred of the President to the Reference
Committee on Reports of the President, Secretary, Executive
Secretary, and special committees.
Report of Secretary
Dr. O. A. Sedlak, Secretary, presented the following report,
as prepared in the handbook, which was referred to the Refer-
ence Committee on Reports of the President, Secretary, Execu-
tive Secretary, and Special Committees:
MEMBERSHIP: The total membership for 1948 was 361.
Of this number 356 paid their annual dues and 5 were Hon-
orary Members. Seven members died during the past year and
18 of those who paid dues in 1947 did not pay their 1948 dues.
It is very gratifying to know that 34 new members were admit-
ted to the Association during this past year.
Table 1 shows the annual membership for the past eight
years. You will note that in 1946, the membership was at its
lowest, there being 335 members in the Association. In 1948,
there were 361, a gain of 26 members in the past two years.
One realizes, of course, that there were a number of deaths and
retirements during this period and that, therefore, the actual
gain in new members was much greater than this figure.
Table 1
Comparison of Annual Membership
1941
1942
1 943
1944
1945
1946
1947
1948
Paid Memberships
374
366
33 1
318
313
322
342
356
Honorary Membs.
Dues Cancelled —
12
10
1 1
10
9
9
8
5
Military Service
14
32
61
59
57
4
—
—
400
408
403
387
379
335
350
361
Table 2 shows that the annual dues for 1949 are coming in
quite promptly. The meeting is somewhat earlier than in pre-
vious years. Twenty-four new members have been admitted
so far in 1949. They are included in the total of 302 paid-up
memberships. A study of the records indicates that several
members who are in active practice have failed to pay their cur-
rent dues. The District Medical Society Secretaries and the
Councillors should use every means possible to collect the dues
of these delinquent members.
30C
The Journal-Lancet
Table 2
April 20
May 5
May 1
April 1 5
1943
1944
1945
1946
1947
1948
1949
Paid-up Members
316
304
294
305
316
320
302
Honorary Members
I 0
10
9
9
8
6
9
To be Honorary
4
Dues (Jan. Mil. Serv. 58
59
57
?
0
0
Associate
1
1
384
373
360
314
324
327
316
FIELD WORK: Visits to our local District Societies had to
be delegated to our Executive Secretary.
Your Secretary, however, did manage to attend a special
meeting in June called by the A.M.A. in regard to a proposed
joint commission of the Blue Cross and Blue Shield. He also
attended a district meeting of the A.M.C.P. at DesMoines,
Iowa, and the national meeting at French Lick Springs, Indiana.
In November, the annual meeting of the North Central Med-
ical Conference in Minneapolis was attended by both Mr. Enge-
bretson and myself. We also attended the annual meeting of
the Secretaries, the meeting of the Public Relations Committee
and the Interim Session of the A.M.A. at St. Louis. A meet-
ing of the "Committee of 53" called by the Council of the
A.M.A. to introduce to the State Medical Associations the
latest A.M.A. program and to launch the educational campaign
of the firm of Whitaker and Baxter, was likewise attended.
In addition to these national and regional meetings, attempts
were made to attend all important committee meetings of the
state organization.
RECOMMENDATIONS
1. In view of the fact that the office of the Secretary of the
State Association is becoming more and more important and
requires more work than an elective officer can devote to the
office, recommendation is made that the Office of the Executive
Secretary be maintained. The importance of this office was
demonstrated by the close watch the Executive Secretary kept
on the Legislature and the prompt action that was taken when
needed. Details are included in the report of the Executive
Secretary.
2. Recommendation is also made that the report of the
Executive Secretary be made the primary report of this office
and that the report of the elective officer become the supple-
mentary report.
Conclusion: Outside of a few differences of opinion, peace
and harmony reigned throughout the Association in the year
1948. Most committees have been very active during the past
year, and I wish to take this opportunity to thank our Presi-
dent, Dr. Liebeler, and the other officers of the Association,
together with the members of the various committees and a
goodly number of others who have given unstintingly of their
time and effort to make our organization a live, working,
authoritative Association.
Report of Executive Secretary
Mr. E. F. Engebretson, Executive Secretary, presented the
following report as prepared in the Handbook, which was re-
ferred to the Reference Committee on Reports of the President,
Secretary, Executive Secretary and Special Committees:
It is again my decided pleasure to make this report covering
the activities of this office during the past year. The report will
be made under separate headings, for the convenience of the
House of Delegates and the reference committees which will
consider this report.
1. General: There remains very fine harmony among the
members of the State Office staff which has served your organi-
zation for the past year. The facilities housing your State Office
remain very adequate.
We have had during the year a new Director of the Vet-
erans Medical Service Division; and we feel that we are very
fortunate in having obtained Mr. John Fox, who is a person
of high caliber and perfectly competent to carry on this impor-
tant work.
Mr. Samuel Gurke, who preceded Mr. Fox, and who was
thought highly of by the members of this organization, resigned
from his position to take on the position of Business Manager
of the Missouri Valley Clinic, Bismarck, North Dakota.
In the Executive Secretary’s office we still have with us our
very able secretary, Miss Rhea McDonald. The work of the
Veterans Medical Service Division has been so streamlined as
to require the services of only one full-time stenographer.
One could not ask for better office equipment than we now
have. It was a great relief to have the old mimeograph re-
placed by a new model, such authorization being given by the
Council at their January meeting. The paper detail of the office
is ever increasing; but we nevertheless encourage the member-
ship to make even fuller utilization of the services we are able
to provide.
2. Meetings: As in prior years the officers, Council and vari-
ous committees appointed by President Liebeler have been active
and effective.
Your Executive Secretary has attended the various meetings
of the Council, such committees having to do with social and
medical economics as the Committee on Medical Economics and
its Sub-Committee on Prepayment Medical Care, and the Com-
mittee on Medical Education.
He has also planned for, and/or attended such programs as
the Annual Conference of District Medical Society Officers; the
meetings of the Medical Center Advisory Council; and of the
State Board of Medical Examiners.
Again, he has had the pleasure of attending the various meet-
ings of the Governor’s State Health Planning Committee with
Dr. A. E. Spear, who so ably represents this organization on
that Committee.
There have been numerous general meetings held by lay
groups which this office has attended, such as negotiations with
the Public Welfare Board; meetings of Farm Safety Confer-
ence; the First Annual Safety Conference; the Cerebral Palsy
Clinic; meetings with the nurses’ organization; the Pharmaceu-
tical Association, and the North Dakota Farmers Union.
In the regional and national field, your Executive Secretary
attended the Interim Session of the House of Delegates of the
A.M.A.; its meeting called by the Council on Medical Service
for a discuss'on of Blue Cross and Blue Shield national poli-
cies; its Medical Society Executives Conference; its Conference
of Secretaries and Editors of State Medical Associations; its
National Public Relations Conference; and the Fifty-Three Man
Committee on Public Relations which served as the groundwork
for explanation and policy of the new A.M.A. National Edu-
cational Campaign.
He also attended such national and regional meetings as the
NPC National Economics meeting; and again a very worth
while meeting of the North Central Medical Conference.
He also visited various North Dakota District Medical So-
cieties at meetings held in Bismarck, Dickinson, Minot, James-
town, and Oakes; and got as far as the railroad station in
the city of Devils Lake when stricken with an inexplicable mala-
dy. He regrets very much that he had at the last moment to
turn down the invitation of the First District Society.
3. Legislative Year: The legislative year always brings addi-
tional activity to the State Office, as your Executive Secretary
is the legislative representative of both the State Association and
the State Board of Medical Examiners.
It is difficult to assay the effectiveness of the work of the
Association in connection with legislative matters without re-
questing the physicians throughout the state to send copies of
all legislative action letters to this office. We feel that this re-
quest would impose an undue burden upon the membership.
We nevertheless very much enjoy receiving this information, as
it is the only certain way of determining whether or not suffi-
cient action is being taken. A few of the doctors have been
sending such copies, and their legislative letters in every instance
have been extremely persuasive. All in all, the last session of
our State Legislature can be reported as a successful one in that
no detrimental legislation was passed.
One of the primary themes of the session was antipathy
towards all state boards and agencies having to do with the
September, 1949
301
regulation and control of various trades and professions. Short-
ages in the lines of certain trades and professions do exist; and
the alleged improper action of one of two individual boards is
credited to all.
Three different bills aimed at all of the various boards and
agencies were introduced, all of which were finally defeated.
Numerous other bills were introduced aiming at individual
boards, such as the plumbers, electricians and hairdressers. The
bill introduced for the licensure of all foreign physicians and
for the conducting of examinations in any foreign language
was one of the latter type.
It was the feeling of practically all legislators that the vari-
ous state boards and agencies have too much power, which can
be and perhaps sometimes is used in an arbitrary manner in
the various trades and professions. It became perfectly appar-
ent during the hearings on the Displaced Physicians bill and
later through the newspaper coverage given the hearings, that
the North Dakota State Board of Medical Examiners is one
of efficient operation, high purpose, and is impartial in its
operation.
4. Finance: In accordance with the instruction of the House
of Delegates last year, the provision for the presentation of
financial statements has been changed. You will find the cur-
rent financial statement of the Office of the Executive Secretary
and that of the office of the Veterans Medical Service Division
in the supplementary report of the Council. It will be found
there as approved or corrected by the Council.
The statements are handled this way so that consideration
might be had of them after action taken by the Council, to
whom the Office of the Executive Secretary is directly respon-
sible in matters of expenditure.
You will note in the statement of items chargeable to the
Executive Secretary’s Office, that there are a number of abso-
lutely necessary expenditures which are not budgeted. As a
result, the Office of the Executive Secretary still exceeds the
budget for the year; although in many cases the amounts for
the items actually budgeted have not been fully utilized.
It is recommended that a miscellaneous item of somewhere
between $750 and $1000 be included in the budget. Salaries
of the various employees are at a satisfactory level, and do not
require adjustments.
It is again recommended that a fund and an adequate
amount be set aside for the payment of the necessary meals of
doctors attending statewide meetings covering the business of
their office or committees. As a method of holding the group
together between afternoon and evening sessions, such a policy
is of practical merit.
5. Woman’s Auxiliary: The Woman’s Auxiliary continues
to grow and prosper. It has had an active year under the presi-
dency of Mrs. W. F. Baillie. It performed well in connection
with this year’s legislative undertakings; and it is recommended
that a resolution of thanks be communicated to that organiza-
tion. It is believed that as the years go on, increasingly impor-
tant work may be undertaken by the Woman’s Auxiliary.
6. Annual Session: Your Executive Secretary wishes to ex-
press his appreciation to the members and committeemen of
the Northwest District Medical Society, with whom he has
worked in connection with the 1949 meeting.
The list of exhibitors supporting the Annual Meeting con-
tinues to grow, till we now have eleven more exhibitors than
we had at the 1947 meeting. Without their financial support
this meeting would be impossible. Members are urged to visit
these exhibits whenever intermissions are held, and show their
appreciation to the exhibitors and their representatives.
7. Your Executive Secretary wishes to express his personal
appreciation to all with whom he has had occasion to work
during the last year. It is his impression that the Association
is becoming more democratic in that more and more of the
members have been taking an active interest in one, several or
all phases of its program.
E. F. Engebretson, Executive Secretary
Report of the Treasurer
Dr. E. J. Larson, Treasurer, presented his report as pub-
lished in the Handbook:
Balance on hand, May 1, 1948 3 9,646.52
RECEIPTS:
Receipts from dues 314.172.50
Interest on bonds 1 12.50 14,285.00
Total receipts 323,931.52
DISBURSEMENTS:
Checks No. 550 to No. 558, inclusive:
6-19-48 State Medical Assn.,
Office Exec. Secretary 32,500.00
Mrs. R. B. Byrne, steno. services 150.00
8-4-48 Dr. J. H. Moore, exp. AMA conv 163.44
Newberry Ins. Agency,
treasurer’s bond ...... ... 25.00
10-12-48 State Medical Assn.,
Office Exec. Secretary ... 2,500.00
1-21-49 North Cent. Med. Conf.,
1949 dues 75.00
State Medical Assn.,
Office Exec. Secretary 2,500.00
4-13-49 State Medical Assn.,
Legislative expense 128.43
State Medical Assn.,
Office Exec. Secretary 335.00
Total checks issued 38,376.87
Bank Exchange 1.50 8,378.37
4-15-49 Balance on hand, James River
National Bank .. ....
Bonds
315,553.1 5
4,500.00
4-15-49 Total assets 320,053.15
Recapitulation of Bank Balance
4-15-49 Balance, James River National Bank,
Jamestown. N. D. 316,016.58
Outstanding checks:
No. 557 3128.43
No. 558 -- 335.00 463.43
4-15-49 Balance — 317,553.1 5
Report of Chairman of the Council, 1948-1949
Dr. A. D. McCannel, Chairman, presented the following
report which was referred to the Reference Committee on Re-
ports of the Council, Councillors, Delegate to the A M. A. and
Member of the Medical Center Advisory Council.
During the past year the Council of the North Dakota State
Medical Association met officially four times. Three of these
meetings were held in conjunction with the 1948 Annual Meet-
ing of the North Dakota State Medical Association; and one
interim meeting was held in Bismarck on January 16, 1949.
The following reports were made and action taken at the
May meetings:
Meeting of the Old Council — 1947-1948
Dr. Arzt, President of the Association, addressed the Council,
outlining the high spots of the work of the Association for the
past year, and complimenting the Council on its very fine work.
Secretary O. A. Sedlak made reference to his report which was
printed in full in the Handbook of the House of Delegates,
announcing that there were 342 paid-up members, and 8 Hon-
orary members. Treasurer E. J. Larson made his financial re-
port by reference to the Treasurer’s Report which was also print
ed in full in the Handbook.
It was moved, seconded and carried that the Council recom-
mend a raise in dues to $50 per member for more proper financ-
ing of this Association. Included in the motion was a provi-
sion for eliminating the annual registration fee of $3.00.
It was moved, seconded and carried that Dr. A. C. Fortney
be reimbursed in the sum of $96.60 for expenses incurred in
attending a meeting at Chicago, April 4, 5 and 6.
After some explanatory remarks by Mr. Cohen, publisher of
the Journal-Lancet, it was moved, seconded and carried, that the
contract with that publication be renewed for one year.
A motion that the House of Delegates give their earnest
study to a plan for the prepayment of medical care, was duly
passed.
Mr. E. F. Engebretson read the financial report of the office
of the Executive Secretary; and Mr. Samuel Gurke read the
report of the Veterans Medical Service Division; copies of which
reports follow:
302
The Journal-Lancet
ACCOUNT OF OFFICE OF EXECUTIVE SECRETARY
June 1, 1947 — April JO, 1948
(Estimated Expenses, April 30 to May 3 1, 1948)
Budgeted
Balance on Hand, June 1, 1947 - #1,647.73
Income, North Dakota State Medical Association __ 7,500.00
Income, Convention (1947) --
Income. Convention (1948)
Unbudgeted Total
#1,504.32 #3,152.05
50.00
1,420.00 8,970.00
Salary. E. F. Engebretson #2,974.88
Social Security withheld
Income Tax withheld
Salary, R. McDonald . 1,645.30
Social Security withheld
Income Tax withheld
Income Tax Paid (withheld) 473.00
Social Security Paid (withheld) 55.50
Social Security Paid (matched) 5 5.50
Furniture and Fixtures 770.56
Office Supplies 338.95
Telephone and telegraph ' 190.88
Rent 275.00
Postage 147.48
Travel 768.05
Express and Cartage 1.00
Woman’s Auxiliary 13.63
Power and Light 17.75
Convention _. .
Council 20.40
Miscellaneous :
Medical Economics 20.3 4
Bank Service Charge 3.61
Rental, Meeting Rooms 83.46
Donations 5.00
Typewriter Repair r 17.36
Dues . 78.85
Cleaning Supplies 5.66
Cleaning 55.00
Personal Property Tax 7.42
Subscriptions 32.75
Court’ Sentence 2.10
Total Expended to April 30, 1948 ... .. #8.059.43
Balance, First National Bank
Estimated Expense, May 600.00
#9,147.73
#2,974.32 #12,122.05
# 32.08
201.30
19.00
235.70
1,371.61
#1.371.61 #9,431.04
1,088.30 1,602.71 2,691.01
600.00
#8,659.43
# 488.30 #1,371.61 #1,602.71 #2,091.01
VETERANS MEDICAL SERVICE DIVISION
TRIAL BALANCE
January 1, 1947 through April 30, 1948
Veterans Administration Center # 6,058.44
Medical Accounts Payable __
Income Fees
First National Bank 8,645.3 1
North Dakota State Medical Association
*Furniture and Fixtures 1,237.16
Old Age Benefit
Withholding Tax
Personal Property Tax 12.37
Salaries and Wages 7,232.38
Printing 63.53
Postage 721.80
^Office Supplies .. . . 1,153.21
Rent ... . 402.50
Power and Light ... 19.37
Telephone and Telegraph .. . 106.98
Miscellaneous (cleaning; bond; bulbs;
keys; misc. labor; bank charge) 252.61
Insurance Old Age Benefit Matched . 67.22
Travel 373.50
# 1 3,456.1 7
7.829.91
5.000.00
5.10
55.20
#26,346.38 #26,346.38
(*#19.73 transferred from Office Supplies to Furniture and Fixtures
per physical inventory of property April 6, 1948.)
The report of the auditing committee, consisting of Drs.
Fawcett, Meredith and Waldschmidt, was presented, and found
to be correct with one exception: Check No. 540, made out to
the North Dakota State Medical Association in the amount of
#2500, had been improperly endorsed, but had been cashed by
the bank.
The following matters were endorsed by the Council:
1. Approval of a uniform expert testimony law, at the re-
quest of the North Dakota Society of Engineers;
2. Approval and support of the work carried on by Miss
Margaret Shearon in her Shearon Legislative Medical Service;
and
3. Endorsement of the North Dakota Association of Medical
Record Librarians.
A request for approval by the American Association of Blood
Banks for support of their program, was postponed until it
might be determined whether their program might in any way
conflict with similar work being done by Melvin Koons at the
State Public Health Laboratory.
After considerable discussion relating to the problem of the
Army Engineers Corps in securing medical practitioners for the
Garrison Dam, it was moved and passed that the Association
tender every possible aid in this repect.
Meeting of the New Council — 1948-1949
At the first session of the new Council, Dr. A. D. McCannel
was re-elected Chairman, and Dr. C. J. Glaspel was re-elected
Secretary. Drs. McCannel, Waldschmidt and Sorkness were re-
appointed to the Executive Committee of the Council.
The following budget for the new year was prepared and
approved by the Council:
Miscellaneous travel #1750
North Central Conference 50
Committee on Medical Economics
Stenographer 150
Journal-Lancet — 800
Salary Executive Secretary 3500
Rental 360
Lights 25
Telephone 200
Office Supplies and Postage ... 650
Stenographer 2100
Traveling expenses, Exec. Sec. 1000
September, 1949
303
This made a total budget of $10,585. There was no set
amount for the Committee on Medical Economics nor for the
Chairman of the Council, or Emergency Fund of the Council.
Traveling expenses of Committee members must be approved
by the Executive Committee.
Note: The material following is not properly a part of the
transactions of the Council, but is included because of a recom-
mendation passed by the House of Delegates last year. The
recommendation reads as follows:
"The committee would suggest that the Executive Secretary
submit a financial statement for the current year, to be added
as a supplemental report for the consideration of this refer-
ence committee. In this way his report and that of the Treas-
urer would both be current.”
Your Executive Secretary of course does submit a current
report each year to the Council. It has not been in the Hand-
book, however, because of an unfortunate practice which we
have been following.
It has been customary to include in the Handbook for the
following year all of the meetings of the Council at the pre-
ceding Annual Meeting. Thus, the 1949 Handbook includes
the minutes of the meeting or meetings of the Council im-
mediately prior to the meeting of the House of Delegates.
Actually, the minutes of such Council meeting or meetings
should not be carried over to the following year, but should
be transcribed immediately and submitted to the House of
Delegates for its consideration. This would clear up a lot of
poor points that now occur; for example, such statements in
the Council report on its first meeting, that the Secretary or
the Treasurer referred to his report "which is printed fully
in the Handbook.” As the situation is now handled, such
reference is to a report which occurred in the Handbook one
year previous.
Properly, the annual work of the Council should begin with
the formulation of the new Council immediately after the
closing of the House of Delegates’ session, and continue
through all meetings of the Council up to and including those
sessions which are held immediately before the House of
Delegates. If this procedure is adopted, all of the confusion
will be eliminated.
* * * *
At an interim meeting of the Council held in Bismarck,
January 16, 1949, Dr. Liebeler was called on to act as Chairman
in the absence of Dr. McCannel.
The report of the Committee on Public Policy and Legisla-
tion relative to legislation then introduced before the 31st Ses-
sion of the North Dakota Legislature, was approved.
A report of the Committee on Medical Economics was adopt-
ed. The Committee on Medical Economics was authorized as
the committee to negotiate with the United Mine Workers in
connection with their proposal for the medical care of miners.
The Council authorized the purchase of a new mimeograph
machine for the State Office.
A letter was then read from the Stutsman County Medical
Society relating to a more vital public relations program. Dr.
E. J. Larson was called on, and stated that some of the younger
men in the Stutsman Society felt no effort was being made to
offset the propaganda against medicine.
The question came up as to whether there was some way we
could put the facts before the public on the radio and in the
newspapers. He suggested that the radio be utilized in explain-
ing the position of medicine to the public.
Dr. Nierling enlarged on the theme, but then added that per-
haps the A.M.A. possibly will serve the purpose, and that it
may not be necessary to form an executive committee or go
to extra expense; stating that perhaps we should wait to see
what comes from Chicago before developing the program here.
Mr. Engebretson stated that he frankly was glad to see the
resolution from the Stutsman District. He further stated that
this was the first time there would be a surplus which could be
put to such a purpose.
Dr. L. W. Larson stated that he thought the Association
should provide the machinery, but did not believe they should
jump into it in the meanwhile. He stated he was convinced
there would be a very effective program outlined by the A.M.A.
and placed in operation. He suggested that:
1. The Committee on Public Policy and Legislation take this
job over, or that a separate committee on Public Relations
be formed which could consider the local situation and
determine how to supplement the A.M.A. program; and,
2. That if funds were available, that $500 should be ear-
marked for that purpose.
Mr. Engebretson stated that with the raise of dues, a sur-
plus would be forthcoming of approximately $5,000 a year,
for expenditure in such way as the Council and members
thought fit. He stated in answer to questions that a minimum
of $3,500 to $4,000 would be required for even a very modest
educational campaign.
Dr. Liebeler stated that in that we do not know what the
national program is going to be, that for the time being a
modest amount of money ought to be allotted.
It was moved, seconded and carried, that a sum of $1,000
be allocated for an educational campaign, to be expended at the
discretion of the Executive Committee of the Council.
Dr. H. B. Huntley of Kindred, state delegate to the National
Committee of the American Association of Physicians and Sur-
geons, was called upon, and gave a very edifying report of the
activities of that organization.
Dr. A. E. Spear was elected successor to the late Dr Nacht-
wey as Speaker of the House of Delegates.
Unanimous approval was given to the Diabetic Detection
Drive, which plan was explained by Dr. Liebeler.
Supplemental Report of the Chairman of the
Council, May 14, 1949
The meeting of the Council was called to order at 4:00 P.M.
by the Chairman, Dr. A. D. McCannel. A quorum was present.
Dr. McCannel welcomed the members of the Council to
Minot.
The minutes of the meetings of the Council since the last
Annual Meeting were read and approved.
Dr. W. A. Liebeler, President of the Association, addressed
the Council, expressing his appreciation of the fine work done
by the Council during the past year, and his personal apprecia-
tion for the aid given him by the Council.
Dr. O. A. Sedlak, Secretary, made reference to his report
which is printed in full in the Handbook of the House of
Delegates, stating that in his opinion the membership for the
present year would be equal or in excess of that accomplished
during the year 1948. He stated further that he would again
like to stress the importance of maintaining the Office of the
Executive Secretary, stating that he was sure no doctor could
devote as much time as the office demands at the present time.
In the absence of the Treasurer, Dr. E. J. Larson, Dr. Sork-
ness made the financial report of the Treasurer, by reference to
the Treasurer’s Report in the Handbook.
The Executive Secretary was called upon to give his report
and read a detailed account of the financial status of the Office
of the Executive Secretary. Both the Financial Report of the
Treasurer and the Office of the Executive Secretary were sub
mitted to the Auditing Committee appointed, consisting of Dr.
Meredith, Chairman, Dr. Gilsdorf and Dr. Schwinghamer,
which read as follows:
304
The Journal-Lancet
Accounts of Office of Executive Secretary
June 1, 1948 - April 15, 1949
Balance on Hand, June 1, 1948
N.D.S.M.A.
5 10.1 1
7,835.00
Bd. Med. Ex.
Convention License
1245.68
Bd. Med. Ex.
Education
N.D.S.M.A.
Education
Totals
1,755.79
725.00
46.61
Income, Bd. Med. Exam. License
Income, Bd. Med. Exam. Education
Income, N.D.S.M.A. Education
566.41
128.43
9,301 .45
E. F. Engebretson, salary ......
(Soc. Sec. 27.08; Inc. Tx. 114.40)
8,345.1 1
3,066.78
1,970.68 46.61
566.41
128.43
1 1,057.24
R. McDonald, salary
(Soc. Sec. 19.25; Inc. Tax 194.70)
Soc. Sec. Pd. (withheld)
Soc. Sec. Matched
Income Tax Pd. (withheld)
Furniture and Fixtures
Office Suppli es
Telephone and Telegraph
Rent
Cleaning
Postage
Travel
Power and Lights
Subscriptions, Dues, Etc.
Repair Office Equip.
Bd. Med. Exam. License
Bd. Med. Exam. Education . ._
N.D.S.M.A. Education
Convention (1948)
Convention (1949)
Miscellaneous:
50 Yr. Club ...
Personal Property Tax
Cleaning Supplies
Express
Flowers
Meeting Rooms
Woman's Auxiliary
Bank Service Charge ..
1,71 1.05
51.00
51.00
349.20
336.54
306.35
206.95
310.00
55.00
164.00
803.19
12.26
223.75
12.50
16.00
13.90
2.98
1.88
31.45
34.76
28.07
3.04
7,791.65
46.61
566.41
889.08
166.37
128.43
553.46
1.055.45
915.23
46.61
566.41
128.43
9,588.55
1 468 69
North Dakota State Medical Association Veterans Medical Service
TRIAL BALANCE
January 1, 1947, through
May 31, 1949
Debit
Credit
First National Bank — May 3 1, 1949
.... # 2,483.90
North Dakota State Medical Assn.
#5,000.00
Medical Accounts Payable
4,708.00
Veterans Administration Center
3.373.91
Income Contract Fees
14,657.37
Old Age Benefit (2nd quarter only)
8.50
Insurance (old age benefit paid)
119.48
Withholding Tax (2nd quarter only)
77.60
Printing
165.83
Salaries and wages
..... 12,798.33
■
1,100.22
Office Supplies
1,305.65
445.08
Rent
772.50
Power and Light
31.26
Telephone and Telegraph
177.94
Furniture and Fixtures
..... 1,296.63
Personal Property Tax
26.27
Miscellaneous (cleaning, bond.
light-bulb, keys, labor)
354.47
Totals
... #24,45 1.47
#24.451.47
The Executive Secretary also explained that the membership
had grown from the time the Handbook was mimeographed to
the present time. At the present time the membership is 330.
He explained the growth of membership last year from that
shown in the Handbook, and stated he expected the member-
ship would grow again this year.
He commented on the $25 A M. A. Assessments, stating that
195 had been processed through his office, with a total of $4,875
turned over to the A.M.A. He recommended that the House
of Delegates pass a strong resolution asking that all members
pay this assessment which is so vital to the tremendous under-
taking newly assumed by the A.M.A.
The Executive Secretary stated further that he wanted to
thank the members of the Council, the State Board of Medical
Examiners, and the membership at large for the great amount
of help given during the last legislative campaign. He stated
that the problems covered were included in the report of the
Committee on Public Policy and Legislation and the Committee
on Displaced Physicians, both of which appear in the Hand-
book. He stated further it is gratifying to know that on legis-
lative matters, help is being received not only from the Doc-
tors but also the Auxiliary.
Motion was made and seconded that the report of the Execu-
tive Secretary be accepted and approved with the exception of
that part of which was referred to the Auditing Committee.
Mr. Cohen, from the Journal-Lancet, spoke to the Council,
recommending that they see fit to recommend to the House of
Delegates that the contract with the Journal-Lancet be renewed
for a period of two years. Discussion was had with Mr. Cohen
regarding News Items in the Journal-Lancet.
The bill submitted by Dr. Moore as Delegate to the Interim
Session of the American Medical Association was approved.
Attention was called to the fact that bills of several officers of
the Association who have attended national, regional and state
meetings have not been presented and instructions were given
that such officers present their bills at the following meeting
of the Council.
Dr. McCannel, a member of the Executive Committee of the
Council, explained to the Council that the Executive Committee
authorized the expenditure of moneys necessary to bring Forest
A. Harness, Ex-Congressman from Kokomo, Indiana, to the
meeting. Mr. Harness was chairman of the Sub-Committee on
Propaganda investigating improper expenditure of federal agen-
cies propagandizing for national compulsory health insurance.
The Council made the following recommendations to the
House of Delegates:
1. It is recommended that the House of Delegates adopt a
resolution in the strongest terms against the passage of any
federal measure for compulsory health insurance.
2. After a very considerable amount of discussion, it was rec-
ommended to the House of Delegates that the incoming
President be advised to appoint a Public Relations Com-
mittee for the carrying on of such campaign as may be
possible to supplement the Educational Campaign of the
A.M.A., and that this Committee be instructed to receive
authority for expenditures from the Executive Committee
of the Council.
3. The Council recommended that the House of Delegates
pass a resolution directed to every member of the Associa-
tion impressing upon them the importance of the work
undertaken by the A.M.A. in their national educational
September, 1949
305
campaign against Compulsory Health Insurance and that
each member of this Association be urged most strongly
to pay their assessment of $25.00 to the A.M.A.
4. The Council recommended that the House of Delegates
renew their contract with the Journal-Lancet for a period
of one year.
The following proposals submitted to the Council were rejected:
1. Request from the I. C. System that the North Dakota
State Medical Association either enter into a contract with
it for the collection of accounts of medical patients or that
the North Dakota State Medical Association give the
I. C. System an endorsement.
2. A request of the North American Accident Insurance
Company that endorsement be given to said company for
group insurance of the membership.
3. A request by the National Sales Foundation for an en-
dorsement of its program in selling a series of articles to
the various druggists tn the State of North Dakota.
The Executive Secretary was instructed to communicate with
the American Medical Association requesting them to provide
information concerning those members of this Association who
have paid their assessment directly to the American Medical
Association rather than through the State Association.
He was also instructed to notify the various secretaries of the
District Medical Societies that the Council recommends that for
the improvement of the Journal-Lancet, all District Secretaries
should co-operate with the Journal-Lancet to the utmost in re-
porting all local news items of interest within their district.
There was a recess during which the Auditing Committee
audited the accounts of the Treasurer and the Executive Sec-
retary.
The meeting was again called to order to receive the Audit-
ing Committee’s report. It was moved and seconded that the
financial reports of the Treasurer and the Excutive Secretary
be approved.
There being no further business to come before the meeting,
the Council adjourned.
Archie D. McCannel, M.D.,
Chairman of the Council
REPORTS OF COUNCILLORS
First District
Eight regular meetings were held during 1948. Meetings were
preceded by dinners. One meeting was a joint meeting with
wives of members. The turnout was excellent, as it seems the
wives were able to get their husbands to attend.
The scientific papers were as good as usual. In April, Dr.
Robert Kierland of the Mayo Clinic spoke on "Dermatological
Manifestations of Systemic Disease.” September, 1948, Dr. O.
A. Sedlak, State Secretary, and our new President, Dr. Liebeler,
spoke to us. October, 1948, Dr. George Aagaard of the Uni-
versity of Minnesota, gave an excellent review on "Management
of Hypertension.” In November, 1948, Dr. George B. Logan
of the Mayo Clinic spoke on "Management of Allergic Diseases
of the Respiratory Tract in Children.” In December, 1948, Dr.
Richard Varco, Assistant Professor of Surgery at the Univer-
sity of Minnesota, spoke on "Surgical Management of Some of
the Congenital Heart Lesions.” March, 1949, Dr. R. E. Ebert,
Veterans Hospital, Minneapolis, Minnesota, spoke on "Pulmo-
nary Emphysema.” February, 1949, Dr. Wallace Rasmussen
of the Mayo Clinic, spoke on "Neurological Manifestations of
Systemic Disease.”
Attendance at the meetings was good. Members of the sur-
rounding local societies and medical staff of the Veterans Hos-
pital were frequent guests.
Drs. Budd Corbus, Allen Moe, Poindexter, Kaylor, LeMar,
Rogers, Lewis, Driver, Hunter, and Schneider, were elected to
full membership. New probationary members were Drs. John
Burton, Howard Hall, Roy E. Kulland, Robert Tudor, Theo-
dore Donat, William Wright, Dean Nelson, Lester Wold and
Ahern.
Richland County Medical Society became a part of Cass
County Medical Society in February, 1949. The name of the
Society was changed to the First District Medical Society in
March, 1949. Total paid-up members are 63, which gave the
Society one more delegate. The new delegate is Dr. Beithon
of Wahpeton.
The new officers elected for 1949 were: President, Dr.
Charles Heilman; vice president, Dr. Earl Haugrud; secretary-
treasurer, Dr. John H. Bond; board of censors, Drs. B. A.
Mazur, Stephen Bacheller and William Nichols; delegates to
state convention, Drs. A. C. Fortney, B. M. Urenn and E. J.
Beithon; alternate delegates, Drs. Earl Haugrud and C. M.
Hunter.
James F. Hanna, M.D., Councillor
Second District
The Devils Lake District Medical Society had five regular
meetings in the past year, all but one of which an outside
speaker was present. The meetings were interesting and well
attended, and interest is running fairly high. We have, of
course, had considerable bad luck in attendance from outside
men because of the severe winter, but imagine other societies
have had the same problem.
Since the last report this society has definitely taken on the
Medical Service Plan as presented on a state-wide basis, and at
the present sitting the community has been canvassed for the
first time for membership. At the time this report is made out,
I am not informed as to the success of the campaign to date.
With talking to individuals about town who have been con-
tacted, I would say that interest is not particularly high.
This society has lost one man, Dr. John D. Graham, from
its membership through death in the past year. There have
been two men who have dropped their membership and four
new members. The name of Dr. W. F. Sihler has been pre-
sented by our society to the State Association in normination
for honorary membership.
John C. Fawcett, M.D., Councillor
Third District
The Grand Forks District Medical Society has had a con-
structive year. We have sixty active and four honorary mem-
bers, every doctor in our district belonging to the society. Dur-
ing the year eight well-attended meetings were held. Guest
speakers included A. R. Burt of Winnipeg, E. M. Hammes, Jr.,
of St. Paul, Francis Lynch of Minneapolis, Richard Marwin of
the University of North Dakota, and Ben Sommers of St. Paul.
The following officers were elected in January 1949: President,
Nelson A. Youngs, Grand Forks; vice president, Ralph Ma-
howald. Grand Forks; secretary-treasurer, L. B. Silverman,
Grand Forks; delegates to the state medical meeting, T. Q.
Benson, Grand Forks; R. W. Vance, Grand Forks; George
Waldren, Cavalier and R. O. Goehl, Grand Forks, alternate.
President Youngs has recently suggested that due to the un-
certain conditions of the roads in January and February, the
meetings in these months be eliminated and replaced by meet-
ings in June and August. The society has favorably acted on
his suggestion and it was especially approved bv the members
residing outside of Grand Forks. If this new plan proves suc-
cessful it could be copied by other districts in the state. His
program committee is formulating an all-day meeting late in
June in which several phases of chest diseases will be discussed
by guest speakers including Dr. W. L. Wallbank, San Haven,
on Tuberculosis; Thos. Kinsella, Minneapolis, on Surgical As-
pects; and Dr. Schmidt of the Mayo Clinic on Bronchoscopic
Aspects. An internist and a roentgenologist will also speak.
A general invitation is extended to all doctors to attend.
The officers of the Traill-Steele District Medical Society are:
President, H. A. LaFleur, Mayville; vice president, R. C. Little,
Mayville; secretary-treasurer, Syver Vinje, Hillsboro; delegate,
T. M. Cable, Hillsboro; alternate delegate, H. A. Lalleur,
Mayville.
Paid-up members for 1948 was nine, this including every
doctor in the district.
Three regular meetings and one special meeting were held
during the year, guest speakers being Dr. J. J. Stratte, Grand
Forks, and Dr. Lester E. Wold of Fargo.
C. J. Glaspel, M.D., Councillor
Fourth District
The Northwest District Medical Society now has a mem-
bership of 63 members, there being a gain of five members dur-
ing the past year.
During the past year the meetings have been held alternately
at St. Joseph’s Hospital and Trinity Hospital. Both have been
306
excellent meeting places and we have always been served good
meals.
During the year nine regular meetings were held and we were
privileged to have the following speakers:
In January, Dr. Gordon Kamman of St. Paul, Minnesota,
talked on "Psychiatry in General Practice.”
In February, Dr. Malcolm McCannel discussed "The Prob-
lems in Squint,” and emphasized the advice to be given to
parents when first observed in children.
At the March meeting, Mr. Harry Northam discussed
"Prepayment Insurance.”
In April, Dr. Kinsella of Minneapolis, Minnesota, dis-
cussed "Surgical Conditions of the Chest.”
The May meeting was turned over to the delegates to the
state convention who reported on the meeting held at James-
town.
At the September meeting, Mr. Eddie Showers of Bis-
marck, field man for the American Red Cross, discussed "The
Part of the Red Cross in the Blind Program.”
At the October-November meeting, Mr. Engebretson, our
Executive Secretary, and Mr. Eagles of the Blue Cross, dis-
cussed "Prepayment Insurance.”
The December meeting consisted of an open discussion of
prepayment insurance by the members.
The invitation by the Northwest District Medical Society to
entertain the State Medical Association was accepted by the
State Association. We feel that with our new hotel we should
have good facilities for taking care of the meeting. We are
urging as many members to come as possible as we are going
to have our famous Smorgasbord at the Country Club. All
plans are underway and all committees are functioning in prepa-
ration for the convention on May 16 and 17.
Archie D. McCannel, M.D., Councillor
Fifth District
Herewith is the Councillor’s report for the Fifth District So-
ciety for the year 1948.
The membership of our society did not change during the
past year. Of the eleven men in our society, nine practice in
Valley City and two in Cooperstown. One of our members,
Dr. A. W. Macdonald, of Valley City, had the distinction of
bceoming an honorary member of the State Association in 1948.
Two regular meetings of our society were held during the
year. The annual meeting in January, 1948, was devoted to the
election of officers, and to the discussion of medical-economic
subjects. The Councillor for the District reported on the recent
Council meeting held in Bismarck. Among subjects discussed
at this meeting were the selection of a journal to represent the
North Dakota Medical Association; Veteran’s medical examina-
tion and treatment program, and State Welfare Board fees with
particular relation to the recent adoption of the maximum
allowance.
In November a scientific dinner meeting was held at Mercy
Hospital at which Dr. Allen Moe of the Fargo Clinic gave an
excellent address on the subject of recent advances in cardio-
vascular medicine. The classification of various types of heart
diseases, and suggested methods of treatment were outlined by
the use of lantern slides.
Much of the scientific program of our society is related to
the discussion of clinical cases at our Hospital Staff meetings.
Officers elected for 1949 are: President, Dr. G. Christianson;
vice president. Dr. Kent Westley; secretary-treasurer, Dr. C. J.
Meredith; delegate, Dr. W. H. Gilsdorf; alternate, Dr. Paul
Cook.
Excellent harmony and cooperation prevails in our society.
C. J. Meredith, M.D., Councillor
Sixth District
Four meetings have been held during the past year with an
average attendance of forty. The membership in the society
is sixty-three.
The various members of the society discussed "Prepayment
Medical Insurance” at one meeting. Dr. M. A. Perlstein of
Chicago spoke on "The Differential Diagnosis of Convulsions
in Children” and also discussed drug treatment in cerebral palsy
cases. Dr. M. G. Fredricks of the Department of Dermatology.
Duluth Clinic, presented a paper on "Treatment of Special
Interest in Common Skin Diseases.” Various members of the
The Journal-Lancet
society presented a "Symposium on Gastric and Duodenal
Ulcers.”
The present officers of the Sixth District are: President, T.
W. Buckingham, Bismarck; vice president, C. A. Arneson, Bis-
marck; secretary-treasurer, C. H. Peters, Bismarck.
New members admitted during the year were Drs. Robert
Cochran, Bismarck; J. M. Bahamonde, Elgin; R. D. Schoregge,
Bismarck; W. R. Enders, Hazen; G. A. Dahlen, Bismarck;
W. A. Craychee, Mandan; Philip Blumenthal, Mandan.
Two members, Dr. DeWitt Baer and Dr. W. M. Smith, died
during the past year. Dr. A. M. Brandt has retired and
moved away and has discontinued his membership. Dr. Mary
Soules, now of Billings, Montana, has transferred her member-
ship and Dr. L. B. Moyer, now of Lake Preston, South Da-
kota, transferred his membership. Dr. W. H. Bodenstab, Dr.
Fannie D. Quain and Dr. E. P. Quain have been made honor-
ary members of the society.
R. H. Waldschmidt, M.D., Councillor
Seventh District
The Stutsman County Medical Society, which is the Seventh
District Society, had eight meetings during the year 1948, and
have had two thus far in 1949.
On January 27, 1949, the following officers were elected:
President, Dr. John N. Elsworth; vice president, Dr. Clarence
Martin; secretary-treasurer, Dr. R. D. Nierling; delegate, Dr.
P. G. Arzt; alternate, Dr. T. E. Pederson; censors, Drs. George
Holt, F. O. Woodward and Robert Woodward.
At this meeting a report of the meeting of the District So-
ciety Officers and the Councillors at Bismarck, January 15 and
16 was given by Drs. Larson and Nierling, who attended the
meeting.
At the February 24th meeting a colored film was shown on
"Anomalies of the Bile Duct.”
— 1948 —
At the January meeting, following the election of officers
a discussion on prepayment medical care was carried out, fol-
lowed by a sound film on "The Role of the Gastroscope in the
Diagnosis of Gastric Disease.”
The next meeting was held on February 26, 1948, at which
time Dr. G. Wilson Hunter of the Fargo Clinic gave an inter-
esting paper on "Surgical Sterilization of Women, and the
Medicolegal Aspects of Such,” followed by a colored film on
"The Anemias.”
The next meeting was held on March 25th, at which time
Dr. Gerrish was recommended for honorary membership in
the State Association after 50 years of service in the state.
A film was shown on Obstetrical Maneuvers on the Ayer
Mannkin.
Another meeting was held on April 29. Discussion of the
State Medical Association meeting was carried on, followed by
a film on "The Problem Child.”
A business meeting was held on August 26, the primary
purpose of this meeting was to discuss the North Dakota Phy-
sicians Service Plan.
At the October 28th meeting a motion was made and car-
ried that the North Dakota Physicians Service Plan be rejected
bv the Society, this was carried. Two reels were shown on
"Cesarean Section.”
At the meeting November 19, Mr. Forsyth Engebretson,
Executive Secretary of the State Association, and Mr. Donald
Eagles, representing the Blue Cross and the Blue Shield, were
present. They presented an outline of the North Dakota Phy-
sicians Service to date. A three-reel film on Sulfanilamide
Therapy was shown.
The last meeting of the year was held on December 10. The
subject of propaganda against the Medical Profession was dis-
cussed. After this a resolution was adopted to combat the
situation, which was to be presented to the Councillors at the
January meeting.
Joseph Sorkness, M.D., Councillor
Eighth District
Two meetings were held during the past year, both at La-
Moure. At the first meeting in November, 1948. Mr. Don
Eagles of Fargo and our Executive Secretary. Mr. E. F. Enge-
bretson of Bismarck, were present and the discussion centered
on Blue Cross and prepayment medical plans.
September, 1949
307
At the second meeting held December 9, 1948, Dr. Corbus
of Fargo was the guest speaker, the subject of his paper being
Urological Conditions.
F. W. Fergusson, M.D., Councillor
Ninth District
The Tri-County Medical Society held four meetings since its
last report.
Dr. P. H. Woutat addressed the society at one meeting, dis-
cussing the Radiological Diagnosis of diseases of the colon.
Mr. Don Eagles discussed the North Dakota Physicians Serv-
ice at another meeting. Approval of this plan was voted and
payment of the enrollment fee has been made by the majority
of the members.
A report on the meeting of presidents and councillors in Bis-
marck was made by Drs. Gilliland and Schwinghamer at a
meeting held on January 25, 1949. At that meeting the
A.M.A. special assessment of $25.00 was approved and all who
were in attendance made their payment at that time.
Dr. C. G. Owens of New Rockford was admitted to the
society during the year and the applications for memberships
of Drs. Glenn W. Seibel, New Rockford, and Lowell Boyum,
Flarvey, were received and approved. Officers for the year are:
President, Dr. W. C. Voglewede; vice president, Dr. P. A.
Boyum; secretary-treasurer, Dr. D. W. Matthaei; delegate, Dr.
R. F. Gilliland; alternate, Dr. C. G. Owens; councillor, Dr.
E. J. Schwinghamer.
E. J. Schwinghamer, M.D., Councillor
Tenth District
The Southwest District Medical Society now has 23 mem-
bers. During the past year we have gained two new members,
Dr. A. J. Spanjers, who is associated with the Dickinson Clinic,
Dickinson, North Dakota, and Dr. Clarence A. Bush of Beach,
North Dakota. One member, Dr. Charles A. Vogl of Bowman,
North Dakota, has moved to Miles City, Montana, where he
is associated with the Garberson Clinic.
It is with our deepest regret that we report one of our oldest
members, Dr. A. P. Nachtwey, passed away on June 28th.
He had been a very active member in the local district as well
as the State Medical Association, having been delegate to the
A.M.A. for many years, and during 1948 was Speaker of the
North Dakota House of Delegates. The society has lost a very
valuable member.
During the year the society held three meetings. In March,
after a dinner at the St. Charles Hotel, Dr. Howard of Miles
City, Montana, presented a paper on Rh factor in pregnancy.
In October a meeting was held at which time the problem of
participation in the "Blue Shield” plan was taken up. After
full discussion of the problem, it was unanimously decided by
those present that the District Society should go on record as
supporting the North Dakota Physicians Service Plan, and that
signing up of those desiring this protection should be accom-
plished as soon as feasible.
On January 8, 1949, after a dinner, Dr. Cartwright of Bis-
marck presented a paper on the problem of Amcebic Dysentery.
Guests at the meeting also included Mr. Don Eagles, Secretary
of the Blue Cross, and Mr. E. F. Engebretson, Executive Sec-
retary, who discussed the problem of Blue Shield.
Response of the members of the society to the assessment by
the A.M.A. of Twenty-five Dollars per member has not been
too satisfactory. This may be partly due to the fact that the
roads have been almost impassable during the past winter, and
that it has been impossible to have personal contact with the
doctors in the smaller communities. In the large centers where
more active discussion by the members was possible the response
was 100 per cent, but at present only about 50 per cent of the
total society membership have remitted their assessment. It is
our hope that this can be raised to 100 per cent.
During this spring a program of vaccination and immuniza-
tion of the school children was undertaken. For those finan-
cially able to pay, it was felt that a very nominal charge should
be made, but no child was refused because of inability to pay.
In the district where this was carried out, all the local groups
of doctors were invited to participate, and the monies so ob-
tained deposited to the account of the District Medical Society.
It is planned to use this fund to obtain guest speakers and
promote other society activities.
Dr. A. R. Gilsdorf, Councillor, Tenth District, has been
taking postgraduate work at the University of Minnesota for
the past nine months and has therefore been out of contact
with the proceedings of the society. At his request the above
report is submitted.
R. W. Rodgers, M.D., Acting Councillor
REPORTS OF STANDING COMMITTEES
The following reports of the Standing Committees were re-
ferred to the Reference Committee on Reports of Standing
Committees, except the Report of the Committee on Medical
Economics and its Subcommittees on Prepayment Medical Care,
Veterans Medical Service, and Rural Health.
Medical Education
The Committee on Medical Education of the North Dakota
State Medical Association has had but one formal meeting dur-
ing the past year. Your chairman, however, has kept in close
touch with the progress of the University Medical Center and
did co-operate with all interested organizations in carrying on
the campaign for the passage of the one mill levy. Such or-
ganizations, in addition to the University Medical Center Ad-
visory Council, include the University of North Dakota Alumni
Association, the officials of the University of North Dakota,
the Dean of the Medical School and the National Accrediting
Agencies. He attended the January meeting of the University
Medical Center Advisory Council.
The Committee on Medical Education of the North Dakota
State Medical Association, meeting at Grand Forks, March 12,
1949, has reviewed the legislative action of the 31st Legislative
Session dealing with the one mill levy amendment to the Con-
stitution passed at the general election November 4, 1948.
This committee, representing the practicing physicians of
the State of North Dakota, interprets these actions as follows:
1. The mill levy is interpreted as being clearly a demand
of the people of North Dakota for more competent medical
care in the immediate foreseeable future. With this in mind we
realize that the mill levy proceeds will not be available until
sometime in 1950. This would mean at least a loss of one year
in carrying out the wishes of the people of North Dakota.
We suggest that the Board of Higher Education explore the
utilization of the present biennial appropriation for the Uni-
versity Medical School of 1949-1950; or that they explore the
possibility of issuing tax anticipating certificates against the
one mill levy in order to carry out the following expanded
program.
This committee envisions two major important phases:
1 . That it is imperative that the Board of Higher Education
and the Administration of the University of North Dakota
take immediate energetic steps to fulfill the demands of the
American Association of Medical Colleges and the American
Medical Association Division of Education and Hospitals. These
minimum demands are set forth as follows:
The following are the changes necessary to bring the School
of Medicine up to the standard required for accreditation as
outlined by Dr. Anderson, Secretary of the Council on Med-
ical Education and Hospitals of the American Medical Associa-
tion and Dr. Smiley, Secretary of the Association of American
Medical Colleges to Mr. John A. Page and Dr. W. F. Potter
of the University.
Department of Biochemistry: This department should have
the teaching services of at least two men whose full obliga-
tion should be to the Medical School and the department
should receive its budget from the School of Medicine.
Department of Physiology and Pharmacology: This de-
partment, which is really two departments, should have three
teachers of professorial rank (from assistant professor up) in
addition to the dean.
Department of Pathology: The pathology department
should have the services of two full-time or three part-time
men of professorial rank and of recognized standing in the
field of pathology.
Department of Bacteriology: The present staff of this de-
partment appears adequate, but additional help will be re-
quired for teaching nurses, technologists, etc.
Medical Library: A full-time librarian should be employed
and given adequate secretarial help. To build up the collec-
308
The Journal-Lancet
tion of journals, monographs and textbooks will require the
expenditure of about $15,000 per year for several years.
Department of Clinical Medicine: The local medical men
teaching in this department should receive part-time remunera-
tion and should be allowed a small budget for the purchase
of necessary equipment and supplies required for their teach-
ing.
The Dean’s Office: An additional secretary, or typist,
should be employed to take care of the voluminous corres-
pondence involved in admissions, transfers and the like.
Someone should be appointed to serve as assistant dean to
take care of the routine correspondence of the office. (The
suggestion was made by Dr. Anderson that Dr. French, Dean
Emeritus, might be willing to continue to handle this work.)
Department of Anatomy: The Department of Anatomy
should have a full-time gross anatomist and a full-time micro-
scopic anatomist with a third man attached to both divisions
capable of adequately substituting in either in emergencies.
These men should be in addition to the dean emeritus, who
would devote most of his time to the work of the dean’s office.
The committee has analyzed these demands and finds that
they require the immediate procurement of at least ten qualified
faculty members for the maintenance of a Class A accredited
two year medical school.
This committee finds that housing facilities at Grand Forks
are lacking and suggests that the Administration of the Uni-
versity begin immediately to reserve in advance adequate hous-
ing facilities for new staff members.
This committee after extensively discussing means of obtain-
ing physicians feels that it would be proper for the Board of
Higher Education to use such receipts from the one mill levy
as necessary to subsidize:
1. North Dakota graduates for the two year medical school,
and/or
2. To make immediately available graduate physicians for in-
ternship training; to subsidize such graduates of other
schools that have finished four years of medicine to the
extent of one thousand dollars per year in return for
which scholarships or subsidies they would agree to intern
or practice in some rural community for one year for each
thousand dollars received, and that in the event of their
failure to return to North Dakota said scholarship or
subsidization would be refunded to the University Medical
Center at an interest rate of 4 per cent per annum.
This committee suggests that the Medical Center Advisory
Council and the North Dakota Hospital Association, the Ad-
ministration of the University of North Dakota, and the North
Dakota University Medical School co-operate and set up a divi-
sion of internship training under the supervision of a full-time
medical school faculty member to be selected for his knowledge
of organizing and maintaining intern training programs. Such
a program conceivably can co-ordinate the larger private hospi-
tals of the state, the State Mental Hospital, the State Tuber
cular Hospital, the hospital at Grafton and other health facili-
ties in the state into an integrated teaching organization that
would provide not only good internship training programs with-
in the state, but also acquaint the graduates of such system with
the facilities and needs of the state of North Dakota.
In addition this committee endorses the recommendation of
the Medical Center Advisory Council to the State Board of
Higher Education in all respects when and if they become
feasible, urging, however, that matters contained in this com-
mittee report be given primacy; said recommendations of the
Medical Center Advisory Council to the State Board of Higher
Education are herewith included in totem:
The Recommendations of the Medical Center Advisory Council
to the State Board of Higher Education
To recognize the mandate of the people to activate the Med-
ical Center Enactment and to make funds available through
the State Board of Higher Education, the following is recom-
mended:
1. That the present two-year Medical School at the Univer-
sity of North Dakota be strengthened as soon as possible
so that it may obtain the unqualified approval of recog-
nized accrediting agencies.
2. That a study of ways and means by which general med-
ical practitioners can be made available to the people of
North Dakota through scholarships, stipends, and intern-
ships. After such a study that an administrative plan be
established.
3. That a study be made of means by which state-wide patho-
logical, library, postgraduate, and psychiatric services can
be made available to the people of the state.
4. That co-operation is requested with the League of Nursing
Education; the State Nurses’ Association, and the State
Board of Nurse Examiners, in developing a School of
Nursing on the collegiate level, at the University.
5. That the University offer courses leading to academic de-
grees for medical technologists and x-ray technicians.
6. That the State Medical Center co-operate with public and
private health agencies to augment and implement an
adequate health program for the people of the state of
North Dakota.
Moved by Mr. George Aljets, seconded by Dr. A. D. Mc-
Cannel, that the above resolutions be adopted. Motion carried.
R. E. Leigh, M.D., Chairman
Pneumonia
The Committee on Pneumonia held no formal meetings dur-
ing the current year. It is the opinion of your chairman that
efforts of the committee in prior years have fairly well accom-
plished the job of establishing types of treatment and develop-
ing keen interest among the profession in this disease. While
there did not seem to be an urgent necessity for a meeting of
the committee, it is thought that the following state totals for
the incidence of pneumonia, the place of treatment and kind of
treatment will be of interest to the profession.
Pneumonia Cases by Month Pneumonia Cases by Age and Sex
Month
Cases
Age Group
Male Female
J anuary
91
Linder 1 month
6
10
February
... 117
Over 1 month and
March
133
under 1 year
94
82
. 107
1 to 4
91
95
89
5 to 9
30
19
64
10 to 14
10
9
July ..
46
15 to 19 ...
10
4
53
20 to 29 ..
36
24
3 0 to 3 9
33
10
69
40 to 49
34
1 0
Novembe
49
“>0 to 5 9 ..
40
10
December
66
60 to 6 9
36
28
—
70 and over
71
59
Total 918
Not stated
46
21
Totals
537
381
Kin
d of Pneumonia
Place
of Treatment
... 211
34
600
. 622
Other
57
. 262
Not stated 50
Total 918
Total
918
Type o:
Treatment
Sulfa .
52
Penicillin
384
Sulfa and Penici
din
46
Streptomycin and
Penicillin
13
Duracillin
22
No information
382
Eskadiazine ...
19
Pneumonia Deaths
1947
1948*
Broncho
93
83
Lobar
... 71
43
Virus, atypical
9
2
Pneumonia, unspecified 27
20
Total 200
48
*Provisional
Statistics are obviously incomplete and somewhat inconclusive.
Reporting is sporadic and not complete enough in detail. Death
rate 16 per cent.
O. W. Johnson, M.D., Chairman
Necrology and Medical History
In accordance with the traditions of our profession we pause
in our usual activities to pay our respect to those of our col-
leagues who have left our ranks for the Great Beyond, since last
we met. This we do with sincerity, marking well their accom-
plishments; their ethical cooperation and their great devotion
to duty and our profession.
September, 1949
309
We tender our sympathy to beloved ones who mourn their
loss. May they feel, as we feel, that those departed still furnish
strength and inspiration to us who must still carry the burden.
WILLIAM H. WELCH
Dr. William H. Welch, 93, passed away May 11, 1948, at
his home in Larimore. He was a native of Caledonia, Vermont,
where he received his early education. He graduated from the
Academy of Medicine of Vermont and went to the west coast
as physician for a lumber concern in 1883. He returned, how-
ever, to locate at Crookston, Minnesota, where he practiced un-
til 1889, when he moved to Larimore. Dr. Welch served as
physician for the Grand Forks County Hospital for a number
of years and as medical advisor for the Great Northern Railway
for many years. He was a member of the Grand Forks County
Medical Society and the American Medical Association. He
was married to Elizabeth Morrison of Groton, Vermont, Jan-
uary 14, 1882. Mrs. Welch died in 1924. They had no children.
WILLIAM MELVILLE SMITH
Dr. William Melville Smith, 49, died in early June, 1948,
in New York. He was a native of Olean, New York, where he
obtained his early education. Later he attended the Kentucky
Military School and LaFayette College in Easton, Pennsylvania.
He graduated from the University of Buffalo, Medical Depart-
ment, in 1924. He earned the degree of Master of Public
Health in 1938, from Johns Hopkins University. Dr. Smith
joined the staff of the North Dakota State Department of
Health on November 26, 1945. He was appointed Acting
State Health Officer following the resignation of Dr. George
F. Campana. Dr. Smith served in that capacity until April 1,
1947, when he resigned to return to private practice in the city
of his birth, Olean, New York. Dr. Smith is survived by Mrs.
Smith and two daughters residing in Olean.
ALOYSIUS P. NACHTWEY
Dr. Aloysius P. Nachtwey, 58, passed away in St. Joseph’s
Hospital, Dickinson, North Dakota, June 29, 1948. He was a
native of Marshfield, Wisconsin. He was one of the first four
doctors to enter practice in Dickinson and had remained in his
location for thirty-five years. His death was attributed to an
ailment of the heart. Dr. Nachtwey was graduated from Mar-
quette University with the class of 1912, and was licensed to
practice his profession in North Dakota, January 9, 1914. Dr.
Nachtwey was a man of dynamic personality and gave much
time to the affairs of his profession. He had served for many
years as the delegate of the North Dakota State Medical Asso-
ciation to the meetings of the American Medical Association
and had served his first term as Speaker of the House of Dele-
gates of the State Association, to which office he had been
elected at the annual meeting in 1947. He served in World
War I, as a major. At the time of his death he had been a
member of the Board of Directors of the First National Bank
for thirty years and held the offices of vice persident and chair-
man of the board. He was a member of the executive com-
mittee of the Lehigh Briquetting Company of Dickinson. He
was prominent in church and fraternal circles. Dr. Nachtwey
will be much missed, especially at our annual meetings. Mrs.
Nachtwey survives.
DeWITT BAER
Dr. DeWitt Baer, 63, Steele, passed away November 11,
1948, enroute to a Bismarck hospital. An ailment of the heart
caused his death. Dr. Baer was a native of Ashgrove, Iowa,
and was left an orphan by the death of his parents when he
was six years of age. He graduated from the University of
Iowa in 1908. He was licensed to practice in North Dakota,
January 14, 1909. Coming to North Dakota the same year he
located at Driscoll and at times had practiced at Tuttle and
Braddock. He later came to Steele, where he had practiced for
the past 19 years. He took a prominent part in community
affairs; a churchman, a Shriner, Mason, and a member of the
Lions Club. Mrs. Baer died in 1943. He is survived by a
daughter, a son, three grandchildren, two brothers and a sister.
He was the only practicing physician in Kidder county.
GILBERT HENDRICKSON
Dr. Gilbert Hendrickson, 60, of Enderlin, passed away De-
cember 27, 1948, in a Minneapolis hospital. His illness of sev-
eral months followed surgery to which he submitted in June.
Dr. Hendrickson was born at Christine, North Dakota, May 4,
1888. He studied medicine at the University of Minnesota
and graduated in 1914. He was licensed to practice in North
Dakota July 3, 1919. He served as health officer of the city
of Enderlin for many years. He was a member of the Lutheran
Church. He served as a medical officer during World War I.
Dr. Hendrickson was much interested in community affairs and
especially in athletics for the boys of the area. He donated the
land on which was built the athletic park, which bears his name
as Hendrickson Field. He was a staunch supporter of the En-
derlin Legion Junior baseball team. He was pleased and re-
warded by living to see an Enderlin team win the state cham-
pionship and go on to participate in the national tournament.
Dr. Hendrickson never married. Survivors are two brothers and
two sisters.
DAVID GENTHER SAMPSON
Dr. David Genther Sampson, 57, a resident of Lisbon, North
Dakota, died there January 20, 1949. He was a native of
Elmer, Missouri, and was educated at the University of Mis-
souri. Dr. Sampson spent most of his professional life in
government service, as a captain in World War I, and as
district physician at Pedro Miguel, Canal Zone, retiring because
of ill health after 29 years of service. Besides Mrs. Sampson
he leaves a son, Don David; a daughter, Jan Louise, a brother
and a sister.
JOHN D. GRAHAM
Dr. John D. Graham, 47, passed away in a hospital of his
home city. Devils Lake, January 26, 1949. His illness was due
to a condition of the heart. Dr. Graham was born in Montreal,
Quebec, February 4, 1901. He took his preparatory work at
Harbord School and graduated in medicine from the Univer-
sity of Toronto. After his internship at Western Hospital,
Toronto, a year’s practice in that city, a period of time devoted
to special work in obstetrics, he came to Starkweather and en-
tered practice with the Late Dr. W. C. Fawcett. In 1928 he
came to Devils Lake, where he became a partner in the Lake
Region Clinic. In his college days he was a famed athlete,
both in football and basketball. He was an excellent swimmer.
One of his hobbies was stamp collecting. Dr. Graham was ac-
tive in professional and community affairs. He served as presi-
dent of the Devils Lake District Medical Society, Exalted Ruler
of the Elks Lodge; a member of the board of education, Ki-
wanis and the Knights of Columbus. Survivors are Mrs. Gra-
ham; a son, student in medicine at the State University; two
daughters at home, Judy and Deidre; and a brother, Rev. James
Graham of Toronto.
WALTER C. AYLEN
Dr. Walter C. Aylen, 58, died February 24, 1949, in his
home city of Auburn, Washington. Dr. Aylen was a native
of North Dakota and a one-time resident of Fargo. He re-
ceived his college education at N.D.A.C. and at the University
of North Dakota. He earned his medical degree at Nashville,
Tennessee, Vanderbilt University. Dr. Aylen was a son of the
late Dr. and Mrs. J. P. Aylen, known to all of the older prac-
titioners of the state. He had practiced at Mandan before
going West. He was a veteran of World War I. He was
licensed in North Dakota, July 9, 1915. Survivors are Mrs.
Aylen, a daughter, a son, and seven grandchildren.
EDWIN H. MAERCKLEIN
Dr. Edwin H. Maercklein, 68, Ashley, died March 7, 1949,
in Fort Snelling Veterans Hospital, St. Paul. He was a grad-
uate of the Class of 1903 from Milwaukee Medical College and
was licensed to practice in North Dakota, January 14, 1904.
Dr. Maercklein was one of six men, of the same name, and
related, who came to North Dakota to practice medicine. For
years they were located in the territory embraced by the original
Southern District Medical Society, the counties of McIntosh,
LaMoure, Dickey and Logan. He was a practitioner of our
profession for forty years and knew the trials well of the pio-
neer doctor. Dr. Maercklein was a medical officer of the A.U.S.
and was buried in the Fort Snelling National Cemetery. Sur-
vivors are Mrs. Maercklein, two daughters and five brothers.
T. M. MacLACHLAN
Dr. T. M. MacLachlan, 72, passed away December 28, 1948,
in California, to which state he had moved after retiring from
active professional life. He was a graduate of Harvard Uni-
versity, in the class of 1900, and was licensed to practice in
310
The Journal-Lancet
North Dakota two years later. He was a resident of Bismarck
for many years and for a time was a member of the Sixth
District Medical Society.
P. F. RICE
Dr. P. F. Rice died as a result of injuries received in a car
accident in Michigan. He passed away April 25, 1948. Dr.
Rice graduated from Detroit Medical College in 1901 and was
licensed in North Dakota July 9, 1906. He practiced for years
at Solen, North Dakota.
E. S. FITZMAURICE
Dr. E. S. Fitzmaurice, 70, died in June, 1948, at Ft. Lauder-
dale, Florida, where he was living with a son. Mrs. Fitzmaurice
passed away in North Dakota May 20, 1948, and the doctor
shortly thereafter. Dr. Fitzmaurice graduated from Rush in
1902 and was licensed in North Dakota, October 23 of the
same year. He held the field at Mohall and at one time was
a member of the Northwest District Medical Society.
F. L. Wicks, M.D., G. M. Williamson, M.D.,
Co-Chairmen
Maternal and Child Welfare
The Committee on Maternal and Child Welfare of the
North Dakota State Medical Association met in Bismarck, on
January 8, 1949. The committee submitted the following recom-
mendations:
1. At the 1948 meeting of the Committee on Maternal and
Child Welfare, a request was made to gather information con-
cerning the relationship between German measles and other virus
infections during pregnancy and certain abnormalities occurring
in the newborn. To emphasize the need for this information,
the committee again went on record to continue its investiga-
tions to prepare factual data. A letter will be prepared to all
physicians re-emphasizing the relationship between' German
measles and certain abnormalities with a request that all doc-
tors doing obstetrics cooperate in this study.
2. As there has been considerable interest and several reported
cases of methemoglobinemia, which is directly associated with
nitrates in drinking water, Mr. Willis Van Heuvelen, chief of
the Sanitation Section, Division of Laboratories, North Dakota
State Department of Health, gave a resume of his investiga-
tions of over 1,000 samples of drinking water. The Committee
on Maternal and Child Welfare recommended that this infor-
mation be brought to the attention of the several medical soci-
eties.
3. The Committee on Maternal and Child Welfare formally
discussed stillbirth rates and the causes of stillbirths. In the
interest of lowering stillbirth rates, the committee recommended
that this recently collected information be sent to all physicians
in the state, perhaps through the State Medical Association’s
News Letter.
4. The Committee on Maternal and Child Welfare formally
approved a pamphlet entitled "Help for the Unmarried
Mother” prepared by the Division of Child Welfare of the
Public Welfare Board of North Dakota.
5. The resolutions and actions of the 1948 meeting were
reviewed and discussed with no formal action taken on them.
P. W. Freise, M.D., Chairman
Cancer
The North Dakota Cancer Society has been incorporated.
The By-Laws provide for a Board of Directors consisting of
thriteen members, of which at least seven shall be physicians.
Accordingly, and by authority of the House of Delegates’ action
last year, the membership of the Committee on Cancer has been
increased from four to seven. This will assure adequate medical
representation on the Board.
The North Dakota Cancer Society has continued its general
policy of stressing lay and professional education during the
past year. The annual campaign for funds during the month
of April focuses the attention of the public on the cancer prob-
lem but the policy of the society is designed to extend the edu-
cational program throughout the year. This is being done
through study groups, farm organizations, 4-H Clubs, exhibits
at fairs and conventions, etc. Reports from all parts of the
country indicate that the story of early diagnosis and adequate
prompt treatment is reaching the public and the program of
the American Cancer Society and its state divisions is undoubt-
edly responsible for this progress. The North Dakota Cancer
Society has given careful consideration to methods used in other
states to promote cancer control, especially through Detection
Centers and mobile uints. To date the society has not deemed
it wise to embark on such programs, but rather to promote the
slogan, "Every Doctor’s Office a Detection Center.” Since the
general practitioner invariably sees the cancer patient first, and
therefore is primarily responsible for the early diagnosis and
prompt institution of adequate treatment, the need for alerting
the entire medical profession to an interest in cancer is apparent.
For this reason, the society is continuing to sponsor postgrad-
uate courses in cancer for general practitioners. A course was
given at the University of Minnesota in early March and a sec-
ond course is scheduled for June of this year. Physicians are
urged to avail themselves of this opportunity to attend these
courses at no financial expense to them.
It would seem unnecessary to stress the need for a greater
interest in, and support of, the North Dakota Cancer Society
by the Physicians in the state. The lay people, especially the
women, who are giving freely of their time and money are
entitled to the support of the medical profession. They look
to us for guidance and they are keenly aware of the medical
viewpoint. They earnestly desire to do something to decrease
the morbidity and mortality from the second cause of death;
naturally they feel frustrated if their family physicians do not
manifest an interest in the problem.
L. W. Larson, M.D., Chairman
Tuberculosis
The Committee on Tuberculosis is happy to report a steady
progress in the control of tuberculosis in our state. Our death
rate per 100,000 for 1947 was 14.8 as compared with 33.2
per 100,000 for the United States.
Dr. W. L. Wallbank reports increased length of time of
treatment now with full personnel available. Anyone interested
in further detail should consult the very complete biennial re-
port of the state of North Dakota Tuberculosis Sanatorium,
for the period ending June 30, 1949; this report is by Dr.
W. L. Wallbank, superintendent and medical director.
The committee submits the following report from Russell O.
Saxvik, M.D., State Health Officer:
"In 1948, the two mobile x-ray units took 70 mm. chest
plates on 70,246 people. Of this 67,839 were negative; 1,361
(1.9%) were suspicious; 116 (1.2%) were positive; 930 (1.3%)
were demonstrated other pathology and 2,407 (3.4%) were
referred to physicians for follow-up.
"As of April 20, 1948, 36% of the entire eligible popula-
tion, that is individuals 15 years and over, had at least one
x-ray.
"From July 1, 1947, to December 31, 1948, 506 new cases
of tubercuolsis from all sources were reported. As of Decem-
ber 31, 1948, 953 cases were held in the Central Registrar as
being under medical supervision.
"The 1949 survey is underway, and, in an effort to improve
follow-up services, is being scheduled in areas that have facili-
ties for such follow-up. This generally means that a public
health nurse is available for this activity. It is estimated that
80,000 individuals will be x-rayed this year and we can antici-
pate about the same results as demonstrated in 1948.”
Dr. Saxvik also reports:
"Information has been received from Dr. Fred T. Foard,
Director of Health, Bureau of Indian Affairs, that a wide scale
vaccination with the BCG vaccine will be carried out among
the Indian school children in the United States during April,
May and June. This work will be the first effort to extend
services to all Indian children who are shown by tests to be free
of tuberculosis. To carry out the program eight vaccination
teams will be employed and sent to the field beginning March
15. Each team will be composed of one physician, one public
health nurse, a recording clerk, and probably a medical student.
"Dr. Foard has invited physicians to observe this vaccina-
tion program as it unfolds.”
A. F. HAMMARGREN, M.D., Chairman
Public Policy and Legislation
A meeting of the Committee on Public Policy and Legisla-
tion was held in Bismarck, January 15, 1949. The following
action was taken on bills which had already been introduced
September, 1949
311
by that time; this action is followed by parenthetical explana-
tion of the final action taken by the legislature.
House Bill No. 8, relating to the time within which burial
must be made, was approved. (Bill passed and signed by the
Governor.)
Senate Bill 28, relating to the prevention of congenital syph-
ilis, was approved. (This bill was passed and signed by the
Governor.)
Senate Bills 29 and 30, relating to the grading and labeling
of milk, the former being introduced by the Health Depart-
ment and the latter by the Dairy Commissioner. The com-
mittee approved Senate Bill 29, and went on record as oppos-
ing Senate Bill 30. (These two bills were the basis of one of
the largest political controveries of the session. As a result,
Senate Bill 29 was defeated. Later Senate Bill 30 was defeated,
but due to a series of unprecedented political maneuvers was
recalled the last week and passed.)
House Bill 49, relating to a survey or census of the mentally
handicapped, was approved. (This bill was indefinitely post-
poned.)
House Bill 55, being an appropriation for the Health De-
partment, was approved. (This bill was passed and signed by
the Governor at the figure recommended by the Budget Board.)
A review was had of the action taken by the State Board of
Medical Examiners regarding DP physicians; and the committee
highly commended the board for its action.
The committee went on record to give support to any move-
ment which would eradicate brucellosis in cattle in the state.
It was moved by Dr. Waldschmidt, seconded by Dr. Nierling,
and passed, that the committee recommend to the council that
Dr. G. M. Williamson and Dr. R. D. Campbell be elected to
Honorary Membership in the State Association.
After a discussion of the initiation of a Fifty-Year Club, it
was moved that such a club be established.
A sum of $500 was set up as an educational fund, to be
expended under the direction of the Executive Committee of the
Council.
In addition to the above-mentioned bills, there were a num-
ber that came up later in the session in which the Association
had a decided interest.
House Bill 122, which was introduced on January 17, gave
us considerable concern. This bill provided for the licensure
of all foreign physicians, requiring the State Board of Medical
Examiners to give examinations in any foreign language chosen
by the applicant. The bill was defeated by the cooperation of
the members of the State Board of Medical Examiners, the
membership of this Association, the aid of the Catholic Rural
Life Conference, the Lutheran Aid Society, the North Dakota
Hospital Association, the North Dakota Pharmaceutical Asso-
ciation, and — by no means not least — the Woman’s Auxiliary
to the North Dakota State Medical Association. The presence
of Dr. Marcinczyk, a displaced physician at St. John’s Hospital,
Fargo, was most helpful.
Senate Bill 227, which was a bill for automatic licensure of all
trades and professions upon graduation from a North Dakota
institution under the supervision of either the Industrial Com-
mission or the Board of Higher Education, was indefinitely
postponed in the Senate. Had this bill passed, a medical grad-
uate from any future four-year medical school would not have
been entitled to reciprocity in any state in the United States.
Senate Bill 127, which was introduced more or less as a
companion measure for the Medical Center appropriation bill,
and which bill provided for the integration of hospitals, train-
ing of interns, nurses and other hospital personnel, was killed
in the House only after the one mill levy appropriation had
successfully passed. (This bill was in suggestive form only, and
such parts of it as might be desirable can be carried out under
present authority given to the Medical Center Advisory Council
and the Board of Higher Education.)
Senate Bill 231, being a one mill levy appropriation for the
University Medical Center, was passed and signed by the Gov-
ernor.
Your Association was also instrumental in introducing an-
other fireworks bill, prohibiting the sale of fireworks, similar
to the bill introduced in the 1947 legislative session. When
the committee hearing was held, the committee reported unani-
mously in favor of the bill, and we were lulled into a state of
false security. Unexpected opposition arose, and the bill was
defeated by four votes.
A. D. McCannel, M.D., Chairman
Crippled Children
Under the auspices of this committee, the second annual
Cerebral Palsy Clinic for North Dakota, by the joint invitation
of the North Dakota State Medical Association, the North
Dakota Department of Public Welfare, the North Dakota De-
partment of Public Health, and the North Dakota Chapter of
the National Society for Crippled Children and Adults, was
held at Bismarck, October 13, 14 and 15, 1948
The objectives of the program were:
1. To stimulate new interest, and to direct activities in the
field of cerebral palsy;
2. To promote discussions of the principles underlying the
treatment of cerebral palsy;
3. To establish a clinic series providing case studies, diagnosis
and treatment recommendations for selected cerebral palsy chil-
dren and adults;
4. To bring doctors, parents and workers in the field together
in order that acquaintanceship and better understanding might
be fostered.
The clinic this year, as last, was ably directed by Dr. M. A.
Perlstein, a member of the Medical Advisory Council of the
National Society for Crippled Children and Adults, Chicago,
Illinois. Dr. L. G. Pray of Fargo was chairman of the general
meeting.
The clinic was well attended by workers in the Welfare De-
partment and the Health Department. A good choice of
clinical material was present for the demonstration clinic, ably
directed by Dr. Perlstein and his staff. More physicians at-
tended this year than last; but it would be better if a larger
attendance could be accomplished.
It would be well worth the time of all physicians in the
state to visit the Crippled Children’s School at Jamestown,
North Dakota, and gain first-hand information on what can
be done for these unfortunates. The school is presently in the
process of expansion; and a new wing which will largely in-
crease the potential enrollment for the school, nears completion.
A. R. Sorenson, M.D., Chairman
Public Health
The Committee on Public Health of the North Dakota State
Medical Association met in Valley City, North Dakota, March
13, 1949. Those in attendance were Drs. Miller, Gilsdorf, and
Saxvik. The following resolutions were discussed and passed
upon favorably:
1. As there is considerable evidence of a widespread preva-
lence of amcebic dysentery in North Dakota, it is recommended
that the laboratory personnel of the several hospitals become
better acquainted with the technique of diagnosis. It is further
recommended that the Division of Laboratories, State Depart-
ment of Health, upon request, give assistance to these techni-
cians through a short training program.
2. As Senate Bill 28, a law for the prevention of congenital
syphilis, has been approved by the 31st Legislative Assembly
and as this law requires prenatal blood examinations to be done
by either the State Health Department’s Laboratories or ap-
proved hospital laboratories, it is recommended that a coopera-
tive approval system for serologic examinations be developed.
3. As North Dakota continues to have a relatively high rate
of diphtheria, whooping cough and other preventable diseases,
it is recommended that immunizations be given to all children
under 1 year of age by his attending physician.
4. The Committee on Public Health wishes to go on record
that although the 31st Legislative Assembly placed the respon-
sibility for grading and labeling of milk and milk products in
the office of the Dairy Commission, these duties should be un-
der the supervision of the local health officer.
It wishes to recommend that all physicians make a special
effort to report all milk-borne infections to the Division of
Preventable Diseases, State Health Department.
Further, it wishes to record an acknowledgment to the sev-
eral state-wide organizations for their effort to maintain the
health aspects of milk under the local health officers’ jurisdiction.
R. O. Saxvik, M.D., Chairman
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The Journal-Lancet
Public Health — Garrison Dam Project
The Sub-Committee on Public Health — Garrison Dam Proj-
ect— of the North Dakota State Medical Association, met in
Bismarck, North Dakota, on March 14, 1949. Those who
attended were Drs. Vinje and Saxvik. The following resolu-
tion was discussed and passed upon favorably:
1. As the Sub-Committee on Public Health — Garrison Dam
Project — was established primarily to assist in the supervision
and control of the medical problems in the Garrison Dam area
as related to federal agencies and since, in the course of the
past year, the Federal agencies did not launch their anticipated
medical care program in that area, or tn any other area in the
state of North Dakota, and there is no indication that the sev-
eral Federal agencies anticipate establishing a medical care pro-
gram, it is recommended that the Sub-Committee on Public
Health — Garrison Dam Project — be dissolved as its anticipated
functions do not exist.
R. O. Saxvik, M.D., Chairman
Official Publication
No complaints concerning the Journal-Lancet have reached
the committee during the past year, so it is assumed that our
official journal is satisfactory. The proceedings of the House of
Delegates have been published in good form and the papers
presented at the 1948 session are appearing without undue
delay. One of the issues of the Journal-Lancet this spring will
be devoted entirely to papers submitted by North Dakota phy-
sicians.
L. W. Larson, M.D., Chairman
Fractures
No meetings were held during 1948 by the Committee on
Fractures. We have urged the continuance of the policies car-
ried out in previous years.
R. J. Waldschmidt, M.D., Chairman
Report of the Committee on Medical Economics
and Its Subcommittees
The report of the Committee on Medical Economics and its
Sub-Committees was referred to the Reference Committee to
consider the report of the Committee on Medical Economics,
including the Sub-Committees on Prepayment Medical Care,
Veterans Medical Service and Rural Health.
Report of the Committee on Medical Economics as a whole:
Your chairman attended the following national meetings:
1. A M. A. Conference on Rural Medical Care.
2. Northwest Regional Conference.
3. National Conference on Medical Care.
4. National Physicians Committee.
In the national field, the subjects of political medicine versus
voluntary prepayment of medical care, improvement in rural
medical care, trends in medical education, and above all the
$25.00 assessment of all members of the American Medical
Association, and its resulting campaign directed by the firm of
Whitaker and Baxter, have been in the foremost.
Since the general election of last November, the proponents
of socialized medicine have been, on paper at least, in a very
strong position. Nevertheless, the passage of the so-called
Wagner-Murray-Dingle bill is by no means inevitable. Atten-
tion is called to the fact that the two major political parties —
that is, the Republican party and the Democratic party — both
made a campaign issue of further federal participation in the
field of health.
The Democratic party of course favored the concept of na-
tional compulsory health insurance financed primarily by a pay-
roll deduction tax, to be further subsidized as necessary out of
general taxation. Such a program is intended to cover all of the
citizens of the United States without regard to financial ability
to pay for medical services.
The Republican party largely supported a plan for the par-
ticipation of the Federal Government in the field of health serv-
ices, which would provide for grants in aid to the various
states for the payment of medical services to both the indigent
and the so-called medically indigent. This plan would be
financed by general taxation. It would not include those citi-
zens, who with reasonable management of their income, could
afford to pay for medical care.
Immediately after the general election, there was a widespread
feeling that the Truman proposal might very well be enacted
at the current session of Congress, although there were those
who felt that the Administration would be too busy with other
parts of their legislative program.
Since that time, an additional hope has arisen, due to the
formation of a coalition between Southern Democrats and Re-
publicans in Congress. It is impossible to tell over which issues
this coalition will stand against the Presidential program. It is
interesting to note, however, that last week a bill was introduced
by Senator Hill, a Democrat from Alabama, and sponsored by
a Democrat, Senator O’Connor, and Democrat Withers of
Kentucky, and Republicans Aiken of Vermont and Morse of
Oregon, which was offered as voluntary health insurance bill
and a substitute measure for the Wagner-Murray-Dingle bill.
This bill embodies principles which are largely accepted by the
American Medical Association, and it is entirely conceivable
that a bill with contents similar to this one may be passed
either at this or at some early session.
Mr. Oscar Ewing continues to press for increased power and
for the all-out expansion of the FSA agency under a depart-
mental status of cabinet rank, towards the establishment of the
largest bureaucracy ever known to this country.
Great stress should be laid on the singularly forward steps
taken by the A.M.A. in combatting the enactment of a na-
tional compulsory health insurance scheme. Unprecedented ac-
tion was taken by the House of Delegates of the A.M.A. at
its interim meeting in St. Louis, when an assessment of $25.00
per member was voted for the first time in the history of the
American Medical Association. The eminent firm of public
relation counselors, Whitaker and Baxter, were hired to carry
out this program.
This money will not be used as a "slush fund” for lobbying
in the various legislatures of the various states; nor will it be
used for such purposes in connection with the Federal Con-
gress. Rather, these moneys will be used for the establishment
of a "grass roots” educational campaign throughout the entire
United States. The campaign will be formulated around a
thirteen-point program adopted by the A.M.A. The backbone
of this thirteen-point program is the promotion of voluntary
prepaid medical care plans, since such plans are proposed as the
very best method of easing the problem of payment for medical
care in America, and held forth as highly superior to the con-
cept of national compulsory health insurance.
Approximately 40 per cent of the members of this Associa-
tion have paid their assessment through the State Office. While
this is a satisfactory start, collections of assessments should reach
100 per cent, as failure to pay will not only cripple the pro-
gram but give encouragement, comfort and ammunition to the
proponents of national compulsory health insurance.
In North Dakota, the left wing elements are at present con-
centrating on propaganda for the passage of a national com-
pulsory health insurance plan. They are not at the present
time promoting actively any changes in the method of medical
practice in the state of North Dakota.
In the field of medical education, emphasis continues to grow
upon the education of general practitioners. The general prac-
titioners’ section of the American Medical Association and the
annual General Practitioner Award have given impetus to this
trend. In North Dakota the passage of the one mill levy for
the financing the University Medical Center may very well in
the future play an important part towards this end. It is,
however, too early to anticipate the program of the Univer-
sity Medical Center; but it is recommended that sincere con-
sideration be given to the report of the Committee on Medical
Education.
Your committee has had extensive negotiations with the
Welfare Board during the past year relative to the Welfare
Board fee schedule which has been followed for some years.
Inasmuch as the recommendation which will follow is a drastic
change in policy, it becomes necessary to review the history of
our experience with the Public Welfare Board. The Public
Welfare Board system was set up during the depression years
as an honest effort to bring order out of the chaos which ex-
isted in relief matters. Doctors, having an age-old tradition of
treating indigents on a charity basis, were quick to co-operate
with this new program. Since that time the Public Welfare
Board has grown in importance, until it is probably the largest
September, 1949
313
single agency today in the state of North Dakota. The trend
of both State and Federal legislation is such that the Welfare
Board is bound to have an increasing influence on the affairs
of all the citizens of North Dakota.
The rise in the Social Security system has introduced the con-
cept that individual charity is no longer a duty of either the
American people or the American medical profession. To the
contrary, the Federal Government promotes the concept that
indigents are recipients of all of the services provided by the
Federal Government as a matter of absolute right. The Govern
ment proclaims that it, itself, is now taking care of all of the
needs of the indigent.
It was quite natural that the medical profession, having been
accustomed to taking care of the medical needs of the indigent
on a charity basis, should have been most co-operative in set-
ting up a fee schedule for the indigents on a basis of charges
greatly reduced from the normal charge to the ordinary patient.
In this, the medical profession was unique in that all other
vendors to Public Welfare recipients charge the normal amount
for their services or merchandise. At no time has it ever been
pointed out that medical care is only being supplied to their
clientele because of the fact that the doctors are working at
a low fee schedule and are in effect contributing approximately
50 per cent of the cost of this care.
The Public Welfare Board and its parental agencies, the So-
cial Security Agency and the FSA, are continually pressing for
legislative enactment which will increase the number of persons
who will receive their services, and for the general expansion of
the scope of their program. Since the Government is under-
taking this responsibility, we should see that the Government
assumes its responsiblity in full.
The recommendations that will be forthcoming in this report
would not be necessary if it were possible to negotiate with the
Welfare Board so that a reasonable fee schedule might be
adopted. Such, however, is not the case. The original fee
schedule was set up in 1937, with the intention that it would
reflect a schedule approximately 50 per cent of the average and
normal fee charged by doctors in North Dakota. This was
revised very moderately in 1944. At the present time the fee
schedule probably does not reflect a charge of much more than
one-third of that which is charged the normal patient.
Extended negotiations were had not only with the Public
Welfare Board last summer, but also with representatives of the
various county welfare boards and their executive directors.
While the persons representing the various county welfare
boards were wholly in agreement with the items and the fee
schedule which the Association sought to have changed, the
Public Welfare Board itself nevertheless undertook to turn down
and refuse approval of the various items.
It is felt that it is futile to negotiate further with the
Board. Their attitude has resulted in the controlling of fees
at an absolutely unreasonable low level. North Dakota doctors
cannot permit an agency of such importance as this one to arbi-
trarily control the economics of medical practice.
Accordingly, it is recommended that the North Dakota State
Medical Association notify the Public Welfare Board that the
advisory fee schedule now in effect is considered to be rescinded;
and that in the future doctors in North Dakota will feel free
to charge Public Welfare Board cases such fee as in their own
opinion seems proper.
In closing the report of the committee as a whole, I would
like to express the appreciation of this committee for the splen-
did work done by Dr. Lancaster and his Committee on Prepay-
ment Medical Care; Dr. Radi and his Committee on Veterans
Medical Service; and Dr. Jacobson and his Committee on
Rural Health. It is recommended that these three committees
be continued. The reports of each committee follow and each
report has the approval of the Committee on Medical Econom-
ics as a whole.
W. A. Wright, M.D., Chairman
Prepayment Medical Care
This past year has seen some accomplishment and some reali-
zation in the expansion of the North Dakota Physicians Service
throughout the state. The success of the program has been defi-
nitely minimized to some extent because of the fact that certain
district medical societies have seen fit not to approve of, nor
participate in, the program.
Voluntary prepaid medical insurance has become universally
accepted in the United States as the strongest answer to national
compulsory health insurance. Enrollment through the various
state plans has progressed by leaps and bounds. The "grass
roots” educational program of the A M. A., directed by the firm
of Whitaker & Baxter, uses the concept of voluntary prepaid
medical insurance as the premises on which to fight national
compulsory health insurance. In order that the state of North
Dakota may properly hold up its end of this battle, the state
should be provided with a strong prepaid medical insurance
program on a statewide basis.
As stated in the report on the Committee on Medical Econom-
ics, it is probable that either at the present session of Congress
or at some early session, some legislative proposal will be enacted
for the further participation of the Federal Government in the
field of medical care. It is hoped that this expanded participation
may be limited to the contribution of Federal moneys towards
the medical care of the indigent, as distinguished from the care
of the total population regardless of their ability to pay.
The Taft-Ball-Smith Bill of the last session, and the Hill
Bill of this session, are both of the preferred type. Both bills
would provide grants in aid to the various states for the aid
in caring for the indigent and the so-called medically indigent.
Both would permit the expenditure of these Federal moneys for
the payment of premiums in voluntary prepaid medical insur-
ance plans.
There follows a resume of the various meetings of the Pre-
payment Committee throughout the year, together with action
taken at such meetings; and further together with a report of
the present status of the development of the North Dakota
Physicians Service within the state of North Dakota.
At the last meeting of the House of Delegates, that House
unanimously approved a recommendation that the Committee
on Medical Economics and the Sub-Committee on Prepayment
Medical Care be authorized to proceed with the necessary ar-
rangements with the existing North Dakota Physicians Service
operating in Cass County, so that this plan might be extended
on a state-wide basis. It was further provided that any arrange-
ments effected by this committee should be presented to the
Council for final approval.
Such a meeting was held in Fargo, July 2, 1948. At that
time all necessary arrangements were made for the eventual
transfer of control of the North Dakota Physicians Service from
its Board of Directors, constituted of the Cass County physi-
cians, to a state wide board. The reserve of $21,000.00 was also
transferred. The details of these arrangements were then sub-
mitted to the Executive Committee of the Council, and were
approved.
As a result of the announcement issued by the State Office
of these accomplishments, a number of complaints were re-
ceived. In order that all might be heard, the Committee on
Prepayment Medical Care then sponsored a general meeting
held in Bismarck, September 12, 1948. At that time numerous
complaints were voiced as to the service feature of the plan, the
opponents stating that physicians should be entitled to charge
those having high incomes an additional charge in excess of the
fee schedule. Objections were also made as to the fee schedule,
stating that the same was too low.
Upon the close of the open meeting, the Committee on Pre-
payment Medical Care met shortly to inquire as to whether an
effort should be made to compromise the program. The out-
come of the meeting was to propose a modification of the plan,
changing it from a complete service to a so-called partial service
and indemnity plan. Under such a plan persons having an in-
come lower than a stipulated amount would be guaranteed that
they would receive no further bill for medical services. Those
above the stipulated income level would be subject to such
further charge as the doctor believed proper.
A further outcome of this meeting was the decision to find
out what increases in the fee schedule would make the plan
more satisfactory. The members of the committee were instruct-
ed to go back to their various communities and talk this matter
over with the members of the local societies, and be prepared
for a further meeting to be held in Fargo, October 2, 1948.
At the meeting in Fargo October 2, reports made it clear
that the new proposal would be more acceptable throughout the
state. The outcome of the meeting was the adoption of the
so-called Partial Income, Partial Indemnity Plan; with enroll-
ment limitations of $3,000 for a single individual, and $5,000
for a family.
314
The Journal-Lancet
Under this plan an enrolling doctor would guarantee the com-
plete service for all items covered for all individuals having an
income of $3,000 or less; but might make additional charges
for all individuals whose income is higher. Likewise, the enroll-
ing physician would guarantee service for all policies covering
families having an annual income of $5,000 or less; but would
be entitled to make additional charges in the case of all fam-
ilies receiving an income in excess of $5,000. The fee schedule
was readjusted so that the old maximum payment of $150 was
now raised to $250.
A further meeting of the Committee on Prepayment Med-
ical Care was held in January in Bismarck, at which time a
report was made as to the status of the North Dakota Physi-
cians Service.
The most recent meeting was held in Fargo, April 2, 1949,
at which time this report to the House of Delegates was formu-
lated, and the program was again reviewed. At the present
time extension of the North Dakota Physicians Service is being
promoted in the following locations: Valley City, Oakes, La-
Moure, Devils Lake and Dickinson. Further promotion will be
effected in the Traill-Steele District, Williston, and such other
areas as have indicated their desire to participate. Adverse wea-
ther conditions and bad roads have slowed expansion in enroll-
ment, although more than 2,000 of the subscribers have been
enrolled since the latter part of January. The following Dis-
trict Societies have so far indicated their disapproval of the
plan, although some have stated that they have not intended
their action to be final: Bismarck, Minot, Grand Forks and
Jamestown.
There has been a liberalization in the ruling that all pro-
cedures must be performed in hospitals; and tonsillectomies,
fractures and obstetrical cases are now paid even though per-
formed outside of a hospital. Liberalization of the Blue Cross
plan is now in the process of being effected; and it is' the opin-
ion of the committee that the combined coverage will be excel-
lent, and that the fee schedule is most favorable.
It is therefore recommended that the House of Delegates
commend and approve the expansion thus far of the North
Dakota Physicians Service, and that all members of this Asso-
ciation be urged to participate in this program so that it may
be expanded into all areas in the state of North Dakota.
W. E. G. Lancaster, M.D., Chairman
Rural Health
Your chairman of the Committee on Rural Health has very
little further to report for the 1949 Handbook, on the exten-
sion of rural medical service. Due to weather conditions, your
chairman was unable to attend the National Rural Health Coun-
cil meeting in Chicago, and cannot personally report on this
meeting. He has, however, asked Dr. Larson of Bismarck and
our Executive Secretary to make a few comments on this
meeting.
Blue-print work for the development of better rural medicine
in North Dakota has been continued throughout the year. The
Medical Center Advisory Council, this Association’s Committee
on Medical Education, and the Board of Higher Education are
working on a plan to attract younger physicians to the rural
areas in the state. It is hoped that this can be accomplished
through the University Medical Center, now adequately financed
through the one mill levy.
Plans are being worked out for the possible use of scholar-
ships to induce graduate physicians to return to North Dakota
for internship and a period of medical practice in rural com-
munities.
The action taken by the North Dakota State Board of Med-
ical Examiners relative to the Displaced Physician also produces
hope for the more adequate supply of more rural physicians.
Again the development of small rural hospitals, properly
placed, will attract these younger physicians.
The shortage of nurses still prevails. The production of prac-
tical nurses under the practical nurses schools, while slow, is
having some success in meeting the shortage of bedside nurses.
Weather conditions have prevented the organization of the
experimental Local Health Council at Elgin, North Dakota.
The subject has been discussed by the Board of Directors of the
new hospital, and all members are interested in establishing such
a Council.
It is thought that the exchange of experience and information
relative to the newly established rural hospitals in North Dakota
may be of some value. With that in mind, such information is
herein given in connection with the Elgin Hospital; and at-
tempts will be made to obtain like information concerning other
rural hospitals for distribution.
The Lorenzen Memorial Hospital, located at Elgin, North
Dakota, is a community type of hospital, consisting of 3 I adult
beds and 12 bassinets in the nursery. The building was designed
by Dr. E. Salomone, one of the associates of the three-doctor
clinic located in the city of Elgin. An attempt was made to
design a building that would suit the needs of the community,
and also be within the financial means of this community.
The cost of the building was $120,000, and the cost of the
equipment $30,000. The hospital was built by general con-
tractors Cummings & Meissner of Bismarck, North Dakota, on
a cost-plus basis, 10 per cent on materials and 15 per cent on
labor. Wiring, heating, plumbing and sewer contracts were sepa-
rate, on a cost-plus basis. All material was purchased by a local
committee.
The hospital was financed by local contributions. To date
$117,000 in cash has been contributed; $28,000 more will be
needed. At the present time there are 12,000 contributors, with
an average contribution of $90.75 per contributor. Another
$24.00 per contributor will raise the balance of the money
needed. This $24.00 per contributor may seem like a small
amount; but the chairman of the finance committee can assure
you that a lot of work and planning will still have to be done
to secure the $28,000 needed. The finance committee is now
busy making plans to hold a Hospital Day in early May, with
the attraction of an old-time Western barbecue.
The Elgin Hospital participated in Federal moneys in the
Hill-Burton bill only on the equipment, which amounted to a
little in excess of $10,000; which arrangement worked out very
nicely. This hospital did not participate in Federal money for
the building because the building was almost completed before
the Federal moneys were released; and secondly, the building
does not meet all of the Federal rquirements, primarily because
floor space was reduced below Federal level requirements.
As experience data becomes available to your chairman on the
hospital completed at Hazen, those in the construction and
planning stages at Hettinger, Watford Gity and Cooperstown,
such information will be distributed.
There followed a report for nine months’ operation of the
Elgin hospital.
M. S. Jacobson, M.D., Chairman
Veterans Medical Service
The following is the report of the chairman of the Sub-
Committee on Veterans Medical Service of the Committee on
Medical Economics of the North Dakota State Medical Asso-
ciation. Activities of the North Dakota Veterans Medical Serv-
ice Division during the year 1948 appear to be satisfactory to
all concerned. The Division has handled a large volume of
work. There has been very little criticism either from the Vet-
erans Administration or from the practicing physicians through-
out the state who are co-operating in the program. Mr. John
Fox, the present director, who replaced Mr. Samuel Gurke, is
handling the office very capably. It was hoped that at the time
of this report that a definite decision would have been made in
regard to one point regarding financial arrangements between
the Veterans Administration and the Medical Service Division.
The problem referred to refers to payment of administrative
procedures and processes for uncompleted examinations of vet-
erans examinations. Negotiations in this regard have been going
on for some time and if the approximate 10 per cent to which
the Veterans Medical Service Division is entitled for completed
examinations can be extended to uncompleted examinations, the
sustaining amount paid by the North Dakota State Medical
Association can be repaid or equalized. Prospects are that this
procedure will be approved so that there will be reimbursement
of the loss sustained in operation since the inception of the pro-
gram and it is hoped and felt that some sort of financial settle-
ment will be made in the near future.
Currently, in the matter of cancellations the situation has im-
proved since a rendition of last year’s report. For the calendar
year 1948 the figure would be approximate^' 11 per cent. Part
of this percentage is attributable to the inability of the veterans
to report for examination because of snow-block roads.
A fiscal report for the year 1948 should be of interest to the
physicians in this state. Authorizations were received in the
September, 1949
315
total amount of $93,600.27 and the average authorization
amounted to $19.15. The actual amount vouchered, that is,
the amount actually handled in examination and treatment
amounted to $81,643.33, which is approximately a $12,000 loss
during the year, or $1,000 a month, as compared to the authori-
zations received. The total amount of rating examinations, or
examinations otherwise authorized, amounted to the total of
$49,300 and authorizations for treatment amounted to a total
of $30,800; the ratio of examinations to treatment is approxi-
mately five to three.
The total amount received for examinations and treatments
by the Veterans Medical Service Division as stated above, is
$81,643.33.
Actual amount paid to doctors in the State of N.D. . $74,012.77
Total operating cost 7,291.94
Income fees collected 7,423.00
It can be seen, therefore, that the balance for the year 1948
is on the positive side.
It is the feeling of the chairman of this committee that the
Veterans Medical Service Division is being well handled and
efficiently and the general trend is one of progress rather than
of regression.
R. B. Radl, M.D., Chairman
SPECIAL COMMITTEES
The following reports of Special Committees were referred to
the Reference Committee to consider the Reports of the Presi-
dent, Secretary, Executive Secretary, and Special Committees:
Industrial Health
The survey of all industries in the state to be conducted by
the State Board of Health and the Workmen’s Compensation
Bureau has not been completed to date.
In reviewing the vital statistics for 1948, we find that there
were 23 accidental deaths occurring in industry as compared
with 117 deaths on the highways, 46 in agriculture, 23 in fires,
and 27 by drowning.
There is evidence which tends to indicate that the physical
condition of the employee was often a factor in the occurrence
of the accident and it would seem desirable that some effort be
made to develop the practice of utilizing physical examinations
before assignment of workers to many types of occupation
Faulty vision is often a factor in industrial accidents.
The new form of death certificate which is now used cor-
rectly goes into more detail relative to the circumstances of the
injury and death. We request the active cooperation of every
doctor in filling out such certificates in detail to the end that
more positive information may be available to the Bureau of
Vital Statistics, which in turn may lead to better accident con-
trol in industry.
C. J. Glaspel, M.D., Chairman
Emergency Medical Service
Since our last state meeting at Jamestown there have been no
further meetings of the Committee on Emergency Medical
Service. There was a meeting in Chicago at which state chair-
men were requested to be present, but the chairman of your
committee was not notified in time and incidentally was out of
the state at the time of the meeting, so he was not able to
attend.
There is still considerable stress being made regarding knowl-
edge of atomic warfare and there have been several postgraduate
courses which have been under the auspices chiefly of the mili-
tary in order to disseminate information regarding diagnosis,
treatment, and care of radiation casualties. Although they are
of very little practical importance to the individual doctor in
this state, they would be a refreshing type of course as well as
extremely interesting and those that would be interested are
encouraged to take such a course.
No further emergencies have arisen in the state which have
needed action by the medical profession. As you know, there is
a definite shortage of medical officers for the Armed Forces.
The American Medical Association has been able to promote
their ideas on the procurement of medical personnel for the
Armed Forces and apparently not too good results have resulted.
Within the last sixty days the executive secretaries of the state
associations have been notified of doctors in their states who are
believed to be eligible and also who it is felt should volunteer
for service in the Armed Forces. At this time, I believe, we
have only been called upon for two men. One resides in a
small rural area and without any question is necessary in that
locality. The other doctor practices in an area where there is
sufficient local medical care, and probably it will be expected of
that individual to make some move. It is felt that we should
move slowly in this matter. That is the way it appears at this
time, but this picture could rapidly change in the case of a
national emergency. Probably it is just as well that we do not
act too hasty in trying to force any of the doctors in the
service. However, if the pressure does become too great and
there are not sufficient doctors in the service, there will undoubt
edly be special provisions made by Congress for drafting of
doctors. Public opinion is going to demand that. If we are
to put young men into the Armed Forces, they will have to
have adequate medical care, and, if necessary they will be
drafted for that purpose.
A. C. Fortney, M.D., Chairman
Mental Hygiene
The Committee on Mental Hygiene met at the North Da-
kota State Hospital, Jamestown, N. D., March 15, 1949.
We took the view that the mental hygiene of an individual
is related to his thinking, feeling, behavior, heredity and en-
vironment and other factors. There is no line of separation in
the human between those subjective experiences commonly asso-
ciated with mental health and his organic well-being. From a
medical point of view the body and mind are so interrelated
as to become fused in the person of the individual. Accord-
ingly, such studies and recommendations as were made were
so done on the basis of regarding the human being as a socio-
psycho-biologic unit.
Last year’s report of Dr. A. M. Fischer, superintendent of
the North Dakota State Hospital, was reviewed and was again
endorsed. Dr. Fischer is to be commended for the manner in
which he conducted the hospital of which he is superintendent,
particularly under the circumstances of stress during the war
years, with shortages of help and without the facilities that
mieht otherwise have been available to him.
The committee estimates conservatively that there are between
25,000 to 50,000 people m the state of North Dakota who are
more or less disabled through emotional or mental ailments.
This represents not only a great deal of distress to the indi-
viduals concerned but also to those who are related or intimately
associated with these ailing people. For the most part these con-
ditions are remediable through an enlightened program involving
understanding and skilled attention. These ailments cause a
loss of productive power through inefficiency or inability to
work, an economic loss that runs into millions of dollars. Fur-
thermore, they create a drain on public funds in substantial
amount for the support of those whose ailments have progressed
so far that they cannot support themselves.
The state of North Dakota is not singular in the forty-eight
states with respect to the burden that exists in impaired mental
health. The mental hygiene of the people is so much a national
problem that the Federal Government took a forward step to
meet it by creating the National Mental Health Act of 1946.
By this Act, states which show interest in helping themselves
to improve the lot of the emotionally and mentally ill will re-
ceive some aid from the Federal Government.
This committee feels that some stigma has become associated
with the word "insane”, and accordingly considers the use of
the word "insane” or any of its derivatives unfortunate. We
recommend the avoidance of the word medically or officially
insofar as is possible, and such terms as "hospital for the in-
sane,” "insanity commissioner,” "insanity hearing,” should be
abolished. The word "insanity” has a rather vague meaning
medically and legally and at the present time is offensive.
The population generally, including public officials, organiza-
tions and all leaders should be made aware of the existence of
nervous and mental ailments and should be advised that most
of these conditions can be helped. Actually, the aim of a good
Mental Hygiene Program should be directed to the general
welfare of all the people of the state, and for the present time
its center of activity should be removed from the locale of a
hospital which is given over entirely to the treatment of the
mentally ill.
Efforts toward the improvement of the mental health of the
state should radiate from some central agency such as a State
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Board of Health or a medical center. This agency should co-
ordinate all efforts that are directed to this common purpose,
and should serve as a source of enlightenment to the general
population and should stand ready to counsel such officials,
organizations or other agencies that might seek its help. In this
field of medicine considerable is to be gained by creating a
central point of information and responsibility with defined and
limited authority.
This committee feels that it would be advisable and appro-
priate to encourage every general hospital in the state, built or
being built, insofar as its facilities will permit, to put aside sev-
eral beds or a ward for short term treatment of the emotionally
or mentally ill patients. Since from a medical point of view
there is no greater shame in suffering with a psychoneurosis
than there is in having a broken leg or appendicitis, the patient
should be spared as much as possible the stigma that unfor-
tunately exists at the present time in being referred to a hos-
pital for the mentally ill, and he should be permitted to enter
a general hospital. In this way, in due time with increased facili-
ties and trained personnel more people will be getting better
treatment, who perhaps are now getting none, and the patient
load would be taken off the state institutions which are in-
tended for the chronically ill.
The present forms of commitment to a hospital for the men-
tally ill are outmoded. The present procedure for sending a
patient to a hospital for the mentally ill is quasi-judicial. It
involves a county judge, a hearing with witnesses and perhaps
a jail and a sheriff. If a man had gallstones he would be spared
this archaic procedure, and would be referred to a hospital by
his physician if necessary. This committee recommends that a
person who is emotionally or mentally ill should be treated as
a sick human and that he be permitted to enter a hospital for
the mentally ill on the recommendation of only one duly
licensed medical practitioner, or on his own voluntary applica-
tion for examination, providing the superintendent consents to
his admission.
In a review of 30,000 cases where patients have been admitted
to a hospital for mentally ill for examination only on the rec-
ommendation of a physician, there has been only one instance
where there was a question of the abuse of the patient’s rights
in the matter of admission to the hospital. In the ordinary
course of transactions between human beings one error in 30,000
admissions presents a percentage error that is probably less than
that which occurs among humans in most fields of endeavor.
The patient could be referred to a hospital for the mentally
ill or to the ward of a general hospital for examination on the
recommendation of one physician and there is little likelihood
of the patient’s rights being abused, since so many other factors
and individuals enter into his hospital life, and he always has
the right of communication with his relatives or his attorney,
and he has the right of appeal before the courts if he thinks
his liberties are being abused and he has the right of habeas
corpus, as any person has who is admitted to a general hospital.
Bearing in mind our concept of a human as a socio-psycho-
biologic unit all forces should unite in making his lot a happier
one, and it is recommended that teachers, clergy, court officials,
social service workers, and others charged with the responsibility
of influencing or guarding the public character should have a
course in normal psychology and abnormal psychology, if they
have not had training in this field, and should have access to
experts in mental hygiene for particular advice.
In regard to education, intelligence and personality tests
should be conducted in all schools. Where children are found
to be emotionally disturbed or mentally handicapped or excep-
tional, they should be looked after by a teacher who has been
specially trained in these problems, one who might by kindness
and understanding and special coaching help these children to
become adjusted. It is recommended that these children insofar
as is possible be kept in or near their home environment, and
as previously remarked special classes should be held in large
schools in Grand Forks, Fargo, Valley City, lamestown, Bis-
marck, Dickinson, Mandan, Williston, Minot, Devils Lake and
in other communities where such classes could be sustained.
At the present time the Department of Public Instruction of
the state of North Dakota is sympathetic to the problem of so
examining the school children and has recommended a battery
of tests for this purpose, but only a few schools use these tests.
Probably the best work and the most extensive testing along
these lines is done under the supervision of Dr. William L.
Neff, superintendent of Mandan schools, Mandan, N. D. After
testing there still remains a question as to what shall be done
wtih a child who varies from the normal average or presents a
problem. The recommendations previously set forth point to a
solution.
There are some short form tests that are suitable for the use
of a physician or any capable person in making an approximate
determination of the personality and the intelligence of the in-
dividual, and these were endorsed by the committee.
In the matter of juvenile delinquency the committee felt that
several factors were responsible. It was also felt that remedial
measures existed in enlightening all those who have contact with
children, particularly parents; and the committee felt that
among the best bulwarks against juvenile delinquency were the
Sunday schools, the Boy Scouts of America, the Girl Scouts
of America, the 4-H Clubs and other organizations which are
inclined to instruct and to give constructive expression to the
energies of our youth. The juvenile officer should have access
to a physician competent and trained in matters of mental
health.
A conference was held in the office of the Attorney General.
An attempt was made to define certain terms such as "com-
petence”, "degree of guilt”, "insanity”, "civil liability”, "testa-
mentary capacity”, "free will”, "extenuating circumstances”, and
other medico-legal terms. The laws of North Dakota are in the
vanguard of understanding of the problems of the "nervous”
individual, but there is still some residual tradition in the ter-
minology and the attitude of the law towards the emotionally
or mentally ill person. It appears that opinions on medico-legal
jurisprudence are at the present time based upon the North
Dakota Revised Code of 1943 (which gives a very ambiguous
definition of "insanity”), the Northwestern Digest of 1931,
Herzog’s Medical Jurisprudence, American Jurisprudence and
other books on law relating to the subject. This committee re-
spectfully recommends that the courts should have access to the
advice of a competent psychiatrist who might in good faith
advise the court without bias, not acting either for the defense
or for the prosecution. This service to the courts should be
available both in criminal matters when desired and even in
civil matters such as would require the determining of the com-
petence of a testator.
This committee asked for a statement of policy from the
Public Welfare Board with respect to the treatment of those
who are emotionally or mentally ill. The Public Welfare Board
replied in a letter which briefly outlined its policy and indicated
that it was interested in the mental health of those who required
its assistance. This committee recommends that all social serv-
ice workers study normal and abnormal psychology and apply
their learning to the field of social service work. It is also rec-
ommended to the Committee on Medical Economics of the
North Dakota State Medical Association that they consult with
the Public Welfare Board with a view to setting up a schedule
of fees for the out-patient treatment of those who are mentally
or emotionally ill and who are eligible through economic circum-
stances to receive assistance from the Public Welfare Board.
The schedule of fees of the Veterans Administration for out-
patient private care of veterans might serve as a guide.
It is recommended that a psychiatrist should be on the Parole
Board for the North Dakota Penitentiary and should be avail-
able to all state institutions where persons are either kept in
custody or are supported as guests.
It is recommended that in the future the North Dakota
State Board of Medical Examiners shall not permit candidates
for license to practice medicine in North Dakota who do not
show an understanding of the human as one unit mentally and
organically, and who do not show a general fundamental knowl-
edge pertaining to mental health, for example in the field of
subnormal intelligence, psychoneuroses, organic and constitu-
tional psychoses, and what is commonly termed as psychosomatic
or somato psychic medicine. Certainly anyone not understanding
the fundamentals of a medical problem which affects so vitally
such a large portion of the population is not properly prepared
to practice in this state.
In May 1947, the undersigned submitted to the North Da-
kota Department of Health a preliminary rough draft for a
Mental Hygiene Program for the state of North Dakota for
inspection and discussion. This committee is impressed by the
September, 1949
317
interest that is shown by the North Dakota Department of
Health in the problem of Mental Hygiene for the state and is
pleased to note the efforts made by this department in the field
of intelligence and personality testing.
This committee feels that a Mental Hygiene program for
the state of North Dakota should be directed towards betttering
the lot of all the people in the state and should have in mind
not only the few thousand who require institutional care but
the tens of thousands in the general population who are in-
disposed. An outline of a proper Mental Hygiene program for
the state of North Dakota is an essay in itself, and it is not
intended to go into detail with respect to such a program in
this report. However, the general principle should be noted
that the program is intended for all the people of the state,
and it should invite the study and efforts of all those who are
in key positions in guiding the people. While it is expected that
in time a number of clinics for the purpose of improving mental
health will be established throughout the state, this committee
feels that it would be advisable to start with one clinic of a
particualr type which will serve people of all ages and at all
economic levels for various emotional and mental ailments. Such
a clinic could be modelled after a pattern which would include
the best features that exist in other mental hygiene clinics such
as exist in the state of Maryland or the province of Ontario.
This clinic would be a beginning, and would be a pilot clinic
from which we might derive experience as to our needs, and
most efficient methods, and could provide us with data which
would apply more particularly in many respects to our own
state. A minimum staff of such a clinic should consist of a
psychiatrist, a psychologist, a nurse who may act as a social
service worker, and a secretary. Questions of location of the
clinic, administration, standardization of records, and other mat-
ters could be solved in time. The chief obstacles at the present
time would seem to be the lack of funds and qualified personnel.
The committee noted the present mental health program of
the Veterans Administration in regard to the out-patient care
of veterans in this state. The committee commends the Vet-
erans Administration for its enlightened program and believes
that the veterans are getting fairly satisfactory out-patient care.
The care of the veteran away from a hospital for the mentally
ill and near his own home has a definite advantage for the
veteran over ward care in a hospital, except in unusual circum-
stances.
Practitioners of medicine have in recent years become increas-
ingly aware of the existence of other than purely organic fac-
tors that force so many people to consult the doctor because
of a variety of aches and complaints. So often the informed
practitioner has not been satisfied with the organic findings as
a cause for the somatic complaints of his patients. More and
more we are inclined to agree with Dr. Walter C. Alvarez’
short and pointed question when investigating a patient’s com-
plaint, "Are you happy?” — so frequently the very key to the
understanding of the complaint which at first glance seems to
be organic in its origin.
R. H. Breslin, M.D., Chairman
Nursing Education
There having been no urgent problems presented by the
Nurses Association this year, your committee on Nursing Ed-
ucation has not met. Your chairman, however, has been kept
in touch with the nursing situation through the state office.
A representative of the state office has attended nursing group
meetings.
G. W. Toomey, M.D., Chairman
Displaced Physicians
This is a new committee appointed as a result of action taken
by the North Dakota State Board of Medical Examiners at
its January 1949 meeting. It is yet too early to make a worth-
while report as to the status of the displaced physician as car-
ried out under the proposal of the State Board. Two displaced
physicians are now located in North Dakota, one at St. Alexius
Hospital, Bismarck, and one at St. John’s Hospital, Fargo. Ar-
rangements are being made for the location of two displaced
physicians in St. Luke’s Hospital, Fargo.
The primary work of this committee thus far has been the
public explanation of the problems faced in locating displaced
physicians. In this respect a review of the situation surrounding
House Bill 122 is in order:
House Bill 122 was introduced into the legislative hopper
without any warning. Several of the committees of the State
Medical Association had just terminated a session in Bismarck
on Sunday, January 16, and the following day this bill was
introduced. It was feared that there would be some type of
medical legislation introduced but the exact nature had never
been determined. You are all acquainted with the bill and we
are all acquainted with the resolution which was passed by the
State Board of Medical Examiners at their meeting in Grand
Forks in January. This resolution which was adopted was the
first one in the United States for which some concrete pro-
posal was advanced for the displaced physician and to all of us
who studied it, it seems to be entirely satisfactory except for
perhaps a few minor deviations.
House Bill 122 showed the lack of knowledge by the sponsor
of the situations that faced a displaced physician on coming to
this country as well as a failure to understand the means by
which they were brought here. It further seemed to indicate
that certain people felt that the North Dakota State Board
of Medical Examiners was deliberately keeping doctors out of
this state to further their own ends. For that reason and for
that reason only can we see any reason why they wish to place
a reviewing board above the North Dakota State Board of
Medical Examiners.
First, we must all realize that the bill was not a party bill.
There were many of us who felt that there was a direct political
faction behind this but after arriving in Bismarck and discuss-
ing the situation with Mr. Engebretson as well as noting the
members who had signed the bill and introduced the bill and
afterwards in talking to other legislators who are and always
have been sympathetic toward the medical profession, we found
that this bill stemmed from a dire need of physicians in the
rural areas. I do not believe for one minute that the bill was
intended for any other reason than this and although the judg-
ment that was used in the wording of the bill was not the best,
certainly the shortage of physicians in the rural areas was the
motivating cause. It was interesting to note that the legislators
are really a pretty good group of people once you get to know
them and get a chance to talk to them separately. Those that
we talked to were conscientious and were willing to know the
facts of the case. Many of them had been misinformed and
many of them did not understand the orderly processing of
doctors in this state. But once they were shown the dangerous
pitfalls that could occur if House Bill 122 went into effect, they
promptly changed their minds and promised support to quash
the bill. It is of interest to note that in our personal discussions
with the legislators, especially those who were on the committee
to hear the bill, only one really gave us trouble.
Mr. Engebretson arranged to meet with the legislators and
arranged the line of attack for the various groups who were to
testify against House Bill 122 before the committee. We all
knew what we were going to say beforehand and we all knew
what we were going to do if we were confronted with an em-
barrassing question because we felt that as a group any ques-
tion they could ask us would not be embarrassing since the rep-
resentation there was adequate to take care of it. It is interest-
ing that just such a thing did take place. Our hearing before
the committee went off in 1-2-3 order. Dr. Spear’s clearly and
easily understood dissertation on the actions and functions of
the State Board of Medical Examiners dispelled any ideas of
favoritism by the Board. The explanation given by Miss Clem-
entson and Father Hylden as to how displaced persons were
brought to this country quickly showed the committee that
there were not thousands and thousands of displaced doctors
in Europe that were available nor could hundreds and hundreds
be brought into this country with a beckon of the hand. As
a matter of fact, they clearly showed how minutely these dis-
placed persons were screened and the time that it takes and
the slowness of the entire process. Finally the crowning blow
against House Bill 122 was the very fine dialogue put on by
Father Andrews and Dr. Marcinczyk, the displaced physician
from Fargo. Several questions were asked and, I believe, all
of them were promotlv and satisfactorily answered to the com-
mittee men. Mr. Wolfe, chairman of the committee, I believe,
was really sincere in his bill but his approach was one which
stems from a feeling of panic and before the session was over
it was obvious that he had lost his usual good control and prac-
tically agreed to anything to get his bill through. However,
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very sensible committee men simply stated that if the bill would
be of no value it was no use to pass and it was soon killed
when the committee went into executive session.
It is not a difficult thing to testify and to present the facts
before these legislative groups when one is telling the truth.
It must be a rather difficult process when someone is scheming
and trying to take advantage. There is no question but what
a dire need exists in this state for doctors. It is true that at
present our over-all ratio is one doctor to 1,450 patients but the
sad thing is that the distribution is not equal. There are areas
constituting an entire county in this state that have no doctors.
This is regrettable but as has been explained to everyone, we
are not able to tell doctors where they have to go and what
they must do, that is, American educated doctors. As the reso-
lution passed by the State Board of Medical Examiners is ob-
served, it will be noted that for at least five years the problem
of doctors in rural areas actually is answered since after finish-
ing their internship or indoctrination they are required to go
to the locality that is selected by the sponsoring agency and
approved by the Board of Medical Examiners where they prac-
tice medicine for four or five years on a temporary permit. At
the end of this probationary period, they are given their full
permit and of course they can then practice where they wish.
It is hoped that by the end of five years, these men will so
like the area that they are in, that they will make it their home.
Now, as to the number of physicians which the Board will ac-
cept for examination. Eight was given as the number in the
resolution. This had to be done because the sponsoring societies
had to have a quota and secondly, having had no experience
with this kind of problem it was felt that we were safe in
dealing with eight. This figure eight became of paramount im-
portance to everyone on the committee and this was soon rec-
ognized. After a telephone consultation with the members of
the Board of Medical Examiners, it was felt that this figure
need not be a permanent one but could be changed according
to the number of DP’s that come in and also according to the
ability of the various institutions in the state to handle them.
This was agreed as being quite satisfactory by the committee.
As to the time of indoctrination or internship after hearing
Dr. Marcinczyk’s testimony, it was obvious that all of the com-
mittee thought it was a wise and highly desirable move. Now
that this bill has been killed, we must not sit back and fold
our hands complacently and wait until the next session of the
legislature. We must do everything within our power to im-
prove medical care in the rural areas, whether it be by obtain-
ing doctors or inducing doctors to go into these areas or by
improving methods of communication and evacuation of sick
and injured in those areas to the larger places. Much thought
must be given by the Medical Association and other groups
interested in the welfare of the people of this state during the
next few months. And certainly something should be worked
out. Never before in the history of the legislature has there
been so much talk in the halls of both the House and the
Senate of medical care in the rural areas. Everyone was talking
about it and one prominent legislator told me that it was un-
questionably one of the hot topics of this session. I believe that
we should encourage hospitals that have the facilities to try and
help to indoctrinate these DP’s as they come. An inquiry is
now being mailed to the American College of Surgeons to note
whether the taking on of these DP’s will in any way influence
the standing of the hospital for the regular internships and
fellowships. It has been mentioned already to one of the ex-
aminers who thought it was a very noble enterprise and did not
think that it should have any reflection whatsoever upon the
standing of the hospital insofar as it was accredited for intern-
ships and fellowships.
Finally, the value of having someone who understands both
the medical and legislative side of medicine was beautifully ex-
emplified. I believe that the legislative committee of the State
Association should be very active. Many of the representatives
and senators have mentioned how they like to see doctors
around the halls because from them thev can get important in-
formation and ideas about what to do when certain things, such
as House Bill 122, spring up. However, the halls are certainly
conspicuous bv the absence of doctors. Finally, I should like to
say that Dr. Stucke, who has been a long time legislator from
North Dakota, sort of delivered the final punch to our cause
and we should be justly proud and thankful of the way he
gave the coup de grace.
A. C. Fortney, M.D., Chairman
Report of the Delegate to the
American Medical Association, Chicago, June 1948
and St. Louis, November 1948
Delegate attendance, both in Chicago and St. Louis was
almost 100 per cent. The proceedings of both sessions have been
so well publicized in the Journal of the American Medical Asso-
ciation, in the Secretary’s letters and in special bulletins and
news letters that it seems superfluous to attempt to recapitulate.
Rather, certain trends and highlights of both sessions should
be emphasized.
Your delegate was assigned to the reference committee which
had as its major concern the Red Cross Blood Bank Program.
Debate on this matter occupied some six hours of our time. The
report of our reference committee was adopted by the House
of Delegates. Its main recommendations were: (1) That no
blood banks be established by the Red Cross without Medical
Society sponsorship and professional direction and (2) That
the Blook Bank Committee of the American Medical Associa-
tion be instructed to meet more frequently with a similar com-
mittee from the Red Cross and agree on procedures to be fol-
lowed. This action, in Chicago, should do much to remedy
what was developing into a bad situation.
Rumblings of dissatisfaction with the Associated Medical
Care Plans, heard in Chicago, came out into the open at St.
Louis. Open hearings were held in St. Louis. The chief debate
centered upon whether or not a national insurance company
should be created to supervise all state and local plans and to
function where no such plans were operative. The opponents
of such a plan had all the best of the arguments and no such
insurance company was authorized; rather, A.M.C.P. was in-
structed to devote its energies to coordinating and strengthening
the voluntary plans now in operation and those to be formed.
Federal encroachment into the field of medical education came
in for discussion and some censure when the American Acad-
emy of Pediatrics received a rebuke for having sought such aid.
This may be another sign that the House of Delegates is look-
ing at Federal subsidies as the first step in Federal control.
If so, it is a very hopeful sign and points out a real danger
to American Medicine.
The highlight of the St. Louis session was the voting of a
voluntary assessment of twenty-five dollars each upon all physi-
cians by the House of Delegates, the first time in the history
of the American Medical Association that any assessment has
been voted. Your delegate heartily supports this assessment and
would add the thought that it should have been voted a num-
ber of years ago. We expected — and we got — a very "bad
press” when the announcement of this assessment was first
announced at St. Louis. In recent weeks, however, press and
editorial comment has been changing and opposition to National
Compulsory Health Insurance is growing in non-medical circles.
We need more open forums, at the District Medical Society
level and sponsored by District Medical Societies, where this
question can be discussed with laymen in a frank and friendly
manner. The question, it seems to your delegate, is not merely
one of "socialized medicine” but of the creation of a Totali-
tarian State. If one doubts this, he would do well to read some
of the recent pronouncements from Altmeyer, Ewing, et ah,
as to the aims of the Social Security Agency. When it is rec-
ommended, among other things, that State Workmen’s Com-
pensation insurance acts and Old Age Assistance be adminis-
tered from Washington do we need to look any further for
the obvious intent? Did anyone ever hear of a Bureaucracy
voluntarily relinquishing power? It would seem that an Act of
Congress, abolishing the present Social Security Agency and
establishing in its place a physician as Secretary of Health with
Cabinet rank should be one of the major objectives of those
millions of American citizens who still believe in the principles
of American Democracy. If I recall my history correctly, this
country was founded by those who wanted to escape the tyran-
ny of too much centralized government.
John H. Moore, M.D.
The Medical Center Advisory Council
The advisory Council of the North Dakota State Medical
Center held two meetings during the past year. The first meet-
ing was held in Grand Forks on October 5, 1948, which I was
September, 1949
319
unable to attend. This meeting was devoted entirely to a dis-
cussion of the proposed amendment to the Constitution of the
State of North Dakota, providing for a special levy of one mill
upon all taxable property within the State of North Dakota to
produce a fund for the North Dakota State Medical Center at
the University of North Dakota. A program of publicity was
outlined, and ways and means of utilizing the publicity to the
best advantage were agreed upon. The publicity campaign in-
cluded advertisements over the radio and in the newspapers,
distribution of a pamphlet which gave the reasons for voting
"yes” on the proposed amendment, and a letter addressed to
every physician in the state, with the pamphlet enclosed, urging
him to assist in the campaign.
The amendment carried by a 23,000 majority. It was too
late to spread the levy on the 1948 tax roll, and there was some
question as to whether or not an appropriation bill needed to
be introduced in the 1949 legislature. Accordingly, the Council
met in Bismarck on January 20, 1949, to review the situation
and to make recommendations to the Board of Higher Educa-
tion. Your representative attended this meeting. President
John C. West of the University discussed the functions of the
Medical Center Advisory Council as an advisory group to the
Board of Higher Education. Mr. Harry D. Keller, representa-
tive of the State Hospital Association, stressed the urgency of
taking definite action to institute some of the services contem-
plated by the Medical Center law. Dr. R. E. Leigh, chairman
of our Association’s Committee on Medical Education, discussed
the problems confronting the Medical Center and urged the
Council to consider carefully a plan to subsidize intern training
in the state as a means of attracting doctors to locate in the
state. The following recommendations were made by the Ad-
visory Council to the Board of Higher Education:
1. That the present two-year Medical School at the Univer-
sity of North Dakota be strengthened as soon as possible so that
it may obtain the unqualified approval of recognized accrediting
agencies.
2. That a study be made of ways and means by which gen-
eral medical practitioners can be made available to the people
of North Dakota through scholarships, stipends, and intern-
ships. After such a study, that an administrative plan be
established.
3. That a study be made of means by which state wide patho-
logical, library, postgraduate, and psychiatric services can be
made available to the people of the state.
4. That the cooperation of the League of Nursing Education,
the State Nurses’ Association, and the State Board of Nurse
Examiners, be solicited in developing a School of Nursing on
the collegiate level, at the University.
5. That the University offer courses leading to academic de-
grees for medical technologists and x-ray technicians.
6. That the State Medical Center cooperate with public and
private health agencies to augment and implement an adequate
health program for the people of the state of North Dakota.
The Council also discussed ways and means by which the
money provided by the constitutional amendment could be made
available to the Board of Higher Education for the purpose
intended. It was agreed that the leaders of both houses of the
legislature be asked to sponsor a bill at the 1949 Session which
would make the funds available when they are collected in
1950. This was done and virtually a blank check was issued
by the legislature for the expenditure of the fund.
The Advisory Council appears to have a sound viewpoint con-
cerning the State Medical Center. Most of its members have
been on the Council since its inception, and are thoroughly
familiar with all of the problems involved. The Council agreed
that the vote of the people on the constitutional amendment
last November demands that every effort be made to develop
the State Medical Center at Grand Forks. However, the first
essential is to strengthen the present two-year school, so that
it may obtain the unqualified approval of the Council on Med-
ical Education and Hospitals of the American Medical Associa-
tion. The new science building will probably be completed for
use next fall, and every effort is being made by President West
and Dean Potter to employ an adequate staff of qualified in-
structors. Further development of the State Medical Center will
depend on the return from the tax levy and the continued sup-
port of the majority of the voters in the future.
L. W. Larson, M.D.
NEW BUSINESS
Report of the Committee on Resolutions
The following report of the Committee on Resolutions was
referred to the Reference Committee on Resolutions and New
Business:
RESOLUTION
Whereas, it is well accepted that the disease, Diabetes Mel-
litus, is of great importance and that the early detection of
diabetes is of great value, and,
Whereas, a diabetes detection program conducted in the city
of Grand Forks was very successful,
Now, therefore, be it resolved, that the House of Delegates
endorse a state-wide Diabetes Mellitus Detection Program to be
conducted by the individual and component medical societies in
the state. It is suggested that any such program be patterned
after the Grand Forks plan used in December, 1948, which
plan was affiliated with the National Diabetes Detection Drive
sponsored by the American Diabetes Association It is felt that
the formation of a state-wide organization will assist in the
efficiency of such diabetes detection.
Be it further resolved, that the House of Delegates endorse
the formation of the North Dakota Diabetes Association, Inc.,
as an affiliate unit of the American Diabetes Association.
* * ^
The Speaker announced that he had, upon the request of
various members and delegates, submitted to the Resolutions
Committee resolutions to be formulated on the following sub-
jects:
1. Socialized medicine.
2. Vote of appreciation to the City of Minot and the North-
west District Medical Society for this convention.
3. Greetings to the Woman’s Auxiliary.
4. Resolution on the $25 assessment by the A.M.A.
5. Resolution on the subject matter of the approval of the
I.C. Credit System.
6. Resolution on the subject matter of group insurance re-
quested by the North American Casualty Company.
7. Resolution on the subject matter of a special form of mem-
bership for residents and fellows.
The following resolution effecting a change in the constitu-
tion and by-laws, which was introduced at the 1948 meeting
and laid on the table, was then read as follows:
RESOLUTION
Whereas, it is entirely within the realm of possibility that the
duly elected Speaker of the House of Delegates would be unable
to serve in that capacity for various reasons, and
Whereas, there has been no provision made in the Constitu-
tion and By-Laws of the North Dakota State Medical Associa-
tion for a presiding officer, in the event the Speaker would be
unable to preside at the Annual Meetings of the House of
Delegates, and,
Whereas, it would seem advisable that there should be a Vice-
Speaker, duly elected by the House of Delegates, in the event
the Speaker could not preside, who would have the same duties
and privileges as the Speaker,
Be it therefore resolved: That Article 9, Section 1, of the
Constitution of the North Dakota State Medical Association
be amended to read as follows:
"The officers of this Association shall be a President, a
President-elect, a First Vice-President, a Second Vice-Presi-
dent, a Secretary, a Treasurer, a Speaker of the House of
Delegates, a Vice-Speaker of the House of Delegates, and
ten Councillors.”
* * *
It was pointed out by the Speaker that while the proposed
amendment provided for the office of a Vice-Speaker, it did
not provide a method for his election or appointment. After
considerable discussion the Speaker ruled that the nominating
committee will bring in a nomination for the office of an acting
Vice-Speaker and the Committee on Resolutions will bring in
a proper amendment to Section 3, Article 9, providing for a
method of election of a Vice-Speaker.
Dr. Liebeler announced that the Veterinarian Association
had made a request of this Association that a resolution backing
them in the state Brucellosis Campaign to eliminate brucellosis
in cattle be passed at this session.
320
The Journal-Lancet
All of the foregoing subjects for resolutions and resolutions
were referred to the Committee on Resolutions.
The next order was the setting of the Annual Dues, which
after a short discussion were set at $50.00 for the year 1949-50.
It was moved, seconded and passed, that the amendment
offered at the 1948 meeting relative to the designation of an
office of Vice-Speaker be adopted by this House of Delegates.
Nominating Committee
The Speaker announced the appointment of the following
members to the Nominating Committee: Drs. A. D. McCannel,
chairman; C. J. Meredith, C. M. Hunter, J. C. Fawcett, and
R. W. Rodgers.
Adjournment
The First Session of the House of Delegates was adjourned
to reconvene at 2:30 P.M., May 15, 1949. On motion of Dr.
Fortney and seconded by Dr. Radi, the motion was carried and
the First Session adjourned at 9:30 P.M.
SECOND SESSION OF THE
HOUSE OF DELEGATES
Sunday Afternoon, May 15, 1949
The Second Session of the House of Delegates was called to
order by the Speaker, Dr. A. E. Spear, at 2:30 P.M., in the
Skyline Room of the Clarence Parker Hotel, Minot, North Da-
kota, May 15, 1949.
The Secretary called the roll. Eighteen delegates responded
and the Speaker declared a quorum present. The following
delegates were present:
Drs. A. C. Fortney, Fargo; E. J. Beithon, Wahpeton; E. M.
Haugrud, alternate, Fargo; G. W. Toomey, Devils Lake; T. Q.
Benson, Grand Forks; George Waldren, Cavalier; R. W. Vance,
Grand Forks; A. K. Johnson, alternate, Williston; D. J. Halli-
day, Kenmare; A R. Sorenson, Minot; M. G. Flath, Stanley;
W. H. Gilsdorf, Valley City; R. B. Radi, Bismarck; V. D. Fer-
gusson, alternate, Edgeley; R. W. Rodgers, Dickinson; P. G.
Arzt, Jamestown; H. A. LaFleur, alternate, Mayville; R. F.
Gilliland, Carrington.
The reading of the minutes of the first session was dispensed
with on motion of Dr. A. C. Fortney, which was seconded by
Dr. H. A. LaFleur and carried.
On motion of Dr. Radi, duly seconded and passed, the order
of business was changed for the purpose of submitting a Reso-
lution for adoption which would change the number of officers
to be nominated for offices of this Association. The following
resolution was passed on the motion of Dr. Radi, seconded by
Dr. Fergusson:
Whereas, the present Councillor of the Eighth Councillor
District, Dr. F. W. Fergusson, and the Alternate Delegate,
Dr. V. D. Fergusson of the Southern District Medical Society
have advised that it is the feeling that there are insufficient
physicians present in that area for the Southern District Med-
ical Society to function satisfactorily, and for that reason that
Society requests that it be dissolved,
Now, therefore, be it resolved, that the Southern District
Medical Society be dissolved, and that the constituent members
thereof be entitled to the privilege of joining component med-
ical societies in accordance with Chapter 12, Section 8, of the
By-Laws.
Be it further resolved, that in accordance with the authority
in Chapter 4, Section 10 of the By-Laws, that the Eighth
Councillor District be dissolved as such and that its present geo-
graphic confines be included in those of the Seventh Councillor
District, and that the Seventh District Councillor assume the
duties and obligations previously held by the Eighth Councillor,
Be it further resolved, that the present Tenth Councillor
District be numbered the Ninth Councillor District and the
present Ninth Councillor District be numbered the Eighth
Councillor District.
Election of Officers
Dr. C. J. Meredith, acting chairman of the Nominating
Committee, presented the following report: The Speaker an-
nounced that there was nothing in the report of the committee
that precluded additional nomination of officers from the floor
and inquired as to whether any additional nominations were
to be made. Hearing none, he declared that a motion would
be in order to declare the nominees duly elected to their re-
spective offices. On a motion made that the nominees be elected
unanimously, which motion was seconded, all voted Aye and
the officers were elected unanimously.
President — W. A. Wright, Williston.
President-elect — L. W. Larson, Bismarck.
First Vice-President — W. E. G. Lancaster, Fargo.
Second Vice-President — O. W. Johnson, Rugby.
Speaker of the House of Delegates — A. E. Spear, Dickinson.
Vice-Speaker of the House — G. A. Dodds, Fargo.
Secretary — O. A. Sedlak, Fargo.
Treasurer — E. J. Larson, Jamestown.
Delegate to the A.M.A. — W. A. Wright, Williston.
Alternate Delegate to A.M.A. — G. W. Toomey, Devils Lake.
Councillors (terms expiring 1952) — Second district: J. C.
Fawcett, Devils Lake; Seventh district: Joseph Sorkness,
Jamestown; Ninth district: A. R. Gilsdorf, Dickinson.
Recommended to the State Board of Medical Examiners —
C. J. Glaspel, Grafton, N. D.; Joseph Sorkness, James-
town; D. J. Halliday, Kenmare.
State Health Council: M. S. Jacobson, Elgin.
University Medical Center Advisory Council: L. W. Larson,
Bismarck.
Selection of 1950 Meeting Place
The Speaker announced that he would be glad to entertain
an invitation for a place for the 1950 meeting to be held. Dr.
T. Q. Benson stated that the Grand Forks District Medical
Society extends a cordial invitation for the Sixty-third Annual
Meeting to be held at Grand Forks, in 1950. It was moved
by Dr. Radi and seconded by Dr. Halliday that the invitation
be accepted. All voted Aye.
REPORTS OF REFERENCE COMMITTEES
Reference Committee to Consider the Reports of the
President, Secretary, Executive Secretary and
Special Committees
Dr. G. W. Toomey, chairman, presented the following report
which was adopted section by section and as a whole:
1. Report of the President : We all realize the diligence with
which our President, Dr. W. A. Liebeler, has pursued the duties
of this office. He has consistently and conscientiously spent an
enormous amount of time coordinating the many branches of
our Society into a smooth-functioning unit. We also all realize
the responsibility of the Office of President in such trying times
as these, with the many problems both scientific and economic,
which are confronting the medical profession. Dr. Liebeler has
obviously had an excellent understanding of these problems.
2. Report of the Secretary: It is gratifying to note that
there has been an increase of the paid membership of the
Society. However, it is obvious that the local societies have
been lax in bringing pressure to bear upon a sizable number
of active practitioners who do not belong to the Society. Your
Secretary is to be complimented on the amount of field work
he has done. The recommendations in his report are definitely
endorsed by your Reference Committee.
3. Report of Executive Secretary: The report of the Execu-
tive Secretary is exceedingly concise and complete. There is no
doubt that the office of the Executive Secretary has been run
efficiently and conscientiously. Your Executive Secretary has been
alert at all times and has been very prompt in informing all
members of the Society of all important problems. The com-
mittee endorses the recommendation that $750 to $1,000 be
included in the budget for miscellaneous items, and recommends
the Council give attention to this matter.
4. Report of Committee on Industrial Health: Your com-
mittee has considered the report of Dr. C. J. Glaspel on Indus-
trial Health. The committee commends the use of the form
of the new death certificate which gives the Bureau of Vital
Statistics more detail which may lead to a better control of
accidents in industry.
5. Report of Committee on Mental Hygiene: The committee
notes the great deal of time and effort that has been put in
on the report of Dr. R. H. Breslin on Mental Hygiene. It
would be well worthwhile that all members read this detailed
report carefully. The committee is cognizant of the increasing
importance of the field of Mental Hygiene. The committee
recommends that this committee remain active.
September, 1949
321
6. Report of Committee on Emergency Medical Service:
Your committee has considered the report of Dr. A. C. Fortney
on Emergency Medical Service. The committee recommends
that the membership give thought to the necessity of procure-
ment of an adequate number of physicians for the Armed Serv-
ices and that Doctors within the prescribed classification be en-
couraged to volunteer to enter the Service.
7. Report of Committee on Nursing Education : The com-
mittee has considered the report of Dr. Toomey on Nursing
Education. Your chairman of this committee realized that the
current problems of nursing care are no different than they have
been in the past several years. However, with the present legis-
lative set-up there is very little that the physicians as a group
can do to remedy the situation. It is hoped that the admittance
of displaced nurses may help to relieve the current nursing
shortage. It is fortunate that we are now able to license nurses
aids, thereby avoiding the stringent regulations imposed upon
candidates for R.N. by the Schools of Nursing.
8. Report of Committee on Displaced Physicians : The report
of Dr. A. C. Fortney on the Committee on Displaced Physicians
is very complete and the committee should be highly commend-
ed on the expeditious and diplomatic manner in which they
have handled such a delicate and highly publicized problem.
G. W. Toomey, M.D., Chairman
M. S. Jacobson, M.D.
B. M. Urenn, M.D.
R. B. Woodhull, M.D.
Reference Committee to Consider the Reports of the
Council, Councillors, Delegate to the A.M.A., and
Member of the Medical Center Advisory Council
Dr. W. H. Gilsdorf, chairman, presented the following re-
port, which was adopted section by section, and as a whole:
1. Report of Chairman of the Council: Your reference com-
mittee has reviewed the report printed in the Handbook of
Dr. McCannel, chairman of the Council, and wishes to compli-
ment the Council on the thorough manner in which a large
amount of work was completed last year. We were also very
pleased to review the supplemental report of Dr. McCannel
for the Council meeting held May 14, 1949. This, with the
Executive Secretary’s Supplemental Report, brought all reports
of the business of the Association up to the present date. This
method will eliminate a lot of confusion in the future.
This Committe concurs most heartily with the Stutsman
County Medical Society in recommending increased educational
effort to combat adverse medical propaganda.
2. Reports of Councillors: Your Reference Committee re-
viewed the reports of the Councillors and noted an increase in
the number and quality of meetings of most district societies.
We hope this trend continues.
3. Report of Delegates to the A.M.A.: The report of the
Delegate to the A.M.A. was read with considerable interest.
Your committee encourages each member to pay the $25.00
assessment to the A.M.A. at once as a minor gesture on his
part to help prevent socialized medicine.
4. Report of Member of Medical Center Advisory Council:
Your committee reviewed the report of the Member of the
Medical Center Advisory Council. The committee agrees that
one of the main objects of the Advisory Council at the pres-
ent time should be to strengthen the two year medical school
so it may obtain the unqualified approval of recognized accredit-
ing agencies.
W. H. Gilsdorf, M.D., Chairman
H. A. LaFleUr, M.D.
A. K. Johnson, M.D.
Reference Committee to Consider the Reports of the
Standing Committees Except the Report of the Committee
on Medical Economics and its Sub-Committees on
Prepayment Medical Care, Veterans Medical Service,
and Rural Health
Dr. R. W. Vance, chairman, presented the following report,
which was adopted section by section, and as a whole:
1. Report of Committee on Medical Education: Your ref-
erence committee was impressed by the report of the Committee
on Medical Education and feels they deserve to be especially
commended Your committee has also reviewed the recommen-
dations of the Medical Center Advisory Council to the State
Board of Higher Education and we feel that the next few years
this should be carefully guided so that the goals set up shall
be fulfilled.
2. Report of Committee on Pneumonia: Your reference
committee moves the adoption of the report of the Committee
on Pneumonia.
3. Report of the Committee on Necrology and Medical His-
tory: Your reference committee moves the adoption of the
report on Necrology and Medical History. At that time the
Speaker announced that the Chair would request the House of
Delegates to rise for one moment in silent tribute to the mem-
bers who have passed on. Thereupon followed a moment of
silence with all delegates and guests standing.
4. Report of Committee on Maternal and Child Welfare:
Your reference committee has reviewed the report of the Com-
mittee on Maternal and Child Welfare and moves its adoption.
5. Report of the Committee on Cancer: Your reference com-
mittee has reviewed the report of the Committee on Cancer and
moves its adoption.
6. Report of the Committee on Tuberculosis: Your reference
committee has reviewed the report of the Committee on Tuber-
culosis. Your committee feels that a report on the follow-up
of the results of BCG vaccine in the Indian territory be given
because of the widespread interest of this newer means of con-
trolling tuberculosis.
7. Report of Committee on Public Policy and Legislation:
Your reference committee wishes to compliment the Committee
on Public Policy and Legislation for their untiring efforts in
disposing of very controversial matters in a most satisfactory
manner.
8. Report of Committee on Crippled Children: Your ref-
erence committee has reviewed the report of the Committee on
Crippled Children and moves its adoption.
9. Report of Committee on Public Health: Your reference
committee has reviewed the report of the Committee on Public
Health and moves its adoption.
10. Report of the Sub-Committee on Public Health — Garri-
son Dam Project: Your reference committee has reviewed the
report of the Sub-Committee on Public Health — Garrison Dam
Project, and moves its adoption.
11. Report of Committee on Official Publication: Your ref-
erence committee has reviewed the report of the Committee on
Official Publication and moves its adoption.
12. Report of the Committee on Fractures: Your reference
committee has reviewed the report of the Committee on Frac-
tures and moves its adoption.
13. Report of the Committee on Venereal Disease: Your
reference committee notes that no report has been made on
Venereal Disease.
R. W. Vance, M.D., Chairman
George Waldren, M.D.
F. W. Fergusson, M.D.
M. G. Flath, M.D.
Reference Committee to Consider the Reports of the
Committee on Medical Economics, including the Sub-
Committees on Prepayment Medical Care,
Veterans Medical Service and Rural Health
Dr. T. Q. Benson, chairman, presented the following report
which was adopted section by section and as a whole:
1. Report of Committee on Medical Economics as a Whole:
Your reference committee submits the following report:
Whereas, Dr. W. A. Wright as chairman of the Committee
on Medical Economics has attended the following national
meetings: A.M.A. Conference on Rural Medical Care; North-
west Regional Conference; National Conference on Medical
Care; and National Physicians Committee, and has rendered a
report in writing in an excellent manner and has also, in care-
fully considered paragraphs, stated the conditions as they exist
in regard to the controversy between the Public Welfare Board
and the physicians; namely, a refusal of the Public Welfare
Board to arbitrate an adequate fee schedule, in which it is rec-
ommended that the North Dakota State Medical Association
notify the Public Welfare Board that the advisory fee schedule
now in effect is considered to be rescinded; and that in the
future doctors in North Dakota will feel free to charge Public
Welfare Board cases such fee as in their own opinion seems
proper; we recommend that Dr. W. A. Wright be officially
commended for his untiring efforts.
322
2. Report of Sub-Committee on Prepayment Medical Care:
Your Reference Committee has reviewed the report of Dr.
W. E. G. Lancaster.
Several meetings were held during the past fiscal year. At
the meeting in Fargo, July 2, 1948, it was proposed that a
compromise program be put into effect modifying the present
plan. In Fargo, October 2, 1948, the partial income, partial
indemnity plan was adopted. There has been a liberalization
in the ruling that all procedures must be performed in hospi-
tals— this is in regard to tonsillectomies, fractures and obstetrical
cases.
It is recommended that the House of Delegates approve the
expansion thus far of the North Dakota Physicians Service
so that it may be expanded into all areas of the state of
North Dakota.
3. Report of Sub-Committee on Rural Health: Your ref-
erence Comittee to consider the report of the Sub-Committee
on Rural Health submits the following:
The reference committee agrees heartily with the plans for
encouraging medical men to locate in rural areas. Plans for
scholarships, internships and residencies and also plans for loca-
tion of small hospitals at proper places are commendable. The
Lorenzen Memorial Hospital at Elgin is given as an example
of a small community hospital.
4. Report of Sub-Committee on Veterans Medical Service:
Your reference committee has reviewed the report of Dr. R. B.
Radi, chairman of the Sub-Committee on Veterans Medical
Service.
It states’ it is the feeling of the chairman of this committee
that the Veterans Medical Service Division is being well han-
dled and efficiently, and shows progress rather than regression.
T. Q Benson, M.D., Chairman
P. G. Arzt, M.D.
E. M. Haugrud, M.D.
Speaker Spear made the following remarks directed toward
the chairman and members of the reference committees: "I want
to thank the chairmen and members of the committees for the
thoroughness with which they have prepared their reports. These
have been very short and concise, helping to make the work of
this session go more smoothly and speedily.”
Dr. Wright then asked for the floor to make a remark con-
cerning the membership of the Medical Economics committee.
He stated:
"This is the last year I will be serving on the Medical Eco-
nomics Committee. I would like to extend my own personal
thanks to the many men who have worked on this committee
and sub-committees. We have had a very fine group of fellows
who have put in a lot of time and work. The boys do most
of the work and I seem to have received most of the credit.
I would, therefore, like to put in a plug for all the men on
these committees for all the time and work they have put in.
The members in many instances turned out very well to meet-
ings and it has been a real help to the affairs of the Associa-
tion. I would like to extend my personal thanks to all of these
fellows.”
Reference Committee on Resolutions
Dr. R. B. Radi, chairman, presented the following report
which was adopted section by section and as a whole:
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, the Sixty-second Annual Meeting of the North
Dakota State Medical Association held in Minot, N. D., May
14th to 17th, presents an outstanding scientific and entertain-
ment program.
Now, therefore, be it resolved, that the House of Delegates
offer its thanks and appreciation to the Northwest District Med-
ical Society, to the several local program and entertainment com-
mittees to Dr. Liebeler, State President, and to the city of
Minot, for the contributions they have made to insure the suc-
cess of this meeting.
Your Committee on Resolutions wishes to present the fol-
lowing resolution:
Whereas, the Women’s Auxiliary of the North Dakota State
Medical Association under the distinguished leadership of Mrs.
Baillie of Fargo has rendered yeoman service to our Association
by its support to our organization in its stand against the so-
cialization of medicine,
The Journal-Lancet
Now, therefore, be it resolved, that the House of Delegates
express its gratitude to the Auxiliary for its untiring efforts
in behalf of the Medical Association.
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, the American people now enjoy the privileges of
the highest level of health, the best standards of scientific medi-
cine and the free choice of medical care,
And Whereas, the American people now enjoy the privileges
of the highest level of health, the best standards of scientific
medicine and the free choice of medical care,
And Whereas, the accomplishments of American medicine
were attained by free people, working under a system of free
enterprise,
And Whereas, the experience of all countries where govern-
ment has assumed control of medical care there has been a pro-
gressive deterioration of medical standards and medical care to
the detriment of the health of those people,
Now, therefore, be it resolved, that the House of Delegates
assembled at this Sixty-second Annual Meeting, strongly pro-
test to the Congress of the United States the passage of any
legislation imposing upon the people of this Nation any form
of compulsory health insurance, or any system of medical care
designed for national bureaucratic control,
Be it further resolved, that a copy of this resolution be for-
warded to the chairman of the Appropriations Committee of
the United States Senate and House of Representatives, and
to the Congressmen from the state of North Dakota.
Your Resolutions Committee wishes to present the following
resolution:
Whereas, the President of the United States has seen fit to
propose a form of compulsory medical insurance, and,
Whereas, the best efforts of the A.M.A. and the State So-
cieties are unalterably opposed to this form of legislation, and,
Whereas, opposition to this form of bureaucracy can best be
proposed by an educational program,
Now, therefore, be it resolved, that the President of the
Association appoint a Public Relations Committee of at least
five members to promote the educational campaign of the
A.M.A. in the state of North Dakota, and that this committee
be instructed to receive authority for expenditures from the
Executive Committee of the Council.
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, an appeal has been made by the I. C. System for
an endorsement by the Association for the purpose of acting
as an official collecting agency for doctors,
Now, therefore, be it resolved, that the House of Delegates,
as a Society, refuse this endorsement.
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, an endorsement for group insurance of the mem-
bers of the medical society has been sought by the North
American Accident Insurance Company,
Now, therefore, be it resolved, that the House of Delegates
refuse this endorsement.
We wish to present the following resolution:
Whereas, the National Sales Foundation has requested an
endorsement from the State Medical Association for the pur-
pose of selling to the druggists of the state, articles and adver-
tising relative to health programs,
Now, therefore, be it resolved, that the House of Delegates
refuse the endorsement of this form of advertising.
We wish to present the following resolution:
Whereas, Aloysius P. Nachtwey has served this Association
for many years as State Delegate to the A.M.A., and served
one term as Speaker of the House of Delegates,
And whereas, Aloysius P. Nachtwey has served this Associa-
tion faithfully and well, and
Whereas, he was loved and honored by the medical frater-
nity, and
Whereas, Almighty God has seen fit to take him from his
labors amongst us,
Now, therefore, be it resolved, that this House of Delegates
express to his bereaved wife the sincerest condolences and sym-
pathy in the passing of her beloved husband.
The Speaker then asked all to rise for a moment of silence
September, 1949
323
in tribute to Dr. Nachtwey. All members and guest arose
and a moment of silence followed.
Your Committee on Resolutions moves the adoption of the
recommendation of the Council,
That the contract with the Journal-Lancet, the official pub-
lication of the North Dakota State Medical Association, be
renewed for one year.
Your Committee on Resolutions wishes to present the fol-
lowing resolution:
Whereas, it is well accepted that the disease, Diabetes
Mellitus, is of great importance, and that the early detection
of diabetes is of great value, and
Whereas, a Diabetes Detection program conducted in the
city of Grand Forks was very successful,
Now, therefore, be it resolved, that the House of Delegates
endorse a state-wide Diabetes Mellitus detection program to be
conducted by the individual and component medical societies
in the state. It is suggested that any such programs be pat-
terned after the Grand Forks plan used in December, 1948,
which plan was affiliated with the National Diabetes Detection
Drive sponsored by the American Diabetes Association. It is
felt that the formation of a state-wide organization will assist
in the efficiency of such diabetes detection.
Be it further resolved, that the House of Delegates endorse
the formation of the North Dakota Diabetes Association, Inc.,
as an affiliate unit of the American Diabetes Association.
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, Brucellosis is an important disease affecting humans
and animals,
Be it therefore resolved, that the House of Delegates be
placed on record to give its support to any movement which
would eradicate Brucellosis in cattle in the state of North
Dakota.
Your Committee on Resolutions wishes to present the follow-
ing resolution:
Whereas, Drs. E. P. Quain, Fannie Dunn Quain, and W. H
Bodenstab, members of the Sixth District Medical Society, and
W. F. Sihler of Devils Lake, member of the Devils Lake Dis-
trict Medical Society, have met with the requirements of Article
IV, Section 4 of the Constitution, referring to honorary mem-
bers,
Now, therefore, be it resolved, that these doctors be elected
to honorary membership in the State Association, and that the
Secretary be instructed to notify these physicians of the
honorarium.
Dr. R. B. Radi suggested that the Constitution and By-Laws
be reprinted next year and that a copy of the Constitution and
By-Laws be sent out to the newly elected delegates next year.
The Resolutions Committee then submitted the following pro-
posed amendments to the Constitution:
The Committee on Resolutions wishes to submit the follow-
ing Amendments to the Constitution:
Whereas, changes have been necessary regarding the number
and locations of the Councillor Districts and Councillors, it is
necessary to amend the Constitution, and
Whereas, it is also necessary to amend the Constitution in
order that there be proper authority for the Vice-Speaker of
the House of Delegates,
The following amendments to the Constitution are submitted
for your consideration:
That the first sentence of Article 6, Section 1, pertaining to
the Council be amended to read as follows:
"The Council shall be the Executive Body of the Association
and shall consist of Nine Councillors.”
After considerable discussion this proposed amendment was
amended by Dr. Radi to read as follows:
Your Committee on Resolutions will submit the following
Amendment:
"The Council shall be the Executive Body of the Association
and shall consist of one Councillor from each Councillor Dis-
trict.”
This amendment to the Constitution was laid on the table
until the 1950 Annual Meeting.
Your Committee on Resolutions wishes to submit the follow-
ing Amendment to the Constitution:
That Article 9, Section 1, pertaining to officers, be amended
to read: "The officers of this Association shall be President,
President-elect, a First Vice-President, a Second Vice-President,
a Secretary, a Treasurer, a Speaker of the House of Delegates,
a Vice-Speaker of the House of Delegates, and one Councillor
from each Councillor District.”
The proposed amendment to the Constitution was tabled
until the 1950 Annual Meeting.
Your Committee on Resolutions wishes to submit the follow-
ing Amendment to the Constitution:
That Article 9, Section 3, pertaining to officers, be amended
to read as follows:
"The Speaker and the Vice-Speaker of the House of Dele-
gates shall be elected by the House of Delegates at its Second
Session each year. Each may, but need not be, elected from
among the members of the House of Delegates.”
This proposed amendment to the Constitution was tabled
until the 1950 Annual Meeting.
It was stated by Dr. Radi that some provision should be made
for members in the North Dakota State Medical Association
for Residents and/or Fellows, in graduate training. Therefore,
the following amendment to the Constitution is submitted for
your consideration: the changes pertaining to Article 4, cov-
ering the composition of the Association to number the present
Section 4, pertaining to Honorary Members, as Section 5, and
that a new Section 4 be added as follows:
"Residents and/or Fellows: Residents and/or Fellows in grad-
uate training may become Associate Members of this Associa-
tion when elected as Associate Members of the Component
Society of the District in which such physician lives. Such
members shall be designated as Associate Members and shall
enjoy the same privileges as regular members except the right
to vote or be elected to office. They shall be charged no dues.”
After considerable discussion and the putting of the question
before the House of Delegates, the vote was in the negative
and the proposed amendment to the Constitution lost.
Your Committee on Resolutions wishes to submit the follow-
ing Amendments to the By-Laws:
That Chapter 6, Section 5, referring to the duties of officers,
be changed to read as follows: "The Speaker, and in his ab-
sence, the Vice-Speaker, of the House of Delegates shall pre-
side at the meetings of the House of Delegates and shall per-
form such duties as custom and parliamentary usage require
o^ a presiding officer. He shall have the right to vote, only
when his vote shall be the deciding vote.”
That Chapter 13, referring to Amendments, be amended as
follows: "These By-Laws may be amended at any Annual Ses-
sion by a majority vote of all the delegates present at that
session. Any such amendment may be introdcued at any session
of the House of Delegates but shall be laid upon the table for
that current session, but may be acted upon at any later session
of the House of Delegates.”
R. B. Radl, M.D., Chairman
D. J. Halliday, M.D.
E. J. Beithon, M.D.
The Speaker, Dr. Spear, expressed his appreciation to the
members of the Reference Committee on Resolutions for the
vast amount of work and time spent on resolutions and amend-
ments.
Unfinished Business
The Speaker then called upon the Executive Secretary to ex-
plain the Fifty Year Club: "Numerous state associations
throughout the country have felt a good deal as Dr. Wald-
schmidt feels, that the requirements of the American Medical
Association are too great to receive the honor of becoming an
honorary member. Accordingly, in order to give members of
long years of practice some recognition in their state associa-
tions, quite a few of the associations have adopted these Fifty
Year Clubs. There is very little difference between a Fifty Year
Club Member and an Honorary Member. There is at least one
requirement that can be waived. In order to become an Hon-
orary Member of the various state associations, a doctor must
have been licensed to practice medicine in the state for fifty
years. However, with the Fifty Year Club, a doctor can move
from one place to another; that is, from one state to another,
and the time accumulates for him on that basis so that he may
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The Journal-Lancet
become a member of the Fifty Year Club if he has practiced
medicine for fifty years. The Club in North Dakota has been
authorized by the Council at the January meeting. I think it
is a very nice idea for those doctors who have been practicing
and serving their communities for such a long while surely
should be given recognition. The ceremony that is planned
during the annual meeting will be very brief and I think will
probably be tinged with a lot of fun, rather than being too
serious. I do not believe the doctors care to have the thing
made too serious. It will be handled at the banquet tomorrow
night by Dr. Frank Darrow of Fargo. He will give the new
members of the Fifty Year Club their charge in the manner
in which he sees fit.”
The Speaker concluded with the inquiry as to whether any
new business or resolutions were to be brought before the House
and stated "if not, your Speaker wishes to congratulate you in
the highest manner possible for the very excellent cooperation
he has had from every member of this House. I think you
have accomplished a great deal in a remarkably short time. Let
me thank you heartily for the wonderful cooperation you have
given me.”
Motion was made by Dr. Radi that this session of the Sixty-
second Annual Meeting of the House of Delegates be ad-
journed.
Adjournment
The Speaker declared the House of Delegates adjourned
sine die at 5:00 P.M.
SCIENTIFIC PROGRAM
Monday, May 16, 1949
Clarence Parker Hotel, Minot, N. D.
8:30 to 9:30 A.M. — Registration and Movies.
9:30 to 10:00 — "Surgical Management of the Low Back Syn-
drome”— Dr. G. A. Kernwein, Minot.
10:00 to 10:30 — Intermission. View exhibits.
10:30 to 11:00 — "Cancer of the Larynx” — Dr. Jerome A.
Hilger, St. Paul, Minn.
11:00 to 11:30 — "Carcinoma of the Lung; Bronchial Secre-
tion Studies in Early Diagnosis” — Dr. G. A. Dodds, Fargo.
2:00 to 2:30 P.M. — "Surgical Diseases of the Kidney” — Dr.
N. O. Brink, Bismarck.
2:30 to 3:00 — "The Cytologic Diagnosis of Cancer” — Dr.
J. R. McDonald, Mayo Clinic, Rochester.
3:00 to 3:30 — Intermission. View exhibits.
3:30 to 4:00 — "Some Common Pediatric Surgical Problems”
— Dr. Oswald S. Wyatt, Minneapolis.
4:00 to 4:30 — "Surgical Therapy for Peptic Ulcer” — Dr. A.
L. Cameron, Minot.
4:30 to 4:40 — Report on the State Diabetic Detection Drive
in the Grand Forks District — Dr. E. A. Haunz, Grand Forks,
N. D., Chairman of State Diabetic Detection Program.
Tuesday, May 17, 1949
9:45 to 10:00 A.M. — A playing of the Ewing Interrogation
on the Cloakroom of the Air.
10:00 to 10:30 — Presidential Address — Dr. W. A. Liebeler,
President, Grand Forks; Inaugural Address — Dr. W. A.
Wright, President-elect, Williston.
10:30 to 11:00 — Intermission for viewing exhibits.
11:00 to 11:30 — "Headache and Head Pain” — Dr. J. J.
Ayash, Minot.
11:30 to 12:00 — "Surgery of the Sympathetic Nervous Sys-
tem”— Dr. Collin S. MacCarty, Mayo Clinic, Rochester.
12:00 Noon — Drawing for door prize.
Joint Service Club Meeting followed by Public Address of the
Honorable Forest A. Harness.
Installation of President
Dr. Liebeler: I now have the pleasure of introducing to you,
your next President, and so that he may well know the duties,
responsibilities and the dignity that this office can give to him
and which he can continue to make noble, I am going to ask
Drs. Ramstad, Campbell, Bodenstab and Burton to conduct
Dr. Wright to the chair.
My friend, Willard, I can not present you anything finer in
this world than the office of State President of the North Da-
kota State Medical Association. I have never known as fine
a group to deal with. You are our next President, Dr. Wright.
Dr. Wright: Thank you, Mr. President, and thank you very
much, Drs. Ramstad, Campbell, Bodenstab and Burton.
Dr. W. A. Wright’s Inaugural Address
I approach my term in office with some misgiving as to my
ability to maintain the high standards which have been set by
the sixty doctors who have preceded me.
To those who have held this office before me we owe a great
debt, as of course, we do to many others, who have worked
unceasingly for the good of Medicine in North Dakota. Our
past Presidents have been men of dignity and stature, who have
commanded the respect of the profession as a whole. It has
been my pleasure to have known personally and to have count-
ed as a real friend thirty-three of them. From these men, I
have learned much and I could only wish that their combined
wisdom could be ours and that we might have all of their
knowledge and experience to help us in the days that lie ahead.
Unfortunately, this may not be so, but I believe that we may
be able to apply many of the lessons learned from these out-
standing North Dakota doctors.
Without intending to imply any depreciation of the other
past Presidents, I would like to single out two of them for
special mention, because they are primarily responsible for me
assuming this office today. From them, I received the initial
stimulus and later guidance and encouragement to participate
increasingly in the affairs of our Association.
My first guide and counsellor was the late Dr. Harry Bran-
des, a man, who at all times had the deep respect and admira-
tion of those who were associated with him. To me, he was
the perfect physician, well trained in medicine, with a keen but
open scientific mind and a nice sense of discrimination. Not
only was his professional work above reproach, but in addition,
he displayed to a remarkable degree that desirable attribute
(only too rare in doctors) of being able to meet the lay mind
at its own level and to project his sound thinking into the
minds of those with whom he had to deal. Anyone who had
the privilege of knowing and working with Harry Brandes
could not help but admire his courageous and courteous ap-
proach to medical, social and economic problems. I appreciate
and seize on this opportunity to pay some slight tribute to his
memory, though no words of mine could add to his lustre in
the memory of his friends.
I have heard it said that a certain Minot doctor is so well
known that if he were lost in the middle of the Sahara Desert,
some Sheik would ride up, extend his hand and say, "Hello,
Archie. What brings you here?” And if Archie McCannel
were to be found in that locality, it would probably be because
he was using some of his boundless energy and tremendous en-
thusiasm to further a good cause.
Archie has worked unceasingly for the good of North Dakota
doctors, the people of North Dakota, and the city of Minot,
where we are happy to be holding our 1949 Convention. He
has been a good friend to all of us and for many years has
provided me with stimulation, sage advice, enthusiastic support
and the privilege of his friendship. For all of this, I am ex-
tremely grateful and thankful to be able to acknowledge this
debt here in Minot, his home.
In other days, both the Presidents and members of the Asso-
ciation have always been concerned with problems, which curi-
ously enough throughout the years have had a similar basic pat-
tern, a struggle for control of the profession. We have always
looked upon ourselves as a group of free individuals capable of
directing and guiding the practice of Medicine into channels
best both for patients and ourselves. This freedom, which we
so prize, we do not consider as freedom to unduly exploit our
fellow man, but rather as the liberty to do that which we ought
to do. During the years, many persons for a variety of reasons
have sought to restrict our freedom and divert control of the
practice of Medicine into lay or legislative channels. Unceas-
ingly, irregular practitioners, philanthropic foundations, some
hospitals, so-called cooperatives, welfare organizations and coun-
ty, state and Federal governments have worked to either assume
or direct the art of healing the sick. In some instances their
motives are completely selfish, and in others, they are more altru-
istic, but the end result of their activities would all be detri-
mental to the practice of our profession, at a high level of
efficiency. I am sorry to say that most of these problems are
still with us but the one with which we are chiefly concerned
September, 1949
325
at the present time is that of the proposed inroads on the prac-
tice of Medicine by the Federal Government.
Increasing domination by the Federal Government seems
almost inevitable, because if our avowed enemies do not produce
a complete program, our friends are going to produce a sub-
stitute program, which may well have somewhat the same effect.
Thus, we have President Truman’s proposal for straight social-
ized medicine, Senator Taft’s of Federal subsidies to the state
for the care of the indigent and Senator Flill and associates
for paying voluntary health insurance premiums for those un-
able to pay for themselves. All of these things tend somewhat
to cloud the issue but one thing is absolutely clear and that is
that the profession must unite on some common ground and
work unceasingly to save all that is good in private practice.
Many changes in the structure of social organizations and
governments have occurred because a few determined people
knew exactly what they wanted to do while the many, who
were opposed to them, were unable to unite on any common
basis. Nowhere has this been better expressed than by the late
and unlamented Adolf Hitler, who wrote in Mein Kampf :
"The forces in opposition to us have lacked the clearness of
plan, the unity of motive and the certainty of conviction to
make their cause prevail.”
We, as doctors, are becoming more and more scientific and
we are prone to search for the exact answers to all medical
problems. We have developed technical and scientific methods
of approach which are superior to anything that we have ever
had before. We think that we, at all times, should have the
exact diagnosis, the best method of treatment and we should
apply in every case the finest that it is possible for a person to
receive. This certainly is a commendable scientific method of
carrying on our affairs. But, this is not the method pursued
by people working in the social and economic fields. They have
no mechanical or scientific criteria to guide them. They are apt
to arrive at extremely unwarranted conclusions and their meth-
od of solving a given problem is too often based on an inade-
quate study and on considerable empiricism in the matter of
the solution. This is the type of thinking with which we have
to deal and it behooves us doctors not to believe that we must,
before we deal with such problems, have the final and best
answers.
No one solution of the medical care question is going to
satisfy everyone, nor will that solution necessarily be valid for
a long period of time. Changes are necessary as conditions in
this country change. We must use every possible method to
combat those who seek to dominate not only us, but all citi-
zens of this country, and it is too much to expect that each
one of us will agree that every proposed action is advisable,
or that something that we think how is the right thing to do
might not be discarded later and some other method followed.
Loyal support from our members is an absolute essential and
in accepting this office, I am going to ask each and every one
of you to do all you can in the following year to further the
best interest of our Association. I hope that all of us, wherever
and whenever possible, will forego selfish interest and work for
the common good of the profession in North Dakota.
Presidential Address
W. A. Liebeler, M.D., Grand Forks, North Dakota
Mr. Chairman, Members of the North Dakota State
Medical Association, Ladies of the Auxiliary, and
Visitors:
Belatedly, I extend to you the customary word of
greeting and welcome to the fair city of Minot and to
the Sixty-second Annual Meeting of this Association.
This might be particularly for those whom I may have
missed in my visits to rooms one, through 200, in this
Hotel, the Country Club, and other places better not
mentioned. But, on second thought, my remarks will be
for all, for I intend to use these remaining moments in
examination of our heritage and in testimonial of a
group of men who served as Presidents of this Associa-
tion through World War I, and are still carrying on the
battle. Too often we tend to lose sight of basic values
because of absorption in the problems and the fears of
the day. Yes, even to the point of sometimes losing
perspective.
Let’s look at these men through the eyes of North
Dakota’s only medical historian, James Grassick. The
total sum of their lives and the lives of all the others
who have worked arduously for this Association has
built the heritage now ours:
Dr. W. H. Bodenstab, our 15th President, 1903-1904.
Said Dr. Grassick: "Dr. Bodenstab is an acknowledged
authority in internal medicine, having fitted himself in
this department of the healing art by investigation and
study in the leading medical centers at home and
abroad. His contributions to medical literature have been
frequent and characterized by a thoroughness and a
saneness that give them value.” My own note is that he
makes the best Martini in the state of North Dakota.
Dr. R. D. Campbell, our 18th President, 1906-1907.
Said Dr. Grassick: "Dr. Campbell has been no laggard
in his profession. In 1908 and in 1913 he went abroad
and studied in the great medical centers: Berlin, Vienna,
Paris, London and Edinburgh. Thus fitted, he has well
fitted many positions of honor and responsibility calling
for scholarship and executive ability. He has held the
position of Lecturer on Surgery in the Medical School
of the University of North Dakota since its organiza-
tion. He is surgeon for the Great Northern and North-
ern Pacific Railroad Companies and a charter member
of the American College of Surgeons.” My note — as
fine a gentleman as I ever expect to know.
Dr. J. E. Countryman, our 21st President, 1909-1910.
Of him, Dr. Grassick said: "Dr. Countryman is a gen-
tleman of good address and pleasing personality. He
has made a success of his profession by keeping in close
touch with the progress of medicine and surgery, by
paying strict attention to the details of practice, by eth-
ical and honorable dealings with his fellow practitioners
and by painstaking and sympathetic treatment of his
patients. His ideals are high and in his social, business
and professional life, integrity is a controlling factor.”
Dr. V. J. LaRose, our 28th President, 1916-1917.
Again said Dr. Grassick: "Dr. LaRose has held so many
positions of trust and responsibility that he has been
'tried as if by fire’. He is progressive and yet is so
modest in his bearing among his professional associates
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that the quality of the man is often hidden from view,
but as the necessity arises he can always be relied upon
to 'deliver the goods’. He is conscientious and thorough
in his work and hates sham and superficiality in others.
As a member of the profession and of the Society, Dr.
LaRose ranks high.”
Dr. G. M. Williamson, our 29th President, 1917-1918.
Quoting Dr. Grassick: "Dr. Williamson was chairman
of the committee that passed the Medical Practice Act
of 1911, than which there is none better on the statute
books of any state in the Union. In 1911 he was ap-
pointed as a member of the North Dakota State Board
of Medical Examiners and on the organization of that
body, was elected as its secretary, which position he has
held continuously since that time. It is not too much
to say that the burden of the work fell on his shoulders
and that he has given it his best efforts and made it a
model, the equal of any board of similar nature in the
country. His work in the state was recognized by the
Federation of State Examining Boards and he served
on the Executive Committee of the National Organiza-
tion from 1919 to 1922.”
Our Association has been extremely fortunate in its
Presidents of the past. With scarcely an exception, they
have been not only of the highest standings in their pro-
fession, but men who would have graced any position
of trust or responsibility to which they might have
aspired. We can truthfully say, and we do, with some
pride, "We have been captained well.”
It is these men and the others who have gone before
us who have set the high standards of medical practice
in the state of North Dakota. Some of them were re-
sponsible for the establishment and success of the Uni-
versity of North Dakota School of Medicine and gave
directly of their time as lecturers. It is up to us to carry
the school forward. We are on the verge of great new
realizations in this respect. The one mill levy has pro-
vided a system of adequate and permanent finance for
the school. We must see to it that plans are adopted to
provide the best possible medical education for the bene-
fit of both the students and the people of the state of
North Dakota. In passing, one cannot omit reference to
Dr. H. E. French, Dean Emeritus. His stamp will for-
ever be found on the institution. His unselfish devotion
has carried the school through long years of impossibly
inadequate finance, with the result that the reputation
of his graduates have ranked among the best in the land.
One hears a lot about "group practice” these days.
Men before us in North Dakota have been pioneers in
that field. Group practice has been common in Medical
Center Areas in North Dakota for several decades. To-
day one witnesses large clinics with fine buildings and
fine equipment in all of the large centers of the state.
It is stated by many individuals and groups of individ-
uals, both patients and professional men, that group
practice is the only means for supplying adequate med-
ical care. This, like so many broad generalizations, I
believe to be an over-simplification of the problem. Both
individual and group practice definitely have their place
in North Dakota. The very satisfactory balance achieved
between the two in this state has resulted in a quality of
medical care which is difficult to surpass anywhere in the
United States. We are further fortunate in the rather
excellent balance between general practitioners and spe-
cialists located here.
Still others of our great group of leaders have lent
their abilities to the establishment and guidance of the
North Dakota State Board of Medical Examiners, a
body charged with the great duty and responsibility of
seeing to it that only those of high competency and
moral qualifications be permitted to practice in North
Dakota. The present board meets its obligations well.
It has been recognized probably more acutely by physi-
cians than even the public that a physician shortage
occurred both during the war years and the years that
followed. The board has been anxious that new men
come to the state — but only well qualified men. Their
handling of the problem of the Displaced Physician is
well illustrative of the fact. It is further most encour-
aging to note the large number of well trained American
physicians who are being atracted to our state.
All of these things bode well for the future of the prac-
tice of medicine in North Dakota. High quality of care,
service, and integrity must always be the goal of all of
us. With the realization of the goal our patients will
be with us in all we stand for.
The Woman’s Auxiliary has grown to adult dimen-
sions and, with the ardent enthusiasm I have seen dis-
played this past year, we may with certainty depend on
this fine organization to continue aid in educating their
friends and organizations in a good for all concerned.
And I do not mean the medical profession and their
families, but the people of their acquaintance who may be
and are being misinformed by professional bureaucracies.
May I congratulate and thank the Woman’s Auxiliary
for their splendid cooperation and achievement.
Perhaps I should mention the A.M.A. National Cam-
paign to educate and set right the thought of many in-
dividuals. Apparently, they have seen fit to educate the
physicians first with the real facts and the sinister meth-
ods that some of our electors have seen fit to use in dis-
torting the ideas and thoughts of the American public.
I hope in the near future we will be thoroughly acquaint-
ed with the facts and be able to turn our efforts to others
who may not be as fortunate to learn the truth as we
have been.
The American way is the way in which we have gained
our position as the greatest nation in the World. It will
read a few paragraphs from a talk given by DeWitt
Emery, President of the National Small Business Men’s
Association:
"Our American Way of Life is made up of many
things — bathtubs and automobiles; big cities and small
towns; farms and victory gardens; mammoth steel mills
and village machine shops; colossal educational institu-
tions and the little red schoolhouse beside the road;
churches and hospitals; railroads and airlines; chewing
gum and ice cream; department stores and crossroad
general stores; specialty shops and beauty parlors; pool
rooms and race tracks; Hollywood, Broadway and the
September, 1949
327
Highschool play; laughter and sorrow; eagerness and
despair; and people — millions of all kinds of people —
gathered together from the four corners of the earth,
drawn by the magnet of Freedom, Opportunity and
Justice.
"Our American Way of Life provides each individual
an opportunity to go as far and climb as high as his
willingness to work, his skill, ingenuity and integrity
will carry him.
"Our American Way of Life recognizes that the indi-
vidual has the right to work when and where he wishes,
the right to worship as he pleases, to speak his mind on
any subject, to meet with his fellow men for any peace-
ful purpose, to be secure in his possessions and to have
his day in a free court. It recognizes that the individual
is superior to the State, that our public officials are serv-
ants of the people and that they derive their just powers
from the consent of the people.
"These things taken together created the atmosphere
of freedom and an economic climate which made possible
in the United States the greatest production of wealth
in the history of the world and the establishment of a
standard of living which is the envy of all other nations
in the world.
"In short, the American Way of Life is the greatest
blessing ever bestowed on mankind any place on the face
of the earth.”
Now I quote from an article written by Mr. J. C.
Penney:
"Two streams of thought united to produce the
American Republic. One stream took its rise in the
teachings of Socrates and Aristotle. These men taught
that the human is and should be free; that a man has
the inalienable right to think for himself; and should
not be coerced intellectually. Aristotle warned that de-
mocracy can degenerate into tyranny. The demagogue,
with his ability to excite the passions of the crowd with
vague promises of material things, may lure them away
from freedom.
"This is exactly what happened in ancient Rome. The
greatest exponent of Greek thought in the Roman Em-
pire was Marcus Cicero, who as consul of the Republic
of Rome crushed the Cataline Rebellion when the left-
wing forces of the Empire sought to establish a collective
economy. The speeches of Cicero’s opponents read ex-
actly like the demogogic harrangues of the present day.
He held them off for awhile, but they finally defeated
him under the adroit manipulation of one of the shrewd-
est politicians who ever lived, Julius Caesar.
"Caesar told the people he would give them anything
they wanted without their working for it, and they be-
lieved him. He instituted a planned economy — in fact,
one planned economy after the other, because each of
them in turn failed — until there came a time when 20
per cent of the population of Rome was on the public
payroll. (No wonder Caesar stayed in office.) Taxes
became so high that the farmers, unable to pay them,
had no alternative but to allow their farms to revert
to the state. This exorbitant taxation ruined business.
Thousands of formerly prosperous merchants became
mendicants upon the streets of Rome.
"The economic confusion deepened, currency inflation
developed, and there was a vast unemployment. Col-
lective farming was attempted, but it was impossible to
induce the people to work because the government had
taken care of them so long and so completely that they
had lost the habits of labor. A deterioration in character
followed. Men who once roared like lions for liberty,
now bleated like sheep for security.”
As a result, a darkness settled down upon the world,
known historically as the Dark Ages.
Laws are being proposed before the Congress of the
United States clearly designed to undermine our sys-
tem of free enterprise and when one delves below the
surface, one soon realizes they are smug schemes to take
industry of private individuals and companies, and turn
it over to the government. One of these measures is the
Wagner-Murray-Dingle Bill.
Let not the other professions, the business men, large
or small, the farmers and even those who are so-called
laborers be fooled that they are not included in the
scheme of present-day Caesars and group of professional
bureaucrats who wish to establish themselves as saviors
without apparent study of existing history and fact.
In the words of Abraham Lincoln, shortly after a
bloody war to establish a freedom: "Surely every man
has as strong a motive now to preserve our liberties as
each had then to establish them.”
Let us again pledge ourselves, here and now, to keep
our profession clean, noble and good. To ever aspire
that we here in America will continue to work to the end
that this nation will maintain its kindliness to the human
individual and lead a struggling, tired, confused world
to happiness by cooperation and the contributions of our
great profession.
328
The Journal-Lancet
North Dakota State Medical Association Roster-1949
MEMBERSHIP BY DISTRICTS
First District
Heilman, C. O., Pres Fargo
Rond, J. H., Sec .. Fargo
Bacheller, S. C. Enderlin
Baillie, W. F. ... Fargo
Baird, J. A. Fargo
Bakke, H. Lisbon
Bateman, C. V. Wall pet on
Beithon, E. J. Wahpeton
Beltz, M. E. Wahpeton
Bond, J. H. __ Fargo
Borland, V. G. ... Fargo
Burt, A. C. Fargo
Burton, P. H. Fargo
Clark, I. I.).. Jr. Casselton
Corbus, B. C. Fargo
Darner, C. B. ... _ Fargo
Darrow, F. I. (Rtd.) Fargo
Darrow, K. E. Fargo
DeCesare, F. A. Fargo
Dillard, J. R. Fargo
Dodds, G. A. Fargo
Elofson, C. E Fargo
Fjelde, J. H Fargo
Fortin, H. J. Fargo
Fortney, A. C. _ Fargo
Foster, G. C. Fargo
Geib, Marvin Fargo
Gronvold, F. O. Fargo
Hanna, J. F. Fargo
Haugrud, E. M. ... Fargo
Hawn, H. W. Fargo
Heilman, C. O. Fargo
Hunter, C. M. Fargo
Hunter, G. W. .... Fargo
Huntley, H. B. ' Kindred
Ivers, G. U. Fargo
Joistad, A. H. (Rtd.) ... . Fargo
Klein, A. L. Fargo
Lancaster, W. E. G. Fargo
Larson, G. A. Fargo
LeMar, John Fargo
Lewis, A. K. . Fargo
Lewis, T. H. __ Fargo
Long, W. H. Fargo
Mazur, B. A. Fargo
Miller, H. W. ... Casselton
Moe, A. E. Fargo
Morris, A. C. . ._ Fargo
Nichols, A. A. Fargo
Nichols, W. C. Fargo
Oftedal, Trygve Fargo
Poindexter, M. H., Jr. Fargo
Pray, L. G. Fargo
Richter, E. H. Hunter
Rogers, R. G. Fargo
Sand, Olaf (Rtd.) ... Fargo
Schleinitz, F. B. Hankinson
Schneider, J. F. Fargo
Sedlak, O. A. ... Fargo
Stafne, W . A. Fargo
Swanson, J. C. Fargo
Tainter, Rolfe Fargo
Thompson, Andrew M. Wahpeton
Tronnes, Nels (Rtd ). Fargo
Urenn, B. M. Fargo
First — (Continued )
Veitch, Abner Lisbon
Watson, E. M. (Rtd.) Fargo
Weible, R. D. . . Fargo
Wasemiller, E. R .... Wahpeton
Miller, H. H. Wahpeton
Devils Lake
Mahoney, J. H., Pres. Devils Lake
Fawcett, D. W., Sec. Devils Lake
Engesather, J. A. D. Brocket
Fawcett, D. W. Devils Lake
Fawcett, J. C. Devils Lake
Fawcett, R. M. Devils Lake
Fox, W. R. — Rugby
Gerber, L. S. Lakota
Horsman, A. T. (Hon.) Dunseith
Johnson, C. G. Rugby
Jones, E. A. Liverpool, Eng.
Keller, E. T. .... Rugby
MacDonald, J. A. ... Cando
Mahoney, J. H. .... Devils Lake
Miles, A. M. ... Rolla
Palmer, D. W. Cando
Sihler, W. F. (Hon.) Devils Lake
Smith, Clinton Devils Lake
Stickelberger, J. S. (Rtd.) ... Oberon
Toomey, G. W. Devils Lake
Van Lier, P. C. Rugby
Vigeland, G. N. Maddock
Grand Forks
Youngs, N. A., Pres. Grand Forks
Silverman, L. B., Sec Grand Forks
Alger, L. J. Grand Forks
Benson, T. Q. . ... Grand Forks
Benwell, H. D. Grand Forks
Brown, B. E. (Rtd.) Grand Forks
Brown, G. F. Grand Forks
Burrows, F. N. (Hon.) Bathgate
Campbell, R. D. (Hon.) Grand Forks
Caveny, K. P. Portland, Ore.
Countryman, G. L. . Grafton
Countryman, J. E. (Hon.)
Arch Cape, Ore.
Culmer, A. E., Jr. Grand Forks
Dailey, W. C. . Grand Forks
Deason, F. W. Grafton
Field, A. B. (Hon.) Forest River
Flaten, A. N. .. Edinburg
French, H. E. Grand Forks
Fritzell, K. E. ....... Grand Forks
Glaspel, C. J. Grafton
Goehl, R O. Grand Forks
Graham, C. M. Grand Forks
Graham, John Grand Forks
Grinnell, E. L. ....... .. Grand Forks
Hardy, N. A. Minto
Haugen, C. O. Larimore
Haunz, E. A. Grand Forks
Jenson, A. F. Grand Forks
Johann, O. P. Grafton
Lamont, J. G. Grafton
Landry, L. H Valhalla
Leigh, R. E. Grand Forks
Liebeler, W. A. ... Grand Forks
Grand Forks — (Continued)
Lohrbauer, L. T. Grand Forks
Lommen, C. E. Fordville
Mahowald, R. E. Grand Forks
Moore, J. H Grand Forks
Mulligan, V. A. .. Langdon
Muus, J. M. ... McVille
Muus, O. H Grand Forks
Olson, P. A. Grand Forks
Panek, A. F. ._ __ Milton
Peake, F. Margaret Grand Forks
Piltingsrud, H. R. Park River
Quale, V. S. Grand Forks
Ralston, Lloyd S. Larimore
Rand, C. C. ... .... Grafton
Ruud, H. O. Grand Forks
Ruud, M. B. .... Grand Forks
Saiki, A. K. Grand Forks
Sandmeyer, J. A. Grand Forks
Silverman, L. B. .... Grand Forks
St. Clair, R. T. Northwood
Sterns, Donald Grand Forks
Stratte, J. J. . Grand Forks
Strom, A. D. Langdon
Thorgrimson, G. G Grand Forks
Tompkins, C. R. Grafton
Turner, R. C. Grand Forks
Vance, R. W. Grand Forks
Waldren, G. R. Cavalier
Waldren, H. M., Jr. Drayton
Weed, F. E. Park River
Williamson, G. M. (Hon.)
Grand Forks
Witherstine, W. H. Grand Forks
Woutat, P. H. Grand Forks
Youngs, N. A. Grand Forks
Kotana
Johnson, A. K., Pres. Williston
Hagan, E. J , Sec. Williston
Carlson, R. J. Watford City
Craven, J. D. Williston
Craven, J. P. Williston
Hagan, E. J. Williston
Johnson, A. K. Williston
Johnson, P. O. C. ..... Watford City
Korwin, J. J. Williston
Lund, C. M. . Williston
McPhail, C. O. Crosby
Wright, W. A. Williston
Northwest
Garrison, M. W., Pres. ... Minot
Kermott, L. Henry, Sec. Minot
Ball, W. J Minot
Barris, R. W. Minot
Beck, Charles ... .. Harvey
Bethea, R. O., Jr. .... Minot
Blatherwick, Robert Parshall
Blatherwick, W. E. Sanish
Breslich, P. J. — Minot
Cameron, A. L Minot
Combs, A. B. Minot
Conroy, M. P. Minot
Carise, O. S. ... Towner
Devine, J. L., Jr. Minot
September, 1949
329
Northwest (Continued )
Devine, J. L., Sr. Minot
Duane, T. D. Minot
Dyson, R. E. Minot
Erenfeld, F. R. Minot
Fischer, V. J. Minot
Flath, M. G. - — Stanley
Gammell, R. T. Kenmare
Garrison, M. W. ... Minot
Goodman, Robert Powers Lake
Greene, E. E. Westhope
Haas, W. R. ... .. Minot
Halliday, D. J. ... Kenmare
Halverson, C. H. Minot
Halverson, Henry L. Minot
Hammargren, A. F. Harvey
Hurly, W. C. .. .. Minot
Ayash, J. J. Minot
Ingalls, C. L. Minot
Johnson, H. Paul Minot
Johnson, J. A. Bottineau
Johnson, O. W. Rugby
Kermott, L. Henry Minot
Kermott, Louis H. Minot
Kernwein, G. A. Minot
Knudson, K. O. Glenburn
Kositsky, A. Chicago, 111.
Lampert, M. T. Minot
Livingston, N. B., Jr. ... Mohall
McCannel, A. D. Minot
McCannel, M. A. . Minneapolis, Minn.
McGauvran, T. E. Minot
Malvey, Kenneth Bottineau
Naegeli, F. D. ..... ... Minot
Nelson, L. F ... Robbinsdale, Minn.
Neve, H. E. Rolette
Peabody, C. S ... Minot
Ransom, E. M. ... Minot
Rowe, P. H. Minot
Seiffert, G. S. Minot
Sorenson, A. R. Minot
Sorenson, Rodger Minot
Spomer, J. P. .... .... ... Minot
Timm, J. F. (Hon.) ... Portland, Ore.
Uthus, O. S. Minot
Wall, W. W. .. .. Minot
Wallbank, W. L. ... San Haven
Wheelon, F. E. ... ... Minot
Woodhull, R. B. ... Minot
Sheyenne Valley
Merrett, J. P., Pres. Valley City
Meredith, C. J., Sec. Valley City
Almklov, L. Cooperstown
Christianson, G. Valley City
Cook, P. T. Valley City
Gilsdorf, W. H. Valley City
Macdonald, A. C. Valley City
Macdonald, A. W. (Hon.)
Valley City
Meredith, C. J. .... __ Valley City
Merrett, J. P. Valley City
Van Houten, J ... Valley City
Westley, K. F. Cooperstown
Wicks, F. L. — Valley City
Sixth
Buckingham, T. W., Pres. Bismarck
Peters, C. H., Sec Bismarck
Arneson, C. A. Bismarck
Bahamonde, J. M. Elgin
Sixth — (Continued)
Baumgartner, C. J. Bismarck
Benson, O. T N. Hollywood, Calif.
Berg, FI. M. ... Bismarck
Bertheau, H. J. Linton
Bixby, Harriet Bismarck
Blumenthal, Philip Mandan
Bodenstab, W. H. (Hon.) Bismarck
Boerth, E. H. Bismarck
Breslin, R. H. ... Mandan
Brink, N. O. Bismarck
Buckingham, T. W Bismarck
Cartwright, John Bismarck
Cochran, R. B. Bismarck
Constans, G. M. Bismarck
Craychee, W. A. .... .. Mandan
Dahlen, G. A. . Bismarck
DeMouIly, O. M. Flasher
Diven, W. L. . .. Bismarck
Driver, Donn R. Fargo
Enders, W. R. ... Hazen
Fredricks, L. H. Bismarck
Freise, P. W. . _ Bismarck
Gaebe, O. C. New Salem
Griebenow, F. F. .... Bismarck
Grorud, A. C. Bismarck
Heinzeroth, George Turtle Lake
Henderson, R. W. . Bismarck
Hetzler, A. E . Mandan
Hill, F. J. Minneapolis, Minn.
Icenogle, G. D. Bismarck
Jacobson, M. S. . Elgin
LaRose, V. J. (Rtd.) .. . ... Bismarck
Larson, L. W. Bismarck
Lipp, G. R. Bismarck
Monteith, George .... Hazelton
Nuessle, R. F. Bismarck
Orr, A. C. Bismarck
Owens, P. L. Bismarck
Perrin, E. D. Bismarck
Peters, C. I 1 Bismarck
Pierce, W. B. Bismarck
Quain, E. P. (Hon.) Eugene, Ore.
Quain, F. D. (Hon.) Bismarck
Radi, R. B. Bismarck
Ramstad, N. O. (Rtd.) Bismarck
Roan, M. W. (Rtd.) Bismarck
Rosenberger, H. P. Bismarck
Salomone, E. Elgin
Saxvik, R. O. Bismarck
Schoregge, C. W. Bismarck
Schoregge, R. D. Bismarck
Smith, C. C. Mandan
Spielman, George Mandan
Thompson. Arnold ... Bismarck
Vinje, E. G. Hazen
Vinje, Ralph Beulah
Vonnegut, F. F. Linton
Waldschmidt, R. H. Bismarck
Weyrens, P. J. Hebron
Wheeler, H. A. Mandan
Southern
Wolfe, F. E., Pres. Oakes
Meunier, I 1 J . Sec. Oakes
Fergusson, F. W. Kulm
Fergusson, V. D. Edgeley
Lynde, Roy . Ellendale
Maloney, B. W. LaMoure
Meunier, H. J. Oakes
Van Houten, R. W. Oakes
Wolfe, F. E. Oakes
Southwestern
Gumper, A. J., Pres. Dickinson
Reichert, H. L., Sec. Dickinson
Bowen, J. W. Dickinson
Bush, C. A. Beach
Drury, Omer H. Beach
Dukart, C. R. Dickinson
Dukart, Ralph Dickinson
Gilsdorf, A. R. Dickinson
Goulding, R. L. Bowman
Guloien, H. E. Dickinson
Dach, J. L Hettinger
Smith, Oscar M Killdeer
Gumper, A. J. .... Dickinson
Hill, S. W. __ Regent
Maercklein, O. C. (Rtd.) Mott
Olesky, E. .. Mott
Reichert, D. J. Dickinson
Reichert, H. L. Dickinson
Rodgers, R. W. ... Dickinson
Schumacher, N. W. (Rtd.) Hettinger
Spanjers, A. J. Dickinson
Spear, A. E. . ... Dickinson
Vogl, Charles Miles City, Mont.
Larsen, H. C. Dickinson
Schumacher, Wm. A. Hettinger
Stutsman
Elsworth, J. N., Pres. Jamestown
Nierling, R. D., Sec. ... Jamestown
Arzt, P. G. Jamestown
Carpenter, G. S. Jamestown
Culbert, M. H. (Rtd.) Medina
Cuthbert, W. H. Jamestown
Elsworth, J. N. Jamestown
Fisher, A. M. Jamestown
Gerrish, W. A. (Hon.) .. .. Jamestown
Holt, G. H. Jamestown
lansonius, J. W. ..... . Jamestown
Larson, E. J. Jamestown
Lucy, R. E. ... ...Jamestown
McFadden, R. L. ..... Jamestown
Martin, C. S. Kensal
Miles, James V. Jamestown
Nierling, R. D. .. Jamestown
Pederson, T. D. Jamestown
Sorkness, Joseph Jamestown
Wood, W. W. Jamestown
Woodward, F. O. .... Jamestown
Woodward, R. S. ... Jamestown
Traill-Steele
LaFleur, H. A., Pres Mayville
Vinje, Syver, Sec ... Hillsboro
Cable, T. M. Hillsboro
Cleary, H. G. Northwood
Dekker, O. D. Finley
Kjelland, A. A. . Hatton
Knutson, O. A. Buxton
LaFleur, H. A. .. Mayville
Little, R. C. ... Mayville
Savre, M. T. Northwood
Vinje, Syver . Hillsboro
Tri-County
Voglewede, W. C., Pres. Carrington
Boyum, Lowell E. Harvey
Boyum, P. A ... Harvey
Gilliland, R. F. . . Carrington
Owens, C. G. New Rockford
Schwinghamer, E. J New Rockford
Voglewede, Wm. C Carrington
330
The Journal-Lancet
Roster, North Dakota State Medical Association-1949
Alger, L. J. ...
Grand Forks
Almklov, L. „
Cooperstown
Dailey, W. C.
Grand Forks
Hammargren, A. F, .
Harvey
Arneson, C. A. . .
Bismarck
Hanna, j. F.
. Fargo
Arzt, P. G. _.
Jamestown
Ay ash, J. J,
Minot
Larimore
Bacheller, S. C.
Enderhn
Haugrud, E. M.
Fargo
Bahamonde, J. M.
Bailin'. W. F.
Elgin
Haunz, E. A.
Grand Forks
Fargo
Hawn, H. W.
Fargo
Baird, J. A.
Bakke, H.
Heinzeroth, G. E.
Turtle Lake
Ball, W. J.
... Minot
Henderson, R. W. ....
Bismarck
Bateman, C. V. __
Wahpeton
Dillard, J. R '
Hetzler, A. E.
Mandan
Baumgartner, C. ....
Bismarck
Diven, W. L.
Bismarck
Hill, F. J. Mi
inneapolis, Minn.
Beck, C. A. .
Hill, S. W. ...
Regent
Beithon, E. |
Wahpeton
Holt. G H
Jamestown
Beltz. M. E. ..
... Wahoeton
Drury, O H
Horsman. A. T. (Hon.) Dunseith
Benson, O. T .... N. Hollywood, Calif.
Duane, T. D
Minot
Hunter, C. M.
Fargo
Benson, 1 (,)
Grand Forks
Dukart, C R
Dickinson
Hunter, G. W.
Fargo
Benwell, H. D
Grand Forks
Dukart, Ralph
Dickinson
Huntley, H. B.
Kindred
Berg, H. M.
Hurly, W. C.
Minot
Bertheau, H. J.
Bethea, R. O., Jr.
Bixby, Harriet
Dach J L
Icenogle, G D.
. Bismarck
Ingalls, C L. ...
Minot
Bismarck
Elsworth, J. N.
Jamestown
Ivers, G. U
Fargo
Blatherwick, Robert
Parshall
Engesather, J. A. D.
Brocket
Jacobson, M. S.
Elgin
Blatherwick, W. E.
Sanish
Jansonius, J. W.
Jamestown
Blumenthal, Philip
. - .... Mandan
Enders, W. R.
- Hazen
Jensen, A. F.
Grand Forks
Bodenstab, W. H.
(Hon.) ..Bismarck
Fawcett, D. W.
Devils Lake
Johann, O. P.
Grafton
Boerth, E. H
Bismarck
Fawcett, J. C. ...
Devils Lake
Johnson, A. K.
Williston
Bond, J. H.
Johnson, C. G.
Rugby
Borland, V. G.
Fargo
Fergusson, F. W
Kulm
Johnson, H. P.
Minot
Bowen, J. W. (Rtd.
) Dickinson
Fergusson, V. D.
... Edgeley
Johnson, J. A.
Bottineau
Boyum, L. E.
Harvey
Field, A. B. (Hon.) . .
Forest River
Johnson, O. W.
Rugby
Boyum, P. A.
Harvey
Fischer, V. J.
.... Minot
Johnson, P. O. C.
Watford City
Breslich, P. J.
Minot
Fisher, A. M.
Jamestown
Joistad, A. H.
. Fargo
Breslin, R. H.
Fielde J H
Jones, E. A. ....
. Liverpool, Eng.
Brink, N. O .
Bismarck
Flaten, A. N
.... Edinburgh
Keller, E. T.
Rugby
Brown, Bernice E.
(Rtd.)
Grand Forks
Flath, M. G.
Fortin, H. J.
... Stanley
Fargo
Kermott, L. Henry
Kermott, Louis H. ...
Minot
Minot
Brown, G. F.
Grand Forks
Fortney, A. C.
Fargo
Kernwein, G. A.
Minot
Buckingham, T. W
Bismarck
Foster, G. C.
Fargo
Kjelland, A. A
Hatton
Burrows, F. N. (H
on.) Bathgate
Fox, W. R.
Rugby
Klein, A. L.
Fargo
Burt. A. C.
Knudson, k U.
Glenburn
Burton, P. H
Knutson, O. A
Buxton
Bush, C. A.
Korwin, J, J.
Williston
Parris, R. W.
Minot
Fritzell, K. E,
Grand Forks
Kositsky, A.
...... Chicago, 111.
Cable, T. M. .
Hillsboro
Gaebe, O. C.
New Salem
LaFleur, H. A.
Mayville
Cameron, A. L.
Campbell, R. D. (F
Minot
Gammell, R. T.
Kenmare
Lamont, J. G.
Grafton
don.) Grand Forks
Garrison, M W.
Minot
Lampert, M. T. . ...
... M inot
Carlson, R. J
Carpenter, G. S.
~ Watford City
Ge.b, M. J.
Fargo
Lancaster, W. E. G.
Fargo
Jamestown
Gerber, L. S.
.. Lakota
Landry, L. H.
Walhalla
Cartwright, John
— ... Bismarck
Gerrish. W. A. (Hon.)
. . lamestown
LaRose, V. J. (Rtd.)
Bismarck
Caveny, K. P.
— . Portland, Ore.
Gilliland, R F.
Carrington
Larson, E. J.
Jamestown
Christianson, G
Valley City
Gilsdorf, A. R
Dickinson
Larson, G. A.
Fargo
Clark, I. D.. Jr.
— Casselton
Gilsdorf , W H
.... Valley City
Larson, L. W.
Bismarck
Cleary, H. G.
Northwood
Glaspel, C. J.
Grafton
Leigh, R. E.
Grand Forks
Cochran, R. B.
Bismarck
Goehl, R O.
Grand Forks
LeMar, John ... ...
Fargo
Combs, A. B. __
Minot
Goodman, Robert
Powers Lake
Lewis, A. K.
Fargo
Conroy, M. P
Minot
Goulding, R L.
Bowman
Lewis, T. H.
Fargo
Constans, G. M
Bismarck
Graham, C. M.
Grand Forks
Liebeler, W. A.
Grand Forks
Cook. P T.
Lipp, G R
Bismarck
Corbus, B. C.
Fargo
Greene, E. E
Westhope
Little, R C.
Mayville
Countryman, G L
Grafton
Griebenow, F. F.
Bismarck
Livingston, IN. B., Jr.
Mohall
Countryman, J. E.
(Hon.)
Arch Cape, Ore.
Grinnell, E. L.
Gronvold, F O
Grand Forks
Fargo
Lohrbauer, L. 1 .
Lommen, C. E.
Grand Forks
Fordville
Craise, O S.
Long, W. H.
Fargo
Craven, | D
Williston
Guloien, H. E.
Dickinson
Lucy, R. E.
Jamestown
Craven, J. P.
Williston
Gumper, A J.
Dickinson
Lund, C. M.
Williston
Craychee, W. A.
Mandan
Haas, W. R.
Minot
Lynde, Roy
Ellendale
Culbert, M. H.
Medina
Hagan, E J
Williston
Larsen, H. C.
Dickinson
Culmer, A. E., Jr.
Grand Forks
Halliday, D J.
Kenmare
McCannel, A. D.
Minot
Cuthbert, W. H.
Jamestown
Halverson, C. H.
Minot
McCannel, M. A. M
inneapolis, Minn.
September, 1949
331
McFadden, R. L.
McGauvran, T. E.
McPhail, C. O.
Macdonald, A. C.
Macdonald, A. W.
... Jamestown
Minot
Crosby
Valley City
(Hon.)
Valley City
Maercklein, O. C.
(Rtd.) Mott
Mahoney, J. H.
Devils Lake
Mahowald, R. E. ..
Grand Forks
Maloney, B. W. ....
LaMoure
Malvey, Kenneth ..
Bottineau
Martin, C. S.
Kensal
Mazur, B. A.
Fargo
Meredith, C. J. ....
Valley City
Merrett, J. P.
Valley City
Meunier, H. J.
Oakes
Miles, A. M.
Rolla
Miles, J. V. ...
Jamestown
Miller, H. W. ...
Casselton
Moe, A. E.
Fargo
Monteith, George
Hazelton
Moore, J. H.
Grand Forks
Morris, A. C.
... Fargo
Mulligan, V. A. ...
Langdon
Muus, J. M.
.. .. McVille
Muus, O. 1 1
Grand Forks
Miller, H. H.
Wahpeton
Naegeli, F. D.
.. Minot
Nelson, L. F.
Robbinsdale, Minn.
Neve, H. E.
Rolette
Nichols, A. A.
Fargo
Nichols, W. C.
Fargo
Nierlmg, R. D. ....
Jamestown
Nuessle, R. F.
Bismarck
Oftedal, Trygve ....
Fargo
Olesky, E.
Mott
Olson, P. A.
Grand Forks
Orr, A. C.
Bismarck
Owens, C. G.
New Rockford
Owens, P. L
Bismarck
Palmer, D. W.
Cando
Panek, A. F.
Milton
Peabody, C. S.
Minot
Peake, F. Margaret
Grand Forks
Pederson, T. D.
Jamestown
Perrin, E. D. ......
Bismarck
Peters, Clifford
Bismarck
Pierce, W. B.
Bismarck
Piltingsrud, H. R.
Park River
Poindexter, M. H.
Fargo
Pray, L. G. Fargo
Quain, E. D. (Hon.) Salem, Ore.
Quain, F. D. (Hon.) Bismarck
Quale, V. S. Grand Forks
Radi, R. B. Bismarck
Ralston, L. S. Larimore
Ramstad, N. O. (Rtd.)—- Bismarck
Rand, C. C. Grafton
Ransom, E. M. _ Minot
Reichert, D. J. Dickinson
Reichert, H. L. Dickinson
Richter, E. H. Hunter
Roan, M. W. (Rtd.) .... Bismarck
Rodgers, R. W Dickinson
Rogers, R. G ... ... Fargo
Rosenberger, H. P Bismarck
Rowe, P. H. ... Minot
Ruud, H. O. ... ... Grand Forks
Ruud, M. B. ... Grand Forks
Saiki, A. K. Grand Forks
Salomone, E. J. Elgin
Sand, Olaf (Rtd.) .. Fargo
Sandmeyer, J. A. Grand Forks
Savre, M. T. Northwood
Saxvik, R. O Bismarck
Schlemitz, F. B. Hankinson
Schneider, J. F. Fargo
Schoregge, C. W. Bismarck
Schoregge, R. D. .... Bismarck
Schumacher, Wm. A. Hetinger
Schumacher, N. W. (Rtd.). Hettinger
Schwinghamer, E. J New Rockford
Sedlak, O. A. Fargo
Seiffert, G. C. Minot
Sihler, W. F. (Hon.) Devils Lake
Silverman, Louis .. Grand Forks
Smith, C. C. Mandan
Smith, Clinton Devils Lake
Sorenson, A. R. ... ... Minot
Sorenson, Rodger Minot
Sorkness, Joseph . Jamestown
Spanjers, A. J. ... Dickinson
Spear, A. E. .... Dickinson
Spielman, G. H. Mandan
Spomer, J. P. Minot
St. Clair, R. T. ... ... Northwood
Stafne, W. A. Fargo
Sterns, Donald . .... Grand Forks
Stickelberger, J. S. (Rtd.) Oberon
Stratte, J. J. Grand Forks
Strom, A. D. Langdon
Swanson, J. C. Fargo
Smith, Oscar M. Killdeer
Tainter, Rolfe Fargo
Thompson, Andrew M. Wahpeton
Thompson, Arnold Bismarck
Thorgrimson, G. G. Grand Forks
Timm, J. F. (Hon.) „ Portland, Ore.
Tompkins, C. R. ... . . Grafton
Toomey, G. W. . ... Devils Lake
Tronnes, Nels (Rtd.) Fargo
Turner, R. C. _ . Grand Forks
Urenn, B. M. ... ... Fargo
Uthus, O. S. . ... Minot
Vance, R. W. ... ... Grand Forks
Van Houten, J. Valley City
Van Houten, R. W. Oakes
Van Lier, Peter C. Rugby
Veitch, Abner ... ... Lisbon
Vigeland, G. N. . Maddock
Vinje, E. G. Hazen
Vinje, Ralph Beulah
Vinje, Syver Hillsboro
Vogl, Charles ... Miles City, Mont.
Voglewede, W. C. Carrington
Vonnegut, F. F. ... Linton
Waldren, G. R. Cavalier
Waldren, H. M., Jr. ... Drayton
Waldschmidt, R. H. ..... Bismarck
Wall, W. W. ... ... Minot
Wallbank, W. L. .. San Haven
Watson, E. M. (Rtd.) Fargo
Weed, F. E. . Park River
Weible, R. D. .... Fargo
Westley, K. F. Cooperstown
Weyrens, P. J. ..... Hebron
Wheeler, H. A. Mandan
Wheelon, F. E. _. .... Minot
Wicks, F. L. Valley City
Williamson, G. M. (Hon,)....
Grand Forks
Witherstine, W. H Grand Forks
Wolfe, F. E. _ Oakes
Wood, W. W. . ... Jamestown
Woodhull, R. B. Minot
Woodward, F. O. Jamestown
Woodward, R. S. Jamestown
Woutat, P. H. ... Grand Forks
Wright, W. A. .. .. Williston
Wasemiller, E. R. Wahpeton
Youngs, N. A. Grand Forks
332
The Journal-Lancet
THIRD ANNUAL MEETING
WOMAN’S AUXILIARY TO THE NORTH DAKOTA STATE MEDICAL ASSOCIATION
Minot, North Dakota, May 15, 16, 17, 1949
The Third Annual meeting of the Woman’s Auxiliary to the
North Dakota State Medical Association, held in Minot, North
Dakota, was formally opened by Mrs. W. F. Baillie, State
President, at 10:00 A.M., May 16, 1949. The place of meeting
was the Sky Room of the Clarence Parker Hotel in Minot.
Mrs. Baillie presented her Parliamentarian, Mrs. F. L. Wicks
of Valley City.
The "pledge” was given by Mrs. R. W. Rodgers of Dickin-
son and repeated in unison by the members present.
Dr. W. A. Liebeler of Grand Forks, President of the North
Dakota State Medical Association, was then presented by Mrs.
Baillie. Dr. Liebeler gave a short talk, stating that the State
Association was fortunate in having an Auxiliary to aid them
in the important work they are trying to do. He urged mem-
bers of the Auxiliary to fight for the "American Way,” as
opposed to socialization and conveyed the best wishes of the
State Medical Association for a successful convention for the
Auxiliary.
The Address of Welcome was given by Mrs. M. T. Lampert
of Minot on behalf of the Woman’s Auxiliary of the Northwest
District.
The Response was given by Mrs. G. G. Thorgrimson of
Grand Forks, who thanked Minot for being host at the conven-
tion and also the ladies of the Auxiliary for attending.
Mrs. Baillie then presented the President-elect, Mrs. H. M.
Berg of Bismarck. Mrs. Berg stated that she hoped all mem-
bers would work hard for the good of the Auxiliary and that
our organization would continue to grow.
Mrs. John Devine, Jr., Chairman of the Convention Com-
mittee, then was introduced. She in turn presented the mem-
bers of her committees.
Mrs. Baillie then introduced the guest of the convention,
Mrs. Harold F. Wahlquist, President, Woman’s Auxiliary,
Minnesota State Medical Association.
A Memorial for Mrs. G. M. Williamson of Grand Forks,
who died during the past year, was read by Mrs. Thorgrimson
of Grand Forks.
The Roll was then called and the following were present:
Officers: Mrs. W. F. Baillie, President; Mrs. H. M. Berg,
President-elect; Mrs. E. T. Keller, 1st Vice-President; Mrs.
John L. Devine, Jr., 2nd Vice-President; Mrs. V. G. Borland,
Treasurer.
State Chairmen: Mrs. N. O. Ramstad, Historian; Mrs. H.
M. Berg, Organization; Mrs. W. B. Pierce, Legislation; Mrs.
H. Paul Johnson, Program; Mrs. C. R. Dukart, Hygeia; Mrs.
J C. Fawcett, Revisions; Mrs. F. L. Wicks, Parliamentarian;
Mrs. P. G. Arzt, Nominating Committee.
Councillors: Mrs. V. D. Fergusson, Eighth District; Mrs.
R. W. Rodgers, Tenth District; Mrs. W. H. Gilsdorf, Fifth
District.
Presidents: Mrs. G. G. Thorgrimson, Grand Forks; Mrs. A.
K. Johnson, Kotana; Mrs. F. L. Wicks, Sheyenne Valley; Mrs.
O. DeMoully, Sixth District; Mrs. F. W. Fergusson, Southern
District.
Cass County 3 representatives
Devils Lake 4
Grand Forks 4
Kotana 1
Northwest 1 1
Sheyenne Valley 2
Sixth District 4
Southern 2
Southwestern 3
Stutsman 2
Traill-Steele 1
Tri-County 1
Mrs. Baillie, President, then gave her president’s report to
the Convention. She told of the accomplishments of the Auxil-
iary during the past year and stressed the issue of our obliga-
tions to the community as doctors’ wives. A copy of this re-
port will be sent to the component Auxiliaries.
Mrs. Baillie then requested Mrs. H. M. Berg, President-elect,
to tell the Convention a few highlights of her recent trip to
Europe. Mrs. Berg spoke briefly on her observations in con-
nection with socialized medicine in Europe and the type of
medical care these peoples are now receiving.
The following reports were then given by the officers, state
chairmen, councillors and Auxiliary presidents:
Mrs. H. M. Berg, President-elect
Mrs. V. G. Borland, Treasurer
Mrs. N. O. Ramstad, Historian
Mrs. F. O. Woodward, Bulletin
Mrs. W. B. Pierce, Legislative Chairman
Mrs. H. P. Johnson, Program
Mrs. C. R. Dukart, Hygeia
Mrs. V. D. Fergusson, Councillor
Mrs. R. W. Rodgers, Councillor
Mrs. W. H. Gilsdorf, Councillor
Mrs. V. G. Borland, Cass County Auxiliary
Mrs. D. W. Fawcett, Devils Lake
Mrs. G. G. Thorgrimson, Grand Forks
Mrs. A. K. Johnson, Kotana
Mrs. F. L. Wicks, Sheyenne Valley
Mrs. O. DeMoully, Sixth District Auxiliary
Mrs. F. W. Fergusson, Southern District
Mrs. A. J. Gumper, Southwestern District
Mrs. P. G. Arzt, Stutsman District
Mrs. T. M. Cable, Traill-Steele
The complete reports will be combined into a handbook,
which will be sent to the various Auxiliaries.
President’s Report
Two years ago you named me President-elect of the Woman’s
Auxiliary to the North Dakota State Medical Association. This
was an honor I felt very humble in accepting. I am grateful
for your faith in me. I hope I have not failed you. Now,
after serving as your President for the past twelve months,
I am presenting my annual report for your consideration and
approval.
Being such a new Auxiliary we were not able to accomplish
as much as could be desired. Many of our groups were not
ready to carry a very heavy program, as it seemed important
to stress the social side and get acquainted. However, as you
hear their reports you will realize they have all been busy and
have accomplished much more than I ever thought would be
possible. I am very proud of their work. Owing to the severe
winter, it was impossible for many of our district auxiliaries to
meet often.
Our first year was given over almost entirely to organization
and we are very proud to report every medical district with an
auxiliary, all coming in as charter members.
As your president it was my privilege to attend the National
Convention of the Woman’s Auxiliary to the American Med-
ical Association, held in Chicago, June, 1948. I also attended
the Conference of Presidents and Presidents-elect held in Chi-
cago November 4th and 5th. These meetings were a great
inspiration to me and I came away realizing more fully our
responsibility as doctors’ wives to carry far and wide the mes-
sage of good medicine, and with a determination to put forth
every effort toward fulfilling my duties in the office entrusted
to me.
The Fall Board meeting of our State Auxiliary was held in
Fargo, September 30, 1948, with a very good attendance of
officers and state chairmen.
I attended the Red River Valley Health Day held in Crooks-
ton, Minnesota, in October, 1948. This was sponsored by the
Woman’s Auxiliary to the Red River Valley Medical Society.
Perhaps the most rewarding of all your president’s activities
was attending the regular meeting of several of our district
September, 1949
333
auxiliaries. Words cannot express the personal satisfaction it
gave me to see these groups in action and to note the friend-
ship and cooperation which existed among their members. My
one regret is that I could not visit every Auxiliary.
Feeling that it was vital for our membership to be informed
as to the problems facing the medical profession, I mailed out
packets of literature to each Auxiliary. I furnished material for
two club papers and placed material in our Masonic library,
to be used as source material for programs throughout the state.
Our membership has made a slight increase over last year.
Subscriptions to the Bulletin and Hygeia have not increased as
much as we could wish. However, I definitely feel we have
gone forward in enthusiasm and interest.
I am firmly convinced that the work of the Woman’s Auxil-
iary is very important. The role of the doctor’s wife may not
appear to have materially changed but the scope of her activities
and responsibilities has broadened, even as our world has become
smaller. Health has no limits, disease knows no boundaries.
The work of medicine is a world problem. We must create a
feeling of partnership between the medical profession and the
public, with one end in view, the continual improvement of
health and medical care. People recognize that medicine is the
life work of the physician. They must be reassured that the
medical world is interested in the welfare of every man, woman
and child. To bring this assurance, to further health education
is the work of the Auxiliary.
The program of the Auxiliary is definite, concrete and far-
reaching. It is all-inclusive yet it is basically simple, because
it touches at the very foundation of our lives. It is a program
that challenges our best efforts and affords everyone an oppor-
tunity to participate in some measure, no matter how slight may
be the contribution.
While we carry out our program in our community, our
county, state and nation, we cannot but be aware of the world
levels. We here in America have the opportunity to set up a
pattern of health that will carry through the world. We of the
Auxiliary have it in our power to play a leading and decisive
part in the fulfillment of this aim. As a doctor’s wife, each
member of the Auxiliary is a representative of the medical
profession.
Our most important function has been and will be to help
carry out the aims of the American Medical Association which
are to help provide the highest quality of medical and health
care for the people of our nation, but it is equally important
that we do our utmost to help educate the public to the dangers
inherent in the proposals for compulsory health insurance and
its many ramifications. We must do more than "fight fire with
fire.” We must fight false theories with facts. And we must
be alert to recognize false and vicious propaganda when it shows
itself, in order that we may act without delay to refute it.
The first need for the Auxiliary is to be basically informed
on the issues at stake. We should obtain factual material. Only
if we present the factual side of the problem of medical care
to the people can we expect to preserve the principles of volun-
tary medical care. Our national president, Mrs. Kice, has rec-
ommended that every member read and study the impartial
report of the Brookings Institute, "The Issue of Compulsory
Health Insurance.” The findings of this respected and unbiased
organization should be placed before every local group interested
in health, so that the general public may have a better under-
standing of all phases of this problem, and may be warned
against the dangers of government-controlled medical care.
Armed with the facts, Mrs. Doctor can actually be the diplo-
matic expert on Socialized Medicine in her own home. Many
doctors are too busy healing the sick and studying new medical-
scientific trends to study the social and political aspects of their
profession. William Doscher, Assistant Director of Public Rela-
tions Department of the American Medical Association says,
"Intelligent women have a special ability and agility to sense
the subtle attacks on the freedom of the profession made by
power-seeking bureaucrats. Women can arm their own hus-
bands with the facts and encourage him to express himself to
others in his community about this alarming problem. In your
own quiet, influential way you can simply present the facts so
that those that know you will at least not be ignorant of the
dangers inherent in government medicine.”
It is natural for doctors’ wives, who have many interests in
common, to enjoy each other’s company socially. That is fine.
But as public relations ambassadors, our Auxiliaries should not
solely concentrate on social activities. Nothing could create a
poorer impression on state and local newspapers and on the
community. Each time a county publicity chairman writes a
story for the newspapers, she can stress the social service, health
and welfare activities of your meetings, rather than the purely
social ends. Otherwise, the general public begins to think of
doctors’ families as socialites, rather than as thoughtful persons
who have a sincere interest in the general welfare of the public.
Before closing this report, I wish to thank Mr. Engebretson
and the North Dakota State Medical Association for their
splendid cooperation and assistance during the year. Without
their assistance our Auxiliary would have had a much more
difficult time in getting started. Mr. Engebretson was always
very gracious when we called upon him for help and you may
be assured it was necessary to call upon him many times during
the year.
I wish to express my appreciation to the women of Minot
for their wonderful response in planning for this convention.
To each one individually I say thank you.
To the officers, state chairmen, Councillors, district Auxiliary
presidents and to the members of the Auxiliary individually
goes my deepest appreciation. Because of you my life has been
made richer, fuller and vastly rounder. I shall forever cherish
the friendships formed this year.
Mrs. W F. Baillie, President
Historian’s Report
Although our history at this time is necessarily very brief,
it is packed with action.
May 26, 1947, is an important date in our annals. On that
day, after a delightful luncheon at El Zagal Clubhouse in
Fargo, with the help of Mrs. Leo J. Schaefer of Salina, Kansas,
who was at that time second Vice President of the National
Woman’s Auxiliary to the American Medical Association, our
Woman’s Auxiliary to the North Dakota State Medical Asso-
ciation was organized. During that momentous Monday and
the following busy Tuesday, officers and councillors were ap-
pointed and elected, so that from then on, we were ready to
assist our husbands and our state in a more efficient manner.
Between the time of that May meeting in Fargo and our sec-
ond annual meeting in Jamestown on May 22, 1948, all ten
major districts in our state were organized.
On October 29, 1947, in Jamestown, there was held a very
important Executive Board meeting, which speeded up the work
by completing plans for the state-wide organization. The effi-
ciency and rapidity with which these plans were carried out
show how well chosen were our first officers and councillors.
At the 1948 Convention in Jamestown it was decided to in-
clude as charter members, all groups who had paid their dues
by June 30, 1948.
According to our handbook our history should include lists
of names and achievements of all officers, committee chairmen,
and councillors. Such a list is appended and included in the
Historian’s file.
As all of you have read copies of the reports of our two
conventions, I shall not even recapitulate here, except to say
that in both Fargo and Jamestown the business of the orgniza-
tion was so efficiently conducted that we scarcely realized we
were working, and the doctor’s wives of both cities instilled such
a cordial hospitality into all activities that we felt as though we
had been attending great social occasions. Full reports of these
conventions are in the file. The Board meetings were composed
of small groups, but much work was accomplished in a short
time.
Twenty-seven officers, committee chairmen and councillors
attended a Board meeting in Fargo on September 30, 1948.
Names and special measures recommended at this time are in
this file, but I should like to mention that Mrs. Borland re-
ported that even at that early date we had 204 paid member-
ships and a balance on hand of $127.00.
Our Handbook also directs that this report should include
a list of the objectives of our organization. Thus far, perhaps
the most important of these objections has been "one hundred
per cent registration.”
Next we should consider ourselves a state-wide Public Rela-
tions Committee regarding the following points:
1. The benefit of Voluntary Group Health Insurance.
334
2. The real meaning of compulsory Government Health In-
surance.
3. Let the public know that doctors have a better plan.
4. Make the public realize that our husbands are greatly over-
worked.
5. Assist with public health work in all possible ways.
6. Because uninformed prejudice does no good, we should
keep ourselves informed, so that we may speak intelligently
and coherently on matters pertaining to public health.
7. Refrain from mumbling disapproval.
8. Undertake no project without the approval of our ad-
visors.
Although the names of all officers, councillors, committee
chairmen and guest speakers are mentioned in the Historian’s
file, I cannot close this report without remarking on our great
good fortune at the very beginning of our history in having
such excellent officers. Mrs. Hanna, Mrs. Weible, Mrs. Arzt,
Mrs. Baillie and Mrs. Berg — all had a gift for organizing, but
Mrs. Arzt, Mrs. Baillie and Mrs. Berg put in much hard work
traveling when it was next to impossible and spending long
hours in correspondence. Mrs. O. M. Smith of Killdeer and
Mrs. R. G. Rodgers of Fargo have also spent many hours at
Auxiliary correspondence and their excellence as secretaries did
much to accelerate our progress. Mrs. V. G. Borland of Fargo
contributed greatly to our organization by her clear thinking
and comprehension of 'financial matters. As we shall hear re-
ports of the work of all of our officers, chairmen and council-
lors and as they are all contained in our files, I will desist
from further repetition.
In one of his advisory talks to us, Dr. Arzt said "So many
people are talking of so many things and so many know so
little. Hence, I shall soon pursue only silence.”
If this file may serve as a beginning for our next Historian,
I shall be very glad to give it to her and only hope its contents
may prove to be of value in the progress of our Woman’s Aux-
iliary to the North Dakota State Medical Association.
Edna Winchester Ramstad, Historian
Program Chairman’s Report
My report to Mrs. Pohlmann, National Program Chairman,
dealt not so much on the individual Auxiliary programs but
on the achievements made in organization in North Dakota.
With two years of good organization efforts past, the next
year should take advantage of the wealth of material for pro-
grams offered by the National Auxiliary.
I should like to suggest that as soon as the program chair-
men for the individual groups are appointed that they send
their names to the State Chairman.
The National Auxiliary send splendid material to the state
and if we are to work as a unit in the state organization, we
should follow definite plans as given to the state by the
National.
Since many objectives and plans are suggested, certainly one
can be found suitable to the wishes of the individual groups.
And there is much satisfaction at the end of the year in the
reports to find that all of the efforts placed together show how
much can be accomplished by the State Auxiliary.
One more suggestion — read the Bulletin of the Woman’s
Auxiliary to the American Medical Association. You will un-
derstand its objectives and realize how much of a part your
group can take in this large undertaking.
Mrs. H. P. Johnson, Program Committee
Auxiliary President’s Report — Devils Lake District
There were three meetings of the Auxiliary during the past
year, one in November, 1948, one in April, 1949, and one in
May, 1949.
There are thirteen members in the Auxiliary, all active and
interested in the work.
The Auxiliary during the past year worked on two projects
to benefit the District Medical Society. The first was to get
non-auxiliary friends to write to the state legislators and express
their opposition to H.B. 122 regarding licensing displaced doc-
tors in the state. The second project involved obtaining mov-
ing pictures designed to stir up interest in nursing and taking
these movies with nurses from the local hospitals to explain the
advantages of a nursing career, to the high school assemblies
throughout the district for showing. The pictures were shown
The Journal-Lancet
a total of eleven times. Considerable and gratifying interest was
shown by the high school students after each of these showings.
There are still several doctors’ wives in the district who do
not belong to the Auxiliary. We are hoping these too will be
active members by next year.
Mrs. D. W. Fawcett, President
Auxiliary President’s Report — Grand Forks District
On May 6, 1948, the ladies of the Grand Forks District met
and organized, with 22 members for the year. The present
membership is 32 out of an eligible number of 60. One mem-
ber died in 1949.
I attended the Executive Board meeting in Fargo, September
3, 1948. In October I met with the officers of our district
board and committee members to outline plans for the coming
year. It was decided to hold dinner meetings the same evening
as the doctors held their meetings. A short business meeting
followed the dinner, after which we had a music program or
played bridge at the home of one of the members. We held
four meetings with an average attendance of twenty members.
A constitution and by-laws were drawn up and adopted by the
group.
At our April meeting we elected the officers for the coming
year and they will be installed in May.
Mrs. G. G Thorgrimson. President
Auxiliary President’s Report — Kotana District
The Auxiliary to the Kotana District Medical Society has
seven members this year, one less than last year, since Mrs.
Skjelset has moved away. The annual meeting was held Feb-
ruary 9, 1949, with a luncheon down town. All the members
were present.
Mrs. Willard Wright reported that she had given a talk at
the P.E.O. meeting on Bill 122. Mrs. Alan Johnson reported
that she had arranged that Attorney Everett Palmer write a
letter to our state representative on the same bill, stating the
views of this Auxiliary.
All members paid the arrears dues of $2.00 and the dues for
the coming year.
Election of officers was held.
Mrs. A. K. Johnson, President
Auxiliary President’s Report
Sheyenne Valley District
The Sheyenne Valley Medical Auxiliary has ten paid mem-
berships, as against eleven of a year ago. This one ex-member
is an out-of-town eligible and we have been unable to ascertain
why she has not joined but believe it to be her absence from
the state and also her inability last year to attend meetings on
account of bad roads. Therefore we think our ten of eleven
eligtbles to be very creditable. We also think our average attend-
ance of eight is pretty good.
We were late getting started this year but with the April
meeting, we will have had four very good ones.
The President is very gatified with the manner in which the
members have participated in discussions and bringing their own
material, other than that which was sent by the state president,
Mrs. Baillie, and which was passed out to be read and reported
on by the various members.
The highlight of our year was when our state president, Mrs.
Baillie, was invited to visit us and on her acceptance we prompt-
ly planned a dinner, which was held at the home of Mrs. C. J.
Meredith. Following the dinner, helpful suggestions by Mrs.
Baillie and questions by members made this a memorable occa-
sion. We all felt a little social life can be quite a stimulus-
to members and can be mixed with the serious side of meetings.
Mrs. Paul Cook has conducted a survey of all doctors’ and
dentists' offices and the libraries in town, to find out just how
widely Hygeia is being used. If we find where it could be use-
ful we may place it there. Also, if our finances permit, we hope
to purchase copies of the Brookings Institute Report and place
one in our State Teachers College library and one in our public
library.
We have delayed doing anything about the National Bul-
letin, as we were resting on the assurance that "something dif-
ferent” was to take its place in the National field.
We have amended our local constitution in two places: one,
to make it flexible enough to take care of national and state
dues; the other, to have new officers elected before instead of
after the state meeting.
September, 1949
335
At the last meeting on April 20th our program chairman,
Mrs. Christianson, hopes to have the public school nurse talk
to us and thereby deviate from our discussions which this year
have been mostly concerned with the trend toward compulsory
health insurance.
A number of our members helped to contact legislators and
thereby lent our bit toward killing the bill in committee on
displaced doctors.
Mrs. F. L. Wicks, President
Auxiliary President’s Report — Sixth District
There are fifty-two doctors’ wives in the county who are
eligible for membership in our Auxiliary. At the beginning
of our first year we had twenty-six members but during the
year one member died and one moved out of the district. At
present we have thirty-two paid-up memberships, a gain of
eight over last year.
Auxiliary meetings are held four times a year with an average
attendance of twenty. At our first meeting held in October,
State Health Officer spoke on Mental Hygiene. At our second
meeting held in December we had an outside speaker, who gave
an interesting talk on Crippled Children, showing movies cov-
ering methods of treatment, recreation and education. Both
were interesting and educational. Due to impassable roads the
February meeting was cancelled.
I believe all members were interested and cooperated in every
way possible to help defeat House Bill 122.
Dinner meetings held at the same time as the Medical Society
of the Sixth District have been our only social activity and
have helped the members to become better acquainted. Notices
of meetings are reported to the local press.
Due to members receiving postcard notices for renewal of the
National Bulletin, I was unable to determine the exact number
of subscriptions for this year. We had 19 subscriptions last year
The general attitude of our Medical Society has been co-
operation.
Our third dinner meeting was held April 26, 1949. Mrs
Baillie, our State President, was our guest speaker and spoke
to us on Compulsory Health Insurance. Mrs. W. B. Pierce of
Bismarck gave a reading by Dr. Elmer L. Henderson, Chairman
of the Board of Trustees, American Medical Association. The
subject was "A Doctor’s Diagnosis of President Truman’s Com-
pulsory Health Insurance Program.” We also had the election
of officers.
Mrs. Oliver M. DeMoully, President
Auxiliary President’s Report — Southwestern District
1. We have sixteen doctors’ wives that are eligible for mem-
bership.
2. One year ago we had ten active members. At present we
have eleven active members.
3. Our meetings are held four times a year, with an average
attendance of ten members.
Program: Our meetings consist of work regarding the place-
ment of Hygeia in schools and offices, discussions on socialized
medicine and current topics regarding the National Medical
situation. We have had one outside speaker discussing the
legislation on the medical bills. Also a discussion on the Blue
Shield plan, which our Southwestern Medical Society sanctioned
Hvgeia: We have credit for ten subscriptions to Hygeia.
All members are interested in receiving the state news letters.
We have ten Bulletin subscribers.
Our social activities have consisted of dinner and our meet-
ings.
Mrs. C. R. Dukart and Mrs. R. VC Rodgers attended the
State Convention and the State Auxiliary meeting held in
Fargo.
Our delegates to the State Convention will be Mrs. C. R
Dukart and Mrs. R. W. Rodgers of Dickinson.
Mrs. A. J. Gumper, President
Auxiliary President’s Report — Stutsman County
The Auxiliary to the Stutsman County Medical Society has
had 16 members for the past year. A year ago we also had
16 members. During that time we have gained 2 members and
lost 2 members. The average attendance at our meetings has
been 12 members.
Our first meeting was a business meeting. Dues were dis-
cussed, committee chairmen were named, and Bulletin and Hy-
geia subscriptions were taken. It was voted that we give one
Hygeia subscription to a rural school and to supply the local
President and Secretary-Treasurer with the year’s subscription
to the Bulletin.
At Christmas time we prepared and delivered two large boxes
of food, clothing and miscellaneous gifts to needy families. One
was to a local Jamestown family and one to a rural family.
At our next meeting we had a dinner and had Dr. Richard
Nierling as our guest speaker. Dr. Nierling gave us a very
interesting and educational talk on what progress had been made
toward a prepaid medical plan for the state of North Dakota.
Our last meeting was for election of officers for the coming
year and electing delegates for the State Convention.
We have a possibility of three new members for the coming
year.
We feel that the past year has been a successful one and have
hopes for improvement in the future.
Mrs. J. N. Elsworth, President
Auxiliary President’s Report — Traill-Steele District
Our membership remained the same but we will be losing one
member soon because they are moving to another location. We
have eight paid-up members, which is 100 per cent. Of our
members there usually are about five at a meeting.
We have had only two meetings so far this year and they
were spent having dinner together and then a social hour at one
of the homes. We have not had any planned program since the
group decided they wanted to be purely social and informal.
We all subscribed to the Bulletin last year and I believe most
of the members renewed their subscriptions.
Our one project this year was to give three gift subscrip-
tions to Hygeia to our local hospitals.
Mrs. T. M. Cable, President
A motion was made by Mrs. Borland, seconded by Mrs. Ram-
stad that all reports be accepted as read and that the said re-
ports be placed on file.
Mrs. Pierce then suggested that each Auxiliary make a de-
termined effort to have various groups and clubs in their com-
munities go on record as being opposed to socialized medicine.
This should be done in the form of a resolution adopted by
the organization as a whole, copies of which should be sent to
the President of the United States, congressmen and state
legislators.
Mrs. Borland presented the following budget for the Auxil-
iary for the fiscal year 1949-1950 and moved that the Conven-
tion adopt the budget:
INCOME
Dues from 220 members $440.00
From State Medical Association 200.00
Total Income $640.00
PROPOSED EXPENDITURES
President:
(1) Discretionary fund (visiting districts and
entertaining guests, etc.) $ 50.00
(2) Miscellaneous fund (telegrams, telephone
and stamps) .... 25.00
(3) Toward expenses to Chicago Board Meeting 25.00
(4) Railroad fare plus $50.00 to the National
Convention 75.00
President-elect (1) Chicago Board Meeting 25.00
Treasurer 8.00
Standing Committees (10 to have $5.00 each) 50.00
Convention Fund 200.00
Miscellaneous Fund 82.00
$640.00
After a discussion Mrs. Borland’s motion was seconded by
Mrs. Pierce and upon vote the budget was declared adopted
unanimously.
Mrs. Keller then gave the report of the Auditing Committee,
stating that the Treasurer’s books balanced and were in proper
order, with all entries made. It was moved by Mrs. Berg and
seconded by Mrs. Pierce that the report be accepted and upon
being put to a vote the motion carried.
Mrs. Keller then made a motion that the sum of $100.00
be taken from the Treasury of the Women’s Auxiliary to the
State Medical Association and that the sum of $50.00 be given
336
The Journal-Lancet
to Mrs. Arzt, past president of the Auxiliary, and a like sum
of $50.00 be given to Mrs. Baillie, president, to reimburse them
for expenses incurred during their tenures as presidents. The
motion was seconded by Mrs. Devine, Jr., and upon being put
to a vote carried unanimously and the Treasurer was instructed
to make the disbursements as stated in the motion.
Mrs. Keller made a motion that all bills incurred by the
officers and chairmen of the state committees during the fiscal
year and all bills in connection with the state convention be
presented to the Treasurer and upon presentation said bills be
paid out of the funds in the treasury of the Woman’s Auxiliary.
Mrs. Thorgrimson seconded the motion and upon being put to
a vote it carried unanimously.
The meeting was then adjourned to reconvene at 2:00 o’clock
P.M. in the Sky Room of the Clarence Parker Hotel.
The Convention reconvened at 2:00 o’clock P.M., May 16,
1949. The meeting was called to order by Mrs. W. F. Baillie,
presiding officer.
Mrs. Baillie read a telegram from Mrs. Leo J. Schaeffer,
Director of the National Auxiliary, who sent the convention
her best wishes for a successful meeting.
Mrs. Baillie then presented Mr. Engebretson, Executive Sec-
retary of the State Medical Association. Mr. Engebretson spoke
on the importance and necessity of getting literature on social-
ized medicine to the public and also the benefits of "good pub-
lic relations.” He suggested that the Auxiliary have "Health
Program Days” as one of their projects and pointed out the
benefits of having all agencies in a community who are interest-
ed in health matters cooperating to let the public know what
is being done for them in their locale. He also informed the
Convention that the Council had voted the sum of $200.00
yearly for the Auxiliary, to help defray its expenses. Mr. Enge-
bretson also impressed upon the Auxiliary the great effect the
efforts of the Auxiliary have had and urged the members to
make their wishes felt, as they can have a tremendous influence
on public opinion.
Mrs. Arzt made a motion that the reading of the minutes of
the Second Annual Convention held in Jamestown, May 24 and
25, 1948, be suspended. The motion was seconded by Mrs. Berg
and upon being put to a vote carried.
Mrs. Baillie then called for the report of the Registration
Committee, who reported a registration of 52 members.
Mrs. Boyum, Harvey, Councillor for the Ninth District, and
Mrs. McCannel, Councillor for the Fourth District, submitted
their resignations as Councillors. It was moved by Mrs. R. W.
Rodgers and seconded by Mrs. Devine, Jr., that these resigna-
tions be accepted and that the Nominating Committee be in
structed to nominate two other people for the vacancies thus
created. Upon vote the motion carried.
A motion was made by Mrs. Ramstad and seconded by Mrs.
Thorgrimson. that all Auxiliaries be accepted as Charter Mem-
bers of the Woman’s Auxiliary to the State Medical Associa-
tion. Upon being put to a vote, the motion carried.
The "Fiscal Year” of this Association was explained fully
to the ladies of the Auxiliary. The "Fiscal Year” runs from
convention to convention. New officers of component auxiliaries
should be elected at the last meeting preceding the convention
and should take office the following fall, to serve until the next
convention.
Mrs. Baillie explained that the cost of a Handbook would
have been $45.00 and it was decided by the Executive Board
that this was too high a price for the benefits that would occur.
M rs. P. G. Arzt, Chairman of the Nominating Committee,
then submitted the following report:
For President — Mrs. H. M. Berg, Bismarck.
President-elect — Mrs. E. T Keller, Rugby.
1st Vice President — Mrs. V. D. Fergusson, Edgeley.
2nd Vice Pres. — Mrs. G. G. Thorgrimson, Grand Forks.
Secretary — Mrs. J. Jansonius, Jamestown.
Treasurer — Mrs. R. W. Rodgers, Dickinson.
For Councillors —
2nd District — Mrs. G. W. Toomey, Devils Lake.
7th District — Mrs. Cuthbertson, Jamestown.
10th District — Mrs. C. R. Dukart, Dickinson.
9th District — Mrs. R. F. Gilliland, Carrington.
Mrs. Baillie then asked for nominations from the floor for
these officers. As there was none, she then requested a motion
nominating the slate of officers. It was moved, seconded and
carried, that the Secretary be instructed to cast a unanimous
ballot for the entire slate of officers. All voted "Aye”.
The following resolution was then offered by Mrs. Pierce,
who moved its adoption:
Whereas: the United States under its voluntary system of
medical care has made greater progress in the application of
medical and sanitary science than any other country, and,
Whereas: the advances in health in the United States in the
past four decades do not suggest basic difficulties in the Ameri-
can system of medical care, and,
Whereas: more than one out of every three Americans is
now covered by voluntary hospital insurance, and one out of
every four is covered by voluntary surgical or medical and
surgical insurance, and coverage is continuing to rapidly in-
crease, and
Whereas: compulsory health insurance would necessitate a
high degree of governmental regulation and control over per-
sonnel and the agencies engaged in providing medical care, and
Whereas: the enactment of compulsory health insurance
would destroy the personal relationship between the physician
and patient, undermine the quality of medical care and pro-
duce deterioration in the health of the people, and,
Whereas: workers in European countries that have adopted
compulsory health insurance have lost from 50 per cent to 100
per cent more days per year because of illness than American
workers, and,
Whereas: compulsory health insurance would create a tax
burden of unbearable proportions on an already overstrained
economy, and,
Whereas: compulsion is a totalitarian concept and contrary
to American principles,
Now, therefore, be it resolved, by the Woman’s Auxiliary
to the North Dakota State Medical Association in convention
assembled in Minot, North Dakota, May 15, 16, 17, 1949, that
we continue our unalterable opposition to the adoption of any
program of compulsory health insurance or government con-
trolled medicine, for the American people.
The motion was seconded by Mrs. Ramstad and upon being
put to a vote carried unanimously and the above resolution was
declared adopted by this Convention.
A Resolution to Amend Article IV (Membership) Section
2 and 3, of the Constitution of the Woman’s Auxiliary to the
State Medical Association was then presented. After a long
discussion the resolution was referred back to the Resolutions
Committee, which was instructed to turn it over to the state
chairman of the Revisions Committee for further study and
clarification.
The matter of a quarterly "News Letter” was then discussed.
The following motion was made by Mrs. Keller and seconded
by Mrs. Arzt:
"That the Woman’s Auxiliary to the State Medical Associa-
tion sponsor a News Letter’ for a period of one year; that a
State Publicity Chairman be appointed by the State President;
and that the duties of said State Publicity Chairman be to
gather and coordinate news and information sent in by local
Auxiliaries and cooperate with the Executive Secretary of the
State Medical Association in publishing a quarterly 'News
Letter.”
Upon being put to a vote the motion carried.
It was suggested that each Auxiliary President appoint a
publicity chairman, whose duty it will be to see that items for
this bulletin are sent to the State Publicity Chairman. This
material can consist of news about any project undertaken by
the component Auxiliary, personal items or local news which
would be of interest to all members.
The recommendation of the Executive Board that each Aux-
iliary purchase two copies of the Brookings Institute Report and
place them in the public libraries and schools was confirmed by
the Convention.
It was moved by Mrs. R. W. Rodgers and seconded by Mrs.
Keller that the Woman’s Auxiliary to the State Medical Asso-
September, 1949
337
ciation have a "President’s Pin”; that all past presidents be
eligible for this pin; and that a committee be appointed to
decide upon such a pin. Upon being put to a vote, the motion
carried.
The Convention then adjourned, to reconvene Tuesday, May
17, at 11:00 o’clock A M. at the Country Club at Minot.
* * * *
The Woman’s Auxiliary to the State Medical Association
reconvened at 11:00 o’clock A M. at the Country Club at
Minot, on Tuesday, May 17, 1949.
The meeting was called to order by Mrs. Baillie, President.
Mrs. Kernwein made a motion that the Revisions Committee
make a thorough study of the Constitution and By-Laws of
the Auxiliary and present their recommendations for changes
and amendments at the next board meeting to be held in the
fall. The motion was seconded by Mrs. Keller and upon being
put to a vote, carried.
It was moved by Mrs. Keller that when the minutes are com-
pleted that a Reading Committee be appointed by the Presi-
dent, Mrs. Baillie, whose duty it would be to check the minutes
for any omissions, corrections or substitutions and also to write
a summary of these minutes, to be read at the next convention.
The motion was seconded by Mrs. Ramstad and upon vote
carried.
Mrs. Baillie then appointed the following Reading Commit-
tee: Mrs. C. R. Dukart, Dickinson; Mrs. R. W. Rodgers,
Dickinson.
It was moved by Mrs. Rodgers and seconded by Mrs. Mc-
Cannel that a memorial be written for those members of the
Auxiliary who had died during the preceding year and that
said memorial be placed in the Historian’s files. Upon vote the
motion carried.
Mrs. Thorgrimson nominated Mrs. Devine of Minot as dele-
gate to the National Convention, to be held in Atlantic City,
New Jersey, June 6-10, 1949. The motion was seconded by
Mrs. Keller and upon vote, Mrs. Devine was declared elected.
Mrs. Keller then nominated Mrs. G. W. Toomey of Devils
Lake as second delegate to the said convention. The nomina-
tion was seconded by Mrs. McCannel and upon vote Mrs.
Toomey was declared elected.
Mrs. Baillie then called for the report of the Courtesy Com-
mittee and Mrs. C. R. Dukart gave the following report:
"On behalf of the entire Auxiliary to the North Dakota
State Medical Association, may I extend our sincere thanks
and appreciation to the Minot Auxiliary for the courtesies ex-
tended us during the Convention and for our very fine meeting,
so well planned and carried out.
"From former experiences you all realize the plans, prepara-
tions, work and time which is so necessary to make these con-
ventions a success and it is very visible that none of these were
spared by our Minot hosts and hostesses in making our stay so
enjoyable and yet beneficial.
May I mention a few details which I have overheard: very
favorable comments from various members; our welcoming ad-
dress from Dr. Liebeler; and especially the excellent and inspir-
ing talks of Dr. Wright and Ndrs. VC^ahlquist, as well as the
pledge of assistance from Mr. Engebretson, which he has so
willingly given to the Auxiliary.
"The mixer at the Country Club Sunday evening proved
very successful and it gave everyone an opportunity for meeting
and renewing acquaintances.
The food was excellent, particularly our lovely banquet, and
the floral centerpieces and corsages added not only a touch of
beauty but also of thoughtfulness.
"So to Mrs. Devine, Jr., who so ably acted as General Chair-
man, and to each member of her committees — thank you, thank
you very much.’’
It was moved by Mrs. Keller and seconded by Mrs. Fergusson
that the report of the Courtesy Committee be accepted and that
a copy be made and sent to the President of the Northwest
District Auxiliary. Upon vote the motion carried unanimously.
Mrs. Erenfeld, Jr., then made the following motion:
"I move that the State Legislative Chairman, with consulta-
tion of the Advisory Committee, compose a letter to be used
as a sample for County Presidents to distribute to all women’s
groups in her county, asking them to oppose compulsory health
insurance. A statement of facts which may be used in this
resolution should accompany the letter.”
Mrs. Halvorson seconded the motion and upon being put to
a vote the motion carried unanimously.
The following motion was then offered by Mrs. Fergusson:
"I move that each member, as far as possible, contact fifteen
people in their community, asking them to send a personal letter
to the President of the United States and their congressmen
and senators, opposing compulsory health insurance, making this
letter brief and to the point.”
The motion was seconded by Mrs Sorenson and upon being
put to a vote, carried.
The President of the Northwest Auxiliary then asked for
the floor and requested that the members of the Auxiliary give
a rising vote of thanks to Mrs. Baillie for the very successful
job she has done as President of the State Auxiliary.
Mrs. Baillie then requested that a rising vote of thanks be
given Mrs. Wahlquist, President of the Minnesota Auxiliary,
who has given so freely of her time and energies in attending
this Convention.
Mrs. Erenfeld, Sr., then spoke briefly about the work of the
patients at the State Sanitarium at San Haven and suggested
that the Auxiliary members remember that the handiwork of
these patients is for sale.
Mrs. Baillie then turned the meeting over to Mrs. Wahl-
quist, who requested that all the new officers and Mrs. Baillie
stand up. She then congratulated them on their new duties and
formally installed them in their new offices.
Mrs. Baillie then thanked the Auxiliary for their cooperation
during her tenure as President and turned the meeting over to
the new President, Mrs. H. M. Berg, of Bismarck.
Mrs. Berg stated that a regular Post-Convention Board meet-
ing would not be held. She set the third week in September
as the tentative date for the fall Board meeting but stated that
she would advise the members of the Board later.
She then appointed the following State Committee Chairmen:
Historian — Mrs. N. O. Ramstad, Bismarck.
Organization — Mrs. Ted Keller, Rugby.
Bulletin — Mrs. F. O. Woodward, Jamestown
Legislation — Mrs. W. B. Pierce, Bismarck.
Public Relations — Mrs. W. A. Wright, Williston.
Press and Publicity — Mrs. L. J. Alger, Grand Forks.
Program — Mrs. A. P. Nachtwey, Dickinson.
Hygeia — Mrs. C. O. Heilman, Fargo.
Revision — Mrs. V. G. Borland, Fargo.
Parliamentarian — Mrs. J. R. Pence, Minot.
Nominating Committee — Mrs. W. F. Baillie, Fargo.
There being nothing further to come before the meeting, it
was duly moved, seconded and carried that the meeting be
adjourned.
338
The Journal-Lancet
1949 MEMBERSHIP ROSTER
WOMAN’S AUXILIARY TO THE NORTH DAKOTA STATE MEDICAL ASSOCIATION
(Membership by Districts)
First District
President: Mrs. B. C. Corbus,
Secretary: Mrs. R. E. Lewis
Jr Fargo
Fargo
Bacheller, Mrs. S. C.
Enderlin
Baillie, Mrs. W. F. ...
719 Broadway, Fargo
Bateman, Mrs. C. V.
529 Fourth St. N., Wahpeton
Beithon, Mrs. E. J.
429 Fifth St. N., Wahpeton
Beltz, Mrs. M. E.
207 Sixth St. N., Wahpeton
Bond. Mrs J. H.
921 South 9th St., Fargo
Borland, Mrs. V. G.
1514 South 9th St., Fargo
Corbus, Mrs. B. C , Jr
424 Fourteenth Ave. S., Fargo
DeCesare, Mrs. F. A
1401 South 9th St., Fargo
Dillard, Mrs. J. R.
620 South 8th St., Fargo
Elofson, Mrs. C. E.
1334 North 3rd St., Fargo
Fjelde. Mrs. J. H.
1526 South 8th St., Fargo
Fortney, Mrs. A. C.
... 1122 South 9th St., Fargo
Hanna, Mrs. J. F.
907 Twelfth Ave. S., Fargo
Haugrud, Mrs. E. M.
1310 North 3rd St., Fargo
Heilman, Mrs. C. O.
__ .... 1338 North 2nd St., Fargo
Hunter, Mrs. C. M.
Irvine, Mrs. V. S.
Kaylor, Mrs. C. C
.1426 Fourteenth Ave. S., Fargo
Klein, Mrs. A. L
.... .... 1441 South 9th St., Fargo
Kellogg, Mrs. I. W.
Fairmount
Lancaster, Mrs. W. E. G.
1437 S. 8th St., Fargo
Larson, Mrs. G. A.
1538 S. 9th St., Fargo
1 e.Vlar. Mrs. John D. ....
1249 N. 10th St., Fargo
Lewis, Mrs. T. H.
121 N. 5th St., Fargo
Long, Mrs. W. H.
Mazur. Mrs. B. A.
1237 N. 3rd St.. Farcro
Moe, Mrs. Allan E. ... .. 1112 Sixth Ave. S., Moorhead, Minn.
Miller. Mrs. H. H. 609 Fourth St. N.. Wahoeton
Ostfield, Mrs. J. H. ..
Poindexter, Mrs. M. H. ....
721 S. Fourth, Moorhead, Minn.
1526 S. Seventh St., Fargo
Pray, Mrs. I G.
Richter, Mrs. E. H. ...
Hunter
Rodgers, Mrs. R. G.
Sasse, Mrs. Sophia
Schneider, Mrs. J. F. ...
Sedlak, Mrs. O. A. .. .
Stafne, Mrs. W. A.
Swanson, Mrs. J. C. . _.
1220 S. Eighth St., Fargo
Schleinitz, Mrs. F. B. .
Hankinson
Weible, Mrs. R. D
Weible, Mrs. R. E. .
714 S. Eighth St., Fargo
Thompson, Mrs. A. M. 313 Seventh St. N., Wahpeton
Wasemiller, Mrs. E. R 531 First St. N., Wahpeton
Devils Lake
Secretary: Mrs. R. M. Fawcett
Treasurer: Mrs. W. R. Fox
Devils Lake
Rugby
Engesather, Mrs. J. A. D.
.. Brocket
Fawcett, Mrs. D. W.
1105 Fifth St , Devils Lake
Fawcett, Mrs. J. C .
1125 Fifth St., Devils Lake
Fawcett, Mrs. R. M.
Fox, Mrs. W R
Rugby
Graham, Mrs. J. D.
510 Tenth Ave., Devils Lake
Gerber, Mrs. L. S
Hughes, Mrs. B. J. ...
Rolla
Keller, Mrs. E. T.
Rugby
Mahoney, Mrs. J. H. ... .. .
915 Eighth St., Devils Lake
Palmer, Mrs. D. W.
Sihler, Mrs. W. F.
Toomey, Mrs. G. W.
Van Lier, Mrs. P. C. .
412 Seventh St., Devils Lake
418 Seventh St., Devils Lake
Rugby
Vigeland, Mrs. G. N.
Maddock
Grand Forks
President: Mrs. W. A. Liebeler Grand Forks
Secretary: Mrs. E. A. Haunz Grand Forks
Alger, Mrs. L. J. 81 Fourth Ave. S., Grand Forks
Benson, Mrs. T. Q. 1101 Reeves Drive, Grand Forks
Brown, Mrs. G. F. _ .121 Fenton, Grand Forks
Culmer, Mrs. A. E., Jr 1 503 Oak, Grand Forks
Dailey, Mrs. W. C. ... 1404 Chestnut, Grand Forks
Flaten, Mrs. A. N. Edinburg
Goehl, Mrs. R. O. 1015 Reeves, Grand Forks
Haugen, Mrs. C. O. Larimore
Haunz, Mrs. E. A. 1027 Lincoln Drive, Grand Forks
Johann, Mrs. O. P. , Grafton
Landry, Mrs. L. H. Walhalla
Leigh, Mrs. R. E. . 17 Conkling Ave., Grand Forks
Liebeler, Mrs. W. A. 619 Belmont Road, Grand Forks
Lommen, Mrs. C. E. Fordville
Sandmeyer, Mrs. J. A. 1722 University Ave., Grand Forks
Stratte, Mrs. J. J. 403 Division Ave., Grand Forks
Sterns, Mrs. Donald 130214 University Ave., Grand Forks
Thorgrimson, Mrs. G. G. 1215 Lincoln Drive, Grand Forks
Vance, Mrs. R. W. 75 Fourth Ave. S., Grand Forks
Waldren, Mrs. H. M., Jr. ... Drayton
Waldren, Mrs. H. M., Sr. Drayton
Weed, Mrs. F. E. Park River
Witherstine, Mrs. W. H. 214 Eighth Ave. S., Grand Forks
Woutat, Mrs. P. H. 1205 Lincoln Drive, Grand Forks
Kotana
President: Mrs. A. K. Johnson ... Williston
Secretary -Treasurer: Mrs. J. J. Korwin .... Williston
Craven, Mrs. J. D. 915 Second Ave. W., Williston
Craven, Mrs. J. P. 409 Third Ave. E., Williston
Hagan, Mrs. E. J., Sr 410 Second Ave. E., Williston
Johnson, Mrs. A. K. 71714 Second Ave. E., Williston
Korwin, Mrs. J. J. __ 701 Second Ave. E., Williston
Lund, Mrs. C. M. ... 701 First Ave. E., Williston
Wright, Mrs. W. A. 822 Second Ave. E., Williston
Northwest
President: Mrs. Henry Kermott Minot
Secretary: Mrs. O. S. Uthus ... Minot
Treasurer: Mrs. R. B. Woodhull .... Minot
Ball, Mrs. W. J. 405 Thompson Apts., Minot
Beck, Mrs. Charles Harvey
Bethea, Mrs. R. O., Jr. 121 Ninth Ave. N.W., Minot
Brelich, Mrs. P. J. .... 818 Fourth St. S.E., Minot
Cameron, Mrs. A. L. 318 Eighth Ave. S.E., Minot
Combs, Mrs. A. B. 624 S. Main, Minot
Conroy, Mrs. M. P. 301 Thompson Apts., Minot
Devine, Mrs. J. L., Jr. — 901 Fourth St. S.E., Minot
Duane, Mrs. T. D. . 118 Ninth Ave. S.E., Minot
Erenfeld, Mrs. H. M. 306 Ninth St. S.E., Minot
Erenfeld, Mrs. F. R. 616 Lincoln Ave., Minot
Fischer, Mrs. V. J .... 707 Third St. S.E., Minot
Garrison, Mrs. M. M .. . 612 Mt. Curve Ave., Minot
Goodman, Mrs. Robert Powers Lake
Haraldson, Mrs. Olaf 918 Second Ave. S.E., Minot
Halverson, Mrs. H. L. ... 912 Second St. N.W., Minot
Ingalls, Mrs. C. L. ... ... 434 Fifth Ave. N.W., Minot
Johnson, Mrs. H. P. 1124 Eighth St. N.W., Minot
Johnson, Mrs. O. W. Rugby
Kermott, Mrs. Henry 21 Seventh St. N.W., Minot
Kernwein, Mrs. G. A. 809 First St. S.E., Minot
Lampert, Mrs. M. T 101 Tenth St. N.W., Minot
Lyman, Mrs. F. V. .. M.S.T.C., Minot
September, 1949
339
McCannel, Mrs. A. D. ..... ...... 505 Main St. S., Minot
Nacgeli, Mrs. F. D. ... ... 920 Third Ave. N.W., Minot
O’Neill, Mrs. R. T. ... 529 Third St. S.E., Minot
Peabody, Mrs. C. S. 201 Thomas Apts., Minot
Pence Mrs. J. R. No. 4 Emerson Apts., Minot
Dyson, Mrs. R. E. 717 Fourth St. S.E., Minot
Flurly, Mrs. W. C. 920 Third Ave. S.E., Minot
Ransom, Mrs. E. M. ... 715 First Ave. N.W., Minot
Rowe, Mrs. H. J. 517 Second St. S.E., Minot
Seiffert, Mrs. G. S. — P.O. 389, Minot
Smith, Mrs. J. A. ..... ..... 412 Seventh St. N.W., Minot
Spomer, Mrs. J. P. 115 Seventh St. S.E., Minot
Sorenson, Mrs. A. R. ... — 114 Sixth St. S.E., Minot
Sorenson, Mrs. Roger . 1000 Fourth Ave. N.W., Minot
Uthus, Mrs. O. S. 301 Thomas Apts., Minot
Woodhull, Mrs. R. B. 203 Thompson Apt., Minot
Sheyenne Valley
President: Mrs. W. H. Gilsdorf
Secretary-Treasurer: Mrs. C. J. Meredith
Cook, Mrs. P. T.
Christianson, Mrs. Gunder
Gilsdorf, Mrs. W. H.
Merrett, Mrs. J. P.
Meredith, Mrs. C. J.
Macdonald, Mrs. A. C.
Macdonald, Mrs. A. W.
Wicks, Mrs. F. L.
Brown, Mrs. Nida
Crosby, Mrs. Kate
Sixth
President: Mrs. C. A. Arneson Bismarck
Secretary: Mrs. P. W. Freise Bismarck
Treasurer: Mrs. C. C. Smith Mandan
Arneson, Mrs. C. A. 714 Second St., Bismarck
Baumgartner, Mrs. C. J. 615 Washington, Bismarck
Bahamonde, Mrs. J. B. , . Elgin
Berg, Mrs. H. M. 214 Avenue A, Bismarck
Brandes, Mrs. Marion E. .. .... 601 Fifth Ave., Bismarck
Boerth, Mrs. E. H 610 Avenue B, Bismarck
Breslin, Mrs. R. H. __ 107 First Ave. N.W., Mandan
Buckingham, Mrs. T. W. 1030 Fifth Ave., Bismarck
Constans, Mrs. G. M. 621 Mandan St., Bismarck
DeMoully, Mrs. O. M Flasher
Diven, Mrs. W. L. 119 Ave. B West, Bismarck
Fredricks, Mrs. L. H. 112 Ave. B West, Bismarck
Freise, Mrs. P. W. 831 Mandan, Bismarck
Gaebe, Mrs. O. C. New Salem
Icenogle, Mrs. G. D. 232 Ave. C West, Bismarck
Jacobson, Mrs. M. S. Elgin
LaRose, Mrs. V. J. __ 522 Sixth St., Bismarck
Larson, Mrs. L. W. 219 Ave. B West, Bismarck
Nickerson, Mrs. Evelyn 309 Fifth Ave. N.W., Mandan
Nuessle, Mrs. R. F. 106 Ave. D, Bismarck
Perrin, Mrs. E. D. 102 Ave. D, Bismarck
Peters, Mrs. Clifford ... 220 Ave. A West, Bismarck
Pierce, Mrs. W. B. 615 Raymond, Bismarck
Ramstad, Mrs. N. O. 824 Fourth St., Bismarck
Roan, Mrs. M. W. 222 Park St., Bismarck
Rosenberger, Mrs. FT P. 404 Ave. C, Bismarck
Salomone, Mrs. E ... Elgin
Saxvik, Mrs. R. O. 622 Eighth St., Bismarck
Schoregge, Mrs. C. W. 507 Sixth St., Bismarck
Smith, Mrs. C. C. 503 Third St. N.W., Mandan
Thompson, Mrs. Arnold 1124 Fourth St., Bismarck
Vinje, Mrs. E. G Hazen
Waldschmidt, Mrs. R. FI 600 Washington, Bismarck
Southwestern
President: Mrs. A. P. Nachtwey Dickinson
Secretary-Treasurer: Mrs. A. J. Spanjers, Jr Dickinson
Bowen, Mrs. J. W 221 Seventh Ave. W., Dickinson
Dukart, Mrs. C. R. 208 Fourth Ave. N., Dickinson
Dukart, Mrs. Ralph ... 46 W. Fifth St., Dickinson
Guloien, Mrs. H. E. 41 Fifth Ave. W., Dickinson
Gumper, Mrs. A. J. 7 E. Fourth, Dickinson
Hill, Mrs. S. W. Regent
Nachtwey, Mrs. A. P. .115 Fifth Ave. W., Dickinson
Olesky, Mrs. E. Mott
Riechert, Mrs. H. L. 543 First Ave. W., Dickinson
Rodgers, Mrs. R. W. 146 West Sixth St., Dickinson
Smith, Mrs. O. M. Killdeer
Spanjers, Mrs. A. J., Jr. 119 Seventh Ave. W., Dickinson
Spear, Mrs. A. E. _ 610 First Ave. W., Dickinson
Southern
Fergusson, Mrs. V. D. 1 Edgeley
Fergusson, Mrs. F. W. ... ... Kuhn
Maloney, Mrs. B. W. Lamoure
Van Houten, Mrs. R. W. Oakes
Wolfe, Mrs. F. E. Oakes
Stutsman
President: Mrs. R. D. Nierling .... Jamestown
Secretary-Treasurer: Mrs. Robert Woodward Jamestown
Arzt, Mrs. P. G. . 502 Fourth Ave. S.E., Jamestown
Carpenter, Mrs. G. S. ... State Hospital, Jamestown
Cuthbert, Mrs. W. H. State Hospital, Jamestown
DePuy, Mrs. T. L. 301 Second Ave. S.E., Jamestown
Elsworth, Mrs. J. N. .... 605 Fifth Ave. N.E., Jamestown
Jansonius, Mrs. John 405 Fourth Ave. S.E., Jamestown
Larson, Mrs. E. J. 321 Second Ave. S.E., Jamestown
Lucy, Mrs. R. E. 523 Third Ave. S.E., Jamestown
Miles, Mrs. J. V. . ... 420 Fourth Ave. N. E., Jamestown
Nierling, Mrs. R. D. 415 Ninth Ave. S.E., Jamestown
Pederson, Mrs. Thomas ...... 316 Fourth Ave. N.E., Jamestown
Robertson, Mrs. C. W .106 Sixth St. N.W., Jamestown
Sorkness, Mrs. Joseph 318 Third Ave. S.E., Jamestown
Wood, Mrs. W. W. 509 Second Ave. N.E., Jamestown
Woodward, Mrs. F. O. 722 Third St. N.E., Jamestown
Woodward, Mrs. R. S. 114/i N.E. Third, Jamestown
Traill-Steele
President: Mrs. C. G. Owens .... New Rockford
Cable, Mrs. T. M. Hillsboro
Cleary, Mrs. H. G. Northwood
Dekker, Mrs. O. D. Finley
Kjelland, Mrs. A. A. Hatton
Knutson, Mrs. O. A Buxton
LaFleur, Mrs. H. A. Mayville
Little, Mrs. R. C. Mayville
Vinje, Mrs. Syver Hillsboro
Tri-County
President: Mrs. T. M. Cable Hillsboro
Secretary: Mrs. O. A. Knutson Buxton
Boyum, Mrs. P. A. Harvey
Gilliland, Mrs. R. F Carrington
Owens, Mrs. C. G. New Rockford
Schwinghamer, Mrs. E. J. . ... New Rockford
Voglewede, Mrs. Wm. Carrington
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
Valley City
340
The Journal-Lancet
American College Health Association News
Plans are getting under way for the annual meeting
of the American College Health Association at the
Henry Hudson Hotel, New York City, December 29-30,
1949. The tentative program is as follows:
The first morning session will be opened by an address
by the President to be followed by a scientific session
on Evaluation of Screening Programs in College Health
Services. At noon there will be the Association luncheon
at which a well-known speaker will be present. The
afternoon session will be held at the Institute of Re-
habilitation and will be devoted to a symposium on
Physical Medicine with Dr. Howard Rusk in charge.
Two panel discussions will be held the second morn-
ing— one on Health Problems of Women in Colleges,
under the guidance of Dr. Ruth Boynton of the Uni-
versity of Minnesota, and the second on the Problems
of Recognition and Standards for Health Services, under
the direction of Dr. Warren Forsythe of the University
of Michigan. The latter panel will probably be made up
of former presidents of the Association. A business
meeting and a session on Problems of Nutrition as
Applied to College Health, with Dr. Norman jollifee
presiding, will wind up the two-day meeting.
Meet Our Contributors
G. Wilson Hunter, M.D., of the Fargo Clinic is a past
president of the North Dakota Society of Obstetrics and
Gynecology. He is a graduate of Northwestern Univer-
sity Medical School; a member of the Central Associa-
tion of Obstetrics and Gynecology, the Minnesota Society
of Obstetrics and Gynecology, AMA, the Cass County
Medical Society, FACS, FISC; and joined the American
Board of Obstetrics and Gynecology in 1938.
Dean F. Nelson, M.D., was graduated from North-
western University Medical School, class of 1943, and
later took work at the St Joseph Hospital in Chicago.
He now specializes in obstetrics and gynecology at the
Fargo Clinic.
Charles Blair Darner, also of the Fargo Clinic, was
graduated in 1937 from the medical school of the Uni-
versity of Michigan and served as lieutenant in the
USNR from 1942 to 1946. He is secretary of the North
Dakota Society of Obstetrics and Gynecology; a member
of the Central Association of Obstetrics and Gynecology,
the AMA, and the Cass County Medical Society. He
joined the American Board of Obstetrics and Gynecology
in 1947.
Budd Clarke Corbus, Jr., M.D., attended Harvard and
Louisiana State medical schools. A specialist in urologi-
cal surgery, he serves as staff member of St. John’s Hos-
pital in Fargo, North Dakota, as consultant in the Fargo
Veterans Hospital, and urological consultant of the
North Dakota Crippled Children’s Bureau. He is a mem-
ber of the Chicago Urological Society, the North Central
Section of the American Urological Association, Sigma
Xi, a Fellow of AMA, and a Diplomate of the National
Board of Medical Examiners.
Dr. Carl C. San Socie was recently appointed col-
lege physician on the staff of State Teachers College,
a branch of the State University of New York, at
Brockport, N. Y.
The State Teachers College at Brockport, N. Y.,
has an opening for a medical doctor or doctor of public
health for the college year beginning September I, 1949.
The position pays a salary of $5265 for the ten-month
college year. Additional money at the rate of $100 a
week is paid if the person remains to teach in the six
or eight week summer sessions. The salary quoted is the
minimum for a full professorship. Annual increments
of $250 each for four years bring the maximum $1000
higher. The duties include general supervision of the
health services to college students and the children of
our School of Practice. This involves annual examina-
tions, clinical services, emergency work and the possible
teaching of from three to six hours of courses in one or
more of the following fields: anatomy, physiology, bac-
teriology, public health, personal hygiene, community
hygiene.
News Briefs
North Dakota
Named chief of surgical service at Fargo Veterans
hospital is Dr. Fred H. Wiechman, who has served as
acting chief since last October. A native of Freeport,
Minn., Dr. Wiechman was graduated from University
of Minnesota medical school in 1929. Following private
practice at Sleepy Eye and Montgomery, Minn., he
served five years in the army, and later completed three
years postgraduate training for the American Board of
Surgery.
Addition of six doctors to the Fargo Veterans Hos-
pital staff and a corresponding increase in other person-
nel has enabled the Fargo VA center to increase the
number of hospital beds in use from 227 to 280.
Rated bed capacity of the hospital is 415. The man-
agement hopes to open another ward soon, increasing
beds in use to 313.
The hospital waiting list, which once numbered sev-
eral hundred, has been decreasing steadily and the hope
of the manager is to open sufficient wards soon to enable
the hospital to accommodate applicants with no waiting.
New doctors are Dr. Julius Weinberg, Dr. James B.
Blair, Dr. Henry Edstrom, Dr. Dominic Cavalieri, Dr.
Donald D. Davis and Dr. Mabel Hoiland.
!
drowsiness minimized. . .
allergic patients remain alert
Clinical reports describing the use of
Thephorin in 2564 patients with hay fever
and other allergies indicate an incidence
of drowsiness of only 2.92%. In contrast
wTith other antihistamines, Thephorin can
therefore be given to motorists and other
patients who have to remain alert. Highly
effective and well tolerated in most cases,
Thephorin is available in 25-mg tablets
and as a palatable syrup which permits
convenient adjustment of dosage.
HOFFMANN -LA ROCHE INC • NIITLEY 10 • N. J.
Thephorin
brand of phenindamine
'Roche'
i
•
i
i
342
The Journal-Lancet
Gov. Fred G. Aandahl reappointed two members
and named one new member to the state board of med-
ical examiners. Dr. Joseph Sorkness, Jamestown, and
Dr. D. J. Halliday, Kenmare, both were reappointed
to three-year terms expiring August 1, 1952. Dr. C. J.
Glaspel, Grafton, was named to succeed Dr. G. M.
Williamson, Grand Forks, also for a three-year term.
Dr. John T. Boyle, physician and surgeon, Newark,
N. J., began practicing in Garrison in partnership with
Dr. Martin Fdockhauser, who took over the practice of
Dr. E. C. Stucke when he retired from the medical
profession last December.
Dr. Boyle is a graduate of Holy Cross College and
attended New York Medical College, where he was
president of his graduating class. Dr. Boyle served in-
ternship at Newark City Hospital and took one year
of specialized training there.
Dr. Anton Zukovsky, one of the first DP physi-
cians to undertake training in the United States, is be-
ginning a year’s work in St. Aloisius hospital at Harvey,
N. D. Following the training here Dr. Zukovsky will
take the state board examinations and is scheduled to
practice at Steele, N. D.
Dr. Zukovsky is Polish by birth and is a graduate of
the medical school at the famous University of Cracow.
He was chief doctor of Polish hospitals for seven years
and for four years worked in DP camps under the super-
vision of the United States army.
Dr. George C. Hanson of Minot, physician, surgeon
and specialist on eye, ear, nose and throat, has an-
nounced his retirement after 33 years in Minot. He
and Mrs. Hanson will make their home in Seattle.
Dr. F. M. Walsh has recently taken the North Da-
kota medical examination and secured his license to prac-
tice in the state. Dr. Walsh, who came from Winnipeg,
is associated with Dr. H. M. Waldren, at Drayton.
Dr. D. J. Halliday, chairman of the Kenmare Dea-
coness hospital board, recently accepted a check for
$1,585.00, from Byron Krantz, secretary-treasurer of the
American Legion hospital benefit project. The check was
earmarked for the purchase of a new operating room
table for the hospital.
South Dakota
South Dakota has 14 newly licensed medical doc-
tors. The young physicians were approved by the newly-
formed state board of medical and osteopathic examin-
ers’ meeting at Pierre July 19th, in its first official session
since it was created by the 1949 lesgislature.
In addition to processing the new doctors, the board
also administered examinations to four other physicians,
set up internship regulations and elected its own officers.
Faris Pfister, Webster, was named president; J. H.
Cheney, Sioux Falls, vice president; and C. E. Sherwood,
Madison, secretary. Other members of the board are
C. B. McVay, Yankton, and D. L. Kegaries, Rapid City.
The newly licensed physicians and their places of prac-
tice are: J. W. Donahue, W. R. Anderson, A. K. My-
rabo and D. F. Rayl, all in Sioux Falls; J. E. Harroun,
Brookings; A. B. Scales, Pickstown; K. M. Keane, Elk
Point; D. J. Glood, Viborg; J. W. O’Brien, Winner;
A. J. Miller, Aberdeen; C. W. Hogan, J. V. Yackley,
and P. H. Koren, all in Rapid City; and F. C. Tucker,
Vermillion.
Dr. Donald F. Rayl has opened an office at the
Sioux Falls clinic for the practice of general and thoracic
surgery. Dr. Rayl received his M.D. at the Johns Hop-
kins university school of medicine in February, 1943.
He is an associate staff member of the McKennan and
Sioux Valley hospitals, a member of the American Tru-
deau society, and the attending physician in thoracic
surgery at the Royal C. Johnson Veterans hospital.
Gov. Mickelson reappointed Dr. R. B. Fleeger, Lead,
to the medical panel provided for by the South Dakota
occupational disease disability law.
The appointment is effective through July 1, 1955.
Other members of the medical panel are Dr. Donald H.
Breit, Sioux Falls, and Dr. J. L. Calene, Aberdeen.
Dr. John W. Donahoe has joined his father and
brother, Drs. S. A. and Robert R. Donahoe, in practice
at Sioux Falls.
Dr. Donahoe received his M.D. at the Georgetown
School of Medicine in 1943. He interned at the George-
town university hospital during part of 1944. He began
a fellowship at the Mayo clinic, Rochester, Minn., Octo-
ber 1, 1944, leaving in July, 1946, to enter the army,
but later completed it following his discharge.
Announcement was made of the association of Dr.
Wilford A. Councill, who becomes a member of the
staff at the Clark Medical Clinic.
Dr. Councill, a former resident of Baltimore, Mary-
land, is a graduate of the University of Virginia and
served his internship at Johns Hopkins Hospital. He
has had special training in urological surgery.
Dr. N. W. Stewart of the Homestake Mining Com-
pany hospital staff at Lead, was recently appointed assist-
ant chief surgeon succeeding Dr. N. E. Mattox, who
has retired.
Dr. Stewart has been on the Homestake medical staff
since January, 1931. He is a graduate of the University
of Minnesota School of Medicine with the class of 1927
and practiced at Brainerd and Mankato, Minn., before
coming to Lead.
Dr. Mattox plans to continue special practice in eye,
ear, nose and throat in the offices formerly occupied by
the late Dr. W. L. Matlock in Deadwood.
Dr. Sam Namminga of Scotland, S. D., will accept
a position as a civilian doctor in the Veterans Hospital
at Ft. Mead near Sturgis, S. D. A number of years ago
he purchased the Scotland Clinic from its founder, Dr.
Landmann, and since then has had a large practice em-
bracing a wide area around Scotland.
Cancer Symposium: A Foreword
Only a few years ago many cancers went undiagnosed and the resultant deaths were
ascribed to other conditions. However, significant advances and diagnostic procedures have
been made in recent years. Endoscopy, for instance, has contributed significantly to diagnosis
of malignancy by making it possible to procure biopsy material from suspicious lesions and
obtain aspirations for microscopic study. X-ray inspection has been helpful during the last
decade or so in determining the presence of lesions in such organs as the stomach and the
lung, and locating areas of disease which can be investigated by other methods with reference
to etiology.
In this issue of Journal-Lancet, McDonald and Woolner bring to date our knowledge
on cytological diagnosis of carcinoma. The value of this procedure is emphasized, particu-
larly in carcinoma of the uterus and lungs.
Probably every localized primary cancer could be cured by surgical removal if its pres-
ence were known and its location determined at the right time. In Hilger’s article, Car-
cinoma of the Larynx, Hilger states that early diagnosis coupled with adequate therapy can
in a mid-vocal cord lesion of small size promise a 92 per cent five-year cure rate. The accessi-
bility of this area to examination makes early diagnosis possible if the individual is seen by
a physician who does an adequate examination.
Dodds in his article calls attention to Ochsner’s statement that of every 25 cases of car-
cinoma of the lung, only nine are suitable for pulmonary resection, and only two of the nine
survive five or more years. Thus the vast majority of lung cancer patients cannot be treated
successfully by surgery because of metastases before operations are performed.
The article "The Cancer Problem Today,” by Wangensteen is a fine, over-all presenta-
tion of the entire cancer situation. He leads the reader into every phase of this field and
states not only what is known, but what is still needed to solve the problem.
J. A. Myers, M.D.
344
The Journal-Lancet
The Cancer Problem Today
Owen H. Wangensteen, M.D.f
Minneapolis, Minnesota
Anyone who has concerned himself with some of the
.serious aspects of the cancer problem must confess
to a feeling of awe and bewilderment before the confu-
sion and the unsolved mysteries of cancer. We know
very little about cancer; it would be foolhardy to deny
this.
The scope of the cancer problem has broadened in
our day to touch the interests and include the activities
of chemists, physicists, biochemists, histochemists, bio-
physicists, geneticists, zoologists, biologists, biometricians,
morphogeneticists, physiologists, virologists, enzymolo-
gists and experimentalists in the broad interphases be-
tween these recognized specialists, as well as endocrinolo-
gists, hematologists, pathologists, oncologists, roentgen-
ologists, radiotherapeutists and surgeons and many sur-
gical specialists. I disclaim any intent of trying to portray
the present status of the cancer problem from any other
point of view than that of a clinical surgeon, nor is my
perspective broad enough to correlate for you the sig-
nificant advances in each of these fields. Historically it
is of interest that whereas studies of organ structure date
back for centuries, the study of function is essentially a
modern development. It is reasonable to believe that
new disciplines will come into being between the inter-
phases of chemistry, physics and endocrine physiology
to help resolve the enigma.
The ancient military axiom of divide and conquer is
still ultra-modern even for the understanding of such
a problem as that posed by cancer. If a young scholar
were, with the promise of long life, to outline for him-
self the laudable objective of mastering all the knowl-
edge bearing upon cancer, I think he would die in the
first library alcoves of available cancer literature. Despite
the enormity of the literature, the salient facts are still
too few. Moreover, persons capable of synthesizing
already existing and related facts into workable concepts
are fewer still. Getting the available information into
the hands of those to whom it has some meaning is also
imperative. The gleaners whose bits of information nar-
row the borders between interphases of specialty knowl-
edge always make an important contribution to the un-
derstanding of a problem.
*A lecture sponsored by the Minnesota chapter of Sigma Xi
and given at the Northrop Memorial Auditorium February 20,
1948.
fFrom the Department of Surgery, University of Minnesota
Medical School.
This presentation is based upon work prosecuted under the
following sources of support: Grants from the National Cancer
Institute and include the following local sources of support for
cancer research: 1. Flora L. Rosenblatt Fund, 2. Malignant Dis-
ease Research Fund, 3. Donald P. and Marian S. Ordway Fund,
4. Mr. and Mrs. R. C. Lilly Fund, 5. Mr. and Mrs. L. A.
Pritzker Fund, 6. Tillie L. Nelson Fund.
What Is Cancer?
Cancer though local in origin is probably not the re-
sult of a single insult. In other words, the factor or
factors responsible for bringing a malignant tumor into
being in one organ or tissue may be inoperative in an-
other. The mystery of the beginnings of cancer is as
baffling as are the questions hedging about the origins
of life itself. The ways of nature are not simple. He
who professes an interest in the biology of cancer has
much to learn concerning the factors which influence the
rapidity as well as the character of cell division and
growth. When we have a better understanding of the
natural processes of growth, we shall be able to appraise
in a more intelligent manner the intangible unknowns
which hover about the beginnings of cancer. As the fol-
lowing discussion will suggest, it is more than likely that
different agents or varying combinations of agents may
be responsible for inciting the beginnings of cancer in
various organs of the body.
Much has been learned from the chimney sweep’s
cancer of the scrotum, described by the Englishman,
Percival Pott, in 1775. The Japanese observers, Yama-
giwa and Ichikawa (1915), found that tar painted on
the ears of rabbits resulted in the production of skin
cancers. The demonstration of carcinogenic properties
of chemicals (dibenzanthracene) isolated from tar by
Kennaway and his associates (1924) was the first step
in classifying the nature of the origin of skin cancers.
Demonstration of carcinogenic substances in the sex hor-
mones was another important step. And just in the same
manner that x-rays or radium are curative agents for
certain cancers, within doses that are safe for the skin,
and carcinogenic when the dose applied is caustic, so the
sex hormones may produce cancer in mice and when ad-
ministered to man, may not uncommonly be followed by
temporary disappearance of certain cancers, especially
breast and prostatic. This dual effect of the x-rays and
sex hormones is shared by at least one other agent, ure-
thrane, which has been used to treat leukemia and pro-
static cancer in men. While the administration of ure-
thrane may reduce the white blood cell count in mice
with leukemia, it may at the same time induce malignant
tumors of the liver (Kirschbaum, 1948) .
Those forces in the body limiting physiological growth
have no control over cancerous growth, which is termi-
nated only by the death of the host. Cancer is essen-
tially a disease of a group of cells in a certain tissue.
Cancer of the skin is the most frequent of all cancers.
Fortunately, about 90 per cent of skin cancer occurs
below the wristline of the hand and above the collar line,
which suggests that its causes are largely external or
environmental; that long exposure to sunlight and wind
October, 1949
345
has brought it about; that the development of a cancer
on the skin of the face or the back of the hand was
preceded by a local precancerous condition which in turn
was brought into being by exposure to the ultraviolet
light or actinic rays of sunshine. These precancerous
conditions identified ordinarily as small, rough, pig-
mented excrescences on the skin look innocent enough
and often remain unchanged for long periods of time.
Insidiously, growth and ulceration, occasionally heralded
by pain, indicate that they are not as harmless as their
apparent inertness had suggested.
Tissue Susceptibility
Now, whereas skin cancer is essentially an environ-
mental disease, appearing in older persons, whose hands
and faces have long been exposed to sun and wind, there
is a wide divergence in tissue susceptibility. The Negro,
having more pigment in his skin, is almost immune to
skin cancer and when he does have it, is apparently as
likely to exhibit it in covered portions of his body as on
exposed surfaces. Light-complexioned, fair-haired per-
sons, on the contrary, now and then exhibit unusual sen-
sitiveness to sunlight to the extent that moderate ex-
posure at an early age invites the development of cancer
— a condition known as Xeroderma pigmentosum. If
these persons are to avoid cancer, they must live in a
dark cellar or venture out only when dressed up like a
Crusader going to fight the Saracens.
Tissue susceptibility to cancer, though well docu-
mented for various conditions of life, is not well under-
stood. Whether organ susceptibility results from a sys-
temic or a local influence is not generally known. The
term "precancerous lesions” is used with some justifica-
tion in speaking of skin keratoses on the face or hands
and in polyps of the rectum, colon, stomach, bladder and
larynx. However, it is very unlikely that polyps are the
precursor of most gastric cancers; if there are local pre-
cursors of breast, uterine and lung cancer, we do not
know what they are. Whether it is local or systemic,
whether genetic, environmental or hormonal remains to
be resolved. And obviously all these factors may par-
ticipate and to varying extents in different organs.
Civilization and Cancer
Cancer, it is frequently said, is an accompaniment of
civilization. It must be remembered, however, that one
of the benefactions of advance from barbarism and
primitive societies is longer life. And, as length of life
increases, death from cancer increases in a more than
arithmetic progression. Approximately 90 per cent of
cancer occurs after 40 years of age. Wherever people
live to be old, no matter where or under what environ-
mental conditions, cancer is frequent. A study of the
comparative mortality from various countries supports
this thesis. In India, where the average life expectancy
at birth is approximately 26 years, cancer occurs, but
by no means as frequently as in those countries where
the life expectancy is more than 60 years, including most
countries of western and northern Europe, North Amer-
ica, Australia, New Zealand and the Union of South
Africa. Similarly, in Japan, Italy and Portugal, where
life expectancy is still considerably lower (46 to 56
years) than in Western Europe and here the overall
mortality from cancer is also less than here. As the
longevity in these countries approaches our own, it is
likely that the apparent difference in cancer mortality
will also become less marked. Civilization is probably
an abettor of cancer only insofar as it creates the op-
portunity for more people to live to be old.
Frequency of Cancer
The sources of information on the occurrence of can-
cer are the following: (I) vital statistics of the various
countries (published and prepared for the United States
under the supervision of the Census Bureau) ; (2) statis-
tical surveys of illness and death among policyholders of
large insurance companies; (3) diagnoses from hospital
charts; (4) autopsies; and (5) tumor and cancer regis-
tries in states requiring the reporting of observed cancer.
In the mortality tables of the vital statistics, the oppor-
tunities for error are obvious. In general, however, vital
statistics and postmortem studies agree quite well as to
the frequency of the various kinds of cancer, with deaths
in the postmortem series favoring a larger proportion of
deaths from internal cancers.
Clinical hospital diagnoses, checked by autopsies (Na-
gayo 1933; Pohlen and Emerson 1942) suggest that
cancer probably occurs more frequently than is indicated
by clinical studies alone, perhaps by an additional 20
to 30 per cent over reported clinical incidences. And
it is probably fair to suggest that a similar underevalua-
tion of cancer frequency is present in the vital statistics,
for patients do die without the advantage of hospital
study.
All sources of information confirm the impression that
cancer is a common disease. In fact, cancer accounts for
one among 8 deaths in this country counting all ages
of life. Among men in the United States, one death
in 9 is due to cancer; among women, one in every 6.5.
In the years between 40 and 60, more than 25 per cent
of all deaths in women in this country are caused by
cancer. Women live to be older, and this may in part
account for the larger mortality from cancer in women.
Another reason may be the fact the cancers which take
the greatest toll among men are largely internal can-
cers, not readily recognized; in women, on the contrary,
cancers of the uterus and breast are the frequent cancers
and more easily detectable.
Age Incidence of Various Cancers
Cancer is no respecter of persons. It attacks the infant
in his crib; the child at play; the person on the threshold
of a career; men in military service; it may work its
wrath upon the man in prison or seek out the public
benefactor.
In the early years of life, in both sexes, leukemia, tu-
mors of the brain, bone and kidney are the most frequent
cancers. Some of these continue to occur throughout
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the life span, becoming relatively less important only
because they are superseded in frequency by other can-
cers. Among men in the middle twenties, cancer of the
testis is the most frequent tumor, though measured
against the broader background of the overall cancer
incidence, it does not appear important. Among women
in the same age group, cancer of the breast and uterus
take an early lead, which they maintain throughout most
of life, outdistanced only in the upper age brackets by
cancer of the stomach and the large intestine (colon and
rectum considered together) . In the male, cancer of the
stomach, large intestine (colon and rectum) and the
prostate take the largest toll. The first two begin to loom
formidably at 45 to 50 years of age, whereas cancer
of the prostate takes an increasingly larger toll each
year from 60 well up into the eighties.
Environmental or Genetic Differences
in Cancer Incidence
A number of studies suggest that the overall inci-
dence of cancer mortality is approximately the same
among people with similar life spans. It is not always
easy to separate what might be a genetic from an en-
vironmental influence. Although the frequent occurrence
of breast cancer among certain strains of mice had been
looked upon as the inheritance of a genetic influence,
Bittner (1936) showed by a relatively simple experiment
that an important factor in this transmission was the
suckling of the mother by the infant mice. If the young
were removed immediately at birth and were foster fed
by a lactating mother from a non or low cancer strain
of mice, the incidence of cancer in the litter fell sharply.
This finding has been amply confirmed. Moreover, the
influence of the milk-factor may be largely set aside —
at least in certain susceptible strains of mice — if the
ovaries of the young females, who might otherwise de-
velop breast cancer, are removed shortly after birth.
Further, severe caloric restriction to the extent that fer-
tility of the ovary is compromised also results in a low
incidence of breast cancer among susceptible mice. In
other words, in these mice the hereditary (genetic), en-
vironmental (milk factor), and the hormonal (ovary)
influences cooperate in producing breast cancer.
It should be noted that the food shortage endured by
the peoples of England and Wales, Holland, Denmark
and Norway from 1940 to 1945 did not reduce the
death rate from cancer in these countries, as indicated
in the vital statistics.
Is Cancer Hereditary?
Although in mice the influence of heredity is distinctly
important, the evidence is by no means so clear among
humans. The development of a pure strain of mice in
which the influence of heredity presupposes that inbreed-
ing— brother-to-sister mating — has been continued for
20 generations. Obviously no race of people today pre-
sents that type of genetic control for observation. On
the contrary, people who are Jewish, Scandinavian, or
no matter what for generations, are by contrast hetero-
zygous, as is even more definitely the typical American.
Nevertheless, there are circumstances which suggest a
certain tendency to inheritance of cancer in the same or-
gan at about the same age as cancer was observed in the
parent. If this occurrence held true generally, the prob-
lem of cancer detection would be far simpler than it is.
But whereas a mouse may have one or two definite can-
cer susceptibilities, the human has many. All of us carry
within our bodies the latent seeds of many illnesses in-
cluding perhaps several kinds of cancer which have no
opportunity to develop because we die of something else
in the meantime.
The patient with Xeroderma pigmentosum does not
inherit cancer, but a special susceptibility to the damag-
ing effects of actinic rays; so similarly with mice and the
milk factor.
Importance of Age in Cancer Frequency
One thing is clear, cancer is decidedly a disease of
advancing years. If every infant born alive were to
escape death from whatever cause till age 60, it is evi-
dent that the number of persons dying from cancer
would be increased enormously.
However much we like to glory in the accomplishment
of pediatrics and public health measures in reducing the
mortality of children, it is indeed a real challenge to
medicine that of 100 infants born alive, a greater num-
ber will die in the first year than in any other year of
their life span. In fact, there is a larger mortality among
infants in the first year of life in the United States than
there will be in that same group during the next 29
years! Cancer is responsible for a negligible number of
first-year deaths and only 10 per cent of the mortality
is due to congenital malformations. Obviously here is
an area in which there is still room for considerable
improvement.
I think it may be said, men are quite indifferent con-
cerning what they may die of; they are concerned of
how and when death will overtake them in their journey
between two unknown shores. We want the excursion
to be as long and as pleasant as possible. And when
our leaky vessels sink, we wish them to submerge swiftly,
silently and without suffering.
It is the surgeon’s misfortune to observe too often the
recognition of cancer after it is too late to do anything
about it. It is his privilege, too, to observe with what
dignity and resignation people generally accept that un-
welcome verdict. If those of us who suffer from imagined
ills or are unhappy because fortune has dealt less kindly
with us than we would have her do, could emulate the
courage of those who must accept with equanimity the
fate of the late cancer sufferer, what good medicine
it would be for us. The difficulty, however, is to recog-
nize which threatening ills are real. Cancer is not a dis-
ease to be fought in its early phases with a defeatist
attitude.
Society’s Interest in the Individual
There should be no stigma nor disgrace attached to
having cancer. Cancer is not contagious. Early disclos-
October, 1949
347
ure to the physician of the suspicion of cancer is desir-
able not only in the interest of that individual, but of
his family and society as a whole. The late cancer is
easy to recognize and difficult to cure; the early cancer
is often easy of cure, but difficult to recognize. It costs
the individual or society a great deal to treat the late
cancer; it will cost money and effort to recognize the
early cancer, but it is a far more profitable expenditure.
I believe you will agree with the admonition that we
heed the cost less and the result more.
Because cancer is primarily a problem of advancing
years, every society with an increasing number of old
people must reckon with it. There are probably still a
few skeptics about who believe that the chief contribu-
tion of the medical profession is prolonging the lives of
the unfit, and who believe that we are undermining the
Spartan vigor of society by our misguided efforts. How-
ever, I hold that the mission of physicians is not to
attempt to doctor society as well as the patient. Our
authority comes from society and those of us who have
assumed the Hippocratic Oath must continue to strive
to prolong life and relieve suffering.
The Surgeon’s Accomplishment in
Late Cancer
A development which has been evolving slowly, in
many surgical clinics, and particularly in this country,
is demonstration that radical surgery can be undertaken
in patients with somewhat advanced visceral cancer with
relatively low operative risks. Several things have con-
tributed to this improvement, most important of which
are better anesthesia, better preoperative preparation of
the debilitated patient, employment of more precise op-
erative techniques, and more intelligent management of
the postoperative recovery period. The constant lament
of surgeons, however, is that we are working largely with
late cases. Even for the late case, the accomplishment
of the surgeon is real. Our constant hope is that we may
have earlier cases to deal with. When cancer can be
detected readily in its early stages, it will cease to be
the dread affliction it is now.
The Latent or Silent Interval of
Visceral Cancers
Unfortunately, cancer of the viscera, the most fre-
quent of lethal cancer, is silent; that is, frank cancer is
present some time before it asserts itself and causes func-
tional disturbances of the organ upon which it is para-
sitic. And in some organs, such as the colon or rectum,
there is frequently a local precursor, the polyp from
which the cancer begins. Moreover, these polyps in the
colon and rectum are often inert and relatively symptom-
less for long periods of time, occasionally for two years
or more; in the stomach, the latent interval of transition
between innocence and malignancy is probably even
longer. In excisions for gastric cancer, when the path-
ologist finds upon microscopic examination of the tissue
I removed that cancer was left in the proximal line of
resection, although the surgeon has removed all other
visible traces of the disease, the interval before recur-
rence of symptoms is ordinarily 15 to 20 months and
occasionally longer. This observation repeated in sev-
eral patients affords some idea of the latency of actual
cancer. How much longer the interval is between con-
version of a precursor into cancer is not definitely known.
Importance of Early Diagnosis
The importance of early diagnosis in overcoming can-
cer is well documented. As long as cancer is a local
disease in the organ where it began, the cure rate by
effective therapy is high. When the lymph nodes, the
first area beyond the original site, become infested with
cancer, even though they too are dealt with, the possi-
bilities for cure are decreased considerably.
Until we have a biologic test by which the presence
of cancer can be detected in its earliest phases, one of
the intelligent and practical ways to fight the enemy is
the Cancer Detection Clinic. Whereas cancer may come
at any time, more than 90 per cent of deaths from can-
cer occur after the age of 40. In women there is a
sharper rise in cancer incidence at 30 years than in men,
suggesting that attendance at the Cancer Detection Cen-
ters should begin at 30 years of age for women and
40 for men. However much we deplore the patient’s
failure to heed portentous symptoms, the delay occa-
sioned by the long silent interval of visceral cancers is
even more damaging to the prospect of a satisfactory
cure.
The Cancer Detection Center is by no means the
final answer to the early recognition of cancer, but it
is one of the best means we have today. Surveys sug-
gest that from one to three per cent of those persons
presenting themselves for examination are found to have
signs of beginning cancer. The labor involved in exam-
ining a patient to tell him or her that he or she does not
have cancer, is real. Moreover, the detection of a lesion
in the breast, cervix, stomach, colon or rectum indicates
that a tumefaction or ulcerous defect is already present.
Yet we know that the detection of lesions in this stage
is, in the main, synonymous with the promise of a satis-
factory result, providing such lesions are dealt with
promptly. It is delay that spells defeat. Alertness to the
possibility of cancer, re-enforced by careful periodic
organ scrutiny, employing the best available diagnostic
resources, must replace the old passive policy of wait
and see.
Dissatisfaction with Present Methods
Much as we extoll the Cancer Detection Center today,
we are hopeful that it in turn will be replaced by more
delicate and precise techniques of examination. Detec-
tion of a cancer when a palpable tumor or a large ulcer-
ous defect is present is far from satisfying. We would
like to be more certain that negative findings would ex-
clude with definitiveness an incipient cancer. If we
could only know in which patients a cancer was develop-
ing, the finding of that cancer would be a simpler task
than at present. Battles always have to be fought, how-
ever, with the weapons and ammunition available.
The labor involved in detecting internal cancers is
considerable, yet there is no substitute for the systematic
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The Journal-Lancet
scrutiny of organs in which cancer is often found. It
becomes mandatory, therefore, to survey a large number
of people, some of whom may never have cancer, to
detect its presence in someone who harbors it unknow-
ingly. We may never be able to prevent the develop-
ment of cancer, but with consistent early diagnosis, we
shall be able to reduce materially its threat to life. To
that extent, cancer is preventable as well as curable.
Special Techniques
Papanicalaou of the New York Hospital has shown
in early cases of uterine cancer that the diagnosis may
be made from the vaginal secretions when properly
stained. This technique has been used with considerable
success in the detection of cancer of the lung from bron-
chial secretions, and bids fair to be helpful in many
areas of the body.
While a surgical intern, my colleague Dr. George
Moore (1947), observed that brain tumors, whether
benign or malignant, have an affinity for fluorescein in-
jected intravenously. The nature of the concentration
of the dye, whether by the tumor or its stroma, is such
that use of this technique by the brain surgeon will
become a sine qua non in helping him decide, in the
presence of infiltrating, uncircumscribed tumors, when
he has gotten beyond the lesion. Moreover; Moore
(1948), by introducing radio-active iodine into the flu-
orescein molecule and going over the head of a patient
suffering from conjectured brain tumor with a Geiger-
Mueller counter, has been able to tell (1) whether he
has a tumor; (2) where it will be found; and (3) some-
thing of its grade of malignancy, in that the more be-
nign tumors exhibit less affinity for the dye. In addi-
tion, non-tumorous conditions such as brain abscess or
subdural hematoma give negative findings. This use of
a vital dye in the detection of a neoplasm constitutes
an important advance in diagnosis to be followed, we
hope, by the finding of other vital dyes which exhibit
similar affinities for more frequent types of cancer.
Separation of Environmental and
Genetic Factors
The importance of the genetic factor in skin cancer
already has been pointed out; however, the exposure to
actinic rays of the sun is an even more important agent.
The Kennaways have shown that, among workers doing
heavy manual labor not exposed to tar, pitch or lubricat-
ing oils, cancer of the scrotum though far less frequent
than among workers with coal tar products — occurs more
commonly than among white-collar workers. In other
words, those who by choice or for social reasons find it
necessary to wash often are immune from scrotal cancer.
Cancer of the vulva in the female is an old lady’s cancer.
It may well be, too, that liberal use of soap and water
for the removal of sebaceous secretions may lessen the
threat of that cancer in the same manner that soap and
water protects against the occurrence of scrotal cancer
in the professional worker.
In this connection, the immunity of the Jewish male
to cancer of the penis deserves mention. To be sure,
in this country it is a rare cancer — according to hospital
figures responsible for only 1 to 3 per cent of cancers
among males. Among Jews the world over it is prac-
tically non-existent. Whether this is a genetic influence
or an unexpected gratuity from the ritual of circum-
cision is not known. There is, however, good reason to
believe that the prevention of accumulation of smegma
under an adherent prepuce by the liberal use of soap
and water constitutes an excellent antidote for cancer
of the penis. Leitch (1924) has shown that sebaceous
material coming from dermoid cysts of the ovary in-
creases the carcinogenic properties of oils which cause
cancer when rubbed on the skin of mice. Moreover,
it has been suggested by Twort and Bottomly (1932)
that the retention of sebaceous-like secretion in the breast
may be one of the important causes responsible for the
frequency with which cancer affects it. In countries
where sex hygiene is poor by our standards, the incidence
of cancer of the penis is far greater than here. In India
and China, cancer of the penis accounts for a surpris-
ingly large fraction of the total deaths from cancer
among males. It is probably safe to conclude that cir-
cumcision, if need be, and the liberal use of soap and
water will prevent cancer of the penis. Moreover, in the
prevention of cancer of the scrotum and vulva, soap and
water are probably equally as important.
Among cancers which are frequent, it is of interest
that cancer of the uterine cervix in women is far less
frequent in Jewish women than among other peoples.
This is true the world over and is well documented.
The strange part of it all is that whereas there appears
to be a large salvage of life among Jewish women from
a cancer which ordinarily takes a large toll, yet the over-
all mortality from cancer among Jewish women, no mat-
ter where they live, is at least as great as among their
Gentile sisters in the same environment.
Among countries of our own culture, where people
live to approximately the same age, although there are
differences in the organ distribution of cancer, the over-
all mortality is much the same. This suggests there may
be an internal drive with reference to the occurrence of
cancer that is seeking expression. That hormonal influ-
ence has an important bearing on cancer is well estab-
lished for mice and men. Castration decreases the suscep-
tibility of certain strains of mice to cancer of the breast.
Yet in other mice, the adrenal appears to substitute for
the missing ovary, to the extent that susceptibility to
breast cancer continues. Here, then, is a difference in
response to a hormonal behavior which is genetically
linked. Similarly, castration in the male, when done be-
fore sexual maturity, means failure of development of
secondary sex characters. The prostate fails to develop,
and as the work of Huggins at the University of Chi-
cago has shown, castration causes regression of cancer
of the prostate, even though that improvement holds
usually only for a period varying from one to two or
more years. Moreover, the administration of the female
sex hormone, estrogen, will often effect the same re-
October, 1949
349
sponse. Interestingly enough, when there is clinical evi-
dence of cessation of response to the treatment, switch-
ing about and adding estrogen administration to castra-
tion or vice versa not infrequently affords the patient
another free interval. In late cases of cancer of the.
breast, it has been found that administration of either
estrogen or androgens may be accompanied by disappear-
ance of the tumor and free intervals of varying length.
Moreover, there is ample evidence to suggest that car-
cinogens and sex hormones are chemically related com-
pounds which characterization is shared also by the
adrenal cortex. Further the sex hormones and adrenals
are probably not the only naturally occurring carcinogens
within the body. Methylcholanthrene and the bile acids
secreted in bile have somewhat similar structural for-
mulas.
The overall mortality from cancer in Norway is much
the same as in the United States. And yet in Norway
the mortality from cancer of the gastro-intestinal tract
is so much higher — greater than any place in the
world save Japan. Is this an environmental circum-
stance? Are there carcinogens in the diet of Scandina-
vians and particularly Norwegians and Japanese? Or
is it a lack of something in their diets which favors
the development of cancer? Or a combination of genetic
susceptibility, ingestion of carcinogens and lack of essen-
tial protective elements in the diet? Experimental evi-
dence suggests that, for the mouse, vitamin A deficiency
and the ingestion of reheated fat, employed for cooking,
favor the development of precursors of gastric cancer
as well as actual malignancies. It may even be that the
ingestion of oils, such as mineral oil which interferes
with the absorption of vitamin A, may make some con-
tribution to the development of alimentary tract malig-
nancies. Moreover, it has been shown by Ahlborn in
Sweden (1936) that women with iron-deficient anemias
(sideropenia) accompanied by dysphagia are very prone
to develop cancer of mouth, pharynx or upper esophagus.
One reason it is so difficult to identify the significance
of likely causative external agents with certainty is the
long lag interval. In regard to the milk factor in suscep-
tible mice, this interval averages ten months with a total
life expectancy of approximately two years. The lag in-
terval is probably correspondingly long in the longer life
span of man. The fact that such differences occur in
the site of malignant tumors among various peoples
should encourage the belief that environmental circum-
stances do influence significantly the development of
cancer. This variation in geographic distribution of can-
cer among different peoples merits careful study. Occu-
pational cancers such as cancer of the urinary bladder
of aniline dye workers and lung cancers among miners
where radio-active ore is being mined lend further proof
to the suggestion that environmental influences play an
important role in the genesis of cancer.
It has been admitted that the nature of organ or tissue
susceptibility to cancer is unknown; that the occurrence
of cancer may represent an internal drive seeking expres-
sion; that many persons carry latent tissue susceptibili-
ties, for one or more kinds of cancer which may or may
not attain complete development. If we could have com-
plete protection against the development of cancer in one
of such organs, would the susceptibility for cancer de-
velopment be increased in other organs? Bittner (1947)
has shown that elimination of the milk factor in certain
strains of mice does not protect them from lung cancer.
Moreover, it would be interesting to know whether early
excision of the breasts in susceptible mice getting the
milk factor would be followed by the development of
some other type of tumor.
If cancer experts were asked the following hypotheti-
cal question they would by no means give a uniform
type of reply, for facts are not available to answer the
question with finality. The question: If there were a
fairly large group of women who had lost both breasts
and uterus for whatever reason and not because of can-
cer, would there be an increase in other malignancies
in this group? This inquiry in cancer biology has obvi-
ously more than an academic interest.
Support of Research
I enjoy the privilege of sitting in on the deliberations
of committees authorized to expend public monies for
cancer research. Liberal grants have been given to men
in this and other areas of our country for the support
of projects which appear to have merit. Yet a need
which is equally great in all areas where cancer research
is being done is for facilities in which to do the research.
Every community must make its own contribution toward
the erection of buildings which lend momentum to can-
cer research. In this respect, the Memorial Hospital in
New York shows the happy result when the challenging
practical aspects of the cancer problem in the patient
and an active staff engaged in both clinical and experi-
mental research are united under one roof. A similar
enterprise has gotten under way at Bethesda, Maryland,
under Federal auspices, although in a somewhat different
manner — the research interest having preceded the clin-
ical development. At Yale, the Universities of Chicago,
California and Wisconsin, as well as in other places in
this country, research groups are concentrating on cancer.
In this area a small but notable beginning was made
in 1925 when the Citizens Aid Society under the leader-
ship of Mrs. George Chase Christian built and equipped
the present Cancer Institute of the University of Min-
nesota. That generous gift stimulated considerable in-
terest in research in cancer, until at the present time,
it constitutes one of the important occupations of many
departments of the School of Medicine of this Univer-
sity. The Minnesota Division of the American Cancer
Society has generously proposed to supplement the needs
of the present cancer research at the University of Min-
nesota by pledging an additional $250,000 for facilities
in the new Mayo Memorial. Yet, if the cancer research
in this area is to be lent the full force that it could
have, even more monies must be forthcoming.
350
The Journal-Lancet
Reading the minutes of the Congressional committee
charged with hearing the testimony ( 1946) concerning
an effective program of cancer research, it is difficult to
escape the impression that the disposition of the com-
mittee was to grant a considerably larger sum of money
than was asked. Yet listening to committees of scien-
tists whose function it is to find and support worthy
projects, one encounters a disposition to be conservative
in spending. In other words, your stewards are anxious
lest, in expending the taxpayer’s money, they build up
premature hopes of an early solution to this dread afflic-
tion. This attitude of conservatism in the committees
indicates that it is new and original ideas that are
wanted. Facilities, equipment, and labor are not the
equal of new ideas or original techniques, but money and
effort expended during the long intervals between the
appearance of such ideas will lend real impetus to solv-
ing the problem.
Summary
Cancer is truly a dangerous enemy. In 1944, more
than 170,000 persons died of cancer in this country;
in 1946, 182,000. It is predicted that by 1950, its an-
nual death toll will be 200,000 lives — a fifth of a million
people, more than half of all American military losses
in World War II.
Early recognition is the best means known today, to
immobilize this enemy. Non-resistance is fatal and de-
moralizing to both sufferers and observers. Cancer is a
local disease, even though silent for long periods of time;
in that phase it is curable. A large scale exploration of
techniques permitting earlier and easier detection appears
.to be in order until a simple, reliable biologic test is
available. Cancer prevention and effective chemothera-
peutic agents will be forthcoming only when we know
considerably more about the biology of cancer.
Research is the promise of the future. When the
nature of cancer is better understood, the mapping of
plans for treatment and prevention will have far more
intelligent direction than now. Coordinated research in
the many interphases of the cancer problem will quicken
progress by bringing new facts to light. More clinicians
must enter cancer research mindful that data derived
from studies upon man will never present that force
of finality obtainable in better controlled experiments
upon mice. They must look for smaller, statistically
important differences which will help untangle the con-
fusing interrelationships between genetic, hormonal and
environmental influences in cancer genesis.
One need not be euphoric to suggest that research in
this field holds as much promise of reward as does that
in the field of vascular degenerative diseases. Solution
of the cancer problem would give promise of longer
useful life to a large number of people. Our outlook
upon the problem must relate to persons now alive as
well as to generations yet unborn.
NEW COMPOUND MADE TO FIND CANCER AND MUSCLE CHEMICALS
Creation of a new kind of substance for finding chemicals involved in cancer and other
chemicals basically responsible for muscle movement was announced on September 10 by
Dr. H. S. Bennett of the University of Washington Medical School.
The new substance is a chemical compound that contains mercury. When it combines
with a special type of sulfur-containing compound, it signals the sulfur compound’s location
in red so that the scientist can see where the sulfur is. The particular sulfur chemicals
located are ones containing a combination of sulfur and hydrogen known as sulfhydryl.
The sulfhydryl combination is important both in muscle functioning and in cancer chemistry.
The new mercury red-signal compound is believed the first chemical ever created to let
scientists trace body chemicals by sight. Radioactive chemicals used as tracers or tags for
body chemicals signal either by the sound of the Geiger counter or by taking their own
picture on an X-ray plate which then must be correlated with the optical picture of the tissue
under study.
October, 1949
351
Carcinoma of the Lung
Bronchial Secretion Studies in Early Diagnosis
G. Alfred Dodds, M.D.f
Fargo, North Dakota
Early recognition of carcinoma of the lung has not
paralleled the surgical treatment. There appears to
be an increased incidence of bronchogenic carcinoma and
it is now a frequently encountered malignancy, second
in males only to carcinoma of the stomach.
That the present results of treatment leave much to
be desired is emphasized in a recent report by Ochsner1
where it is shown that out of every twenty-five cases of
carcinoma of the lung only nine are suitable for pulmo-
nary resection and of these nine only two will survive
five or more years. These same results are duplicated
in other clinics. However, Ochsner did show that when
the growth was limited to the lung at the time of sur-
gery the survival rate was 42.8 per cent at the end of
five years. These figures emphasize the imperative need
of earlier diagnosis. The cytologic examination of bron-
chial secretions is a measure helpful in meeting this re-
quirement. Before discussing the indications for, and
technique used in examining these secretions, the symp-
toms and present diagnostic agents should be reviewed.
Carcinoma of the lung is predominantly a disease of
males in the ratio of 9:1. Cough is the most frequent
early symptom in 90 per cent of cases. The sputum
raised is usually scant, increasing in amount as bronchial
obstruction progresses. Chest pain occurs in 60 to 70
per cent. This pain may be mild but often the patient
alone can localize the lesion by a sensation of pain deep
in the chest. Hemoptysis varying from a few streaks
to several ounces of blood occurs in 60 per cent of cases.
Such bleeding should be considered the result of an
intrabronchial growth unless x-ray and sputum examina-
tions are positively those of bronchiectasis or tubercu-
losis. Half of the cases present histories of previous
respiratory tract infections. The diagnosis of a virus or
unresolved pneumonia in a male over 40 years is haz-
ardous until carcinoma of the lung is excluded. Uni-
lateral wheeze is of definite diagnostic significance be-
cause it is usually the result of some degree of bronchial
obstruction.
There is no one symptom characteristic of lung car-
cinoma. It masquerades as one of the more common
lung disorders. Valuable time must not be wasted
through erroneous diagnoses of unresolved pneumonia,
lung abscess, bronchiectasis, heart disease, and asthma.
In the diagnosis the roentgenogram of the chest will
show an abnormal shadow in almost every instance of
lung carcinoma, but it will not make a positive diagnosis.
The shadows cast demand active investigation. Second
*Read at the North Dakota State Medical Association meet-
ing at Minot, North Dakota, May 16, 1949.
fFrom the Fargo Clinic, Fargo, North Dakota.
to the chest x-ray in establishing a diagnosis is bronchos-
copy. The direct inspection of the bronchial tree gives
valuable information and in bronchiogenic carcinoma a
positive tissue biopsy can be obtained at most in only
60 per cent of the cases. It must be remembered that
in one-half of the cases the growth is in either upper
left or upper right lobe, making access to the lesion
virtually impossible. It is in the attempt to increase the
percentage of positive diagnosis prior to surgery that
cytologic examination of bronchial secretions has ap-
peared as a distinct advance. This procedure was de-
scribed by Dudgoen and Wrigley ~ of England in 1935,
but to Papanicolaou'1 goes a great deal of credit for plac-
ing the cell smear method of diagnosing cancer on a
sound basis.
In preparing sputum smears a freshly expectorated
specimen from the bronchi is collected in 95 per cent
alcohol, with the patient previously instructed to collect
only that sputum raised from the lower respiratory tract.
The best specimen is usually obtained in the morning.
This specimen is smeared on a glass slide, fixed with
alcohol and ether, and then stained with hematoxylin
and eosin. When a bronchoscopy is performed the tech-
nique differs in that specimens are obtained from the
right and left main stem bronchi using separate aspirat-
ing tips in each instance. Then the bronchus of the lobe
harboring the lesion under suspicion is lavaged with
2 to 5 cc. of normal saline while the patient is rotated
to that side; the lavaged material is then aspirated as a
single specimen. Bronchial secretions collected in this
way are then centrifuged. The material thus thrown
down is smeared on slides and processed exactly as sputa
smears. Five slides are made of each specimen. Prepared
slides are then screened by a technician trained in cytol-
ogy. Slides showing suspicious malignant cells are exam-
ined by our pathologist, Dr. John LeMar. No slide is
reported negative until after a twenty-minute search has
been made. The method is time-consuming and requires
one trained in this procedure, the percentage of positive
results increasing with the experience of the cytologist.
The general characteristics of cancer cells in bronchial
secretions are scant cytoplasm and the nuclei are large
in proportion to the cytoplasm. Recognition of the tu-
mor cell is by nuclear changes. The nucleus is hyper-
chromatic, its border sharp appearing almost like a re-
touched photograph. The nucleoli are large, often mul-
tiple and prominent. Mitotic figures are rarely encoun-
tered as these are cells sloughed from the surface of the
tumor and are not from the active growth center. There
is close correlation between the cells of the smear and
those of the tissue specimen from the same patient.
352
The Journal-Lancet
The results of various workers in this field are rather
uniform. Gibbon, et al,4 report a positive preoperative
diagnosis of bronchiogenic carcinoma in 90 per cent of
cases. Thirty-six per cent of these cases were negative
to bronchoscopic examination and positive diagnosis was
made on cytology of bronchial secretions. Liebow, et al,'J
report a 48 per cent increase in preoperative diagnosis
over bronchoscopic biopsies.
The following case presentations illustrate the points
emphasized in this paper:
Case 1, No. 86494. A 46-year-old white female was
first seen complaining of generalized aching in her joints,
Fig. 1. Chest x-ray Case 1 showing small area (arrow) pneu-
monitis right middle lobe.
a nocturnal cough productive of mucopurulent sputum,
and some dyspnea on climbing stairs. Past history was
negative. Family history revealed one paternal grand-
mother died of carcinoma, site unknown. Physical ex-
Fig 2. Group of tumor cells from sputum Case 1. Note
prominent nucleoli.
amination was essentially negative. A chest x-ray taken
at this time showed a slight patchy infiltration in the
right lower lung field (Fig. 1). Sputum specimens were
obtained and the second specimen was reported positive
for neoplastic cells (Fig. 2). Subsequent bronchoscopy
revealed an entirely normal tracheobronchial tree but
bronchial secretions obtained from the right middle lobe
bronchus were reported positive for neoplastic cells. On
the basis of this evidence, the patient was prepared for
surgery and an exploratory thoracotomy was performed
on the right side through the bed of the fifth rib. Upon
examining the right lung I was impressed by one thing;
namely, the absence of positive findings, a direct con-
trast to previous experience in carcinoma of the lung.
There was a slight feeling of induration toward the
periphery of the middle lobe on its inferior surface.
With the evidence of two positive smears, one being
from the right middle lobe, a total right pneumonectomy
Fig. 3. Right lung removed at operation Case 1. Lower arrow
points to site of undifferentiated bronchiogenic carcinoma middle
lobe, upper arrow to lymph node producing bronchial compres-
sion and secondary bronchiectasis.
was then carried out. There was no hilar lymph node
involvement. The patient withstood surgery well and
the postoperative course was uneventful. The patholo-
gist’s report on the surgical specimen was "specimen con-
sists of the entire right lung (Fig. 3). A nodule meas-
uring 2x 1x0.5 cm. is present beneath the pleura of the
middle lobe on the lateral inferior surface. Microscopic
examination of this nodule (Fig. 4) shows an undiffer-
entiated carcinoma infiltrating between groups of alveoli.
Sections of hilar lymph nodes are negative. Diagnosis:
Carcinoma, undifferentiated type, right middle lobe.”
The patient returned to an active life three weeks after
surgery. Figure 5 shows her chest x-ray seven months
following surgery. It would seem that the chances of
this patient having a permanent cure of her bronchio-
October, 1949
353
Fig. 4. Microscopic appearance undifferentiated bronchiogenic
carcinoma Case 1.
genic carcinoma were excellent despite the fact that this
was of the undifferentiated type.
Case 2, No. 64976. A 64-year-old white male de-
veloped chills, temperature 103°, cough, and pain in the
left upper chest. He was given 300,000 units of one of
the longer acting penicillin preparations by his referring
physician and in twenty-four hours was afebrile, but a
productive cough persisted. X-rays at this time showed
Fig. 5. Case 1, seven months after right pneumonectomy.
Fig. 6. Case 2 showing a persisting left upper lobe pneu-
monitis secondary to squamous cell bronchiogenic carcinoma.
a pneumonitis of the left upper lobe. X-rays taken ten
days later, when the patient was referred for further
study, showed a persistence of the pneumonitis in the
left upper lobe (Fig. 6). Sputum was negative for neo-
plastic cells. On the basis of roentgenograms a bronchos-
copy was done, with findings negative except for edema
at the orifice of the left upper lobe bronchus. There was
nothing present for biopsy. Bronchial secretions from
Fig. 7. Bronchial secretion tumor cells Case 2. Squamous cell
carcinoma.
the left upper lobe showed squamous cell carcinoma
(Fig. 7). This case illustrates the previously empha-
sized point of a persisting pneumonitis in a male over 40,
the frequently negative bronchoscopic findings in an up-
per lobe lesion, and the fact that a higher percentage of
positive cytologic studies will be obtained from bronchial
aspirations than from sputa studies.
354
The Journal-Lancet
Comments and Conclusion
Diagnostic methods, until recently, have not kept pace
with the surgical treatment of bronchiogenic carcinoma.
Now cytologic examination of bronchial secretions is an
established reliable means of diagnosing lung cancer. It
does not replace already proven diagnostic measures but
is an adjunct that can increase to 90 per cent the per-
centage of preoperative diagnosis, thus enabling the
thoracic surgeon to proceed more confidently with radical
surgery. Future statistics as to five-year survivals follow-
ing pneumonectomy should reveal decided increase
through this method of earlier diagnosis.
References
1. Ochsner, Alton, DeBakey, Michael E., and Dixon, Leon-
ard: Primary Pulmonary Malignancy Treated by Resection.
Ann. Surg. 125:522-539, 1947.
2. Dudgeon, L. S., and Wrigley, C. H.: On the Demon-
stration of Particles of Malignant Growth in Sputum by Means
of the Wet-film Method. J. Laryng. and Otol. 50:752-763,
1935.
3. Papanicolaou, George N.: Diagnostic Value of Exfoliated
Cells from Cancerous Tissues. J A M. A. 131:372-378, 1946.
4. Gibbon, John H., Jr., Cleif, Louis H., Herbert, Peter A.,
and DeTuech, John J.: Diagnosis and Operability of Bron-
chiogenic Carcinoma. J. Thoracic Surg. 17:419-427, 1948.
5. Liebow, Averill A., Lindshag, Gustav E., and Bloomer,
William E.: Cytologic Studies of Sputum and Bronchial Secre-
tions in the Diagnosis of Cancer of the Lung. Cancer 1:223-
237, 1948.
FUNDS GIVEN FOR CANCER RESEARCH
The Federal Security Administration has announced Public Health Service grants
totaling $3,250,000 to assist in the construction of cancer research facilities at nine
institutions.
The grants were made by the National Cancer Institute of the National Institutes of
Health, Research Branch of the Public Health Service upon recommendation of the Na-
tional Advisory Cancer Council, and approved by Surgeon General Leonard A. Scheele of
the Public Health Service.
All the construction grants were made to institutions with a strong affiliation to medical
schools, Dr. Scheele pointed out. "These grants will tend to strengthen the medical schools,
by forging a closer link between medical research and medical education. Our chief aim in
making the grants is to further cancer research by helping provide more adequate facilities
for cancer investigators, but the strengthening of medical education, especially in regard to
the cancer training of future physicians, is an important by-product.”
"The Federal grants permit additions to existing structures, or supplement funds con-
tributed by the institutions themselves or by outside donors.”
UNIVERSITY OF MINNESOTA GRANT
At the University of Minnesota, Minneapolis, Dr. Harold S. Diehl announced its por-
tion, a grant of $200,000 for two floors of clinical research at the Mayo Memorial Medical
Center now being built to house medical research at the University.
Ray Amberg, director of University of Minnesota Hospitals, said the university soon
will ask for bids on preparation of the site — expected to come to some $150,000. The site
will be the now-open space facing the University hospitals. There is a possibility that the
tower at the Center may go as high as 22 stories. Foundations will be built to carry that
high a structure, and the university will seek alternate bids for from 18 to 22 floors.
October, 1949
355
Cytologic Diagnosis of Carcinoma
John R. McDonald, M.D.,f and Lewis B. Woolner, M.D.J
Rochester, Minnesota
The rationale for the examination of secretions as a
diagnostic method is based upon the desquamation
of carcinoma cells from malignant tumors having a free
surface. Carcinoma cells may be collected and stained
by appropriate methods in whatever medium they occur,
sputum, vaginal secretions, or urine. The cells are then
recognized by certain atypical characteristics which they
possess, including large size, variation in size and shape,
hyperchromasia of the nucleus, and the presence of large
Fig. 1. Carcinoma cells in sputum. The nuclei are small
but there are prominent nucleoli (hematoxylin and eosin stain;
x 750) .
nucleoli (Figs. 1 and 2) . Occasionally, one finds actual
pieces of tumor tissue in the secretion.
Carcinoma of the Uterus
The use of vaginal smears in the diagnosis of car-
cinoma was first reported by Papanicolaou 1,2 in 1928.
In 1943, Papanicolaou and Traut " reported that micro-
scopic examination of vaginal smears failed to disclose
carcinoma cells in 3.2 per cent of 127 cases of carcinoma
of the cervix. They also said that this diagnostic method
failed to disclose carcinoma cells in 9.3 per cent of 53
cases of primary carcinoma of the uterine fundus.
Fremont-Smith, Graham and Meigs 4 reported that a
falsely positive diagnosis of carcinoma was made on the
*Read at the North Dakota State Medical Association meet-
ing at Minot, North Dakota, May 16, 1949.
jSection on Surgical Pathology, Mayo Clinic, Rochester,
Minnesota.
basis of examination of vaginal smears in 55 (1.6 per
cent) of 3,327 cases in which carcinoma was not present.
In general, examination of vaginal smears has been
found to be a more accurate diagnostic method in cases
of carcinoma of the cervix than it has been in cases of
carcinoma of the fundus. Essentially similar findings
have been reported by Ayre and by Jones, Neustaedter
and Mackenzie.1’
Microscopic examination of vaginal smears is most
useful in the diagnosis of pre-invasive carcinoma, or
carcinoma in situ. The gross appearance of this lesion
usually is not typical. At present, it is impossible to
Fig. 2. Carcinoma cells in sputum. The cells are larger than
those in figure 1 and the nucleoli are very prominent (hema-
toxylin and eosin stain; x 750) .
say how frequently carcinoma in situ of the cervix leads
to the development of infiltrative carcinoma and how
much time elapses before this transition occurs. The lit-
erature, however, contains reports of cases which suggest
that this lesion occasionally leads to the development of
infiltrative carcinoma. It is not known whether or not
carcinoma in situ is reversible in certain instances. Fre-
mont-Smith, Graham and Meigs 1 reported that this
diagnostic method disclosed carcinoma cells in 15 of 17
cases of carcinoma in situ of the cervix. An attempt was
made to obtain a specimen for biopsy in 13 of the 17
cases. In 1 of the 13 cases, a specimen could not be
obtained; in another case, the specimen was inadequate
and an attempt was not made to obtain another speci-
356
The Journal-Lancet
men. In 5 of the remaining cases, microscopic examina-
tion disclosed carcinoma in situ. In 1 of the 5 cases, the
first specimen was inadequate and it was necessary to
obtain another specimen. Foote and Stewart 8 made a
study of the site of the lesion in 27 cases of carcinoma
in situ of the cervix. They concluded that a positive
diagnosis of carcinoma could have been made in 25 of
the 27 cases if a specimen for biopsy had been removed
from the central junctional area of both the anterior
and posterior lips of the cervix and from the lateral
angles of the internal os in all of the 27 cases. It seems
reasonable to assume that microscopic examination of
vaginal or cervical smears will result in a more wide-
spread sampling of the cervical mucosa than will similar
examination of a single specimen which has been re-
moved for biopsy. The incidence of carcinoma in situ
of the cervix is more common than has been appreciated.
Pund and Auerbach'1 found that this lesion was present
in 3.9 per cent of 1,200 cervices which had been re-
moved by hysterectomy for pathologic conditions other
than carcinoma.
Some authors have maintained that examination of
vaginal or cervical smears could be applied profitably to
the screening of the female population at large in order
to detect carcinoma of the cervix in its early stages.
Foote and Li 10 have pointed out some practical objec-
tions to the use of this diagnostic method in such a
program. Assuming that carcinoma of the cervix affects
1 of every 1,500 women who are more than 35 years of
age and that it is necessary to examine 2 smears for each
woman, 3,000 smears would have to be examined in
order to detect a single instance of carcinoma. The mi-
croscopic examination of these smears would require at
least five hundred hours, or approximately 20 per cent
of a normal working year of three hundred working
days of eight hours each. It is obvious that a patholo-
gist could not afford to spend so much time examining
normal smears. It has been shown, however, that tech-
nicians can be trained to screen out smears which do not
contain any carcinoma cells. It is possible that this will
be the solution to the economic phase of the problem.
Carcinoma of the Lung
The practical application of cytologic examination of
sputum was first shown by Dudgeon and Wrigley 11 in
1935. They were able to detect carcinoma cells in spu-
tum in 68 per cent of 58 cases of proved carcinoma of
the lungs or respiratory tract. Herbut and Clerf 12 have
utilized bronchial secretions and washings, as obtained
by the bronchoscopist, for cytologic examination. They
have expressed the opinion that the examination of spu-
tum is time-consuming and that the results of such ex-
aminations are too inaccurate to be worth while. In our
laboratory at the Mayo Clinic, a diagnosis of carcinoma
of the lung has been made by means of cytologic exam-
ination of both sputum and bronchial secretions.13"17
The smears are fixed in ethyl alcohol and stained with
hematoxylin and eosin. It is our feeling that the ex-
perience of the person who is examining the smears is
more important than the type of stain that is used. In
examining sputum, we have prepared 5 smears of each
specimen of sputum and have attempted to obtain 3
specimens of sputum in each case.
Although smears are easier to prepare from fresh
sputum than from sputum that has been collected in
95 per cent ethyl alcohol, the collection of sputum in
ethyl alcohol has many advantages. One of these is that
the time that elapses between the collection of the spu-
tum and the preparation of the smear is not important.
In cases in which roentgenographic examination reveals
evidence of an intrathoracic lesion, we examine smears
of sputum routinely for carcinoma cells provided the
patients can produce sputum. The results which we have
obtained with this diagnostic procedure have been re-
ported previously. The advantages of using sputum in-
stead of bronchial secretions are obvious. Since sputum
is easy to obtain, multiple specimens can be examined
without causing the patient any discomfort. On the
other hand, examination of the sputum has certain dis-
advantages. It takes longer than the examination of
bronchial secretions or washings. In our experience, ex-
amination of smears of sputum or bronchial secretions
has resulted in a striking increase in the number of cases
in which a preoperative diagnosis of pulmonary neo-
plasm has been made. In general, it will disclose car-
cinoma cells in approximately 70 per cent of cases of
bronchogenic carcinoma whereas biopsy will reveal a
malignant lesion in about 40 per cent of such cases.
In from 1 to 2 per cent of cases in which examination
of smears of sputum has appeared to disclose carcinoma
cells, the resulting diagnosis of carcinoma of the lung
has proved to be erroneous. This percentage of error
is low enough to be accepted by clinicians and surgeons.
The method is of no value in the diagnosis of adenoma
of the lung. It is only of limited value in the diagnosis
of metastatic tumors of the lung because such tumors
frequently do not produce any ulceration of the bron-
chial mucosa. It is of value, however, in the diagnosis
of alveolar cell tumors.
Cytologic examination of sputum or bronchial secre-
tions is especially useful in the diagnosis of carcinomas
of the upper lobe which are beyond reach of the bron-
choscope. It likewise is useful in cases in which a car-
cinoma is situated at the periphery of either lung. It
is interesting to note that this method may disclose car-
cinoma cells in cases of such inaccessible neoplasms as
superior sulcus tumors.
Carcinoma of the Urinary Tract
If cytologic examination of urinary smears is to be
of value in the diagnosis of carcinoma of the urinary
tract, it is our opinion that it must be fairly accurate
in disclosing carcinoma cells in cases of carcinoma of
the kidney, particularly in cases of carcinoma of the
renal cortex or hypernephroma. Its value in cases of
carcinoma of the bladder is limited because the bladder
can be visualized easily with the cystoscope. On the
other hand, the kidney cannot be examined visually ex-
cept at open operation or after nephrectomy. In our
October, 1949
357
experience, examination of urinary smears has disclosed
carcinoma cells in approximately 50 per cent of cases
of hypernephroma. On the other hand, in more than
10 per cent of cases in which this method has appeared
to disclose carcinoma cells, the resulting diagnosis of a
malignant lesion has proved to be erroneous. Since this
figure is too high to make the use of the method prac-
ticable, we have almost abandoned its use in the diag-
nosis of carcinoma of the kidney.
The diagnosis of occult carcinoma of the prostate is
a difficult problem. A preliminary investigation has dis-
closed that examination of prostatic smears obtained
after prostatic massage is a fairly accurate method of
making the diagnosis of carcinoma of the prostate. In
such smears one can actually find clumps of tumor
tissue. The clusters of cells differ from other forms of
exfoliated cells in that the cells are forcibly broken off.
This method, however, will need more careful evalua-
tion before its final role in the diagnosis of carcinoma
of the prostate can be determined.
Carcinoma of the Stomach
There has been considerable difficulty in obtaining
satisfactory material for cytologic examination in cases
of carcinoma of the stomach. The main difficulty lies
with the enzymes of the stomach, which very quickly
destroy nuclear detail of exfoliated cells. In the main,
two types of material have been used for cytologic ex-
amination in cases in which the presence of carcinoma
of the stomach is suspected: (1) gastric contents which
are obtained by aspiration after the patient has fasted
for at least twelve hours, and (2) gastric washings which
are obtained by washing the stomach with isotonic so-
dium chloride solution after the gastric contents have
been evacuated. In our experience, cytologic examina-
tion of the gastric contents or gastric washings has
proved to be an accurate method for detecting the pres-
ence of carcinoma of the stomach but the number of
cases in which it has resulted in an erroneous diagnosis
of carcinoma |ras been higher than desirable.
In cases of carcinoma of the lower end of the esopha-
gus or of the cardia of the stomach, cytologic examina-
tions of smears of material obtained by the esophagosco-
pist by direct vision frequently will disclose carcinoma
cells. This method of diagnosis is particularly valuable
in such cases because it is difficult to obtain specimens
for biopsy. In our experience, the use of this method
has resulted in a diagnosis of carcinoma of the lower end
of the esophagus or of the cardia of the stomach in
approximately 100 cases. The diagnosis of carcinoma
subsequently was proved to be erroneous in only 3 of
these cases. In each of these 3 cases, the lesion proved
to be a benign ulcer which was situated at the cardio-
esophageal juncture.
Summary
Cytologic examination of body secretions is a time-
consuming task which requires considerable experience.
It also is an expensive procedure. We have found that
this method of examination is most useful in the diag-
nosis of bronchogenic carcinoma. It is of little value in
the diagnosis of carcinoma of the urinary tract. It if
of definite value in the diagnosis of carcinoma of the
cervix. In cases of carcinoma of the stomach, esophagus
or prostate, it must be evaluated further before definite
statements can be made.
References
1. Papanicolaou, G. N.: New Cancer Diagnosis, Proc.
Third Race Betterment Conference, p. 528, 1928.
2. Papanicolaou, G. N.: A New Procedure for Staining
Vaginal Smears, Science, n.s. 95:438, 1942.
3. Papanicolaou, G. N., and Traut, H. F.: Diagnosis of
Uterine Cancer by the Vaginal Smear, New York, The Com-
monwealth Fund, p. 56, 1943.
4. Fremont-Smith, Maurice, Graham, Ruth M., and Meigs,
J. V.: The Cytologic Method in the Diagnosis of Cancer, New
England J. Med. 238:179, 1948.
5. Ayre, J. E.: A Simple Office Test for Uterine Cancer
Diagnosis, Canad. M. A. J. 51:17, 1944.
6. Jones, C. A., Neustaedter, Theodore, and Mackenzie, L.
L. : The Value of Vaginal Smears in the Diagnosis of Early
Malignancy; A Preliminary Report, Am. J. Obst. & Gynec.
49:159, 1945.
7. Fremont-Smith, Maurice, Graham, Ruth M., and Meigs,
J. V.: Vaginal Smears as an Aid in the Diagnosis of Early
Carcinoma of the Cervix, New England J. Med. 237:302, 1947.
8. Foote, F. W., Jr., and Stewart, F. W.: The Anatomical
Distribution of Intraepithelial Epidermoid Carcinomas of the
Cervix, Cancer 1:431, 1948.
9. Pund, E. R., and Auerbach, S. H.: Preinvasive Carcino-
ma of the Cervix Uteri, J.A.M.A. 131:960, 1946.
10. Foote, F. W., and Li, Katherine: Smear Diagnosis of
In Situ Carcinoma of the Cervix, Am. J. Obst. & Gynec.
56:335, 1948.
11. Dudgeon, L. S., and Wrigley, C. H.: On the Dem-
onstration of Particles of Malignant Growth in the Sputum by
Means of the Wet-film Method, J. Laryng. & Otol. 50:752,
1935.
12. Herbut, P. A., and Clerf, L. H.: Cancer Cells in Bron-
chial Secretions, M. Clin. North America 30:1384, 1946.
13. Woolner, L. B., and McDonald, J. R.: Bronchogenic
Carcinoma: Diagnosis by Microscopic Examination of Sputum
and Bronchial Secretions: Preliminary Report, Proc. Staff Meet.,
Mayo Clin. 22:369, 1947.
14. Woolner, L. B., and McDonald, J. R : Carcinoma Cells
in Sputum and Bronchial Secretions; a Study of 150 Consecu-
tive Cases in Which Results Were Positive, Surg., Gynec. &
Obst. 88:273, 1949.
15. Woolner, L. B., and McDonald, J. R.: Diagnosis of
Carcinoma of the Lung; the Value of Cytologic Study of
Sputum and Bronchial Secretions, J.A.M.A. 139:497, 1949.
16. Albers, D. D., McDonald, J. R., and Thompson, G. J.:
Carcinoma Cells in Prostatic Secretions, J.A.M.A. 139:299,
1949.
17. McDonald, J. R., and Woolner, L. B.: Cytologic Exam-
ination of Sputum and Bronchial Secretions in Diagnosis of
Bronchogenic Carcinoma (Editorial) , Surg., Gynec. & Obst.
88:676, 1949.
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358
The Journal-Lancet
Carcinoma of the Larynx"
Jerome A. Hilger, M.D.
St. Paul, Minnesota
Because the cure of a carcinoma so often implies
sacrifice of function, carcinoma of the larynx is
viewed with dread by doctor and patient. Actually laryn-
geal carcinoma is a most favorable malignancy when it
is confined within the laryngeal box. Early diagnosis
coupled with adequate therapy can, for example, in a
mid-cord lesion of small size, promise a 93 per cent five-
year cure rate.
Forty per cent of laryngeal carcinoma occurs in the
decade from 50 to 60 years of age. The spread, how-
ever, is from age 10 to 90 years. It is predominantly,
but not exclusively, a disease of males. The etiology
is as obscure as it is in most carcinoma.
For purposes of discussion it is important that lesions
within the larynx be differentiated from those involving
the extrinsic aspects of the larynx.
To be truly intrinsic a lesion must be cordal with infil-
tration confined between the verticular band and im-
mediate subglottic area. The early symptom is hoarse-
ness. Approximately 90 per cent originate on or near
the free, phonating margin of the cord. A change in
voice is inevitable, and in a social world one can ask
for no more expressive and apparent symptom. Hoarse-
ness demands an adequate laryngeal view. False assur-
ance and palliative piddling expend valuable time and
are reflected in rapid decline in curability rate.
Intrinsic laryngeal malignancy tends to be of grade one
or two malignancy of the squamous cell type. There is
question as to the value of grading. Nevertheless, grade
one and two may be accepted as having a better prog-
nosis than grade three and four. The extension of the
lesion plus the grade of malignancy is of more prognostic
value than grade alone.
Surgery, radiation therapy, or combinations of the two
are the usually accepted modes of treatment. Cody has
recently made a signal contribution to therapy by assem-
bling the figures in 25,000 cases reported over the last
decades by otolaryngologists, general surgeons, and ra-
diologists. Clarification in this manner is impartial and
invaluable. Few medical men are blessed with the long-
evity and tumor volume necessary to formulate opinions
as sound as those accumulated from many sources of
diverse viewpoint.
Intralaryngeal surgery through one of several direct
endoscopic approaches to the larynx has a very limited
place in treatment of laryngeal carcinoma. A 5 milli-
meter midcord lesion treated adequately in this manner
can expect a 93 per cent cure rate.
*Read at the North Dakota State Medical Association meet-
ing at Minot, North Dakota, May 16, 1949.
Midline or near-midline division of the thyroid car-
tilage through a central neck approach, so-called laryngo-
fissure, gives clear access to the larynx and permits ex-
cision of lesions of one cord showing good mobility
without involvement of artenoid posteriorly or commis-
sure anteriorly. Those lesions reaching within millimeters
of the anterior end of the cord at the commissure should
be approached by the modified, so-called commissure,
technique to the normal side of midline. Lesions which
cross the anterior commissure to the opposite cord in
any degree should not be condemned to a conservative
laryngofissure, but should have laryngectomy. Adherence
to these principles can produce a five-year cure rate of
76 per cent in lesions of laryngofissure extent. Postopera-
tive death from laryngofissure is but 2 per cent. Irradia-
tion in this type of case offers a cure rate of 67 per cent.
Irradiation has a greater morbidity and is attended by
more complications.
Intrinsic laryngeal carcinoma of wider extent than the
select cases above require a total laryngectomy. It offers
a five-year cure rate of 60 per cent. If cervical nodes
are already involved metastatically and are removed by
block dissection the rate can still be 30 per cent. If,
through unwise conservatism, one has performed an un-
successful fissure, the follow-up total laryngectomy can
provide a five-year cure in only 39 per cent, as compared
with 60 per cent as a first procedure, while irradiation
can provide a 35 per cent cure rate. If cervical nodes
appear after a total laryngectomy, a block dissection can
offer a 40 per cent five-year cure.
If one is moved to select irradiation as a mode of
therapy for a case which would be amenable to total
laryngectomy, resection of the laryngeal cartilages to
avoid the continuing misery of perichondritis is a recog-
nized first step. Irradiation after cartilage resection can
offer a five-year cure rate of 38 per cent as compared
with 60 per cent for total laryngectomy. Irradiation as
salvage therapy for operated cases is of real value and
can salvage 30 per cent of cases with recurrence. As a
palliative measure in extensive inoperable cases, irradia-
tion is inadmissible. It increases suffering and shortens
life.
Extrinsic laryngeal carcinoma originates outside the
glottic larynx and tends most frequently to appear on the
epiglottis and on the posterior aspect of the cricoid ring.
Symptoms appear late. Pain, often referred through
tenth nerve pathways to the ipsilateral ear, and obstruc-
tive dysphagia are most common. The lesion may be well
advanced at the time of first complaint. There is no
substitute for a thorough mirror examination of all hypo-
pharyngeal complaints. Many are functional but one
cannot differentiate from the far side of a consultation
desk. Extrinsic lesions tend to be of grade two and three
October, 1949
359
malignancy and for this reason they are sometimes
spoken of as "radio sensitive.” One should not confuse
radio sensitivity with radio curability, as they are not
synonymous.
Free-margin epiglottic lesions can be completely re-
moved with surgical diathermy with a suspension laryn-
goscopic exposure. The prognosis will be good. If the
lesion has extended to the tongue base, its destruction
with cautery and implantation of the base with radon
seeds can give a cure rate of less than 50 per cent.
Post-cricoid lesions have the least favorable outlook of
all laryngeal lesions. Radio curability approximates nil.
Progressive dysphagia, eventual gastrostomy, laryngeal
extension, or inferior laryngeal nerve invasion with pa-
ralysis, and eventual tracheotomy form a succession of
tragic preludes to death. Laryngectomy combined with
pharyngectomy and upper esophagectomy is indicated if
extensions and fixation do not prevent. A large cervical
skin flap can be utilized to join hypopharynx to esopha-
gus and is closed in tube-like pharyngeal fashion at a
second procedure in several weeks.
Partial laryngeal removal through intralaryngeal or
laryngofissure approach impairs laryngeal function but
does not destroy it. The patient retains a hoarse but
useful voice. Total laryngectomy brings the breathing
stoma of the trachea to a permanent position at the base
of the neck anteriorly and leaves no natural phonatory
mechanism. Artificial voice production through a reed-
like attachment to the tracheal stoma has many disad-
vantages including the handling of a conspicuous and
messy mechanical device and the duck-like quality of the
resultant speech. Phonation with an electric buzzer plate
applied near the hyoid area has also the nuisance of
device and batteries and the production of an abnormal
tone. Eructation of small amounts of air aspirated into
the esophagus can, on the other hand, produce a tone of
amazing clarity which can be molded into speech in the
normal manner. Esophageal speech produced in this way
is an adequate substitute for laryngeal speech and is a
skill within the power of the average individual to de-
velop to a fine degree. It removes much of the disability
which formerly was the penalty incurred in laryngeal
surgery.
To all who deal with malignant disease frustrations
and defeat are commonplace. One too often labors dili-
gently in surgery for hours and struggles with a patient
through a difficult and trying postoperative period — and
then confronts a recurrence, local or metastatic, when
all had seemed to be going so well. It must occur to all
of us in our present-day handling of malignant disease
that we are cutting down the tree by whittling it away
a twig at a time. Until better methods are brought for-
ward we must continue to whittle, because it is better to
attack a problem in an unsatisfactory manner than not
to attack it at all. It is to be hoped that the bulk of
funds from our national cancer campaigns will continue
to be spent at the trunk of the problem and not be
frittered away in popular magazine assaults on imaginary
mitotic figures.
Summary
1. Laryngeal carcinoma appears in the practice of the
average physician at some time in his career.
2. In the majority of cases the symptom of voice
change appears early in the disease.
3. The prognosis for cure is exceptionally high for
malignant disease.
4. The five-year cure rate declines rapidly with delay
in diagnosis.
5. The proper method of treatment varies in the indi-
vidual case and is reasonably well established on statis-
tical grounds.
6. Loss of speech function is no longer an irremediable
tragedy.
CORTISONE MAY HELP VICTIMS OF HAYFEVER
Cortisone, the new and famous though scarce remedy for rheumatoid arthritis, may point
the way to better treatment for hayfever, asthma and other allergies. This suggestion comes
from Dr. Louis Prickman of the Mayo Clinic where only four months ago Cortisone’s value
in rheumatoid arthritis was discovered.
Cortisone is not suggested directly as a remedy for allergies in Dr. Prickman’s report.
He sees its success in relieving arthritis symptoms as showing "a promising new direction for
allergic research.”
"Rheumatoid arthritis and allergic diseases,” he points out, "have any number of features
in common and the underlying mechanism may be the same.”
The allergic reaction, whether it comes as hayfever, asthma, hives or a reaction to peni-
cillin, is a defensive process, Dr. Prickman explains. It is a "warning on the part of nature”
that the cells of the body have met a harmful substance.
360
The Journal-Lancet
Surgical Therapy for Duodenal Ulcer
Angus L. Cameron, M.D.*
Minot, North Dakota
Controversy still continues about treatment of pep-
tic ulcers of the duodenum. A generation ago the
most lively discussions concerned the question of medical
versus surgical management. At that time the surgeons
were in almost complete agreement. With few excep-
tions they advocated and performed gastro-enterostomy
or pyloroplasty, usually the former, as routine surgical
procedures for chronic duodenal ulcer. The introduction
of partial gastric resection for peptic ulcer cases in 1918
by Finsterer caused some controversy among the surgeons
themselves over the operation of choice, but for longer
than a decade this technique won relatively few converts
in America. The time was near at hand, however, when
practically all would abandon their time-honored prefer-
ment for gastro-enterostomy or pyloroplasty in favor of
partial gastric resection. The explanation for this radical
and quite universal switch in surgical procedure was
found in the realization, after long years of observation,
that gastro-enterostomy and pyloroplasty failed too often
to help cure the ulcer whereas partial gastric resection
gave promise of much better results.
The notable slowness of surgeons to employ partial
gastric resection was also due to several other factors.
In the first place it was found to be a much more diffi-
cult operation to perform than gastro-enterostomy. Seri-
ous misinformation about what constituted a satisfactory
partial gastric resection prevailed for a long time. Dan-
gerous and wholly unnecessary innovations increased
greatly the already alarmingly high mortality and mor-
bidity rates even in the best surgical clinics of this coun-
try. Teaching institutions had to learn the hard way
that skill and experience count more for the success of
this operation than they do for many other major ab-
dominal procedures and that unusual care and super-
vision are necessary in training young surgeons in this
field. About twenty years of trial and error with partial
gastric resection were necessary before it achieved its
present well-deserved place as a relatively safe and satis-
factory operation when performed by a competent sur-
geon. In most places it has earned and enjoyed this
status for less than a decade. Thus Dr. Henry F. Gra-
ham reported that the mortality of subtotal gastric re-
section at the Methodist Hospital in Brooklyn for both
gastric and duodenal ulcer cases from 1936 to 1940
"was so high that I hate to mention it” and he didn’t,
but he did report that from January 1, 1940 to May,
1944 there had been only one death among 77 such
operations performed there. The initial mortality rate
at the University of Iowa was 28 per cent. McKittrick
reported a mortality rate of 8.1 per cent for 124 duo-
*The Department of Surgery, Northwest Clinic, Minot,
North Dakota.
denal ulcer cases at the Massachusetts General Hospital
from 1936 through 1941 and he found in addition to
this 27 major postoperative complications which endan-
gered the life of the patient. According to his report,
therefore, 37 or 30 per cent of this group of 124 duo-
denal ulcer cases subjected to subtotal gastrectomy either
died or had some serious complication. On the other
hand, during 1942 and 1943, 94 duodenal ulcer patients
had subtotal resections at the Massachusetts General
Hospital without a death and with very few complica-
tions. This data is quite typical of the remarkable im-
provement in mortality and morbidity rates for such
operations in recent years in leading surgical clinics of
this country.
Almost simultaneously with these notable achievements
of subtotal gastrectomy has been the re-introduction of
vagotomy as a preferable operation for these ulcer cases.
So the controversy flares up anew over the question of
how best to treat them surgically, and to add to this
confusion gastro-enterostomy and pyloroplasty are again
finding favor as adjuncts to vagotomy. Time will be
required to settle a lot of the present-day conflicting
claims and contentions. In the meantime we will be con-
tent at the Northwest Clinic to depend upon adequate
subtotal gastric resection as the operation of choice for
the 10 to 15 per cent of chronic duodenal ulcer cases
which fail, for one reason or another, to obtain satisfac-
tory results under medical management. We feel that
our experience in a small series of cases together with our
knowledge of the excellent results obtained in numerous
leading surgical centers in this country amply justify
our stand.
The primary purpose of this or any other operation
or treatment for ulcer is, or should be, to curtail the
corrosive action of gastric juice sufficiently to permit
healing. Adequate gastric resection accomplishes this
in several ways. Resection of two-thirds to three-fourths
of the stomach removes a substantial and usually a suffi-
cient mucosal area of acid-secreting cells. An adequate
resection also eliminates completely the very potent gas-
trin-forming and acid-cell-stimulating antral glands which
are found not only in the mucosa of the antrum itself
but also along the lesser curvature of the stomach almost
to the esophagus. A third important factor, no doubt
attributable to the operation, is the dilution and neu-
tralization of the remaining gastric juice by the content
of the duodenum which now mixes more freely with it.
Still another factor in ulcer healing is the isolation of
the duodenal ulcer which is no longer subjected to the
mechanical and chemical insults which it normally sus-
tains.
October, 1949
361
One of these several factors conducive to ulcer healing
requires special consideration. I refer to the so-called
antral cells and the necessity for their complete removal.
Failure to accomplish this was an early mistake and no
doubt continues to be one though much less frequently
than formerly. Finsterer himself was largely responsible
for this because of his so-called resection for occlusion
in cases of difficult closure of the duodenal stump. Clos-
ure in these cases was accomplished by transecting the
antrum and leaving part of it behind — mucosa and all —
for easier and more secure suturing than that afforded
by an unsatisfactory duodenal stump. Even though ev-
eryone now concedes the positive necessity of complete
removal of the antral mucosa in every case failure to
accomplish this is still a not infrequent error which is
quite certain to cause serious trouble promptly.
The best way of insuring complete removal of all
antral cells is to perform a partial gastric resection in-
cluding all of the antrum and practically all of the lesser
curvature. This is possible in most instances, but it is
conceded that there are occasional cases in which closure
of the duodenal stump is likely to present almost insur-
mountable technical difficulties if none but duodenal
tissue is available for suturing. I have never encountered
such a case and do not believe that they occur nearly
as often as some surgeons report. However, in the pres-
ence of marked scarring, shortening of the first and sec-
ond portions of the duodenum, and bewildering involve-
ment of adjacent structures, an operation short of the
ideal type finds favor in many places. A two-stage op-
eration may be performed in which transection of the
antrum is carried out in the first stage with sufficient
amount of the distal segment left for closure. It is much
easier and safer to remove this antral segement at a sec-
ond operation after subsidence, in part at least, of the
inflammatory reaction about the pylorus. It should be
emphasized, however, that the second stage of the op-
eration must follow the first after an interval of not
more than a few weeks because of the great danger of
early stomal ulceration due to the retained antral mucosa.
Another procedure is a one-stage operation in which the
antrum is transected and utilized for closure but only
after removal of its mucosa. The latter may prove to be
quite a bloody and otherwise uninviting procedure with
a high incidence of incomplete removal of the mucosa.
All of this discussion about the technical difficulties
encountered in and about the first and second portions
of the duodenum shows that here is the most difficult
part of most gastric resections for ulcer. The changes
in the duodenal stump to be closed incident to ulcera-
tion and operative procedures give rise to these difficul-
ties. Care in preserving all duodenal tissue possible for
closure is of the greatest importance and is too often
disregarded. As far as ultimate results are concerned,
it does not matter whether the duodenal ulcer is cut
through, cut out, or left entirely undisturbed. On the
other hand, in regard to the immediate postoperative
results, it is of greatest importance to preserve for clos-
ure every millimeter of duodenum possible with its blood
supply intact regardless of whether it bears an ulcer or
part of an ulcer. Avoidance of clamps will aid materially
in this effort at conservation without the introduction of
any objectionable features. Transection of the duodenum
can then be done very accurately just beyond the py-
lorus without sacrificing any of it. If this planned divi-
sion of the duodenum fails of perfect accomplishment
because of partial or complete division by traction at
the site of ulceration, one should of course still try to
preserve all duodenal tissue possible. Needless dissection
should be studiously avoided. This has led to many
deaths and serious complications by contributing to the
insecurity of duodenal closure with resulting postopera-
tive leakage. The most dangerous type of needless dis-
section attends the efforts to excise, not only the ulcer,
but the so-called ulcer-bearing area of the duodenum.
This has been referred to as an ideal objective without,
to my knowledge, any convincing evidence to support it.
As already stated, it is the very exceptional ulcer which
fails to heal if favorable conditions are created for heal-
ing. Therefore the employment of involved and risky
excision technic without promise of compensating bene-
fits appears to be inexcusable. Happily for the patient
few surgeons now advocate and practice this technic.
Some of the most experienced and skillful operators
have tried it and found it too dangerous for continued
employment. By his ill advised attempt to remove the
ulcer and ulcer-bearing duodenum an occasional operator
in this difficult field of surgery can quickly create a
situation too complicated for him to handle.
In no field of surgery is the often quoted dictum of
Deaver more applicable than here, which is: "cut well,
sew well, get well.” The duodenal stump can be trusted
to heal kindly and satisfactorily only when handled
according to this rule. No drain will then be necessary
although there is no objection to the use of a soft
rubber one.
Mention has already been made of the present-day
failure to remove adequate lengths of the lesser curva-
ture. Resection of practically all of it does occasionally
increase the difficulty of the operation, but this can be
readily accomplished without undue risk and should
always be done. A somewhat inaccurate and yet quite
satisfactory means of determining adequate removal in
this region is to measure the resected stomach segment.
It should equal 10 centimeters or more along its lesser
curvature. It has been observed quite consistently that
the incidence of recurrent ulcer symptoms is much
greater in the group with lesser curvature segments
shorter than 10 centimeters.
When gastric resections include all antral tissue and
two-thirds to three-fourths of the stomach there is little
likelihood of a recurrence of ulcer symptoms because of
the lasting curtailment of hydrochloric acid production.
This is true regardless of the exact type of resection em-
ployed. With the corrosive action of the gastric juice
eliminated permanently there is no preference, so far as
recurrent ulcer symptoms are concerned, between a
Polya, a Hofmeister, a Billroth No. 2, or any other type
of reliable resection. Likewise, when adequate gastric
362
The Journal-Lancet
resection has been performed, there is no evidence which
establishes the superiority of one type of good function-
ing anastomosis between gastric segment and jejunum
over another so far as the occurrence of stomal ulcers
and recurrent ulcer symptoms are concerned. Too much
has been written on this subject and too frequently im-
pressions of the authors have been given instead of sub-
stantial proof. There are real pitfalls too in the at-
tempts to translate results from animal experimentations
into deductions which apply to clinical cases. For the
cases under consideration there is no proven advantage
of the short loop posterior gastro-jejunostomy over the
long loop anterior type. Therefore both may be used
indiscriminately. I usually employ a Hofmeister type of
resection and a short loop posterior colic type of anasto-
mosis but if an anterior type of anastomosis appears to
be preferable I have no hesitancy in performing it.
Strict observance of these important factors in gastric
resection for duodenal ulcer will give, in good hands,
end results which are extremely satisfactory in 90 per
cent or more of cases and with mortality rates which
have dropped to as low as 1 or 2 per cent in recent out-
standing reports. This is particularly noteworthy in view
of the fact that under more or less accurate medical
management ulcer symptoms continued in these refrac-
tory cases and not infrequently were life-threatening due
to such serious complications as hemorrhage and obstruc-
tion. Also, a relatively high percentage of these cases
fall into the group which are major surgical problems
even for the most skillful and experienced operators.
These results are also gratifying because they concern
for the most part individuals who are relatively young
and therefore have the promise of many years of active
life if cured of their ulcer symptoms.
The present-day deaths and complications arise for
the most part from leakage of the duodenal stump — the
most usual cause of peritonitis and subdiaphragmatic in-
fection and abscess formation. These complications may
also originate from infection primary in and about the
ulcer and from contamination resulting from either nec-
essary or dangerous dissection.
Closed or so-called aseptic type of operative technic
has to be broken in many of these cases when one pre-
fers to employ it. It provides no safeguards over the
open type of resection and anastomosis so far as peri-
tonitis is concerned. The latter complication, as already
stated, arises from postoperative leakage of the suture
line, nearly always of the duodenal stump, and this leak-
age, whenever and wherever it occurs, is independent of
whether the suturing was done by the open or closed
technic. I always employ the open technic without any
clamp except the Von Petz, which simplifies and ex-
pedites closure of the open end of the proximal gastric
segment.
Wound sepsis or infection occurs occasionally but it
appears to be less frequent in recent years. It has made
its appearance in mild form ;n three of my cases on
whom I employed a transverse or modified transverse
incision and cut across one or both recti muscles. Since
discarding this incision for a left rectus or left para-
medial one, wound healing has been uneventful.
Every person subjected to extensive gastric resection
for ulcer must be prepared for a more or less long period
of readjustment in the matter of his greatly diminished
gastric capacity. The small stomach segment remaining
immediately after operation does not permit the inges-
tion of a full meal. After the lapse of a few months
to a year this limited capacity for food usually improves
considerably. In the meantime food must be taken
oftener than usual. Six meals per day are not infrequent.
Care should be exercised in the amount of food and
drink taken at one sitting. Overloading of the segment
of stomach remaining occurs frequently and easily,
especially during the first few months of convalescence.
The most frequent symptoms which follow subtotal gas-
tric resection, whether due to indiscretions in diet or not,
are epigastric distress, belching of gas, nausea, and vom-
iting after meals. Quite rarely some or all of these
symptoms occur in more aggravated form together with
sweating and weakness. This reaction, which has been
called the "dumping” syndrome, is usually an unex-
plained chain of symptoms which may be quite disturb-
ing but is seldom serious and as a rule clears up satis-
factorily with or without treatment.
Weight loss is frequent although substantial post-
operative gains are usual. Disturbing symptoms from
weight loss are infrequent; when present, weakness is
most likely to be the complaint.
The most disturbing symptoms which may follow
gastric resection after postoperative recovery are those
of continued or recurrent ulcer activity. Our experience
leads us to believe that such symptoms should be looked
upon as fairly reliable evidence of inadequate gastric
resection and, therefore, in the last analysis not due to
shortcomings inherent in the operation.
We continue to be interested in clinical laboratory
tests for acidity following an Ewald meal in order to
gain information about the adequacy of the gastric re-
section. Our patients have consistently shown no free
hydrochloric acid at any time postoperatively and, as is
to be expected under this favorable condition, no ulcer
symptoms either persistent or recurrent have confront-
ed us.
I have performed what I consider and have described
here as an adequate gastric resection for duodenal ulcer
on nineteen men and one woman since 1942. The young-
est was 28 years of age and three were 67 years old.
Of the remaining sixteen, three were in the fourth dec-
ade of life, nine in the fifth, and four in the first half
of the sixth. All, including the youngest, had had ulcer
symptoms over a period of years and all had received
medical treatment. In most instances it had been carried
out for long periods of time in an approved manner and
with satisfactory cooperation of the patient.
This group therefore represents the 10 to 15 per cent
of duodenal ulcer cases which fail to obtain satisfactory
relief on medical management and which should be
October, 1949
363
treated surgically. In fact, three of the group had
already been operated upon for ulcer — one had closure
of a perforation and the remaining two gastro-enterosto-
mies. A gastro-jejuno-colic fistula developed in one of
these cases and was causing severe symptoms at the time
of the gastric resection. Noteworthy bleeding had oc-
curred in nine of the 20 cases and in six of them it had
been repeated, massive and life-threatening, over periods
of several years. An unusual and distinct affliction, co-
arctation of the aorta, aggravated greatly the occurrence
of, and danger from, bleeding in one of these massive
hemorrhage cases, present in the youngest of the group.
Two of the bleeding ulcer cases also had high-grade ob-
struction. Only two others were likewise afflicted.
Six of the group had so-called refractory symptoms
without bleeding and without obstruction. In only one
instance was a gastric as well as a duodenal ulcer present.
The gastric ulcer, situated at the pylorus, was the cause
of the most disturbing symptoms which were those of
high-grade obstruction.
At the time of operation bewildering inflammatory
and scar tissue changes were found in five cases which
were due to ulcers penetrating into the pancreas and
hepato-duodenal ligament. In four more cases dense
adhesions made the operation difficult and closure of the
duodenal stump a matter of concern. Thus in nine or
nearly half of these 20 extensive gastric resections by far
the greatest technical difficulty was found in and about
the pyloric end of the stomach. In no instance was ex-
cision of the ulcer a primary objective and in no instance
was it known to be removed completely. A one-stage re-
section was employed exclusively. The pyloric end of
the stomach was always removed completely; no transec-
tions of the antrum with or without removal of the
mucosa were performed. The lengths of the lesser cur-
vature of the excised gastric segments were less than 10
centimeters in some of our earlier cases, but the latter
ones have measured from 13 to 18 centimeters.
No bleeding case was operated upon as an emergency.
All were well prepared for operation over a period of
days and weeks. There have been no deaths either opera-
tive or otherwise.
Two instances of subphrenic abscesses occurred. This
serious complication became manifest both times after
an apparently satisfactory immediate postoperative re-
covery and after discharge from the hospital. Both pa-
tients returned for successful drainage operations. Evi-
dence of infection in the right upper abdominal quadrant
appeared in two more cases after an uneventful imme-
diate postoperative convalescence and discharge from
the hospital. In each instance recovery without operation
followed subsequent hospitalization.
There is only one woman patient among these twenty
cases and she developed the so-called "dumping” syn-
drome without x-ray evidence of abnormal passage of
the barium meal into the jejunum and with no free
hydrochloric acid present after an Ewald meal. Two-
thirds of her stomach was removed for a refractory ulcer.
She complained of extreme nervousness, insomnia, pal-
pitation, occasional nausea and frequency of urination
before operation in addition to her ulcer symptoms.
After operation she felt well for a few weeks and then
began complaining again of nervousness, nausea, vom-
iting after meals, loss of weight, weakness and discour-
agement. Examination elsewhere including an x-ray
gastro-intestinal study failed to show anything note-
worthy. Now, twenty months after operation, she has
less trouble with nausea and vomiting and is able to
do her housework. Weight loss has not been regained.
All of these patients have had and are continuing to
have follow-up attention which, with few exceptions,
consists of repeated examinations at our clinic. They
all continue to live in this territory. None complain of
ulcer symptoms and all seem to be free from them.
Ewald test meals taken at all periods of time after op-
eration have shown no free hydrochloric acid. No bleed-
ing ulcer case has had a recurrent hemorhrage. No in-
stance of poorly functioning stoma has occurred. Most
of the group are farmers and many are performing the
hardest kind of farm work. In not a single case is
weight loss a matter of serious concern.
In summary, this report concerns twenty duodenal
ulcer cases which failed to obtain relief from symptoms
after more or less prolonged and accurate medical man-
agement. All have survived adequate gastric resections
without return of ulcer symptoms and with good evi-
dence of the complete and permanent elimination of the
corrosive action of the gastric juice. All, for whom time
and age permit, have resumed their work. Nineteen
or 95 per cent have had excellent results from surgical
therapy. There is reason to hope still for excellent re-
sults in 100 per cent of this group of duodenal ulcer
cases.
In all four of these cases considerable difficulty at
operation was encountered at the pylorus due to pene-
trating ulcers in two instances and adhesions with marked
distortion in all. The closure of the duodenal stump was
likewise difficult in all these cases but in each instance
it was considered satisfactory. Whether a subsequent
infection was due to leakage from the duodenal stump
in any of this group was never revealed. Unavoidable
contamination at operation is a likely explanation.
ANNOUNCEMENT
The University of Minnesota announces a continuation course in Traumatic and Pe-
diatric Surgery to be presented at the Center for Continuation Study on November 10, 11,
and 12, 1949. The course, which is intended for general physicians, will emphasize the diag-
nosis and management of surgical conditions occurring in children.
364
The Journal-Lancet
American College Health Association News
Infectious Mononucleosis*
C. J. D. Zarafonetis, M.D.
Ann Arbor, Michigan
nfectious mononucleosis is an important health
problem at many of our colleges and universities.
At the University of Michigan Student Health Service,
for example, 2,128 cases have been diagnosed since 1929
Table 1
Infectious Mononucleosis Occurring at the Univeristy of
Michigan*
Comparison of Cases — Years 1928-29 to 1947-48
Year
Number of Cases
Men Women Total
1928-29
1
0
1
1929-30
5
4
9
1930-31
1
4
5
1931-32
3
0
3
1932-33
3
4
7
1933-34
11
2
13
1934-35
19
4
23
1935-36
20
12
32
1936-37
27
10
37
1937-38
35
27
62
1938-39
41
18
59
1939-40
39
48
87
1940-41
63
58
121
1941-42
61
37
98
1942-43
40
29
69
1943-44 ....
87
49
136
1944-45
260
369
629
1945-46
105
102
207
1946-47
260
140
400
1947-48
88
42
130
(to March 1)
Totals 1169
959
2128
*University of Michigan Student Health Service. Data
through courtesy of Dr. W. E. Forsythe.
(Table 1). Although it is generally regarded as a
benign disease, over one-half of these student cases re-
quired hospitalization. After these patients recovered
sufficiently to leave the infirmary many experienced lassi-
tude, weakness, and ease of fatigue for prolonged
periods. Some students lost so much time from their
classes or did so poorly in their studies during the period
of convalescence that they were compelled to leave school
for the term. It is apparent, then, that infectious mono-
nucleosis is a significant health, academic, and economic
problem to many students as well as to educational
institutions. Furthermore, there are appearing in the
literature with increasing frequency, reports which indi-
cate that infectious mononucleosis cannot be dismissed
*From the Department of Internal Medicine, University of
Michigan, Ann Arbor, Michigan. This study has been made
possible by a grant from the Charles Stewart Mott Foundation.
as a benign disease of no clinical importance. Indeed,
infectious mononucleosis is a systemic infection which
may at times endanger life itself or cause serious resid-
ual damage to vital organs. Fatal cases, for example,
have been ascribed to infectious mononucleosis with
manifestations of central nervous system involvement.1
Encephalitis, meningeo-encephalitis, and the Guillain-
Barre syndrome have been observed in association with
this infection. Recovery from the acute process usually
occurred but in some instances paralytic sequellae re-
sulted.1,4 Splenomegaly, a common feature of infec-
tious mononucleosis, has been complicated occasionally
by spontaneous rupture of the organ.3,4 About half of
these cases terminated fatally.
The occurrence of a transient myocarditis in infec-
tious mononucleosis has been repeatedly demonstrated
in electrocardiographic studies.0’0 There are instances
of mitral stenosis which are believed to have been caused
by an attack of this disease.7
X-ray studies in some patients have revealed pulmo-
nary infiltrations indistinguishable from those of pri-
mary atypical pneumonia.0
The presenting complaint has at times been severe
abdominal pain suggestive of appendicitis and some of
these patients have undergone surgical procedures. Hepa-
titis, with or without jaundice, is relatively frequently
encountered. That renal involvement also occurs is evi-
dent from the occasional finding of gross or microscopic
hematuria, proteinuria, and casts. Thrombocytopenic
purpura, acute hemolytic anemia, and hemoglobinuria
have rarely been observed in infectious mononucleosis.
These examples by no means constitute an exhaustive
survey of the clinical features of infectious mononucleo-
sis. They are cited merely for the purpose of demon-
strating that the infection can give rise to serious clin-
ical manifestations. In addition, it is evident from these
findings that the problem of differential diagnosis in
infectious mononucleosis has become exceedingly com-
plex. The majority of cases present sore throat, lymph
gland enlargement and irregular fever but these symp-
toms and signs are by no means pathognomonic. When
one includes the occasional occurrence of skin rashes
in addition to the previously indicated findings, it is
evident that the clinician must rely on laboratory aids
in arriving at the diagnosis of infectious mononucleosis.
Ideally, this would be accomplished by the isolation
and identification of the causative agent but this is im-
practical, of course, since the etiology of the disease re-
October, 1949
365
mains unknown. Most observers, including ourselves,
believe it to be a virus infection and transmission experi-
ments to practically every known laboratory animal and
even to a few adult humans have been attempted with-
out success. Isolation studies carried out in this labora-
tory have also yielded negative results. Occasional claims
of successful passage have not been substantiated, and
Koch’s postulates remain unfulfilled.
There are two ancillary means of arriving at the lab-
oratory diagnosis of infectious mononucleosis. The first
of these is the examination of the blood for the presence
of an absolute lymphocytosis due largely to the appear-
ance of abnormal, though chiefly mature, lymphocytes.*
This finding is responsible for the name attached to the
condition by Sprunt and Evans.9 No attempt will be
made herein to characterize the morphologic aspects of
the cell changes observed in infectious mononucleosis
but it should be emphasized that the appearance of the
atypical lymphocytes in the blood of patients with this
disease is part of a dynamic response to the infection.
This is important since these so-called infectious mono-
nucleosis cells are known to persist for long periods after
the clinical attack and their presence in the blood of a
patient may have no relation whatsoever to the present
illness. The exact clinical significance of these cells,
especially when they are present in low numbers, can be
demonstrated only through repeated blood studies and
a comparison of findings. Progressive changes in the
number and morphology of these cells during the pa-
tient’s illness and convalescence would strongly suggest
the diagnosis of infectious mononucleosis. On the other
hand, if the cytologic picture remains relatively static,
it would mitigate against the diagnosis. Using these
criteria, the diagnosis can usually be made from the
characteristic leukocyte changes as they are observed to
occur in serial blood studies. Unfortunately, the cellular
response is not sufficiently characteristic in a significant
number of patients to warrant the unequivocal diagnosis
of infectious mononucleosis. It may be that the response
did occur but was not observed because of the timing
of blood examinations. There are cases, however, which
have been closely followed hematologically, in whom the
cellular picture could not be differentiated from that ob-
served in other conditions. Infectious hepatitis, for ex-
ample, gives rise to lymphocytic changes which are quite
similar to those seen in some patients with infectious
mononucleosis.1" Since jaundice is encountered at times
in the latter disease, it may be impossible to distinguish
these conditions either on clinical grounds or on the
basis of the blood findings. Thus, it is apparent that
laboratory examination of the blood may fail under cer-
tain circumstances to provide the evidence needed to
arrive at the correct diagnosis.
This lack of uniform success in the diagnosis of infec-
tious mononucleosis from the examination of the blood,
combined with the extremely varied clinical manifesta-
tions, led us to investigate the second laboratory pro-
cedure used in the diagnosis of this disease. This test,
the so-called heterophile agglutination reaction, is based
on the accidental discovery of Paul and Bunnell 11 that
serum specimens from patients with infectious mono-
nucleosis will agglutinate in high titre the red blood cells
of sheep. The test has not been entirely satisfactory in
the past and a significant number of so-called ''false
positive” reactions have been reported. A review of the
literature, however, suggested that many of the difficul-
ties were not inherent in the test but were due instead to
differences in technique, artifacts, and errors of interpre-
tation. Therefore it was decided to adopt a standardized
procedure and to study anew the heterophile agglutina-
tion reaction.
Basically, the technique of test used in this study is the
Paul-Bunnell method with the modifications suggested
by Stuart, et al,12 and by Keiper.13 Stuart and his asso-
ciates have shown that the concentration of sheep cells
employed in the test and the temperature at which the
tests are incubated exert a profound influence on the
degree of agglutination. The former of these variables
is rendered constant by making the final concentration
of sheen cells equal to 0.5 per cent in all of our tests.
Stuart further demonstrated that human sera may con-
tain antibodies which agglutinate sheep erythrocytes in
the cold and that this phenomenon is reversed by incuba-
tion at 37.5° C. Agglutination of sheep red blood cells
by infectious mononucleosis sera, on the other hand,
occurs at 37.5° C. This titre may be increased by over-
night refrigeration at 4° C. In order to dispel any
possible "cold agglutinin” effect the test should be re-
turned to the water bath (37.5° C) for two hours and
the final reading made.
The test employed in this study involves the use of
0.5 ml. volumes of serial two-fold dilutions of sera which
have been previously inactivated for 20 minutes at
56° C. To each tube is then added 0.5 ml. of a 1 per
cent suspension of washed sheep cells which are not
more than one week old. The sera and cells are mixed
thoroughly and incubated at 37.5° C for four hours.
At the end of this time the test is read and then placed
in the refrigerator where it remains overnight. On the
following morning another reading is taken immediately
after removing the tubes from the refrigerator. The test
is then returned to the water bath for two hours after
which the final reading is made. Readings range from
4+ (complete) to 0 (none). Agglutination of 2+ is
recorded when at least half of the cells in a tube are
estimated to be agglutinated. Any agglutination less
than 2+ is arbitrarily ignored in recording the end-
point titre.
The reason for using fresh sheep cells under one week
old is based on an important observation by Keiper.13
He noted that the use of sheep cells stored in 3.8 per
cent sodium citrate solution yielded inconsistent results
in heterophile antibody tests. In some instances, the
titres fell from as high as 1:1000 initially to 1:100 after
three weeks of storage.
Another important contribution by Keiper was his
demonstration that cells from different sheep are agglu-
tinated to a different degree by the same serum sample
from a case of infectious mononucleosis. Indeed, in
tests with cells from nine different sheep, one serum
gave titres ranging from 1:400 to 1:1400. Obviously,
366
The Journal-Lancet
such variations are of significant magnitude and must
be controlled if the test is to be of value. This can be
accomplished only by utilizing certain criteria which
apply to all serologic tests for acute infectious diseases.
The problem has been stated elsewhere 14 as follows:
" . . . serologic tests are most reliably diagnostic when
they reveal a progressive rise in titre in successive serum
samples taken during the course of illness and conva-
lescence. The determination of two or more points on
the arc of antibody dynamics is usually adequate for
diagnostic purposes. Occasionally, however, two serum
specimens may give identical titres having caught the
antibodies at the same level first during their rise and
then during their fall from an intermediate peak. In
addition, a plateau effect may be encountered, giving
rise to similarity of titres in samples taken during that
period.” The latter situation is more apt to occur when
the agglutination titres are high. This is in part a reflec-
tion of limitations inherent to the geometric method of
performing serum dilutions. While a rise in titre is the
most satisfactory index of antibody response to the dis-
ease process, it is also possible to make diagnostic infer-
ences from a progressive fall in titre. This becomes
necessary when the first blood sample is drawn after the
peak of antibody response has already been reached.
With these points in mind, it is evident that not only
must the technique be standardized, but there must also
be several blood specimens drawn from each patient.
In view of the wide differences in agglutinability of
sheep cells as indicated above all the sera from a patient
must be run in the same test in order to obtain a rela-
tive picture of the antibody change. To be sure, the
titres on the same sera can and do vary with different
lots of sheep cells. This is of no consequence since it
is only necessary to demonstrate a rise or fall in titre
to arrive at a serologic diagnosis. The tests on the sub-
jects studied in the present investigation have been
standardized in procedure as outlined above and for final
analysis all sera from each patient have been run to-
gether in the same test. Altogether, 3,385 serum samples
Table 2
Sheep Cell Agglutination Study of Mononucleosis at University
of Michigan (May 1946 to April 1948)
Number
Diagnosis Cases
Infectious mononucleosis 158
? Infectious mononucleosis 315
? Recurrent infectious mononucleosis 12
94 Miscellaneous clinical entities 737
Total 1222*^
*3385 serum samples from these patients.
from 1,222 individuals have been tested so far (Table
2) . Interpreted by the criteria presented above, the
results of these tests indicate that 158 of the patients
had infectious mononucleosis. Examples of the types of
responses obtained in these patients are presented in the
accompanying tables. A typical "rise and fall” type of
antibody curve is shown in Table 3, while Table 4
Table 3
Serologic Studies of Mononucleosis at University of Michigan.
Agglutination tests on a student nurse.
Days
Sheep Cell Agglutination Titre After:
from
4 hours
overnight
2 hours
Onset
at 37.5° C
at 4° C
at 37.5° C
4
1/64
1/256
1/64
10
1/256
1/1024
1/256
15
1/512
1/2048
1/512
22
1/256
1/1024
1/256
36
1/64
1/512
1/128
53
1/32
1/256
1/64
67
1/32
1/128
1/64
82
1/16
1/64
1/64
120
1/16
1/128
1/64
illustrates simply a progressive fall in sheep cell agglu-
tination titre. The slope of the downward curve justifies
the inference that it followed a recent rise in titre of the
antibody responsible for sheep cell agglutination.
Table 4
Serologic Studies of Mononucleosis at University of Michigan.
Agglutination titre changes in a male student.
Days Sheep Cell Agglutination Titre After:
from
Onset
4 hours
at 37.5° C
overnight
at 4° C
2 hours
at 37.5° C
10
1/2048
1/4096
1/2048
17
1/2048
1/2048
1/2048
23
1/512
1/2048
1/1024
31
1/512
1/1024
1/512
37
1/256
1/1024
1/512
46
1/128
1/512
1/256
53
1/128
1/512
1/128
60
1/64
1/256
1/64
68
1/32
1/256
1/64
108
1/16
1/64
1/16
From these serologic studies, the diagnosis of infec-
tious mononucleosis was made in 158 patients. In 315
other patients suspected of having the disease and in
12 patients with possible recurrence of infection, the
serologic data would not permit the diagnosis of infec-
tious mononucleosis. In addition, tests were performed
on sera from 737 patients with various other clinical
entities. The purpose of testing these sera was to deter-
mine the degree of specificity of the heterophile agglu-
tination reaction as performed in this study. The pre-
viously indicated criteria were applied to these results
and all were negative. Some interesting findings were
made, however, which will illustrate the necessity for
rigid adherence both to the technique of the test and
to the criteria for its interpretation. In Table 5, for
example, are given the serologic findings in a patient
with chronic myelogenous leukemia. The sera from this
patient have "cold agglutinins” for sheep cells up to a
dilution of 1:256. It appears likely that the "positive”
heterophile agglutination tests ascribed to leukemia in
the past were due to cold agglutinin effects such as was
encountered in this case.
October, 1949
367
Not infrequently the question is raised as to what con-
stitutes a "positive” titre for infectious mononucleosis in
the heterophile agglutination reaction. The answer,
Table 5
Serologic Studies of Mononucleosis at University of Michigan.
Agglutination tests in a 40-year-old female with
chronic myelogenous leukemia.
Sheep Cell Agglutination
Titres After:
Date of
4 hours
overnight
2 hours
Specimen
at 37.5° C
at 4° C
at 37.5° C
3-4-48
0
1/256
1/16
3-12-48
0
1/256
1/16
3-22-48
0
1/256
1/16
3-26-48
0
1/256
1/16
4-1-48
0
1/256
1/16
4-14-48
0
1/256
0
which cannot be over-emphasized, is that no single titre
is sufficient of itself to make the diagnosis of infectious
mononucleosis. To be sure, a very high agglutination
titre may be present in a patient who has a highly com-
patible clinical picture and the characteristic hematologic
findings. But the diagnosis is really made on the latter
features. The serologic diagnosis can only be made when
an antibody response is demonstrated through the exam-
ination of several blood samples from the patient in the
same test. This point is well illustrated by the findings
in tests on sera from a 60-year-old patient suffering from
Table 6
Serologic Studies of Mononucleosis at University of Michigan.
Agglutination tests on a 60-year-old male with polycythemia
rubra vera and gout.
Sheep Cell Agglutination Titres After:
Date of
Specimen
4 hours
at 37.5° C
overnight
at 4° C
2 hours
at 37.5° C
3-26-47
1/256
1/512
1/512
4-10-47
1/512
1/512
1/512
5/2/47
1/512
1/512
1/512
7-15-47
1/512
1/512
1/512
9-11-47
1/256
1/512
1/512
10-14-47
1/512
1/512
1/512
1 1-9-47
1/512
1/512
1/512
1-17-48
1/512
1/512
1/512
2-20-48
1/512
1/512
1/512
3-23-48
1/512
1/512
1/512
polycythemia and gout. In Table 6 it can be seen that
his heterophile antibody titre was 1:512 in March, 1947.
Subsequent studies during the following year revealed
that this was a constant finding. There was no clinical
or hematologic evidence of infectious mononucleosis in
this case. Admittedly, as in infectious mononucleosis,
the reason for the agglutination of sheep cells by his
sera is not known. However, the prolonged maintenance
of the agglutination titre at the same level indicates that
it is not a response to an acute process such as infec-
tious mononucleosis.
In Table 7 are presented the serologic findings in a
patient who appears to have had both syphilis and in-
Table 7
Serologic Studies of Mononucleosis at University of Michigan.
Agglutination tests in an 18-year-old girl with mononucleosis
and probably syphilis.
Days
from
Onset
Sheep
cell agglutination titres
Kahn
Units
Positive*
C F Cardio-
lipin Units
Positive*
4 hours
at 37.5° C
overnight
at 4° C
2 hours
at 37.5° C
10
1/512
1/1024
1/512
40
AC.
17
1/256
1/512
1/512
80
224
20
1/256
1/512
1/256
80
—
35
1/64
1/256
1/128
80
224
49
1/64
1/64
1/64
40
—
56
1/16
1/64
1/32
40
224
70
1/16
1/64
1/32
160
224
108
0
1/32
1/8
160
AC.
143
0
1/16
1/8
160
1
248
0
1/32
0
600
256
339
0
1/16
■ 0
400
384
*Sera
also positive
in Mazzini,
Mazzini cardiolipin, Kline
exclu-
sion, Kline cardiolipin, and Kolmer complement-fixation tests
for syphilis.
fectious mononucleosis at the same time. It is well
known that infectious mononucleosis may give rise to
false positive reactions for syphilis. This effect is tran-
sient and the tests will usually become negative within
a few days or weeks.15 The probability of a simultaneous
occurrence of the two diseases is extremely remote and
this case is presented for its incidental interest.
Finally, it should be mentioned that there has been
no experience in this study with the absorption tests
devised by Davidsohn 15 to differentiate sheep cell agglu-
tination due to the injection of horse serum from that
caused by infectious mononucleosis. Some workers have
apparently noted discrepancies in the results obtained
with his test. Furthermore, modern therapy has prac-
tically eliminated the use of horse serum in this country
so this problem will be encountered less frequently in
the future.
In summary, it may be stated that infectious mono-
nucleosis constitutes a significant student health problem.
The etiologic agent is not yet known but is believed to
be a virus. Clinically, it is now recognized as a gener-
alized systemic disease with an extremely variable and
varied range of manifestations. More serious forms of
the disease have been noted and a few fatalities have
occurred.
Repeated examinations of the blood for the charac-
teristic leukocyte response and the testing of serial blood
samples for sheep cell agglutinins are the most helpful
diagnostic aids. Preliminary results of a study of the
heterophile agglutination reaction have been presented
and although this study is not yet completed, it is be-
lieved that sufficient data have been accumulated to in-
dicate the pattern of response in infectious mononucleo-
sis and also to delineate the criteria for its use in the
serologic diagnosis of the disease.
Grateful acknowledgment is made to Dr. Cyrus C.
Sturgis, chairman of the Department of Internal Medi-
cine, for many helpful suggestions during the course of
this study.
368
The Journal-Lancet
Sincere appreciation is expressed to the professional
and technical staff at the University Health Service for
their continued wholehearted cooperation. Dr. W. E. For-
sythe, Dr. W. M. Brace, and Dr. Margaret Bell and
their associates have aided greatly in this investigation.
References
1. Ricker, W., Blumberg, A., Peters, C. H., and Wider-
man, A.: The Association of the Guillain-Barre Syndrome with
Infectious Mononucleosis: Report of 2 Fatal Cases. Blood 2:217,
1947.
2. Slade, John deR.: Involvement of the Central Nervous
System in Infectious Mononucleosis. Report of 2 Cases. New
Eng. J. Med. 234:753, 1946.
3. Smith, E. B., and Custer, R. P.: Rupture of the Spleen
in Infectious Mononucleosis. A Clinicopathologic Report of
7 Cases. Blood 1:317, 1946.
4. Vaughan, S. L., Regan, J. S., and Terplan, K.: Infec-
tious Mononucleosis Complicated by Spontaneous Rupture of
the Spleen and Central Nervous System Involvement. Blood
1:334, 1946.
5. Geraghty, F. J.: Heart Complications in Infectious
Mononucleosis. S. Med. J. 39:693, 1946.
6. Wechsler, H. F., Rosenblum, A. H., and Sills, C. T.:
Infectious Mononucleosis. Report of an Epidemic in an Army
Post. Ann. Int. Med. 25:113-133, 236-265, 1946.
7. Bradshaw, R. W.: Mitral Stenosis Following Infectious
Mononucleosis. Ohio State Med. J. 27:717, 1931.
8. Wintrobe, M. M.: Clinical Hematology. 2nd edition.
Lea & Febiger, Philadelphia, 1946.
9. Sprunt, T. P., and Evans, F. A.: Mononuclear Leuco-
cytosis in Reaction to Acute Infections ("Infectious Mononu-
cleosis”), Bull. Johns Hopkins Hosp. 31:410, 1920.
10. Havens, W. P., and Marck, Ruth E.: The Leucocytic
Response of Patients with Experimentally Induced Infectious
Hepatitis. J. Med. Sci. 212:129, 1946.
11. Paul, J. R , and Bunnell, W. W.: The Presence of Het-
erophile Antibodies in Infectious Mononucleosis. Amer. J.
Med. Set. 183:90, 1932.
12. Stuart, C. A., Burgess, A. M., Lawson, H. A., and
Wellman, H. E.: Some Cytologic and Histologic Aspects of
Infectious Mononucleosis. Arch. Int. Med. 54:199, 1934.
13. Keiper, T. W.: Pitfalls in the Use of Sheep Cells in
Complement-Fixation and Heterophilic Antibody Reactions.
Amer. J. Clin. Path. 15:66, 1945.
14. Zarafonetis, C. J. D., Ecke, R. S., Yeomans, A., Mur-
ray, E. S., and Snyder, J. C.: Serologic Studies in Typhus-
Vaccinated Individuals. III. Weil-Felix and Complement-Fixa-
tion Findings in Epidemic Typhus Fever Occurring in the Vac-
cinated. J. Immunol. 53:15, 1946.
15. Kahn, R. L.: Are There Paradoxic Serologic Reactions
in Syphilis? Arch. Derm, and Syph. 39:92, 1939.
16. Davidsohn, I.: Serologic Diagnosis of Infectious Mono-
nucleosis. J.A.M.A. 108:288, 1937.
Meet Our Contributors
George Alfred Dodds, M.D., of the Fargo Clinic, was
graduated from the medical school at the University of
Oregon. A specialist in thoracic and abdominal surgery,
he is chief of staff at St. Luke’s Hospital, consultant in
thoracic surgery at the Veterans Hospital at Fargo, North
Dakota, a fellow of the American College of Surgeons,
and a Diplomate of the American Board of Surgery.
Angus L. Cameron, M.D., has practiced surgery in
Minot, North Dakota, for twenty-five years. A graduate
of Rush Medical College, Dr. Cameron is a member of
the Western Surgical Association, the American Associa-
tion for the Surgery of Trauma, the American College
of Surgeons, A.M.A., and is on the staff of Northwest
Clinic.
Jerome Andrew Hilger, M.D., a graduate of the Uni-
versity of Minnesota Medical School, has specialized in
otolaryngology in St. Paul since 1939. He is a member
of the Ramsey County Medical Society, the Minnesota
Medical Association, the American Academy of Ophthal-
mology and Otolaryngology, and the American Laryn-
gological, Rhinological and Otological Society.
John Roland McDonald, M.D., heads the Section of
Surgical Pathology at the Mayo Clinic in Rochester and
as professor of pathology, teaches in the Mayo Founda-
tion Graduate School. He is a graduate of the University
of Manitoba Medical School and a member of the Min-
nesota State Medical Association, A M A., American So-
ciety of Clinical Pathologists, American Society for Tho-
racic Surgeons, Sigma Xi, and is a Fellow of the College
of American Pathologists.
Owen Harding Wangensteen, M.D., a graduate of the
University of Minnesota Medical School, heads the De-
partment of Surgery at that school. He holds member-
ship in county and state medical associations, A.M.A.,
American College of Surgeons, American Association for
Thoracic Surgery, American Physiological Society and
American Surgical Association. He is the recipient of
the Samuel Gross Prize in Philadelphia in 1935; the
John Scott Medal and Award in Philadelphia in 1941;
the Alvarenga Prize in 1949; and a grant in ulcer re-
search from the U. S. Public Health Service for Cancer.
Lewis Benjamin Woolner, M.D., is a graduate of the
medical school of Dalhousie University, Halifax, Nova
Scotia. A specialist in surgical pathology, he is an asso-
ciate in the Section of Surgical Pathology at the Mayo
Clinic and instructor in pathology of the Mayo Founda-
tion Graduate School, University of Minnesota. He is
a member of the Minnesota State Medical Association,
A M. A., American Society of Clinical Pathologists and
Sigma Xi.
Chris J. D. Zarafonetis, M.D., is a graduate of the
University of Minnesota Medical School, a specialist in
internal medicine, assistant professor of internal medicine
at the University of Michigan, and a member of the
Central Society for Clinical Research, a fellow of the
A M. A., the American Federation Societies for Clinical
Research.
Official Journal of the American College Health Association
Great Northern Railway Surgeons’ Association, Minneapolis Academy of Medicine, North Dakota State
Medical Association, Northwestern Pediatric Society, South Dakota Public Health Association,
North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
ADVISORY COUNCIL
Dr. J. A. Myers, Chairman
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J. Glaspel
Dr. J. F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J. H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. J oseph Sorkness
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Secretary
North Dakota State Medical Association
Dr. W. A. Wright, President
Dr. L. W. Larson, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
North Dakota Society of Obstetrics and Gynecology
Dr. B. M. Urenn, President
Dr. E. H. Boerth, Vice President
Dr. C. B. Darner, Secretary-T reasurer
Minneapolis Academy of Medicine
Dr. Cyrus O. Hansen, President
Dr. Chauncey Bowman, Vice President
Dr. John Haugen, Secretary
Dr. Karl Sandt, T reasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, V ice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
370
The Journal-Lancet
Editorial
TESTS OFFER HOPE IN CANCER
DIAGNOSIS
The average life span in the United States in 1890
was 44 years; now it is approximately 66 for men and
70 for women. Thus, almost a quarter of a century has
been added. The increase was due in large part to the
control of diseases which caused great destruction during
the first two or three decades of life, especially those of
infants and young children. One may predict that the
recently acquired sulfonamides and antibiotics will pre-
vent so many untimely deaths from infections, particu-
larly pneumonia, as to further increase the span of
human life by several years.
Cancer is one of the conditions which has continued
the destruction of life almost unabated. Five years ago,
170.000 deaths were so reported. This was increased by
12.000 in 1946 and it is believed that 200,000 lives will
be lost in 1950. When the span of human life was only
44 years, deaths from cancer did not play such a large
role as other conditions in holding the average length
of life at this level because approximately 90 per cent
of its victims die after the age of 40 years. While it
does occur among infants and young children, it is rare
and, in fact, only 10 per cent of all cancer deaths are
reported under the age of 40. Obviously the more per-
sons who live to be old, the higher will be the incidence
of cancer among them.
The total absence of significant symptoms of early and
small cancers in organs with large functional reserve —
the so-called silent period — permits the condition to be-
come large and all too often to metastasize before the
patient is seen by the physician. In an organ like the
lung, containing no sensory pain fiber, this silent phase
may be of definitely greater duration than in organs
richly supplied with such fibers.
Involvement of the stomach is the first cause of cancer
deaths and that of the lungs, second. The five-year sur-
vival rate following surgical treatment of cancer of the
stomach varies somewhat in reports but is in the neigh-
borhood of 8 to 10 per cent. This is not because of
the inability of surgeons, but largely because of the lack
of significant symptoms until metastases have occurred.
Much progress has been made in diagnostic procedures
in recent years. If opportunity is given to make neces-
sary examinations, including x-ray inspections, bronchos-
copy and biopsy as well as cytological studies of sputums,
gastric washings and bronchial aspirations, cancer of the
lungs can now be diagnosed with considerable accuracy.
In any such condition that is microscopic in the begin-
ning and that evolves slowly, there is no hope of becom-
ing aware of its presence until gross lesions have devel-
oped. In the entire cancer control program the most
urgent need is a specific test that will detect the pres-
ence of malignancy soon after it appears. As soon as
this test indicates the presence of the disease, the physi-
cian could begin to make frequent, careful examinations
of those parts of the body most frequently attacked by
cancer. Thus, one might hope to determine the location
of most cancers as soon as they are large enough to be
found by our present diagnostic armamentarium. Unless
such a test becomes available, it is probable that we will
continue to diagnose cancer, particularly of internal or-
gans, after the majority have metastasized.
We now have such specific tests for a number of
other diseases. For example, tuberculin is highly specific
and accurate in determining the presence of tuberculous
lesions long before they can be located. By carefully
examining tuberculin reactors periodically one is often
able to locate the chronic, slowly progressive lesions on
an average of two or three years before symptoms or
contagion are present. Every physician recognizes the
need of such a specific and accurate test for cancer be-
fore lesions can be located. A large volume of work has
already been done in this field. Some persons have lost
hope. However, encouragement may be found in the
fact that since the 20th century began, specific tests have
come into being and have great practical value in the
early diagnosis of several diseases. Since nothing is so
needed in the entire cancer field, a great deal of time,
money and effort should be spent in seeking such a diag-
nostic agent.
J. A. Myers, M.D.
American College Health
Association News
A number of vacancies in College Health Services
have been reported.
Wayne University, Detroit 1, Michigan, reports a
vacancy for a male physician. The position is a perma-
nent, full-time appointment and carries the usual privi-
leges of paid vacations, sick-leave, and retirement bene-
fits. The physician will be assigned to the medical super-
vision of the University inter-collegiate and intra-mural
athletic program. The starting salary is good with an-
nual increments. Write to Dr. Irvin W. Sander, M.D.,
5050 Cass, Detroit 2, Michigan.
There is also a vacancy in the Student Health De-
partment of the State University of Iowa. For further
information, write to Dr. C. I. Miller, Director Student
Health, Iowa City, Iowa.
The University of Pennsylvania, Philadelphia, Penn-
sylvania, will need a full-time physician for next July 1st.
Anyone interested may write to Dr. H. D. Lees, Student
Health Service, University of Pennsylvania.
Several inquiries have been received regarding the
availability of positions for graduate, registered nurses
for student health work in colleges and universities. Any
information about such openings would be appreciated.
October, 1949
371
News Briefs
North Dakota
Specialists in internal medicine from North and
South Dakota and Canada met in Grand Forks Septem-
ber 10 for the third annual regional meeting of the
American College of Physicians. Special guest at the
session was Dr. George F. Strong of Vancouver, B. C.,
first vice president of the college, who presented a paper
on infectious mononucleosis.
More than 30 members of the American College of
Physicians attended the meeting.
Dr. Fd. W. Miller, who began his career as a "coun-
try doctor” in Casselton in 1912, made plans to retire
after pneumonia hospitalized him recently. Dr. Miller’s
faithfulness to serve prompted the Casselton Commer-
cial Club to sponsor a Dr. H. W. Miller Appreciation
Day on June 10, 1945.
John A. Page, of the University school of education,
has been granted a year’s leave of absence by the board
of higher education to take up full time duties as director
of the North Dakota medical center. The appointment
took effect September 1.
The new full-time director came to Grand Forks in
1935 from Bismarck where he had served for eight years
as state director of secondary education.
Dr. Frank M. Melton of Louisville, Ky., dermatol-
ogy specialist, has joined the staff of the Dakota Clinic.
A graduate of the University of Louisville Medical
School, Dr. Melton served with the U. S. Public Fdealth
Service. From 1946 to 1948 he did postgraduate work
at the University of Pennsylvania. Prior to coming to
Fargo Dr. Melton was associate in dermatology at Duke
Fdospital, Durham, N. C.
Dr. Gordon Magill of Fargo, accompanied by his
wife, sailed recently from New York for Cairo, Egypt,
where he will spend two years in general medical research
with emphasis on his special interest, diseases of the liver
and bile ducts.
Dr. Magill has been on the staff at St. Albans naval
hospital, St. Albans, N. Y. His wife, also a physician,
completed her internship this year at a Brooklyn hos-
pital. While in Egypt, Dr. Magill will be a member of
the medical research unit established in 1943.
Dr. Ilmar Otto Kiesel, first of the DP doctors to
be brought to North Dakota through the Lutheran
Welfare program, arrived in Fargo recently. Dr. Kiesel,
a former resident of Estonia, will serve as physician in
the Page community following an internship of a year
at St. Luke’s hospital in Fargo. In Europe, Dr. Kiesel
specialized in internal medicine and x-ray diagnosis.
A new member of the staff of New Rockford City
Hospital is Dr. Julius Kolacskovszky, native of Hun-
gary who in September began the serving of a year of
internship at the local hospital.
Dr. Kolacskovszky is a graduate of the University of
Budapest. Following his year of internship at City Hos-
pital, Dr. Kolecskovszky will open his own practice in
Buffalo, N. D.
New Appointments . . .
Dr. William Tompkins, to the staff of the Tompkins
Countryman Clinic at Grafton.
Dr. Charles M. Graham as city health officer at
Grand Forks. A 1936 graduate of the University of
North Dakota, Dr. Graham received his medical degree
from Northwestern university in 1939.
New Locations . . .
Dr. P. C. Van Lier, associated with the Johnson
Clinic at Rugby for the past year and a half, is estab-
lishing a practice in Sioux Falls, S. D.
Dr. G. S. Wheeler, formerly of Winnipeg, Mani-
toba, has opened offices in Portland.
Dr. John McNeil of Hettinger will serve as resi-
dent surgeon at the Bismarck Hospital in Bismarck, N.
D., for the next few months, reopening his Hettinger
office about January 1, 1950.
South Dakota
The University of South Dakota school of medi-
cine has recently been awarded $5,000 from the Federal
Security Agency to coordinate and improve cardiovas-
cular teaching. Project director is Dr. T. E. Eyres,
professor of public health.
Dr. Willard O. Read of the University of Missouri
was recently appointed associate in physiology; Dr. Don-
ald F. Rayl, associate in clinical physiology; and Dr.
Tom Billion, clinical associate in physiology. Dr. T. H.
Sattler, assistant professor of medicine, will handle the
clinical end of the teaching correlating it with the basic
science facet of cardiovascular teaching. Dr. James C.
Steele has been appointed assistant professor of radio-
logical anatomy and clinical assistant professor of radi-
ology. Also, Dr. F. J. Abts has been raised to clinical
associate professor of gynecology and Dr. C. B. McVay
has been raised to associate professor of surgical anatomy.
A committee has been appointed to outline plans for
Brookings county to participate in the campaign to raise
funds for the construction of a crippled children’s hos-
pital and school in eastern South Dakota.
Four Huron doctors have each practiced medicine
more than 50 years and in observance of their work
have been awarded membership in the 50-year club by
the South Dakota Medical Association. They are Dr.
O. R. Wright, Dr. F. L. Class, Dr. H. L. Saylor and
Dr. T. J. Wood. There are now six doctors in the state
who hold the 50-year award.
372
The Journal-Lance i
With the retirement of Dr. F. H. Creamer in Sep-
tember Dupree is really without a doctor for the first
time in its history. Dr. Creamer came to Dupree with
the opening of settlement in 1910 and has been there
ever since with the exception of the time he served in
the Army in World War I. Since then he has admin-
istered to the people of the West River Country, a terri-
tory more than 100 square miles and is no doubt the
largest territory any practicing doctor in the United
States covered in his regular practice.
Relocations and Appointments . . .
Dr. R. W. McMullen, a graduate of the school of
medicine, College of Medical Evangelists, at Loma
Linda, California, with service as a medical missionary in
China, has opened medical practice in Bowdle, S. D.
Dr. J. V. Yackley, formerly of Denison, Iowa, is
now associated with Dr. John Erickson in Rapid City.
Dr. Yackley is a graduate of the medical college at
Creighton university and served his internship at St.
Catherine’s hospital in Omaha.
Dr. Robert F. Swanson, of Dwight, Illinois, and a
graduate of the Northwestern University Medical
School, is opening a practice in Platte.
Lt. JG Robert J. Foley, of Blair, Nebraska, has
been assigned to the Rapid City air base hospital. Lt.
Foley is a recent graduate of the Air Force School of
Aviation Medicine at Randolph, Texas.
Minnesota
For distinguished service in cancer control, Dr.
Owen H. Wangensteen, head of surgery at University
of Minnesota, received the first annual medal of the
Minnesota division of the American Cancer Society on
September 23.
The cancer society’s announcement described the Min-
neapolis surgeon as "world famous in many fields.”
It cited his development of an infection-preventing
technique of sewing together the intestine and the stom-
ach a fter surgery, aggressive surgery of gastro-intestinal
cancers including removal of parts of adjacent organs
and his leadership in urging early diagnosis of stomach
cancer.
Dr. E. S. Mariette, superintendent of Glen Lake
sanatorium since 1916, resigned September 8 because
of illness.
Born in Blue Earth county in 1888, Dr. Mariette
attended Pillsbury academy at Owatonna, Minn., and
the University of Minnesota. He interned at University
Hospitals, joined the Glen Lake staff in 1916 and soon
became superintendent and medical director.
He is an assistant professor of medicine at the Uni-
versity of Minnesota and a member of nineteen medical
and health organizations.
He was twice on the National Tuberculosis Associa-
tion’s board of directors and in 1935-36 an executive
committee member. He has headed the Minnesota
Trudeau Society, the Hennepin County Tuberculosis
Association, the Minnesota Hospital Association, the
Minnesota Sanatorium Association, the Mississippi Val-
ley Trudeau Society and the Mississippi Valley Tuber-
culosis Conference.
Three graduates-of the University of Minnesota med-
ical school were elected officers of the Northwestern hos-
pital staff at the annual meeting at the hospital on Sep-
tember 19.
Dr. Erling W. Hansen was elected president, suc-
ceeding Dr. R. S. Ylvisaker. Dr. Claude J. Ehrenberg
was elected vice president to succeed Dr. Edwin Benja-
min and Dr. Albert T. Hays was re-elected secretary-
treasurer.
Believed to be the first project of its kind on a com-
unity-wide basis, the health committee of the Virginia
Chamber of Commerce will sponsor a diabetic survey
during the week of October 10-16.
Aim of the survey is to uncover unsuspected cases of
diabetes which has been one of the leading causes of
death in Minnesota durmg the last twelve years. Last
year it occupied seventh place among leading causes of
death.
Dr. Philip S. H. Hench and Dr. Edward C. Ken-
dall, Mayo clinic men who launched the spectacular
new use of cortisone — compound E — for arthritis, will
share a high scientific honor. It is a 1949 Lasker award
for administrative and scientific achievement — a $1,000
prize and a figure of "Winged Victory.” They will re-
ceive the award in New York City October 25 at the
annual meeting of the American Public Health Associa-
tion.
Dr. Tom Davis, Jr., of Wadena, has made arrange-
ments to spend three months doing specialized work in
eye surgery in India, and will leave Wadena in October
for that country. He will work and study in a Catholic
mission 200 miles north of Calcutta. Dr. Davis has been
specializing in eye, ear, nose and throat work.
A dinner of staff doctors of the Rice Memorial Hos-
pital was held at which time the medical men paid trib-
ute to Dr. E. H. Frost, who on April 11 completed fifty
years as a medical practitioner in Willmar.
The American Academy of Neurology at its first
national scientific meeting elected Dr. A. B. Baker of
Minneapolis president, Dr. Pearce Bailey of Charleston,
S. C., vice-president, and Dr. Joe R. Brown, Rochester,
secretary. Three hundred attended the sessions; 38 pa-
pers were presented.
Myron Weaver, M.D., formerly on the staff of the
University of Minnesota Medical School, and now at
the University of British Columbia, will take part in
a round-table discussion at the 60th meeting of the As-
sociation for American Colleges to be held at Colorado
Springs in November.
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new product Entozyme) now makes it possible to release these three
important digestants in fully active form to that part of the
gastrointestinal tract where pH conditions for optimum activity prevail.
Clinical research1 indicates that Entozyme's greatest field of usefulness is in chronic
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374
The Journal-Lancet
Future Meetings
The North Dakota Health Officers Association is
holding its annual meeting with the North Dakota Pub-
lic Health Association in Grand Forks, November 10,
11 and 12, 1949. Of special interest this year is the ban-
quet session at which Dr. F. S. Crockett, chairman of
the committee on rural health of the A.M.A., will be
the guest speaker.
The University of Minnesota offers these special
courses in medicine at the Center for Continuation
Study on the campus:
Occupational and Physical Therapy, October 13
and 14. Dr. H. D. Bouman, professor of physical medi-
cine, University of Wisconsin Medical School, will be
the guest speaker.
Diseases of the Chest, October 20, 21 and 22.
Sponsored by the Minnesota Chapter of the American
College of Chest Physicians, this course is intended for
general physicians.
Pediatric Roentgenology, October 31 through No-
vember 5. Intended for radiologists and pediatricians.
Obstetrics, November 17, 18 and 19. Dr. S. R. M.
Reynolds of the Carnegie Institute of Washington and
Johns Hopkins Medical School, will be guest faculty
member.
Child Pyschiatry, November 28 through December
3. Intended for pediatricians and general physicians,
this course will emphasize normal, emotional, intellectual
and social development of infants and children. Dr.
Adrian Vander Veer of the Department of Psychiatry,
University of Chicago, will participate as a visiting fac-
ulty member.
Dr. John Caffey, associate professor of pediatrics in
the College of Physicians and Surgeons at Columbia
University, New York, will present the annual Leo G.
Rigler lecture at the University of Minnesota Medical
School Wednesday, November 2, at 8:15 P.M. Dr.
Caffey will speak on the subject, "Some Normal Varia-
tions in the Growing Skeleton: Their Clinical Signifi-
cance” and his lecture will be given in the auditorium
of the Minnesota Museum of Natural History.
Opportunities Offered
The American Goiter Association again offers the
Van Meter Prize Award of Three Hundred Dollars and
two honorable mentions for the best essays submitted
concerning original work on problems related to the
thyroid gland. The award will be made at the annual
meeting of the Association which will be held in Hous-
ton, Texas, March 9, 10 and 11, 1950, providing essays
of sufficient merit are presented in competition.
The competing essays may cover either clinical or re-
search investigations; should not exceed three thousand
words in length; must be presented in English; and a
typewritten double-spaced copy in duplicate sent to the
Corresponding Secretary, Dr. George C. Shivers, 100
East St. Vrain Street, Colorado Springs, Colorado, not
later than January 15, 1950. The committee, who will
review the manuscripts, is composed of men well qualified
to judge the merits of the competing essays.
A new program of scholarships will be offered to un-
dergraduate students by the Minnesota Medical Foun-
dation, Dr. Owen H. Wangensteen, president, an-
nounced. The scholarships will be awarded annually in
amounts totalling $2,500. Individual grants will range
between $500 and $1,000. Members of the sophomore,
junior and senior classes are eligible to apply for the
scholarships.
Deaths
Dr. Martin U. Ivers, 81, Richland county physician
46 years, died on September 13 in Fargo, N. D. He
entered University of Minnesota medical school and re-
ceived his doctor’s degree there in 1902. In 1903, he
began the practice of medicine at Abercrombie, contin-
uing there until 1918. Dr. Ivers and his brother, Dr.
Lewis U. Iverson of Christine, cared for patients in a
territory ranging from Wahpeton to Fargo, covering the
district with horse and buggy in early days and later by
car. In addition to caring for his patients, Dr. Ivers pre-
pared his own drugs each evening.
Dr. H. H. Daniels, 70, a physician in the Hankin-
son, LaMoure and Milnor area for the past 1 1 years,
died unexpectedly last month in his office-residence
at Milnor, North Dakota.
Dr. Alexander B. Field, 86, pioneer doctor of the
Forest River area, died August 29 at a Grafton, North
Dakota, hospital. He had practiced medicine in Forest
River since 1892. He was a member of the Forest River
city council and the school board for many years. Dr.
Field was born at Blackstock, Ont., Canada, on June 12,
1863, and obtained his medical degree at the University
of Toronto in 1891.
Dr. Norman R. Schneidman, 42, chief of pulmo-
nary diseases section at Veterans Hospital, Minneapolis,
died September 6. Only recently he completed post-
graduate work at the university in internal medicine.
Dr. Walter E. Camp, leading Minneapolis eye and
ear doctor for the last 30 years, died Sunday at North-
western hospital after a long illness. He was 60. Dr.
Camp was born in Springfield, Mo., September 21, 1889.
He received his bachelor of arts degree from University
of Missouri in 1912, and his master of arts and doctor
of medicine degrees for the University of Minnesota in
1915.
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376
The Journal-Lancet
Dr. Fayette D. Kendrick, probably St. Paul’s oldest
physician, died August 24th in Miller Hospital. He
would have been 94 in November. Dr. Kendrick had
been a resident of St. Paul since 1903.
Dr. George E. Malmgren, formerly of St. Paul,
died August 24th in Los Angeles following an opera-
tion. He was 47 years old. He had served on the staff
of the Mayo Clinic at Rochester for several years until
he left for California 12 years ago.
Book Reviews
Constructive Uses of Atomic Energy, edited by S. C. Roth-
mann. New York: Harper and Brothers, 223 pages, 1949,
#3.00.
Much has been said about the destructive value of atomic
energy and there has been some speculation about the use of
atomic energy in everyday life. Mr. Rothmann has collected the
contributions of fourteen scientists who are among the leaders
in atomic research in many fields. Each of these individuals
has attempted to express his thoughts on the value of atomic
energy for constructive purposes.
As one reads about atomic energy he becomes impressed with
the amount of scientific know-how that went into the work
of learning how to split the atom. Although science had been
aware of the atomic theory for several hundred years, it took
the necessity created by a war to cause the scientific minds to
be brought together and learn how to use the atom. Several
billion dollars were spent to accomplish this purpose, but to
date very little of this money has been recovered and only the
destructive value of atomic energy has been enthusiastically pur-
sued. As one reads and learns of the many possible uses already
thought up for atomic energy, he realizes quite possibly we
humans are entering on an atomic age where the constructive
uses for atomic energy will be widespread and will more than
pay for its original cost of discovery. The medical applications
alone should be well worth the expenditure.
Dr. C. P. Rhoads in his section on "The Medical Uses of
Atomic Energy" points out that only two elements have been
proven to be therapeutically useful but he also suggests that we
have only just started our investigations and that radioactive
isotopes may be the answer to not only the therapeutic treat-
ment of diseases such as cancer but, more important, there will
come a new era of knowledge of the fundamental chemical
processes of the body. Most people think of atomic energy
as a destructive force which, when released as a bomb, causes
sudden death if one is in the direct path of it, or a lingering
death if the radioactive waves are encountered. Throughout
the book it is pointed out that man can use atomic energy with
safety if he takes proper precautions. As man loses his fear
of the atom and commences to harness it for his own purposes,
so will the atomic age gain momentum. S.C.R.
Emotional Maturity: The Development and Dynamics of
Personality, by Leon J. Saul, M.A., M.D. Philadelphia:
J. B. Lippincott. 338 pages. 1947. #5.00.
The primary interest of modern psychiatry as Dr. Saul points
out in his preface is no longer the insane or psychotic but rather
the emotional behavior of neurotic individuals and so-called nor-
mal people. The broadening of this horizon which now includes
all mankind within the purview of psychiatry must also broaden
the horizon of all practitioners of medicine to include the emo-
tional aspects in the consideration of the problems involved in
any case. These are the grand concepts which led to the writing
of this book.
Saul draws heavily upon his recent wartime naval experience.
His opportunity to observe extreme emotional behavior prob-
lems seen among military personnel on combat duty gave him
a good share of the illustrative material he uses here.
The Premature Baby, by V. Mary Crosse, M.D. Philadel-
phia: The Blakiston Company, 156 pages with 14 illustra-
tions, 1947. #3.00.
This book is a complete review of our up-to-date knowledge
concerning the premature baby. The author has placed all the
information into eight chapters, each one of which presents in
detail but in a practical way the most essential factors necessary
to take care of the premature infant from the moment of birth
through the first period of his life. Nothing has been over-
looked. Emergencies and complications are mentioned and treat-
ed accordingly. The monograph is highly recommended for
general practitioners and nurses, obstetricians and pediatricians.
A.V.S.
A Primer of Electrocardiography, by George E. Burch,
M.D., F.A.C.P., and Travis Winsor, M.D., F.A.C.P. Sec-
ond edition, 245 pages with 265 illustrations. 1949. Phila-
delphia: Lea & Febiger. #4.50.
The revision of this standard primer by Dr. Burch, Hender-
son Professor of Medicine at Tulane University, and Dr. Win-
sor, Assistant Clinical Professor of Medicine at the Southern
California Medical School, should be welcomed by practitioners
and students unfamiliar with the subject for the fundamentals
of electrocardiography are presented in a most direct manner.
Mechanisms responsible for the various patterns of infarction
are discussed in detail and are supported by numerous new
illustrations. Unipolar leads replace bipolar precordial leads and
the illustrations and comments have been changed accordingly.
A new feature is a discussion of the intrinsic deflection.
The material is presented from a mechanistic point of view
for the authors believe that only with a knowledge of the mech-
anism is it possible for the reader of electrocardiograms to un-
ravel individual tracings.
This fully up-to-date primer offers a foundation upon which
to build a useful, practical and theoretical mastery of electro-
cardiography. After thorough understanding of fundamentals
presented in this primer, a more advanced study of the subject
can follow.
Correlative Neuroanatomy, by J. J. McDonald, M.D.,
J. G. Chusid, M.D., and J. Lang, M.D.; 4th edition; Palo
Alto: University Medical Publishers, 1948, #3.00.
This is a manual planned for Stanford University students
in gross anatomy, neuroanatomy, neurodiagnosis and neurology.
It includes the clinical findings of the important neurologic dis-
orders. The first part deals with peripheral nerves, and the
autonomic system. Part two is devoted to neurological diag-
nosis including diagnostic procedures such as electromyography
and electroencephalography. The third part is devoted to the
important diseases, and is followed by an appendix outlining
signs, syndromes, atrophies and distrophies.
The book is paper bound with a plastic spiral-type binding.
It is brief, clear and entirely in outline form, with important
words and phrases underlined, numerous line illustrations, and
several charts. Either the student or clinician wishing to refresh
by means of this outline technique could make good use of this
book. H. W.
A Layman’s Handbook of Psychiatry, 6y Winfred Over-
holser, M.D., and Winifred V. Richmond, Ph.D. Phila-
delphia: J. B. Lippincott Company, #4.00.
The authors have presented this informative, nontechnical
handbook to the public in an effort to provide more knowledge
and appreciation of the field of psychiatry. It should prove val-
uable in dispelling the popular misconception about mental ill-
ness, its etiology, treatment, and prognosis. A discussion of the
schools of psychiatric thought and explanations of the mech-
anisms involved in producing various types of mental disorders
are given with clarity and conciseness. Illustrative cases are
chosen wisely. A discussion of the relation of mental illness to
war and crime is also commendable. The treatment of the entire
subject is prudent and refreshingly unsensational with no loss
of the reader’s attention and enjoyment.
R. B.
F. T.
Surgery of the Sympathetic Nervous System*
Collin S. MacCarty, M.D.f
Rochester, Minnesota
Because of recent advances in surgery of the sympa-
thetic nervous system, it seems appropriate at this
time to review the subject. A critical analysis should em-
phasize its importance and also indicate its abuses.
This type of surgery was introduced by Jabolay 1 in
1899. Alexander 2 and Jonnesco 3 also were pioneers in
this field. Although Jabolay introduced periarterial sym-
pathectomy, its extensive use by neurologic surgeons is
chiefly attributable to the work of Leriche.4 Royle,;j
Adson u and other neurologic surgeons have described
new technics and have made other valuable contributions
to this field.
Anatomy
In man, the spinal sympathetic centers extend from
the first thoracic to the second lumbar spinal segments.
The paravertebral ganglia extend down to the coccygeal
region and up into the neck where there are only three
instead of eight cervical ganglia. The inferior cervical
ganglion is formed by fusion of the seventh and eighth
ganglia, the middle cervical gangion is formed by fusion
of the fifth and sixth ganglia, and the superior cervical
ganglion is formed by fusion of the upper four cervical
ganglia.
The sympathetic nerve supply of the skin of the head,
neck and occulopupillary region is as follows.' The pre-
ganglionic fibers arise in the lateral horn of the spinal
cord at the level of the first and second thoracic seg-
ments, with occasional variation upward or downward.
These fibers pass outward through the anterior root and
enter the sympathetic chain without synapse. They
*Read at the meeting of the North Dakota State Medical
Association, Minot, North Dakota, May 17, 1949.
tSection on Neurologic Surgery, Mayo Clinic.
ascend in the sympathetic trunk to the superior cervical
sympathetic ganglion where they synapse with postgang-
lionic fibers. The postganglionic fibers ascend in the
sheath of the internal carotid artery to the orbit and in
the sheath of the external carotid artery to the skin of
the face, the salivary glands and the cervical plexus.
Some fibers from the superior cervical ganglion seem
to join the phrenic nerve.
The sympathetic nerve supply of the upper extremi-
ties (Fig. 1) is segmental in its distribution.7 The pre-
ganglionic fibers arise in the second to tenth thoracic
spinal segments or thereabouts. They ascend without
synapse in the sympathetic trunk. They then synapse
with the postganglionic fibers in the first thoracic gan-
glion and inferior cervical ganglion (stellate ganglion) .
A few synapses occur with the middle cervical ganglion.
The postganglionic fibers, the majority of which are in
the stellate ganglion, join the roots of the brachial plexus.
It is clear from this description that the upper ex-
tremity, neck and head can be easily denervated by any
procedure that interrupts the sympathetic fibers at the
stellate ganglion or the second thoracic ganglion. Anom-
alous arrangement of parts of the sympathetic system,
however, is notably common, particularly around the
great plexuses. In this particular region, it has been dif-
ficult to perform a procedure which is complete on all
occasions. The inadequacy of the cervicothoracic pro-
cedure in the past has been explained on the basis of
sensitivity to epinephrine if a postganglionic sympathec-
tomy was performed. In the upper extremity, if the stel-
late ganglion is removed, the operation is postganglionic
because the nerves whose cell bodies lie in this ganglion
and whose axons go to the brachial plexus have been
377
378
The Journal-Lancet
Fig. 1. Sympathetic innervation of the upper extremity. Pre-
ganglionic fibers originate in the lateral horns of the spinal cord
from the first thoracic segment to the tenth thoracic segment.
The fibers ascend in the sympathetic trunk to the middle cer-
vical, stellate and second thoracic ganglia. The postganglionic
fibers originate here and send their axons to the brachial plexus.
destroyed. If, however, the second thoracic ganglion is
removed, the postganglionic cells sending fibers to the
brachial plexus are left intact and the sympathetic sup-
ply to the extremity is disconnected only from its central
nerve supply in the cord. This constitutes a pregangli-
onic sympathectomy. Fatherree, Adson and Allen 8
proved the discrepancy in the preganglionic and post-
ganglionic theory of sensitivity to epinephrine, and since
the report of their work the tendency has been toward
making the cervicothoracic sympathectomy more com-
plete anatomically.
The extent of sympathectomy can best be determined
by sweating tests which outline the areas of anhidrosis
(Fig. 2). A satisfactory cervicothoracic sympathectomy
produces absence of sweating on the face, neck and up-
per extremity. If the stellate ganglion is removed, Hor-
ner’s syndrome results. I prefer a sympathectomy that
removes the stellate and upper four thoracic ganglia.
This is easily accomplished from an extrapleural ap-
proach by removing the third rib posteriorly.
Considering briefly the sympathetic nerve supply of
the heart ' (Fig. 3), the preganglionic fibers arise in the
lateral horns of the cord at the first to the fifth spinal
segments. Some fibers, those arising from the first to
the third thoracic segments, ascend to the cervical
ganglia. The rest go to the corresponding paravertebral
ganglia. These preganglionic fibers synapse with the
postganglionic fibers in the three cervical ganglia and
the upper five thoracic ganglia. The postganglionic fibers
form the cardiac nerves and cardiac plexus. The superior
cardiac nerve arises from the superior cervical ganglion,
the middle cardiac nerve arises from the middle cervical
ganglion, and the inferior cardiac nerve arises from the
sympathectomy
Fig. 2. Cervicothoracic sympathectomy with removal of stel-
late ganglia and second, third and fourth thoracic ganglia. Area
of anhidrosis indicates extent of sympathetic denervation.
stellate ganglion. The other postganglionic fibers go di-
rectly to the cardiac plexus from the upper five para-
vertebral ganglia.
The surgical importance of this anatomic description
rests in the fact that visceral sensory fibers from the
heart travel over the middle and inferior cardiac nerves
and upper five thoracic sympathetic nerves. The superior
cardiac nerve does not seem to carry visceral afferent
fibers from the heart. It is clear that while removal of
the stellate ganglion eliminates the afferent supply from
the cardiac nerves it does not interfere with the direct
Fig. 3. Sympathetic nerve supply of the heart. Preganglionic
fibers arise in upper five thoracic segments. Postganglionic fibers
arise in superior, middle and inferior cervical ganglia and upper
five thoracic ganglia. Visceral afferent fibers from the heart
travel over this system exclusive of the superior cardiac nerve.
November, 1949
379
supply from the upper thoracic nerves; therefore, to ob-
tain the best relief from cardiac pain one should resect
the posterior roots of the upper five thoracic nerves
through which most of the visceral sensory axons from
the heart run.9
The sympathetic supply to the abdominal viscera
(Fig. 4) is about as follows.1 The preganglionic fibers
arise in the lateral horns of the spinal cord from about
the fourth or fifth thoracic to the second lumbar seg-
ment. The preganglionic fibers pass through the corres-
ponding paravertebral ganglia to the three splanchnic
nerves. The greater splanchnic nerve begins at the fourth
or fifth spinal segments and it also receives fibers from
segments as low as the ninth thoracic. The lesser splanch-
nic nerve is composed of fibers from the tenth and
eleventh thoracic segments. The lowest splanchnic nerve
consists of fibers derived from the twelfth thoracic and
first lumbar segments. The preganglionic fibers travel
in the splanchnic nerves and upper lumbar rami, and
synapse with the postganglionic fibers in the celiac, su-
perior mesenteric and aorticorenal ganglia. The post-
Fig. 4. Sympathetic nerve supply of the viscera is derived
from the fourth thoracic segment to the second lumbar segment.
The preganglionic fibers travel over the splanchnic nerves to the
celiac and aorticorenal ganglia and suprarenal medulla. Post-
ganglionic fibers arise in the celiac and aorticorenal ganglia and
travel by the blood stream to the viscera.
ganglionic fibers arising in these ganglia join the main
blood vessels by which they reach the various organs.
The sympathetic nerves to the adrenal gland are also pre-
ganglionic and are derived from the splanchnic nerves
and from the upper lumbar chain.
The operations devised by Adson,10 Craig and Ad-
son,11 Peet,12 Smithwick,14 Poppen 14 and others have
been designed for the explicit purpose of denervating the
viscera by removing the splanchnic nerves, paravertebral
ganglia and plexuses for the control of hypertension.
The sympathetic supply to the lower extremity (Fig.
5) is as follows.1 The preganglionic fibers arise between
the tenth thoracic and second lumbar segments. They
descend in the sympathetic trunk. They synapse in the
segmental paravertebral ganglia connected with the seg-
mental nerves supplying the obturator, femoral and sci-
atic nerves. The sciatic nerve consists of fibers derived
Fig. 5. Sympathetic nerve supply of the lower extremity.
Preganglionic fibers arise from the tenth thoracic segment to
the second or third lumbar segments. The postganglionic fibers
arise segmentally in the paravertebral ganglia and go to the cor-
responding roots making up the femoral, obturator, and sciatic
nerves.
from the roots of the fourth and fifth lumbar and the
first three sacral nerves. The femoral and obturator
nerves consist of fibers derived from the roots of the
first three lumbar nerves. The postganglionic fibers arise
in these paravertebral ganglia and travel over the corres-
ponding nerves to the lower extremity. Denervation of
the lower extremity (Fig. 6) is thus a relatively simple
matter. Removal of the first two or three lumbar ganglia
sympathectomy
Fig. 6. Incision and areas of anhidrosis established by sever-
ing the first, second and third lumbar ganglia or the second
and third lumbar ganglia.
380
The Journal-Lancet
will interrupt the sympathetic nerve supply of the entire
leg. In men, sterility is more likely to occur after removal
of the first, second and third lumbar ganglion than it is
after removal of the second and third lumbar ganglia
only.
Since Flothow liJ and Pearl 16 described the anterior,
extraperitoneal, muscle-splitting approach to the lumbar
sympathetic chain, the problem of lumbar sympathecto-
my has been simplified. Shelden, Pudenz, and I 17 have
added an S-shaped incision. I more or less routinely
operate on both sides at one time, thus eliminating many
days of hospitalization and the morbidity which formerly
occurred when the posterior approach through the flank
was used. By this method the patient is spared an extra
operation and anesthesia. It is possible to interrupt the
sympathetic nerve supply of the entire lower extremity
by removing the upper three lumbar ganglia, or to re-
move this innervation of only the lower part of the leg
and foot by removing the second and third lumbar
ganglia.
Indications for Sympathectomy
Peripheral Vascular Disease of Vasospastic Origin.
Raynaud’s disease occurs five times as frequently in
females as it does in males. The onset usually occurs
before the age of 40 years. The disease is characterized
by episodes, in the distal portion of the extremities, of
pallor, cyanosis and rubor on exposure to cold or emo-
tional stress. It is usually bilateral. Massive gangrene
is rare. There is an absence of any other primary dis-
ease, such as occlusive arterial disease.
Sympathectomy is the most effective treatment. One
can expect almost 100 per cent relief in the lower ex-
tremities. In the upper extremities, because of the diffi-
culty of sympathetic denervation due to anomalies of
the nerves and other poorly understood reasons, the re-
sults are not so good. Ten to 15 per cent of the patients
can expect complete and permanent relief, 50 per cent
can expect partial relief, and the remaining 35 to 40
per cent can not expect any relief.16 As surgeons learn
how to denervate the upper extremity more effectively,
they can expect better results.
Diffuse scleroderma is less likely to be associated with
circulatory disturbances than are acroscleroderma and
sclerodactylia. Sclerodactylia is limited to the extremities
and is more likely to be associated with circulatory dis-
turbances. If Raynaud’s phenomenon is predominant,
sympathectomy is indicated; otherwise, it will be of no
avail.
The pernio syndrome , or acute or chronic chilblain,
is a reaction of the peripheral blood vessels to cold,
usually affecting women. It causes recurring erythema-
tous and ulcerating lesions of the lower extremities. Re-
missions occur in the summer. Healing is associated with
considerable pigmentation. Sympathectomy is beneficial
in the cases in which the disease is severe.
Trench foot and immersion foot are caused not only
by injury of the peripheral circulation but also by in-
jury of tissue produced by exposure to cold and damp-
ness together with a mild, usually sterile inflammatory
reaction, and by trauma. Because of the injury of tissue,
sympathectomy has not been beneficial.
After frostbite, the affected extremity may remain
sensitive to cold for many months or even years, and in
occasional instances chronic pernio or Raynaud’s phe-
nomenon may appear subsequently. Sympathectomy
should not be carried out in the early stages because in-
creased circulation might increase edema and produce
a breakdown of tissue. If the disease progresses to
chronic pernio or Raynaud’s phenomenon, sympathec-
tomy, of course, is indicated.
Livedo reticularis is a reddish-blue mottling and blotch-
ing of the extremities due to spastic narrowing of the
arterioles and anoxic dilatation of the capillaries and
venules. It affects much more peripherally situated ves-
sels than does Raynaud’s disease, which involves the
large vessels of the digits and extremities. Livedo reticu-
laris involves the vessels in the skin. In 30 per cent of
the cases the disease is associated with hypertension.19
In three of 13 cases reported by Barker, Hines and
Craig, the disease process progressed to gangrene. Sym-
pathectomy is indicated in cases in which the disease is
severe.
Acrocyanosis is a disease which is similar to livedo
reticularis. It is characterized by persistent coldness and
cyanosis of the extremities. It is usually not severe
enough to warrant sympathectomy, which, however, is
effective if indicated.
Peripheral vascular disease of the occlusive type. There
are certain major occlusive diseases of the peripheral cir-
culation which, under certain circumstances, should be
treated by operations on the sympathetic nervous system.
One must remember that once gangrene is established,
such operations will not save the involved extremity or
digit.
The following criteria have been established as a basis
for determining whether or not arteriosclerotic occlusion 16
should be treated by sympathectomy. The patient should
be less than 60 years of age and should not have demon-
strable coronary disease, ulcers or gangrene. The vaso-
motor response, an indication of associated vasospasm,
should be good. Owing to improvements which have
been made in the operative technic, we recently have
become less rigid in the application of these criteria in
selecting patients who are to be treated by sympathec-
tomy at the Mayo Clinic. These improvements have re-
duced the mortality and the postoperative morbidity.
As a result, it now is possible to perform sympathectomy
in cases of more advanced arteriosclerosis in which the
patients are more than 60 years of age. The results
which we have obtained with this procedure in such cases
have been most gratifying and we possibly have saved
extremities which otherwise might have had to be am-
putated.
Thromboangiitis obliterans is a disease which is mani-
fested by arterial obstruction, vasospasm and venous ob-
struction. It usually affects persons who are between 25
and 50 years of age. Allen, Barker and Hines 18 said
that the youngest patient with this disease who has been
November, 1949
381
observed at the Mayo Clinic was 17 years of age. The
disease occurs almost exclusively in males. According
to these authors, 25 per cent of the patients with this
disease who have been observed at the clinic have been
Jews whereas only six per cent of all patients who come
to the clinic are Jews. Most of the patients who have
the disease are and have been heavy smokers, using an
average of 20 or more cigarettes per day. Although nico-
tine is not believed to be a cause of the disease, it most
certainly aggravates it, just as does exposure to cold.
New lesions of superficial phlebitis or evidence of fur-
ther arterial occlusion rarely is seen in cases in which the
patients have stopped smoking.
The disease is usually bilateral but asymmetric. The
progression of pallor, cyanosis and rubor, known as Ray-
naud’s phenomenon, may occur. The arterial and venous
circulation time is prolonged. Gangrene, ulcers, edema
and superficial phlebitis are characteristic symptoms of
thromboangiitis obliterans.
Sympathectomy increases the blood flow through an
artery in a limb three or four times.2'1 Because it abol-
ishes sweating of the extremity it helps prevent excessive
cooling of the limb. It is, however, of little benefit in
the presence of gangrene or a poor vasomotor index.
If, however, there is a good elevation of skin tempera-
ture following sympathetic paralysis, a good result may
be expected from sympathectomy. According to Hor-
ton,-’1 some type of amputation was performed in 15.6
per cent of all cases of thromboangiitis obliterans which
were observed at the Mayo Clinic in the years 1917 to
1937 inclusive. Amputations of the foot, leg or hand
comprised 71 per cent of the amputations which were
performed for thromboangiitis obliterans from 1918 to
1927 inclusive, 63 per cent of those which were per-
formed from 1928 to 1937 inclusive, and 48 per cent of
those which were performed from 1933 to 1937 inclu-
sive. It seems evident that since 1937 there has been
a further decrease in the percentage of cases in which
it has been necessary to amputate a foot, leg or hand.
In general, lumbar sympathectomy should be performed
bilaterally in cases of thromboangiitis obliterans. It
rarely is contraindicated except in cases in which the dis-
ease is very mild or extremely severe. In the treatment
of this disease, just as in the treatment of arteriosclerosis
obliterans, it should be understood that sympathectomy
does not remove the cause of the disease but produces
improvement chiefly by increasing the circulation.
In cases of sudden arterial occlusion due to any dis-
ease, sympathectomy may be beneficial if the condition
of the patient warrants its use. Our experience at the
clinic indicates that the use of sympathectomy is not
justified in cases of thrombophlebitis. This procedure,
however, may be of value in cases of surgical or trau-
matic occlusion of major vessels of the extremities.
Painful conditions amenable to sympathectomy. Caus-
al gia, which was described in 1864 by Mitchell, More-
house and Keen,2- is caused by injury of the large nerves
and blood vessels of the extremities or by injury of ad-
jacent structures. It is characterized clinically by burning
pain and considerable hyperactivity of the sympathetic
nerve supply of the extremity as manifested by color
changes and excessive sweating. It can be cured by
sympathectomy if recognized and treated promptly.
Visceral pain of chronic relapsing pancreatitis can be
eliminated by section of the greater, lesser and least
splanchnic nerves on one or both sides.2'1 Whether or
not this procedure will be effective in an individual case
can be determined preoperatively by injecting a local
anesthetic agent into the splanchnic nerves. Section of
the splanchnic nerves has produced uniformly good re-
sults at the Mayo Clinic. These results are being re-
ported by Craig.21
The burning pain of phantom limb 2,> also has been
relieved by sympathectomy. The other aspects of this
syndrome, including the paresthesia and the sensation of
the presence of the amputated limb, have not been re-
lieved by sympathectomy.
As previously stated, cervicothoracic sympathectomy
produces varying results in cases of angina pectoris. The
best results, however, are obtained by sectioning the pos-
terior roots of the upper four or five thoracic nerves.
Hypertension. In this country, Adson, Craig, Peet,
and Crile 2t’ were the first surgeons to perform operations
on the sympathetic nervous system for the relief of hy-
pertension. Adson and Craig devised the infradiaphrag-
matic sympathectomy. Crile resected the celiac ganglion,
and Peet devised a supradiaphragmatic operation. In the
late 1930’s, Smithwick used a combination of the pro-
cedures devised by Adson and Craig, and Peet. Many
modifications of these surgical procedures are being used
at present.
Wagener and Keith2' proposed a system of correlat-
ing the changes in the ocular fundi with the severity of
the disease. This system is used widely today, and is of
considerable prognostic value. In malignant hypertension
or hypertension, group 4, the characteristic findings are
papilledema, hemorrhages and exudates, with sclerotic
and spastic changes in the retinal arteries. Hypertension,
group 3, is characterized by severe retinopathy without
papilledema. In hypertension, group 1 and group 2,
there are no hemorrhages, exudates or papilledema but
only sclerosis and variation in the size of the retinal
vessels.
At the clinic, it has been our experience in general
that the better the appearance of the ocular fundi, the
better the results of sympathectomy in cases of hyper-
tension. There are other important criteria in selecting
patients for this type of operation. The patient should
be less than 50 years of age. The hypertension should
be somewhat labile. There should be no history or evi-
dence of congestive heart failure, renal failure or recent
coronary occlusion. Increased intracranial pressure is a
contraindication for surgical treatment. Progression of
the disease is a strong indication for sympathectomy.
Poppen and Lemmon 28 have expressed the opinion that
the duration of the disease has little influence on the
results, provided the patient meets the other requirements
for sympathectomy. Enlargement of the heart is not
necessarily a contraindication. Advanced arteriosclerosis
or coarctation of the aorta is a contraindication. Angina
382
The Journal-Lancet
makes the prognosis unfavorable although we occasion-
ally operate in cases in which it is present.
Careful urographic evaluation is important. The occa-
sional presence of unilateral renal lesions may thus be
ascertained, and nephrectomy can be performed. We are,
however, inclined to perform sympathectomy simultane-
ously with nephrectomy in order doubly to assure our-
selves of a good result and to avoid a second surgical
procedure should the nephrectomy prove valueless.
It should be emphasized that only those patients whose
disease has not been controlled by medical treatment be
chosen for surgical treatment.
There is considerable controversy regarding the results
of this type of operation. It is difficult to interpret and
evaluate the results. This much can be said definitely.
Anyone who has performed the operation in a large
number of cases can cite numerous brilliant results.
From October, 1946, until December, 1947, I performed
extensive thoracolumbar sympathectomies of a modified
Smithwick type in 35 cases of hypertension. In 23 of
the 35 cases, information regarding the physical condi-
tion of the patients was obtained at least once during
an interval of from six months to two-and-a-half years
after the respective operations. In cases in which the
patients or their family physicians reported that the
blood pressure was normal, and in cases in which subse-
quent examination at the clinic disclosed that the blood
pressure was normal, the result was classified as good.
In cases in which the blood pressure occasionally was
higher than normal but was normal on other occasions,
the result was classified as fair. In the remaining cases,
the result was classified as poor. In some of the cases
in which the result was classified as poor, improvement
has occurred in the appearance of the ocular fundi, the
blood pressure has been lower than it had been before
the operation and the patients have been free of symp-
toms of hypertension. On this basis, the results were as
follows: good in eight cases, fair in five cases, and poor
in ten cases. This is only an indication of the results of
this extensive operation. In four of the ten cases in
which the results were poor, the patients subsequently
have died. I am recording these preliminary observations
because the results seem to be similar to those reported
by other authors. The operative mortality rate should be
less than one per cent.
In 1947, Poppen and Lemmon 28 reported 100 cases
in which extensive sympathectomy was performed. The
results were as follows: good in 47 per cent, fair in 24
per cent, and unsatisfactory in 22 per cent of the cases.
Grimson 29 reported that extensive sympathectomy pro-
duced good results in 38 per cent, fair results in 33 per
cent, and unsatisfactory results in 14 per cent of 97
cases of hypertension. In both of these series of cases,
71 per cent of the patients were improved. It seems
that, all other things being equal, the more extensive
the procedure, the better the results. At the present time
I am employing a procedure similar to that described
by Poppen.
The extent of sympathectomy can be determined by
sweating tests after the operation. The Adson-Craig
W and
sub- diaphragmatic
splanchnics
and a portion of
coehac ^ancShon
Adson - Crai$J
sympathectomy
Fig. 7. Adson-Craig sympathectomy for hypertension; in-
cision, extent of sympathectomy and area of anhidrosis.
infradiaphragmatic operation produces anhidrosis from
the groin or knees downward (Fig. 7). The supradia-
phragmatic and infradiaphragmatic operation of Smith-
wick produces anhidrosis from the umbilicus downward
(Fig. 8). Thoracic sympathectomy (Fig. 9) produces
varying degrees of anhidrosis of the abdomen and thorax,
depending on the extent of the procedure. The Poppen
operation, which removes the third thoracic to the third
Wi Qnd
splanchnics
Smithwick type
sympathectomy
Fig. 8. Smithwick type of thoracolumbar sympathectomy for
hypertension; incision, extent of sympathectomy and area of
anhidrosis.
November, 1949
383
Fig. 9. Thoracic type of sympathectomy for hypertension;
extent of sympathectomy and area of anhidrosis.
lumbar ganglia inclusive, produces anhidrosis over the
entire body except the arms and head (Fig. 10). Total
sympathectomy usually produces complete anhidrosis.
In 1948, Ray and Console 30 described a phenomenon
which we also observed in 30 per cent of cases in which
extensive sympathectomy has been performed at the
clinic (Fig. 11). This is a persistence or return of sweat-
ing in the anterior part of the thighs in a segment cor-
responding to the twelfth thoracic and the first three
lumbar dermatomes. Ray and Console showed that this
can be obliterated only by intraspinal removal of the
anterior roots of the twelfth thoracic and the first two
lumbar nerves. This graphically illustrates some of the
aberrant patterns of the sympathetic system.
Fig. 11. Ray-Console anomalous sweating patterns following
extensive sympathectomies with return of sweating in the area
supplied by the twelfth thoracic to the third lumbar dermatomes
inclusive.
Modified Poppen
sympathectomy
Fig. 10. Modified Poppen thoracolumbar sympathectomy for
hypertension; modified incision, extent of sympathectomy and
area of anhidrosis.
Summary
For years, it has been known that operations on the
sympathetic nervous system are of definite value in the
treatment of vasospastic disease of the peripheral blood
vessels and in the treatment of some occlusive diseases
of the peripheral vessels. Recently it has become appar-
ent that operations on the sympathetic nervous system
also are of value in the treatment of causalgia, visceral
pain and some aspects of phantom limb. They are of
limited value in cases of angina pectoris.
Operations on the sympathetic nervous system are an
aid in the treatment of hypertension in cases in which
medical therapy has failed. They are of particular value
in the treatment of progressive hypertension before the
malignant phase has been reached.
I would like to emphasize that the use of the word
"cure” has been carefully avoided in this paper and that
it should be used only as medical science proceeds beyond
its present stage.
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The Journal-Lancet
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Quoted by Smithwick, R. H.: Surgery of the Autonomic
Nervous System. New England J. Med. 240:543, 1949.
23. Rienhoff, W. F., Jr., and Baker, B. M.: Pancreolithiasis
and Chronic Pancreatitis; Preliminary Report of a Case of
Apparently Successful Treatment by Transthoracic Sympathec-
tomy and Vagectomy, J.A.M.A. 134: 20, 1947.
24. Craig, W. McK.: Personal communication to the author.
25. Livingston, K. E.: The Phantom Limb Syndrome; a
Discussion of the Role of Major Peripheral Nerve Neuromas,
J. Neurosurg. 2:251, 1945.
26. Crile, George: Genesis and Surgical Treatment of Es-
sential Hypertension, Pennsylvania M. J. 40:1017, 1937.
27. Wagener, H. P., and Keith, N. M.: Diffuse Arteriolar
Disease with Hypertension and the Associated Retinal Lesions,
Medicine 18:317, 1939.
28. Poppen, J. L., and Lemmon, Charles: The Surgical
Treatment of Essential Hypertension, J.A.M.A. 134:1, 1947.
29. Grimson, K. S.: Quoted by Williams, A. C., Hyperten-
sion: Recent Trends in the Surgical Treatment, J. Florida M.A.
35:211, 1948.
30. Ray, B. S., and Console, A. D.: Residual Sympathetic
Pathways After Paravertebral Sympathectomy, J. Neurosurg.
5:23, 1948.
TUBERCULOSIS RESEARCH
Of nearly $7,000,000 spent for tuberculosis research in the United States in a twelve-
months’ period during 1947-1948, about two-thirds was expended for the study of drugs in
tuberculosis treatment. Total allocations for tuberculosis research in the period covered came
to $6,710,141, of which $4,388,039 was spent on chemotherapy studies, mostly as the result
of intensive research on streptomycin and other chemotherapeutic agents in tuberculosis
treatment. The survey showed that the greatest expenditure on tuberculosis research was by
official agencies, principally federal, with a total of $3,814,050, of which $3,073,200 was
allocated to chemotherapy investigations.
November, 1949
38 5
Treatment of Rheumatic Diseases with
Glucuronic Acid*
A Preliminary Report
Joseph H. Hodas, M.D., Harvey Brandon, M.D., and John F. Maloney, M.D.
New York City, New York
The rheumatic diseases have presented a continuous
challenge throughout the history of medicine. Every
medical advance and discovery has been applied to their
treatment without furnishing a definitive cure, finding
the causes, or exposing the true nature and course of this
disease group. To quote a most recent example, the ex-
cellent reports on Compound E, highly promising as
they are, state plainly that the success lasts only as long
as the treatment is continued. In a rather similar prob-
lem, we cannot call insulin the definitive treatment of
diabetes mellitus, yet we appreciate its value as a con-
trolling factor. Just as in diabetes mellitus, a complete
solution of the rheumatic problem has still not been
given. Undoubtedly, some of these questions will be
answered as experience with Compound E develops. But
until now, we seemed to have reached an impasse both
in the etiological approach and the mode of treatment.
It therefore seemed promising to attempt a long
neglected approach — a treatment along physiological
lines in which we tried to replace the deficiency encoun-
tered in certain of these diseases in an effort to restore
normal body functions. Such a substance is glucuronic
acid, which works as a detoxifying agent and also enters
into the formation of collagen. In rheumatic and related
diseases it is deficient, and the response to its administra-
tion has been encouraging enough to warrant its further
trial in various manifestations and stages of this dis-
ease group.
Biochemists have long known that glucuronic acid or
its salts appear as conjugate substances with various tox-
ins and putrefactive substances and are excreted in the
urine as such. Utilization of the acid in the body has
been difficult to study and is mentioned infrequently in
the literature, due possibly to the scarcity of the product
and the expensive and elaborate manufacturing process.
Its clinical use and study is comparatively recent. Glu-
curonic acid was first mentioned in medical literature in
1878 by Jaffe1 and subsequently by Schmiedeberg and
Meyer.2 At the turn of the century it was demonstrat-
ed that glucuronic acid was present in the urine and
blood of man and cattle.3,4 Shortly afterwards, Cam-
midge 5 reported increased glucuronic acid in the urine
of patients with pneumonia, chronic bronchitis, measles,
scarlet fever, smallpox, and pancreatic diseases.
Subsequently, it was found that glucuronic acid did
not exist in a free state in the urine, but was conjugated
*From the Medical Service, Misericordia Hospital, New York
City.
with various substances, including toxins and metabolic
products. This demonstrated the body’s utilization of
the acid as a detoxifying agent. Substances such as sul-
fonamides, chloral hydrate, phenol, antipyrin, and a great
many other chemical substances, when introduced into
the body, were finally excreted as conjugated glucuronic
acid compounds. In addition, various aromatic com-
pounds which resulted from putrefactive changes in
proteins, e. g., indole and skatole, found in the intes-
tines, were also excreted in this way. Glucuronic acid
excretion appeared to increase in certain conditions such
as jaundice, diabetes mellitus, bone diseases, and exten-
sive traumatism to the muscles. Deficiencies of most
vitamins, with the exception of riboflavin, produce a
decreased excretion of the acid.
Glucuronic acid is a six-carbon chain compound and
usually exists as a bound compound or glucoside which
can be split by acid hydrolysis. It is formed from carbo-
hydrate stores in the human body and when these are
depleted, it may also be derived from glucogenic amino
acids. Possibly the liver and muscles are involved in its
manufacture and storage.
In spite of the early experimental and biochemical
studies in the latter part of the 19th century, no new
work appeared in literature until the late twenties when
Ambrose/’ Sherwin,1 and Quick * again stimulated in-
terest in the study and clinical application of glucuronic
acid. Few additional biochemical studies 9 were done dur-
ing the following years, but in December, 1947, Peter-
man 10 published an excellent paper giving the results
of his study in the toxicity, utilization, and some clinical
application of glucuronic acid in arthritis, which sug-
gested its use in various other nutritional and toxic dis-
eases. Its theoretical possibilities in the collagen disease
group, as well as in barbiturate, morphine and sulfa poi-
soning, toxemia, liver diseases, diabetes mellitus, general
debilitation and various allergic states, bear further inves-
tigation.
No matter whether we assume the rheumatic diseases
to be a generalized toxicity, a nutritional deficiency, a
defective collagen cement substance, or a combination of
these, as long as glucuronic acid fits all these concepts,
it seems logical and reasonable to apply it for the treat-
ment of this disease group.
When glucuronic acid or its salts are ingested, some
will appear as conjugated phenols or some may appear
in the free state in the urine if the ingestion is massive.
It plays an important role as a detoxifying agent in the
386
The Journal-Lancet
body, and is utilized for the conjugation of aromatic
acids, phenols, and tertiary alcohols. The excretion of
glucuronic acid will be increased with the administration
of a variety of substances with which it combines as a
detoxicant and with which it appears in the urine, such
as menthol, morphine, certain sulfonamides, indole, ska-
tole, steroids (estrogenic hormones) , and possibly cer-
tain carcinogenic substances.
Glucuronic acid is an essential constituent of the fi-
brous tissue of the body, particularly the cartilage, fascia,
periosteum, nerve sheath, joint capsule, tendon and joint
fluid. The intercellular cement substance and blood ves-
sel walls 10 are also composed in part of this substance.
The importance of these tissues is of increasing interest
to rheumatologists because of the recent stress on colla-
gen diseases.
In the study of roentgen treatment of Marie-Striim-
pell arthritis, Dr. Harry C. Blair 12 made some interest-
ing observations on the chemistry and metabolism of car-
tilage and allied tissue involving glucuronic acid. Car-
tilage and mucin contain chondroitin sulphuric acid and
mucoitin sulphuric acid respectively, both of which are
composed chiefly of glucuronic acid combined with sul-
phur. Sulphur, used empirically for 2500 years in the
treatment of arthritis, has recently been found ineffective
by many experimenters.14 The other component, glu-
curonic acid, has remained unexplored and untested.
Peterman 10 suggests that the destruction of cartilage
and bone may be due to deficiency of the glucuronic
acid required for body metabolism. No attempt is made
here to argue the cause of the destruction, whether it
be toxic, bacterial, allergic, or endocrine in nature. It
is possible that the same underlying metabolic disturb-
ance may be involved in the cement substance of the
collagen diseases. It remains for further investigation to
determine or disprove this more fully.
In the opinion of Bauer 1,1 and many other investi-
gators, general body nutrition and hygiene are, at pres-
ent, the paramount therapeutic factor in rheumatic dis-
eases. Of particular interest in Peterman’s study was the
general feeling of well-being, the increase of appetite,
and gain of weight in his trial subjects. This has been
borne out by our own observation. It is known that most
vitamin deficiencies produce a decrease in glucuronic acid
excretion. Possibly the deficiency of glucuronic acid may
be a factor in the lack of utilization and metabolism of
the various vitamins. There appears to be some relation-
ship, but this too, at present, remains an unsolved prob-
lem.
Clinical Observation
A total of 50 cases of rheumatic diseases were treated
with the object of determining what types could best be
treated with glucuronic acid. They were therefore not
especially selected, but studied as they presented them-
selves. The results are summarized as follows:
Our cases, consisting of 15 men and 35 women from
17 to 70 years of age, were observed and followed for
a period of six months to a year. The main types, as
to be expected, were osteoarthritis and rheumatoid ar-
thritis. There were 17 cases of osteoarthritis and four
mixed types, which in accordance with the recommenda-
tions of the American Rheumatism Association are clas-
sified in the rheumatoid group.14 The remainder of the
cases were sub-classified where recognizable as: two cases
of shoulder-hand syndrome; two, Marie-Striimpell type;
two post-rheumatic fever joints; one infectious arthritis;
one palindromic arthritis; and two gout. In addition,
there were: one case associated with bursitis, and five
associated with sciatica, not included in the arthritis
group.
Blood counts, sedimentation rates, and x-rays were
taken in order to confirm the diagnosis, to define the
stage of the disease, and to follow the progress whenever
possible. Clinical observation and the patient’s subjective
response were closely correlated to objective findings,
such as decrease of swelling, redness, improvement of
flexibility, and freedom of affected joints. The thera-
peutic results were evaluated in accordance with the cri-
teria of the American Rheumatism Association.1''
Three preparations were used: syrup containing 5
grains per drachm, and capsules and tablets with 7/i
grains (500 milligrams) each of Glucuronolactone.* In
equivalent doses these preparations were used inter-
changeably. The dose given in our series averaged 10
to 15 grains three or four times a day. In two cases,
total daily doses up to 150 grains (10 grams) were taken
without untoward effect. Treatment was maintained
from one week to one year, with two months as the
average duration. Medication was discontinued when
the patient’s symptoms remained stationary or showed
no further improvement. In several instances, the treat-
ment has been maintained continuously for one year
because the patient’s symptoms flared up after one or
two weeks’ cessation of treatment and subsided promptly
on resumption of glucuronic acid treatment. Up to now,
there have been no exacerbations during therapy.
More recently, we have been using a 10 per cent buf-
fered solution of glucuronic acid made for injection.
We have not as yet sufficient experience to include the
cases of this series in our present report.
Undesirable side effects were noted in three cases, one
with flushing of the face, another with diarrhea, and a
third with gastric upset which promptly abated on reduc-
tion of dosage or discontinuance of the drug. Follow-up
urinalysis showed no kidney damage after glucuronic
acid therapy; only one case had a trace of albumin, and
there the microscopic findings were normal.
Since our cases were unselected, most had been pre-
viously treated by various other forms of therapy, in-
cluding salicylates, succinate, bee-sting therapy, gold,
non-specific proteins, typhoid and rheumatic-streptococcus
vaccines, high vitamin doses of the B, C, or D groups.
In addition, some received various local applications;
physical therapy; treatment by change of climate, hy-
gienic measures, removal of foci such as infected teeth
and tonsils, and last, but not least, by nutritional meas-
*Supplied through the courtesy of Commercial Solvents Cor-
poration.
November, 1949
387
ures alone. We have, therefore, a fair basis of compari-
son with other methods of treatment. More than one-
half of our patients have run the gamut of all these
treatments with no appreciable results.
Evaluation of Therapy in Specific Types
Osteo-arthritis. The cases in our series that responded
best were the comparatively early cases of osteo-arthritis,
especially those in which this disease was less than one
year in duration. Those of longer duration responded
less dramatically, but in almost all of this type there
was some subjective improvement even though x-ray find-
ings remained essentially unchanged. In addition to the
lessening of pain and swelling in the joints, the general
feeling of well-being and the gain of weight were out-
standing symptoms. In a few cases, this improvement
was maintained even after therapy had been discontin-
ued. Glucuronic acid was of special value in cases of
osteo-arthritis associated with Heberden’s nodes, at times
actually causing diminishing in size of the involved
joints. This has also been observed by other investiga-
tors.11
Mixed types. In the four cases of mixed arthritis there
was considerable improvement; not as marked as in the
former group, but found to be of some therapeutic
value. Here, too, the duration of the disease seemed to
have a bearing on the effect of the therapeutic response.
Rheumatoid arthritis. In the rheumatoid group and its
various subdivisions, the results were less effective and
at times equivocal. Clinical improvement of varying de-
grees occurred in almost half of the cases. This improve-
ment did not necessarily correspond to a fall in the sedi-
mentation rate, and usually stopped when the medication
was ended. Two of our cases were associated with post-
encephalitis syndromes, one of which was a true Parkin-
sonian type. Both of these cases showed improvement
in this condition as well as a diminished tremor and an
increased use of hands. Our treatment of shoulder-hand
syndrome achieved mixed results: one case responded
very well, the other failed. The two cases of Marie-
Striimpell disease under our observation also showed
a mixed response.
Two cases with post-rheumatic fever joints, whose
attacks were of recent etiology, responded very well. The
result in the case with bursitis was questionable, while
those associated with sciatica showed very satisfactory re-
sults. In fact, both from our observations and those of
other investigators, this appears to be the most promis-
ing field for the use of glucuronic acid. To date, we
have ten additional cases (not included in this report)
which showed dramatic response to this treatment.12
Two of our cases of sciatica were definitely associated
with arthritis; one was radicular in type. Two cases of
gout responded well to treatment. Many more cases
should be observed before a definite conclusion can be
reached. These were both early cases and spontaneous
cures at this stage are not uncommon.
Infectious, as well as palindromic arthritis, is usually
shortlived and leaves no permanent effects so that the
response to any treatment again cannot be exactly eval-
uated. Peterman reported excellent results with the treat-
ment of fibrositis. Since we had no cases of this type
in this series we can give no results on this condition,
but indications are that glucuronic acid may be of some
value here, and should be investigated further.
An interesting observation, and not reported in our
series, was the effective treatment of an arthritis case
of only a few days’ duration accompanied by swollen
joints following a diffuse ecchymotous rash — the allergic
sequellae of penicillin treatment. These joint involve-
ments are being seen quite commonly by dermatologists
as an accompaniment to the various allergic states of
different etiology. The association of allergy and arthral-
gia has given rise to the theory that many of our real
arthritides may be serous-membrane responses to allergic
reactions, possibly of the anti-body-toxic type. At times,
the joint symptoms associated with an urticarial rash
may prove quite troublesome and persist beyond the
original manifestations of allergy. Here too, glucuronic
acid may be of value in treatment.
Two of our cases of arthritis (one of which was a
possible Kimmelstein-Wilson type) were associated with
diabetes mellitus. Under treatment, the joint symptoms
receded and the diabetes, too, showed signs of improve-
ment. Somewhat less insulin was required in both cases
for proper control of the disease. No definite conclusion
can be drawn from these two cases since many other sub-
stances can influence the diabetic state, such as large
doses of vitamin B, E, liver extracts or estrogens. There
have been no actual control studies on the effect of
glucuronic acid in diabetes. A few cases showed a false
positive sugar reaction in the urine due to glucuronic
acid administration. This should be watched for and
evaluated.
Discussion
The results obtained in the preliminary survey justify
our belief that glucuronic acid has a definite place in the
treatment of rheumatic diseases. Certainly our results
were comparable to, and sometimes better than, those ob-
tained with the standard methods of therapy. The dos-
age of glucuronic acid will have to be regulated further.
Perhaps the method of administration may have to be
modified after absorption and excretion have been more
fully studied. We do not believe that this is the long
awaited panacea in the treatment of arthritis. Most
assuredly, the treatment with glucuronic acid, in our
opinion, is more logical and physiological than any of
the previously used drugs. It does not have the dangers
of toxicity of either gold or high-vitamin D therapy and
combines the detoxifying faculty with a blood vessel
building nutrient material. This is obviously more than
a symptomatic treatment and deserves wider application
and trial. With the exception of sciatica, where the relief
was usually dramatic and prompt, glucuronic acid does
not appear to have the analgesic effect of salicylates, and
may have to be supplemented with codeine or salicylates
in the initial phase of the disease where symptomatic
relief of pain is the most urgent problem.
The difficulties in evaluating therapy of rheumatic
diseases are well appreciated. In an attempt to set up
more specific criteria in this heretofore vague field, the
American Rheumatism Association has defined standards
and issued score cards in an attempt to make an accurate
388
The Journal-Lancet
comparison for types of therapy. A large number of
cases, accurate control, and detailed laboratory studies
are essential, but it is difficult to achieve this with the
rheumatic patient who can neither be hospitalized nor
followed up for a sufficient length of time for detailed
comparison. Many more cases will need to be studied,
and further laboratory work be done, before this or any
type of therapy can be properly evaluated. This report
is essentially clinical. We hope to extend our observa-
tions and studies in subsequent reports.
In keeping with the therapeutic score cards,1'1 our re-
sults were graded by the four degrees:
1. Complete remission
2. Major improvement
3. Minor improvement
4. Unimproved or worse
With evaluation of our 50 cases, 9 showed complete re-
mission, 19 showed major improvement, 14 minor im-
provement, while 8 cases remained unimproved or be-
came worse.
Table I
-a
Q C
S c
E £
> „
£ <£
-Q 3
S-2
>— (
u £
i- £
1 £
Type of
||
o o
ns o
O
•s §
1*
Arthritis
Z'o
u"S
S a
2 a
O 8
I
Rheumatoid groups
14
l
4
5
4
Mixed
4
2
1
1
Shoulder-hand syndrome
2
1
1
Marie-Strumpell type
2
1
1
11
Osteoarthritis
16
2
6
6
2
III
Special types:
Post-rheumatic
fever joints
2
2
Infectious arthritis
Palindromic
1
1
i
i
Bursitis
Sciatica
1
5
4
i
Gout
2
2
Most other therapeutic procedures, properly evaluated,
give about 50 per cent in the improved groups, with the
failures running about 25 to 35 per cent. The compari-
son of our results with others previously published shows
that we have done as well as many, possibly somewhat
better. In selected forms, such as sciatica, gout and early
osteo-arthritis, the results are promising, and because of
the absence of toxic effects, should be given a further
trial. This substance may point the way to a better un-
derstanding and more successful therapy in the future.
References
1. Jaffe, M.: Zur Kenntnis der synthetischen Vorgaenge im
Thierkoerper. Ztschr. f. physiol. Chem. 2:47-64, 1878.
2. Schmiedeberg, O., and Meyer, H.: Ueber Stoffwechsel-
produkte nach Kampferfuetterung. Ztschr. f. physiol. Chem.
3:422-450, 1879.
3. Mayer, P., and Neuberg, C.: Ueber den Nachweis ge-
paarter Glucoronsaeuren und ihr Vorkommen im normalen
Ham. Ztschr. f. Physiol. Chem. 39:236-273, 1900.
4. Mayer, P.: Ueber unvollkommene Zuckeroxydation im
Organismus. Deut. med. Wchnschr. 27:243-248, 262-265, 1901.
5. Cammidge, P. J.: Observations in the urine in chronic
diseases of the pancreas. Proc. Roy. Soc. 81:372-380, 1909.
6. Ambrose and Sherwin: Ann. Review Biochem. 2:377,
1933.
7. Harrow and Sherwin: ibid. 4:263, 1935.
8. Quick, J.: J. Biol. Chem. 69:549 (1926); 98:537 (1932);
Ann. Rev. Biochem. 6:201 (1937).
9. Lipschitz and Bueding: Biol. Chem. 122:649, 1937.
10. Peterman, E. A.: Glucuronic acid deficiencies in the
rheumatic diseases. Journal-Lancet 67:451, 1947.
11. Blair, Harry C.: Portland, Oregon: unpublished investi-
gation, quoted with the author’s permission.
12. Laage, Herbert A.: unpublished investigation, quoted
with the author’s permission.
13. Bauer, Walter (Boston): Rheumatoid arthritis, J.A.M.A.
138:6:397-399, 1948.
14. Primer on the rheumatic diseases: J.A.M.A. 139:10-68-
1076, 1949.
15. Recommendation of the committee to investigate thera-
peutic criteria. American Rheumatism Association.
16. Steinbrocker, O., and Blazer, A.: A therapeutic score
card for rheumatoid arthritis. New England J. Med. 235:501-
506, 1946.
AIR POLLUTION CONFIRMED
Continuing pollution of air in present-day industrial communities not only can cause
death, as it did last year at Donora, Pennsylvania, where 20 persons died during a prolonged
smog, but it has other grave health implications, Federal Security Administrator Oscar R.
Ewing declared. In addition to the 20 deaths, the illness of 5,910 persons — 43 per cent of
the population — was caused by the smog which hung over Donora and the nearby com-
munity of Webster for five days beginning October 27, 1948.
November, 1949
389
Headache and Headache Pain*
John J. Ayash, M.D.f
Minot, North Dakota
Headache and head pain are quite common in a
variety of diseases. The otolaryngologist and the
ophthalmologist are frequently the first consulted by the
patient or referred to by the general practitioner, due to
the exaggerated belief that refractive error and sinusitis
constitute the primary cause of headache in a majority of
cases. These two conditions account for only a small per-
centage of headaches as compared to other more frequent
causes. Chronic sinusitis in particular, when unassociated
with pain-causing factors, is rarely, if ever, the cause of
headache.
To the EENT specialist falls the responsibility of
identifying the type of headache experienced by the pa-
tient and of ruling out any EENT pathology that can
be the etiological factor. If other causes are responsible,
he must identify the cause and refer the patient to his
doctor with specific recommendations as to the treatment.
Mechanism of headache. After a tremendous amount
of experimental and clinical research within the last dec-
ade, our concept of the mechanism of headache and the
factors involved has changed and many of the previous
theories have been discarded or modified.
Headache and head pain are divided into two main
divisions — intracranial causes and extracranial causes,
which are further subdivided into vascular and neuralgic.
The pain-sensitive structures within the cranium are
the venous sinuses and their tributaries, the dural ar-
teries, the cerebral arteries of the base of the skull (circle
of Willis), and the dura of the base of the brain.
The non-sensitive structures are the cranium, the brain
proper, the dura, except the dura of the base, and the
pia, the lining of the ventricles, and the choroid plexus. l a
Headache or pain may be caused by any or a com-
bination of the following factors: 1,b (I) dilatation and
distension of intracranial arteries, (2) traction on the
veins and venous sinuses with displacement, (3) traction
of the middle meningeal arteries and arteries of the base
of the brain, (4) inflammation in or about any of the
pain-sensitive structures of the head, (5) direct pressure
by growth of tumors on the nerves.
Extracranial sensitive structure.1,0 The skin, the muscles
especially around the arteries, the gala, and the arteries
are all sensitive to pain; the veins are less sensitive. The
nonsensitive areas are the bone with its diploic and
emissary veins, the periosteum, except where it attaches
to the gala at the brows, the temple, and the occipital
region.
Intracranial pressure changes result in a bilateral dif-
fuse headache, but the intensity of the headache is not
directly proportionate to the increase or decrease of the
^Presented before the North Dakota State Medical Meeting,
Minot, North Dakota, May 17, 1949.
fFrom McCannel Clinic, Minot, North Dakota.
pressure. The cause of the headache is not the change
of pressure but the displacement and distortion of the
pain-sensitive structures within the cranium, especially
the arteries at the base of the brain. The post-lumbar
puncture headache is due to a decreased cerebrospinal
fluid pressure by a removal of a large quantity of fluid
or a gradual leakage of fluid from the puncture of the
dura after the lumbar puncture. 1,d
Brain tumors. Headache caused by brain tumors and
other space-occupying lesions is a deep, aching, steady,
dull, non-throbbing pain. Brain tumors are divided clin-
ically into supratentorial and infratentorial.
In supratentorial tumors, the headache is referred to
an area on the cranium externally, anterior to a line
drawn across the vertex from ear to ear, and the pain
is referred through branches of the fifth nerve. If the
tumor is growing slowly, there may be no headache
at all. Headache starts unilaterally on the side of the
tumor and stays so until papilledema develops. In the
latter case the pain would be radiated to the occipital
region and would usually become generalized by the in-
creased intracranial pressure.
In infratentorial tumors, the headache is referred to
the occipital region and the posterior aspect of the neck
through the ninth, tenth, and upper cervical nerves. The
headache starts occipitally but soon becomes generalized
and is referred to the temporal and frontal area by
virtue of the early increased intracranial pressure. Thus,
there is no localizing importance to the headaches caused
by these tumors. In fact, any time the intracranial pres-
sure is increased, as shown by papilledema, the headache
becomes generalized or is referred elsewhere. Jolting of
the head in patients with increased intracranial pressure
may exaggerate the pain in a special location in the head.
This is a localizing point and shows the site of the tumor.
Subdural hematoma. This type of lesion has been
more and more recognized and operated on with success.
Headache is the main symptom and is found in 70 per
cent of the cases. Subdural hematoma is caused by a
rupture of a tributary vein to one of the venous sinuses
of the cranium by a trauma to the head." The trauma
may be minimal or insignificant and forgotten by the
patient, especially in the chronic incapsulated type.3
The headache starts a few days after the accident or
trauma, and the severity increases progressively during
the first six to eight weeks, after which it remains sta-
tionary unless relieved by surgery. The pain is dull,
diffuse, like a brain tumor pain, and is localized to the
side of the hematoma early, but generalized later on,
or it may be generalized from the onset. The spinal
fluid is xanthochromic early in the course. Encephalo-
grams and ventriculography confirm the diagnosis.
The following case history shows a typical course of
390
The Journal-Lancet
a subdural hematoma. A 46-year-old mail carrier was
first seen on May 3, 1948, complaining of a severe, con-
tinuous, pulsating, diffuse headache for two months.
The onset followed a jolt caused by falling on his back
while trying to crank a car. The symptoms increased
in severity until he was completely incapacitated. The
spinal fluid examination showed normal pressure and
dynamics, proteins 22 mg. per cent, no cells, and no
xanthochromia. An x-ray showed a displacement of a
calcified pineal body to the left, indicating a space-occu-
pying lesion on the right. The patient was referred to
the Mayo Clinic, where he was kept under observation
for two weeks in the neurological department. His
symptoms improved slightly on bed rest but he showed
no neurological findings until two weeks after admis-
sion, when he experienced severe vertigo, nausea, vom-
iting, and headache. A craniotomy was performed and
a large subdural hematoma was found covering the en-
tire parietal lobe on the right side and extending to the
frontal and temporal lobes. It was incapsulated and was
removed in toto. This patient has been active and in
good health since the operation.
Subarachnoid hemorrhage. This condition is caused
by a rupture of a congenital aneurysm at the base of
the brain without any precipitating trauma or accident.4
Arteriosclerosis and pre-existent periodic headaches, like
migraine, are predisposing factors. Onset is usually in
the fourth decade. It starts with a dramatic and excru-
ciating pain in the occipital area described by the patient
as something that snaps in the head. There is vomiting,
drowsiness, and neck rigidity, sometimes followed by
convulsions and coma.1'6 Thirty-three per cent die in
the first week. There may be a recurrence within a year
but prognosis is good for survival after one year. The
headache increases in severity for two weeks and usually
disappears completely within two months. It is important
to diagnose this condition, as surgery and ligation of the
aneurysm can save many patients. Site of the aneurysm
can be demonstrated by arteriograms. (See Table I.)
Table I
Headache
Subdural
Hematoma
Subarachnoid
Hemorrhage
Age
Any age
Commonest in 4th
decade
Cause
Trauma —
rupture of vein
No trauma —
rupture of congenital
aneurysm
Onset
After lapse of few
days
Sudden dramatic
Course
Increase of headache
up to 8 weeks —
then steady
Maximum in 2 wks.,
disappears in 8 wks.
A ssociated
Symptoms
Few
Many, with cranial
N. Paralysis and
pressure symptoms
Recurrence
Rare
Usually recurs
Site
Frontal —
rarely occipital
Mostly occipital
C.S.F.
Xanthochromic
Hemorrhagic
Headache due to generalized dilatation of intracranial
arteries. Generalized dilatation of the intracranial ar-
teries resulting from a variety of conditions causes an
intense, generalized, diffuse, pulsating headache. The
headache is temporarily relieved by pressure on the ar-
terial carotid which decreases the blood flow, or by pres-
sure on the jugular which increases the cerebrospinal
fluid pressure, thus supporting the walls of the arteries
externally and preventing their maximum dilatation and
decreasing the amplitude of pulsations.
The following types of headaches fall under this cate-
gory: (1) headache induced by intravenous histamine
injections which appears within a minute of the start of
the injection of 0.1 to 0.2 mg. of histamine; (2) caf-
feine withdrawal headache in those who stop taking cof-
fee after indulging for a time; (3) anoxemia of any
cause such as carbon monoxide poisoning, high altitude,
congestive diseases, etc., by the direct action of the de-
creased oxygen tension on the vasomotor centers; (4)
fevers; (5) alcoholic hang-overs; (6) nitrite headache
where nitrite is absorbed over a long period of time
medicinally or in industry; (7) constipation headache
through a reflex dilatation of the intracranial arteries
caused by distension of the rectum.1 f
Headaches of extracranial origin :
Temporal arteritis headache. Dilatation of any artery
causes pain, while constriction of the arteries causes no
pain. Pain caused by inflammation of the temporal ar-
teries gives a characteristic picture and is discussed
separately. The cause is an inflammation of the tem-
poral artery, usually unilateral, resulting from a sub-
acute focus of infection somewhere in the body. Onset
is acute, affects older people from the sixth to eighth
decade, is accompanied by a mild fever, malaise, leuko-
cytosis, and other symptoms and signs of infection.
There is a severe, steady, throbbing pain, unilateral, and
localized to the distribution of the temporal artery. The
artery is tender to palpation and seems distended and
tortuous. The disease is self-limited and subsides in a
few months. Novocaine injection around the artery re-
lieves the pain temporarily and is diagnostic. If the
symptoms are severe enough, sectioning of the artery
would relieve all symptoms.1,8
Hypertensive headaches. The characteristics of a so-
called hypertensive headache are a bilateral, dull, throb-
bing, frontal and temporal headache that appears every
morning on awakening and improves quickly as the pa-
tient moves about, especially after breakfast. The cause
of the headache is dilatation of the external carotid
arteries and their branches, and also the dural arteries
to a lesser extent.1 ,h It is not caused by dilatation of
cerebral arteries, however, as experimentally this head-
ache is not relieved by the usual means that relieve dila-
tation of cerebral arteries. Although this headache is as-
sociated with hypertensive disease, it is not proportional
to the degree of hypertension and its severity is not
greatly influenced by the variation of the tension.1 h
The onset, however, is always related to an increase in
blood pressure. This headache should not be confused
with the headache of hypertensive encephalopathy of
November, 1949
391
malignant hypertension with renal failure where the
headache is continuous, severe, and is relieved by hyper-
tonic intravenous glucose. The etiology of the latter is
edema of the brain. 1,1
Patients improve on regulation of their activities, gen-
eral treatment of hypertension, and raising the posters
of the head of the bed by a block of wood which tends
to decongest and possibly prevent dilatation of the car-
otid arteries during sleep. Moench believes that potas-
sium thiocyanate is the most effective of the hypotensive
drugs to control the hypertensive headache with a var-
iable dose of 65 to 200 mg. daily and blood level of
5 to 8 mg/’
Migraine. This is a very prevalent headache and has
been studied extensively. Eight per cent of all patients
seem to have it to a variable degree. Migraine has a
characteristic group of symptoms and signs that are easy
to recognize. The characteristics are the following:
It is a vascular, throbbing, periodic headache with a var-
iable period of complete relief between attacks. It starts
with an aura in 10 per cent of cases, followed by a rap-
idly progressive headache. It is unilateral at onset, may
become generalized, and is associated with irritability,
depression, nausea, and vomiting, constipation or diar-
rhea, and polyuria. The duration of the attack varies
from a few hours to many days with complete relief of
headache between attacks. The attack characteristically
starts in the early hours of the morning. The aura may
be visual in type of bright flashes, moving scotoma, pho-
tophobia, or emotional with euphoria, hyperesthesia, or
auditory hallucination. The aura is caused by a vaso-
constriction of the intracranial cerebral arteries. 1,J
The migraine attack is caused by a vasodilation of the
branches of the external carotid arteries. The dural and
cerebral arteries participate to a minor degree. Migraine
is more than just a dilatation of the external carotids as
shown by the many associated symptoms such as nausea,
polyuria, vasomotor responses. It has a hereditary tend-
ency in 60 per cent of cases and psychological, mental,
and emotional states have a great deal to do with its
occurrence. Its relation to menses is not merely coinci-
dental as it is caused by an excess of gonadotropins of
the pituitary. Follicular ovarian extracts inhibit the for-
mation of gonadotropins and help in controlling migraine
related to menstruation/' Its relation to allergy from
food is possible but not too common.
Any vasoconstrictor that can decrease the amplitude
of pulsation by 50 per cent will relieve the headache
provided it is given early enough in the attack.1 k The
reason for non-effectiveness of vasoconstrictors late in
the attack is due to the edema of the vessel wall which
will resist vasoconstriction of the drugs.
Ergotamine tartrate (Gynergen) .5 mg. intramuscu-
larly or intravenously is the best drug to cut short the
attack. Relief comes within forty-five minutes to one
hour. It acts directly on the smooth muscles of the ves-
sels and not as an antagonist to the sympathetics. Relief
occurs in 90 per cent of the cases. It should not be re-
peated within seven days. Ergotamine may be given by
mouth to those patients who do not have nausea or
vomiting early in the attack, and it is more effective and
less nauseating if the pills are crushed and put under the
tongue. The dose is 5 mg. by mouth and 3 mg. under
the tongue as one dose, followed by 2 mg. every half
hour to one hour if no relief occurs. Maximum dose is
10 mg.
Dehydroergotamine tartrate (DHE 45) ‘ is better tol-
erated with less nausea and less uterine effect. Conflict-
ing reports about its results have been reported but ap-
parently it has not been used in large enough doses.
One mg. may not be enough and 2 mg. in one dose may
give better results.
Caffergone, "Sandoz”, is a combination of caffeine
100 mg. and ergotamine 1 mg. with a synergic action be-
tween the two vasoconstrictors. The dose is two tablets
at onset of the headache and one every thirty minutes
for two or three times until relief is obtained.8
Follicular extract is given before the menstrual period
to those patients where the migraine is associated with
menstruation.6
Histamine 2.75 mg. as infusion with 500 cc. of saline
in glucose given intravenously may relieve the attack by
lowering the blood pressure, but its effect is unpredictable
as histamine dilates the arteries. A test for migraine,
as used by Schnitker,9 is to give the patient 1/50 of a
grain of nitroglycerine sublingually. A reproduction of
a mild attack results within thirty minutes. Butler and
Thomas 10 believe migraine is due to a lower tolerance
to histamine and intravenous histamine infusions increase
tolerance to it. This has been successfully tried in quite
a number of cases to ameliorate or prevent recurrence
of attacks.
Histamine cephalalgia. This type of vascular head-
ache has been studied by Dr. Horton 11 of the Mayo
Clinic. It has many similarities to migraine and to Slu-
der’s sphenopalatine ganglion syndrome and differs from
these in some aspects. Like migraine, it is caused by
dilatation of the external carotid artery. Onset is in the
fourth or fifth decade, frequently preceded by migraine
in earlier years. It is a sharp, throbbing, acute pain. The
attack starts after retiring to bed or in the early morning
hours and lasts a very short time, only one to two hours.
It recurs almost daily with periods of relapses. It is
accompanied by vasomotor symptoms such as heat sensa-
tions, sweating, lacrimation, rhinorrhea, and blockage of
the nose. It is unilateral and frequently starts in the
forehead and temple with the occipital region frequently
involved. The primary etiological cause of this headache
is a lowered tolerance to histamine. A cold stimulus will
liberate histamine locally and start the dilatation of the
external carotid artery or its branches.
Atkinson 12 believes that skin tests are positive in his-
tamine-sensitive patients; 0.05 cc. (0.01 mg.) of histamine
dihydrochloride is used. A wheel of more than /2 inch
and a flare of more than 2 to 2/4 inches in diameter
with persistence of reaction of more than twenty minutes
is positive. Presence of pseudopodia is very significant.
For the subcutaneous test, Horton 11 injects .35 mg. sub-
cutaneously. The test is positive if a headache is repro-
392
The Journal-Lancet
duced within a short time. For the intravenous test,
Moench uses .1 to .2 mg. of histamine acid phosphate
intravenously. A typical headache is reproduced in thirty
to forty-five minutes, which is not to be confused with
the immediate histamine headache caused by the intra-
venous injection that would be diffuse and would last a
few minutes in normal individuals.
Patients do well on desensitization. The term desensi-
tization is a misnomer as histamine is not antigenic.
Histamine therapy may increase the body tolerance to
histamine, stimulate histaminase, or alter the vasomotor
lability.1 4 The following technique, as used by Horton,11
has been used by us with good results. Starting with
.15 cc. of histamine acid phosphate (0.275 mg. in 1 cc.),
the dose is increased by .05 cc. until a maximum dose of
1 cc. is reached. These injections are given twice daily,
and after twenty injections, a maintenance dose of the
maximum tolerated by the patient is given twice weekly
or less often, as needed. A quicker and probably a better
way of desensitization is through histamine intravenous
infusions; 2.75 mg. of histamine acid phosphate dis-
solved in 500 cc. of glucose or saline is given intra-
venously. The rate of the infusion depends upon the
reaction of the patient. This can be repeated every other
day for five doses, or daily if well tolerated.
Here is a typical case for an illustration. A 45-year-
old man was seen two years ago for headache of ten
years duration with all the typical signs of a histamine
headache. The attacks recurred daily and started on
awakening or would wake the patient in the middle of
the night. He was histamine positive by a skin test and
an attack of pain was reproduced by an intravenous test.
He was given a course of histamine subcutaneously and
has had no recurrence since, in a period of two years
of observation.
Histamine desensitization subcutaneously was success-
ful in the following case of migraine. Mrs. F., 42 years
of age, had headaches for the last thirty years with
periodic attacks, typical of migraine. She had the hista-
mine subcutaneous course with complete cure. This pa-
tient needs, however, a maintenance dose once a month
to keep her asymptomatic. In our experience about 50
per cent of migraine cases are improved or greatly im-
proved with histamine desensitization. (See Table II.)
Referred Headache:
Nose and sinuses. The sensitive parts of the nose and
the sinuses vary at different sites.11 The ostia of the
maxillary and frontal sinuses are extremely sensitive
while the mucous membrane of the sinuses proper are
very slightly so, except with acute purulent inflammation.
The septum and the vestibule are sensitive to pain. The
pain is projected along the branches of the sphenopala-
tine ganglia and the ethmoid nerve of the ophthalmic.
Acute sinusitis: This causes headache and pain and is
easily diagnosed by the associated tenderness and puru-
lent discharge. In the absence of acute sinusitis, pressure
by a deviated septum or hypertrophic turbinates causes
referred pain and headache. Cocainization of the pres-
sure area relieves the pain and surgery removes it per-
manently.
Table II
Migraine
Histamine
Cephalalgia
Pathogenesis
Dilation of external
arteries
Same
F amity
History
Present
Absent (may be preceded
by history of migraine)
Age
Adolescence
Fourth to sixth decade
A ura
Present
Absent
Duration
Many hours
or days
1 to 2 hours
Onset
Early morning
During night or on
awakening
Periodicity
A week or more
between attacks
Daily, with remissions
Type
Pulsating, unilateral,
may become bilateral
Pulsating, unilateral
A ssociated
Nausea, vomiting,
No nausea or vomiting.
Symptoms
polyuria, mental
apprehension,
photophobia
Lacrimation, nasal
obstruction, swelling of
parts affected
T ests
Nitroglycerin
Histamine
T reatment
Vasoconstrictors,
histamine
desensitization
Vasoconstrictors (attack
too short for action)
histamine desensitiza-
tion
Maxillary sinuses: Headache originating in the max-
illary sinus starts in late morning and is relieved by eve-
ning. The pain is usually referred to the teeth and fre-
quently to the forehead, simulating frontal sinusitis.14
Frontal sinuses: Headache originating from the
frontal sinuses starts on awakening or early morning and
disappears in late morning. The pain and headache are
localized to the forehead on the side affected, with pres-
ence of tenderness by palpation.
Anterior ethmoid sinuses: The pain is across the nose
and above the eyes.
Posterior ethmoid and sphenoid sinusitis: The pain
may be referred anywhere due to the proximity of the
sphenopalatine ganglion. The pain is felt deep in the
nasopharynx, vertex, and occiput.
Chronic sinusitis: Chronic inflammation rarely causes
headache or pain. In fact, the presence of a headache
speaks against such a diagnosis.
Eyes. Headache of eye origin is common but greatly
exaggerated. Pain-sensitive structures in the eye are the
following:
Conjuctival disease: localized pain only, no headache.
Corneal inflammation: very severe, localized pain and
photophobia; occasional frontal headache relieved by
local anesthetic and occlusion of the eye.
Iritis and cyclitis: the pain is localized to the eyeball
with the headache in the temples of the affected side,
relieved by atropine. The pain is caused by a spasm
of the iris and ciliary muscle.
Glaucoma: Only the acute congestive type is extremely
painful. The chronic type with a slow course may not
show any symptoms except decreased visual acuity and
November, 1949
393
constriction of the visual fields. The pain of glaucoma
is constant, extremely severe, and is accompanied by
headache in the forehead and temples and usually in
the occiput as well, secondary to muscle spasm of the
occipital area. Nausea and vomiting are common. Vision
is blurred. Mydriatics, caffeine, rapid ingestion of water,
and mental upsets may precipitate an attack, especially
in the narrow angle type.
Refractive errors: Only hyperopia and astigmatism
cause headache not related to the degree of abnormality.
Myopia causes headache only if it is over-corrected and
thus rendered artificial hyperopia. The characteristics of
this type of headache are: The onset is usually in the
afternoon or after the use of the eyes for close work,
movies, or traveling in or seeing moving objects. It is
relieved by rest of the eyes or sleep. Thus, it is easily
differentiated from histamine, hypertensive, and migraine
headaches, all of which occur in the early morning and
have no relation to the use of the eyes. The etiology of
this headache is a sustained ciliary contraction in an
effort to accommodate.
Muscular imbalance: only the phorias with good fu-
sion and binocular vision cause headache as the extra-
ocular muscles sustain a spasm in an effort to keep a
normal axis. The headache may start after a short use
of the eyes. When binocular vision is lost by loss of
fusion as in squint, there is no headache. With the
headache of phorias, there is often dizziness, nausea, and
vomiting. Occipital pain is frequently due to spasm of
the occipital muscles, especially in sustained abnormal
tilting of the head or holding it in fixed positions.
Ears, mastoid, and their complications. The ears par-
ticipate in referred pain from many areas and send re-
ferred pain to the same areas, due to the combined nerve
supply from V, VII, IX, and X nerves and upper cer-
vicals. Thus, inflammation of the larynx, pharynx, ton-
sils, nasopharynx, lower molars, and temporal mandibu-
lar joint may refer the pain to the ear on the same side.
Inflammation of the ear refers the pain to these different
areas, either directly through these nerves or indirectly
by a secondary muscle spasm of the temporal, masseter,
and occipital muscles. From these, new foci of pain
radiate to further areas.
Deep seated constant headache following a mastoid-
ectomy may indicate a brain abscess. The triad of Gra-
denigo’s syndrome, with discharge from the ear, sixth
nerve palsy, and trigeminal neuralgia indicate petrositis.
Cerebellopontine angle tumors cause vertigo, deafness,
and headache. Labyrinthine tests with involvement of all
the semicircular canals of the affected side and only the
vertical canals of the opposite side point to this diagnosis.
Herpes zoster of the ear with possible facial paralysis
and neuralgia with typical vesicles in the auricle and
drum should be easy to diagnose.
Teeth. Pain and headache originated from teeth are
familiar. The upper teeth refer the pain to the cheek
and temple; the lower teeth, especially the molars, refer
the pain to the ear and postauricular area. Occipital pain
is common by secondary muscular spasm.
Temporomandibular joint. Headache and pain origin-
ating from involvement of this joint are commonly over-
looked even by dentists. The pain is referred to the ear
and the headache is present in the temple and occiput.
There is commonly a spastic tenderness over the mas-
seter and temporal muscles. The cause is usually mal-
occlusion, ill-fitting dentures, or absence of molars on
one side, thus causing pressure on the joint.1'1 Obstruc-
tive deafness is commonly due to eustachian tube block-
age. Correction of the malocclusion or building up of
the molars will relieve the symptoms.
Myalgias and Occipital Pain. This is perhaps the com-
monest type of pain because it may be primary or it may
be secondary to all the other types of pain already dis-
cussed through a reflex spastic contraction. In such a
case, these muscles become a source of pain radiating to
the occiput and neck. The temporal and frontal muscles
participate to a lesser degree. This type of headache is
a deep, steady ache, not throbbing in type, as compared
with vascular headaches, which are intermittent and
throbbing. There is tenderness in spots at the insertion
of the muscle involved with painful and tender nodules
and a sensation of stiffness. The cause is probably a
reduced blood supply by a vascular reflex constriction
with ischemia and pain.
The types are as follows:1”1 (1) spasm referred from
foci of pain in eyes, sinuses, teeth, ear, and temporo-
mandibular joint; (2) anxiety — a tension headache with
sustained contraction of the muscles which can be
brought about voluntarily by holding the head in a fixed
position; (3) exposure to colds and drafts; (4) myositis
— rheumatic headache following respiratory infections,
sore throats, and flu — present on awakening, aggravated
by sudden jolting of the head, and accompanied by stiff-
ness and tenderness of the muscles, with a course of
from two to eight weeks; and (5) arthritis of the cer-
vical spine with pressure on the spinal nerves, and a
steady and radiating pain which is worse at night and
continues in the daytime.
Treatment: All these occipital neuralgias respond to
the same treatment. (1) The primary focus of pain in
the reflex spastic type must be removed. (2) Heat from
any source may be applied, followed by massage with or
without an ointment, such as imadyl ointment, which
contains histamine, followed again by further heat. (3)
Sedatives of the barbiturates group may be used. (4)
Novocaine, 1 per cent, injected in the tender spots may
start relaxation of the muscles and be effective for days
and even weeks.
Post-traumatic headache. Headache caused by sub-
dural and epidural hematomas, subarachnoid hemor-
rhage, and basal adhesions has been discussed.
A recurrent type of headache following injuries is a
common one and may be of two varieties: (1) pressure
such as constant non-throbbing headache, due to muscle
spasm; and (2) recurrent, periodic, throbbing headache
due to external carotid dilatation, migraine-like. These
two are usually co-existent.1’”
About 50 per cent of these cases that sustain head
injury severe enough to need hospitalization develop
394
post-traumatic headaches. A good quiet rest after the
accident diminishes the severity of the headache and
early ambulation precipitates it. The headache develops
much more frequently in the emotional and anxious pa-
tients, especially those who think the trauma was their
fault or someone else’s, and those who are looking for
compensation as a result of the injury. Anxiety, how-
ever, and mental exhaustion after hard mental work may
precipitate the attack in the late afternoon. Dizziness
and vertigo, with sudden change of position of the head,
are common symptoms by the excitation of the vestibular
centers through overflowing of the painful stimuli over
the affected nerves. Although the headache is post-
traumatic, it does not have any pathological basis in the
injured part of the head but is extracranial in origin,
similar to migraine and occipital neuralgias.
Atypical facial neuralgias. These are variable head
pains related in mechanism to migraine. The attack is
precipitated by emotional strain or conflicts. They are
caused by a vasodilatation of the external carotid artery,
especially the internal maxillary branch.1,0 This type of
pain may be confused with neuralgias and must be dif-
ferentiated, as alcohol injections are not needed and
may be useless. This type of pain is steady, deep, aching,
unilateral, localized to the lower half of head and face,
involving cheek, eye, orbit, low forehead, temple, ear,
and occipital area. It is usually accompanied by smooth
muscle and vasomotor phenomena like swelling of mu-
cous membranes, lacrimation, photophobia, and nasor-
rhea. Under this type of headache falls the Sluder or
sphenopalatine ganglia syndrome, vidian nerve syndrome,
and histamine cephalalgia.1,0 Sluder 1 ' believes they are
caused by a stimulation of the sphenopalatine ganglia
and its branches. Wolff 1,0 believes they are due to in-
ternal maxillary dilatation as they are relieved by ergota-
mine. Correction of a septal deviation or hypertrophic
turbinates may relieve the pain if it is due to a stimu-
lation of the nerve ending in the nose. Cocainization of
the affected area proves the etiology if it relieves the
pain. Novocaine injection in the sphenopalatine ganglia
may relieve the syndrome for a variable time.
T ypical neuralgias. These are low head pains similar to
atypical neuralgias in location. The pain is intermittent,
shooting, severe, with deeply-localized component and a
superficial burning component. The pain is limtied to
the distribution of the nerves, precipitated by a stimula-
tion of trigger zones such as during talking, eating, or
mere touch.
Vasoconstriction of the vessels supplying the nerve
ganglia is probably the primary cause as a large dose of
a vasodilator early in the attack may improve the pain.1,p
Alcohol injections to the nerve ganglia, or nerves proper,
and intracranial resection remain to be the only available
treatment. Trichlorethylene inhalations remove the pain
originating in the fifth nerve for a short period and
The Journal-Lancet
must be repeated frequently, making such treatment im-
practical. (See Table III.)
Table III
Facial Neuralgias
Atypical
Typical
Age
Young
Old
Site
Not related to typical
nerve distribution
Related to typical
nerve distribution
T ype
Steady, deep,
diffused type
Short, intense, shooting,
paroxysmal pain with
burning of skin
T rigger zone
Absent
Present
T reatment ■
V asoconstrictors,
anesthesia of affected
areas topical or
into ganglia
Vasodilators —
alcohol injection,
resection of nerves
Pathogenesis
Dilatation of ext.
carotid, stimulation
of nerve endings
Vasoconstriction of
nerve ganglia
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November, 1949
395
Analytical Hypertension: Clinical Observation
of 2,163 Male Students
Charles A. McDonald, M.D.* and William J. O’Connell, M.D.f
Providence, Rhode Island
William James, it is said, described some people as
tough and others as tender. We have found that
between ages 18 and 24 there are also many who are
tensive. Numerous workers have tried the experimental
method to show constitutional factors in patients mani-
festing tensive reactions. The literature contains many
fine articles from which many practical inferences may
be drawn. James Paget 1 coined the expression "clinical
science” and said of it, that, "within our range of study,
that alone is true which is proved clinically, and that
which is clinically proved needs no further evidence.”
Review of Clinical Reports
The literature abounds with studies in which mean
blood pressure values have been established for subjects
in the age group of college students. 2,3,4,s Levy et al 0,7
have described "transient hypertension.” Various investi-
gators subscribe to the neurogenic origin of hypertension
in effect, for they agree that the nervous system is the
central point of disturbance before any structural chan-
ges have taken place. There is disagreement, however,
as to the etiological influence on the nervous system:
Weiss 8,9 and his co-workers account for the influence
on a psychosomatic basis; Ehrstrom 10 and Ginsberg 11
on a psychogenic basis; Urschel 12 and Stieglitz 13 on
an emotional basis; Barker 14 on a neurogenic vasomotor
basis. Diehl4 states that nervousness and excitement are
the most frequent factors in producing temporary ar-
terial hypertension in young people and that fatigue of
blood vessel musculature perpetuates tension. Hines 15
described vascular hyperreaction mediated through nerve
reflexes in clinical measurement of blood pressure re-
actions to a standard stimulus. Schroeder 10 et al on an
experimental basis used drugs to measure nervous re-
sponses. Actuarial 17 as well as clinical 7 and experimen-
tal studies lo are in agreement that vascillation in early
hypertension statistically antedates sustained hyperten-
sion. These investigators have observed or measured
exaggerated responses of the nervous system resulting
from normal stimuli of various kinds. In practical sig-
nificanc they are not very far in advance of Sir Clifford
Allbutt 18 who recognized more than fifty years ago that
arterial hypertension sometimes arises in the absence of
renal disease.
As pertinent as these studies may be they are not
accepted with finality by such writers as Bradley 19 who
in reviewing the subject of neurogenic reflexes states that
*Neurologist, University Health Services, Brown University,
Providence, Rhode Island.
fPhysician, University Health Services, Brown University,
Providence, Rhode Island.
there is no quantitative footing to support the hyper-
reactor and emotional theories of hypertension. There
is general disagreement among workers as to the simi-
larity between experimental and human hypertension as
produced by the Goldblatt method of constricting the
blood supply to the kidney.20 Pathologists who have
studied the blood vessels of hypertensive patients are at
variance as to the relationship the occasional vascular
structural changes bear to the clinical progress of hyper-
tension.
Review of Clinical Study
Current popular forms of treatment are experiencing
declining usefulness for such investigators as Proger 21
and Goldring 20 accept the low salt regime only when
myocardial failure accompanies hypertension. Proger
further feels that restrictive therapy in the form of the
Rice Diet is of value in treatment only when renal and
myocardial failure accompanies hypertension. Surgical
interruption of nervous pathways22’23,24,25,26 over which
abnormal tensive influences are judged to pass is being
used with increasing caution as it becomes apparent that
a social sympathectomy is more inclusive than a surgical
sympathectomy. Pharmacological blocking 21 of the same
pathways produces effects too transient to be more than
a minor adjunctive form of therapy.
The literature reveals pertinent observations and sug-
gestions as to the treatment of hypertensive subjects.
Brush,28 Campbell,29 and Brooks and Carroll 30 in clin-
ical studies of the effect of rest and sleep on blood pres-
sure observed a significant fall during rest or sleep which
was proportionate to the number and length of rest
periods. Adson and Allen recommended lying down at
midday in a dark, quiet room. Jacobsen 31 suggests re-
laxation on a progressive basis. Barker 14 states that the
time to be successful in treatment is in the early stages.
With such introduction as this review of the litera-
ture serves, we wish to present our experiences gained in
the examination of 2,163 male students, aged 18 to 24,
examined between February 1, 1947, and June 1, 1948,
and in which 382 or 17.6 per cent were found to have
elevated blood pressure.
In the freshman year every student underwent a phys-
ical examination. Those students with a blood pressure
greater than 130 millimeters mercury systolic and 85
millimeters diastolic reported to the University Health
Center on three successive days for re-examination. On
each occasion the same nurse recorded the blood pressure
at the level of the heart, on the right arm with the stu-
dent comfortably supine, then on the left arm while
still supine, followed in two minutes on the left arm
396
The Journal-Lancet
while standing. Beginning one week later every tensive
student had blood pressure readings at one, two, three
and four week intervals successively. Subsequent read-
ings were taken at monthly intervals throughout the
school year.
All determinations were on the arm, using the auscul-
tatory method, and following the criteria established by
the American and British Committees on the Standardi-
zation of Blood Pressure in 1930. In each determination
the blood pressure cuff was inflated above the systolic
pressure level and the pressure allowed to drop grad-
ually through the diastolic level which was regarded as
the pressure at the point where there was a distinct muf-
fling of sounds. Whereas the first four readings in every
case were taken by the nurse, all subsequent readings
were taken by the physician. In checking the values with
each other it was found that readings tallied with an
accuracy of 4 mm. in over 95 per cent of cases.
On the initial physical examination 382 ( 17.6 per cent)
of the 2,163 students had blood pressure readings great-
er than 130 systolic and 85 diastolic pressure. The 382
students with blood pressure readings greater than
130/85 have been restudied and it was found that: 132
(34.5 per cent) students had blood pressure readings
subsequently come within normal limits more often than
not; 231 (60.5 per cent) students whose values were
more often elevated than not; 19 (4.9 per cent) stu-
dents whose values were elevated as many times as they
were below 130/85. Urinalysis performed at the time of
each set of blood pressure readings revealed 33 students
whose urine persistently contained albumin and sugar.
Since there are a small number of cases, 33 (8.6 per
cent), having blood pressure readings greater than
130/85 and albumin and sugar in the urine relative to
the number, 349 (91.3 per cent), without albuminuria
and glycosuria, our working principle has been that an
abnormally elevated blood pressure is due to nerve ten-
sion or nerve hypertension. The Health Service has
further looked upon these cases as renogenic (kidney
origin) or neurogenic (nervous origin) respectively, hav-
ing clinically excluded the less common disease causes
of hypertension (coarctation of aorta, adrenal tumors,
pituitary syndromes, pyelonephritis, etc.) . The renogenic
group is differentiated from the neurogenic hypertensives
solely by the urinary findings — albuminuria and glyco-
suria. A study of the urinary sediment in each case was
essentially negative for findings of kidney disease. More-
over, each case had a normal concentration — dilution
kidney function test, as well as a negative test for ortho-
static albuminuria. In further excluding a disease basis
for tensive cases, every student had an examination of
the eye grounds reported as within normal limits.
Accepting these principles as true, treatment was insti-
tuted in all cases having elevated blood pressures, feeling
that those with persistent albuminuria and glycosuria
(renogenic) were just as worthy of treatment as those
with nerve hypertension without urinary findings (neu-
rogenic) .
Treatment has consisted of one-hour daily rest periods
in the University Health Center in a dark, quiet room
during the middle of the day. Since the rest periods for
students are regarded as the equivalent of physical educa-
tion our practice has been to divide the day in two by a
period of physical medicine. The object of treatment
is to train tensive students in the art of nerve relaxation.
It is hoped that they may be conditioned to the acquired
habit of rest periods that will continue down through the
years. Early in the course of treatment, three confer-
ences with the examining physician are arranged for
every tensive student, in which the philosophy of con-
scious relaxation is discussed. The calculated disciplinary
control of blood pressure that is expected as a result of
treatment is emphasized. At the conclusion of each school
year a colloquium is arranged for all those under treat-
ment. Included in this meeting is a report of the average
blood pressure values at the beginning and end of treat-
ment and a questionnaire period for individual problems.
Every student we are reporting was examined by an
eye, ear, nose and throat physician, a dentist, an internist,
a surgeon and a neurologist under the same conditions.
We have established a generous standard of 130 milli-
meters (mercury) systolic and 85 millimeters diastolic
pressure and selected our patient-students as abnormal,
if their blood pressures were greater than this empirical
standard. By our observations, the observations of the
nurses and a blood pressure cuff we have found a pat-
tern in 17.6 per cent of students which we call tensive.
We emphasize that we did not make the elevated blood
pressure, we measured it. We consider it a part of the
whole organism rather than a measurement of a division
of the nervous system.
By way of making an incomplete report on the per-
sonality traits in hypertension, our nursing staff has used
the following adjectives in describing over one third of
our tensive students: unduly anxious, impulsive, irritable,
high-strung, over-assertive.
Discussion
While we do not say when hypertension begins we do
say that to study hypertension, study adolescence. In
support of this recommendation, Barker14 has pointed out
that the time to be successful in study and treatment of
hypertension is in the early stages. Robinson and Brucer'1
point out that a person whose blood pressure fluctuates
higher than 120/80 during a twenty-four hour day and
continues to do so throughout the years will become
within a ten-year period definitely hypertensive. An
editorial of the British Medical Journal 32 of May 7,
1949, observes: "It is fundamental to the understanding
of essential hypertension to realize that an increase in
the blood pressure due to any cause, physiological or
pathological may be followed by a further increase, this
secondary hypertension often persisting after the primary
cause has ceased to operate.”
The principle of rest treatment has been well docu-
mented clinically and experimentally. Our means of
resting in order to interrupt the daily routine appears
to have been anticipated by others. Smirk 42 states that
"the concept of numerous causes of hypertension should
lead to investigation of the responsible causes in every-
day life.” The editor of the British Medical Journal of
November, 1949
397
May 7, 1949, states that "the tendency to exhibit the
transient hypertension in response to mental and other
stimuli may be taken to indicate a physiological makeup
which is likely to express itself in daily life by abnor-
mally strong and frequent blood pressure elevations.”
It is further held by the same author that the "raised
blood pressure in essential hypertension precedes patho-
logical changes in arterioles— it follows that renal is-
chemia due to vascular changes cannot be the initial
factor in the production of essential hypertension. It is
conceivable that in youth the disease is etiologically dif-
ferent from that arising after middle life.”
Variability of blood pressure levels in our studies has
been more characteristic and more constant than eleva-
tion and we feel that this supports our neurogenic pat-
tern. We feel that our observations regarding variability
include what is regarded by others as transient hyper-
tension (and certainly our age groups match the age
groups of the subjects of other investigators) . It is
equally interesting to note that there existed as much
vascillation of blood pressure in the renogenic as in the
neurogenic group.
Summary
We believe the favorable response to progressive re-
laxation that we have reported to our tensive students
following sustained disciplinary control of the basic
neurogenic factors is due to assuming the position of
relaxation daily and losing the effort of posturing.
While our study shows that one out of 12 students with
hypertension is renogenic it also shows that 11 out of 12
are neurogenic; it is this latter group that percentage
wise is most worthy of continued observation and we
hope that our work will be provocative to further inves-
tigation.
%
The authors are indebted to Frances F. S. Koran, R.N., and
Helen M. Ford, R.N., for their assistance in coordinating the
management of this study.
References
1. F. M. R. Walshe, Victor Horsley Memorial Lecture, de-
livered at National Hospital, Queens Square, London, Novem-
ber, 1946, quoted by James Paget.
2. Boynton, R. E., and Todd, R. L.: Blood pressure read-
ings of 75,258 university students. Arch. Int. Med. 80:45, 1947.
3. Alvarez, W. C.: Blood pressures in 15,000 university
freshmen. Arch. Int. Med. 32:17, 1923.
4. Diehl, H. S., and Sutherland, K. H.: Systolic blood
pressures in young men. Arch. Int. Med. 36:151, 1925.
5. Robinson, S. C., and Brucer, M.: Range of normal blood
pressure. Arch. Int. Med. 64:409, 1939.
6. Levy, R. L., et al: Transient hypertension. J A M. A.
128:1059, 1945.
7. Levy, R. L., et al: Transient hypertension. J.A.M.A.
126:829, 1944.
8. Weiss, E.: Psychosomatic aspects of hypertension.
J.A.M.A. 120:1081, 1942.
9. Weiss, E., and Kleinbert, M.: Psychosomatic aspects of
arterial hypertension. Penn. Med. Jr. 49:1321, 1946.
10. Ehrstrom, M. C.: Psychogenic hypertension in war-time.
Acta med. Scandinav. 122:546, 1945.
11. Ginsberg, A. M.: High blood pressure, psychogenic
factor. J. Missouri Med. Assoc. 42:24, 1945.
12. Urschel, D. L.: Emotional hypertension. Jr. Ind. Med.
Assoc. 38:128, 1945.
13. Stieglitz, E. J.: Emotional hypertension. Am. 1. Med.
Sci. 179:775, 1930.
14. Barker, P. S.: Hypertension: remarks concerning its cause
and treatment. J. Mich. State Med. Soc. 45:489, 1946.
15. Hines, E. A., Jr.: The significance of vascular hyperten-
sion as measured by the cold pressor test. Am. Heart Jr. 19:408,
1940.
16. Schroeder, H. A., and Goldman, M. L.: Test for the
presence of the hypertensive diencephalic syndrome using hista-
mine. Am. Jr. Med. 6:162, 1949.
17. Wenstrand, D. E. W.: Blood pressure and life insurance.
Quart. Bull. Northwest. Univ. Med. School 20:149, 1946.
18. Allbutt, Sir Clifford: Abstr. Trans. Hunterian Soc. 38,
1895-96.
19. Bradley, Stanley F.: Physiology of essential hypertension.
Am. Jr. Med. 4:313, 1948.
20. Goldring, W., and Chasis, H.: Hypertension and hyper-
tensive disease. Comm. Fund, N. Y., 1944.
21. Proger, S. H.: An approach to the treatment of hyper-
tension. Bull. N.E. Med. Cent. 10:193, 1948.
22. Adson, W., and Allen, E. W.: Proc. Staff Meeting
Mayo Clinic 12:1, 1937.
23. Smithwick, R. H.: Surgical treatment of hypertension.
Arch. Surg. 49:180, 1944.
24. Smithwick, R. H.: Surgical treatment of hypertension.
Am. Jr. Med. 4:744, 1948.
25. Peet, M. M.: Results of bilateral supradiaphragmatic
splanchnicectomy for arterial hypertension. New Eng. Jr. Med.
236:270, 1947.
26. Adson, A. W. et al: Surgery in its relation to hyperten-
sion. Surg., Gyn. and Obs. 62:314, 1936.
27. Lyons, R. H. et al: The effects of blockade of the auto-
nomic ganglia in man with tetraethylammonium. Am. Jr. Med
Sci. 213:315, 1947.
28. Brush, C. E., and Fayweather, R.: Observations on the
changes in blood pressure during normal sleep. Am. Jr. Physiol
5:199, 1901.
29. Campbell, N. E., and Blankenhorn, M. A.: The effect
of sleep on normal and high blood pressure. Am. Heart Jr
1:151, 1925-26.
30. Brooks, H., and Carroll, J. H.: A clinical study of the
effect of sleep and rest on blood pressure. Arch. Int Med
10:97, 1912.
31. Jacobsen, E.: Progressive Relaxation. Chicago University
Press, 1929.
32. Smirk, F. H.: Pathogenesis of essential hypertension.
British Med. Jr., No. 4609, May 7, 1949.
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398
The Journal-Lancet
What Can Be Done for the Deaf Patient
William K. Wright, M.D.
Fargo, North Dakota
Deafness is a very common condition. It is also one
of the most disabling afflictions possible, for hear-
ing and speech are the universal methods of communica-
tion. Without hearing the congenitally deaf child re-
mains a deaf mute and the school-age child lapses into
inattention and is wrongly considered stupid. Deafened
adults may be deprived of desirable positions and in old
age may be joked about. Non-hearing continually makes
the deaf patient a subject of misunderstanding or forces
on him a reputation for indifference toward his friends.
Rehabilitation of these individuals, therefore, becomes a
very needed and much neglected phase of medicine
which has heretofore been left largely to the hearing-aid
salesman. The management of deaf patients clearly be-
longs in the hands of the physician. In fact, diagnosis
of the cause of deafness as well as much of the specific
therapy can often be carried out by the general physician.
Types of Deafness — Diagnostic Methods
Normal hearing requires an intact functioning conduc-
tion mechanism consisting of a patent auditory canal,
an intact ear drum, a normal middle ear, and a mobile
ossicular chain. It also requires a normal inner ear con-
sisting of a normal nerve and a normal cochlea contain-
ing a normal organ of corti. Deafness can thus be
divided into conduction deafness due to a breakdown in
part of the conduction mechanism and nerve, or percep-
tion, deafness due to a lesion in the inner ear or hear-
ing nerve. Central hearing pathways partially cross
and are thus seldom the cause of hearing defects. The
differentiation of these two main types of deafness is
of prime importance in therapy for although all forms
of conduction deafness can be cured with the restoration
of functional hearing, very little can be done medically
for nerve deafness. The differential diagnosis of these
two types depends upon two facts. Both types have
diminished hearing by air conduction. However, hear-
ing by bone conduction is diminished in nerve deafness
and normal in conduction deafness. Bone conduction
is the index of nerve function. This can very nicely be
brought out by clinical audiometry which separately
measures the loss in decibels for both air conduction and
for bone conduction (Figs. 1 and 2) . This quantitative
determination is especially valuable when there is a mix-
ture of the two types of deafness. From a practical
standpoint, however, the following qualitative tests with
tuning forks enable us to make the diagnosis of the type
of deafness very nicely:
1. The Rinne test in which the patient’s air and bone
conduction are compared by alternately holding the
prongs of the tuning fork 1 cm. from his ear and then
placing the handle of the tuning fork against the pa-
tient’s mastoid process. In conduction deafness the pa-
tient will hear by bone conduction much longer than by
air conduction.
Fig. 1. Conduction Deafness. Audiogram — Hearing normal
by bone and decreased by air. Rinne Test — Bone conduction
better than air conduction. Schwabach Test — Bone conduction
normal. Possible clinical characteristics: (1) uses quiet voice,
(2) hears better in noisy place.
Fig. 2. Nerve Deafness. Audiogram — Hearing by bone and
air decreased equally. Rinne Test — Air conduction better than
bone conduction. Schwabach Test — Bone conduction below
normal. Possible clinical characteristics: (1) uses loud voice
without realizing it, (2) poor voice quality in long standing
deafness, (3) hears very poorly in noisy place.
2. The Schwabach test in which the bone conduction
of the patient is compared with the bone conduction of
the normal hearing examiner by placing the handle of
the fork alternately against the patient’s mastoid process
and then the examiner’s mastoid process. Shortening of
the patient’s bone conduction as compared to the exam-
iner's means nerve deafness.
3. The Weber test. This is the least important of the
November, 1949
399
tests, useful in unilateral deafness. The tuning fork
handle is placed against the patient’s forehead and he
is asked in which ear it is heard. In nerve deafness the
fork is lateralized to the good ear while in conduction
deafness it is lateralized to the deafened ear.
For maximum accuracy, several frequencies of tuning
forks are used in these tests, but for practical purposes
the 256 fork will usually be adequate. Clinical distinc-
tion between these types of deafness is often possible
from the history alone. The patient with conduction
deafness having normal bone conduction hears his own
voice well. Therefore, he speaks in a very quiet voice
and hears well in noisy places. In nerve deafness the pa-
tient hears better in quiet places and, since he has poor
bone conduction, he hears his own voice poorly and is
inclined to talk loudly and even to shout without realiz-
ing it. In long standing cases there may be a gradual
loss of voice quality from omitting sounds not heard
well for years.
Classification of Deafness
CONDUCTION DEAFNESS
There are seven causes of conduction deafness. For
all of these there is a medical treatment which can result
in a restoration of functional hearing.
1. Occlusion of the external auditory canal by wax,
foreign bodies, swelling, stenosis, or bony closure. Diag-
nosis is by inspection and therapy is obvious.
Drum Drum
after before
Fig. 3. Perforated Tympanic Membrane. Hearing improved
following closure of perforation by 1 1 weekly treatments.
X X =: Before treatment. X X = After treatment.
2. Perforation of the tympanic membrane (Fig. 3)
from trauma or infection. Diagnosis is by inspection.
Regardless of size or duration, these perforations can
usually be closed. Treatment consists of destroying the
epithelium on the edge of the perforation at weekly
intervals with 50 per cent (saturated solution) trichlor-
acetic acid after 2 per cent pontocaine anesthesia. The
granulations thus produced slowly close the perforation.
The acid is applied with a tiny cotton ball on the end
of a thin wire applicator. It should be moist but not
dripping with acid and the white eschar thus formed
on the drum should be at least 1 mm. wide all the way
around the edge of the perforation. If the ear is dry
the drum must be kept moist with a small piece of cot-
ton packed against the perforation and moistened with
glycerite of hydrogen peroxide twice daily. Euthymol
and antiseptic solution N.F. have also been used as
moistening agents. If the ear is draining it must be
dried up before closure is effected. In doing this, local
cleansing and drops are necessary. It is also necessary
to: Remove aural polyps, clear up chronic sinusitis, nasal
allergy, enlarged adenoids, and occasionally to irradiate
lymphoid tissue in the mouth of the eustachian tube
with the radium applicator. If cholesteatoma is present,
usually with a marginal or total perforation, closure
should not be attempted and a radical or modified rad-
ical mastoid operation should be done. Closure is af-
fected in four weeks to nine months, depending upon
the size of the perforation. Where there is extensive
scarring of the middle ear and ossicles, closure of a per-
foration may not restore the hearing. However, the pa-
tient is still benefited as he has a dry ear which does not
drain after swimming or bathing and the hearing can
later be restored if desired by a fenestration operation.
3. Absence of tympanic membrane from infection or
following a radical mastoidectomy. Diagnosis is by in-
spection. Therapy is not necessary when the condition
is unilateral. If a bilateral hearing loss is present, the
hearing may be restored nicely in many cases by the
Pohlman 1 artificial ear drum which the patient wears
during the day with no less discomfort than eye glasses.
A hollow ear mold is made for the patient and Cargile
membrane is stretched across the bottom of the mold.
A 20 gauge nylon rod is pushed through this membrane
to touch and conduct sound near to the oval window.
Hearing is good and adjustment for the patient is easy.
4. Secretory otitis media (Fig. 4) due to occlusion of
the eustachian tube. This is the most frequent cause of
hearing impairments in school children. It is character-
ized by a fluctuating or intermittent deafness often asso-
ciated with earaches or colds. Small bubbles are seen
behind the ear drum or a retracted amber colored drum
may be present. The diagnosis is confirmed when the
hearing is greatly or totally restored by inflation of the
eustachian tube. Treatment consists of correction of the
cause plus inflation of the eustachian tubes occasionally
preceded by myringotomy. There are eight causes of
secretory otitis media:
(a) The presence or recurrence of enlarged chronically
infected adenoids. These are best removed surgically but
occasionally the use of the radium applicator will result
in a cure, particularly in adults.
(b) Hypertrophy of the lymphoid tissue around the
mouth of the eustachian tube following adenoidectomy.
400
The Journal-Lancet
This is best treated by the radium applicator after the
method of Crowe.'
(c) Acute and chronic sinusitis.
(d) Nasal allergy.
(e) Acute head colds.
(f) Mal-occlusion of the temporal mandibular joint.
This condition often follows the removal of molar teeth
which allows the powerful mastication muscles to cause
an abnormal compression of the joint structures and the
adjoining eustachian tube. The patient should be re-
ferred to a dentist for reconstruction of his bite.
(g) Carcinoma of the nasopharynx.
(h) Aero-otitis media caused by the failure of the
eustachian tube to open during the rapid descent of an
airplane. This may be predisposed to by a mild nasal
infection or allergy.
Fig. 4. Secretory Otitis Media. Showing immediate hearing
improvement following inflation of the eustachian tube (Politzer-
ization) .
5. Acute suppurative otitis media. Diagnosis is by
history and inspection of the ear drum. Therapy con-
sists in the use of appropriate antibiotics. Myringotomy
and occasionally a simple mastoidectomy may be neces-
sary.
6. Chronic adhesive deafness is the result of scar tis-
sue adhesions to the drum and ossicles following an acute
necrotic suppurative otitis media. Diagnosis: History of
a nonfluctuating deafness immediately following such a
process. Examination shows a retracted scarred tympanic
membrane with a conduction deafness not improved after
inflation of the eustachian tube. Therapy as in No. 7
consists in the performing of a fenestration operation.
Prognosis following this operation is as good as in oto-
sclerosis, providing the tympanic membrane is intact.
7. Otosclerosis, (Fig. 5) the most common cause of
deafness in early and middle adult life is due to a spongy
bone overgrowth on the stapes interfering with its vibra-
tion. This disease affects about one out of one hundred
adults in America and causes a slowly progressive deaf-
ness which is more common in women and has a slight
hereditary tendency. Exacerbations are common follow-
ing pregnancy. Both of these last two types of conduc-
tion deafness are amenable to the fenestration operation
in which serviceable hearing can be restored in about
80 per cent of selected cases. Improvements made in the
fenestration operation during the last few years have
almost eliminated closure of the new window as a prob-
lem. Once hearing is restored there is a 95 per cent
chance that the gain will be permanent.
Fig. 5. Otosclerosis. Showing hearing gain following a
fenestration operation.
X X = Air conduction. ] ] r= Bone conduction.
NERVE OR PERCEPTION DEAFNESS
There are sixteen important causes of nerve deafness.
The first seven of these have no known medical treat-
ment or cure. They are:
1. Congenital nerve deafness due to absence or mal-
formation of the organ of Corti. Familial tendencies
and the acquisition of rubella or other virus infections
in the first three months of pregnancy has been found
to be etiological factors in some cases.
2. Congenital nerve deafness due to quinine poisoning
from large doses of quinine taken by the mother during
her pregnancy. It is possible to have a fetus totally
deafened by a dose of quinine which will merely cause
the mother’s ears to ring temporarily.
3. Cerebrospinal meningitis. This may cause a com-
plete and permanent destruction of hearing by invading
the labyrinth through the cochlear aqueduct or internal
auditory meatus.
4. Basal skull fracture passing through the labyrinth
or nerve. This condition is usually irreversible. Tinnitus
may persist for a long period following the fracture.
5. Hemorrhage, embolus, or thrombosis of the coch-
lear division of the internal auditory artery. This is an
end artery and results in a sudden permanent loss of
hearing accompanied by tinnitus and often vertigo.
6. Senile nerve deafness occurs universally over the
age of 40. It is manifested by a gradual loss of hearing
for the high tones; at about the age of 60 the conver-
sational tones may be affected. Occasionally in certain
families there is a predisposition for this condition to
come on earlier.
7. Labyrinthine otosclerosis. This is a rare condition
and differs from the usual type of otosclerosis in that the
November, 1949
401
labyrinth rather than the stapes is invaded by otosclerotic
bone. Diagnosis during life is very difficult but the
condition probably accounts for an occasional case of
nerve deafness of unknown etiology.
While there is no medical treatment for these types
of deafness, the physician has a very definite responsi-
bility in the management of these people. If the deaf-
ness is bilateral, they should be directed to clinics or
centers where:
(a) Properly fitted hearing aids can be selected to
make use of residual functional hearing. Special speech
tests are used to test the patient while he wears different
makes of hearing aids. The same make of hearing aid
does not fit all patients best, and the scores obtained fre-
quently show real differences in performance.
(b) Lip reading can be taught so that the patient can
fill in with his eyes the sounds which he misses even
with his hearing aid.
(c) He can use table model hearing aids with ex-
treme amplification to hear speech sounds which he
usually misses. This helps to maintain voice quality.
(d) Congenitally deaf children can be taught speech
and lip reading. Many of these children are then able
to lead normal lives associated with normal hearing chil-
dren. A few have even received university degrees.
In many mild cases, especially if the hearing loss
curve is flat, this intensive program is not necessary. The
patient will probably get serviceable hearing from any
of several hearing aids and he will pick up adequate lip
reading if the doctor will only advise him to watch the
lips of those with whom he talks.
Medical treatment of the last nine causes of nerve
deafness is often effective if diagnosis is established early
and treatment is started without delay. These causes are:
8. Congenital syphilis which causes deafness as a part
of Hutchinson’s triad. The Wassermann test is not an
accurate index of this condition. The loss usually oc-
curs some years later than interstitial keratitis and is
usually rapidly progressive, unless the condition is rec-
ognized and vigorously treated.
9. Acquired syphilis may cause a degeneration of the
ganglion cells of the cochlea. Recognition and prompt
treatment is necessary. In all cases with nerve deafness
a Wassermann test should be done.
10. Acoustic trauma. These patients have a typical
history that following exposure to continuous or sudden
intense loud noises they suffered a temporary deafness
accompanied by loud tinnitus. When the acoustic insult
is not continued the tinnitus gradually disappears and
the hearing is at least partially restored. The most great-
ly affected frequency and the last to recover is the 4,096
vibration frequency. Therapy consists in the recognition
of the condition and the withdrawal of the subject from
exposure to such acoustic trauma. If this is not done,
permanent deafness ensues.
11. Acoustic neuroma causes a progressive unilateral
deafness accompanied by a loss of vestibular function on
the same side followed by involvement of the fifth, sixth,
and seventh cranial nerves and by cerebellar ataxia. Ev-
ery case of unilateral progressive nerve deafness should
have caloric tests for vestibular function.
12. Serous or suppurative labyrinthitis secondary to
otitis media. Both of these conditions should be treated
intensively with antibiotics. If a serous labyrinthitis is
present, a complete or partial recovery may occur over
the first month or so, but after that the residual hearing
loss is permanent.
13. Toxic nerve deafness from acute infections such
as scarlet fever, rheumatic fever, influenza, measles, pneu-
monia, and mumps. (Mumps usually causes a unilateral
deafness.) The hearing loss occurs during the acute
toxic stage of the infection. Partial recovery may occur
during the first month or so of convalescence after which
the hearing defect remains stationary. Penicillin, anti-
toxin, and convalescent serum may be helpful adjuncts
toward preventing or minimizing the deafness.
14. Toxic nerve deafness from drugs. These include
particularly quinines, streptomycin, salicylates, and sul-
fonamides. Usually the loss is accompanied by a high
pitched tinnitus. Individual idiosyncrasies and the total
dose of the drug taken are the determining factors re-
garding the damage. Early recognition and withdrawal
of the drug may be followed by improvement over the
first month or so but then residual hearing loss is per-
manent.
15. Toxic nerve deafness from focal infection is prob-
ably a relatively infrequent condition. Nevertheless ev-
ery patient who develops a progressive nerve deafness of
unknown etiology should have obvious foci of infection
(abscessed teeth, tonsils, and sinuses) cleared up to ar-
rest possible progressive deterioration of the hearing.
16. Meniere’s disease (labyrinthine hydrops). The
pachology consists in the dilatation of the endo-lymphatic
sytem. The etiology of this condition is not known,
although some form of allergy is to be suspected. The
condition is characterized by sudden attacks of vertigo
and tinnitus with a fluctuating progressive nerve type
deafness. Conservative therapy consists of allergy tests,
a low salt diet, the use of nicotinic acid, histamine,
potassium nitrate, phenobarbital, and hyoscine. Acute
attacks may be aborted by adrenalin, histamine, or bena-
dryl. Where medical management is unavailing the
Cawthorne or Day 4 operation and more recently the
destruction of central vestibular nuclei with streptomycin
are to be considered to relieve distressing attacks of
vertigo.
In all of these last nine cases of nerve deafness the
treatment consists in the removal of the cause and even
if hearing is not regained progression of deafness may be
arrested. If deafness persists and is bilateral, manage-
ment should be carried out as outlined under noncurable
nerve deafness. In addition the patient should be cau-
tioned about possible causes of further hearing loss so
that he may conserve residual hearing intact.
Many nonspecific medications have been suggested
and tried in the therapy of nerve deafness such as thia-
mine chloride, vitamin B complex, multiple vitamins
plus amino acid, nicotinic acid, and histamine. These
medications may be tried as adjuncts even in long
402
The Journal-Lancet
standing nerve deafness and can certainly do no harm.
However, their actual value in therapy is still open to
question.
PSYCHOGENIC DEAFNESS
This type of deafness, more common than is generally
realized, is an hysterical phenomenon precipitated by the
usual causes of hysteria. It is frequently encountered
as a psychogenic overlay or increase in deafness super-
imposed upon an already existing organic deafness of
milder order. The commonly recognized characteristics
of this form of deafness are:
1. Wide fluctuations in the hearing loss.
2. Greater loss for pure tones than for speech.
3. Equal loss for both air and bone conduction. Few
hysterical deafness cases have enough insight to simulate
a conduction deafness.
4. Frequent temporary or permanent recovery from
suggestion therapy or any convincingly given therapy.
5. The Doerfler-Stewart 5 test in which the patient’s
hearing is tested by speech tests in a noise background.
As the noise is gradually increased the psychogenic deaf-
ness patient will hear much more poorly than an equiva-
lent organic deafness.
6. Narcosynthesis.0 The patient’s hearing is tested
with the audiometer. He is then put under light pento-
thal anesthesia or hypnosis and the hearing retested. The
organic deaf patient will make the same score while the
hearing of the psychogenic deaf patient will come up to
normal or in a psychogenic overlay to the level of or-
ganic deafness.
Treatment consists in psychotherapy to resolve the
conflicts causing the deafness. Many cases may be
cleared up by any therapy in which the patient has con-
fidence. This fact may account for some of the spec-
tacular cures of long standing nerve deafness by vita-
mins, histamine, and other medication. It even enters
into the fenestration picture. Dr. George E. Sham-
baugh, Jr., has stated that an occasional case of fenestra-
tion for otosclerosis, about 1 in 500, will produce an im-
provement in the unoperated ear equal to that in the
fenestrated ear. This can only be explained as a case of
unilateral otosclerosis cured by fenestration with an op-
posite ear psychogenic deafness cured by suggestion.
Future work done on cures for nerve deafness and even
conduction deafness should rule out psychogenic deaf-
ness before therapy is started.
Conclusion
Deafness is a ubiquitous, disabling handicap for which
much can be done. The patient’s welfare demands that
the physician take over the management of this condi-
tion. The responsibilities of the general physician con-
sist of:
1. Early recognition and diagnosis of the cause of
deafness.
2. Therapy within the limits of his equipment and
skills.
3. Referral of the remaining problems to hearing
clinics and centers.
The functions of these hearing clinics and centers are:
1. To again screen the patients to single out those
cases amenable to medical treatment.
2. To administer specialized medical care where pos-
sible.
3. To care for the balance of these patients by select-
ing hearing aids, teaching lip reading and speech.
References
1. Pohlman, Max Edward: Artificial Middle Ear, Ann.
Otol., Rhin., & Laryng., 56:647-657, 1947.
2. Crowe, S. J.: The Local Use of Sulfadiazine Solution,
Radon, Tyrothricin, and Penicillin in Otolaryngology, Ann.
Otol., Rhin., & Laryng., 53:227-241, 1944.
3. Cawthorne, Terence: Meniere’s Disease, Ann. Otol.,
Rhin., & Laryng., 56:18-39, 1947.
4. Day, Kenneth: Hydrops of the Labyrinth (Meniere’s
Disease), The Laryngoscope, 56:33-42, 1946.
5. Doerfler, L., and Stewart, K.: Malingering and Psycho-
genic Deafness, J. of Speech Disorders, 2:181-186, 1946.
6. Hardy, Wm. G.: Psychogenic Deafness, Ann. Otol.,
Rhin., & Laryng., 57:65-95, 1948.
HEART DISEASE CONFERENCE SLATED FOR JANUARY
A National Conference on Cardiovascular Diseases will be held in Washington, D.C.,
January 18-20, 1950, under the joint sponsorship of the American Heart Association and
the National Heart Institute of the U. S. Public Health Service.
November, 1949
403
Well Baby Care
H. G. Skinner, M.D.*
Rapid City, South Dakota
The Well Baby Care plan is one of the easier ways
in which a general practitioner can introduce pre-
ventive medicine into his practice. The idea is simple.
Babies are checked at stated intervals, even if they ap-
pear to be in excellent health. This presentation will
outline a method of conducting such a plan.
For convenience the Well Baby Care plan may be
divided into several parts, including the spacing of visits,
history, measurements, laboratory examinations, physi-
cian’s examination and recommendations. The spacing
of visits, measurements and laboratory examinations are
outlined in Table I. Table II gives the history and phys-
Table I
A. Frequency of Examinations
Age 1-12 months — Each month starting at one month
Age 1-2 years — Four times a year
Age 2-5 years — Twice a year
B. Frequency of Laboratory Examinations
Hemoglobin — 1st, 4th, 7th and 12th month
2nd, 3rd, 4th and 5th year
Pinworm — 6th month, 1st, 2nd, 3rd, 4th and 5th year
Urine — 1st month, 1st, 2nd, 3rd, 4th and 5th year
C. Frequency of Measurements
Head — Each visit
Weight — Each visit
Length — Each visit
ical examination form. We use the tables published by
Professor J. D. Boyd of the University of Iowa for the
normal weight, length, and head size.
Frequently a low hemoglobin is found in children.
According to Dr. Louis K. Diamond 1 a hemoglobin of
11 gm. is normal for 3 months of age, and about 12 gm.
is normal for 6 months and one year. A series that we
are studying at present indicates that hemoglobins lower
than this are frequent. Many children with low hemo-
globin are nervous, irritable, naughty or shy. Liquid
iron-liver preparations or injections of liver frequently
correct the hemoglobin level and the behavior problems.
Pinworm tests are done by means of the cellophane
technique. We occasionally find pinworms in a six-
months-old child. By the preschool age 20 per cent of
the children may be infected.
The feeding problems that are most frequently en-
countered are related to vitamins and the use of meats
in the diet. Often the children are not taking orange
juice because they are allergic or do not like it. Fdere
we advise ascorbic acid, 50 mgm. tablets, one tablet
crushed and given each day. Many mothers do not give
codliver oil until the need is pointed out to them.
Children are often started on strained meat as early
as the second month because we have the impression
*Director, Pennington County Health Department, Rapid
City, South Dakota.
that such a practice results in a high hemoglobin level
and better health. The meat sheet we use is reproduced
in Table III. We warn against the use of strained meat
Table III
Meat for Your Baby
Start your baby on strained meat.
Advantages: Meat is a good source of proteins, vitamins, and
iron.
Disadvantages: It may constipate your baby. To overcome this
tendency use prunes or apple sauce.
The difficulties for baby: Consistency of food is different. Has
to learn to swallow without sucking.
Serving:
A. Mixing with formula. This is rather difficult. Two tea-
spoonfuls for bottle is plenty. Don’t forget to enlarge
the holes in the nipple.
B. Heat: 1. By emptying contents of can into double boiler.
2. By opening tin and placing in pan of water.
The disadvantage of heating is that the left-over
portion is dried out.
C. Cold. Some children seem to enjoy the meat as well if
it is not heated.
D. It is often essential to mix the strained meat with apple
sauce so that the child will not find the mixture too
sticky.
Storage: Unused portions may be left in the can. The can
should be covered and left in the refrigerator.
We suggest that you give:
1. Beef heart lamb pork veal liver
2. Serve it (a) in formula, (b) heat, (c) cold, (d) cold or
warm mixed with apple sauce.
3. Start with teaspoonful and increase by tea-
spoonful per day.
4. If meat constipates your baby use prunes and/or apple
sauce.
5. Feed him the meat times a day at
too long. Some children should start chopped meat at
6 to 8 months — almost all before one year. Children do
not need teeth to break up meat and other lumpy foods.
It is our practice to start meats and fruits before cereals.
We give the fruits with a purpose. Apple-sauce is mixed
with the meat to overcome the excessive stickiness, and
prunes are used to overcome any tendency to constipa-
tion.
Psychological problems discussed include those relating
to toilet training, forcing the child to eat foods the
mother believes are good for him, and numerous cases
of "nervous” mothers. Spock 2 and the books entitled
Infant Care/’ and Your Child from One to Six / con-
tain references for the mothers.
The most convenient means of handling this type of
work is to have the history, laboratory work, and meas-
urements done before the doctor sees the patient. Then
the doctor reads the recorded material, does a physical
and makes recommendations. We have found that when
404
The Journal-Lancet
Table II
Infant and Preschool Medical Conference Record
Name Sex Race Date of Birth
Parent’s Name Tel. No Referred by
Address Physician _..
HISTORY
Birth and Neonatal
Period of gestation Delivery: Spontaneous
Birth weight .... Birth Registered .. Condition of Child at Birth
Neonatal Period
Operative
Nutrition
Date |
Codliver Oil |
Vitamin C
Milk |
Water |
Sugar
Meat
Cereal |
Fruit |
Vegetable |
(T — table; S — strained; C — chopped)
Immunizations and Date
Smallpox
Diphtheria
Diph.-Tet.
Wh. Cough
Typhoid
Others
Operations
LABORATORY
Hemoglobin
Pinworm
Sat up
First tooth
Head steady
Crawled
Development
Walked
Formed sentences
..Dressed self
Notes on Table II —
On the back of the sheet is an area entitled "Observations, Personal Hygiene and Physical Examinations.’ Down the left side
are these headings: Date, age, height, weight, temperature, sleep, skin, scalp, head measurement, eyes, nose and throat, mouth and
teeth, ears, lymph nodes, chest, abdomen, genitalia, spine, and extremities. There is room to record these findings for ten visits.
Below that is a blank space for recommendations.
November, 1949
405
a clinic is run as a community service it is best that the
recommendations which the doctor makes be explained
to the mother by the nurse after the child has been seen
by the doctor.
In private practice the doctor usually finds it advan-
tageous to explain recommendations himself. Some doc-
tors have booked all well baby examinations for the same
office period, finding that concentration and routiniza-
tion of this work lends to speed and increased efficiency.
The question of the fee for this care is important.
It has been found by many that the office fee plus lab-
oratory charges is not excessive. Others give one year’s
care for a flat fee. One thing must be made clear — the
parent is paying for the examination and ordinary advice
on feeding problems. Extra fees are charged if the child
is ill or if unusual feeding problems arise. Too many
doctors do not charge for examinations or advice on well
babies, with the result that the doctor’s professional time
is not paid for, and the examination is often not well
done.
If the principle of well baby care is accepted it can be
used readily and will do much to further the practice of
preventive medicine. A Well Baby Plan incorporated
into a general practice can serve a most useful purpose
and afford much real satisfaction.
References
1. Diamond, Louis K.: Textbook of Pediatrics i860,
Mitchell-Nelson, 1945.
2. Spock, Benjamin: Common Sense Book of Baby and
Child Care, April 1946. This book is also published under
the name of The Pocket Book of Baby Care.
3. Infant Care, U. S. Children’s Bureau, Publication No. 8,
1945.
4. Your Child from One to Six, U. S. Children’s Bureau
Publication No. 30, Revised 1945.
Note: There are six standard forms for the graphic repre-
sentation of growth as compiled by Professor J. D. Boyd. They
are: Boys 0-12 months, Girls 0-12 months, Boys 0-6 years,
Girls 0-6 years, Boys 5-18 years, Girls 5-18 years.
These forms, which come in pads of 100 and cost $1.00
each, are available at Department of Publications, East Hall,
State University of Iowa, Iowa City, Iowa.
American College Health Association News
The following is a list of new directors of student
health services which have been coming in during the
past few months.
Dr. Seth E. Smoot, Brigham Young University,
Provo, Utah.
Dr. E. L. Persons, Duke University, Durham, North
Carolina.
Dr. B. W. Lafene, Kansas State College of Agricul-
ture and Applied Science, Manhattan, Kansas.
Dr. Harold W. Potter, New Jersey College for Wom-
en, New Brunswick, New Jersey.
Dr. Herbert R. Glenn, Pennsylvania State College,
State College, Pennsylvania.
Dr. Quin Constantz, State Teachers College, Man-
kato, Minnesota.
Dr. George X. Trimble, Washington, St. Louis,
Missouri.
Dr. J. K. Whittal, University of British Columbia,
Vancouver, Canada.
Dr. Ralph Alley, University of Idaho, Moscow,
Idaho.
Dr. George H. Agate, Illinois State Normal Univer-
sity, Normal, Illinois.
Dr. Joel J. White, University of New Hampshire,
Durham, New Hampshire.
Miss Elizabeth Marshon, Cornell College, Mt. Ver-
non, Iowa.
Dr. Albert G. Lewis, University of Alabama, Uni-
versity, Alabama.
Dr. Joseph Garnet, Director, Student Health Service
of Iowa State Teachers College, writes in to say that
Dr. Thaddeus A. Staskiewicz of Chicago, Illinois, has
joined the staff as Assistant Director. Dr. Staskiewicz
is a graduate of Loyola University and University of
Chicago School of Medicine, 1944.
The program for the annual conference in Decem-
ber is taking shape. Time will be given in the program
for participation by members in attendance at the meet-
ing. The topics selected will be of interest to all health
personnel on a college campus. It is hoped that you will
encourage the attendance of all health personnel at the
meeting. Make your reservations at the Henry Hudson
Hotel, New York City, immediately in order to be
assured of a room. There are so many conventions be-
ing held at that time that rooms are at a premium. We
want you to come to the meeting.
The
LANCET
Official Journal of the American College Health Association
Great Northern Railway Surgeons’ Association, M inneapolis Academy of Medicine, North Dakota State
Medical Association, Northwestern Pediatric Society, South Dakota Public Health Association,
North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
Dr. J. A. Myers, Chairman
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J. Glaspel
Dr. J. F. Hanna
Dr. J ames M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J. H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr. J. H. Simons
Dr. S. A. Slater
Dr. Joseph Sorkness
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Secretary
ADVISORY COUNCIL
North Dakota State Medical Association
Dr. W. A. Wright, President
Dr. L. W. Larson, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
North Dakota Society of Obstetrics and Gynecology
Dr. B. M. Urenn, President
Dr. E. H. Boerth, Vice President
Dr. C. B. Darner, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Cyrus O. Hansen, President
Dr. Chauncey Bowman, Vice President
Dr. John Haugen, Secretary
Dr. Karl Sandt, Treasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-T reasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-Treasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
November, 1949
407
Editorial
REVISED PRINCIPLES OF ETHICS
When the principles of medical ethics of the Ameri-
can Medical Association were adopted by the house of
delegates at Atlantic City, on June 4, 1912, it was con-
cluded that while those principles express in a general
way the duty of the physician to his patients and col-
leagues, it is not to be supposed that they cover the
whole field of medical ethics, or that the physician is
not under many obligations besides those herein set
forth. In a word, it is incumbent on the doctor that
his bearing toward patients, the public and fellow prac-
titioner should be characterized by a gentlemanly de-
portment under all conditions, and he should behave
towards others as he desires them to deal with him.
Finally, these principles are primarily for the good of
the public, and their enforcement should be conducted
in such a manner as shall deserve and receive the en-
dorsement of the community.
At the annual session held in the same city and in
the same month, but thirty-seven years later, the judicial
council submitted a restatement and revision of the prin-
ciples of medical ethics and it was promptly adopted by
the house of delegates. The most outstanding changes
relate to group, clinics, contract practice, and purveyal
of medical service. Ethics "are not laws to govern but
principles to guide . . . An upright man instructed in
the art of healing” seldom needs to refer to the code.
Because it is one of the aims of the national association,
however, to guard the high moral standards of the pro-
fession, the frequent perusal of these principles of ethics
is not only recommended but should be a must on each
physician’s graduating anniversary.
A. E. H.
DATA ON TWINS REQUESTED
The study of twins is of great value in providing in-
formation concerning the respective importance of
hereditary predisposition and environmental influences
in disease in man. The results of the use of this method
have shown a hereditary predisposition to tuberculosis,
diabetes, and tumor formation, and a high, medium or
low intelligence quotient.
There is some a priori evidence showing an hereditary
predisposition for peptic ulcer. Only six cases of the oc-
currence of peptic ulcer in the one or both of mono-
or dizygous twins have been reported in the readily
accessible literature. Since twins are born in 1 of 86
births and identical twins in 1 of 344 births and the
general incidence of ulcer is from 5 to 10 per cent there
should be plenty of material available.
I should like to ask physicians to cooperate in assem-
bling such material by sending me cases in which (1)
one or both twins develop peptic ulcer, (2) the site of
the ulcer, (3) the age of onset of ulcer, (4) the type
of twins (monovular or diovular), (5) the sex of the
twins, (6) the date of birth of the twins, and (7) the
number and age of the brothers and sisters and the
absence or presence of ulcer in each.
A. C. Ivy, M.D.,
Department of Clinical Science,
University of Illinois,
1853 West Polk Street,
Chicago 12, Illinois
THE UNIVERSITY MEDICAL SCHOOL
SEMINARS
The first of a series of state-wide seminars on heart
disease, cancer, and psychosomatic medicine for profes-
sional groups has been successfully inaugurated at Be-
midji. On September 27 the first of eight consecutive
weekly classes was held for the physicians of the Bemidji
area at the Bemidji Lutheran Hospital. The faculty of
the University of Minnesota School of Medicine, aug-
mented by eminent practicing specialists, have provided
lecturers for the physicians’ meetings. Sponsored by the
Minnesota State Medical Association, the University
of Minnesota School of Medicine, and the Minnesota
Department of Health, the Bemidji Seminar has been
received with great enthusiasm by the physicians of the
locality and it is believed that this will be duplicated
at other seminars throughout the state.
Nurses of the Bemidji area have been utilizing the
occasion of the physicians’ seminar to hold eight meet-
ings of their own the same evening and hour. The
nurses’ sessions are sponsored by the 1 1th District
Nurses’ Association, the University of Minnesota School
of Nursing, and the Minnesota Department of Health.
Minnesota’s second seminar, which will be held at
Fergus Falls, is scheduled to start October 26. During
the 1949-50 season these professional seminars, designed
to disseminate postgraduate education throughout the
state, are planned for nine Minnesota areas. As pres-
ently organized, the 1949-50 schedule marks the begin-
ning of a continuous five-year educational program for
professional groups.
Buy Christmas Seals
Help Stamp Out TB
The Journal-Lancet
408
News Briefs
North Dakota
The September meeting of the Grand Forks Dis-
trict Medical Society was held in Grafton, North Da-
kota, on September 21. The guest speaker was Dr.
Graham Kernwein of Minot, N. D., who discussed some
of the problems involved in treating fractures of the
ankle and wrist. About thirty doctors attended the
meeting.
At their September meeting, the Stutsman Dis-
trict Medical Society voted to join the list of District
Medical Societies who are participating in the North
Dakota Physicians Service Plan, for the prepayment of
surgical, obstetrical and fracture care.
The North Dakota Pediatric Society held their
fall meeting on October 15 at the Gardner Hotel, in
Fargo.
Dr. R. H. Ray, physician in Garrison since 1905,
and Mrs. Ray were honored at an open house preceding
their departure for California where they will make
their home. Sponsored by the Garrison Civic Club, the
open house was attended by more than 200 persons.
First president of the Garrison Civic Club which was
organized about 22 years ago, the veteran McLean coun-
ty physician is a native of the Dakota territory. He was
born near Belmont in Traill county April 22, 1875. A
graduate of the University of North Dakota in 1897,
he received his M.D. degree from the Medico Chirugici,
a medical school in Philadelphia which now is a part
of the University of Pennsylvania. He practiced medi-
cine in Walnut Grove, Minn., for four years before
coming to Garrison.
Th'rty-one wives of medical men of Cass county
attended the first fall dinner of the Cass County Med-
ical Association’s Auxiliary Monday evening in the
Gardner Hotel at Fargo. Mrs. B. C. Corbus of Fargo,
president of the group, presided. Mrs. Orren Short of
Fargo, state advisor on women’s activities for the Na-
tional Foundation for Infantile Paralysis, was the
speaker.
Dr. Julius Tosky of Winnipeg, Manitoba, has
located in Larimore, N. D., replacing Dr. Lloyd Ralston,
who has moved to Grand Forks, N. D., where he will be
associated with Dr. W. E. Liebeler.
Dr. James D. Cardy, Fellow in Pathology in the
Medical School of the University of Minnesota from
1946 to 1949, early this summer moved to Grand Forks,
N. D., where he took over his post as professor and
chairman of the Department of Pathology at the Med-
ical School at the University of North Dakota.
Dr. Frank M. Melton has recently joined the staff
of the Dakota Clinic as head of the Department of
Dermatology. Dr. Melton is a native of Kentucky and
served his internship in the Louisville City Hospital.
He received his postgraduate training in dermatology
in the University of Pennsylvania Hospital, Philadel-
phia, and last year was an associate in dermatology at
Duke University Hospital in Durham, N. C. He is
a World War II veteran. He is certified by the Board
of Dermatology and Syphilology.
Dr. Joseph P. McEvoy, St. Paul, Minnesota, has
joined the staff of the Quain and Ramstad clinic at
Bismarck.
Dr. McEvoy, who is an eye specialist, is a graduate
of Minnesota Medical School and completed his intern-
ship at Ancker Hospital, St. Paul. Before coming to
Bismarck he was associated with the Philadelphia Gen-
eral Hospital, Philadelphia, Pa.
The Kotana Medical Society, in cooperation with
the District Health office and the Williston hospitals,
conducted the annual Diabetes Week October 10-16.
The purpose of Diabetes Week, a national function,
is to detect undiscovered cases of diabetes before they
become dangerous. For this purpose, free detection cen-
ters were set up in Williston during the week, to inform
victims and refer them to physicians for treatment.
Dr. Alan K. Johnson, president of the Kotana Med-
ical Society, was chosen chairman of the local diabetes
detection committee, assisted by Dr. I. S. AbPlanalp
and Dr. J. D. Craven. The members of the Kotana
society who aided in the detection work, in addition to
the members of the committee, were Drs.W. A. Wright,
J. J. Korwin and E. J. Hagan of Williston and Drs.
P. O. C. Johnson and Carlson of Watford City.
Dr. Dean F. Nelson, associated with the Fargo
Clinic since June, 1948, has resigned to become a part-
ner with Dr. Clyde Geiger and Dr. John R. Durburg
in Chicago under whom he previously received training.
Dr. Nelson will be in charge of the training program
for obstetrics and gynecology at St. Joseph’s Hospital
which is associated with Northwestern University, and
also will be in charge of the obstetrical and gynecological
outpatient department.
The Commercial Club of Zeeland appointed a com-
mittee of local businessmen to study ways and means
toward the establishment of a local doctor in Zeeland,
with facilities to handle minor cases and emergency
cases, in the form of a local clinic and first aid station.
Dr. Charles B. Porter has joined the staff of the
Grand Forks clinic with his practice confined to diseases
of the ear, nose and throat. The staff total 15. Dr.
Porter received his advanced and medical education at
Johns Hopkins University and Medical School in Bal-
timore and served his internship there. He joined the
Mayo Clinic staff as a fellow in surgery in 1940, serving
there until this fall, except for four years in the army
medical corps during the war.
November, 1949
409
South Dakota
Dr. Lyle Hare, Spearfish doctor, has for the second
time in as many years been named South Dakota’s gen-
eral practitioner of the year. The honor was voted by
the council of the South Dakota State Medical Asso-
ciation at its fall council meeting in Huron.
Two hundred fifty people gathered at the Legion
Auditorium in Presho on Monday evening, September
26, to pay tribute to Dr. and Mrs. F. M. Newman, who
have been residents of Presho and Lyman county since
1905. This event marked forty-four years that Dr.
Newman has given medical and civil service to this com-
munity.
Plans are under way for the organization of the
Scotland Hospital and Home Association with a tem-
porary board of directors including Dr. J. C. VanFerney
as chairman. If the present plans are carried out, the
South Dakota Hospital Management Association, head-
ed by Dr. Arthur S. Schade, will give the necessary
assistance in securing capable personnel for the clinic
operation.
Dr. H. P. Rosenberger, eye, ear, nose and throat
specialist with the Quain and Ramstad clinic in Bis-
marck for the past fifteen years, plans to go into prac-
tice with his brother-in-law, Dr. Fred Bunker, in
Aberdeen.
Prior to coming to Bismarck, Dr. Rosenberger was
with the Miller clinic in St. Paul and was an instructor
in the postgraduate school at the University of Min-
nesota.
Dr. James H. Chalmers recently accepted a posi-
tion as internist at the newly constructed Veterans’ Hos-
pital in Sioux Falls.
Dr. Chalmers was graduated from the University of
Minnesota Medical School in 1941, including an intern-
ship at the Swedish Hospital in Minneapolis. From
1941 to 1942 Dr. Chalmers interned at Medical Center,
Jersey City, New Jersey. For the past three and a half
years Dr. Chalmers has had a rotating fellowship in
Internal Medicine through the University of Minne-
sota, including General Hospital, St. Barnabas Hospital,
Veterans Hospital at Fort Snelling, University Hospital
and the Research Laboratory at the University of Min-
nesota.
Minnesota
Dr. E. A. Boyden, Professor and Head, Department
of Anatomy, University of Minnesota School of Medi-
cine, has announced promotions of several staff mem-
bers in that department. Dr. Lemen J. Wells has been
promoted to Professor in the Department of Anatomy.
Promotions to Associate Professor have been given to
Drs. W. Lane Williams and Berry Campbell. Dr.
Ronald M. Ferry has recently joined the faculty as
Instructor in the Department of Anatomy.
Television became another medium for public health
education recently for the Minnesota Heart Association.
In a program via TV station KSTP, Minneapolis-St.
Paul, Dr. Paul F. Dwan, former president of the Min-
nesota affiliate, appeared in a telecast devoted to rheu-
matic fever.
New Members of the Minnesota Medical Founda-
tion are: Dr. Harold A. Williamson, Heron Lake, Min-
nesota; Dr. Howard A. Shaw, Minneapolis; Dr. E. S.
Lippman, Minneapolis; Dr. B. A. Weis, St. Paul; Dr.
T. J. Catlin, Buffalo, Minnesota; Dr. C. A. Fosmark,
Madison, Wisconsin; and Dr. E. E. Greene, Westhope,
North Dakota.
Establishment of the James Hoffman Bentson fund
to provide a memorial for the late Dr. James H. Bent-
son at Mount Sinai Hospital was announced in Min-
neapolis. Dr. Bentson, 31, a fellow at Mayo Clinic,
Rochester, Minn., died June 28 in New York.
Two Minnesotans were honored at the Minnesota
public health conference September 30 for their long
fight against tuberculosis. The conference is the Public
Health Workers’ Association annual meeting at the
Nicollet Hotel. It conferred honorary memberships on:
Dr. Walter J. Marcley, tuberculosis consultant for the
state health department, who in 1897 opened the doors
for the first state tuberculosis sanatorium in the United
States, at Rutland, Mass.; and Dr. Ernest S. Mariette,
who retired last month because of ill health, after 33
years’ service as superintendent and medical director
of Glen Lake sanatorium.
Dr. Robert F. McGandy was installed as president
of the Hennepin County Medical Society at the annual
meeting recently. He replaced Dr. Edward D. Ander-
son, who became chairman of the board of directors.
Thomas P. Cook, executive secretary, announced a
15-year lease has been signed for the society’s headquar-
ters on the 20th floor of the Medical Arts Building.
Neiv Locations
Dr. J. J. Ahlfs and Dr. H. W. Hermann of Cale-
donia announced this week that they have formed a
partnership and will conduct their professional services
under the firm name of the Caledonia Clinic.
Dr. Martin Munson will set up practice in Barnum.
A graduate of the University of Minnesota in 1946,
Dr. Munson served his internship in St. Luke’s Hos-
pital in Duluth. He served two years in the Army.
Dr. L. H. Flancher of Des Moines, Iowa, director
of Sand Beach Sanatorium at Lake Park from 1925 to
1941, will return to the same post in the near future.
Dr. Flancher will succeed Dr. R. R. Hendrickson, who
resigned recently to become superintendent of Sunny-
rest Sanatorium at Crookston. Since leaving in 1941,
Dr. Flancher has been head of the tuberculosis depart-
ment of the state department of health in Iowa.
410
The Journal-Lancet
North Dakota Communities Desiring
Services of a General Practitioner
ANAMOOSE, McHenry County. Estimated popula-
tion 600. Estimated drawing territory: 25 miles to south,
west and north, 10 miles to east. Distance to nearest
hospital: 16 miles to Harvey. Two-room office space
available with adjoining waiting room, completed 1947.
These spaces adjoin those of the dentist. Living quar-
ters, a four-room apartment to the rear of the office space
on the same floor level, available. There are no doctors
between Anamoose and Minot and only one within the
county. Nearest competition to the south is the doctor
at McClusky; to the northwest, Towner, and to the
northeast, Rugby. Hospital at Harvey is open to any
doctor who wishes access to the hospital. Dentist set up
practice in September 1948. Further information may be
obtained by contacting Dr. L. C. Misslin, D.D.S., Ana-
moose, North Dakota.
GACKLE, Logan County. Estimated population 850.
Estimated drawing territory: 25 mile radius. Distance
to nearest hospital 40 miles. Community building mod-
ern health center, to be completed about December 1,
1948. 4900 sq. ft. building, brick and tile construction.
Includes doctor’s office, lobby, dentist office, laboratory,
consultation room with dressing rooms; doctor’s lab and
x-ray; four double bed rooms with baths, delivery-operat-
ing room; utility rooms, kitchen and storage rooms, etc.
Radiant heat in the floor. Board of trustees plan to per-
mit the doctor to have more or less free rein in this
project. Center being built by private individuals, with-
out government assistance. Further information may be
obtained by contacting C. C. Lehr, First State Bank,
Gackle, North Dakota.
GLEN ULLIN, Morton County. Estimated popula-
tion 1300. Estimated drawing territory: 30 miles all di-
rections. Distance to nearest hospital 30 miles to Elgin.
Office space (very nice) available. Housing can be ar-
ranged. Heart Butte dam is under construction by the
Bureau of Reclamation 18 miles south of Glen Ullin.
Town growing rapidly and can use a progressive doctor.
Presently wonderful hunting facilities and with the com-
pletion of the dam, the best fishing possible. Further in-
formation may be obtained by contacting Jack Curtis,
Publisher, The Times, Glen Ullin, North Dakota.
GOODRICH, Sheridan County. Estimated popula-
tion: 600. Estimated drawing territory: 90 miles south,
30 miles north, 60 miles east, 20 miles west. Distance
to nearest hospital 30 miles. Office space will be made
available by Goodrich Commercial Club. Living quar-
ters will be made available. (24 business places in town,
6 churches, good school, good bank). Need for doctor
is great. Further information may be obtained by con-
tacting W. A. Muralt, Goodrich, North Dakota.
McHENRY, Foster County. Estimated population
300. Serves rural area of 17 miles radius which includes
three towns of 150 population each. Distance to nearest
hospital, 34 miles. Nearest doctor, 31 miles. Home, con-
veniently located so it would serve equally well as an
office, is available. Community nurse with considerable
experience would be willing to assist doctor if desired.
Town served by state and county highways that are
maintained all year. Also served by McHenry Flying
Service with all-weather flying. Community composed
of prosperous farmers of mixed ancestry. Two churches,
and several new buildings in business section. Further
information may be obtained by contacting S. J. Hoff-
man, President, McHenry Commercial Club.
PEMBINA, Pembina County. Estimated population
750. Rural area with drawing territory 3 miles north to
Canadian border and a 15-mile radius in other directions.
Distance to nearest hospitals, 22 miles to Hallock,
Minn., and 28 miles to Drayton, N. D. Modern com-
munity. Office and dwelling accommodations could be
arranged. For further information contact F. F. Moris,
City Auditor, Pembina, N. D.
RUTLAND, Sargent County. Estimated population
300. Estimated drawing territory a 25-mile radius. Dis-
tance to nearest hospital 32 miles. Community has a
large house with surrounding lots, ideal for a hospital of
six to eight beds or more, with office downstairs, or ideal
for office and doctor’s home. If doctor should not wish
to purchase it himself, the town is prepared to form an
association to remodel, purchase and assist in equipping
same for the doctor. Many new commercial buildings
being built in town. Has supported a doctor in the past.
Nurses available. Further information may be obtained
by contacting Mrs. Otto Meyers, Rutland, N. D.
STRASBURG, Emmons County. Estimated popula-
tion 850. Estimated drawing territory: 25 miles west,
6 miles north, 25 miles east and 30 miles south. Towns
south of Strasburg have no doctor. Distance to nearest
hospital 78 miles northwest to Bismarck with very good
hard-surfaced all-weather road. Office space available.
Living quarters can be arranged. Located in rich grain
belt and cattle community with the last nine years very
prosperous. Community made up mostly of German-
Russians with a Holland settlement south of town. Fur-
ther information may be obtained by contacting J. M.
Klein, Secretary, Strasburg Civic Club, Strasburg, N. D.
VELVA, McHenry County. Estimated population
1400. Estimated drawing territory, 25-mile radius. Dis-
tance to nearest hospital 22 miles. Office space and living
quarters available. Previous doctor left to continue edu-
cation in specialized work. Further information may be
obtained by writing L. E. Kittilsby, Velva, N. D.
WILTON, McLean County. Estimated population
850. Serves rural area of 12-mile radius. Distance to
November, 1949
411
nearest hospital, 25 miles, hard-surfaced highway. Office
space and living quarters available. Good territory, well-
paying people. Some coal-mining nearby. Further infor-
mation may be obtained by writing the City of Wilton,
Wilton, N. D.
ASFfLEY, county seat of McIntosh County. Estimat-
ed population 2000. Drawing territory radius of 35 miles.
Distance to nearest hospital: Eureka, S. D., 32 miles.
Cases usually hospitalized in Bismarck, N. D., or Aber-
deen, S. D. Doctor who had been there deceased March
1949. Doctor’s office and equipment, including drugs,
available. Apartment available. One elderly doctor locat-
ed in Ashley. Nearest doctors: Wishek, 25 miles; Kulm,
56 miles; Ellendale, 45 miles. Main industry in territory
is farming. Very good business center. Business men in
town working toward building a small hospital or clinic.
Same was hindered in past due to lack of water and
sewage facilities. These are now available, and there is
the possibility that after a doctor locates there the busi-
ness men will go through with it. County roads well
maintained, snow removal equipment available. Further
information may be obtained by writing Mrs. E. H.
Maercklein, Ashley, N. D.
BUFFALO, Cass County. Estimated population 300.
Estimated drawing territory: 20-mile radius. Distance
to nearest hospitals: 40 miles to Fargo; 20 miles to Val-
ley City. Hard surface roads open the year round. Good
farming community. Office space available. Drug store
located in community. Living quarters could be made
available. Further information may be obtained by writ-
ing Mr. Lewis Easton, Chairman, Board of Village
Trustees, Buffalo, N. D.
GRENORA, Williams County. Estimated population
600. Estimated drawing territory, radius of 20 miles.
Nearest hospital, Williston, N. D. Community has a
good school system, modern, with water and sewer, 40
business places, and will be the scene of the large pump-
ing plant for the Missouri Diversion project. Drug store
with registered pharmacist; good theatre, golf course,
dual tennis court, nearby lake. Community contemplat-
ing building a hospital, but are waiting for a doctor to
locate and give it his supervision. Further information
may be obtained by writing Vern Steele, President,
Grenora Commercial Club, Grenora, N. D.
LIDGERWOOD, Richland County. Estimated pop-
ualtion 1500. Estimated drawing territory, radius of 30
miles. Modern office building available. Living quarters
will be available. Hospital facilities available at Wah-
peton, N. D., and Breckenridge, Minn., both on hard
surface highways. A good business community located
in farming territory. Further information may be ob-
tained by writing E. R. Dawson, Secretary, Lidgerwood
Junior Chamber of Commerce, Lidgerwood, N. D.
RAY, Williams County. Estimated population 650.
Drawing territory, radius of 25 miles. Distance to near-
est hospital and doctor 35 miles. Completely remodeled
building available for drug store, doctors offices, dental
office, with two apartments upstairs. Farming and ranch-
ing community. Further information may be obtained
by writing P. M. Schmitz, Secretary, Ray Health Cen-
ter, Ray, N. D.
RICHARDTON, Stark County. Estimated popula-
tion 1000. Estimated drawing territory unlimited North
and South. Located on U. S. Highway 10, about 30
miles from Dickinson. A 20-bed hospital to be com-
pleted fall of 1949, equipped for major surgery. Office
space and living quarters available. Good schools,
churches, water, sewage, natural gas, dentist, drug store.
Further information may be obtained by writing J. C.
Klein, Pharmacist, Richardton, N. D.
Opportunities Open
HIPPOCRATES ESSAY CONTEST
A $100 government savings bond will be awarded
for the best essay on "The Meaning of Hippocrates in
the Medical World Today” by the United States Chap-
ter of the International College of Surgeons. Entries,
which will not be restricted to any certain number of
words, must be postmarked no later than March 1,
1950. Although primarily of interest to medical stu-
dents, the contest is open to anyone who wishes to enter.
The contest is being held in connection with the cele-
bration of Hippocrates Day by the International Col-
lege of Surgeons in Chicago October 23, 1949. Send
entries to Essay Contest, care of International College
of Surgeons, 1516 Lake Shore Drive, Chicago 10, 111.
$1,000 IODINE RESEARCH AWARD
Any member of the American Pharmaceutical Asso-
ciation may propose a nominee for the 1950 Iodine
Educational Bureau, Inc., Research Award. An award
of $1,000 and an allowance up to $250 for travel ex-
pense will be given to the person who, in the opinion
of the award committee of Iodine Educational Bureau,
Inc., has done the most outstanding research in the
chemistry and pharmacy of iodine and its compounds
as applied in pharmacy or medicine. Nominations for
the 1950 Award must be submitted to the Secretary of
the American Pharmaceutical Association, 2215 Con-
stitution Avenue, Washington 7, D. C., on or before
January 1, 1950.
The nominations must be submitted in writing with
eight (8) copies of each of the publications of the nom-
inee dealing with his researches and eight (8) copies of
a biographical sketch of the nominee including his date
of birth and list of his publications. A nominee must
be a resident of the United States or Canada. He must
have accomplished outstanding research in the chemistry
or pharmacy of iodine and its compounds as applied in
pharmacy or medicine. During the period covered by
the nomination the nominee shall have been actively
engaged in, shall have completed, or shall have published
a report upon the line of investigation for which the
award is made.
412
The Journal-Lancet
Meet Our Contributors
John Joseph Ayash, M.D., was graduated from the
American University of Beirut in Lebanon, served a resi-
dency at the Massachusetts Eye and Ear Infirmary in
Boston, and was the recipient of a Cancer Research Grant
in Boston in 1946. A specialist in otolaryngology, he
serves on the staff of McCannel Clinic in Minot, N. D.,
and is a member of the Northwest District Medical So-
ciety and the A.M.A.
Harvey Brandon, M.D., a graduate of the medical
school in Hamburg, Germany, specializes in internal
medicine, and serves as assistant attendant physician at
the City Hospital and as clinical assistant at Misericordia
Hospital, New York City. He is a member of the New
York County Medical Society and a Fellow of the A.M.A.
Joseph Henry Hodas, M.D., a graduate of Bellevue
Hospital Medical College and a specialist in internal
medicine, serves as attending physician at the Miseri-
cordia Hospital and associate attendant at the New York
City Hospital. He is a member of the A.M.A., the New
York County Medical Society, and the New York Cardio-
logical Society.
John Francis Maloney, M.D., was graduated from
Queens Medical College in 1941; took graduate work at
the School of Tropical Medicine in California and the
Lahey Clinic in Boston; is now assistant attendant physi-
cian at the Misericordia and New York City Hospitals,
and clinical assistant in surgery at St. Vincent’s, all in
New York City. He is a member of the New York
County Medical Society and the A.M.A.
Collin S. MacCarty, M.D., was graduated from Johns
Hopkins Medical School, is now a neurosurgeon and in-
structor in neurological surgery at the Mayo Clinic in
Rochester. He is a member of the A.M.A., the Harvey
Cushing Society, the American College of Surgeons, the
Neurological Society of America.
Charles A. McDonald, M.D., a graduate of Harvard
Medical School, practices in Providence, R. I., as con-
sultant at the Massachusetts General Hospital and the
Rhode Island Hospital; visiting physician, department of
medical psychology, Rhode Island Hospital; chief, de-
partment of neurology and psychiatry, St. Joseph’s Hos-
pital. He is a member of American Neurological Asso-
ciation, the American Psychiatric Association; American
Psychopathological Association, Association for Research
in Nervous and Mental Diseases, A.M.A. and Sigma Xi.
William J. O’Connell, M.D., Tufts Medical School, is
on the staff of the University Health Services, Brown
University, the Out-Patient Department of Medicine,
Rhode Island Hospital, St. Joseph’s Hospital, and the
Charles V. Chapin Hospital, Providence, Rhode Island.
Hugh Grant Skinner, M.D., is a graduate of Queens
University, and now directs the Pennington County
Health Unit at Rapid City, South Dakota. He was a
Life Insurance Medical Research Fellow in 1946-47 and
assistant professor of pharmacology, University of South
Dakota in 1947-48.
William K. Wright, M.D., a graduate of Northwestern
University, took his internship at Cook County Hospital,
Chicago, served an ENT Residency, Barnes Hospital, St.
Louis; ENT Fellowship at Northwestern University, as
assistant doctor, George E. Shambaugh Jr. Hospital; is
now at the Fargo Clinic, N. D.
Book Reviews
Radiologic Exploration of the Bronchus, by S. Di Rienzo,
Chief of the Radiology Department of the Institute of Can-
cer, The University of Cordoba, Argentina. Published by
Charles C. Thomas, Springfield, Illinois, 1949.
The author has succeeded admirably in his purpose of dem-
onstrating abnormalities in bronchial anatomy and physiology
by radiographic means. There are 466 figures in 319 pages
and the pictorial method of presentation makes for interesting
reading.
Practical embryology of the respiratory tract is discussed
briefly and this is followed by chapters on bronchial histology
and anatomy. The purposes of this discussion are to emphasize
the importance of determining the conformation, segmentation
and dynamism of the bronchial tree.
The bronchographic image of the normal bronchus is clearly
explained. The anatomic characteristics are indicated by the
calibre, outline and branching of the bronchus. The broncho-
physiologic details are demonstrated by the filling rhythm, the
bronchial tone and the mechanism of the muscular sphincter as
well as the respiratory variation in calibre, the peristaltic waves
and the effects of cough.
Technique of injection of contrast media is outlined in detail
beginning with the preparation of the patient and ending with
the position best suited to fill various lobes and segments. The
type and technique of anesthesia is described meticulously. The
author recognizes that there are occasional hazards including
anesthetic reactions, hemorrhage and toxic reactions to the con-
trast media. The measures necessary to reduce these hazards to
a minimum are discussed.
Tomography of the bronchus is considered a valuable pro-
cedure not only for the knowledge gained but because there is
no contra-indication and no instrument or chemical substance
is introduced. The author believes and rightly so that the rela-
tive merits of tomography, bronchography and bronchoscopy
can never be determined since these methods complement each
other and are not interchangeable. Tomography is especially
indicated in those cases where the disease is in the trachea, pri-
mary bronchi or main lobar bronchi.
Bronchopulmonary malformations are considered important
because of their unsuspected frequency and varied forms. The
malformations that makes extrauterine life impossible are un-
important and are primarily of interest to the pathologist. The
remainder frequently are not recognized unless superimposed
infections supervene. These include lung agenesia, air cyst,
alveolar agenesia, cystic bronchiectasis and bronchial diverticulum.
The relative importance of infection, bronchial obstruction,
atelectasis and pulmonary fibrosis in the etiology of bronchiecta-
sis has been widely discussed. The author believes the basis of
acquired bronchiectasis is the development of obstruction in the
terminal bronchi with the development of micro-atelectasis. The
obstruction in the terminal bronchi is caused by infection, edema
and secretions. The obstruction causes difficulty in expiration
of air which is sharply intensified on coughing and bronchiecta-
sis results. The author’s explanation is rational but still does
not eliminate infection and weakening of the bronchial wall as
the initiating factor in certain cases. At times, bronchial ob-
struction may precede infection but in many cases infection
antedates the obstruction.
In emphysema and asthma the principal change is in bron-
chial dynamism. The opaque substance is not "sucked in” bv
November, 1949
413
the fine branches during respiration but remains mostly in the
medium and large bronchi. The author further states that the
opaque material has a tendency to form constant images instead
of transient and changeable images, which is normal. The
calibre of the secondary branches is smaller than normal, indi-
cating spasm which reduces their lumen and dynamism. There
is a scarcity of foliage.
Bronchography, tomography and bronchoscopy complement
one another in the diagnosis of bronchial carcinoma. The
author believes tomography should precede bronchography and
that bronchography should precede bronchoscopy. The author
does not believe bronchography need delay surgical intervention
provided strict bronchographic technique is observed. Bronchog-
raphy in lesions affecting only fine bronchi and small areas is
probably useless. This type of examination is most beneficial
where the carcinoma begins in a first or second order bronchus.
The author emphasizes that radiologic exploration does not
give images of absolute diagnostic value. It only gives informa-
tion of the degree of canalicular patency and the characteristics
of the obstruction of the bronchial branches.
The value of bronchography in hydatid cyst and pulmonary
suppuration is discussed.
The student of diseases of the chest will be delighted with
this book. The reproductions of roentgenograms are marvelous
and the publisher deserves special praise for the excellent print-
ing. A complete bibliography for each section is included. This
volume is highly recommended to all physicians interested in
diseases of the chest. S. C.
Outlines of Internal Medicine. Edited by C. J. Watson,
M.D. In five parts. Sixth edition, 1949. Dubuque, Iowa:
William C. Brown Co. Prices: Part I, $2.60; Part II, $1.95;
Part III, $2.10; Part IV, $1.50; Part V, $1.85.
The Outlines of Internal Medicine have been written by
members of the faculty of the Medical School of the Univer-
sity of Minnesota and edited by the chief of the Department
of Medicine. The outlines are used by junior and senior stu-
dents as their text in medicine. Assigned readings of the Out-
lines serve the purpose commonly designed for didactic lectures;
consequently time usually allowed for instruction by lecture
may be used for demonstration and clinical teaching. By this
pedagogical method, the head of the department — and each of
the faculty — is aware of what the students are told about all
subjects.
The Outlines are published in two formats: a set of five
paper-covered, wire bound volumes, convenient for student use,
a single cloth-bound volume, containing all five parts, suitable
for reference and general reading.
Part I includes infectious diseases, pulmonary tuberculosis
and other diseases of the lungs, allergic diseases and chronic
rheumatoid disease.
Part II includes diseases of the blood; of the liver; biliary
tract and pancreas; of the mouth, esophagus, stomach, duo-
denum, small intestine and colon.
Part III comprises lectures on heart failure; Bright’s disease;
electrocardiography; rheumatic fever and rheumatic heart dis-
ease; congenital heart disease; pericarditis; aortic stenosis; pul-
monary arteriosclerosis; syphilis of the heart and aorta; hyper-
tensive heart disease; arteriosclerosis of coronary arteries; car-
diac arrythmias; and peripheral vascular diseases.
Part IV includes deficiency diseases; endocrine diseases; dia-
betes mellitus.
Part V is a manual of clinical chemistry and microscopy.
The sixth edition of the Outlines has been done by offset
printing, a method which permits comparatively easy correction
and revision. A revised or new edition of the Outlines has been
issued about every year since the first writing in 1938. The
material is presented in concise form, without extensive historical
or literary background, but, except for a few tabular outlines,
in finished, readable style. Suggestions for collateral reading are
appended to each major section. The loose-bound separate vol-
umes have blank pages interpolated for student’s notes.
The information given in the Outlines is authoritative and
well seasoned, and, although planned for undergraduate stu-
dents, could profitably be assimilated by any busy practitioner.
J. B. C.
Blakiston’s New Gould Medical Dictionary: First Edition.
Editors, Harold Wellington Jones, M.D., Normand L.
Hoerr, M.D., and Arthur Osol, Ph.D. With the co-
operation of an editorial board and 80 contributors. 252
illustrations on 45 plates, 129 in color. The Blakiston Com-
pany, Philadelphia, Toronto, 1949.
Blakiston’s New Gould Medical Dictionary will be welcomed
by physicians and those working in closely allied fields. This is
not a revision or another edition of an old book, but an entirely
new one; thus a first edition. This volume of 1294 pages was
edited by three experts assisted by an editorial board of six per-
sons and nearly one hundred contributors. Dr. Morris Fishbein,
editor of the Journal of the American Medical Association ,
served as editorial consultant.
Such rapid and numerous advances have been made in medi-
cine and closely allied fields during the past decade or so that
many new words have appeared in the literature. These new
words, together with their pronunciations, and meanings, are
included in this dictionary. The present need for an up-to-date
dictionary is greater than that of any other period during the
past century except the last two decades of the 19th and the
first decade of the 20th century when so much progress was
made in determining etiology of various diseases as well as their
treatment and prevention. One of the most progressive eras in
the entire history of medicine with particular reference to ac-
curacy of diagnosis, surgical techniques, chemotherapy and pre-
vention has occurred during the past 15 years. Those who use
this dictionary will be impressed by the tremendous volume of
work which made it possible; for example, the clinical and sys-
tematic examination of over 300 standard modern tests reflect
ing current usage and nomenclature in all the basic fields of
medicine, surgery and the biological sciences, as well as large
numbers of journals, yearbooks and indices of specialties.
Tables and lists and illustrative plates, the abbreviations used
in definitions, explanatory notes, notes on pronunciation found
in the front of the book are helpful. Defined words are in bold
blackface, legible type. Pronunciation is shown by syllable divi-
sion and accent, and whenever necessary, by phonetic respelling.
There are 252 illustrations, of which 129 are in color, bound
into the center of the book. An appendix of 137 pages is in-
cluded, 80 of which are devoted to anatomical tables of arteries,
veins, nerves, bones, joints and muscles. The remainder of the
appendix contains excellent material on diets, hormones, medical
signs and symbols, micro-organisms pathogenic to man, pre-
scription writing, veterinary doses, vitamins, weights and meas-
ures. This dictionary should be made available to every med-
ical student and physician as well as all working in closely
allied fields. J. A. M.
1949 Year Book of Medicine. Edited by Paul B. Beeson,
M.D., J. Burns Amberson, M.D., George R. Minot, M.D.,
William B. Castle, M.D., Tinsley R. Harrison, M.D.,
and George B. Eusterman, M.D. 832 pp.; 139 illustra-
tions. Chicago: The Year Book Publishers. Price, $4.50.
The 1949 Year Book of Medicine is now available, somewhat
earlier than the annual publication date. The abstracts of the
literature of infectious diseases, diseases of the chest, heart,
gastro-intestinal tract — including liver, biliary system and pan-
creas, and of the blood have been well chosen and ably edited
by Drs. Beeson, Amberson, Minot and Castle, Harrison and
Eusterman. The pithy editorial comments, characteristic of
Year Book compendiums, enhance the value of the original con-
tributions, often by criticism or disagreement.
Subjects particularly emphasized are: Antibiotics and chemo-
therapy for infectious diseases; cytologic examination of sputum
in diagnosis of lung cancer; vitamin B12 for pernicious anemia;
nitrogen mustards, urethane, stilbamidine and aminopterin for
therapy of Hodgkin’s disease, multiple myeloma and leukemia;
bone marrow studies; agglutination, immunological and other
blood group and type phenomena; coagulation of blood and
anticoagulants; potassium metabolism; diagnosis of congenital
heart disease. Careful perusal of this Year Book should fur-
nish satisfactory knowledge of matter for practical application
derived from work now being done in the several medical spe-
cialties. J. B. C.
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A Study of 258 Cases of Appendicitis
Based on Pathological Findings*
Henry B. Wightman, M.D.
Ithaca, New York
At college and university health services, appendicitis
ids one of the common surgical conditions encoun-
tered. The diagnosis is at times difficult. Although the
surgical treatment has changed in recent years, the symp-
tom complex leading to the diagnosis has remained essen-
tially the same. This study was undertaken to review
this symptom complex in light of the pathologist’s find-
ings.
From September, 1940 until September, 1948, a period
of eight years, all appendices removed at operation have
been sent to the pathologist for his opinion as to extent
of involvement. In the eight-year period, 274 appendec-
tomies have been performed at the Cornell Infirmary.
Sixteen cases were omitted because of insufficient data,
leaving the data of 258 cases as the basis of this study.
The pre-operative records were reviewed, and the clinical
and laboratory findings were correlated with the patho-
logical diagnoses.
The group is composed of 197 males and 61 females.
This approximate three male to one female ratio has
been present during the eight years in a student body
where the total enrollment has varied from 7,500 to
9,500. Proportionately, the sexes seem affected with
equal frequency. The number of appendectomies per-
formed per year has varied from 17 in 1946 to 55 in
1944.
Pathology. Of the 258 appendices examined by the
pathologist, 182 or 70 per cent were listed as "acute”,
*From the Department of Clinical and Preventive Medicine,
Cornell University, Ithaca, New York.
38 or 14.5 per cent as "subacute”, and 38 or 14.5 per
cent as "no diagnosis”. In the "acute” group are those
described as "acute suppurative”, and "acute gangre-
nous.’ In the "subacute” group are those described as
"subacute”, "fibrous”, and "chronic”.
Table J
Acute 182 (70%)
Subacute 38(14.5%'
No diagnosis 38 (14.5%)
Monthly Incidence. The highest incidence is in the
month of March and the lowest in July. Account must
be taken of the fact that the university enrollment in
the summer is less than in the winter, and a vacation of
a week in December at Christmas and of a week in late
March or April would influence the total number occur-
ring in these months respectively. The corn season in
late summer and the cider season in early fall have been
suspected as a cause of enteritis and possible appendi-
citis. The figures do not confirm this suspicion. There
seems to be more association with the enteritis combined
with respiratory symptoms so common in health services
during the
winter
months.
Table
II
January
23
May...
26
September
14
February
17
June
17
October
16
March
41
July ....
13
20
April
26
August
19
December
-226
415
416
The Journal-Lancet
History. Practically all the cases had pain in the ab-
domen. The original site of the pain, the shifting of the
pain from one region of the abdomen to another, and
the ultimate localization of the pain was thought to be
important. This sequence fitted into three general head-
ings: (1) those beginning in the epigastrium and local-
izing in the right lower quadrant; (2) those beginning
in the lower abdomen and going to the right lower
quadrant, and (3) those beginning as epigastric and re-
maining that way. The pain of 58 per cent of the
"acute” group (Table I) started in the epigastrium and
progressed to the right lower quadrant, whereas 25 per
cent and 22 per cent of the "subacute” and "no diag-
nosis” groups followed this pattern. In the two latter
groups, the pain in 56 per cent and 62 per cent respec-
tively, begins in the lower abdomen and shifts to the
right lower quadrant. This difference is shown in Table
III and will be commented upon below.
Table III
No
Acute Subacute Diagnosis
Epigastric to R.L.Q. 94(58%) 8(25%) 7(22%)
Lower abdomen to R.L.Q. 34(21%) 18(56%) 19(62%)
Epigastric ... ._. 33 (20%) 6(19%) 5(16%)
Cases where history was definite 161 32 31
Symptoms. Nausea exists with equal frequency in the
"acute” and the "subacute” group. Vomiting was pres-
ent more often in the "acute” group, whereas diarrhea
occurred in proportionately few (Table IV). This com-
pares with the cases reported by Quigley and Contralto,1
where in acute appendicitis vomiting was present in 38
per cent and diarrhea in 4 out of 60 (6.6 per cent) of
their cases.
Table IV
Acute
Subacute
No
Diagnosis
Nausea
...... 96(53%)
20(52%)
15(39%)
Vomiting
.. 58(22%)
6(15%)
6(15%)
Diarrhea
21(11%)
3 (8%)
3(3%)
Pam — relation to nausea. This relationship was inves-
tigated and it was found that 88 or 49 per cent of the
cases in the "acute” group had pain before the nausea.
In the "subacute” and the "no diagnosis” groups, only
18 per cent described their symptoms this way.
Pam — duration before operation. There is a shorter
duration of pain in the acute group as shown in Table V.
Table V
No
Acute
Subacute
Diagnosis
24 hours or less
123(67%)
12(37%)
6(19%)
More than 24 hours .
59(31%)
20(63%)
26(68%)
Temperature. The highest preoperative temperature
was recorded. The initial reading was taken rectally
and a degree was subtracted to conform to other read-
ings. On observing the figures in Table VI, it is seen
that the three groups are essentially similar.
Table VI
Acute
No
Subacute Diagnosis
Below 99“ __
76(42%)
17(45%) 23(60%)
99° to 100.8° ...
95(52%)
20(52%) 11(34%)
101° or above
11(6%)
1(3%) 2(6%)
Pulse Rate. Here again the highest preoperative read-
ing is noted. Eighty beats per minute were arbitrarily
taken as a possible high normal. The findings listed
below are seen to be similar.
Table VII
No
Acute
Subacute Diagnosis
80 beats per min. or below ...
58(32%)
15(39%) 13(36%)
Above 80
124(68%)
23(61%) 23 (64%)
Leucocytosis. Here the highest preoperative blood
count is recorded. There is a much higher percentage
of blood counts of over 13,000 per cu. mm. in the
"acute” group. The number of cases in the "acute”
group (34 per cent) showing a count of over 20,000
per cu. mm. was greater than expected. Possibly young
adults have a greater leucocyte response because of their
age and general good health.
Table VIII
Acute
Subacute
No
Diagnosis
13,000
or below
26(14%)
20(54%)
17(54%)
13,000
to 20,000
- - 95(51%)
11(29%)
9(24%)
Above
20,000
61(34%)
0
0
Polymorphonucleosis. Eighty per cent polymorpho-
nuclears was arbitrarily taken as evidence of true poly-
nuclear response. Here the chart below shows that 60
per cent of the "acute” group had more than 80 per
cent polynuclears, whereas the figures for the other two
groups are 29 per cent and 33 per cent respectively.
Physical Signs. Abdominal tenderness is present in
nearly all the cases. There is a much higher incidence
of muscle guarding or spasm in the "acute” group.
Table IX
No
Acute
Subacute Diagnosis
Polys 80% or below
74(40%)
22(71%) 18(66%)
Above 80% ....
108(80%)
9(29%) 9(33%)
Complications found at operation. In the "subacute”
group, 22 or 58 per cent had evidence of bands, kinks,
December, 1949
417
and adhesions or fecoliths at operation. In the "no diag-
nosis” group, 1 1 or 29 per cent had such evidence.
Table X
No
Acute
Subacute
Diagnosis
Tenderness - .
178(99%)
35(92%)
33(89%)
Spasm ...
123 (67%)
16(42%)
15(45%)
Comment
This study of 258 cases was made after eight years’
data had accumulated. By correlating preoperative symp-
toms and signs, certain trends are evident. A number of
questions are raised, some of which are: How accurate
are clinical observations as checked with pathological
diagnoses? Do the facts bear out the impressions regard-
ing temperature, pulse, and leucocytosis? How impor-
tant is a carefully taken history in relations to nausea,
vomiting, and diarrhea? Is the progressive location of
the pain and its ultimate localization verified in compar-
ing preoperative diagnoses and pathological reports?
All cases operated upon were studied and were thought
to warrant surgery. It is the general policy at the Cor-
nell infirmary to perform an appendectomy even though
the indications are not absolute. It is felt justified for
two reasons: (1) The operative risk is slight, and (2)
Since appendicitis sometimes is very atypical in its signs
and symptoms, occasionally an acutely inflamed appendix
is found, the degree of involvement being unsuspected
before operation. In the "no diagnosis” group, there
were 27 cases ( 10.4 per cent) where no complications
such as kinks, adhesions, bands, or fecoliths were found
at operation. This compares favorably with a series of
1,100 cases reported by Rosenberg " in which 100 cases
showed no pathology in the appendix. No attempt was
made to follow up these cases to determine the degree of
symptomatic relief experienced.
Preoperative pulse rate and temperature are of little
value m distinguishing the three groups. However, leu-
cocytosis is decidedly higher in the "acute” group as well
as the percentage of polymorphonuclear leucocytes.
Nausea was present with equal frequency in the three
groups. Vomiting was more prevalent in the "acute”
group, whereas the complaint of diarrhea occurred in
less than 10 per cent of the groups and was of little
diagnostic aid.
A carefully taken history with particular attention to
the sequence and progression of the pain seemed to be
of value. This follows the teachings of the late Dr.
John B. Murphy, writing in Keen’s Surgery, in which he
states,'5 "The symptoms of appendicitis are at first pain
in the abdomen, sudden and severe, primarily referred
to the epigastrium, followed by nausea and vomiting,
most commonly three to four hours after the pain.” This
sequence was observed in 58 per cent of the cases listed
above as "acute”, and in only 25 per cent of the other
two groups. Pain preceded the nausea in 49 per cent of
the "acute” group and in only 18 per cent of the other
groups. The original site of the pain, its ultimate local-
ization in the right lower quadrant, and the observation
that the pain precedes the nausea, all noted by Dr. Mur-
phy some time ago, are brought out in this statistical
analysis.
Summary
1. 258 appendectomies are analyzed after pathological
diagnosis.
2. The cases are studied from the history, tempera-
ture, pulse, and leucocyte response.
3. The importance of the pain, its original site and
subsequent localization, and its relation to nausea and
vomiting is emphasized.
4. Muscle spasm is a more important physical sign
than tenderness in distinguishing the "acute” from the
"subacute” cases.
References
1. Quigley, T. B., and Contralto, A. W.: Differential
diagnosis of appendicitis with gastroenteritis in college men.
New Eng. J. of Med. 226:787-790, 1942.
2. Rosenberg, N.: Syndrome of acute appendicitis, Amer.
J. of Surg. 58:365-367, 1942.
3. Keen’s Surgery; vol. IV, p. 750. W. B. Saunders Com-
pany, 1908.
An improved cancer case-finding aid may be evolved from a technique used in the in-
stantaneous processing of radar photographs. An Army invention, the process has potential
value in the rapid examination of individuals for cancer of the stomach. Instantaneous
processing of photofluorographic films will reduce the cost of x-ray screening for signs of
early gastric cancer. Development of this equipment will be under the supervision of Dr.
Russell H. Morgan, professor of radiology at Johns Hopkins University, Baltimore, Md.
418
The Journal-Lancet
Acute Pancreatitis
Frank W. Quattlebaum, M.D.*
St. Paul, Minnesota
Early anatomists, among them Galen and Vesalius,
considered the pancreas only a cushion to support
and protect the stomach and other organs. In 1641
Moritz Hoffman discovered the main pancreatic duct in
the rooster. He conveyed his discovery to Wirsung who
demonstrated it in the human pancreas. G. Dominici
Santorini first described the accessory pancreatic duct.
Bidloo first noted the papilla common to both the pan-
creatic and bile duct. Many anamolous ducts were soon
being reported and it was Meckel’s significant statement
that atrophy of the duodenal end of the accessory duct
was the developmental rule and this fact accounted for
the many anomalies.
Mettler2' states that pancreatic removal had been ex-
perimentally practiced by the Dutch surgeons in the 18th
century and similar experiments were repeated in the
19th century. Thus, Nicholas Senn (1844-1908) ex-
plored the possibility of pancreatic surgery in 1886.
Moring and Minkowski 29 did experiments in 1889 that
were definitely superior to all of the earlier work. Their
classic experiments were concerned with total pancreat-
ectomy in the dog and observations in the diabetic course
of the animals. Their article is of further historical in-
terest because it was one of the first in experimental
operative procedures in which comments were included
upon bacteriology and operative asepsis.
Lancereaux first suggested the possibility that gall-
stones lodged in the ampulla of Vater could cause dis-
ease of the pancreas by obstructing the main pancreatic
duct. Korte in 1898 noted the frequent association of
biliary tract disease and pancreatitis.
Balser 4 first described the presence in pancreatitis of
nodules and patches of necrotic fat tissue in the mesen-
tery. Reginald Fitz 1 ‘ of Boston in 1889 wrote the first
description of acute pancreatitis. This paper is a classic
and at that time it aroused a great deal of interest in the
subject. No surgical treatment was practiced, however,
on the cases reported by Fitz, and many of his observa-
tions were completed at autopsy after a long and diffi-
cult illness was terminated.
It is obvious that the historical aspects of acute pan-
creatitis should include the earlier work on the sphincter
of Oddi. Glisson was one of the first anatomists to
describe annular fibers surrounding the outlet of the
common duct. His work, however, was without con-
firmation. Gage, in America, was the first to demon-
strate these fibers microscopically. He showed circular
fibers around the distal common bile duct and the pan-
creatic duct, and a few fibers common to both ducts.
His work was done with the cat. Oddi 29 in 1887 and
1889 demonstrated the same muscle bundles in human
^Surgical Staff Seminars, Minneapolis Veterans Hospital.
autopsy specimens. In 1911, Archibald,3 unknowingly
reported some of Oddi’s anatomical work. He did, how-
ever, make important physiological contributions on the
sphincter mechanism. His work was done with dogs.
Anatomy
This phase of the subject will be sharply limited to
the terminal end of the major pancreatic duct and to the
terminal end of the common bile duct. It is the ana-
tomical relationship of these two systems that has so
much to do with the occurrence of acute pancreatitis.
Glisson first described and Gage, Hendrickson 20 and
Oddi 29 demonstrated the distal common bile duct to be
surrounded by a distinct smooth muscle bundle, inde-
pendent of the intestinal muscle and apparently arising
from the duct itself. Oddi called this bundle the sphinc-
ter du choledoque. He also actually demonstrated in-
constant sphincter fibers around the distal pancreatic
duct.
Boyden 22, ' has contributed very complete details of
the intrinsic musculature of the ducts and ampulla. The
components are as follows:
(1) The sphincter choledochus
(2) The longitudinal fascicles
(3) The sphincter pancreaticus
(4) The sphincter ampulke
The sphincter choledochus is the most highly devel-
oped of the intrinsic muscle of the ducts. It encircles
a much longer segment of duct than usually considered
and extends from the slit-like opening in the circular
muscles of the duodenum that admits the common duct
to the juncture of the common and pancreatic ducts.
When contracted it can prevent the passage of bile into
the duodenum. When contracted alone, however, the
ductus choledochus does not produce a "common chan-
nel.” The sphincter pancreaticus is a smaller bundle at
the distal end of the pancreatic duct. It is present in
30 per cent of individuals. The sphincter ampullae sur-
rounds the ampulla and the distal pancreatic and bile
ducts. By its contracting, bile and pancreatic juice are
blocked, and bile may flow into the pancreatic duct or
pancreatic juice may flow into the common duct. Boy-
den found the sphincter ampullte to be well developed
in only 17 per cent of individuals. This incidence agrees
with a frequency of 23 per cent of reflux into the major
pancreatic duct as shown by Leven 24 with cholangio-
grams. The longitudinal fascicles are two bundles sit-
uated between the common and pancreatic ducts and
has to do with erection of the papilla.
The anatomical relationship of the distal choledochal
and pancreatic ducts has long intrigued workers in this
field. The relative occurrence of the "common channel”
has long been a source of disagreement. Opie 30 found
December, 1949
419
a common opening in 89 per cent of autopsy specimens
but pointed out that a common channel did not neces-
sarily mean that the common and pancreatic duct could
be converted into a freely communicating system by an
impacted biliary calculus. He decided that in only 30
per cent of cases could reflux be caused by a distal ob-
struction. Judd decided after a study of 170 necropsy
specimens that a common channel could exist in only
4.5 per cent of specimens. Mann and Giordano
pointed out that a common channel could be created
only in specimens in which the length of the ampulla
was greater than its diameter. This occurred in only
3.5 per cent of the specimens examined by them. Cam-
eron and Noble 9 concluded from detailed and ingenu-
ous experiments that in 66 per cent of specimens it was
anatomically possible to convert the biliary and pan-
creatic systems into a common channel. They prepared
their specimens by impacting a 3 mm. gallstone into the
ampulla, pouring Wood’s metal into the system, and
thus obtaining casts of the injected system. Their fig-
ures contrast sharply with those of Judd and with those
of Mann and Giordano. The latter two investigations
were carried out with fixed specimens while those of
Cameron and Noble were done with fresh specimens.
At the present time it is felt that the figures of Cam-
eron and Noble are more nearly correct. Rienhoff and
Pickrell 34 have recently studied the problem again.
They felt that a common channel should not be so
called if it is less than 2 mm. from the end of the
septum between the two systems to the summit of the
papilla. With this criteria they found that in 32 per
cent of specimens a common channel exists of a length
(over 2 mm.) to suggest the possibility of regurgitation
from one system to another. These latter figures seem
at least to be a compromise between the two widely
divergent opinions expressed above.
Definition
Acute pancreatitis in its several forms is entirely dif-
ferent in clinical course and ultimate prognosis. One
must be aware of this difference in interpretation of the
literature. Only recently have observers become aware
of the milder form, the so-called acute edematous or
interstitial pancreatitis as compared to the long recog-
nized acute hemorrhagic pancreatitis, or acute pancreatic
necrosis, as it is sometimes known.
Abell 1 and Gonshorn 18 believe that acute edematous
pancreatitis is merely a step in the development of acute
hemorrhagic pancreatitis. Robinson and Alfenito 39
simply divide the disease into the hemorrhagic and non-
hemorrhagic types. Archibald,3 in 1919, insisted that the
more severe form of pancreatitis should be called acute
hemorrhagic necrosis of the pancreas. He found that
the essential pathological lesion was a necrosis of pan-
creatic cells or masses of cells, with hemorrhage, gan-
grene and suppuration occurring secondarily. No doubt
Archibald was correct regarding the severe form of the
disease, but he failed to recognize a milder form of pan-
creatitis as a distinct clinical entity. R. Fitz 1 ‘ in 1889
gave the first accurate description of acute hemorrhagic
pancreatitis and since then the disease has held a prom-
inent place in medical literature and a great deal of
study has been carried out in an attempt to clarify the
etiology and pathogenesis. Most of this work has been
directed toward acute hemorrhagic pancreatitis as op-
posed to acute edema of the pancreas. Jones 21 pointed
out in 1943 that there were two distinct forms of the
disease with an almost identical onset but being quite
different thereafter. In 1924 Zoepffel 40 had differen-
tiated four cases of acute edema of the pancreas seen at
operation, from seven others characterized by hemor-
rhage and necrosis of the pancreas. In 1933 Elman 15
collected from the literature, 33 cases of acute edema
of the pancreas. He added four cases of his own to es-
tablish a pathological and clinical entity, the undoubted
occurrence of a special type of acute pancreatic disease,
tentatively designated as acute interstitial pancreatitis or
acute edema of the pancreas. This type of pancreatitis
is characterized by the presence of edema, swelling and
induration of the gland, and without necrosis, hemor-
rhage, or suppuration. Thus, since Elman’s description
in 1933, this milder form of pancreatitis has been rec-
ognized as a distinct clinical entity.
It is important to remember that when a great deal of
the investigative work was being done, the edematous
type of pancreatitis was unknown. This probably con-
tributed to discrepancies in the literature, particularly
in case fatality statistics.
Etiology
Without giving credence to any specific factors it is
well to first study an outline of the factors usually con-
sidered in the etiology of acute pancreatitis. This table
is adapted from R. Jones, Jr.21
CLASSIFICATION OF ETIOLOGIC FACTORS
IN ACUTE PANCREATITIS
I. Pancreatitis of Infectious Origin.
A. Lymphogenous.
B. Hematogenous.
C. Extension via pancreatic ducts, from duodenum
or bile ducts.
D. Direct extension from infective foci or adjacent
viscera.
E. Activation of enzymes by bacteria in normal
gland.
II. Pancreatitis of Non-inf ectious Origin.
A. Reflux into pancreatic duct of
1. Bile — "common channel”, as caused by stone,
edema, or spasm of sphincter of Oddi.
2. Duodenal contents.
B. Obstruction of Pancreatic Ducts by epithelial
hyperplasia, stone, tumor, or edema.
C. Trauma.
D. Vascular accidents.
III. Combination of Factors.
It is obvious from the above outline that the modus
operandi is not clear, however, certain factors are more
than an incidental finding. These factors, singly or in
combination, seem to have a relationship to the develop-
ment of acute pancreatitis in the majority of cases. They
420
The Journal-Lancet
will be discussed in detail later in the text. These fac-
tors are:
I. A "common channel” mechanism. According to
Jones,21 this mechanism was present in an average of
60 to 70 per cent of collected autopsy reports. In addi-
tion, two other factors must exist, i.e., there must be an
obstruction to the outflow of bile into the duodenum and
pancreatic enzymes, must be activated either in the pan-
creatic or biliary ducts.
II. There is a frequency of associated biliary disease
in acute pancreatitis. Backus 6 states that the collected
reports reveal an association of the two diseases in 70
per cent of cases of acute pancreatitis. Wangensteen
et al believe that if there is any common denominator of
acute pancreatic necrosis it is gallstones or chronic dis-
ease of the gallbladder.
III. Acute bouts of alcoholism and dietary debauches
seem to be the initiating factor in some attacks of acute
pancreatitis.
Lancereaux first suggested the possibility that gall-
stones lodged in the ampulla of Vater could cause dis-
ease of the pancreas by obstructing the main pancreatic
duct. Since Opie’s 30 classical autopsy finding in 1901
in Halsted’s Clinic of a common duct stone producing
a "common channel,” the argument has continued re-
garding the relationship of biliary disease to pancreatitis.
As stated previously, Judd and Mann and Giordano
felt that the "common channel” arrangement was seldom
present, whereas Opie,30 Cameron and Noble9 and Rien-
hoff and Pickrell 34 concluded that it was present be-
tween 30 to 60 per cent of cases. At the present time
it is generally concluded that the "common channel” is
often present and is an etiological factor in acute pan-
creatitis. Of greater practical importance, however, is
the occurrence of the "common channel” mechanism in
cases that actually have the disease. This frequency is
not known at the present time.
Opie believed that a common duct stone was the pre-
cipitating factor in the disease by its blockage of the
"common channel” mechanism. Time has proven him
to be wrong. Thus in Van Schmieden and Sebening’s
series of 1278 cases of acute hemorrhagic pancreatitis
collected from Germon Clinics, Opie’s classic findings
were noted in only 4.4 per cent of cases. These findings
have been borne out in this country.
The sphincter spasm mechanism as first described by
Archibald3 (in cats) is gaining current popularity. It
was refuted by Mann and Giordano since they found
such a low percentage of common channel specimen,
they were unable to postulate a "common channel”
mechanism on the basis of spasm, causing regurgitation
into Wirsung’s duct. Culp and Doubilet 11,12 and
Leven 24 found with routine cholangiography, however,
that a filling of the duct of Wirsung occurred in 20 per
cent of cases. Lanshorn 18 states that 50 per cent of
cases of acute pancreatitis are associated with chronic
biliary disease, usually chronic cholecystitis with stones.
Paxton and Payne,31 in 1947 reported the largest single
group, a total of 307 cases seen in a 14 year period.
They agree that biliary disease is present in over 40 per
cent of cases. In 5 per cent of cases a common duct
stone is present and probably in a larger group there is
a spasm of the sphincter of Oddi with reflux of bile
into the pancreatic duct. Paxton and Payne found that
25 per cent of cases of acute pancreatitis have their onset
after a heavy meal. There is a past history of pan-
creatitis in 43 per cent. Eighteen per cent are intoxicated
or recovering from a recent debauch.
Physiology
The pancreas secretes three ferments, amylase, lipase
and trypsin. These act respectively upon carbohydrates,
fats and proteins. With regard to the first, it is con-
stantly present in pancreatic juice, and cannot be said
to be diagnostic of pancreatic fluid inasmuch as it occurs
in fair quantity in other fluids, as for example, the ascitic
fluid. Lipase has been reported present in most cases of
pancreatic cyst fluid and fistula fluid. The main atten-
tion, however, is focused on trypsin and the proteolytic
activity of pancreatic juice. Aldis 2 notes that the litera-
ture varies in reporting the tendency of pancreatic juice
of an external fistula to produce digestion of the ab-
dominal wall. In some cases it has been a major prob-
lem, in others it has been no problem at all. The tra-
ditional explanation is that trypsin is inactive until it
comes in contact with the specific enzyme, enterokinase
of the duodenal secretion. Support of this is given by
the extensive tissue destruction of a duodenal fistula.
Thus, theoretically, a pancreatic fistula would not have
proteolytic activity. Since such a fistula is locally de-
structive at times, it must be presumed therefore that
substances other than enterokinase can activate the tryp-
sinogen. Thus calcium chloride, exposure to air, bac-
teria, bile, and bile salts are at times effective in splitting
up the trypsin-inhibitor complex.
Morton 28 states that the origin of the normal blood
content of amylase is unknown. It is absent in the new-
born; appears at 2 months; is measurable at 3 months;
and reaches a normal level in one year. It is not in-
fluenced later by age, sex, amount or type of food, fast-
ing, dehydration, diuresis, exercise, or sleep. Acute
pathological conditions in the salivary glands or pan-
creas cause a quick rise and quick subsidence to normal
levels. Injury to the pancreas increases the level; injury
to the liver or kidney decreases the level.
Popper and Necheles 32 cannulated the thoracic duct
in three dogs and occluded the portal vein in a fourth.
They then determined the amylase and lipase activity of
the portal blood, peripheral blood, and the lymph. They
concluded that the main pathway of pancreatic enzymes
into the peripheral blood following injury to the pan-
creas was by way of the portal vein and to a much lesser
degree through the lymph into the thoracic duct.
Archibald 3 demonstrated that the sphincter muscle
(in dogs) could resist a pressure of 60 cms. of water
and that it could be put into spasm by duodenal or gas-
tric irritability. He also demonstrated that a vagotomy
provoked an intense and prompt spasm of the sphincter.
Archibald demonstrated that by sphinctotomy this pres-
December, 1949
421
sure could be reduced from 60 to 7 cms. of water, and
that this reduction was permanent for at least eight
weeks. Bergh ° has shown that the measurements in
humans reveal the "normal” sphincter resistance to be
between 9 and 15 cms. of water.
Morton 28 states that pancreatic ferments do not affect
living tissues. Sterile pancreatic juice has been injected
intraperitoneally and intravenously without any harmful
effects. Bile injected into pancreatic ducts causes pan-
creatic necrosis by its local cytolytic and destructive
properties and not because of the activation of intra-
ductal trypsinogen. Active trypsin cannot digest living
tissue; it acts as a catalyst in facilitating the hydrolysis
of protein by the alkali of the pancreatic juice. The
local destructive action of pancreatic juice is dependent
on the concentration of the alkali of the juice. Infected
bile is more destructive than sterile bile. The toxic effect
is neutralized by the proteins of the blood serum. Hem-
orrhage is believed by Morton 2IS to be a protective mech-
anism but few observers agree.
Pathogenesis
It is now generally accepted that the pathological
changes of acute pancreatitis are caused by the effect of
activated ferments on the pancreatic tissues. The exact
manner in which these ferments act is a moot point.
It is thought that the entrance of bile into the duct of
Wirsung is the most likely immediate cause.
Many observers believe that the bile causes the activa-
tion of trypsinogen into trypsin with autodigestion of the
pancreas. Dragstedt 13 and his workers could find no
support of the above thesis. They felt that the already
present lipase in the pancreas acted upon cellular lipoids
and accounted for a great deal of tissue destruction.
Bradley 8 had previously demonstrated that the bile salts
are strong cytolytic agents and that the pancreas is par-
ticularly susceptible to the cytolytic action of bile. Drag-
stedt and his workers therefore inferred that the reaction
between bile salts and pancreatic cells resulted in frank
exudation or frank hemorrhage. It is true that infection
plays a part, since experimentally, infected bile provokes
a much greater pancreatic reaction when injected into
the pancreatic ducts, than does non-infected bile. A
higher concentration of certain elements of the bile, the
taurocholates for instance, likewise provokes an increased
pancreatic response.
Gonshorn 18 believes that when pancreatic secretion
leaks into the substance of the gland, the lipase digests
fats and causes typical fat necrosis. The trypsin, result-
ing from activation of trypsinogen by intercellular juices,
without the presence of enterokinase, causes a digestion
of the tissues and vessel walls with necrosis and hem-
orrhage. The mildness and severity of the clinical attack
is directly proportional to the amount and nature of the
escaping pancreatic juice. In the mild form, there is a
small leak, the secretion contains little trypsin; there is
edema from irritation and some fat necrosis, but no
necrosis of the pancreas and no hemorrhage. In the
severe hemorrhagic type, there is an escape of secretion
rich in trypsin, such as is found after a large meal or
alcoholic debauch. The secretion therefore causes a
greater digestion and necrosis. If large vessels are in
the vicinity, their walls are digested and an active hem-
orrhage occurs in and around the gland.
Acute pancreatitis was produced in dogs by Chisholm
and Seibel 10 according to the method used by Rich
and Duff.'*'1 Thus, fresh bile was injected through the
cannulized duct of Santorini. Changes occurred in the
pancreas immediately and were observed under direct
vision. A small volume of bile injected under low pres-
sure produced what would be comparable in man to
acute edema of the pancreas. A larger volume injected
with a higher pressure, i. e., over 18 cms. of water, pro-
duced an acute hemorrhagic pancreatitis, followed
shortly thereafter by areas of fat necrosis.
Rich and Duff have done much to re-establish the
trypsin theory in the pathogenesis of acute hemorrhagic
pancreatitis. In autopsy slides they found vascular
lesions which were described as being indistinguishable
from those seen in the kidneys in a case of malignant
nephrosclerosis. They experimentally produced the
lesions in dogs by injection of bile and pure trypsin,
and concluded that the lesion, viz., areas of focal necro-
sis in the media and adventitia, was due to direct action
of trypsin on the vessel wall. They found that this
lesion could be produced by pancreatic juice containing
inactive trypsinogen. Although a great deal of their
work depends on interpretation of microscopic changes,
it has not been refuted. Since this work, few additional
studies of this aspect of the problem have appeared in
the literature.
In summary, although the question is not settled be-
yond doubt, it can be said that the release of active
trypsin into the interacinar tissue is the factor of prime
importance in the pathogenesis of acute pancreatitis. If
trypsin comes into contact with a vessel wall it causes
hemorrhage and this furthers the process by damaging
tissue and releasing more trypsin.
Pathology
In 1889 Fitz 11 wrote an article in the Boston Medical
and Surgical Journal entitled, "Acute Pancreatitis: A
Consideration of Pancreatic Hemorrhage, Hemorrhagic,
Suppurative and Gangrenous Pancreatitis and Dissem-
inated Fat Necrosis.” This was the first comprehensive
discussion of this acute pancreatic catastrophy. Rather
than the term "acute hemorrhagic pancreatitis,” it is
known now that a variety of inflammatory manifesta-
tions occur in the pancreas. The hemorrhage tendency
and occurrence of necrosis are related to the reaction of
activated pancreatic enzymes. In the absence of necrosis
and hemorrhage, the pancreas may be the seat of a gross
edema only. On the other hand, severe edema may be
followed by suppuration; and indeed, edema, suppura-
tion, hemorrhage, and necrosis may be associated togeth-
er in any combination or may occur in sequence.
When the abdomen is opened in acute pancreatitis,
a blood tinged fluid is often encountered. White, firm
areas of so-called "fat necrosis” may be seen. These
areas are seen on the pancreas omentum, surrounding
422
The Journal-Lancet
viscera, and parietal and visceral peritoneum. They are
caused by the hydrolysis of neutral fat by activated pan-
creatic enzyme, into glycerin and fatty acids; the acids
combine with calcium to form insoluable soaps. (R.
Langerhaus, 1899.)
Edmondson and Berne 14 further investigated the cal-
cium changes in acute pancreatic necrosis. They studied
the total calcium content of the lesions of fat necrosis
around the pancreas. These lesions were excised at
autopsy and found to contain from 200 to 1732 mgs.
of calcium by actual weight. No serious cases were seen
in which the serum calcium was not lowered. Death
occurred in all cases in which the serum calcium fell
below 7 mg./ 100 cc.
As stated above, any stage or combination thereof of
inflammation of the pancreas may occur in acute pan-
creatitis. The organ may appear large, dark, soft, and
hemorrhagic. Gradually it may appear to be replaced
in part or whole by extensive necrosis or a suppurative
process. It may be a simple diffuse edematous involve-
ment. If recovery from an initial severe attack has oc-
curred at a later date, the pancreas may be the site of
cyst or abscess formation. As an aftermath of repeated
sub-lethal attacks, the pancreas may be extensively
fibrotic and calcium will be laid down so that pancreati-
colithiasis will be the final picture. The predominant
histologic features are extensive acinar necrosis, hemor-
rhage into the pancreatic tissue, interstitial edema and
infiltration with neutrophiles.
Diagnosis
Previous to 1938 when the serum amylase determina-
tions became available, the diagnosis of acute pancreati-
tis was, at best, uncertain.
Severe epigastric pain struck in a middle age obese
individuals. If this pain was accompanied by shock, vom-
iting, tenderness in the epigastrium, absence of fever,
a rapid pulse, and a high white count, the diagnosis
became more certain. An attempt would be made to rule
out perforated peptic ulcer by flat plate of the abdomen.
Acute biliary disease would be considered inasmuch as
jaundice would often be present. Possibility of coronary
occlusion would be evaluated by electrocardiogram.
Mesenteric thrombosis, intestinal obstruction and peri-
tonitis would be considered. After all these considera-
tions, surgery would often be resorted to, inasmuch as
one would be anxious to avoid overlooking an acute sur-
gical condition. Morton, 2s Elmon and Schwarz,11' God-
frey,19 Puestow et al,33 and Paxton and Payne 13 attest
to the difficulty of making a bedside diagnosis of acute
pancreatitis. The correct diagnosis prior to surgery or
autopsy is rarely 50 per cent when based on clinical
efforts above, in fact, many series have been reported
in the past without a single correct diagnosis being made
at the bedside.
Obviously what was needed was an accurate laboratory
test, simple in execution, that could be completed in
less than one hour. The serum lipase was very accurate
but required 24 hours for completion. The Somogyi
method of serum amylase determination was the answer
to that need. Low values and high values could be esti-
mated with accuracy. Backus 6 states that an increase in
serum amylase in the blood has great diagnostic signifi-
cance in acute pancreatitis. Early and frequent deter-
minations are important, particularly in transitory at-
tacks of pancreatitis. A sudden drop in serum amylase
content can mean either improvement of a mild attack
or such extensive destruction of the pancreas as to pre-
clude any appreciable amylase level. Comfort stresses
that in severe acute pancreatitis the maximum amylase
level is reached in 12 to 24 hours, and in 3 to 4 days
the amylase level has returned to normal. To be of
value the test must be performed early. Although it is
more difficult to do, the serum lipase is of value, partic-
ularly in the late phases of the disease, inasmuch as it
remains positive for 6 to 7 days after the onset of an
acute attack.
There have been many tests developed for determin-
ing the concentration of amylase in the blood. They are
all based on the following methods: (1) The iodine
test, originally proposed by Wohlgemuth, depends upon
the disappearane of the iodine-starch blue color as hy-
drolysis of the starch is in progress. (2) Viscosimetric
method depends upon changes in viscosity of a starch
enzyme mixture. (3) The copper reduction method or
saccharigenic method, which depends upon the amount
of sugar formed from starch by a known amount of
enzyme.
The diastatic ferments are active at different stages
of starch digestion, hence the results obtained differ with
the various methods. Therefore the results depend upon
personal experience and available laboratory facilities.
It is worth repeating that the serum amylase determi-
nation is the greatest single aid in making a correct
diagnosis of acute pancreatitis. A moderate to marked
increase in serum amylase is almost always associated
with pancreatic disease. The test should be utilized in
all upper abdominal diseases when there is any doubt of
the correct diagnosis. It should be used more often.
Clinicians are becoming more "pancreatitis-minded” and
by using the test are recognizing an ever increasing num-
ber of the milder forms of acute pancreatitis.
A detailed list of the reagents and the procedure of
serum amylase determination as it is used at the Min-
neapolis Veterans Hospital is given below:
AMYLASE (Somogyi Method)
Sample: 1 ml. serum, fresh and unhemolyzed.
Normal: Amylalytic activity is defined as mg. of reducing
sugars expressed in glucose per 100 ml. serum. Normal values
are from 40 to 110, averaging about 60.
Reagents: 1. Starch — Place 50 grams pure starch in a liter
glass stoppered cylinder, add 500 ml. HC1 and shake intermit-
tently during one hour. After sedimentation pour off acid, add
about 500 ml. of 0.05 per cent NaCl and shake thoroughly.
After sedimentation, pour off salt solution and repeat washing
with another 500 ml. portion of salt solution. Finally, spread
out the starch on a pad of filter paper and allow it to air dry.
2. Starch solution — Grind 1.5 mg. of the dried starch in a
mortar with 5 ml. of distilled water while 90 ml. water are
heated to boiling in an Erlenmeyer flask. Transfer the ground
starch paste to the boiling water with vigorous agitation, using
5 ml. water to rinse mortar. Boil for 1 min. with stirring.
Cover the mouth of the flask with a beaker and heat in a boil-
December, 1949
423
ing water bath 20 to 30 minutes. Make to 100 ml. when cool.
Cover with tuluone and store in refrigerator.
3. Sodium tunstate — 6 per cent.
4. Copper sulfate solution — 5 per cent.
5. Sodium chloride solution: Dissolve 10 gm. NaCl in water
and transfer to 1 liter flask. Add 3 ml. N HC1 and dilute to
mark with water. ]0
Procedure: In each of two 14-16 mm. test tubes, place 5 ml.
of starch solution and 2 ml. of NaCl solution. Warm tubes to
37-38° C. in a water bath. Leave tubes in bath. To Tube 1
add 1 ml. serum. Place both tubes in 37.5° C. incubator for
exactly 30 minutes. Remove tubes from bath and add at once
to Tube 11, 1 ml. serum, then to both tubes add 1 ml. 5 per
cent copper sulfate solution and shake hard; 1 ml. 6 per cent
sodium tungstate solution, shake hard. Centrifuge at once. Do
usual blood sugar determination on 1 ml. of clear supernatant
fluid from each tube. Boil 20 min.
Calculation: Mg. per cent glucose in the incubated serum
filtrate minus the mg. per cent glucose in the unincubated serum
filtrate equals the units of amylase activity per 100 ml. serum.
Clinical Course
Acute pancreatitis occurs in the middle-age group,
with a much higher incidence in men than in women.
Biliary disease is present in over half of the cases. The
individual is often obese, corpulent, and well fed. The
history of alcoholism is too common to be of casual in-
terest. An attack often follows a heavy meal.
The pain is sudden in onset, severe, prolonged, and
"tearing” in nature. The pain usually begins in the epi-
gastrium and is often referred to the loins, back, and
left subscapular region. Collapse may occur quickly.
The pulse is rapid and the blood pressure falls. The
skin becomes clammy and a peculiar cyanosis may de-
velop. Patches of slate-blue color may be distributed
over the abdomen and limbs and is known as the Groy-
Turner sign.
The patient often vomits, and diarrhea and bloody
stools may be a terminal occurrence. There is extreme
upper abdominal tenderness, but the muscle spasm is not
what one would expect with such tenderness.
Unfortunately, acute pancreatitis does not always
offer such dramative features. The disease is often not
suspected and the abdomen is opened with another diag-
nosis, only to find the diffuse areas of fat necrosis,
bloody fluid, and a diffusely enlarged pancreas.
Within the past decade, particularly since the wide-
spread use of the serum amylase determination, milder
forms of pancreatitis are being diagnosed. The type of
onset may be similar to that described above, but its
duration is brief and the outlook is much better.
All investigators agree that there is a systemic toxemia
in addition to the local lesion in acute pancreatitis. At
the present time, the mode of action of this toxic agent
is unknown. The solution of this problem is essential
if we are to reduce the high mortality associated with
acute hemorrhagic pancreatitis. It has been suggested
that the agent might be the trypsin in pancreatic juice,
the products of digestion of pancreatic tissue, or bac-
terial toxins liberated by bacteria proliferating in the
necrotic tissue. Dragstedt and his workers refuted all
of these theories by actually repeating the work that had
been done to establish these mentioned theories. The
nature of this toxic agent is thus unknown.
Prognosis and Treatment
The value of prophylaxis in the treatment of acute
pancreatitis is difficult to evaluate. In patients having
had mild recurrent attacks it seems fundamental that
alcohol and large, heavy meals should be avoided. It
appears evident likewise that biliary disease is of etiologic
importance. Since gallbladder disease has been more vig-
orously treated during the past 20 years and since the
incidence of acute hemorrhagic pancreatitis is apparently
diminishing, it would seem that early treatment of biliary
tract disease has been of prophylactic value.
Although the actual incidence of acute hemorrhagic
pancreatitis or acute pancreatic necrosis seems to be on
the wane as stated above, the over-all incidence of the
acute pancreatitis group is certainly increasing. The
availability of the serum aniylase test is chiefly respon-
sible for the increased diagnosis of mild pancreatitis.
The cause of death in acute pancreatitis is as yet un-
determined. It is usually attributed to the previously
mentioned profound toxemia. The nature of this toxin
is unknown. Evidence is fairly conclusive that it is not
due to elements present in the activated pancreatic juice.
It has likewise been shown that it is not due to absorp-
tion of the products of autolysis or of enzymatic diges-
tion of the dead pancreas. Certainly the existing high
mortality can probably be lowered if the nature of this
toxin can be determined.
Apart from the above mentioned little understood
toxin, the profound shock that accompanies some of
these cases probably contributes to the fatal outcome.
The mortality is related to the severity of the early clin-
ical manifestation and particularly to the degree and
duration of the accompanying shock.
It is understandable that mortality figures depend
directly upon the period of the report, i. e., whether or
not a relatively large proportion of the cases were of the
milder type, so included because of improvement in
diagnostic measures. The mortality figures are also im-
proved, due to the recent use of more conservative meas-
ures of therapy.
Without listing detailed source of figures one can
easily note that the above factors influence mortality fig-
ures tremendously. Until the past decade, when acute
edematous pancreatitis was recognized as an entity, the
cases were all grouped together. They were operated
early and the mortality was appalling. It varied from
50 to 90 per cent. At the present time, with relatively
more cases of acute edematous pancreatitis being recog-
nized and treated conservatively, it is expected that the
mortality figure of the combined group would be less
than 30 per cent. It still is true, however, that the mor-
tality of the separated group of acute pancreatic necrosis
following early operation, is near 50 per cent. Treated
conservatively, acute edematous pancreatitis should have
practically a 0 per cent mortality. Thus one would con-
clude that the overall picture has improved, but in pan-
creatic necrosis the mortality is too high for compla-
cency.
Factors m the surgical management of an attack of
424
The Journal-Lancet
acute pancreatitis are variable. No didactic course can
be followed. The status of the disease, the condition of
the patient, statistical teachings, and personal experience
must guide one in making a decision. In the extreme
crisis, it is likely that the damage has been wrought when
the patient is first seen. Nothing can be done to undo
the damage. Any operation is hazardous and there is a
question as to the good that can be accomplished.
Drainage of the lesser sac and cholecystostomy is all
that can be attempted in such a critically ill patient.
There is apparently misunderstanding as to what is
referred to in the literature as "conservative manage-
ment” of an attack of acute pancreatitis. This means
that one should not operate in a situation as discussed
in the previous paragraph. One is practicing "conserva-
tive management” however when he operates from two
to twelve days following an acute attack if the clinical
course shows evidence of failure of the process to resolve
or to localize. Thus a "delayed operation” is done if
the disease is not self-controlled. Wangensteen M prac-
ticed conservative management of acute pancreatitis as
early as 1932. He was the first, at least in the English
literature, to advocate conservatism in this disease.
With the above thoughts in mind one can suggest a
general plan of surgical treatment. This outline in gen-
eral is followed at the Minneapolis Veterans Adminis-
tration hospital.
1. A patient is never operated upon until the shock,
if it exists, is controlled.
2. After preparation and recovery from shock, the
patient is operated upon as an emergency if a diag-
nosis of pancreatitis cannot be made, and there
exists a possibility of a "surgical emergency” such
as a perforated viscus, etc. If acute edematous pan-
creatitis alone is found, the abdomen should be
closed without any procedure being done. If an
acute pancreatic necrosis exists, drainage of the less-
er sac and decompression of the biliary tract can be
carried out, but a high risk must be assumed. If,
however, the serum amylase points to acute pan-
creatitis and other emergencies can be reasonably
ruled out, operation should be deferred.
3. The real trial comes in making the decision as to
advisability of an operation from the second to the
tenth day. The patient has gone through the crisis
of onset and shock period. Fluid may be collected
in the lesser sac or pancreas. A large pancreatic
abscess or slough may be present. These situations
are improved by surgery and the "delayed opera-
tion” in this situation is definitely superior to early
operation. It is when these conditions are present
that Morton 2S advocates surgery — not in the ini-
tial period. In addition to the enzymatic and blood
sugar level, the clinical course of the patient aids
in the decision as to advisability of operation. Rise
in pulse rate, white count, sedimentation rate, ab-
dominal pain and distention, and continued hyper-
bilirubinemia or other indication of common bile
duct stone would render operative intervention
essential. On the other hand, if in this early de-
layed period, the signs of inflammation continued
to improve, operation should be deferred indefi-
nitely.
4. In those patients who are successfully managed in
a conservative manner, interval and elective sur-
gery may be required for chronic cholecystitis and
cholelithiasis. At such surgery, the common duct
should be routinely explored and decompressed for
a prolonged period — at least six months.
Whatever course of surgical management is pursued,
general surgical principles are carefully followed regard-
ing treatment of shock and maintenance of proper fluid
and electrolytic balance. It is extremely important to
suppress pancreatic secretion in any phase of acute pan-
creatitis. Any oral intake will naturally stimulate pan-
creatic flow. Therefore one depends upon parenteral
fluids and constant intra-gastric suction. The nasal suc-
tion acts three-fold: The stomach is decompressed and
paralytic ileus, so common in acute pancreatitis is com-
bated. Most important of all, the stomach acids are not
allowed to pass over the duodenal mucosa, thus stimu-
lating pancreatic flow by the secretin mechanism. Phar-
macologic depression of pancreatic secretion by the use
of atropine and ephedrine may be utilized. The anti-
biotics are of great benefit in handling these processes,
either with operative or nonoperative cases.
Summary
1. Generally speaking, there are two forms of acute
pancreatitis. The milder type is known as acute inter-
stitial pancreatitis or acute edema of the pancreas. The
more severe type is called acute hemorrhagic pancreatitis
or acute pancreatic necrosis.
2. As an overall picture, acute pancreatitis is becom-
ing more common. Acute hemorrhagic pancreatitis is
less common. Acute edema of the pancreas is more
common.
3. The "common channel” mechanism, associated
biliary disease, and precipitating dietary and alcoholic
debauches are factors commonly related to onset of acute
pancreatitis.
4. The release of active trypsin into the acinar tissue
is probably the factor of prime importance in the patho-
genesis of acute pancreatitis.
5. The serum amylase is the greatest single aid in the
diagnosis of acute pancreatitis.
6. Death in acute hemorrhagic pancreatitis is prob-
ably caused by a systemic toxemia of unknown origin.
7. Treatment is conservative whenever the individual
case can be so treated.
8. The mortality rate should be nil in the cases of
acute edema of the pancreas that are not operated upon.
9. The mortality rate in acute pancreatic necrosis is
still too high. It is near 50 per cent in the cases oper-
ated early and around 30 per cent in the "delayed op-
erations.”
* * * *
Below are presented the figures on 13 cases of acute
pancreatitis seen at the Minneapolis Veterans Hospital
December, 1949
425
from January 1, 1947, to March 15, 1948. This covers
a period of 14 '/2 months.
Age — Between 24 and 73 years, average 42.
Previous attacks — 46 per cent.
History of alcohol or dietary debauch — 46 per cent.
Average duration when seen — 3.6 days.
Shock on admission — None.
Serum amylase determinations — 70 per cent over
240 units.
Concomitant biliary tract disease — 61 per cent.
Jaundice, history or present — 40 per cent.
3 Deaths — mortality of 23 per cent.
Cause of Death: (1) Delirium tremor, (2) Pulmo-
nary embolism-senility, (3) Generalized Ca.
Treatment: No surgery — 4 cases with 1 death; delayed
surgery — 7 cases with 1 death; early surgery — 2 cases
with 1 death; results with conservative management —
18 per cent mortality.
References
1. Abell, I.: Acute pancreatitis. Surg. Gyn. Obst., 66:348,
1938.
2. Aldis, A. S.: The enzymatic activity of pancreatic secre-
tion. Brit. Jour. Surg., 33:323, 1946.
3. Archibald, E.: The experimental production of pancreati-
tis in animals as the result of the resistance of the common duct
sphincters. Surg., Gyn. & Obst., 28:529, 1919.
4. Balser, W.: Ueber Fettnekrose, eine zuweilen todtliche
Krankheit des Menschen. Virchow’s Arch. f. path. anat. u.
Physiol, u. f. kein. med. 90:520, 1882.
5. Bergh, G. S.: The sphincter of Oddi in man. Minn.
Med., 31:189, 1948.
6. Backus, H. L.: Gastroenterology, vol. 111:734, The
Saunders Co., 1946.
7. Boyden, E. A.: Hypertrophy of the sphincter chole-
dochus. Surgery, 10:567, 1941.
8. Bradley, H. C.: Quoted from Backus.
9. Cameron, A. L., and Noble, J. F.: Reflux of bile up the
duct of Wirsung caused by an impacted biliary calculus.
J.A.M.A. 82:1410, 1924.
10. Chisholm, T. C., and Seibel, R. E.: Acute pancreatitis;
an experimental study with special reference to x-ray therapy.
Surg., Gyn. & Obst. 85:794, 1947.
11. Colp, R., and Doubilet, H.: The operative incidence of
pancreatic reflux in cholelithiasis. Surgery, 4:837, 1938.
12. Idem, The clinical significance of pancreatic reflux. Ann
Surg., 108:243, 1938.
13. Dragstedt, L. R., Hammond, H. E., and Ellis, J. C.:
Pathogenesis of acute pancreatitis (acute pancreatic necrosis) .
Arch. Surg. 28:232, 1934.
14. Edmondson, H. A., and Berne, C. J.: Calcium changes
in acute pancreatic necrosis. Surg., Gyn. & Obst., 79:240, 1944.
15. Elman, R.: Acute interstitial pancreatitis. Surg., Gyn.
& Obst., 57:291, 1933.
16. Elman, R., and Schwarz, H.: The pancreas — contribu-
tions of clinical interest made in 1945. Gastroenterology, 8:24,
1945.
17. Fitz, R. H.: Acute pancreatitis — a consideration of pan-
creatic hemorrhage; hemorrhagic, suppurative and gangrenous
pancreatitis, and disseminated fat necrosis. Boston Med. &
Surg. Jour., 120:181, 1889.
18. Gonshorn, J. A.: Acute pancreatitis. Bull. Vancouver
Med. Assoc., 23:12, 1946.
19. Godfrey, N. G.: Acute pancreatitis. Brit. Med. Jour.,
1:203 (Feb.) 1946.
20. Hendrickson, W. F.: A study of the musculature of the
entire extrahepatic biliary system. Bull. Johns Hopkins Hosp.,
9:221, 1898.
21. Jones, R., Jr.: Etiology and pathogenesis of acute hem-
orrhagic pancreatitis. Am. J. M. Sc., 205:277, 1943.
22. Kreilkamp, B. L., and Boyden, E. A.: Variability in the
composition of the sphincter of Oddi. Anat. Rec., 76:485, 1940.
23. LeDentu, M.: (1865) Bull. Soc. Anat. Paris, 10 Mar.
24. Leven, N. L.: Reflux into major pancreatic duct during
cholangiography. Proc. Soc. Exper. Biol. & Med., 38:808, 1938.
25. Mann, F. C., and Giordano, A. S.: The bile factor in
pancreatitis. Arch. Surg. 6:1, 1923.
26. Mering, J., and Minkowski, O.: Diabetes Mellitus nach
Pankreasextirpation. Arch. f. exper. Path. u. Pharmacol.,
26:371, 1890.
27. Mettler, Cecilia C.: History of medicine. The Blakiston
Co., Toronto, 1947, pp. 916, 467.
28. Morton, J.: Acute pancreatitis. Surgery, 17:475, 1945.
29. Oddi, R.: D une disposition a’ sphincter speciale de l’ou-
verture du canal choledoque. Arch. ital. de biol., 8:317, 1887.
30. Opie, A. L.: The etiology of acute hemorrhagic pan-
creatitis. Bull. Johns Hopkins Hosp., 12:182, 1901.
31. Paxton, J. R., and Payne, J. H.: Acute pancreatitis.
Surg., Gyn. & Obst., 86:69, 1947.
32. Popper, H. L., and Necheles, H.: Proc. Soc. Exp. Biol.,
68:232, 1941.
33. Puestow, C. B., Leahy, W. E., and Risley, T. C.: Acute
pancreatitis. Am. J. Surg., 72:818, 1946.
34. Rienhoff, W. F., and Pickrell, K. L.: Pancreatitis, an
anatomical study of the pancreatic and extrahepatic biliary sys-
tems. Arch. Surg., 51:205, 1945.
35. Rich, A. R., and Duff, L. G.: Experimental and patho-
logical studies on the pathogenesis of acute hemorrhagic pan-
creatitis. Bull. Johns Hopkins Hosp., 58:212, 1936.
36. Robinson, H. C., and Alfenito, F. S.: Acute pancreatitis,
Gastroenterology, 4:388, 1945.
37. Von Schmieden, and Sebening, W.: Surgery of the
pancreas; with special consideration of acute pancreatic necrosis.
Surg., Gyn., & Obst., 46:735, 1928.
38. Wangensteen, O. H., Leuen, N. L., and Monson, M. H.:
Acute pancreatitis, an experimental and clinical study with spe-
cial reference to the significance of the biliary tract factor. Arch.
Surg., 23:47, 1931.
39. Wangensteen, O. H.: Acute pancreatic necrosis with
comments on diagnosis and therapy. Minn. Med., 15:201, 1932.
40. Zoepffel: Quoted by Elman.
426
The Journal-Lancet
Ankle Protection*
A Study of Methods Used in Athletics
Harry R. McPhee, M.D.f
Princeton, New Jersey
Urr> he athlete is as good as his legs” is an axiom of
1 unknown origin to which it is safe to add "and
the legs are as good as the ankles,” for when they are
injured the athlete operates with diminished efficiency
if at all. It is important therefore that every precaution
be taken to protect the ankle from injury during play.
At least that is the attitude of most doctors and trainers
connected with athletics. The method of protection is
largely a matter of individual choice founded on experi-
ence and confidence. This article is written in answer
to a self-imposed challenge as to whether or not our
training staff at Princeton University was using the best
method of protecting ankles.
During the winter and spring, the training staff and
the doctors assigned to athletic teams meet every week
to mull over current problems, review anatomy and
physiology, and check the results of methods. It came
to light during these discussions that the rate of injury
to the ankle in football had increased from 80 per thou-
sand players before the war, to 127 per thousand since.
Why? Was it a normal cycle? Were the players too
careless in applying their ankle wraps? Was a greater
percentage than normal slipping out without protection?
Or was there something to be desired in the method of
protection?
The idea of a normal cyclic increase was set aside
because the percentage had stayed up too long. A care-
ful check of the records indicated that the unprotected
ankles were injured more severely when they were in-
jured but the number involved was no greater than be-
fore, whereas the quantity of injuries to wrapped ankles
had increased. The figure-of-eight wrap, anchored with
tape and emphasizing the upward pull on the outer turn,
was the method of choice because it was simple to teach
and simple for the individual to apply on himself. This
wrapping was carefully inspected in all ankle injuries
in which it had been used as a protection to determine
whether it had been applied according to instructions.
Practically all met specifications. This led to question-
ing the method and to the decision to investigate how
much protection the different known styles give.
A good scheme for conducting this study was sug-
gested by one of the trainers who had read Scott’s article
on ankles m a Navy Medical Bulletin.1 In it the author
had used the x-ray to demonstrate the effective limita-
tion to inversion of the foot by specially placed pads in
Navy shoes. By far the largest proportion of ankle in-
juries in football happen to the ligaments attaching to
the fibula on the anterior and lateral aspects of the
*From the American College Health Association.
■(■Department of Health, Princeton University.
malleolus, namely the anterior tibio-fibular and the lat-
eral collateral ligaments. Such injuries occur when the
foot and consequently the ankle are forced into a posi-
tion of hyperinversion with some extension. The aim of
protective support is to prevent that inversion or at least
hold it within normal limits. This is accomplished by
applying the support with the foot at right angles to the
leg, slightly everted and emphasizing the upward pull of
the external elements of the wrap or tape. The various
methods in use include the figure-of-eight wrap, the
figure-of-eight wrap with turns around the heel to lock
it as described by Quigley 2 of Harvard in the Journal
of the American Medical Association, a patented loop-
wrap which seeks to lock the heel with a specially pre-
pared loop at the start of the wrap, some modification
of the Gibney 3 taping and the figure-of-eight taping.
It was decided to test all these methods and although
Scott used the pads after injury his method was in-
cluded because it suggested some interesting possibilities
for prevention.
In order to have everything uniform for purposes of
comparison, the author was chosen as the guinea pig;
the head trainer applied the wraps and tape, and the
Fig. 2. X-rays of ankle without protection in normal posi-
tion (left) and fully inverted (right).
December, 1949
427
Fig. 4. X-ray of ankle showing limitation to inversion by
figure-of-eight wrap with heel loops as illustrated at right.
locking the heel (Fig. 4). The next method to be tested
was the patented-loop-wrapper which locks the heel first
(Fig. 5) and finishes with a figure-of-eight. A modified
Gibney taping applied directly to the skin previously
treated with tincture of benzoin to enhance the adhesive
Fig. 6. X-ray of ankle showing limitation to inversion by
Gibney taping as illustrated at right.
The resulting x-rays were compared as follows: The
sole of the shoe was taken as the plane of the foot and
the mid-line of the tibia as the vertical line of the leg.
A perpendicular was dropped from the point where this
vertical line intersected the articular surface of the tibia
at the ankle, to the plane of the foot. The angle between
the vertical line of the leg and this perpendicular gives
an index of the effectiveness of the various methods of
protection assuming that the other factors are the same.
To make the comparison more effective, the results were
superimposed upon each other to give a composite dia-
gram (Fig. 9) . Line 1 represents the ankle in the nor-
mal position and line 2 is the ankle inverted to the
extreme without support. The latter indicates rather
closely the limit of safety for inversion of the particular
Fig. 5. X-ray of ankle showing limitation to inversion by
patented-loop wrapper as illustrated at right.
qualities was investigated next (Fig. 6) . This was re-
moved and the skin prepared again for the application
of the plain figure-of-eight with 2-inch adhesive (Fig. 7) .
The final x-ray was made using the shoe with pads glued
to the inside over the inner and outer malleoli and the
tongue as described by Scott (Fig. 8) .
x-ray studies were made as nearly the same as humanly
possible. Figure 1 indicates how spring scales were set
on the x-ray table and the x-ray tube centered on the
ankle with the cassette immediately behind and 36 in-
ches from the tube filament. Marks were made on the
platform of the scales so that the shoe would be in the
same place each time, and the scales registered the
amount of weight or pressure applied.
The first and second x-rays (Fig. 2) were made of the
ankle without benefit of support other than the sock
Fig. 3. X-ray of ankle showing limitation to inversion by
figure-of-eight wrap as illustrated at right.
and shoe which was used in all exposures. The view
on the left portrays the ankle in its normal position
while the one on the right shows it fully inverted. The
inverting was done by merely turning the ankle over
and shifting all the weight possible to it so as to stretch
the lateral ligaments to the utmost. It was noted that
the scales registered 119 pounds (author weighs 145)
when the x-ray was taken. In all subsequent studies, the
exposures were made with the ankle inverted and the
pressure at 119 pounds. Furthermore, the muscles of
the leg were relaxed as completely as possible each time
to put the full burden on the protection being tested.
The ankle was first protected with the plain figure-of-
eight wrap using a strip of two-inch muslin six feet long
and anchored with one-inch adhesive (Fig. 3). This
was followed by the figure-of-eight wrap with loops
428
The Journal-Lancet
ankle used and thereby provides a base for examining
the effectiveness of the methods tested as shown by
lines 3 through 8, which correspond with figures 3
through 8.
Fig. 7. X-ray of ankle showing limitation to inversion by
adhesive figure-of-eight as illustrated at right.
Line 3 represents the plain figure-of-eight wrap to
which our faith has been pinned for years. It is self-
evident that this support has little value over the un-
protected ankle and our fortunes in the past hung on
a slender thread. The patented-loop wrapper is some
better but does not offer much improvement as indicated
by line 5. The greatest limitation to inversion at the
ankle is offered by the figure-of-eight, adhesive strap
(line 7), but unfortunately it has a decided tendency
Fig. 8. X-ray of ankle showing limitation to inversion by
padded shoe as illustrated at right.
to irritate the tendons of the tibialis anterior and exten-
sor hallucis longus muscles and set up a painful synovi-
tis. This leaves Quigley’s method (line 4), the modified
Gibney taping (line 6) and the padded shoe (line 8),
all of which have a healthy margin of safety to recom-
mend them. The player cannot apply the Gibney upon
himself. It is the method used by the staff to protect
previously injured ankles and the ankles of a few select-
Fig. 9. Composite diagram:
(1) standing in football shoe: (2)
ankle inverted with no protection:
(3) ankle inverted with figure-of-
eight wrap: (4) ankle inverted
with figure-of-eight wrap and heel
lock: (5) ankle inverted with
patented loop-wrapper: (6) ankle
inverted with modified Gibney
tape: (7) ankle inverted with fig-
ure-of-eight taping: and (9) ankle
inverted with padded shoe.
ed men in games. This policy will be continued as the
results have been satisfactory and the test indicates it
to be effective. Expense and time consumed make it
impractical to adopt the Gibney for general use. The
players other than those mentioned, must apply their
own protection. The staff is educating them to do so
with the figure-of-eight wrap incorporating turns around
the heel to lock it. The effect of this new regime will
be watched carefully to determine whether an adequate
answer has been found to our self-imposed challenge
regarding protection to the ankles in athletics. In the
meantime the interesting possibility in the padded shoe
will be studied.
References
1. Scott, W.: Sprained ankles — a new form of treatment,
Naval Med. Bulletin, 45:679, 1945.
2. Quigley, T. B., Cox, J., and Murphy, J.: A protective
wrapping for the ankle. J.A.M.A. 132, Dec., 1946.
3. Gibney, V. P.: Sprained ankle. New York M. J.,
61:193, 1895.
r A
CHANGE OF ADDRESS
In order to help us maintain an accurate mailing list,
please send your change of address promptly to The
Journal-Lancet, 84 So. 10th St., Minneapolis 3, Minn.
V.
December, 1949
429
Results of Reducing Diets for Overweight
University Students
Ramona L. Todd, Ph.D., M.D., and Dorothy P. Siemers, B.S.
Minneapolis, Minnesota
That obesity is a definite detriment to health is gen-
erally accepted by physicians and dietitians. Recom-
mendations for weight reduction are made frequently
and the hope is expressed that such suggestions are fol-
lowed with some degree of success. The' Students’
Health Service at the University of Minnesota has on
its staff a dietitian for instruction and guidance of stu-
dents for whom special diets are prescribed by staff phy-
sicians and return visits for observation are encouraged.
Since such an organization affords an excellent oppor-
tunity for evaluation of the success of special diets, a
study of a group of overweight individuals placed on
weight reduction diets was undertaken to determine re-
sults of such regimes and to learn more effective methods
of guidance of overweight patients.
Selected for study were the individuals who were
placed on reduction diets at the Students’ Health Service
during the school years 1946-47 and 1947-48. The rea-
sons for choosing those two years were: (1) the people
had been on diets sufficiently long to allow evaluation
of results and (2) most of these students were still avail-
able for interviews at the time the study was made.
There were 364 (118 men and 246 women) in the
group. The ages of the patients were distributed as fol-
lows: 18-27 years, 80.5 per cent; 28-37 years, 15.6 per
cent; 38 years and over, 3.9 per cent.
Only 14.5 per cent of the group had significant phys-
ical defects other than obesity. There were 22 men and
10 women who had hypertension, 7 men and 8 women
had allergic manifestations such as hay fever or asthma,
two men had duodenal ulcer, two women had iron defi-
*From the Students’ Health Service, University of Minne-
sota.
ciency anemia, and one man had mitral stenosis and
mitral insufficiency.
Almost half (47 per cent) had basal metabolism tests
as a part of the examination made before the reducing
diet was begun (Table I). Of the 172 who had metabo-
lism tests, 42, or 24.4 per cent, had rates of — 11 per
cent or below. Comparison with a group of 148 indi-
viduals who were not overweight shows that low basal
metabolism rates were no more common in the over-
weight people than in the control group which had 36,
or 23.9 per cent, with rates of — 11 per cent or below.
Neither group contained persons who had had thyroid
surgery, or any one who was being treated with thyroid
extract at the time of the test; otherwise, no selection
was made. A more detailed analysis of the data revealed
no correlation between degree of over- or underweight
and basal metabolism rate.
The height-weight per cent of each person was com-
puted according to the Medico-Actuarial tables. Only
those whose height-weight per cent was greater than 110
were considered sufficiently overweight to be referred for
weight reduction. Before institution of the dietary regime,
the men in the series tended to be more overweight than
the women, as 65 per cent of the women were in the
groups of 111 to 130 per cent while 60 per cent of the
men were above 130 per cent (Table II).
Of the 364 individuals who consulted the dietitian,
69 per cent of the men and 60 per cent of the women
returned for follow-up observations. The following com-
putations and discussion refer to the 243 men and wom-
en who were kept under observation during the period
of dieting. There were 49, or 20.2 per cent, who con-
tinued on a reducing diet until a weight of 110 per cent
Table I
BASAL METABOLISM RATES OF OVERWEIGHT PERSONS COMPARED TO A CONTROL GROUP
Basal Metabolic
Rate
(Per Cent)
Height-Weight Per Cent*
110 and Under
111 an
d Above
MEN
WOMEN
TOTAL
MEN
WOMEN
TOTAL
No.
1 %
No. |
% 1
No.
1 %
No.
Cf
| No.
1 % 1
No.
%
Total Cases
53
| 100.0
98 |
100.0 I
151
| 100.0
45
| 100.0
| 127
| loo.o |
172
100.0
+ 11 and over
16
| 30.2
10 |
10.2 |
26
! 17.2
11
| 24.4
15
11.8 1
26
15.1
—10 to +10
27
j 50.9
62 |
63.3 |
89
58.9
32
71.1
1 72
1 56.7 I
104
60.5
O
fNI
I
o
T
10
18.9
23 |
23.4
33
21.9
2
4.4
35
27.6 |
37
21.5
— 21 and below
-
|
3 I
3.1 |
3
| 2.0
-
1
1 5
3.9 |
5
2.9
II II II II II II
Total — 11 and below
10
| 18.9
_J6_L
26.5 |
36
| 23.9
2^
| 4.4
| 40
1 31.5 |
42
24.4
*According to Medico-Actuarial Tables.
430
The Journal-Lancet
Table II
DEGREE OF OVERWEIGHT AT BEGINNING OF
REDUCTION DIET
Height- Weight
MEN
WOMEN
Pet Vent Group
No.
Per Cent
No.
Per Cent
111—120
14
12
86
35
121—130
34
28
74
30
131—140
29
25
42
17
141 — 150
22
19
25
10
151 and over
19
16
19
8
or less was reached. In this respect, the women did con-
siderably better than the men as 27.6 per cent of the
women and 8.5 per cent of the men were successful.
As noted above, a larger number of the women were
only mildly overweight. The men showed a greater av-
erage weight loss in every height-weight per cent group
except the 111-120 per cent group (Table III). The
Table III
AVERAGE WEIGHT LOSS ACCORDING TO HEIGHT-WEIGHT
PER CENT AT BEGINNING OF REDUCTION DIET
Height-Weight
Per Cent Group
Sex
No.
Ave. Total
Pounds Lost
Pet. Suc-
cessful
111 — 120
Men
10
6.8
50
Women
52
7.2
52
121—130
Men
22
12.8
9
Women
45
9.2
20
131—140
Men
20
14.3
0
Women
25
10.2
0
141 — 150
Men
15
16.3
0
Women
15
13.3
7
151 and over
Men
15
21.3
0
Women
12
11.2
0
only persons who were successful in reducing to 110
per cent or below were in the 111-120 and 121-130 per
cent groups with the exception of 7 per cent of the
women in the 141 to 150 per cent group who followed
the diets until their goals were reached. Further analysis
of the data revealed no correlation between age of the
patient and weight loss.
A daily allowance of 800, 1000, 1200, or 1500 calories
was prescribed. The 1000 calorie diet was used most
frequently for women, and 1200 calorie diet most fre-
quently for men (Table IV). In general, greater losses
were recorded for those in the 1200 and in the 1500
calorie groups. The more restricted allowances of 800
and 1000 calories apparently were not followed as well
Table IV
AVERAGE TOTAL WEIGHT LOSS ACCORDING TO PRESCRIBED
DAILY CALORIC INTAKE
Calories
Sex
Number
on Diet
Ave. Total
Pounds Lost
Per Cent
Successful
800
Men
2
14.2
0
Women
49
9.1
26.5
1000
Men
34
11.1
8.8
Women
88
9.6
28.4
1200
Men
40
15.8
2.2
Women
15
11.1
33.3
1500
Men
17
15.0
11.8
Women
3
21.7
33.3
as were the more lenient diets. A perusal of Table IV
indicates that a 1500 calorie diet was the most accept-
able of the four groups; however, the small numbers of
men on 800 calories and women on 1500 calories are not
sufficient for accurate comparison with the other groups.
Further observations would be necessary before any con-
clusions could be drawn regarding calorie allowances and
success of diets.
There were 23 women for whom Dexedrine sulfate
was prescribed to decrease the desire for food. These
women lost an average of 7.2 pounds during the first
month of their diets and the total average loss was 10.1
pounds. The women for whom no medication was pre-
scribed lost an average of 5.5 pounds during the first
month and their total average loss was 7.5 pounds. These
results would indicate that Dexedrine sulfate was help-
ful but the group of 23 is too small to permit accurate
generalization regarding the effectiveness of this drug.
Summary and Conclusions
1. Of 172 overweight persons, 42, or 24.4 per cent,
had basal metabolism rates of — 11 per cent or below.
There were 36, or 23.8 per cent, of 148 individuals who
were not overweight who had rates of — 1 1 or below. In
this series, low metabolism rates are not more common
in overweight people.
2. There were 49, or 20.2 per cent, of 243 persons
placed on weight reduction diets who were successful in
reaching a weight of 1 10 per cent or below. Most of
these were only mildly or moderately overweight.
3. A small group of 23 women for whom Dexedrine
sulfate was prescribed showed a greater average weight
loss for the first month of their diets as well as a greater
average total loss than women without medication.
A ten-year project at Yale University headed by Dr. Arnold Gesell reveals for the first
time the detailed development of vision in infants and children and produced findings that
establish a new approach to the problems of child vision. These findings show that the child
is never a miniature adult even in his visual equipment, and that it should not be necessary
to wait until belated adolescent and adult years to determine the efficiency of his visual
functions.
December, 1949
431
Postpartum Optic Neuritis Due to
Multiple Sclerosis"
Hugh W. Hawn, M.D.f
Fargo, North Dakota
Multiple sclerosis is a disease of unknown etiol-
ogy characterized by scattered areas of sclerotic
plaques in the brain, spinal cord, and optic nerves. The
sclerotic changes consist of demyelinization and glial
tissue formation in both the white and gray matter. The
disease occurs in all races and, according to Marburg,1
is found more often in the female than in the male.
Because of the hit-and-miss distribution of the plaques
the symptoms are quite varied. Most commonly the in-
dividual first notices transient paresthesias of the extrem-
ities or visual impairment due to inflammatory changes
in the optic nerve. The onset is generally abrupt and
may follow an acute infectious disease, acute fatigue,
or, as will be shown further, a normal pregnancy. The
triad of Charcot-nystagmus, intention tremor, and scan-
ning speech is not found in early cases, but is a mani-
festation of late involvement of the disease."
The ocular signs are very important in the diagnosis
of multiple sclerosis. Nystagmus, muscle paresis, and
optic neuritis are frequently encountered in the early
stages of the disease.
In this report, the term optic neuritis will be used to
designate sclerotic involvement of the optic nerve.
Strictly speaking, an optic neuritis signifies involvement
of the optic nerve anterior to the point of exit of the
central retinal vein and is manifested by papilledema
whereas retrobulbar neuritis is caused by the same lesion
posterior to the exit of the central retinal vein and is
differentiated by the absence of papilledema.
According to McIntyre ''' optic neuritis is found in
50 per cent of all cases of multiple sclerosis at some
stage of the disease. Conversely Benedict and Koch 4
in their series found that 50 per cent of the diagnosed
cases of optic neuritis are suffering from multiple
sclerosis.
Usually the first symptom of optic neuritis is mild
pain in the eye aggravated by movement of the eye.
Moving the eye causes a stretching of the optic nerve
which in the inflamed state produces pain. This is fol-
lowed shortly by a rather abrupt partial loss of vision
which reaches a maximum intensity in twenty-four to
thirty-six hours. Most commonly only one optic nerve
is affected at a time, although bilateral cases do occur.
The visual impairment is generally not complete and
typically is manifested by a dense central scotoma with
preservation of good peripheral vision, so that the indi-
vidual while unable to read or recognize small objects
is not hindered in getting about.
*Presented at the meeting of the North Dakota Society of
Obstetrics and Gynecology on October 22, 1949.
fFrom the Fargo Clinic, Fargo, North Dakota.
The loss of vision is most intense during the first two
or three weeks and then gradually improves over the
next two or three weeks. In rare cases there is a perma-
nent loss of vision. Permanent visual loss is most apt
to occur in those cases with marked edema of the optic
nerve due to spread of the edema to the macular area
with consequent retinal pigment changes remaining after
disappearance of the edema. Examination of the fundi
after visual recovery generally demonstrates a pale optic
disk due to partial atrophy, although a few cases will
not show any change in color of the optic disk. It
might be mentioned here that the degree of pallor of
the optic nerve head is no indication of the degree of
visual loss.
Recurrence of optic neuritis is the rule and may in-
volve the previously unaffected eye or the same eye.
With each succeeding attack the prognosis for complete
visual recovery becomes progressively less.
Treatment consists of rest, mild sedation, large doses
of vitamin B complex and multiple intravenous injec-
tions of triple typhoid vaccine. In recent years histamine
has often been used instead of typhoid vaccine. How-
ever, there is little difference in the clinical response.
As was mentioned previously, multiple sclerosis is occa-
sionally first manifested after a normal pregnancy. Preg-
nancy, and some of the other predisposing factors,
merely activate what was previously a latent or sub-
clinical form of multiple sclerosis.
In these women the first symptom of the disease
often is a sudden onset of blurred vision occurring sev-
eral months after delivery. The course of the disease
and its response to treatment is no different in these
cases than in those not associated with pregnancy.
During the past two years we have followed five pa-
tients who developed signs and symptoms of multiple
sclerosis after pregnancy. The following two brief case
reports illustrate the occurrence of symptoms of multiple
sclerosis following an uncomplicated pregnancy:
Case 1. Mrs. C. H., age 22. This woman noticed a sudden
onset of blurred vision of the left eye four months following
delivery of a normal child. The vision of the left eye was re-
duced to hand movements peripherally. Visual fields for this
eye showed a lower nasal quadrant contraction with a para-
central scotoma. Ophthalmoscopic examination revealed a low-
grade edema of the left optic disk. Examination of the right
eye was normal. Following treatment with intravenous triple
typhoid vaccine and vitamin B complex the vision became nor-
mal. Three months later the optic nerve of this eye was some-
what pale in color due to partial optic atrophy. The visual field
was normal at this time.
Case 2. Mrs. R. K., age 30. This patient noticed an abrupt
onset of visual diminution of the left eye ten weeks after de-
livery of a normal baby. Her past history showed that nine
432
The Journal-Lancet
years before she had partial temporary blindness occurring sud-
denly in the right eye which lasted for three weeks. This first
attack had followed pregnancy by six weeks. Prior to the second
attack of visual impairment she had transient attacks of numb-
ness of the lower extremities lasting two to three weeks. Ocular
examination showed the vision of the left eye limited to hand
movements. Visual fields demonstrated a marked contraction
of the temporal portion which extended over the fixation area.
The fields for the right eye were normal. Ophthalmoscopic
examination showed a marked pallor of the right optic disk
due to partial atrophy as a result of the attack of blindness
following the first pregnancy. The left optic disk at this time
was normal. After treatment with triple typhoid vaccine intra-
venously and oral vitamin B complex her vision improved so
that at the end of three months it was again normal. The visual
fields at this time were normal, but now both optic disks were
pale.
Two months after treatment was discontinued this patient
again became pregnant. She delivered a normal baby without
complications. Immediately following delivery a sterilization
procedure was performed. Three months after delivery this pa-
tient again developed an optic neuritis of the left eye with
markedly reduced vision. Improvement in vision was complete
after four weeks treatment with intramuscular histamine and
oral vitamin B complex.
These two cases show that pregnancy can initiate an
attack of optic neuritis in women who previously had no
stigma of multiple sclerosis or who had been free of
symptoms for a number of years prior to pregnancy and
delivery.
The question arises as to whether a woman who has
proven multiple sclerosis should become pregnant. Also
whether interruption of pregnancy is indicated in women
suffering from multiple sclerosis. One of our cases, not
cited here because of inadequate follow-up, developed,
within three months of delivery, bilateral optic neuritis
resulting in partial permanent blindness, loss of bowel
and bladder control, and inability to use the lower ex-
tremities so that she has been confined to bed since that
time.
On the other hand Birner and also Kushner 0 each
reported a case of multiple sclerosis that improved neuro-
logically following pregnancy.
Fleck 1 divides the cases of women in the child-bearing
age who have multiple sclerosis into two groups. In the
group where there is no progression of the symptoms of
multiple sclerosis and little or no disturbance of function
or psychic disturbance he does not advocate either ster-
ilization or interruption of pregnancy. In the second
group where there is gross disturbance of physical and
psychic capacity he believes pregnancy should be inter-
rupted and sterilization done.
According to Hunter and Darner s women who have
an acute exacerbation of multiple sclerosis in the post-
partum period should be sterilized following their third
pregnancy even though they are relatively free from
symptoms of the disease between pregnancies.
Although the decision to allow a pregnancy to go on
to term or to prevent the occurrence of pregnancy is not
a decision the ophthalmologist must make we believe one
should be governed by the principles laid down by
Fleck. Each case must be considered individually and
the decision reached with the full cooperation and under-
standing of the patient.
References
1. Marburg, O.: Zur Statistik der multipier Sklerose.
Jahrb. f. Psychiat. und Neurol., 48:303-316, 1932.
2. Walsh, F. B.: Clinical Neuro-Ophthalmology. Williams
and Wilkins Company, p. 776, 1947.
3. McIntyre, H. A., and McIntyre, A. P.: Prognosis of
multiple sclerosis. Arch. Neurol, and Psychiat., 50:431-438,
1943.
4. Benedict, W. L., and Koch, F. L. P.: Optic neuritis and
retrobulbar neuritis. Jour. Mich. State Med. Soc., 1937.
5. Birner, I. M.: Pregnancy and multiple sclerosis — case
report. New York State Jour. Med., 45:634-635, 1945.
6. Kushner, J. I.: Pregnancy complicating multiple sclero-
sis. Amer. Jour. Obst. and Gyn., 51:278-279, 1946.
7. Fleck, U.: Multiple Sklerose and Schwangerschaftsunter-
brechung wie Unfruchtbarmachung aus arztlichen Grunden.
Allg. Ztschr. f. Psych., 109:9-15, 1938.
8. Hunter, G. Wilson, and Darner, C. B.: Surgical sterili-
zation in women. Journal-Lancet, 68:118-120, 1948.
WISCONSIN BUILDS HEART RESEARCH INSTITUTE
Through a grant of $291,000 from the federal government, the University of Wiscon-
sin next spring will begin construction of a Heart Research institute which will consolidate
all phases of cardio-vascular research.
Plans call for a fifth and sixth floor addition to McArdle Memorial laboratory to house
this important research project. The move will facilitate coordination between heart research
in physiology, pharmacology, anesthesiology, medicine, surgery, and anatomy.
The quarters, expected to be ready next fall, will be new, but the research program is
not. Wisconsin scientists have been heavy contributors to heart research since the first course
in medicine was offered at the University back in 1904.
December, 1949
433
A New Vaginal Speculum
Joseph F. Bicek, M.D.
St. Paul, Minnesota
The word speculum is derived from the Latin word
specio, or, translated, to see. Also, speculum refers
to mirror, and in many instances, such a combination has
been used, namely, both as speculum and a mirror.
To trace the appearance of the speculum, we must
embody a large part of the history of gynecology itself.
The history of the speculum demonstrates that gyne-
cology did not advance in a straight line, but rather in
a circle, for many discoveries, or which were thought as
such, were only rediscoveries which had in some manner
been forgotten.
Gynecology can only be traced with clearness to the
Greeks, but there is evidence that under the Ptolomies
of Egypt, the practice of gynecology was regulated by
a book on the art, as indicated in the writings of Homer
and Herodotus. But when the Saracens destroyed the
Alexandrian Library, all these records were lost. Since
the Greeks and the Egyptians varied much in charac-
teristics, it is perhaps safe to say that little of the Egyp-
tian learning was found in Grecian records. The oldest
records of gynecology were those of Hippocrates, writ-
ten about 450 B.C. Although some of his ideas were
very crude, others have not been bettered to this day.
Because the Romans derived their knowledge mainly
from the Greeks, their observations probably were not
original. Celsus and Galen were the main writers of
this time, and there is enough of their work extant to
show that as early as the first century of the Christian
era, the speculum, rediscovered by Recamier in 1816,
was not unknown, and allusions were made to digital
examinations for diagnostic use. In the excavations of
the ruins of Pompeii and Herculaneum, 79 A.D., after
having been buried for nearly 1800 years, there were
found two speculas which were probably in use at the
time of the eruption.
After an interim of almost 500 years, we find Celsus
and Aetius working in the Library of Alexandria. From
their writings, we know of the medicine of Egypt a
millennium and a half ago. The tetrabiblus of Aetius
is very good on the status of gynecology, and treats of
the ovaries, uterus and instruments for the ocular exam-
ination of the uterus, and mentions sounds. Paul of
Agina wrote following Aetius, but he is referred to
*In 1922, as a Fellow in the Obstetrical and Gynecological
Department at the University of Minnesota, under the late
Dr. J. C. Litzenberg, I was requested to write a history of the
vaginal speculum. Therefore, it is to this great national figure
and a most loyal friend of mine that I dedicate this presenta-
tion.
Credit is also given for the excellent illustrations to Miss
Jean Hirsch of the University of Minnesota Medical Art Shop;
to Miss Virginia Moore of the same Art Shop.
as a plagiarist. During the next thousand years the
Saracens sought to make amends for the destruction of
the Alexandrian Library, but little progress was made
because of the tenets of the Moslem religion, which for-
bade visual and digital examinations of the female geni-
talia. In the Arabian writings of Albucasis in the 14th
century, we find an occasional allusion to the speculum.
Although Albucasis was a Jew, his practice did not dif-
fer from that prescribed by the Moslems, and, if so,
perhaps he never used a speculum. It is apparent from
the subsequent writings of Pare and Scultetus that the
speculum was not forgotten, but nevertheless, a thousand
years before its rediscovery by Recamier, if it is a re-
discovery, the speculum was a lost instrument and gyne-
cology a lost art.
The first reference to a speculum in American gyne-
cology is around 1717. In England, gynecology pro-
gressed under Hunter, but in America, the Revolution-
ary War diverted attention and cooperation for the
seven years, and perhaps ten years, after. The Ameri-
cans were soon stimulated, however, mainly through
Recamier’s revival of the speculum, and their works
were not much inferior to those of Hunter. The first
American of note was Ephraim McDowell, born in
1771, who did the first ovariotomy prior to the first use
of anesthesia in 1809. McDowell’s work was transferred
to England because he previously studied under John
Bell, and to him he sent a paper on the ovariotomy.
J. Marion Sims, rightfully called the father of Ameri-
can gynecology, was born in 1813, and his fame rests
on the first successful attempt to cure vesicovaginal fis-
tula, through which feat came the discovery of the
vaginal speculum.
Before 1852, the stumbling block of gynecology was
the relief of vesicovaginal fistula. Surgeons, from Pare
on, had attempted operations on fistulse, but failed.
Lombolle wrote on fistula cases, but could report only
failures. The first successful operation reported in 1787,
was by Meltaner of Virginia, but the first real work on
that condition was that of Sims. Peculiarly, before 1805,
Sims practiced medicine, but abhorred treatment of
women’s diseases, usually referring those types of cases
to someone else. Once called upon to treat a Negro
servant with fistula, he told the woman that he would
send her home, and that he could do nothing for her.
Getting into his buggy to make his morning visits to his
patients, he was also called to see a woman who had
been thrown from a horse and was suffering with terrific
back and bearing-down pains and tenesmus of the blad-
der and rectum. He found the uterus retroverted and
took it for granted that it was the result of the fall.
434
The Journal-Lancet
Remembering the lectures of Dr. Pruloeau, he put her
in the genu-pectoral position, and first used one finger,
but, being only able to reach the uterus, he used two
fingers and turned the palm up and down. Suddenly
he felt no uterus, and the woman said she was relieved.
She fell over from exhaustion, and in so doing there was
a noise as of air escaping from the bowel, but which
Sims knew was the air that had entered the vagina as a
result of his manipulations, and which had caused the
uterus to be righted. Sims was reminded of his fistula
cases, and thought that if he could distend the vagina
he could get a better view of the parts than before.
Procuring a large pewter spoon, he hurried back and
saw the Negro woman, who had not yet left the hos-
pital. Placing her in the genu-pectoral position, and
placing a student on each side, he instructed them to
lay hold of the nates and spread them forcibly apart,
which caused air to rush in, distending the vagina. By
putting in the spoon, which he bent, and drawing back
the perineum, the fistulous opening and the sides were
evident, the cervix was visible, and the vaginal walls were
seen closing around it on all sides. This at once gave
him the idea that he could pare the edges of the fistula
and bring them together with sutures. He collected
many of the fistula cases, and operated on them, al-
though anesthesia was not yet used. He encountered
many difficulties — first the drainage, then the tying of
the sutures high up. He finally introduced successfully
the use of a silver suture.
His speculum was a single type and is still known
today as the Sims speculum. In the course of time,
various men devised bi-valve or duck bill instruments,
cylindrical instruments and other variations, always go-
ing back to the same definition of the word, to see.
Again, with the progress of gynecology, other procedures
were devised, such as the dilatation of the cervix and
the curett by which the endometrium can be scraped and
microscopically examined. Because of the need of get-
ting tissues from the cervix, which at times is difficult
because of the mixing of cervical and endometrial tissue,
we have come to utilize various devices for the so-called
screening processes. Up to the present time, any specu-
lum, single or bi-valved, offers little help in retrieving
uterine or cervical scrapings from the vaginal vault.
We must remember that with the woman on her back,
and the legs in stirrups, the vaginal canal runs backwards
and downwards. The speculum has to depress the
perineum down in order to visualize the cervix, and,
with the type of speculae we have today, no means are
afforded to retrieve the tissues obtained by currettage,
or otherwise. Usually, resort is made to the use of an
ordinary teaspoon or tablespoon, or the sponging out
with gauze and a long uterine dressing forcep. It was,
therefore, felt that without making too radical a de-
parture from the instruments in use, a speculum could
be devised which would facilitate the retrieving of tis-
sues and screening.
Two figures of the newly devised speculum are pre-
sented. Figure a. shows a view of the speculum from
the side and a trifle from the side and above. From
this figure it can be noted that the vaginal blade is
deeper than most of the old speculae, and that the end
of the inserting tip comes up, the purpose of which is
to collect tissues obtained. The new feature incorporat-
ed, of course, is the side delivery spout, which facilitates
the retrieving of the tissue. It can also be seen that the
handle is set farther forward, thereby bringing the end
of the speculum farther towards the operator and away
from the perineum.
Fig. a. Essentially a lateral view with a slight superior
aspect of the vaginal blade, showing the deeper blade and the
speculum extending back of the handle with the spout going
backward and downward.
Fig. b. A superior view of the vaginal blade showing the
spout extending laterally and also downward.
Figure b. represents a superior view and demonstrates
the blade and the side spout. In the use of the specu-
lum, it is suggested that the patient’s buttocks be
brought low down and over the edge of the table so that
the whole speculum can be tilted downward, facilitating
the flow of the tissue through the side spout and into
a suitable container. The flow can be facilitated by use
of a small gauze pledget which can whisp the tissues
forward. The majority of the previous specula; had no
posterior spouts and most of them had grooves in the
handles, so that the wanted tissues were lost or spilled
over the hands of the operator. A model was first
molded crudely in clay, which served as a working guide
by Harold Bjostad of the Brown & Day firm of St.
Paul, Minnesota, under whose hands the new creation
was consummated. The first original new speculum
which is illustrated will perhaps need few minor changes.
A manufacturer can easily produce it in various sizes.
No claim is made for an extraordinary innovation,
but as shown by the history of the speculum, the need
of an instrument presented itself. There is no wish for
carving of a niche in the hall of history but a hope
to submit a useful new type of instrument.
References
1. Reference Handbook of Medical Sciences.
2. History of J. Marion Sims, by his son, B. Marion Sims.
3. History of Medicine, by Garrison.
4. American System of Gynecology, by Mann.
5. History of Vaginal Speculum, Seminar Paper, 1922, by
Dr. Joseph F. Bicek.
6. Funk & Wagnall’s New Practical Standard Dictionary.
December, 1949
435
Interstitial Pregnancy*
John H. Moore, M.D., and Frank A. Hill, M.D.
Grand Forks, North Dakota
The implantation and growth of the fertilized ovum
in the interstitial portion of the fallopian tube con-
stitutes an interstitial pregnancy. Development takes
place within the uterine wall outside the uterine cavity
because of the thinness of the tube in this portion. Rup-
ture takes place relatively late due to the muscle charac-
ter in this area. Early in the gestation, the signs and
symptoms may be those of a normal pregnancy, and the
differential diagnosis between this condition and a true
cornual pregnancy is often difficult.
Interstitial pregnancy is rare, yet more common than
primary ovarian or primary abdominal pregnancies.1
Incidence figures vary from 3.3 to 13 per thousand cases
of ectopic pregnancy.2 Wynne reported an incidence of
1.16 per cent in his series of which 23 were unruptured
at time of surgery.3,4 One hundred ninety-nine cases
were reported in the literature as of July, 1943, per
Grusetz and Polayes who reported the fourth case going
to term unruptured.5
Report of Case
Mrs. D. M. A., a 21-year-old German war bride, was
first seen December 12, 1948, with complaints of onset
of dysmenorrhea two months previously, moderately
severe and lasting the first two days of her period. Past
history was non-contributory. Physical examination in-
cluding pelvis was normal with the exception of a slight-
ly enlarged uterus and right ovary. The impression was
acquired dysmenorrhea and possible cyesis. She was next
seen on the 22nd of June, 1949, with the history of
normal menses until April at which time she was two
weeks late. Following this period she continued to bleed
every 8 to 10 days for a period of four or five days
using 8 to 10 pads for the interval of bleeding. This
was accompanied by nausea and non-localizable dull ab-
dominal pain. Physical examination revealed prominent
areolar tubercles and a symmetrical soft abdominal mass
extending 13 cm. above the pubis. The patient was pal-
lorous, not in shock, the blood pressure 92/ 60. Pelvic
examination confirmed the pelvic origin of mass de-
scribed above, apparently uterus, soft and slightly tender.
The cervix was enlarged, soft, patulous with cloudy,
bloody discharge.
Anterior and oblique x-rays of the lower abdomen
showed an oval mass extending to a little above the
sacro-promontory; no fetal parts were seen.
*From the Section of Obstetrics and Gynecology, Grand
Forks Clinic, 221 South Fourth Street, Grand Forks, North
Dakota.
Laboratory examinations: Urine analysis within nor-
mal limits; hemoglobin 59 per cent (17 gram Sahli) ;
erythrocytes 3,020,000; leucocytes 8,000; sedimentation
rate (Westergren) 41; blood group A, and the Rh fac-
tor negative. The blood Wassermann was negative.
The patient received a transfusion of appropriate
blood in preparation for surgery.
The uterus was sounded to 13.7 cm., the cavity seemed
symmetrical and was curreted of many old blood clots
and a moderate amount of necrotic appearing tissue.
The uterus was packed with iodoform gauze. At lapa-
rotomy, the uterus was symmetrically enlarged to a
point just below the umbilicus. The distal two thirds
of the left fallopian tube showed chronic inflammatory
changes, the left ovary contained a corpus luteum. The
right tube appeared grossly normal as did the right
ovary. Just below and anterior to the right cornua there
was a superficial mass, spongy to the touch, with prom-
inent, tortuous serosal vessels coursing over the surface.
The mass was incised followed by the immediate ex-
pression of a male fetus 8.8 cm. crown-rump length
within an amniotic sac and attached to a placenta. No
communication to the uterine cavity could be demon-
strated although a careful search was made. The incision
was closed with interrupted catgut sutures. On the third
postoperative day the patient passed a decidual cast per
vagina. The postoperative course was uneventful and
subsequent check revealed a well involuted uterus.
The pathologist’s report of the curettings was old
blood clots with necrotic decidua. There was a male
fetus and placental tissue.
Conclusions
1. Interstitial pregnancy is a rare type of ectopic
gestation.
2. Rupture occurs relatively late.
3. A case report of an unruptured interstitial preg-
nancy is presented.
References
1. TeLinde, R.: Operative Gynecology, J. B. Lippincott
Co., 1946.
2. Thunig, L. A.: Am. J. of Obst. and Gynec. 48:114,
1944.
3. Wynne, H. M. N.: Bull. Johns Hopkins Hospital
29:29, 1948.
4. Wynne, H. M. N.: Amer. J. Surg. 7:382, 1929.
5. Grusetz, M. W., and Polayes, S. H.: Am. J. Obst. and
Gynec. 48:379, 1944.
436
The Journal-Lancet
The Use of Iodine in a Solusalve Base
as an Antiseptic
Irving Kass, M.D.
Chicago, Illinois
The use of organomercurials as antiseptics, as well
as their implied potency has been the subject of
many papers. The Council on Pharmacy and Chemistry
of the American Medical Association in its most recent
comment 1 felt that the proof of their effectiveness did
not fully satisfy the standards of scientific criticism.
This dissatisfaction with the commonly used antiseptics
caused a renewed interest in iodine, an antiseptic which
has been used since early in the 19th century.
In 1839 the French surgeon Boinet used iodine in the
treatment of an inguinal abscess. He injected 80 cc. of
1:15 dilution of iodine into the drainage tract of the
abscess. The unnecessarily strong concentration caused
intense pain, but 12 days later the abscess had healed
and 20 years later the patient was reported in good
health. Koch, in 1881, discovered that bichloride of
mercury in dilute solution had a bactericidal effect.
Eight years later Geppert challenged his findings, in-
sisting that Koch’s technique did not account for the
bacteriostatic action of mercury. It is now apparent that
any critical evaluation of an antiseptic must record both
the initial potency as well as the secondary bacteriostatic
effects occasioned by the adherency of the compound to
the bacteria cell.
Bacterial Power
Morton, North and Engley 2 tested the bactericidal
powers of the following organomercurials: (1) the di-
sodium salt of 2,7-dibrom-4-hydroxymercurifluorescein,
merbromin, N.F., Mercurochrome, (2) sodium ethylmer-
curithiosalicylate, Merthiolate, (3) the anhydride of
4-nitro-3 hydroxymercuri-orthocreso, Metaphen. They
seeded hemolytic streptococci (Streptococcus pyogenes-
strain C203M) in a medium consisting of beef broth
to which 10 per cent horse blood was added. Mercuro-
chrome, Metaphen and Merthiolate undiluted and in
1:2 dilution were added to the culture. After intervals
of 5, 10 and 15 minutes exposure to the antiseptic the
organisms were subcultured in the thioglycolate medium
(Linden’s Formula) The fact that both vegetative cells
and spores are still infectious while in a state of bacterio-
stasis is sufficient reason for taking precautions to elim-
inate the bacteriostatic effect of mercury while testing
mercurial compounds in vitro for germicidal activity.
In the light of their investigation of the organo-
mercurial compounds the authors of the above-cited re-
port - made the following statements as to the antiseptic
effectiveness of Merthiolate, Mercurochrome and Meta-
phen:
Merthiolate: "Merthiolate 1:1,000, aqueous, when
allowed to act on a culture of hemolytic streptococci for
ten minutes was not a disinfectant because mice injected
with such mixtures invariably died. In all 16 out of 17
mice injected with such mixtures died.”
Mercurochrome and Metaphen: "Mercurochrome
2 per cent and Metaphen 1:1,500 failed to kill strepto-
cocci within an exposure period of even 15 minutes when
the culture germicide mixtures were subcultured into
the thioglycolate medium; and they failed to protect all
the mice from fatal infections. When the cultures of
the streptococci were treated with the marketed concen-
trations of these compounds diluted 1:2 and then inject-
ed into mice nearly all the mice died.”
Comparable tests were made on iodine in a solusalve
base* by the Chicago Board of Health.4 The procedure
was much the same as that followed by Morton et al.2
The germicidal agent was one gram of iodine in solu-
salve diluted in 10 ml. of sterile saline solution. One
milliliter of this solution was added to the broth culture
in the test tube. The tube was shaken vigorously and
at the time intervals, 1, 2(4, 5 and 10 minutes, 1.1 mis.
of the culture-germicide mixture was removed and placetL
in a culture medium as follows:
(a) 0.5 ml. in a sterile Petri dish to which 10 mis. of
melted blood agar were added and mixed thor-
oughly.
(b) 0.5 ml. in 5 ml. of thioglycolate medium.
(c) 0.1 ml. in veal infusion broth.
These cultures were incubated at 37° for 48 hours.
Cultures which showed no growth after 48 hours were
subcultured and those subcultures were incubated for
seven days at 37° C. Cultures showing growth were ex-
amined microscopically and also plated on red blood
agar.
At the ten-minute interval two mice were injected with
1 m 1. and 14 m 1. of the culture Vodine solution respec-
tively. Mice were injected with 1 ml. and .25 ml. of the
hemolytic streptococcic culture as controls for the patho-
genicity of the organism.
*Vodine — iodine 2 per cent, sodium iodide 2.4 per cent, Solu-
salve (Polyethylene glycol ointment base).
December, 1949
437
The results of the test were as follows:
Heart Blood
Mice
Result
Culture
1.00 ml. of streptococci
culture
Died
in 9J4 hours
Positive
.25 ml. of streptococci
culture
Died
in 96 hours
Negative
Iodine solution
1.00 ml.
Died
in 29 hours
Negative
.25 ml.
Died
in 29 hours
Negative
Iodine solution
and streptococci
1.00 ml.
Died
in 29 hours
Negative
.25 ml.
Died
in 120 hours
Negative
BACTERIOSTATIC TEST
Time in
Culture
Subculture
Minutes
Medium
Results
Results
1
Blood agar plates
No growth
No growth
214
Blood agar plates
No growth
No growth
5
Blood agar plates
No growth
No growth
10
Blood agar plates
No growth
No growth
15
Blood agar plates
No growth
No growth
Hemolytic streptococci failed to grow after one minute ex-
posure to the iodine solution diluted to 1 to 10 in sterile saline
solution.
BACTERICIDAL TEST
Time in
Culture
Subculture
Minutes
Medium
Results
Results
1
Veal infusion broth
No growth
No growth
214
Veal infusion broth
No growth
No growth
5
Veal infusion broth
No growth
No growth
10
Veal infusion broth
No growth
No growth
15
Veal infusion broth
No growth
No growth
1
Fluid thioglycolate
No growth
No growth
214
Fluid thioglycolate
No growth
No growth
5
Fluid thioglycolate
No growth
No growth
10
Fluid thioglycolate
No growth
No growth
15
Fluid thioglycolate
No growth
No growth
Hemolytic streptococci failed to grow after one minute ex-
posure to a sterile saline solution containing one gram of the
iodine preparation in 10 mis. of solution.
One milliliter of this solution, when injected intra-
peritoneally into a mouse weighing 18 grams, proved
fatal in one hour. One milliliter of this solution, with
hemolytic streptococci added, when injected intraperi-
toneally into a mouse weighing 18 grams proved fatal
in 29 hours.
In these tests no hemolytic streptococci were found in
the heart’s blood of the mice injected with the germicide-
culture mixture. The pathogenicity of the organism for
mice was proved by the fact that the animals injected
with hemolytic streptococci culture alone died in 9/i
hours and the organisms were isolated from the heart’s
blood. Mice injected with the germicide-culture died
after 29 hours. This indicated that the cause of death
was other than the streptococci infection. Tests on the
fungicidal efficiency of the iodine solution for M. albi-
cans and T. interdigitale revealed that neither fungus
grew after one minute exposure.
Relative Toxicity of Iodine and Mercurials
The antibacterial action of mercurial compounds is
much reduced in the presence of blood serum and
Waller '' found that a final concentration of 1:5,000
Merthiolate destroyed the anti-Rh agglutinins in human
serum.
In 1935 Salle and Lazarus (l determined the highest
bacteria killing dilutions of a number of antiseptics in-
cluding Mercurochrome, Metaphen, Merthiolate and
iodine. They also ascertained the dilutions of these sub-
stances which permitted no tissue growth. By dividing
the latter by the former they obtained a toxicity index.
It is obvious that if the dilution sufficient to kill the
tissues were higher than that necessary to kill bacteria,
the toxicity index would be more than 1.0 and the
"germicide” would be seriously deficient. The results of
the tests were as follows:
T oxicity
Germicide Index
Iodine 0.09
Hexylresorcinol 3.0
Metaphen 12.7
Phenol 12.9
Merthiolate 35.3
Mercurochrome 262.0
The above work indicates that Metaphen, Merthio-
late and Mercurochrome were 12, 35, and 262 times
more toxic for embryonic tissue cells than for Staphylo-
coccus aureus. Nye ‘ and Welch 8 also found the same
three mercurials more toxic for leucocytes than for bac-
teria cells.
The objections to the U.S.P. tincture is that the sol-
vent is lost by evaporation and the iodine by volatiliza-
tion. Beal et al 0 reported that a survey of 13 household
samples of strong iodine tincture had shown a tendency
to be somewhat stronger than official specifications.
Iodine in the solusalve base was compared with U.S.P.
XIII hydrophilic iodine ointment, as to stability and
penetration.
COMPARISON OF VODINE AND U.S.P. XIII HYDROPHILIC OINTMENT*
Percentage Iodine
Temperature At Start 24 Hrs. 96 Hrs.
Vodine
23.5°C.
1.84
1.86
1.83
U.S.P. XIII Hydrophilic
37.5°C.
1.84
1.86
1.81
ointment 2.0% iodine;
23.5°C
2.02
1.61
1.33
2.4% sodium iodide
37.5°C
2.02
1.42
1.06
The iodine in Vodine remained practically unchanged
while that in the U.S.P. hydrophilic ointment was vola-
tilized to a marked extent. After 96 hours at 23.5° C.
(room temperature), about 33 per cent of the iodine in
the hydrophilic ointment was lost, and at 37.5° C. the
loss was approximately 47.0 per cent.10
The difference in penetration of Vodine and U.S.P.
iodine ointment also was compared. A 4 per cent agar
solution with starch dissolved as an indicator was poured
*U.S.P. XIII hydrophilic ointment — iodine 2.0%, sodium
iodide 2.4%; ointment base, (wood fat 5.0%, yellow wax 5.0%,
petrolatum 90.0%).
438
The Journal-Lancet
into test tubes and allowed to set. The ointment was
put into the tubes in the space above the agar. The
extent of the diffusion of the iodine into the agar was
indicated by the blue color the iodine formed with the
starch. The results are given in the table below:
PENETRATION TESTS
VODINE AND U.S.P. IODINE OINTMENT
Time after start
Depth of Penetration
U.S.P. Iodine
Vodine Ointment
1 day
15 mm.
6 mm.
3 days
25 mm.
8 mm.
6 days
32 mm.
8 mm.
9 days
36 mm.
9 mm.
18 days
47 mm.
9 mm.
The U.S.P. iodine ointment remained practically sta-
tionary whereas the Vodine preparation penetrated to a
depth of 47 mm. in 18 days.11
Vodine was used on 200 patients treated in the admit-
ting room of a Chicago hospital. All age groups were
represented, the oldest being 77 years and the youngest
26 months. The medication was used on all parts of the
body for lacerations, abrasions, stab wounds, dermato-
phytoses, burns and dog bites. Pain did not accompany
the application, nor was any discomfort reported even
when the affected area was relatively large.
In some cases the skin became slightly softened but
this appeared to be of no clinical importance. There was
no crusting and the preparation was easily removed.
None of the patients complained of any soreness or ten-
derness of the skin even after repeated applications.
Bandaging and body temperature in no way affected
the consistency of the preparation.
In all cases infection was prevented and healing was
normal and uneventful. In wounds which had been
sutured, integrity of the wound or sutures was not in-
terfered with. No allergic reactions were observed, even
with repeated applications.
Summary
1. Iodine solutions have been found to be superior to
organomercurial compounds as antiseptics.
2. The stability and penetrative ability of Vodine was
found to be greater than U.S.P. XIII hydrophilic iodine
ointment.
3. Clinically, Vodine was found to have the potency
of liquid iodine preparations without the traditional dis-
advantages of being an irritant or lacking in stable
iodine strength.
References
1. Smith, A.: A report to the Council on Pharmacy and
Chemistry on Organo-Mercurial Compounds. J.A.M.A. 136:36,
1949.
2. Morton, H. E.; North, L. L.; Engley, F. B.: The bac-
teriostatic and bactericidal actions of some mercurial compounds
on hemolytic streptococci, J.A.M.A. 136:37, 1948.
3. Pittman, M.: A study of fluid thioglycolate medium for
the sterility test, J. Bact. 51:19-32, 1946.
4. Chicago Health Department: Bactericidal and bacterio-
static tests of Vodine on hemolytic streptococci in vivo and
vitro, personal communication, March 3, 1948.
5. Waller, R. K.: The action of sodium ethylmercurithio-
salicylate on human anti-Rh serums. Am. J. Clin. Path. (Tech.
Sup.) 8:116-117, 1944.
6. Salle, A. J., and Lazarus, A. S.: A comparison of the
resistance of bacteria and embryonic tissue to germicidal sub-
stances: I. Merthiolate, Proc. Soc. Exper. Biol, and Med. 32:
pp. 665-667, 1935. II. Metaphen, 937-938; Mercurochrome,
pp. 1057-1060.
7. Nye, R. N.: The relative in vitro activity of certain anti-
septics in aqueous solution, J.A.M.A. 108:280-287, 1937.
8. Welch, H.: Mechanism of the toxic action of germicides
on whole blood measured by the loss of phagocytic activity of
leukocytes, J. Immunol. 37:525-533, 1939.
9. Beal, G. D.; Water, K. L., and Block, P.: Stability of
iodine solutions and tinctures, J. Am. Pharm. 36:206, 1947.
10. Mattikow, M.: The volatility of iodine in Vodine com-
pared with iodine in U.S.P. hydrophilic ointment, personal
communication, April 27, 1948.
11. Mattikow, M.: Agar penetration tests on Vodine and
U.S.P. XIII hydrophilic iodine ointment, personal communica-
tion, Feb. 1, 1947.
HIGHER PAY APPROVED FOR ARMY PHYSICIANS AND DENTISTS
The effect of the recently passed Career Compensation Act of 1949 on the income of
medical and dental officers was analyzed recently by Major General R. W. Bliss, Surgeon
General of the Army. He pointed out that a physician who has completed his internship, or
a graduate dentist, may be commissioned as a first lieutenant, either in the Regular Army or
in the Medical or Dental Corps Reserve, and now receive total pay and emoluments amount-
ing to $473.88 a month (if married or with dependents), or $458.88 a month (if single and
without dependents). These figures compare with former pay totals of $417 and $361,
respectively.
LANCET
n\
Official journal of the American College Health Association
Great Northern Railway Surgeons’ Association, Minneapolis Academy of Medicine, North Dakota State
Medical Association, Northwestern Pediatric Society, South Dakota Public Health Association,
North Dakota Society of Obstetrics and Gynecology
BOARD OF EDITORS
ADVISORY COUNCIL
Dr. J. A. Myers, Chairman
Dr. A. B. Baker
Dr. Ruth E. Boynton
Dr. H. S. Diehl
Dr. Ralph V. Ellis
Dr. W. A. Fansler
Dr. J. C. Fawcett
Dr. A. R. Foss
Dr. C. J. Glaspel
Dr. J. F. Hanna
Dr. James M. Hayes
Dr. A. E. Hedback
Dr. W. E. G. Lancaster
Dr. L. W. Larson
Dr. W. H. Long
Dr. O. J. Mabee
Dr. A. D. McCannel
Dr. J. C. McKinley
Dr. Irvine McQuarrie
Dr. Henry E. Michelson
Dr. J. H. Moore
Dr. Martin Nordland
Dr. K. A. Phelps
Dr. C. E. Sherwood
Dr. E. Lee Shrader
Dr. E. J. Simons
Dr, J. H Simons
Dr. S. A. Slater
Dr. Joseph Sorkness
Dr. S. E. Sweitzer
Dr. G. W. Toomey
Dr. E. L. Tuohy
Dr. M. B. Visscher
Dr. R. H. Waldschmidt
Dr. O. H. Wangensteen
Dr. S. Marx White
Dr. H. M. N. Wynne
Dr. Thos. Ziskin, Secretary
North Dakota State Medical Association
Dr. W. A. Wright, President
Dr. L. W. Larson, President-Elect
Dr. O. A. Sedlak, Secretary
Dr. E. J. Larson, Treasurer
North Dakota Society of Obstetrics and Gynecology
Dr. B. M. Urenn, President
Dr. E. H. Boerth, Vice President
Dr. C. B. Darner, Secretary-Treasurer
Minneapolis Academy of Medicine
Dr. Cyrus O. Hansen, President
Dr. Chauncey Bowman, Vice President
Dr. John Haugen, Secretary
Dr. Karl Sandt, T reasurer
Northwestern Pediatric Society
Dr. L. G. Pray, President
Dr. Northrop Beach, Vice President
Dr. Elizabeth Lowry, Secretary-Treasurer
American College Health Association
Dr. L. B. Chenoweth, President
Dr. Grace Hiller, Vice President
Dr. Edith Lindsay, Secretary-T reasurer
Great Northern Railway Surgeons’ Association
Dr. W. W. Taylor, President
Dr. R. C. Webb, Secretary-Treasurer
South Dakota Public Health Association
Dr. J. M. Butler, President
Dr. C. E. Sherwood, Vice President
440 —
The Journal-Lancet
Editorial Future Meetings
URGENT NEED FOR GERIATRIC CARE
We are nearly always aware of the infectious disease,
which makes dramatic forays and causes sudden, acute
sickness. The chronic illness, on the other hand, with
its quiet onset in the later years of life, makes no arrest-
ing demands for our attention. Yet these chronic ill-
nesses of the aging group are our primary medical prob-
lem today.
Diseases of the heart and coronary arteries, cerebral
hemorrhage, and cancer now account for about two out
of three deaths in the upper age bracket. Diabetes,
which ranked 27th as a cause of death in 1900, was 8th
in 1944. Arteriosclerosis, in 34th place in 1900, was
10th in 1944. Dr. Howard Rusk reports in the Septem-
ber issue of the Medical Women’s Journal that 75 years
ago chronic diseases caused one-fifteenth of all deaths;
today they cause as much as three-fourths.
Part of this increase, of course, is due to the length-
ening span of life. Two thousand years ago, according
to Dr. Rusk, the average length of life was 25 years;
today it is 66. In 1900, one person in 25 was 65 years
or older; in 1980 it is estimated that the ratio will be
one in 10. By our great advances in medical and sur-
gical care we have prevented death and produced an
aging population.
And older persons need more medical care, Dr. Rusk
points out. In 1940, the 26.5 per cent of the country’s
population over 45 required over half of the nation’s
medical services. It is expected that by 1980 the people
over 45 will make up nearly half of the total population.
What makes the problem still more grave is that
chronic disease develops most frequently among families
of low income, depleting the income and the financial
reserves still further. In Illinois, for instance, 23 per
cent of public assistance recipients were chronic invalids;
in Connecticut, 20 per cent. In New Jersey 38 of those
on old age pensions were chronically ill.
When old people are well, they can get along with
the essentials of housing, food and clothing. But when
they fall sick, they need medical services, nursing care,
and hospitalization. In most sections of the country
there are simply no places equipped to care for the
chronically ill. Nursing homes and rest homes are crowd-
ed to overflowing, hospitals need their beds for surgery
and the more acute types of illness, and homes for old
people often have inadequate infirmary facilities or none
at all. In general, these homes will not accept an appli-
cant with serious chronic illness.
These needs of old people, of course, are not entirely
unrecognized. More and more forward-looking com-
munities are redesigning their social services to include
a geriatric program. In Minneapolis, for instance, the
Family and Children’s Service announced recently that
it was expanding its services available to the aged, rich
and poor alike, who are beset with problems of their
advanced years.
The University of Minnesota announces the follow-
ing continuation courses to be held at the Continuation
Center on the campus:
Cardiovascular Diseases on January 5-7, 1950. Dr.
Tinsley Harrison, Professor of Medicine at Southwest-
ern Medical College, Dallas, Texas, will act as visiting
faculty member for the course.
Obstertics, on December 16 and 17. The course is
intended for general physicians and will be held at the
Center for Contmuation Study. Etiology, diagnosis, and
management of obstetrical complications will be pre-
sented by means of lectures and round tables.
Clinical Neurology, January 30 to February 11,
1950. The course is intended for doctors of medicine
who are interested in increasing their knowledge of clin-
ical neurology. It is particularly recommended for neur-
ologists, psychiatrists, pediatricians, internists, and neuro-
surgeons. Visiting faculty members consist of Dr. Fred
Mettler, Neurological Institute, Columbia University,
New York City; Dr. Walter Klingman, Department of
Neurology, University of Virginia Hospital, Charlottes-
ville, Virginia; Dr. Harold Veris, Neurologic Surgery,
Mercy Hospital, Chicago, and Dr. Earl Walker, Neuro-
logical Surgery, Johns Hopkins University, New York
City.
Cities Launch Diabetes Detection Drives
Grand Forks medical and health officials launched
the city’s second annual diabetes detection program on
October 10. Those in charge included Dr. G. G. Thor-
grimsen, Ruth Noren, University nurse; Dr. W. C.
Dailey, Dr. L. S. Ralston, Dr. Richard Leigh, Mother
Rita Claire and Sister Constant of St. Michael’s Hos-
pital; John A. Page, director of the University medical
center; Harry D. Keller, manager of Deaconess Hos-
pital; Dr. E. A. Haunz, chairman of the North Da-
kota detection program, and Dr. T. Q. Benson, chair-
man of the Grand Forks campaign.
* *-
The drive in Bismarck began Monday, October 10,
and continued through Saturday, October 15. Dr. R.
B. Radi is chairman of the committee in charge for the
Bismarck Medical Club that is sponsoring the campaign.
A Winona intern made the highest score in a test
of cancer knowledge recently taken by 8,994 students
in 32 of the nation’s medical schools. He is Dr. John
K. Meinert, son of Dr. Albert E. Meinert of Winona,
Minnesota. The young man took the test while a senior
at the University of Minnesota last spring. He now
is an intern at the University of Michigan Hospital
in Ann Arbor. Meinert scored 150 points out of pos-
sible 180, or 83 per cent.
V.L.D.
December, 1949
447
American College Health Association News
A welcome is extended to all those interested in the
college and university health program to assemble at the
Henry Hudson Hotel, New York City, on December
29-30. The annual meeting of the American College
Health Association will bring together men and women
in the field of college health for the purpose of exchang-
ing information and clarifying problems. The meeting
will feature constructive discussions of subjects directed
to the improvement of the health and well-being of
college students.
Dr. J. E. Sawhill, New York University, Dr. Irwin
Sander, Wayne University, and Dr. L. B. Chenoweth,
University of Cincinnati, have organized an excellent
two-day program. A change from previous years has
been incorporated — that of panel discussions for every
session. This method of presentation provides oppor-
tunity for participation of a larger number of the mem-
bers. It permits an exchange of various points-of-view
and also stimulates general discussion. Each session has
been allotted sufficient time to explore the ramifications
of a specific subject.
The conference is scheduled to open at 9:30 A.M.,
December 29, with an address by the President, Dr.
Laurence B. Chenoweth. The first session at 10:00
A.M. will be a panel discussion on "The Role of Health
Education in the College Curriculum” with the follow-
ing participants: Dr. Edith M. Lindsay, Assistant Pro-
fessor of Public Health, University of California; Dr.
Herbert Ratner, Director of Health Service, Loyola
University, Chicago; an administrator to be selected;
and Dr. Ernest I. Stewart, Assistant Professor of Phys-
ical Education, Columbia University, New York.
At noon an Association luncheon will highlight Dr.
Willard C. Rappleye, Dean of the College of Physicians
& Surgeons, and Vice-President of Columbia University,
on the topic, "Current Problems in Medical Education.”
At 2:30 Dr. Howard Rush will be in charge of a
symposium on Physical Medicine to be held at the In-
stitute of Rehabilitation.
The morning of December 30 is divided into two
parts. The first panel will be under the guidance of
Dr. Ruth Boynton, University of Minnesota, and will
discuss "Health Problems of Women in Colleges.” Dr.
Warren Forsythe, University of Michigan, will act as
the moderator of the second panel discussion on "Prob-
lems of Recognition and Standards for Health Services.”
A business meeting of the Association will open the
afternoon session. This will be followed by a discussion
of the "Problems of Nutrition as Applied to College
Health” under the able leadership of Dr. Norman
Jolliffe.
Dr. Sawhill, chairman of the local arrangements com-
mittee, reports that many conventions are meeting in
New York on the same date. Because of the crowded
conditions in hotels, Dr. Sawhill recommends making
reservations immediately. You should have already re-
ceived a preliminary program and a hotel reservation.
If not, write directly to the Henry Hudson Hotel for
your reservation.
Will each of you accept the responsibility of inform-
ing all health personnel in your institution of the an-
nual meeting and encourage their attendance. The pro-
gram committee has been working hard to formulate a
worthwhile program but it needs your support to make
the meeting a real success.
The Executive Committee of the American College
Health Association has accepted the application for
membership of the following institutions: University
of New Mexico (Dr. J. E. J. Harris, Director Student
Health Service) , Albuquerque, New Mexico; Univer-
sity of California — Davis Campus (Dr. Charles L. Mc-
Kinney, Director Student Health Service), Davis, Cali-
fornia. The final election to membership of these in-
stitutions will be made by a vote of the delegates at
the annual meeting in December.
Dr. John E. Gillick is the new Director of Health
and Medical Services at Adelphi College, Garden City,
New York.
Sarah Lawrence College also has a new college physi-
cian and Director of Health. She is Dr. Caroline F.
Burpeau.
The Cook County Graduate School of Medicine, 427
South Honore Street, Chicago, Illinois, is pleased to
announce the addition to its staff of John W. Neal,
who will serve as Comptroller and Assistant Registrar.
Mr. Neal is a graduate of Northwestern University
School of Law and has been engaged in practice in
Chicago for the past eleven years. He is a member of
the Chicago, the Illinois State and the American Bar
Associations. He is associated with the Illinois State
Medical Society as General Counsel, and as Executive
Secretary of its Committee on Medical Service and Pub-
lic Relations. Mr. Neal is the son of the late Dr. John
R. Neal, who was Dean of the Cook County Graduate
School of Medicine at the time of his death.
Ohio University (5,000 students) needs two internists
or general practitioners in near future to complete four-
doctor staff. Experience in psychiatry or in athletic in-
juries desirable. No age restriction; state retirement
provisions, regular hours and generous vacation periods,
fine working conditions in new Health Center. E. Hern-
don Hudson, M.D., Director, Athens, Ohio (Phone
24532).
448
The Journal-Lancet
News Briefs
North Dakota
The belief in a four-year medical program at the
University of North Dakota without immediately add-
ing to the buildings on the campus was stated by Dr.
Roy Calkins at the October 19 meeting of the Grand
Forks District Medical Society. Dr. Calkins is a pro-
fessor of obstetrics and gynecology at the University of
Kansas Medical School. He inspected the facilities at
the University and was much impressed with the new
medical science building, and the "excellent, forward-
looking faculty.”
Ground breaking ceremonies were held in Garri-
son, N. D., on Friday, October 21, for the new Garrison
Municipal Hospital. Participating in the event were Dr.
E. C. Stucke, retired Garrison physician, member of
the hospital board and a representative of the state
health department.
The annual fall meeting of the North Dakota
Society of Obstetrics and Gynecology was held Satur-
day, October 22, in the Prince Hotel at Bismarck.
The afternoon meeting featured business and scien-
tific discussions, followed by an evening banquet. Fea-
tured speaker was Dr. John Faber of the Mayo Clinic,
Rochester, Minn. Dr. Harry Wheeler, Mandan, is the
retiring president and Dr. B. M. Urenn, Fargo, the
incoming president.
The North Dakota Public Health Association
stressed the theme, "Public Health is Everybody’s Busi-
ness,” during its sixth annual meeting from November
10 to 12 in Grand Forks. The convention’s principal
address was given by Dr. Franklin S. Crockett of La-
fayette, Indiana, chairman of the rural health committee
of the American Medical Association.
With two-thirds of the 30 members of the North
Dakota Pediatric Society in attendance, the first interim
meeting of the society was held at the Gardner Hotel
in Fargo in October.
The society was organized last spring, with Dr. R. E.
Dyson of Minot as president.
Dr. and Mrs. J. J. Stratte of Grand Forks spent
the week end of October 22 in Minneapolis renewing
contacts with Swedish doctors whom they had met two
years ago while attending a conference of Scandinavian
surgeons in Stockholm, Sweden. A delegation of Swe-
dish doctors in this country for a two months tour of
medical centers had arrived in Minneapolis to visit its
hospitals and the University of Minnesota school of
medicine. They were headed by Dr. John Hellstrom,
chief of surgery at the University of Stockholm, an
acquaintance of Dr. Stratte.
Dr. L. G. Pray, pediatrician of Fargo Clinic, pre-
sided over session of the Northwest Pediatrics Society
in Minneapolis in October. Also attending were Dr. B.
A. Mazur, pediatrician of Dakota Clinic, and Dr. M.
H. Poindexter, who is associated with Fargo Clinic.
When St. Luke’s Hospital $380,000 building cam-
paign opens in Fargo in a few weeks, it will have a
"kitty” of $100,000 to start with, more than 700 resi-
dents of the Fargo-Moorhead area were told at a dinner
in Fargo on November 2.
Dr. H. B. Huntley of Kindred attended the annual
meeting of the Association of American Physicians and
Surgeons as a delegate from North Dakota. Other dele-
gates from North Dakota were Dr. Spears of Dickin-
son and Dr. Leeblar of Grand Forks.
Dr. Milton J. Johnson will soon take over the office
of Dr. Kent F. Westley in Cooperstown. Dr. Westley
left for New York City to resume studies.
Dr. Johnson received his medical degree in California
and has just finished special surgical training in Colo-
rado. He was a resident of Minnesota for 13 years.
The medical firm of Drs. Wright, Lund and John-
son, of Williston, announced that Dr. Donald E. Skjei
has become associated with the firm in the practice of
medicine and surgery.
A graduate of Williston high school class of 1938,
Dr. Skjei completed three years of college studies at
the University of North Dakota and two years of medi-
cine there. He graduated from Temple University
School of Medicine at Philadelphia in 1946.
Dr. Skjei interned at St. Mary’s Hospital in Detroit,
Michigan, and entered the Army medical corps in 1947.
South Dakota
Dr. D. H. Breit of Sioux Falls is the newly elected
president of the South Dakota branch of the American
Cancer Society.
Dr. E. S. Watson, Brookings, was elected president
of the State Mental Health Association at its annual
meeting in Pierre on October 11.
The regular fall meeting of the Yankton District
Medical Society was held at the state hospital on Oc-
tober 20. Medical students from the University at
Vermillion joined the group for an address by the guest
speaker, Dr. R. R. Greene, of Chicago.
Dr. Greene is professor of obstetrics and gynecology
and a member of the staff at Wesley Memorial Hos-
pital, Chicago. His subject of discussion was "Gyneco-
logical Problems and Endocrine Disturbances.”
December, 1949
449
After two years of working and planning, the Platte
Community Memorial Hospital was dedicated October
20. Dr. Arthur Schade of Huron, secretary of the
South Dakota Hospital and Home Management Asso-
ciation, will manage the institution.
For the academic year 1946-47, South Dakota
ranked 27th in the nation in the number of freshman
medical students on the basis of population. Last year,
however, it ranked seventh.
The school has graduated 646 students since its found-
ing in 1907. Of these, 436 were resident students and
through 1941 the average for state residents was 67 per
cent. Hard said the average for postwar years rose to
80 per cent and presently is 96 per cent.
Only 86 of the state’s 451 licensed physicians are
graduates of the school, but the school’s real contribu-
tion is noted in the high number of graduates supplied
to neighboring states.
A new ten-room clinic opened for the examining
and receiving of patients opened in Martin in October.
The new clinic is under the direction of Dr. F. U.
Sebring and his new associate, Dr. R. S. Westby, Jr.
New Appointments . . .
Drs. David M. Witter, Newell, and Charles Carl,
formerly of the Missouri state health department, were
appointed staff members at the South Dakota state
health department recently.
Dr. Walter A. Patt, head of pediatrics in the Trip-
ler General Hospital in Honolulu for the past eighteen
months, has joined the staff of the Brookings Clinic as
pediatrician.
A native of St. Joseph, Missouri, Dr. Patt received
his M.D. from the Washington University Medical
School in St. Louis in 1946 and took further training
at the Miami Valley Hospital in Dayton, Ohio, and
the Colorado University Medical School at Denver, and
spent two years in the Army medical corps.
Dr. Thomas G. FitzGibbons of Sioux Falls has
joined the medical staff of the Homestake Mining Com-
pany Hospital.
Dr. FitzGibbons is a graduate of the Creighton Uni-
versity School of Medicine in Omaha, took his intern-
ship at St. Joseph Hospital in Omaha and went into
private practice at Huron. From 1926 to 1930 Dr. Fitz-
Gibbons held a fellowship at the Mayo Clinic and then
spent several years in Army and Veterans Administra-
tion medicine.
Dr. R. W. McMullen of Texas joined the staff
of the McIntosh Clinic in Eureka. Dr. McMullen re-
ceived his training in Los Angeles, California, and com-
pleted his intern work in that city in 1944. For a time,
he served as physician and surgeon in the mission field
in China, until hostilities in that country necessitated
his leaving.
Minnesota
Dr. W. L. Benedict, Rochester, was elected execu-
tive secretary-treasurer by the American Academy of
Ophthalmology and Otolaryngology, a society of eye,
ear, nose and throat specialists meeting in Chicago.
Dr. Jan T. Tillisch, consultant in medicine at the
Mayo Clinic and the Mayo Foundation of the Univer-
sity of Minnesota at Rochester, was elected to the board
of directors of Mid-Continent Airlines, Inc.
Appointment of Dr. P. M. Mattill as acting super-
intendent of Glen Lake Sanatorium, to serve until a
successor to Dr. E. S. Mariette is chosen, was announced
recently.
Dr. Abe Baker, head of the deparment of neurology
at the University of Minnesota Medical School, spoke
to members of the Red River Valley Medical Society
following a recent meeting. Dr. Baker spoke about
poliomyelitis, its diagnosis and treatment. Between 40
and 45 members of the society were expected to attend.
Dr. B. J. Branton, mayor of Willmar, was elected
president of the Minnesota Public Health Association.
He succeeds N. Vere Sanders, Albert Lea.
The fifth New Ulm medical man to be elected a
fellow of the American College of Surgeons is Dr.
William A. Black. He is associated with Dr. O. J.
Seifert, also a fellow of the college. Other New Ulm
fellows are Dr. F. H. Dubbe, Dr. Alfred and Dr. T. R.
Fritsche.
Dr. Gerrit Beckering of Edgerton, Minnesota, was
chosen president of the Southwestern Minnesota Med-
ical Association at its annual meeting. Dr. Peter J.
Pankratz, Mountain Lake, was elected vice-president
and Dr. O. M. Heiberg of Worthington, secretary-
treasurer.
Dr. Beckering and Dr. E. W. Arnold, Adrian, were
elected to the state house of delegates with Dr. C. L.
Sherman, Luverne, and Dr. W. B. Wells, Jackson, as
alternates. Dr. Arnold and Dr. B. M. Stevenson, Fulda,
will represent the association on the state board of
censors.
Dr. Arthur A. Zierold, Minneapolis surgeon and
University of Minnesota surgery professor, was named
a member of the high ranking International Society of
Surgery at their meeting in New Orleans. Dr. Zierold
was scheduled to comment on a lecture on gallbladder
disease by a Viennese surgeon.
Four Rochester surgeons appeared on the program
of the International College of Surgeons’ fourteenth
assembly and convocation November 7 through 12, in
Atlantic City, New Jersey. Then men are Drs. Alfred
W. Adson, Albert Faulconer, Harold I. Lillie and
Henry W. Meyerding. Dr. Meyerding is president-
elect of the organization.
450
The Journal-Lancet
Dr. W. F. Wilson of Lake City was elected secre-
tary of the Wabasha County Medical Society for the
fifty-fourth year at a recent meeting of the organization.
Dr. Wilson was first elected to the secretaryship in July
of 1896. Other officers are Dr. L. M. Elkstrand, Wa-
basha, president; Dr. William P. Gjerde of Lake City,
vice-president, and Dr. Wilson, secretary-treasurer.
New Appointments and Locations . . .
Dr. Leo Whitehill, formerly a physician with the
Norwich, Connecticut, state hospital, has joined the staff
at the Anoka State Hospital.
* * *
Dr. E. Pasek, who has been practicing with his
brother, Dr. A. W. Pasek of Cloquet, for some time,
has opened an office in Carlton for full-time practice.
* * *
Dr. Robert W. Keyes has accepted a position on the
staff of the Shipman Hospital, Ely, Minnesota. During
the past year, Dr. Keyes has been practicing at Has-
tings, Minnesota.
* * *
Dr. Kenneth Douglas purchased the practice of
the late Dr. V. J. Telford in Litchfield and is now
established there. He practiced for several years on the
west coast and the last three years has been in surgery
at a clinic in St. Peter, Minnesota.
* * *
Dr. Carlton Nelson of Minneapolis has joined the
staff of the Worthington clinic as a surgeon, following
three-and-a-half years of training at the Minneapolis
General Hospital.
* * *
Dr. A. S. Midthune has opened an office for prac-
tice of medicine in the village of Lake Park.
* * *
Dr. R. E. Stewart, formerly of the Twin Cities and
Duluth, has joined the staff of the Northwestern Clinic,
Crookston. Dr. Stewart has just completed a four year
fellowship in surgery at the Veterans Hospital in St.
Paul and University Hospital, Minneapolis.
* * *
Dr. Reta Adams of San Antonio, Texas, assumed
her new duties November 1 on the staff of the Fergus
Falls State Hospital. Dr. Adams is a graduate of the
New York Medical College and has had extensive ex-
perience in mental health work.
* * *
Dr. A. R. Andrejek of Madison, Minnesota, has
joined the Henry Clinic at Milaca. Dr. Andrejek is a
graduate of the University of Minnesota Medical
School, took special training in obstetrics, and has just
completed two years at the Madison Clinic at Madison,
Minnesota.
* * *
Dr. Michael F. Koszalka recently began practicing
internal medicine at 100 Lowry Avenue N. E., Minne-
apolis, in association with Dr. Leonard A. Borowicz.
* * *
Dr. William D. Misbach, a native of Fairmont,
opened his practice in that city in medicine and surgery
in association with Dr. E. E. Zemke. For the past six
months, Dr. Misbach has been receiving postgraduate
training at Midway Hospital, St. Paul, and University
Hospital, Minneapolis.
DR. MYERS AWARDED PLAQUE
A plaque for distinguished service in the field of
tuberculosis control was presented to J. Arthur Myers,
M.D., chairman of the Journal-Lancet editorial
board, at the annual Christmas Seal dinner October 25,
held at Coffman Memorial Union. The award was
made by the Minnesota Public Health Association on
the occasion of the publication of Dr. Myers’ latest
book, Inn ted and Conquered, a 700-page history of
tuberculosis in Minnesota. Over 12 years in the writing,
Invited and Conquered tells how early settlers encour-
aged immigration of consumptives, how Minnesota be-
came a "resort for invalids,” how through concerted
effort the state is now nearing the point where it may
say that tuberculosis was invited — and conquered.
Dr. Myers is a past president of the National Tuber-
culosis Association, Mississippi Valley Conference on
Tuberculosis and the American College of Chest Physi-
cians. He is editor-in-chief of the latter organization’s
official publication, Diseases of the Chest, and a mem-
ber of the editorial board of the American Review of
T uberculosis.
Dr. Myers is a member of the sub-committee on tuber-
culosis of the National Research Council, chief of the
Minneapolis General Hospital tuberculosis service, chief
of the University of Minnesota chest clinic, and con-
sultant in tuberculosis for the Veterans Administration.
Dr. Harold S. Diehl, dean of the University of
Minnesota medical school, left the campus Monday,
November 21, for Great Britain, where he and two
other medical school deans will make a study of Britain’s
nationalized medical service. Dr. Diehl, Dr. L. R. R.
Chandler, dean of Stanford university medical school,
and Dr. Stanley Dorst, dean of the University of Cin-
cinnati medical school, will study the effects of the
British nationalized medical service on medical schools
and medical education.
Commemorating the 30th anniversary of St. Ga-
briel’s hospital medical staff, a testimonial dinner was
held October 12 at St. Francis Hall in Little Falls.
The staff was organized in 1919 with five physicians,
Drs. J. G. Mtllspaugh, E. L. Fortier, J. B. and C. F.
Foist and L. M. Roberts.
Active on the staff today are: Drs. A. M. Watson
and S. W. Watson, Royalton; D. L. Johnson, R. V.
Fait, R. A. Stoy, G. P. Schmitz, G. M. A. Fortier,
Little Falls; C. B. Messa, radiologist, St. Cloud; R. T.
Healy and R. J. Stein, Pierz; E. J. Schmitz, and R. C.
Smith, Holdingford; J. T. Laughlin, Grey Eagle, and
E. G. Knight and E. J. Simons, Swanville. Dr. S. G.
Knight, Randall, is a retired staff member.
Dr. H. P. Lillie was named president of the Mayo
Clinic staff at the annual meeting of the group on
November 21. The other officers are Dr. F. P. Moersch,
vice president; E. N. Cook, secretary, and Dr. C. W.
Rucker and Dr. C. H. Watkins, first and second coun-
selor, respectively.
December, 1949
45.1
Deaths
Dr. C. Anderson Aldrich, a children’s doctor who
believed that "babies are human beings,” died in Roches-
ter on October 6. Dr. Aldrich was a noted pediatrician
— the director of Rochester’s pioneering Child Health
institute and a Mayo clinic staff member.
He came to Rochester in January, 1944, to launch the
Child Health Institute — a project to guide the mental
and physical health of every child born in Rochester
from that date on.
♦ * *
Dr. Lyle L. Brown, Croolcston city health officer
since 1928, died October 11, ending a life-long career of
public service to this community. He had suffered from
a heart illness for the past several years and had been
only partially active as pediatrician of the Northwestern
Clinic of Crookston up to the time of his last illness.
Dr. Joseph Owen McKeon, former mayor of Mont-
gomery, Minnesota, for eight years, died in November
in San Angelo, Texas, where he had been civilian med-
ical officer at Goodfellow army air base since June.
* * *
Services for Dr. Robert Best, Pipestone, Minne-
sota, were held October 10th. Dr. Best, who had been
with the United States Indian Service at Pipestone, died
there October 6th.
* * *
Dr. Paul N. Jepson, orthopedic surgeon and former
associate of the Mayo Clinic, died suddenly October
24th while examining patients at Pottstown (Pennsyl-
vania) Hospital. He was a resident of nearby Phoenix-
ville.
* * *
Dr. Hugh Legatt McLean, son of John and Jane
McLean, pioneers of Dakota territory, South Dakota,
died at the Veterans Hospital in Lexington, Kentucky,
September 14, 1949, after a long illness, at the age of
84 years.
Meet Our Contributors
Joseph Frederick Bicek, M.D., was gradated from the
University of Minnesota Medical School, specialized in
obstetrics and gynecology. He holds membership in the
A.M.A., the Minnesota State Medical Society, the Ram-
sey County Medical Society, and the Minnesota Obstet-
rics and Gynecological Society.
Irving Kass, M.D., is a graduate of the University of
Kansas Medical School and specializes in internal medi-
cine. He is a member of Phi Beta Kappa, and the
A.M.A. Now at the J.C.R.S. Sanatorium, Spevak, Colo-
rado, he is investigating the problem of streptomycin in
tuberculosis.
Frank A. Hill, M.D., was graduated from Rush Med-
ical College in 1940, served in the army medical depart-
ment, held a three-year fellowship at the Milwaukee
County General Hospital, now specializes in obstetrics
and gynecology in Grand Forks, North Dakota. He is a
member of the district and state medical societies, the
North Dakota Society of Obstetrics and Gynecology, and
the Association of Military Surgeons.
Frank W. Quattlebaum, M.D., was graduated from the
University of Georgia School of Medicine in 1939, re-
ceived his M.S. in surgery from the University of Min-
nesota in 1947, is now a clinical instructor in surgery at
the University of Minnesota, and consultant in surgery
at the Minneapolis Veterans Hospital. He is a member
of the American College of Surgeons and the American
Board of Surgery.
Henry B. Wightman, M.D., was graduated from Cor-
nell Medical College, and is now associate professor of
clinical medicine and attending physician of the infir-
mary at the same institution. From 1931 to 1942 he
practiced pediatrics in New Rochelle, N. Y., and served
on the American Board of Pediatrics in 1940. He is a
member of the A.M.A., county and state medical socie-
ties, and the American Academy of Allergy.
Dorothy Pietila Siemers took a dietetic internship at
the Stanford University Medical School in San Fran-
cisco, and for the past three years has been a dietitian
at the Students Health Service at the University of Min-
nesota.
Harry Roemer McPhee, M.D., is a graduate of the
Western Reserve University Medical School. Since 193 3
he has been team physician at Princeton University, also
serves as president of the Princeton Board of Health.
He is a member of the American College Health Asso-
ciation and the Pennsylvania-New Jersey Student Health
Association.
Ramona L. Todd, M.D., is a graduate of the Univer-
sity of Minnesota Medical School, and for the past seven
years has been with the Students’ Health Service at that
school. She is a member of Sigma Xi, the Hennepin
County Medical Society, Minnesota State Medical So-
ciety, and the A.M.A.
Hugh W. Hawn, M.D., was graduated from the med-
ical school of the University of Minnesota, specializes
in ophthalmology at the Fargo Clinic in Fargo, North
Dakota. He is a member of the First District Medical
Society, the A.M.A., the American Academy of Oph-
thalmology and Otolaryngology.
John H. Moore, M.D., a graduate of Northwestern
Medical School, specializes in obstetrics and gynecology
in Grand Forks, North Dakota. He is a member of dis-
trict and state medical societies; American Gynecological
Society; American Association of Obstetricians, Gyne-
cologists and Abdominal Surgeons; Chicago Gyneco-
logical Society; Los Angeles Society of Obstetrics and
Gynecology; Minnesota Society of Obstetrics and Gyne-
cology; a fellow of the A.M.A., a diplomate of the
American Board of Obstetrics and Gynecology; and a
past president of the Central Association of Obstetrics
and Gynecologists.
452
The Journal-Lancet
Classified Advertisements
Advertisers' Announcements
ROBITUSSIN
With its formulation based entirely on scientific observations,
a new cough syrup, Robitussin, is being extensively promoted
by A. H. Robins Company, Inc., of Richmond, Va. As a prod-
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the management of cough. As such, the firm claims Robitussin
should logically supersede and replace those empirical formula-
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remedies. Robitussin (per 1 teaspoonful) contains: Glyceryl
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1 mg. (in a palatable aromatic syrup).
According to investigators who evaluated practically all the
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Robitussin’s second ingredient, desoxyephedrine hydrochloride,
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of the most palatable of all antitussive-expectorants.
FOR SALE
Maico Audiometer in perfect condition, used only by
Maico of Fargo and guaranteed by them. #150, F O B.
Fargo. Write Student Health Center, N. Dakota Agric.
College, Fargo, N. Dak.
WANTED
Physician to join the Medical Staff of the North Da-
kota State Hospital. If interested correspond with Super-
intendent, Jamestown, North Dakota.
FOR SALE
Portable G.E. 15 M.A. X-ray for sale. Merrill W.
Pangburn, M.D., Miller, South Dakota.
ASSISTANCE AVAILABLE
Woodward Medical Personnel Bureau (formerly Aznoes
— Established 1896) have a great group of well trained
physicians who are immediately available. Many desire
assistantships. Others are specialists qualified to head
departments. Also Nurses, Dietitians, Laboratory, X-Ray
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confidential. For biographies please write Ann Wood-
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Wabash, Chicago.
AQUEOUS VITAMIN A SOLUTION
U. S. Vitamin Corporation, and its affiliate, Casimir Funk
Laboratories, Inc., announce the acceptance of their Aquasol
Vitamin A Drops by the Council of Pharmacy and Chemistry
of the American Medical Association. As stated in a recent
full page, two-color advertisement in the Journal of the Ameri-
can Medical Association, this is the "first and only” aqueous
vitamin A solution to be accepted by the Council.
Extensive clinical studies now prove conclusively that aqueous
solutions of vitamin A, as provided in Aquasol Vitamin A
Drops, are more rapidly absorbed than vitamin A in oil solu-
tions. This makes Aquasol Vitamin A Drops especially useful
in patients with dysfunctions of the liver, pancreas and biliary
tract which interfere with utilization of fats; in celiac disease
and certain other diarrheal states.
The Research Laboratories of U. S. Vitamin Corporation
in 1943 pioneered and developed the making of aqueous solu-
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one of several U. S. Vitamin preparations providing the advan-
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WANTED
Starting January 1, 1950, assistant or associate who
has completed internship, or Fellow in surgery who needs
another year or two of association with Diplomate of
American Board. Write Box 893, Journal-Lancet.
OFFICE FOR RENT
Good location for general practice in Anoka. Office
for rent on ground floor — downtown on Main Street.
Can make money if willing to work. Equipment for sale
includes good X-ray — reasonable. George H. Schlessel-
man, M.D., 320 E. Main St., Anoka, Minn.
FOR RENT
Office suite for rent. Three rooms or more. Over
drug store on corner of 50th and France South in Edina.
Will decorate to suit renter. Lease if desired. Mr. A. L.
Stanchfield, 4424 W. 44th St., Ma. 3371, Wa. 4806.
"OLOTHORB” CAPSULES
Sharp & Dohme, Philadelphia, has announced the national
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patients over a period of months without the appearance of any
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neo-synephrine hydrochloride constricts the engorged mucosa surrounding tht
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Ammonium Chloride 12 gr.
Sodium Citrate 5 gr.
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